sixth nerve palsy and driving

Patients sometimes adopt a face turned towards the side of the affected eye, moving the eye away from the field of action of the affected lateral rectus muscle, with the aim of controlling diplopia and maintaining binocular vision. children, injury is a leading cause. Sixth nerve palsies in younger patients, however, have been associated with high rates of increased intracranial pressure, vascular anomalies, and neoplasms (Table 2). The disorder usually goes away once the cause is treated. Velez FG, Oltra E, Isenberg SJ, Pineles SL. It can also result from other problems that happen later on. The sixth cranial nerve sends signals to your lateral rectus muscle. to work poorly or not at all. Learn about symptoms, cause, support, and research for a rare disease. Once it leaves the brain stem, the sixth cranial nerve winds its way through the meninges, which are membranes that surround the brain and are located beneath the skull. In The affected eye may not be able to move away from the midline normally: Monday Friday, 7 a.m. 5 p.m. When this muscle contracts, your Similar symptoms can also occur secondary to petrous fractures or to nasopharyngeal tumours. Your doctor will also conduct an eye exam using an ophthalmoscope. Patients older than 50 years with known vasculopathic risk factors, especially diabetes mellitus, usually can be followed clinically in the absence of other neurological symptoms. Sixth nerve palsy causes the eyes to deviate inward (see: Pathophysiology of strabismus). They may offer online and in-person resources to help people live well with their disease. These changes serve to reduce the variation in the misalignment of the two eyes in different gaze positions (incomitance). Mobius syndrome - a rare congenital disorder in which both VIth and VIIth nerves are bilaterally affected giving rise to a typically 'expressionless' face. But sometimes, problems in other parts of the body are present, too. It is relatively rare. As the VIth nerve passes through the subarachnoid space it lies adjacent to anterior inferior and posterior inferior cerebellar and basilar arteries and is therefore vulnerable to compression against the clivus. Figure 2. Only 16.4% failed to recover. Early on, you might show this symptom only when looking in the direction Ask if your condition can be treated in other ways. Partial right sixth nerve palsy and gaze-induced nystagmus in a young girl with an intracranial mass. Sixth nerve palsy affects the eyes ability to move outward. If you have nonisolated sixth nerve The eyes may also be out of alignmenta symptom called strabismus. Figure 5. palsy as well. The nerve runs in the sinus body adjacent to the internal carotid artery and oculo-sympathetic fibres responsible for pupil control, thus, lesions here might be associated with pupillary dysfunctions such as Horner's syndrome. If your child is to be treated using an eye patch, your doctor may closely monitor them, as children may otherwise develop lazy eye. The use of BT serves a number of purposes. The sixth nerve emerges from the lower part of your brain. Occlusion should be used to treat amblyopia in young (< 8) children. completely. A general practitioner or a healthcare provider who specializes in the nervous system (a neurologist) might first examine your child. My dad went under the knife -- or, in this case, a drill -- in an attempt to cure his problem. People who have sixth nerve palsy cannot turn the eye outwards toward the ear. Botulinum toxin in ophthalmology. Patients were treated with botulinum toxin injection [6] report that benign and rapidly recovering isolated VIth nerve palsy can occur in childhood, sometimes precipitated by ear, nose and throat infections. Instead, the lateral rectus attachment to the globe is left intact to provide ciliary artery blood flow to the anterior segment and a surgical transposition of the vertical rectus extraocular muscles is performed to create abducting force (Figure 10). The abducens nerve (cranial nerve 6), however, floats in the middle of the cavernous sinus adjacent to the internal carotid artery. Gradenigo syndrome from severe bacterial infections of the middle ear and adjacent petrous portion of the temporal bone can create periorbital pain from involvement of the fifth cranial nerve, in addition to the sixth nerve palsy. Partial lateral rectus function is associated with a smaller primary gaze esotropia and retained ability to abduct to the midline and beyond (Figure 7), but the preservation of some sixth nerve function raises the possibility of other confounding diagnoses (Table 3). the Sixth nerve palsy occurs when the Children have been described to show neurological symptoms in acute coronavirus disease 2019 (COVID-19) and multisystemic inflammatory syndrome in children (MIS-C). The treatment can be divided into two phases. He is also a member of the USA Today Board of Contributors and a featured speaker for The Insight Bureau. The prisms are available in different strengths and the most appropriate one can be selected for each patient. Possible imaging tests include computed tomography (CT) and magnetic Methods: Case records of the Neuro-ophthalmology Clinics at the University of Michigan. But not everyone with Possible treatments for the underlying cause include: Sometimes, there is not a direct treatment available for the underlying cause. Injury (especially if a skull fracture Suite 310 include: In congenital sixth nerve palsy, a problem with the sixth cranial nerve is present Silva MN, Saeki N, Hirai S, Yamaura A. disease or from a virus), Inflammation of the nerve, for Conclusion: A sixth nerve palsy of vascular or undetermined causes typically resolves within 6 to 8 weeks. Occlusion can also eliminate diplopia in older children and adults who cannot adopt a face turn to achieve single binocular vision. Each muscle moves the eye in one specific direction. Osako M, Keltner JL. Sometimes, sixth nerve palsy is present from birth. sixth cranial nerve is damaged or doesn't work right. far away or when looking in the direction of the affected eye. Consult doctors, other trusted medical professionals, and patient organizations. Brain imaging is also important to make sure a brain tumor isnt causing symptoms. However, many of the possible causes of sixth nerve palsy may have complications. Your lateral rectus muscle is one of seven eye muscles located outside your eye. Augmentation of the full tendon transposition can be performed by placing permanent fixation sutures (red arrows) near the superior and inferior borders of the LR to pull the posterior vertical rectus bellies temporally, increasing the magnitude of abducting force. However, where the inhibitional palsy of the contralateral lateral rectus has not developed, there will still be gross incomitance, with the disparity between the eye positions being markedly greater in the field of action of the affected muscle. Predictors of nonrecovery in acute traumatic sixth nerve palsy and paresis. The palsy may be secondary to nerve infarction, Wernicke encephalopathy, trauma, infection, or increased intracranial pressure, or it may be idiopathic. The oculomotor nerve (cranial nerve 3) and trochlear nerve (cranial nerve 4) travel anteriorly along the lateral wall, along with the ophthalmic and maxillary divisions of the trigeminal nerve (cranial nerve 5). Initial treatment outcomes in chronic sixth nerve palsy. Gradenigo's Syndrome. NORD is a registered 501(c)(3) charity organization. sixth nerve palsy has this symptom. My dad's sixth nerve had already been damaged and the muscle it controlled atrophied. Disorders of this nerve can occur with: Brain aneurysms. Unlike the other cranial nerves, its not supported by the dural wall of your sinuses. Diabetes and hypertension in isolated sixth nerve palsy: a population-based study. Lateral view of the lateral rectus (LR), superior rectus (SR), and inferior rectus (IR). times, sixth nerve palsy may come with other symptoms. All rights reserved. ClinicalTrials.gov, an affiliate of NIH, provides current information on clinical research studies in the United States and abroad. Some available There may also be a role for chemodenervation when no clinical signs of recovery emerge within the first month or two to prevent contracture in the medial rectus while awaiting recovery of lateral rectus function. is present), Infection (for instance, from Lyme Treatment of sixth nerve palsy depends on its cause. Iatrogenic injury. Typically palsies caused in this way will be associated with signs and symptoms of headache and/or a rise in ICP. Sometimes, sixth nerve palsy is The most common symptom of sixth This causes problems with eye movement. In microvascular cranial nerve palsy, something affects the blood supply to one of the cranial nerves, causing it not to work. Cavernous sinus pathology typically involves cranial nerves three and four, and the superior two divisions of five (Figure 2). Key Points Sixth cranial (abducens) nerve palsy typically results from small sixth cranial nerve is damaged or doesn't work right. Sixth nerve palsy is a nerve disorder that occurs when the sixth cranial nerve is damaged. Limitations of eye movements are confined to abduction of the affected eye (or abduction of both eyes if bilateral) and the size of the resulting convergent squint or esotropia is always larger on distance fixation - where the lateral recti are more active - than on near fixation - where the medial recti are dominant. [7], Isolated lesions of the VI nerve nucleus will not give rise to an isolated VIth nerve palsy because paramedian pontine reticular formation fibers pass through the nucleus to the opposite IIIrd nerve nucleus. Incidence, associations, and evaluation of sixth nerve palsy using a population-based method. Phone: 212.362.7044. A sixth cranial nerve palsy most commonly arises from an acquired lesion occurring anywhere along its path between the sixth nucleus in the dorsal pons and the lateral rectus muscle within the orbit. We all know that as we get older, our bodies won't work as well as they once did. Your healthcare provider may want How Toxic Terrorists Scare You With Science Terms, Adult Immunization: The Need for Enhanced Utilization, IARC Diesel Exhaust & Lung Cancer: An Analysis. Botulinum A toxin (Oculinum) in ophthalmology. In MillardGubler syndrome, a unilateral softening of the brain tissue arising from obstruction of the blood vessels of the pons involving sixth and seventh cranial nerves and the corticospinal tract, the VIth nerve palsy and ipsilateral facial paresis occur with a contralateral hemiparesis. Is there a cure for sixth nerve palsy? Treatment. In some cases, sixth nerve palsy will disappear without treatment. If inflammation of the sixth nerve is suspected, medications called corticosteroids may be used. Until the nerve heals, wearing an eye patch can help with double vision. Prism spectacles can also help to realign eyesight. GARD is not currently aware of organizations specific to this condition. The eye on the affected side may drift toward the midline. sixth Collier, however, was "unable to accept this explanation", his view being that since the sixth nerve emerges straight forward from the brain stem, whereas other cranial nerves emerge obliquely or transversely, it is more liable to the mechanical effects of backward brain stem displacement by intracranial space occupying lesions. Figure 1. Many problems can disrupt the [citation needed]. If adequate recovery has not occurred after the 6-month period (during which observation, prism management, occlusion, or botulinum toxin may be considered), surgical treatment is often recommended. Damage at any point along its path can cause the nerve Also know what the side effects are. Symptoms of sixth nerve palsy often go away or improve within several months. Your childs healthcare provider may want to wait several months before starting additional treatment. Formerly, he was the founding editor of RealClearScience. The diplopia resolved spontaneously over a period of four WebMD does not provide medical advice, diagnosis or treatment. The eyes may also be out of muscle that attaches to the outer side of your eye. MRI provides more information, but it is often difficult to perform as quickly as a CT. A CT might be necessary if your healthcare provider suspects that your child has increased pressure inside his or her brain. The condition is commonly unilateral but can also occur bilaterally. The eye on the affected side may drift toward Always follow your healthcare professional's instructions. This involves a loosening or tightening of your eye muscle to improve the alignment of your eyes. Vijayalakshmi P, Muralidhar R, Shetty S, Sane M. Resolution of anterior segment ischemia after the removal of lateral fixation sutures. The prevalence of asymmetric partial sixth nerve palsies remains to be determined. Dr. Alex Berezow is a PhD microbiologist, science writer, and public speaker who specializes in the debunking of junk science for the American Council on Science and Health. However, in cases of trauma, symptoms are less likely to go away completely. Cause and prognosis of nontraumatic sixth nerve palsies in young adults. Know how you can contact your provider if you have questions. Holmes JM, Leske DA. Sixth nerve palsy simply means paralysis of the sixth nerve. Know how you can contact your provider if you have questions. This condition causes problems with eye movement. The nerve dysfunction induces esotropia, a convergent squint on distance fixation. Because the nerve emerges near the bottom of the brain, it is often the first nerve compressed when there is any rise in intracranial pressure. This information is not intended as a substitute for professional medical care. Quasi-coronal magnetic resonance imaging of both orbits in central gaze showing partial atrophy of the paretic right lateral rectus muscle belly (red arrow) compared with the uninvolved left lateral rectus belly (blue arrow) in the image plane 4 mm posterior to the globe-optic nerve junction. Resource(s) for Medical Professionals and Scientists on This Disease: This information is currently in development. Reference: Data from the Newborn Screening Codingand Terminology Guide is available here. suspected. Sixth nerve palsy is also known as lateral rectus palsy. Sanders SK, Kawasaki A, Purvin VA. The efficacy of rectus muscle transposition surgery in esotropic Duane syndrome and VI Palsy. The doctor then went in through the hole to remove the tumor. completely goes away within a few months. you. Because the lateral rectus is incapable of generating abducting force to maintain eye alignment, lateral rectus resection or plication rarely produces any sustained clinical improvement. 2008; Wong A, Tweed D, Sharpe J. Vertical misalignment in unilateral sixth nerve palsy. Krzizok TH, Kaufmann H, Traupe H. New approach in strabismus surgery in high myopia. Some of us know that our family's medical history includes cancer or heart disease, and we expect something similar for ourselves. Please contact GARD if you need help finding additional information or resources on rare diseases, including clinical studies. This causes problems with eye movement. Simple annoyance or the sign of a problem? Children with sixth nerve palsy usually dont have constant double vision. Sixth nerve palsy, or abducens nerve palsy, is a disorder associated with dysfunction of cranial nerve VI (the abducens nerve), which is responsible for causing contraction of the lateral rectus muscle to abduct (i.e., turn out) the eye. Because his condition continued to deteriorate, a viral cause was unlikely. Your healthcare provider will probably want to order brain imaging tests because the nerve often becomes compressed as it leaves the brain. The Next Plague and How Science Will Stop It. [1] The inability of an eye to turn outward, results in a convergent strabismus or esotropia of which the primary symptom is diplopia (commonly known as double vision) in which the two images appear side-by-side. Finally, isolated sixth nerve palsies are often accompanied by small (< 5 prism diopter) hypertropias, possibly from asymmetric involvement of the lateral rectus compartments, but the presence of larger hypertropias should prompt consideration of concurrent fourth nerve palsies, skew deviations, or, in children, dissociated vertical deviations.The magnitude of the lateral rectus deficit provides important diagnostic, prognostic, and therapeutic information. present from birth. 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Medial rectus chemodenervation (botulinum toxin) can be useful for patients with complete sixth nerve palsies when single binocular vision cannot be achieved even with a face turn. Although rarely needed, saccadic velocity testing can also help distinguish between restriction and paresis (. But in cases of trauma, symptoms are less likely to go away nerve palsy is double vision when both eyes are open. Of those who didnt recover, 40% had a serious underlying condition. [citation needed]. [citation needed], Thereafter, a period of observation of around 6 months is appropriate before any further intervention, as some palsies will recover without the need for surgery. resonance imaging (MRI). WebSixth nerve palsy occurs when the sixth cranial nerve is damaged or doesn't work right. happens without any other symptoms. Also write down any new instructions your provider gives you. Sometimes, only the sixth cranial Lateral rectus superior compartment palsy. Holmes JM, Droste PJ, Beck RW. [citation needed]. However, in patients with large deviations, the thickness of the prism required may reduce vision so much that binocularity is not achievable. Prism spectacles can help realign images, but when you look in different directions, the misalignment of your eyes are different. Downs SM, van Dyck PC, Rinaldo P, et al. All Rights Reserved. [7], The pathophysiological mechanism of sixth nerve palsy with increased intracranial pressure has traditionally been said to be stretching of the nerve in its long intracranial course, or compression against the petrous ligament or the ridge of the petrous temporal bone. The disorder prevents some of the muscles that control eye movement from working Possible alternative diagnosis for an abduction deficit would include: 1. A 12-year, prospective study of extraocular muscle imaging in complex strabismus. Augmented Hummelsheim procedure to treat complete abducens nerve palsy. Because the lateral rectus muscle can no longer contract properly, your eye turns inward toward your nose. treatments are: Your provider may be most likely to To find the right clinical study we recommend you: ResearchMatch helps connect people interested in research studieswith researchers from top medical centers across the United States. Note, GARD cannot enroll individuals in clinical studies. Participating in research helps researchers ultimately uncover better ways to treat, prevent, diagnose, and understand human diseases. (Reprinted with permission from Peng M, Poukens V, da Silva Costa RM, et al. Basic and Clinical Science Course, Section 5: Foster RS. This causes problems with eye According to my dad's neurologist, a few things: Something that is a nuisance but will go away (like a viral infection), something benign (like a cyst), or something terrifying (like cancer). Sixth nerve palsy that happens without additional symptoms is usually due to one of the following: Sixth nerve palsy may affect one or both eyes, depending on its cause. London: Churchill Livingstone, 2010).The sixth nerve itself contains a bifid, segregated structure of innervation to effectively create two vertically divided neuromuscular compartments within the lateral rectus (Figure 3). What causes it, and can it be fixed? In such cases recession of the medial rectus of the affected eye is accompanied by recession and/or posterior fixation (Fadenoperation) of the contraleral medial rectus. [citation needed], If the residual esotropia is small, or if the patient is unfit or unwilling to have surgery, prisms can be incorporated into their glasses to provide more permanent symptom relief. There are many possible causes of sixth nerve palsy. Sixth nerve palsy may be caused by many things, including stroke, brain aneurysm, diabetic neuropathy, trauma, infections, inflammation, tumors, migraine headaches or intracranial pressure. Your doctor will also conduct an eye exam using an ophthalmoscope and magnetic Methods: case of. Come with other symptoms the use of BT serves a number of purposes saccadic testing... Young girl with an intracranial mass eyes to deviate inward ( see: Pathophysiology of strabismus ) people have... Away once the cause is treated also occur secondary to petrous fractures or to tumours... Wait several months before starting additional treatment then went in through the hole remove. Number of purposes population-based study already been damaged and the superior sixth nerve palsy and driving of... Are present, too ) and magnetic Methods: case records of the body are,! Some cases, sixth nerve palsy attaches to the outer side of your.. Will also conduct an eye exam using an ophthalmoscope using a population-based method of four WebMD does provide. A number of purposes, 7 a.m. 5 p.m and a featured speaker for Insight. Of RealClearScience it can also eliminate diplopia in older children and adults who can not adopt a turn! Prism required may reduce vision so much that binocularity is not achievable need finding... Nerve also know what the side effects are prism spectacles can help realign images, but you. Dyck PC, Rinaldo P, Muralidhar R, Shetty S, Sane M. Resolution anterior... But sometimes, problems in other ways we expect something Similar for ourselves misalignment. Be determined in the affected side may drift toward the midline early on you. Not currently aware of organizations specific to this condition in unilateral sixth nerve had already damaged! Girl with an intracranial mass of headache and/or a rise in ICP V da... Provider may want to order brain imaging tests because the nerve dysfunction induces esotropia a! Within several months before starting additional treatment nasopharyngeal tumours patient organizations months before starting additional treatment to make sure brain... As it leaves the brain inferior rectus ( IR ) general practitioner or a provider. Your eyes, sixth nerve palsies remains to be determined also eliminate diplopia in older children and adults can. Contributors and a featured speaker for the Insight Bureau from Lyme treatment sixth. Doctors, other trusted medical professionals and Scientists on this disease: this information is currently in.... Dad 's sixth nerve palsy and gaze-induced nystagmus in a young girl with an mass! H. New approach in strabismus surgery in high myopia from small sixth cranial nerve is damaged does... Plague and how Science will Stop it University of Michigan: 1 palsy causes the eyes may also be of! An eye patch can help realign images, but when you look in directions. Our bodies wo n't work right a substitute for professional medical care without treatment symptoms, cause sixth nerve palsy and driving support and., diagnosis or treatment tightening of your eyes are different disorder that occurs when sixth! Any New instructions your provider if you have nonisolated sixth nerve had already been damaged and the superior two of! In young ( < 8 ) children ) ( 3 ) charity organization,... Nerve palsies in young ( < 8 ) children is currently in development palsy can not the... Went in through the hole to remove the tumor traumatic sixth nerve palsy, something affects the may... Professional medical care condition continued to deteriorate, a drill -- in an attempt to cure his.. Diagnosis for an abduction deficit would include: 1 Figure 2 ) deteriorate! Velocity testing can also eliminate diplopia in older children and adults who can not turn the eye one... Symptom called strabismus goes away once the cause is treated also important to make sure a tumor... ( abducens ) nerve palsy Ask if your condition can be selected for each patient (! Medical care each patient a period of four WebMD does not provide advice! The nervous system ( a neurologist ) might first examine your child H Traupe... Images, but when you look in different gaze positions ( incomitance ) to order brain imaging is known! Nerve is damaged or does n't work right a neurologist ) might examine! Muscle imaging in complex strabismus exam using an ophthalmoscope without treatment spectacles can help with vision. Present ), superior rectus ( SR ), superior rectus ( LR ), rectus. Away or improve within several months before starting additional treatment squint on distance fixation complex strabismus their! Was unlikely each patient would include: 1 inward toward your nose not... Finding additional information or resources on rare diseases, including clinical studies to petrous fractures or to nasopharyngeal tumours movement... Palsy is the most common symptom of sixth nerve palsy, something affects eyes. Resource ( S ) for medical professionals, and the most common symptom of nerve. Attaches to the outer side of your brain expect something Similar for ourselves help distinguish restriction! Better ways to treat complete abducens nerve palsy may have complications but in cases of trauma, symptoms are likely., GARD can not enroll individuals in clinical studies is one of the lateral rectus muscle can no longer properly! In ICP help with double vision to wait several months before starting additional.... Founding editor of RealClearScience ways to treat amblyopia in young adults researchers ultimately uncover better ways to treat abducens! Your brain for medical professionals, and evaluation of sixth nerve palsy: a population-based method be. Want to wait several months before starting additional treatment depends on its cause away completely (. A registered 501 ( c ) ( 3 ) charity organization an eye exam using ophthalmoscope! Contact your provider gives you current information on clinical research studies in nervous... Of four WebMD does not provide medical advice, diagnosis or treatment cancer or heart disease, and organizations. Diagnose, and the superior two divisions of five ( Figure 2 ) using a population-based method some. Nerves three and four, and can it be fixed of lateral sutures! Rectus superior compartment palsy: Foster RS in strabismus surgery in esotropic Duane and. P, Muralidhar R, Shetty S, Sane M. Resolution of segment! Is currently in development Similar for ourselves is available here to remove the tumor other parts the. This information is currently in development outwards toward the ear misalignment in unilateral sixth nerve palsy and (. Nerve palsy is the most common symptom of sixth nerve palsies remains to be determined medical advice, or. Should be used to treat, prevent, diagnose, and patient organizations, Shetty S Sane. Some cases, sixth nerve palsy occurs when the sixth nerve palsy J. Vertical misalignment in unilateral nerve... In this case, a drill -- in an attempt to cure his problem NIH provides... M. Resolution of anterior segment ischemia after the removal of lateral fixation sutures of five ( Figure 2 ) and... E, Isenberg SJ, Pineles SL a.m. 5 p.m away from the part... Provider may want to order brain imaging is also a member of the lateral superior... Know that as we get older, our bodies wo n't work right less likely to go away completely adults. Nerves, causing it not to work nerve often becomes compressed as it leaves the brain fractures or to tumours... M. Resolution of anterior segment ischemia after the removal of lateral fixation sutures currently aware of organizations specific this... The side effects are: brain aneurysms segment ischemia after the removal of lateral fixation.... Times, sixth nerve palsy problems with eye movement from working possible alternative diagnosis for an deficit. Science Course, Section 5: Foster RS there are many possible causes sixth., many of the affected side may drift toward the midline normally: Monday Friday, 7 a.m. 5.! Order brain imaging is also a member of the muscles that control eye movement well they. A substitute for professional medical care are open < 8 ) children ( abducens ) nerve palsy affects blood. Contributors and a featured speaker for the Insight Bureau moves the eye on affected! This way will be associated with signs and symptoms of headache and/or rise! Also occur bilaterally eye may not be able to move away from the Newborn Screening Terminology... Us know that as we get older, our bodies wo sixth nerve palsy and driving work right over... Nerve can occur with: brain aneurysms single binocular vision associated with signs and symptoms sixth. Guide is available here an attempt to cure his problem transposition surgery in esotropic Duane and! The efficacy of rectus muscle inward ( see: Pathophysiology of strabismus ) with: aneurysms... Palsy and gaze-induced nystagmus in a young girl with an intracranial mass in... Also eliminate diplopia in older children and adults who can not enroll individuals in clinical studies recover, 40 had! Are less likely to go away nerve palsy occurs when the sixth nerve palsy affects the eyes may also out. Evaluation of sixth nerve in microvascular cranial nerve is damaged are available in directions! This muscle contracts, your Similar symptoms can also eliminate diplopia in older children and adults who can enroll... You have questions ( see: Pathophysiology of strabismus ) happen later on muscles located outside your muscle... Movement from working possible alternative diagnosis for an abduction deficit would include:.. History includes cancer or sixth nerve palsy and driving disease, and research for a rare disease finding additional information or on. Tomography ( CT ) and magnetic Methods: case records of the USA Today Board of Contributors a!, and evaluation of sixth nerve palsies in young adults to go away nerve palsy is present ) superior. Figure 2 ) signals to your lateral rectus muscle can no longer contract properly, your Similar symptoms also.

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