How JustAnswer Works:

  • Ask an Expert
    Experts are full of valuable knowledge and are ready to help with any question. Credentials confirmed by a Fortune 500 verification firm.
  • Get a Professional Answer
    Via email, text message, or notification as you wait on our site.
    Ask follow up questions if you need to.
  • 100% Satisfaction Guarantee
    Rate the answer you receive.

Ask Dr. Dan B. Your Own Question

Dr. Dan B.
Dr. Dan B., Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 3205
Experience:  Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology
36528250
Type Your Eye Question Here...
Dr. Dan B. is online now
A new question is answered every 9 seconds

Is there a possibility I have fourth nerve palsy in my right

Customer Question

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.

Submitted: 1 year ago.
Category: Eye
Expert:  Dr. Dan B. replied 1 year ago.

Dr. Dan B. :

Hello and thanks for your question. Are you available to chat?

Customer:

Yes.

Dr. Dan B. :

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...

Dr. Dan B. :

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.

Dr. Dan B. :

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.

Dr. Dan B. :

Does this make sense?

Customer:

Yes. I see your point.

Customer:

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?

Dr. Dan B. :

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.

Customer:

Heh yeah, I can see that happening.

Dr. Dan B. :

Do you have any other concerns or questions about this topic?

Customer:

From your experience with fourth nerve palsy, have you seen cases where the vertical deviation is latent (phoria) rather than tropia?

Customer:

Because I don't have a constant strabismus, just a latent one I think.

Dr. Dan B. :

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.

Customer:

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.

Dr. Dan B. :

No, not at all--sometimes, though not nearly in every case.

Dr. Dan B. :

I'm sorry. I must step away from my computer for about 5-7 minutes. I promise I will be right back to continue this. Please bear with me. However, if you're satisfied with the information you've received, then...


Your feedback is important to me and will help me improve my encounter with future customers. Please rate your encounter with me by providing positive feedback (by pressing the smiley face); any bonus you may feel prompted to provide would be welcomed and is appreciated. If you feel like your concerns are not resolved or you have a problem or issue with anything I have said or haven’t said, please don’t issue a negative feedback rating—My goal is your satisfaction and I would rather work together to solve your concerns, until you are satisfied, than have you leave our encounter unhappy and unsatisfied.


 


My opinion is solely informative and does not constitute a formal medical opinion or recommendation. For a formal medical opinion and/or recommendation you must see an eye doctor. Thanks for your inquiry!

Customer:

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?

Dr. Dan B. :

Okay, I'm back. Sorry. Let me look at and respond to your question.

Dr. Dan B. :

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.

Customer:

Would a hyperphoria count?

Dr. Dan B. :

Yes

Customer:

Ok, thanks for your help.

Dr. Dan B. :

My pleasure. Good luck to you.


Please rate your encounter with me by providing positive feedback (by pressing the smiley face); any bonus you may feel prompted to provide would be welcomed and is appreciated. If you feel like your concerns are not resolved or you have a problem or issue with anything I have said or haven’t said, please don’t issue a negative feedback rating—My goal is your satisfaction and I would rather work together to solve your concerns, until you are satisfied, than have you leave our encounter unhappy and unsatisfied.

Dr. Dan B., Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 3205
Experience: Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology
Dr. Dan B. and 2 other Eye Specialists are ready to help you

JustAnswer in the News:

 
 
 
Ask-a-doc Web sites: If you've got a quick question, you can try to get an answer from sites that say they have various specialists on hand to give quick answers... Justanswer.com.
JustAnswer.com...has seen a spike since October in legal questions from readers about layoffs, unemployment and severance.
Web sites like justanswer.com/legal
...leave nothing to chance.
Traffic on JustAnswer rose 14 percent...and had nearly 400,000 page views in 30 days...inquiries related to stress, high blood pressure, drinking and heart pain jumped 33 percent.
Tory Johnson, GMA Workplace Contributor, discusses work-from-home jobs, such as JustAnswer in which verified Experts answer people’s questions.
I will tell you that...the things you have to go through to be an Expert are quite rigorous.
 
 
 

What Customers are Saying:

 
 
 
  • I feel so much better today, and upon further investigation believe that there is a chance that the responses I got saved me from a serious, even life threatening situation. I am very grateful to the experts who answered me. Susan O. USA
< Last | Next >
  • I feel so much better today, and upon further investigation believe that there is a chance that the responses I got saved me from a serious, even life threatening situation. I am very grateful to the experts who answered me. Susan O. USA
  • Wonderful service, prompt, efficient, and accurate. Couldn't have asked for more. I cannot thank you enough for your help. Mary C. Freshfield, Liverpool, UK
  • This expert is wonderful. They truly know what they are talking about, and they actually care about you. They really helped put my nerves at ease. Thank you so much!!!! Alex Los Angeles, CA
  • Thank you for all your help. It is nice to know that this service is here for people like myself, who need answers fast and are not sure who to consult. GP Hesperia, CA
  • I couldn't be more satisfied! This is the site I will always come to when I need a second opinion. Justin Kernersville, NC
  • Just let me say that this encounter has been entirely professional and most helpful. I liked that I could ask additional questions and get answered in a very short turn around. Esther Woodstock, NY
  • Thank you so much for taking your time and knowledge to support my concerns. Not only did you answer my questions, you even took it a step further with replying with more pertinent information I needed to know. Robin Elkton, Maryland
 
 
 

Meet The Experts:

 
 
 
  • Dr. Dan B.

    Board Certified Ophthalmologist

    Satisfied Customers:

    2903
    Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology
< Last | Next >
  • http://ww2.justanswer.com/uploads/DoctorDanB/2010-6-7_6228_just_answer_profile_picture_60_pixels.jpg Dr. Dan B.'s Avatar

    Dr. Dan B.

    Board Certified Ophthalmologist

    Satisfied Customers:

    2903
    Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology
  • http://ww2.justanswer.com/uploads/anupamadesai/2010-04-13_122313_Dr._A.S.Desai_new_photo.jpg Dr. A.S. Desai's Avatar

    Dr. A.S. Desai

    Ophthalmologist

    Satisfied Customers:

    1903
    MS Ophthalmology with 11 years of surgical expereince
  • http://ww2.justanswer.com/uploads/gsokoye/2009-10-28_181751_Dr._Stan.JPG Dr. Stan's Avatar

    Dr. Stan

    Ophthalmologist

    Satisfied Customers:

    895
    Johns Hopkins Fellowship Trained, Certified and Licensed Medical Physician and Surgeon
  • http://ww2.justanswer.com/uploads/eyemd/2009-04-07_180315_pic.jpg Dr. Stevens's Avatar

    Dr. Stevens

    Ophthalmologist

    Satisfied Customers:

    629
    Board Certified Ophthalmologist
  • http://ww2.justanswer.com/uploads/CO/CorneaDoc/2012-2-18_0390_photo6.64x64.jpg Dr. Susan's Avatar

    Dr. Susan

    Ophthalmologist

    Satisfied Customers:

    217
    Board Certified & Fellowship trained eye surgeon.
  • http://ww2.justanswer.com/uploads/neuph94/2009-10-11_164729_gif_pic.GIF Dr. JP's Avatar

    Dr. JP

    Ophthalmology, Oculoplastic Surgery

    Satisfied Customers:

    28
    Harvard Medical School, Massachussetts Eye and Ear
  • http://ww2.justanswer.com/uploads/JA/JACUSTOMERjcufyksv/2012-3-13_44825_crop3.64x64.jpg Dr-Trace's Avatar

    Dr-Trace

    Board Certified Ophthalmologist

    Satisfied Customers:

    26
    Board Certified in General Ophthalmology
 
 
 
Chat Now With An Eye Doctor
Dr. Dan B.
Dr. Dan B.
Comprehensive Ophthalmologist
3197 Satisfied Customers
Eye surgeon experienced in cataracts, glaucoma, retina & neuro-ophthalmology