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Correct! An incomitant esotropia with image separation greatest in right gaze suggests a right abduction deficit, even if you cannot see it. Many processes can cause an abduction deficit, but when you add an ipsilateral Horner syndrome, you are closing in on the place where the oculosympathetic pathway and the sixth nerve pathway come together—the cavernous sinus. In the cavernous sinus, the sixth nerve is the only cranial nerve lying within the venous lake (the other cranial nerves travel in the outer dural wall).

The sixth nerve passes inferolateral to the carotid artery. On the outer wall of the carotid artery, you will find the oculosympathetic nerve. The combination of sixth nerve palsy and Horner syndrome is common with lesions arising within the cavernous sinus, including aneurysms and metastases.

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