Difference between revisions of "Abducens nerve palsy"

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==Background==  
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==Background==
* Also called 6th cranial nerve (CN VI).
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*Also called 6th cranial nerve (CN VI)
* Most common ocular nerve palsy
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*Most common ocular nerve palsy
* Innervates the ipsilateral lateral rectus muscle controlling eye abduction
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*Innervates the ipsilateral lateral rectus muscle controlling eye abduction
* Esotropia of the affected eye due to the unopposed action of the medial rectus muscle, innervated by the oculomotor nerve (CN III). <ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref>
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*Esotropia (eye moves inward) of the affected eye due to the unopposed action of the medial rectus muscle, innervated by the oculomotor nerve (CN III) <ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref>
  
==History==
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===Causes===
Patient with abducens nerve palsy may complain of:<ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref>
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*Nuclear lesion
 +
**Congenital, [[MS|demyelinating]], [[CVA|ischemia]], traumatic
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*Inflammatory
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**[[Vasculitis]]
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**[[Sarcoidosis]]
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**[[Systemic lupus erythematosus]]
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*Infectious
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**[[Lyme disease]]
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**[[Syphilis ]]
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**[[Tuberculosis]]
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**[[Meningitis ]]
 +
*Orbital lesions
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**Neoplastic
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**Inflammatory
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**Infectious
  
*Frequently present with '''diplopia''' upon attempting lateral gaze and '''esotropia''' at rest
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==Clinical Features==
*May have a '''head turn''' to help correct their diplopia
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===History===
*Vision loss
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*May complain of:<ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref>
*Hearing loss
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*''[[Diplopia]]'' (frequent complaint) upon attempting lateral gaze and ''esotropia'' at rest
*Symptoms of vasculitis, most commonly giant cell arteritis (headache, tenderness of the scalp, jaw claudication, reduced visual acutity, tinnitus, fever
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**May have a ''head turn'' to help correct their diplopia
*Ask about history of diabetes, hypertension, stroke, fever, and headache.
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*[[Vision loss]]
 +
*[[Hearing loss]]
 +
*Symptoms of [[vasculitis]], most commonly [[giant cell arteritis]] (headache, tenderness of the scalp, jaw claudication, reduced visual acuity, tinnitus, fever_
 +
*+/- history of [[diabetes]], [[hypertension]], [[stroke]], [[fever]], and [[headache]]
  
==Examination==
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===Examination===
*A typical workup of the abducens nerve involves: excluding paresis of the other cranial nerves, checking the ocular muscle movements, for papilledema, and testing pupillary response.
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*Excluding paresis of the other cranial nerves
*To test the ocular motor nerves (CN III, IV, and VI), one can trace a full H-pattern with their finger and have the patient follow the finger only with their eyes. Patients with abducens nerve palsy are unable to move the affected eye laterally. In order to avoid diplopia, patients will turn their heads away from the lesion so that both eyes are looking sideways. Check deep tendon reflexes and strength to exclude corticospinal tract involvement. <ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref>
+
*Check ocular muscle movements
 +
*Check for papilledema
 +
*Test pupillary response
 +
*Test ocular motor nerves (CN III, IV, and VI)<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref>
 +
**Trace a full H-pattern with finger and have the patient follow the finger only with their eyes
 +
**Patients with abducens nerve palsy are unable to move the affected eye laterally
 +
**In order to avoid diplopia, patients will turn their heads away from the lesion so that both eyes are looking sideways
 +
**Check deep tendon reflexes and strength to exclude corticospinal tract involvement
  
==Differential Diagnosis==
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==Differential Diagnosis==
* ''Increased intracranial pressure (ICP)'': Because of its position and intracranial length, increased ICP from any cause can lead to injury and dysfunction
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*''[[Elevated ICP|Increased intracranial pressure (ICP)]]'': Because of its position and intracranial length, increased ICP from any cause can lead to injury and dysfunction
* ''Vascular'': Aneurysm, central venous thrombosis
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*''Vascular'': Aneurysm, central [[venous sinus thrombosis]]
* ''Inflammatory'': Post-viral, demyelinating, sarcoid, [[giant cell arteritis]], Miller-Fisher Syndrome variant of [[Guillian-Barre Syndrome]]
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*''Inflammatory'': Post-[[viral syndrome|viral]], [[MS|demyelinating]], [[sarcoidosis]], [[giant cell arteritis]], Miller-Fisher Syndrome variant of [[Guillian-Barre Syndrome]]
* ''Neoplastic'': Lesions in the cerebellopontine angle. In children – pontine glioma
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*''Neoplastic'': [[brain tumor|Lesions]] in the cerebellopontine angle. In children – pontine glioma
*''Degenerative/deficiency'': Vitamin B deficiency, Wernicke-Korsakoff syndrom
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*''Degenerative/deficiency'': [[vitamin B12 deficiency|Vitamin B deficiency]], [[Wernicke-Korsakoff syndrome]]
*''Idiopathic'': Post-lumbar puncture, status-post surgery involving head
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*''Idiopathic'': Post-[[lumbar puncture]], status-post surgery involving head
 
*''Infection'': [[Meningitis]], [[lyme disease]], [[syphilis]]
 
*''Infection'': [[Meningitis]], [[lyme disease]], [[syphilis]]
 
*''Congenital'': Rare to find true congenital sixth nerve palsy
 
*''Congenital'': Rare to find true congenital sixth nerve palsy
 
*''Autoimmune'': [[Myasthenia Gravis]]
 
*''Autoimmune'': [[Myasthenia Gravis]]
*''Trauma'': Especially if a torsional head motion or medial wall [[orbital fracture]](with entrapment of the medial rectus muscle
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*''[[head trauma|Trauma]]'': Especially if a torsional head motion or medial wall [[orbital fracture]] (with entrapment of the medial rectus muscle
*''Endocrine'': Diabetic cranial mononeuropathy - the incidence of palsy in the 3rd, 6th, and 7th cranial nerves is significantly higher in patients with [[diabetes]]. <ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> <ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/26314216</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/17157701</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/11555800</ref>
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*''Endocrine'': [[diabetic neuropathy|Diabetic cranial mononeuropathy]] - the incidence of palsy in the 3rd, 6th, and 7th cranial nerves is significantly higher in patients with [[diabetes]]<ref name="tint">Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546</ref><ref name="rosen">Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013</ref> <ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/26314216</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/17157701</ref><ref>http://www.ncbi.nlm.nih.gov/pubmed/11555800</ref>
  
 
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==Evaluation==
==Diagnostic Evaluation==
 
===Evaluation===
 
*See [[Abducens_nerve_palsy#Examination|Examination]] above
 
*[[Neurologic exam|Complete neuro exam]]
 
 
===Work-up===
 
===Work-up===
*POC glucose
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*Workup will depend on suspected etiology, may include
*CBC
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**POC glucose
*BMP
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**CBC
*ESR
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**BMP
*Lyme Titer
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**ESR
*RPR (If suspect syphilis)
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**Lyme titer
*Lumbar puncture with cerebrospinal fluid analysis indicated to exclude meningitis
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**RPR (if suspect syphilis)
*Antinuclear antibody test
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**[[Lumbar puncture]] to exclude meningitis, Guillain-Barré
*CT head: before LP to exclude acute bleed or mass
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**Antinuclear antibody test
*MRI: indicated for brainstem findings on the exam and to exclude pontine glioma in children and in adults where the abducens nerve palsy does not improve. <ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref>
+
**[[CT head]]: exclude acute bleed or mass
 
+
**[[brain MRI|MRI]]: indicated for brainstem findings on the exam and to exclude pontine glioma in children and in adults where the abducens nerve palsy does not improve<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref>
  
 
==Management==
 
==Management==
 +
*Treat by underlying etiology
 +
*Consider neuro/optho consult
 +
*Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye
 +
*Adults: Lenses can be fogged with clear tape, paint, or nail polish to decrease diplopia. Neurology can prescribe Fresnel prisms as an alternative.
 +
*[[Giant cell arteritis]]: treat with [[prednisone]] or intravenous [[Methylprednisolone]].
  
 
==Disposition==
 
==Disposition==
*Dispo appropriate to etiology, consult either Neuro or Ophtho.
+
*Dispo appropriate to etiology
*True isolated cases: often benign; can be followed up by neurologist for serial exams.
+
*Truly isolated cases: often benign, can be followed up by neurologist for serial exams
*Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye
+
*Surgery: If patient does not improve within 6 months after treatment and serial check-ups, surgery may be required<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref>
*Adults: Lenses can be fogged with clear tape, paint, or nail polish to decrease diplopia. Neurology can prescribe Fresnel prisms as an alternative.
 
*[[Giant cell arteritis]]: TX with prednisone or intravenous methylprednisolone.
 
*Surgery: If patient does not improve within 6 months after treatment and serial check-ups, surgery may be required
 
<ref name="oph">Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013</ref><ref name="eye">Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins</ref>
 
  
 
==See Also==
 
==See Also==
Line 71: Line 92:
 
{{Reflist}}
 
{{Reflist}}
  
 
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[[Category:Ophthalmology]]
[[Category:Ophtho]]
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[[Category:Neurology]]
[[Category:Neuro]]
+
[[Category:Symptoms]]

Latest revision as of 15:39, 23 October 2019

Background

  • Also called 6th cranial nerve (CN VI)
  • Most common ocular nerve palsy
  • Innervates the ipsilateral lateral rectus muscle controlling eye abduction
  • Esotropia (eye moves inward) of the affected eye due to the unopposed action of the medial rectus muscle, innervated by the oculomotor nerve (CN III) [1]

Causes

Clinical Features

History

Examination

  • Excluding paresis of the other cranial nerves
  • Check ocular muscle movements
  • Check for papilledema
  • Test pupillary response
  • Test ocular motor nerves (CN III, IV, and VI)[3][4]
    • Trace a full H-pattern with finger and have the patient follow the finger only with their eyes
    • Patients with abducens nerve palsy are unable to move the affected eye laterally
    • In order to avoid diplopia, patients will turn their heads away from the lesion so that both eyes are looking sideways
    • Check deep tendon reflexes and strength to exclude corticospinal tract involvement

Differential Diagnosis

Evaluation

Work-up

  • Workup will depend on suspected etiology, may include
    • POC glucose
    • CBC
    • BMP
    • ESR
    • Lyme titer
    • RPR (if suspect syphilis)
    • Lumbar puncture to exclude meningitis, Guillain-Barré
    • Antinuclear antibody test
    • CT head: exclude acute bleed or mass
    • MRI: indicated for brainstem findings on the exam and to exclude pontine glioma in children and in adults where the abducens nerve palsy does not improve[3][4]

Management

  • Treat by underlying etiology
  • Consider neuro/optho consult
  • Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye
  • Adults: Lenses can be fogged with clear tape, paint, or nail polish to decrease diplopia. Neurology can prescribe Fresnel prisms as an alternative.
  • Giant cell arteritis: treat with prednisone or intravenous Methylprednisolone.

Disposition

  • Dispo appropriate to etiology
  • Truly isolated cases: often benign, can be followed up by neurologist for serial exams
  • Surgery: If patient does not improve within 6 months after treatment and serial check-ups, surgery may be required[3][4]

See Also

External Links

References

  1. 1.0 1.1 1.2 Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. 763, 1037, 1546
  2. 2.0 2.1 Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013
  3. 3.0 3.1 3.2 3.3 Yanoff M, Duker JS. Opthalmology. Mosby International Ltd; 2013
  4. 4.0 4.1 4.2 4.3 Gerstenblith AT. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Lippincott Williams and Wilkins
  5. http://www.ncbi.nlm.nih.gov/pubmed/26314216
  6. http://www.ncbi.nlm.nih.gov/pubmed/17157701
  7. http://www.ncbi.nlm.nih.gov/pubmed/11555800