Sixth cranial nerve (abducens nerve) palsy in children
- Andrew G Lee, MD
Andrew G Lee, MD
- Professor of Ophthalmology, Neurology, and Neurological Surgery
- Weill Cornell College of Medicine
- Paul W Brazis, MD
Paul W Brazis, MD
- Section Editor — Neuroophthalmology
- Professor of Neurology, Department of Ophthalmology
- Mayo Clinic College of Medicine
- Section Editors
- Evelyn A Paysse, MD
Evelyn A Paysse, MD
- Section Editor — Pediatric Ophthalmology
- Professor of Ophthalmology and Pediatrics
- Baylor College of Medicine
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Chief of Neurology
- Children’s Hospital Los Angeles
- Vice Chair of Neurology
- USC Keck School of Medicine
Dysfunction of the sixth cranial nerve (abducens nerve) can result from lesions occurring anywhere along its path between the sixth nucleus in the dorsal pons and the lateral rectus muscle within the orbit. The lesions can be congenital or acquired (table 1).
The manifestations and diagnosis of sixth nerve palsy, also known as lateral rectus palsy and abducens nerve palsy, are reviewed here. Palsies of the third and fourth cranial nerves are discussed separately. (See "Third cranial nerve (oculomotor nerve) palsy in children" and "Fourth cranial nerve (trochlear nerve) palsy in children".)
Each sixth nerve nucleus in the dorsal pons contains all of the neurons responsible for ipsilateral horizontal gaze. They include the motor neurons for the ipsilateral lateral rectus muscle and the interneurons to the contralateral third nerve medial rectus muscle subnucleus in the midbrain. The interneurons travel through the medial longitudinal fasciculus to the contralateral third nerve subnucleus.
The sixth nerve fascicle leaves the nucleus and travels within the substance of the pontine tegmentum, adjacent to the medial lemniscus and adjacent to the corticospinal tract. It leaves the brainstem at the pontomedullary junction, enters the subarachnoid space (prepontine cistern), courses nearly vertically along the clivus, and travels over the petrous apex of the temporal bone where it is tethered at the petroclinoid ligament in Dorello canal. It enters the substance of the cavernous sinus lateral to the internal carotid artery and medial to the ophthalmic division of the trigeminal nerve. The sixth nerve enters the orbit via the superior orbital fissure to innervate the lateral rectus muscle, which abducts the eye (table 2) .
Patients with sixth nerve palsies typically complain of binocular (ie, requires both eyes to be open) horizontal diplopia that worsens with gaze toward the paretic lateral rectus muscle. However, children may not complain of diplopia.
Subscribers log in hereLiterature review current through: Oct 2017. | This topic last updated: Jun 08, 2017.References
- Lee MS, Galetta SL, Volpe NJ, Liu GT. Sixth nerve palsies in children. Pediatr Neurol 1999; 20:49.
- Currie J, Lubin JH, Lessell S. Chronic isolated abducens paresis from tumors at the base of the brain. Arch Neurol 1983; 40:226.
- Dumas S, Shults WT. Abducens paresis. A rare presenting sign of posterior-inferior cerebellar artery aneurysm. J Clin Neuroophthalmol 1982; 2:55.
- Gurinsky JS, Quencer RM, Post MJ. Sixth nerve ophthalmoplegia secondary to a cavernous sinus lesion. J Clin Neuroophthalmol 1983; 3:277.
- Moster ML, Savino PJ, Sergott RC, et al. Isolated sixth-nerve palsies in younger adults. Arch Ophthalmol 1984; 102:1328.
- RUCKER CW. Paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1958; 46:787.
- Rucker CW. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1966; 61:1293.
- Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol 1981; 99:76.
- Rosenberg ML. Spasm of the near reflex mimicking myasthenia gravis. J Clin Neuroophthalmol 1986; 6:106.
- Nirankari VS, Hameroff SB. Spasm of the near reflex. Ann Ophthalmol 1980; 12:1050.
- Griffin JF, Wray SH, Anderson DP. Misdiagnosis of spasm of the near reflex. Neurology 1976; 26:1018.
- Goldstein JH, Schneekloth BB. Spasm of the near reflex: a spectrum of anomalies. Surv Ophthalmol 1996; 40:269.
- Galetta SL, Smith JL. Chronic isolated sixth nerve palsies. Arch Neurol 1989; 46:79.
- Savino PJ, Hilliker JK, Casell GH, Schatz NJ. Chronic sixth nerve palsies. Are they really harbingers of serious intracranial disease? Arch Ophthalmol 1982; 100:1442.
- Kim JH, Hwang JM, Hwang YS, et al. Childhood ocular myasthenia gravis. Ophthalmology 2003; 110:1458.
- Savino PJ. Diplopia and sixth nerve palsies. Semin Neurol 1986; 6:142.
- Werner DB, Savino PJ, Schatz NJ. Benign recurrent sixth nerve palsies in childhood. Secondary to immunization or viral illness. Arch Ophthalmol 1983; 101:607.
- Mutyala S, Holmes JM, Hodge DO, Younge BR. Spontaneous recovery rate in traumatic sixth-nerve palsy. Am J Ophthalmol 1996; 122:898.
- Mahoney NR, Liu GT. Benign recurrent sixth (abducens) nerve palsies in children. Arch Dis Child 2009; 94:394.
- King AJ, Stacey E, Stephenson G, Trimble RB. Spontaneous recovery rates for unilateral sixth nerve palsies. Eye (Lond) 1995; 9 ( Pt 4):476.
- Holmes JM, Beck RW, Kip KE, et al. Botulinum toxin treatment versus conservative management in acute traumatic sixth nerve palsy or paresis. J AAPOS 2000; 4:145.
- Holmes JM, Droste PJ, Beck RW. The natural history of acute traumatic sixth nerve palsy or paresis. J AAPOS 1998; 2:265.
- Holmes JM, Beck RW, Kip KE, et al. Predictors of nonrecovery in acute traumatic sixth nerve palsy and paresis. Ophthalmology 2001; 108:1457.
- Aroichane M, Repka MX. Outcome of sixth nerve palsy or paresis in young children. J Pediatr Ophthalmol Strabismus 1995; 32:152.
- Lee J, Harris S, Cohen J, et al. Results of a prospective randomized trial of botulinum toxin therapy in acute unilateral sixth nerve palsy. J Pediatr Ophthalmol Strabismus 1994; 31:283.
- Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev 2012; :CD006499.
- Repka MX, Lam GC, Morrison NA. The efficacy of botulinum neurotoxin A for the treatment of complete and partially recovered chronic sixth nerve palsy. J Pediatr Ophthalmol Strabismus 1994; 31:79.
- Holmes JM, Leske DA, Christiansen SP. Initial treatment outcomes in chronic sixth nerve palsy. J AAPOS 2001; 5:370.