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There are a variety of vertical misalignments with a variety of etiologies. The reason many people don't know that hypertropias exist is because they can also be subtle. Regardless of the magnitude of a hypertropia, this deviation can make a person very symptomatic. Because of the subtlety and etiologies, individuals with a vertical deviation should be seen by a provider such as a residency-trained neuro-optometrist, neuro-ophthalmologist, or a pediatric ophthalmologist.

Some conditions that can cause a hypertropia:

1. Congenital hypertropia: A congenital hypertropia is the most common type of vertical deviation. While a congenital deviation is present from an early age it does not always show up until later in life. The superior oblique is the muscle most commonly affected with a congenital hypertropia.

2. Inferior rectus entrapment: The eye has 6 muscles that help it move in all fields of gaze. The inferior rectus, as you guessed it, this muscle is connected to the inferior part of the eye and helps the eye move down. The inferior rectus can become entrapped after a traumatic event. Some studies have estimated that 10-25% of facial fractures include orbital bones. This deviation can spontaneously resolve but in certain cases surgical intervention may be indicated.

3. Fourth cranial nerve palsy: The brain contains twelve cranial nerves, five of which have links to the eye. Three of those nerves control eye movements, they are cranial nerves III, IV, and VI (yes for the record cranial nerves are notated with roman numerals). Cranial nerve IV innervates the superior oblique muscle so it doesn't just affect the vertical alignment of the eye, it can actually affect the torsion of the eye and some horizontal eye movements. Generally a person who is suffering from a fourth nerve palsy will have a head tilt to help alleviate double vision. A fourth nerve palsy can be congenital or acquired.

4. Brown Syndrome: Brown Syndrome is a disorder that affects a tendon sheath. The superior oblique is the only extra-ocular muscle that goes through a pulley to help with specific ocular movements. Brown Syndrome doesn't allow a muscle to move freely through the pulley. Because the muscle is unable to move through the pulley the eye that has the affected superior oblique muscle is unable to look upward. Brown Syndrome can be congenital or can be acquired. It can also spontaneously resolve, which is not common.

This list is not an exclusive but more a sampler of different types of vertical eye misalignments. Treatment types can also vary. Some vertical misalignments require immediate intervention and can be caused from serious etiologies. Some serious etiologies can include lesions within the brain, traumatic brain injury side effects, and vasculature issues such as aneurysms.

Anytime a vertical misalignment is detected further testing with a neuro-optometrist or neuro-ophthalmologist is indicated to determine etiology and proper treatment to help alleviate symptoms.