Surgery for Superior Oblique Palsy

Unilateral Superior Oblique Palsies (Illustrated for Right SOP)

Class R. Hyper R.Gaze SOUA IOOA Treatment
1 <15 None 0 to -1 +2 to +3 RIOc
2 <15 None -1 to-2 +3 to +4 RIOc vs myectomy
3a <15 None -2 to -4 0 to +1 LIRc
3b <15 As 3 a but with significant torsion RSOt or Harada-Ito + LIRc
4 >15 Significant 0 to -2 +3 to +4 RIOc + RSRc
5 >15 Significant -2 to-3 0 to +2 RIOc + LIRc
6 >30 Significant >15 -2 to -3 +3 to +4 RIOc + LSRs & LIRc
7a <15 With spread of commitance  RSRc
7b >15 With spread of commitance  RSRc + RIRs or LIRc
8 <20 Fallen eye syndrome  LIRc

SOP: Superior Oblique Palsy
Sig: significant
SOUA: Superior oblique underaction
IOOA: Inferior oblique overaction
Treatment: Suggested treatment
RIOc: Right Inferior Oblique recessions or other weakening procedure
RSOt: Right Superior Oblique Tuck
LIRc: Left Inferior rectus recession
LSRc: Left Superior rectus recession
RSRc
: Right Superior rectus recession
RIRs: Right Inferior rectus resection

Based on Scott WE, Kraft SP, Classification and Treatment of Superior Oblique Palsies:I. Unilateral Superior Oblique Palsies. Transactions of the New Orleans Academy of Ophthalmology. 1986: 15-38.

 

Bilateral Superior Oblique Palsies

Class HT V IOOA SOUA Torsion DMR AHP Treatment
1 No 22 > +2 -1 to 0 No 10° No BIOc
2 No 16 0 to +1 > -2 Yes 13° Chin down BSOt or Harada-Ito
3 No 40 > +2 > -2 Yes 14° Chin down BIOc & BSOt or Harada-Ito*
4a Yes 21 > +2 asym > -2 Yes 14° Tilt Bilat. Harota-Ito or SOt and unilat IOc
4b Yes 20 +1 to +2 > -2 asym Yes 12° Tilt BSOt or Harada-Ito & IRc or SRc ± BIOc
4c Yes 22 > +2 asym > -2 asym Yes 15° Tilt BIOc & BSOt or Harada-Ito & IRc or SRc
5** Yes 10 > +2 unilat -1 to -3 unilat No 6°-11° Tilt Unilat IOc ± IRc brings out contralateral SOP

HT: Hypertropia in primary gaze
V: mean amount of V pattern present in upgaze/downgaze
IOOA: Inferior oblique over action
SOUA: Superior oblique under action
Torsion: Subjective torsion
DMR: Average torsion on Double Maddox Rod test
AHP: Abnormal head position
Treatment: Suggested treatment
BIOc: Bilateral Inferior Oblique recessions or other weakening procedure
BSO Tuck: Bilateral Superior Oblique Tuck
IRc: Inferior rectus recession
SRc: Superior rectus recession
Asym: Asymmetrical under or over action
Bilat: Bilateral
Unilat: Unilateral
SOP: Superior Oblique Palsy

* For class 3 patients: consider Bilateral Medial Rectus Recessions for Esodeviation > 8 diopters
** Masked Bilateral Superior Oblique Palsy (9-16% of all Bilateral Superior Oblique palsies)

Based on Scott WE, Kraft SP, Classification and Treatment of Superior Oblique Palsies:II. Bilateral Superior Oblique Palsies. Transactions of the New Orleans Academy of Ophthalmology. 1986: 265-91.