Journal List > J Korean Ophthalmol Soc > v.48(10) > 1007944

Na, Lee, and Lee: Ocular Torsion in Unilateral Superior Oblique Palsy



We evaluated the concordance of laterality of the paretic eye and the torsional eye in unilateral superior oblique palsy showing an inferior oblique overaction.


Thirty-nine patients diagnosed as having a unilateral superior oblique palsy were evaluated for visual acuity, refractive manifestation, ocular movement, prism cover test, and fundus photograph. Of these patients, 32 derived from congenital causes and 7 acquired the condition from trauma. An ocular movement exam was performed to check an inferior oblique overaction, and a fundus photograph was used to measure the ocular torsional amount. Inferior oblique myectomy or recession was performed along with horizontal strabismus surgery.


Objective extorsion was presented in paretic eyes of 29 patients (74.4%) and nonparetic eyes of 10 patients (25.6%). The congenital superior oblique palsy patients were divided into two groups by the concordance of laterality of paretic eyes and torsional eyes. In the concordance group of 22 patients, the torsional amount was decreased from +17.69°to +7.98°and inferior oblique overaction from +2.27°to +0.25°after an inferior oblique muscle weakening procedure. In the discordance group of 10 patients, torsional amount was decreased from +16.97°to +8.73°and inferior oblique overaction from +2.50°to +0.21°postoperatively. In acquired oblique palsy patients, all patients showed the concordance of laterality, and the torsional amount was decreased from +16.76°to +8.80°and inferior oblique overaction from +2.5° to +0.21°after inferior oblique weakening procedure.


We found that the paretic eye and the torsional eye may not coincide in congenital superior oblique palsy but always coincide in acquired oblique palsy after trauma. After an inferior oblique muscle weakening procedure, ocular torsional amount of paretic or sound eye is decreased in every case.


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Figure 1.
The relationships of the inferior oblique overaction and torsional amount in superior oblique palsy. The graph shows a positive correlationship in congenital superior oblique palsy (A). However, in acquired oblique palsy, it is difficult to define correlation because of small number of patients (B).
Table 1.
Demographics of patients
Number of Patients 39
Average age (years) 6.4
Sex (M/F)
 M 22 (56.4%)
 F 17 (43.6%)
SO* palsy
 Congenital 32 (82.1%)
 Acquired 7 (17.9%)
Weakening procedure
 Myectomy 17 (43.6%)
 Recession & transposition 22 (56.4%)
Combined with horizontal strabismus 35 (89.7%)
Not combined with horizontal strabismus 4 (10.3%)
Head tilt 36 (92.3%)
Facial asymmetry 24 (61.5%)

* : Superior oblique.

Table 2.
Changes of the torsional angle in superior oblique palsy
Torsion (Op* eye)
Torsion (TOE)
Pre Post Pre Post
SO palsy
Congenital (n=32) Group 1 (n=22) 17.69±5.94 7.98±6.30 (p=0.0000) 8.51±4.60 8.88±3.98 (p=0.749)
Group 2 (n=10) 10.59±2.73 8.09±1.40 (p=0.537) 16.97±5.09 8.73±3.14 (p=0.000)
Acquired (n=7) Group 1 (n=7) 16.76±1.39 8.80±3.31 (p=0.006) 9.22±2.94 7.02±2.48 (p=0.072)
Group 2 (n=0) - - - -

* : Operation.

: The other eye.

: Superior oblique.

Table 3.
Change of inferior oblique overaction after weakening procedure of the inferior oblique muscle
Preoperative Postoperative Corrected
IOOA* IOOA* amount
SO palsy
Congenital 2.27±0.71 0.25±1.09 2.02±0.59
Acquired 2.50±1.04 0.21±0.39 2.29±0.77

* : Inferior oblique overaction.

Superior oblique.

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