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Dr Hassan Thabet
Let's analyze the case :
1- from history , there is head tilt
since v. longtime with no Trauma or
diplopia . this is going with congenital
2- in primary position there is Rt HT
which increase on looking nasal (i.e to
left gaze) and al...so
increase on head tilt to same side of HT
(i.e Rt side)
3- this means that the patient has Rt
congenital SO palsy.
4- the patient adopt left head tilt to
avoid diplopia .
5- the patient has Rt IOOA +3 or +4 . 6-
my plane for management is to do RT IO
myectomy .
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I agree with Dr Hassan
,Superior
oblique palsy is the most common oculo-motor nerve
palsy seen by strabismologists and should not
present any diagnosis difficulties
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 ,
finally the
compensatory head tilt to the opposite side of the
paralytic eye is a well known diagnostic feature .
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1. Hypertropia in the
1ry position |
2. Hypertropia on
looking nasally |
3. Hypertropia On
head tilt
to the same side |
Another
striking feature in this girl is the facial
asymmetry with a much larger cheek on the right side
- the side of the paretic hypertropic eye -
this larger cheek is diagnostic of congenital origin
of the paretic SO. In a case like this it is
especially important to determine the status of the
superior oblique tendon. This is the type of patient
where the tendon may be absent or extremely loose.
It is the responsibility of the surgeon to do
careful superior oblique tendon traction test , if laxity is
suspected , it should be confirmed by exploration of the
superior oblique tendon at the time of surgery. This
is a very important point in decision making , loose SO
tendon favors SO tucking , while normal SO tendon
favors IO myotomy
In the time of operating this girl , SO traction
test is normal , a decision of Rt IO myotomy is taken
, with a satisfactory surgical outcome for me and
for her.
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