Abstract #1402477: Sixth-Nerve Palsy in Uncontrolled Type 1 Diabetes with Insulin Dependence

Abstract

Diabetic retinopathy is the most common and well-known ophthalmologic complications in diabetic patients. However, oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. Specifically, sixth nerve palsy is the most common, however infrequently studied. Our patient is a 51-year-old female with a past medical history of insulin-dependent diabetes mellitus, hypertension, chronic sinusitis, and chronic pain syndrome that presented with complaints of worsening headache and diplopia. Patient was hemodynamically stable on admission. Upon examination of the eye, the patient's right eye did not cross the midline in lateral gaze and was found to have diplopia in primary and lateral gaze of left eye. She was found to have recurrent sixth nerve palsy upon further evaluation of her visual deficit. Labs showed creatinine of 0.61 mg/dl (0.66-1.25 mg/dL), sodium of 129 mmol/L (135-145 mmol/L), potassium of 4.4 mmol/L (3.5-5.1 mmol/L), an anion gap of 2 mmol/L (3-13 mmol/L), blood glucose in the 300-400 mg/dL range (70-100 mg/dL) with most recent blood glucose of 168 mg/dL. Her hemoglobin A1C is 13.0 (< 6%). Her complete blood count shows a white blood cell count of 6,000/uL (3,600-10,700/uL) and a hemoglobin of 14 g/dL (13.0-18.0 g/dL). Magnetic resonance venography of the head was negative for cerebral venous sinus thrombosis and magnetic resonance imaging of the brain was negative for acute abnormalities. She was treated with basal insulin of 30 units nightly and bolus insulin of 3 units three times a day before meals for type 1 diabetes with hyperglycemia with long-term insulin use. Visual deficit was treated by observation by ophthalmology with symptomatic help through eyeglass prisms. She was discharged after one night of hospital stay with recommendations to control her home basal insulin with a carbohydrate-controlled bolus dose during meals. She was recommended to follow-up with endocrinology outpatient to discuss use of insulin pump to better control her diabetes. Sixth-nerve palsy is a frequent but lesser-known neuro-ophthalmologic complication of poorly controlled diabetic patients. Studies have shown a higher incidence of diabetes in patients with sixth-nerve palsy, warranting a more focused medical evaluation along with close observation and tighter control of blood glucose levels and hemoglobin A1C.