Abducens Nerve Palsy Clinical Presentation

  • Author: Michael P Ehrenhaus, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 14, 2012
 

History

Clinical history includes the following:

  • Esotropia
  • Head-turn
  • Binocular diplopia (worse at distance)
  • Vision loss
  • Pain
  • Hearing loss
  • Symptoms of vasculitis, particularly giant cell arteritis
  • Trauma
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Physical

Physical findings include the following:

  • An esodeviation that increases on ipsilateral gaze and is often greater at a distance
  • An isolated abduction deficit
  • Slowed ipsilateral saccades
  • Papilledema (if increased intracranial pressure)
  • Nystagmus (usually in children, ie, secondary to pontine glioma)
  • Otitis media
  • Orbital wall fracture
  • Tender, enlarged, nonpulsatile temporal arteries in giant cell arteritis
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Causes

Not all abduction deficits are cranial nerve VI palsies. Mimickers are orbital lesions, medial wall fractures, Duane syndrome, thyroid disease, and myasthenia gravis.[4]

  • Elevated intracranial pressure can result in downward displacement of the brainstem, causing stretching of the sixth nerve secondary to its anatomic location within the Dorello canal. This is believed to be the reason that about 30% of patients with pseudotumor cerebri have an isolated abducens nerve palsy.
  • Subarachnoid space lesions can be causes of abducens nerve palsy (eg, hemorrhage, infection, inflammation, space-occupying tumor, cavernous sinus mass). Inflammatory (eg, postviral, demyelinating, sarcoid, giant cell arteritis)
  • Vascular
  • Metabolic (eg, vitamin B, Wernicke-Korsakoff syndrome)
  • Neoplasm (children) - Pontine glioma
  • Infectious (eg, Lyme disease, syphilis)
  • Congenital absence of the sixth nerve (eg, Duane syndrome)[5]
  • Trauma, particularly if it results in a torsional head motion[6, 7, 8, 9]
  • Post–lumbar tap[10]
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Contributor Information and Disclosures
Author

Michael P Ehrenhaus, MD  Director, Department of Cornea, External Disease & Refractive Surgery, Assistant Professor, Department of Ophthalmology, State University of New York Downstate Medical Center

Michael P Ehrenhaus, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Contact Lens Association of Ophthalmologists

Disclosure: Nothing to disclose.

Coauthor(s)

Mohammedyusuf E Hajee, MD  Clinical Instructor, Staff Physician, Department of Ophthalmology, Director, Blood Flow Laboratory, State University of New York-Downstate Medical Center

Mohammedyusuf E Hajee, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, and National Medical Association

Disclosure: Nothing to disclose.

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew W Lawton, MD  Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Brian R Younge, MD  Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.

References

  1. Evans NM. Ophthalmology. 2nd ed. Oxford University Press Inc; 1995.

  2. Kline LB, Bajandas FJ. Neuro-ophthalmology Review Manual. 3rd ed. University of Alabama, Birmingham; 1988.

  3. Yanoff M, Duker JS. Ophthalmology. Mosby International Ltd; 1999.

  4. Ayberk G, Ozveren MF, Yildirim T, et al. Review of a series with abducens nerve palsy. Turk Neurosurg. Oct 2008;18(4):366-73. [Medline].

  5. Denis D, Dauletbekov D, Girard N. Duane retraction syndrome: Type II with severe abducens nerve hypoplasia on magnetic resonance imaging. J AAPOS. Feb 2008;12(1):91-3. [Medline].

  6. Calisaneller T, Ozdemir O, Altinors N. Posttraumatic acute bilateral abducens nerve palsy in a child. Childs Nerv Syst. Jul 2006;22(7):726-8. [Medline].

  7. Dwarakanath S, Gopal S, Venkataramana NK. Post-traumatic bilateral abducens nerve palsy. Neurol India. Jun 2006;54(2):221-2. [Medline].

  8. Kurbanyan K, Lessell S. Intracranial hypotension and abducens palsy following upper spinal manipulation. Br J Ophthalmol. Jan 2008;92(1):153-5. [Medline].

  9. Hanu-Cernat LM, Hall T. Late onset of abducens palsy after Le Fort I maxillary osteotomy. Br J Oral Maxillofac Surg. Dec 16 2008;[Medline].

  10. Anwar S, Nalla S, Fernando DJ. Abducens nerve palsy as a complication of lumbar puncture. Eur J Intern Med. Dec 2008;19(8):636-7. [Medline].

  11. Tsai TH, Demer JL. Nonaneurysmal cranial nerve compression as cause of neuropathic strabismus: evidence from high-resolution magnetic resonance imaging. Am J Ophthalmol. Dec 2011;152(6):1067-1073.e2. [Medline]. [Full Text].

  12. Rhee DJ, Pyfer MF. The Wills Eye Manual: Office and Emergency Room diagnosis and treatment of eye disease. Lippincott Williams & Wilkins; 1999.

 
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