Abducens Nerve Palsy Clinical Presentation
- Author: Michael P Ehrenhaus, MD; Chief Editor: Edsel Ing, MD, FRCSC more...
Clinical history includes the following:
- Binocular diplopia (worse at distance)
- Vision loss
- Hearing loss
- Symptoms of vasculitis, particularly giant cell arteritis
Physical findings include the following:
- An esodeviation that increases on ipsilateral gaze and is often greater at a distance; prism measurements in different positions of gaze can reveal the magnitude of misalignment and its incomitance (asymmetry)
- An isolated abduction deficit
- Slowed ipsilateral saccades
- Papilledema (if increased intracranial pressure)
- Altered sensation in the V1 or V2 distribution with cavernous sinus lesions
- Nystagmus (usually in children, ie, secondary to pontine glioma)
- Otitis media
- Petrous bone fracture
- Horner syndrome (Foville brainstem syndrome, carotid oculosympathetic plexus involvement in cavernous sinus)
- Tender, enlarged, nonpulsatile temporal arteries in giant cell arteritis
Not all abduction deficits are cranial nerve VI palsies. Mimickers are orbital lesions, medial wall fractures, Duane syndrome, thyroid disease, myasthenia gravis, and spasm of the near reflex.
- 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)
- 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)
- Trauma, particularly if it results in a torsional head motion[6, 7, 8, 9]
- Post–lumbar tap
Evans NM. Ophthalmology. 2nd ed. Oxford University Press Inc; 1995.
Kline LB. Neuro-ophthalmology Review Manual. 6th ed. SLACK Inc; 2008.
Yanoff M, Duker JS. Ophthalmology. Mosby International Ltd; 1999.
Ayberk G, Ozveren MF, Yildirim T, et al. Review of a series with abducens nerve palsy. Turk Neurosurg. 2008 Oct. 18(4):366-73. [Medline].
Denis D, Dauletbekov D, Girard N. Duane retraction syndrome: Type II with severe abducens nerve hypoplasia on magnetic resonance imaging. J AAPOS. 2008 Feb. 12(1):91-3. [Medline].
Calisaneller T, Ozdemir O, Altinors N. Posttraumatic acute bilateral abducens nerve palsy in a child. Childs Nerv Syst. 2006 Jul. 22(7):726-8. [Medline].
Dwarakanath S, Gopal S, Venkataramana NK. Post-traumatic bilateral abducens nerve palsy. Neurol India. 2006 Jun. 54(2):221-2. [Medline].
Kurbanyan K, Lessell S. Intracranial hypotension and abducens palsy following upper spinal manipulation. Br J Ophthalmol. 2008 Jan. 92(1):153-5. [Medline].
Hanu-Cernat LM, Hall T. Late onset of abducens palsy after Le Fort I maxillary osteotomy. Br J Oral Maxillofac Surg. 2008 Dec 16. [Medline].
Anwar S, Nalla S, Fernando DJ. Abducens nerve palsy as a complication of lumbar puncture. Eur J Intern Med. 2008 Dec. 19(8):636-7. [Medline].
Tsai TH, Demer JL. Nonaneurysmal cranial nerve compression as cause of neuropathic strabismus: evidence from high-resolution magnetic resonance imaging. Am J Ophthalmol. 2011 Dec. 152(6):1067-1073.e2. [Medline]. [Full Text].
Rhee DJ, Pyfer MF. The Wills Eye Manual: Office and Emergency Room diagnosis and treatment of eye disease. Lippincott Williams & Wilkins; 1999.