Superior oblique palsy is the most commonly occurring
cranial nerve palsy seen by the strabismologists .
Occasionally, patients' old pictures demonstrating a
head tilt and chin depression are useful in supporting
the diagnosis of congenital cases.
In Bilateral cases the
severity of the paralysis is often asymmetrical, and the
involvement of the second eye may not become apparent
until the eye with the more severe defect has been
operated on (masked bilateral superior oblique paresis)
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
In
patients with bilateral paralysis the vertical deviation
in primary position is usually
unnoticed
A right hypertropia in left gaze and a left hypertropia
in right gaze, as well as a positive Bielschowsky test
with the head tilted to either
side ( Reversing Bielschowsky test )
, are the only signs we consider
diagnostic
for
bilateral involvement
There is little agreement among experts when it comes to
surgical treatment of bilateral superior oblique
asymmetrical palsy . Bilateral weakening of the
inferior obliques is favored by many, including me, some
add Superior Oblique tendon tuck in the eye with the
more sever palsy in case of SO tendon laxity confirmed
by duction test and others
add recession of the inferior rectus in the eye with the
less sever palsy
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