scholarly journals MON-701 Uncontrolled Diabetes Presenting as Isolated Sixth Nerve Palsy

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Paola Andrea Sanchez Garay ◽  
Rommel Zerpa ◽  
Gabriela Zuniga ◽  
Deyger Navarrete ◽  
Robert Lichtenberg
Keyword(s):  
Eicosapentaenoic Acid ◽  
Nerve Palsy ◽  
Acid Ethyl Ester ◽  
Abducens Nerve ◽  
Acute Onset ◽  
Abducens Nerve Palsy ◽  
Double Vision ◽  
Diagnostic Challenge ◽  
Sixth Nerve Palsy ◽  
Sixth Nerve

Abstract BACKGROUND Our case report demonstrates acute onset of diplopia due to Isolated Sixth Nerve Palsy (ISNP) secondary to uncontrolled T2DM, presenting as an ophthalmoplegia. The most frequent one, is ISNP with an incidence of 11.3/100.000 1. Vasculopathic ISNP is associated with atherosclerosis in patients older than 50 years 1. CASE PRESENTATION A 63 year-old male with history of T2DM, HTN, HL, came for evaluation of acute onset double vision 3 days prior. He noted diplopia while attempting to park his car; he saw that tracking to the left with his eyes would elicit double vision. Denied recent travel, trauma, headache or dizziness. He was awake and alert, BP 200/110mmHg, BMI 33. No pathologic murmur. He had PERRLA bilaterally but impaired lateral rectus muscle movement on the left side. Otherwise, EOMI on the right side. No facial asymmetry or ptosis. Overall, findings positive for ISNP. BMP only remarkable for a glucose of 297, HA1c was 10.0. Head CT was negative for any acute intracranial abnormality. Orbital MRI did not show acute infarction or masses. Patient was admitted for acute diplopia due to ISNP. Differential diagnoses were neoplasm, migraine, MS and diabetic neuropathy. Based on the aforementioned data, we suggested that T2DM was the probable cause. Counseling on improving glycemic control was given. Unfortunately, patient was lost to follow up. DISCUSSION ISNP remains an elusive entity; atherosclerotic risk factors such as DM, HTN, HL, hyperhomocysteinemia 2 or viral infections 3 have been reported in association. This type of palsy seems to be more frequent in children and can be recurrent in nature. In adults, the most likely cause of ISNP seems to be ischemic mononeuropathy or more aggressive etiologies such as temporal arteritis 4. Inconclusive images prove even a higher diagnostic challenge 3. Of note, we found a case demonstrating evidence for Eicosapentaenoic Acid in the improvement of ISNP with recovery in as shortly as 8 weeks. The basis of this treatment lies in the recovery of endothelial function focusing on the anti-platelet and anti-inflammatory effects of the drug2,4. REFERENCES (1). Elder, Christopher, et al. “Isolated abducens nerve palsy: update on evaluation and diagnosis.” Current neurology and neuroscience reports 16.8 (2016): 69. (2). Takenouchi, Yasuhiro, et al. “Eicosapentaenoic acid ethyl ester improves endothelial dysfunction in type 2 diabetic mice.” Lipids in health and disease 17.1 (2018): 118. (3). Azarmina, Mohsen, and Hossein Azarmina. “The six syndromes of the sixth cranial nerve.” Journal of ophthalmic & vision research 8.2 (2013): 160. (4). Yanai, Hidekatsu, and Mariko Hakoshima. “Eicosapentaenoic Acid for Diabetic Abducens Nerve Palsy.” Journal of Endocrinology and Metabolism 7.4 (2017): 131–132.

scholarly journals Opthalmoplegic Migrane with Recurrent Sixth Nerve Palsy: A Rare Presentation of Headache in a Young Lady

1970 ◽  
Vol 10 (2) ◽  
pp. 139-141
Author(s):  
Monzurul H Chowdhury ◽  
Zannatun Nur ◽  
Hosne Ara Begum ◽  
Md Shahriar Mahbub ◽  
HAM Nazmul Ahasan
Keyword(s):  
Nerve Palsy ◽  
Cranial Nerves ◽  
Abducens Nerve ◽  
Young Lady ◽  
Double Vision ◽  
Rare Presentation ◽  
Third Nerve Palsy ◽  
Sixth Nerve Palsy ◽  
The Right ◽  
Sixth Nerve

Migraine is a common presentation of headache but migraine with opthalmoplegia with third nerve palsy is rare and with fourth or sixth nerve palsy is very rare. Although it represents a benign course, duration and severity are variable among the patients. We demonstrated a young lady presenting with right hemicranial headache for 12 days with several episodes of vomiting. She also complained of double vision for 7 days. The headache started from the inner canthus of right eye and gradually spread throughout the right half of head over 2 hours and was throbbing in nature. She also complained of double vision from 5th day after onset of headache. Interestingly, she informed similar types of attack for two episodes in last 1 year which persisted for around 22-25 days each time. On examination, she appeared ill looking with convergent squint on right lateral gaze. Cranial nerves examinations showed all the cranial nerves were intact except right sixth cranial nerve palsy. Laboratory investigations and neuroimaging were normal. Our case fulfilled the International Classification of Headache Disorders (ICHD II) criteria for opthalmoplegic migraine with recurrent six nerve palsy which responded dramatically with prednisolone therapy 1mg/kg/day which also prevented recurrence within 6 months. Keyword: Migraine, Opthalmoplegic migraine, Abducens nerve palsy.   doi: 10.3329/jom.v10i2.2833   J MEDICINE 2009; 10 : 139-141

scholarly journals The right eye abducens nerve palsy as a cranial neuropathy of dengue fever: The benefit of corticosteroids in an unusual dengue sequela

2019 ◽  
Vol 1 (2) ◽  
pp. 145-151
Author(s):  
Mohd Khairul Bin Abd Majid
Keyword(s):  
Dengue Fever ◽  
Nerve Palsy ◽  
Abducens Nerve ◽  
Acute Onset ◽  
Favourable Outcome ◽  
Abducens Nerve Palsy ◽  
Oral Steroid ◽  
Cranial Neuropathy ◽  
Systemic Corticosteroids ◽  
The Right

Dengue fever is very common in tropical climate countries and the number of reported cases in Malaysia shows an increasing trend recently, according to the Malaysian Clinical Practice Guidelines. Although dengue fever is common, cranial nerve mononeuropathy is a very rare manifestation in relation to other neurological-associated syndromes. We report a rare case of cranial mononeuropathy of dengue fever in Malaysia and highlight the option of steroid usage as an alternative treatment to hasten the neurological recovery. The patient, a 25-year-old healthy policeman, presented with symptomatic viral fever, which was serologically confirmed as dengue fever. He developed acute-onset binocular diplopia, which was secondary to right eye isolated abducens nerve palsy during the critical phase of dengue fever. His visual acuity was 6/6 in both eyes with slightly restricted abduction of the right eye, consistent with right abducens nerve palsy, which was confirmed with a Hess test. There was corresponding diplopia over the right paracentral visual field. Urgent contrasted brain imaging was done, which ruled out the life-threatening intracranial pathology; therefore, a diagnosis of possible subclinical inflammatory changes causing sixth nerve palsy was made. Subsequently, he was treated with intravenous methylprednisolone 500 mg daily for 3 days and regained full extraocular muscle movement after 1 week. Oral steroid was not initiated. In conclusion, although the isolated unilateral cranial mononeuropathy may improve spontaneously within a certain period of time, a short course of systemic corticosteroids may be considered to hasten the recovery, as it has a favourable outcome.

scholarly journals The diagnostic dilemma of a pregnant woman presenting with an isolated sixth nerve palsy: A case report

2019 ◽  
Vol 13 (4) ◽  
pp. 195-197
Author(s):  
Nithya Rengaraj ◽  
Anish Keepanasseril ◽  
Gowri Dorairajan ◽  
Murali Subbaiah ◽  
Pradeep P Nair ◽  
...  
Keyword(s):  
Case Report ◽  
Pregnant Woman ◽  
Pregnant Women ◽  
Nerve Palsy ◽  
Sinus Thrombosis ◽  
Abducens Nerve ◽  
Cavernous Sinus Thrombosis ◽  
Diagnostic Dilemma ◽  
Sixth Nerve Palsy ◽  
Sixth Nerve

Pregnant women presenting with isolated cranial palsies are uncommon. Isolated sixth nerve (abducens nerve) palsy can occur for a variety of reasons and neuroimaging is often performed to identify an underlying cause. We report a case of a woman in her third pregnancy with preeclampsia who presented with an isolated sixth nerve palsy. The diagnosis of aseptic cavernous sinus thrombosis was made and she subsequently made a full recovery.

scholarly journals Eicosapentaenoic Acid for Diabetic Abducens Nerve Palsy

2017 ◽  
Vol 7 (4) ◽  
pp. 131-132
Author(s):  
Hidekatsu Yanai ◽  
Mariko Hakoshima
Keyword(s):  
Eicosapentaenoic Acid ◽  
Nerve Palsy ◽  
Abducens Nerve ◽  
Abducens Nerve Palsy

Recurrent Isolated Sixth Nerve Palsy in Childhood—Review on a Rare Phenomenon

2022 ◽  
Author(s):  
Sandra D. K. Kingma ◽  
Berten Ceulemans
Keyword(s):  
Rare Case ◽  
Nerve Palsy ◽  
Pediatric Patients ◽  
Abducens Nerve ◽  
Extensive Investigation ◽  
Increased Intracranial Pressure ◽  
Young Females ◽  
Sixth Nerve Palsy ◽  
Rare Case Report ◽  
Sixth Nerve

AbstractSixth nerve palsy is an ominous sign in pediatric neurology. Due to the long and tortuous course of the sixth (abducens) nerve, it is generally considered a sign of intracranial pathology. Sixth nerve palsy is associated with increased intracranial pressure and neoplasms, among other less frequent causes. In ∼5 to 15% of cases, no cause can be identified. These cases are classified as idiopathic or “benign” and recovery is typically complete. A recurrence of symptoms is very rare. We provide a rare case report of recurrent benign sixth nerve palsy in a 5-year-old child. In addition, we provide an overview of all earlier published cases of recurrent isolated sixth nerve palsy. To date, only 72 pediatric patients with recurrent isolated sixth nerve palsy have been reported. Young females with left-sided sixth nerve palsy and recent immunization are at risk of recurrence. Pathophysiological mechanisms have been discussed, but have yet to be clarified. Recurrent isolated sixth nerve palsy is only rarely associated with severe causes and the need for extensive investigation may be questioned.

scholarly journals Abducens Nerve Palsy as the First Manifestation of Type Two Diabetes Mellitus

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A362-A363
Author(s):  
Amira Ibrahim ◽  
Victoria Loseva
Keyword(s):  
Diabetes Mellitus ◽  
Emergency Department ◽  
Cranial Nerve ◽  
Cranial Nerve Palsy ◽  
Nerve Palsy ◽  
Reference Range ◽  
Abducens Nerve ◽  
Abducens Nerve Palsy ◽  
Double Vision ◽  
Sixth Cranial Nerve

Abstract Introduction: Diabetes mellitus has varied presentations at different times from onset. One of the uncommon presentations is cranial nerve palsy secondary to microvascular ischemia. Approximately 20% of isolated abducens nerve palsies are secondary to vascular microangiopathy. Clinical Case: A 53-year-old female with no significant past medical history presented to the emergency department with concerns of double vision. The patient first noticed her symptoms five days prior to presentation. The patient endorsed blurry vision and stated that she has double vision in certain gazes that resolves with shutting either eye. Furthermore, she has also developed headaches during that period, described as a pressure-like sensation in her forehead and behind her eyes. She otherwise denied any tearing, redness, or pain. On review of systems, she denied numbness, tingling, changes in hearing, changes in speech, or extremity weakness. Due to the persistence of symptoms the patient presented to the emergency department. On exam, the patient’s vitals were normal. Pupils were equal and briskly reactive to light with no relative afferent pupillary defect. External examination was unremarkable without scalp tenderness, proptosis, or ptosis. Color vision was intact. Ocular motility testing revealed limited abduction of the left eye causing double vision on lateral gaze. Confrontation visual fields were full in each eye. Bilateral lower extremity exam revealed decreased sensation in the sole of the foot. The rest of the physical exam was unremarkable. Laboratory work revealed blood glucose level of 305 mg/dl (Reference range 70–99 mg/dl). HBA1C was 12.3% (Reference range 3.8–5.6%). CT head and CTA of the neck was performed and were unremarkable. Given the normal imaging and findings on examinations, her ocular motor findings were attributed to diabetes mellitus. The patient was started on insulin, aspirin, and received diabetic education for lifestyle modification, and was scheduled for outpatient follow up. The patient’s acute isolated left sixth cranial nerve palsy was most likely owing to microvascular ischemia from previously undiagnosed diabetes mellitus. A study of 59 patients with an isolated sixth cranial nerve palsy showed a 6-fold increase in the odds of having diabetes compared with controls.(1) Conclusion: Given the infrequent presentation of Diabetes with Abducens nerve palsy, diagnosis is usually delayed with the expense of ordering costly investigations that put a financial and psychological burden on patients. Thus, we urge clinicians’ awareness when encountering cases of isolated cranial nerve palsies. References: 1) Sanders SK, Kawasaki A, Purvin VA. Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol. 2002;134(1):81–84.

Differential Diagnosis of Acquired Esotropia in the Elderly

2020 ◽  
Vol 237 (09) ◽  
pp. 1107-1116
Author(s):  
Bettina Roggenkämper ◽  
Antje Neugebauer ◽  
Julia Fricke ◽  
Andrea M. Hedergott
Keyword(s):  
Nerve Palsy ◽  
Abducens Nerve ◽  
The Elderly ◽  
Sudden Onset ◽  
Neurological Symptoms ◽  
Abducens Nerve Palsy ◽  
Double Vision ◽  
Unaffected Side ◽  
Primary Position ◽  
The Individual

Abstract Aim To provide an overview of the differential diagnoses of acquired esotropia that occur in the elderly and to facilitate their differentiation in everyday clinical practice. Methods The data of all patients who presented in our outpatient university department for strabology and neuroophthalmology from March 2014 to October 2015 due to esotropia with diplopia with onset after age 50 were evaluated retrospectively. Exclusion criteria were a known strabismus before the age of 50 and/or vertical deviations in the primary position. Anamnestic characteristics, accompanying findings and orthoptic parameters, were analysed. Results 85 patients were included in the study, 42 of them female and 43 male. The following diagnoses were made: abducens nerve palsy (n = 34, 3 of them both sides), esotropia due to myopia magna (n = 12), esotropia with accompanying neurological symptoms (n = 6) and other etiology (n = 5). In 4 cases, the diagnosis was still unclear at the end of the study. In 24 patients, none of the above diagnoses existed and the diagnosis of “sagging eye syndrome” (ETSAG) was made. The abducens nerve palsy typically showed a sudden onset of double vision, slowed abduction saccades and asymmetrical abduction ability. With unilateral abducens nerve palsy, the esotropia increased continuously from the view to the unaffected side through the primary position to the view to the affected side. Patients with ETSAG and myopia-associated esotropia, on the other hand, reported a gradual onset of double vision, showed normal abduction saccades and a slightly reduced abduction ability. The squint angle often increased slightly to both sides. Esotropia with accompanying neurological symptoms was rare and was seen in various underlying diseases. Conclusions The kind of onset of the double vision, the quality of the saccades, the incomitance pattern and the ability to abduct are important parameters for the etiological assignment of an esotropia in the elderly. The characteristics of the individual diagnoses are described and differential diagnostic aspects are discussed.

scholarly journals A rare presentation of isolated sixth nerve palsy as dolichoectasia of vertebral artery

2021 ◽  
Vol 11 (4) ◽  
pp. 121-123
Author(s):  
Lim Wei Juan
Keyword(s):  
Vertebral Artery ◽  
Nerve Palsy ◽  
Abducens Nerve ◽  
Rare Presentation ◽  
Significant Deterioration ◽  
Lentiform Nucleus ◽  
Sixth Nerve Palsy ◽  
Vertebrobasilar Dolichoectasia ◽  
Ct Brain ◽  
Sixth Nerve

Vertebrobasilar dolichoectasia is a condition where the vertebral arteries are dilated, elongated and distorted, causing significant deterioration of tunica intima. The most common causes of sixth nerve palsy include infection, stroke, brain tumour and injury. We reported a case of a 56-year-old man with underlying of diabetes mellitus and hypertension who presented with diplopia over his left gaze. There are no other associated neurology signs. Computed tomography (CT) brain showed well-defined hypodensities at right lentiform nucleus and brain magnetic resonance angiography (MRA) showed impingement of V4 vertebral artery to anterior lower pons near midline which is the exit of the left abducens nerve from the pons. This case illustrated the importance to investigate thoroughly the causes of sixth cranial nerve palsy.

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