I have this condition. I’ve spent hundreds of dollars going to different doctors to finally find out why I was having double vision when reading and would get worse the longer I tried to read. My background is that I have multiple sclerosis and had a flare up that I feel caused this condition. After seeing a neurologist and neuro ophthalmologist, I finally found an ophthalmologist that was able to see the subtle movement and diagnose the palsy. It is very subtle but extremely debilitating when reading. It’s been very frustrating because I feel like the doctors didn’t believe what I was describing and really just blew me off. I’m sharing this so that other doctors listen to their patients when they describe these symptoms.
This is the first time I've actually understood why you ask a patient to look down and in when u test for superior oblique rather than the movement it makes (which is down and out)!! I've asked a million neurologist to explain it, and none of them ever did! Thank you so much for this!
I appreciate the way you create a positive and inclusive classroom environment. You make an effort to ensure that every student feels comfortable and valued, which is crucial for effective learning.
Great video. I was just diagnosed with this. I have diagonal double vision all the time, not just when reading a book. A few doctors missed the diagnosis, and I had two years of frustrating double vision, so I really appreciate you taking the time to make these videos for your students. I hope many people will be helped sooner than I was.
Excellent explanation. My STEP-1 book for USMLE says head tilts toward the side of lesion and I struggled to understand it. In fact the head tilts away from the lesion. Thanks.
@richiupliftmofo So using the analogy of the elbow and arm pulling at 2:15, he explains why the same muscle (the superior oblique) can move the eye in two different ways depending on where the eye is looking. If the eye is looking towards the nose the elbow pulling pulls it down. If the eye is looking out, then the same elbow movement turns the eye. So you ask the patient to look down and in, because thats when the SO muscle pulls the eye down. Hope that made sense.
Mine was diagnosed as congenital due to my head tilt, which it appears from pictures that I have had for about 4 years. I am 38, and never had trouble with double vision until 2 years ago. I've not had any tests for tumors.
I am 47 year old had the right superior oblique operated on last year to correct the vertical prism sadly the surgery failed and the amount of prism went from 10 to 15 . That is when I was diagnoised with congenital 4th nerve palsy. I have had the inferior rectus operated on left eye taking the vertical from 15 to 3. I have also got 10 horizontal I am waiting for a further operation on a rectus muscle on my right eye. The amount of neurologists opthalmologist and gastro I have seen is crazy. Because I was presenting my self with chronic back neck shoulder and stomach pain. Been a very long road
Thank you! So CN IV damage is visible mostly in eye movement and the affected eye will drift upwards when it moves medially correct? in serious cases would I see uneven eyes without testing motor function? I looked at clip after clip and nobody would just say what the presenting symptoms looked like, this was the most helpful. Thanks!
6 months ago I went to see my ophthalmologist and ge said I have 3rd,4th and 6th nerve palsy. He sent me to ER. I Have DM, and HT both well controlled. Dr. Hussain Chicago
Is infection a common cause for this problem? For me it started 20 years ago with an ear infection. Since then it's been chronic, along with sinus chronic infection, and I'm starting to think my diplopia (which you describe perfectly) is caused by this same infection. I also have other very debilitating symptoms, like dizziness, and I get very uncomfortable sensations and disregulations every time I get into water, which is how my infection started in the first place.
My daughter suffered from a mandibular fracture and head trauma and now she has six nerve palsy I've noticed she has difficulty reading, walking straight,on the stairs too. She's never ever had any eye problems. Shes been seen by seven doctors And an opthomoligist she's never seen before just diagnosed her with Duane's 3 can Duane's be caused by head trauma????
Yes, except I was later diagnosed with ocular Myasthenia Gravis rather than Trochlear Nerve Palsy. On Pyriodostigmine Tablets now and I'm better than ever
I don’t know if you respond, but mines not just affecting me when I can read a book, I’m wearing an eye patch at the minute to not feel sick constantly :( will have multiple scan results tomorrow, I’m super scared :/
Drives me mental ! I get a good few minutes and that's it plus if I put my chin down looking up is spastic ugh! Rear end accident . Many doctors dud nit advice after binocular vision test. I can see Teo noses. Crazy
ive had this 8 weeks now no improvement so cant have psm glasses getting round with blocked off glasses and eye patch in house but keep banging into things does anyone know how long before it goes naturally dont fancy the surgery docs thinks its vasuclar as no head injury although i may have had one when drinking last year
UPDATE. If anyone has this problem it takes a while to improve I had for about 6 months after I got in an accident . I still have it but only when I look to my left so it’s about 40 percent of my vision .
hi there hope you can read my comment and give an honest opinion ii dont have eye grades or astigmatism however my doctor found out i jave 4th cranial nerve palsy, at first sight my eyes look fine but once i look down my right eye will not go down as the left eye. I have a prism with just. 5 power. I am hesistant to wear it as i might get use to it and in the long run i will be needing more n more prism. Wearing it makes me more confidence as my coordination and balance improve a lot. Just that i was concern in the long run it will hurt me tha do good.
Hey so does this mean i can train the muscle or is it completely paralysed and vision therapy wont do anything?? I feel like mine was congenital. Cheers.
0:50 @ you said right lesion, head tilt towards left. I think, head tilts toward the side of lesion. So, it should be right tilt. Correct me if I am wrong
Head tilts AWAY from the side of the lesion. FA 16 says that. To test for CN IV function you do two things. One is you make them gaze contralaterally. So if the lesion is in the right trochlear nerve, you ask them to look left. And the other is, you ask them to tilt their head towards the side of the lesion, so for eg if the right trochlear nerve is busted, you ask them to head tilt towards their right side. Ask them (the effectee) to bring/tilt their head towards the effected side's shoulder (right in our example) In both cases ( ie contralateral gaze and head tilting ipsilaterally), the effected eye will move upwards, sort of towards 2 o'clock position (up and medial), instead of staying horizontal at the 3 o'clock position (like the uneffected eye). Normally when you tilt your head ( in any direction), your eyes will stay in a horizontal plane and in the middle, so that you can focus in front of you. The eyes will remained focused no matter how you tilt or move your head or hang upside down. That positioning is achieved by the combined coordinated efforts of the eye muscles. However if you have a CN IV palsy, one muscle is down and so the eye can no longer remain focused / positioned when certain maneuvers are performed. So with activities that make the effected side's eye "move up and medial" like reading or going down stairs, the patient deliberately head tilts CONTRALATERALLY to compensate and avoid diplopia. So NO, head does not tilt towards the side of the lesion. Hope that made sense.
The right and left trochlear nerves decussate (cross the midline) once they originate from the midbrain so that the left CN IV supply the superior oblique of the right eye and the right CN IV supply the superior oblique of the left eye i.e. contralateral innervation. So when you say tilting to the same or opposite side, referring to what? If you’re talking referring to the affected eye, then compensatory tilting will be to the opposite side. But also remember that the affected is innervated by the contralateral trochlear nerve so tilting will be to the same side of the lesion i.e. the affected trochlear nerve.
Hi, I understand how it could be confusing, but the answer is that the head tilts away from the side Affected to bring the eye back into the plane of focus. The unaffected eye can intort, while the affected eye cannot.
I have this condition. I’ve spent hundreds of dollars going to different doctors to finally find out why I was having double vision when reading and would get worse the longer I tried to read. My background is that I have multiple sclerosis and had a flare up that I feel caused this condition. After seeing a neurologist and neuro ophthalmologist, I finally found an ophthalmologist that was able to see the subtle movement and diagnose the palsy. It is very subtle but extremely debilitating when reading. It’s been very frustrating because I feel like the doctors didn’t believe what I was describing and really just blew me off. I’m sharing this so that other doctors listen to their patients when they describe these symptoms.
Taking a 20 page, complicated subject and making it easy to understand in just a few minutes. Thank you! 💜
This is the simplest explanation I’ve found for my condition. Thank you!!
Fantastic video, I'm a medical student and up till now had trouble understanding a CN IV palsy, thanks for making it so clear and understandable!
This is the first time I've actually understood why you ask a patient to look down and in when u test for superior oblique rather than the movement it makes (which is down and out)!! I've asked a million neurologist to explain it, and none of them ever did! Thank you so much for this!
I appreciate the way you create a positive and inclusive classroom environment. You make an effort to ensure that every student feels comfortable and valued, which is crucial for effective learning.
THANK YOU!!! this was short and sweet and exactly what i was looking for
Great video. I was just diagnosed with this. I have diagonal double vision all the time, not just when reading a book. A few doctors missed the diagnosis, and I had two years of frustrating double vision, so I really appreciate you taking the time to make these videos for your students. I hope many people will be helped sooner than I was.
so it went away? completely? what prism optic were you? did you have surgery?
how it was solved ?
I had to have surgery. It is 90% better.
I don't remember what prism optic, but it got bad enough that I could no longer drive safely. Yes, I had surgery. It is 90% better now.
Many thanks !!!
a really excellent explanation. many thanks - i just spent half an hour reading a text book, and couldn't get it...
from med student, uk.
One of best and clear explanations . Thanks a lot.
Excellent explanation. My STEP-1 book for USMLE says head tilts toward the side of lesion and I struggled to understand it. In fact the head tilts away from the lesion.
Thanks.
It thinks it's right that the problem shows up when the eye look toward the lesion ( contralateral to the affected eye)
Sir, you have put the concept very nicely and easy to understand......
Studying for my FNP and this was the first time I understood this concept! Great job!!
just found this channel, life saver. thank u v much..forget about my notes.. doing his videos :)
You Sir, are Awesome, keep up the Great Work, many thanks from the medical community worldwide!
this is fantastic! the analogy with the head and the arm is brilliant! thanks so much!
Wow! Thanks. My son was just diagnosed with this. Great explanation. We have a better understanding of this condition.
what was the cure ?
Excellent doctor.
Dr. Hussain
Thank you so much for posting this video. Fantastic explanation with great ways of remembering the palsy!
I AM SOLD! Absolutely loved the trick with SO muscle function. I have always hated SO and IO BUT NOT ANYMORE!
Excellent video! Thank you for your contribution.
i have never understood the pulley thing until now! Thanks so so much!
I love how you talk.
Your video are fantastic for understanding this orbital anatomy. Many many thanks!
@richiupliftmofo So using the analogy of the elbow and arm pulling at 2:15, he explains why the same muscle (the superior oblique) can move the eye in two different ways depending on where the eye is looking. If the eye is looking towards the nose the elbow pulling pulls it down. If the eye is looking out, then the same elbow movement turns the eye. So you ask the patient to look down and in, because thats when the SO muscle pulls the eye down. Hope that made sense.
Thank you very much 😄 from a medical student in Belgium
Thank you for making such a tricky topic so easy to understand!
this was extremely helpful..thank you very much
Mine was diagnosed as congenital due to my head tilt, which it appears from pictures that I have had for about 4 years. I am 38, and never had trouble with double vision until 2 years ago. I've not had any tests for tumors.
I am 47 year old had the right superior oblique operated on last year to correct the vertical prism sadly the surgery failed and the amount of prism went from 10 to 15 . That is when I was diagnoised with congenital 4th nerve palsy. I have had the inferior rectus operated on left eye taking the vertical from 15 to 3. I have also got 10 horizontal I am waiting for a further operation on a rectus muscle on my right eye. The amount of neurologists opthalmologist and gastro I have seen is crazy. Because I was presenting my self with chronic back neck shoulder and stomach pain. Been a very long road
Hi James, i have the same problem could we talk?
Such a good explanation .. omg this video is 11 y/o 😳😳
brilliant videos thank you very much, keep it up!
Thank you! It actually makes sense now.
the future of education. down with traditional lectures
Thank you! So CN IV damage is visible mostly in eye movement and the affected eye will drift upwards when it moves medially correct? in serious cases would I see uneven eyes without testing motor function?
I looked at clip after clip and nobody would just say what the presenting symptoms looked like, this was the most helpful. Thanks!
Man i can't thank you enough, thank you so much for making this clear =)
6 months ago I went to see my ophthalmologist and ge said I have 3rd,4th and 6th nerve palsy. He sent me to ER.
I Have DM, and HT both well controlled.
Dr. Hussain Chicago
Can u pls tell me . How soon it will be curable for a 60years old woman and wat r the step of treatment should we go for ? Thanks
Can eye exercises be done to treat this condition, or is surgery the corrective action? Thanks
this video is brilliant, thanks for the upload!
Amazingly well taught!
Excellent Video Thank you!
Thank you the video was really informative
Is infection a common cause for this problem? For me it started 20 years ago with an ear infection. Since then it's been chronic, along with sinus chronic infection, and I'm starting to think my diplopia (which you describe perfectly) is caused by this same infection. I also have other very debilitating symptoms, like dizziness, and I get very uncomfortable sensations and disregulations every time I get into water, which is how my infection started in the first place.
My daughter suffered from a mandibular fracture and head trauma and now she has six nerve palsy I've noticed she has difficulty reading, walking straight,on the stairs too. She's never ever had any eye problems. Shes been seen by seven doctors And an opthomoligist she's never seen before just diagnosed her with Duane's 3 can Duane's be caused by head trauma????
It's an Awesome job! Thank you for making great video.
very good work and good luck.
Thank u very much. God bless u
Awesome! thank you!
You are great! Thanks!
But how come tilting the neck away from lesion helps the patient to cope diplopia?
BEAUTIFUL
I suffer this condition, really want to get rid of it. Got a pair of prism glasses to help, i hope I don't have to operate on my eye though
Hi
was it solved since i am suffering from the some condition
Yes, except I was later diagnosed with ocular Myasthenia Gravis rather than Trochlear Nerve Palsy. On Pyriodostigmine Tablets now and I'm better than ever
Can we talk on FB ?
Are these nerve palsies the same as medial longitudinal fasciculus?
Are they related to MS?
Are there other symptoms?
Awesomeness. thanks.
thx simple and informative
thank u so much!
Thanks!!
I don’t know if you respond, but mines not just affecting me when I can read a book, I’m wearing an eye patch at the minute to not feel sick constantly :( will have multiple scan results tomorrow, I’m super scared :/
thanks alot for this!!!
Many thanks
great video, thxs
Does anyone know how to cure this disease?I really need some help. Many thanks in advance
thanks
Ty
@AnakinSolo2002 What did you do to cure it.
what is the function of superior oblique? some book that i read said, down and out and some book said down and in. im a bit confused!
Drives me mental ! I get a good few minutes and that's it plus if I put my chin down looking up is spastic ugh! Rear end accident . Many doctors dud nit advice after binocular vision test. I can see Teo noses. Crazy
ive had this 8 weeks now no improvement so cant have psm glasses getting round with blocked off glasses and eye patch in house but keep banging into things does anyone know how long before it goes naturally dont fancy the surgery docs thinks its vasuclar as no head injury although i may have had one when drinking last year
Has this improved for you
UPDATE. If anyone has this problem it takes a while to improve I had for about 6 months after I got in an accident . I still have it but only when I look to my left so it’s about 40 percent of my vision .
@yazmannn aahhhhhhhhhhh ok! I've got it! thank u very much. I understand why is so difficult to diagnose! ;)
Can it be fixed?
hi there hope you can read my comment and give an honest opinion
ii dont have eye grades or astigmatism however my doctor found out i jave 4th cranial nerve palsy, at first sight my eyes look fine but once i look down my right eye will not go down as the left eye.
I have a prism with just. 5 power. I am hesistant to wear it as i might get use to it and in the long run i will be needing more n more prism.
Wearing it makes me more confidence as my coordination and balance improve a lot.
Just that i was concern in the long run it will hurt me tha do good.
Prims, unlike spectacle prescriptions don't usually alter and stay stable as it is to do with musculature.
Hope this helps.
@yazmannn instead....I didn't undertand! why u test down and in?
may i know what app you make these cartoons with?
Hey so does this mean i can train the muscle or is it completely paralysed and vision therapy wont do anything??
I feel like mine was congenital. Cheers.
You got company
cooooool thank you
Awesome. Thank you. M1 Wayne State Univeristy
Cheers :)
0:50 @ you said right lesion, head tilt towards left. I think, head tilts toward the side of lesion. So, it should be right tilt. Correct me if I am wrong
I agree. First Aid 2016 also says the head tilts toward the side of lesion.
Head tilts AWAY from the side of the lesion. FA 16 says that.
To test for CN IV function you do two things. One is you make them gaze contralaterally. So if the lesion is in the right trochlear nerve, you ask them to look left.
And the other is, you ask them to tilt their head towards the side of the lesion, so for eg if the right trochlear nerve is busted, you ask them to head tilt towards their right side. Ask them (the effectee) to bring/tilt their head towards the effected side's shoulder (right in our example)
In both cases ( ie contralateral gaze and head tilting ipsilaterally), the effected eye will move upwards, sort of towards 2 o'clock position (up and medial), instead of staying horizontal at the 3 o'clock position (like the uneffected eye). Normally when you tilt your head ( in any direction), your eyes will stay in a horizontal plane and in the middle, so that you can focus in front of you. The eyes will remained focused no matter how you tilt or move your head or hang upside down. That positioning is achieved by the combined coordinated efforts of the eye muscles. However if you have a CN IV palsy, one muscle is down and so the eye can no longer remain focused / positioned when certain maneuvers are performed.
So with activities that make the effected side's eye "move up and medial" like reading or going down stairs, the patient deliberately head tilts CONTRALATERALLY to compensate and avoid diplopia.
So NO, head does not tilt towards the side of the lesion. Hope that made sense.
the lesioned eye will be extroverted, and the way to correct this is head tilting away from the lesion side ( to make the eye stay horizontal )
The right and left trochlear nerves decussate (cross the midline) once they originate from the midbrain so that the left CN IV supply the superior oblique of the right eye and the right CN IV supply the superior oblique of the left eye i.e. contralateral innervation.
So when you say tilting to the same or opposite side, referring to what?
If you’re talking referring to the affected eye, then compensatory tilting will be to the opposite side. But also remember that the affected is innervated by the contralateral trochlear nerve so tilting will be to the same side of the lesion i.e. the affected trochlear nerve.
Hi, I understand how it could be confusing, but the answer is that the head tilts away from the side Affected to bring the eye back into the plane of focus. The unaffected eye can intort, while the affected eye cannot.
❤
I had one when I was in third grade, it sucked.