Tuesday, September 11, 2018

Question: Squint manifestations


A patient presented with his head tilted towards right. On examination, he was having Left hypertropia which is increased on looking towards right or medially. The muscle which is mostly likely paralyzed is?
1) Left superior oblique
2) ‎Left inferior oblique
3) ‎Right superior oblique
4) ‎Right inferior oblique
Answer in 24 hours

Answer is 1) Left superior oblique

So, you can see above question is based on Park 3 steps method. I will try to simplify it as much as possible. Let us try to find out what essential information we get from above from above question. So I find three things.

-Left hypertropia.
-Increases on looking towards right.
-Head tilted towards right  (For compensating diplopia)

To proceed further, I want you to take care of two things .
1) Draw clinical eye movement diagram for squint not anatomical diagram
2) In this technique we go with parameters which increases diplopia for patients.

So, hold your horses and let us get started.

Step 1: Left hypertropia= Right hypotropia

So, basically you have to solve now question for two eyes instead of one. This is the same reason option 3 and option 4 could be right as well. So, when you draw clinical diagram for same you have to highlight muscles which are paralyzed leading to above criteria.

So, left hypertropia is caused by paralysis of the inferior muscles - Superior oblique and Inferior rectus.
In right hypotropia, superior muscles are paralyzed -Inferior oblique and Superior rectus. 
So our diagram will be as follow. We need to concentrate on four muscles only

Step 2: Now let us go to second clue. Diplopia increases on looking towards right. So, out of our four selected muscles let us see which muscles moves eyeball towards right.
 In right eye, it is Superior rectus.
In left eye, it is Superior oblique.

Our diagram will be as follow and your muscles will be narrowed down to two. Each from one eye.

Step 3: So this is final step. The End game. (Reminds me Taylor swift!)

  We have one last finding and that is patient's head is tilted towards right. Remember that this is compensatory method of patient for avoiding diplopia which actually suggests that patient is experiencing diplopia maximum when head is tilted towards left.

So in our last step we will be using clue as head tilted towards left! (Remember we go to maximum diplopia.)

So, this time hold your pencil in the centre of our clinical diagram and tilt it towards left. Obviously do this for both eyes individually. Simply like this
Now, this will narrow down your two muscles into one. Let us do it for right eye first. We will get muscle IO which is not among of our selected two muscles so discard it. Now go to left eye, do same over here. You will get answer as SO

Hope that makes your job easy as far as squint is considered.
-Demotional bloke

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