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Br J Ophthalmol. 2013 Feb;97(2):180-3. doi: 10.1136/bjophthalmol-2012-302422. Epub 2012 Nov 10.

Horizontal deviation as diagnostic and prognostic values in isolated fourth nerve palsy.

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1
Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto 606-8507, Japan. trj74h6@kuhp.kyoto-u.ac.jp

Abstract

BACKGROUND/AIMS:

To investigate the causes of isolated fourth nerve palsy (IFNP) and the association among aetiology, prognosis and ocular deviation.

METHODS:

A total of 126 consecutive cases of IFNP was retrospectively reviewed. According to aetiologies, all patients were classified into five groups: microvascular, congenital, decompensation of congenital, traumatic and others. We investigated the recovery rate of IFNP patients who could be followed for more than 6 months or until they recovered completely. Patients also had the magnitude of vertical and horizontal ocular deviations (prism diopter) measured in the primary eye position on the first visit.

RESULTS:

Major causes of IFNP were microvascular (47%) and decompensated (33%). The rate of recovery was significantly different between microvascular IFNP and decompensated IFNP (92% vs 55%, p<0.001). There were no differences in both age of onset or mean vertical deviation between the two aetiologies (68.6±9.8 vs 65.4±13.3, 5.7±3.3 vs 7.8±7.9). However, for mean horizontal deviation, there was a significant difference between microvascular and decompensated IFNP (0.4±3.0 vs 4.9±5.6, p<0.001). Although the fourth nerve abducts the eyeball, 69 of 126 cases (55%) showed exotropia. The microvascular IFNP group included more cases of exodeviation, while the decompensated IFNP group included more cases of esodeviation (p<0.001).

CONCLUSIONS:

Contrary to previous thinking, the horizontal deviation of IFNP mainly showed exodeviation, and the degree of horizontal deviation is useful for making a determination between vasculopathic and decompensated IFNP. This differentiation could be critical for predicting the outcome.

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