Skip to main content

Effects of inferior oblique muscle-weakening surgery on the Bielschowsky head-tilt phenomenon in patients with superior oblique palsy habitually fixating with the paretic eye



To evaluate the usefulness of inferior oblique (IO) weakening surgery on a paretic eye for correcting vertical deviation in three positions of gaze by comparing the surgical results in 2 types of unilateral superior oblique (SO) palsy.


The patients were divided into 2 groups: 27 patients fixated with the paretic eye and 61 patients fixated with the non-paretic eye (control). The former had hypotropia and the latter hypertropia. All patients underwent IO recession of the paretic eye. We compared the corrective effects, percentage changes in the decrease of vertical deviation of the primary position (PP), vertical deviation on ipsilateral head tilt, i.e., the Bielschowsky head-tilt phenomenon (BHP), and differences in vertical deviation between ipsilateral and contralateral head tilt (BHTD) relative to the preoperative values between the 2 groups.


Mean percentage decrease in vertical deviation of the BHP and BHTD in the control group was larger at 3, 6, and 12 months, but no significant difference was observed between the 2 groups except for the BHP at 12 months (52% for case vs. 70% for control, p = 0.04).


IO weakening in the paretic eye was effective irrespective of the preferred eye for fixation on PP and head-tilt position.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6


  1. Knapp P. Diagnosis and surgical treatment of hypertropia. Am Orthop J. 1971;21:29–37.

    CAS  Google Scholar 

  2. Knapp P. Paretic squints. Symposium on strabismus. Trans New Orleans Acad Ophthalmol. 1978;24:350–7.

    Google Scholar 

  3. Kushner BJ. Ocular torsion: rotations around the “WHY” axis. J AAPOS. 2004;8:1–12.

    Article  PubMed  Google Scholar 

  4. Mori R. Studies on the binocular counter-rolling induced by head tilt in man. Part 1. On the coordination of the counter-rolling of both eyes in normal cases. Nippon Ganka Gakkai Zasshi. 1973;77:753–60.

    CAS  PubMed  Google Scholar 

  5. Collewijn H, Van der Steen J, Ferman L, Jansen TC. Human ocular counterroll: assessment of static and dynamic properties from electromagnetic scleral coil recordings. Exp Brain Res. 1985;59:185–96.

    CAS  Article  PubMed  Google Scholar 

  6. Simonsz HJ, Crone RA, van der Meer J, Merckel-Timmer CF, van Hourik-Noordenbos AM. The Bielschowsky head-tilt test. I. Ocular counterrolling and Bielschowsky head-tilt test in 23 cases of superior oblique palsy. Vision Res. 1985;25:1977–82.

    CAS  Article  PubMed  Google Scholar 

  7. Fujiwara Y. The study of ocular counterrolling using CCD cameras with video-based technique. 1. On normal subject. Nippon Ganka Gakkai Zasshi. 1988;92:565–72.

    CAS  PubMed  Google Scholar 

  8. Schworm HD, Yagge J, Pansell T, Lennerstrand G. Assessment of ocular counterroll during head tilt using binocular video oculography. Invest Ophthalmol Vis Sci. 2002;43:662–7.

    PubMed  Google Scholar 

  9. Hamasaki I, Hasebe S, Ohtsuki H. Static ocular counterroll: video-based analysis after minimizing the false-torsion factors. Jpn J Ophthalmol. 2005;49:497–504.

    Article  PubMed  Google Scholar 

  10. Esmail F, Flanders M. Masked bilateral superior oblique palsy. Can J Ophthalmol. 2003;38:476–81.

    Article  PubMed  Google Scholar 

  11. Kushner BJ. Errors in the three-step test in the diagnosis of vertical strabismus. Ophthalmology. 1989;96:127–32.

    CAS  Article  PubMed  Google Scholar 

  12. Russmann W. Messung der Kopfzwangshaltung. In: Kaufmann H, editor, Strabismus. Stuttgart: Enke; 1994. p. 457–9.

  13. Ohtsuki H. Cyclovertical strabismus. In: Uemura Y, editor. Practice of orthoptics. Tokyo: Igaku Shoin; 1992. p. 95–128.

    Google Scholar 

  14. Wright KW. Inferior oblique muscle surgery. In: Wright KW, editor. Color atlas of ophthalmic surgery strabismus. Philadelphia: Lippincott; 1991. p. 173–200.

    Google Scholar 

  15. Dickey CF, Scott WE, Cline AR. Oblique muscle palsies fixating with the paretic eye. Surv Ophthalmol. 1988;33:97–107.

    CAS  Article  PubMed  Google Scholar 

  16. Olivier P, von Noorden Gk. Excyclotropia of the nonpareitc eye in unilateral superior oblique muscle paralysis. Am J Ophthalmol. 1981;93:30–3.

    Article  Google Scholar 

  17. Mahmoud TA, Flanders M. Treatment of Knapp class V superior oblique palsy with contralateral inferior rectus muscle recession. Can J Ophthalmol. 2009;44:320–2.

    Article  PubMed  Google Scholar 

  18. Prieto-Diaz J, Gamio MS. The surgical innervational effect: utilizing it to treat monocular elevation deficiency strabismus. Binocul Vis Strabismus Q. 2007;22:169–78.

    PubMed  Google Scholar 

  19. Schulz E, Haase W. Okulomotorische Fehlregenerationen: operative Massnahmen. Z prakt Augenheilkd. 1985;6:261–4.

    Google Scholar 

  20. Ohtsuki H, Konishi Y, Hasebe S, Tadokoro Y. Surgery for oculomotor nerve palsy with misdirection syndrome. Rinsho Gannka. 1990;44:1889–93.

    Google Scholar 

  21. Gonzalez C, Chen HH, Ahmadi MA. Sherrington innervational surgery in the treatment of chronic six nerve paresis. Binocul Vis Strabismus Q. 2005;20:159–66.

    PubMed  Google Scholar 

  22. Kaufmann H. Paretischen scielen. In: Kaufmann H, editor. Strabismus. Stuttgart: Enke; 1986. p. 466–9.

    Google Scholar 

  23. Morad Y, Weinstock VM, Kraft SP. Outcome of inferior oblique recession with or without vertical rectus recession for unilateral superior oblique paresis. Binocul Vis Strabismus Q. 2001;16:23–8.

    CAS  PubMed  Google Scholar 

  24. Hayat A, Tardieu C, Tabary JC, Tabary C. Effects of denervation on the reduction of sarcomere number in cat soleus muscle immobilized in shortened position during seven days. J Physiol. 1978;74:563–7.

    CAS  Google Scholar 

  25. Goldspink G, Tabary C, Tabary JC, Tardien C, Tarden G. Effect of denervation on the adaptation of sarcomere number and muscle extensibility to the functional length of the muscle. J Physiol. 1974;236:733–42.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  26. Simonsz HJ. The mechanics of squint surgery. In: Weiss J-B, editor. Acta Strabologica. Paris: CERES; 1990. p. 17–9.

  27. Mataftsi A, Strickler J, Klainguti G. Vertical and torsional correction in congenital superior oblique palsy by inferior oblique recession. Eur J Ophthalmol. 2006;16:3–9.

    CAS  Article  PubMed  Google Scholar 

  28. Metten M, Link H, Staubach F, Bach M, Lgreze WA. Dose–response relationship in inferior oblique muscle recession. Graefe’s Arch Clin Exp Ophthalmol. 2008;246:593–8.

    Article  Google Scholar 

  29. Crone RA. Ocular torticollis in cases of eye muscle palsy. In: Diplopia. Amsterdam: Excerpta Medica; 1973. pp. 210–1.

  30. Ichikawa R. Surgical treatment of superior oblique palsy. Part 1. Long term surgical effects with reference to ocular dominance and Bielschowsky head-tilt test. Rinsho Gannka. 1981;35:611–20.

    Google Scholar 

  31. Ichikawa R. Surgical treatment of superior oblique palsy. Part 2. Long term effect of superior rectus recession of the paretic eye. Rinsho Gannka. 1982;36:925–32.

    Google Scholar 

  32. Kushner BJ. The influence of head tilt on ocular torsion in patients with superior oblique palsy. J AAPOS. 2009;13:132–5.

    Article  PubMed  Google Scholar 

Download references


This study was supported in part by a Grant-in-Aid for Scientific Research in Japan (no. 22591964) and the Koyama Fund.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Fumiko Kishimoto.

About this article

Cite this article

Kishimoto, F., Hasebe, S. & Ohtsuki, H. Effects of inferior oblique muscle-weakening surgery on the Bielschowsky head-tilt phenomenon in patients with superior oblique palsy habitually fixating with the paretic eye. Jpn J Ophthalmol 55, 525–533 (2011).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Superior oblique palsy
  • Paretic eye fixation
  • Inferior oblique recession
  • Corrective effect
  • Bielschowsky head-tilt phenomenon