Clinical Approach to Diplopia and oculomotor nerve palsy.

1. Double Trouble

3. Case 1

18. NEXT STEP(S)?

23. EXAMINATION AS SHOWN MOTILITY 15/15 15/15 COLOR WNL WNL FUNDUS FULL FULL CVF 5 -> 3 7 -> 6 PUPILS 20/40 20/60 VISION OS OD

27. MRI: T2-WEIGHTED

28. MRI: T1-WEIGHTED WITH GADOLINIUM

31. R L

33. Evaluation of Isolated TNP Complete Partial Pupil involved ? No Ischemic risk factors ? Yes Observe MRI/MRA (or CTA) Yes Pupil involved ? Yes No Re-evaluate after 1 week involved spared Observe if ischemic risk factors, otherwise consider Imaging, LP Modified from clinical pathways in neuro-ophthalmology , AG Lee

34. PUPIL SPARING REPORTED IN 8-15% OF III-PALSY DUE TO ANEURYSMS PUPIL SPARING CN III PALSY 10 YEARS OLD MRI / MRA 20 YEARS OLD MRI / MRA, ? A-GRAM 40 YEARS OLD MRI / MRA, ? A-GRAM 60 YEARS OLD B/P, FBS, ?ESR, FOLLOW DAILY

37. Different scenario Pseudo Von-Graffe’s sign Lid retraction in adduction

38. MRA WILL PICK UP 95% OF ANEURYSMS > 3mm MRA CONVENTIONAL A-GRAM

39. MRA

40. CTA or MRA ? 5-6 mm aneurysms can be missed Aneurysm detection Evaluation of Neck vessels Flexibility of display Contrast Patients with implanted metal Scanning time Superior Problematic Superior Not necessary in 3D TOF and 2D TOF Iodinated contrast Contraindicated Can be used Longer Short MRA CTA

42. Motility

44. Video Fatigability

45. Case 23 Orbicularis weakness OD >OS