Inferior oblique cross-sections were similar in SOP and SES. Maximum cross-section of the palsied SO was much smaller than contralaterally and in SES ( P < 2 × 10 −5). Eighteen others had normal SO size but MRI findings of SES. Twenty-three subjects had unilateral SOP manifested by SO atrophy. Rectus pulley coordinates were determined in SES cases fulfilling the 3ST. Multiple supervised machine learning methods were employed to evaluate diagnostic accuracy. Alignment was measured by Hess screen and prism-cover testing. We studied hypertropic subjects who underwent surface-coil magnetic resonance imaging (MRI) demonstrating either SO cross-section reduction indicative of congenital or acquired palsy (SOP group) or lateral rectus muscle sag (SES group). We sought to determine if alignment measurements can distinguish unilateral SOP from hypertropia in SES. Although the three-step test (3ST) is typically used to diagnose superior oblique palsy (SOP), sagging eye syndrome (SES) has clinical similarities.
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