Managing the patient with oculomotor nerve palsy

Abstract

Management of oculomotor nerve palsy depends in part upon the underlying cause and anatomical location of the lesion. Careful clinical evaluation and appropriate imaging can identify a definitive cause in most cases. Surgical options depend on the number, extent, and severity of the muscles involved as well as the presence or absence of signs of aberrant regeneration. The clinician should also address issues that arise due to involvement of the pupil and accommodation. Strabismus surgery can be challenging but also rewarding with appropriate selection and staging of procedures.

Isolated oculomotor nerve palsy resulting from acute traumatic tentorial subdural hematoma

“…Injuries to cranial nerves can be direct or indirect, with possible causes of direct injury to the CNIII leading to palsy, including rootlet avulsion, distal fascicular damage, stretching of the nerve (including the parasellar segment), and a decrease in blood supply 14,18,19. In trauma, hemorrhagic injury to the brain stem may result in damage to the nuclear or fascicular portions of the nerve, while more peripheral segments of the nerve can be damaged by fractures or intracranial hemorrhage that extend through the cavernous sinus or superior orbital fissure 18,19.…”

“…Indirect causes of ONP include increased ICP or local compression and displacement of the nerve along its path as the result of aneurysms, traumatic hematomas, and other lesions 20. These lesions may result in ONP by causing uncal herniation, vascular damage, brain stem central lesions, stretching of CNIII over the clivus of the sphenoid bone, or compression on CNIII as it passes between the posterior cerebral artery and superior cerebellar artery 8,11,13,14,21,22…”

“…In addition to trauma, other leading causes of ONP include vascular disease, posterior circulation aneurysms, inflammatory injury, and neoplasms 8. Patients with ONP may first notice diplopia and ptosis, and upon examination may be found to have anisocoria, pupillary dilation, loss of pupillary reflex, light sensitivity, and weakness of the extraocular muscles resulting in intorsion of the affected eye 14. In cases that can be attributed to trauma, isolated ONP is relatively uncommon, as patients usually present with additional neurological deficits 15.…”

A Comprehensive Review on the Management of III Nerve Palsy

“…36 The anchoring of the globe to the nasal periosteum with the use of non-absorbable polyester suture was a new technique developed by Sharma P et al 31 Similarly, Saxena R et al evaluated the precaruncular approach for globe fixation in the largest case series described till then. 36,37 The suture/Tplate anchoring platform system 38 anchors the globe by sutures to a titanium T-plate screwed to the orbital wall, advantages being reduced risk of anterior segment ischemia and fewer re-operations, with likely longer durability of the system. Figure 3 showing preoperative and post operative pictures of a patient in which right eye medial anchor was done for congenital right third nerve palsy.…”

Triptans and third nerve paresis: a case series of three patients

“…[1][2][3] There are also conditions more rarely associated with isolated cranial nerve paresis, particularly migraine, where the exact mechanism of the nerve damage is not well understood. 4,5 The triptans are among a number of migraine treatments that have a vasoconstrictive mechanism of action.…”