Slide 1University of Louisville School of Medicine
Department of Ophthalmology & Visual Sciences
7/18/2014
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Presentation
CC: Diplopia x 5 days.
HPI: 60 year old male presents with onset of binocular diplopia 5 days ago, with subsequent left lid ptosis 2 days later. No other visual acuity changes.
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History
PMH: Type II diabetes, hypertension, hyperlipidemia, coronary artery disease
Allergies: NKDA
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Exam
Exam
Assessment
60 year old male presents with left pupil-sparing 3rd nerve palsy. MRI/MRA negative. Observe.
Follow-up
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uncommon
May occur 2/2 reduced perfusion through small, paramedian-penetrating blood vessels. Complex of nuclei – E-W for pupillary constrictor muscles. Subnuclei for inferior, inferior oblique, medial. Single central caudal nucleus controls both levator palpebrae superioris muscles. Superior rectus fascicles decussate just after emerging from their subnuclei. So lesions can affect or spare both upper eyelids, and may bilaterally affect the superior rectus muscles
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Benedikt syndrome - contralateral ataxia or tremor (red nucleus & substantia nigra)
Claude syndrome – contralateral ataxia (superior cerebellar peduncle)
Uncal Herniation
Uncal herniation
Uncal, innermost part of temporal lobe, squeezed, moves towards tentorium and puts pressure on the brainstem.
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Aneurysm at junction of posterior communicating artery and internal carotid artery
Partial pupil involvement in 25-47% of patients with posterior communicating artery aneurysms
Pupillary dysfunction results from loss of parasympathetic input. The pupillomotor fibers reside superficially in the medial aspect of the nerve adjacent to the posterior communicating aneurysm. Monitor for possible involvement in incomplete 3rd nerve palsy
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pupillary involvement in up to 20% (typically mild ≤ 1mm anisocoria)
may present with pain
Aberrant regeneration
NOT WITH MICROVASCULAR ISCHEMIA
Normal pupillary function, complete loss of eyelid and ocular motor functions of the 3rd nerve
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Case Report
Grunwald L, Sund NJ, Volpe NJ. Pupillary sparing and aberrant regeneration in chronic third nerve palsy secondary to a posterior communicating aneurysm. BR J Ophthalmol 2008;92:715-716.
3rd Nerve Palsy
Divisional
Children
ophthalmoplegic migraine – ophthalmoplegia develops days after onset of head pain
Children – pupillary involvement the rule. Resolution of symptoms in 10 daysl
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References
Zarbin M, Chu D. The evaluation of isolated third nerve palsy revisited: An update on the evolving role of magnetic resonance, computed tomography, and catheter angiography. Surv Ophthalmol 2002 47:137-157.
BCSC 2013-2014 Section 5 NeuroOphthalmology. Pages 209-218.
Jacobson DM. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology 2001 27;56(6):797-8.
Sobreira I, Sousa C, Raposo A, Fagundes F, Dias A. Ophthalmoplegic migraine with persistent dilated pupil. J Child Neurol 2013 28:275.
Thank you.