Oblique Superior Myokymia

Oblique superior myokymia is eye tremor, which is very rare in this form. It is therefore often not recognized diagnostically. The symptoms are felt very intensely by those affected, although the prognosis of the disease is usually favorable.

Oblique Superior Myokymia

What is superior oblique myokymia?

Oblique superior myokymia is an extremely rare eye condition in which microtremor occurs in the eye. The eye trembling occurs episodically and unilaterally and is often only noticed by the person affected. The eye movements can often only be identified with a special apparatus. However, the patient sees double vision at the moment of the seizure. See aviationopedia for Microscopic Polyangiitis Explanations.

However, this form of eye tremor should not be confused with nystagmus. In the case of nystagmus, the balance organ is damaged. Superior oblique myokymia is caused by uncontrolled activity of the trochlear nerve. As the fourth cranial nerve, the trochlear nerve innervates the superior oblique muscle.

This muscle is responsible for lowering the eye and rolling it inwards. Superior oblique myokymia is a benign eye condition that is extremely bothersome to the person affected.


The cause of superior oblique myokymia is not fully understood. It is assumed that the trochlear nerve is compressed by the posterior cerebral artery. However, this has not yet been clearly proven. The occurrence of superior oblique myokymia in lead poisoning and in adrenoleukodystrophy has been described in the medical literature.

Adrenoleukodystrophy is an inherited neurological disease. Simultaneous occurrence of superior oblique myokymia and epilepsy has also been described. However, these disorders may have nothing to do with triggering eye tremors. A coincidental meeting is also suspected.

A series of neurological examinations was carried out using MRI, which confirmed the assumption of a compression disorder of the trochlear nerve by the cerebral artery. Based on the results of this series of studies, it is discussed whether superior oblique myokymia can be described as a neurovascular compression syndrome.

Symptoms, Ailments & Signs

Oblique superior myokymia is characterized by episodic eye tremors that are not even noticed by outsiders. However, the patients feel this fine, vertical and rotating trembling of the eyes very clearly. You feel the symptoms very intensely through the development of tilted double images and apparent movements.

Overall, the seizures only last a few seconds. However, the attacks can repeat themselves several times a day. After the attack is over, the findings return to normal. Eye trembling can sometimes be provoked by the affected person looking down. In this situation, however, the examiner can hardly see anything because the trembling movement is masked by many other normal physiological movements.

However, when those affected look straight ahead again, the ophthalmologist is likely to be able to perceive the fine trembling of the eyes with special equipment. Overall, the course of the disease is benign. Paralysis occurs only in rare cases. However, other neurological disorders almost never occur.

Diagnosis & course of disease

Oblique superior myokymia could be diagnosed very easily if people were always taken seriously when describing their symptoms. Since nothing can be seen on the outside, they are often seen as hysterical. However, these are very typical symptoms that an experienced physician would immediately suspect superior oblique myokymia. Using a slit lamp, the ophthalmologist can then recognize the fine trembling of the eyes in the event of a provoked seizure.


Patients suffer from eye tremors due to oblique superior myokymia. In most cases, patients do not recognize the tremor themselves, so this complaint can usually only be recognized and diagnosed by outsiders. As a rule, those affected appear bizarre and unnatural to other people. The trembling of the eyes itself usually leads to visual problems and thus to double vision or squinting due to oblique superior myokymia.

Blurred vision can also occur due to oblique superior myokymia and reduce the patient’s quality of life. However, the tremor usually only occurs for a very short time and disappears on its own. In some cases, this can also lead to paralysis of the eyes or the entire field of vision, so that those affected can be restricted in their everyday life.

Particular complications or a serious course of the disease do not usually occur in oblique superior myokymia. Superior oblique myokymia can be treated with medication. This can limit most complaints. There are no complications. In some cases, however, surgical interventions are necessary. The life expectancy of those affected is usually not affected by this disease.

When should you go to the doctor?

If the eyelids tremble, there is often an overload of the organism. If the symptoms reduce after a rest phase or a restful night’s sleep, no doctor is required. If the tremor occurs during a tense and stressful phase of life for the person concerned, it should be monitored further. It is also necessary to check whether there is a deficiency. If the symptoms decrease as soon as everyday life returns to normal, freedom from symptoms often occurs after some time without medical treatment.

If the eye tremor is persistent, severe, or episodic, a doctor is needed. The complaints should be clarified. A diagnosis is used to determine the need for treatment. If you experience double vision or other visual impairments, see a doctor. If there is an increased risk of accidents, dizziness or paralysis of the eyelid, the person concerned needs help.

Bei einer inneren Unruhe und Nervosität sowie einem allgemeinen Unwohlsein sollte ein Arzt aufgesucht werden. Kommt es zu Problemen bei der Alltagsbewältigung, einem Aufmerksamkeitsdefizit oder zu Störungen der Konzentration, ist ein Arztbesuch anzuraten. Stellen sich emotionale Unregelmäßigkeiten oder Verhaltensauffälligkeiten ein, sollten die Beschwerden mit einem Arzt besprochen werden. Bei Schielen, Lähmungen im Gesichtsbereich oder einem Rückzug aus dem gesellschaftlichen Leben sollte medizinische Hilfe in Anspruch genommen werden.

Behandlung & Therapie

The treatment of superior oblique myokymia depends on the patient’s subjective symptoms. The symptoms are often felt to be very intense. There are cases of spontaneous healing. However, these are very rare. If the symptoms are severe, medication can be used. Such drugs as carbamazepine or beta-receptor blockers are used.

Carbamazepine is used for mood disorders (mania) or seizures, as well as neuralgia. Beta-receptor blockers such as propranolol or betaxolol inhibit the formation of adrenaline and noradrenaline. In addition to being used for cardiac arrhythmias, they are also used for anxiety disorders or tremors.

Overall, however, the side effects of these drugs outweigh their benefits when used for superior oblique myokymia. Symptoms often do not improve after months of drug treatment. In these cases, severing the tendon of the superior oblique muscle can help. However, this operation leads to paralysis, which can be satisfactorily remedied by further surgical interventions on the eye muscles.

The result is defective healing, since the initial state cannot be fully restored. Currently, however, this radical surgical intervention is the best way to prevent the tremor from recurring. As an alternative to these treatment methods, the trochlear nerve can be relieved by so-called microvascular decompression. In some cases good results have been achieved.

Microvascular decompression is a neurosurgical procedure in which abnormal contacts between certain cranial nerves and arteries are severed. This operation involves opening the skull and then removing the contact between the affected cranial nerve and the artery by interposing (interposing) a pad of muscle tissue or a Teflon sponge.

The results in oblique superior myokymia are good. This already indicates that this disease is caused by pressure compression of the trochlear nerve. However, recurrences can occur due to slippage of the interposition.

Outlook & Forecast

In rare cases, the prognosis for oblique superior myokymia is good. It sometimes heals spontaneously on its own. However, in most cases this is not the case.

Therefore, it is more the rule that the pronounced subjective symptoms at least lead to drug therapy. Either carbamazepine is used to stabilize the membrane, or treatment with beta-receptor blockers is an option. Significant side effects are to be expected with both types of medication. Whether the existing complaints justify them must be clarified on a case-by-case basis.

Often there is no improvement in oblique superior myokymia despite drug treatment. In this case, only operational options are left to choose from. For example, cutting and removing the superior oblique tendon could be considered. This usually results in paralysis of the eye. However, this can also be corrected surgically. This requires one or more interventions on the eye muscles. However, if superior oblique myokymia is not treated consistently, it usually leads to a recurrence. That worsens the prognosis.

An alternative treatment option is neurosurgical offloading. Microvascular pressure relief of the trochlear nerve can sometimes be successful. In addition, the success of this treatment suggests that superior oblique myokymia may be caused by pressure on the nerve.


There is no known way to prevent oblique superior myokymia.


Follow-up care for superior oblique myokymia depends on the previous therapy and the actual cause of the disease. If treatment is symptomatic, strict monitoring of the medication is recommended. The drugs are usually very rich in side effects and only offer the desired effect if the dosage is precisely adjusted.

If the cause of the myocomy turns out to be overexertion or a deficiency symptom, the same applies to aftercare as to therapy: alleviation of symptoms by minimizing causes. This means sufficient rest periods, enough sleep and relaxation. A balanced diet is also necessary to achieve freedom from symptoms in the long term.

Various relaxation techniques such as meditation exercises can also be useful to avoid a recurrent illness. If even a surgical intervention is necessary, it is imperative to protect the eyes afterwards. Medical monitoring of the healing is also important.

In the case of a neurological cause for the superior oblique myokymia, such as irritation of the trochlear nerve by a nearby vessel, surgery is usually recommended. The prognosis for full recovery after surgery is good. Should muscle tremors occur again after a successful procedure, this can often be explained by renewed attachment of the nerve to a vessel. Further steps should then be discussed with the doctor treating you.

You can do that yourself

The eye tremor of superior oblique myokymia can cause visual disturbances and squinting. As long as the tremor is only temporary for a short duration, people can deal with it quite well. However, if the symptoms appear more frequently, everyday activities suffer.

Patients should listen to their doctor’s advice on medication. In many cases, this can reduce the symptoms. The typical trembling of the eyelids can also indicate overload. Here it is advisable to give your eyes a rest. Getting enough sleep and relaxation will help alleviate the symptoms. Nevertheless, those affected should monitor the symptoms closely. The trembling of the eyes may also be due to a deficiency symptom. In this case, normalization of everyday life is required. Nevertheless, the patients have to reckon with the fact that they will not be completely free of symptoms. Meditation exercises can be used to specifically combat the shaky feeling.

However, in the case of severe and episodic seizures, people suffering from superior oblique myokymia should definitely consult a doctor. If there is a special need for therapy, it is important to follow the medical recommendations. In any case, an increased risk of accidents must be avoided. Therefore, if you experience dizziness or paralysis of the eyelid, you should go to the doctor’s office.