What is included in the preoperative care of trochlear nerve palsy (fourth nerve palsy)?

Updated: Oct 08, 2019
  • Author: Zafar A Sheik, MD, MD; Chief Editor: Andrew G Lee, MD  more...
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Careful assessment of deviation in all fields of gaze should be performed.

Multiple measurements should be taken to ensure that deviations are stable.

Ductions should be evaluated to determine if there is inferior oblique overaction. [36]

Presence of V-pattern esotropia is highly suggestive of bilateral superior oblique palsy.

It may not be possible to determine if there is superior rectus restriction in clinic, and this test may be performed in operating suite.

Photographs that show head position and ocular motility findings, including head tilts, are useful for documentation.

Infants presenting with torticollis may be suspected of having superior oblique palsy.

To differentiate true cases of strabismus from neuromuscular causes of torticollis, patch test may be performed in the office. After 20 minutes of monocular occlusion, the child is reevaluated, still wearing the patch. If head tilt was adopted for fusional purposes, it will be reduced after patching.

There is a low risk of amblyopia in affected children presumably because they can achieve intermittent fusion by using head tilt and large fusional amplitudes. Loss of compensatory head position by a child suggests loss of fusion and may be associated with development of amblyopia.

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