Strabismus pp 115-141 | Cite as

Vertical Deviations

  • Burton J. Kushner


Like horizontal deviations, vertical deviations can be paretic or non-paretic. Proper diagnosis of non-paretic deviations relies on history (infantile onset, prior surgery, trauma, etc.), and relevant systemic illness (thyroid eye disease [TED], etc.). The diagnosis of paretic deviations relies on the pattern of misalignment and ductions and versions. In general, the greatest deviation will be in the field of action of the paretic muscle, unless secondary changes have occurred in other muscles, e.g., contracture causing a spread of comitance. The Parks three-step test relies on this principle [1], taking the actions of the muscles on forced head tilt into account according to the teachings of Bielschowsky [1, 2]. The three-step test has become the mainstay in diagnosing vertical strabismus. However, it is only designed to tell which of the eight cyclovertical muscles might be palsied. It does not tell if you are in fact dealing with a palsy of one cyclovertical muscle. And when patient presents to you, it is your job to determine whether or not that is what your patient has. There are numerous causes of vertical strabismus for which the three-step test may incorrectly implicate one muscle as being paretic.


Anti-elevation syndrome Brown syndrome Cranioacial syndromes Dissociated vertical divergence (DVD): Definition, Pathophysiology, Treatment Duane syndrome Inferior oblique (IO) anterior transpositions Inferior oblique (IO) overaction IO palsy Myasthenia Overdepression in adduction Overelevation in adduction Prism under cover test Pulley abnormalities Restriction Skew Superior oblique (SO) Superior oblique palsy (SOP) SO incarceration SO overaction Three Step Test: Errors in Torsion-objective Torsion-subjective Vertical rectus overaction Vertical rectus palsy Vertical strabismus: Diagnosis, Measurement of 


  1. 1.
    Parks MM. Isolated cyclovertical muscle palsy. Arch Ophthalmol. 1958;60:1027–35.CrossRefGoogle Scholar
  2. 2.
    Bielschowsky A. Lectures on motor anomalies: I. The physiology of ocular movements. Am J Ophthalmol. 1938;21:843–55.CrossRefGoogle Scholar
  3. 3.
    Kushner BJ. Errors in the three-step test in the diagnosis of vertical strabismus. Ophthalmology. 1989;96:127–32.CrossRefPubMedGoogle Scholar
  4. 4.
    Jampolsky A. Management of vertical strabismus. In: Symposium on pediatric ophthalmology: transactions of the New Orleans academy of ophthalmology. New York: Raven; 1986. p. 141–71.Google Scholar
  5. 5.
    Bechtel RT, Kushner BJ, Morton GV. The relationship between dissociated vertical divergence (DVD) and head tilts. J Pediatr Ophthalmol Strabismus. 1996;33:303–6.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Wong AM. Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy. J AAPOS. 2010;14:61–7.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Moore S, Cohen R. The head tilt test in horizontal strabimsus. Am Orthopt J. 1987;37:105–8.CrossRefGoogle Scholar
  8. 8.
    Kushner BJ. Ocular torsion: rotations around the “WHY” axis. J AAPOS. 2004;8:1–12.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Jampolsky A. Superior rectus revisited. Trans Am Ophth Soc. 1981;79:243–56.Google Scholar
  10. 10.
    Kushner BJ. Multiple mechanisms of extraocular muscle “overaction”. Arch Ophthalmol. 2006;124:680–8.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Capo H, Guyton DL. Ipsilateral hypertropia after cataract surgery. Ophthalmology. 1996;103:721–30.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kushner BJ. Extraocular muscle contracture and overaction syndrome occurring after periocular anesthesia. J AAPOS. 2004;8:182–3.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kushner BJ. The diagnosis and treatment of bilateral masked palsy. Am J Ophthalmol. 1988;105:186–94.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kushner BJ. Simulated superior oblique palsy. Ann Ophthalmol. 1981;13:337–43.PubMedGoogle Scholar
  15. 15.
    Ellis FJ, Stein LA, Guyton DL. Masked bilateral superior oblique muscle paresis. A simple overcorrection phenomenon? Ophthalmology. 1998;105:544–51.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kushner BJ. The inferior oblique muscle adherence syndrome. Arch Ophthalmol. 2007;125:1510–4.CrossRefGoogle Scholar
  17. 17.
    Kushner BJ. Restriction of elevation in abduction after inferior oblique anteriorization. J AAPOS. 1997;1:55–62.CrossRefGoogle Scholar
  18. 18.
    Santiago AP, Isenberg SJ, Apt L, Roh YB. The effect of anterior transposition of the inferior oblique muscle on ocular torsion. J AAPOS. 1997;1:191–6.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Kushner BJ. Torsion as a contributing cause of the anti-elevation syndrome. J AAPOS. 2001;5:172–7.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Clark RA, Miller JM, Rosenbaum AL, Demer JL. Heterotopic muscle pulleys or oblique muscle dysfunction? J AAPOS. 1998;2:17–25.CrossRefGoogle Scholar
  21. 21.
    Demer JL. The orbital pulley system: a revolution in concepts of orbital anatomy. Ann N Y Acad Sci. 2002;956:17–32.CrossRefGoogle Scholar
  22. 22.
    Kushner BJ. Pseudo Inferior oblique overaction associated with Y and V patterns. Ophthalmology. 1991;98:1500–5.CrossRefGoogle Scholar
  23. 23.
    Wilson M, Hoxie J. Facial asymmetry in superior oblique muscle palsy. J Pediatr Ophthalmol Strabismus. 1993;30:315–8.PubMedGoogle Scholar
  24. 24.
    Rao R, Morton G, Kushner B. Ocular torticollis and facial asymmetry. Binocul Vis Strabismus. 1999;14:27–32.Google Scholar
  25. 25.
    Smith J, Flynn J, Spiro H. Monocular vertical oscillations of amblyopia. The Heimann-Bielschowsky phenomenon. J Clin Neuroophthalmol. 1982;2:85–91.PubMedGoogle Scholar
  26. 26.
    Guyton DL. Exaggerated traction test for the oblique muscles. Ophthalmology. 1981;88:1035–40.CrossRefGoogle Scholar
  27. 27.
    Kushner BJ. Superior oblique tendon incarceration syndrome. Arch Ophthalmol. 2007;125:1070–6.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kushner BJ. Vertical rectus surgery for Knapp class II superior oblique muscle paresis. Arch Ophthalmol. 2010;128:585–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Awadein A, Pesheva M, Guyton DL. “inverted Brown pattern”: a tight inferior oblique muscle masquerading as a superior oblique muscle underaction—clinical characteristics and surgical management. J AAPOS. 2006;10:565–72.CrossRefPubMedGoogle Scholar
  30. 30.
    Sato M. Magnetic resonance imaging and tendon anomaly associated with congenital superior oblique palsy. Am J Ophthalmol. 1999;127:379–87.CrossRefPubMedGoogle Scholar
  31. 31.
    Jampolsky A. A new look at the head tilt test. In: Fuchs A, Brandt T, Buttner U, Zee DS, editors. Contemporary ocular motor and vestibular research: a tribute to David A Robinson. Stuttgart: Thieme; 1994. p. 432–9.Google Scholar
  32. 32.
    Kushner BJ. Multiple mechanisms of extraocular muscle “overaction”. Arch Ophthalmol. 2006;124:680–8.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Kushner BJ. The effect of anterior transposition of the inferior oblique muscle on the palpebral fissure. Arch Ophthalmol. 2000;118:1542–6.CrossRefGoogle Scholar
  34. 34.
    Kushner BJ. ‘V’ esotropia and excyclotropia after surgery for bilateral fourth nerve palsy. Arch Ophthalmol. 1992;110:1419–22.CrossRefPubMedGoogle Scholar
  35. 35.
    Guyton DL, Cheeseman EW Jr, Ellis FJ, Straumann D, Zee DS. Dissociated vertical deviation: an exaggerated normal eye movement used to damp cyclovertical latent nystagmus. Trans Am Ophthalmol Soc. 1998;96:389–424.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Guyton DL. Dissociated vertical deviation: etiology, mechanisms, and associated phenomena. Costenbader Lecture J AAPOS. 2000;4:131–44.CrossRefPubMedGoogle Scholar
  37. 37.
    Brodsky MC. Dissociated vertical divergence: a righting reflex gone wrong. Arch Ophthalmol. 1999;117:1216–22.CrossRefPubMedGoogle Scholar
  38. 38.
    Esswein MB, von Noorden GK, Coburn A. Comparison of surgical methods in the treatment of dissociated vertical deviation. Am J Ophthalmol. 1992;113:287–90.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Schwartz T, Scott W. Unilateral superior rectus recession for the treatment of dissociated vertical deviation. J Pediatr Ophthalmol Strabismus. 1991;28:219–22.Google Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Burton J. Kushner
    • 1
  1. 1.Department of Ophthalmology and Visual SciencesUniversity of Wisconsin-MadisonMadisonUSA

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