J Korean Ophthalmol Soc.  2014 Jan;55(1):155-160.

A Case of Bilateral Trochlear Nerve Palsy Following Cisternography

• Kim KH
• Yoon SH
• Kim SY

Abstract

PURPOSE
To report a case of bilateral trochlear nerve palsy following cisternography.
CASE SUMMARY
A 43-year-old male with intermittent watery rhinorrhea persisting for 3 months visited the neurosurgery department of our institute. His past medical history included removal of a pituitary adenoma 22 years prior to presentation. Cerebrospinal fluid leakage was suspected and cisternography was performed. The patient was referred to our ophthalmology department for diplopia 3 days after the cisternography. An alternate prism cover test showed 5 prism diopter (PD) right hypertrophia in the primary position, and underaction of bilateral superior oblique muscles and overaction of the left inferior oblique muscle. A positive Bielschowsky test with the head tilted to either side was observed and excyclotorsion was 9degrees on the double Maddox rod test. The patient was diagnosed with bilateral trochlear nerve palsy. After 2 years of follow-up, diplopia persisted and recession of the bilateral inferior oblique muscles was performed. After the surgery, diplopia disappeared, the fundus photography showed no excyclotorsion, and the double Maddox rod test indicated 3degrees of excyclotorsion.
CONCLUSIONS
Cisternography should be carefully performed due to the possibility of bilateral trochlear nerve palsy, an extremely rare but possible occurrence following the procedure.

Keyword

Cisternography; Lumbar puncture; Trochlear nerve palsy

MeSH Terms

Adult
Cerebrospinal Fluid
Diplopia
Follow-Up Studies
Head
Humans
Male
Muscles
Neurosurgery
Ophthalmology
Photography
Pituitary Neoplasms
Spinal Puncture
Trochlear Nerve Diseases*
Trochlear Nerve*

Figure

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  Figure 1. Nine cardinal photographs at the first visit showing underaction of bilateral superior oblique muscles and overaction of the left inferior oblique muscle.

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  Figure 2. Fundus photographs at the first visit showing excyclotorsion in the right eye.

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  Figure 3. Lumbar spine MRI with postcontrast fat-suppressed T1-weighted sagittal image showing increased epidural enhancement (arrow).

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  Figure 4. Preoperative nine cardinal photographs showing underaction of bilateral superior oblique muscles and marked overaction of the left inferior oblique muscle.

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  Figure 5. Hess screen test chart of the patient with bilateral trochlear nerve palsy.

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  Figure 6. Nine cardinal photographs after recession of the bilateral inferior oblique muscles presenting no overaction of bilateral inferior oblique muscles and mild underaction of the left superior oblique muscle.

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  Figure 7. Fundus photographs after weakening of bilateral inferior oblique muscles showing no excyclotorsion in both eyes.

Reference

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