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Year : 1962  |  Volume : 10  |  Issue : 4  |  Page : 103-106

Superior oblique sheath syndrome

Institute of Ophthalmology, Calcutta, India

Date of Web Publication17-Mar-2008

Correspondence Address:
I S Roy
Institute of Ophthalmology, Calcutta
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How to cite this article:
Roy I S. Superior oblique sheath syndrome. Indian J Ophthalmol 1962;10:103-6

How to cite this URL:
Roy I S. Superior oblique sheath syndrome. Indian J Ophthalmol [serial online] 1962 [cited 2021 Jun 21];10:103-6. Available from: https://www.ijo.in/text.asp?1962/10/4/103/39556

The purpose of this paper is to reveal the nature of a type of verti­cal squint due to congenital abnor­mality of the sheath of the superior oblique muscle which prevents the active and passive elevation of the eye in adducted position.

It was first reported by H. W. Brown (1949). So far no such case has yet been reported from India and so the following two cases are reported in this country for the first time.

A short description of the sheath and tendon of the superior oblique muscle is necessary to understand the mechanism of the syndrome. The strong fibrous sheath of superior oblique tendon has two attachments, one in front to the outer margin of the pulley and the other behind on the postero-superior quadrant of the eye ball along with the tendon of insertion of the superior oblique muscle. The linear distance from the pulley to the in­sertion of the muscle decreases on adduction and increases on adduc­tion of the eye. [Figure - 1]. Normally this sheath acts as the check liga­ment of the inferior oblique muscle. If however, the sheath is taut in the primary position adduction will not be possible unless the eye is de­pressed. [Figure - 2].

The superior oblique sheath syn­drome is a structural anomaly of the anterior tendon sheath ap­parently associated with congenital paralysis of the inferior oblique muscle. The anterior tendon sheath of superior oblique is congenitally short and so it is quite natural that the action of the inferior oblique gets restricted. This restriction is only manifested when the sheath is taut due to increase in the linear distance from the pulley to the in­sertion during the adduction of the affected eye. This abnormal short­ening of the sheath will also restrict any passive elevation of the affect­ed eye in the adducted position. In the true sense the inferior oblique could elevate or a passive elevation would have been possible had the tightness of the sheath been relaxed. Brown has shown that transverse section of the sheath makes the passive elevation possible and there is some improvement in the action of inferior oblique too. There is con­siderable improvement in the head tilt as well. Johnson (1950), Lyle (1953), Nutt (1954) have shown that severance or partial excision of the sheath makes the passive elevation possible with some improvement of the action of inferior oblique action. Duke-Elder has labelled these rather rare cases under the heading of "Insufficiency of the Inferior Obli­que". He thinks its occurrence may be due to its late developmental se­paration from the inferior rectus. The restricted active and passive elevation of the eye in adducted position give support to Brown's view of a short superior oblique sheath.

Following clinical characteristics are noted :­

1. Failure of the elevation move­ment of the affected eye beyond the horizontal plane when it is fully adducted This paralysis of inferior oblique is apparent.

2 As the affected eye is made to follow a finger from the abduct­ed and elevated position to one of adduction and elevation the limit of elevation will be parallel to a straight line joining the inner canthus to nearly normal limit of elevation in the midline.

3. When the affected eye is abducted, there will be nearly normal muscle equilibrium.

4. There is sometimes widening of the palpebral fissure on adduc­tion.

5. Traction test is positive i.e. the passive elevation of the eye in adducted position will be re­stricted. Surgical treatment like cutting the sheath of superior oblique and strengthening of the inferior oblique is only ad­vocated when there is a disfigur­ing backward head tilt.

Case 1. G. R., Muslim, 23 years of age, of average health who was a sea-man by profes­sion had a vertical squint in the upward gaze to the left for as long as he could remember and was not bothered by it. For his dimness of vision he attended the ophthalmic department of Medical College Hospital on 12-10-60. Right vision im­proved to 6/6 with-0.25D sph. -1.50D cyl. 125' and left vision improved to 6/6 with -0.50D sph. -1.75D cyl. 55 . The extra ocular movements revealed the following features. In the primary position there was slight narrowing of the palpebral fissure of the right eye and eyes were almost straight. In the upward gaze to the left the elevation of the right eye was limited to the horizontal plane and during adduction there was some amount of widening of the right palpebral fissure. Cover test revealed left hyper­phoria in the upward gaze to the right. Muscle balance was normal in the downward gaze to the left or right. The right eye could not be elevated above the horizontal plane with a pair of forceps under anaesthesia. Hess chart revealed an under acting inferior oblique on the right and an overact­ing superior rectus on the left. As there was no subjective symptom, opera­tive treatment was not advised.

Case 2. F. S. Christian, 5 years of age, was brought to the ophthalmic department, Medical College Hospital, by her mother for the in­vestigation of the peculiar vertical squint. She had a backward head tilt with a slight turn to the left since age 6 months. In the primary position the eyes were straight. In the up­ward gaze to the left there was marked limitation of elevation of the right eye. There was normal muscle balance in all other posi­tions of gaze. Traction test could not be performed as the mother did not allow a general anaesthe­tic.[3]

Acknowledgement:- Thanks are due to Prof. K. L. Sen and Prof. M. Sengupta for their kind permission to publish these cases.

  References Top

Allen, J. H. (1958), Strbismus Ophthalmic Symposium II, C. V. Mosby Company, St. Louis p. 410­  Back to cited text no. 1
Brown, II. W. (1950).  Back to cited text no. 2
Duke-Elder, W. S. (1949), Text book of Ophthalmology, Henry Kimpton, London, Vol. IV, p. 4087.  Back to cited text no. 3


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


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