Acute Transient Oculomotor Nerve Palsy from Presumed Cavernous Angioma in an Infant

Cavernous angiomas of the cranial nerves are extremely rare, and those of the oculomotor (third) cranial nerve are rarer still, with no previous cases having been reported in the literature. We report herein the first case of a presumed cavernous angioma involving the subarachnoid portion of the left third nerve presenting as an acute left third nerve palsy in an infant. The child was followed without intervention and the palsy completely resolved. Given the poor functional results with attempted surgical excision and the potential for spontaneous improvement in oculomotor nerve function, it is reasonable to follow patients with these lesions without intervention.     

头颅外伤患者的眼运动神经麻痹(英文)

目的:了解头颅外伤患者眼运动神经麻痹的情况。方法:收集2006-03/2006-09 Shahid Rahnemon医院神经外科收治的300名头颅外伤患者的资料,包括眼科检查和调查问答,采用SPSS软件卡方和F检验进行数据分析。结果:300例患者中242例为男性(81. 1% ), 58例为女性(18.9% ),年龄为1~87(平均46)岁。意外跌伤是头部外伤最常见的原因,共247例患者(82. 3% )因此致伤;大多数患者的GCS得分为13~15(82.3% )。最多见的颅脑外伤为硬膜下腔、蛛网膜下腔出血。滑车神经或外展神经麻痹(28.6% )、其他眼运动神经麻痹或同时两处眼运动神经麻痹(常见第3颅神经和第4颅神经麻痹,14.3% )是最常出现的情况。结论:虽然头颅外伤同时出现颅神经麻痹的几率较小,但是在急诊时应根据情况进行神经眼科检查。     

Oculomotor Nerve Palsy Presented with Isolated Unilateral Ptosis and Minimal Upgaze Palsy

This case with unilateral complete blepharoptosis and slight limitation of upgaze as ocular findings due to midbrain infarction represents an unusual form of intra-axial oculomotor nerve involvement. A 65-year-old man was admitted with acute unilateral ptosis of the left eyelid and gait ataxia. He had chronic hypertension in the medical history. The neurologic examination revealed that he had a complete ptosis of the left eyelid, slight limitation of elevation in the left eye, bilateral dysmetria, and gait ataxia. Magnetic resonance imaging showed acute infarction in the central part of midbrain tegmentum. Previous models for arrangement of oculomotor fascicle in the midbrain suggest that a lesion involving the most caudal fibres for levator palpebrae and superior rectus without affecting other extraocular muscles and pupillomotor fibres is the most likely aetiology.     

Episodic Oculomotor Nerve Palsy in a Patient with Leptomeningeal Metastatic Adenocarcinoma of the Breast

A 43-year-old female with a history of breast adenocarcinoma developed an episodic oculomotor nerve palsy of the right eye. Subsequent evaluation and work-up revealed the presence of leptomeningeal metastatic adenocarcinoma. In the absence of additional findings to explain the cause of her intermittent oculomotor palsy, we diagnosed the episodic oculomotor nerve palsy as secondary to her metastatic disease.     

Incidence of pupillary involvement,course of anisocoria and ophthalmoplegia in diabetic oculomotor nerve palsy

Aims:

To derive a reliable estimate of the frequency of pupillary involvement and to study the patterns and course of anisocoria in conjunction with ophthalmoplegia in diabetes-associated oculomotor nerve palsy.

Materials and Methods:

In this prospective analytical study, standardized enrolment criteria were employed to identify 35 consecutive patients with diabetes-associated oculomotor nerve palsy who were subjected to a comprehensive ocular examination. Standardized methods were used to evaluate pupil size, shape, and reflexes. The degree of anisocoria, if present and the degree of ophthalmoplegia was recorded at each visit.

Results:

Pupillary involvement was found to be present in 25.7% of the total number of subjects with diabetic oculomotor nerve palsy. The measure of anisocoria was < 2 mm, and pupil was variably reactive at least to some extent in all cases with pupillary involvement. Majority of patients in both the pupil-involved and pupil-spared group showed a regressive pattern of ophthalmoplegia. Ophthalmoplegia reversed much earlier and more significantly when compared to anisocoria.

Conclusions:

Pupillary involvement in diabetes-associated oculomotor nerve palsy occurs in about 1/4^th of all cases. Certain characteristics of the pupil help us to differentiate an ischemic insult from an aneurysmal injury to the 3^rd nerve. Ophthalmoplegia resolves much earlier than anisocoria in diabetic oculomotor nerve palsies.     

123例单纯性动眼神经麻痹的MRI病因学分析

目的 探讨单纯性动眼神经麻痹的MRI表现及病因。设计 回顾性病例系列。研究对象123例单纯性动眼神经麻痹患者。方法 回顾性分析患者的MRI表现,结合动眼神经的解剖特点,分析动眼神经麻痹的病因。主要指标  MRI表现。结果 123例动眼神经麻痹病例中,MRI表现异常者87例（70.7%）。其中海绵窦区病变62例（71.2%）（炎症45例,颈内动脉动脉瘤8例,鼻咽部/蝶窦/鞍区/鞍旁占位性病变累及海绵窦者6例,颈内动脉海绵窦瘘2例,颈内动脉海绵窦段增粗迂曲1例）;脑干病变16例（18.4%）（中脑梗塞15例,中脑炎症1例）;颅眶沟通性病变5例（5.7%）（炎症3例,肿瘤2例）;动眼神经脑池段及其周围病变4例（4.6%）（动眼神经炎性病变2例,动眼神经神经鞘瘤1例,脚间池胆脂瘤压迫动眼神经1例）。结论 单纯性动眼神经麻痹的病因多样,海绵窦区病变占大多数。MRI检查有助于明确动眼神经麻痹的病因。（眼科, 2015, 24： 304-308）     

Acquired oculomotor synkinesis

Paradoxical patterns of pupillary, lid and eye movement may follow oculomotor nerve palsy or they can develop spontaneously in patients with no known history of oculomotor palsy. The mechanism of this condition, known variously as aberrant regeneration of the third nerve, oculomotor misdirection or acquired oculomotor synkinesis, is not known, although the prevailing opinion has held that it occurs when axons regenerating within an oculomotor nerve become misdirected and innervate muscles for which they were not intended. However, there is evidence against this hypothesis. The authors critically review the various hypotheses and elucidate the controversy concerning the pathogenesis of acquired oculomotor synkinesis.     

Pupil-Sparing Inferior Divisional Palsy of Third Cranial (Oculomotor) Nerve in Tolosa-Hunt Syndrome

Pupil-sparing inferior divisional oculomotor nerve palsy is rare and has not been described in Tolosa-Hunt syndrome (THS). A 24-year-old man with right supraorbital pain and binocular vertical diplopia for 2 weeks underwent full neuro-ophthalmolgical evaluations including brain magnetic resonance imaging (MRI). The patient showed right exo- and hypertropia with impaired depression and adduction of the right eye. The pupils were normal. Other findings of neurological examination and brain MRI were normal. The headache and ophthalmoplegia improved within 2 days of corticosteroid treatment. In view of the pupil sparing, the patient may have a lesion selectively involving the shorter branch of the oculomotor inferior division in the orbit. THS may manifest with pupil-sparing inferior divisional oculomotor palsy.     

Brainstem Infarction in Pupil-Sparing Oculomotor Nerve Palsy Detected by Diffusion-Weighted Magnetic Resonance Imaging

The usefulness of diffusion-weighted magnetic resonance imaging studies in pupil-sparing oculomotor nerve palsy due to midbrain infarction is illustrated in two interventional case reports. Two cases are presented illustrating the superior sensitivity of diffusion-weighted magnetic resonance imaging in detecting midbrain infarction in this clinical situation.     

A Rare Case of Penetrating Trauma Resulting in Isolated Third Nerve Palsy

A 23-year-old male presented to the emergency department with right eye pain, right upper eyelid ptosis, blurry vision, and binocular diplopia that developed immediately after he bent over in a parking lot and the antenna of a car penetrated his right upper eyelid. An extensive workup was performed, and he was found to have an isolated traumatic oculomotor nerve palsy with pupil involvement. No other ocular findings of a traumatic injury were present. The patient was observed for 14 months, during which he continually improved, with almost complete resolution of his diplopia, anisocoria, and ptosis.     

Isolated Inferior Rectus Palsy: A Case Report and Review of Literature

A case of sudden-onset isolated inferior rectus paresis is described. This is a rare presentation of isolated oculomotor nerve paresis and its features are described. Lesions of the oculomotor nerve can affect any of the functions of the extraocular muscles depending on the location and the aetiology of the lesion. An interesting subgroup of patients having isolated paresis of inferior rectus muscle without involvement of the other muscles has always drawn special interest. The purpose of this article is to report a case of binocular vertical diplopia resulting from an isolated, unilateral inferior rectus paresis followed by a review of the existing literature along with a discussion of neuroanatomy, aetiology, clinical features and management. Clinicians may increase their awareness of the spectrum of various possible causes that can present with isolated IRM palsy.     

Oculomotor nerve palsy in childhood

BACKGROUND: The management of children with oculomotor nerve palsy is complicated by their variable presentation, amblyopia, potential loss of binocularity, and associated neurological disease. Our purpose was to evaluate the causes, neurological associations, treatment, and sensorimotor outcomes of a group of children who developed oculomotor nerve palsy. METHODS: We identified 18 children aged 14 years or younger, of whom 13 (72%) were less than 8 years old, through a retrospective record review of all children with oculomotor nerve palsy seen between January 1995 and January 2001 by one of the authors (C.J.L.). RESULTS: Congenital-onset oculomotor nerve palsy was the most frequent presentation, followed by traumatic, neoplastic, vascular, and migrainous or para-infectious etiologies. Pupil sparing was seen in 1 patient with neoplastic etiology. Primary aberrant regeneration was the presenting sign in a child with neurofibromatosis type 2. Amblyopia developed in 7 (39%) children and was successfully treated in 5 of the 7 (71%). Stereopsis was maintained in 6 (33%) children of whom 2 were within the amblyogenic age group. Six (33%) patients underwent strabismus surgery, and 3 of them (50%) achieved orthotropia and maintained stereopsis. INTERPRETATION: Children with oculomotor nerve palsy require neuroimaging. Their pupillary signs, unlike those of adults, are not helpful in differentiating compressive etiologies from other causes. Good visual acuity was obtained in children within the amblyogenic age group with appropriate occlusion therapy. Stereopsis was uncommon in children who developed third nerve palsy during the amblyogenic period; preservation of stereopsis was dependent either on rapid and complete recovery, or on the child's adoption of a compensatory head position.     

Parinaud's and Nuclear Oculomotor Nerve Syndromes in a Patient with Mesencephalic Hematoma

Primary hematomas of the mesencephalon are extremely rare. We report in this article a case of Parinaud's syndrome and nuclear oculomotor nerve palsy due to a mesencephalic hematoma, as a rare cause. Neuro-ophthalmological examination revealed incomplete bilateral ptosis. All vertical movements were restricted; she could not elevate or depress either eye. She could not carry out convergence and Bell's phenomenon was negative. Both pupils were slightly dilated and were unreactive to direct and consensual light stimulation. Magnetic resonance imaging (MRI) revealed hematoma of the mesencephalon. The Ppatient was followed conservatively and after six months her neuro-ophthalmological examination improved almost completely. A repeat cranial MRI revealed resolution of the midbrain hematoma.     

针刺配合康复训练治疗动眼神经麻痹的疗效研究

目的：探究传统中医针刺疗法配合常规康复训练对动眼神经麻痹患者的临床疗效。方法：选取2005-05/2012-09来我院就诊的110例动眼神经麻痹患者,依据治疗方法的不同分为治疗组和对照组,每组55例。给予对照组康复训练疗法进行治疗,治疗组采用针刺联合康复训练法进行治疗。观察治疗前及治疗8wk后患者的对光反射、屈光度情况、眼裂宽度及眼球运动改善总有效率的情况。结果：治疗8wk后,治疗组患者对光反射改善情况、屈光度情况改善及眼裂宽度增大情况均好于对照组（P〈0.05）; 治疗组眼球运动改善47例（85.5%）优于对照组／〖36例（65.5%）,P〈0.05／〗。结论：针刺疗法联合康复训练可明显减轻动眼神经麻痹患者的临床症状,提高患者的生存质量。     

Oculomotor Palsy as the Initial Finding in Neurofibromatosis Type 2

A 15-year-old boy with oculomotor palsy in the left eye as the initial finding of neurofibromatosis type 2 (NF2) was presented. The eye motility examination revealed restriction in adduction, elevation and depression of the left eye and mild ptosis of the left eye. Cranial magnetic resonance imaging (MRI) showed a 3 cm sized mass in the cerebellar vermis that showed features of a schwannoma; bilateral lesions in the acoustic canals and bilateral optic nerve buckling: these findings were consistent with a diagnosis of NF2. Further thin-section MRI revealed a mass in the left cavernous sinus segment of the oculomotor nerve and a thickening of the right oculomotor nerve.     

Simultaneous, bilateral diabetic ophthalmoplegia. Report of two cases and discussion of differential diagnosis

Two patients presented with simultaneous oculomotor nerve palsies clinically associated with diabetes mellitus. Although unilateral cranial nerve palsies frequently occur in diabetes mellitus, this report is the first documented occurrence of simultaneous, concurrent diabetic (vasculopathic) oculomotor nerve palsies. The differential diagnosis of bilateral ophthalmoplegia is discussed in detail.     

Steroids in the Management of Synkinesis after Traumatic Oculomotor Palsy in India

Traumatic oculomotor nerve palsies may result in aberrant regeneration and synkinesis that can impair normal facial function. We retrospectively investigated 16 patients with traumatic oculomotor nerve palsies who were treated with and without steroids to evaluate the rates of aberrant regeneration. The overall rates of aberrant regeneration were similar between the two groups and in line with other published series. Some limitations to our study may limit our ability to detect real differences, and additional studies would be beneficial.     

Pupil sparing incomplete third nerve palsy secondary to a cavernous sinus meningioma: challenges in management

Background: The diagnosis of incomplete third nerve palsy can be clinically challenging because the aetiologies, as well as presentations, can be variable and subtle. The optometric clinician should be familiar with the association of third nerve palsy with compressive lesions, including the clinical presentations and management of these patients. Case report: We present a 68‐year‐old hypertensive male complaining of intermittent diplopia for the previous six months. Neurological examination revealed a mild deficit in adduction, reduced range of vertical motility and questionable ptosis, all limited to the OD. No pupillary involvement was noted. MRI revealed a cavernous sinus meningioma. The patient elected against surgery, choosing MRI every six months. Conclusion: Due to the subtle clinical presentation of incomplete pupil sparing third nerve palsy, this ophthalmoplegia may be easily overlooked. The associated aetiologies of palsy of cranial nerve three (CN3) carry increased risk of morbidity and mortality. Management should include evaluation for mass lesions and/or vascular aetiologies, regardless of pupillary involvement.     

Ischaemic Oculomotor Nerve Palsy Isolated to the Levator: A Case Report

ABSTRACT

Ischaemic oculomotor nerve (CN III) palsies frequently present with abrupt onset ptosis, ophthalmoplegia, diplopia, ipsilateral pain, and little to no anisocoria. An isolated microvascular ischaemic insult to the superior division of CN III is uncommon, and usually affects both the superior rectus and levator muscles. We present a rare case of an ischaemic CN III palsy isolated to the levator palpebrae superioris muscle only. Although rare, microvascular ischaemic CN III palsies should be on the differential of isolated ptosis. Other causes of isolated ptosis, such as myasthenia gravis or an orbital lesion, should be excluded.     

Unusual case of temporal dermoid cyst presenting as oculomotor nerve palsy

Dermoid cysts are choristomas resulting from the inclusion of ectodermal tissue during closure of the neural tube and occur along the epithelial lines of fusion. Frontotemporal dermoids are the most common type and generally present as an asymptomatic mass. We present an unusual case of frontotemporal dermoid presenting as sudden onset oculomotor nerve palsy in young male patient and describe the neurosurgical approach in its management.