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Double Vision and New Onset Strabismus in an Adult
Published in Amy-lee Shirodkar, Gwyn Samuel Williams, Bushra Thajudeen, Practical Emergency Ophthalmology Handbook, 2019
Isolated fourth nerve palsy: A fourth cranial nerve palsy results in poor superior oblique function. Patients present with a contralateral head tilt and report vertical, oblique or torsional diplopia, worse on down gaze. Cover test shows an ipsilateral hypertropia worse on gaze to the contralateral side and ipsilateral head tilt. Fundoscopy may show excyclotorsion of ipsilateral eye which is apparent only when assessing the position of the arcades relative to the optic disc. Causes include head trauma (which may be bilateral), myasthenia gravis and thyroid eye disease. Decompensating congenital fourth nerve palsy can present with intermittent diplopia and old photographs may show a head tilt. This is colloquially called a ‘family album tomogram’.
Neuro-Ophthalmic Literature Review
Published in Neuro-Ophthalmology, 2019
David Bellows, Noel Chan, John Chen, Hui-Chen Cheng, Peter MacIntosh, Jenny Nij Bijvank, Michael Vaphiades, Konrad Weber
Sixty-six patients aged 0–19 years old were included in this study. Neoplasia involving the central nervous system was the most common cause of third, fourth and sixth cranial nerve palsies both in children (20%) and adolescents (31%). Overall, apart from neoplasm (23%), the most common causes included idiopathic (14%), inflammation (11%) and non-aneurysmal vascular contact (11%). The most common cause of fourth cranial nerve palsy was late decompensation of congenital fourth nerve palsy (46%) with the evidence of absence or atrophy of fourth nerve and/or superior oblique muscle in the paretic eye. Only four patients presented with combined ocular motor nerve palsies of which 75% were attributable to Miller Fisher syndrome (MFS), while one patient was secondary to cavernous sinus thrombophlebitis. Of note, three patients with intracranial haemorrhage presented with isolated cranial nerve palsy without other additional neurological signs. Among six patients with MFS, two of them presented with bilateral sixth cranial nerve palsies and one presented with unilateral sixth cranial nerve palsy. The authors suggested to consider the possibility of MFS in cases of isolated third, fourth or sixth cranial nerve palsy as well.