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Grand Rounds

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Nuclear 3rd Nerve Palsy. uncommon . May occur 2/2 reduced perfusion through small, paramedian-penetrating blood vessels. Complex of nuclei E-W for pupillary ... – PowerPoint PPT presentation

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Title: Grand Rounds


1
Grand Rounds
  • Brooke LW Nesmith, M.D., J.D.
  • University of Louisville School of Medicine
  • Department of Ophthalmology Visual Sciences
  • 7/18/2014

2
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.

3
History
  • POH Proliferative diabetic retinopathy OU
    s/p panretinal photocoagulation
  • PMH Type II diabetes, hypertension,
    hyperlipidemia, coronary artery disease
  • Allergies NKDA

4
Exam
14
20/25
  • VAsc P T


(-) RAPD
20/400
14
5
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-

6
Exam
7
Exam
8
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.

9
3rd Nerve Palsy
  • Anatomy
  • Causes

10
3rd Nerve Pathway
11
3rd Nerve Pathway
12
3rd Nerve Pathway
13
3rd Nerve Pathway
14
3rd Nerve Palsy
  • Nuclear
  • Fascicle syndromes (brainstem)
  • Uncal herniation
  • Cavernous Sinus
  • Isolated
  • Pupil-involving
  • Pupil-sparing
  • Divisional
  • Younger patients

15
Nuclear 3rd Nerve Palsy
  • uncommon

16
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)

17
Uncal Herniation
  • Uncal herniation

18
Cavernous Sinus Syndrome
  • Cavernous Sinus other cranial nerves

19
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

20
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

21
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 200892715-716.
22
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

23
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 47137-157.
  • 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 2756(6)797-8.
  • Sobreira I, Sousa C, Raposo A, Fagundes F, Dias
    A. Ophthalmoplegic migraine with persistent
    dilated pupil. J Child Neurol 2013 28275.

24
  • Thank you.
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