Third nerve palsy: Difference between revisions

 
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== Background ==
==Background==
[[File:Gray785.png|thumb|Figure showing the mode of innervation of the recti lateralis from CNII.]]
[[File:Capture2.PNG|thumbnail|Right eye]]
[[File:Extraocular muscle actions and innervation.png|thumb|Eye movements by extra-ocular muscles and cranial nerve innervation]]
*Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) <ref>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.</ref>
*Third (oculomotor) nerve, innervates eyelid muscles and external ocular muscles (except lateral rectus and superior oblique) <ref>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.</ref>
*Nerve also carries parasympathetic fibers on external surface allowing for pupillary constriction  
*Nerve also carries parasympathetic fibers on external surface allowing for pupillary constriction  
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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 palsies|cranial nerve deficits]]
*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]]


== Clinical Features==
==Clinical Features==
[[File:PMC4134542 OJO-7-103-g001.png|thumb|Complete (isolated) third nerve palsy showing (a) left-sided ptosis, (b) restricted adduction movement of left eyeball, and (c) normal abduction movement of left eyeball.]]
*Eye deviates laterally and down  
*Eye deviates laterally and down  
*Pupil exam:  
*Pupil exam:  
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==Differential Diagnosis==
==Differential Diagnosis==
===Monocular Diplopia===
*Cataract
*[[Lens dislocation]]
*Macular disruption
===Binocular Diplopia===
*Basilar Artery Thrombosis
*[[Posterior Communicating Artery (PCOM) Aneurysm|Posterior communicating artery (PCOM) aneurysm]]
*[[vertebral and carotid 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>
*[[Lambert-Eaton Myasthenic Syndrome |Lambert-Eaton Syndrome]]
*[[Botulism]]
*[[Cavernous sinus thrombosis]]
*[[Intracranial mass]], brainstem mass
*Miller Fischer variant [[Guillain-Barre]]<ref>Bushra JS: Miller Fisher syndrome: An uncommon acute neuropathy. J Emerg Med 2000; 18:427-430</ref>
*[[Multiple Sclerosis (MS)| MS]]
*[[Hyperthyroidism | Hyperthyroid]] Proptosis
*Basilar [[Meningitis]]
*[[Stroke (Main) |CVA]]
*Muscular Entrapment from [[Maxillofacial Trauma |Trauma]]
*[[Third nerve palsy]]


== Diagnosis  ==
==Evaluation==
*If complete CNIII involvement with ptosis, mydriasis, and ophtalmoplegia:
*If complete CNIII involvement with ptosis, mydriasis, and ophtalmoplegia:
**assume a compressive etiology from an intracraneal anurysm. 
**Assume a compressive etiology from an intracranial aneurysm (PCOM aneurysm for example)
**Proceed to a CTA brain
**Proceed to a CTA brain
*If complete oculomotor nerve palsy without pupil involvement then strongly favor an ischemic process
*If complete oculomotor nerve palsy without pupil involvement then strongly favor an ischemic process
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**CTA brain followed by MRI/MRA brain
**CTA brain followed by MRI/MRA brain


== Management ==
==Management==
*If ischemic cause  
*If ischemic cause  
**Medical management with most self resolving in 6-8 wks
**Medical management, plus or minus [[ASA]], with most self resolving in 6-8 weeks
**Ophthalmology f/u
**Ophthalmology follow up
*If aneurysm/mass  
*If aneurysm/mass  
**Neurosurgery consult  
**Neurosurgery consult  
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*[[Cranial nerves]]
*[[Cranial nerves]]
*[[Diplopia]]
*[[Diplopia]]
*[[Ocular palsy]]


== References ==
==References==
<references/>
<references/>


[[Category:Ophtho]]  
[[Category:Ophthalmology]]  
[[Category:Neuro]]
[[Category:Neurology]]
[[category:Symptoms]]

Latest revision as of 16:21, 26 September 2020

Background

Figure showing the mode of innervation of the recti lateralis from CNII.
Right eye
Eye movements by extra-ocular muscles and cranial nerve innervation
  • 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

Complete (isolated) third nerve palsy showing (a) left-sided ptosis, (b) restricted adduction movement of left eyeball, and (c) normal abduction movement of left eyeball.
  • 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