PATIENT’S Details

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 dyslipid 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 emia 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 c 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 ontinuous 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 hand 6/6
movement.
Near visual acuity - Good

2) INSPECTION
 There was no syndromic feature on patient’s face.
Right eye Left eye
Red reflex Absent Presence
Lid No ptosis and swelling No ptosis and swelling
Eye position Light fell on the pupil Light fell on the centre of
margin temporally. pupil
Conjunctiva White, not injected White, not injected
Cornea Clear Clear
Anterior chamber Normal (deep) Normal (deep)
Pupil Normal - Irregular (oval in shape)
- Presence of 3 stitches at 10,
11 and 12 o’clock 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 (indirect) Present Present
reflex
RAPD Negative Negative

4) DIRECT OPHTALMOSCOPY

Right eye Left eye

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

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 asymmet 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 ry
 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 noti 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 ced 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.

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

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

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.
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 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
Unable to move r 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 ight eye to the
right.
(B) Cerebello-pontine tumor or metastases
POINTS SUPPORTING
 Unable to move right eye to the
right
POINTS AGAINST
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
POINTS AGAINST
 No signs of malignancy 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 to the
right.
 Patient is afebrile hence viral
infection is possible.
 No history of recent infection.
 No signs of meningitis like 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 patient’s diabetes is controlled since the
last 3 months.
  Fasting blood sugar (FBS) - to check whether patient’s 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 patient’s 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.
NAME : SITI NUR BAITI BINTI SHAIK KHAMARUDIN

COORDINATOR : DR KHAING

DATE : 3RD APRIL 2017

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