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Year : 2022  |  Volume : 15  |  Issue : 1  |  Page : 109-110  

Pseudo double elevator palsy

Department of Ophthalmology, Government Medical College, Nagpur, Maharashtra, India

Date of Submission19-Feb-2021
Date of Decision18-Jul-2021
Date of Acceptance18-Jul-2021
Date of Web Publication02-Mar-2022

Correspondence Address:
Dr. Rajesh Subhash Joshi
77, Panchatara Housing Society, Manish Nagar, Somalwada, Nagpur - 440 015, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_54_21

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Keywords: Cysticercosis, double elevator palsy, inferior rectus, intraconal tumors

How to cite this article:
Joshi RS. Pseudo double elevator palsy. Oman J Ophthalmol 2022;15:109-10

How to cite this URL:
Joshi RS. Pseudo double elevator palsy. Oman J Ophthalmol [serial online] 2022 [cited 2023 Mar 26];15:109-10. Available from: https://www.ojoonline.org/text.asp?2022/15/1/109/338893

A 22-year-old male presented to the outpatient department of ophthalmology with complaints of binocular diplopia in upward gaze, pain, and proptosis of the right eye for 2 months. On examination, visual acuity of both eyes was 20/20. Axial proptosis of the right eye was observed (right eye 22 mm and left eye 20 mm). On palpation, no mass was felt and no local tenderness was noted. The ocular movements of the right eye were restricted in the upward and downward gaze. In the primary position, the right eye was hypotropic by 12 Δ [Figure 1] and [Figure 2]. Magnetic resonance imaging (MRI) of the orbit and brain revealed a well-defined oval lesion measuring 1.4 mm × 2.7 mm involving the posterior aspect of the right inferior rectus. Marked enlargement of the inferior rectus was observed [Figure 3]. Cystic areas were observed within the lesion. No signs of neurocysticercosis were observed. The patient was administered an oral dose (15 mg/kg body weight) of albendazole divided into two doses for 4 weeks combined with oral prednisolone acetate at a dose of 1 mg/kg body weight once daily for 3 weeks. The doses were then tapered over 2 weeks, following which the patient started showing signs of improvement. Within 2 months, the diplopia resolved and proptosis started resolving. MRI of the orbit after 4 months showed complete regression of the lesion.
Figure 1: Showing restriction of right eye movement in up gaze

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Figure 2: Showing restriction of the right eye movement in down gaze

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Figure 3: Magnetic resonance imaging of the orbit showing cyst in the posterior aspect of the inferior rectus (arrow)

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Restricted ocular movements of the right eye in the upward gaze associated with diplopia gave an impression of double elevator palsy. Double elevator palsy usually presents with the paralysis of the two ocular elevators (superior rectus and inferior oblique), hypotropia, and pseudoptosis.[1],[2] In our patient, the eye was hypotropic but not ptotic. Ocular movement was restricted in down gaze also. Therefore, we termed this condition pseudo double elevator palsy. We would like to add cysticercosis of the inferior rectus, as observed in our case, as the cause of pseudo double elevator palsy.

Cysticercosis of the inferior rectus is rare but should be considered a differential diagnosis in cases with restricted extraocular muscle motility and proptosis of recent onset with a high index of suspicion, particularly in the endemic areas.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Sundaram PM, Jayakumar N, Noronha V. Extraocular muscle cysticercosis-A clinical challenge to the ophthalmologists. Orbit 2004;23:255-62.  Back to cited text no. 1
Shashni A, Pujari A, Bajaj MS, Kumar P. Superior oblique muscle cysticercosis: Importance of long-term assessment by a single observer. Can J Ophthalmol 2018;53:e193-5.  Back to cited text no. 2


  [Figure 1], [Figure 2], [Figure 3]


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