Case of the week 114 (
May 2013 )
Left superior
oblique palsy
44 years old man complains of sudden onset
of double vision 3 days ago. No history of DM or
Hypertension, no history of head or ocular
trauma. Examination shows the diplopia is
binocular in nature, both fundi are normal.
See video of this patient
Superior
oblique palsy is the most common oculo-motor nerve
palsy encountered by strabismologists and should not
present any diagnosis difficulties .
when a strabismologist is asked about head tilt
found in old photographs , the diagnosis of
congenital superior oblique palsy
should arise as a first possibility.
In a patient with a left superior oblique
paralysis who habitually fixates with the
paretic eye and in whom overaction of the
homolateral inferior oblique muscle has
developed, less than the normal amount of
innervation will be required when he or she is
looking up and to the right. Since the
innervation flowing to the right normal eye is
determined by the left inferior oblique muscle,
the right superior rectus will seem paretic. The
head tilt test is then used to determine which
of the two muscles, left superior oblique or
right superior rectus, is paretic.
The 3 step test
(positive Bielschowsky test) - Hypertropia in
the primary position increases on looking nasally
and on head tilt to the same side of the hypertropia
- is diagnostic of SO palsy In cases of class I superior oblique palsy
like this case with a maximum hyperdeviation of no greater than 25
prism diopters weakening of the antagonist inferior
oblique is effective.
الموقع المصري للحول
وامراض الجهاز الحركي للعين
The Egyptian Site of
Strabismus & Oculomotor Disorders
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