Recurrent Benign Sixth Nerve Palsy
A young patient presented with acute onset of crossed eyes and diplopia. He reported no associated vision changes in either eye. His examination revealed right eye esotropia of 6 prism diopters (PD) in primary gaze, 14 PD in right gaze, and 4 PD in left gaze. The right eye exhibited a -2 limitation in abduction, without globe retraction in any gaze. His visual acuity and intraocular pressure were normal for his age, and both the anterior and posterior segments were normal on examination. Prior to this presentation, the patient had experienced three similar episodes, each resolving spontaneously within 5 to 6 weeks. A brain MRI and MRA conducted at an outside hospital during his first episode were normal. He was followed up in the clinic. Over the next four years, he had six more episodes, all of which resolved spontaneously. He had two additional brain MRIs, both of which were negative. After a seven-year period without recurrence, he experienced similar symptoms two weeks after receiving the COVID-19 vaccine, marking his 11th episode. A brain and orbital MRI were normal, and lab tests for myasthenia gravis were also normal. He was treated temporarily with a Fresnel prism to alleviate diplopia. However, this time, his diplopia and 6th nerve palsy did not resolve spontaneously, and his esodeviation worsened over a two-year period. Strabismus surgery with superior rectus transposition and medial rectus recession was performed. His esotropia was corrected by the procedure, and he had no diplopia post-operatively other than extreme right gaze and resolution of his anomalous head posture. The patient is currently being followed up in the clinic.
Presentation Date: 09/05/2024
Issue Date: 09/25/2024
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