Abducens Nerve Palsy (Sixth Cranial Nerve Palsy) Treatment & Management

Updated: Mar 02, 2021
  • Author: Michael P Ehrenhaus, MD; Chief Editor: Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC  more...
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Medical Care

Truly isolated cases of abducens nerve palsy are often benign. They can be followed with a serial examination, at least every 6 weeks, over a 6-month period to note decreasing symptoms (diplopia) and resolution of the paretic lateral rectus (increasing motility). [12, 3] Prism measurements are a simple objective method of documenting any changes in the esotropia.

Children with sixth nerve palsy who are in the amblyopic age group can be treated with an alternating patching to decrease their chances of developing any amblyopia in the paretic eye. Additionally, prescribing the full amount of hyperopic correction helps to decrease the esodeviation by relaxing the child's accommodative effort.

Adult patients and those children beyond the amblyopic age can be patched or have their lenses "fogged" with clear tape or nail polish to reduce their diplopia. Fresnel prisms also can be prescribed as an alternative.

Older patients in whom giant cell arteritis is suspected should start the standard treatment with prednisone or intravenous methylprednisolone.


Surgical Care

If, after 9-12 months of follow-up care, the remaining deviation is still unacceptable and is too large to be corrected with prisms, surgical corrective options should be discussed with the patient. The procedure that is chosen depends on the remaining function of the lateral rectus and the experience of the surgeon.

If some residual function exists in the lateral rectus, a graded recession of the medial rectus or botulinum toxin to the medial rectus, and resection of the lateral rectus or lateral rectus bupivacaine (Marcaine) injection can be performed.

When little or no residual function is present, a transposition of the vertical recti toward the lateral rectus (eg, Hummelsheim, Jensen, or Nishida procedure), can be considered in conjunction with weakening of the ipsilateral medial rectus.



Patients with abducens palsy can benefit from consultation with a neurologist, ophthalmologist, or neuro-ophthalmologist, especially if the lesion does not resolve.



Patients who occlude an eye to alleviate diplopia should be warned that the resulting effects on depth perception may interfere with their ability to drive or perform certain occupations safely.