Grand Rounds

Brooke LW Nesmith, M.D., J.D.

University of Louisville School of Medicine
Department of Ophthalmology & Visual Sciences
7/18/2014
 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.
 History
POH: Proliferative diabetic retinopathy OU s/p
panretinal photocoagulation

PMH: Type II diabetes, hypertension,

hyperlipidemia, coronary artery disease

Allergies: NKDA
 Exam

20/25 3 2mm 14

VAsc P (-) RAPD T

20/400 3 2mm 14
 Exam Findings
OD OS

Ext/L/L wnl wnl

Conj wnl wnl
K wnl wnl
AC wnl wnl
Iris/Lens PCIOL PCIOL

DFE -panretinal photocoagulation-

Exam
Exam
 Assessment
60 year old male presents with left pupil-sparing 3rd
nerve palsy. MRI/MRA negative. Observe.

Follow-up
3rd nerve palsy resolved at two month follow-up.
 3rd Nerve Palsy

Anatomy
Causes
3rd Nerve Pathway
3rd Nerve Pathway
3rd Nerve Pathway
3rd Nerve Pathway
 3rd Nerve Palsy
Nuclear

Fascicle syndromes (brainstem)

Uncal herniation

Cavernous Sinus

Isolated
Pupil-involving
Pupil-sparing
Divisional
Younger patients
 Nuclear 3rd Nerve Palsy
uncommon
 Fascicle Syndromes
Weber syndrome contralateral hemiparesis (cerebral peduncle)

Benedikt syndrome - contralateral ataxia or tremor (red nucleus &

substantia nigra)

Claude syndrome contralateral ataxia (superior cerebellar

peduncle)
 Uncal Herniation
Uncal herniation
 Cavernous Sinus Syndrome

Cavernous Sinus other cranial nerves

 Pupil Involving 3rd Nerve Palsy
Aneurysm at junction
of posterior
communicating artery
and internal carotid
artery

Partial pupil
involvement in 25-47%
of patients with
posterior
communicating artery
aneurysms
 Pupil Sparing 3rd Nerve Palsy

Microvascular ischemia most common cause

pupillary involvement in up to 20% (typically mild
1mm anisocoria)
may present with pain
diplopia improves within 3 months

Aberrant regeneration
common after trauma or compression by aneurysm or tumor
NOT WITH MICROVASCULAR ISCHEMIA
 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

Rare causes
tumor, inflammation (sarcoid), vasculitis, infection
(meningitis), infiltration (lymphoma, carcinoma), trauma
(pupil involving)

Divisional
lesion of anterior cavernous sinus or possibly posterior orbit

Children
ophthalmoplegic migraine ophthalmoplegia develops days after
onset of head pain
 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.