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Treatment of Superior Oblique Palsy
The treatment of superior oblique palsy follows a logical course including: 1) an understanding of the various causes, 2) a mastery of examination techniques leading to a quantitative diagnosis, and 3) culminating in a treatment plan which in most cases means surgery.
The surgical options for treatment of superior oblique palsy (SOP) are initially aimed at reducing (eliminating) the vertical deviation by weakening or "strengthening"muscles acting in a field producing the vertical deviation. In addition, torsional deviations must be addressed, and finally the esotropia in down gaze causing "V" pattern must be dealt with in bilateral superior oblique palsy.
Prisms for treatment of superior oblique palsy are used mostly for small angle acute vascular SOP which is usually self limiting or for temporary relief in congenital or acquired cases who eventually need surgical treatment.
In a series of 190 patients, 44 wore prism pre op and 9 wore prism post op.
Inferior Oblique Weakening
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177/190 |
LSO palsy shown
Weakening of the antagonist inferior oblique is the most commonly performed surgical procedure. Myectomy (as shown) is simple and effective. Some prefer recession. Partial myotomy is not an effective alternative. |
The surgical procedures shown were done alone or in combination on 190 consecutive patients undergoing surgery for superior oblique palsy. The number of times each procedure was done is shown; for example inferior oblique weakening was done in 177 patients.
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Inferior Rectus Weakening
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36/190 |
Recession of the yoke inferior rectus |
LSO Palsy shown
O.S. class III & IV palsy large angle
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Superior Oblique Strengthening
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Superior Oblique Tuck
26/190 |
Or |
Superior Oblique Resection
9/190 |
 After S.O. tuck or resection, the traction test should be equal or nearly so to avoid post operative iatrogenic Brown
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Indications for superior oblique strengthening:
Superior oblique underaction
Lax tendon on traction test
Long, loose tendon at exploration |
Superior Oblique Anterior Lateral Shift (Harada-Ito Equivalent)
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Left excyclotropia shown
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Anterior/lateral shift of the superior oblique (Harada-Ito)
15/190 |
This procedure is done for torsion when the superior oblique tendon is of normal length and tension. The need for anterior lateral shift of the superior oblique tendon arises most often in bilateral superior oblique palsy. |
Superior Rectus Weakening
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32/190 |
In cases of tight ipsilateral superior rectus as occurs in class IV superior oblique palsy, this muscle is recessed. In this class of S.O.P., it is always necessary to treat at least one additional muscle. (The ipsilateral inferior oblique, yoke inferior rectus or both) |
Class IV LSO palsy shown
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Other Surgical Options
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Appropriate horizontal rectus surgery should be done for ET or XT |
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Occasionally vertical shift of horizontal recti or horizontal shift of vertical recti is done |
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19/190 |
3/190 |
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In cases of absence of the superior oblique tendon the following surgical procedures may be done:
1) Weaken ipsilateral inferior oblique
2) Recess ipsilateral superior rectus with temporal shift
3) Recess yoke, contralateral inferior rectus
In 190 patients treated surgically for S.O.P. a total of 317 muscles were treated or 1.67 muscles per patient done in 1.26 operations per patient. The patients were treated by a surgical team followng the plan described in the two previous "Minutes" (Vol. 2, No. 15 and 16). In this series 166/181 patients examined personally by us (92%) were asymptomatic one to five years post operatively. All surgery and follow up was done by Eugene M. Helveston,M.D., Justin S. Mora, M.D., Stephen N. Lipsky, M.D., David A. Plager, M.D., Forrest D. Ellis, M.D., Derek T. Sprunger, M.D., and Naval Sondhi, M.D. To see the article Surgical Treatment of Superior Oblique Palsy consult Transactions of the American Ophthalmological Society Vol. XCIV, 1966 or write to us for a reprint. Eugene M. Helveston, M.D., 702 Rotary Circle, Indianapolis, IN 46202 or contact by e-mail ehelveston@strabismusminute.org
The Strabismus Minute
, Vol.2, No. 17 Copyright (C) 2000 Eugene M. Helveston All Rights Reserved
Editor-in-Chief: Eugene M. Helveston, M.D.
Associate Editor: Faruk H. Orge, M.D.
Editorial Board: Bradley C. Black, M.D.
Edward R. O'Malley, M.D.
David A. Plager, M.D.
Derek T. Sprunger, M.D.
Daniel E. Neely, M.D.
Naval Sondhi, M.D.
Senior Editorial Consultant: Gunter K. von Noorden, M.D.
Graphics: Michelle L. Harmon
Technical Support: George J. Sheplock, M.D.
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