Vertical Deviations

Question 1

Types of hyperdeviations

Answer 1

• IV nerves
• DVD
• rhabydosarcoma
• IR palsy
• double depressor palsy
• myasthenia gravis
• myositis

Question 2

Dissociated vertical deviation - DVD - features and management

Answer 2

• Spontaneous elevation of either eye, when stimulus to fixate is downwards
• differential diagnosis with IO overaction
• surgery if frequent spontaneous elevation of one or both eyes
• anterior transposition of IO, moving the insertion towards equator removes elevating action
• SR recession

Question 3

Inferior rectus palsy features and management

Answer 3

• congenital/acquired
• A pattern
• chin depression
• hypertropia with/without exo
• vertical diplopia
• limitation on down gaze

Management
- prisms
- surgery
- if mild, weakening of contralateral SO, ipsilateral IR resection with SR recession, BSV present in PP then weaken contralateral IR

Question 4

Rhabdomyosarcoma features

Answer 4

• highly malignant tumour of an EOM
• usually presents in childhood
• proptosis
• restriction of ocular movement
• radio therapy and chemo

Question 5

Orbital myositis features and treatment

Answer 5

• acute/chronic
• inflammatory disease of one or more EOMs
• painful diplopia, increasing in action of affected muscle
• vertical deviation common
• corticosteroids usually enough to treat

Question 6

Double depressor palsy - features and management

Answer 6

• congenital
• initial IR palsy
• secondary ipsilateral SR contraction
• spreads to limit of downgaze and adduction and abduction

Management
- inferior transposition of horozontal rectus muscles
- recession of ipsilateral SR

Question 7

Double elevator palsy features

Answer 7

• limitation of elevation in adduction and abduction
• congenital
• ptosis/pseudoptosis with hypodeviation
• chin elevation if bilateral