Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Background and Aims Diplopia secondary to sixth nerve palsy is a rare complication following unintentional or intentional dural-arachnoid puncture. This complication typically involves the sixth cranial nerve and is associated with intracranial hypotension. Symptoms can appear between 24 hours until 8 weeks post-puncture, and most cases are preceded by post dural puncture headache. Treatment with epidural blood is controversy, and usually ineffective.

Methods We present the case of a 42-year-old female patient who underwent a second cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for recurrent peritoneal ovarian tumor. Before anesthesia induction, an inadvertent dural puncture occurred at T11-T12 level. The patient developed characteristic headaches two days post- surgery, which improved with symptomatic treatment, and diplopia after hospital discharge.

Results Seven days after surgery, the patient returned with horizontal binocular diplopia, headache, and photophobia. A cranial CT scan showed no abnormalities, and she was diagnosed with intracranial hypotension and right sixth nerve palsy. An epidural blood patch was performed in the first 24 hours, leading to improvement in photophobia and headache. However, two months after the inadvertent puncture, the patient continued to experience mild diplopia, which improved gradually with prism glasses and rest.

Conclusions This case highlights the potential for sixth nerve palsy following dural puncture due to CSF loss, emphasizing the need for awareness and timely intervention to mitigate symptoms. Further research is needed to better understand this rare complication and optimize treatment strategies.