Clinical profile and management of sixth nerve palsy in pediatric patients (0–15 years) in Southern India – A hospital-based study

Purpose: This study was done to evaluate the clinical profile in pediatric patients (0–16 years) presenting with acute onset esotropia due to sixth nerve palsy and its management options in a tertiary care set up of Southern India. Methods: A total of 12 patients presenting to our OPD with acute onset esotropia due to sixth nerve palsies were included in this retrospective study. All patients were observed for 6 months and managed with prism and/or patching while waiting for spontaneous resolution and later managed surgically. Neuroimaging was done in all cases. Results: The mean deviation of esotropia at presentation was 30.17 ± 5.7 Prism Diopter (range 12–50 Prism Diopter 95% CI, SD 10.11). Mean age of the patients during presentation was 8.6 ± 2.4 years (range: 1–15 years, SD 4.27). Among the common causes of sixth nerve palsy in our study population were trauma and idiopathic intracranial hypertension followed by tumor and miscellaneous causes. Only three patients underwent surgical correction of residual deviation after a waiting period of 6 months for self?resolution. Spontaneous resolution was observed in 41.6% patients, and surgical correction (unilateral resection–recession) was done in 25% of the patients with good surgical outcome. Conclusion: At 1?year follow up, the motor outcome was satisfactory except for one patient who had diffuse pontine glioma and had worsening neurological symptoms on follow?up

Anterior segment ischemia following Hummelsheim procedure in a case of sixth nerve palsy.

A, 46‑year‑old Indian male, known hypertensive presented with left esotropia of 25 prism diopters (PD) after head injury in a roadside accident 9 months back. The deviation was constant in nature and was associated with complaints of diplopia in left lateral gaze. Traumatic sixth nerve palsy was diagnosed. The patient underwent left medial rectus recession of 5 mm and a split‑tendon transposition of the left superior and inferior recti to the lateral rectus insertion (Hummelsheim procedure). On the first postoperative day, the patient developed corneal edema and anterior chamber reaction of flare 2+ and cells 2+. The pupil was semi‑dilated and was sluggishly reacting to light. Anterior segment ischemia was diagnosed, which was managed with topical and systemic steroids.

The diagnostic yield of neuroimaging in sixth nerve palsy - Sankara Nethralaya Abducens Palsy Study (SNAPS): Report 1.

Aims: The aim was to assess the etiology of sixth nerve palsy and on the basis of our data, to formulate a diagnostic algorithm for the management in sixth nerve palsy. Design: Retrospective chart review. Results: Of the 104 neurologically isolated cases, 9 cases were attributable to trauma, and 95 (86.36%) cases were classified as nontraumatic, neurologically isolated cases. Of the 95 nontraumatic, isolated cases of sixth nerve palsy, 52 cases were associated with vasculopathic risk factors, namely diabetes and hypertension and were classified as vasculopathic sixth nerve palsy (54.7%), and those with a history of sixth nerve palsy from birth (6 cases) were classified as congenital sixth nerve palsy (6.3%). Of the rest, neuroimaging alone yielded a cause in 18 of the 37 cases (48.64%). Of the other 19 cases where neuroimaging did not yield a cause, 6 cases were attributed to preceding history of infection (3 upper respiratory tract infection and 3 viral illnesses), 2 cases of sixth nerve palsy were found to be a false localizing sign in idiopathic intracranial hypertension and in 11 cases, the cause was undetermined. In these idiopathic cases of isolated sixth nerve palsy, neuroimaging yielded no positive findings. Conclusions: In the absence of risk factors, a suggestive history, or positive laboratory and clinical findings, neuroimaging can serve as a useful diagnostic tool in identifying the exact cause of sixth nerve palsy. Furthermore, we recommend an algorithm to assess the need for neuroimaging in sixth nerve palsy.

Spontaneous Carotid Cavernous Fistula in a Case with Protein S Deficiency that Newly Developed Ophthalmoplegia after Embolization

BACKGROUND: Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. The pathogenesis of spontaneous CCF remains unclear, although sinus thrombosis is known to be a predisposing factor for dural arteriovenous fistula. Because spontaneous CCFs are mainly of the dural type, we considered that thrombogenic conditions, such as, protein S deficiency might be associated with CCF. CASE REPORT: A 42-year-old woman complained of conjunctival injection and retro-orbital pain that first appeared 1-month before visiting our hospital. She had no history of head trauma or intracranial surgery. Exophthalmos and chemosis were observed in her left eye, which also had lower visual acuity and higher intraocular pressure than the right eye. Magnetic resonance images and cerebral angiography revealed a left dural CCF. Her protein S was low, at 41% (normal range: 70-140%), but other hematologic values related to coagulation were normal. Her symptoms were relieved after initial transvenous coil embolization. However, a newly developed sixth-nerve palsy was detected 4 days after initial embolization. Follow-up angiography revealed a minimal shunt, and thus transvenous coil embolization was repeated. Two days later, the ophthalmoplegia started reducing, and 1-month later it had almost disappeared. CONCLUSIONS: To the best of our knowledge, this is the first report of spontaneous dural CCF in a Korean patient with concurrent protein S deficiency. Interestingly, transient sixth-nerve palsy developed after transvenous coil embolization in this patient. This additional symptom caused by the residual fistula was relieved after additional transarterial embolization.

Cryptococcus meningitis in an immunocompetent teenage boy presented early with diplopia / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To report a case of cryptococcus meningitis in an immunocompetent teenager that presented early with diplopia and bilateral poor vision.METHODS:A case report RESULTS:A 17-year-old boy presented with blurring of vision in both eyes and diplopia for 3 weeks. It was associated with severe throbbing headaches, nausea and vomiting. He was also having low grade fever. On physical examination he was afebrile with no sign of meningism. His vision was 6/15 in both eyes with constricted visual field. Anterior segment was normal in both eyes. Extraocular muscles movement showed bilateral sixth nerve palsies. Fundoscopy revealed bilateral hyperaemic and slightly elevated optic disc. CT scan of the brain was normal with no evidence of intracranial mass or abnormal ventricles. Lumbar puncture revealed high opening pressure >300mmH2O. Cerebrospinal fluid(CSF) microscopically and culture showed presence of cryptococcus neoformans . This case was combinedly managed with neuro-medical team. Patient was started on intravenous Amphotericin B and fluconazole. His neurological symptoms recovered after a week. His vision was improved to 6/6 in both eyes with recovery of peripheral visual field. The diplopia improved with recovery of sixth nerve palsies in both eyes. Unfortunately, patient developed nosocomial lower respiratory tract infection and was treated for the problem.CONCLUSION: This case highlights the indolent nature of cryptococcus meningitis and the fact that the overt signs of meningism may not be present even in immunocompetent person. Diplopia may be one of the early presentations of meningitis patient.

Presumed Metastasis of Breast Cancer to the Abducens Nucleus Presenting as Gaze Palsy

A 51-year-old woman with breast cancer presented with progressive diplopia. Neuro-ophthalmologic examination revealed right gaze palsy and peripheral facial nerve palsy. Brain magnetic resonance imaging (MRI) was normal. However, two months later a repeat brain MRI revealed an enhancing round nodular mass at the right facial colliculus of the lower pons, at the location of the abducens nucleus. Localized metastasis to the abducens nucleus can cause gaze palsy in a patient with breast cancer.

Clinical Features of the Sixth Cranial Nerve Palsy

PURPOSE: To evaluate the clinical features and natural course of sixth cranial nerve palsy. METHODS: We reviewed the medical records of 50 patients who were diagnosed with sixth nerve palsy from January 2000 to December 2006 to analyze the age of onset, etiology, recovery, and natural course of this disease. RESULTS: The mean age at onset was 43.2 years old. Vascular disease (n=17, 34.0%) was the most common cause of sixth cranial nerve palsy, followed by undetermined causes (n=14, 28.0%), trauma (n=10, 20.0%), and neoplasm (n=3, 6.0%). According to age group, vascular disease (n=7, 46.7%) was the most common cause in patients in their fifties and sixties, and trauma and undetermined causes (n=10, 76.9%) were the most common causes of this disease in patients in their twenties and thirties. Of the 40 patients who were followed up for more than 6 months, 28 (70.0%) showed improvement of paresis and 26 (65.0%) achieved complete recovery. The mean period to recovery was 3.7 months. No significant differences were observed in sex, age, laterality, and etiology between non-recovered and completely-recovered patients, but completely-recovered patients showed a significantly smaller initial angle of deviation than non-recovered patients. CONCLUSIONS: Vascular disease was the most common etiology of sixth nerve palsy. Sixty-five percent of patients showed spontaneous complete recovery, and completely-recovered patients showed a significantly smaller initial angle of deviation compared to that of non-recovered patients.

Antiphospholipid syndrome manifesting as papilledema / 国际眼科杂志(Guoji Yanke Zazhi)

·AIM: To report a rare case of antiphospholipid syndrome presenting as papilledema and sixth nerve palsy in right eye due to superior sagittal sinus thrombosis, and regression of papilledema following anticoagulation and acetazolamide therapy.·METHODS: A 44-year-old Chinese gentleman presented with headache, diplopia and mild blurring of vision. Clinical examination revealed the presence of sixth nerve palsy in right eye and papilledema. There was enlargement of blind spot in the visual fields and red green deficiency in both eyes.Computed tomography and magnetic resonance imaging showed superior sagittal sinus thrombosis. Hematological investigation confirmed the presence of antiphospholipid syndrome as the underlying cause.·RESULTS: The condition was treated successfully in three months with the adjunctive use of anticoagulation and acetazolamide. Reversal of papilledema changes in the optic disc to normal indicates the anatomical recovery, while reduction of enlargement of blind spot to normal size,recovery of red green deficieny to normal colour vision in both eyes and visual improvement after regression of papilledema in right eye indicate functional recovery in this patient.·CONCLUSION: Antiphospholipid syndrome should be considered in the differential diagnosis of papilledema, and oral acetazolamide is an important adjunct therapy to anticoagulation in cases of refractory papilledema to protect the optic nerve from potential damage which results in blindness.

Causes and Natural Course of the Sixth Cranial Nerve Palsy

PURPOSE: To evaluate the causes and natural course of sixth nerve palsy. METHODS: The records of 37 patients with the sixth nerve palsy were reviewed to analyze the age of onset, etiology, angle of deviation, natural course of the palsy, and percentage of intervention. RESULTS: The mean age of onset was 38.3 (3~77) years old. Causes and associations were: head trauma (n=11, 30%), idiopathic cause (n=9, 24%), neoplasm (n=7, 19%), aneurysm (n=2, 5%), and others (n=8, 22%). Complete recovery was observed in 80% of patients with nonhemorrhagic trauma and 33.3% with hemorrhagic trauma; 78% of patients with idiopathic cause; and 42.9% of patients with neoplasm. CONCLUSIONS: Head trauma was the most common cause of the sixth nerve palsy. Spontaneous complete recovery was observed in 80% of nonhemorrhagic trauma and 78% of idiopathic cases.

Neuro-Behcet's disease presenting with isolated unilateral lateral rectus muscle palsy

The authors present the clinical findings of a 30-year-old female and a 29-year-old male who both had isolated unilateral lateral rectus muscle palsy in neuro-Behcet's disease. The clinical feature related to isolated abduscens nerve palsy was identified by CT, systemic assessment and extraocular examination. These patients' constellation of findings appear to be unique: it does not follow any previously reported pattern of ocular manifestations of neuro-Behcet's disease.

A Case of Guillain-Barre Syndrome Presented as Bilateral Sixth Nerve Palsy

Guillain-Barre syndrome, acute inflammatory polyradiculoneuropathy, is sometimes accompanied by a typical ophthalmoplegia, usually with bilateral sixth nerve palsy. It also has a similar clinical appearance with Miller-Fisher syndrome, but it is differentiated by limb weakness without ataxia. We observed a 47 year old man with acute onset diplopia and bilateral sixth nerve palsy one week after URI symptoms, diagnosed as Guillain-Barre syndrome with ophthalmoplegia.