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
VAsc
20/400
14
3  2mm
P
(-) RAPD
3  2mm
T
14
Exam Findings
Ext/L/L
Conj
K
AC
Iris/Lens
DFE
OD
OS
wnl
wnl
wnl
wnl
PCIOL
wnl
wnl
wnl
wnl
PCIOL
-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 &

Claude syndrome – contralateral ataxia (superior cerebellar
substantia nigra)
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.