Post on 08-Jul-2015
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