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1. Dr Md Ferdous Islam
FCPS Part 2 Trainee
Dept of Ophthalmology
CMH, Dhaka
3rd Cranial Nerve Palsy

2. 3rd cranial nerve
OCULOMOTOR NERVE
 Entirely motor in function
 Supplies –
o All the Extraocular muscles except
superior
oblique and lateral rectus
o Levator palpebrae superioris
oIntra ocular muscles- Sphincter
pupillae and cilliary muscle

3. Nucleus
Located in midbrain at the level of
superior colliculus, ventral to the
Sylvian aquiduct.
Composed of
 Unpaired levator subnucleus
 Paired superior rectus sub nuclei
 Paired medial rectus, inferior rectus
and inferior oblique subnuclei

4. Course
Can be divided into –
Fascicular
Basilar
Intracavernous
Intraorbital part

5. Course

7. Intracavernous portion of 3rd
nerve

8. Intraorbital portion of 3rd
nerve

9. complex
lesion of 3rd nerve palsy
Vascular occlusion – Diabetes &
Hypertension
Neoplastic lesions – primary
tumour or metastasis
Haemorrhage

10. Major causes of fascicular
lesion of
3rd nerve palsy
 Vascular occlusion – Diabetes &
Hypertension
 Neoplastic lesions – primary tumour or
metastasis
 Haemorrhage
 Demyelination

11. Syndromes of Fascicular
lesion
 Benedikt syndrome- Ipsilateral 3rd nerve palsy
and contralateral extrapyramidal signs
 Weber syndrome- Ipsilateral 3rd nerve palsy and
contralateral hemiparesis
 Nothnagel syndrome- Ipsilateral 3rd nerve palsy
and cerebellar ataxia
 Claude syndrome

12. Major causes of lesion in
Basilar
region
 The 3rd nerve traverses the basilar part
unaccompanied by any other cranial
nerves.
 Isolated 3rd nerve palsies are commonly
basilar.
The important causes are
 Aneurysm
 Head trauma-Extradural or subdural

15. Major causes of
Intracavernous
lesion
 Usually associated with involvement of
4th, 6th nerves & first division of 5th
nerve.
 Diabetes – causes pupil sparing 3rd
nerve palsy
 Pituitary apoplexy
 Others – Aneurysm, Meningeoma,
Carotid-cavernous fistula.

16. Intraorbital causes of 3rd
nerve
palsy
 Trauma
 Vascular
 Neoplasm
 Inflammation

17. Pupillomotor fibers
 Parasympathetic fibers
 Located superficially between the
brainstem and the cavernous sinus
 Blood supply derived from the pial blood
vessels
 Main trunk of 3rd nerve supplied by the
vasa nervorum

19. Causes of isolated 3rd nerve
palsy
 Idiopathic – about 25%
 Vascular – Hypertension & Diabetes
(commonly pupil sparing)
 Aneurysm – posterior communicating
artery at its junction with internal carotid
artery
 Trauma – subdural haematoma with
uncal herniation
 Miscellaneous

20. Clinical features of total 3rd
nerve
palsy
SYMPTOMS
 Drooping of eyelid
 Binocular double vision
 Pain (may be present)

21. SIGNS
 Ptosis
 Abduction of globe
 Intortion of the globe which increases on
attempted down gaze
 Limitation of adduction
 Limitation of elevation
 Limitation of depression
 Dilated pupil with defective accommodation

23. History of Patient
 Onset
 Duration
 Diplopia
 Trauma
 Associated systemic disorders

24. Examination
 Pupillary reactions
 Motility restrictions
 Ptosis
 Other cranial nerves

25. Investigations

26. Investigations

27. Treatment
Non-surgical
 Treatment of underlying cause
 Diplopia – Occlusion patch or prism in
involved eye
 Monitor children for development of amblyopia
Surgical
 Neurosurgery – Aneurysm or haematoma
 Strabismus or ptosis surgery – Not earlier
than 6 months from time of onset

28. Follow-up
 Pupil sparing – Observe daily for 5 days
for pupil involvement
 Recheck every 4 to 6 weeks
 If secondary to ischemia function usually
returns within 3 months

29. Thank
You