Hydrocephalus Revealed by Relapsing Bilateral Fourth Cranial Nerve Palsy

Introduction: Uni- or bi-lateral fourth cranial nerve palsy due to hydrocephalus and/or after VPS placement is a very rare oculomotor manifestation. We report a case of relapsing bilateral fourth nerve palsies demonstrating recurring hydrocephalus. We reviewed the literature (table1) in order to inform the clinician about the clinical assessment, the past medical history and the radiological findings that prompt research for this peculiar entity and to avoid misdiagnoses like palsies of the sixth cranial nerve. Diagnosis, intervention and outcome: The patient presented with recurrence of diplopia in reading position, partially resolved after a second VPS placement. A diagnosis of bilateral fourth nerves palsies was done after complete neuro-ophthalmological evaluation. A close follow-up demonstrated fluctuating level of diplopia by changing VPS valve resistance. An optimal placement of the VPS offered reduction and stability of diplopia. A final strabismus surgery was necessary to obtain complete symptoms release.

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Outcomes of half-width vertical rectus transposition augmented with posterior fixation sutures for sixth cranial nerve palsy

International Journal of Ophthalmology ◽

10.18240/ijo.2021.12.17 ◽

2021 ◽

Vol 14 (12) ◽

pp. 1921-1927

Author(s):

Ortal Fogel-Tempelhof ◽

◽

Chaim Stolovitch ◽

Oriel Spierer ◽

◽

...

Keyword(s):

Cranial Nerve ◽

Cranial Nerve Palsy ◽

Nerve Palsy ◽

Rectus Muscle ◽

Half Width ◽

Medial Rectus ◽

Posterior Fixation ◽

Sixth Cranial Nerve ◽

Sixth Cranial Nerve Palsy

AIM: To describe the experience with half-width vertical muscles transposition (VRT) augmented with posterior fixation sutures. METHODS: The clinical charts of all patients, who underwent half-width VRT augmented with posterior fixation sutures for sixth cranial nerve palsy from January 2003 to December 2018, were retrospectively reviewed. For each patient, pre- and post-operatively, the largest measured angle was used for the calculations, usually resulting with the angle for distance, except in young infants, where measurements were made at near fixation using the Krimsky test. RESULTS: Fifteen patients met the inclusion criteria for the study, of them 9 (60.0%) had also medial rectus muscle recession at the time of surgery. Mean follow-up period was 21.4±23.2mo (range 1.5-82mo). Preoperative mean esotropia was 51.3±19.7 prism diopter (PD; range 20-90 PD). Postoperative mean deviation on final follow-up was 7.7±20.2 PD (range -40 to 35 PD; P=0.018). In all patients with preoperative abnormal head position, improvement was noted. Ten (66.7%) patients had improvement in abduction and 10 (66.7%) patients reported improvement in their diplopia, by final follow-up. The addition of medial rectus recession was correlated with a larger change in postoperative horizontal deviation compared to baseline (P=0.026). Two (13.3%) patients developed a vertical deviation in the immediate postoperative period which had resolved in one of them. CONCLUSION: Half-width VRT augmented with posterior fixation suture, with or without medial rectus muscle recession, is an effective and safe procedure for esotropia associated with sixth cranial nerve palsy. A major improvement in the angle of deviation is expected. Most patients will have improvement in their abnormal head position and diplopia.

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