The term is generally used to describe diminished ocular elevation present in all fields of gaze. Clinical Manifestations Double elevator palsy is characterized by reduced elevation in all positions of gaze. When the patient fixates with the nonparetic eye, the paretic eye will become hypotropic and the lid may become ptotic. Fixation with the paretic eye will cause a hypertropia of the nonparetic eye. Provided that the elevator muscle is not involved, the ptosis will also disappear.
Patients often present with a chin-up position to maintain binocular vision.
If a patient with double elevator palsy is orthophoric in primary position, surgery is not indicated. If there is a vertical deviation in primary position, a forced duction test is necessary. In patients with a positive forced duction test, indicating restriction to elevations, an inferior rectus recession is indicated. As much as 35 prism diopters of hypotropia can be corrected with the Knapp procedure. However, only a modest increase in elevation is usually observed after this procedure.