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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 3  |  Page : 326-330

Trochlear nerve palsy with contralateral Horner's syndrome: A rare presentation post trauma

Consultant, Department of Pediatric Ophthalmology and Strabismus, Payyannur Eye Foundation, Payyannur, Kerala, India

Date of Submission28-Apr-2021
Date of Decision29-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication08-Dec-2021

Correspondence Address:
Dr. Remya Edachery
Payyanur Eye Foundation, Co-operative Hospital, Payyanur - 670 307, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_98_21

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We describe a case of posttraumatic vertical diplopia and Horner's syndrome (HS). The patient presented 2 weeks post road traffic accident with acute onset double vision more in left gaze and right tilt. The left eye had mild ptosis. The apparent elevation deficit in the left eye in levoelevation was misinterpreted as left eye superior rectus paresis instead of right eye inferior oblique overaction and thus mimicked superior division third nerve palsy in the left eye. Anisocoria was more in the dark. Computerized tomography of the brain and orbit was normal. Magnetic resonance imaging of the cervical spine showed left C6–C7 nerve root avulsion. A diagnosis of right fourth nerve palsy with left eye HS secondary to brachial plexus injury was made. We could not find a previous description of fourth nerve palsy with contralateral HS following trauma in the literature.

Keywords: Brachial plexus injury, Horner's syndrome, trochlear nerve palsy

How to cite this article:
Edachery R. Trochlear nerve palsy with contralateral Horner's syndrome: A rare presentation post trauma. Kerala J Ophthalmol 2021;33:326-30

How to cite this URL:
Edachery R. Trochlear nerve palsy with contralateral Horner's syndrome: A rare presentation post trauma. Kerala J Ophthalmol [serial online] 2021 [cited 2022 Aug 8];33:326-30. Available from: http://www.kjophthal.com/text.asp?2021/33/3/326/331926

  Introduction Top

Trochlear nerve palsy may be congenital or acquired. The causes of acquired trochlear nerve palsy are vascular injury, trauma specifically closed head trauma, intracranial space-occupying lesions, demyelination etc., Trochlear nerve palsy is the most common cause for a single cyclovertical muscle palsy. Posttraumatic isolated trochlear nerve palsies are usually seen in closed head injuries.[1] Approximately 18% of all trochlear nerve palsies are due to trauma.[2] We describe a case of posttraumatic ptosis with vertical diplopia that caused a confusion in the diagnosis. The patient presented with left head tilt with right hypertropia more in left gaze and right tilt. The patient had mild ptosis with miosis in the left eye that was secondary to Horner's syndrome (HS) associated with brachial plexus injury. HS is common in injuries to the brachial plexus.[3],[4] Acquired trochlear nerve palsy with ipsilateral HS was previously reported in brainstem stroke and cavernous sinus lesions.[5],[6],[7] Trochlear nerve palsy with contralateral HS has also been described in the literature.[8],[9] However, we were unable to find any reports of trochlear nerve palsy with contralateral HS following trauma in the scientific literature.

  Case Report Top

A 21-year-old male with a history of fall from a motorcycle 2 weeks back was referred to our outpatient department with complaints of binocular vertical diplopia. There was no history of loss of consciousness, vertigo, or vomiting. He had paresis of left upper limb secondary to left brachial plexus injury [Figure 1] with left C6 and C7 nerve root avulsion. The best-corrected visual acuity was 6/6 in both eyes. The anterior segment was normal except for anisocoria with the left pupil smaller than the right. The direct and consensual pupillary reactions and posterior segment were normal.
Figure 1: Left brachial plexus injury

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The patient had a left head tilt with mild ptosis in the left eye [Figure 2]. The Hirschberg reflex was central, and the cover test revealed right hypertropia [Figure 3]. The right side appeared more hypertropic on general examination because the inferior limbus to lower lid margin was higher on the right side. The Parks three-step test showed right hypertropia more in left gaze and right tilt [Figure 4] and [Figure 5], suggestive of right trochlear nerve palsy. [Figure 6] shows the nine cardinal gazes. Extraocular movements were full except for apparent elevation deficit in the left eye which was due to the inferior oblique overaction in the right eye secondary to right superior oblique underaction. The computerized tomography image of the brain and orbit was normal [Figure 7]. The forced duction test under topical anesthesia did not show any restriction.
Figure 2: Left head tilt

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Figure 3: Right hypertropia

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Figure 4: Right hypertropia more in left gaze

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Figure 5: Right hypertropia more in right tilt

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Figure 6: Extraocular movements in nine cardinal gazes - RE SO underaction with IO overaction, LE - apparent SR underaction

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Figure 7: Normal computed tomography brain and orbit

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Diplopia charting [Figure 8] showed crossed diplopia with right hypertropia more in left gazes, maximum being in the levoelevation, suggesting right inferior oblique overaction secondary to SO palsy. The apparent elevation deficit in the left eye with ptosis was initially provisionally diagnosed as superior division third nerve paresis of the left eye.

A detailed orthopedic evaluation was done. Magnetic resonance imaging of the cervical spine showed left C6–C7 nerve root avulsion with pseudomeningocele [Figure 9].
Figure 8: Diplopia chart showing maximum separation of images in the levoelevation

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Figure 9: Magnetic resonance imaging cervical spine-C6, C7 nerve root avulsion with pseudomeningocele

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The left eye also showed inverse ptosis with the lower lid margin to the inferior limbus distance being less on the left side. The anisocoria [Figure 10] was more in dark compared to bright light. The findings of mild ptosis and miosis in the left eye with adduction being normal led to the diagnosis of HS secondary to the left brachial plexus injury and excluded a diagnosis of superior division third nerve paresis.
Figure 10: Anisocoria with left eye miosis

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A final diagnosis of post traumatic fourth nerve palsy in the right eye associated with left eye HS secondary to brachial plexus injury was made.

  Discussion Top

Isolated fourth nerve palsy either unilateral or bilateral can occur following head trauma.[1],[10] It usually presents with vertical diplopia with hypertropia more in the opposite gaze and same side tilt (Parks-Bielschowsky test) and excyclotorsion. Bilateral palsy is common in closed head injuries as the two nerves decussate at the anterior medullary velum.[11] Patients usually present with V pattern esotropia with torsional diplopia and >15° extorsion. Hypertropia usually prominent in one eye reverses in side gazes. We should always suspect bilateral injury if the hypertropia reverses in any of the nine cardinal gazes.[12]

Usually superior oblique palsy causes double vision more in downgaze. It is unusual to have an inferior oblique overaction secondary to a traumatic superior oblique palsy within few days of trauma. In this case, the inferior oblique overaction was more which resulted the maximum separation of images in the levoelevation and misinterpreted as left eye superior rectus underaction in the diplopia chart. Superior rectus involvement with ptosis led to a diagnostic dilemma.

About 12% of all third nerve injuries are due to direct injuries such as trauma, indirect injuries such as compression, and ischemia at different sites. Isolated traumatic third nerve palsies are usually associated with intracranial injuries or even minor head trauma and orbital injuries.[13],[14] Isolated oculomotor palsies are mostly basilar. Complete third nerve palsy presents with complete ptosis with or without mydriasis and the eye adopting a down and out position due to the uninvolved lateral rectus and superior oblique function. Partial third nerve palsies present with similar features but to a lesser extent.

Patients usually adopt a head posture in paralytic strabismus either to improve their binocular field or to separate the images extremely far to avoid double vision. The head tilt in this case was due to superior oblique palsy.

HS, a triad of ptosis, miosis, and anhidrosis, results from the interruption of the sympathetic chain from eye to the hypothalamus.[15] Ptosis is usually mild (<2 mm) as the tone sympathetically innervated Muller's muscle causing the initial elevation of the eye is lost. In this case, the lower lid to the inferior limbus distance was more in the right eye, confirming an upside down or inverse ptosis [Figure 11] in the left eye. The pupil in HS will be small on the involved side due to the loss of sympathetic tone of the dilator pupillae, but direct and consensual reactions will be normal. The anisocoria will be more in dark, as the parasympathetic tone will be more in dark. Lesions anywhere in the oculosympathetic pathway results in central (first order), preganglionic (second order), or postganglionic (third order) HS. The present case had an injury to the brachial plexus and is a second-order HS.
Figure 11: Inverse ptosis left eye

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Fourth nerve palsy with ipsilateral Horners has been previously described in a case of brain stem strokes and cavernous sinus involvement such as tumors and Tolosa-Hunt syndrome.[5],[6],[7]

Trochlear palsy with contralateral HS has been described by Guy et al. in two patients, one with arteriovenous malformation and the other with a mass in the brain stem.[8] Recently, a similar case has been described with mesencephalic hemorrhage as the etiology.[9] In all these cases, the presentation has a localizing value. However, in this case, both are two separate entities presenting in the same patient. Neurological imaging is necessary to find the causes of combined fourth nerve palsy and HS.

  Conclusion Top

Proper assessment of ocular motility and assessment of associated ocular and systemic findings are necessary to arrive at the correct diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Diora JR, Plager DA. Sudden-onset trochlear nerve palsy: Clinical characteristics and treatment implications. J AAPOS 2019;23:321.e1-0000.  Back to cited text no. 1
Dosunmu EO, Hatt SR, Leske DA, Hodge DO, Holmes JM. Incidence and etiology of presumed fourth cranial nerve palsy: A population-based study. Am J Ophthalmol 2018;185:110-4.  Back to cited text no. 2
Rai W, Olcese V, Elsheikh B, Stino AM. Horner's syndrome as initial manifestation of possible brachial plexopathy neurolymphomatosis. Front Neurol 2019;10:4.  Back to cited text no. 3
Stasiowski M, Zuber M, Marciniak R, Kolny M, Chabierska E, Jałowiecki P, et al. Risk factors for the development of Horner's syndrome following interscalene brachial plexus block using ropivacaine for shoulder arthroscopy: A randomised trial. Anaesthesiol Intensive Ther 2018;50:215-20.  Back to cited text no. 4
Bazan R, Braga GP, Gomes DL, Yamashita S, Betting LE, Resende LA. Trochlear nerve palsy associated with Claude Bernard-Horner syndrome after brainstem stroke. Case Rep Neurol 2011;3:248-51.  Back to cited text no. 5
Ebner R. Fourth nerve paresis and ipsilateral Horner's syndrome: An unusual association. Neuroophthalmology 2019;43:289-90.  Back to cited text no. 6
Kuroda Y, Kakigi R, Shibasaki H, Oono S. Case of Tolosa-Hunt syndrome presenting trochlear nerve palsy and Horner's syndrome. Rinsho Shinkeigaku 1983;23:495-500.  Back to cited text no. 7
Guy J, Day AL, Mickle JP, Schatz NJ. Contralateral trochlear nerve paresis and ipsilateral Horner's syndrome. Am J Ophthalmol 1989;107:73-6.  Back to cited text no. 8
Martín-Moro JG, Arrojo FG, Rodríguez Del Valle JM, Sanz AS, González-López JJ, Pilo de la Fuente B, et al. Fourth nerve palsy plus contralateral Horner syndrome secondary to mesencephalic haemorrhage: An unusual crossed syndrome. Clin Exp Optom 2015;98:571-3.  Back to cited text no. 9
Ray D, Gupta A, Sachdeva V, Kekunnaya R. Superior oblique palsy: Epidemiology and clinical spectrum from a tertiary eye care center in South India. Asia Pac J Ophthalmol (Phila) 2014;3:158-63.  Back to cited text no. 10
Lee J, Flynn JT. Bilateral superior oblique palsies. Br J Ophthalmol 1985;69:508-13.  Back to cited text no. 11
Sydnor CF, Seaber JH, Buckley EG. Traumatic superior oblique palsies. Ophthalmology 1982;89:134-8.  Back to cited text no. 12
Coello AF, Canals AG, Gonzalez JM, Martín JJ. Cranial nerve injury after minor head trauma. J Neurosurg 2010;113:547-55.  Back to cited text no. 13
Dhaliwal A, West AL, Trobe JD, Musch DC. Third, fourth, and sixth cranial nerve palsies following closed head injury. J Neuroophthalmol 2006;26:4-10.  Back to cited text no. 14
Martin TJ. Horner syndrome: A clinical review. ACS Chem Neurosci 2018;9:177-86.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]


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