Skip to main content

Third Nerve Palsy

  • 344 Accesses

Abstract

Partial or complete palsies of the oculomotor nerve are not common but are somewhat more frequent than many neuro-ophthalmologic abnormalities. Interest in oculomotor nerve palsies, therefore, is not driven by the frequency of these events but rather by the relatively large number of different pathologic mechanisms that can be involved and the potential severity of some of these diagnoses. A correct diagnosis is important in devising the correct treatment.

Keywords

  • Oculomotor nerve
  • Third nerve
  • Microvascular cranial mononeuropathy
  • Posterior communicating artery aneurysm
  • Cavernous sinus
  • Midbrain
  • Brainstem
  • Orbit
  • Vasculitis

This is a preview of subscription content, access via your institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • DOI: 10.1007/978-3-030-74103-7_12
  • Chapter length: 11 pages
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
eBook
USD   89.00
Price excludes VAT (USA)
  • ISBN: 978-3-030-74103-7
  • Instant PDF download
  • Readable on all devices
  • Own it forever
  • Exclusive offer for individuals only
  • Tax calculation will be finalised during checkout
Softcover Book
USD   119.99
Price excludes VAT (USA)
Hardcover Book
USD   169.99
Price excludes VAT (USA)

References

  1. Bruce BB, Biousse V, Newman NJ. Third nerve palsies. Semin Neurol. 2007;27(3):257–68. https://doi.org/10.1055/s-2007-979681.

    CrossRef  PubMed  Google Scholar 

  2. Newman NJ, Biousse V. Third nerve palsies-less frequent but just as concerning. JAMA Ophthalmol. 2017;135(1):29–30. https://doi.org/10.1001/jamaophthalmol.2016.4448.

    CrossRef  PubMed  Google Scholar 

  3. Biousse V, Newman NJ. Third nerve palsies. Semin Neurol. 2000;20(1):55–74. https://doi.org/10.1055/s-2000-6833.

    CAS  CrossRef  PubMed  Google Scholar 

  4. Modi P, Arsiwalla T. Cranial nerve III palsy. Treasure Island: StatPearls; 2020.

    Google Scholar 

  5. Bienfang DC. Crossing axons in the third nerve nucleus. Investig Ophthalmol. 1975;14(12):927–31.

    CAS  Google Scholar 

  6. Choi YJ, Lee SH, Park MS, Kim BC, Kim MK. Midbrain infarction presenting with monocular elevation palsy and ptosis: topographic lesion analysis. J Neuroophthalmol. 2015;35(2):175–8. https://doi.org/10.1097/WNO.0000000000000208.

    CrossRef  PubMed  Google Scholar 

  7. Ksiazek SM, Repka MX, Maguire A, Harbour RC, Savino PJ, Miller NR, Sergott RC, Bosley TM. Divisional oculomotor nerve paresis caused by intrinsic brainstem disease. Ann Neurol. 1989;26(6):714–8. https://doi.org/10.1002/ana.410260605.

    CAS  CrossRef  PubMed  Google Scholar 

  8. Tooley AA, Bhatti MT, Chen JJ. Ischaemic oculomotor nerve palsy isolated to the levator: a case report. Neuroophthalmology. 2019;43(6):391–3. https://doi.org/10.1080/01658107.2018.1520902.

    CrossRef  PubMed  Google Scholar 

  9. Ismail II, Al-Hashel JY, John JK, Ibrahim M. Isolated oculomotor nerve palsy secondary to fascicular midbrain infarction. Neurosciences (Riyadh). 2019;24(3):245–6. https://doi.org/10.17712/nsj.2019.3.20190015.

    CrossRef  Google Scholar 

  10. Cavalheiro S, Canullo ML, Silva da Costa MD, Dastoli PA, Mendonca Nicacio J, Stavale JN. Glioependymal cyst on the third cranial nerve: case report. J Neurosurg Pediatr. 2019:1–5. https://doi.org/10.3171/2019.8.PEDS19317.

  11. Liu GT, Crenner CW, Logigian EL, Charness ME, Samuels MA. Midbrain syndromes of Benedikt, Claude, and Nothnagel: setting the record straight. Neurology. 1992;42(9):1820–2. https://doi.org/10.1212/wnl.42.9.1820.

    CAS  CrossRef  PubMed  Google Scholar 

  12. Silverman IE, Liu GT, Volpe NJ, Galetta SL. The crossed paralyses. The original brain-stem syndromes of Millard-Gubler, Foville, Weber, and Raymond-Cestan. Arch Neurol. 1995;52(6):635–8. https://doi.org/10.1001/archneur.1995.00540300117021.

    CAS  CrossRef  PubMed  Google Scholar 

  13. Corrivetti F, Moschettoni L, Lunardi P. Isolated oculomotor nerve palsy as presenting symptom of bilateral chronic subdural hematomas: two consecutive case report and review of the literature. World Neurosurg. 2016;88:686 e689–12. https://doi.org/10.1016/j.wneu.2015.11.012.

    CrossRef  Google Scholar 

  14. Trobe JD. Isolated third nerve palsies. Semin Neurol. 1986;6(2):135–41. https://doi.org/10.1055/s-2008-1041456.

    CAS  CrossRef  PubMed  Google Scholar 

  15. Muhammad S, Niemela M. Management of oculomotor nerve schwannoma: systematic review of literature and illustrative case. Surg Neurol Int. 2019;10:40. https://doi.org/10.25259/SNI-75-2019.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  16. El Asri AC, Arnaout MM, Gerges MM, Gazzaz M, El Mostarchid B, Schwartz TH. Prognosis factor in oculomotor schwannoma: a case of endoscopic endonasal approach and systematic review of the literature. World Neurosurg. 2019;129:72–80. https://doi.org/10.1016/j.wneu.2019.05.170.

    CrossRef  PubMed  Google Scholar 

  17. Dandurand C, Haw CS. Oculomotor palsy in spontaneous intracranial hypotension: case report and review of the literature. Can J Neurol Sci. 2016;43(5):747–9. https://doi.org/10.1017/cjn.2016.276.

    CrossRef  PubMed  Google Scholar 

  18. Bosley TM, Schatz NJ. Clinical diagnosis of cavernous sinus syndromes. Neurol Clin. 1983;1(4):929–53.

    CAS  CrossRef  Google Scholar 

  19. Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: a clinico-pathological study. Brain. 1970;93(3):555–66. https://doi.org/10.1093/brain/93.3.555.

    CAS  CrossRef  PubMed  Google Scholar 

  20. Siddique N, Durcan R, Smyth S, Tun TK, Sreenan S, McDermott JH. Acute diabetic neuropathy following improved glycaemic control: a case series and review. Endocrinol Diabetes Metab Case Rep. 2020;2020 https://doi.org/10.1530/EDM-19-0140.

  21. Al Saleh M, Bosley TM. Microvascular cranial nerve palsies in an Arabic population. J Neuroophthalmol. 1999;19(4):252–6.

    CrossRef  Google Scholar 

  22. Kumar S. Acute onset binocular diplopia: a retrospective observational study of 100 consecutive cases managed at a tertiary eye centre in Saudi Arabia. Eye (Lond). 2019; https://doi.org/10.1038/s41433-019-0705-7.

  23. Fritz D, Voortman M, van de Beek D, Drent M, Brouwer MC. Many faces of neurosarcoidosis: from chronic meningitis to myelopathy. Curr Opin Pulm Med. 2017;23(5):439–46. https://doi.org/10.1097/MCP.0000000000000401.

    CAS  CrossRef  PubMed  Google Scholar 

  24. Taga A, Russo M, Florindo I, Pavesi G. Isolated third cranial nerve palsy leading to the diagnosis of disseminated Burkitt lymphoma: a case report and literature review. Neurologist. 2017;22(5):182–5. https://doi.org/10.1097/NRL.0000000000000130.

    CrossRef  PubMed  Google Scholar 

  25. Wei H, Yin H, Huang M, Guo Z. The 2019 novel coronavirus pneumonia with onset of oculomotor nerve palsy: a case study. J Neurol. 2020; https://doi.org/10.1007/s00415-020-09773-9.

  26. Tamhankar MA, Biousse V, Ying GS, Prasad S, Subramanian PS, Lee MS, Eggenberger E, Moss HE, Pineles S, Bennett J, Osborne B, Volpe NJ, Liu GT, Bruce BB, Newman NJ, Galetta SL, Balcer LJ. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology. 2013;120(11):2264–9. https://doi.org/10.1016/j.ophtha.2013.04.009.

    CrossRef  PubMed  Google Scholar 

  27. Bobeff EJ, Sanchez-Viguera C, Arraez-Manrique C, Arraez-Sanchez MA. Suprasellar epidermoid cyst: case report of extended endoscopic transsphenoidal resection and systematic review of the literature. World Neurosurg. 2019;128:514–26. https://doi.org/10.1016/j.wneu.2019.05.100.

    CrossRef  PubMed  Google Scholar 

  28. Tsirigotaki M, Ntoulios G, Lioumpas M, Voutoufianakis S, Vorgia P. Tolosa-Hunt syndrome: clinical manifestations in children. Pediatr Neurol. 2019;99:60–3. https://doi.org/10.1016/j.pediatrneurol.2019.02.013.

  29. Rai S, Rattan V. Traumatic superior orbital fissure syndrome: review of literature and report of three cases. Natl J Maxillofac Surg. 2012;3(2):222–5. https://doi.org/10.4103/0975-5950.111392.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  30. Badakere A, Patil-Chhablani P. Orbital apex syndrome: a review. Eye Brain. 2019;11:63–72. https://doi.org/10.2147/EB.S180190.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  31. Morya AK, Jangid K, Naidu A, Bhandari S, Prakash S, Gogia S. Acute isolated medial rectus palsy due to infarction as a result of hypercoagulable state: a case report and literature review. Indian J Ophthalmol. 2019;67(11):1898–900. https://doi.org/10.4103/ijo.IJO_216_19.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  32. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988;8(Suppl 7):1–96.

    Google Scholar 

  33. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9–160. https://doi.org/10.1111/j.1468-2982.2003.00824.x.

    CrossRef  Google Scholar 

  34. Petruzzelli MG, Margari M, Furente F, Costanza MC, Legrottaglie AR, Dicuonzo F, Margari L. Recurrent painful ophthalmoplegic neuropathy and oculomotor nerve schwannoma: a pediatric case report with long-term MRI follow-up and literature review. Pain Res Manag. 2019;2019:5392945. https://doi.org/10.1155/2019/5392945.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  35. Smith SV, Schuster NM. Relapsing painful ophthalmoplegic neuropathy: no longer a “migraine,” but still a headache. Curr Pain Headache Rep. 2018;22(7):50. https://doi.org/10.1007/s11916-018-0705-5.

    CrossRef  PubMed  Google Scholar 

  36. Forderreuther S, Ruscheweyh R. From ophthalmoplegic migraine to cranial neuropathy. Curr Pain Headache Rep. 2015;19(6):21. https://doi.org/10.1007/s11916-015-0492-1.

    CrossRef  PubMed  Google Scholar 

  37. Trobe JD. Isolated pupil-sparing third nerve palsy. Ophthalmology. 1985;92(1):58–61. https://doi.org/10.1016/s0161-6420(85)34067-8.

    CAS  CrossRef  PubMed  Google Scholar 

  38. Trobe JD. Third nerve palsy and the pupil. Footnotes to the rule. Arch Ophthalmol. 1988;106(5):601–2. https://doi.org/10.1001/archopht.1988.01060130655019.

    CAS  CrossRef  PubMed  Google Scholar 

  39. 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(1–2):35–9. https://doi.org/10.1016/j.jns.2003.12.003.

    CrossRef  PubMed  Google Scholar 

  40. Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor nerve palsies. Arch Ophthalmol. 1994;112(7):961–6. https://doi.org/10.1001/archopht.1994.01090190109029.

    CAS  CrossRef  PubMed  Google Scholar 

  41. Kodsi SR, Younge BR. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol. 1992;114(5):568–74. https://doi.org/10.1016/s0002-9394(14)74484-8.

    CAS  CrossRef  PubMed  Google Scholar 

  42. Margolin E, Lam CTY. Approach to a patient with diplopia in the emergency department. J Emerg Med. 2018;54(6):799–806. https://doi.org/10.1016/j.jemermed.2017.12.045.

    CrossRef  PubMed  Google Scholar 

  43. Jacobson DM, Trobe JD. The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy. Am J Ophthalmol. 1999;128(1):94–6. https://doi.org/10.1016/s0002-9394(99)00107-5.

    CAS  CrossRef  PubMed  Google Scholar 

  44. Kung NH, Van Stavern GP. Isolated ocular motor nerve palsies. Semin Neurol. 2015;35(5):539–48. https://doi.org/10.1055/s-0035-1563568.

    CrossRef  PubMed  Google Scholar 

  45. Micieli JA, Shu HG, Newman NJ. Third nerve palsy due to a malignant oculomotor nerve sheath tumor. J Neuroophthalmol. 2020;40(1):100–3. https://doi.org/10.1097/WNO.0000000000000832.

    CrossRef  PubMed  Google Scholar 

  46. Lee D, Kim WJ, Kim MM. Recurrent isolated oculomotor nerve palsy caused by schwannoma in a pediatric patient. Indian J Ophthalmol. 2018;66(9):1367–9. https://doi.org/10.4103/ijo.IJO_340_18.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  47. Lai G, Rodriguez MI, Scumpia AJ. Oculomotor nerve palsy secondary to cavernous internal carotid aneurysm. Clin Pract Cases Emerg Med. 2018;2(1):93–4. https://doi.org/10.5811/cpcem.2017.10.35510.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  48. Chan LW, Lin CW, Hsieh YT. Superior divisional oculomotor nerve palsy caused by fronto-ethmoidal sinusitis. Can J Ophthalmol. 2018;53(4):e138–40. https://doi.org/10.1016/j.jcjo.2017.10.024.

    CrossRef  PubMed  Google Scholar 

  49. Elmalem VI, Hudgins PA, Bruce BB, Newman NJ, Biousse V. Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol. 2011;31(2):103–9. https://doi.org/10.1097/WNO.0b013e3181f8d985.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  50. Fifi JT, Meyers PM, Lavine SD, Cox V, Silverberg L, Mangla S, Pile-Spellman J. Complications of modern diagnostic cerebral angiography in an academic medical center. J Vasc Interv Radiol. 2009;20(4):442–7. https://doi.org/10.1016/j.jvir.2009.01.012.

    CrossRef  PubMed  Google Scholar 

  51. Okahara M, Kiyosue H, Yamashita M, Nagatomi H, Hata H, Saginoya T, Sagara Y, Mori H. Diagnostic accuracy of magnetic resonance angiography for cerebral aneurysms in correlation with 3D-digital subtraction angiographic images: a study of 133 aneurysms. Stroke. 2002;33(7):1803–8. https://doi.org/10.1161/01.str.0000019510.32145.a9.

    CrossRef  PubMed  Google Scholar 

  52. White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology. 2000;217(2):361–70.

    CAS  CrossRef  Google Scholar 

  53. Thurtell MJ, Longmuir RA. Third nerve palsy as the initial manifestation of giant cell arteritis. J Neuroophthalmol. 2014;34(3):243–5. https://doi.org/10.1097/WNO.0000000000000116.

    CrossRef  PubMed  Google Scholar 

  54. Lazaridis C, Torabi A, Cannon S. Bilateral third nerve palsy and temporal arteritis. Arch Neurol. 2005;62(11):1766–8. https://doi.org/10.1001/archneur.62.11.1766.

    CrossRef  PubMed  Google Scholar 

  55. Bondeson J, Asman P. Giant cell arteritis presenting with oculomotor nerve palsy. Scand J Rheumatol. 1997;26(4):327–8. https://doi.org/10.3109/03009749709105324.

    CAS  CrossRef  PubMed  Google Scholar 

  56. Davies GE, Shakir RA. Giant cell arteritis presenting as oculomotor nerve palsy with pupillary dilatation. Postgrad Med J. 1994;70(822):298–9. https://doi.org/10.1136/pgmj.70.822.298.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  57. Genevay S, Hayem G, Hamza S, Palazzo E, Meyer O, Kahn MF. Oculomotor palsy in six patients with systemic lupus erythematosus. A possible role of antiphospholipid syndrome. Lupus. 2002;11(5):313–6. https://doi.org/10.1191/0961203302lu205oa.

    CAS  CrossRef  PubMed  Google Scholar 

  58. Lee JS, Roh YB, Oum BS, Kwak IS. Isolated oculomotor nerve palsy with pupillary abnormality in systemic lupus erythematosus. J Pediatr Ophthalmol Strabismus. 2000;37(4):241–3.

    CAS  CrossRef  Google Scholar 

  59. Nakamagoe K, Yanagiha H, Miyake Z, Kondo Y, Hiyama T, Ishii A, Kaji Y, Oshika T, Sumida T, Tamaoka A. Monocular oculomotor nerve disorder manifesting as cranial neuropathy in systemic lupus erythematosus. Intern Med. 2018;57(23):3445–9. https://doi.org/10.2169/internalmedicine.1106-18.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  60. Corr P, Bhigjee A, Lockhat F. Oculomotor nerve root enhancement in meningovascular syphilis. Clin Radiol. 2004;59(3):294–6. https://doi.org/10.1016/j.crad.2003.10.019.

    CAS  CrossRef  PubMed  Google Scholar 

  61. Rosenhall U, Lowhagen GB, Roupe G. Oculomotor dysfunction in patients with syphilis. Genitourin Med. 1987;63(2):83–6. https://doi.org/10.1136/sti.63.2.83.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  62. Drenckhahn A, Spors B, Knierim E. Acute isolated partial oculomotor nerve palsy due to Lyme neuroborreliosis in a 5 year old girl. Eur J Paediatr Neurol. 2016;20(6):977–9. https://doi.org/10.1016/j.ejpn.2016.05.022.

    CrossRef  PubMed  Google Scholar 

  63. Savas R, Sommer A, Gueckel F, Georgi M. Isolated oculomotor nerve paralysis in Lyme disease: MRI. Neuroradiology. 1997;39(2):139–41. https://doi.org/10.1007/s002340050382.

    CAS  CrossRef  PubMed  Google Scholar 

  64. Fisher CM. Ocular palsy in temporal arteritis. I. Minn Med. 1959;42:1258–68; contd.

    CAS  PubMed  Google Scholar 

  65. Barricks ME, Traviesa DB, Glaser JS, Levy IS. Ophthalmoplegia in cranial arteritis. Brain. 1977;100(2):209–21. https://doi.org/10.1093/brain/100.2.209.

    CAS  CrossRef  PubMed  Google Scholar 

  66. Walters B, Lazic D, Ahmed A, Yiin G. Lessons of the month 4: Giant cell arteritis with normal inflammatory markers and isolated oculomotor nerve palsy. Clin Med (Lond). 2020;20(2):224–6. https://doi.org/10.7861/clinmed.2019-0504.

    CrossRef  Google Scholar 

  67. Annamalai A, Francis ML, Ranatunga SK, Resch DS. Giant cell arteritis presenting as small bowel infarction. J Gen Intern Med. 2007;22(1):140–4. https://doi.org/10.1007/s11606-006-0024-0.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  68. Hassan WU, Daymond TJ. Small bowel infarction in association with giant cell arteritis. Br J Rheumatol. 1993;32(10):942. https://doi.org/10.1093/rheumatology/32.10.942-a.

    CAS  CrossRef  PubMed  Google Scholar 

  69. Phelan MJ, Kok K, Burrow C, Thompson RN. Small bowel infarction in association with giant cell arteritis. Br J Rheumatol. 1993;32(1):63–5. https://doi.org/10.1093/rheumatology/32.1.63.

    CAS  CrossRef  PubMed  Google Scholar 

  70. Srigley JR, Gardiner GW. Giant cell arteritis with small bowel infarction. A case report and review of the literature. Am J Gastroenterol. 1980;73(2):157–61.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Thomas M. Bosley .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and Permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Verify currency and authenticity via CrossMark

Cite this chapter

Bosley, T.M. (2021). Third Nerve Palsy. In: Henderson, A.D., Carey, A.R. (eds) Controversies in Neuro-Ophthalmic Management. Springer, Cham. https://doi.org/10.1007/978-3-030-74103-7_12

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-74103-7_12

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-74102-0

  • Online ISBN: 978-3-030-74103-7

  • eBook Packages: MedicineMedicine (R0)