Long-term prognosis in patients with vasculopathic sixth nerve palsy

doi:10.1016/S0002-9394(02)01439-3

American Journal of Ophthalmology

Volume 134, Issue 1, July 2002, Pages 81-84

https://doi.org/10.1016/S0002-9394(02)01439-3 Get rights and content

Abstract

PURPOSE: To better define the long-term prognosis in patients with a vasculopathic sixth nerve palsy (6NP), specifically addressing the degree of recovery and incidence of recurrent similar episodes.

DESIGN: Observational case series.

METHODS: Retrospective chart review.

SETTING: An outpatient neuroophthalmic practice.

STUDY POPULATION: Patients with one or more vascular risk factors and an acute, isolated 6NP that spontaneously recovered.

OBSERVATION PROCEDURE: Information regarding resolution of the 6NP, subsequent vascular events and recurrent ocular motor nerve palsy was obtained from chart review of follow-up clinic visits, mailed questionnaires and telephone interviews. The duration of follow-up ranged from 2 to 13 years.

MAIN OUTCOME MEASURES: Resolution of 6NP (complete or incomplete) and incidence of recurrent ocular motor nerve palsy.

RESULTS: Fifty-nine patients were identified with a mean age of 65.3 years ± 11.6 (range 34–90 years). Fifty-one patients (86%) experienced complete resolution of their first episode of vasculopathic 6NP and eight patients (14%) had incomplete resolution. A subsequent episode of ocular motor mononeuropathy occurred in 18 of 59 (31%) patients. The number of recurrences ranged from one (in 14 patients) to four (in one patient). There was no association between any risk factor and recurrence of ocular motor nerve palsy. Similarly, incomplete resolution of the vasculopathic 6NP was not associated with any risk factor.

CONCLUSIONS: Patients with a vasculopathic 6NP usually have complete resolution of their ophthalmoplegia, but nearly one third of patients in our study later experienced at least one episode of recurrent vasculopathic ocular motor nerve palsy.

Section snippets

Methods

A diagnosis of vasculopathic 6NP was considered in patients with acute onset of an isolated sixth (abducens) nerve palsy and a history of at least one of the following: age ≥ 50 years, HTN, DM, HCHL, and/or TOB. We used the term “isolated” to indicate that there were no other focal neurologic deficits and no altered sensorium or constitutional symptoms at the time of initial examination. Other causes for 6NP were excluded by history, physical examination, imaging studies, edrophonium test,

Results

For the 59 patients with vasculopathic 6NP for whom follow-up data were collected (Table 1), the mean age was 65.3 years with a standard deviation of 11.6 and a range of 34–90 years (median age 67 years). Thirty-two (54%) of the patients were male and 27 (46%) were female. All but three were Caucasian. The follow-up period was 6.1 years with a range of 2 to 13 years.

Ninety-three percent of patients were over 50 years of age. Forty-two (71%) of the patients had hypertension (HTN), 32 (54%) were

Discussion

The presumed mechanism of vasculopathic ocular motor nerve palsy involves thickening and hyalinization of nutrient vessels, which results in ischemic demyelination of a portion of the nerve. Actual vascular occlusion has not been demonstrated. Decreased perfusion in vascular border zones of the nerve due to transient relative systemic hypotension may also play a role. Following infarction and demyelination of the cranial motor nerve, the area of ischemic demyelination subsequently undergoes

Acknowledgements

We wish to thank the Midwest Eye Foundation for support of this project. We are grateful to Dr. Linda Williams for her assistance in statistical analysis of the data.

References (8)

D.M. Jacobson
Progressive ophthalmoplegia with acute ischemic abducens nerve palsies
Am J Ophthalmol
(1996)
E.C. Schrader et al.
Neuro-ophthalmic evaluation of abducens nerve palsies
Arch Ophthalmol
(1960)
A.U. Teuscher et al.
Ischemic oculomotor nerve palsy. Clinical features and vascular risk factors
J Neurol
(1985)
D.M. Jacobson et al.
Risk factors for ischemic ocular motor nerve palsies
Arch Ophthalmol
(1994)

There are more references available in the full text version of this article.

Cited by (60)

Stroke risk after ocular cranial nerve palsy – A systematic review and meta-analysis
2022, Journal of Clinical Neuroscience
Isolated ischemic ocular cranial nerve palsies (OCNP) involving the 3rd, 4th and 6th cranial nerves (CN) are prevalent conditions in ophthalmic practice. However, it is not clearly established whether such patients are at increased risk of stroke after onset of OCNPs.
Medline, PubMed, Embase and Cochrane Central registers were systematically searched for eligible studies comparing isolated ischemic OCNPs against matched controls on the subsequent development of stroke with at least two years of follow up. Case reports and series were excluded. Appropriate studies were entered for meta-analysis to determine hazard ratios. Search and data extraction was completed on 22 Feb 2021. Random effect models were used to generate pooled hazard ratios (HRs) and 95% confidence intervals (CIs).
Three studies were suitable for meta-analysis (total n = 2,756 OCNP cases and 21,239 matched controls). The meta-analysis demonstrated a hazard ratio of 5.96 (4.20–8.46 95% CI) of subsequent stroke after isolated OCNP within the first year. The hazard ratio reduced to 3.27 (2.61–4.10 95% CI) after five years although remains raised at 2.49 (1.53–4.06 95% CI) up to 12 years. The highest risk was demonstrated with 3rd cranial nerve palsies. Two additional studies assessed the risk of stroke with newly diagnosed diabetics and compared OCNPs against lacunar stroke. These studies did not demonstrate a significant increased risk of stroke, although they may be statistically underpowered.
Ischemic OCNPs represent a significant risk factor for development of subsequent stroke in a similar magnitude to transient ischemic attack within the first year.
Association of Obesity and Incidence of Third, Fourth, and Sixth Cranial Nerve Palsies
2022, American Journal of Ophthalmology
Retrospective cohort study.
To assess the association between obesity and the development of third, fourth, and sixth cranial nerve palsy (CNP).
We analyzed a cohort of 4,067,842 adults aged between 20 and 90 years who underwent health checkups within the National Health Insurance Service between January 1 and December 31, 2009. The participants were followed until December 31, 2017. Cox proportional hazards regression analysis was used to determine the adjusted hazard ratios (HRs) for CNP. Model 3 (the main analysis model) was adjusted for age, sex, smoking status, alcohol consumption, and physical activity. Model 4 was additionally adjusted for hypertension, dyslipidemia, and diabetes mellitus in the setting of model 3.
A total of 5,835 individuals were diagnosed with CNP during the follow-up period (7.3 years). General obesity (body mass index [BMI] ≥25 kg/m²) was associated with an increased risk of CNP compared to individuals without general obesity (model 3, HR 1.248, 95% CI 1.184-1.315; model 4, HR 1.162, 95% CI 1.102-1.227). Abdominal obesity (waist circumference [WC] ≥90 cm in men and ≥85 cm in women) also showed an increased HR compared to individuals without abdominal obesity (model 3, 1.239, 95% CI 1.170-1.313; model 4, HR 1.127, 95% CI 1.062-1.196). Compared to the group without either type of obesity, the group with only abdominal obesity (model 3, HR 1.167, 95% CI 1.035-1.317), the group with only general obesity (HR 1.19, 95% CI 1.14-1.24), and the group with both obesity types (HR 1.317, 95% CI 1.236-1.404) showed increased HRs for CNP.
Based on our population-based cohort study, both general and abdominal obesity increased the risk of CNP. Also, the combination of general and abdominal obesity may further increase the risk of CNP.
Cause of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in patients aged 20 to 50 years in Korea: A high resolution magnetic resonance imaging study
2019, Journal of the Neurological Sciences
Citation Excerpt :
However, non-granulomatous inflammation, such as idiopathic inflammation or bacterial and fungal sphenoid sinusitis, could also cause ocular motor nerve palsy [11–13]. When the inflammation is confined to the cranial nerves, inflammatory neuropathy may be difficult to distinguish from ischemic optic neuropathy [14] and both of them could have benign clinical courses [4,15–18]. Therefore, it is possible that a certain proportion of patients were assigned to the wrong ischemia and inflammation categories or had ischemia and inflammation of a complex nature.
This study aimed to describe the etiologies of acquired onset of diplopia due to isolated third, fourth, and sixth cranial nerve palsies in young adults in Korea.
This retrospective study included 127 patients aged 20 to 50 years with acquired onset isolated third, fourth, and sixth cranial nerve palsies who received care at the Strabismus and Neuro-ophthalmology Department of Samsung Medical Center from 2013 to 2017. The etiologies of the palsies determined by clinical assessment, high-resolution magnetic resonance imaging (MRI) with three-dimensional constructive interference in steady state, and laboratory testing were analyzed.
Fifty-nine patients manifested sixth cranial nerve palsy. Forty-six patients had fourth cranial nerve palsy and 22 patients had third cranial nerve palsy. The most common etiologies of the ocular motor nerve palsies were presumed inflammatory lesions (21.3%), followed by presumed microvascular causes (17.3%), and neoplasms involving the central nervous system (15.7%). Neoplasms were the most common cause of sixth cranial nerve palsy (25.4%). The most common cause of fourth cranial nerve palsy was presumed microvascular ischemia (28.3%), and presumed inflammatory lesions was the most common cause of third cranial nerve palsy (36.4%). Other non-traumatic causes included vascular lesions, ischemic brainstem stroke, intracranial hemorrhage, non-aneurysmal neuro-vascular contact, multiple sclerosis, and infection.
A substantial proportion of young adult patients with ocular motor nerve palsies manifested pathologies other than presumed microvascular ischemia or idiopathic causes. Neuroimaging and laboratory tests have important roles in the evaluation of patients aged 20–50 years with acquired ocular motor nerve palsies.
Oculomotor palsy in diabetics
2018, Journal Francais d'Ophtalmologie
Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. It generates less interest in the literature than the other ocular manifestations. Our goal was to study the clinical, epidemiological, therapeutic and prognostic characteristics of oculomotor palsy in the diabetic.
This is a retrospective study of 24 diabetic patients with oculomotor palsy. The ophthalmological examination emphasized ocular motility. We performed an orthoptic assessment and a Hess–Lancaster test. Neuro-imaging was ordered in case of IIIrd and IVth nerve involvement, bilateral involvement, multiple ocular cranial nerve palsy or associated optic neuropathy. Treatment consisted of glucose management and alternating monocular occlusion or prisms for the diplopia. Data were entered and analyzed on SPSS 11.5 software.
The mean age of the patients was 58.5 ± 11.9 years. Binocular diplopia was the main symptom. The oculomotor palsy involved the VIth nerve in 50% of cases and was bilateral in two cases. Three patients also had an optic neuropathy. The mean duration of diabetes was 11.7 ± 11 years; poorly controlled diabetes was found in 75% of cases and an association with diabetic retinopathy was noted in 56% of cases.
Long-standing uncontrolled type 2 diabetes, hypertension, coronary artery disease, left ventricular hypertrophy, and elevated hematocrit are the most common risk factors. The VIth nerve is commonly involved. Certain characteristics of the pupillary light reflex can help to differentiate an ischemic insult from an aneurysmal injury to the IIIrd nerve.
La paralysie oculomotrice est l’une des complications neuro-ophtalmologiques les plus fréquentes du diabétique. Elle soulève moins d’intérêt dans la littérature que les autres manifestations oculaires. Notre objectif était d’étudier les caractéristiques cliniques, épidémiologiques, thérapeutiques et évolutives de la paralysie oculomotrice du diabétique.
Étude rétrospective sur 24 diabétiques atteints de paralysie oculomotrice. Nous avons insisté sur l’examen de l’oculomotricité complété par un bilan orthoptique et un test de Hess–Lancaster. L’imagerie cérébrale était demandée en cas d’atteinte des nerfs III et IV, d’affection bilatérale, de paralysies multiples ou de neuropathie optique associée. Le traitement consistait à équilibrer le diabète et à l’occlusion monoculaire alternée ou les prismes pour la diplopie. Les données ont été saisies et analysées sur le logiciel SPSS 11.5.
L’âge moyen des patients était de 58,5 ± 11,9 ans. La diplopie binoculaire était le principal symptôme. La paralysie oculomotrice concernait le VI^e nerf dans 50 % des cas et elle était bilatérale dans deux cas. Trois patients avaient une neuropathie optique associée. La durée moyenne d’évolution du diabète était de 11,7 ± 11 ans, un diabète déséquilibré était trouvé dans 75 % des cas et une association avec la rétinopathie diabétique était notée dans 56 % des cas.
Un diabète de type 2 déséquilibré et ancien, l’hypertension artérielle, la coronaropathie, l’hypertrophie ventriculaire gauche, l’hématocrite élevé sont les facteurs de risque les plus fréquents. Le VI^e nerf est communément concerné. Le réflexe photomoteur peut aider à différencier une lésion ischémique d’une lésion anévrysmale du III^e nerf.
Extrinsic paralysis of the common motor ocular nerve revealing a type 2 diabetes
2017, Presse Medicale
Retrospective Analysis of Factors Related to the Long-Term Recovery of Third, Fourth, and Sixth Cranial Nerve Palsy with Etiologies and Clinical Course in a Tertiary Hospital
2024, Clinical Ophthalmology

View all citing articles on Scopus

¹: InternetAdvance publication at ajo.com Feb 28, 2002.

View full text

Long-term prognosis in patients with vasculopathic sixth nerve palsy1

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Am J Ophthalmol

Neuro-ophthalmic evaluation of abducens nerve palsies

Arch Ophthalmol

Ischemic oculomotor nerve palsy. Clinical features and vascular risk factors

J Neurol

Risk factors for ischemic ocular motor nerve palsies

Arch Ophthalmol

Long-term prognosis in patients with vasculopathic sixth nerve palsy¹