inferior oblique palsy vs brown syndrome

Careers. Common Neuro-Ophthalmic Pitfalls: Case-Based Teaching. Mayo Clin Proc. The amount of suppression, which can vary from small suppression scotomas in binocular fusion to large suppression areas on the affected side and amblyopia, depends on various factors such as the size of the strabismus and age of onset. Piotr Loba Horizontal eye movement networks in primates as revealed by retrograde transneuronal transfer of rabies virus: differences in monosynaptic input to slow and fast abducens motoneurons. [4]. [2] Some advocate labelling vertical misalignments based on if the deviated eye manifests as a hypertropia or hypotropia. It can present in different ways causing somatic extraocular muscle dysfunction (superior, inferior, and medial recti; inferior oblique; and levator palpebrae superioris) and autonomic (pupillary sphincter and ciliary) muscles. Boyd TA, Leitch GT, Budd GE. Treasure Island (FL): StatPearls Publishing; 2023 Jan. J AAPOS. Torsion can be testing with the double maddox rod test. The nucleus gives rise to the IV nerve fascicle which decussates at the level of the anterior medullary velum (the roof of the aqueduct) just caudal to the inferior colliculus. Passing through the trochlea it changes direction, passes deep to the superior rectus muscle, and inserts into the superior . Brown's Syndrome - an overview | ScienceDirect Topics Signs and symptoms associated with CN II,III, V, VI and II. Thacker NM, Velez FG, Demer JL, Rosenbaum AL. If the deviation has become comitant due to superior and inferior rectus contractures, respective recessions should be performed. 2008;126(7):899-905. doi:10.1001/archopht.126.7.899, Lee J, Flynn JT. Miller JE. Congenital Fibrosis of the Extraocular Muscles: May affect any extraocular muscle, but sometimes affects solely the inferior rectus. [4][17], Other features: Mild extorsion (<10); compensatory head tilt to the contralateral side and face turn towards the contralateral shoulder, sometimes associated with a facial asymmetry; contralateral inferior rectus overaction (fallen eye)[4]; large vertical fusional amplitudes when congenital.[4][2]. American Academy of Ophthalmology. If superior rectus palsy: Superior transposition of half tendon lengths of medial and lateral recti or Knapp procedure. Patching is also an acceptable alternative for patients who defer prisms or surgery. When the eye is abducted the visual axis and the muscle plane become more perpendicular and the SOM function is mostly intorsion. [3] Idiopathic cases may improve or completely resolve over a matter of weeks. Superior oblique tightening procedures - "tucks"- are indicated in congenital SO palsy with tendon laxity tested through forced duction or when there is minimal IO overaction with the vertical deviation being greatest in downgaze. When bilateral, the vertical deviation of each eye is not related to the other, as in true hypertropia (no yoke muscle overaction is present).[4][41]. Several patterns have been described for the type of vertical incomitance observed (eg, A or V patterns), depending upon the relative increase or decrease in the horizontal deviation during the vertical eye movement. Thyroid eye disease leads to enlargement of the extraocular muscles and restrictive strabismus. : Following strabismus surgery). Klin Monbl Augenheilkd. Direction of vertical displacement of horizontal recti in pattern strabismus- Medial rectus is shifted towards the apex and lateral rectus is shifted towards the base of A or V pattern. Strabismus in craniosynostosis. 1989 Nov-Dec;34(3):153-72. If congenital, the intorsion is frequently only objective and not subjective, since there is sensory adaptation. Pseudo-Brown's syndrome as a complication of glaucoma drainage implant surgery. Forced duction testing is very useful in the diagnosis of Brown syndrome, and will demonstrate restriction to passive elevation in adduction. Presence of an ipsilateral or contralateral rAPD without loss of visual acuity, color vision, or peripheral vision in an apparently isolated CN IV palsy suggests superior colliculus brachium involvement. The IV nerve then courses around the cerebellar peduncle and travels between the superior cerebellar and posterior cerebral arteries in the subarachnoid space. 1999;97:1023-109. Decompensated congenital fourth nerve palsy presents as intermittent diplopia in a patient with a long-standing head tilt (obvious on old photographs). Congenital Brown's Syndrome: Intraoperative Findings Surgical Procedures and Postoperative Results Andreea Ciubotaru Brave Inferior Oblique Vincent Paris Early Strabismus Surgery can improve Facial Asymmetry in Anterior PlagiocephalyLeila S Mohan Superior Oblique Tendon Elongation with Bovine Pericardium (Tutopatch) for Brown Syndrome. [1][2] The clinical features were similar to those of an inferior oblique palsy, although there was minimal superior oblique muscle overaction. A very rare form of isolated IR affection has been described[37], In addition to the restrictive elevation, there is also a SO paresis. 1999;97:1023-109. Careful examination is necessary in traumatic cases as the CN IV palsies can by asymmetric if bilateral and can be masked or become apparent after strabismus surgery for a presumed unilateral CN IV palsy. If the SO is tight, it cannot pass through the trochlea due to swelling or anatomic variants or, possibly, if the insertion is anomalous the eye cannot elevate in adduction. Stiffness of the inferior oblique neurofibrovascular bundle. Acquired double elevator palsy in a child with pineacytoma. If vertical deviation of >10DP: Ipsilateral SO weakening + contralateral SR weakening. Relocate horizontal rectus muscle. Congenital Brown syndrome is characterized by limited elevation particularly during adduction from mechanical causes [].The pathogenesis of congenital Brown syndrome is still controversial, and we have previously found normal-sized trochlear nerves and superior oblique (SO) muscles on high-resolution magnetic resonance imaging (MRI) in nine patients with congenital Brown syndrome []. Clinical photograph of the patient showing A-pattern exotropia associated with bilateral superior oblique overaction. Myectomy and extirpation/denervation have been described but are not preferred procedures by the authors, as the results may be unpredictable, and anteriorization cannot be achieved by these procedures. J Pediatr Ophthalmol Strabismus, 1987; 24:10-7.. Sometimes it can give rise to an acquired Browns syndrome, due to SO contracture (for the differential diagnosis between SO overaction and Browns syndrome, see the differential diagnosis section). Dawson E,Barry J,Lee J. Spontaneous resolution in patients with congenital Brown syndrome. 2012 Jun;90(4):e310-3. Likewise, pseudo V-exotropia may be seen in intermittent divergent strabismus, wherein the patient fuses for downgaze and breaks in upgaze, manifesting exodeviation. 1998;6(4):191-200. doi:10.1076/stra.6.4.191.620, Girkin CA, Perry JD, Miller NR. Incidence and Etiology of Presumed Fourth Cranial Nerve Palsy: A Population-based Study. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Isolated Inferior Oblique Paresis from Brain-Stem Infarction: Perspective on Oculomotor Fascicular Organization in the Ventral Midbrain Tegmentum, Spoor TC, Shipmann S. Myasthenia Gravis Presenting as an Isolated Inferior Rectus Paresis. If bilateral, even if asymmetric: Bilateral IO weakening procedures (myectomy, recession, anteriorization) should be performed, except if amblyopia is present (surgery on the good eye is discouraged). PubMedGoogle Scholar, 2017 Springer International Publishing AG, Kushner, B.J. Apart from the basic strabismus work-up, the additional assessment needed in the presence of patterns is to look for: The management of pattern strabismus can be difficult. During surgery, Brown discovered a shortened tendon sheath of the superior oblique tendon, which was thought to restrict passive elevation movement in the adducted field. Most frequently idiopathic or iatrogenic (following inferior oblique surgery or retrobulbar block). Various inferior oblique weakening procedures are: Various superior oblique weakening procedures are: Video 2: Posterior Tenectomy of Superior Oblique, Figure 10. In Browns syndrome there is a Y-pattern, whereas a lambda pattern is present in SO overaction and an A pattern in IO paresis. 2020;101383. When an eye is in adduction and the superior oblique muscle (SO) contracts, the eye depresses because the SO inserts posterior to the center of rotation. [Jaensch-Brown syndrome--etiology and surgical procedure]. If cosmetically intolerable or if noticeable: If associated with an IO overaction: Sole IO graded anteriorization, If associated with an SO overaction: Treat the A pattern with horizontal muscle transpositions, or an undercorrected SO weakening procedure, since the latter may aggravate the symptoms of DVD, If both eyes can fixate: Bilateral SR recessions, with asymmetric recessions if asymmetric, If overcorrected: Associate an IR plication or resection. Classification and surgical management of patients with familial and sporadic forms of congenital fibrosis of the extraocular muscles, Guyton DL. PMID 32088116. https://eyewiki.org/w/index.php?title=Hypertropia&oldid=91972, Elevation deficit and VS worst in adduction, occasional over-depression in adduction, Elevation deficit and VS worst in adduction, Depression deficit and VS worst in adduction, Worse with ipsilateral tilt, alternates if bilateral, Over-elevation in adduction. due to a paresis of another vertical muscle, it may give rise to a V pattern, with additional convergence in downgaze. 1985. doi:10.1136/bjo.69.7.508. J Neuro-Ophthalmology. Brown's syndrome with contralateral inferior oblique - PubMed Ugolini G, Klam F, Dans MD. [2][3], Associated findings include: Intraocular pressure may increase when looking away from the restriction, [4][2] proptosis, lid retraction, compressive optic nerve dysfunction, conjunctival hyperemia, chemosis, and corneal affections due to exposure[5][6][7]. MeSH PMC Kushner BJ. Figure 1. Dissociated vertical deviation: Etiology, mechanism, and associated phenomena.J. The clinical features were similar to those of an inferior oblique palsy, although there was minimal superior oblique muscle overaction. Paralytic Strabismus: Third, Fourth, and Sixth Nerve Palsy. For this review, true Brown syndrome is due to congenital cause, with a constant limitation of elevation and a positive traction test secondary to a tight, superior oblique tendon. Introduction. Oh SY, Clark RA, Velez F, Rosenbaum AL, Demer JL. After extensive further investigation, it was demonstrated that key clinical features were a V or Y pattern strabismus, divergence in upgaze, downdrift in adduction, and a positive forced duction test for ocular elevation in the nasal field. If masked bilateral involvement or asymmetric involvement is suspected: Bilateral IO graded anteriorization + contralateral IR recession or bilateral graded IO anteriorization + Harada-Ito procedure on the more affected side. Clinical photograph of the patient showing V-pattern exotropia associated with bilateral inferior oblique overaction. Neurology. [6] Sudden onset, of a painless, neurologically isolated CN IV without a history of head trauma or congenital CN IV palsy in a patient with risk factors for small vessel disease implies an ischemic etiology. An inverse Knapp procedure may be necessary. 1996 Jan;208(1):37-47. doi: 10.1055/s-2008-1035166. Specific methods for testing are detailed in the highlighted link above. ent with apparently isolated inferior oblique muscle overac-tion (with minimal superior oblique underaction in the involved eye) and correlative extorsion, although . The type of surgery is governed by the underlying pathophysiology of the pattern and directed towards the implicated extraocular muscle. (Courtesy of Vinay Gupta, BSc Optometry), Figure 2. Fourth cranial nerve palsy and brown syndrome: Two interrelated The key finding in Brown syndrome is limited elevation in AD-duction. ), Innervational anomaly of the superior division of the III cranial nerve, Neoplastic (ex. [1][2], Congenital Considerations on the etiology of congenital Brown syndrome. The key feature is inability to elevate the adducted eye. Ipsilateral hypertropia and excyclotorsion are frequently seen due to the superior obliques function of intorsion and depression the eye. Determining if there worsening of the hypertropia in left or right head tilt can identify the involved muscle from the remaining two choices following steps 1 and 2 of the three step test. 2019 American Academy of Ophthalmology. For example, with a right hypertropia, the potentially involved muscles include the right superior oblique, right inferior rectus, left inferior oblique and left superior rectus. [4] Translucent occluders of Spielman are particularly helpful.[44]. Scleral buckle with posterior slippage, entrapment or splitting of extraocular muscles and anterior displacement of an oblique muscle. Patients can present with binocular, vertical or torsional diplopia. Determining the hypertropic eye reduces the potentially involved muscles to four. In fourth nerve palsy the Double Maddox rod should demonstrate unilateral excyclotorsion. These signs include supranasal orbital pain, tenderness, intermittent limitation of elevation in adduction, and pain that is associated with this ocular movement. In this chapter, we will discuss in detail the various types of pattern strabismus, its mechanisms, and the appropriate surgical intervention for the same. If there is a large hypotropia in upgaze even in the case of a <8PD deviation in primary position: IR recession and an additional contralateral asymmetrical IR recession or contralateral SR recession may be indicated. Ex. For example, Brown's syndrome (superior oblique tendon sheath syndrome), which causes tethering of the superior oblique muscle, has a similar eye movement pattern to an inferior oblique paresis. If >15PD in primary position: Ipsilateral IR recession plus contralateral SR recession. Inferior Oblique Overaction Over-elevation of the eye in adduction Other features: If primary and bilateral, it gives rise to a Y-pattern, with divergence in upgaze; if secondary, i.e. : pseudo-Brown's syndrome), or following retinal surgery: Sometimes associated with a hypertropia in adduction, due to aberrant innervation of vertical muscles or a restrictive lateral muscle. A recent population-based study finds only 4% of trochlear nerve palsies to be idiopathic, citing increased improved identification of vasculopathic risk factors. A translucent occluder for study of eye position under unilateral or bilateral cover test. Pediatric Ophthalmology and Strabismus BCSC, Leo, 2011-2012. Brown Syndrome. Special focus should be given to the sensory-motor examination, including strabismus measurements in all cardinal positions of gaze, ocular motility, and binocular function/stereopsis. -. The Academy uses cookies to analyze performance and provide relevant personalized content to users of our website. The trochlear nerve gains entry to the orbit via the superior orbital fissure, passes outside the tendinous ring of Zinn and innervates the SOM. Note convergence in straight upgaze, an important point of differentiation from Brown syndrome. Amblyopia is generally absent. Strabismus. This patient had no abnormal neurologic findings. Bilateral involvement is rare in non-traumatic cases but is relatively more frequent after trauma (crossed, dorsal exit). Palsies of the Trochlear Nerve: Diagnosis and LocalizationRecent Concepts. Before Diplopia and eye movement disorders | Journal of Neurology Monocular Elevation Deficit Syndrome (MEDS), Other complex forms of strabismus or involving multiple muscles, Differentiating between a Paresis and a Restriction of the Antagonist, Three Step Test for Cyclovertical Muscle Palsy, Differentiating between Browns Syndrome, Superior Oblique Overaction and Inferior Oblique Paresis, Differential Diagnosis between DVD and Inferior Oblique Overaction, Vertical Strabismus Exam Findings by Etiology, Pseudo - Inferior Rectus Underaction (as in orbital floor fracture and muscle entrapment). Superior oblique split tendon elongation for Brown's syndrome: Long Increased vertical deviation on head tilt to the ipsilateral side. Brown syndrome (inelastic superior oblique muscle-tendon complex . Coussens T, Ellis FJ. Vertical deviation, that increases on adduction of the affected eye. predisposition to congenital Brown syndrome, however, most cases are sporadic in nature. (PDF) Brown's Syndrome - ResearchGate Knapp P: Vertically incomitant horizontal strabismus, the so-called A and V syndromes. : Overcorrections following inferior rectus weakening procedures as in thyroid ophthalmopathy ), Innervational anomaly of the inferior division of the III cranial nerve, Muscle aplasia (The inferior rectus is most frequently affected, it can be associated with craniofacial disorders). Other less commonly performed procedures are: Occurrence of a pattern in horizontal comitant strabismus is an interesting phenomenon. Secondary to an ipsilateral superior oblique paresis or a contralateral superior rectus paresis. It is very important to correctly diagnose the cause of A and V patterns, because one may have the false impression of oblique muscle affection. Strabismus Following Implantation of Baerveldt Drainage Devices. (PDF) Sndrome de Weber hemorrgico: a propsito de un caso Hemorragic Uses of the Inferior Oblique Muscle in Strabismus Surgery HHS Vulnerability Disclosure, Help Other features: Larger extorsion than in unilateral paresis (>10); esotropia increasing in down gaze (>10) V pattern of the ''arrow subtype''. Cerebral palsy Risk factors Definition/Back - breech birth, low APGAR, prematurity, infections, Rh incompatibility . Two images are perceived in the same location, due to a misalignment of retinal correspondence points on the fovea. Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA, You can also search for this author in Brown syndrome refers to the apparent weakness of the inferior oblique muscle (i.e., limited upgaze, particularly in adduction) secondary to pathology of the superior oblique tendon sheath, usually at the trochlea. It is seen in bilateral inferior oblique overaction, Brown syndrome, or Duane syndrome (DS). This page was last edited on December 31, 2022, at 00:59. Conversely, when an eye with a normal SO elevates in adduction, the SO insertion moves posteriorly, pulling the SO tendon through the trochlea. The disorder can be distinguished clinically from an inferior oblique palsy by the presence of positive forced duction testing, the absence of superior oblique overaction, and, typically, normal alignment in primary gaze. (Courtesy of Vinay Gupta, BSc Optometry), Figure 9. Late overcorrections are frequent. Brown Syndrome secondary to an inflammatory condition is frequently associated with orbital pain and tenderness on movement or palpation of the trochlea. Unauthorized use of these marks is strictly prohibited. The patient presented with a gradual progressive right hypertropia after insertion of a glaucoma drainage device. Munoz M, Parrish Rk. The nucleus gives rise to the IV nerve fascicle which decussates at the level of the anterior medullary velum (the roof of the aqueduct) just caudal to the inferior colliculus. Strabismus secondary to implantation of glaucoma drainage device. Examiners should consider obtaining the following: visual acuity, motility evaluation, binocular function and stereopsis, strabismus measurements at near, distance, and in the cardinal positions of gaze, and evaluation of ocular structures in the anterior and posterior segments. If Brown syndrome is considered in the context of a CCDD, then an anomalous innervation of the superior oblique muscle by fibers of the third cranial nerve intended either for the medial rectus and/or inferior oblique muscle has to be presumed (Table 2). : Craniosynostosis; extorted orbit), Iatrogenic (ex. 2009;13:1168. It is the most common cause of an isolated vertical deviation. Acquired Superior Oblique Palsy: Diagnosis and Management. syndrome should be differentiated from the following conditions: Management of Brown syndrome depends on symptomatology, etiology, and the course of the disease. Right inferior oblique muscle palsy. The trochlear nucleus is in the midbrain, dorsal to the medial longitudinal fasciculus at the level of the inferior colliculus. Curr Opin Ophthalmol, 22: 432-440. The procedure of choice is the recession of affected muscles. Following ocular surgery (Ex. Neely KA, Ernest JT, Mottier M, Combined Superior Oblique Paresis and Brown's Syndrome After Blepharoplasty. Although any extra-ocular muscle can be involved, the inferior rectus is the most frequently affected, followed by the medial rectus muscle . (Courtesy of Vinay Gupta, BSc Optometry), Figure 8. By convention, the misalignment is typically labelled by the higher, or hypertropic, eye. Saccadic eye movements should remain unaffected in contrast to Superior Oblique Myokymia (SOM). There is evidence of chronicity as shown by the following: Overaction of the ipsilateral inferior oblique in adduction (the eye shoots up in adduction) Long-term Results of Adjustable Suture Surgery for Strabismus Secondary to Thyroid Ophthalmopathy. Differentiation between IO palsy and SO restriction of Browns can be done using Forced Duction Test. In the case of a traumatic cause, it is advised to wait for 6 months and reevaluate for a potential recovery. The incidence of Brown's Syndrome was unrelated to tuck size. Brown Syndrome. To make everything a bit more confusing, a Y pattern can also be present when there is an aberrant innervation of the lateral recti, in upgaze,[42] or in the case of a bilateral inferior oblique overaction (see above). Lee AG. (Courtesy of Vinay Gupta, BSc Optometry), Figure 4. Brown 2004. Some authors recommend following such patients for resolution over time and control of the vasculopathic risk factors alone. This is a preview of subscription content, access via your institution. [Brown's atavistic superior oblique syndrome: etiology of different types of motility disorders in congenital Brown's syndrome]. In this head position, the ipsilateral superior rectus will compensate for the weak intorsion of the ipsilateral superior oblique, but will elevate the eye and further worsen the hypertropia. Furthermore, careful history including associated symptoms and other past medical history can help distinguish a CN 4 palsy from other items on the differential. Plager A, Buckley EG. A longitudinal long-term study of spontaneous course. Seven easy steps in evaluation of fourth-nerve palsy in adults. Superior oblique muscle paresis and restriction secondary to orbital mucocele. Part of Springer Nature. This patient had no abnormal neurologic findings. Brown syndrome is attributed to a disturbance of free tendon movement through the trochlear pulley. Sagittalization of the oblique muscles as a possible cause for the A, V, and X phenomena. 2004 Oct;8(5):507-8. doi: 10.1016/j.jaapos.2004.06.001. : Following glaucoma, oculoplastics or strabismus surgery; ENT surgery), Inflammation of the trochlea (Ex. adalimumab) have been used in refractory cases. Brown Syndrome: Practice Essentials, Background, Pathophysiology - Medscape This page has been accessed 158,873 times. The .gov means its official. Neuro-ophthalmology Illustrated Chapter 13 - Diplopia 5 - 4th Nerve Palsy Pain is a feature. A preliminary report. Google Scholar. Flowchart showing various theories for pattern strabismus. Brown syndrome due to inflammatory disease with associated pain may transiently benefit from injection of steroids to the trochlear area. (Courtesy of Vinay Gupta, BSc Optometry). This page has been accessed 120,859 times. When the cover is switched back to the right eye again, there is NO upward refixation movement of the left eye. : Rheumatoid arthritis; systemic lupus erythematosus), Tight superior oblique muscle (Ex. Other features: Chin elevation[2]and ipsilateral true or pseudo-ptosis. In this procedure it is important to keep the anterior IO fibres posterior to the IR insertion in order to avoid a hypercorrection and consequent hypodeviation. The pathophysiology of this phenomenon is multifactorial and has been attributed to factors including oblique muscle dysfunction, horizontal or vertical recti anomaly, displacement of muscle pulleys, and orbital anomalies. Based on the 9-gaze pattern, it can be confused for an inferior oblique palsy. Determining the onset, severity, and chronicity of symptoms can be vital in delineating between the various etiologies of a CN 4 palsy. So, in a patient with right hypertropia that worsens in left gaze, this suggests either right superior oblique or a left superior rectus involvement. Surgery can be considered in the following circumstances: The following surgical procedures can be performed: Image added in courtesy of Dr Agathi Kouri, MD, FRCS, Panagiotis and Aglaia Kiriakou Children's Hospital, Athens, Greece. In a fourth nerve palsy, ocular torsion and hypertropia should be unaffected by positional changes. The https:// ensures that you are connecting to the In order to evaluate this, the physician needs to check for a vertical deviation of the occluded eye, while the patient looks either side. The superior oblique causes eye depression in adducted gaze. Dawson E, Barry J, Lee J. Spontaneous resolution in patients with congenital Brown syndrome. sharing sensitive information, make sure youre on a federal Kushner BJ. There are specific symptoms of this syndrome, such as limited elevation in . Other features: If primary and bilateral, it gives rise to a Y-pattern, with divergence in upgaze; if secondary, i.e. The diagnosis of Brown Syndrome is based on the clinical findings and history. In a patient with hypertropia that worsens in left gaze and right head tilt is most compatible with a right superior oblique palsy. : Thyroid ophthalmopathy; secondary to superior oblique overaction). Poor movement of the superior oblique tendon through the trochlea leads to limited elevation of the eye in adduction, frequently with an associated exotropia in upgaze. [4][30]. A relative afferent pupillary defect without any visual sensory deficit. Am J Ophthalmol. Hereby, lateral recti are moved towards the open end of the pattern (up in V, down in A), while medial recti are transposed to the closed end of the pattern (down in V, up in A), Medical: Teprotumumab has recently been approved by the U.S. F.D.A, and may rapidly become the first line therapy. Phillips PH, Hunter DG. Patients with BS can have a widening of the palpebral fissure in. Brown It is more frequently bilateral. In: StatPearls [Internet]. Loss of fusion and the development of A or V patterns. With tenotomy and tenectomy, care should be taken for overcorrections. This is a rare disorder described by Harold W. Brown in 1950 and first named as the "superior oblique tendon sheath syndrome.". oblique palsy after surgery for true Brown's syndrome Jan 1958 82-86 oblique palsy after surgery for true Brown's syndrome. In the case of a large angle strabismus, a contralateral superior rectus recession may be indicated. Computed Tomography (CT) brain showing right-sided plagiocephaly (yellow arrow) with thin superior oblique on the affected side (yellow dashed arrow). Leads to an elevation deficit in adduction and greater vertical deviation with tilt to the contralateral side. Immunosuppressants (i.e. X- pattern, It is caused by a tight, contracted lateral rectus. Left hypertropia in right gaze and left tilt, right hypertropia in left gaze and right tilt, the hypertropia is less evident than in unilateral superior oblique paresis. If main problem is extorsional diplopia (as in partially recovered post-traumatic paresis), with minimal hypertropia and V-pattern: Harada-Ito procedure. Restriction of elevation in abduction after inferior oblique anteriorization. (Courtesy of Vinay Gupta, BSc Optometry), Figure 6. 2013. doi:10.1016/j.ophtha.2013.04.009, Lee AG. CrossRef (Courtesy of Vinay Gupta, BSc Optometry). Restrictive Horizontal Strabismus Following Blepharoplasty. We would like to extend sincere thanks to Mr. Vinay Gupta, BSc Optometry, for the contribution of figures in this chapter. It manifests when binocular fusion is interrupted either by occlusion or by spontaneous dissociation.
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