how to diagnose and recognize vertical deviations
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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. - PowerPoint PPT PresentationTRANSCRIPT
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, MDEye Doctors of WashingtonEye Doctors of Washington
Double image recreated by pt.
Superior Oblique Palsy
Dr. G.Vicente
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.
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• 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
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 4closed 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
Think Bilateral If…Think Bilateral If…
V pattern is presentV pattern is presentEsotropia in downgazeEsotropia in downgazeGreater than 10 degrees of excyclotorsion Greater than 10 degrees of excyclotorsion on double maddox testing.on double maddox testing.
Add double maddox rod pic Add double maddox rod pic
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.
Floppy tendon tuckFloppy tendon tuckfor Superior Oblique palsiesfor Superior Oblique palsies
Congenital Superior oblique palsysurgery to shorten floppy tendon
SR
MR
LR
IR
SR
LR
RM
IRIOIO
Dr. G.Vicente
SO
Congenital Superior oblique palsysurgery to shorten floppy tendon
SR
LR
RM
IRIOIO
Dr. G.Vicente
SO SR
MR
LR
IR
Congenital Superior oblique palsysurgery to shorten floppy tendon
SR
LR
RM
IRIOIO
Dr. G.Vicente
SO SR
MR
LR
IR
Congenital Superior oblique palsysurgery to shorten floppy tendon
SR
LR
RM
IRIOIO
Dr. G.Vicente
SO SR
MR LR
IR
Congenital Superior oblique palsysurgery to shorten floppy tendon
SR
LR
RM
IRIOIO
Dr. G.Vicente
SO SR
MR LR
IR
Congenital Superior oblique palsysurgery to shorten floppy tendon
SR
LR
RM
IRIOIO
Dr. G.Vicente
SO SR
MR LR
IR
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.
IO recession and IO recession and contralateral inferior rectus contralateral inferior rectus
recession recession for large vertical deviationsfor large vertical deviations
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)
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.
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 OveractionSuperior Oblique Overaction
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.
Superior Oblique Overaction“A” pattern
Dr. G.Vicente
Superior Oblique OveractionDown shoot
Dr. G.Vicente