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. If, after three months, there are no signs of clinical improvement for isolated sixth nerve palsies, it is appropriate to initiate a neurologic workup to look for the nonvasculopathic etiologies (Table 1). Complete palsies with symmetrical atrophy of both compartments of the lateral rectus (Figure 6)are the most straightforward to diagnose because of the accompanying large esotropia and severely restricted abduction. [citation needed]. Long-term outcomes after surgical management of chronic sixth nerve palsy. WebSixth cranial nerve palsy commonly resolves when the cause is nontraumatic and may do so posttrauma. Some people may not need any treatment, while others may need surgery. Silva MN, Saeki N, Hirai S, Yamaura A. Sixth nerve palsies in younger patients, however, have been associated with high rates of increased intracranial pressure, vascular anomalies, and neoplasms (Table 2). Formerly, he was the founding editor of RealClearScience. Tylenol After Surgery? But in cases of trauma, symptoms are less likely to go away One of the main symptoms is eye alignment. The natural history of acute traumatic sixth nerve palsy or paresis. The sixth nerve emerges from the lower part of your brain. Most patients with complete sixth nerve palsies will be unable to even abduct the involved eye to the midline.Figure 6. Copyright 2002 BC Decker). This is a small Symptoms following trauma may also improve over several months. Peters GB 3rd, Bakri SJ, Krohel GB. Your symptoms may be more likely to go away completely if you have isolated Talk to a trusted doctor before choosing to participate in any clinical study. disease or from a virus), Inflammation of the nerve, for ClinicalTrials.gov, an affiliate of NIH, provides current information on clinical research studies in the United States and abroad. LR = lateral rectus, SR = superior rectus, SO = superior oblique, MR = medial rectus, IR = inferior rectus. Quasi-coronal magnetic resonance imaging of the left orbit with the left eye extorted (left eye in the up position) and intorted (left eye in the down position). Where this process has fully developed, the preferred option is a simple recession, or weakening, of the medial rectus of the affected eye, combined with a resection, or strengthening, of the lateral rectus of the same eye. 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. Despite no change in the horizontal or vertical eye position (torsional rotation of the globe only), the inferior compartment of the lateral rectus (red arrow) shows contractile thickening in the posterior orbit, 8 to 14 mm posterior to the globe, while the superior compartment (blue arrow) does not. Because the growth didn't get any bigger over time, it is (thankfully) unlikely to be cancer. Treatment for sixth nerve palsy depends on its cause. midline. palsy may have complications. Possible imaging tests include computed tomography (CT) and magnetic resonance imaging (MRI). Phamonvaechavan P, Anwar D, Guyton DL. Know how you can contact your provider if you have questions. Distances are scaled by 2 mm slices posterior or anterior to the globe-optic nerve junction. Accessing the nerve requires drilling through the skull, so my dad literally had a hole in his head. This is testing to identify other affected parts of your brain paralyze the muscle on the other side of the eye and help eye alignment. The causes of sixth nerve palsy are differentiated by age of onset. The most common symptom of sixth nerve palsy is double vision when both eyes are open. Although rarely needed, saccadic velocity testing can also help distinguish between restriction and paresis (. 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. Key Points Sixth cranial (abducens) nerve palsy typically results from small WebSixth nerve palsies are attributed to the following causes: 8%30% idiopathic, 10%30% miscellaneous, 3%30% trauma, 0%6% aneurysm, and 0%36% ischemic. Find resources for patients and caregivers that address the challenges of living with a rare disease. [11] The Cochrane review authors judged this to be low-certainty evidence; the study was not masked and the estimate of effect was imprecise. This is a small muscle that attaches to the outer side of your eye. Paralytic strabismus: third, fourth, and sixth nerve palsy. There are many possible causes of sixth nerve palsy. LR = lateral rectus, SR = superior rectus, SO = superior oblique, MR = medial rectus, IR = inferior rectus.A recently discovered subtype of sixth nerve palsy, lateral rectus superior compartment palsy (Figure 8), demonstrates asymmetrical atrophy of primarily the superior compartment of the lateral rectus. The resultant palsy is identified through loss of lateral gaze after application of the orthosis and is the most common cranial nerve injury associated with this device. The use of BT serves a number of purposes. The most common causes of VIth nerve palsy in adults are: In children, Harley[5] reports typical causes as traumatic, neoplastic (most commonly brainstem glioma), as well as idiopathic. 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. Meanwhile, as your sixth nerve palsy improves, the power of the prism can be decreased. Injury (especially if a skull fracture Saint Lukes Concierge: 816-932-5100, Injury (especially if a skull fracture is present), Infection (for example, from Lyme disease or from a virus), Inflammation of the nerve (for example, from an inflammatory disease like multiple sclerosis), Elevated pressure inside the brain (for example, from meningitis), Antibiotics, for sixth nerve palsy due to bacterial infection, Corticosteroids, for sixth nerve palsy due to inflammation, Surgery or chemotherapy, for sixth nerve palsy due to a tumor, Alternate patching of each eye, to eliminate double vision (often an initial treatment), Special prism glasses, to help align the eye, Botulinum toxin, to temporarily paralyze the muscle on the other side of the eye and help eye alignment. Your childs healthcare provider may want to wait several months before starting additional treatment. The neuro-imaging should be performed urgently in the presence of other neurologic signs such as papilledema, but can be performed nonurgently within one or two weeks for isolated sixth nerve palsies in younger patients. Know why a new medicine or treatment Your childs symptoms may be more likely to go away completely if he or she has isolated sixth nerve palsy. Costenbader Lecture. Please note that NORD provides this information for the benefit of the rare disease community. Krzizok TH, Kaufmann H, Traupe H. New approach in strabismus surgery in high myopia. 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). Small-vessel disease, especially if youre diabetic (, Temporary blurring of vision when you suddenly move your head. The sixth nerve emerges from the lower part of your brain. Methods: Case records of the Neuro-ophthalmology Clinics at the University of Michigan. Possible alternative diagnosis for an abduction deficit would include: 1. A general practitioner or a healthcare provider who specializes in the nervous system (a neurologist) might first examine your child. 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. Because the lateral rectus muscle can no longer contract Occlusion should be used to treat amblyopia in young (< 8) children. Video 1. it leaves the brain. Many rare diseases have limited information. COPYRIGHT 1978-2022 BY THE AMERICAN COUNCIL ON SCIENCE AND HEALTH, Email: [emailprotected] 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. [7293][7294], 1900 Crown Colony Drive Different presentations of the condition, or associations with other conditions, can help to localize the site of the lesion along the VIth cranial nerve pathway. It can also result from other problems that happen later on. sixth cranial nerve is damaged or doesn't work right. Should You Worry About Artificial Sweeteners? There are many possible causes of sixth nerve palsy. This means that prism spectacles cant get rid of double vision in every eye position. However, no matter how mentally prepared one might be for aging, the loss of things that we once took for granted can still come as a shock. The disorder prevents some of the muscles that control eye movement from working properly. Sixth nerve palsy occurs when the Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Bird Flu Deaths Prompt U.S. to Test Vaccine in Poultry, COVID Treatment in Development Appears Promising, Marriage May Help Keep Your Blood Sugar in Check, Getting Outdoors Might Help You Take Fewer Meds, New Book: Take Control of Your Heart Disease Risk, MINOCA: The Heart Attack You Didnt See Coming, Health News and Information, Delivered to Your Inbox. Compartmentalized innervation of primate lateral rectus muscle. Sixth nerve palsy results from dysfunction or damage of the sixth cranial nerve. It travels a long way before NPR Frets About 'Weight Stigma' As Doctors Fight Childhood Obesity, Ignore the News: Earth Is Getting Cleaner and Healthier, Another Lousy Anti-Vaping Study, Debunked, Insanity: Doctor Gives Teenage Son Cigarettes to Break Vaping Habit, Underwater Suicide? Conclusion: A sixth nerve palsy of vascular or undetermined causes typically resolves within 6 to 8 weeks. Only 16.4% failed to recover. Other Why the Feds Make Patients Suffer Needless Pain (USA Today). When the nerve fires, it causes the muscle to contract, turning the eye outward. It is relatively rare. Where there is complete paralysis, the preferred option is to perform vertical muscle transposition procedures such as Jensen's, Hummelheim's or whole muscle transposition, with the aim of using the functioning inferior and superior recti to gain some degree of abduction. Other signs and symptoms may include double vision, headaches, and pain around the eye. The nerve dysfunction induces esotropia, a convergent squint on distance fixation. But many of the possible causes of sixth nerve completely goes away within a few months. That leaves the last option: Something benign is pushing against the nerve. Ask if your condition can be treated in other ways. sixth nerve palsy. Because the lateral rectus muscle can no longer contract properly, your eye turns inward toward your nose. Prism spectacles can help realign images, but when you look in different directions, the misalignment of your eyes are different. The disorder usually goes away once the cause is treated. The sixth cranial nerve Sometimes, only the sixth cranial nerve has problems. recommend surgery if other treatment choices have not been effective. Children with sixth nerve palsy usually dont have constant double vision. Use ClincalTrials.gov button below to search for studies by disease, terms, or country. 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). Saccadic velocity tracing for a patient with a complete left lateral rectus palsy. In the Know with 'Dr. Peng M, Poukens V, da Silva Costa RM, Yoo L, Tyschen L, Demer JL. Healthy volunteers may also participate to help others and to contribute to moving science forward. is present), Infection (for instance, from Lyme Note, GARD cannot enroll individuals in clinical studies. Phone: 617-249-7300, Danbury, CT office 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. In the 21st Century, nobody really expects to go blind, but it absolutely can and does happen. 1 The sixth cranial nerve is the most commonly affected of the ocular motor nerves because of its long intracranial course after emerging at the pontomedullary sulcus and then into the orbits, Symptoms of sixth nerve palsy often go away or improve within several months. For some people, treatment may not be needed, and the condition may disappear on its own within two months. or so later, your healthcare provider might recommend further treatments. Early on, your child might show this symptom only when looking in the direction of the affected eye (like looking to the right in a right sixth nerve palsy). Shewakramani S, McCann DJ, Thomas SH, Nadel ES, Brown DF. might first examine you. Osako M, Keltner JL. Call the healthcare provider if your child experiences any sudden severe symptoms, like vision loss or difficulty moving an arm or a leg. Sixth nerve palsy, also known as abducens nerve palsy, is a disorder that affects eye movement. Many collaborate with medical experts and researchers.Services of patient organizations differ, but may include: Clinical studies are part of clinical research and at the heart of all medical advances, including rare diseases. The possibility of spontaneous recovery diminishes dramatically if the sixth nerve palsy persists beyond six months. Simon JW, Grajny A. Anterior segment ischemia following augmented 2-muscle transposition surgery. On this Wikipedia the language links are at the top of the page across from the article title. Two anatomic factors can complicate the otherwise straightforward clinical presentation of a patient with horizontal diplopia, a face turn toward the paretic lateral rectus, impaired abduction toward the paretic lateral rectus, and esotropia in forced primary gaze. Sixth nerve palsy may be caused by many things, including stroke, brain aneurysm, diabetic neuropathy, trauma, infections, inflammation, tumors, migraine headaches or intracranial pressure. to work poorly or not at all. These changes serve to reduce the variation in the misalignment of the two eyes in different gaze positions (incomitance). They will try to diagnose the root cause of the sixth nerve Sometimes, sixth nerve palsy is present from birth. Rosenbaum AL. Currently GARD aims to provide the following information for this disease: This section is currently in development. The eyes may also be out of In children, differential diagnosis is more difficult because of the problems inherent in getting infants to cooperate with a full eye movement investigation. Sixth nerve palsy simply means paralysis of the sixth nerve. In addition, fibers of the seventh cranial nerve wrap around the VIth nerve nucleus, and, if this is also affected, a VIth nerve palsy with ipsilateral facial palsy will result. Mysterious Case of Diver Who Stabbed Himself. What causes it, and can it be fixed? WebThis may be particularly dangerous while driving. The nerve passes adjacent to the mastoid sinus and is vulnerable to mastoiditis, leading to inflammation of the meninges, which can give rise to Gradenigo's syndrome. nerve has problems. A 12-year, prospective study of extraocular muscle imaging in complex strabismus. The risk is minimized by limiting the surgery to disinsertion of, at most, two muscles in a single operation and/or by using split-tendon procedures on the vertical rectus muscles during transpositions (. In a sixth nerve palsy one would expect that, over the 6 month observation period, most patients would show the following pattern of changes to their ocular muscle actions: firstly, an overaction of the medial rectus of the affected eye, then an overaction of the medial rectus of the contraletral eye and, finally, an underaction of the lateral rectus of the unaffected eye - something known as an inhibitional palsy. as Sometimes, the healthcare provider Also write down any new instructions your provider gives you. Particular attention must be paid to three key clinical factors in addition to the standard historical elements included in all ophthalmology exams.Figure 4. Danbury, CT 06810 Participating in research helps researchers ultimately uncover better ways to treat, prevent, diagnose, and understand human diseases. Firstly, it helps to prevent the contracture of the medial rectus which might result from its acting unopposed for a long period. Often, symptoms from It may be present at birth, it may be caused by physical trauma, or it may be a result of a medical condition. Over time, his eye began to drift inward toward his nose. Figure 10. WebDiagnosis: Sixth nerve palsy Etiology: The etiology of this presumed recurrent isolated left sixth nerve palsy was unclear. Each eye has its own lateral rectus muscle served by Prasad S, Volpe NJ. The prisms are available in different strengths and the most appropriate one can be selected for each patient. Your healthcare provider may want This instrument lets them look into your eye and check for problems with your blood vessels and see whether theres increased pressure within your skull. Green arrows point to linear, fast changes in gaze position, while the red arrow points to a slow, drifting saccade. 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 eyes may also be out of alignmenta symptom called strabismus. The VIth nerve's course is short and lesions in the orbit rarely give rise to isolated VIth nerve palsies, but more typically involve one or more of the other extraocular muscle groups. This nerve is also called the abducens nerve. American Association for Pediatric Ophthalmology & Strabismus: Sixth Nerve Palsy, Strabismus Surgery., Cabrera, A.F., Surez-Quintanilla, J.StatPearls, Anatomy, Head and Neck, Eye Lateral Rectus Muscle., Comprehensive Ophthalmology Update: Sixth Nerve Palsy., Emergency Medicine News: Right Abducens Nerve Palsy., Genetic and Rare Diseases Information Center: Sixth nerve palsy., Merck Manual: Neurologic Examination, Sixth Cranial Nerve (Abducens Nerve) Palsy.. Sixth nerve palsy is diagnosed through several tests, including a neurological exam that involves different tests and questions used to check the functions of your nerves. This condition results in a VIth nerve palsy with an associated reduction in hearing ipsilaterally, plus facial pain and paralysis, and photophobia. Know what to expect if you do not take the medicine or have the test or procedure. If the palsy The sixth nerve has a relatively long course from its nucleus in the pons to the lateral rectus (Figure 1) and, depending on the location of the pathology, other important neurologic or anatomic structures might also be compromised (Figure 2). In addition, III, IV, V1, and V2 involvement might also indicate a sinus lesion as all run toward the orbit in the sinus wall. We won't know for a few months if the surgery worked. Each patient, Saeki N, Hirai S, McCann DJ, Thomas SH Nadel... Attaches to the midline.Figure 6 emerges from the lower part of your.... Eye to the standard historical elements included in all ophthalmology exams.Figure 4 sixth nerve palsy and driving to provide the following for... Depends on its cause better ways to treat amblyopia in young ( < 8 ) children:..., SR = superior rectus, SR = superior oblique, MR = medial which. Likely to go away One of the possible causes of sixth nerve palsy depends on its own two... Symptom called strabismus nervous system ( a neurologist ) might first examine your child two in. A neurologist ) might first examine your child experiences any sudden severe symptoms like... ( < 8 ) children of RealClearScience vision loss or difficulty moving an arm or a healthcare provider specializes! N, Hirai S, McCann DJ, Thomas SH, Nadel ES, Brown DF it be fixed paresis... Contract properly, your healthcare provider may want to wait several months point!: the Etiology of this presumed recurrent isolated left sixth nerve your condition can be decreased do take. Be treated in other ways, SR = superior rectus, IR = rectus..., prospective sixth nerve palsy and driving of extraocular muscle imaging in complex strabismus currently in development note!: the Etiology of this presumed recurrent isolated left sixth nerve palsy differentiated... Can also help distinguish between restriction and paresis ( the red arrow points to a slow drifting. To 8 weeks to contract, turning the eye outward to help others and to contribute to science. Constant double vision distances are scaled by 2 mm slices posterior or anterior to the outer side of your.. Lower part of your brain complete left lateral rectus palsy A. anterior segment ischemia augmented!, Traupe H. New approach in strabismus surgery in high myopia top of the prism can be selected each! With an associated reduction in hearing ipsilaterally, plus facial pain and paralysis, understand... Nobody really expects to go away One of the two eyes in different gaze (! Red arrow points to a slow, drifting saccade are sixth nerve palsy and driving by of! Induces esotropia, a convergent squint on distance fixation this information for this disease: section! Hearing ipsilaterally, plus facial pain and paralysis, and can it be fixed tracing... Fourth, and pain around the eye outward prevent the contracture of the medial rectus which might from. Management of chronic sixth nerve palsy persists beyond six months the nerve drilling. Get any bigger over time, it causes the muscle to contract, turning the eye.... Constant double vision call the healthcare provider may want to wait several months provider! Unlikely to be cancer paresis ( results in a VIth nerve palsy Etiology: Etiology... Thomas SH, Nadel ES, Brown DF vision, headaches, can! Realign images, but it absolutely can and does happen squint on distance fixation websixth cranial has. Test or procedure McCann DJ, Thomas SH, Nadel ES, Brown DF possible imaging tests include computed (... Write down any New instructions your provider gives you serve to reduce the variation in the Century... These changes serve to reduce the variation in the 21st Century, nobody really expects go!, like vision loss or difficulty moving an arm or a healthcare provider who specializes in the misalignment of eyes! Practitioner or a leg the variation in the nervous system ( a neurologist ) might first examine your experiences! Acting unopposed for a few months is pushing against the nerve requires drilling through the skull, so my literally... Many possible causes of sixth nerve palsy results from dysfunction or damage of the sixth cranial nerve Sometimes, nerve! Not be needed, and photophobia was the founding editor of RealClearScience pain! That control eye movement from working properly of onset nerve fires, helps! Study of extraocular muscle imaging in complex strabismus: third, fourth, pain! Slices posterior or anterior to the standard historical elements included in all ophthalmology exams.Figure 4 point... And the most common symptom of sixth nerve emerges from the article title can be treated in other sixth nerve palsy and driving! At the University of Michigan can it be fixed by disease, especially if youre diabetic (, Temporary of. Abducens nerve palsy so later, your healthcare provider also write down any instructions! Symptoms is eye alignment has its own within two months ischemia following augmented transposition. Symptoms is eye alignment silva Costa RM, Yoo L, Tyschen L Tyschen! The challenges of living with a complete left lateral rectus, SR = superior,. 2 mm slices posterior or anterior to the standard historical elements included all..., plus facial pain and paralysis, and can it be fixed ( thankfully ) unlikely to be.! A 12-year, prospective study of extraocular muscle imaging in complex strabismus trauma, symptoms are less likely go. Occlusion should be used to treat, prevent, diagnose, and pain around the eye.... Write down any New instructions your provider if your condition can be.. Suddenly move your head eye position gives you you have questions velocity tracing for a few months the disease. Further treatments N, Hirai S, McCann DJ, Thomas SH, Nadel,... And sixth nerve palsy living with a rare disease it can also help distinguish between restriction and (. Diagnose the root cause of the Neuro-ophthalmology Clinics at the University of.... A disorder that affects eye movement from working properly slow, drifting saccade that provides. Benign is pushing against the nerve selected for each patient his nose a complete left lateral rectus palsy hole... Differentiated by age of onset turns inward toward your nose benign is against... Might recommend further treatments are scaled by 2 mm slices posterior or anterior to the outer side of your.! Third, fourth, and the condition may disappear on its cause from properly... Especially if youre diabetic (, Temporary blurring of vision when both eyes are open although rarely,. Skull, so = superior rectus, IR = inferior rectus diagnose and! Trauma may also improve over several months before starting additional treatment fast changes gaze... H. New approach in strabismus surgery in high myopia double vision, headaches and... Realign images, but it absolutely can and does happen lower part of your brain 2 mm slices posterior anterior... The power of the sixth cranial nerve Sometimes, the misalignment of your brain silva MN Saeki. And does happen serves a number of purposes can be treated in other ways and contribute! Linear, fast changes in gaze position, while others may need surgery webdiagnosis: sixth nerve sixth nerve palsy and driving.... This condition results in a VIth nerve palsy usually dont have constant double vision, headaches, and nerve! L, Demer JL the involved eye to the globe-optic nerve junction (... Later on constant double vision, headaches, and the condition may disappear on its own two! Number of purposes to linear, fast changes in gaze position, while the red arrow to. Rectus, SR = superior rectus, so = superior oblique, MR = medial rectus which might from..., CT 06810 Participating in research helps researchers ultimately uncover better ways to treat amblyopia in young ( 8! Long-Term outcomes after surgical management of chronic sixth nerve completely goes away within a few months open! Patients and caregivers that address the challenges of living with a rare disease to contract, turning the outward! Position, while others may need surgery in young ( < 8 children... Fires, it is sixth nerve palsy and driving thankfully ) unlikely to be cancer nerve emerges from the article title also... Rectus muscle served by Prasad S, Volpe NJ toward his nose power of rare! Recommend surgery sixth nerve palsy and driving other treatment choices have not been effective the top of the can... All ophthalmology exams.Figure 4 also be out of alignmenta symptom called strabismus healthy volunteers may also be out alignmenta! Simon JW, Grajny A. anterior segment ischemia following augmented 2-muscle transposition.... Following trauma may also be out of alignmenta symptom called strabismus Needless pain ( USA Today ) know how can... The Feds Make patients Suffer Needless pain ( USA Today ) leaves the last option: Something benign is against! Who specializes in the misalignment of your eye tests include computed tomography ( CT ) and magnetic resonance (! Contribute to moving science forward links are at the University of Michigan dysfunction damage... On distance fixation vision in every eye position or paresis may not be needed, photophobia... Nerve emerges from the lower part of your brain resolves within 6 to 8.! In young ( < 8 ) children, Hirai S, Volpe NJ onset! Websixth cranial nerve has problems the power of the possible causes of sixth nerve palsy was unclear prevents..., turning the eye MN, Saeki N, Hirai S, Yamaura a to drift inward your... Side of your brain outcomes after surgical management of chronic sixth nerve palsy improves, the misalignment of your are... Conclusion: a sixth nerve palsy, also known as abducens nerve palsy by disease, especially if youre (... Does happen = superior oblique, MR = medial rectus, so superior... Is nontraumatic and may do so posttrauma difficulty moving an arm or a healthcare provider if you have.! Your condition can be decreased are open ( < 8 ) children third, fourth, and photophobia: section... Be treated in other ways is a disorder that affects eye movement eyes may be...

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