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Superior oblique myokymia?

  • 1.  Superior oblique myokymia?

    Posted 04-13-2026 09:40
    Good morning – question to the hive!
    Any ideas on how to further treat superior oblique myokymia? Patient is already taking carbamazepine 200 mg TID and has been intolerant to topical timolol all in the past.
    Also, I have not been able to observe or elicit the myokymia in clinic – I only saw him once so far-- patient wants to go up on the dose of Carbamazepine to 400 mg TID on his own.

    Best regards,

    Rashmi Verma MD
    Adult and pediatric Neuro Ophthalmologist
    Fellow of the North American Neuro-Ophthalmology Society


  • 2.  RE: Superior oblique myokymia?

    Posted 04-13-2026 09:50
    Try low dose gabapentin.  (Tomsak et al. Gabapentin attenuates superior oblique myokymia. AJO 2002; 133: 721-723)

    Bob Tomsak





  • 3.  RE: Superior oblique myokymia?

    Posted 04-13-2026 09:52
    Thanks, Bob. He tried that in the past as well. I can consider doing it again, but the issue is that I have never seen the myokymia by myself despite trying very hard on the slit lamp.
    Is there something that I can do to elicit the myokymia? I would feel better treating him if I could see it.

    Best regards,

    Rashmi Verma MD
    Adult and pediatric Neuro Ophthalmologist
    Fellow of the North American Neuro-Ophthalmology Society





    Original Message


  • 4.  RE: Superior oblique myokymia?

    Posted 04-13-2026 09:57
    Are his symptoms monocular episodic oscillopsia?  If so, I doubt that it could be anything else.

    Bob



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  • 5.  RE: Superior oblique myokymia?

    Posted 04-13-2026 10:25
    In the office, he did complain of oscillopsia and diplopia, but when we examined him at that exact point of time under the slitlamp, no myokymia was detected

    Best regards,

    Rashmi Verma MD
    Adult and pediatric Neuro Ophthalmologist
    Fellow of the North American Neuro-Ophthalmology Society





    Original Message


  • 6.  RE: Superior oblique myokymia?

    Posted 04-13-2026 10:33
    I have very nice selfie videos from patients with SOM - I tell them it is their homework.

    Karl Golnik, MD, MEd
    Professor, Barrow Neurological Institute
    Ophthalmology Foundation Chair for Education





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  • 7.  RE: Superior oblique myokymia?

    Posted 04-13-2026 10:36
    Hi Karl 
    Yes, I did ask him to do that – I am seeing him later today. We will see if he remembered his homework! Thanks.

    Best regards,

    Rashmi Verma MD
    Adult and pediatric Neuro Ophthalmologist
    Fellow of the North American Neuro-Ophthalmology Society



    Original Message


  • 8.  RE: Superior oblique myokymia?

    Posted 04-13-2026 22:28
    Try topical betablocker. It’s in the literature and I’ve had good response most of the time.

    Charles Rheeman


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  • 9.  RE: Superior oblique myokymia?

    Posted 04-18-2026 17:51

    Some of my patients with SO myokymia with poor response to medications benefit from light filtering glasses - as often the trigger for the myokymia is light induced - screen light, fluorescent lights - Cutting down light intensity has helped reduced frequency and severity of the myokymia as a supplement to the medications (Timolol drops + Carbamazepine or Gabapentine). Different patients have found FL41 filters, Avulux, Theraspecs, blue light blocking glasses, etc useful in symptom control

    Regards,

    Shivanand Sheth

    -------------------------------------------



  • 10.  RE: Superior oblique myokymia?

    Posted 04-18-2026 20:42
    Don't forget the surgical option which was curative in three cases I have done; Tenectomy of the Superior oblique and ipsilateral IO weakening. 
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












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  • 11.  RE: Superior oblique myokymia?

    Posted 04-19-2026 03:32

    ...& don't forget the natural history which is sometimes good!

     

    Lionel




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  • 12.  RE: Superior oblique myokymia?

    Posted 05-01-2026 09:23
    Good morning,

    I have a patient with severe asthma, NASH with elevated liver enzymes with R SO myokymia. She has minimal relief with Gabapentin and experiences drowsiness with increase in doses, she is 65. Are there any other meds that might work? Memantine? Look forward to your thoughts, thanks. 

    Shruthi Harish 



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  • 13.  RE: Superior oblique myokymia?

    Posted 05-01-2026 09:27
    try topical timolol



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  • 14.  RE: Superior oblique myokymia?

    Posted 05-01-2026 10:43
    Can you use the timolol with severe asthma? I would clear it with pulmonology first and then use punctual  occlusion after placement of the drops if you did.

    Matt

    Sent from my Galaxy




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  • 15.  RE: Superior oblique myokymia?

    Posted 05-01-2026 11:05
    I agree with Matthew. One can use Tegretol as well but LFT's must be watched regularly
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine












    Original Message


  • 16.  RE: Superior oblique myokymia?

    Posted 05-01-2026 11:15
    Agree with Matt's stated precautions befoe one would  try timolol



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  • 17.  RE: Superior oblique myokymia?

    Posted 05-01-2026 11:29
    Do not use timolol. It can trigger status asthmaticus in a patient with known severe asthma. You could try betoptic s, although I would try other measures first. 



    Russ Edwards



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  • 18.  RE: Superior oblique myokymia?

    Posted 05-01-2026 11:05
      • Carbamazepine  (Tegretol)
      • Gabapentin (Neurontin)
    RL Tomsak et al. Am J Ophthalmol 133:721-723, 2002
    S Kang et al. Neurology 80:e134-135, 2013
      • Propranolol (both topical and oral)
    PE Williams et al. J AAPOS 11:254-257, 2007
      • Memantine (Namenda)
    S Jain et al. J AAPOS 12:87-88, 2008
      • CBD Oil
    J Ma et al. J Neuro-Ophthalmol 41:e192-193, 2021

    And of course if meds are ineffective or not tolerated, consider superior oblique tenectomy combined with ipsilateral inferior oblique myectomy.






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