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. 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. 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.

History POH: Proliferative diabetic retinopathy OU s/p panretinal photocoagulation POH: Proliferative diabetic retinopathy OU s/p panretinal photocoagulation PMH:Type II diabetes, hypertension, hyperlipidemia, coronary artery disease PMH:Type II diabetes, hypertension, hyperlipidemia, coronary artery disease Allergies:NKDA Allergies:NKDA

Exam VAsc P T VAsc P T 20/25 3  2mm (-) RAPD 20/400 14

Exam Findings ODOS Ext/L/Lwnlwnl Conjwnl wnl Kwnlwnl ACwnlwnl Iris/LensPCIOLPCIOL DFE -panretinal photocoagulation-

Exam

Exam

Assessment  60 year old male presents with left pupil-sparing 3 rd nerve palsy. MRI/MRA negative. Observe. Follow-up  3 rd nerve palsy resolved at two month follow-up.

3 rd Nerve Palsy  Anatomy  Causes

3 rd Nerve Pathway

3 rd Nerve Palsy Nuclear Nuclear Fascicle syndromes (brainstem) Fascicle syndromes (brainstem) Uncal herniation Uncal herniation Cavernous Sinus Cavernous Sinus Isolated Isolated –Pupil-involving –Pupil-sparing –Divisional –Younger patients

Nuclear 3 rd Nerve Palsy uncommon uncommon

Fascicle Syndromes Weber syndrome Weber syndrome – contralateral hemiparesis (cerebral peduncle) Benedikt syndrome Benedikt syndrome - contralateral ataxia or tremor (red nucleus & substantia nigra) Claude syndrome Claude syndrome – contralateral ataxia (superior cerebellar peduncle)

Uncal Herniation Uncal herniation Uncal herniation

Cavernous Sinus Syndrome Cavernous Sinus – other cranial nerves Cavernous Sinus – other cranial nerves

Pupil Involving 3 rd Nerve Palsy Aneurysm at junction of posterior communicating artery and internal carotid artery Aneurysm at junction of posterior communicating artery and internal carotid artery Partial pupil involvement in 25-47% of patients with posterior communicating artery aneurysms Partial pupil involvement in 25-47% of patients with posterior communicating artery aneurysms

Pupil Sparing 3 rd Nerve Palsy Microvascular ischemia – most common cause 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 Aberrant regeneration –common after trauma or compression by aneurysm or tumor –NOT WITH MICROVASCULAR ISCHEMIA

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 Ophthalmol 2008;92:

3 rd Nerve Palsy Rare causes Rare causes  tumor, inflammation (sarcoid), vasculitis, infection (meningitis), infiltration (lymphoma, carcinoma), trauma (pupil involving) Divisional Divisional –lesion of anterior cavernous sinus or possibly posterior orbit Children Children –ophthalmoplegic migraine – ophthalmoplegia develops days after onset of head pain

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. Surv Ophthalmol : 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. Surv Ophthalmol : BCSC Section 5 NeuroOphthalmology. Pages BCSC Section 5 NeuroOphthalmology. Pages Jacobson DM. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology ;56(6): Jacobson DM. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology ;56(6): Sobreira I, Sousa C, Raposo A, Fagundes F, Dias A. Ophthalmoplegic migraine with persistent dilated pupil. J Child Neurol :275. Sobreira I, Sousa C, Raposo A, Fagundes F, Dias A. Ophthalmoplegic migraine with persistent dilated pupil. J Child Neurol :275.

Thank you.