An anomalous superior oblique tendon, an anomalous site of its insertion, or a defect in the trochlea are now recognized as causes of some congenital fourth nerve palsies;
[aao.org]
The examiner notes any anomalous head position (Figs. 5-8, 5-9), versions, ductions, cover test measurements in cardinal fields of gaze, any secondary deviation, forced (Bielschowsky
[guwsmedical.info]
The 4 th patient was an 11-year-old girl with Bosley-Salih-Alorainy syndrome who presented with anomalous horizontal eye movements and complete congenital deafness since birth
[cags.org.ae]