Vertical Deviations

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V and A Pattern

  • Occur due to abnormal balance of horizontal vectors during upward and downward gaze
  • Can be caused by abnormal positioning of the rectus pulleys
  • Approximately 50% of strabismus forms have an associated A or V pattern

V Pattern

  • Significant if the difference between upward and downward gaze is >15 prism dioptres
  • Causes:
    • Primary inferior oblique overaction
      • 2/3 of patients with congenital esotropia
    • Trochlear nerve palsy (congenital, acquired)
    • Brown syndrome

A Pattern

  • Significant if the difference between upward and downward gaze is >10 prism dioptres
  • Can cause reading problems in binocular patients
  • Causes:
    • Primary superior oblique overaction
      • Usually associated with exodeviation in primary position
    • Inferior oblique underaction/paralysis with consequent superior oblique overaction

Dissociated Vertical Divergence (DVD)

  • Disease
    • Unclear etiology, associated with early loss of binocular vision
    • Usually occurs before the age of 1 year
    • Associated with congenital eso- and exotropia
  • Findings
    • Upward movement of the eye with excycloduction, when covered or spontaneously during visual inattention
    • Latent or manifest
    • Hering’s law does not apply to DVD
    • Usually bilateral, can be asymmetrical
    • Surgical correction possible if cosmetically unacceptable
  • Associations
    • Nystagmus
    • Inferior oblique overaction
    • Congenital esotropia
    • Present in isolation in about 40% of patients

Differential Diagnoses

Sources

  • EyeWiki Hypertropia
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Kalla Gervasio MD, Travis Peck MD et al; Lippincott Williams&Wilkins; 8th Edition (2021)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)