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Medical Forum / General / Vision / January 2005Double Vision due to Damage to Cranial Nerve IV
My 8 year old son injured his right eye-lid while sledding on Christams day 2004. His sled went into brushes and most likely a tree branch hit his eye-lid causing the injury. He got 3 stitches on his right eye-lid. The wound seems to have healed well and his stitches were removed 5 days after the injury. A detailed exam of his eye by two opthalmologists did not reveal any damage to the retina or the optic nerve. That's the good part. However, he now has double vision which is consistently seen in the down vertical position and also in the right tilt position. An MRI of the brain and the orbits did not reveal anything remarkable. A pediatric opthalmologist feels the double vision is most likely caused by IV nerve palsy. He feels very optimistic that this problem will self-correct, albeit in several months. I would appreciate any insights any one has to offer regarding this. > My 8 year old son injured his right eye-lid while sledding on Christams > day 2004. His sled went into brushes and most likely a tree branch hit [quoted text clipped - 12 lines] > will self-correct, albeit in several months. > I would appreciate any insights any one has to offer regarding this. I'm not a doctor, and don't treat patients, but have some experience with eye movements. The description of double vision on down gaze is consistent with a trochlear palsey (that's nerve IV). The deviation is also worse when the head is tilted toward the side of the problem--check. This head tilt test is part of the diagnostic criteria. For a trochlear palsey, when the head is tilted down on the side of the lesion (the right side in this case), if you look at the eyes, the right eye would appear to be looking up compared to the left eye (a right hypertropia). The most diagnosed cause for this is head trauma, which is sometimes mild--also consistent. The MRI ruled out some other possible causes. The "bible" of clinical eye movements says that "If the results of inaging of the head and orbit are normal, and test results for diabetes and myasthenia are negative, then the outcome is usually favorable". With the onset involving the mild trauma, diabetes and myasthenia don't seem real likely. The MRI was probably appropriate to rule out some nasty stuff, and the description seems very appropriate for trochlear palsey given the normal MRI. Sounds like you've seen some good ophthalmologists. Scott I am not a strabismologist, but have seen numerous cases of acquired CN IV palsy, with most of those being idiopathic or due to trauma. I wish I could be as optimistic, but I cannot remember a single case of remission. Maybe improvement, but not total recovery. DrG "Dr. Leukoma" <drg@leukoma.com> wrote in news:1105566396.697694.13330 @f14g2000cwb.googlegroups.com: > I am not a strabismologist, but have seen numerous cases of acquired CN > IV palsy, with most of those being idiopathic or due to trauma. I wish > I could be as optimistic, but I cannot remember a single case of > remission. Maybe improvement, but not total recovery. > > DrG Emedicine cites a Mayo study stating that ideopathic cases have a greater than 50% chance of sponteneous recovery, and that trauma cases were less likely to recover, but half these cases show some degree of improvement. http://www.emedicine.com/oph/topic697.htm Leigh and Zee doesn't say anything much beyond "favorable". There's also some surgical procedures available if this doesn't resolve, and these procedures seem to have good results. I would think that it makes sense to wait to see if it goes away on its own before going that route, but the docs probably can offer much better advice on this than I can. Scott > I am not a strabismologist, but have seen numerous cases of acquired CN > IV palsy, with most of those being idiopathic or due to trauma. I wish > I could be as optimistic, but I cannot remember a single case of > remission. Maybe improvement, but not total recovery. > > DrG Dear Dr. Leukoma, Thanks for your reply, I appreciate it a lot. At the time of my son's injury, I didn't notice any bruise or cuts on his forehead and skull. He was wearing a woolen hat and a parka though, so it possible that he did have an impact on his forehead along with the injury to the eyelid. I say all this to talk about the cause of the IV th nerve palsy which is suspected to be the cause of double vision. Given that there are no obvious signs of head trauma (also supported by unremarkable MRI of the brain and the orbits), could the IV th nerve have been damaged by the penetrating injury to the surface of the eye-lid? I recall the pediatric opthalmologist measured the degree of misalignment, and I believe it was 6 Diaopters. As I mentioned earlier, he thinks this will self-correct in 6 months. However, as a parent it has been extremely difficult to just let the faith keep me patient. Amul > > I am not a strabismologist, but have seen numerous cases of acquired > CN [quoted text clipped - 26 lines] > > Amul Amul, The degree of misalignment is relatively small. From what I know of the anatomy of the nerve, it inserts into the body of the muscle too far back into the orbit to have been damaged from whatever pierced the eyelid. What there any direct damage to the globe? Anyway, time will tell. The MRI was negative, and your son hasn't any brain injury -- looking on the bright side, of course. DrG > > > I am not a strabismologist, but have seen numerous cases of > acquired [quoted text clipped - 43 lines] > > DrG Dear Dr. Leukoma, Thanks again your response. Yesterday, I took my son to the same opthalmologist who treated him on the day of the injury. His assessment of the double vision is that it is most likely due to a mechanical obstruction of the various eye muscles. One scenario being the 2 muscles behind the eye-lid are not moving freely. The assumption here is that whatever pierces the skin of the eye-lid might have caused some damage to the muscle. That said, the doctor felt this was less likely because my son is able to move the globe down, albeit not all the way. Another scenario he raised was a hair-line fracture in the bone under the eye which might have caused some restriction of the muscle. When I brought the liklihood of IV th nerve palsy, he opined that double vision due to nerve damage would be in ALL positions, unlike my son's case where he complains of it in downgaze and right tilt. He recommends waiting for six weeks (at least this recommendation is the same as that of the pediatric opthalmologist who thinks there is IV th nerve palsy). However, I am torn as to what diagnosis I should trust more. Now the answer to your question. We were told in ER that there was some laceration of the white of the eye. On follow-up visit, the pediatric doctor said the laceration was healing okay. There was a big red spot to right of the pupil but it is pretty much gone away. I see faint reddishness in his eye now. In conclusion, I don't believe there was damage to the globe. Thanks again. Regards, Amul Now, given your premises, what hampers you in starting the self-treatment with rest methods? You cannot do any harm, if not to the business of the doctors. Enquire better in the true science of the eye! Of course, there is the possibility that some trauma may have occurred directly to the muscle or its insertion, except that the insertion of the superior obliques is slightly posterior to the equator, hence its primary action as a depressor in temporal gaze. In cases of orbital floor fracture, the inferior rectus/oblique may become entrapped, causing restriction of elevation. I also disagree that a fourth nerve palsy would cause diplopia in all positions, as that has never been my experience. This is why patients abopt a compensatory head tilt to eliminate double vision. I will say a little prayer for your son. The accident could have had a much worse outcome. DrG Dr. Leukoma, Thanks again for your insights. Today marked 3 weeks since my son's accident. While we are still in the wait and see mode, I do think about how lucky we are in some ways as this accident could have been much worse. While no one has been able to tell us for sure whether our son will ever get back to normal vision, we are definitely sure and thankful to God that this could have been much worse. I now realize this may be the only way to keep ourselves optimistic amidst the sometimes uneasy uncertainty of medical field. One more question for you Sir. Assuming that the double vision does not completely go away on its own and surgery is not recommended, can the remaining double vision be corrected with Prism lenses (I think I read about that somewhere)? My son has 20/40 vision and needed glasses anyway as of his checkup two months ago, but his optometrist told us to wait. Anyways, if the answer to my question is yes, are there any downsides to that? Finally, what about vision therapy? There seems to be plenty of info. on that on internet. Please advise. Thanks, Amul > Of course, there is the possibility that some trauma may have occurred > directly to the muscle or its insertion, except that the insertion of [quoted text clipped - 12 lines] > > DrG Dear Amul, In answer to your question, I have used prism to help patients with fourth nerve palsy. My most recent case actually underwent surgery. While it did not completely resolve the double vision, it did change the position of the double vision from down gaze to up gaze. This meant that he could read without double vision. Because the magnitude of the deviation is not constant and changes depending on eye position, there is no single prescription that will eliminate double vision in all fields of gaze. In this case, the patient had a residual amount of deviation in the straight-ahead and down gaze which was of a fairly constant value, and so I prescribed it. He will still experience double vision when looking up beyond the midline. However, nature endows the visual system with great resilience. Your son will probably eventually come to suppress one of the images, tilt the head, and so forth. Unfortunately, I know very little about the utility of vision therapy in treating this type of problem. In school, it was taught that paralytic strabismus is fairly difficult to manage with therapy. One would think that therapy could be useful, since it has great utility in other areas of rehabilitation. It should be possible for a limited amount of damaged nerve to be regenerated, or at least on would hope. DrG Dr. Leukoma, Many thanks for educating me on issues related to double vision. Yesterday, I consulted a neurologist family friend of mine, who continues to believe that the root cause of my son's double vision is most likely 4th nerve damage. But he also was very optimistic of this nerve healing over time (perhaps a few months). I will keep you posted on how things are progressing, as we wait for our next appointment with the doctor(s) in late Feb. Finally, this may be of little help now, but as I was explaining to my neurologist friend yesterday the events in the ER on the day of injury, I mentioned that the attending opthalmologist injected anasthesia just below my son's eyebrow prior to stitching his cut skin. After listening to this, my neurologist friend raised the possibility of the injection itself potentially causing some trauma to the nerve, though he did say this is uncommon (maybe 1 in 10). If so, nothing can be done about that. I guess those things do happen (my friend also acknowledged that he may have done that too inadvertently in his 35 plus years of practice). Be that as it may, we will wait and keep on praying and see what happens. Thanks again, Amul PS; Thanks to all who have contributed to this discussion, I have learned a lot. > Dear Amul, > [quoted text clipped - 21 lines] > > DrG An ophthalmologist injecting anesthetic in this area stands almost NO chance of doing anything. You have to be at least a 1/2 inch into the orbit to even get at the tendon, which would not usually be damaged by an injection, The nerve itself it very deep in the orbit, and you would need a very loong neele to get anywhere near it. The issue is, it is a IV nerve palsy (due to head injury), or a mechanical restriction of the tendon due to local scarring/injury, a disrupted tendon, or a muscle palsy due to a sudden stretch. Certainly a penetrating injury to the tendon area can cause an inflammatory reaction that can cause restriction to eye movement. This can be usually sorted out of forced duction and active force generation testing in the office on a cooperative patient. (Age may be a limiting factor here.) If there is a restriction to passive movement, a local steroid injection may be of help, mainly in the relatively early stage. Once it is well healed, this would be of not real help. For example, I have seen a case of a finger injury to an eye, pushing it upwards rather hard. The inferior rectus seemed torn near its insertion, as the possible cause of the muscle weakness. However, suturing it back where it should be did not help - the muscle remained paretic (weak) as if the nerve was injured, which did not happen directly. However, just a vigorous stretch, as in this case, can cause a permanent muscle weakness. On 1/17/05 9:39 AM, in article 1105983550.355578.57360@c13g2000cwb.googlegroups.com, > Dr. Leukoma, > [quoted text clipped - 56 lines] >> >> DrG Dr, Robins, Thanks for your comments. I assume you have browsed through the background information I had provided in a few different messages. We are not sure if there was any kind of head trauma, we think there wasn't any. MRI of the brain was unremarkable and so was that of the orbits. At this point in time, the two opthalmologists I have consulted with believe in different root cause of my son's double vision in down gaze and right tilt of the head. The pediatric doctor feels strongly about IVth nerve palsy whereas the opthalmologist who treated my son in ER feels there is a mechanical restriction somewhere. Both have advised us to wait for several weeks, and have said that there should be improvement, if not complete recovery, in vision in time. However, I am getting a sense from reading the various comments posted here (including the Mayo clinic study) that acquired IVth nerve palsy does not have a favorable outcome. I am a materials scientist so I understand that research studies / findings need to be looked at in their context. But I am a lay man when it comes to medical field and despite my education, my thinking is influenced by the information I see. It seems to me that there appears to be a convergence of opinions about some degree of permanent double vision in my son's case. Not very encouraging outlook, though I keep reminding myself to look on the bright side and that we were lucky that his eye was saved on the day of the injury. Amul PS: The comment about the injection was not just a case of grasping for straws. I was merely trying to take into account everything that happened including the medical treatment. I did see the needle (at least an inch long) go all the way into the eye just below the eye brow. However, you guys are the experts and know what can and cannot happen with injections. Thanks. > An ophthalmologist injecting anesthetic in this area stands almost NO chance > of doing anything. You have to be at least a 1/2 inch into the orbit to even [quoted text clipped - 83 lines] > >> > >> DrG > wasn't any. MRI of the brain was unremarkable and so was that of the > orbits. At this point in time, the two opthalmologists I have [quoted text clipped - 4 lines] > opthalmologist who treated my son in ER feels there is a mechanical > restriction somewhere. There's a distinguishing clue in the specific pattern of the restriction, but it takes a cooperative subject and careful testing. Did anyone do the "forced duction" test Dr. Robins mentioned? > Both have advised us to wait for several weeks, > and have said that there should be improvement, if not complete > recovery, in vision in time. The injection was underneath, right? The fourth nerve runs superiorly in the eye socket, well away from the injection site. If there's a fourth nerve palsy, it may well be unrelated to the injection. If there's a bone puncture or soft tissue damage at the injection site, it's too subtle to show up on MRI? > see. It seems to me that there appears to be a convergence of opinions > about some degree of permanent double vision in my son's case. Not > very encouraging outlook, though I keep reminding myself to look on the > bright side and that we were lucky that his eye was saved on the day of > the injury. He is quite young? They make amazing adaptations when necessary. -MT Mr. Tyner, Thanks for your comments. The opthalmologist who applied stitches advised me of a test, I believe it is this 'forced duction' test you and Dr. Robins have mentioned, that could be done if things have not improved by the time of the next scheduled visit, Feb. 24th. It will have been almost 2 months by that time since the accident. He mentioned giving a general anasthesia to my son, then prying his eyelids apart and forcing the eye ball to move with tweezers. I believe he said the purpose would be to determine any restriction of movement. Is this what you mean by 'forced duction'? I do notice my son adopting a compensating posture when looking down. His injured eye, though devoid of black / blue appearance now, still looks a bit smaller in vertical dimension than the good eye. Here again, I don't know if this will improve with time or will it remain noticeably smaller for the rest of his life. In the final analysis, I could perhaps accept a permanent cosmetic compromise, but would very much like for his double vision to go away. Amul > > wasn't any. MRI of the brain was unremarkable and so was that of the > > orbits. At this point in time, the two opthalmologists I have [quoted text clipped - 28 lines] > > -MT > mentioned giving a general anasthesia to my son, then prying his > eyelids apart and forcing the eye ball to move with tweezers. I > believe he said the purpose would be to determine any restriction of > movement. Is this what you mean by 'forced duction'? Yes. An experienced examiner might get the same information from careful testing, without anesthesia, but it'd take patience, skill and some luck. > I do notice my son adopting a compensating posture when looking down. I read today that the most common adaptation to fourth nerve palsy is tilting the head toward the opposite shoulder. > His injured eye, though devoid of black / blue appearance now, still > looks a bit smaller in vertical dimension than the good eye. Here > again, I don't know if this will improve with time or will it remain > noticeably smaller for the rest of his life. I'm guessing that will get better, but a cosmetic problem is better than double vision. Judge it by the distance above the pupil for each lid, not by an "overall impression." -MT Regarding the injection, some do place a nerve block for the superior opthalmic nerve that runs through a notch at the upper oribt/bro area, rather than placing a direct injection into the laceration, since it does not cause fluid swelling at the laceration, making it easier to close. Stikkm son't have to inject that deeply to get at it. I still suspect a mechanical restriction; that is the one that can be determined by a force-duction test (the one he mentioned under anesthesia, probably done only at the time of surgery - no need to find out now.) However, if there is a mechanical restriction, a local injection of steroid could make some difference, but it is invasive, so decisions need to be made. David Robins, MD Board certified Ophthalmologist Pediatric and strabismus subspecialty Member of AAPOS (American Academy of Pediatric Ophthalmology and Strabismus) On 1/18/05 9:58 AM, in article 1106071097.880328.239910@c13g2000cwb.googlegroups.com, > Dr, Robins, > [quoted text clipped - 155 lines] >>>> >>>> DrG Thanks again for your comments. We are waiting anxiously for the next appt. on Feb. 21st and 24th. If the problem has not gone away or improved by then, we will undoubtedly need to make some decisions about invasive procedures. I will keep you posted. Thanks. > Regarding the injection, some do place a nerve block for the superior > opthalmic nerve that runs through a notch at the upper oribt/bro area, [quoted text clipped - 177 lines] > >>>> > >>>> DrG "Dr. Leukoma" <drg@leukoma.com> wrote in news:1105755906.770773.295210 @z14g2000cwz.googlegroups.com: > hence its > primary action as a depressor in temporal gaze. The primary action of the superior oblique is intorsion. Depression in temporal gaze is a secondary action. The latter might be more noticable clinically becuase torsion is not a foveating movement, but its still a secondary action. Abduction is a tertiary action. Scott > "Dr. Leukoma" <drg@leukoma.com> wrote in news:1105755906.770773.295210 > @z14g2000cwz.googlegroups.com: [quoted text clipped - 8 lines] > > Scott Thanks, for the revisit to ocular anatomy 101! Furthermore, the secondary action is depression on adduction and not on abduction. DrG "Dr. Leukoma" <drg@leukoma.com> wrote in news:1106013937.426185.41850 @c13g2000cwb.googlegroups.com: >> "Dr. Leukoma" <drg@leukoma.com> wrote in > news:1105755906.770773.295210 [quoted text clipped - 19 lines] > > DrG You're right-- nasal gaze. I might not have it all down, but I'm glad my brainstem seems to get it right. Scott Because I too believe that the trochlear nerve inserts too far back in the orbit to be affected by a something piercing the eyelid, I wonder whether the diplopia may not be caused by muscle swelling associated with the trauma. Perhaps the globe is being prevented from making a complete range of movements by simple mechanical forces? If this is true, then time and healing could be on your side. In anycase, it seems like a case of "wait and see". >> I am not a strabismologist, but have seen numerous cases of acquired > CN [quoted text clipped - 26 lines] > > Amul > healing could be on your side. In anycase, it seems like a case of "wait > and see". All cases are of "wait and see". The problem is the circumstances into which you force your patients to "wait and see". Usually, you force them to stay into strain, effort, suffering. Why you do this? > > healing could be on your side. In anycase, it seems like a case of > "wait [quoted text clipped - 6 lines] > Usually, you force them to stay into strain, effort, suffering. > Why you do this? WTF are you talking about? I hasten to add that the patient usually adopts a compensatory head posture to alleviate the double vision. DrG |
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