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CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 39-40

Double elevator palsy with hypotropia, exotropia, and ptosis with dissociated vertical deviation in other eye managed with knapp's procedure


1 Department of Ophthalmology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Ophthalmology, Baroda Medical College, Vadodara, Gujarat, India

Date of Web Publication8-May-2017

Correspondence Address:
Akash Pankaj Shah
27-A Shrinagar Society, Productivity Road, Akota, Vadodara - 390 020, Gujarat
India
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DOI: 10.4103/1858-6538.205800

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  Abstract 

The aim of this study is to report a case of double elevator palsy (DEP) managed with Knapp's procedure. An 18-year-old female presented to us with a complaint of drooping of the right eyelid since childhood. Best-corrected visual acuity was 6/12 in right eye and 6/6 in left eye. Elevation in right eye was absent. Her right eye showed 14–16 prism diopter (PD) hypotropia with 10 PD exotropia, and the left eye showed dissociated vertical deviation (DVD). Her palpebral fissure height was 6 mm in right eye and 9 mm in left eye with marginal reflex distance-1, 1 and 4 mm, respectively. Levator palpebrae superioris action was 7 mm in right eye and 14 mm in left eye. Bell's phenomenon was absent in right eye. Diagnosis of right eye DEP with ptosis and exotropia on left eye DVD was made. Knapp procedure in right eye was performed with postoperative orthophoria in primary position. Knapp's procedure is the surgery of choice in a case of DEP.

Keywords: Double elevator palsy, Knapp's procedure, ptosis


How to cite this article:
Shah AP, Shah A, Singh MD, Kotadia B. Double elevator palsy with hypotropia, exotropia, and ptosis with dissociated vertical deviation in other eye managed with knapp's procedure. Albasar Int J Ophthalmol 2017;4:39-40

How to cite this URL:
Shah AP, Shah A, Singh MD, Kotadia B. Double elevator palsy with hypotropia, exotropia, and ptosis with dissociated vertical deviation in other eye managed with knapp's procedure. Albasar Int J Ophthalmol [serial online] 2017 [cited 2021 Jul 29];4:39-40. Available from: https://www.bijojournal.org/text.asp?2017/4/1/39/205800


  Introduction Top


Paralysis of both elevator muscles (superior rectus [SR] and inferior oblique [IO] 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. Fixation with paretic will cause a hypertropia of the nonparetic eye, and ptosis may disappear provided the levator palpebrae superioris (LPS) 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.[1]


  Case Report Top


We reported an 18-year-old female presented to us with a chief complaint of drooping of the right eyelid since birth. She has no history of trauma. There was no evidence of endocrine myopathy or family history of the same complaint. Her best-corrected visual acuity was 6/12 in right eye and 6/6 in left eye. On examination, she has ptosis in the right eye [Figure 1]. Her palpebral fissure height was 6 mm in right eye and 9 mm in left eye. Her marginal reflex distance-1 was 1 mm in right eye and 4 mm in left eye. LPS action was 7 mm in right eye and 14 mm in left eye with Burke's method. Bell's phenomenon was absent in right eye and present in left eye. Her right eye elevation was absent. Leavo- and dextro-elevation were also absent. Forced duction test (FDT) is negative. Other ocular movements were normal [Figure 2]. She has 14–16 prism diopter (PD) hypotropia with 10 PD exotropia in right eye and dissociated vertical deviation (DVD) in left eye. Anterior segment examination was within normal limits of both eyes. Posterior segment examination of both eyes also reveals no abnormality. On the basis of above history and examination, diagnosis of the right eye double elevator palsy (DEP) with hypotropia, exotropia, and ptosis with the left eye DVD was carried out. The patient underwent Knapp's procedure in the right eye. Postoperatively, she was orthophoric in primary gaze [Figure 3]. Her elevation was improved.
Figure 1: Right eye: Ptosis with exotropia

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Figure 2: Preoperative right eye hypotropia and exotropia in primary position with the absence of elevation in right eye

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Figure 3: Postoperative photograph showing orthophoria in primary position

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  Discussion Top


DEP of one eye that results in a hypotropia on the affected side is unusual. DEP with DVD is rare. It may be congenital or acquired. Etiology may lie in inherited faulty ectodermal organization early in fetal life or on nuclear damage from fine brain hemorrhages at the time of birth. The anatomic improbability that both SR and IO weakened by a single lesion suggest that a long-standing SR palsy may be underlying cause. The acquired cases have all been adults who have small lesions in the pretectum.[2] There are many choices available for the surgery of this DEP. The etiopathogenesis of this condition is heterogeneous, which makes it difficult to treat it with a single surgical formula. Successful alignment of DEP has been described following different surgical modalities. The procedure of choice is determined by the FDT, which ascertains whether the cause is either paretic due to SR palsy and/or IO palsy or restrictive due to inferior rectus (IR) restriction.[3] Surgical treatment by transferring the entire tendon of both the medial and lateral rectus muscle to the ends of the SR insertion. The Knapp's procedure is the surgery of choice. If IR muscle is restricted, it has to be recessed. Knapp reported 15 patients in whom correction of hypotropia ranged from 21 to 55 PD with a mean of 38 PD. Good results were obtained in 14 out of 15 patients (93%).[4]


  Conclusion Top


Knapp's procedure is the surgery of choice with the recession of IR if it is restricted in a case of DEP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bavishi AK, Patel CK, Nagari Muni CH. Double elevator paralysis (a study of 15 cases). Indian J Ophthalmol 1979;27:135-6.  Back to cited text no. 1
  [Full text]  
2.
Jampel RS, Fells P. Monocular elevation paresis caused by a central nervous system lesion. Arch Ophthalmol 1968;80:45-57.  Back to cited text no. 2
    
3.
Bandyopadhyay R, Shetty S, Vijayalakshmi P. Surgical outcome in monocular elevation deficit: A retrospective interventional study. Indian J Ophthalmol 2008;56:127-33.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Knapp P. The surgical treatment of double-elevator paralysis. Trans Am Ophthalmol Soc 1969;67:304-23.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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