Korean J Ophthalmol.  2011 Dec;25(6):459-462. 10.3341/kjo.2011.25.6.459.

Horner's Syndrome with Abducens Nerve Palsy

• Kang NH
• Lim KH
• Sung SH

• KMID: 1031197
• DOI: http://doi.org/10.3341/kjo.2011.25.6.459

Abstract

A 68-year-old male patient presented with a week of sudden diplopia. He had been diagnosed with nasopharyngeal cancer 8 months prior and had undergone chemotherapy with radiotherapy. Eight-prism diopter right esotropia in the primary position and a remarkable limitation in abduction in his right eye were observed. Other pupillary disorders and lid drooping were not found. After three weeks, the marginal reflex distance 1 was 3 mm in the right eye and 5 mm in the left eye. The pupil diameter was 2.5 mm in the right eye, and 3 mm in the left eye under room illumination. Under darkened conditions, the pupil diameter was 3.5 mm in the right eye, and 5 mm in the left eye. After topical application of 0.5% apraclonidine, improvement in the right ptosis and reversal pupillary dilatation were observed. On brain magnetic resonance imaging, enhanced lesions on the right cavernous sinus, both sphenoidal sinuses, and skull base suggested the invasion of nasopharyngeal cancer. Lesions on the cavernous sinus need to be considered in cases of abducens nerve palsy and ipsilateral Horner's syndrome.

Keyword

Abducens nerve diseases; Cavernous sinus; Horner's syndrome; Nasopharyngeal neoplasms

MeSH Terms

Abducens Nerve Diseases/*etiology
Aged
Carcinoma, Squamous Cell/complications/pathology/therapy
Cavernous Sinus/pathology
Combined Modality Therapy
Horner Syndrome/*etiology
Humans
Magnetic Resonance Imaging
Male
Nasopharyngeal Neoplasms/complications/pathology/therapy

Figure

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  Fig. 1 Ocular movements. Right esotropia and limitation of abduction in the right eye consistent with right abducens nerve palsy were observed.

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  Fig. 2 (A1,B1) Before topical application of 0.5% apraclonidine in room light. Pupil right eye (OD) measured 2.5 mm (A1), pupil left eye (OS) measured 3.0 mm (B1). (A2,B2) After topical application of 0.5% apraclonidine in bright light. Pupil OD measures 5.0 mm (A2), pupil OS measured 4.0 mm (B2). Reversal of pupillary dilatation under topical application of 0.5% apraclonidine was detected. (C1,C2) Note also the improvement of the mild ptosis in the right side after topical application of 0.5% apraclonidine.

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  Fig. 3 Axial T1-weighted contrast-enhanced magnetic resonance images. Ill-defined right cavernous sinus lesion extending into the sphenoidal sinus and encasement of the internal carotid were found.

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  Fig. 4 A photomicrograph of the frozen biopsy during the functional endoscopic sinus surgery showing the moderately to poorly differentiated squamous cells in the right sphenoid sinus (H&E, ×200).

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  Fig. 5 Schematic drawing demonstrating the anatomy of the posterior portion of the cavernous sinus on the right side. Oculosympathetic nerve fibers leave the internal carotid artery, and then join the abducens nerve for a short distance in the posterior portion of the cavernous sinus (arrow). CN III = oculomotor nerve; CN IV = trochlear nerve; CN V = trigeminal nerve; ICA = internal carotid; CN VI = abducens nerve; Sym = oculosympathetic nerve.

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