Elsevier

Ophthalmology

Volume 109, Issue 7, July 2002, Pages 1315-1325
Ophthalmology

Vertical misalignment in unilateral sixth nerve palsy1 Historical image,

https://doi.org/10.1016/S0161-6420(02)01067-9Get rights and content

Abstract

Objective

To detect and determine the magnitude of vertical deviation in patients with unilateral sixth nerve palsy.

Design

Prospective consecutive comparative case series.

Participants

Twenty patients with unilateral peripheral sixth nerve palsy, 7 patients with central palsy caused by brainstem lesions, and 10 normal subjects.

Methods

Subjects were tested by the prism and cover test, Maddox rod and prism test, and magnetic search coil recordings in nine diagnostic eye positions. They were also tested during static lateral head tilt by the prism and cover, and Maddox rod and prism tests.

Main outcome measures

The magnitudes of horizontal and vertical deviations.

Results

All patients had an abduction deficit and incomitant esodeviation that increased in the field of action of the paretic muscle, indicating sixth nerve palsy. Mean vertical deviations, for all positions of gaze in peripheral palsy were 0.3 ± 0.8 prism diopters (PD) by prism and cover test, 1.3 ± 1.6 PD by Maddox rod and prism test, and 2.0 ± 1.4 PD by coil recordings. Mean vertical deviations in normal subjects were 0.0 ± 0.0 PD by prism and cover test, 1.0 ± 0.9 PD by Maddox rod and prism test, and 1.9 ± 2.1 PD by coil recordings. Therefore, peripheral palsy did not cause abnormal vertical deviation. In central palsy, for all positions together mean vertical deviations were 0.9 ± 1.3 PD by prism and cover test, 1.4 ± 1.6 PD by Maddox rod and prism test, and 2.5 ± 1.6 PD by coil recordings; they were not different from normal values. During static head roll, patients with peripheral palsy had a right hyperdeviation on right head tilt and a left hyperdeviation on left head tilt, regardless of the side of the palsy. In contrast, in central palsy, head tilt caused vertical strabismus that remained on the same side on head tilt to either side.

Conclusions

Small vertical deviations in sixth nerve palsy are consistent with normal hyperphorias that become manifest in the presence of esotropia. In peripheral sixth nerve palsy, static head roll to either side induces hyperdeviation in the eye on the side of the head tilt. Hyperdeviation of the same eye induced by head tilt to either direction implicates a brainstem lesion as the cause of paretic abduction. Quantitative study of sixth nerve palsy demonstrates that if a vertical deviation falls within the normal range of hyperphoria, multiple cranial nerve palsy or skew deviation may not be responsible. Conversely, vertical deviation > 5 PD indicates skew deviation or peripheral nerve palsy in addition to abduction palsy.

Section snippets

Material and methods

Twenty-seven consecutive patients with unilateral sixth nerve palsy were recruited from the Neuro-ophthalmology Unit at the University Health Network, Toronto, Ontario, Canada. A complete history was taken, and detailed ophthalmic and neurologic examinations were performed. The age of onset, the presence or absence of risk factors for ischemia (diabetes mellitus and hypertension), duration of diplopia, range of duction, horizontal and vertical deviations (see Orthoptic Assessment ), and

General characteristics of patients

Twenty patients had peripheral palsy caused by an idiopathic, presumed ischemic, peripheral lesion (Table 1). The mean age was 61 ± 14 years (age range, 21–77 years; median age, 64 years); 11 of them were men. The duration of symptoms ranged from 2 weeks to 96 months, with a mean duration of 20 ± 17 months. Mean follow-up duration was 10 months (range, 8–22 months). Fourteen had normal MR imaging and six had normal CT scanning of the brain. Five of the six patients with normal CT scan had

Discussion

Information about vertical strabismus in sixth nerve palsy is sparse. Kestenbaum1 stated that “in abducens paresis a vertical component is sometimes found,” and this slight vertical component can be up to 3 diopters before one can conclude that a vertical muscle is involved pathologically.1 Smith2 cited Dr. F. Walsh, stating that “one could accept up to 2 to 3 prism diopters of vertical deviation with a VI nerve palsy alone, but any amount more than that was significant.”2 They1, 2 did not

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    Supported by the E. A. Baker Foundation (Canadian National Institute for the Blind Toronto, Canada), the Visual Science Research Program (University of Toronto, Ontario, Canada), and Canadian Institutes of Health Research Ottawa, Canada (Grants MT 15362 and ME 5504).

    1

    The authors have no commercial interests in any products described in this article.

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