Trochlear Nerve | Cranial Nerve IV / CN IV Assessment

Eye movements are controlled by three cranial nerves: the oculomotor, trochlear, and abducens nerves. Weakness of one or more of the extraocular muscles impairs movement of the affected eye and restricts its ability to gaze in a particular direction.

The Trochlear Nerve controls downward eye movement toward the nose and can be distinguished from the abducens nerve (CN VI) which controls horizontal eye movement and the oculomotor nerve (CN III) which moves the eye in all other directions.

Pupil Assessment

Examination of the cranial nerves III, IV & VI is usually carried out together and starts with the pupils. Inspect the size shape and symmetry of the pupils. The pupillary light reflex is elicited by shining a light into the eyes and assesses the oculomotor nerve which innervates the sphincter pupillae muscle constricting the pupil.

Shining a light into one eye should result in constricting of that eye’s pupil, called the direct response, as well as constriction of the other pupil called the indirect response. Damage to the oculomotor nerve results in absence of the light reflex.

Next assess the accommodation reflex. The patient is asked to first look into the distance and then focus on the tip of their nose in the second step. Here the pupil should also constrict.

Eye Movement Assessment

Eye movements in each direction can be assessed in six steps. Without moving the head, the patient is asked to gaze:

1. Upward and to the right
2. Upward and to the left
3. Horizontally to the right
4. Horizontally to the left
5. Downward and to the right
6. And downward and to the left

Alternatively, ask the patient to follow a hatpin or pen in an H-Pattern. Ask the patient if they experience double vision and check for failure of movement.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

• • Name*
• • Email*

Δ

Learn more about the assessment of all cranial nerves below:

• Cranial Nerve I: Olfactory Nerve
• Cranial Nerve II: Optic Nerve
• Cranial Nerve III: Oculomotor Nerve
• Cranial Nerve V: Trigeminal Nerve
• Cranial Nerve VI: Abducens Nerve
• Cranial Nerve VII: Facial Nerve
• Cranial Nerve VIII: Vestibulocochlear Nerve
• Cranial Nerve IX: Glossopharyngeal Nerve
• Cranial Nerve X: Vagus Nerve
• Cranial Nerve XI: Accessory Nerve
• Cranial Nerve XII: Hypoglossal Nerve

Damodaran, O., Rizk, E., Rodriguez, J., & Lee, G. (2014). Cranial nerve assessment: a concise guide to clinical examination. Clinical Anatomy, 27(1), 25-30.