Selective plication and grading of plication for correction of torsion in superior oblique palsy

Acquired palsy of the trochlear nerve has been associated with closed-head injuries. We report the case of a 33-year-old male patient, who presented with complaints of torsional diplopia in the straight gaze which increased in the down gaze following head trauma. After a detailed ophthalmic evaluation, the patient was diagnosed with bilateral superior oblique (SO) palsy causing torsional diplopia. To counteract excyclotorsion, we have plicated the anterior one-third of the fibers of the SO in both eyes. Postoperatively, the patient was diplopia free and orthophoric, which maintained up to 3-month follow-up. Correction of excyclotorsion by selective plication of anterior fibers of the SO has already been reported in literature. However, the amount of plication to be performed for various degrees of torsion has not been appropriately described in the previously reported articles. We aim to improve the efficacy of plication anterior fibers of the SO by objective gradation.