Ignite Creation Date:
2024-10-25 @ 8:06 PM
Last Modification Date:
2024-10-26 @ 3:35 PM
Study NCT ID:
NCT06512636
Status:
COMPLETED
Last Update Posted:
None
First Post:
2024-07-16
Brief Title:
A Decade-Long Dance With Diplopia Unraveling the Enigma of Recurrent 6th Nerve Palsy
Sponsor:
None
Organization:
None
Study Overview
Official Title:
A Decade-Long Dance With Diplopia Unraveling the Enigma of Recurrent 6th Nerve Palsy
Status:
COMPLETED
Status Verified Date:
2024-07
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
No
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
Abstract
Introduction and Importance
Recurrent diplopia poses a diagnostic challenge necessitating a thorough evaluation to elucidate its underlying etiology and guide its management We present the case of a 39-year-old farmer with recurrent 6th nerve palsy for over a decade highlighting the complexity and persistence of this condition
Case Presentation
A 39-year-old farmer presented with recurrent diplopia attributed to 6th nerve palsy with eight episodes over 14 years Despite systemic steroid treatment the symptoms recurred every 12-18 months Clinical examination revealed right eye abduction impairment- no other abnormalities were detected Magnetic resonance imaging MRI indicated rhinosinusitis and the results of the autoimmune antibody test were negative
Clinical Discussion
This case challenges conventional diagnostic approaches underscoring the need for a comprehensive evaluation and tailored management strategies Despite extensive investigations the etiology remains elusive emphasizing the complexity of recurrent diplopia
Conclusion
Continued monitoring and further investigation are warranted to unravel the enigma of recurrent diplopia in this unique case highlighting the importance of individualized approaches to guide optimal management
Introduction and Importance
Recurrent diplopia poses a diagnostic challenge necessitating a thorough evaluation to elucidate its underlying etiology and guide its management We present the case of a 39-year-old farmer with recurrent 6th nerve palsy for over a decade highlighting the complexity and persistence of this condition
Case Presentation
A 39-year-old farmer presented with recurrent diplopia attributed to 6th nerve palsy with eight episodes over 14 years Despite systemic steroid treatment the symptoms recurred every 12-18 months Clinical examination revealed right eye abduction impairment- no other abnormalities were detected Magnetic resonance imaging MRI indicated rhinosinusitis and the results of the autoimmune antibody test were negative
Clinical Discussion
This case challenges conventional diagnostic approaches underscoring the need for a comprehensive evaluation and tailored management strategies Despite extensive investigations the etiology remains elusive emphasizing the complexity of recurrent diplopia
Conclusion
Continued monitoring and further investigation are warranted to unravel the enigma of recurrent diplopia in this unique case highlighting the importance of individualized approaches to guide optimal management
Detailed Description:
A Decade-Long Dance with Diplopia Unraveling the Enigma of Recurrent 6th Nerve Palsy
ABSTRACT
Introduction and Importance
Recurrent diplopia poses a diagnostic challenge necessitating a thorough evaluation to elucidate its underlying etiology and guide its management We present the case of a 39-year-old farmer with recurrent 6th nerve palsy for over a decade highlighting the complexity and persistence of this condition
Case Presentation
A 39-year-old farmer presented with recurrent diplopia attributed to 6th nerve palsy with eight episodes over 14 years Despite systemic steroid treatment the symptoms recurred every 12-18 months Clinical examination revealed right eye abduction impairment- no other abnormalities were detected Magnetic resonance imaging MRI indicated rhinosinusitis and the results of the autoimmune antibody test were negative
Clinical Discussion
This case challenges conventional diagnostic approaches underscoring the need for a comprehensive evaluation and tailored management strategies Despite extensive investigations the etiology remains elusive emphasizing the complexity of recurrent diplopia
Conclusion
Continued monitoring and further investigation are warranted to unravel the enigma of recurrent diplopia in this unique case highlighting the importance of individualized approaches to guide optimal management
Keywords Recurrent diplopia 6th nerve palsy autoimmune disease systemic steroid neuro-ophthalmology
Highlights
Recurrent diplopia is a diagnostic puzzle especially in terms of etiology
Despite treatment the patient experienced recurrent diplopia attributed to 6th nerve palsy for 14 years highlighting the chronic nature of the condition
Extensive evaluation failed to identify the underlying cause which illustrates the diagnostic complexity of recurrent diplopia
Systemic steroid treatment provided temporary relief but the recurrence persisted necessitating long-term management
This case emphasizes the need for tailored approaches and ongoing monitoring to effectively address the challenges in managing recurrent diplopia
INTRODUCTION Recurrent diplopia presents a diagnostic problem especially when associated with 6th nerve palsy The etiology of recurrent diplopia in older individuals has yet to be well described in the literature1 We present a case of a 39-year-old male farmer with eight episodes of diplopia over 14 years each responding to systemic steroid therapy but recurring every 12-18 months Despite the patients clinical response the underlying etiology remains elusive emphasizing the complexity of this rare condition This case prompts a thorough exploration of the potential inflammatory or autoimmune origins of recurrent 6th nerve palsy addressing the disorders symptomatic relief and recurrent nature12 This report contributes to the limited literature on such cases shedding light on the challenges and considerations in managing this recurrent neuro-ophthalmological condition
CASE REPORT
In this case a 39-year-old male a married farmer was presented to the Neuromedicine OPD for a follow-up examination of recurrent diplopia attributed to 6th nerve palsy The patient reported no recent instances of double vision or associated complaints during the follow-up visit Notably the last episode of diplopia occurred 13 months prior and the patient had experienced eight such episodes over 14 years since 2008
During the previous episode the patient sought medical attention with the chief complaint of acute-onset double vision persisting for 10 days No significant concurrent medical or surgical issues were reported aside from a recurrent history of diplopia and treatment during previous occurrences involving systemic steroid administration resulting in the complete resolution of symptoms Recurrence typically manifest within 12-18 months of treatment
Clinical examination revealed that the patient could not abduct the right eye whereas the remaining ocular and systemic examinations yielded normal results Notably there were no signs of myasthenia gravis ptosis and pain on the movement of the eyeballs decreased visual acuity trauma red eyes headache focal neurological deficits or meningeal or cerebellar abnormalities Brain MRI revealed no abnormalities except for the presence of rhinosinusitis
A comprehensive antibody panel including anti-acetylcholinesterase receptor antibodies and anti-MUSK antibody tests was used to investigate the possibility of an autoimmune etiology All results from these tests were negative further complicating the determination of the underlying cause of recurrent diplopia Continued monitoring and further investigations may be necessary to elucidate the nature of this unique case and to guide appropriate management
DISCUSSION
The case of a 39-year-old male farmer with recurrent diplopia attributed to 6th nerve palsy highlights the diagnostic challenges and complexities of managing this rare condition Despite the patients clinical response to systemic steroid therapy the underlying etiology remains elusive emphasizing the need for thorough exploration of the potential inflammatory or autoimmune origins of recurrent 6th nerve palsy
The literature suggests that benign recurrent 6th nerve palsy in children is rare and recurrences are rarer3 4 This condition typically occurs following viral illnesses infections and immunization involving attenuated live vaccinations In adults the evaluation and management of recent-onset diplopia in adults with a history of long-standing strabismus can be perplexing and challenging5 The causes of isolated recurrent ipsilateral sixth nerve palsies in older adults have not been well described in the literature and the etiology of recurrent isolated sixth nerve palsies in older adults has not been well described1 The clinical presentation of isolated recurrent diplopia from a sixth nerve palsy should prompt a neurologist or ophthalmologist to order a brain MRI with and without gadolinium as part of the initial workup to rule out a non-microvascular cause such as a compressive lesion1 The exact pathophysiologic mechanism of the relapsing and remitting course of the sixth nerve palsy has yet to be fully understood This may be related to a structural lesion or an inflammatory process1 The etiological diagnosis of diplopia is a clinical challenge4 Binocular diplopia is referred to in the literature as the most common type and there are several etiological mechanisms of binocular diplopia including orbital disorders extra-ocular muscle disorders neuromuscular junction dysfunction and primary or secondary visual cortex diseases4 In conclusion the case of a 39-year-old male farmer with recurrent diplopia attributed to 6th nerve palsy highlights the diagnostic challenges and complexities of managing this rare condition The literature suggests that benign recurrent 6th nerve palsy in children is rare and recurrences are rarer By contributing to the existing literature on this rare condition we aimed to enhance awareness among clinicians and foster a multidisciplinary approach to patient care ultimately improving outcomes in individuals with similar presentations
Consent
Written informed consent was obtained from the patient for the publication of this case report A copy of the written consent form is available for review by the editor-in-chief of the journal upon request
Ethical Approval
Ethical approval is not required for case report
Source of Funding
There is no source of Funding
Research Registration
Research registration is not required as this is only a case report
Author contribution
PP Conceptualization project administration supervision writing -review and editing KRB Conceptualization project administration supervision writing-review and editing RKC Formal analysis writing -original draft writing-review and editing NR Writing- original draft writing-review and editing SM Resources supervision writing-original draft writing-review and editing BA Resources writing-original draft writing-review and editing KS Resources writing-original draft writing-review and editing
Conflict of Interest
The authors declare that they have no conflicts of interest The work has been reported as being in line with SCARE criteria
Guarantor
Prabesh Panta
Data availability statement
The datasets are available from the corresponding author on reasonable request
REFERENCES
1 Chan JW Albretson J Causes of isolated recurrent ipsilateral sixth nerve palsies in older adults a case series and review of the literature Clin Ophthalmol Auckl NZ 20159373 Available from httpswwwncbinlmnihgovpmcarticlesPMC4348047
2 Patel SV Mutyala S Leske DA Hodge DO Holmes JM Incidence associations and evaluation of sixth nerve palsy using a population-based method Ophthalmology 2004 Feb 1112369-75 Available from httpslinkinghubelseviercomretrievepiiS0161642003011849
3 Gonçalves R Coelho P Menezes C Ribeiro I Benign Recurrent Sixth Nerve Palsy in a Child Case Rep Ophthalmol Med 20178276256 Available from httpswwwncbinlmnihgovpmcarticlesPMC5763058
4 Kushner BJ Recently Acquired Diplopia in Adults With Long-standing Strabismus Arch Ophthalmol 2001 Dec 1119121795-801 Available from httpsdoiorg101001archopht119121795
5 Alves M Miranda A Narciso MR Mieiro L Fonseca T Diplopia A Diagnostic Challenge with Common and Rare Etiologies Am J Case Rep 2015 Apr 1316220-3 Available from httpswwwncbinlmnihgovpmcarticlesPMC4410729
ABSTRACT
Introduction and Importance
Recurrent diplopia poses a diagnostic challenge necessitating a thorough evaluation to elucidate its underlying etiology and guide its management We present the case of a 39-year-old farmer with recurrent 6th nerve palsy for over a decade highlighting the complexity and persistence of this condition
Case Presentation
A 39-year-old farmer presented with recurrent diplopia attributed to 6th nerve palsy with eight episodes over 14 years Despite systemic steroid treatment the symptoms recurred every 12-18 months Clinical examination revealed right eye abduction impairment- no other abnormalities were detected Magnetic resonance imaging MRI indicated rhinosinusitis and the results of the autoimmune antibody test were negative
Clinical Discussion
This case challenges conventional diagnostic approaches underscoring the need for a comprehensive evaluation and tailored management strategies Despite extensive investigations the etiology remains elusive emphasizing the complexity of recurrent diplopia
Conclusion
Continued monitoring and further investigation are warranted to unravel the enigma of recurrent diplopia in this unique case highlighting the importance of individualized approaches to guide optimal management
Keywords Recurrent diplopia 6th nerve palsy autoimmune disease systemic steroid neuro-ophthalmology
Highlights
Recurrent diplopia is a diagnostic puzzle especially in terms of etiology
Despite treatment the patient experienced recurrent diplopia attributed to 6th nerve palsy for 14 years highlighting the chronic nature of the condition
Extensive evaluation failed to identify the underlying cause which illustrates the diagnostic complexity of recurrent diplopia
Systemic steroid treatment provided temporary relief but the recurrence persisted necessitating long-term management
This case emphasizes the need for tailored approaches and ongoing monitoring to effectively address the challenges in managing recurrent diplopia
INTRODUCTION Recurrent diplopia presents a diagnostic problem especially when associated with 6th nerve palsy The etiology of recurrent diplopia in older individuals has yet to be well described in the literature1 We present a case of a 39-year-old male farmer with eight episodes of diplopia over 14 years each responding to systemic steroid therapy but recurring every 12-18 months Despite the patients clinical response the underlying etiology remains elusive emphasizing the complexity of this rare condition This case prompts a thorough exploration of the potential inflammatory or autoimmune origins of recurrent 6th nerve palsy addressing the disorders symptomatic relief and recurrent nature12 This report contributes to the limited literature on such cases shedding light on the challenges and considerations in managing this recurrent neuro-ophthalmological condition
CASE REPORT
In this case a 39-year-old male a married farmer was presented to the Neuromedicine OPD for a follow-up examination of recurrent diplopia attributed to 6th nerve palsy The patient reported no recent instances of double vision or associated complaints during the follow-up visit Notably the last episode of diplopia occurred 13 months prior and the patient had experienced eight such episodes over 14 years since 2008
During the previous episode the patient sought medical attention with the chief complaint of acute-onset double vision persisting for 10 days No significant concurrent medical or surgical issues were reported aside from a recurrent history of diplopia and treatment during previous occurrences involving systemic steroid administration resulting in the complete resolution of symptoms Recurrence typically manifest within 12-18 months of treatment
Clinical examination revealed that the patient could not abduct the right eye whereas the remaining ocular and systemic examinations yielded normal results Notably there were no signs of myasthenia gravis ptosis and pain on the movement of the eyeballs decreased visual acuity trauma red eyes headache focal neurological deficits or meningeal or cerebellar abnormalities Brain MRI revealed no abnormalities except for the presence of rhinosinusitis
A comprehensive antibody panel including anti-acetylcholinesterase receptor antibodies and anti-MUSK antibody tests was used to investigate the possibility of an autoimmune etiology All results from these tests were negative further complicating the determination of the underlying cause of recurrent diplopia Continued monitoring and further investigations may be necessary to elucidate the nature of this unique case and to guide appropriate management
DISCUSSION
The case of a 39-year-old male farmer with recurrent diplopia attributed to 6th nerve palsy highlights the diagnostic challenges and complexities of managing this rare condition Despite the patients clinical response to systemic steroid therapy the underlying etiology remains elusive emphasizing the need for thorough exploration of the potential inflammatory or autoimmune origins of recurrent 6th nerve palsy
The literature suggests that benign recurrent 6th nerve palsy in children is rare and recurrences are rarer3 4 This condition typically occurs following viral illnesses infections and immunization involving attenuated live vaccinations In adults the evaluation and management of recent-onset diplopia in adults with a history of long-standing strabismus can be perplexing and challenging5 The causes of isolated recurrent ipsilateral sixth nerve palsies in older adults have not been well described in the literature and the etiology of recurrent isolated sixth nerve palsies in older adults has not been well described1 The clinical presentation of isolated recurrent diplopia from a sixth nerve palsy should prompt a neurologist or ophthalmologist to order a brain MRI with and without gadolinium as part of the initial workup to rule out a non-microvascular cause such as a compressive lesion1 The exact pathophysiologic mechanism of the relapsing and remitting course of the sixth nerve palsy has yet to be fully understood This may be related to a structural lesion or an inflammatory process1 The etiological diagnosis of diplopia is a clinical challenge4 Binocular diplopia is referred to in the literature as the most common type and there are several etiological mechanisms of binocular diplopia including orbital disorders extra-ocular muscle disorders neuromuscular junction dysfunction and primary or secondary visual cortex diseases4 In conclusion the case of a 39-year-old male farmer with recurrent diplopia attributed to 6th nerve palsy highlights the diagnostic challenges and complexities of managing this rare condition The literature suggests that benign recurrent 6th nerve palsy in children is rare and recurrences are rarer By contributing to the existing literature on this rare condition we aimed to enhance awareness among clinicians and foster a multidisciplinary approach to patient care ultimately improving outcomes in individuals with similar presentations
Consent
Written informed consent was obtained from the patient for the publication of this case report A copy of the written consent form is available for review by the editor-in-chief of the journal upon request
Ethical Approval
Ethical approval is not required for case report
Source of Funding
There is no source of Funding
Research Registration
Research registration is not required as this is only a case report
Author contribution
PP Conceptualization project administration supervision writing -review and editing KRB Conceptualization project administration supervision writing-review and editing RKC Formal analysis writing -original draft writing-review and editing NR Writing- original draft writing-review and editing SM Resources supervision writing-original draft writing-review and editing BA Resources writing-original draft writing-review and editing KS Resources writing-original draft writing-review and editing
Conflict of Interest
The authors declare that they have no conflicts of interest The work has been reported as being in line with SCARE criteria
Guarantor
Prabesh Panta
Data availability statement
The datasets are available from the corresponding author on reasonable request
REFERENCES
1 Chan JW Albretson J Causes of isolated recurrent ipsilateral sixth nerve palsies in older adults a case series and review of the literature Clin Ophthalmol Auckl NZ 20159373 Available from httpswwwncbinlmnihgovpmcarticlesPMC4348047
2 Patel SV Mutyala S Leske DA Hodge DO Holmes JM Incidence associations and evaluation of sixth nerve palsy using a population-based method Ophthalmology 2004 Feb 1112369-75 Available from httpslinkinghubelseviercomretrievepiiS0161642003011849
3 Gonçalves R Coelho P Menezes C Ribeiro I Benign Recurrent Sixth Nerve Palsy in a Child Case Rep Ophthalmol Med 20178276256 Available from httpswwwncbinlmnihgovpmcarticlesPMC5763058
4 Kushner BJ Recently Acquired Diplopia in Adults With Long-standing Strabismus Arch Ophthalmol 2001 Dec 1119121795-801 Available from httpsdoiorg101001archopht119121795
5 Alves M Miranda A Narciso MR Mieiro L Fonseca T Diplopia A Diagnostic Challenge with Common and Rare Etiologies Am J Case Rep 2015 Apr 1316220-3 Available from httpswwwncbinlmnihgovpmcarticlesPMC4410729
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None