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Answers: 2009 Series -  August 25, 2009 Lecture 19 of 52  NEXT»

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This 12-year-old girl has had three prior surgeries for an original diagnosis of left superior oblique palsy. Her slight facial asymmetry with a fuller face on the right helps confirm the original diagnosis. She is presented by her parents who are concerned that she frequently tilts her head to the right. She has a small right hypertropia. Otherwise ductions and versions are not remarkable. Visual acuity is 6/9 in each eye. A moderate myopia with astigmatism is fully corrected with her glasses. The right head tilt is always present when the left eye is covered (fixing with the right eye), never seen when fixing with the right eye covered (fixing with the left eye), and present about half of the time with both eyes open and uncovered. The patient denies diplopia.

1. The abnormality is most likely:

a -- in the right eye

Since the head posture abnormality occurs when fixing with the right eye and not with the left, the problem in this patient is most likely in the right eye.  This is in line with the behavior in a case manifesting a secondary deviation.

2. This head tilt could be caused by:

b -- incyclodeviation of the right eye

This is a little more difficult.  In this case the girl could be tilting her head to the right to bring the horizontal axis of the right eye to a parallel plane.  This would be the case if the right eye were incyclodeviated.  You might want to take a look at the material on cyclodeviations in E-Resources.

3. Treatment for this could be:

c -- nasal shift of the right superior rectus

If this girl's head posture was caused by incyclodeviation of the right eye, the only logical surgical option among those presented is nasal shift of the right superior rectus.


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