Differential Diagnosis and Management of Hyperdeviations: Non-4th Nerve Palsy—Dissociated Vertical Deviations and Skew Deviations

Abstract

The differential diagnosis and management of dissociated vertical deviation (DVD), inferior oblique overaction (IOOA), and skew deviation are reviewed. As with other types of strabismus, there is no universal consensus on the exact treatment methods of these hyperdeviations. Management is guided by the clinical context and the magnitude and frequency of the deviation. Some patients are observed with optimal refractive correction; others undergo surgical intervention when clinically indicated. Superior rectus recessions are typically performed to treat significant DVD. In cases of DVD with concurrent IOOA, anterior transposition of the inferior oblique insertion may be considered. Primary IOOA, as is commonly seen in association with infantile esotropia, is typically managed with inferior oblique recession or myectomy. In cases of secondary IOOA, correction of the primary problem should be considered in order to control the IOOA. Hyperdeviations that have patterns different from those of a cranial nerve palsy, DVD, or oblique dysfunction are known as skew deviations and are notoriously difficult to manage and may require evaluation with neuroimaging.