Is there a possibility I have fourth nerve palsy in my right eye? I went to a pediatric ophthalmologist the other day with complaints of eyestrain and intermittent double vision. He performed a Hess screen and assessed my ocular motility and couldn't find anything to suggest an eye alignment problem. However, I do notice that when I tilt my head to the left, I can read faster with less strain. Also, when I have double vision, it is diagonal with a little bit of torsion. When I do activity that involves a lot of precise eye work, like scanning photos for particular faces, I get nauseous very quickly.My question is: would a "normal" assessment of ocular motility and Hess screen rule out FNP?I'd just like to know if it is still a possibility before I make another appointment, since I'm paying $500 per visit to that ophthalmologist.
Hello and thanks for your question. Are you available to chat?
As a physician and ophthalmologist, I always hesitate to deal in absolutes. So, in this case, I would hesitate to say that you a fourth neve palsy is absolutely ruled out by this normal exam and normal Hess screen done by a pediatric ophthalmologist. Every doctor is human and I'm sure it's possible that you may have a fourth nerve palsy and he didn't catch it. However...
I would say that an in-depth examination by the ultimate subspecialist, the final authority in strabismus amongst physicians that comes out as normal means there's a pretty darn good chance that you don't have a fourth nerve palsy.
That being said, second opinions are never a bad idea--they can help by either re-inforcing what the first doctor found, or bringing up new options or data that was not thought of by the first. Not all doctors are made the same, nor are our experiences the same, either.
Does this make sense?
Yes. I see your point.
I did notice the ophthalmologist didn't test my vertical amplitudes or do the head tilt test though. Do you think it would help if I asked him to test those?
I think that those provide additional data to either make the case for, or against a fourth-nerve palsy. However, if at all possible, I would consider getting a second opinion from another pediatric ophthalmologist, or perhaps even a neuro-ophthalmologist before I would go back and suggest additional tests for him to do. I like to think I'm not one of these doctors, but given the tendency for many doctors to have very large egos, I could imagine a scenario where asking him to do these additional tests that you thought of and researched that he didn't do, would intimate that he didn't know how to do his very specialized job, and it may end up a fruitless endeavor for you--hate to see your hard earned money be wasted, not to mention your time.
Heh yeah, I can see that happening.
Do you have any other concerns or questions about this topic?
From your experience with fourth nerve palsy, have you seen cases where the vertical deviation is latent (phoria) rather than tropia?
Because I don't have a constant strabismus, just a latent one I think.
If it's a congenital fourth nerve palsy, and a small-angle deviation, yes, I could see this happening with you. However, if this were an acquired 4th nerve palsy, I've never seen this be a latent scenario.
Ok. And is there always a nasal upshoot on left gaze with right FNP? Because I've taken photos of myself looking to the extreme left, and I don't notice much. There might be a very subtle one, but it's not obvious.
No, not at all--sometimes, though not nearly in every case.
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No problem. I just have one more question. Since the things I just asked you about don't necessarily prove a FNP, what would you say is/are the defining features of this condition, the criteria that would prove one is there?
Okay, I'm back. Sorry. Let me look at and respond to your question.
Well, primarily, I would need to see, on exam, a hypertropia (one eye that is vertically misaligned, and higher than the other). If it were right eye, I would expect that the magnitude of right eye vertical deviation would be higher on left gaze and on right head tilt. The Hess screen and vertical amplitudes and others are confirmatory tests. It's a clinical diagnosis meaning it's made on history and exam--the other tests don't make the diagnosis, they confirm it.
Would a hyperphoria count?
Ok, thanks for your help.
My pleasure. Good luck to you.
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