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Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
Oculomotor palsy
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Oculomotor palsy

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  • 1. Occulomotor Palsy with Multiple Cranial Nerves Neuropathy By: Abhimanyu Parashar Pharm D Intern
  • 2. Oculomotor Palsy (3rd Nerve Palsy) • Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch • The Oculomotor nerve supplies the majority of the muscles controlling eye movements • In a complete Oculomotor nerve palsy, the affected eye will normally be in a down and out position relative to the other eye • The affected eye will also have a ptosis, or drooping of the eyelid, and pupil dilation
  • 3. Types of Oculomotor Palsy  Congenital Oculomotor Palsy  Acquired Oculomotor palsy        Vascular disorders Lesions or Tumors Inflammation or Infection Trauma Demylenating Disease AIDS Post Operative Neurosurgery Symptoms  Ptosis  Downward and Outward positioning of Eye Unable to adduct, infraduct, supraduct Dilated pupil with sluggish reaction
  • 4. Muscles Innervated by 3rd Cranial Nerve • 1) Superior Rectus muscle (extraocular muscle) • 2) Inferior Rectus muscle (extraocular muscle) • 3) Medial Rectus muscle (extraocular muscle) • 4) Inferior Oblique (extraocular muscle) • 5) Levator palpebrae superioris (muscle to upper eye lid)
  • 5. External Ocular Paralysis Muscle Direction of pull Result of paralysis Cranial nerve Medial rectus Medially Lateral III Superior rectus Upwards Downwards III Lateral rectus Laterally Medial VI Inferior rectus Downwards Upwards III Superior oblique Down and out Up and in IV Inferior oblique Up and out Down and in III
  • 6.      Pathophysiology lesions at Oculomotor Nucleus (Midbrain) Lesions at Oculomotor Nerve Fascicles Lesions at Subarachnoid place Lesions within cavernous sinus & Superior orbital fissure Lesions within Orbit Differential Diagnosis Myasthenia Gravis Thyroid associated orbitopathy Internuclear ophthalmoplegia Chronic progressive external ophthalmoplegia Orbital pseudotumor Giant cell Arteritis
  • 7. Optic Neuritis • Optic neuritis is an inflammation of the optic nerve • Optic neuritis usually affects one eye, although it may occur in both eyes simultaneously. • Symptoms: Pain Vision loss Loss of color vision Flashing lights
  • 8. Etiology:  Multiple Sclerosis (incidence rate 50%)  Neuromylitis Optica  Sarcoidosis  SLE  Infections: Lyme's Disease, Syphilis, measles, mumps, herpes .  Cranial Arteritis  Vasculitis  Diabetes Mellitus  Drugs (Ethambutol, Chloramphenicol)  Radiation
  • 9. OP No. 1116060 IP No. 279206 Age 55 Yrs Sex Male Weight 86 Kgs Unit Neurology OPD Evaluation c/o Diplopia, Blurring of vision and headache since 1day Not a k/c/o DM & HTN BP: 160/90 mmHg o/e: Left eye impaired, abduction/ elevation absent Left third nerve palsy Imp: Demyelination ? Left 3rd nerve palsy Adv: MRI
  • 10. MRI Brain Optic Nerve: • Rt Optic nerve: 3.5 mm & Normal. • Lt Optic nerve: 4.0 mm & Enlarged in size and Normal in outline. • The optic chiasma, the lateral geniculate body, the thalami and the optic tracts are Normal Impression: Features S/O Left Optic Neuritis Neurologist opinion: Left optic Neuritis ? 3rd Nerve Palsy ADV: Admit to ward
  • 11. Day 1 • C/O: Diplopia, painful movement of eye, blurring of vision since 2 days • H/O headache • No Hx of similar complains in past • Not a k/c/o DM & HTN Provisional diagnosis: Left optic neuritis
  • 12. General examination: • CNS: conscious oriented • CN : Lt eye impaired abduction/ elevation/ depression absent Motor system: • Tone: Normal • Power: 5/5 in all limbs • Reflexes: Normal • Plantar: Extensor Sensory/ cerebeller system: Normal Adv: HIV, VDRL, Rx as per chart
  • 13. Treatment chart DRUGS DOSE F R from Inj. Prednisolone 1 g in 100 ml 1-0-0 IV 16/1 Inj. rabeprazole 20 mg 1-0-0 IV 16/1 Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1 Syp. sucralfate 2 tsp 1-0-1 PO 16/1 T. Paracetamol + Aceclofenac 500 + 50 mg 1-0-1 PO 16/1 T. Amitriptylline + Chlordiazepoxide 25 + 10 mg 0-0-1 PO 16/1
  • 14. Day 2 BP: 130/80 mmHg Pulse: 76 BPM • O/E Pt feeling slightly better • MRI brain: feature suggestive of left optic neuritis • Left eye ptosis + • Abduction/ elevation impaired ADV: treatment as per chart, LP CSF, Ophthalmologist opinion, neuro-surgeon opinion for any surgical cause • 4 PM Lumbar puncture done
  • 15. HIV Negative VDRL Negative FBS 84 mg/dl PPBS 148 mg/dl LP - CSF Normal
  • 16. Ophthalmologists opinion: • Unable to open left eye, sudden in onset • Diplopia only force open the left eye • Pupils dilated • O/E Alternating exotropia • Ptosis – severe • Fundus: WNL • Temporal pallor of disc + • Macula + • IMP: Resolving 3rd cranial nerve palsy • Will be reviewed tomorrow
  • 17. Treatment chart DRUGS DOSE F R from Inj. Prednisolone 1 g in 100 ml 1-0-0 IV 16/1 Inj. rabeprazole 20 mg 1-0-0 IV 16/1 Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1 Syp. sucralfate 2 tsp 1-0-1 PO 16/1 T. Paracetamol + Aceclofenac 500 + 50 mg 1-0-1 PO 16/1 T. Amitriptylline + Chlordiazepoxide 25 + 10 mg 0-0-1 PO 16/1
  • 18. Day 3 BP: 150/80 mmHg Pulse: 84 BPM • O/E: pt symptomatically better • CNS: conscious oriented • CN 3rd : Lt eye ptosis + pupils are reactive to light abduction decreased • Neurosurgeon opinion: No visual activity symptoms, left 3rd nerve paresis No active neurological intervention required • Ophthalmologists opinion: ADV: Review after 1 month Pupil Sparing 3rd Nerve Paresis
  • 19. Swinging Flashlight Test of Pupillary constriction
  • 20. Treatment chart DRUGS DOSE F R from Inj. Prednisolone 1 g in 100 ml 1-0-0 IV 16/1 Inj. rabeprazole 20 mg 1-0-0 IV 16/1 Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1 Syp. sucralfate 2 tsp 1-0-1 PO 16/1 T. Paracetamol + Aceclofenac 500 + 50 mg 1-0-1 PO 16/1 T. Amitriptylline + Chlordiazepoxide 25 + 10 mg 0-0-1 PO 16/1 T. Aspirin 75 mg 0-1-0 PO 18/1
  • 21. Day 4 • • • • BP: 150/80 mmHg O/E: Vital stable No fresh complains ADV: treatment as per chart Pulse: 76 BPM
  • 22. Treatment chart DRUGS DOSE F R from Inj. Prednisolone 1 g in 100 ml 1-0-0 IV 16/1 Inj. rabeprazole 20 mg 1-0-0 IV 16/1 Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1 Syp. sucralfate 2 tsp 1-0-1 PO 16/1 T. Paracetamol + Aceclofenac 500 + 50 mg 1-0-1 PO 16/1 T. Amitriptylline + Chlordiazepoxide 25 + 10 mg 0-0-1 PO 16/1 T. Aspirin 75 mg 0-1-0 PO 18/1
  • 23. Day 5 • • • • BP: 140/80 mmHg O/E: Vital stable No fresh complains ADV: Discharge Pulse: 80 BPM
  • 24. Treatment chart DRUGS DOSE F R from inj. Prednisolone 1 g in 100 ml 1-0-0 IV 16/1 Inj. rabeprazole 20 mg 1-0-0 IV 16/1 Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1 Syp. sucralfate 2 tsp 1-0-1 PO 16/1 T. Paracetamol + Aceclofenac 500 + 50 mg 1-0-1 PO 16/1 T. Amitriptylline + Chlordiazepoxide 25 + 10 mg 0-0-1 PO 16/1 T. Aspirin 75 mg 0-1-0 PO 18/1
  • 25. Discharge medications DRUGS DOSE F R T. Paracetamol + Aceclofenac 500 + 50 mg 1-0-1 PO T. Amitriptylline + Chlordiazepoxide 25 + 10 mg 0-0-1 PO T. Aspirin 75 mg 0-1-0 PO Tab. Prednisolone 40 mg 1-0-0 PO Tab. Rabeprazole 20 mg 1-0-0 PO
  • 26. Pharmaceutical Care Plan Subjective Evidence  Diplopia  Blurred Vision  Left eye Impaired  Adduction, Elevation, Depression Absent  Ptosis of Left eye  Headache  Exotropia Left eye Objective Evidence  MRI: Features S/O Left Optic Neuritis  Swinging Flashlight test: Pupil sparing Oculomotor palsy
  • 27. Final Diagnosis Oculomotor Nerve (3rd Cranial Nerve) Palsy with Multiple cranial nerves neuropathy
  • 28. Goals of Therapy • To relive presenting signs and symptoms • To rule out the underlying etiology • To prevent further progression and complication of the disease • To align the eye surgically* • To improve health related quality of life (*) : Optional
  • 29. Treatment Options Pharmacological: • NSAID’s • Corticosteroids Non Pharmacological: • Patching of Eye • Using Prism Lens Spectacles Surgical: • Eye muscle surgery (Strabismus Surgery) • Lid lift surgery (Blepharoplasty) • Clipping, Gluing, Coiling, wrapping of Aneurysms*
  • 30. Goals Achieved • Patient was started on symptomatic pharmacotherapy • Patient symptoms improved before he was discharged
  • 31. Problems Identified • • • • Use of Cefoperazone + Sulbactum Use of IV Proton Pump Inhibitor Untreated indication: Hypertension Monitoring Error: Lipid Profile not done Clinical Pharmacy Services Provided Drug Information: Oral Proton Pump inhibitors Vs. IV Proton Pump Inhibitors Intervention: • Use of IV proton pump inhibitors • Untreated indication – Hypertension
  • 32. Monitoring Parameters • • • • • • • • MRI Blood Pressure Blood Glucose Lipid Profile CT Scan* Fundoscopy Ophthalmoscopy Carotid Doppler*
  • 33. Patient Counseling
  • 34. About Disease • What is a third nerve palsy? • What are the symptoms of third nerve palsy? • What causes third nerve palsy? • What can be done to correct third nerve palsy? About Medications – Name and purpose – Dose and frequency – Medication adherence – Possible adverse effects – Missed dose – Caution with Corticosteroids
  • 35. About Lifestyle modifications • Patient should avoid driving • Patient should keep an eye patch to cover the affected eye • Using 1 eye will impair 1/3 of the vision and patient may not be able to judge depth and height so be careful in making any judgment • Patient should wear prism lenses to avoid Diplopia • Patient Should avoid consuming alcohol as it can precipitate the ischemic neuropathy • Patient should reduce the salt intake and fatty food in order to reduce the blood pressure. • Patient should take sufficient rest • Patient should be counseled about cosmetic issues related to Oculomotor palsy and can be prepared for strabismus surgery*

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