Fourth cranial nerve palsy impairs the superior oblique muscle, causing paresis of vertical gaze, mainly in adduction.
Fourth cranial (trochlear) nerve palsy is often idiopathic. Few causes have been identified. Causes include closed head injury (common), which may cause unilateral or bilateral palsies, and infarction due to small-vessel disease (eg, in diabetes). Rarely, this palsy results from aneurysms, tumors (eg, tentorial meningioma, pinealoma), or multiple sclerosis.
Because the superior oblique muscle is paretic, the eyes do not adduct normally. Patients see double images, one above and slightly to the side of the other; thus, going down stairs, which requires looking down and inward, is difficult. However, tilting the head to the side opposite the palsied muscle can compensate and eliminate the double images.
Examination may detect subtle impaired ocular motility, causing symptoms but not signs.
Oculomotor exercises or prism glasses may help restore concordant vision.