What is sixth nerve palsy?

Sixth nerve palsy occurs when the sixth cranial nerve is damaged or doesn't work right. It's also known as the abducens nerve. This condition causes problems with eye movement.

The sixth cranial nerve sends signals to your lateral rectus muscle. This is a small muscle that attaches to the outer side of your eye. When this muscle contracts, your eye moves away from your nose. Each eye has its own lateral rectus muscle served by its own cranial nerve.

The sixth nerve emerges from the lower part of your brain. It travels a long way before reaching the lateral rectus. Damage at any point along its path can cause the nerve to work poorly or not at all. Because the lateral rectus muscle can no longer contract correctly, your eye turns inward toward your nose.

Sometimes, sixth nerve palsy happens without any other symptoms. This is called isolated sixth nerve palsy. Other times, sixth nerve palsy may come with other symptoms. This is called nonisolated sixth nerve palsy.

Sometimes, sixth nerve palsy is present from birth. It can also result from other problems that happen later on. In children, injury is a leading cause. In adults, stroke is one of the most common causes. It is relatively rare.

What causes sixth nerve palsy?

Many problems can disrupt the function of the sixth cranial nerve, causing sixth nerve palsy. Possible causes include:

• Injury (especially if a skull fracture is present)

• Stroke

• Infection (for instance, from Lyme disease or from a virus)

• Brain tumor

• Inflammation of the nerve, for instance, after a vaccine

• Multiple sclerosis

• Elevated pressure inside the brain (for instance, from meningitis)

In congenital sixth nerve palsy, a problem with the sixth cranial nerve is present from birth. This may happen as a result of injury during birth. Sometimes, the cause of sixth nerve palsy is unknown. Sixth nerve palsy that happens without additional symptoms is usually due to one of the following:

• Injury

• Congenital cause

• Viral illness

• High blood pressure

• Diabetes

What are the symptoms of sixth nerve palsy?

Sixth nerve palsy may affect one or both eyes, depending on its cause.

The most common symptom of sixth nerve palsy is double vision when both eyes are open. This is more common when looking far away or when looking in the direction of the affected eye. But not everyone with sixth nerve palsy has this symptom.

The eyes may also be out of alignment—a symptom called strabismus. The eye on the affected side may drift toward the midline. Early on, you might show this symptom only when looking in the direction of the affected eye (like looking to the right in a right sixth nerve palsy). If the palsy gets worse, the affected eye may drift toward the midline, even when looking straight ahead.

If you have nonisolated sixth nerve palsy, additional symptoms may be present as well. Depending on the other structures affected, you might have symptoms, such as:

• Hearing loss

• Facial weakness

• Decreased facial sensation

• Droopy eyelid

• Fever

• Headache

• Nausea and vomiting

How is sixth nerve palsy diagnosed?

Diagnosis begins with a thorough medical history and physical exam. Your healthcare provider will do a detailed neurological exam. This is testing to identify other affected parts of your brain and nervous system. A general practitioner or a healthcare provider who specializes in the nervous system (a neurologist, optometrist, ophthalmologist, or neuro-ophthalmologist) might first examine you. They will try to diagnose the root cause of the sixth nerve palsy as well.

Your healthcare provider will probably want to order brain imaging tests because the nerve often becomes compressed as it leaves the brain. Brain imaging is also important to make sure a brain tumor isn’t causing symptoms. Possible imaging tests include computed tomography (CT) and magnetic resonance imaging (MRI). MRI provides more information. But it is often hard to do as quickly as a CT. A CT might be needed if your healthcare provider suspects that you have increased pressure inside your brain.

Sometimes, the healthcare provider might order other tests if they suspect a specific cause of the sixth nerve palsy. For example, you might need blood tests and a lumbar puncture if meningitis is suspected.

How is sixth nerve palsy treated?

Treatment of sixth nerve palsy depends on its cause. Possible treatments for the underlying cause include:

• Antibiotics, for sixth nerve palsy due to bacterial infection

• Corticosteroids, for sixth nerve palsy due to inflammation

• Surgery or chemotherapy, for sixth nerve palsy due to a tumor

Sometimes, there is not a direct treatment available for the underlying cause.

Your healthcare provider may want to wait a few months before starting additional treatment. Often, symptoms from sixth nerve palsy improve on their own. Sixth nerve palsy following a viral illness often completely goes away within a few months. Symptoms following trauma may also improve over several months. But in cases of trauma, symptoms are less likely to go away completely. Your symptoms may be more likely to go away completely if you have isolated sixth nerve palsy.

If you still have symptoms 6 months or so later, your healthcare provider might recommend further treatments. Some available treatments are:

• Alternate patching of each eye to eliminate double vision (often an initial treatment)

• Special prism glasses to help align the eye

• Botulinum toxin to temporarily paralyze the muscle on the other side of the eye and help eye alignment

• Surgery

Your provider may be most likely to recommend surgery if other treatment choices have not been effective.

What are possible complications of sixth nerve palsy?

Isolated sixth nerve palsy itself does not usually cause complications. But many of the possible causes of sixth nerve palsy may have complications. Like any procedure, surgery for sixth nerve palsy carries a risk for complications.

When should I call my healthcare provider?

Call the healthcare provider if you have any sudden severe symptoms, like vision loss or problems moving an arm or a leg.

Key points about sixth nerve palsy

Sixth nerve palsy occurs when the sixth cranial nerve is damaged or doesn't work right. This causes problems with eye movement. The affected eye may not be able to move away from the midline normally.

• Sometimes, only the sixth cranial nerve has problems. But problems in other parts of the body can occur, too.

• There are many possible causes of sixth nerve palsy. In children, trauma is one of the most common causes.

• Treatment for sixth nerve palsy depends on its cause.

• Symptoms of sixth nerve palsy often go away or improve within several months.

• If the symptoms don’t completely go away, you might need other treatments and possibly surgery.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed and how it will help you. Also know what the side effects are.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your healthcare provider if you have questions, especially after office hours or on weekends.