Sixth Nerve Palsy Research Articles

Case Report: Bilateral optic disc swelling in a patient with tuberculoma

BACKGROUND: In children, tuberculosis of the central nervous system most usually manifests as tubercular meningitis, hydrocephalus post-tubercular meningitis, and, in rare cases, space-occupying lesions known as tuberculoma. We address the diagnostic difficulty in an adult patient with mainly ocular symptoms who was diagnosed with tuberculoma. A 19-year-old young man came with painless bilateral blurring of vision. Bilateral optic disc swelling and bilateral sixth cranial nerve palsy were present. METHODS: Brain imaging revealed ring-enhancing lesions in the cerebellar vermis, left cerebellar hemisphere and left middle cerebral peduncle with surrounding extensive perilesional edema causing effacement of fourth ventricle leading to obstructive hydrocephalus suggestive of tuberculoma. RESULTS: He had a high erythrocyte sedimentation rate and a positive Mantoux test. His Quantiferon-TB Gold test result was positive. The examination of cerebrospinal fluid suggested a high opening pressure. Following anti-tubercular medication along with systemic steroids, his vision improved due to decreased optic disc swelling. CONCLUSION: We wish to highlight that visual loss and grave consequences of tuberculoma can be averted with early recognition and treatment.

Isolated sixth nerve palsy as an initial manifestation of systemic lupus erythematosus – A rare case report

A 35-year-old female presented to our neuro-ophthalmology OPD with chief complaints of binocular double vision for the past 4 days, which increased in right lateral horizontal gaze. On ocular examination, the patient had restriction of abduction in the right eye, suggestive of right sixth nerve palsy. Investigations revealed antinuclear antibodies positive with titer 1:1000 speckled homogenous pattern suggestive of systemic lupus erythematosus (SLE). Neuroimaging revealed no evidence of an aneurysm in the brain, after which the patient was treated with intravenous methylprednisolone 1 gm once daily pulse steroids for 3 days followed by oral steroids 1 mg/kg was given. The patient improved clinically after 1 month. Although most patients demonstrate the classic diagnostic signs of skin rash and arthritis, the case reported here of an isolated sixth cranial nerve palsy suggests that such an uncharacteristic presentation of SLE is possible.

Abducens Nerve Palsy in a 4-month-old Girl.

Abducens Nerve Palsy in a 4-month-old Girl.

Postdural Puncture Headache, Subdural Hematoma, and Sixth Cranial Nerve Palsy Lumbar Following Spinal Drain, Resolved with Epidural Blood Patch: Case Report

BACKGROUND: Postdural puncture headache (PDPH) is a known potential complication of lumbar drain placement. Data regarding incidence of PDPH after lumbar drain placement varies, with a range of 0% to 47%. Furthermore, spinal drain placement has been associated with a significantly increased risk of debilitating neurologic complications. CASE REPORT: In this article, we describe the case of a patient who developed PDPH, subdural hematoma, and abducens nerve palsy after lumbar drain. The patient was treated successfully with epidural blood patch. To our knowledge, this is the first case report of a patient who developed all 3 of these complications following spinal drain placement. CONCLUSION: Dural puncture, whether accidental or purposeful, carries a risk of multiple serious neurological sequelae. After spinal drain placement, close monitoring for symptoms of intracranial hypotension should ensue with a plan for treatment in the event the patient develops a PDPH or other neurologic sequelae. KEY WORDS: Epidural blood patch, headache, postdural puncture headache

Marginless 5-Fraction Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol

Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution's 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with marginless 5-fraction robotic radiosurgery. Between 2010-2020, patients who completed marginless 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method. Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 28.8 Gy (range: 25 Gy-30 Gy), was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.9 Gy). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (>20 cc). The treatment of unfavorable nonfunctioning pituitary macroadenoma with marginless 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. However, tumors with GTV's greater than 20 cc may require conventionally fractionated treatment with a margin to optimize local control.

Magnetic Resonance Imaging of Globe Translation in Abducens Palsy

PurposeIt has been supposed that rectus muscle paralysis would cause proptotsis due to reduction in active posterior tension. This study aimed to test this proposition by evaluating globe translation during horizontal duction in abducens palsy. DesignProspective, single-center, fellow-eye controlled, case series. MethodsHorizontal globe rotation and translation were quantified using orbital MRI of patients with isolated unilateral abducens nerve palsy without other ocular motility disorder. Unaffected fellow eyes served as controls. Digital image analysis was performed. ResultsA total of 5 female and 2 male patients of mean age 52±15 years (standard deviation) were included. The average esotropia was 39.0±9.7Δ. Mean adduction was similar at 54.9±10.4° in palsied eyes and 52.0±7.1° in fellow eyes. However, abduction in palsied eyes was significantly less at -11.4±7.1° than -37.1±11.4° in fellow eyes (P=0.0023). Average anteroposterior translations in adduction was 0.46±0.42 mm in palsied orbits, similar to 0.35±0.47 mm in fellow orbits (P=0.90). Anteroposterior translation in abduction averaged 0.17±0.53 mm in palsied orbits, similar to 0.27±0.73 mm in fellow orbits (P=0.80). Average horizontal translation in adduction at -0.32±0.23 mm in palsied orbits was statistically similar to -0.12±0.44 mm in fellow orbits (P=0.54). Average horizontal translation in abduction at 0.19 ± 0.18 mm in palsied orbits was similar to 0.33±0.15 mm in control orbits (P=0.38). ConclusionAbducens palsy does not alter normal eye translation during horizontal duction.

Voice and quality of life results in patients with unilateral vocal fold abduction paralysis treated with medialization thyroplasty

Voice and quality of life results in patients with unilateral vocal fold abduction paralysis treated with medialization thyroplasty

Diagnosis and management of Neuro-Behçet disease with isolated intracranial hypertension: a case report and literature review

BackgroundNeuro-Behçet's disease (NBD), characterized by isolated intracranial hypertension, is a rarely encountered condition, especially in children. In this study, we describe the treatment of a pediatric patient with NBD, who exhibited isolated intracranial pressure elevation as indicated by the initial manifestation of diplopia and physical examination finding of papilledema.Case presentationAn 8-year-old boy was admitted to the hospital with a confirmed diagnosis of Behçet's disease (BD) over eight months. The patient also presented with the symptom of diplopia for three days. The evaluation of the patient’s nervous system did not reveal any apparent abnormalities. The measurement of cerebrospinal fluid pressure yielded a reading of 470 mm H2O. The examination of the fundus indicated papilledema, and imaging scans revealed evidence of focal demyelination. The symptoms of the child showed alleviation after the administration of mannitol, methylprednisolone, and azathioprine. Furthermore, this study involved a comprehensive analysis of 18 cases of NBD with isolated intracranial hypertension, comprising one case reported herein and 17 cases from the literature review. Three cases were children, and an equal distribution of males and females 9:9 was noted. The average age at the onset of symptoms was 24.7 years (8-38 years). Headache (90%) was the most commonly reported clinical manifestation, followed by blurred vision or diplopia (80%). The ocular manifestations included papilledema (100%), abducent nerve paralysis (20%) and local eye hemorrhages in the retina (30%). Notably, 88.9% of these ocular manifestations were relieved or cured after treatment.ConclusionThis study presents the first reported case of NBD with isolated intracranial hypertension in the pediatric population of China. In a child with Bechet's disease presenting with features of raised intracranial pressure, it is important to be aware of neuro Bechet's presenting with intracranial hypertension without other neurological abnormalities. This will help make early diagnosis, institute treatment and prevent sequelae resulting from untreated raised intracranial pressure.

Giant Hydatic Cyst in a 2-Year-Old Infant

Background: Infantile cerebral hydatidosis is a serious infection and represents a major problem of public health that threatens the economy of countries in which it is endemic. It imposes a large-scale prophylaxis based on the interruption of the parasite cycle. Case description: We present a case of a 2-year-old girl with no medical history living in a rural region (Sidi Ifni), where contact with dogs, sheep, and cattle is not uncommon. One month before her admission, increased intracranial pressure (ICP) symptoms appeared made of headaches, vomiting, and visual disturbances. 15 days later, motor deficits and impaired consciousness were installed. The clinical examination found a sleepy infant with a Glascow Coma Scale at 14, left hemiparesis at 2/5 (Medical Research Council score), and bilateral 6th nerve palsy, A brain CT scan was performed, showing a round hypodense intraparenchymal lesion at the right frontal lobe. The intervention was performed to remove the gliant hydatic cyst according to the Dowling-Orlando technique. Postoperatively the patient had no motor deficit. The histopathological exam confirmed the diagnosis of an echinococcus granulosis cyst. Conclusion: Presentation of such a giant cyst in a 2-year-old infant is very rare. In such cases, genotype analysis of the parasite should be performed. The surveillance of dogs and periodic testing of their stools, with treatment if they are found to be infected, and preventing their access to raw offal at slaughterhouses and farms, will be effective in controlling the menace of hydatidosis.

Transient lateral rectus palsy associated with acute coronary syndrome treated with percutaneous coronary intervention: a case report

BackgroundPatients who experience angina and acute myocardial infarction often receive diagnostic coronary angiography and percutaneous coronary intervention.Case presentationA 54-year-old Persian man with acute coronary syndrome was admitted to the hospital and underwent elective percutaneous coronary intervention. Two hours after the procedure, the patient experienced ophthalmoplegia and diplopia. The diagnosis was abducens nerve palsy resulting in transient lateral rectus palsy. The cause is presumed to have been an ischemic event affecting the unilateral abducens nerve. This could have occurred owing to the microembolism during the percutaneous coronary intervention, which resulted in left lateral rectus palsy. Within 1 month, the diplopia was relieved completely, and the physical examination was normal.ConclusionThe occurrence of neuro-ophthalmic complications that may arise from percutaneous coronary intervention is extremely rare. To our knowledge, this is the second reported case of unilateral rectus palsy associated with percutaneous coronary intervention.

Mass Effect After Flow Diversion for Unruptured Large and Giant Cavernous or Paraclinoid Internal Carotid Artery Aneurysm

The mass effect associated with large or giant intracranial aneurysms is difficult for traditional endovascular treatment. This study investigated whether flow diverters can relieve the aneurysmal mass effect caused by aneurysmal compression symptoms. Fifty-five patients with unruptured large and giant intracranial aneurysms treated by a flow diverter at our institution from January 2014 to February 2022 were retrospectively evaluated. In this study, 53 patients were included. Initially, 27 patients (51.9%), including 10 with compressive optic neuropathy, 12 with third nerve palsy, 2 with facial hyperesthesia, and 11 with sixth nerve palsy, were symptomatic. The symptom duration was shorter in the improved group (n=2.2±4.0 vs. n=3.1±3.9, P=0.49). Thrombus formation following the flow diversion procedure was typically observed on magnetic resonance imaging (MRI) performed immediately and was not significantly associated with symptomatic improvement (OR=0.395; 95% CI (0.058-2.698), P=0.343). However, symptomatic improvement was seen in most patients when the aneurysm size decreased on MRI. A reduction in the aneurysm size on the MRI at the 3-month follow-up was correlated with symptomatic improvement in the multivariate analysis (OR=0.08, 95% CI (0.013-0.485), P<0.05). A flow diverter might help alleviate compression symptoms caused by large or giant intracranial aneurysms. Shrinkage of the aneurysm within 3months postoperatively and a shorter duration of symptoms contribute to the favorable outcomes of mass effect. Ultimately, prompt treatment is crucial for improving symptomatic intracranial artery aneurysms.

A multicenter retrospective analysis of clinical outcomes of intracranial chondrosarcoma in 26 patients

Intracranial chondrosarcoma is a rare tumor with limited reports. We reviewed the clinical outcomes, imaging findings, and pathological characteristics at three centers to improve the diagnosis and treatment of intracranial chondrosarcoma. We retrospectively analyzed 26 patients with intracranial chondrosarcoma who had undergone surgical treatment at Tangdu Hospital of Air Force Military Medical University, Mianyang Central Hospital, and Nanchong Central Hospital from January 2010 to July 2022. Clinical manifestations, imaging features, surgical treatment, prognosis, and overall survival (OS) were analyzed. All 26 chondrosarcomas were located at the skull base. Gross total resection (GTR), subtotal resection (STR), and partial resection (PR) were performed in 14, 10, and 2 cases, respectively. Four cases underwent endoscopic transnasal surgery, while the remaining cases underwent craniotomy. The clinical symptoms were evaluated 1 week after surgery, and 15 cases were relieved to varying degrees. Postoperative complications included pulmonary infection, subcutaneous hydrops, dysphagia and choking, facial numbness, abducens paralysis, and intracranial infection (ICI). Fifteen cases received postoperative adjuvant radiotherapy. Seven cases showed recurrence: two with PR, four with STR, and one with GTR. Six cases received reoperation or radiotherapy after tumor progression, and one untreated patient died 5 months after tumor recurrence. The extent of tumor resection (HR 21.74, 95% CI 1.25–376.6, P = 0.03) and pathological grading (HR 131.99, 95% CI 4.05–4300.5, P = 0.006) were associated with improved OS. We presented our experience in the treatment of intracranial chondrosarcoma at three centers in the past 12 years. Intracranial chondrosarcoma lacked typical imaging features and are difficult to differentiate from other skull base lesions. Maximum extent of tumor resection with minimal injury to neurological function remains the most important treatment strategy. The extent of surgical resection and pathological grading were found to be predictors for OS.

Recovery of Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Adenoma and Meningioma Patients.

This retrospective, observational cohort study aimed to determine recovery rate and recovery time of ocular motor nerve palsies (OMP) of third (CN III), fourth (CN IV), or sixth cranial nerves (CN VI)-and associated prognostic factors-in meningioma and pituitary adenoma (PA) patients. A total of 25 meningioma (28 eyes) and 33 PA patients (36 eyes), treated at the Leiden University Medical Center in the Netherlands from January 1, 1978 to January 31, 2021, were included. OMPs were evaluated according to a newly created recovery scale using on-clinical and orthoptic examinations, which were performed every 3-4 months until palsy recovery, or at 18 months follow-up. Recovery rates of CN III (meningioma 23.5% vs PA 92.3%), CN IV (meningioma 20% vs PA 100%), and CN VI (meningioma 60% vs PA 100%) palsies were observed at 18 months follow-up, with differences between the 2 tumor types being observed in the treated patients only. Median recovery time of all OMPs combined was significantly longer in meningioma patients (37.9 ± 14.3 months vs 3.3 ± 0.1 months; P < 0.001). No significant protective or risk factors for recovery rate or time were identified. OMP recovery rates in treated patients were more favorable in patients with PA compared with patients with meningiomas, independent of OMP cause. With these new insights in OMP recovery, more accurate prognoses and appropriate follow-up strategies can be determined for meningioma and PA patients with OMPs.

Cranial Nerve Palsies in the Setting of Arachnoid Cysts: A Case Series and Literature Review.

Arachnoid cysts (ACs) are benign lesions typically believed to not cause neurologic defects in the adult population and are most often found incidentally on imaging. We describe 2 patients with ACs potentially leading to isolated cranial nerve (CN) dysfunction. We describe 2 patients, 1 with a fourth nerve palsy and the other with a sixth nerve palsy found to have ACs on MRI brain imaging in locations that potentially caused a compressive CN palsy. We review previous literature of ACs presenting with CN III, IV, or VI palsy. Patient 1 was a 62-year-old man who presented with a 22-year history of diplopia with strabismus examination consistent with a congenital CN IV palsy. Despite multiple surgeries, his CN IV palsy insidiously worsened. An AC in the posterior fossa with mass effect on the quadrigeminal plate and asymmetric atrophy of the right superior oblique was identified on imaging. Patient 2 was an 80-year-old man who presented with an 18-year history of diplopia and was found to have a left esotropia and abduction deficit consistent with complete CN VI palsy. An AC in the left cavernous sinus was identified on imaging. He underwent strabismus surgery with satisfactory resolution of diplopia. We identified a total of 18 previously published cases: 8 reports of CN III palsy, 4 reports of CN IV palsy, and 6 reports of CN VI palsy. Patient ages ranged from 1 to 67 with a median of 34.5. In 16/18 (89%) cases, the diagnosis of ACs was made within 1 year of symptom onset. Surgical removal of the AC was successful in resolving diplopia in 7/12 (58%) cases. In no case was strabismus surgery performed as primary treatment. Although ACs are typically congenital asymptomatic lesions, we present a case series of 2 patients with ACs in anatomic locations that potentially caused chronic, progressive, isolated CN palsies leading to strabismus. Our literature review revealed that most published cases detailing this clinical scenario resulted in neurosurgical fenestration of ACs with mixed results. Our cases represent 2 patients with AC-associated CN palsy treated with strabismus surgery.

Multiple Sclerosis Presenting as Intracranial Hypertension in the Setting of COVID-19 Infection

Background: Multiple sclerosis (MS) and idiopathic intracranial hypertension (IIH) occur more commonly in women of childbearing age. There are altered cerebrospinal fluid dynamics in both diseases, causing them to have similar presentations at times. Coronavirus disease 19 (COVID-19) has also been reported to affect the central nervous system (CNS) of any age. Case Presentation: We report a19 year old male who initially presented with headaches and fever, and was diagnosed with COVID-19 infection. A few days later, he developed acute severe left eye pain, blurred vision, diplopia, and left ear tinnitus. The patient was found to have reduced visual acuity, left sixth nerve palsy, esotropia and asymmetric bilateral papilledema. Later, he developed left facial nerve palsy. MRI of the brain showed extensive demyelinating lesions. Lumbar puncture revealed significantly increased intracranial pressure (ICP) and positive oligoclonal bands. Conclusion: This is a unique case of MS presenting with intracranial hypertension (IH) in the setting of COVID-19 infection that could have been the trigger for the MS clinical attack.

Isolated Sixth Nerve Palsy and COVID-19: A Recurrent Case in a 7-Month-Old Child and Analysis of Reported Cases.

With the SARS-CoV-2 pandemic (COVID-19), data on central and peripheral nervous system involvement, including those causing cranial nerve 6 (CN6) palsy, have been limited to case reports. To extract clinically relevant features of COVID-19-related CN6 palsy, we report on a recurrent pediatric case and analysis of reported cases associated with infection or immunization. A PubMed search revealed 18 cases of isolated CN6 palsy in addition to the index case (n = 19). Clinical characteristics, workup, and temporal associations between systemic symptoms onset or vaccination, symptoms onset, and resolution were compiled and analyzed. The median age of CN6 onset was 43 years (interquartile range [IQR]: 28-52). Sixteen cases (84.2%) were associated with COVID-19 illness and 3 (15.8%) were associated with COVID-19 vaccination. Four cases (23.5%) had positive neuroimaging findings. The median latency from first COVID-19 symptoms or vaccination to onset of CN6 palsy was 6 days (IQR: 2.3-16), and the median time from onset to resolution was 30 days (IQR: 14-60). Latency to onset of CN6 palsy was significantly and directly associated with time to resolution (R 2 = 0.401, P = 0.010). Patients who had a positive SARS-CoV-2 antibody test had significantly longer days from symptoms to onset (6.0 vs 24.5, P = 0.030), and patients with a positive SARS-CoV-2 polymerase chain reaction test had a significantly shorter time to resolution (17.50 vs 90, P = 0.042). Isolated CN6 palsy from COVID-19 is rare, can occur in infants as young as 7 months, and can be recurrent. Longer latency from systemic symptoms onset portends greater recovery times, and this relationship may reflect multiple mechanisms by which COVID-19 (and/or an immune response thereto) causes cranial neuropathies with direct clinical relevance.

995 Cavernous Sinus Thrombosis Secondary to Dental Neglect

Abstract Background Cavernous sinus thrombosis is a rare, potentially life-threatening condition often caused by a cervicofacial bacterial infection. Prompt diagnosis and management improve prognosis and help prevent permanent complications. Clinical case A 54-year-old man with a background of alcohol excess attended the emergency department following a collapse at home. He presented with a potassium of 1.5 and a firm right parotid swelling with associated facial nerve weakness and was admitted to ICU for management of severe sepsis and electrolyte disturbance. CT imaging out of hours showed swelling of right parotid and submandibular areas and generalised oedema parapharyngeally. Further clinical examination by the maxillofacial team noted a right sided 6th nerve palsy, raising concern about intracranial spreading infection from a dental source and MRI was requested. The patent continued to deteriorate and developed bilateral chemosis and proptosis. MRI scan confirmed bilateral cavernous sinus thrombosis and right cerebral hemisphere subdural collection and the patent was transferred to a neurosurgical unit for a craniotomy, temporal lobe washout and dental clearance. Upon further review of imaging by a specialist head and neck radiologist the cavernous sinus thrombosis was noted on the initial scans. Conclusions Raise awareness of this condition and its management – much rarer more now due to antibiotics in developed world. Importance of thorough clinical examination to pick up subtle signs such as cranial nerve palsies. Vital to have multidisciplinary involvement in diagnosis and management; both radiology to help with diagnosis and neurosurgery, ENT and maxillofacial to carry out surgery as required.

Spasm of the near reflex misdiagnosed as bilateral VI nerve palsy

Spasm of the near reflex misdiagnosed as bilateral VI nerve palsy

Endoscopic extended transforaminal approach (medial subchoroid) as an alternative to the classical transchoroidal approach: Technical note

The extended transforaminal endoscopic approaches allows visualization and manipulation of the middle and posterior third of the III ventricle. In selected cases where the venous anatomy is favorable, the medial subchoroidal approach can be performed as an alternative to the classic transchoroidal approach (via trans-taenia fornicis) with increased protection over the fornix and without the need to sacrifice the septal vein.We present a 14-year-old male with history of Neurofibromatosis type 1 referred for two weeks of clinical evolution with headache, dizziness, gait instability and appearance of a right VI nerve palsy. Magnetic resonance imaging showed obstructive tri-ventricular hydrocephalus due to stenosis of the aqueduct of Sylvius with suspicion of an underlying tumor. An endoscopic surgical procedure was performed through a single approach with III cisternostomy and resection of the tissue that produced the stenosis. The anatomopathological diagnosis showed reactive glial tissue with no signs of malignancy. In conclusion, the medial subchoroidal approach is a plausible alternative in the endoscopic approach to the III ventricle structures in a safe and comfortable manner.

Diplopía binocular: estudio retrospectivo de 204 casos

ObjectivesTo describe the prevalence and form of onset of different causes of binocular diplopia in our setting. MethodsWe conducted a single-centre, cross-sectional, retrospective study reviewing the medical records of all patients visiting a tertiary-level centre between May 2019 and June 2021 with binocular diplopia as the main symptom. All patients underwent a complete neuro-ophthalmological evaluation and complementary tests for the aetiological diagnosis of diplopia. Data were collected on demographic variables, ocular deviation pattern, complementary test results, and diagnosis. ResultsA total of 204 patients with binocular diplopia were identified during the study period. The most frequent causes of diplopia overall were fourth nerve palsy (19.12%), sixth nerve palsy (14.71%), decompensated strabismus (14.22%), sagging eye syndrome (12.25%), third nerve palsy (10.78%), myasthenia (7.35%), supranuclear disorders (6.37%), and myopic esotropia (5.88%). Presentation was acute (≤2 weeks progression) in 51% of cases. The most frequent causes of acute-onset diplopia were sixth nerve palsy (27.88%), third nerve palsy (21.15%), fourth nerve palsy (19.23%), supranuclear disorders (12.5%), and decompensated strabismus (6.73%). The most frequent causes of subacute/chronic presentation (more than 2 weeks) were decompensated strabismus (22%), sagging eye syndrome (22%), fourth nerve palsy (19%), myopic esotropia (12%), and myasthenia (11%). ConclusionsThe most frequent aetiology of diplopia in our environment was fourth nerve palsy, followed by sixth nerve palsy, decompensated strabismus, and sagging eye syndrome. Knowing the frequency of each cause of diplopia can help prioritise neuroimaging studies in each case.