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Grand Rounds

Grand Rounds. Brooke LW Nesmith, M.D., J.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 7 /18/2014. Presentation. CC: Diplopia x 5 days.

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Grand Rounds

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  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. 3 2mm 3 2mm Exam VAsc P T 14 20/25 (-) 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 Ophthalmol2008;92:715-716.

  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. SurvOphthalmol2002 47:137-157. • 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 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.

  24. Thank you.

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