Superior Oblique Paralysis

Noorden, Gunter K. von; Murray, Elizabeth; Wong, S. Y.

doi:10.1001/archopht.1986.01050240045037

Cited by 190 publications

(38 citation statements)

References 18 publications

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“…6 The significantly greater lateral displacement of the SR pulley, combined with tendencies for greater displacement in the MR and IR pulleys, in bilateral SO palsy may explain the associated V-pattern and large excyclotorsion often observed clinically. 32 In the current study, the clinical findings in unilateral and bilateral SO palsy did not significantly differ, perhaps due to small number of cases of bilateral SO palsy, or mixture of symmetrically and asymmetrically palsied bilateral cases.…”

Section: Discussioncontrasting

confidence: 54%

Rectus Pulley Displacements without Abnormal Oblique Contractility Explain Strabismus in Superior Oblique Palsy

Suh

Clark

et al. 2016

Ophthalmology

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Purpose Using high-resolution magnetic resonance imaging (MRI), we investigated whether rectus pulleys are significantly displaced in superior oblique (SO) palsy, and if displacements account for strabismus patterns. Design Prospective, case-control study. Participants Twenty-four patients diagnosed with SO palsy based on atrophy of SO muscle on MRI, and 19 age-matched orthotropic control subjects. Methods High resolution, surface coil MRI was obtained in multiple, contiguous, quasicoronal planes during monocular central gaze fixation. Pulley locations in oculocentric coordinates in the following subgroups of patients with SO palsy were compared with normal in subgroups of patients with SO palsy: unilateral vs bilateral, congenital vs acquired, and isotropic (round shape) vs anisotropic (elongated shape) SO atrophy. Expected effects of pulley displacements were modeled using Orbit 1.8® computational simulation. Main outcome measures Rectus pulley positions and ocular torsion. Results Rectus pulleys were typically displaced in SO palsy. In unilateral SO palsy, on average the medial rectus (MR) pulley was displaced 1.1 mm superiorly, the superior rectus (SR) pulley 0.8 mm temporally, and the inferior rectus (IR) pulley 0.6 mm superior and 0.9 mm nasal from normal. Displacements were similar in bilateral SO palsy, with SR pulley additionally displaced 0.9 mm superiorly. However, the lateral rectus (LR) pulley was not displaced in either unilateral or bilateral SO palsy. The SR and MR pulleys were displaced in congenital SO palsy, while the IR and MR pulleys were displaced in acquired palsy. Pulley positions did not differ between isotropic and anisotropic palsy, or between patients with cyclotropia <7° versus ≥7°. Simulations predicted that the observed pulley displacements alone could cause patterns of incomitant strabismus typical of SO palsy, without requiring any abnormality of SO or inferior oblique strength. Conclusion Rectus pulley displacements alone, without abnormal oblique muscle contractility, can create the clinical patterns of incomitant strabismus in SO palsy. This finding supports accumulating evidence that clinical binocular misalignment patterns are not reliable indicators of contractile function of the SO muscle. Ocular torsion does not correlate with and thus cannot account for pulley displacements in SO palsy.

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Section: Discussioncontrasting

confidence: 54%

Rectus Pulley Displacements without Abnormal Oblique Contractility Explain Strabismus in Superior Oblique Palsy

Suh

Clark

et al. 2016

Ophthalmology

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“…Because diplopia may be the first symptom of neurological disease, and because superior oblique palsy treatment is often surgical, 4 diagnostic confirmation can be important. The extensive differential diagnosis of alternative causes of incomitant hypertropia necessitates a sensitive and specific test for superior oblique palsy diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…1 The clinical signature of unilateral superior oblique palsy includes: (1) ipsilesional central gaze hypertropia, (2) greater in contralesional than ipsilesional gaze, (3) and greater in ipsilesional than contralesional head tilt. 2–4 The three-step test presumes that there is unopposed activity of the palsied superior oblique muscle’s antagonist, the inferior oblique, that increases hypertropia in contralateral gaze. 5 The head tilt phenomenon is supposed to result from deficit of the palsied superior oblique’s incycloduction during ocular counterrolling (OCR).…”

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confidence: 99%

Sensitivity of the three-step test in diagnosis of superior oblique palsy

Manchandia

Demer

2014

Journal of American Association for Pediatric Ophthalmology and

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Purpose Although the Parks-Bielschowsky three-step test is the cornerstone of cyclovertical strabismus diagnosis, it has not been validated against an external benchmark. We evaluated the test’s sensitivity in clinical diagnosis of superior oblique palsy in patients with unequivocal magnetic resonance imaging (MRI) evidence of superior oblique atrophy. Methods A total of 73 strabismic patients were selected from a prospective MRI study because they exhibited superior oblique atrophy indicative of superior oblique denervation and thus confirmatory of superior oblique palsy. Of these, 50 patients who had no confounding factors were included for detailed study. Ocular motility data were evaluated to determine sensitivity of single and combined clinical findings in diagnosis of superior oblique palsy. Results Maximum mean ipsilesional superior oblique cross section was reduced to 9.6 ± 0.6 mm2 (mean ± standard error) in superior oblique palsy, representing 52% of the 18.5 ± 0.6 mm2 contralesional superior oblique maximum cross section and 52% of the 18.4 ± 0.4 mm2 control maximum superior oblique cross section (P < 0.001). Of the 50 patients, 35 (70%) with superior oblique atrophy fulfilled the entire three-step test. In 14 (28%) patients two steps were fulfilled; in 1 patient (2%), only one step. Affected superior oblique cross section was similar in orbits that fulfilled the three-step test (9.8 ± 0.9 mm2) and those that did not (9.1 ± 0.7 mm2; P = 0.58). Conclusions The complete three-step test fails to detect 30% of cases of superior oblique atrophy. Often only two of three steps are positive in superior oblique palsy.

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“…von Noorden et al1 reported it to be the most common paralytic strabismus. The causalities of superior oblique palsy are mostly congenital and traumatic but may also be idiopathic, or develop in association with tumor, vascular ischemia, diabetes mellitus, hypertension, or other vascular diseases 2-5.…”

mentioning

confidence: 99%

The Effect of Graded Recession and Anteriorization on Unilateral Superior Oblique Palsy

Moon

Lee

2006

Korean J Ophthalmol

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PurposeWe wanted to examine the effect of graded recession and anteriorization of the inferior oblique muscle on patients suffering from unilateral superior oblique palsy.MethodsInferior oblique muscle graded recession and anteriorization were performed on twenty-two patients (22 eyes) with unilateral superior oblique palsy. The recession and anteriorization were matched to the degree of inferior oblique overaction and hypertropia. The inferior oblique muscle was attached 4 mm posterior to the temporal border of the inferior rectus muscle in six eyes, 3 mm posterior in five eyes, 2 mm posterior in five eyes, 1 mm posterior in five eyes, and parallel to the temporal border in one eye.ResultsThe average angle of vertical deviation prior to surgery was 11.3±3.9 prism diopters (PD). The total average correction in the angle of vertical deviation after surgery was 10.8±3.8 PD. In the parallel group, the average reduction was 14 PD. After surgery, normal inferior oblique muscle action was seen in eighteen of twenty-two eyes (81.8%).ConclusionsGraded recession and anteriorization of the inferior oblique muscle is thought to be an effective surgical method to treat unilateral superior oblique palsy of less than 15 PD.

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Superior Oblique Paralysis

Cited by 190 publications

References 18 publications

Rectus Pulley Displacements without Abnormal Oblique Contractility Explain Strabismus in Superior Oblique Palsy

Rectus Pulley Displacements without Abnormal Oblique Contractility Explain Strabismus in Superior Oblique Palsy

Sensitivity of the three-step test in diagnosis of superior oblique palsy

The Effect of Graded Recession and Anteriorization on Unilateral Superior Oblique Palsy

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