Trochlear Nerve: What To Know

Medically Reviewed by Jabeen Begum, MD on October 11, 2022
4 min read

A complex system of nerves and muscles enables the human eye to blink, gaze, and shift focus. The trochlear nerve is one of six cranial nerves that carry electrical impulses from the brain to the eye. It controls the movements of the superior oblique muscle, which helps your eye move down and rotate. 

A range of medical conditions can impair the trochlear nerve, though, and restrict your ability to move your eye. Understanding trochlear nerve anatomy and ways to protect it can thus help you safeguard your eyesight.

The trochlear nerve is the fourth of 12 cranial nerves that emerge from the brain and extend down the head, neck, and torso. Cranial nerves help control sensory innervation: i.e., the ability to experience sensations like smell and touch. Some cranial nerves also contribute to voluntary and involuntary muscle movements. 

The trochlear nerve, also known as cranial nerve 4 (CN IV), controls the superior oblique muscle in your eye. This muscle allows you to move your eyeball down and shift your gaze from side to side. 

Interesting facts about the trochlear nerve: 

  • The trochlear nerve’s name comes from the Latin word Trochlea, which means “pulley.” This name refers to the sling of connective tissue that holds part of the nerve, as well as the way that the nerve works with your superior oblique muscle to rotate your eye down. 
  • The trochlear nerve is the only cranial nerve that exits the brain from the rear. As a result, this nerve travels the longest distance through the cranium.

The cranial nerves supply autonomic, motor, and sensory stimulation to the head and neck, but each cranial nerve has a distinct function. Purely afferent nerves carry sensory information from the organs and skin to the brain. Purely efferent nerves work in the opposite way, transmitting impulses that control motor movement from the brain to the muscles. Some cranial nerves have both afferent and efferent functions. 

The trochlear nerve function is purely efferent. It works as a pulley system to control the movement of the superior oblique muscle. The trochlear nerve interacts with two components related to the eye:

Superior oblique muscle. This muscle works alongside other extraocular muscles to rotate your eyeball downward. You also use this muscle to turn your eye inward or outward. When you climb stairs or look down to read a paper, you use your trochlear nerve and superior oblique muscle. 

Trochlea. This cartilaginous tissue holds the tendon of the superior oblique muscle.  

Several other cranial nerves also affect the eye, including the: 

Optic nerve (CN II): This nerve collects light and images as they enter the eye and sends this information to the cerebral cortex for processing. It also adjusts pupil size as lighting changes. 

Oculomotor nerve (CN III): This nerve controls most of the extraocular eye muscles. CN III is responsible for functions like moving the eye from side to side and holding the eyelid open. 

Trigeminal nerve (CN V): One branch of this forked nerve controls the corneal reflex and the production of tears.

The trochlear nerve connects to the brainstem and the top of the eyeball. Between these locations, the fiber travels through several structures. 

Ambient cistern. An area located near the dura (outer tissue that encases and protects the brain). 

Cavernous sinus. This hollow cavity is located in the center of the skull. 

Orbit. This bony socket contains your eyeball.

Damage to your trochlear nerve can severely impact your vision. If your eyes hurt or feel strange, those symptoms may indicate an injury or other condition. 

Here are a few common signs that you may notice if you suffer from fourth nerve palsy (paralysis of your trochlear nerve): 

  • Double vision that duplicates images vertically
  • Facial asymmetry around the cheekbones and eye sockets  
  • Images that appear sideways or tilted
  • Misaligned eyes 
  • Unusual head posture

If you or somebody else notices these symptoms, you should consult with a healthcare provider.

A range of medical conditions can impact the trochlear nerve, such as:  

Congenital conditions.Fourth nerve palsy can be congenital, meaning some babies may be born with the condition. 

Trauma. Fast and jerky head movements can tear the fragile trochlear nerve. Such an injury can occur during car accidents or other incidents where you experience whiplash. 

Guillain-Barre Syndrome. This poorly understood syndrome occurs when your immune system attacks your nerve cells, causing numbness, temporary paralysis, and other symptoms. Many people fully recover from this syndrome, though. 

Lyme disease. Ticks transmit this bacterial infection to humans through a bite. This disease has many symptoms, including facial drooping and vision issues.

Meningioma. This form of cancer causes slow-growing tumors to form on the meninges: layers of membranes that cover the brain. A tumor that presses on the trochlear nerve can cause fourth nerve palsy.  

Shingles. People who contract chickenpox may later also contract shingles. This disease appears as a painful rash that can cause lingering pain. 

Some of these conditions can be fatal, so you should immediately seek medical care if you experience fourth nerve palsy. 

Treatment of fourth nerve palsy may include: 

  • Prism glasses to manage double vision
  • Botulinum toxin injections in the inferior oblique muscle
  • Surgery to repair the superior oblique muscle

Congenital trochlear palsy and injuries are often unavoidable. However, you can use a few simple strategies to protect this important nerve, including:  

  • Adding safety equipment like baby gates or grab bars to your home to protect infants and the elderly from falls that may cause head injuries 
  • Using a seatbelt in the car to reduce your odds of experiencing whiplash during a wreck 
  • Wearing a helmet during physical activities that can result in a head injury, like playing football or riding a bike 

Safeguarding your head and neck from injury can help you maintain the health of your trochlear nerve and preserve your vision.