Comparison of subjective cyclovertical deviation and objective ocular torsion in sagging eye syndrome and superior oblique palsy.

Purpose: To compare the differentiating clinical features of subjective cyclovertical deviation and objective ocular torsion in elderly patients with cyclovertical sagging eye syndrome (CSES) versus superior oblique palsy (SOP). Study design: Prospectivestudy. Methods: Patients with CSES (n = 22) and unilateral SOP (n = 20) aged ≥50 years were included. Subjective cyclovertical deviation was measured in the primary, secondary, and third-gaze positions using a synoptophore. The disc-fovea angle (DFA), which evaluates objective ocular torsion, was measured using fundus photographs. Results: The subjective vertical deviation of the primary position was 1.3° (median) in the CSES group and 4.3° in the SOP group (p < .001). Vertical deviation was larger in the SOP than CSES group in all gaze positions (p < .05). The subjective cyclodeviation of the primary gaze was -6.0° (-: excyclo) in the CSES and SOP groups(p = .48). Cyclodeviation was larger in the SOP group in downgaze positions (p < .05). The mean DFAs were -11.5° in CSES group and -11.8° in SOP group for the hypertrophic eye (p = .85), and -12.2° in CSES group and -16.3° in SOP group for the hypotropic eye (p < .01). The ratio of patients with a larger DFA in the hypertropic than hypotropic eye was 9/22 (41.0%) in the CSES group and 4/20 (20%) in the SOP group. Conclusions: SOP has a larger hypertropia than SES. Excyclotorsion does not help distinguish in primary position but if it is somewhat larger in downgaze more likely SOP. DFA showed no obvious clinical differences; it is difficult to distinguish the two diseases from DFA.