Session: Poster session B
Don't trust a book by its cover: tips to diagnose and treat a traumatic fourth nerve palsy.
Introduction: Bilateral traumatic trochlear nerve palsy is common after car accident with whiplash syndrome. This condition is often misdiagnosed and patients' quality of life is severely impacted. We would like to present the case of a young man who had a head injury to illustrate the potential issues regarding the diagnosis and the surgical management.
Methods: A 39-years-old man was referred to our squint department for vertical diplopia. He had a past history of a car accident in 2007 associated with loss of consciousness. Afterwards, he described double vision for more than 2 years associated with a head tilt. He finally had a plication of 4 mm of the left superior rectus muscle in 2009 for what was considered as a pure vertical deviation. Ten years later, the patient complained again with double vision and right hypertropia of 25 diopters without torsion was noted. A second surgery was underwent by his surgeon, consisting in the recession of the left inferior rectus muscle of 4 mm and a plication of the right inferior rectus muscle of 4 mm in 2019. Because of the persistence of diplopia in down-gaze, he was referred to our department. A marked restriction of down- gaze in the left eye was observed. Hess-Weiss testing and fundus photography demonstrated an undoubtful bilateral asymmetric excyclotorsion. The Bielschowsky head-tilt test was positive on left shoulder. We decided to relocate the previous muscles operated in their initial insertion and underwent a left inferior oblique (IO) recession of 10 mm and a right IO anterior nasal transposition.
Results: Objective and subjective excyclotorsion normalized without any residual vertical.deviation.
Conclusion : Traumatic fourth nerve palsy due to midbrain lesions should be suspected after brain injury and careful observation of torsional clues such as head tilt, V-pattern, fundus photography or Hess-Weiss test is warranted. The only logical and efficient approach has to be based on oblique muscles surgery.
Methods: A 39-years-old man was referred to our squint department for vertical diplopia. He had a past history of a car accident in 2007 associated with loss of consciousness. Afterwards, he described double vision for more than 2 years associated with a head tilt. He finally had a plication of 4 mm of the left superior rectus muscle in 2009 for what was considered as a pure vertical deviation. Ten years later, the patient complained again with double vision and right hypertropia of 25 diopters without torsion was noted. A second surgery was underwent by his surgeon, consisting in the recession of the left inferior rectus muscle of 4 mm and a plication of the right inferior rectus muscle of 4 mm in 2019. Because of the persistence of diplopia in down-gaze, he was referred to our department. A marked restriction of down- gaze in the left eye was observed. Hess-Weiss testing and fundus photography demonstrated an undoubtful bilateral asymmetric excyclotorsion. The Bielschowsky head-tilt test was positive on left shoulder. We decided to relocate the previous muscles operated in their initial insertion and underwent a left inferior oblique (IO) recession of 10 mm and a right IO anterior nasal transposition.
Results: Objective and subjective excyclotorsion normalized without any residual vertical.deviation.
Conclusion : Traumatic fourth nerve palsy due to midbrain lesions should be suspected after brain injury and careful observation of torsional clues such as head tilt, V-pattern, fundus photography or Hess-Weiss test is warranted. The only logical and efficient approach has to be based on oblique muscles surgery.