Motsch S., Mühlendyck H.

Department of Strabismology and Neuroophthalmology, University Eye- Clinic; Robert-Koch-Str. 40, 37075 Göttingen, Germany

Introduction: In patients with severe head tilt caused by superior oblique palsy often only a very small excyclodeviation (5-8°) is measured although the Bielschowsky head tilt test is strongly positive (on the side of the head tilt almost no vertical deviation while on the opposite side up to 15°).
Method: The type of muscle surgery to be performed was determined by the vertical deviation in side gaze in the direction of action of the involved superior oblique muscle while the head tilt remained unchanged. If there was no vertical deviation under these conditions only the anterior part of the tendon was tucked and transposed towards the corneal limbus (modified Harada-Ito operation)
Results: In most cases we found the superior oblique tendon insertion further back from the corneal limbus than normal. For a short time postoperatively an incyclodeviation with a paradox Bielschowsky test was present. Both phenomena usually resolved within a few days. In several cases the head tilt with similar clinical findings reappeared so that the operation had to be reinforced.
Summary: The disproportion between measurable and real excyclodeviation in cases with a marked Bielschowsky phenomenon might be explained as follows. The cyclo component of the paretic superior oblique action is compensated for by an increased innervation of the ipsilateral superior rectus muscle. This leads to a reduction of the excyclodeviation that is measured. According to our results these cases should be treated by tucking the anterior part of the superior oblique tendon only.

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