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1 Alternating Hypertropias - Bilateral 4th Nerve Palsies and Alternating Skew DeviationSeen here are two patients with alternating hypertropias. The first is a 70-year-old woman with a diagnosis of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). In the video, both spontaneous downbeat nystagmus (DBN) and gaze-evoked nystagmus (GEN) are apparent, in addition to a...Skew Deviation; Alignment; Fourth Nerve Palsy; Cerebellar Pathology; Jerk Nystagmus; Downbeat Nystagmus; Gaze Evoked Nystagmus
2 Cavernous sinus mass causing right 3rd and 4th nerve palsies25-yo-man who complained of diplopia and was initially found to have right 4th and 6th nerve palsies in the setting of a right cavernous sinus mass (subsequently diagnosed as Ewing's sarcoma). When seen in follow-up (this video), there was a new right 3rd nerve palsy, still with a right 4th nerve pa...Third (Oculomotor) Nerve Palsy; Third subnuclear; Fourth (Trochlear) Nerve Palsy
3 Central 4th nerve palsy with contralateral Horner's syndromeThis is a 60-yo-woman who presented with a complaint of diplopia. Examination demonstrated a left hypertropia that worsened in right and down gaze as well as in left head tilt, and a left 4th nerve palsy was diagnosed. There was also evidence of a mild motility deficit in down/medial gaze OS, consis...Horner's, Fourth nerve palsy, Mesencephalon
4 Inferior oblique overaction in a congenital 4th nerve palsy60-yo-man complaining of intermittent oblique diplopia. There was a left hypertropia that worsened in down gaze, right gaze and in left head tilt. There was a large vertical fusional amplitude in addition to a longstanding rightward head tilt, and on examination there was left inferior oblique overa...Fourth (Trochlear) Nerve Palsy
5 Isolated Central 4th Nerve PalsyThis is a 40-year-old man with a right hypertropia that worsened in left and down gaze in addition to right head tilt, and improved in left head tilt. There was subjective excyclotorsion OD with double Maddox rod testing. This was consistent with a right 4th nerve palsy. He had a known left midbrain...Fourth Nerve Palsy; OMS Midbrain
6 Leukemic leptomeningeal carcinomatosis causing 4th and 6th nerve palsiesThis is a 55-yo-man with CML that recurred as AML. Diagonal diplopia developed, and on examination he was found to have a partial right 6th nerve palsy, in addition to a left hypertropia that increased in right gaze, down gaze, and in left head tilt consistent with a left 4th nerve palsy. There was ...Abnormal Range, Fourth Nerve Palsy, Sixth Nerve Palsy
7 Superior Oblique Myokymia - Three Patients with Recorded Attacks Using VOG and Frenzel GogglesPatients with superior oblique myokymia (SOM) commonly present with complaints of monocular oscillopsia and/or vertical diplopia, which are related to the primary and secondary actions of the SO (incycloduction and depression, respectively). In many cases, SOM represents a neurovascular compression ...Superior Oblique Myokymia; Fourth Troclear Nerve; Abnormal Alignment
8 Test Your Knowledge - Bilateral 4th Nerve PalsiesWatch the video until instructed to stop. Which of the following features is likely to be present given her exam findings? A. Gaze-evoked nystagmus and impaired smooth pursuit B. History of traumatic brain injury C. History of blepharoplasty or brow lift surgery and prominence of superior sulcus on ...Abnormal Alignment; Fourth Nerve; Trochlear Nerve
9 Third Nerve Palsy Due to Tolosa Hunt SyndromeThis is a 20-year-old woman presenting with severe left eye pain and diplopia for several days. Examination was consistent with a pupil sparing left 3rd nerve palsy with complete external ophthalmoplegia (involving levator palpebrae, medial rectus, superior rectus, inferior rectus). Abduction OS was...Third Nerve Palsy; Tolosa Hunt Syndrome
10 Third and Sixth Nerve Palsies Due to Cavernous Sinus MeningiomaThis is a 60-year-old woman with a large meningioma that was compressing the right cavernous sinus. Examination demonstrated a pupil-involving right 3rd nerve palsy with near complete external ophthalmoplegia (involving levator palpebrae, medial rectus, superior rectus, inferior rectus). There was a...Third Nerve Palsy; Fourth Nerve Palsy; Sixth Nerve Palsy
11 Unilateral 3rd, 4th, and 6th nerve palsies due to cavernous sinus meningiomaThis is a 50-year-old woman presenting with a partial 3rd nerve palsy (mild pupil involvement), partial 6th nerve palsy, and no clear incyclotorsion with downgaze, suggestive of additional 4th nerve palsy, all on the left. With compressive lesions involving the 3rd nerve, often aberrant regeneration...Abnormal Range, Third Nerve Palsy, Aberrant Regeneration, Fourth Nerve Palsy, Sixth Nerve Palsy, Jerk Nystagmus, Downbeat Nystagmus, Gaze Evoked Nystagmus, Abnormal Saccades
12 Vertical Vergence and Fusional AmplitudeEssential information on vertical fusional vergences.Normal Alignment; Abnormal Alignment; Fourth Nerve Palsy; Vergence; Fusional Amplitudes
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