Background: Traditionally, eyecare providers employ a wait-and-see approach with respect to older patients presenting with a presumed vasculopathic isolated sixth nerve palsy. However, given review of recent literature and the potential of morbidity in these patients, acute neuroimaging should be strongly considered. Eyecare providers are often faced with challenging decisions when patients present with acute isolated oculomotor nerve palsies. This case highlights the diagnostic dilemma of an older patient with significant vasculopathic risk factors who presents with an isolated sixth nerve palsy. For patients older than 50, a vasculopathic etiology is the most likely cause, however, a small but significant percentage of these patients may suffer from a more ominous condition such as, giant cell arteritis, intracranial mass, or aneurysm. As evidenced by our case, acute neuro imaging should be considered in all isolated sixth nerve palsies.
Case Report: A 69- year old Caucasian male presented to the VA Connecticut Healthcare System with new onset diplopia. The patient reported a recent history of mild orbital pain and headaches. Evaluation revealed an isolated left sixth nerve palsy. A microvascular etiology was presumed given his strong vasculopathic history. One week later the patient returned to clinic with a new left pupil-sparing third nerve palsy in addition to his original left sixth nerve palsy. Magnetic resonance imaging of the brain and orbits with and without contrast revealed a left cavernous sinus mass. The patient was transferred to the Smilow Cancer Hospital at Yale-New Haven and received gamma knife radiosurgery for the presumed neoplastic lesion.
Conclusion: Although support can be made for both a “wait-and-see” approach and acute diagnostic imaging, our case highlights the benefits of early imaging. Appropriate acute neuro imaging in patients with presenting isolated sixth nerve palsies can be lifesaving.
Seropositive Muscle-Specific Tyrosine Kinase Myasthenia Gravis Presenting as a Late-Onset Isolated Sixth Nerve Palsy: A Case Report and a Brief Review of Subtypes of Myasthenia Gravis
