J Korean Ophthalmol Soc.  2018 Nov;59(11):1087-1090. 10.3341/jkos.2018.59.11.1087.

Trochlear Nerve Palsy Caused by Quadrigeminal Cistern Lipoma

• Choi NH
• Kim WJ
• Kim MM

• KMID: 2426372
• DOI: http://doi.org/10.3341/jkos.2018.59.11.1087

Abstract

PURPOSE
To report a case of trochlear nerve palsy caused by quadrigeminal cistern lipoma located in the dorsal midbrain.
CASE SUMMARY
A 65-year-old male visited our clinic for intermittent vertical diplopia over 2-year period. Symptoms of diplopia had worsened over the past two weeks. He had no previous medical history except having had diabetes for 1 month. The best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. Pupillary examination was not remarkable. Extraocular examination showed 4 prism diopters (PD) left hypertropia at distant gaze and 4 PD exotropia at near gaze, with adduction elevation of the left eye. The Bielschowsky head tilt test revealed 6 PD left hypertropia on the left gaze and orthotropia on the right tilt. Fundus examination showed excyclotorsion of the right eye and incyclotorsion of the left eye. Brain magnetic resonance imaging revealed quadrigeminal cistern lipoma. Prism glasses were prescribed to alleviate diplopia, and we followed up the lesions without further treatment.
CONCLUSIONS
Trochlear nerve palsy can be caused by quadrigeminal cistern lipoma; however, it is uncommon for this condition to be caused by a compressive lesion. Prompt neuroimaging can be helpful to rule out the causes of this condition in patients with atypical symptoms.

Keyword

Diplopia; Lipoma; Quadrigeminal cistern; Trochlear nerve palsy

MeSH Terms

Aged
Brain
Diplopia
Exotropia
Eyeglasses
Glass
Head
Humans
Lipoma*
Magnetic Resonance Imaging
Male
Mesencephalon
Neuroimaging
Strabismus
Trochlear Nerve Diseases*
Trochlear Nerve*
Visual Acuity

Figure

• 

  Figure 1 Image of the patient in nine diagnostic position and both side tilting. The patient showed left hypertropia at primary position with elevation in adduction of the left eye. The hypertropia of the left eye increased in left side tilting position.

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  Figure 2 T1-weighted magnetic resonance imaging (MRI) of brain. (A) Sagittal T1-weighted magnetic resonance imaging (MRI) of brain showed a well-defined hyperintensity suggesting lipoma in median region of quadrigeminal cistern adjacent to the anterior medullary vellum (arrow). (B) Axial T1-weighted MRI image demonstrated lipoma located adjacent to the emerging site of trochlear nerve fiber (arrowhead).

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