Skip to main content

Sixth Nerve Palsy

  • 337 Accesses

Abstract

Sixth nerve palsy is the most frequent isolated ocular motor nerve palsy, and causes can range from self-limiting to life threatening. The management of these cases, including neuroimaging and further diagnostic testing, can be tailored according to the history, presentation, and clinical course. Specifically, the age of the patient; medical history including the presence of microvascular risk factors, known cancer (past or present), or recent trauma; timing of onset and progression of symptoms; and presence of other neurologic signs or symptoms should be considered when determining the need for neuroimaging. When neuroimaging is deemed appropriate, MRI of the brain and orbits with gadolinium should be performed, with inclusion of high-resolution skull base imaging for better visualization of the cranial nerves whenever possible. Further evaluation with serum and cerebrospinal fluid laboratory testing may be needed in some cases.

Keywords

  • Sixth nerve palsy
  • Abducens palsy
  • Neuroimaging
  • Magnetic resonance imaging (MRI)

This is a preview of subscription content, access via your institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • DOI: 10.1007/978-3-030-74103-7_13
  • Chapter length: 10 pages
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
eBook
USD   89.00
Price excludes VAT (USA)
  • ISBN: 978-3-030-74103-7
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
Softcover Book
USD   119.99
Price excludes VAT (USA)
Hardcover Book
USD   169.99
Price excludes VAT (USA)

References

  1. Rucker CW. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol. 1966;61(5):1293–8. https://doi.org/10.1016/0002-9394(66)90258-3.

    CAS  CrossRef  PubMed  Google Scholar 

  2. Park UC, Kim SJ, Hwang JM, Yu YS. Clinical features and natural history of acquired third, fourth, and sixth cranial nerve palsy. Eye (Lond). 2008;22(5):691–6. https://doi.org/10.1038/sj.eye.6702720.

    CrossRef  Google Scholar 

  3. Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol. 1981;99(1):76–9.

    CAS  CrossRef  Google Scholar 

  4. Richards BW, Jones FR, Younge BR. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol.1992;113(5):489–96. https://doi.org/10.1016/s0002-9394(14)74718-x.

    CAS  CrossRef  PubMed  Google Scholar 

  5. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Incidence, associations, and evaluation of sixth nerve palsy using a population-based method. Ophthalmology. 2004;111(2):369–75. https://doi.org/10.1016/j.ophtha.2003.05.024.

    CrossRef  PubMed  Google Scholar 

  6. Bendszus M, Beck A, Koltzenburg M, Vince GH, Brechtelsbauer D, Littan T, Urbach H, Solymosi L. MRI in isolated sixth nerve palsies. Neuroradiology. 2001;43(9):742–5.

    CAS  CrossRef  Google Scholar 

  7. Chou KL, Galetta SL, Liu GT, Volpe NJ, Bennett JL, Asbury AK, Balcer LJ. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci. 2004;219(1–2):35–9. https://doi.org/10.1016/j.jns.2003.12.003.

    CrossRef  PubMed  Google Scholar 

  8. Nair AG, Ambika S, Noronha VO, Gandhi RA. The diagnostic yield of neuroimaging in sixth nerve palsy–Sankara Nethralaya Abducens Palsy Study (SNAPS): report 1. Indian J Ophthalmol. 2014;62(10):1008–12. https://doi.org/10.4103/0301-4738.146000.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  9. Peters GB, Bakri SJ, Krohel GB. Cause and prognosis of nontraumatic sixth nerve palsies in young adults. Ophthalmology. 2002;109:1925–8.

    CrossRef  Google Scholar 

  10. Miller RW, Lee AG, Schiffman JS, Prager TC, Garza R, Jenkins PF, Sforza P, Verm A, Kaufman D, Robinson W, Eggenberger E, Tang RA. A practice pathway for the initial diagnostic evaluation of isolated sixth cranial nerve palsies. Med Decis Mak. 1999;19(1):42–8.

    CAS  CrossRef  Google Scholar 

  11. Tamhankar MA, Biousse V, Ying GS, Prasad S, Subramanian PS, Lee MS, Eggenberger E, Moss HE, Pineles S, Bennett J, Osborne B, Volpe NJ, Liu GT, Bruce BB, Newman NJ, Galetta SL, Balcer LJ. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology. 2013;120(11):2264–9. https://doi.org/10.1016/j.ophtha.2013.04.009.

    CrossRef  PubMed  Google Scholar 

  12. Warwar RE, Bhullar SS, Pelstring RJ, Fadell RJ. Sudden death from pituitary apoplexy in a patient presenting with an isolated sixth cranial nerve palsy. J Neuroophthalmol. 2006;26(2):95–7.

    CrossRef  Google Scholar 

  13. Chrousos GA, Dipaolo F, Kattah JC, Laws ER. Paresis of the abducens nerve after trivial head injury. Am J Ophthalmol. 1993;116(3):387–8. https://doi.org/10.1016/s0002-9394(14)71368-6.

  14. Robertson DM, Hines JD, Rucker CW. Acquired sixth-nerve paresis in children. Arch Ophthalmol. 1970;83(5):574–9.

    CAS  CrossRef  Google Scholar 

  15. Lepore FE. False and non-localizing signs in neuro-ophthalmology. Curr Opin Ophthalmol. 2002;13(6):371–4.

    CrossRef  Google Scholar 

  16. Durkin SR, Tennekoon S, Kleinschmidt A, Casson RJ, Selva D, Crompton JL. Bilateral sixth nerve palsy. Ophthalmology. 2006;113(11):2108–9. https://doi.org/10.1016/j.ophtha.2006.06.026.

    CrossRef  PubMed  Google Scholar 

  17. Sanders SK, Kawasaki A, Purvin VA. Long-term prognosis in patients with vasculopathic sixth nerve palsy. Am J Ophthalmol. 2002;134(1):81–4.

    CrossRef  Google Scholar 

  18. Teuscher AU, Meienberg O. Ischaemic oculomotor nerve palsy. Clinical features and vascular risk factors in 23 patients. J Neurol. 1985;232(3):144–9.

    CAS  CrossRef  Google Scholar 

  19. Chan JW, Albretson J. Causes of isolated recurrent ipsilateral sixth nerve palsies in older adults: a case series and review of the literature. Clin Ophthalmol. 2015;9:373–7. https://doi.org/10.2147/OPTH.S78319.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  20. Volpe NJ, Lessell S. Remitting sixth nerve palsy in skull base tumors. Arch Ophthalmol. 1993;111(10):1391–5.

    CAS  CrossRef  Google Scholar 

  21. King AJ, Stacey E, Stephenson G, Trimble RB. Spontaneous recovery rates for unilateral sixth nerve palsies. Eye (Lond). 1995;9(4):476–8.

    CrossRef  Google Scholar 

  22. Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor nerve palsies. Arch Ophthalmol. 1994;112(7):961–6.

    CAS  CrossRef  Google Scholar 

  23. Patel SV, Holmes JM, Hodge DO, Burke JP. Diabetes and hypertension in isolated sixth nerve palsy: a population-based study. Ophthalmology. 2005;112(5):760–3. https://doi.org/10.1016/j.ophtha.2004.11.057.

    CrossRef  PubMed  Google Scholar 

  24. Jacobson DM. Progressive Ophthalmoplegia with acute ischemic abducens nerve palsies. Am J Ophthalmol. 1996;122(2):278–9. https://doi.org/10.1016/s0002-9394(14)72029-x.

    CAS  CrossRef  PubMed  Google Scholar 

  25. Simha A, Irodi A, David S. Magnetic resonance imaging for the ophthalmologist: a primer. Indian J Ophthalmol. 2012;60(4):301–10. https://doi.org/10.4103/0301-4738.98711.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  26. Kontzialis M, Choudhri AF, Patel VR, Subramanian PS, Ishii M, Gallia GL, Aygun N, Blitz AM. High-resolution 3D magnetic resonance imaging of the sixth cranial nerve: anatomic and pathologic considerations by segment. J Neuroophthalmol. 2015;35(4):412–25. https://doi.org/10.1097/WNO.0000000000000313.

    CrossRef  PubMed  Google Scholar 

  27. Yousry I, Camelio S, Schmid UD, Horsfield MA, Wiesmann M, Brückmann H, Yousry TA. Visualization of cranial nerves I-XII: value of 3D CISS and T2-weighted FSE sequences. Eur Radiol. 2000;10(7):1061–7.

    CAS  CrossRef  Google Scholar 

  28. Yagi A, Sato N, Taketomi A, Nakajima T, Morita H, Koyama Y, Aoki J, Endo K. Normal cranial nerves in the cavernous sinuses: contrast-enhanced three-dimensional constructive interference in the steady state MR imaging. AJNR Am J Neuroradiol. 2005;26(4):946–50.

    PubMed  PubMed Central  Google Scholar 

  29. Galetta SL, Smith JL. Chronic isolated sixth nerve palsies. Arch Neurol. 1989;46(1):79–82.

    CAS  CrossRef  Google Scholar 

  30. Moster ML, Savino PJ, Sergott RC, Bosley TM, Schatz NJ. Isolated sixth-nerve palsies in younger adults. Arch Ophthalmol. 1984;102(9):1328–30.

    CAS  CrossRef  Google Scholar 

  31. Sakalas R, Harbison JW, Vines FS, Becker DP. Chronic sixth nerve palsy. An initial sign of basisphenoid tumors. Arch Ophthalmol. 1975;93(3):186–90.

    CAS  CrossRef  Google Scholar 

  32. Savino PJ, Hilliker JK, Casell GH, Schatz NJ. Chronic sixth nerve palsies. Are they really harbingers of serious intracranial disease? Arch Ophthalmol. 1982;100(9):1442–4.

    CAS  CrossRef  Google Scholar 

  33. Shrader EC, Schlezinger NS. Neuro-ophthalmologic evaluation of abducens nerve paralysis. Arch Ophthalmol. 1960;63:84–91.

    CAS  CrossRef  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Amanda D. Henderson .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and Permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Verify currency and authenticity via CrossMark

Cite this chapter

Jeyaseelan, P., Henderson, A.D. (2021). Sixth Nerve Palsy. In: Henderson, A.D., Carey, A.R. (eds) Controversies in Neuro-Ophthalmic Management. Springer, Cham. https://doi.org/10.1007/978-3-030-74103-7_13

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-74103-7_13

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-74102-0

  • Online ISBN: 978-3-030-74103-7

  • eBook Packages: MedicineMedicine (R0)