University of Gondar college of

Medicine and Health science

Department of Optometry
Vertical deviations of the eye

By: Elias Abera

(Msc. Opto.1st )
Vertical deviation
contents
 Definitions

 IO overaction
 SO overaction
 DVD
 IO muscle palsy
 SO muscle palsy
 monocular deviation deficiency

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Vertical deviation
A vertical misalignment of the visual axes, or vertical
deviation, may be comitant or incomitant
(noncomitant), either form can occur alone or be
associated with a horizontal deviation.

 Theyare associated with dysfunctional overactions or

underactions of the superior and inferior oblique
muscles, paralysis of 1 or more of these cyclovertical
muscles, or restriction of vertical movement.

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 Vertical deviation
 Nearly every vertical paralytic deviation is incomitant at
onset but may with time approach comitance unless there
are associated restrictions, such as might occur with an
orbital blowout fracture or thyroid eye disease.

 A vertical deviation is described according to the

direction of the deviating non fixating eye.

 Accordingly, if the right eye is higher than the left and the
left eye is fixating, the deviation is termed a right
hypertropia.

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Inferior Oblique Muscle Overaction
 Overaction of IO muscle is termed primary when it
is not associated with SO muscle paralysis.

 Itis called secondary when it accompanies paresis or

palsy of the IO muscle's antagonist SO muscle or
yoke SR muscle.

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Inferior Oblique Muscle Overaction
Clinical Features
 Primary inferior oblique muscle overaction has been

reported to develop between ages 1 and 6 years in up

to two-thirds of patients with infantile esotropia.

 The entity also occurs, less frequently in association

with acquired esotropia or exotropia and
occasionally in patients with no other form of
strabismus.

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Inferior Oblique Muscle Overaction

The eye is elevated in

adduction, both
horizontally and in up gaze

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 Inferior Oblique Muscle Overaction
 A bilateral overaction can be asymmetric, because of
either different times of onset or different degrees of
severity.

 Alternate cover testing shows that the higher eye

refixates with a downward movement and that the lower
eye does so with an upward movement.

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Inferior Oblique Muscle Overaction
 When inferior oblique overaction is bilateral, the higher
and lower eyes reverse in the opposite lateral gaze.

 These features differentiate inferior oblique overaction

from dissociated vertical deviation (DVD) in which
neither eye refixates with an upward movement whether
adducted, abducted or in primary position.

A V-pattern horizontal deviation and extorsion are

common with overacting inferior oblique muscles.

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Superior Oblique Muscle Overaction

 For clinical purposes, almost all cases of bilateral

superior oblique muscle overaction can be considered
primary, because paralysis of the inferior rectus and
inferior oblique muscles is uncommon.

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 Superior Oblique Muscle Overaction
Clinical Features
 A vertical deviation in primary position often occurs with

unilateral or asymmetric bilateral overaction of the

superior oblique muscles.

 The lower eye contains the unilaterally or more

prominent bilaterally overacting superior oblique muscle.

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 Superior Oblique Muscle Overaction

An associated horizontal

deviation, most often exotropia.
may be present.
The overacting superior oblique
muscle also results in hypotropia of
the adducting eye in opposite
lateral gaze, which is prominent in
the lower field. An alternative term
for this finding is overdepression in
adduction.

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 Dissociated Vertical Deviation (DVD)
 Dissociated vertical deviation (DVD) is an
innervational disorder found in more than 50% of
patients with infantile esotropia and in other forms of
strabismus.

 Explanation for DVD is that it may be the result of

compensating mechanisms for latent nystagmus, with
the oblique muscles having the principal role.

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 Dissociated Vertical Deviation (DVD)
Clinical Features
 DVD usually presents after age 2 years, whether or not

the horizontal deviation it usually accompanies has been

surgically corrected.

 Eithereye slowly drifts upward and outward, with

simultaneous extortion, when occluded or during periods
of visual inattention.

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 Dissociated Vertical Deviation (DVD)
Some patients attempt to
compensate by tilting the
head, for reasons that still
have not been
conclusively identified.

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 Dissociated Vertical Deviation (DVD)
 As the vertically deviated eye moves down (and intorts) to
fixate when the previously fixating fellow eye is occluded,
the latter makes no downward movement.

 Note that with true hypertropia, when the hypertropic eye

refixates, the occluded fellow eye moves downward into a
hypotropic position of equal magnitude.

 The vertical movement usually predominates, but

sometimes the principal dissociated movement is one of
abduction (dissociated horizontal deviation or DHD).

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 Dissociated Vertical Deviation (DVD)
 The condition is usually bilateral though frequently
asymmetric.

 It may occur spontaneously (manifest DVD) or only

when 1 eye is occluded (latent DVD).

 In addition to DHD, latent nystagmus and horizontal

strabismus are often associated with DVD. These
entities are manifestations of poor fusion.

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 Dissociated Vertical Deviation (DVD)
 Measurement of DVD is difficult and imprecise. One
method uses base-down prism in front of the upwardly
deviating eye while it is behind an occluder.

 Theoccluder is then switched to the fixating lower eye,

and the base-down prism power is adjusted until the
deviating eye shows no downward movement to refixate.

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Dissociated Vertical Deviation (DVD)
 Resultsare similar when a red Maddox rod is used
to generate a horizontal stripe viewed by the
dissociated higher eye while the other eye fixates on
a small light; vertical prism power is used to
eliminate the separation of the light and the line.

 Each eye is tested separately in cases of bilateral

DVD. The deviation can also simply be graded on a I
+ (least) to 4+ (most) scale.

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Superior Oblique Muscle Paralysis (Palsy or Paresis)
 The most common Single cyclovertical muscle paralysis
encountered by the ophthalmologist is the fourth
cranial (trochlear) nerve palsy, involving the superior
oblique muscle.

 Itcan be congenital or acquired, the latter usually as a

result of closed head trauma or, somewhat less
commonly central nervous system vascular problems,
diabetes and brain tumors.

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Superior Oblique Muscle Paralysis (Palsy or
Paresis)
 To differentiate congenital from acquired superior
oblique muscle paralysis, the clinician will find it helpful
to examine old family photographs to detect a
compensatory head tilt present in childhood.

 Facial asymmetry from long-standing head tilting

indicate chronicity.

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Superior Oblique Muscle Paralysis (Palsy or
Paresis)

 The distinction is important because recently diagnosed

paralysis that cannot be attributed to known trauma
suggests the possibility of a serious intracranial lesion
and the need for neurologic investigation.

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Superior Oblique Muscle Paralysis (Palsy or Paresis)

Clinical Features
 Examination of versions usually reveals underaction of

the involved superior oblique muscle and overaction of

its antagonist inferior oblique muscle; however, the
action of the superior oblique muscle can appear
normal.

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Superior Oblique Muscle Paralysis (Palsy or
Paresis)

 The diagnosis of superior oblique muscle paralysis is

further established by results of the 3-step
determination and double Maddox rod testing to
measure torsional imbalance.

 However,
3-step test results can be confounded by
DVD and entities involving restriction.

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Superior Oblique Muscle Paralysis (Palsy or Paresis)
 To differentiate bilateral from unilateral superior oblique
muscle paresis or palsy, the following criteria are used:-
 Unilateral cases usually show little if any V pattern and

less than 5° of excyclotorsion.

 The 3-step test yields positive results for the involved

side only.
 Abnormal head positions are common, usually a tilt

toward the shoulder opposite the side of the weakness.

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Superior Oblique Muscle Paralysis (Palsy or Paresis)
 Amblyopia is common in congenital but not in acquired
palsies.

 Bilateral cases usually show a V-pattern.

 Excyclotorsion is at least 5° and is highly diagnostic

when it is 10ᵒ and more.

A complaint of apparent tilting of objects is common in

acquired bilateral cases.

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Superior Oblique Muscle Paralysis (Palsy or Paresis)
 The 3-step head-tilt test yields positive results on tilt to
each side-that is, right head tilt shows a right hypertropia
and left head tilt a left hypertropia.

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Inferior Oblique Muscle Paralysis
 Whether inferior oblique muscle paralysis is actually
exists has been questioned.

 Itis difficult to understand how a selective lesion of the

branch of the inferior division of cranial nerve (CN)
III that specifically serves the inferior oblique muscle
might occur.

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Inferior Oblique Muscle Paralysis
 When the 3-step test results are not clear, such cases may
represent asymmetric or unilateral primary superior
oblique muscle overaction with secondary underaction of
the inferior oblique muscle.

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Inferior Oblique Muscle Paralysis
Clinical Features
 As with Brown syndrome elevation is deficient in the

adducted position of the eye.

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Inferior Oblique Muscle Paralysis

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Monocular Elevation Deficiency (Double Elevator
Palsy )
 Although the term double elevator palsy implies a
paralysis of the inferior oblique and superior rectus
muscles of the same eye, it has become an umbrella term
for any strabismus manifesting deficient elevation in all
horizontal orientations of the eye.

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Monocular Elevation Deficiency (Double Elevator
Palsy )
 Because this motility pattern is well known to be caused
by restriction to elevation as well as by weakness of I
or both elevator muscles. "double elevator palsy" is a
misnomer as an inclusive term and has been replaced by
monocular elevation deficiency.

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Monocular Elevation Deficiency (Double Elevator
Palsy )
Clinical Features
 In monocular elevation deficiency, there is hypotropia

of the involved eye that increases in upgaze, a chin -up

position with fusion in downgaze, and ptosis or
pseudoptosis.

 Anelement of true ptosis is present in 50% of patients. If

any other feature of third cranial nerve paralysis is
present, that condition should be suspected rather than
monocular elevation deficiency.

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Monocular Elevation Deficiency (Double Elevator
Palsy )

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Monocular Elevation Deficiency (Double
Elevator Palsy )
Three types of monocular elevation deficiency are found:
1. restriction
 positive forced duction for elevation
 normal elevation force generation and elevation saccadic

velocity (no muscle paralysis).

 poor or absent Bell phenomenon.

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Monocular Elevation Deficiency (Double Elevator
Palsy )

2. elevator muscle weakness

 free forced ductions
 reduced elevation force generation and saccadic velocity
 Bell phenomenon often preserved (indicating a supra

nuclear cause)

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Monocular Elevation Deficiency (Double Elevator
Palsy )

3. combination
 positive forced duction for elevation.
 reduced force generation and saccadic velocity for

elevation.

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 References

 Bcsc
 Duanes

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Thank you

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