cyclovertical deviation

2. Right eye hyperdeviation
Left eye covered and right forced to fixate
Left hypotropia of
same magnitude
True vertical tropia
Left -same position
Right DVD
Left eye raises
under cover
B/L DVD
Left hypotropia of
less magnitude
Combination

3. Principles in cyclovertical
deviations
 Incomitant hyperdeviation in horizontal plane -Oblique muscle
 Comitant hyperdeviation in horizontal plane - Vertical rectus
 Most common causes of a true vertical tropia - fourth nerve palsy.
 If the deviation is incomitant in the horizontal plane or is long-
standing and comitant, perform a head-tilt test .
 In a case of superior oblique palsy, the clinician must assume the
palsy is bilateral until it is proven otherwise

4. Park 3 step test
 Primary position – which eye ?
 Gaze ?
 Head tilt ?
Sensitivity -70%(1)
Sensitivity of the three-step test in diagnosis of superior oblique
palsy Ajay M. Manchandia et al J AAPOS. 2014 December ; 18(6): 567–571. doi:10.1016/j.jaapos.2014.08.007.

7. Classification
 Dissociated vertical deviation
 Incomitant vertical deviation
1. IO overaction
2. SO overaction
3. SO underaction
4. IO underaction
 Comitant vertical deviation

8. 1.Dissociated vertical deviation
 Etiology-
 50% of patients with infantile
esotropia
 Clinical features-
 Head tilt
 Excycloduction of the elevated eye
and incycloduction of the fixating
eye
 Latent nystagmus

10.  Diagnostic test
1. Spielmanns translucent
occluder
2. Bielschowsky phenomenon
3. Red filter test
 Measurement
 Using Red filter
 Using base down prism

11. Treatment
Medical
1. Refractive error
2. Occlusion
3. Prisms
Surgical
1. When ?
2. What ?

12. Condition Treatment
IOOA & mod. DVD Recession with
anterior positioning IO
IOOA & Severe DVD Recession with anterior positioning
IO +
Superior rectus-recession 7-10 mm
DVD & no IOOA: Superior rectus-recession 7-10 mm +
Inferior rectus resection

13. Inferior Oblique Muscle Over action
 Etiology
1. Primary
2. Secondary
 Clinical Features
 Management
 Weakening procedure on the
inferior oblique muscle

14. Dissociated vertical
deviation
Inferior oblique over
action
Elevation In adduction abduction
and primary postion
Maximal in adduction
never in abduction
Superior oblique action May over act Usually under action
V pattern Absent Present
Incycloduction on
refixation
Present Absent
Saccadic velocity of
refixation movement
10–200/s 200–400/s
Latent nystagmus Often present Absent
Bielschowsky
phenomenon
Often present Absent

15. Superior Oblique Muscle Over action
 Clinical Features
1. Overdepression in
adduction.
2. Associated with exo
 Management
 Superior oblique tendon
weakening procedure

16. 4.Superior Oblique Muscle
Paralysis
 Most common Single cyclovertical muscle paralysis.
 Etiology
 Congenital vs acquired
 Head trauma
 Vascular problems of the central nervous system,
 Diabetes mellitus, or a brain tumor

17. Clinical features
 Head tilt
 Hypertropia
 Excyclotorsion
 Esotropia

18. Fundus Torsion
direct Ophthalmoscope View

19. Fundus Torsion
Indirect Ophthalmoscope View

21. Maddox wing
 The amount of cyclophoria is determined by asking the patient to move
the red arrow so that it is parallel with the horizontal row of numbers

22. Double maddox rod

23. Treatment
Greatest deviation in Treatment
Affected eye elevated in adduction I/l IO recession
Affected eye depressed in adduction I/L SO tucking
In all contralateral gazes Hypertropia<25 pd I/L IO
recession
Hypertropia> 25 pd I/L IO
recession + RSO tuck
In all contralateral gazes and in all down
gazeS
As in class 3+ C/L IR
recession/ I/L SR recession
In all down gazes I/L SO tuck + C/L LIR recession
Bilateral with V pattern Bilateral IO weakening or
modified Harada Ito
In all contralatreral gazes , down gazes
and in primary position
Explore trochlea

24. 4.Inferior Oblique Muscle Paralysis

25. IO paralysis Brown syndrome
Forced duction Negative positive
Strabismus pattern A pattern V pattern
SO overaction Present None or minimal
 Management
 I/L SO or C/L SR weakening

26. Monocular Elevation Deficiency

27. Three forms of monocular elevation deficiency are as
follows:
1. Restriction
2. Elevator muscle innervational deficit
3. Combination
Management
Restrictive –recession of IR
No restriction – Knapp procedure

28. Refernces
 Binocular vision and occular motility - Von noorden
5th edition
 Handbook of Pediatric Strabismus and Amblyopia
Kenneth W. Wright, MD
 PEDIATRIC Ophthalmologyand Strabismus - Creig S
Hoyt -4thedition
 Pediatric Ophthalmology and Strabismus -Section
6 2015-2016- American academy of ophthalmology.