Bilateral Sixth Nerve Palsy Research Articles

Orthoptic treatment and eye movement recordings in Guillain-Barré syndrome: A case report

A 50-year-old patient with Guillain-Barre syndrome developed a symmetrical, bilateral sixth nerve palsy which resulted in constant esotropia and diplopia. The patient was treated with both prisms and orthoptics, which eliminated the diplopia. This treatment also improved both fu-sional divergence amplitudes and vergence adaptation. Objective eye movement recordings revealed subtle abnormalities of fixation, pursuit and saccades, i.e., square-wave jerks and intermittent saccadic dysmetria.

Convergence substitution for paralysed horizontal gaze.

Three patients with paralysed horizontal gaze are presented. Involuntary use of convergence to assist horizontal gaze was noted as a late feature. All patients showed (1) unilateral or bilateral horizontal gaze palsy (two patients had one and a half syndrome, the other had bilateral nuclear sixth nerve palsies), (2) adduction of both eyes on attempted gaze into the paralysed field, (3) miosis which coincided with adduction. Convergence substitution should be considered in the differential diagnosis of gaze induced strabismus.

Divergence paralysis versus bilateral sixth nerve palsy in an incomplete Miller-Fisher syndrome

Despite the fact that the ophthalmological picture of divergence paralysis is well known for so many years, there are still questions whether it is an entity distinct from bilateral abducens palsy.

Modern management of sixth nerve palsy.

Between November 1982 and September 1991, 179 patients with unilateral or bilateral sixth nerve palsy were treated in the Botulinum Toxin Strabismus Clinic at Moorfields Eye Hospital. Indications for treatment included prophylaxis (as part of a prospective treatment trial), maintenance therapy, diagnosis and adjunct to surgical therapy. A management plan for established sixth nerve palsy based on the rational use of toxin and surgery is suggested.

Ocular Control of the Environment following High Cervical Cord Fractures and Bilateral Sixth Nerve Palsy: A Case Report

Ocular Control of the Environment following High Cervical Cord Fractures and Bilateral Sixth Nerve Palsy: A Case Report

Coeliac disease presenting with cerebellar degeneration

A case of rapidly progressive cerebellar degeneration with bilateral sixth nerve palsies is described in whom investigation revealed the presence of unsuspected coeliac disease. In spite of treatment with a gluten free diet, rapid fatal deterioration occurred. Coeliac disease should be considered in patients with encephalopathy of obscure origin.

Otitic hydrocephalus: An uncommon complication of a common condition

A 14-year-old girl presented with bilateral sixth nerve palsies and papilledema after a two-week history of ear drainage and progressive right-sided temporal headache. A computed tomography scan of the head was normal, as were plain films of the mastoids. Lumbar puncture revealed a markedly elevated opening pressure with an otherwise normal cerebrospinal fluid examination, and she was given the diagnosis of pseudotumor cerebri. Despite treatment with acetazolamide, prednisone, and repeated lumbar punctures, her symptoms worsened. A magnetic resonance imaging study revealed thrombosis of the right sigmoid sinus, and repeat computed tomography showed evidence of mastoiditis. Definitive therapy consisted of a right mastoidectomy and antimicrobial therapy, to which the patient responded promptly. This case illustrates an unusual sequela of otitis media--termed otitic hydrocephalus--that resulted from obstruction of the sigmoid sinus. Although otitis media is generally a benign illness, clinicians must be alert to suppurative complications, which may evolve insidiously.

Treatment of Sixth Nerve Palsy in Adults with Combined Botulinum Toxin Chemodenervation and Surgery

This study reports the results of treating unrecovered sixth nerve palsy in adults with a combination of botulinum toxin and surgery. Twenty-two adults, 11 with unilateral and 11 with bilateral unrecovered sixth nerve palsy, were treated with injections of botulinum toxin to the contracted medial rectus followed by transposition surgery to the vertical rectus muscles. This management technique produced a satisfactory reduction in esotropia, averaging 46 prism diopters (PD), comparable with that achieved by conventional surgery in other series. The advantages of this form of treatment are discussed.

Pseudotumor Cerebri (Benign Intracranial Hypertension): Etiopathogenesis, Diagnosis, And Management

Pseudotumor Cerebri (Benign Intracranial Hypertension): Etiopathogenesis, Diagnosis, And Management

Botulinum toxin treatment of acute sixth and third nerve palsy

Thirty-four patients with acute sixth nerve palsy and nine patients with acute third nerve palsy were treated with botulinum toxin injection to the antagonist, nonparalytic horizontal rectus muscle. In a control group of 52 patients with acute sixth nerve palsy not treated with botulinum in the acute stage, only 16 (31%) recovered spontaneously and did not require surgery. Twenty-two of the 31 surviving patients who could be followed with acute sixth nerve palsy had lateral rectus recovery and surgery was avoided. Four required prisms in their glasses to obtain fusion. Nine patients developed chronic sixth nerve palsy and required surgery. In this group of acute sixth nerve palsy patients, eleven were bilateral. Seven of these eleven developed chronic sixth nerve paralysis, and required strabismus surgery. This suggests the prognosis for recovery following botulinum treatment in cases of acute bilateral sixth nerve palsy is not as good as in the unilateral cases. Botulinum toxin treatment does not appear to be effective in chronic sixth nerve palsy, as judged by results of treatment in one patient known to have a chronic palsy. Nine of nine patients with acute third nerve palsy had medial rectus recovery with fusion horizontally in primary gaze. None have required surgery. Only four of nine showed improvement in vertical rotations. The remaining five patients avoid vertical diplopia by a compensatory chin position. Botulinum toxin treatment of patients with acute sixth and third nerve palsy appears beneficial. However, since some in this group of patients may recover spontaneously, a randomized, double-blind study may be necessary to more definitively determine the effectiveness of this therapy.

Transient first-degree av block and sixth nerve palsy in a patient with closed head injury

We present the case of an 8-year-old girl who suffered a closed head injury with the development of bilateral sixth-nerve palsies, and who was noted upon arrival to the emergency department to be in first-degree AV block. The sixth-nerve palsies and the first-degree AV block resolved simultaneously within 24 hours of injury. We discuss dysrhythmias and ECG changes previously reported with central nervous system diseases and their proposed etiology.

Paralytic strabismus: the role of botulinum toxin.

Five adults with acute extraocular muscle palsies followed by limited recovery of muscle function were treated with injections of botulinum toxin A to the ipsilateral antagonist of the affected muscle. Three were cases of unilateral sixth nerve palsy, one of bilateral sixth nerve palsy, and one of third nerve palsy. After a period of paralysis, during which the strabismus was overcorrected, the injected muscle recovered and binocular sensory and motor functions were restored and have been maintained for periods of up to 21 months. The treatment is a safe and effective alternative to surgery, particularly in cases in which a general anaesthetic is not advisable.

Möbius syndrome and limb abnormalities with dominant inheritance

A 16-year-old male with bilateral sixth and seventh nerve palsy and arthrogryposis multiplex was evaluated for Mobius syndrome. Nineteen additional members of an extended family of 35 were examined. Six individuals in two generations had sixth and/or seventh nerve palsy with associated digital and/or limb abnormalities. Nine individuals had digital anomalies without sixth or seventh nerve palsy. Four out of nine had a diminished or absent gag reflex. One individual not examined (III-10) was reported to have strabismus and digital anomalies. The pedigree is consistent with dominant inheritance with variable expressivity and incomplete penetrance.

Bilateral sixth cranial nerve palsy in infectious mononucleosis

A 15-year-old girl who presented with a bilateral sixth nerve palsy caused by infectious mononucleosis is described. The neurological presentation of infectious mononucleosis is discussed.

Bilateral Sixth Nerve Palsy

Bilateral abducens nerve pareses were nearly as common as unilateral cases in an inpatient setting (125:143). Cerebrospinal fluid abnormalities were more frequent among the bilateral cases, but generally the same causes produced unilateral and bilateral sixth nerve palsy. The relative ease of diagnosis was in contrast with the large number of undiagnosed or "vascular" cases in previous studies of outpatients. The degree of lateral rectus limitation proved to be of limited help in suggesting the cause or predicting recovery of oculomotor function. The etiology was of some prognostic value, with universal recovery of pressure palsies and rare improvement with tumor involvement. Myasthenia, orbital muscle entrapment, convergence spasm, divergence palsy, and pretectal pseudoconvergence entered into the differential diagnosis, but were only occasionally difficult to exclude.

Pseudotumor Cerebri Syndrome Without Papilledema

An obese, young woman exhibited the classical features of pseudotumor cerebri syndrome, including increased intracranial pressure, normal cerebrospinal fluid and ventricular system, and absence of focal neurologic signs. Despite elevated intracranial pressure of sufficient magnitude to produce bilateral sixth-nerve palsy, papilledema did not develop. The illness resolved spontaneously and on examination 1 1/2 years later, the patient was normal. There are several possible mechanisms that might prevent papilledema from developing under these circumstances.