Vertical & horizontal strabismus of uncertain cause

OMCFumitaka Nonaka

Case 1

• 14yo Female• RE drifting upwards intermittently for some years, no

diplopia• CT: D+N XT with RH• RE poorly reacting to direct light• Other examinations: unremarkable• POH, PMH: nil• CT brain & orbit: normal (not viewed)• TFT: normal

RXT RH

RIR-

RMR-

On Examination

VA-0.50 = 6/8 -0.50 = 6/6

Pupil: R>L

12ΔXT RH16Δ

30ΔXT’ RH’12Δ

Distance

Near

-1-3

MRI

RMR

RIR LIR

LMR

RMR

RIR LIR

LMR

Palsy of the inferior divisionof the third nerve

Superior division

Inferior division

Levator

SR

MR

IR

IO

Sphincter pupillae

Ciliary muscle

Case 2

• 16yo Male• Re: worsening head tilt to right• Noticed LE Amblyopia since 2yo• PMH: Developmental delay• PFH: sister with squint

L Pseudo ptosis

Large LXT, L hypo

Dominant RE can’t depressespecially in R-gaze

On Examination

s gls6/9 6/28

Pupil: ?some asymmetry reaction L>R

25ΔLXT LHypo 25Δ

Distance

RE can’t depressespecially in R-gaze

L Pseudo ptosis

CT

Pre-op Post-op

BSV +

Knapp’s surgical procedure

Treatment Dr Kushner reported the efficacy of “Knapp’s surgical procedure” Simultaneous transposition of

SR toward the insertion of MRLR toward the insertion of IR+ Tenotomy of SO tendon

All 5 patients were free from diplopia in primary position (follow up ranged from 3 to 10 years after surgery)

Surgical Treatment of Paralysis of the Inferior Division of the Oculomotor Nerve. J Kushner, Arch Ophthalmol. 1999;117:485-489

Two cases of congenital inferior division oculomotor palsy were presented.

This is an important diagnosis to make. It has a

very specific & usually successful treatment.