Complete Third Nerve Palsy and Aberrant Regeneration

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Identifier Complete_3rd_nerve_palsy_Aberrant_regeneration
Title Complete Third Nerve Palsy and Aberrant Regeneration
Subject Neuroanatomy; Nerve Palsy; Third Cranial Nerve; RAPD
Creator Andrew G. Lee, MD, Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, TX; Professor of Ophthalmology, Weill Cornell Medicine; Hyewon (Sally) Choi, Baylor College of Medicine Class of 2020
Description Dr. Lee lectures medical students on complete third nerve palsy and aberrant regeneration.
Transcript This patient graciously has agreed to be videotaped. He started at age ten with a painless and progressive ptosis and ophthalmoplegia. He has a complete ptosis in the primary position. When we raise up the ptotic lid, you can see that he has an over 50 prism diopter exotropia in the left eye. And when we shine the pupil light on there, we can see that the left pupil is nonreactive to light. "Can you look at the tip of your nose, sir?". And it does not constrict to near. The right pupil is normal. We're just going to have him look right all the way. And you can see the right eye moves normally; the left eye does not adduction. His abduction is intact in the left eye; the right eye is normal. "And up". The right eye moves normally; the left eye does not elevate. "Look down". The right eye moves normally; the left eye does not depress. And now we're going to show how we can test for fourth nerve function in the setting of a complete third. And what we're going to be looking for is we're going to be looking at that conjunctival vessel. "Look down, sir". And we're going to be looking for the intorsion. "Look up and look down". And so, when we see that intorsion of the vessel that suggests that the superior oblique is intact because its primary action is intorsion of this eye. So, the superior oblique is firing and is demonstrating intorsion. And the second thing we're going to be looking at is his lid when he looks to the right and left. "All the way to the right sir. Open real wide, and to the left, and to the right again". And we can see the lid go up "To the right, and to the left, and to the right". And that is a sign that we have aberrant regeneration of the lid. The medial rectus is firing, but then the lid levator is receiving function. And finally, we're going to test for a reverse RAPD. So, when we have a pupil that is fixed and dilated to light like this, we'd like to see if there is a relative afferent pupillary defect, a RAPD, in this eye. But we have to look at the fellow eye. So, we can see that the right pupil does constrict. And when I swing the light to the left and back to the right, if there was a RAPD in the left eye, there would be dilation of the right pupil upon swinging the light from the right, to the left. And in this particular case, there is no evidence for a left relative afferent pupillary defect by reverse testing. So, this patient probably has a schwannoma of the third nerve that's what accounts for his onset at age 10 and the lack of significant deficit, other than the third nerve findings twenty years later. He demonstrates aberrant regeneration of the lid. He has no relative afferent pupillary defect by reverse testing. And he has an intact intorsion and down gaze; the fourth nerve is intact.
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 2019-02
Type Image/MovingImage
Format video/mp4
Rights Management Copyright 2019. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s6vf1bdn
Setname ehsl_novel_lee
Date Created 2019-03-01
Date Modified 2020-01-13
ID 1403668
Reference URL https://collections.lib.utah.edu/ark:/87278/s6vf1bdn
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