Third nerve palsy: Difference between revisions

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*Ischemia  
*Ischemia  
**[[Diabetes]]  
**[[Diabetes]]  
*Trauma  
*[[Trauma]]
**Temporal lobe herniation through tentorium  
**Temporal lobe [[herniation syndromes|herniation]] through tentorium  
*[[Myasthenia Gravis]]<ref>Appenzeller S, Veilleux, M. Clarke, A. Lupus. Third cranial nerve palsy or pseudo 3rd nerve palsy of myasthenia gravis? A challenging diagnosis in systemic lupus erythematosus. 2009 Lupus. Aug;18(9):836-40. </ref>
*[[Myasthenia Gravis]]<ref>Appenzeller S, Veilleux, M. Clarke, A. Lupus. Third cranial nerve palsy or pseudo 3rd nerve palsy of myasthenia gravis? A challenging diagnosis in systemic lupus erythematosus. 2009 Lupus. Aug;18(9):836-40. </ref>
*[[Cavernous Sinus Thrombosis]]
*[[Cavernous Sinus Thrombosis]]
**often associated with other cranial nerve defecits
**often associated with other cranial nerve defecits
*[[Neurosyphillis]]
*[[Neurosyphilis]]
*Autoimmune vasculitis ([[Systemic Lupus Erythematosus|Lupus]])
*Autoimmune [[vasculitis]] ([[Systemic Lupus Erythematosus|Lupus]])
 
 
*Aneurysm <ref>Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244</ref>
*Aneurysm <ref>Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244</ref>
*[[Carotid cavernous fistula]]  
*[[Carotid-cavernous fistula]]  
*Mass  
*[[intracranial mass|Mass ]]
*Ischemia
*[[Myasthenia gravis]]
*[[Myasthenia gravis]]
*Thyroid associated orbitopathy
*[[Thyroid]] associated orbitopathy
*Internuclear opthalmoplegia
*[[Internuclear ophthalmoplegia]]
*[[Giant cell arteritis]]
*[[Giant cell arteritis]]


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===Monocular Diplopia===
===Monocular Diplopia===
*Cataract
*Cataract
*Lens Dislocation
*[[Lens dislocation]]
*Macular Disruption
*Macular disruption


===Binocular Diplopia===
===Binocular Diplopia===
*Basilar Artery Thrombosis
*Basilar Artery Thrombosis
*[[Posterior Communicating Artery (PCOM) Aneurysm]]
*[[Posterior Communicating Artery (PCOM) Aneurysm]]
*Vertebral Artery Dissection
*Vertebral artery dissection
*[[Myasthenia Gravis]]<ref>Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239</ref>
*[[Myasthenia Gravis]]<ref>Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239</ref>
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]]
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]]
*[[Botulism]]
*[[Botulism]]
*[[Cavernous Sinus Thrombosis]]
*[[Cavernous sinus thrombosis]]
*Brainstem Mass
*[[Intracranial Mass]], brainstem mass
*Intracranial Mass
*Miller Fischer variant [[Guillain-Barré]]<ref>Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430</ref>
*Miller Fischer variant Guillain-Barré<ref>Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430</ref>
*[[Multiple Sclerosis (MS)| MS]]
*[[Multiple Sclerosis (MS)| MS]]
*[[Hyperthyroidism | Hyperthroid]] Proptosis
*[[Hyperthyroidism | Hyperthyroid]] Proptosis
*Basilar Meningitis
*Basilar [[Meningitis]]
*[[Stroke (Main) |CVA]]
*[[Stroke (Main) |CVA]]
*Muscular Entrapment from [[Maxillofacial Trauma |Trauma]]
*Muscular Entrapment from [[Maxillofacial Trauma |Trauma]]
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==Management==
==Management==
*If ischemic cause  
*If ischemic cause  
**Medical management, plus or minus ASA, with most self resolving in 6-8 weeks  
**Medical management, plus or minus [[ASA]], with most self resolving in 6-8 weeks  
**Ophthalmology follow up
**Ophthalmology follow up
*If aneurysm/mass  
*If aneurysm/mass  

Revision as of 18:23, 28 September 2019

Background

  • Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) [1]
  • Nerve also carries parasympathetic fibers on external surface allowing for pupillary constriction
  • Palsy causes diplopia except in lateral gaze (lateral rectus innervated by CN VI)
  • Ptosis, headache

Causes

Clinical Features

  • Eye deviates laterally and down
  • Pupil exam:
    • If dilated/nonreactive likely secondary to space occupying lesion
    • If pupil is spared likely ischemic etiology
  • Loss of accommodation

Differential Diagnosis

Monocular Diplopia

Binocular Diplopia

Evaluation

  • If complete CNIII involvement with ptosis, mydriasis, and ophtalmoplegia:
    • Assume a compressive etiology from an intracranial aneurysm (PCOM aneurysm for example)
    • Proceed to a CTA brain
  • If complete oculomotor nerve palsy without pupil involvement then strongly favor an ischemic process
    • Consider a CTA brain
    • Coronal reconstruction on CT will allow visualization of orbits to rule out compressive process
  • If associated with other neurologic deficits:
    • CTA brain followed by MRI/MRA brain

Management

  • If ischemic cause
    • Medical management, plus or minus ASA, with most self resolving in 6-8 weeks
    • Ophthalmology follow up
  • If aneurysm/mass
    • Neurosurgery consult
  • If diplopia
    • No driving or operating heavy machinery

See Also

References

  1. ↑ Capo, H., M.D., Warren, F., M.D., Kupersmith, M. , M.D. Evolution of Oculomotor Nerve Palsies. J Clin Neuroophthalmol. 1992 Mar;12(1):21-5. (12)1:21-25, 1992.
  2. ↑ Appenzeller S, Veilleux, M. Clarke, A. Lupus. Third cranial nerve palsy or pseudo 3rd nerve palsy of myasthenia gravis? A challenging diagnosis in systemic lupus erythematosus. 2009 Lupus. Aug;18(9):836-40.
  3. ↑ Chaudhary,N. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. J. Neuro-Ophthalmol 2009;29:238-244
  4. ↑ Kusner LL, Puwanant A, Kaminski HJ: Ocular myasthenia: Diagnosis, treatment, and pathogenesis. Neurologist 2006; 12:231-239
  5. ↑ Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430
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