Grand Rounds Brooke LW Nesmith, M.D., J.D. University of
Louisville School of Medicine Department of Ophthalmology &
Visual Sciences 7/18/2014
Slide 2
Presentation CC: Diplopia x 5 days. 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. 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.
Slide 3
History POH: Proliferative diabetic retinopathy OU s/p
panretinal photocoagulation POH: Proliferative diabetic retinopathy
OU s/p panretinal photocoagulation PMH:Type II diabetes,
hypertension, hyperlipidemia, coronary artery disease PMH:Type II
diabetes, hypertension, hyperlipidemia, coronary artery disease
Allergies:NKDA Allergies:NKDA
Slide 4
Exam VAsc P T VAsc P T 20/25 3 2mm (-) RAPD 20/400 14
Assessment 60 year old male presents with left pupil-sparing 3
rd nerve palsy. MRI/MRA negative. Observe. Follow-up 3 rd nerve
palsy resolved at two month follow-up.
Cavernous Sinus Syndrome Cavernous Sinus other cranial nerves
Cavernous Sinus other cranial nerves
Slide 19
Pupil Involving 3 rd Nerve Palsy Aneurysm at junction of
posterior communicating artery and internal carotid artery Aneurysm
at junction of posterior communicating artery and internal carotid
artery Partial pupil involvement in 25-47% of patients with
posterior communicating artery aneurysms Partial pupil involvement
in 25-47% of patients with posterior communicating artery
aneurysms
Slide 20
Pupil Sparing 3 rd Nerve Palsy Microvascular ischemia most
common cause 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 Aberrant regeneration common after trauma or
compression by aneurysm or tumor NOT WITH MICROVASCULAR
ISCHEMIA
Slide 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
2008;92:715-716.
Slide 22
3 rd Nerve Palsy Rare causes Rare causes tumor, inflammation
(sarcoid), vasculitis, infection (meningitis), infiltration
(lymphoma, carcinoma), trauma (pupil involving) Divisional
Divisional lesion of anterior cavernous sinus or possibly posterior
orbit Children Children ophthalmoplegic migraine ophthalmoplegia
develops days after onset of head pain
Slide 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 47:137-157. 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. 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. 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.
Sobreira I, Sousa C, Raposo A, Fagundes F, Dias A. Ophthalmoplegic
migraine with persistent dilated pupil. J Child Neurol 2013
28:275.