Double elevator palsy.

The majority of patients with monocular limitation of elevation probably have an inferior restriction as the cause of limited elevation. When there is no vertical deviation in the primary position, the absence of a superior rectus palsy is most likely. Treatment of cases with inferior restrictions consists of recession of the tight inferior rectus and conjunctival recession. If the vertical deviation in the primary position is large enough, inferior rectus recession may be combined with superior rectus resection. When superior rectus palsy is the cause of limited upgaze, transposition surgery, utilizing the lateral and medial rectus muscles transposed to the superior rectus insertion, can be utilized. This often results in significant correction of the vertical deviation in primary gaze, but only yields modest improvement of elevation. Restrictions, which may also be present, must first be released before transposition surgery can succeed. The evidence suggests that rarely need the mechanism of "double elevator palsy" be invoked to explain monocular limitation of elevation. When there is true weakness of elevation, superior rectus palsy alone can account for the clinical findings.