Isolated Third Nerve Palsy

Examination
Complete the examination routine for eyes or CN as instructed
Proceed to look for intortion of the affected orbit by tilting the head towards the
involved site or looking for intortion when asking patient to look down and
medially of the affected eye; patient maybe tilting his head voluntary away from
the side of the lesion (implies 4th nerve palsy)
Rule out
Thyroid, MG
Superior orbital syndrome and Cavenous sinus syndrome
Proceed with
Neck for LNs
Examine the upper limbs for Cerebellar, hemiplegia, EPSE and areflexia
Look dor DM dermopathy
Request
Corneal reflex (reduced or absent)
Visual fields (bitemporal hemianopia)
Fundoscopy for optic atrophy (MS), DM or hypertensive changes
Visual acuity
Blood pressure
Urine dipstick
Temperature chart
Headache or pain

Presentation
Sir, this patient has an isolated right third nerve palsy as evidenced by presence of
Divergent strabismus involving the right orbit which is in a down and out
position
Complete ptosis/partial ptosis of the right eye
Dilated pupil which is not reactive to direct light and to accommodation

There is no ptosis or superior rectus palsy of the left eye to suggest a III nerve nuclear
lesion.

There are no associated CN palsies to suggest superior orbital fissure syndrome or

cavernous sinus syndrome. I did not find any associated 4th CN palsy with presence of
intortion on asking the patient to adduct the right eye and look downwards. The 6th
CN is also intact. There is also no paraesthesia of the ophthalmic division of the 5th
CN. Gross VA is also intact.

There are no signs of Graves ophthalmopathy (no conjunctival suffusion and

proptosis or lid edema of the right eye)
There is no evidence of fatiguiability to suggest myasthenia gravis.

On examination of the neck, I did not find any enlarged cervical LNs. There is also no
evidence of hemparesis, cerebellar signs, areflexia or tremors or chorea on
examination of the upper limbs. I also did not notice any diabetic dermopathy.
I would like to complete the examination by:
Corneal reflex (reduced or absent)
Visual fields (bitemporal hemianopia)
Fundoscopy for optic atrophy (MS), DM or hypertensive changes
Visual acuity
Blood pressure
Urine dipstick
Temperature chart
Headache or pain

In summary, this patient has an isolated right third nerve palsy. The possible causes
include

Questions
What is the course and anatomy of the 3rd CN?
Nuclear portion at the midbrain
Fascicular intraparenchymal portion close to the red nucleus, emerges from
cerebral peduncle
Fascicular subarachnoid portion meninges, PCA aneurysm(between the PCA
and internal carotid)
Fascicular cavernous sinus portion sella turcica between the petroclinoid
ligament below and interclinoid above
Fascicular orbital portion superior orbital fissure

Axons run ipsilateral except those to the (1)superior rectus which is innervated from
the contralateral 3rd nucleus and (2) the levator palpebrae which has innervations from
both nuclei.

Hence, right sided 3rd nerve palsy can have contralateral ptosis which is often milder
than the ipsilateral ptosis; also the ipsilateral superior rectus can still be affected due
to involvement of the contralateral fascicular intraparenchymal midbrain portion of
the left 3rd nerve.

For pupillary reflex and accommodation, it is served by the Edinger-Westphal nucleus

and all axons are ipsilateral.

What are the causes of an isolated 3rd nerve palsy?

Brainstem
Infarct, haemorrhage, tumour, abscess, multiple sclerosis
For nuclear lesions
Will also have contralateral ptosis and elevation palsy
May have bilateral 3rd nerve palsies (+/- INO)
For fascicular midbrain lesions
Webers (+ contralateral hemiplegia) base of midbrain
 Northnagel (+ contralateral cerebellar) tectum of midbrain
Benedikts (+ contralateral hemiplegia, contralateral cerebellar and
contralateral tremor, athetosis and chorea) tegmentum of midbrain, red
nucleus
Peripheral
Subarachnoid portion- PCA aneurysm, meningitis, infiltrative, others eg
sarcoidosis
Cavernous sinus lesions- Tumour(pituitary adenoma, meningioma,
cranipharyngioma), cavernous sinus thrombosis, inflammatory (Tolosa-Hunt
syndrome which is a non-caseating granulomatous or non-granulomatous
inflammation within cavernous sinus or superior orbital fissure that is treated
with steroids) and ischaemia from microvascular disease affecting the vasa
nervosa, mononeuritis multiplex
Orbital- tumor (meningioma, hemangioma), endocrine (thyroid) and
inflammatory(orbital inflammatory pseudotumor ie Tolosa Hunt)
Mononeuritis multiplex, Miller Fischer and MG

Dont forget migraines and myasthenia! (emergency Coning, Giant cell Arteritis
and aneurysm)

How would patient present?

Diplopia
Ptosis
Symptomatic glare from failure of constriction of pupil
Blurring of vision on attempt to focus of near objects due to loss of accomodation
Pain in certain etiologies
Diabetes mellitus
Tolosa-Hunt syndrome
PCA aneurysm
Migraine

What are the causes of a dilated pupil?

III nerve palsy
Optic atrophy (direct light and accommodation absent with intact consensual
reflex)
Holmes Adie Pupil (Myotonic pupil)
o Unilateral
o Slow reaction to bright light and incomplete constriction to convergence
o Young women
o Reduced or absent reflexes
Mydiatric eye drops
Sympathetic overactivity

Why does a PCA aneurysm results in pupillary involvement whereas conditions such
as DM or hypertension spares the pupil?
 The pupillary fibres are situated superficially and prone to compression whereas
ischaemic lesions tends to affect the core of the nerve thus sparing the pupillary
fibres

How would you investigate?

Imaging
o CT, MRI
o Angiogram
Blood test
Fasting blood glucose, ESR
TFT and edrophonium
LP

How would you manage?

Medical 3rd nerve palsy
Education watchful waiting and avoid driving, heavy machinery and
climbing high places
Treat underlying conditions such as DM and hypertension
Watchful waiting
Spontaneously recover within 8 weeks
Symptomatic treatment
NSAIDs for pain
If complete ptosis, no need to treat diplopia
Use eye patch for severe diplopia and a prism Fresnel paste on for mild
diplopia
Surgical 3rd nerve palsy - surgery