Oculomotor nerve paresis starting as isolated internal ophthalmoplegia

Abstract

Oculomotor nerve palsies involving only the internal eye muscles are extremely rare. The authors report a 33-year-old female who presented with isolated pupillary and ciliary dysfunction that eventually turned into a typical third nerve palsy. In I 979 she developed a tonically dilated pupil with preserved, but reduced accommodation. In I 993 she began to develop diplopia on eccentric gaze direction. The pupil had become dilated and completely immobile and the ciliary muscle was paralytic. Eye motility abnormalities were consistent with a mild third nerve paresis and there was an elevation of the upper eyelid on adduction (primary misdirected regeneration). MRI revealed a parasellar mass lesion, probably a neurinoma, arising from the right oculomotor nerve. The authors decided not to treat this slowly growing tumor. Phone 49707 I 294786 Fax 497071 295038 Oral Presentation at the Meeting of the International Neuro-ophthalmological Society. June 5 -9~ "394 in Freiburg/Gemany Key words tor nerve; cranial nerves; primary aberrant regeneration Third nerve palsy; pupil; tonic pupil; tumor of the oculomo-Oculomotor nerve paresis starting as isolated internal ophthalmoplegia 2 I I Neuroophthalmology Downloaded from informahealthcare.com by McMaster University on 01/05/15 For personal use only.

Pupil evaluation as a test for autonomic disorders

“…The pupil remains round with no sector palsy (see below) and fails to constrict to light or an accommodative effort. Cases of incomplete oculomotor nerve palsy causing isolated pupil and ciliary muscle signs are extremely rare [31]; most patients with signs of damage to the pre-ganglionic parasympathetic fibres have additional ophthalmoplegia or ptosis that localize the lesion to the third cranial nerve.…”

Isolated Palsies of Cranial Nerves III, IV, and VI

“…36 Conversely, an isolated pupillary paralysis without ptosis or ophthalmoparesis is rarely caused by an aneurysm or other subarachnoid lesion. 37,38 Koennecke and Seyfert reported a patient with a common carotid artery dissection from intraoperative trauma whose mydriasis preceded complete third nerve palsy by 12 hours. 39 Isolated Third Nerve Palsy Due to a Cavernous Sinus Lesion Lesions of the third nerve in the cavernous sinus often also involve the other oculomotor nerves, the ophthalmic branch of the trigeminal nerve, and sympathetic fibers.…”

Third Nerve Palsies

“…Because of the dorsal and peripheral location of the pupillary fibers, a dilated pupil may be the first sign of a compressive lesion in the subarachnoid space [76][77][78][79][80][81][82] (Fig. 7).…”