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Case of the week 57 ( May 2012 )
Fixation with the paretic eye : Right Superior oblique palsy

This 22 years old patient complaint is the xt and ptosis of his Lt. eye , he also noticed that his left eye is slightly lower than the right eye
He told me that he had done Lasik for his left eye 6 months ago to correct unilateral myopia , He doesn't know his preoperative readings , but he said that his left eye was amblyopic due to anisometropia since childhood , Lasik surgery doesn't improve the amblyopia , VA still as the same as preoperative .
Two ophthalmologist have examined him separately , they reported the same ( Lt. XT , ptosis and Hypotropia ... for recessing Lt. LR and Resecting Lt. SR )
Do You agree with them ?





I've consulted  prof dr Eugene Helvestone about this case

Dear Sir ,
this patient complaint is the xt and ptosis of his Lt. eye , he also noticed that his left eye is slightly lower than the right eye
He told me that he had done Lasik for his left eye 6 months ago to correct unilateral myopia , He doesn't know his preoperative readings , but he said that his left eye was amblyopic due to anisometropia since childhood , Lasik surgery doesn't improve the amblyopia , VA still as preoperative when he wore his contact lens
Two ophthalmologist have examined him separately , they reported the same ( Lt. XT , ptosis and Hypotropia ... for recessing Lt. LR and Resecting Lt. SR ) , I completely disagree with them
I see this is too much surgery for the wrong eye
I feel this patient has Rt. SO palsy class I with inhibitional palsy of the cotralateral antagonist leading to this pseudoptosis of the Lt. levator ms
Since the normal eye was amblyopic since childhood due to anisometropia he is always fixing with the diseased Rt. eye ,this leads to hypotropia of the Lt.eye even in the primary position ( On OD transoccluder picture you can see the hypertropia of the Rt. eye which is the classic finding of SO palsy on fixing with the normal eye )
It is class I because the most hyperdeviation gaze is on lookig Lt. ( picture 6 )
My surgical decision is Only Rt.IO Myectomy

Here is the answer

Dear Dr. Sobhy,

I agree with you. It is always difficult to convince a patient that he needs surgery on what he (the patient) had been told and continues to assume is the "normal" eye. You might show the patient the right hyper in right head tilt, but that probably would not convince him.
The only thing you can do is continue to do the right thing.

Good luck, great job with this case.

Dr. Eugene Helveston



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