This document summarizes a thesis on superior oblique palsy. It begins by introducing superior oblique palsy and its causes. It then reviews the anatomy and physiology of the superior oblique muscle. Several diagnostic tests for superior oblique palsy are described. Treatment options discussed include superior oblique strengthening procedures like tendon tucks and Harada-Ito surgery, inferior oblique weakening procedures like recession and anterior transposition, and recession of the superior or inferior rectus muscles. Images are provided to illustrate some of the surgical techniques. In closing, the author thanks the readers.

2. Superior Oblique Palsy
Submitted for partial fulfillment
of the Master Degree in
ophthalmology
By
Mohammad Kamel Mohammad Noor El-Mahdy
M.B.B.Ch. - Al-Azhar University

3. Superior Oblique Palsy
Supervised by
Prof. Dr. Attiat Mostafa
El-Sayed Mostafa
Prof. of ophthalmology
Faculty of Medicine
Al-Azhar University
Prof. Dr. Abubakr Mohammad Farid AbulNaga
Prof. of Ophthalmology
faculty of medicine
Al-Azhar University
Dr. Ahmad El-Sayed Hodieb
Lecturer of Ophthalmology
faculty of medicine
Al-Azhar University

4. Aim of the Essay
The aim of this essay is to
review of literature of superior
oblique muscle palsy.

5. Introduction•Bielchowsky was first to describe SOP as the
leading cause of vertical double vision.
•It has no predilection for males or females
•It is the single most common form of paralytic
strabismus diagnosed in routine practice (von
Noorden et al., 1986).

6. Review of literature

7. Anatomy of SO muscle:
• Origin: It arises from the periosteum close to the annulus of Zinn
(the apex of the orbit) above and medial to the optic foramen till
reach the troclea.
• Insertion: Pass under the superior rectus muscle to insert on sclera
along the temporal border of the superior rectus muscle behined the
equator.
• Innervation: The trochlear nerve.

8. Physiology of SO muscle:
1) Action of superior oblique muscle:
 In 1ry position intorte, in 2ry position depress
and in 3ry position abduct the eye.
The maximum action of the superior oblique muscle as
a depressor is in adduction:
In adduction, with adduction of 54°, the angle between the
median plane of the eye and the muscle plane is reduced.
The maximum incyclotortion occurs in abduction:
In abduction, with 36° of abduction, the angle between the
median plane of the globe and the muscle plane increases.

9. 2) Control of superior oblique muscle movement:
 Remember that:
 Ipsilateral Inferior oblique muscle ( D. antagonist)
 Contralateral Superior rectus muscle ( Ind. Antagonist)
 Contralateral Inferior rectus muscle (Yoke m.)
 The muscle governed by The laws of ocular
motility:
 Dander's law: concerned with axis of positions.
 Listing's law: concerned with Cylotortion.
 Hering's law: concerned with Binoccular vision
(innervation of Yoke ms).

10. Management of Superior oblique palsy

11. Causes can be classified as
Congenital palsy: present
at birth may be isolated or
associated with congenital
anomalies.
Aquired palsy: a common
cause is head trauma.

12. Clinical pictureA) Symptoms
Diplopia:
Vertical and homonymous.
notable when reading or, walking down stairs.
Compensatory head posture:
The head tilt to the opposite side and
the face turn to the opposite side
with the chin depressed.
Rt. SOP (mostafa,2004):
• Chin depression.
• Head tilt to left.
• Face turn to left.

13. B) Signs: 1-Ocular motility testing
Lt Superior oblique palsy
Rt Lt

14. 2-Macular Torsion
Macularextorsion seen
by
fluorescein fundus
camera, fovea seen
below that line
(Mostafa, 2004).
Normal macula at
level of horizontal
line drown
between upper2/3
and lower1/3 of
optic disc
Torsion as seen by fluorescein

15. Diagnostic tests:
Diplopia: Vertical and homonymous.
It depends on Hering law,
and aim to investigate the nature
and the extent of EOM imbalance
used to investigate subjective
vs Objective torsion
It identifies which muscle is paretic
in patients with a hypertropia vertical
rectus vs oblique muscle palsy.
Diplopia
Chart
Hess screen
test
Maddox rod
test
Three step
test

16. Diplopia
Chart
Hess screen test
Maddox rod test Three step test
red- green goggles and Lt. SOP
Rt. superior oblique palsy, Rt.
secondary IOOA and Lt. IR
overaction

17. Bielschowsky Park's head tilt
test:
(A) (B) (C)
Rt. Superioroblique palsy: (Mostafa, 2004)
(A)Head tilt to Lt.
(B)Rt. hypertropia on forced head tilt to Rt.
(C)Upshoot on adduction due to Rt.
secondary IOOA.

18. Treatment• Strategies require identifying where the
hypertropia is greatest.
• Surgical methods of treatment are as follows
(Özkan, 2010):
 Superior oblique strengthening procedures.
 Inferior oblique weakening procedures.
 Superior rectus recession in the affected eye.
 Inferior rectus recession in the contralateral
eye.

19. 1- Superior oblique strengthening
procedures
A- Superior Oblique Tuck
 The triad of indications for superior
oblique tendon tuck is:
1) Large angled vertical deviation,
2) Prominent abnormal head posture and,
3) Superior oblique tendon laxity

20. Superior oblique tendon tuck
SR
MR
LR
IR
SR
LR
RM
IR
IOIO
Dr. G.Vicente
SO

21. Superior oblique tendon tuck
SR
LR
RM
IR
IOIO
Dr. G.Vicente
SO SR
MR
LR
IR

22. Superior oblique tendon tuck
SR
LR
RM
IR
IOIO
Dr. G.Vicente
SO SR
MR
LR
IR

23. Superior oblique tendon tuck
SR
LR
RM
IR
IOIO
Dr. G.Vicente
SO SR
MR
LR
IR

24. Superior oblique tendon tuck
SR
LR
RM
IR
IOIO
Dr. G.Vicente
SO SR
MR
LR
IR

25. Superior oblique tendon tuck
SR
LR
RM
IR
IOIO
Dr. G.Vicente
SO SR
MR
LR
IR

26. B-Harada Ito surgery:
• Indications:
(1) Patients whose primary complaint is
torsional diplopia.
This is most often in adult patients with
bilateral, post traumatic superior oblique
muscle palsy.
(2) Patients with little or no vertical
deviation in primary gaze position.
(3) In the treatment of ocular torticollis with
tilt -dependent nystagmus.

27. Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente

28. Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente

29. Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente

30. Harada-Ito
Anterior displacement of ½ SO tendon
Dr. G.Vicente

31. 2-Inferior oblique weakening procedures.
The patient's right eye viewed from below; (a) natural position of the inferior
oblique muscle (b) recession; (c) anterior transposition; (d) anterior nasal
transposition; (e and f) nasal myectomy.

32. 1-Inferior oblique muscle recession:
LR
MR
IR
SR
Is a suitable procedure
for most congenital
SO palsies with a
moderate-to-large
vertical deviation in
adduction, resulting in
a lower incidence of
consecutive Brown's
pattern.
IO

33. Rt. Superior Oblique Palsy (mostafa, 2004(
AHP “preoperative” After Rt. IO recession

34. After Lt. IO recessionLt. Inferior oblique overaction
Lt. SO palsy (mostafa, 2004)

35. 2- Anterior Transposition (AT)
• It weakens the classic functions of the IO
(eliminate IOOA) .
• converts the muscle to an “antielevator”(reserve
the action of IO).
3- Myectomy or myotomy inferotemporally
A complete myotomy is considered by some surgeons
to be as effective as myectomy or recession of the
inferior oblique muscle.

36. 3-Superior Rectus Muscle Recession
• Indication:
In a vertical deviation exceeding 15 prism
diopters.
• In cases with agenesis of the superior
oblique tendon, superior rectus recession
is the procedure of choice with inferior
oblique weakening.

38. 3-Inferior Rectus Muscle Recession in
the contralateral eye
• Indication:
Acquired superior oblique palsy
surgery to improve torsion and vertical
alignment.
• A minimum recession of the inferior rectus
is 2.5 mm.
• A maximum recession of the inferior rectus
under most circumstances is 5 mm.

39. Inferior rectus muscle recession
(contralateral eye(
SR
MR
LR
IR
SR
LR
RM
IR
IOIO
Dr. G.Vicente
Recess IO
Recess IR (contralateral(
Affected eyeLtRt

41. Thank You