Post on 07-May-2015
description
THIRD NERVE PALSY
Prepared by: Anis Suzanna binti Mohamad
Optometrist
What is third nerve palsy? a condition which leads to a wide
impairment of motor function, as this innervates most of the muscles of the eyes.
Aetiologies Types of 3rd
palsyCommon condition(s)
Congenital The palsy is usually incomplete, unilateral and without ptosis, the pupil is spared.
Acquired Microvascular (DM,HPT,atherosclerosis)
>45years old, pupil sparing, rare in children.
Compression (tumor, aneurysms)
The condition usually painful, with ptosis and pupil involvement.
Trauma Pupil involvement
Migrainous The condition occurs upon resolution of a headache, usually involving the pupil.
Infectious Viral illness, bacterial meningitis, or immunizations
Source: Essentials of clinical binocular vision by Erik M. Weissberg
1.Patient profile: Referred by: Ms. E Malay Female 18 years old File no: 5108 Date: 9/2/04
Referred from ophthalmologist at Hospital Tuanku Fauziah, Kangar for squint assessment.
Patient has RE optic neuropathy secondary to trauma, RE exotropia and LE high myope.
2. Presenting signs and symptomsSymptom RE exotropia after accident 14 years ago.
Diplopia appreciated.
Age of onset 11 years old
Mode of onset Accident
Medical or birth
history
Nil
Family history Nil
Previous
treatment
Glasses for high myopia
3. Clinical findings:Current Rx
Distance VA
Near VA
RE: -3.00Ds LE: -5.00Ds
(3/60) (6/6)
Hirschberg
Unil Cover test
(∞)
Unil Cover test
(Near)
~15° exo
RE exotropia with diplopia
RE exotropia with diplopia
Ocular MotilityRSR++
RIR-
‘A’ pattern exo
Vergence
System
Horizontal
vergence
Vertical
Vergence
35/40ΔBI
Exo
50ΔBI
Near: (RE) 35BI & 2BD
Distance: (RE) 35BI & 2BD (RE
hypertropia)
Post-op diplopia
test
Near: Patient see single with 35ΔBI
Distance: Do not appreciate diplopia when
overcorrect until 50ΔBI
4. Diagnosis: Secondary right eye exotropia due to
trauma.
5. Management plan5. Management planSuggest surgery for cosmetic reason.Suggest for unilateral recess and resect.◦7.0mm RLR recess ◦6mm RMR resect.Attached a referral letter to
ophthalmologist at Hospital Tuanku Fauziah, Kangar.
Discussion
Anatomy of third cranial nerve
Anatomic Basis of Neurologic Diagnosis by Cary D. Alberstone
Criteria for ocular motor palsy
Source: Essentials of clinical binocular vision by Erik M. Weissberg
Classification Involved
muscle(s)
Ocular motility Restricted version Ptosis
Complete
(superior and
inferior division)
MR,SR,IR,IO,
levator
Exotropia,
hypotropia,
intorted
Adduction, elevation,
depression
Yes
Superior division
only
SR, levator Hypotropia Elevation Yes
Inferior division
only
MR,IR,IO Exotropia,
hypertropia,
intorted
Adduction, elevation,
depression
No
Isolated muscle MR Exotropia Adduction No
Isolated muscle SR Hypotropia Elevation when adducted No
Isolated muscle IR Hypertropia Depression when
abduction
No
Isolated muscle IO Hypotropia Elevation when
adduction
NoTable of classification, involved muscle and associated signs of third cranial nerve palsy.
Source: Essentials of clinical binocular vision by Erik M. Weissberg
Limitations
Incomplete history taking Clinical findings
Refinement on refractive error.Basic squint assessment hirschberg test, unilateral
cover test, ocular motility, vergence system and post-op diplopia test.
No external observation recorded.Hess chart Post-op diplopia test
LR recession & MR resection in XT
XT (pD) LR recess MR resect
15 4.00 mm 3.00 mm
20 4.00 mm 4.00 mm
25 6.00 mm 4.50 mm
30 6.50 mm 5.50 mm
35 7.50 mm 5.50 mm
• Suggest surgery for cosmetic reason.
• Suggest for unilateral recess and resect.
•7.0mm RLR recess and 6mm RMR resect.
References:I. Millodot, M. 2000. Dictionary of Optometry and Visual
Science. Oxford: Butterworth-Heinemann Ltd.
II. Erik M. 2004. Essentials of clinical binocular vision. Elsevier: Butterworth-Heinemann Ltd.
III. Alec M. Ansons. 2001. Diagnosis and management of ocular motility disorders.Blackwell Science Ltd.
IV. Bruce Evans, David Pickwell. 2004. Pickwell’s binocular vision anomalies: investigation and treatment. Elsevier: Butterworth-Heinemann Ltd.
V. Burian & von Noorden. 2000. Burian von-Noorden’s Binocular Vision and ocular motility: theory and management of strabismus. Elsevier: Butterworth-Heinemann Ltd.
VI. Cary D. Alberstone. 2000. Anatomic Basis of Neurologic Diagnosis. Elsevier: Butterworth-Heinemann Ltd.