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.
Superior Oblique Palsy
Dr. G.Vicente
Unilateral Superior Oblique Palsy
 If the misalignment is worse on left head tilt
then the patient will walk into your office with
a…
 Right head tilt
 How can you differentiate this from a neck
torticollis?
 Patch one eye, the torticollis will improve in
SO palsy pts.
Torticollis patch test
Torticollis patch test
Torticollis patch test
Torticollis patch test
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?
Parks’ three step test algorithm
•
•
• RHT
•
•
•
•
• LHT
•
•
Rt gaze
Lt gaze
Rt gaze
Lt gaze
Rt tilt
Lt tilt
LIO
RIR
Rt tilt
Lt tilt
RSO
LSR
Rt tilt
Lt tilt
RSR
LSO
Rt tilt
Lt tilt
LIR
RIO
Adult superior oblique palsy
Acquired? ie Cranial nerve 4 palsy
– Usually bilateral
– Traumatic
Remember the long course of CN 4
closed head trauma?
MVA?
loss of consciousness?
– Neoplastic, tumor
55 yo AF h/o breast CA, headache, chronic sinusitis
(meningioma)
Congenital but late onset, decompensation
Think Bilateral If…
V pattern is present
Esotropia in downgaze
Greater than 10 degrees of excyclotorsion
on double maddox testing.
Add double maddox rod pic
Superior Oblique Palsy
Surgical treatment
For congenital SO palsy,
– It is really more of a floppy tendon.
– Shorten, or tighten the superior oblique tendon.
For acquired
– Weaken the opposing muscle, inferior oblique
Recession.
– If vertical deviation is large >15PD, consider
recession of contralateral inferior rectus.
– If longstanding and the eye has poor depression, the
superior rectus is likely contracted and should be
recessed.
Floppy tendon tuck
for Superior Oblique palsies
Congenital Superior oblique palsy
surgery to shorten floppy tendon
SR
SO
LR
RM
IR
IO
IO
Dr. G.Vicente
Congenital Superior oblique palsy
surgery to shorten floppy tendon
SR
SO
LR
RM
IR
IO
IO
Dr. G.Vicente
Congenital Superior oblique palsy
surgery to shorten floppy tendon
SR
SO
LR
RM
IR
IO
IO
Dr. G.Vicente
Congenital Superior oblique palsy
surgery to shorten floppy tendon
SR
IO
MR
LR
LR
RM
IR
SR
SO
IR
IO
Dr. G.Vicente
Congenital Superior oblique palsy
surgery to shorten floppy tendon
SR
IO
MR
LR
LR
RM
IR
SR
SO
IR
IO
Dr. G.Vicente
Congenital Superior oblique palsy
surgery to shorten floppy tendon
SR
IO
MR
LR
LR
RM
IR
SR
SO
IR
IO
Dr. G.Vicente
Acquired SO palsies
Weaken the opposing muscle, inferior
oblique
– Recession.
If vertical deviation is large >15PD,
consider recession of contralateral inferior
rectus.
If longstanding and the eye has poor
depression, the superior rectus is likely
contracted and should be recessed.
IO recession and
contralateral inferior rectus
recession
for large vertical deviations
Acquired Superior oblique palsy
Surgery to improve torsion
and vertical alignment
SR
IO
LR
Recess IR (contralateral)
LR
RM
IR
MR
SR
IR
IO
Recess IO
Dr. G.Vicente
Acquired SO palsy
If little vertical deviation but large
extorsional component
Consider Harada-Ito procedure:
Anteriorly displaced anterior half of the SO
tendon.
Tightening the whole tendon would cause
a Brown syndrome.
Lateralizing the anterior fibers intorts the
eye.
Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente
Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente
Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente
Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente
Superior Oblique Palsy
Dr. G.Vicente
Superior Oblique Overaction
Superior Oblique Overaction
 Usually primary since IO palsies are very
uncommon
 Vertical deviation often present in Primary
gaze!
 Ipsilateral hypotropia, worse on adduction.
 XT may be present as well.
 “A” pattern visible
 Tx: SO recession or tendon elongation.
Superior Oblique Overaction
“A” pattern
Dr. G.Vicente
Superior Oblique Overaction
Down shoot
Dr. G.Vicente