A 58-year-old diabetic man presents with sudden horizontal double vision. There is complete inability to abduct the left eye and esotropia greater at distance than near. Neuroimaging is normal. Appropriate initial management is:

• A Occlusion or Fresnel prism for diplopia with review over 3 to 6 months for spontaneous recovery ✓
• B Immediate lateral rectus resection with medial rectus recession
• C Systemic corticosteroids for six weeks
• D Botulinum toxin into the left lateral rectus

Explanation

Isolated sixth nerve palsy in an older vasculopathic patient is most often microvascular, and the majority recover spontaneously within 3 to 6 months. Initial management is therefore symptomatic: patching alternate eyes, a Fresnel press-on prism, or botulinum into the ipsilateral medial rectus to limit contracture, with serial observation. Surgery is deferred until the palsy is judged permanent, typically after 6 months of stable deviation. Steroids have no role in microvascular palsies, and injecting the paretic lateral rectus is irrational.

Reference: Kanski's Clinical Ophthalmology, 9th ed.

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Written and medically reviewed by the StethoPrep medical team.