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Oculomotor nerve palsy
- 1. Dr. Mahziba Rahman MCPS,FCPS Eye Specialist & Surgeon Bangladesh Eye Hospital Ltd.
- 2. 3rd cranial nerve Oculomotor nerve Entirelymotor in function Supplies – • All the Extraocular muscles except superior oblique and lateral rectus • Levator palpebrae superioris • Intra ocular muscles- Sphincter pupillae and cilliary muscle
- 3. Nucleus Located in midbrainat the level of superior colliculus, ventral to the Sylvian aquiduct. Composed of • Unpaired levator subnucleus • Paired superior rectus sub nuclei • Paired medial rectus, inferior rectus and inferior oblique subnuclei • Unpaired Edinger-Westphal nucleus
- 4. Course Can be dividedinto – Fascicular Basilar Intracavernous Intraorbital part
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- 7. Intracavernous portion of3rd nerve
- 8. Intraorbital portion of3rd nerve
- 9. Major causes ofnuclear complex lesion of 3rd nerve palsy Vascular occlusion – Diabetes & Hypertension Neoplastic lesions – primary tumour or metastasis Haemorrhage
- 10. Major causes offascicular lesion of 3rd nerve palsy Vascular occlusion – Diabetes & Hypertension Neoplastic lesions – primary tumour or metastasis Haemorrhage Demyelination
- 11. Syndromes of Fascicularlesion Benedikt syndrome- Ipsilateral 3rd nerve palsy and contralateral extrapyramidal signs Weber syndrome- Ipsilateral 3rd nerve palsy and contralateral hemiparesis Nothnagel syndrome- Ipsilateral 3rd nerve palsy and cerebellar ataxia Claude syndrome-
- 12. Major causes oflesion in Basilar region The 3rd nerve traverses the basilar part unaccompanied by any other cranial nerves. Isolated 3rd nerve palsies are commonly basilar. The important causes are Aneurysm Head trauma-Extradural or subdural haematoma
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- 15. Major causes ofIntracavernous lesion Usually associated with involvement of 4th , 6th nerves & first division of 5th nerve. Diabetes – causes pupil sparing 3rd nerve palsy Pituitary apoplexy Others – Aneurysm, Meningeoma, Carotid-cavernous fistula.
- 16. Intraorbital causes of3rd nerve palsy Trauma Vascular Neoplasm Inflammation
- 17. Pupillomotor fibers Parasympathetic fibers Locatedsuperficially between the brainstem and the cavernous sinus Blood supply derived from the pial blood vessels Main trunk of 3rd nerve supplied by the vasa nervorum
- 18. Continued Type of lesionaffecting Pupillomotor fibers :Surgical Main trunk : Medical
- 19. Causes of isolated3rd nerve palsy Idiopathic – about 25% Vascular – Hypertension & Diabetes (commonly pupil sparing) Aneurysm – posterior communicating artery at its junction with internal carotid artery Trauma – subdural haematoma with uncal herniation Miscellaneous
- 20. Clinical features oftotal 3rd nerve palsy SYMPTOMS Drooping of eyelid Binocular double vision Pain (may be present)
- 21. SIGNS Ptosis Abduction of globe Intortionof the globe which increases on attempted down gaze Limitation of adduction Limitation of elevation Limitation of depression Dilated pupil with defective accommodation
- 23. History of Patient Onset Duration Diplopia Trauma Associatedsystemic disorders
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- 25. Investigations Age < 50years CT or MRI, Cerebral angiography Age > 50 years Pupil sparing FBS and 2HABF, HbA1c, Lipid profile, Check BP, CBC with ESR, CRP Pupil involving FBS and 2HABF, HbA1c, Lipid profile, Check BP, CBC with ESR, CRP, CT or MRI, Cerebral angiography
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- 27. Treatment Non-surgical Treatment of underlyingcause Diplopia – Occlusion patch or prism in involved eye Monitor children for development of amblyopia
- 28. Treatment Surgical Neurosurgery – Aneurysmor haematoma Strabismus or ptosis surgery – Not earlier than 6 months from time of onset
- 29. Follow-up Pupil sparing –Observe daily for 5 days for pupil involvement Recheck every 4 to 6 weeks If secondary to ischemia function usually returns within 3 months
- 30. Differential Diagnosis Myasthenia gravis Thyroidassociated orbitopathy Chronic progressive external ophthalmoplegia Idiopathic orbital inflammatory disease
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