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PATIENTS IDENTIFICATION

Name : Ms Z

Age : 57 years old

Gender : Female

Race : Malay

Religion : Islam

Occupation : Housewife

Address : Klang

Registration number (RN): 1722234

Date of admission : 27/3/2017

Date of clerking : 29/3/2017

CHIEF COMPLAINT
Her son noticed that she has a squint.

HISTORY OF PRESENTING ILLNESS


Ms. Z, with underlying right eye cataract for 1 year, diabetes
mellitus for 9 years, hypertension and dyslipidemia for 5 months,
was apparently well until 5 days ago when his son noticed that
she has a squint . He realized it when she could not move her
right eye to the right side when she was talking to him.

It was sudden and associated with pain at the right eyebrow


region. The eyebrow pain was non-radiating and continuous
throughout the day until now. She herself did not realized her
inability to move her right eye to the right side because she had
lost her right eye vision completely due to cataract since October
2016.

As advised by her friend who is a doctor in Klinik Kesihatan,


she went to see the doctor in Hospital eye clinic on the following
Monday. She was told that she needed to be admitted for further
evaluation.

She has been wearing multifocal eyeglasses for short and


distant vision for 7 years and the last time she went for eye power
check-up was 2 years ago.

Otherwise, she denied fever, history of previous infection,


asymmetrical of her face, any muscle weakness of other part of
the body, loss of weight, loss of appetite or recent trauma to the
head or eye.
PAST MEDICAL HISTORY

Ms. Z has underlying cataract on her right eye for 1 year.


She is compliant to her eye checkup in Eye Ward of Hospital
and she is planned for a cataract surgery this April in HTAR
after her right eye movement is corrected.
Previously, she had the similar cataract problem on her left
eye for 3 years and went for cataract surgery last year. Now
it has been treated.
Besides, she also has been diagnosed with Diabetes Mellitus
for 9 years. Her usual fasting bloos sugar level measured
before breakfast is 6 mmol/L. She is compliant to the
medication and currently on regular follow up at Klinik
Kesihatan.
Other than that, she is also diagnosed with hypertension and
dyslipidemia since 5 months ago. She is compliant to the
medication for both and also on regular follow up at Klinik
Kesihatan.

PAST SURGICAL HISTORY


In 2008, she underwent for carbuncle surgery twice due to
uncontrolled diabetes successful without any post-
operative complications.
In October 2016, she had a cataract removal surgery on her
left eye, done in Hospital successful without any post-
operative complications.
DRUGS AND ALLERGY HISTORY

Currently she is on a few medications for diabetes, hypertension


and dyslipidemia which are:

T. Cliclazide 80mg OD before breakfast


T. Aspirin 300mg OD
T. Simvastatin 20mg
T. Twynsta (telmisartan and amlodipine)
T. Metformin - 4 tablets at night.
SC Insulatard 20 units at night
SC Actrapid 8 units in the morning.

Besides, she was on homeopathy medication for 2 years and


recenlt stopped since she was admitted to the ward.

Otherwise, she has no known allergies to food or other drugs.


FAMILY HISTORY

Ms. Z is the second out of her 7 siblings.


Both of her parents had passed away; her late father died
due to stroke at the age of 59 while her late mother died to
complications of diabetes and renal disease.
Her elder sister has hypertension and her two younger
siblings both are diabetic. Her last 3 siblings are fit and
healthy.
Otherwise, there is no history of malignancy like brain cancer
runs in the family.
SOCIAL HISTORY
Ms. Z is a widow and currently lives with her 3 children in a
single-storey house in Klang.
She teaches kids Al-Quran at her home as her part-time job.
She is financially supported by herself.
Otherwise, she does not smoke, drink alcohol or take illicit
drugs.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient was sitting comfortably on her bed. She was alert,
conscious and well oriented to time, place and person. ID tag was
present on her left wrist. She was not in respiratory distress, no
signs of pallor or jaundice. She was large built with good
hydration and nutritional status.

VITAL SIGNS

Pulse rate : 80 beats/min, regular rhythm, good volume with


normal character

Respiratory rate : 18 breaths/min (normal)

Blood pressure : 135/87 mmHg (hypertensive)

Temperature : 37.0 C
(afebrile)

Weight : 95 kg

Height : 166 cm

BMI : 34 kgm-2
OCULAR EXAMINATION

1) VISUAL ACUITY

Right eye Left eye


Visual acuity Able to recognize 6/6
hand movement.
Near visual acuity - Good

2) INSPECTION
There was no syndromic feature on patients face.

Right eye Left eye


Red reflex Absent Presence
Lid No ptosis and No ptosis and swelling
swelling
Eye position Light fell on the pupil Light fell on the centre
margin temporally. of pupil
Conjunctiva White, not injected White, not injected
Cornea Clear Clear
Anterior Normal (deep) Normal (deep)
chamber
Pupil Normal - Irregular (oval in
shape)
- Presence of 3 stitches
at 10, 11 and 12 oclock
position.
- Presence of whitish
incisional wound scar at
the above pupillary
margin.
Lens Opaque Pseudophakic lens.
3) PUPILLARY EXAMINATION

Right eye Left eye


Direct reflex Absent Present
Consensual Present Present
(indirect) reflex
RAPD Negative Negative

4) DIRECT OPHTALMOSCOPY

Right eye Left eye


Findings The fundus cannot be Well defined optic
appreciated due to the disc outlines.
Colour of optic disc is
presence of cataract.
pink.
Ratio of optic disc to
optic cup is 0.3.
Blood vessels are
seen.
Macula is seen.
No exudates,
haemorrhage or
abnormalities seen.
5) EXTRAOCULAR MOVEMENT

Left eye can move in all direction.


Right eye can move in all direction except to the right
laterally.

6) VISUAL FIELD

Left eye can see all 4 quadrants without blurring of vision.


Right eye visual field cannot be tested due to cataract.

7) SLIT-LAMP EXAMINATION was not done

8) TONOMETRY was not done

CRANIAL NERVE EXAMINATION

5th cranial nerve: Trigeminal nerve

sensory : normal

reflex : normal

7th cranial nerve: Facial nerve

no facial asymmetry
no parotid enlargement
upper and lower motor neuron are intact

8th cranial nerve : Vestibular


hearing is equal at both ears.

SUMMARY

Ms. Z, a 57-year-old Malay lady, with underlying right eye


cataract for 1 year, diabetes mellitus for 9 years and hypertension
and dyslipidemia for 5 months, presented to the hospital because
she was unable to move her right eye to the right as noticed by
her son. She herself did not notice the problem since she had lost
her right eye vision completely due to cataract since 5 months
ago. It was associated with right eyebrow pain which was
continuous throughout the day until the day she was admitted.
Otherwise there was no history of fever, history of previous
infection, asymmetrical of her face, any muscle weakness of other
part of the body, loss of weight, loss of appetite or recent trauma
to the head or eye.

Upon examination, she was unable to move her right eye


temporally upon extraocular motor examination and the visual
field test was not performed on her right eye as she could not see
due to cataract.
PROVISIONAL DIAGNOSIS

Right sixth cranial nerve palsy secondary to uncontrolled


diabetes.

Supporting points:

She was noticed by her son that she could not move her
right eye to the right.
On examination, patient could not perform abduction of
the right eye, but adduction was done very well.
Patient has multiple underlying factors: diabetes mellitus
for 9 years and has a history of carbuncle removal surgery
twice indicating uncontrolled diabetes. Besides, she has
been diagnosed with hypertensive and dyslipidemia as
well.

DIFFERENTIAL DIAGNOSIS

(A) Sixth cranial nerve lesion due to basal skull fracture

POINTS SUPPORTING POINTS AGAINST


Unable to move right eye No history of trauma to the
to the right. face or eye.
(B) Cerebello-pontine tumor or metastases

POINTS SUPPORTING POINTS AGAINST

Unable to move right eye No signs of malignancy


to the right such as loss of appetite,
loss of weight.
No history of primary
malignancy.
No signs of impaired 7th
and 8th cranial nerves.

(C) Acute viral meningitis

POINTS SUPPORTING POINTS AGAINST


Unable to move right eye No history of recent
to the right. infection.
Patient is afebrile hence No signs of meningitis like
viral infection is possible. seizure and photophobia.
Meningitis tends to cause
bilateral nerve palsy.
MANAGEMENT

Proposed investigations:
Full blood count (FBC) to look for signs of infection and
anemia from the white cell count and hemoglobin level
respectively.
HbA1c level to ensure whether patients diabetes is
controlled since the last 3 months.
Fasting blood sugar (FBS) - to check whether patients
blood sugar is controlled.
Renal function test to check for Creatinine level as a sign
of diabetes complication.
Urine FEME (UFEME) to look for presence of albuminuria
as a sign of diabetes complication.

PROPOSED TREATMENT
Patient is admitted to the eye ward in order to control her
blood sugar since diabetes is the primary cause of the palsy.
Plan the right time for patients right eye cataract surgery
only after the abducens nerve palsy is totally treated.
Once she is discharged, patient needs to continue taking her
medications for diabetes, hypertension and dyslipidemia and
come for regular follow up to ensure her condition is stable
and under control.
DISCUSSION

Cranial nerve VI, also known as the abducens nerve,


innervates the ipsilateral lateral rectus (LR), which functions to
abduct the ipsilateral eye. The sixth nerve nucleus is located in
the pons, just ventral to the floor of the fourth ventricle and just
lateral to the medial longitudinal fasciculus (MLF).

Patients usually present with binocular


horizontal diplopia (double vision producing a side-by-side image
with both eyes open), worse in the distance, and esotropia in
primary gaze. Patients also may present with a head-turn to
maintain binocularity and binocular fusion and to minimize
diplopia.

However, in my patient, she does not complaint of having


diplopia or need to turn her head to the right to maintain
binocular vision since she has right eye cataract which causes her
to lose her right eye vision.

Inflammatory and microvascular conditions are risk factors


for abducens nerve palsy. Some risk factors include multiple
sclerosis, encephalitis, meningitis, cavernous sinus thrombosis,
hypertension, hypercholesterolemia, aneurysm, diabetes,
arteriosclerosis, and birth trauma.

My patient is definitely at risk of getting abducens nerve


palsy as she has multiple underlying risk factors long-standing
diabetes, hypertension and dyslipidemia.

Since diabetes is the primary cause of this abducens nerve


palsy, the most relevant treatment is to optimize her blood sugar
level. The best option is to admit her for a few days in the ward to
monitor her blood sugar, as well as her blood pressure readings
and cholesterol level until her condition improves and so that she
will be fit for the planned right eye cataract surgery.
REFERENCE
1. Brad Bowling. Ocular Motor Nerves. Kanski Clinical
Ophthalmology A Systemic Approach, Eighth Edition. 2016;
Chapter 19: Neuro-opthalmology. 828-830.

2. http://emedicine.medscape.com/article/1198383-overview