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• Vertical Strabismus refers to a vertical misalignment of the visual axes of the two eyes in the vertical direction in any of the nine cardinal positions of gaze.
• Vertical Strabismus is more symptomatic than horizontal Strabismus.
• Usually, the vertical recti or the oblique muscles are involved.
• This could be Comitant (Deviation that is the same magnitude regardless of gaze position) or Incomitant (it’s magnitude varies as the patient shifts his or her gaze).
• Associated with horizontal deviation.
•  Types are—

▪︎Hypertropia:– non Fixating eye is higher than Fixating eye.

▪︎Hypotropia:– Fixating eye is higher than non Fixating eye.

CLASSIFICATION OF VERTICAL STRABISMUS :

1. Depending upon the constancy of deviation hyperphoria

• Intermittent Hypertropia
  • Hypertropia

• The direction of deviation in the non Fixing eye

• Hypertropia
  • Hypotropia

• Depending upon the competence of deviation

1. Comitant vertical deviation

• Refractive (induced)
  • End result of long-standing Paralytic deviation

• Incomitant vertical deviation

• Apparent oblique muscle dysfunction interior oblique overaction Inferior oblique Underaction Superior oblique overaction Superior oblique Underaction

• Paretic vertical deviation Congenital unilateral Superior oblique paresis-congenital Superior oblique paresisBilateral Superior oblique paresisMonocular Elevation deficiency Monocular depression deficiency Superior rectus paresis Inferior rectus paresis Skew deviation

• Restrictive vertical deviation-

1. Vertical deviations in Duane’s retraction syndrome. Brown’s syndrome Congenital muscle fibrosis Dysthyroid orbitomyopathy.Post-traumatic orbital wall fractures.Tumors, pseudotumors, and cysts in the orbit.

• Dissociated vertical deviation (DVD)

• Monocular DVD
  • Binocular or alternating DVD

ETIOLOGY :

• Convertion of Incomitant Paralytic hyperdeviation.
•  Ocular muscle weakness  
• Central ocular control disturbances
• Underaction of extraocular muscles.
• Secondary to hemorrhage or mechanical trauma with extraocular muscle atrophy.
• Traumatic neuroparesis.
• Secondary fibrosis of the extraocular muscles.
• Unequal refractive correction.

CLINICAL FEATURES :

Signs:‐

Common signs include —

• Ocular deviation in the vertical direction in any of the nine cardinal positions of gaze position of gaze with either eye fixing on the Hirschberg test and prism cover test.
• Ocular motility tests can show the limitation of movements in the vertical direction.

Symptoms:‐

• Commonly Intermittent than constant.
• Suppression

• Vertical Diplopia
• Amblyopia

• Vertical anomalous retinal correspondence
• Vertical deviation of the eye.
• Abnormal head posture – Tilting of head and chin up or down.

• Repeated measurement shows the overaction of one or more cyclovertical muscle.

TREATMENT :

1. Orthotics:—
2. to eliminate suppression may be indicated prior to surgery.
3. It is impossible to improve Vertical fusional vergence through Orthotic training.

• Prismotherapy:—
• Smaller than 11D can correct prism

              Hypertropia = 5pd BD

              Hypotropia = 5pd BO

• Surgical correction