http://telemedicine.orbis.org/bins/volume_page.asp?cid=1-351-355-518 .2003. Section 2: Diagnostic and Treatment Decisions - 2.

42 Superior Oblique Muscle Paralysis: Diagnosis

Lecture 42 of 59 NEXT

(1 to 3) Patients with superior oblique paralysis usually are seen with a head tilt to the opposite shoulder. Vertical diplopia, torsional diplopia, or a combination of these factors are also common findings. The diagnosis is usually made on the basis of the combination of the findings listed in 1 to 3 in the highlighted boxes. These features are consistently associated with superior oblique paralysis. The remaining features listed in 4 to 10 are variable.24, p.469

(4) Underaction of the involved superior oblique muscle may be subtle and escape detection on examining ductions and versions. In fact, the overaction of the ipsilateral inferior oblique is usually the most prominent finding on examining the ocular motility. (5) The superior oblique muscle of the sound eye may be overacting. This is a secondary deviation, caused by contracture of the ipsilateral superior rectus muscle in cases of superior oblique paralysis with a large hypertropia.29; 54; 71 The increased innervational effort to depress the paralyzed eye causes excessive depression of the normal eye, especially in adduction, causing overaction of the contralateral superior oblique. (6) Examination with the ophthalmoscope and the Maddox double-rod test57, p.54 shows excyclotropia of the involved eye. When the patient fixates habitually with the paralyzed eye, the excyclotropia may occur in the sound eye (paradoxic excyclotropia).43 (7) A head tilt toward the uninvolved side occurs in about 70% of the patients with superior oblique paralysis. In nearly 30% of such cases the head position is normal or the head may actually be tilted toward the paralyzed side (paradoxic head tilt).71 (8) Vertical diplopia, especially in the reading position is frequently reported in patients with superior oblique paralysis. (9) Torsional diplopia occurs only in recently acquired cases and is never seen in congenital superior oblique paralysis. (10) Patients with head tilt from early infancy often develop facial asymmetry. This is a valuable sign to date the onset of the strabismus problem. The fuller facial features are always on the side of the abnormal superior oblique except in cases of brachiocephaly. (11) If a patient habitually fixates with the paralyzed eye, the contralateral superior rectus muscle appears to be paretic or paralyzed. This is called "inhibitional palsy of the contralateral antagonist"58, p.367 and may confound the correct diagnosis of superior oblique paralysis. This condition also produces a pseudoptosis in the sound eye. (12) The Bielschowsky head tilt test determines the correct diagnosis (see 2.42). (13) Bilateral involvement must be suspected in traumatic cases. The paralysis frequently is more pronounced on one than on the other side. In fact, the paralysis on one side may be obscured and not become manifest until the other eye has been operated on. Several diagnostic features are listed whose presence strongly suggests bilateral involvement.