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.
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
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