Vertical Strabismus

1
Vertical Deviations
Vertical Deviations
With regard to strabismus: What does the word comitant mean?

2
Vertical Deviations
Vertical Deviations

It means an ocular misalignment is the same in all fields of gaze
3
Vertical Deviations
Vertical Deviations

Do vertical deviations tend to be comitant, or incomitant?

4
Vertical Deviations
Vertical Deviations


Incomitant (although spread of comitance can occur)
5
Vertical Deviations
Vertical Deviations


What is spread of comitance?

6
Vertical Deviations
Vertical Deviations


What is spread of comitance?

The neuroadaptive process in which an initially incomitant deviation
gradually becomes comitant
7
Vertical Deviations
Vertical Deviations
? ?
The Peds book divvies the vertical deviations

into two broad categories—what are they?
8
Vertical Deviations
Vertical Deviations
2o to oblique dysfunction Uncertain mechanism
The Peds book divvies the vertical deviations

into two broad categories—what are they?
9
Vertical Deviations
Vertical Deviations
2o to oblique dysfunction? Uncertain mechanism?
Which is the more common cause of vertical deviations?

10
Vertical Deviations
Vertical Deviations
Which is the more common cause of vertical deviations?

Oblique dysfunction
11
Vertical Deviations
Vertical Deviations
? ?
What are the two oblique muscles?

12
Vertical Deviations
Vertical Deviations
Superior Inferior
Oblique (SO) Oblique (IO)
What are the two oblique muscles?

13
Vertical Deviations
Vertical Deviations
Superior Inferior
?
Per the Peds book, what are the three basic forms
?
of SO dysfunction leading to a vertical deviation?
?
14
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
Per the Peds book, what are the three basic forms
Palsy
of SO dysfunction leading to a vertical deviation?
Brown syndrome
15
Vertical Deviations
Vertical Deviations
Superior What is the classic exam finding in SO overaction?

Inferior
Overdepression of the eye in adduction
Will vertical misalignment be present in primary gaze?
Overaction It will if the overaction is unilateral or asymmetric
Palsy What is the surgical treatment for SO overaction?
Tenotomy vs silicone expander
Brown syndrome
Why are surgeons reluctant to operate on a patient with bifixation?
Surgery could result in torsional diplopia
16
Vertical Deviations
Vertical Deviations

Inferior
Overdepression
overelevation vs
of the eye in adduction
ABduction vs ADduction
overdepression

Brown syndrome
17
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
18
Vertical Deviations
Bilateral superior oblique overaction

19
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
20
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
21
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
22
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
23
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
24
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
25
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
Surgery could result in torsional
‘direction’ diplopia
26
Vertical Deviations
Vertical Deviations

Inferior
Brown syndrome
27
Vertical Deviations
Vertical Deviations
What is the classic exam finding in SO palsy?

Superior Inferior
Overaction
Palsy
Brown syndrome
28
Vertical Deviations
Vertical Deviations

Overelevation
overelevation vs
of the eye in adduction
ABduction vs ADduction
Superior Inferior overdepression
Overaction
Palsy
Brown syndrome
29
Vertical Deviations
Vertical Deviations

Overelevation of the eye in adduction
Superior Inferior
Overaction
Palsy
Brown syndrome
30
Vertical Deviations
Superior oblique palsy, right

31
Vertical Deviations
Vertical Deviations

Superior Inferior
Oblique (SO) Oblique (IO) Is SO palsy a commonly-encountered entity?
Overaction
Palsy
Brown syndrome
32
Vertical Deviations
Vertical Deviations

Superior Inferior
Yes—it is the most common paralysis of a single
Overaction cyclovertical muscle
Palsy
Brown syndrome
33
Vertical Deviations
Vertical Deviations

Superior Inferior
Palsy Upon encountering a SO palsy, what question
must you consider early on?
Brown syndrome
34
Vertical Deviations
Vertical Deviations

Superior Inferior
Palsy Upon encountering a SO palsy, what question
must you consider early on?
Brown syndrome Whether the palsy is congenital, or acquired
35
Vertical Deviations
Regarding SO palsy: As a general rule:
--congenital SO palsy is much more likely to be unilateral
uni- vs bilateral
Vertical Deviations
--acquired SO palsy is much more likely to be bilateral
uni- vs bilateral
What is the most common cause of acquired SO palsy?

Closed head trauma
2o to oblique dysfunction Uncertain

How can you confirm mechanism
that a SO palsy is congenital?
1) Family-album biopsy (i.e., check old photos for a
longstanding head tilt)
2) Assess for increased vertical fusional amplitudes
Superior Inferior
Oblique (SO) Oblique When
(IO) diagnosing a unilateral SO palsy, what must you be
sure to rule out?
Overaction That it’s not in fact an asymmetric bilateral SO palsy
Palsy
Brown syndrome
36
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
37
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
38
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
39
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
40
Vertical Deviations
Vertical Deviations

Closed head trauma

longstanding head tilt )
several words

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
41
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
42
Vertical Deviations
43
Vertical Deviations
Vertical Deviations

Closed head trauma

three words exactly
Superior Inferior
sure to rule out?
Palsy
Brown syndrome
44
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
45
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
Oblique (SO)Briefly, toOblique the term vertical fusional amplitudes refer?
(IO)
what does
When diagnosing a unilateral SO palsy, what must you be
It refers to the amount of vertical prism a pt can take before fusion breaks down
sure to rule out?
Overaction That it’s
For pts without a history not in fact
of congenital SOanpalsy,
asymmetric
how muchbilateral SO palsy
vertical prism can they
accept without losing fusion?
Palsy Not much--2-3 prism diopters or so
Brown syndrome
How much vertical prism can pts with a congenital SO palsy take without losing fusion?
A lot more—in the 12-15 prism diopter range
46
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
47
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
48
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Palsy Not much; 2-3 prism diopters or so
# to #
Brown syndrome
49
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
50
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
Howhow
In contrast, much vertical
large are normal horizontal
prism can pts withfusional
a congenital SO palsy take without losing fusion?
amplitudes?
Much larger--in the 10-15
A lot more—in theprism
12-15diopter range range
prism diopter
51
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
Howhow
In contrast, much vertical
large are normal horizontal
prism can pts withfusional
a congenital SO palsy take without losing fusion?
amplitudes?
Much larger--in the 10-15
A lot more—in theprism
12-15diopter range range
prism diopter
52
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
53
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
A lot more—in the 12-15
# to # prism diopter range
54
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
(IO)
what does
sure to rule out?
asymmetric
Brown syndrome
55
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
56
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy
Brown syndrome
57
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Palsy Why should you care whether a palsy is unilateral vs bilateral?
All bilateral SO palsies should be assumed to be acquired.
Brown syndrome Thus, absent an appropriate head-trauma hx, a bilateral SO
palsy represents an ongoing intracranial dz process until
proven otherwise. For this reason, it is absolutely vital that
one establish with certainty the uni- vs bilaterality of SO palsy!
58
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Brown syndrome Thus, absent an appropriate head-trauma hx, a bilateral SO
59
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
If a bilateral SO play pt lacks an appropriate trauma hx,
Brown syndrome what should you do?
Thus, absent an appropriate head-trauma hx, a bilateral SO
Image them
60
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Image them
61
Vertical Deviations
Vertical Deviations

Closed head trauma

Superior Inferior
sure to rule out?
Image them
What findings differentiate a one establish with certainty the uni- vs bilaterality of SO palsy!
uni- from a bilateral SO palsy?
62
Vertical Deviations
Vertical Deviations

Closed
Key head trauma in Uni- vs Bilateral SO Palsy
Findings
How much
1) Family-album biopsyET
V-pattern (i.e.,excyclotorsion
check old photos for a
Head-tilt
longstanding present?
head tilt) on Maddox-rod test?
2) Check vertical fusional amplitudes testing?(normal ~ 2;
Superior Inferior can be as
Unilateral Always less Positive to
sure to rule out? yesNo or
one side
no
Overaction SO it’s
That not in fact an asymmetricthan
palsy 10o SO palsy
bilateral only
Palsy
Bilateral May be more Positive to
Brown syndrome yes or
Yes
no both
SO palsy than 10o sides
63
Vertical Deviations
Vertical Deviations

Closed
Findings
How much
Head-tilt
head tilt) on Maddox-rod test?
testing?
2) Check vertical fusional amplitudes (normal ~ 2;
Superior Inferior can be as high as 12-15 in congenital SO palsy)
Always Positive to
Unilateral
When diagnosing aNo
unilateral SO palsy,less
what must
oneyou be
side
Overaction SO to
sure palsy
rule out? than 10 o
only
Palsy
Brown syndrome Yes both
64
Vertical Deviations
Vertical Deviations

Closed
Findings
that a SO How
palsymuch
is congenital?
Head-tilt
head tilt) on double test?
Maddox rod
testing?
Superior Inferior
can be as high as 12-15 in congenital SO palsy)
No one side
diagnosing a unilateral SO than 10 #oof
Overaction SO palsy
When palsy, what
degrees
only
Palsy
SO palsy than 10 #oof
degrees
sides
65
Vertical Deviations
Vertical Deviations

Closed
Findings
that a SO How
palsymuch
is congenital?
Head-tilt
Maddox rod
testing?
Superior Inferior
No one side
diagnosing a unilateral SO than 10what
o
Overaction SO palsy
When palsy, only
Palsy
66
Vertical Deviations
Vertical Deviations

Closed
Findings
that a SO How
palsymuch
is congenital?
1) Family-album
biopsyET check old photos for a
Head-tilt
longsta present? on double test?
Maddox rod
nding head tilt) testing?
Superior Inferior
No one side
diagnosing a unilateral SO than 10what
o
Overaction SO palsy
When palsy, only
Palsy
What is double Maddox rod testing? I’m glad you asked…

67
Vertical Deviations
What is a Maddox rod?
A translucent disc of red plastic constructed of a set of very small cylinders aligned parallel to one another
What does a pt see when shown a point-source of light through a Maddox rod?
The point of light is seen as a line oriented 90o from the orientation of the cylinders
Ok, so what is double Maddox-rod testing, and how is it used to identify and quantify excyclotorsion?
In the double Maddox rod test, a separate Maddox rod is placed before each eye, and a point-source of light
is presented to both eyes simultaneously. Thus, each eye sees its own line, courtesy of its Maddox rod. In
individuals for whom their eyes have identical rotational orientation, the line seen by each eye will be
perceived as parallel to the other. However, because an eye with a SO palsy is excyclotorted, the line
produced by its Maddox rod will be in a different orientation than that experienced by its non-torted fellow
eye. (Bear in mind that it’s not the orientation of the line itself that’s off; rather, it’s the orientation of the retina
perceiving the line that’s off.)
How can double-Maddox rods be used to measure the amount of cyclotorsion?

The Maddox-rod lenses can be mounted in trial frames that allow the orientation of the cylinders to be
changed, and the pt is instructed to do so until s/he perceives the lines to be parallel. The difference in
degrees between the orientation of the two sets of cylinders is the size of the excyclotorsion.
68
Vertical Deviations

69
Vertical Deviations
Maddox rod
70
Vertical Deviations

71
Vertical Deviations
# o from the orientation of the cylinders
The point of light is seen as a line oriented 90 o

72
Vertical Deviations

73
Vertical Deviations

74
Vertical Deviations

75
Vertical Deviations
Sometimes a clear Maddox rod is used for one eye
Double Maddox rod setup

76
Vertical Deviations

77
Vertical Deviations
Black lines indicate the orientation of the lines as seen by each eye.
Double Maddox rod test in individual without strabismus

78
Vertical Deviations

79
Vertical Deviations
Black lines indicate the orientation of the lines as seen by each eye.
Double Maddox rod test in individual with a right SO palsy

80
Vertical Deviations

81
Vertical Deviations

The Maddox-rod lenses are mounted in trial frames that allow the orientation of the cylinders to be changed,
and the pt is instructed to do so until s/he perceives the lines to be parallel. The difference in degrees
between the orientation of the two sets of cylinders is the size of the excyclotorsion.
82
Vertical Deviations

How can the size of the excyclotorsion be used to differentiate between unilateral and bilateral
SO palsies?
The maximum amount of excyclotorsion that can result from unilateral SO palsy is 10 deg.
Thus, if more than this amount is present, bilateral palsies must be present.
83
Vertical Deviations

SO palsies?
The maximum amount of excyclotorsion that can result from unilateral SO palsy is 10 # deg.
84
Vertical Deviations

SO palsies?
85
Vertical Deviations

SO palsies?
This means that if less than 10 deg is present, the palsy must be unilateral, right?
Slow ya roll. It’s true that if only one eye is excyclotorted, the total measured
excyclotorsion is always 10 deg or less. However, if both eyes are only mildly palsied—
say, 4 degree’s worth each—the total excyclotorsion (in this case 8 deg) could be less
than 10. Thus, whereas >10 deg rules out unilateral SO palsy, <10 does not rule it in.
86
Vertical Deviations

SO palsies?
Slow ya roll, bruh. It’s true that if only one eye is excyclotorted, the total measured
say, 4 degree’s worth each—the total excyclotorsion (in this case 8 deg) could be less
than 10. Thus, whereas >10 deg rules out unilateral SO palsy, <10 does not rule it in.
87
Vertical Deviations

SO palsies?
say,
All4that
degree’s
said, itworth each—the
is very totala excyclotorsion
unusual for (in this case 8 deg) could be less
bilateral SO palsy
than 10. Thus,
to present whereas
with >10#5deg
less than degrules out unilateral SO palsy, <10 does not rule it in.
of torsion
88
Vertical Deviations

SO palsies?
say,
All4that
degree’s
bilateral SO palsy
than 10. Thus,
to present whereas
with >105deg
less than deg rules out unilateral SO palsy, <10 does not rule it in.
of torsion
89
Vertical Deviations
produced by its Maddox TLDRrod will be in a different orientation than that experienced by its non-torted fellow
eye. (Bear in mind that it’s
>10notexcyclotorsion
the orientation ofisthe line itself
always that’s off; rather, it’s the orientation of the retina
bilateral
<5 (but greater than 0, duh) is almost always unilateral
How can double-Maddox5-10
rods is
beindeterminate
used to measure the amount of cyclotorsion?
SO palsies?
say,
All4that
degree’s
bilateral SO palsy
than 10. Thus,
to present whereas
with >105deg
less than degrules out unilateral SO palsy, <10 does not rule it in.
of torsion
90
Vertical Deviations
Vertical Deviations

Closed
Findings
that a SO How
palsymuch
is congenital?
Head-tilt
Maddox rod
testing?
Always Positive to
Unilateral
When diagnosing aNo
unilateral SO palsy,less one side
Overaction SO palsy than 10o which
only
side(s)?
Palsy
SO palsy than 10o which
sides
side(s)?
Next question!
91
Vertical Deviations
Vertical Deviations

Closed
Findings
that a SO How
palsymuch
is congenital?
Head-tilt
Maddox rod
testing?
Always Positive to
Unilateral
When diagnosing aNo
what one side
Overaction SO palsy than 10 o
only
Palsy
Next question!
92
Vertical Deviations
Vertical Deviations

Closed
Findings
that a SO How
palsymuch
is congenital?
Head-tilt
Maddox rod
testing?
Always Positive to
Unilateral
When diagnosing aNo
what one side
Overaction SO palsy than 10 o
only
Palsy
What is the head-tilt test? I’m glad you asked…

93
Vertical Deviations
The head-tilt test is also known by what eponymous name?
The Beilschowsky head-tilt test
The head-tilt test is actually a single component of what double-eponymous 3-step test?
The Parks-Bielschowsky 3-step test
Generally speaking, what is the purpose/goal of the Parks-Bielschowsky 3-step test?

To identify the cyclovertical muscle responsible for a vertical deviation
How is the head-tilt test performed?

The pt is told to tilt their head first to one side, then to the other, while you observe their
eyes. A SO palsy is present if the eye on the side toward which the head is tilted responds
to the tilt by drifting up (ie, by becoming hypertropic ).
94
Vertical Deviations


95
Vertical Deviations


96
Vertical Deviations


97
Vertical Deviations


98
Vertical Deviations

To identify the cyclovertical
EOM function muscle responsible for a vertical
direction deviation

99
Vertical Deviations


100
Vertical Deviations

To identify the cyclovertical muscle responsible for a vertical deviation*
How is the head-tilt *Note: The Parks-Bielschowsky test works if and only if weakness of
test performed?
a single
The pt is told to tilt their headmuscle
first to is
oneresponsible
side, thenfor the other,
to the verticalwhile
deviation in question!
you observe their
101
Vertical Deviations


102
Vertical Deviations


103
Vertical Deviations


to the tilt by drifting down
up (ie, by becoming hypertropic
up v
hyper- v hypotropic ).
104
Vertical Deviations


105
Vertical Deviations
Left SO palsy: Positive head tilt test

106
Vertical Deviations
Why does a head-tilt cause an SO palsy eye to become hyperopic?
Generally
It speaking,
has to do with what
a ‘righting is the
reflex’ purpose/goal
in the ocular controlofsystem.
the Parks-Bielschowsky 3-step
When the head is tilted to onetest?
side, the eyes
attempt to remain level (= superior poles pointing toward the ceiling) by counter-torting in the other direction.
So for example, when the head is tilted to the right, to stay upright the right eye will incyclotort (ie, the
How is the
superior polehead-tilt test performed?
will tort toward the midline), while the left eye will excyclotort (ie, the superior pole will tort
The pt is told to tilt
away from the midline). their head first to one side, then to the other, while you observe their
107
Vertical Deviations
Generally
It speaking,
has to do with what
side, the eyes
How is the
108
Vertical Deviations
Generally
It has to do withspeaking, what
the Parks-Bielschowsky
When the head is tilted 3-step
to onetest? side, the eyes
in- vs
So for example, when the head is tilted to the right, to stay upright the right eye will incyclotort excyclotort (ie, the
How is the head-tilt
superior pole will tort towardtest
toward vs performed?
away from
in- vs
the midline), while the left eye will excyclotort
excyclotort (ie, the superior pole will tort
The pt
toward
away vs is told to tilt their head first to one side, then to the other, while you observe their
from the midline).
away from
109
Vertical Deviations
Generally
It speaking,
has to do with what
side, the eyes
How is the
110
Vertical Deviations
Generally
It speaking,
has to do with what
to onetest?
side, the eyes
How is the
away from the midline). Key point:first
The pt is told to tilt their head Theto one
eye on side, thenside
the same to the other,
as the headwhile
tilt willyou observe
attempt their
to intort.
111
Vertical Deviations
Generally
It speaking,
has to do with what
to onetest?
side, the eyes
How is the
eye onside, thenside
the same to the
as other, while
the head youattempt
tilt will observe totheir
intort.
Recall that the intorters of the eye are the superior

EOM rectus and the superior
EOMoblique (you can remember
this with the mnemonic SIN, which stands for Superiors INtort). Thus, when an eye attempts to intort, both
the SR and the SO fire. Note that the SR and the SO also have equal-but-opposite vertical components to
their actions—the SR elevates the eye, while the SO depresses it. So when both muscles fire
simultaneously, their vertical components cancel each other out, and the eye simply intorts.
Now consider what happens upon head tilt if the eye on that side has a SO palsy. Attempted intorsion
results in contraction of the SR only (because the palsied SO cannot contract). Thus, the vertical component
of the SR contraction is unopposed, and because it is unopposed, the eye elevates. This is why an eye with
a SO palsy demonstrates a hypertropia upon head tilt to that side!
112
Vertical Deviations
Generally
It speaking,
has to do with what
to onetest?
side, the eyes
How is the
the same to the
as other, while
the head youattempt
intort.
Recall that the intorters of the eye are the superior rectus and the superior oblique (you can remember
113
Vertical Deviations
Generally
It speaking,
has to do with what
to onetest?
side, the eyes
How is the
the same to the
as other, while
the head youattempt
intort.
114
Vertical Deviations
Generally
It speaking,
has to do with what
to onetest?
side, the eyes
How is the
the same to the
as other, while
the head youattempt
intort.
115
Vertical Deviations
Vertical Deviations
Superior Inferior
Management of unilateral SO palsy:
--If no IO overaction is present: [surgery]
Contralateral IR recession
Overaction --If IO overaction is present, but deviation is <15:
IO weakening procedure
Palsy
--If IO overaction is present and the deviation is >15:
Brown syndromePerform both
Management of bilateral SO palsy:

--If main c/o is torsional diplopia: Harada-Ito procedure
116
Vertical Deviations
Vertical Deviations
Superior Inferior
--If no IO overaction is present: Contralateral IR recession
Palsy

117
Vertical Deviations
Vertical Deviations
Superior Inferior
Wha? Why perform
IO weakening contralateral IR recession for unilateral SO palsy?
procedure
Palsy Patients with an SO
--If IO overaction is palsy c/oand
present diplopia in downgaze.
the deviation This is because the
is >15:
unaffected
Brown syndromePerformeyeboth can depress fully, but the eye with the SO palsy cannot.
The contralateral IR is the yoke muscle for the palsied SO. By recessing
the contralateral
Management of IR, you inhibit
bilateral that eye’s ability to depress, thereby
SO palsy:
eliminating theissource
--If main c/o torsionalof diplopia:
diplopia (i.e., the asymmetry
Harada-Ito in depression). In
procedure
essence, you treat a unilateral motility problem by giving the patient a
bilateral motility problem.
118
Vertical Deviations
Vertical Deviations
Superior Inferior
Wha? Why perform
procedure
is >15:
unaffected
the contralateral
SO palsy:
Harada-Ito in depression).
procedure
In essence, you treat a unilateral motility problem by giving the patient a
119
Vertical Deviations
Vertical Deviations
Superior Inferior
Wha? Why perform
procedure
is >15:
unaffected
the contralateral
SO palsy:
Harada-Ito in depression).
procedure
In essence, you treat a unilateral motility problem by giving the patient a
120
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction --If IO overaction is present, but deviation is <15: [surgery]
Palsy

121
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy

122
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy
--If IO overaction is present and the deviation is >15: [surgery]

123
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy

124
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy

--If main c/o is torsional diplopia: Harada-Ito
[surgery] procedure
125
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy

126
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy Briefly, what is the Harada-Ito procedure?
Both SO tendons are split, and the anterior portion
of each is repositioned anteriorly and temporally

127
Vertical Deviations
Vertical Deviations
Superior Inferior
of each is repositioned anteriorly
direction and temporally
direction

128
Vertical Deviations
Vertical Deviations
Superior Inferior
of each is repositioned anteriorly and temporally

129
Vertical Deviations
Pre Post
Harada-Ito procedure
130
Vertical Deviations
Vertical Deviations
In the present context, what is a skew deviation?
A vertical deviation secondary to dysfunction of the vestibular-ocular system
(aka the vestibular-ocular reflex, VOR )
Why is skew deviation being mentioned here?

2o toBecause
oblique dysfunction
it can easily be mistaken for a SOUncertain
palsy mechanism
Dysfunction of the VOR occurs in one of two general locations—what are they?
Superior Inferior
Overaction
Palsy
Brown syndrome
131
Vertical Deviations
Vertical Deviations
A vertical deviation secondary to dysfunction of the vestibular-ocular
two-words system

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy
Brown syndrome
132
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy
Brown syndrome
133
Vertical Deviations
Vertical Deviations
one word

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy
Brown syndrome
134
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy
Brown syndrome
135
Vertical Deviations
Vertical Deviations
What is the vestibular-ocular system?
It is one of the six ocular motor systems that 1) facilitate bifixation of an object of regard, as well as
Why isand
skew deviation
reorientbeing mentioned here?of regard is detected in the visual periphery
2 toBecause
oblique
o2) smoothly dysfunction
rapidly gaze when mechanism
a new object
palsy
What general term is used to refer to these six control systems?
Because they innervate
Dysfunction theVOR
of the nuclei of the peripheral
occurs in one of nerves that control
two general eye movements,are
locations—what these
they?
systems are referred to as supranuclear pathways
Superior Inferior
Overaction
Palsy
Brown syndrome
136
Vertical Deviations
Vertical Deviations
It is one of the six
# ocular motor systems that 1) facilitate bifixation of an object of regard, as well as
Why is skew deviation
2 toBecause
oblique dysfunction
easily be mistaken for a SOUncertain
o2) smoothly and rapidly
it can
gaze when mechanism
a new object
palsy
Dysfunction theVOR
they?
Superior Inferior
Overaction
Palsy
Brown syndrome
137
Vertical Deviations
Vertical Deviations
Why isand
skew deviation
2 toBecause
oblique
a new object
palsy
Dysfunction theVOR
they?
Superior Inferior
Overaction
Palsy
Brown syndrome
138
Vertical Deviations
Vertical Deviations
Why isand
skew deviation
2 toBecause
oblique
a new object
palsy
Dysfunction theVOR
they?
Superior Inferior
Overaction
Palsy
Brown syndrome
139
Vertical Deviations
Vertical Deviations
Why isand
skew deviation
2 toBecause
oblique
a new object
palsy
Dysfunction theVOR
they?
Superior Inferior
Overaction
Palsy
Brown syndrome
140
Vertical Deviations
Vertical Deviations
Why isand
skew deviation
2 toBecause
oblique
a new object
palsy
Dysfunction theVOR
they?
Superior Inferior
Overaction
Palsy
Brown syndrome
141
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy
Brown syndrome
142
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy
Brown syndrome
143
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
it can Uncertain
easily be mistaken for a SO palsy mechanism
DysfunctionCan’t theyVOR
of the be distinguished via the
occurs in one 3-step
of two test? locations—what are they?
general
Unfortunately no—skew deviation may ‘pass’ the test as a SO palsy
Superior Inferior
Overaction
Palsy
Brown syndrome
144
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
it can Uncertain
easily be mistaken for a SO palsy mechanism
DysfunctionCan’t theyVOR
of the be distinguished via the
occurs in one 3-step
of two test? locations—what are they?
general
Unfortunately no—skew deviation may ‘pass’ the test as a SO palsy
Superior Inferior
Overaction
Palsy
Brown syndrome
145
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy ? ?
Brown syndrome
146
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy Central Peripheral
Brown syndrome
147
Vertical Deviations
In the present context, Vertical Deviations

A ‘central’ VOR lesion—in which portion of the CNS is it located?
what is a skew deviation?
The brainstem
(aka the vestibular-ocular reflex, VOR
Likewise, a ‘peripheral’ ) lesion—to what structure/area does this locate?
VOR
To the vestibular apparatus of the inner ear
2o toBecause
oblique dysfunction
it can easily be mistaken for a SO Uncertain
What are the two major components
palsy mechanism
of the vestibular apparatus?
The semicircular canals, and the otoliths
Superior Inferior
Overaction
Brown syndrome
148
Vertical Deviations

The brainstem
VOR
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Brown syndrome
149
Vertical Deviations

The brainstem
VOR
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Brown syndrome
150
Vertical Deviations

The brainstem
VOR
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Brown syndrome
151
Vertical Deviations

The brainstem
VOR
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Brown syndrome
? ?
152
Vertical Deviations

The brainstem
VOR
2o toBecause
oblique dysfunction
palsy mechanism
The semicircular canals and the otoliths
Superior Inferior
Overaction
Brown syndrome
Semicircular Otoliths
canals
153
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Palsy Central? Peripheral
Brown syndrome
Of the three locations, damage to which is
most likely to result in a skew deviation? Semicircular Otoliths?
canals?
154
Vertical Deviations
Vertical Deviations

2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Overaction
Brown syndrome
most likely to result in a skew deviation? Semicircular Otoliths!
The otoliths canals
155
Vertical Deviations
They can’t reliably be differentiated via the 3-step test…But they can be
differentiated based on a simple clinical observation, as well as a simple maneuver.
What is the observation? Is the Vertical Deviations
eye intorted,
(No what
In the present context, question
or extorted?
a skew going)
isyet—keep deviation?
What is the maneuver? Does the hyper resolve if the pt lies supine?
Positive 3-step Eye intorted, Resolves
test?being mentioned
Why is skew deviation or extorted?
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
SO palsy Yes Extorted No
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Oblique Intorted Yes
Overaction
Brown syndrome
The otoliths canals
156
Vertical Deviations
What is the observation? Is the Vertical Deviations
eye intorted,
(No what
In the present context, question
or extorted?
a skew going)
isyet—keep deviation?
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Overaction
Brown syndrome
The otoliths canals
157
Vertical Deviations
Vertical Deviations
What is the observation? Is the eye intorted, or extorted?
Why is skew deviation ?
or extorted?
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Overaction
Brown syndrome
The otoliths canals
158
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
SO palsy Yes No
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Oblique Yes
Overaction
Brown syndrome
The otoliths canals
159
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
SO palsy Yes ? No
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Oblique ? Yes
Overaction
Brown syndrome
The otoliths canals
160
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Overaction
Brown syndrome
The otoliths canals
161
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Overaction Recall that the SO is an intorter of the eye, so it follows that an

SO palsy results in extorsion. In contrast, the hyper eye in skew
Palsy Central
deviation is usually intorted. Peripheral
Brown syndrome
The otoliths canals
162
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)

Palsy Central
Brown syndrome
The otoliths canals
163
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)

Palsy Central
Brown syndrome
How does one go about determining whether an eye is intorted or extorted?
Probably the best method is during DFE, by taking note of the relative
Of the positions
three locations, damage to which is
of the ONH and macula
The otoliths canals
164
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)

Palsy Central
Brown syndrome
How does one go about determining whether an eye is intorted or extorted?
Probably the best method is via DFE, by taking note of the relative positions
Of the of
three locations, damage to which is
the ONH and macula
The otoliths canals
165
Vertical Deviations
Vertical Deviations
N test?being mentioned
here? when? supine?
2 toeBecause
o oblique dysfunction
palsy mechanism
SO xpalsy Yes Extorted No
t
Superior Inferior
Skew
Oblique
Q (SO) Yes (IO)
Overaction
Brown syndrome
The otoliths canals
166
Vertical Deviations
Vertical Deviations
N test?being mentioned
here? when supine?
2 toeBecause
o oblique dysfunction
palsy mechanism
SO xpalsy Yes Extorted No
t
Superior Inferior
Skew
Oblique
Q (SO) Yes (IO)
Overaction
Brown syndrome
The otoliths canals
167
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
SO palsy Yes Extorted ?
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Oblique Intorted ?
Overaction
Brown syndrome
The otoliths canals
168
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Overaction
Brown syndrome
The otoliths canals
169
Vertical Deviations
Vertical Deviations
here? when supine?
2o toBecause
oblique dysfunction
palsy mechanism
Superior Inferior
Skew(SO)
Oblique Yes (IO)
Overaction
Palsy
Take note—these
Central are thePeripheral
traits that
differentiate skew from SO palsy!
Brown syndrome
The otoliths canals
170
Vertical Deviations
Vertical Deviations
Define Brown syndrome:
Deficient elevation in adduction 2o to restriction of the SO
tendon at the trochlea
2o to oblique dysfunction
Is Brown syndromeUncertain
more commonmechanism
in…
…males or females? Males
…OD or OS? OD
Superior Inferior Double

What common strabismus syndrome has theDVD
opposite
Oblique (SO) Oblique pattern
(IO) (i.e., is more Elevator
common in females and left eyes)?
Duane syndrome Palsy
Overaction Name three causes of trochlear restriction:
Palsy --Idiopathic
--Traumatic
Brown syndrome --Inflammatory
In addition to restricted elevation, what else occurs during

adduction in Brown syndrome?
--The palpebral fissure widens
--The eye may involuntarily depress (called downshoot)
171
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Palsy --Idiopathic
--Traumatic

172
Vertical Deviations
Right Brown syndrome

173
Vertical Deviations
Vertical Deviations
in…
…males or females?
…OD or OS? OD

opposite
Palsy --Idiopathic
--Traumatic

174
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Palsy --Idiopathic
--Traumatic

175
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Palsy --Idiopathic
--Traumatic

176
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Palsy --Idiopathic
--Traumatic

177
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction Name three causes of SO restriction at the trochlea:
Palsy --Idiopathic
--Traumatic

178
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Palsy --Idiopathic/congenital (ie, born with a short tendon)
--Traumatic

179
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
--Traumatic

180
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
--Traumatic

181
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Briefly, what is Duane syndrome? Name three causes of SO restriction at the trochlea:
A motility disorder with the following key--Idiopathic/congenital
findings: (ie, born with a short tendon)
Palsy
--At least some limitation of horizontal movement
--Traumatic
-- Attempted adduction causes the globe to retract , and may cause it to
up- or downshoot
What is the cause?
The nucleus for cranial nerve VI is missing, and the lateral rectus is
innervated by cranial nerve III
182
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--At least some limitation of horizontal
direction movement
--Traumatic
--Inflammatory
up- or downshoot
What is the cause?
183
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
--Inflammatory
up- or downshoot
What is the cause?
184
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Briefly, what is Overaction
Duane syndrome? Name three causes of SO restriction at the trochlea:
Palsy
--At least some limitation of horizontal movement--Traumatic
-- Attempted adduction movement causes the globe to retract
one word , and may cause it to
up-thisoror downshoot
that movement

What is the cause?
185
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
up- or downshoot
What is the cause?
186
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
up- or downshoot
What is the cause?
187
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
up- or downshoot
What is the cause?
The nucleus for cranial nerve VI#
is missing, and the lateral rectus is
#
188
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
up- or downshoot
What is the cause?
189
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
up- or downshoot
No question yet, keep going
What is the cause?
--The palpebral fissure widens How does this…
190
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD

opposite
Overaction
Palsy
--Traumatic
-- Attempted adduction causes the globe to retract , and may cause it to …cause this?
up- or downshoot
No question yet, keep going
In addition
(this oneto
is restricted
rhetorical) elevation, what else occurs during
What is the cause?
191
Vertical Deviations
Vertical Deviations
When someone with an intact oculomotor system adducts their eye, innervation is increased
to the medial rectus (as it should be) Define Brown syndrome:
and decreased to the lateral rectus (also as it should be).
However, in a Duane’s pt CN3 innervates the LR, so when she attempts to adduct her eye,
(No question—continue when ready)
innervation is increased to both the medial rectus and the aberrantly-innervated lateral rectus,
so the2eyeto
o oblique
doesn’t adduct.dysfunction
And when Is two muscles
Brown Uncertain
on opposite
syndrome sides of mechanism
more common the
in…eye contract
simultaneously, the net result will be that the eyeorisfemales?
…males pulled back, ie, it retracts. Further, if this
Males
co-contraction is sufficiently vigorous, one
…OD or the otherOD
or OS? rectus muscle might ‘slip’ upwards or
downwards, causing the eye to up- or downshoot respectively.
Superior Inferior
What common strabismus Double
syndrome has theDVD opposite
Overaction
Palsy
--Traumatic
up- or downshoot
What is the cause?
192
Vertical Deviations
Vertical Deviations
so the2eye
o to oblique
And when two muscles
Is Brown Uncertain
on opposite
syndrome sides of
more common mechanism
the eye contract
in…
simultaneously, the net result will
(Nobe that the eyeorisfemales?
question—continue
…males pulled back,
when ready) ie, it retracts. Further, if this
Males
co-contraction is sufficiently vigorous, one…OD or the otherOD
Superior Inferior
What common strabismus Doublesyndrome has theDVD opposite
Overaction
Palsy
--Traumatic
up- or downshoot
What is the cause?
193
Vertical Deviations
Vertical Deviations
so the2eye
o to oblique
Is Brown Uncertain
on opposite
syndrome sides of
the eye contract
in…
Males
…OD or the other
or OS?
(No question—continue rectus
OD
when ready)muscle might ‘slip’ upwards or
Superior Inferior
Overaction
Palsy
--Traumatic
-- Attempted adduction causes the globe to retract , and may cause it …cause this?
to up- or downshoot
What is the cause?
194
Vertical Deviations
Vertical Deviations
so the2eye
o to oblique
Is Brown Uncertain
on opposite
syndrome sides of
the eye contract
in…
Males
…OD or the otherOD
Superior Inferior
Overaction
Palsy
--Traumatic
to up- or downshoot
What is the cause?
195
Vertical Deviations
Vertical Deviations
Deficient elevation in adduction
However, in a Duane’s pt CN3 innervates the LR, so when she attempts to adduct her eye, 2o to restriction of the SO
tendon attothe trochlea

innervationThis
is increased
finding—that toincreased
both the innervation
medial rectus anand themuscles
agonist aberrantly-innervated
is accompanied by lateral
a rectus,
so the2eyeto
o oblique
simultaneous
decrease in innervation
And when to its
two muscles
Is Brown syndrome Uncertain
antagonist—is
on opposite
more
ubiquitous
sides of
common mechanism
to have been
the eye contract
in…
ratified into law. What is the eponymous name of the law of ‘reciprocal innervation’?
…males pulled back,Males ie, it retracts. Further, if this
Sherrington’s law. You should note that Duane syndrome is an exception to
co-contraction is sufficiently
Sherrington’s vigorous,
law (because this one
…OD or would
factoid the other
or OS?make ODrectus
a goodmuscle
OKAP test might ‘slip’ upwards or
question)
Superior Inferior What common strabismus Double syndrome has theDVD opposite
(IO) (i.e., is more Elevatorcommon in females and left eyes)?
Overaction
Palsy
--Traumatic
to up- or downshoot
What is the cause?
196
Vertical Deviations
Vertical Deviations
Deficient elevation in adduction
However, in a Duane’s pt CN3 innervates the LR, so when she attempts to adduct her eye, 2o to restriction of the SO
tendon attothe trochlea

innervationThis
is increased
finding—that toincreased
both the innervation
medial rectus anand themuscles
agonist aberrantly-innervated
is accompanied by lateral
a rectus,
so the2eyeto
o oblique
simultaneous
decrease in innervation
And when to its
two muscles
Is Brown syndrome Uncertain
antagonist—is
on opposite
more
ubiquitous
sides of
common mechanism
to have been
the eye contract
in…
ratified into law. What is the eponymous name of the law of ‘reciprocal innervation’?
…males pulled back,
Males ie, it retracts. Further, if this
Sherrington’s law. You should note that Duane syndrome is an exception to
co-contraction is sufficiently
Sherrington’s vigorous,
law (this one
…OD
is noteworthy or the other
or OS?
because ODrectus
it would makemuscle
a good might
OKAP ‘slip’ upwards or
question)
Superior InferiorWhat common strabismus Double syndrome has theDVD opposite
Overaction
Palsy
--Traumatic
to up- or downshoot
What is the cause?
197
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
What common strabismus Doublesyndrome has theDVD
opposite
Oblique
What other (SO) couldOblique
two entities (IO) (i.e.,
produce restriction
pattern is more Elevator
of elevation in females and left eyes)?
in adduction?
common
1) IR restriction Duane syndrome Palsy
2) IO palsy
Overaction Overaction
Name three causes of trochlear restriction:
What clinical exam finding must be present if one is to make the diagnosis of Brown syndrome?
--Idiopathic
Palsy Palsy
Forced ductions testing must be positive (i.e., indicate restriction)
--Traumatic
Brown
But forced ductions syndrome
are --Inflammatory
positive in IR restriction as well—how can the two conditions be differentiated?
By retropulsing the globe while performing forced ductions. In IR restriction, retropulsion takes the
In addition
muscle off stretch, thereby rendering forced to restricted
ductions elevation,
‘less positive.’ what retropulsion
In contrast, else occursplaces
during
adductionwill
the SO tendon on stretch, and thus retropulsion in render
Brown thesyndrome?
forced ductions ‘more positive’ in
Brown syndrome. The reverse is true if--The palpebral
the globe fissure widens
is anteropulsed (pulled forward) prior to performing
forced ductions. --The eye may involuntarily depress (called downshoot)
198
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown thesyndrome?
199
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown thesyndrome?
200
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown thesyndrome?
201
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown thesyndrome?
202
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown thesyndrome?
203
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown thesyndrome?
204
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown the
syndrome?
Brown syndrome. (The reverse is true if--The palpebral
the globe fissure widens forward--prior to performing
is anteropulsed--pulled
forced ductions.) --The eye may involuntarily depress (called downshoot)
205
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
opposite
Oblique
produce restriction
in adduction?
common
2) IO palsy
--Idiopathic
Palsy Palsy
--Traumatic
Brown
are --Inflammatory
In addition
ductions elevation,
during
adductionwill
Brown the
syndrome?
Brown syndrome. (The reverse is true if--The palpebral
the globe fissure widens forward--prior to performing
is anteropulsed--pulled
forced ductions.) --The eye may involuntarily depress (called downshoot)
206
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
Oblique
What other (SO)
two entities couldOblique
Differentiating (IO) syndrome
produce restriction
pattern
Brown
is more Elevator
of elevation
(i.e., in females and left eyes)?
in adduction?
common
from IO palsy
2) IO palsy
Forced
Name three Strabismus SO
causes of trochlear restriction:
What clinical exam finding mustductions?
be present if one
--Idiopathic pattern?
is to make the overaction?
diagnosis of Brown syndrome?
Palsy
Forced ductions Palsy
testing must be positive (i.e., indicate restriction)
--Traumatic
IO Palsy
But forced ductions are Negative
positive in IR restriction A pattern Present
as well—how can the two conditions be differentiated?
In addition
ductions elevation,
during
the SO tendon onBrown adductionwill
stretch, and thus retropulsion in render
Brown thesyndrome?
Positive
Brown syndrome. The reverse is true if--The
the globe V pattern
palpebral fissure widens
is anteropulsed Absent
(pulled forward) prior to performing
forced ductions.
Syndrome --The eye may involuntarily depress (called downshoot)
207
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
Oblique
What other (SO)
produce restriction
pattern
Brown
is more Elevator
of elevation
in adduction?
common
from IO palsy
2) IO palsy
Forced
be present if one
Palsy
--Traumatic
IO Palsy
In addition
ductions elevation,
during
Brown thesyndrome?
Positive
the globe V pattern
forced ductions.
208
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
Oblique
What other (SO)
produce restriction
pattern
Brown
is more Elevator
of elevation
in adduction?
common
from IO palsy
2) IO palsy
Forced
be present if one
Palsy
--Traumatic
IO Palsy
In addition
ductions elevation,
during
Brown thesyndrome?
Positive
the globe V pattern
forced ductions.
209
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
Oblique
What other (SO)
produce restriction
pattern
Brown
is more Elevator
of elevation
in adduction?
common
from IO palsy
2) IO palsy
Forced
be present if one
Palsy
--Traumatic
IO Palsy
In addition
ductions elevation,
during
Brown thesyndrome?
Positive
the globe V pattern
forced ductions.
210
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
Oblique
What other (SO)
produce restriction
pattern
Brown
is more Elevator
of elevation
in adduction?
common
from IO palsy
2) IO palsy
Forced
be present if one
Palsy
--Traumatic
IO Palsy
In addition
ductions elevation,
during
Brown thesyndrome?
Positive
the globe V pattern
forced ductions.
211
Vertical Deviations
Vertical Deviations
in…
…OD or OS? OD
Superior Inferior
Oblique
What other (SO)
produce restriction
pattern
Brown
is more Elevator
of elevation
in adduction?
common
from IO palsy
2) IO palsy
Forced
be present if one
Palsy
--Traumatic
IO Palsy
In addition
ductions elevation,
during
Brown thesyndrome?
Positive
the globe V pattern
forced ductions.
212
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
Brown syndrome: Management
Palsy --In acute-onset cases, image…[2 locations]
Brown syndrome --Consider… steroids (systemic and/or local)
--If present, treat… systemic inflammatory disease
--Consider surgery only if…hypotropic in primary gaze
213
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
Palsy --In acute-onset cases, image…sinuses
image…[2 locations]
& orbits
214
Vertical Deviations
Axial STIR (A) and postcontrast fat-saturated T1 (B) images; coronal STIR (C) and postcontrast
fat-saturated T1 (D) images. There is subtle increased STIR signal and mild asymmetric thickening
in anterior portion of the left superior oblique tendon. On postcontrast imaging, there is prominent
enhancement around the trochlea region (B and D, indicated by the arrows).
Acute Brown syndrome

215
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
& orbits
Brown syndrome --Consider… steroids
--Consider…[drug] steroids
(systemic
(systemic
and/orand/or
local) local)
216
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
& orbits
217
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
& orbits
218
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
& orbits
--If present, treat…systemic
treat… systemicinflammatory
inflammatorydisease
disease
219
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
image…[2 locations] & orbits
inflammatorydisease
disease
--Consider surgery only if…hypotropic in primary
[specific strabismic gaze
problem]
220
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction
& orbits
inflammatorydisease
disease
221
Vertical Deviations
Vertical Deviations
Superior Inferior
Overaction ?
Palsy ?
Brown syndrome
222
Vertical Deviations
Vertical Deviations
Superior Inferior
Palsy Palsy
Brown syndrome
223
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Overaction
Overaction Overaction --Eye elevates in… [position]
adduction
--Develops in ~2/3 of congenital ET cases
Palsy Palsy
Brown syndrome
224
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Overaction
Overaction Overaction --Eye elevates in…adduction
Palsy Palsy
Brown syndrome
225
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Overaction
--Develops in ~2/3
% of congenital ET cases
Palsy Palsy
Brown syndrome
226
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Overaction
Palsy Palsy
Brown syndrome
227
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Palsy
--[How common?]
Palsy Palsy --Etiology uncertain
--Clinically similar to…SO overaction
Brown syndrome (can be a difficult differentiation)
228
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Palsy
--Uncommon
229
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Palsy
--Uncommon
230
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Palsy
--Uncommon
Palsy Palsy --Etiology uncertain [another
strabismic entity]
231
Vertical Deviations
Vertical Deviations
Superior Inferior
IO Palsy
--Uncommon
232
Vertical Deviations
Vertical Deviations
Superior Inferior ? ?
Palsy Palsy
Brown syndrome
233
Vertical Deviations
Vertical Deviations
Superior Inferior Double DVD

Oblique (SO) Oblique (IO) Elevator
Palsy
Palsy Palsy
Brown syndrome
234
Vertical Deviations
Vertical Deviations

Palsy
Double Elevator Palsy
--aka…Palsy
Monocular Elevation Palsy
Deficiency
--Catch-all
Brownterm for a strabismus involving…decreased elevation in all fields of gaze
syndrome
--Due to… restriction or elevation insufficiency (or both)
--Presents with… hypotropia that worsens in upgaze
--Often adopt a… chin-up position
--50% have… concomitant ptosis (1/3 of these with… Marcus-Gunn jaw wink)
235
Vertical Deviations
Vertical Deviations

Palsy
Palsy
--aka…Monocular ElevationPalsy
Deficiency
--Catch-all
syndrome
236
Vertical Deviations
Double elevator palsy

237
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
Brownterm for a strabismus involving…decreased
syndrome elevation in all fields of gaze
[basic problem]
238
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
239
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--Due to… [two
restriction or elevation insufficiency (or both)
explanations]
240
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--Due to…restriction or elevation insufficiency (or both)
241
Vertical Deviations
Vertical Deviations
Differentiating between IR restriction and elevator

2o to oblique
insufficiency of a double elevator palsy Uncertain
dysfunction
as the cause mechanism
Forced Force Elevation
ductions? generation? saccades?
Oblique (SO)
Inferior
Positive
Oblique
Normal
(IO) Normal
Elevator
Restriction Palsy
Elevator
Double Elevator
NegativePalsy Reduced Reduced
Insufficiency Palsy
Deficiency
--Catch-all
syndrome
242
Vertical Deviations
Vertical Deviations

2o to oblique
dysfunction
Oblique (SO)
Inferior
Positive
Oblique
Normal
(IO) Normal
Elevator
Restriction Palsy
Elevator
Double Elevator
Insufficiency Palsy
Deficiency
--Catch-all
syndrome
243
Vertical Deviations
Vertical Deviations

2o to oblique
dysfunction
Oblique (SO)
Inferior
Positive
Oblique
Normal
(IO) Normal
Elevator
Restriction Palsy
Elevator
Double Elevator
Insufficiency Palsy
Deficiency
--Catch-all
syndrome
244
Vertical Deviations
Vertical Deviations

2o to oblique
dysfunction
Oblique (SO)
Inferior
Positive
Oblique
Normal
(IO) Normal
Elevator
Restriction Palsy
Elevator
Double Elevator
Insufficiency Palsy
Deficiency
--Catch-all
syndrome
245
Vertical Deviations
Vertical Deviations

2o to oblique
dysfunction
Oblique (SO)
Inferior
Positive
Oblique
Normal
(IO) Normal
Elevator
Restriction Palsy
Elevator
Double Elevator
Insufficiency Palsy
Deficiency
--Catch-all
syndrome
246
Vertical Deviations
Vertical Deviations

2o to oblique
dysfunction
Oblique (SO)
Inferior
Positive
Oblique
Normal
(IO) Normal
Elevator
Restriction Palsy
Elevator
Double Elevator
Insufficiency Palsy
Deficiency
--Catch-all
syndrome
247
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
248
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--Presents with…hypotropia that worsens in upgaze
249
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--Often adopt a… [head
chin-up position
position]
250
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--Often adopt a…chin-up position
251
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--50% have… [another
concomitant
EOMptosis (1/3 of these with… Marcus-Gunn jaw wink)
problem]
252
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--50% have…concomitant ptosis (1/3 of these with…[eponymous
Marcus-Gunn jaw wink)
condition]
253
Vertical Deviations
Vertical Deviations

Palsy
Palsy
Deficiency
--Catch-all
syndrome
--50% have…concomitant ptosis (1/3 of these with…Marcus-Gunn jaw wink)
254
Vertical Deviations
Vertical Deviations
Broadly speaking, what sort of disorder is Marcus-Gunn
jaw wink (MGJW)?
It is one of synkinesis
What does synkinesis refer to?

The involuntary movement of one bodypart in response
to the voluntary movement of another
Is the ptosis of MGJW unilateral, or bilateral?
Unilateral
Superior Inferior What is the clinicalDouble

hallmark of MGJW? DVD
Oblique (SO) Oblique (IO) The ptotic lid elevates in
Elevator response to voluntary masticatory
movements of the jawPalsy
Which jaw movements are involved?
Double Elevator Palsy --Lateral displacement
Palsy
Deficiency
--Protrusion
--Catch-all
syndrome --Wide opening elevation in all fields of gaze
--Due to…restriction or elevation insufficiency
--Clenching (or both)
255
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
256
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
257
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
258
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
259
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
260
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
261
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
262
Vertical Deviations
MGJW
263
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
264
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
265
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
Brownterm for a is
syndrome
What strabismus involving…decreased
--Wide
the classic story opening
regarding elevation
when parents in their
first note all fields
infantof gaze
has MGJW?
--Due to…restriction or elevation
It is while insufficiency
the infant is nursing (or both)
--Clenching
266
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

Unilateral

Palsy
Deficiency
--Protrusion
--Catch-all
Brownterm for a is
syndrome
--Wide
regarding elevation
infantof gaze
has MGJW?
It is while the infant insufficiency
--Clenching
is nursing (or both)
267
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?
An aside: MGJW is a congenital conditionWhat does synkinesis

in which a cranialrefer to?
nerve
The
(dys)innervates a cranial muscle. What is theinvoluntary movement
general term of one bodypart in response
for such
2o to cranial
congenital oblique dysfunction
dysinnervation disorders? Uncertain mechanism
They are called ‘congenital cranial dysinnervation disorders’
Unilateral
Another congenital cranial dysinnervation disorder involving an
Superior
ophthalmic movement shouldInferior
readily come the clinicalDouble
Whattoismind--what is it? of MGJW?
hallmark DVD
Duane syndrome,
Oblique (SO) as discussed previously
Oblique (IO) The ptotic lid elevates in
movements of the jaw
Palsy
Palsy
Deficiency
--Protrusion
--Catch-all
Brownterm for a is
syndrome
--Wide
regarding elevation
infantof gaze
has MGJW?
--Clenching
268
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

nerve
The
for such
2o to cranial
Unilateral
Superior
hallmark DVD
Duane syndrome,
Palsy
Palsy
Deficiency
--Protrusion
--Catch-all
Brownterm for a is
syndrome
--Wide
regarding elevation
infantof gaze
has MGJW?
--Clenching
269
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

nerve
The
for such
2o to cranial
Unilateral
Superior
hallmark DVD
Duane syndrome,
Palsy
Palsy
Deficiency
--Protrusion
--Catch-all
Brownterm for a is
syndrome
--Wide
regarding elevation
infantof gaze
has MGJW?
--Clenching
270
Vertical Deviations
Vertical Deviations
jaw wink (MGJW)?

nerve
The
for such
2o to cranial
Unilateral
Superior
hallmark DVD
Duane syndrome,
Palsy
Overaction
Briefly, what is Duane syndrome? Overaction Which jaw movements are involved?
A motility disorder with the following key findings: --Lateral displacement
Palsy
--aka…Monocular Elevation Palsy
Deficiency
--At least some limitation of horizontal movement --Protrusion
--Catch-all
-- Attempted
Brownterm
adduction for
syndrome
What a is
causes strabismus
theclassic
the involving…decreased
globe to retract
--Wide
story ,opening
and may
regarding whencauseelevation in their
it tofirst note
parents all fields
infantof gaze
has MGJW?
up- or--Due
downshoot
to…restriction or elevation
--Clenching
What is the cause?
The nucleus for cranial nerve VI is missing, and the lateral rectus
--50% have…concomitant
is innervated by cranial nerve III ptosis (1/3 of these with…Marcus-Gunn jaw wink)
271
Vertical Deviations
Vertical Deviations

Palsy
Overaction If aOveraction
patient has a double elevator palsy, but Bell’s phenomenon
Palsy Palsy what can be inferred regarding etiology?
is intact,
The ‘palsy’ is probably supranuclear in origin
Brown syndrome
272
Vertical Deviations
Vertical Deviations

Palsy
Overaction If aOveraction
patient has a double elevator palsy, but Bell’s phenomenon
Palsy Palsy what can be inferred regarding etiology?
is intact,
The ‘palsy’ is probably supranuclear in origin
Brown syndrome
273
Vertical Deviations
Vertical Deviations

Palsy
Double Elevator Palsy: Management
Palsy Palsy --If IR restricted: Recess it
Brown syndrome --If no IR restriction: Knapp procedure
--Be sure to address ptosis if present
274
Vertical Deviations
Vertical Deviations

Palsy
275
Vertical Deviations
Vertical Deviations

Palsy
276
Vertical Deviations
Vertical Deviations

Palsy
277
Vertical Deviations
Vertical Deviations

Palsy
What is the Knapp procedure?
Relocating the LR and MR insertions toward the SR
278
Vertical Deviations
Vertical Deviations

Palsy
What is the Knapp procedure?
Relocating the LR and MR insertions toward the SR
279
Vertical Deviations
Knapp procedure
280
Vertical Deviations
Vertical Deviations

Palsy
281
Vertical Deviations
Vertical Deviations

Palsy
Why is it important to address the ptosis concurrently?

You don’t want to elevate an eye behind a ptotic lid—
it could lead to deprivation amblyopia
282
Vertical Deviations
Vertical Deviations

Palsy

283
Vertical Deviations
Vertical Deviations

Palsy

284
Vertical Deviations
Vertical Deviations
In this context, what does DVD stand for?

Dissociated vertical deviationInferior
Superior Double DVD
Who is the typical DVD pt? Palsy
A child with infantile/congenital ET or XT
What is the Palsy
classic clinical finding?Palsy
An eye will slowly elevate and extort, either spontaneously (manifest DVD)
Brown syndrome
or when occluded (latent DVD). A crucial finding occurs when the drifting
eye reorients downward, and it is this--the fellow eye does not move
downward simultaneously (as would normally be the case).
285
Vertical Deviations
Vertical Deviations

Superior Double DVD
What is the Palsy
Brown syndrome
286
Vertical Deviations
Vertical Deviations

Superior Double DVD
What is the Palsy
Brown syndrome
287
Vertical Deviations
Vertical Deviations

Superior Double DVD
What is the Palsy
Brown syndrome
288
Vertical Deviations
Vertical Deviations

Superior Double DVD
What is the Palsy
Brown syndrome
289
Vertical Deviations
Vertical Deviations

Superior Double DVD
What is the Palsy
Brown syndrome
290
Vertical Deviations
DVD
291
Vertical Deviations
Vertical Deviations

Superior Double DVD
What is the Palsy
Brown syndrome
292
Vertical Deviations
Vertical Deviations

Why Inwould it ‘be the what
this context, case’ that
does DVD
both eyes wouldfor?
stand move downward simultaneously?
In order to maintain
Dissociated visual deviation
vertical cooperation, eye movements are tightly linked—EOMs on
each eye are ‘yoked’ to one another Inferior
Superior Double fashion.
to ensure the eyes move in a coordinated DVD
Oblique
For example, (SO) gaze the
for rightward Oblique
right LR(IO) ElevatorHering’s law
and left MR are yoke muscles.
Who correspondence
of motor is the typical DVD pt?
states Palsy
that yoke muscles receive equal innervation.
How does Hering’s law relate to DVD?
As What
noted, is the Palsy
in DVD the downward
classic finding?Palsy
clinicalreorientation movement by the drifting eye is not
accompanied
An eye will byslowly
a downward
elevatemovement of theeither
and extort, fellow spontaneously
eye. As the muscles that depress
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
crucial findinga occurs
violationwhen
of Hering’s law.
the drifting
293
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
Oblique
Who correspondence
states Palsy
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting
294
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
Oblique
right LR(IO) ElevatorHering’s
and left MR are yoke muscles. eponym law
of motor correspondence states that yoke muscles receive equal innervation.
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting
295
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
Oblique
Who correspondence
states Palsy
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting
296
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
Oblique
Who correspondence
states Palsy
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting
297
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
Oblique
Who correspondence
states Palsy
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting
298
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
Oblique
Who correspondence
states Palsy
As What
noted, is the Palsy
in DVD the downward
classic AnotherPalsy
clinicalreorientation
finding? good potential
movement OKAP
by the drifting eyequestion,
is not IMO
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
crucial findingaoccurs
violation of Hering’s
when law.
the drifting
299
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
each eye Superior Inferior the eyes move in a coordinated
Double fashion. DVD
Asare
an‘yoked’
aside:toIsone another
there suchtoaensure
thing as a dissociated horizontal deviation?
Oblique
for rightward Oblique (IO)
right LRisand leftaMR ElevatorHering’s law
are yoke muscles.
A DHD? Indeed there is. There also dissociated torsional deviation (DTD).
Who correspondence
states Palsy
Together,
A child DVD, DHD and DTD
with infantile/congenital comprise
ET or XT the dissociated strabismus complex.
How does that Overaction
(AllHering’s
being said, to
law relate the Overaction
only one
DVD? the Peds book discusses at length is DVD.)
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting
300
Vertical Deviations
Vertical Deviations

does DVD
both eyes wouldfor?
each eye Superior Inferior the eyes move in a coordinated
Double fashion. DVD
Asare
an‘yoked’
aside:toIsone another
there suchtoaensure
thing as a dissociated horizontal deviation?
Oblique
for rightward Oblique (IO)
right LRisand leftaMR ElevatorHering’s law
are yoke muscles.
A DHD? Indeed there is. There also dissociated torsional deviation (DTD).
Who correspondence
states Palsy
Together,
A child DVD, DHD and DTD
with infantile/congenital comprise
ET or XT the dissociated strabismus complex.
How does that Overaction
(AllHering’s
being said, to
law relate the Overaction
only one
DVD? the Peds book discusses at length is DVD.)
As What
noted, is the Palsy
in DVD the downward
accompanied
a downward
(manifest DVD)the
eyes Brown this
syndrome
orare yokeoccluded
when muscles, means
(latent DVD).that A
DVD represents
violationwhen
of Hering’s law.
the drifting

Vertical Strabismus

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Vertical Strabismus

Uploaded by

Copyright:

Available Formats

1

With regard to strabismus: What does the word comitant mean?

With regard to strabismus: What does the word comitant mean?

With regard to strabismus: What does the word comitant mean?

Do vertical deviations tend to be comitant, or incomitant?

With regard to strabismus: What does the word comitant mean?

Do vertical deviations tend to be comitant, or incomitant?

With regard to strabismus: What does the word comitant mean?

Do vertical deviations tend to be comitant, or incomitant?

What is spread of comitance?

With regard to strabismus: What does the word comitant mean?

Do vertical deviations tend to be comitant, or incomitant?

What is spread of comitance?

The Peds book divvies the vertical deviations

2o to oblique dysfunction Uncertain mechanism

The Peds book divvies the vertical deviations

2o to oblique dysfunction? Uncertain mechanism?

Which is the more common cause of vertical deviations?

2o to oblique dysfunction Uncertain mechanism

Which is the more common cause of vertical deviations?

2o to oblique dysfunction Uncertain mechanism

What are the two oblique muscles?

2o to oblique dysfunction Uncertain mechanism

What are the two oblique muscles?

2o to oblique dysfunction Uncertain mechanism

2o to oblique dysfunction Uncertain mechanism

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

Will vertical misalignment be present in primary gaze?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

Bilateral superior oblique overaction

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

Superior What is the classic exam finding in SO overaction?

2o to oblique dysfunction Uncertain mechanism

What is the classic exam finding in SO palsy?

2o to oblique dysfunction Uncertain mechanism

What is the classic exam finding in SO palsy?

Oblique (SO) Oblique (IO)

2o to oblique dysfunction Uncertain mechanism

What is the classic exam finding in SO palsy?

Superior oblique palsy, right

2o to oblique dysfunction Uncertain mechanism

What is the classic exam finding in SO palsy?

2o to oblique dysfunction Uncertain mechanism

What is the classic exam finding in SO palsy?