Difference between revisions of "Abducens nerve palsy"

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==Background==  
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==Background==
* Also called 6th cranial nerve (CN VI)
+
*Also called 6th cranial nerve (CN VI)
* Most common ocular nerve palsy
+
*Most common ocular nerve palsy
* Innervates the ipsilateral lateral rectus muscle controlling eye abduction
+
*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>
+
*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>
  
==Clinical Features==
+
===Causes===
 +
*Nuclear lesion
 +
**Congenital, [[MS|demyelinating]], [[CVA|ischemia]], traumatic
 +
*Inflammatory
 +
**[[Vasculitis]]
 +
**[[Sarcoidosis]]
 +
**[[Systemic lupus erythematosus]]
 +
*Infectious
 +
**[[Lyme disease]]
 +
**[[Syphilis ]]
 +
**[[Tuberculosis]]
 +
**[[Meningitis ]]
 +
*Orbital lesions
 +
**Neoplastic
 +
**Inflammatory
 +
**Infectious
 +
 
 +
==Clinical Features==
 
===History===
 
===History===
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>
+
*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>
 
+
*''[[Diplopia]]'' (frequent complaint) upon attempting lateral gaze and ''esotropia'' at rest
*Frequently present with '''diplopia''' upon attempting lateral gaze and '''esotropia''' at rest
+
**May have a ''head turn'' to help correct their diplopia
*May have a '''head turn''' to help correct their diplopia
+
*[[Vision loss]]
*Vision loss
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*[[Hearing loss]]
*Hearing loss
+
*Symptoms of [[vasculitis]], most commonly [[giant cell arteritis]] (headache, tenderness of the scalp, jaw claudication, reduced visual acuity, tinnitus, fever_
*Symptoms of vasculitis, most commonly [[giant cell arteritis]] (headache, tenderness of the scalp, jaw claudication, reduced visual acutity, tinnitus, fever
+
*+/- history of [[diabetes]], [[hypertension]], [[stroke]], [[fever]], and [[headache]]
*Ask about history of diabetes, hypertension, stroke, fever, and headache
 
  
 
===Examination===
 
===Examination===
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**Check deep tendon reflexes and strength to exclude corticospinal tract involvement
 
**Check deep tendon reflexes and strength to exclude corticospinal tract involvement
  
==Differential Diagnosis==
+
==Differential Diagnosis==
* ''Increased intracranial pressure (ICP)'': Because of its position and intracranial length, increased ICP from any cause can lead to injury and dysfunction
+
*''[[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]]
+
*''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
+
*''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
+
*''[[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>
+
*''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>
  
==Diagnostic Evaluation==
+
==Evaluation==
 
===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
+
**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>
===Evaluation===
 
*See [[Abducens_nerve_palsy#Examination|Examination]] above
 
*[[Neurologic exam|Complete neuro exam]]
 
  
 
==Management==
 
==Management==
*True isolated cases: often do not need specific treatment
+
*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
 
*Children: Can be treated with alternating patching to decrease probability of developing amblyopia in the affected eye
*[[Giant cell arteritis]]: TX with prednisone or intravenous methylprednisolone.
+
*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
*Adults: Lenses can be fogged with clear tape, paint, or nail polish to decrease diplopia. Neurology can prescribe Fresnel prisms as an alternative.
 
 
*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>
 
*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>
  
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{{Reflist}}
 
{{Reflist}}
  
[[Category:Ophtho]]
+
[[Category:Ophthalmology]]
 
[[Category:Neurology]]
 
[[Category:Neurology]]
 +
[[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