A 6-year-old child presents with acute-onset esotropia and diplopia following a viral illness. On examination, there is restricted abduction of the right eye with intact pupillary responses. Imaging rules out structural lesions. What is the drug of choice for management of this acute sixth nerve palsy?

Explanation

## Acute Sixth Nerve Palsy Management ### Clinical Context Acute sixth nerve palsy in children, especially post-viral, is often inflammatory in origin. The restricted abduction with esotropia and diplopia confirms CN VI involvement. ### Drug of Choice: Prednisolone **Key Point:** Systemic corticosteroids (prednisolone) are the first-line pharmacological treatment for acute inflammatory cranial nerve palsies, including sixth nerve palsy in children. **Mechanism:** - Reduces inflammation of the sixth nerve sheath - Improves nerve conduction and function - Most effective when started early (within 2–3 weeks of onset) **Dosing:** - Typical regimen: 1 mg/kg/day (max 80 mg) for 5–7 days, followed by taper - Higher doses may be used in severe cases **Clinical Pearl:** Post-viral sixth nerve palsies in children have a good prognosis with corticosteroids; ~80% recover completely within 3–6 months. Early intervention improves outcomes. ### Supportive Management - Occlusion therapy (alternate patching) to manage diplopia - Prisms for residual deviation if needed - Orthoptic exercises ### When Botulinum Toxin Is Used **High-Yield:** Botulinum toxin is reserved for: - Chronic/non-resolving strabismus (>6 months) - Patients who decline surgery - Temporary management while awaiting spontaneous recovery - NOT first-line in acute phase ### Surgical Management - Reserved for residual deviation after 6–12 months of observation - Medial rectus recession or lateral rectus advancement [cite:Strabismus and Neuro-ophthalmology, AIIMS Ophthalmology]