Superior oblique palsySuperior oblique palsy

By By Hany EL-DefrawyHany EL-Defrawy

Pediatric fellowPediatric fellowBristol eye hospitalBristol eye hospital

Anatomical considerationAnatomical consideration

Tegmentum of midbrain.Decussating at the anterior medullary velumBetween the PCA and superior cerebellar arteriesCavernous sinusSuperior orbital fissure outside the annulus of Zinn

Actions of superior oblique

•Intorsion

•Depression

•Abduction

EtiologyEtiology

CongenitalCongenital Acquired Acquired

Anomalies of superior oblique Anomalies of superior oblique tendontendon

What are the most common causes of What are the most common causes of acquired IV?acquired IV?

Can you comment?Can you comment?

Congenital vs. Ocular torticolisCongenital vs. Ocular torticolisCongenitalCongenital OcularOcular

Age Age During the 1During the 1stst 6 month after 6 month after birthbirth

Rarely before 18 months Rarely before 18 months after birthafter birth

Head positionHead position Passive or voluntary Passive or voluntary straightening of the head is straightening of the head is difficult or impossibledifficult or impossible

Head can easily be Head can easily be straightened passively or straightened passively or voluntarily and revealed voluntarily and revealed ocular misalignmentocular misalignment

Neck musclesNeck muscles Palpation reveals hardening Palpation reveals hardening of sternocledomastoidof sternocledomastoid

Palpation negativePalpation negative

Vision Vision No visual disturbancesNo visual disturbances Diplopia occurs when head Diplopia occurs when head is straightened or tilted to is straightened or tilted to opposite sideopposite side

Effect on occlusionEffect on occlusion Not influenced by occlusion Not influenced by occlusion of either eyeof either eye

Head straightens on Head straightens on occluding the paretic eye occluding the paretic eye unless there is structural unless there is structural changeschanges

Localization of the lesionLocalization of the lesion

NucleusNucleus FascicleFascicle Subarachnoid spaceSubarachnoid space Cavernous sinusCavernous sinus OrbitOrbit

What is the presentation of the IV What is the presentation of the IV nerve palsy?nerve palsy?

Congenital vs acquired superior Congenital vs acquired superior oblique palsyoblique palsy

EvaluationEvaluation

HistoryHistory Old PhotographsOld Photographs Cover testCover test Hess screenHess screen Three step testThree step test MRI (Why?)MRI (Why?)

Old photographsOld photographs

THREE STEP TESTTHREE STEP TEST

Bilateral Superior oblique palsyBilateral Superior oblique palsy

1.1. History of traumaHistory of trauma

2.2. Spontaneous torsional diplopiaSpontaneous torsional diplopia

3.3. "V" Pattern, ET down gaze"V" Pattern, ET down gaze

4.4. Extorsion >15 degreesExtorsion >15 degrees

5.5. Reversing (or nearly so) Bielshowsky head tilt Reversing (or nearly so) Bielshowsky head tilt testtest

6.6. Chin down, eyes up postureChin down, eyes up posture

Maddox rod testMaddox rod test

How would you manage these How would you manage these scenarios?scenarios?

A 70 year old man who complains of sudden onset of vertical A 70 year old man who complains of sudden onset of vertical and torsional diplopia. Examination revealed 3 D of right HT. and torsional diplopia. Examination revealed 3 D of right HT. Patient has a CHP with head tilt to the left side. Patient has a CHP with head tilt to the left side.

A child aged 5 who presents with a CHP (head tilt to left side) and A child aged 5 who presents with a CHP (head tilt to left side) and vertical misalignment revealed on correction of the head posture.vertical misalignment revealed on correction of the head posture.

An adult who presents with sudden onset of vertical and torsional An adult who presents with sudden onset of vertical and torsional diplopia after head trauma. Assessment revealed 15 D of diplopia after head trauma. Assessment revealed 15 D of hypertropia R/L and torsional diplopia of 10 degrees.hypertropia R/L and torsional diplopia of 10 degrees.

An adult of has hypertropia , torsional diplopia of more than 15 An adult of has hypertropia , torsional diplopia of more than 15 degrees and compensatory chin down position.degrees and compensatory chin down position.

Weaken ipsilateral inferior Oblique

Tuck superior oblique if lax or if not recess yoke inferior rectus.

HT <20Dweaken ipsilateral inferior oblique, > 20D weaken ipsilateral inferior oblique and tuck lax S.O. tendon or weaken yoke inferior rectus

<20D weaken ipsilateral inferior oblique and ipsilateral superior rectus, > 20D add tuck of loose S.O. tendon or recession of yoke I.R.

Recess the ipsilateral superior rectus and the yoke contra lateral inferior rectus or tuck a lax S.O. tendon

What is management of Bilateral What is management of Bilateral superior oblique palsysuperior oblique palsy

Bilateral SO Harada- itoBilateral SO Harada- ito

Case PresentationCase Presentation

Superior oblique strengthening Superior oblique strengthening proceduresprocedures