Abnormal ocular alignment frequently results from damage to the intranuclear portion of the gaze system, including: cranial nerves (CN) III (oculomotor), IV (trochlear), and VI (
abducens), or the myoneural junction or extraocular muscles they innervate.
She was conscious and cooperating, and the results of her system examination were normal, except for the right
abducens nerve paralysis.
Associated symptoms of transient visual changes, pulsatile tinnitus, neck and back pain, nausea, vomiting, photo/ phonophobia, and findings of
abducens nerve palsy or papilledema--while nonspecific--should raise suspicion for elevated ICP and IIH, especially in women who are obese.
In neurological status, a lag of the left eye on upward gaze, right
abducens paresis, horizontal nystagmus on vertical gaze, vertical nystagmus on upward gaze, and diplopia in all directions of gaze, as well as truncal ataxia were observed.
Anatomically [Figure 1], the SOF, which is a pear-shaped structure with the broadest part at the nasal side, is bound laterally by the greater wing of the sphenoid, medially by the lesser wing of sphenoid, and superiorly by the frontal bone, lying at the apex of the orbit and at the border between the roof and the lateral orbital wall.[10] The SOF serves as a pathway that allows communication between the orbit and the middle cranial fossa, thereby transmitting the oculomotor, trochlear, and
abducens nerves (cranial nerves III, IV, and VI), as well as the first three branches of the trigeminal nerve: the frontal, lacrimal, and nasociliary nerves.[11]{Figure 1}
In most cases, the patients are females, and present with orthostatic headaches, as well as nausea, vomiting and even
abducens cranial nerve palsies.
Three cranial nerves carry motor impulses from the brain to the eyeball muscles: 1) oculomotor (cranial nerve III); 2) trochlear (cranial nerve IV); and, 3)
abducens (cranial nerve VI) (Cohen and Hull, 2016).
A probable diagnosis can be made if papilledema is not present but there
abducens nerve palsy.
* Cranial neuropathies must be excluded: optic >
abducens > trigeminal > oculomotor > trochlear, [9] as these may be indicative of invasive disease, and would warrant urgent referral.
Kuehne, "
Abducens nerve palsy in spontaneous intracranial hypotension," Neurology, vol.
