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In page Congenital fourth nerve palsy:
"The cause of congenital fourth nerve palsy is unclear in most cases. It may be neurogenic in origin, due to a dysgenesis of the CN IV nucleus or nerve, but a clinically similar palsy may result from absence or mechanical dysfunction (e.g., abnormal laxity) of the superior oblique tendon. Usually unilateral, congenital fourth nerve palsies can also occur bilaterally. [1] Bilateral congenital fourth nerve palsy may be unmasked only after corrective surgery of one eye for what was thought to be a unilateral palsy.[citation needed]
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