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Sixth Nerve Palsies

Timothy C. Hain, MD Timothy C. Hain, M.D. Page last modified: June 18, 2009


The sixth nerve is shown on the left, emerging just above the anterior inferior cerebellar artery (AICA).

The sixth cranial nerve innervates the lateral rectus muscle of the eye, which pulls the eye laterally. Injury to the 6th nerve generally causes horizontal double vision, worse at distance than at near. The 6th nerve derives from the 6th nerve nuclei located in the pons. Nerve fibers exit from the brainstem and travel upward, bending over the petrous portion of the temporal bone to enter the cavernous sinus. The fibers enter the orbit via the superior orbital fissure to innervate the lateral rectus muscle.

sixth nerve palsy videoSupplemental material on the site DVD: Movie of right 6th nerve palsy.

Common causes of 6th nerve weakness include:

Disorders that can resemble 6th nerve palsy include:

In restriction syndromes, the eye is held back by the medial rectus. Thyroid disease, Duanes and and trauma are the most common source of these. Duanes syndrome is a congenital oculmotor anomaly -- it is manifested by a pseudo-6th as well as ocular retraction and narrowing of the palpebral fissure on adduction (Rutstein, 1992). Restriction syndromes may be differentiated from ocular muscle weakness with the forced duction test.

6th neve palsy has been reported after lumbar anesthesia (Richer and Ritaccca, 1989), epidural anestheisia (Gupta et al), and after myelography.

In spasm of the near reflex, there is intermittent convergence, accomodation and miosis. The miosis on looking to the side is the hallmark of the disease.


A suggested workup for 6th nerve palsy, adapted from Galetta and Lawton Smith (1989) is as follows:

At presentation:

Subsequent Evaluation

In special situations


Copyright August 3, 2016 , Timothy C. Hain, M.D. All rights reserved. Last saved on August 3, 2016