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

<i>Purpose</i>: 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). <i>Study design</i>: Prospectivestudy. <i>Methods</i>: Patients with CSES (<i>n</i> = 22) and unilateral SOP (<i>n</i> = 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. <i>Results</i>: The subjective vertical deviation of the primary position was 1.3° (median) in the CSES group and 4.3° in the SOP group (<i>p</i> < .001). Vertical deviation was larger in the SOP than CSES group in all gaze positions (<i>p</i> < .05). The subjective cyclodeviation of the primary gaze was -6.0° (-: excyclo) in the CSES and SOP groups(<i>p</i> = .48). Cyclodeviation was larger in the SOP group in downgaze positions (<i>p</i> < .05). The mean DFAs were -11.5° in CSES group and -11.8° in SOP group for the hypertrophic eye (<i>p</i> = .85), and -12.2° in CSES group and -16.3° in SOP group for the hypotropic eye (<i>p</i> < .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. <i>Conclusions</i>: 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.