eMedicine Specialties > Ophthalmology > Extraocular Muscles

Trochlear Nerve Palsy: Follow-up

Author: Zafar A Sheik, MD, Director, Department of Ophthalmology, St Joseph's Medical Center
Coauthor(s): Kelly A Hutcheson, MD, Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center,
Contributor Information and Disclosures

Updated: Jun 8, 2009

Outcome and Prognosis

Prognosis of trochlear nerve palsy varies depending on etiology. Best information regarding outcome comes from cases collected at the Mayo Clinic over the past 40 years.

  • Recovery is most likely in patients whose superior oblique palsy is secondary to microvascular disease.
  • Idiopathic cases also have greater than 50% likelihood of spontaneous recovery.
  • Most cases resolve within weeks to months, with the vast majority completely recovering by 6 months.
  • Some cases may resolve slowly over the course of a year.
  • Patients with head trauma were less likely to recover, yet, nearly 50% of these patients showed some degree of improvement.
  • Cases due to aneurysm or neoplasm were least likely to have functional recovery.

Because patients have good fusional abilities, surgery generally produces excellent results. Plager reported a nearly 90% success rate with his surgical algorithm.17 Mitchell and Parks also reported excellent results in correcting excyclotorsion using modified Harada-Ito procedure.18

 


More on Trochlear Nerve Palsy

Overview: Trochlear Nerve Palsy
Treatment: Trochlear Nerve Palsy
Follow-up: Trochlear Nerve Palsy
Multimedia: Trochlear Nerve Palsy
References
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References

  1. Knapp P. Classification and treatment of superior oblique palsy. Am Orthopt J. 1974;24:18-22. [Medline].

  2. Miller NR, Newman NJ. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 5th ed. 1998;1227-1237.

  3. Madigan WP, Zein WM. Recent developments in the field of superior oblique palsies. Curr Opin Ophthalmol. Sep 2008;19(5):379-83. [Medline].

  4. Richards BW, Jones FR Jr, Younge BR. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol. May 15 1992;113(5):489-96. [Medline].

  5. Holmes JM, Mutyala S, Maus TL, et al. Pediatric third, fourth, and sixth nerve palsies: a population-based study. Am J Ophthalmol. Apr 1999;127(4):388-92. [Medline].

  6. Kodsi SR, Younge BR. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol. Nov 15 1992;114(5):568-74. [Medline].

  7. Brazis PW. Palsies of the trochlear nerve: diagnosis and localization--recent concepts. Mayo Clin Proc. May 1993;68(5):501-9. [Medline].

  8. Keane JR. Fourth nerve palsy: historical review and study of 215 inpatients. Neurology. Dec 1993;43(12):2439-43. [Medline].

  9. Robb RM. Idiopathic superior oblique palsies in children. J Pediatr Ophthalmol Strabismus. Mar-Apr 1990;27(2):66-9. [Medline].

  10. Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol. Jan 1981;99(1):76-9. [Medline].

  11. Helveston EM, Krach D, Plager DA, Ellis FD. A new classification of superior oblique palsy based on congenital variations in the tendon. Ophthalmology. Oct 1992;99(10):1609-15. [Medline].

  12. Phillips PH, Hunter DG. Evaluation of ocular torsion and principles of management. In: Rosenbaum AL, Santiago AP, eds. Clinical Strabismus Management. WB Saunders;1999:52-72.

  13. Kono R, Okanobu H, Ohtsuki H, Demer JL. Absence of relationship between oblique muscle size and bielschowsky head tilt phenomenon in clinically diagnosed superior oblique palsy. Invest Ophthalmol Vis Sci. Jan 2009;50(1):175-9. [Medline].

  14. von Noorden GK, Murray E, Wong SY. Superior oblique paralysis. A review of 270 cases. Arch Ophthalmol. Dec 1986;104(12):1771-6. [Medline].

  15. Graf M, Weihs J. Effect of diagnostic occlusion in acquired trochlear nerve palsy. Graefes Arch Clin Exp Ophthalmol. Feb 2009;247(2):253-9. [Medline].

  16. Garnham L, Lawson JM, O'Neill D, Lee JP. Botulinum toxin in fourth nerve palsies. Aust N Z J Ophthalmol. Feb 1997;25(1):31-5. [Medline].

  17. Plager DA. Superior oblique palsy and superior oblique myokymia. In: Clinical Strabismus Management: Principles and Surgical Techniques. 1999:219-229.

  18. Mitchell PR, Parks MM. Surgery of bilateral superior oblique palsy. Ophthalmology. May 1982;89(5):484-8. [Medline].

  19. Kushner BJ. Overaction of the inferior oblique muscle in 4th nerve palsy. Binocul Vis Strabismus Q. 2008;23(4):198-9. [Medline].

  20. Guyton DL. Exaggerated traction test for the oblique muscles. Ophthalmology. Oct 1981;88(10):1035-40. [Medline].

  21. Lee J. Management of Brown syndrome. Semin Ophthalmol. Sep-Oct 2008;23(5):291-3. [Medline].

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Further Reading

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Keywords

trochlear nerve palsy, fourth nerve palsy, fourth cranial nerve palsy, trochlear palsy, superior oblique palsy, vertical diplopia, head-tilt test

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Contributor Information and Disclosures

Author

Zafar A Sheik, MD, Director, Department of Ophthalmology, St Joseph's Medical Center
Zafar A Sheik, MD is a member of the following medical societies: American Academy of Ophthalmology and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Kelly A Hutcheson, MD, Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center,
Kelly A Hutcheson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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