DIPLOPIA & FOURTH CRANIAL NERVE PALSY

CARL V. GOBIN, MD AZ MONICA ANTWERPEN

DIPLOPIA

•  Anamnesis: – Persistent / intermittent – How long – Position double image – Direction of gaze – What distance

DIPLOPIA

•  Inspection: – Spastic closure of the eye – Head posture:

•  Head tilt •  Head turn •  Chin up/ down

Acquired IV nerve palsy

Origin: – Trauma of the skull:

•  Fracture of the skull •  Commotio contusion of the brain •  Trauma of the orbit

– Microvascular accidents: •  Diabetes •  Hypertension

Acquired unilateral IV n. palsy

•  Vertical & torsional diplopia: –  Depression > elevation

•  Torticollis: –  Head tilt towards the non-palsied side

•  Hypertropia in laevo- OR dextroversion: –  Adduction > abduction

•  Excyclotropia •  Positive Bielschowsky head tilt test:

–  Hypertropia is maximal to the palsied side

Acquired unilateral IV n. palsy •  Vertical deviation is not large:

–  Increase in adduction –  Decrease in abduction –  Increase in depression

•  Horizontal deviation: –  Superior oblique muscle is an abductor! –  Small esotropia in downgaze

•  Cyclotropia: –  Superior oblique muscle is an incyclotortor! –  Excyclotorsion due to inferior oblique overaction

Acquired unilateral IV n. palsy

•  Treatment: – Wait for spontaneous recovery – Prisms – Surgery: weakening procedures of the

inferior oblique muscle »  Posterior myotomy »  Anterotransposition » Disinsertion

Acquired bilateral IV n. palsy •  Frequently overlooked!

–  Apparent unilateral trochlear palsy: •  Paralysies à bascule (Hugonnier) •  Postoperative ping pong effect

•  Diplopia is often vaguely, indefinite

•  Marked excyclotorsion (> 10°)

•  V-pattern

Acquired bilateral IV n. palsy

•  Depression of the chin •  Esotropia in depression : V-pattern •  No limitation of eye movements •  Hypertropia in laevo- AND dextroversion •  Cyclotropia •  Bilateral homonymous positive

Bielschowsky head tilt test

Acquired bilateral IV n. palsy

•  Treatment – Wait for spontaneous recovery – Prisms have little value due to incomitances – Surgery:

•  Weakening both inferior oblique muscles •  Combined with horizontal rectus surgery

Case report: cranial trauma

•  Bicycle accident •  Diplopia

– Vertical /oblique – Depression > elevation – Right > left

•  Head tilt •  Fresnel doesn’t work

Case report: cranial trauma

•  Hess-Lancaster: small vertical deviation

Case report: cranial trauma

•  Motility : typical pattern •  overaction left inferior oblique •  Dextro- > laevoversion •  Depression > elevation •  Positive Bielschowsky head tilt test

Case report: cranial trauma

•  Treatment: surgery •  Anterotransposition left inferior oblique •  Posterior myotomy right inferior oblique •  Central tenotomy both lateral recti

•  Result: happy patient, no more diplopia

Case report: microvascular accident

•  73 y. man : hypertension & diabetes •  Diplopia

– Vertical / oblique – Dextro- > laevoversion

•  Small head turn to the left •  No previous treatment

Case report: microvascular accident

•  Hess-Lancaster: right hypertropia, V-pattern

Case report: microvascular accident

•  Motility pattern: typical •  Right inferior oblique overaction •  R/L in laevoversion & depression •  Positive Bielschowsky head tilt test •  V-exo pattern

Case report: microvascular accident

•  Treatment: fresnel prism worked

•  Prism 3 diopter top at 45° before right eye

•  Patient free of complaints

AMICO 2012

•  CASE REPORTS •  Members of BSA •  Assistants of all Belgian

universities •  Your problem is our problem! •  Contact Prof. Yuksel •  Demet.Yuksel@uclouvain.be