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Case presentation: Third nerve palsy

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Shared a case of third nerve palsy in my practice

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Case presentation: Third nerve palsy

  1. 1. THIRD NERVE PALSY Prepared by: Anis Suzanna binti Mohamad Optometrist
  2. 2. What is third nerve palsy?  a condition which leads to a wide impairment of motor function, as this innervates most of the muscles of the eyes.
  3. 3. Aetiologies Types of 3rd palsy Common condition(s) Congenital The palsy is usually incomplete, unilateral and without ptosis, the pupil is spared. Acquired Microvascular (DM,HPT,atherosclerosis) >45years old, pupil sparing, rare in children. Compression (tumor, aneurysms) The condition usually painful, with ptosis and pupil involvement. Trauma Pupil involvement Migrainous The condition occurs upon resolution of a headache, usually involving the pupil. Infectious Viral illness, bacterial meningitis, or immunizations Source: Essentials of clinical binocular vision by Erik M. Weissberg
  4. 4. 1.Patient profile: Referred by:  Ms. E  Malay  Female  18 years old  File no: 5108  Date: 9/2/04  Referred from ophthalmologist at Hospital Tuanku Fauziah, Kangar for squint assessment.  Patient has RE optic neuropathy secondary to trauma, RE exotropia and LE high myope.
  5. 5. 2. Presenting signs and symptoms Symptom RE exotropia after accident 14 years ago. Diplopia appreciated. Age of onset 11 years old Mode of onset Accident Medical or birth history Nil Family history Nil Previous treatment Glasses for high myopia
  6. 6. 3. Clinical findings: Current Rx Distance VA Near VA RE: -3.00Ds LE: -5.00Ds (3/60) (6/6) Hirschberg Unil Cover test (∞) Unil Cover test (Near) ~15° exo RE exotropia with diplopia RE exotropia with diplopia
  7. 7. Ocular Motility RSR++ RIR- ‘A’ pattern exo Vergence System Horizontal vergence Vertical Vergence 35/40Δ BI Exo 50Δ BI Near: (RE) 35BI & 2BD Distance: (RE) 35BI & 2BD (RE hypertropia) Post-op diplopia test Near: Patient see single with 35Δ BI Distance: Do not appreciate diplopia when overcorrect until 50Δ BI
  8. 8. 4. Diagnosis:  Secondary right eye exotropia due to trauma. 5. Management plan5. Management plan Suggest surgery for cosmetic reason. Suggest for unilateral recess and resect. ◦ 7.0mm RLR recess ◦ 6mm RMR resect. Attached a referral letter to ophthalmologist at Hospital Tuanku Fauziah, Kangar.
  9. 9. Discussion
  10. 10. Anatomy of third cranial nerve
  11. 11. Anatomic Basis of Neurologic Diagnosis by Cary D. Alberstone
  12. 12. Criteria for ocular motor palsy Source: Essentials of clinical binocular vision by Erik M. Weissberg
  13. 13. Classification Involved muscle(s) Ocular motility Restricted version Ptosis Complete (superior and inferior division) MR,SR,IR,IO, levator Exotropia, hypotropia, intorted Adduction, elevation, depression Yes Superior division only SR, levator Hypotropia Elevation Yes Inferior division only MR,IR,IO Exotropia, hypertropia, intorted Adduction, elevation, depression No Isolated muscle MR Exotropia Adduction No Isolated muscle SR Hypotropia Elevation when adducted No Isolated muscle IR Hypertropia Depression when abduction No Isolated muscle IO Hypotropia Elevation when adduction No Table of classification, involved muscle and associated signs of third cranial nerve palsy. Source: Essentials of clinical binocular vision by Erik M. Weissberg
  14. 14. Limitations  Incomplete history taking  Clinical findings Refinement on refractive error. Basic squint assessment hirschberg test, unilateral cover test, ocular motility, vergence system and post-op diplopia test. No external observation recorded. Hess chart Post-op diplopia test
  15. 15. LR recession & MR resection in XT XT (pD) LR recess MR resect 15 4.00 mm 3.00 mm 20 4.00 mm 4.00 mm 25 6.00 mm 4.50 mm 30 6.50 mm 5.50 mm 35 7.50 mm 5.50 mm • Suggest surgery for cosmetic reason. • Suggest for unilateral recess and resect. •7.0mm RLR recess and 6mm RMR resect.
  16. 16. References: I. Millodot, M. 2000. Dictionary of Optometry and Visual Science. Oxford: Butterworth-Heinemann Ltd. II. Erik M. 2004. Essentials of clinical binocular vision. Elsevier: Butterworth-Heinemann Ltd. III. Alec M. Ansons. 2001. Diagnosis and management of ocular motility disorders.Blackwell Science Ltd. IV. Bruce Evans, David Pickwell. 2004. Pickwell’s binocular vision anomalies: investigation and treatment. Elsevier: Butterworth-Heinemann Ltd. V. Burian & von Noorden. 2000. Burian von-Noorden’s Binocular Vision and ocular motility: theory and management of strabismus. Elsevier: Butterworth- Heinemann Ltd. VI. Cary D. Alberstone. 2000. Anatomic Basis of

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