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How to diagnose and How to diagnose and recognize vertical recognize vertical deviations deviations Part II Part II Superior Oblique Palsy Superior Oblique Palsy G. Vike Vicente, MD G. Vike Vicente, MD Eye Doctors of Washington Eye Doctors of Washington

How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

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Page 1: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

How to diagnose and How to diagnose and recognize vertical deviationsrecognize vertical deviations

Part II Part II

Superior Oblique PalsySuperior Oblique Palsy

G. Vike Vicente, MDG. Vike Vicente, MD

Eye Doctors of WashingtonEye Doctors of Washington

Page 2: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Double image recreated by pt.

Page 3: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique Palsy

Dr. G.Vicente

Page 4: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Unilateral Superior Oblique PalsyUnilateral Superior Oblique Palsy

If the misalignment is worse on left head tilt If the misalignment is worse on left head tilt then the patient will walk into your office with then the patient will walk into your office with a…a…

Right head tiltRight head tilt How can you differentiate this from a neck How can you differentiate this from a neck

torticollis?torticollis? Patch one eye, the torticollis will improve in Patch one eye, the torticollis will improve in

SO palsy pts.SO palsy pts.

Page 5: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Torticollis patch test

Page 6: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Torticollis patch test

Page 7: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Torticollis patch test

Page 8: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Torticollis patch test

Page 9: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital superior oblique palsy

• Usually unilateral• Watch for contralateral hypoplasia

– Which came first the chicken or the egg?– Is the face small on that side because of the torticollis

or is there a superior oblique palsy because of abnormal facial bone structure?

Page 10: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Parks’ three step test algorithm

• Rt tilt LIO• Rt gaze Lt tilt RIR• RHT• Lt gaze Rt tilt RSO• Lt tilt LSR

• Rt tilt RSR• Rt gaze Lt tilt LSO• LHT• Lt gaze Rt tilt LIR• Lt tilt RIO

Page 11: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Adult superior oblique palsyAdult superior oblique palsy

Acquired? ie Cranial nerve 4 palsyAcquired? ie Cranial nerve 4 palsy– Usually bilateralUsually bilateral– TraumaticTraumatic

Remember the long course of CN 4Remember the long course of CN 4

closed head trauma? closed head trauma?

MVA? MVA?

loss of consciousness? loss of consciousness?

– Neoplastic, tumorNeoplastic, tumor55 yo AF h/o breast CA, headache, chronic sinusitis 55 yo AF h/o breast CA, headache, chronic sinusitis (meningioma)(meningioma)

Congenital but late onset, decompensationCongenital but late onset, decompensation

Page 12: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Think Bilateral If…Think Bilateral If…

V pattern is presentV pattern is present

Esotropia in downgazeEsotropia in downgaze

Greater than 10 degrees of excyclotorsion Greater than 10 degrees of excyclotorsion on double maddox testing.on double maddox testing.

Page 13: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Add double maddox rod pic Add double maddox rod pic

Page 14: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique PalsySuperior Oblique PalsySurgical treatmentSurgical treatment

For congenital SO palsy, For congenital SO palsy, – It is really more of a floppy tendon.It is really more of a floppy tendon.– Shorten, or tighten the superior oblique tendon.Shorten, or tighten the superior oblique tendon.

For acquired For acquired – Weaken the opposing muscle, inferior obliqueWeaken the opposing muscle, inferior oblique

Recession.Recession.

– If vertical deviation is large >15PD, consider If vertical deviation is large >15PD, consider recession of contralateral inferior rectus.recession of contralateral inferior rectus.

– If longstanding and the eye has poor depression, the If longstanding and the eye has poor depression, the superior rectus is likely contracted and should be superior rectus is likely contracted and should be recessed.recessed.

Page 15: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Floppy tendon tuckFloppy tendon tuckfor Superior Oblique palsiesfor Superior Oblique palsies

Page 16: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital Superior oblique palsysurgery to shorten floppy tendon

SR

MR

LR

IR

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO

Page 17: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital Superior oblique palsysurgery to shorten floppy tendon

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Page 18: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital Superior oblique palsysurgery to shorten floppy tendon

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Page 19: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital Superior oblique palsysurgery to shorten floppy tendon

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Page 20: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital Superior oblique palsysurgery to shorten floppy tendon

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Page 21: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Congenital Superior oblique palsysurgery to shorten floppy tendon

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Page 22: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Acquired SO palsiesAcquired SO palsies

Weaken the opposing muscle, inferior Weaken the opposing muscle, inferior obliqueoblique– Recession.Recession.

If vertical deviation is large >15PD, If vertical deviation is large >15PD, consider recession of contralateral inferior consider recession of contralateral inferior rectus.rectus.If longstanding and the eye has poor If longstanding and the eye has poor depression, the superior rectus is likely depression, the superior rectus is likely contracted and should be recessed.contracted and should be recessed.

Page 23: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

IO recession and IO recession and contralateral inferior rectus contralateral inferior rectus

recession recession for large vertical deviationsfor large vertical deviations

Page 24: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Acquired Superior oblique palsySurgery to improve torsion

and vertical alignment

SR

MR

LR

IR

SR

LR

RM

IRIOIO

Dr. G.Vicente

Recess IORecess IR (contralateral)

Page 25: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Acquired SO palsyAcquired SO palsy

If little vertical deviation but large If little vertical deviation but large extorsional componentextorsional componentConsider Harada-Ito procedure:Consider Harada-Ito procedure:Anteriorly displaced anterior half of the SO Anteriorly displaced anterior half of the SO tendon.tendon.Tightening the whole tendon would cause Tightening the whole tendon would cause a Brown syndrome.a Brown syndrome.Lateralizing the anterior fibers intorts the Lateralizing the anterior fibers intorts the eye.eye.

Page 26: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Harada-Ito Anterior displacement of ½ SO tendon

Dr. G.Vicente

Page 27: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Harada-Ito Anterior displacement of ½ SO tendon

Dr. G.Vicente

Page 28: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Harada-Ito Anterior displacement of ½ SO tendon

Dr. G.Vicente

Page 29: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Harada-Ito Anterior displacement of ½ SO tendon

Dr. G.Vicente

Page 30: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique Palsy

Dr. G.Vicente

Page 31: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique OveractionSuperior Oblique Overaction

Page 32: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique OveractionSuperior Oblique Overaction

Usually primary since IO palsies are very Usually primary since IO palsies are very uncommonuncommon

Vertical deviation often present in Primary Vertical deviation often present in Primary gaze! gaze!

Ipsilateral hypotropia, worse on adduction.Ipsilateral hypotropia, worse on adduction. XT may be present as well.XT may be present as well. ““A” pattern visibleA” pattern visible Tx: SO recession or tendon elongation.Tx: SO recession or tendon elongation.

Page 33: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique Overaction“A” pattern

Dr. G.Vicente

Page 34: How to diagnose and recognize vertical deviations Part II Superior Oblique Palsy G. Vike Vicente, MD Eye Doctors of Washington

Superior Oblique OveractionDown shoot

Dr. G.Vicente