Superior Oblique PalsySubmitted for partial

fulfillment of the Master Degree in ophthalmology

ByMohammad Kamel Mohammad Noor El-Mahdy

M.B.B.Ch. - Al-Azhar University

Superior Oblique PalsySupervised by

Prof. Dr. Attiat Mostafa El-Sayed Mostafa

Prof. of ophthalmology Faculty of Medicine Al-Azhar University

Prof. Dr. Abubakr Mohammad Farid AbulNaga

Prof. of Ophthalmology faculty of medicineAl-Azhar University

Dr. Ahmad El-Sayed HodiebLecturer of Ophthalmology

faculty of medicineAl-Azhar University

Aim of the Essay The aim of this essay is to

review of literature of superior oblique muscle palsy.

Introduction• Bielchowsky was first to describe SOP as

the leading cause of vertical double vision.

• It has no predilection for males or females

• It is the single most common form of paralytic strabismus diagnosed in routine practice (von Noorden et al., 1986).

Review of literature

Anatomy of SO muscle:• Origin: It arises from the periosteum close to the

annulus of Zinn (the apex of the orbit) above and medial to the optic foramen till reach the troclea.

• Insertion: Pass under the superior rectus muscle to insert on sclera along the temporal border of the superior rectus muscle behined the equator.

• Innervation: The trochlear nerve.

Physiology of SO muscle:1)Action of superior oblique

muscle: In 1ry position intorte, in 2ry position

depress and in 3ry position abduct the eye.

The maximum action of the superior oblique muscle as a depressor is in adduction:

In adduction, with adduction of 54°, the angle between the median plane of the eye and the muscle plane is reduced.

The maximum incyclotortion occurs in abduction: In abduction, with 36° of abduction, the angle between the

median plane of the globe and the muscle plane increases.

2) Control of superior oblique muscle movement: Remember that: Ipsilateral Inferior oblique muscle ( D. antagonist) Contralateral Superior rectus muscle ( Ind.

Antagonist) Contralateral Inferior rectus muscle (Yoke m.)

The muscle governed by The laws of ocular motility:

Dander's law: concerned with axis of positions.

Listing's law: concerned with Cylotortion. Hering's law: concerned with Binoccular

vision (innervation of Yoke ms).

Management of Superior oblique

palsy

Causes can be classified asCongenital palsy: present

at birth may be isolated or associated with congenital anomalies.

Aquired palsy: a common cause is head trauma.

Clinical pictureA)Symptoms

Diplopia: Vertical and homonymous. notable when reading or, walking down stairs.

Compensatory head posture:

The head tilt to the opposite side and the face turn to the opposite side with the chin depressed.

Rt. SOP (mostafa,2004):

• Chin depression.• Head tilt to left.• Face turn to left.

B) Signs: 1-Ocular motility testing

Lt Superior oblique palsy Rt Lt

2 -Macular Torsion

Macular extorsion seen byfluorescein fundus camera, fovea seen below that line (Mostafa, 2004).

Normal macula at level of horizontal line drown between upper 2/3 and lower 1/3 of optic disc

Torsion as seen by fluorescein fundus camera

Diagnostic tests:

Diplopia: Vertical and homonymous.

It depends on Hering law, and aim to investigate the nature

and the extent of EOM imbalance

used to investigate subjective vs Objective torsion

It identifies which muscle is paretic in patients with a hypertropia vertical

rectus vs oblique muscle palsy.

Diplopia Chart

Hess screen test

Maddox rod test

Three step test

Diplopia Chart

Hess screen test

Maddox rod test Three step test

red- green goggles and Lt. SOP Rt. superior oblique palsy, Rt. secondary IOOA and Lt. IR overaction

Bielschowsky Park's head tilt test :

(A) (B) (C)Rt. Superior oblique palsy: (Mostafa, 2004) (A)Head tilt to Lt.(B)Rt. hypertropia on forced head tilt to Rt. (C)Upshoot on adduction due to Rt. secondary

IOOA.

Treatment• Strategies require identifying where the

hypertropia is greatest.• Surgical methods of treatment are as

follows (Özkan, 2010): Superior oblique strengthening

procedures. Inferior oblique weakening procedures. Superior rectus recession in the

affected eye. Inferior rectus recession in the

contralateral eye.

1- Superior oblique strengthening proceduresA- Superior Oblique Tuck The triad of indications for

superior oblique tendon tuck is: 1) Large angled vertical deviation, 2) Prominent abnormal head

posture and, 3) Superior oblique tendon laxity

Superior oblique tendon tuck

SR

MR

LR

IR

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO

Superior oblique tendon tuck

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Superior oblique tendon tuck

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR

LR

IR

Superior oblique tendon tuck

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR LR

IR

Superior oblique tendon tuck

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR LR

IR

Superior oblique tendon tuck

SR

LR

RM

IRIOIO

Dr. G.Vicente

SO SR

MR LR

IR

B-Harada Ito surgery:• Indications: (1)Patients whose primary complaint

is torsional diplopia. This is most often in adult patients

with bilateral, post traumatic superior oblique muscle palsy.

(2) Patients with little or no vertical deviation in primary gaze position.

(3) In the treatment of ocular torticollis with tilt -dependent nystagmus.

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

2-Inferior oblique weakening procedures.

The patient's right eye viewed from below; (a) natural position of the inferior oblique muscle (b) recession; (c) anterior transposition; (d) anterior nasal transposition; (e and f) nasal myectomy.

1-Inferior oblique muscle recession:

LR

MR

IR

SR

Is a suitable procedure for most congenital SO palsies with a moderate-to-large vertical deviation in adduction, resulting in a lower incidence of consecutive Brown's pattern. IO

Rt. Superior Oblique Palsy (mostafa, 2004)

AHP “preoperative” After Rt. IO recession

After Lt. IO recessionLt. Inferior oblique overaction

Lt. SO palsy (mostafa, 2004)

2- Anterior Transposition (AT)• It weakens the classic functions of the IO

(eliminate IOOA) .• converts the muscle to an

“antielevator”(reserve the action of IO).

3- Myectomy or myotomy inferotemporally

A complete myotomy is considered by some surgeons to be as effective as myectomy or recession of the inferior oblique muscle.

3-Superior Rectus Muscle Recession• Indication:

In a vertical deviation exceeding 15 prism diopters.

• In cases with agenesis of the

superior oblique tendon, superior rectus recession is the procedure of choice with inferior oblique weakening.

3-Inferior Rectus Muscle Recession in the contralateral eye• Indication: Acquired superior oblique palsy

surgery to improve torsion and vertical alignment.

• A minimum recession of the inferior rectus is 2.5 mm.

• A maximum recession of the inferior rectus under most circumstances is 5 mm.

Inferior rectus muscle recession (contralateral eye)

SR

MR LR

IR

SR

LR

RM

IRIOIO

Dr. G.Vicente

Recess IORecess IR (contralateral)

Affected eyeLtRt

Thank You