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Case of the week 163 ( March 2014 )
Dissociated Vertical Deviations ( DVD )
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this 6 years old girl was noticed by her
mother to have one eye is sometimes higher
than the other. The condition started since 1
year . She is otherwise healthy child passing
good at school. Examination reveals bilateral
normal fundus, also, cycloplegic ref. is within
normal. |
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See video of this patient |
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Dissociated Vertical Deviations ( DVD )
(DVD) is the most least understood of all forms
of strabismus, DVD
is an elevation of one eye
when the patient is fatigued or daydreaming or
when fusion is interrupted by covering one eye.
When the cover is removed, the elevated eye will
move slowly downward towards the primary
position.
O ther
features may be present with DVD, these include
extorsion of the
elevated eye
and intortion of the
fixating eye,
when the elevated eye
returns to the primary position it intorts.
Observation of the conjunctival vessels will nearly
always reveal intortion as the elevated eye
returns to the midline.
DVD is totally different from hypertropia. In a
patient with right hypertropia, for example, the
right eye is elevated when the left eye is
fixating or the left eye is depressed when the
right eye is fixating. While, in DVD, either eye
elevates when the fellow eye is fixating. DVD
may be bilateral or may be restricted to one eye.
Therapy
Patients with DVD are usually asymptomatic,
however, when the patient is daydreaming or
fatigued, the elevated eye may disfiguring
to the patient. In that case surgery may be
considered. Personally I have not observed DVD
in adults as often as in children, I share many authors that
DVD tends to improve with time.
Surgical procedures for DVD are :
(1) Recession of the SR
combined with resection of the IR
(2)
Resection of the IR
(3)
Faden suture (posterior fixation) of the SR
combined with or without a recession.
(4) Large recessions (7 to 10 mm) of th e
SR.
(5 )
Anterior displacement of the IO insertion, which
may be combined with SR
recession.
The debate about whether surgery should be
performed in both eyes in cases of unilateral
DVD. It is not
uncommon and quite disappointing to have a
patient return after surgery in one eye with a
DVD in the fellow eye. However, since in my experience this does not happen in every
case of unilateral DVD, I operate
on both eyes only when a DVD is present in both eyes.
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