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An 82-year-old man with binocular oblique diplopia
Digital Journal of Ophthalmology 2015
Volume 21, Number 3
September 12, 2015
DOI: 10.5693/djo.03.2015.05.003
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Gaurav Jindal, MD | Yale–New Haven Hospital, New Haven, Connecticut
Aubrey Gilbert, MD, PhD | Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
Rafeeque Bhadelia, MD | Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Nurhan Torun, MD | Division of Ophthalmology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Ancillary Testing
A provisional clinical diagnosis was made of right trochlear nerve palsy and left abducens nerve palsy, with the assumption that one was chronic and the other new, because simultaneous onset seemed unlikely. Axial T1 postcontrast magnetic resonance imaging (MRI) revealed an enhancing lesion in the right ambient cistern along the course of the trochlear nerve, consistent with right trochlear nerve schwannoma (Figure 1) and thin section axial FIESTA images revealed left abducens nerve compression by an anterior inferior cerebellar artery (AICA) aneurysm (Figure 2).
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Figure 1
Axial T1 postcontrast image revealing an enhancing lesion in the right ambient cistern along the course of the right trochlear nerve (white arrow) consistent with right fourth nerve schwannoma.

Figure 2
Thin-section axial FIESTA image revealing left sixth nerve compression by an anterior inferior cerebellar artery aneurysm (black arrowhead). The cisternal segment of the normal sixth nerve is seen on the right (black arrow).