Ask an Expert: Superior oblique palsy in left eye vision

Eye and Vision Care

Superior oblique palsy in left eye vision
04/09/2009

Question:

I am 44 years old. Three months ago I suffered a head injury from a bicycle accident where the right side of my head hit the street and knocked me out unconscious - ending up in the hospital with a dislocated shoulder and small fracture in my right cheekbone. My left eye vision has been suffering as a result and I was diagnosed with 4th nerve or superior oblique palsy. I had a CT and MRI done and both came out clean. Seeing anything below eye level results in double vision. At a relaxed state, my left eye drifts upward and slightly inward. My right eye has no problem moving completely up and down and side to side but my left one cannot go down below eye level. The pediatric eye doctor I was referred to told me that it would take about six months to clear up. I have not really noticed any improvement at all since the accident. When I exercise or jump up and down, my left ear pops occasionally. When will my problem go away, or will I need surgery? Reading and doing close work or looking down for anything has been quite a challenge and I look forward to having normal vision restored. Thank you!

Answer:

Head trauma can create many problems to the visual system and one of the most common is a superior oblique palsy. This is commonly injured as the nerve (fourth nerve) that controls (innervates) the superior oblique muscle exits the brainstem in a backward direction and then goes forward toward the eye. The other nerves that control eye muscles just go forward. Because the fourth nerve exits posteriorly (backwards), it is more prone to injury.
You are exactly right in that it may be very difficult to look down, as the superior oblique is one of the two muscles that help move the eye downward. This can be very uncomfortable, as this will cause double vision.
Your pediatric ophthalmologist is correct in that it may continue to improve for 6 months to a year; however, full restoration may never be achieved. Hopefully it will continue to improve and become more tolerable, but it may never be perfect.
I would definitely suggest that you wait 6 months to a year to see how the nerve continues to heal; however, if the double vision persists, you may want to pursue a surgical consult.
Make sure you are well informed about the potential outcome of the surgery so that you don't have unrealistic expectations.
I hope that this continues to heal and you make a full recovery.

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Response by:

Aaron Zimmerman, OD, MS
Clinical Associate Professor of Optometry
College of Optometry
The Ohio State University