4th NERVE PALSY ANATOMY

Entirely MOTOR in function. Located at anterior part of gray matter surrounding the cerebral aqueduct of the midbrain Inferior to ocular motor nucleus at level of inferior colliculus Leave the posterior surface of brainstem, emerges from midbrain & decussates with the nerve of the opposite site. Responsible for turning the eye downward & laterally Midbrain ecussates contralaterally carvenous sinus !uperior orbital fissure !uperior oblique m

CAUSES
1. CONGENITAL ysgenesis of "th nerve nucleus, abnormality of peripheral nerve 2. ACCQUIRED #ead trauma $severe w L%&' Microvasculopathy secondary to diabetes, atherosclerosis, or hypertension also may cause isolated fourth nerve palsy (umor )neurysm

PRESENTATION
*ertical, torsional, or oblique diplopia. worse on downga+e and ga+e away In trauma , symptoms immediately after regaining consciousness. #ead tilt, away from affected side to reduce their diplopia $parado-ic head tilt. torticollis' evelop facial asymmetry , with long,standing head tilt

TREATMENT
/risms , small deviations and diplopia without torsional. 0otulinum to-in Eye muscle surgery

6th NERVE PALSY

ANATOMY
!mall motor nerve supplies the lateral rect ! " !cle. Its nucleus situated beneath the floor of the upper part of "th ventricle, close to midline & beneath colliculus facialis. /ass anteriorly through pons & emerge in the groove between lower border of pons & medulla. Entirely MOTOR Responsible for turning the eye laterally. Midbrain &arvenous sinus $lying below & lateral to internal carotid artery' !uperior orbital fissure Lateral rectus

CAUSES
Elevated intracranial pressure can result in downward displacement of the brainstem !ubarachnoid space lesions /ostviral syndrome in younger patients )n ischemic mononeuropathy in the adult population.

PRESENTATION
Esotropia #ead,turn 0inocular diplopia $worse at distance' *ision loss /ain #earing loss !ymptoms of vasculitis, particularly giant cell arteritis (rauma /apilledema $if increased intracranial pressure' 1ystagmus $usually in children, ie, secondary to pontine glioma' %titis media (ender, enlarged, nonpulsatile temporal arteries in giant cell arteritis

TREATMENT
)n alternating patching 2 children /atched or have their lenses 3fogged3 with clear tape or nail polish to reduce their diplopia 2 adult !urgery