A Case of Bilateral Trochlear Nerve Palsy Following Cisternography

Keun Hae Kim; Sook Hyun Yoon; Sook Young Kim

doi:10.3341/jkos.2014.55.1.155

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Kim, Yoon, and Kim: A Case of Bilateral Trochlear Nerve Palsy Following Cisternography

Original Article

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

Published online: 7 September 2014

DOI: https://doi.org/10.3341/jkos.2014.55.1.155

A Case of Bilateral Trochlear Nerve Palsy Following Cisternography

Keun Hae Kim, MD, PhD, Sook Hyun Yoon, MD, Sook Young Kim, MD, PhD

Department of Ophthalmology, Catholic University of Daegu School of Medicine, Daegu, Korea

Address reprint requests to Sook Young Kim, MD, PhD Department of Ophthalmology, Daegu Catholic University Medical Center, #33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea, Tel: 82-53-650-4739, Fax: 82-53-627-0133, E-mail: kimsy@cu.ac.kr

Received 9 August 201327 October 2013 Accepted 7 December 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 9° on the double Maddox rod test. The patient was diagnosed with bilateral trochlear nerve palsy. After 2 years of fol-low-up, diplopia persisted and recession of the bilateral inferior oblique muscles was performed. After the surgery, diplopia dis-appeared, the fundus photography showed no excyclotorsion, and the double Maddox rod test indicated 3° of excyclotorsion.

Conclusions

Cisternography should be carefully performed due to the possibility of bilateral trochlear nerve palsy, an ex-tremely rare but possible occurrence following the procedure.

Keywords: Cisternography, Lumbar puncture, Trochlear nerve palsy

References

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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.

Figure 2.

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

Figure 3.

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

Figure 4.

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

Figure 5.

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

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.

Figure 7.

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

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