“My eyes are playing a cruel joke on me, doc,” Ronnie, a portly gentleman in his early fifties, lamented as he settled into the chair. “They’ve decided to go their separate ways, like a rock band on a bad tour.” I chuckled, but Ronnie’s predicament was no laughing matter. His left eye was turned inwards, a condition known as esotropia, giving him the appearance of someone perpetually trying to peek at their own nose. This was a classic sign of abducens nerve palsy, a dysfunction of the sixth cranial nerve, the little maestro that orchestrates the eye’s outward movement.
“So, what’s causing this ocular rebellion, doc?” Ronnie asked, his voice laced with a mixture of curiosity and concern. “Did I accidentally anger some ancient Egyptian eye god?”
“While I can’t rule out divine intervention,” I replied, “there are a few more likely culprits.” I proceeded to explain the various causes of abducens nerve palsy, from diabetes and high blood pressure to multiple sclerosis and head trauma. I even threw in a few curveballs, like Lyme disease and Wernicke’s encephalopathy, just to keep him on his toes. “But in your case, Ronnie,” I concluded, “I suspect the answer lies a little deeper.” An MRI scan revealed a small tumour lurking in the cavernous sinus, a delicate network of veins and nerves located deep within the skull. This tumour, like an unwelcome guest at a crowded party, was pressing against the abducens nerve, disrupting its delicate communication with the eye muscles.
“So, you’re saying I have a tiny squatter in my brain?” Ronnie asked, his eyes widening. “And it’s throwing a tantrum that’s affecting my vision?” “In a nutshell, yes,” I replied. “But don’t worry, we’re going to evict that squatter.”
Until not so long ago, the cavernous sinus was decreed as ‘no man’s land’. If you entered within, you were sure to damage all eye movement. But now, our technical ability has evolved to be able to preserve function. Nonetheless, operating on the cavernous sinus is like trying to remove a ball of fire from within a volcano. The moment we entered the cavernous sinus, the tumour started bleeding, a leash of blood vessels ready to burst at any attempt of manipulation. We quickly changed our strategy by going around it, instead of getting into it, amidst a downpour of a 2L blood loss in 20 minutes. Our adept anaesthetists made sure the brain was relaxed and blood pressure maintained. After what seemed like an eternity, the tumour was finally excised, a tiny victory in the grand battle against neurological invaders.
Ronnie’s recovery was swift and remarkable. In neurological time, it was a whole 6 months. His eyes, no longer engaged in their private feud, realigned themselves, and his vision returned to normal. “Doc,” Ronnie exclaimed at his follow-up appointment, his eyes twinkling with mischief, “I can finally watch TV without feeling like I’m at a 3D movie marathon!” He paused, then added with a grin, “although, I do miss being able to peek around corners without moving my head.”
Ronnie’s case was a reminder that even the most seemingly innocuous symptoms can sometimes be a sign of something more serious. But it was also a testament to the resilience of the human body, the skill of modern neurosurgery, and the importance of maintaining a sense of humour, even when your eyes are trying to stage a rebellion.
