Hypertropia
Misaligned eyes The actressAmarna Miller has hypertropia.
Specialty	Ophthalmology

Hypertropia is a condition of misalignment of theeyes (strabismus), whereby thevisual axis of one eye is higher than the fellow fixating eye. Hypotropia is the similar condition, focus being on the eye with the visual axis lower than the fellow fixating eye.Dissociated vertical deviation is a special type of hypertropia leading to slow upward drift of one or rarely both eyes, usually when the patient is inattentive.

Refractive errors such ashyperopia andanisometropia may be associated abnormalities found in patients with vertical strabismus. The vertical miscoordination between the two eyes may lead to^{[citation needed]}

• strabismicamblyopia due to cerebral suppression of the deviating eye, particularly when onset occurs well before adolescence, while neural pathways are still highly plastic
• impaireddepth perception, especially in the same instances
• diplopia or double vision, particularly when onset occurs after childhood, when corresponding neural pathways have been so fixed as to prevent the brain from suppressing the deviant image
• cosmetic defect, most noticed by parents of a child so affected and in photographs
• face turn, depending on presence of binocular vision in a particular gaze
• cyclotropia, a cyclotorsional deviation of the eyes (rotation around the visual axis), particularly when the root cause is an oblique muscle paresis causing the hypertropia

Hypertropia may be either congenital or acquired, and misalignment is due to imbalance inextraocular muscle function. Thesuperior rectus,inferior rectus,superior oblique, andinferior oblique muscles affect the verticalmovement of the eyes. These muscles may be either paretic, restrictive (fibrosis) or overactive effect of the muscles. Congenital cases may havedevelopmental abnormality due to abnormal muscle structure, usually muscle atrophy / hypertrophy or rarely, absence of the muscle and incorrect placement.^{[citation needed]}

Specific & common causes include:

• Superior oblique Palsy /Fourth nerve palsy^{[citation needed]}
• Inferior oblique overaction^{[citation needed]}
• Brown's syndrome^{[citation needed]}
• Duane's retraction syndrome^{[citation needed]}
• Double elevator palsy^{[citation needed]}
• Fibrosis of rectus muscle inGraves Disease (most commonly inferior rectus is involved)^{[citation needed]}
• Surgical trauma to the vertical muscles (e.g. duringscleral buckling surgery or cataract surgery causing iatrogenic trauma to the vertical muscles).^{[citation needed]}

Sudden onset hypertropia in a middle aged or elderly adult may be due to compression of thetrochlear nerve and mass effect from a tumor, requiring urgent brain imaging usingMRI to localise anyspace occupying lesion. It could also be due to infarction of blood vessels supplying the nerve, due to diabetes and atherosclerosis. In other instances it may be due to an abnormality of neuromuscular transmission, i.e., Myasthenia Gravis.^{[citation needed]}

In general, strabismus can be approached and treated with a variety of procedures. Depending on the individual case, treatment options include:^{[citation needed]}

• Correction of refractive errors byglasses
• Prism therapy (if tolerated, to manage diplopia)
• Vision Therapy
• Patching (mainly to manageamblyopia in children and diplopia in adults)
• Botulinum toxin injection
• Surgical correction

Surgical correction of the hypertropia is desired to achieve binocularity, managediplopia and/or correct the cosmetic defect. Steps to achieve the same depend on mechanism of the hypertropia and identification of the offending muscles causing the misalignment. Various surgical procedures have been described and should be offered after careful examination of eyes, including a detailed orthoptic examination focussing on the disturbances in ocular motility and visual status. Specialty fellowship trainedpediatric ophthalmologists andstrabismus surgeons are best equipped to deal with these complex procedures.^{[citation needed]}

• List of systemic diseases with ocular manifestations

• Disorders of ocular muscles, binocular movement, accommodation and refraction

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