Differential diagnosis of sagging eye syndrome and superior oblique palsy using objective and subjective measurements
Reviewed by Fiona Rowe

The authors compared subjective cyclovertical deviation in different gaze positions and objective ocular torsion between elderly patients with sagging eye syndrome (CSES) and superior oblique palsy (SOP) diagnoses from clinical findings with a view that subjective and objective measures may be useful as a differential diagnostic aid. This was a prospective cross-sectional observational study of 22 CSES and 20 SOP cases. The CSES group had a mean age of 75.0 ±7.9 years, subjective primary vertical deviation of 1.3º, subjective cyclo angle of -6.0º, objective disc/fovea angle for the hypertropic eye of -11.5º and hypotropia of -12.2º. The SOP group had a mean age of 66.1 ±10.2 years, subjective primary vertical deviation of 4.3º, subjective cyclo angle of -6.0º (greater than CSES in temporal down and down gaze), objective disc/fovea angle for the hypertropic eye of -11.8º and hypotropia of -16.3º. The authors conclude that subjective vertical deviation was larger in patients with SOP and greater excyclotropia for SOP in downgaze. Differential diagnosis requires evaluation of multiple objective and subjective measurements in varying gaze positions.

Comparison of subjective cyclovertical deviation and objective ocular torsion in sagging eye syndrome and superior oblique palsy. 
Kawai M, Goseki T, Ishikawa H, Shaji N.
STRABISMUS
2026;34(1):14–20.