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

2. Double image recreated by pt.

3. Superior Oblique Palsy
Dr. G.Vicente

4. 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.

5. Torticollis patch test

6. Torticollis patch test

7. Torticollis patch test

8. Torticollis patch test

9. 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?

10. 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

11. 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

12. Think Bilateral If… V pattern is present Esotropia in downgaze
Greater than 10 degrees of excyclotorsion on double maddox testing.

13. Add double maddox rod pic

14. 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.

15. Floppy tendon tuck for Superior Oblique palsies

16. Congenital Superior oblique palsy surgery to shorten floppy tendonSR LR RM IR SO SR MR LR IR IO IO
Dr. G.Vicente

17. Congenital Superior oblique palsy surgery to shorten floppy tendonSR LR RM IR SO SR MR LR IR IO IO
Dr. G.Vicente

18. Congenital Superior oblique palsy surgery to shorten floppy tendonSR LR RM IR SO SR MR LR IR IO IO
Dr. G.Vicente

19. Congenital Superior oblique palsy surgery to shorten floppy tendonSR LR RM IR SO SR MR LR IR IO IO
Dr. G.Vicente

20. Congenital Superior oblique palsy surgery to shorten floppy tendonSR LR RM IR SO SR MR LR IR IO IO
Dr. G.Vicente

21. Congenital Superior oblique palsy surgery to shorten floppy tendonSR LR RM IR SO SR MR LR IR IO IO
Dr. G.Vicente

22. 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.

23. IO recession and contralateral inferior rectus recession for large vertical deviations

24. Acquired Superior oblique palsy Surgery to improve torsion and vertical alignmentSR SR LR RM MR LR IR IR IO IO
Recess IR (contralateral)
Recess IO
Dr. G.Vicente

25. 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.

26. Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente

27. Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente

28. Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente

29. Harada-Ito Anterior displacement of ½ SO tendon
Dr. G.Vicente

30. Superior Oblique Palsy
Dr. G.Vicente

31. Superior Oblique Overaction

32. 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.

33. Superior Oblique Overaction “A” pattern
Dr. G.Vicente

34. Superior Oblique Overaction Down shoot
Dr. G.Vicente