Indian Journal of Ophthalmology

: 1979  |  Volume : 27  |  Issue : 4  |  Page : 135--136

Double elevator paralysis (A study of 15 cases)

Anil K Bavishi, CK Patel, CH Nagari Muni 
 Eye Hospital, Ellis Bridge, Ahmedabad-6, India

Correspondence Address:
Anil K Bavishi
Eye Hospital, Ellis Bridge, Ahemadabad-6

How to cite this article:
Bavishi AK, Patel C K, Nagari Muni C H. Double elevator paralysis (A study of 15 cases).Indian J Ophthalmol 1979;27:135-136

How to cite this URL:
Bavishi AK, Patel C K, Nagari Muni C H. Double elevator paralysis (A study of 15 cases). Indian J Ophthalmol [serial online] 1979 [cited 2021 Dec 8 ];27:135-136
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Full Text

Paralysis of both elevator muscles (superior rectus and inferior oblique muscles) is an unusual but not uncommon anomaly of ocular motility. When the patient fixates with the nonparetic eye, the paretic eye will take a hypotropic position and the upper lid may be showing Ptosis. Fxation with paretic will cause a hypertropia of the nonparetic eye, and ptosis may disappear provided the levator palpebrae superioris is not involved. Elevation of the paretic eye from any position of gaze is severely restricted and Bell's phenomenon may be present or absent. A family history of strabis­mus may be positive.

Observations Comments:

In last two years 15 such cases were studied. They are of four different groups:

Group-I Double elevation palsy with pseud­optosis

Group-1I Double elevation palsy with ptosis

Group-III Double elevation palsy with pseud­optosis, affection of one or more branches of oculo motor Nerve.

Group-IV Bilateral double elevation palsy with ptosis with alternate divergent squint.

All these cases were thoroughly examined to rule out any evidence of non-neurogenic pathology. There was no history of trauma, no evidence of endocrine myopathy or myas­thenia gravis, no evidence of tumour restricting the movements of the eye, or fracture of the base of the orbit. A positive force duction test will easily distinguish these conditions from double elevation palsy. In each case examina­tion was done for Bell's Phenomenon which was present in 9 out of 15 cases. 10 cases were purely congenital while in the remaining 5, exact history was not available but it was present since early childhood. Age group in these series varied from 10 years to 60 years and there were 10 males and 5 females. A family history of strabismus was positive in 4 out of 15 cases.

The amount of under-action varies in diffe­rent cases. The usual clinical picture varies with the fixing eye. It is either a cosmetically noticable hypertropia in one eye or both. It is most important to evaluate the lid droop by cover test so as to establish and varify the differential diagnosis of true and pseudoptosis. Failure to recognise this defect can lead to disaster of improper surgical intervention for presumed ptosis, where only pseudoptosis existed. I have seen two cases where ptosis correction was done with no benefit.

Fixation pattern varies in these conditions. We found three patterns. Fixation with the sound eye in 14 cases, fixation with the paretic eye in one case. Alternate fixation in 5 cases. Diplopia was absent in all cases.

Aetiology of this condition is obscure. In this series we have excluded acquired cases due to local muscular or orbital conditions of trauma. Aetiology may lie in inherited faulty ectodermal organisation early in foetal life or on nuclear damage from fine brain haemorrhages at the time of birth. Alder pointed out that a small defect in the extreme anterior portion of the ipsilateral third nerve nucleus can involve the superior rectus and inferior oblique innervation to create this defect. A point against the nuclear theory is the unlikely degree of selectivity and presence of Bell's phenomenon in many cases. A point in favour of the supranuclear theory is the presence of Bell's phenomenon.


Surgical Management in the past has been complicated because of a number of surgical choices. The surgeon could strengthen the defective elevators, weaken the secondarily deviating yoke muscles, weaken the secondarily contracted antagonist muscles or perform any combination of these muscles plus the additional surgery involved for the horizontal component.

We treated these cases by vertical displace­ment of horizontal muscles i.e. supraplacement of the horizontal recti of the involved eye, independent of the fixation status. We do displacement of full tendon width, so that the new insertions are approximately at the level with the insertion of superior rectus.

Any accompanying imbalance can be treated at the same time by combining the displacement with recession or resection of both the horizontal recti.

This procedure offers several advantages.

(1) only two muscles are utilised.

(2) The often complicated choice of what vertical muscle to attach is avoided.

(3) The amount of suraplacement can be graded more easily than grading procedure on vertical muscles.

(4) Any accompanying horizontal imbalance is treated by recession or resection or combina­tion on the two muscle at the same time.

(5) This surgery is monocular.

(6) If the procedure gives the inadequate correction the vertical muscles are still untouch­ed and can be operated as a second procedure.

(7) The procedure in selected cases carries a high success.

We did surgical procedure in five of these cases and the results have been unbelievably good. It is imperetive to remember that the manouver must be confined to those cases having a neurogenic aetiology.