Hypertropia is a condition of misalignment of the eyes (strabismus), whereby the visual 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.

Causes of hypertropia in children

There are several conditions that can cause hypertropia in children.

Fourth cranial nerve palsy

The most common cause of hypertropia in children is fourth cranial nerve palsy. The fourth cranial nerve travels from the brain stem to a muscle on the surface of the eye, called the superior oblique muscle. The nerve sends impulses to the muscle, which controls the downward movement of the eye.

When the fourth cranial nerve is paralyzed (palsy) or weakened, it can’t control the superior oblique muscle correctly. This causes the eye to tilt upward.

A child may be born with a weakened or paralyzed fourth cranial nerve or develop it after a head trauma, such as a concussion.

Brown syndrome

Brown syndrome is a condition that causes a tight superior oblique tendon. That, in turn, restricts the eye’s movement. Doctors aren’t sure what causes the syndrome, but it’s commonly seen at birth.

It’s also possible to acquire Brown syndrome following an injury to the eye socket, such as being hit by a hard object, or by dental or sinus surgery.

Duane syndrome

This is another strabismus problem that people can be born with. For reasons that aren’t entirely clear, one of the cranial nerves may not develop normally. That restricts movement of the eye muscle.

Causes of hypertropia in adults

Causes in adults are different from the causes when first seen in childhood.

Stroke

A neurological event, like a stroke, is the most common reason adults experience a turning of the eye, such as hypertropia. A blood clot that leads to a stroke can also damage the nerves that help control the movement of the eyes.

Graves’ disease

Graves’ disease is an autoimmune disease that targets the thyroid gland. An autoimmune disease is a disease in which your body’s immune system fights against healthy cells.

The damage to the thyroid gland can affect eye muscles, causing them to work improperly.

Trauma

Injury to the bones of the eye socket can lead to a strabismus like hypertropia. Surgery to repair cataracts can also cause this condition although it isn’t common for this to happen.

Brain tumor

A brain tumor can press on the nerves and muscles of the eye, causing the eyes to move out of alignment.

Symptoms of hypertropia

It can be hard to notice the symptoms of this condition. Sometimes it’s a permanent part of your life, or your eye may only wander from time to time when you’re stressed or tired. The most common symptoms are:

• Eye wander. One or both of your eyes will drift up toward the ceiling or sky.
• Double vision. People with this condition often have trouble with eye focus.
• Head tilt. Your head leans or turns to one side to try to clear your vision.
• Eyestrain
• Headaches

Treatment of hypertropia

In general, strabismus can be approached and treated with a variety of procedures. Depending on the individual case, treatment options include:

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

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