Download - 16 superior oblique palsy
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Diagnosis and Management of
Superior Oblique Palsy
Pediatric Ophthalmology
LSU Medical Center
Shreveport
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Superior Oblique Palsy
Most common cause of:Congenital Vertical DeviationAcquired Vertical Deviation
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Anatomy: Superior Oblique
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Function: Superior Oblique
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Functions of Superior Oblique
DepressionGreatest in adduction
IncyclotorsionGreater in down gaze and abduction
AbductionPrimarily in down gaze
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SO Palsy Results In:
HypertropiaGreater in adduction
ExcyclotorsionGreater in down gaze and abduction
EsotropiaPrimarily in down gaze “V” patternPrimarily in bilateral SO palsy
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Causes of SO Palsy
Congenital or childhood onset Head tilt may appear by age 2-4 months
May cause facial asymmetry
Deviation may not be noted until adulthood
Acquired Closed head trauma (most) Vascular disease Neoplasm Inflammation (e.g. temporal arteritis)
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Systemic Workup of SO Palsy
Usually unrewarding if SO palsy isolated (i.e., no other new ocular or neurologic signs or symptoms)
Definitely not needed if signs of childhood onset present
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Evolution of New SO Palsy
Initially:Vertical deviation greatest in field of SO
(i.e., gaze down and in)Later
Contracture of antagonist and changes in other vertical muscles often occurs
Vertical deviation often greater in other fields of gaze
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Spread of Comitance in SO Palsy
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Knapp’s Classification of SO Palsy
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Torsional Diplopia in SO Palsy
Eye itself is extortedVisible on fundus exam
Superior pole of image seen by patient appears intorted
If normal eye is occluded and patient asked to hold object straight, he will hold it in an extorted position
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Fundus Torsion
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Fundus TorsionIndirect
Ophthalmoscope View
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Diplopia in SO Palsy
Diplopia may be vertical, torsional and/or horizontal
Occasionally, torsional diplopia occurs with little or no vertical deviation
Bilateral SO palsy: large amount of torsional diplopia, no vertical deviation in primary if bilateral palsy symmetric
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Signs and Symptoms of SO Palsy
Diplopia
Torticollis
Strabismus
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Torticollis in SO Palsy
Classical:Head tilt to normal sideFace turn to normal sideChin down
Not stereotyped: variations existHead tilt may be “paradoxical”: i.e. to side
of paretic eye
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Torticollis In SO Palsy
Torticollis may be large and noted at age 2-4 months of age
Head tilt may be small and not noted by patientOld pictures (or spouse) helpful
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Torticollis in SO Palsy
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Torticollis in SO Palsy
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Facial Asymmetry in SO Palsy
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Ocular Rotations in SO Palsy
Over 50%: no overt weakness of SOEye appears to move down and in normally
May look like palsy of contralateral SR (if patient fixates with paretic eye in adduction, non paretic eye will be hypotropic)Called inhibitional palsy of contralateral
antagonist of Chavasse
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Park’s Three Step Test for Diagnosis of SO
PalsyOften needed since diagnosis often not clear from versions and ductions
Often cannot localize weak muscle from rotations (ductions and versions)
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Step One
Cover test in primary gaze
Determine if RHT or LHT present in primary gaze
E.g. RHT would mean either:Weak right depressor: RIR or RSO, orWeak left elevator: LSR or LIO
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Park’s Three Step Test
Provides reliable information only if an isolated palsy of a cyclovertical muscle is presentNot helpful in other conditions, such as:DVDThyroid eye diseaseBrown’s syndromeBlowout fracture with entrapped IR
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Park’s Three Step Test:Step Two
Perform cover testing in right and left gaze
Determine if HT greater in right or left gaze
E.g., RHT worse in left gaze: Indicates weak RSO or weak LSR Deviation greater when optical axis aligns with
angle of muscle from origin to insertion
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Park’s Three Step TestStep Three
Step three is Bielschowsky head tilt test
Measure deviation in right head tilt and left head tilt
Determine if deviation greater in right head tilt or left head tilt
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Head Tilt Test
If a superior muscle is weak, HT greater on tilt toward involved muscle
If an inferior muscle is weak, HT greater on head tilt opposite involved side
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Head Tilt with No Muscle Palsy
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Head Tilt in RSO Palsy
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SIN: Superior Muscles Intort
Superior Oblique and Superior Rectus are both intorters
Inferior Oblique and Inferior Rectus are both extorters
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Head Tilt Test
After step one and step two in Park’s three step test, one is always left with two muscles Either two superior muscles or
Two inferior muscles
E.g., RSO or LSR LSO or RSR LIO or RIR RIO or LIR
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Head Tilt Test
Step Three:
E.g., RHT worse on left gaze After two steps, means either weak RSO
or weak LSRHT worse on right head tilt: RSO palsyHT worse on left head tilt: LSR palsy
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SO Palsy: Chart to Memorize
Hypertropia
Gaze where HT larger
Head Tilt where HT larger
RSO Palsy
R L R
LSO Palsy
L R L
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Other Ways to Diagnose SO Palsy
Red lens or Red Maddox rod over one eye Red lens: fixate on a letter Maddox rod: fixate on a bright light
Measure subjectively in: Right and left gaze Right and left head tilt
Very helpful for small acquired deviations
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Bilateral SO Palsy
V pattern with esotropia in downgaze commonExcylotorsion over 10-15 degreesHT changes from right to left gazeE.g., RHT on left gaze, LHT on right gaze
Type of HT changes on head tiltE.g., RHT on right head tilt, LHT on left
head tilt
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Bilateral SO Palsy
Vertical deviation often asymmetric If symmetric, little or no vertical in primary gaze
Often first diagnosed after surgery for apparent unilateral SO palsy (called “masked bilateral SO palsy”)
Double Maddox Rod helpful to diagnose pre-operatively
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Measurement of Torsion
Double Maddox rod placed in trial frame One red, one white (or two red Maddox rods)
Patient views a single white light source
Patient sees a red line and a white line
Rotate one lens to make the two lines parallel (subjectively)
Use vertical prism if needed to separate lines
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Double Maddox Rod to Measure Torsion
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Treatment of SO Palsy
Surgical Treatment
Non-Surgical Treatment
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Non Surgical Treatment of SO Palsy
Wait six months if new palsy occurs Many improve spontaneously
Patch for diplopia Let adult choose which eye to patch, usually non
paretic eye
Prisms May be helpful in adults with diplopia and with
smaller less incomitant deviations
Amblyopia Treat if present May occur in either eye
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Indications for Surgery
StrabismusNoticeable or bothersome to patient
Head tiltNoticeable or bothersome to patient
Diplopia
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Which Muscle to Operate On
Measure vertical deviation in all fields
Pay particular attention to:Primary gazeRight and left gazeOblique gazes opposite palsy
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Important Fields of Gaze
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Surgery for SO Palsy
Surgery planned primarily based on the deviation and where the deviation is largest
Head Tilt primarily useful for diagnosis
Presence of bilateral SO palsy will change treatment plan
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Surgical Treatment of SO Palsy
Some patients, mostly childhood onset types, have laxity in the SO tendonFound with forced duction of SO under
general anesthesia
Patients with laxity of SO tendon need SO surgery (generally SO tuck) to equalize forced duction with normal SO
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Surgical Treatment of SO Palsy
Superior Oblique tuck performed on patient without laxity in the tendon likely to cause a “Brown syndrome”, or inability to look upward in adduction
SO tuck still often indicated in:SO palsy worse in straight down gazeBilateral SO Palsy
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Bishop Tendon Tucker
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Surgical Treatment of SO Palsy
Patients without laxity of SO, primary surgical procedure is weakening (generally recession) of IO, the direct antagonist to the weak SO
Unilateral cases IO weakening done in 50-80% of casesCan be done with adjustable suture
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Surgical Treatment of SO Palsy
If deviation greatest in field of SO and no tendon laxity present, choices are:Weaken opposite inferior rectusTuck SO
Which muscle depends on difference of deviation in primary and lateral gaze,and down and down and lateral gaze
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Surgical Treatment of SO Palsy
Recess ipsilateral superior rectus if:Positive forced duction on attempted
depression of paretic eyeFive diopter or more vertical in abduction of
paretic eye
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How Many Muscles to Operate on
Determine deviation in field of greatest deviationIf that deviation is under 15-20 diopters, operate on one muscleIf that deviation is over 15-20 diopters, operate on two musclesThree muscles: usually results in overcorrection
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IO Weakening
Amount of correction varies with amount of overaction of IO
Can correct 10-15 diopters in primary gaze
Can be done as adjustable suture in adults
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Treatment of Bilateral SO Palsy
Mostly torsional with little vertical deviation: Harada Ito procedure
With large HT in side gaze: tuck SO OU
Usually bilateral IO overaction not seen
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SO Tuck: Dangers
Can easily overcorrect and create restriction if SO tendon is not lax
In the past, large percentage of SO tucks had to be “taken down”
Use forced ductions at surgery as guide to amount of tuck
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Other Surgical Complications
IO weakening Can cause “ adherence syndrome” if fat pad
penetrated: will look like IO overaction on other side (restriction of elevation in abduction of operated eye)
IR Recession Can easily cause lower eyelid retraction Can prevent eyelid retraction with recession of lower lid
retractors
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Amount of Surgery
IO weakeningRecess to just posterior and lateral to IR
insertionCan do asymmetric IO recession OU
SO tuckDetermine at surgeryUsually 6-14 mm, sometimes more
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Amount of Surgery
IR RecessionUsually 3-5 mm: use adjustable suture in
adults
SR RecessionUsually 3-5 mm: use adjustable sutures in
adults
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Work Up of SO Palsy
HistoryTraumaDiplopiaTorticollisOther neurological signs or symptoms
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Work Up of SO Palsy
Observe torticollis
Measurement in all cardinal fields and head tilt right and left
Double Maddox Rod to measure torsion
Observe fundus for torsion
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SO Palsy with Torsion and No Or Minimal HT
Tuck or advance anterior portion of SO tendon
Advancement of anterior SO called Harada Ito procedure
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Harada Ito Procedure
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Canine Tooth Syndrome
Trauma to SO tendon
Results in SO palsy with poor elevation in adduction (“ Brown’s syndrome”)
Rx: difficultFree restrictionsWeaken yoke IR
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Canine Tooth Syndrome
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Types of SO PalsyChildhood Onset
Adult Onset
Size of deviation
Large Small
Fusional Vergence
Large Small
Bilaterality Almost never 25%
Diplopia Rare Always
Usual Rx Weaken IO, +/- SO tuck
Recess IR
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Course of SO Palsy
May present early in childhood with torticollis or strabismus
May present later ( often age 30-50) with symptoms from strabismus or torticollis
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Field of Single Vision
Very important to patient
Often ignored by physician
Measure pre-op and post-op ( can use Goldman perimeter) or estimate
Warn patients that deviation will probably be present in some fields post-op