Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Unilateral Third Nerve Palsy;
Unilateral Oculomotor Third Nerve Palsy;
Third Nerve Microinfarct;
Fascicular Third Nerve Palsy
The video clips are offered in Real Media, Quicktime, Windows Media, Flash and MP4 formats. Use the iPod icon for your mobile device. You must have the appropriate player installed on your computer to view the video.
The formats available for this video are the following, ordered as they appear below: Real Media (Download), Quicktime (Download), Windows Media (Non-Download), and Windows Media (Download), Flash Video (Non-Download, H.264 (Download), and MP4 for iPod (Download).
To download the video onto your computer for offline viewing:
1) Click on an icon with the "DL" notation
2) Right-click ( Ctrl-click on Mac ) on the red Download link when the window opens and choose "Save..." or "Download..."
3) Choose location to save in dialog box that appears.
4) Wait for file to download.
5) Now the video is stored on your computer and you can play it any time, with no Internet connection required.
To view the video without downloading to your computer, choose and click on an icon WITHOUT a "DL" notation.
The patient is an 85 year old man with hypertension and Type II diabetes mellitus.
He presented with a ten day history of drooping of the left eye, unaccompanied by eye pain or headache. With the lid elevated he had double vision in all directions of gaze. He came to the Massachusetts General Hospital and was admitted.
Visual acuity 20/50 OU with mild bilateral cataracts
Pupils 3 mm OU both reacting equally well to light and near
Ocular Motility OS:
Paresis of all the muscles innervated by the third nerve with Marked paresis of the medial rectus and failure to adduct the eye past the midline
Cranial nerves 4 and 6 normal
Bell’s phenomenon (deviation of the eyes up under forced eye closure) absent bilaterally (age related)
Normal sedimentation rate
Elevated blood sugar
Creatinine level and renal function normal
Pupil sparing painless left third nerve palsy
This patient with a pupil sparing left third nerve palsy due to microinfarction had:
• Paresis of all the muscles innervated by the third nerve
• Marked paresis of the medial rectus and failure to adduct the eye past the midline OS
• Cranial nerves 4 and 6 normal
• Bell’s phenomenon (deviation of the eyes up under forced eye closure) absent bilaterally (age related)
No neuroimaging studies were done.
The diagnosis of a third nerve palsy is straight forward but it is important to consider whether it is:
1. A nuclear lesion
2. A complete or partial lesion of the nerve trunk or a
3. Superior division of the third nerve or an
4. Inferior division of the third nerve
A lesion involving the superior division of the third nerve results in paresis of the levator palpebrae muscle and the superior rectus so that the patient will have partial ptosis and paresis of elevation in the line of action of the superior rectus.
A lesion involving the inferior division of the third nerve, involves all the extraocular muscles innervated by the third nerve, except the levator palpabrae and the superior rectus with or without pupil involvement.
Pathological examination of the third nerve in diabetic patients has shown infarction of the nerve in the intercavernous or subarachnoid segment. The core of the nerve is most severely involved, thus sparing the peripherally located pupillary fibers.
Other studies suggest that a common site of nerve infarction in diabetes is within the brainstem. A fascicular third nerve palsy is a possibility in this elderly hypertensive patient. There were no associated brainstem signs.
Review alongside this case ID166-26 Fascicular third nerve palsy.
Microinfarction of the third nerve
Medical control of diabetes and hypertension.
1. Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: a clinicopathological study. Brain 1970;93:555-566. http://www.ncbi.nlm.nih.gov/pubmed/5507015
2. Blake PY, Mark AS, Kattah J, Kolsky M. MR of oculomotor nerve. Am J Neuroradiol 1995;16:1665-1672. http://www.ncbi.nlm.nih.gov/pubmed/7502972
3. Bogousslavsky J, Maeder P, Regli F, Meuli R. Pure midbrain infarction: clinical syndromes, MRI, and etiologic patterns. Neurology 1994;44:2032-2040. http://www.ncbi.nlm.nih.gov/pubmed/7969955
4. Chou KL, Galetta SL, Liu GT, Volpe NJ, Bennett JL, Asbury AK, Balcer LJ. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci 2004;219:35-39. http://www.ncbi.nlm.nih.gov/pubmed/15050435
5. Dreyfus PM, Hakim S, Adams RD. Diabetic ophthalmoplegia. Report of case with postmortem study and comments on vascular supply of human oculomotor nerve. Arch Neurol Psychiatry 1957;77:337-349. http://www.ncbi.nlm.nih.gov/pubmed/13410190
6. Ettl A, Salomonowitz E. Visualization of the oculomotor cranial nerves by magnetic resonance imaging. Strabismus 2004;12:85-96. http://www.ncbi.nlm.nih.gov/pubmed/15672931
7. Eustace P. Partial nuclear third nerve palsies. Neuro-ophthalmology 1985;5:259-262.
8. Kim JS, Kang JK, Lee SA, Lee MC. Isolated or Predominant Ocular Motor Nerve Palsy As a Manifestation of Brain Stem Stroke. Stroke 1993:24:581-586. http://www.ncbi.nlm.nih.gov/pubmed/8465365
9. Kumar P, Ahmed I. Pupil-sparing oculomotor palsy due to midbrain infarction (letter). Arch Neurol 1992;49:348. http://www.ncbi.nlm.nih.gov/pubmed/1558509
10. Leigh JR, Zee DS. Diagnosis of Peripheral Ocular Motor Palsy and Strabismus. Ch 9; 385-474. In: The Neurology of Eye Movements, 4th Edition. Oxford University Press, New York, 2006.
11. Smith BE, Dyck PJ. Subclinical histopathological changes in the oculomotor nerve in diabetes mellitus. Ann Neurol 1992;32:376-385. http://www.ncbi.nlm.nih.gov/pubmed/1416807
12. Weber RB, Daroff RB, Mackey EA. Pathology of oculomotor nerve palsy in diabetes. Neurology 1970;20:835-838. http://www.ncbi.nlm.nih.gov/pubmed/5465853
Relation-Is Part Of
5-1, 163-21, 166-26, 919-2, 939-2, 940-3
Ray Balhorn, Video Compressionist; Steve Smith, Videographer
Spencer S. Eccles Health Sciences Library, University of Utah