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Cyclovertical deviation

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Nishant Nisani

This document discusses various types of vertical eye movement disorders including: principles of cyclovertical deviations; the Park 3 step test for diagnosing superior oblique palsy; classifications of incomitant and comitant vertical deviations including dissociated vertical deviation, inferior oblique overaction, and superior oblique palsy; diagnostic tests and treatments for these conditions; and references for further information.

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Cyclovertical deviation
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
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
Park 3 step test ? Primary position C 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): 567C571. doi:10.1016/j.jaapos.2014.08.007.
Cyclovertical deviation
Cyclovertical deviation
Classification ? Dissociated vertical deviation ? Incomitant vertical deviation 1. IO overaction 2. SO overaction 3. SO underaction 4. IO underaction ? Comitant vertical deviation
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
Cyclovertical deviation
? Diagnostic test 1. Spielmanns translucent occluder 2. Bielschowsky phenomenon 3. Red filter test ? Measurement ? Using Red filter ? Using base down prism
?Treatment Medical 1. Refractive error 2. Occlusion 3. Prisms Surgical 1. When ? 2. What ?
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
Inferior Oblique Muscle Over action ? Etiology 1. Primary 2. Secondary ? Clinical Features ? Management ? Weakening procedure on the inferior oblique muscle
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 10C200/s 200C400/s Latent nystagmus Often present Absent Bielschowsky phenomenon Often present Absent
Superior Oblique Muscle Over action ? Clinical Features 1. Overdepression in adduction. 2. Associated with exo ? Management ? Superior oblique tendon weakening procedure
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
Clinical features ? Head tilt ? Hypertropia ? Excyclotorsion ? Esotropia
Fundus Torsion direct Ophthalmoscope View
Fundus Torsion Indirect Ophthalmoscope View
Cyclovertical deviation
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
Double maddox rod
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
4.Inferior Oblique Muscle Paralysis
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
Monocular Elevation Deficiency
Three forms of monocular elevation deficiency are as follows: 1. Restriction 2. Elevator muscle innervational deficit 3. Combination Management Restrictive Crecession of IR No restriction C Knapp procedure
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.

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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 C 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): 567C571. 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 10C200/s 200C400/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
  • 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
  • 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
  • 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
  • 27. Three forms of monocular elevation deficiency are as follows: 1. Restriction 2. Elevator muscle innervational deficit 3. Combination Management Restrictive Crecession of IR No restriction C 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.