Upward deviation of the eye is usually due to a paresis of one of the muscles that either elevate or depress the eye. Most of the time it is due to one specific muscle known as the superior oblique. The paresis may be congenital (born with it) or acquired. Most of the time, palsy of the superior oblique is congenital but may present itself later in life. For one reason or another the fusion system breaks down and the deviation becomes manifest. An inexperienced doctor may send this patient out for extensive neurological testing including MRI. There are tell tale signs that tell the sophisticated doctor that the turn has been there a long time and one does not have to worry about it such as a head tilt being present in old pictures, etc.
If the hypertropia is a decompensation of a congenital deviation, then treatment may consist of prism glasses and Vision Therapy. Our goal is fusion without prismatic glasses. However, often, treatment requires small amount of prism to hold the eyes in comfortable alignment. Treatment is highly successful. Surgery should be reserved for those cases that do not respond to Vision Therapy. However, if the deviation is newly acquired one must rule out serious neurological causes. Treatment, for newly acquired superior oblique palsies that do not resolve in 6 mos. time, may require surgery. In this case there is a poorer prognosis for complete repair.