| Identifier |
939-2 |
| Title |
Third Nerve Palsy |
| Creator |
Shirley H. Wray, MD, PhD, FRCP |
| Contributors |
Steve Smith, Videographer |
| Affiliation |
(SHW) Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital, Boston, Massachusetts |
| Subject |
Ptosis; Unilateral Third Nerve Palsy; Third Nerve Microinfarct; Oculomotor Nerve; Unilateral Oculomotor Third Nerve Palsy; Fascicular Third Nerve Palsy; Third (Oculomotor) |
| History |
The patient is a 57 year old man who carried a diagnosis of atrial fibrillation and coronary artery disease post CABAG. He was seen in the Massachusetts General Hospital ER with acute double vision and headache and was admitted. Four days prior to admission (PTA) he developed a bifrontal headache accompanied by double vision looking down. He reported that the double vision involved "diagonal images" and was worse on looking to the left. He had no nausea, vomiting or eye pain. One day PTA he developed ptosis of the left eye (OS). Past History: Notable for coronary artery disease with multivessel coronary artery bypass grafts in 1991. Hypercholesterolemia Atrial fibrillation, (not on anti-coagulation) A history of previous episodes of diplopia Ten years PTA, he developed diplopia on left lateral gaze lasting three days. He was seen by an ophthalmologist but no diagnosis was made. His vision returned to normal. One year PTA, he had another attack of double vision and was seen by an ophthalmologist who diagnosed a left sixth nerve palsy. Workup included a brain MRI which was normal. The sixth nerve palsy recovered completely. Social History: Heavy cigarette smoker in the past. General examination: Normal. BP 120/70 Temporal artery pulses normal No carotid or orbital bruits Neuro-ophthalmological examination: Visual acuity 20/20 OU Pupils equal reacting briskly to light and near Visual fields and fundus examination normal Ocular motility: Ptosis OS Marked paresis of superior rectus and inferior oblique Only able to elevate the eye 10 degrees above the horizontal meridian. Paresis of medial rectus, only able to adduct 20 degrees past the midline. Inferior rectus paretic, only able to depress the eye 20 degrees. Cranial nerve 4 and 6 intact No proptosis or ocular pulsation Ocular motility OD normal Motor system: Normal Sensory system: Normal Brain MRI: Normal MR Angiogram: Normal. Blood studies: Complete blood count, differential and platelet count normal Erythrocyte sedimentation rate normal C-reactive protein and fibrinogen normal Tests for diabetes negative Test for syphilis negative Chest -Xray: Normal Lumbar puncture: Cerebrospinal fluid clear Protein 39 mg/ml Sugar 77 mg/dl No cells Diagnosis: Left third nerve palsy involving the nerve trunk and sparing the pupil Etiology: Microinfarction Close observation of all patients with a third nerve palsy, particularly those with a progressive history, as in this patient, should be watched carefully with pupil examinations checked regularly. Anisocoria greater than 2 mm may be considered grounds for an arteriogram Prognosis for recovery: Good. The patient was discharged on the 3rd hospital day. He returned five weeks later 95% recovered with full eye movements and only partial left ptosis. One month later he was fully recovered. |
| Anatomy |
The diagnosis of a third nerve palsy is straight forward but it is important to consider whether it is: 1. A nuclear lesion 2. A complete or partial lesion of the nerve trunk or a 3. Superior division of the third nerve or an 4. Inferior division of the third nerve A lesion involving the superior division of the third nerve results in paresis of the levator palpebrae muscle and the superior rectus so that the patient will have partial ptosis and paresis of elevation in the line of action of the superior rectus. A lesion involving the inferior division of the third nerve, involves all the extraocular muscles innervated by the third nerve, except the levator palpabrae and the superior rectus with or without pupil involvement. |
| Disease/Diagnosis |
Third nerve palsy; Microinfarction of the nerve |
| Clinical |
This patient with a microinfarct of the trunk of the left third nerve had: • Ptosis OS • Paresis of all the muscles innervated by the third nerve, with marked paresis of the inferior oblique and superior rectus • In primary gaze, the left eye deviated down and out due to the unopposed action of the intact lateral rectus and superior oblique muscles. • Pupil normal. A second video clip taken five weeks after the onset of the palsy showed 95% recovery with: Minimal ptosis OS Minimal paresis of elevation of the eye Cover/uncover test showed an alternating exophoria Review alongside this case: ID163-21 Nuclear third nerve palsy. ID919-2 Nuclear third nerve palsy with isolated bilateral ptosis ID166-25 Fascicular third nerve palsy - Claude's syndrome alongside this case. |
| Presenting Symptom |
Double vision |
| Ocular Movements |
Ptosis; Third Nerve Palsy |
| Neuroimaging |
Normal studies |
| Treatment |
Control of risk factors for stroke |
| Etiology |
In adults, the commonest cause of a progressive painful pupil sparing the third nerve palsy is microinfarction of the nerve in association with diabetes, hypertension, temporal arteritis or syphilis. The commonest cause of a progressive painful third nerve palsy involving the pupil is an aneurysm of the posterior communicating or posterior cerebral artery, until proved otherwise and an emergency CT angiogram and/or MR angiogram is indicated. Patients with partial involvement of the pupil and complete paresis of the extraocular muscles and eyelid should also undergo MRI/MRA study and be closely observed. MRA will reveal some but not all aneurysms compressing the third nerve. |
| Date |
1996 |
| References |
1. Blake PY, Mark AS, Kattah J, Kolsky M. MR of oculomotor nerve. Am J Neuroradiol 1995;16:1665-1672. http://www.ncbi.nlm.nih.gov/pubmed/7502972 2. Chou KL, Galetta SL, Liu GT et al. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci 2004;219:35-39. http://www.ncbi.nlm.nih.gov/pubmed/15050435 3. Ettl A, Salomonowitz E. Visualization of the oculomotor cranial nerves by magnetic resonance imaging. Strabismus 2004;12:85-96. http://www.ncbi.nlm.nih.gov/pubmed/15672931 4. Eustace P. Partial nuclear third nerve palsies. Neuro-ophthalmology 1985;5:259-262. 5. Leigh JR, Zee DS. Diagnosis of Peripheral Ocular Motor Palsy and Strabismus. Ch 9; 385-474. In: The Neurology of Eye Movements, 4th Edition. Oxford University Press, New York, 2006. |
| Language |
eng |
| Format |
video/mp4 |
| Type |
Image/MovingImage |
| Source |
3/4" Umatic master videotape |
| Relation is Part of |
Wray Collection |
| Collection |
Neuro-Ophthalmology Virtual Education Library: Shirley H. Wray Collection: https://novel.utah.edu/Wray/ |
| Publisher |
North American Neuro-Ophthalmology Society |
| Holding Institution |
Spencer S. Eccles Health Sciences Library, University of Utah |
| Rights Management |
Copyright 2002. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright |
| ARK |
ark:/87278/s6002zq8 |
| Setname |
ehsl_novel_shw |
| ID |
188507 |
| Reference URL |
https://collections.lib.utah.edu/ark:/87278/s6002zq8 |
