Superior oblique palsy, also known as trochlear nerve palsy or fourth nerve palsy, happens when the superior oblique muscle is weak, resulting in a misalignment of the eyes. This misalignment can be vertical, horizontal or torsional. This weakness can vary in degrees from slight to severe. Even a minor weakness of the muscle can bring on symptoms.
Common Symptoms: Double Vision, Headaches & More
Superior oblique palsy can also cause double vision because the brain sees an image from two different directions. Another common symptom is a head tilt to help with double vision. This head tilt is very noticeable. Without any treatment, a person with superior oblique palsy can also develop headaches, dizziness and nausea.
Superior oblique palsy can be caused by trauma usually involving the head, such as in a concussion, or be congenital, meaning present at birth because of anomalies such as a misshapen skull. In rare cases, superior oblique palsy can also be caused by a stroke, tumor or aneurysm.
Post Concussive Syndrome and Traumatic Brain Injury (TBI)
People who suffer from post concussive syndrome have also been known to experience superior oblique palsy. If you have had a traumatic brain injury (TBI), the oblique muscle connected to a very long nerve can become damaged, leading to weakness and the development of superior oblique palsy.
How to Treat Superior Oblique Palsy
For all cases where you or someone you know has acquired superior oblique palsy, it is essential to figure out the cause first. After the cause is treated, your eye doctor will wait a period of six months to see if the muscles recover and the palsy spontaneously and naturally resolves. During this period, you can manage any double vision symptoms with realigning prism glasses. Prism glasses can also help reduce or eliminate headache and dizziness symptoms.
Prism lenses create a unified image by directing both eyes towards a central middle area so that the brain interprets the two images from the left and right eye as one image. In severe cases, you may need surgery for your eye muscles to correct the double vision, head tilt and the eye drift. Surgery may involve one or both eyes to address the misalignment.
Testing at the Neuro Visual Center of New York
We help our patients identify and then treat binocular vision dysfunction through specialized testing. Dr. Cheryl Israeloff is specially trained in diagnosing and treating vertical heterophoria (VH) and binocular vision dysfunction (BVD) with tailored solutions. She will provide you with a thorough diagnosis and an appropriate method of treatment to address your condition and help you take care of your eyes and health.
Give us a call at (516) 224-4888 to find out more about our specialized eye care services and how we can help you.
I developed blurry and double vision 3 weeks ago went o ER CT of the head done okay except I have 2 meningiomas old dr in ER said it has nothing to do with it vision intact using one eye at a time but when I use both eyes I develop double vision when I tilt my head up or down, vision okay when I look straight, blurry vision when i try to read small prints seen eye dr said I have rt superior oblique muscle weakness. I am frustrated do not know what to do eye dr said prism lenses will not help my condition please help me
Please take our online questionnaire or call the office to discuss your case.
I am experiencing double vision when my eyes are tired, not severe headached
I have a puzzling condition that seems related to the superior oblique muscle. After extensive shooting practice at a shotgun trap shoot range, my left eye (I’m right eyed) began to twitch, the eyeball quickly twisting to the point of over 10 degrees off level center, a few times per second. After a few week, this subsided to a less twisting but the distortion was still obvious My doctor provided eye drops which seemed to work and finally the twisting stopped, but it would start up if I again attempted to shoot trap and skeet. Therefore, I put an end to that sport. For many years, I had no symptoms. Then I started shooting again and the problem returned. I noticed that the upper portion of my occipital bone felt sore, as if bruised. When I applied slight rubbing and pressure, the twitching would stop. This is why I think there is a connection to the Superior Oblique. The eye drops do relieve the extreme twisting but there is still slight movement, sometimes up to 10 times per second. I’ve gotten used to this small movement but fear it could be a sign of something more serious. But the fact the the bone is sensitive and pressure stops the twitch has me puzzled. Any recommendations you can offer would be much appreciated.
It sounds like inflammation of the superior oblique muscle which I have seen. Usually a non steroidal anti-inflammatory helps.
All the best
Dr. Cheryl
Thank you the article Dr. Cheryl. Approximately 20 years ago I began experiencing frequent double vision and vertigo, along with excessive thirst, urination and numbness in my fingertips and lips. Our family doctor diagnosed me with diabetes. Upon discovering that oral meds had no affect on my sugars I went to see an endocrinologist who after various tests determined I had Type 1 diabetes and put me on insulin. Since then I’ve had very good control of my blood sugars but the diplopia persists. My left eye droops directly downward causing things to appear higher than my right, “normal” eye. This is especially worse when I’m fatigued and is relieved somewhat by tilting my head back, causing me to appear to arrogant and “looking down my nose” at people.
I’m curious if this might be a 4th cranial nerve palsy or 3rd, as was suggested by the endo years ago. But more importantly, is my condition possibly treatable with surgery at your clinic?
Thank you so much in advance,
D
Without an examination it is not possible to determine which eye muscle or muscles are involved. There are different options to correct diplopia from surgical to prismatic correction depending on the condition and degree.
I woke up with double vision, no head injury, most likely high blood pressure. I was taking blood pressure meds but probably not enough. CT scan, 2 MRI’s everything ok. My eye doctor made 3 attempts with prisms which did not improved the double vision which is vertical. The double vision goes away when I close either eye. I’m now seeing a ophthalmologist and she said it’s too soon for prisms. She will be checking measurements every month. One eye doctor said it was my left eye, the opthomologist said it’s my right eye that has the pasly. My question is something no one seems to be able to answer. Do I wear a patch on the eye with the palsy or the other eye?
You can wear the patch on either eye as long as you are comfortable.
After head concussion I fractured top of eye socket developed double visit right side. Only gets better when I look to left. I went to Neuro Ophthalmologist she determined it’s my, Superior Oblique, it’s been a month will this double vision go away please help it’s affecting my job and everyday task including my family’s livelihood.
Hi Tom,
We are so sorry that you are suffering. Prismatic correction can help you. If you do not live near New York, please visit the Vision Specialist of Michigan website to find a doctor closest to you.
My son had surgery fo oblique palsy that he was born with about 15 years ago. The surgery was very successful. Recently he has had a could times of double vision and his head is slightly tilting. Is there a possibility it could have returned s do they do a second surgery?
Every case is different. Please consult your doctor.
I have been diagnosed with superior oblique palsy by an ophthalmologist specializing in double vision. I suspect that it is congenital, but it could be secondary to Lyme disease, which I was treated for several years ago.
Most of the time I don’t see double, but I seemed to have significant eye strain, initially being sensitive to glare with nighttime driving, but over the past year and a half (during which time I have had to use a computer much more frequently), with involuntary squinting, much more so with the affected right eye, with running and driving. Otherwise, my eyes feel sore, but I have no headaches. Prism glasses haven’t made much of a difference. Have you seen this as a manifestation of superior oblique palsy, and could surgery correct or improve it? I am also elderly with longstanding myopia, and, naturally, presbyopia.
I would return to your doctor to make sure the prism prescription is extremely accurate. You make need something specific for your computer.
Best of luck,
The Neuro Visual Center
Two weeks ago woke up with blurry double vision..Had a scheduled eye appointment on Wednesday..She said probably dry eyes and use drops..Did not any better..On Saturday did Catscan fine..This past Monday MRI minor Brain Atrophy not uncommon being 70,,Visited my GP..Referred me to eye specialist..Told him my synptoms eyes not working together tilt my heard to left to see..Tole him my Brother had similar symptoms four years ago..Woke up he said with fourth nerve palsy in two months went away..This so called specialist had no clue..I thought there were tests to check for misaligned eyes,,Referred me to muscle nerve Doctor..See better in natural sunlight..When i enter abuilding everything distorted..Any chance my astigmatism could be the cause..Although i think it was aan episode while sleeping that led to palsy..Also when i wake up in morning bright
light hurts my eyes..Thank you for your attention..certainly welcome your help.
Yes, there are tests to check if your eyes are misaligned. Astigmatism could be making your symptoms worse but it sounds like you have double vision. Please visit a neuro optometrist.
my eye doctor told me i have 4th cranial nerve palsy. At first look my eye looks normal but when i look down my right eye dont look down as much as the left eye.
I dont have double vision, eye grade or astigmatism . I was able to compensate but my coordination is very poor and my eyes strains a quickly.
The doctor prescribed a prism with just.5 power and as i remember i think itd a compound prism.
I wonder if in the long run the prism will do me harm than good.
The prism will not harm you at all. It only moves the image and does nothing you your eye.
We hope you are doing well.
The Neuro Visual Center