Given the investigation results for this patient, the diagnosis is ischaemic right abducens (cranial nerve VI) palsy. What are the next steps in management? Answer 6 The MRI of her brain showed mild, small vessel ischaemic changes at the white matter of bilateral cerebral hemispheres, with no other abnormalities. All of the blood tests were within normal limits except for total cholesterol and low-density lipoprotein-cholesterol (LDL-C), which were 6.6 mmol/L and of 4.7 mmol/L respectively. The optic disc and retinal vessels were normal. Ophthalmology review confirmed the initial ocular examination findings. magnetic resonance imaging (MRI) of the brain with gadolinium.What investigations should be considered? Answer 5 The patient’s case was discussed with an ophthalmologist, who agreed with outpatient investigations, and arranged to see her the next working day with the results. The most common cause in those aged >50 years is microvascular ischaemia, but it is important to consider this palsy as a false localising sign for raised intracranial pressure. neoplastic (39–45% in series of children).The causes of abducens (cranial nerve VI) palsy include: 1 The diagnosis at this point of the consultation would be right isolated abducens (cranial nerve VI) palsy. muscular – thyroid eye disease, orbital myositis, tumours, trauma, myopathies (eg chronic progressive external ophthalmoplegia, myotonic dystrophy).neuromuscular – myasthenia gravis, botulism.cranial – isolated cranial nerve III, IV or VI palsy, combined cranial neuropathy (if lesion in cavernous sinus or brainstem).The causes of binocular diplopia include: Monocular diplopia usually suggests a refractive problem at the front part of the eye, such as astigmatism or cataract. Binocular diplopia disappears when one eye is occluded. ![]() The first thing to determine when a patient presents with diplopia is identifying whether it is monocular or binocular. ![]() What are the potential causes of the diagnosed condition? Answer 1 What is the diagnosis at this point? Question 4 What are the causes of binocular diplopia? Question 3 What is the first thing to determine when a patient presents with diplopia? Question 2 Capillary blood glucose was 5.6 mmol/L.įigure 2. ![]() Other cranial nerve and neurological examinations were unremarkable. Fundoscopic examination was unremarkable. Visual acuity was 6/6 and 6/9 for the right and left eye respectively. Her pupils and eyelids were normal to examine. The diplopia was also worse with distance fixation. Other extraocular movements were normal with no pain. It was worse at the right lateral gaze with restricted right eye abduction (Figure 2). Her diplopia disappeared on closing either eye. Examination revealed right-eye esotropia and diplopia in the primary gaze (Figure 1). Her weight was 75 kg and height was 155 cm, making her body mass index (BMI) 31 kg/m 2. There was no family history of diabetes, hypertension or ischaemic heart disease.Ĭlinically, her blood pressure was 152/79 mmHg and pulse was regular at 87 beats per minute. She could not remember the last time she saw a medical practitioner. There was no previous history of diplopia or trauma, headache, vomiting, limb weakness or jaw claudication. She described this as ‘seeing two images side by side’. ![]() A woman, 62 years of age, presented to a general practice with a three-day history of persistent double vision.
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