Vertical deviations

Causes

• Oblique muscle abnormalities (palsies/overaction)

  • Inferior oblique overaction
  • DVD

• Mechanical (normal saccadic velocity)

  • Congenital fibrosis of the extraocular muscles (CFEOM)
  • Thyroid eye disease
  • Myasthenia gravis
  • Trauma/orbital fracture

• Neurological (slowed saccades)

  • Third nerve palsy
  • Fourth nerve palsy (superior oblique palsy)
  • Double elevator palsy (see vertical gaze palsies)
  • Skew deviation
  • Superior oblique myokymia

Inferior oblique overaction

• Common vertical deviation
• Strong association with infantile esotropia. Contributes to:
  • Larger horizontal deviation
  • V pattern
• May also be due to primary or secondary paresis of IO
• Hypotropia of fellow eye
• Surgery with IO recession, myomectomy, extirpation or denervation depending on severity