Double Elevator Palsy

Question 1

What deviation is likely in a double elevator palsy?

Answer 1

hypophoria or Hypotropia (Both elevator muscles are not working in one eye e.g. the SR and IO)

Psuedoptosis or ptosis

Question 2

what is likely aetiology in double elevator palsy ?

Answer 2

Supranuclear in aetiology and usually congenital.
Acquired = contralateral + ipsilateral lesions in rostral midbrain interrupting riMLF to SR + IO.
Presence of Bell’s phenomenon suggests supranucleaur (secondary IR restriction mechanical can affect this)
Absence of Bell’s phenomemnon could indicate upper 3rd Nerve Palsy

Question 3

features of double elevator palsy

Answer 3

Ptosis/Pseudo Ptosis with Hypo deviation
BSV or hypotropia in PP
Intact Bell’s phenomenon if supranuelcear
Chin elevation esp if bilateral double elevator palsy
Minor degree of restriction on ip-gaze with FDT
Associated with Marcus-Gunn jaw winking phenomenon!

Question 4

Differential Diagnosis: double elevator palsy

Answer 4

Congenital fibrosis of IR or accentuated lower lid fold
Blow out fracture of orbital floor
TED
Brown’s syndrome (FDT will indicate severely mechanical)
Congenital absence of SR muscle
Upper division 3rd NP with concomitance spread
Contralateral SO palsy (affected eye used for fixation)

Question 5

non surgical tx for double elevator palsy

Answer 5

May not be required if px has BSV without the need for uncomfortable AHP

Question 6

indications for surgery in double elevator+ guidelines?

Answer 6

Indications
- Hypotropia and pseudoptosis in the primary position.
- Marked abnormal head posture.
- Ptosis interfering with fixation in the primary position or noticeably poor.
General Guidelines
- Strabismus surgery should be carried out before ptosis surgery.

Question 7

sx for double elevator

Answer 7

Procedure Details
- Passive restriction of up-gaze with the FDT is common.
- Surgical treatment involves vertical transposition of horizontal recti using a Knapp procedure.
- If FDT indicates significant contracture of the inferior rectus, recession of the muscle.
- Knapp procedure may be augmented with a Foster suture if necessary.
Undercorrection
- May arise from recession of the inferior rectus as the sole procedure.
- Early intervention required using a Knapp procedure and further recession of the inferior rectus if necessary.
- Botulinum toxin can be used as an alternative if the inferior rectus has already been maximally recessed.
- Performing only a Knapp procedure can lead to persistent hypotropia.
- Improvement in alignment can be achieved by recessing the ipsilateral inferior rectus.