Original articleThe Sensitivity of the Bielschowsky Head-Tilt Test in Diagnosing Acquired Bilateral Superior Oblique Paresis
Section snippets
Methods
The Johns Hopkins Medicine Institutional Review Board approved the study protocol and agreed to a waiver of informed consent for use in this retrospective, single-center study. The study and data collection were in accordance with the Health Insurance Portability and Accountability Act of 1996. We performed a retrospective chart review of the medical records of all patients who were seen by the senior author at the Krieger Children's Eye Center at the Wilmer Eye Institute from 1978 through
Results
Thirty-four patients were identified, of whom 25 met our inclusion and exclusion criteria. The patients' demographic profiles showed a male-to-female ratio of 1.78, with an average age of 31 years (standard deviation [SD], 11.3 years). Twenty-two patients had sustained head trauma after a motor vehicle accident, 1 patient sustained a head injury after a fall, and 2 patients had undergone surgery for resection of a brain tumor. All patients reported vertical diplopia immediately or within
Discussion
We identified 25 patients in whom the diagnosis of acquired bilateral superior oblique paresis was quite certain on the basis of the clinical history and examination. The increase in extorsion from upgaze to downgaze is statistically significant in this group and is in keeping with the findings by synoptophore from Fells and Waddell in their series of patients with bilateral superior oblique paresis.14 Our patients also have undergone strabismus surgery with the expected clinical outcome for
Brinda Muthusamy, MBChB, MRCP, FRCOphth, received her medical degree from the University of Edinburgh, UK. After her medical residency at the Oxford Radcliffe Hospitals, she obtained Membership to the Royal College of Physicians. She then completed her ophthalmology specialist training at the Bristol Eye Hospital, and is a Fellow of the Royal College of Ophthalmologists. She obtained fellowship training in Pediatric Ophthalmology and Adult Strabismus and then Neuro-ophthalmology at The Johns
References (22)
Errors in the three-step test in the diagnosis of vertical strabismus
Ophthalmology
(1989)- et al.
Traumatic superior oblique palsies
Ophthalmology
(1982) Asymmetrical bilateral paresis of the superior oblique muscle
JAAPOS
(2007)- et al.
Masked bilateral superior oblique muscle paresis. A simple overcorrection phenomenon?
Ophthalmology
(1998) - et al.
The Wilmer Information System. A classification and retrieval system for information on diagnosis and therapy in ophthalmology
Ophthalmology
(1988) - et al.
Fusion can mask the relationships between fundus torsion, oblique muscle overaction/underaction, and A- and V-pattern strabismus
J AAPOS
(2013) Lectures on motor anomalies of the eye
Arch Ophthalmol
(1935)Isolated cyclovertical muscle palsy
Arch Ophthalmol
(1958)Simulated superior oblique palsy
Ann Ophthalmol
(1981)- et al.
Masked bilateral superior oblique palsy: clinical features and diagnosis
J Pediatr Ophthalmol Strabismus
(1986)
The diagnosis and treatment of bilateral masked superior oblique palsy
Am J Ophthalmol
Cited by (21)
Torsional incomitance after asymmetrically adjusted Harada-Ito procedures for the simultaneous correction of vertical and torsional deviations in bilateral trochlear nerve palsy
2021, Journal of AAPOSCitation Excerpt :Torsional incomitance patterns are challenging to correct, because any attempt to improve alignment in some ranges of gaze often results in worsening alignment in other gaze directions. As described by Carlos Souza-Dias15 and Muthusamy and colleagues,16 alternating hypertropia in straight side gazes is not always present in bilateral trochlear nerve palsies. It was only present in 5 of our 17 patients, whereas alternating hypertropia in down and side gazes was noted in 7 patients.
Two cases of acquired bilateral trochlea nerve palsy treated by simultaneous inferior rectus muscle nasal transposition and inferior oblique muscle myectomy
2021, American Journal of Ophthalmology Case ReportsCitation Excerpt :Acquired bilateral trochlea nerve palsy often occurs after closed head injury and presents a small vertical deviation in the primary position, large V pattern, large torsional deviation usually exceeding 15° in the primary position, and a bilaterally positive Bielschowsky head tilt test (BHTT).1 A recent study reported that only 70% of superior oblique palsy patients fulfill the Parks 3 step test2; moreover, another study reported that only 40% of true bilateral traumatic superior oblique paresis had a positive Bielschowsky head tilt test on both sides, which may mask the bilateral palsy.3 Therefore, it is recommended to comprehensively judge the diagnosis of bilateral superior oblique palsy and trochlea nerve paresis based on the history, clinical findings including large torsional diplopia, and imaging findings if possible.
Sudden-onset trochlear nerve palsy: clinical characteristics and treatment implications
2019, Journal of AAPOSCitation Excerpt :This could be due to referral patterns in our area of practice, where acute-onset vascular palsies may be seen and monitored to recovery by adult neuro-ophthalmologists without a need for strabismus surgical evaluation. All cases of bilateral superior oblique palsy were secondary to trauma, underlying CNS neoplasm, or stroke; all microvascular and unknown causes were unilateral.9 CNS lesions accounted for 2 cases of bilateral superior oblique palsy and 2 cases of unilateral superior oblique palsy, highlighting the importance of including CNS tumor in the differential diagnosis for both types of acquired palsies.
Paradoxical head tilt in unilateral traumatic superior oblique palsy
2017, Journal of Current OphthalmologyCitation Excerpt :Superior oblique (SO) palsy is a common finding in traumatic strabismus that presents with vertical deviation, excyclotorsion, and abnormal head posture.1,2 Clinical diagnosis of SO palsy is based on the Parks-Bielschowsky three-step test, torsional deviation measured by double Maddox rod, and ipsilateral inferior oblique overaction.3,4 Patients suffering SO palsy usually adopt an abnormal head posture of contralateral head tilt as a compensating effort to reduce the hypertropia.5–7
Strabismus
2015, Primary Care - Clinics in Office PracticeCitation Excerpt :The results from the 3 steps yield the causative palsied muscle. Although the 3-step test is useful, it cannot be used in cases of restrictive processes effecting the muscles or multiple muscle palsies.31 Vertical and torsional diplopia may result from fourth cranial nerve palsies.
Brinda Muthusamy, MBChB, MRCP, FRCOphth, received her medical degree from the University of Edinburgh, UK. After her medical residency at the Oxford Radcliffe Hospitals, she obtained Membership to the Royal College of Physicians. She then completed her ophthalmology specialist training at the Bristol Eye Hospital, and is a Fellow of the Royal College of Ophthalmologists. She obtained fellowship training in Pediatric Ophthalmology and Adult Strabismus and then Neuro-ophthalmology at The Johns Hopkins Hospital, Baltimore, Maryland. She is now a consultant pediatric and adult neuro-ophthalmologist at Addenbrookes Hospital, Cambridge, UK.
David L. Guyton, MD, graduated from Harvard Medical School in 1969 and subsequently completed his residency in ophthalmology at the Wilmer Eye Institute at The Johns Hopkins University in 1976. After fellowship training in strabismus at the Baylor College of Medicine, he returned to the Wilmer Institute as Chief Resident and then as Chief of Pediatric Ophthalmology and Adult Strabismus, where he continues to serve as the Zanvyl Krieger Professor of Ophthalmology. The most recent of his 290+ publications and 11 U.S. Patents deal with remote optical systems and automated screening devices for detection of strabismus and defocus in infants and children.