Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 4657
  • Home
  • Print this page
  • Email this page

   Table of Contents      
LETTER TO THE EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 86-87

Vertical synergistic divergence: To be or not to be, that is the quintessential question


Guru Nanak Eye Centre, Maulana Azad Medical College, University of Delhi, New Delhi, India

Date of Web Publication15-Feb-2013

Correspondence Address:
Pramod Kumar Pandey
Guru Nanak Eye Centre, Maulana Azad Medical College, University of Delhi, New Delhi - 110 002
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.107212

Rights and Permissions

How to cite this article:
Pandey PK, Vats P, Singh A, Rathi N, Sharma A, Sood S. Vertical synergistic divergence: To be or not to be, that is the quintessential question. Indian J Ophthalmol 2013;61:86-7

How to cite this URL:
Pandey PK, Vats P, Singh A, Rathi N, Sharma A, Sood S. Vertical synergistic divergence: To be or not to be, that is the quintessential question. Indian J Ophthalmol [serial online] 2013 [cited 2020 Apr 1];61:86-7. Available from: http://www.ijo.in/text.asp?2013/61/2/86/107212

Dear Editor,

We do not concur and reiterate that clinical picture cascades down consummately to a hallmark bilateral Brown Syndrome (BBS) presentation. [1],[2],[3] Documentation of forced duction test results, ductions, measurements of deviation in prism diopters in nine cardinal gazes with either eye fixing, fundus photographs for torsion, in tandem with findings on neuroimaging/surgical exploration and surgical outcomes would be seminal in sifting the maze, but reports skirt all of that. [1],[3]

Full bilateral elevation in abduction with gross bilateral limitation of elevation in adduction with down-shoot of adducted eye consistently in side, up and down gazes, with globes nailed in down position and negative head tilt test results, unequivocally cohere to a diagnosis of BBS. An alternative diagnosis can only be entertained in the presence of negative exaggerated forced duction tests, which were not done. [1],[3] The report is cryptic as to whether one or both eyes are having 3rd nerve palsy, the extent of involvement, recovery and aberrant innervation, if any present. [1],[3] Either eye is dipping in adduction, and the left eye will also dip if the right eye is allowed to fixate and elevate in slight abduction. [3] No light is shed on the plausible location/pathway/mechanism/causation of the expounded synergistic vertical divergence involving only the right eye, in view of the facts that up gaze fibers freely cross in the posterior commissure, whereas down gaze fibers are uncrossed, and the superior rectus (SR) receives crossed innervation through the opposite subnucleus. It follows that proposed synergistic divergence/convergence cannot be conflated via up gaze fibers at the supranuclear level.

Neither can it be conflated at the nuclear/infranuclear level. Superior oblique (SO) overactions (not known whether it is primary or secondary) as propounded [1],[3] do not produce globes nailed-in down gaze in adduction. In 3 rd nerve palsy, as the depressor action of SO is compromised, they instead cause intorsion. Thus, bilateral overdepression in adduction sans intorsion cannot be ascribed to bilaterally overacting SOs due to (right) 3 rd nerve palsy as surmised. [1],[3] There is nothing proximate to "no significant ocular torsion," as torsional position of the globe is a state and, therefore, it may only be normal or abnormal. [3] Further, the downshoot is only in adduction, not in abduction, and therefore cannot be explained by aberrant innervation of SR as SRs act in abduction. [1],[3] The SR has to be paretic to undergo aberrant innervation; the report does not state so [3] and resultant cocontraction of vertical recti on up gaze will engender convergence retraction instead.

Overaction of SOs, downshoot and widening of palpebral fissure in adduction is known in Brown Syndromes, and is the likely cause of asymmetrical underdepression of both eyes in abduction, the hallmark finding militating against BBS as per the report. [1] No perfidy will be committed anyway if congenital 3 rd nerve palsy and BBS coexist. In the absence of irrefutable documentary evidence on forced duction tests against BBS and nine gaze deviations fixing with either eye, no meaningful conclusions can be drawn about muscle overactions/underactions and any abstruse synergistic vertical divergence/convergence.

Thus, the proposed esoteric expositions about misinnervation and synergistic divergence are bereft of any neuroanatomical substrate at supranuclear/nuclear/infranuclear levels, and are overtly speculative, emanating from a skewed interpretation of a hallmark congenital BBS presentation. [1],[3]

 
  References Top

1.
Jethani J. Vertical synergistic divergence: A distinct separate entity. Indian J Ophthalmol 2010;58:556-7.  Back to cited text no. 1
  Medknow Journal  
2.
Pandey PK, Dadeya S, Singh A, Vats P, Rathi N. Misinnervation in 3 rd nerve palsy: Vertical synergistic divergence or consummate congenital bilateral Brown's syndrome with congenital ptosis? Indian J Ophthalmol 2010;58:555-6.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Jethani J. Misinnervation in 3 rd nerve palsy: Vertical synergistic divergence. Indian J Ophthalmol 2009;57:476-7.  Back to cited text no. 3
[PUBMED]  Medknow Journal  




 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
References

 Article Access Statistics
    Viewed2789    
    Printed16    
    Emailed0    
    PDF Downloaded110    
    Comments [Add]    

Recommend this journal