Bilateral Congenital Superior Oblique Palsy with Intermittent V Exotropia
Parents of this 4y old child complain that the eyes of their child sometimes deviate out they noticed this since early childhood
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.
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
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