Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia

By posted on May 30, 2015 1:07AM
Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia

Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia

C/O :
Parents of this 4y old child complain that the eyes of their child sometimes deviate out they noticed this since early childhood

Motility :

Versions are an extremely important part of the diagnosis of superior oblique palsy. The most tell-tale finding is inferior oblique overaction, and to a lesser extent superior oblique underaction, which occurs to varying degrees.

Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia
Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia
V Exotropia
V Exotropia

Diagnosis of Bilateral SO palsy using the 3 step test is uncertain :
1. No Hypertropia in the 1ry position.
2. Reverse or No Hypertropia on head tilt

Diagnostic features of Bilateral SO palsy :

1. Hypertropia of either eye on looking nasally.
2. Underaction of both SO ( on looking in & down )
3. Overaction of both IO ( on looking up & in )

In this case the most prominent findings – apart from the XT – are the hypertropia ( or the overshoot ) of the adducted eye ( Pic 4 & 6 ) + the underaction of both SO ( Pic 7 & 9 ) , still overaction of both IO ( Pic 1 & 3 ) is the characteristic finding in bilateral SO palsy leading to the V pattern

Management :
There is little agreement among experts when it comes to surgical treatment of bilateral superior oblique palsy. Bilateral weakening of the yoke inferior obliques is favored by many – including me – to treat the ‘V’ and the torsion.

In this case My decision is :
1. Bil LR recession for the XT
2. Bil IO myectomy for torsional palsy & for the V ( 1/2 width upshift could be added to the LR during recession )
the two procedures were done through one conjunctival wound

 

Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia Postoperative
Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia Postoperative

Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia

Dr.Gamal Sobhy

Professor of ophthalmology. Head of Strabismus Unit Memorial Institute of Ophthalmic Research Egypt.

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