Answers: 2004 series - June 22, 2004
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|This 42 year old man is in good health and denies any significant head trauma. He has noted intermittent diplopia for four years. It becomes worse when he is tired and is relieved some by tilting his head. The right hypertropia (left hypotropia) measures 25 prism diopters at the maximum. |
||The most likely diagnosis is: |
b -- This example of right hypertropia, greater in left gaze and with right head tilt (toward the higher eye), and positive Bielschowsky test is clearly an example of right superior oblique palsy.
||The most likely etiology is:|
a -- This is likely to be a congenital right superior oblique palsy. This is indicated by the significant facial asymmetry which is characterized here by a larger face on the right and a shorter distance between the left outer canthus and the left side of the mouth (smaller left side of the face).
A logical treatment plan could include:
d -- A vertical deviation from superior oblique palsy that measures 25 prism diopters requires two muscle surgery. This would include in this case a weakening of the right inferior oblique and the right superior rectus muscles (class 5 superior oblique palsy). In every case where superior oblique palsy is treated, superior oblique traction testing should be done. Only loose tendons can be tucked safely, but not all loose tendons need to be tucked. This is a surgeon's choice.