Torticollis in Paralysis of the Trochlear Nerve

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Abstract
The patient with paralytic strabismus assumes a compensatory head position in which the action of the palsied muscle can be avoided. Horizontal, vertical and torsional diplopia thus will be eliminated and single binocular vision maintained. With IVth nerve palsy the head is, as a rule, tilted toward the nonparetic side. With the head in this position compensatory reflex eye movements are not elicited which cause hypertropia of the palsied eye when the head is straightened or tilted toward the paretic side. In other patients ocular torticollis compensates for pure cyclotropia or is maintained without functional benefit to the patient because of secondary changes in the neck muscles or skeleton. A head tilt may be absent when vertical fusional amplitudes are sufficient to overcome diplopia or, in rare instances, occur toward the palsied side to cause the widest possible separation of the double images.