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
- Clinical Professor of Ophthalmology
- UTMB Galveston
- Clinical Professor of Ophthalmology
- UT MD Anderson Cancer Center Houston
- Adjunct Professor of Ophthalmology
- Baylor College of Medicine and
- 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.
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