2. Anatomical consideration
Tegmentum of midbrain.
Decussating at the anterior medullary velum
Between the PCA and superior cerebellar arteries
Cavernous sinus
Superior orbital fissure outside the annulus of Zinn
8. Congenital vs. Ocular torticolis
Congenital Ocular
Age During the 1st 6 month after Rarely before 18 months
birth after birth
Head position Passive or voluntary Head can easily be
straightening of the head is straightened passively or
difficult or impossible voluntarily and revealed
ocular misalignment
Neck muscles Palpation reveals hardening Palpation negative
of sternocledomastoid
Vision No visual disturbances Diplopia occurs when head
is straightened or tilted to
opposite side
Effect on occlusion Not influenced by occlusion Head straightens on
of either eye occluding the paretic eye
unless there is structural
changes
9. Localization of the lesion
Nucleus
Fascicle
Subarachnoid space
Cavernous sinus
Orbit
10. What is the presentation of the IV
nerve palsy?
16. Bilateral Superior oblique palsy
1. History of trauma
2. Spontaneous torsional diplopia
3. "V" Pattern, ET down gaze
4. Extorsion >15 degrees
5. Reversing (or nearly so) Bielshowsky head tilt
test
6. Chin down, eyes up posture
18. How would you manage these
scenarios?
A 70 year old man who complains of sudden onset of vertical
and torsional diplopia. Examination revealed 3 D of right HT.
Patient has a CHP with head tilt to the left side.
A child aged 5 who presents with a CHP (head tilt to left side) and
vertical misalignment revealed on correction of the head posture.
An adult who presents with sudden onset of vertical and torsional
diplopia after head trauma. Assessment revealed 15 D of
hypertropia R/L and torsional diplopia of 10 degrees.
An adult of has hypertropia , torsional diplopia of more than 15
degrees and compensatory chin down position.
19.
20. HT <20D <20D weaken Recess the
Weaken Tuck superior ipsilateral ipsilateral
oblique if lax or weaken
ipsilateral ipsilateral inferior oblique superior
inferior if not recess and ipsilateral rectus and
inferior oblique,
Oblique yoke inferior > 20D weaken superior rectus, the yoke
rectus. ipsilateral > 20D add tuck contra lateral
inferior oblique of loose S.O. inferior
and tuck lax
tendon or rectus or
S.O. tendon or
weaken yoke recession of tuck a lax
inferior rectus yoke I.R. S.O. tendon
21. What is management of Bilateral
superior oblique palsy
Bilateral SO Harada- ito
Helevston series of 36 congenital superior oblique palsy found 33 with abnormal superior oblique tendon Dysgenesis of IV nerve nucleus, abnormal development of the peripheral nerve or tendon
Head trauma, Microvasculopathy secondary to Diabetes Mellitus, atherosclerosis, hypertension, Thyroid ophthalmopathy Myasthenia gravis,Tumours, aneurysm, multiple sclerosis
Diplopia (Vertical or torsional), Asthenopia, difficulty with reading and going downstairs, head tilt and neck pain. In Longstanding head tilt there is a facial asymmetery
