Session: Poster session B

A case describing the surgical management of a complex sixth nerve palsy secondary to brainstem meningioma and stroke

Aditi DAS¹, Anne-Marie HINDS¹, Katie WILLIAMS¹, Maria THEODOROU¹

¹Moorfields Eye Hospital, London, United Kingdom

Introduction

We describe surgical management of a 51 year old with constant diplopia secondary to a left abducens nerve palsy. Due to the patient’s comorbidities, surgical and medical management plans were limited. Surgical management was challenging and required a multidisciplinary approach. We illustrate our case with pre and post-operative photos in nine positions of gaze.

Methods

Our patient presented with multiple left sided cranial nerve palsies (5th, 6th & 7th) following surgery for brainstem meningioma and stroke. She presented with binocular horizontal diplopia and left exposure keratopathy with a neurotrophic cornea. Vision in the right eye was 0.0 and 1.2 Logmar in the left eye. Orthoptic assessment revealed a marked left esotropia of 50D BO at near and distance with -6 abduction deficit. She was trialled on left medial rectus botox with little effect. She subsequently underwent full tendon transposition of the left superior and inferior recti to the borders of the lateral rectus under local anaesthetic and sedation. Two weeks post-operatively, she had a 8D BI exotropia at near and no horizontal strabismus at distance. However, her esotropia gradually returned and at ten months post surgery, she measured 45-50D BO. Conservative management plans including an occlusive contact lens were contraindicated due to a poor ocular surface. Further surgical options were offered including contralateral surgery (declined), left medial rectus recession (with a risk of anterior segment ischaemia) and augmentation sutures to the left inferior and superior recti. We will carry out augmentation surgery in February 2024 and present our findings.

Conclusion

We describe a cautious multidisciplinary approach to managing a complex case of sixth nerve palsy. Surgical management was challenged by the patient’s compounding health factors. We describe and illustrate our case and the important lessons learnt.