Third nerve palsy a rare presentation

1. THIRD NERVE PALSY CASE
PRESENTATION
DR AISHWARYA S,
JUNIOR RESIDENT,
DEPT OF OPHTHALMOLOGY,
GOVT MEDICAL
COLLEGE,MANJERI

2. PATIENT DETAILS
38 Years old female patient
Nurse by profession

3. PRESENTING COMPLAINTS
Drooping of right upper eyelid for the past 8
months following a neurosurgical procedure

4. HISTORY OF PRESENT ILLNESS
History of drooping of right upper eyelid for the
past 8 months,non progressive in nature,not
assosciated with pain and with out any diurnal
variation
No history of double vision/headache

5. PAST HISTORY
No history of any systemic illness
At the age of 5years,she developed defective
vision in RE ,and she consulted an
ophthalmologist and was managed
conservatively.
At the age of 21 years (in 2005),she had
severe headache and was diagnosed with optic
nerve sheath meningioma and,she was on
follow up since then.

6. At the age of 33 years (in 2017)she developed
protrusion of right eye which was insidious in
onset,gradually progressive, and assosciated
with rapid detioration of vision .
As the tumor increased in size,she was adviced
surgery,but deferred due to risk of further loss
of vision.

7. Then ,she lost vision completely during last
year and so she underwent surgery on
2/6/2022-(Pterional craniotomy Superior
orbitotomy)
The histopathology report confirmed optic
nerve sheath meningioma and she had also
undergone reexpolartion surgery with total
decompression of lesion on 10/6/2022

8. OCULAR EXAMINATION
Head posture-normal
No facial asymmetry except for ptosis in right
eye
Hirschberg test-Right exotropia but exact
amount of deviation could not be assessed
because of dilated pupil and poor fixation in RE
On modified Krimsky test with base in front of LE
corneal reflex almost came to centre by using 20
prism.

9. -
2
-2
-1
-1
-1
f
f f
f
f
f
f
RE LE
OCULAR MOVEMENTS

11. FORCED DUCTION TEST-Negative for
adduction,depression and elevation
FORCED GENERATION TEST-Moderate
CONVERGENCE-Could not be assessed

12. PTOSIS MEASUREMENT
RIGHT EYE LEFT EYE
PFH(In primary
gaze)
6mm 10mm
PFH(In down
gaze)
5mm 5mm
MRD1 -1mm 3mm
MRD2 7mm 7mm
LPS action 12mm 20mm
Marginal limbal
distance
7mm 9mm

14. RIGHT EYE LEFT EYE
Lid fold Present Present
Lid crease Present Present
Bell’s phenomenon Poor Good

15. EYE RIGHT LEFT
VISUAL ACUITY PL(+) PR Inaccurate 6/6
COLOUR VISION Could not be
assessed
Normal
NEAR VISION Could not be
assessed
N6
Field test by
confrontation
Could not be
assessed
Normal
Lids and adnexa Ptosis Normal

16. EYE RIGHT LEFT
CONJUNCTIVA AND
SCLERA
Normal Normal
CORNEA Normal in
size,shape,lustre
and
transparency.Norma
l corneal sensations
in all quadrants
Normal in
size,shape,lustre
and
transparency.Norma
l corneal sensations
in all quadrants
ANTERIOR CHAMBER Normal and regular
in depth ,VH GrIII
Normal and regular
in depth,VH Gr III
IRIS Normal colour and
pattern.No e/o lisch
nodules
Normal colour and
pattern.No e/o lisch
nodules
PUPIL Single,round,5mm
in size,dilated and
fixed
Single,round,3mm
in size,Direct-
brisk,Indirect-

18. FUNDUS RIGHT EYE LEFT EYE
Disc margins not
defined,cup is absent,Glial
tissue is seen over the disc
extending to peripapillary
area ,macula and
midperiphery.Vessels are
not visualized.Macula
shows diffuse chorioretinal
atrophy Periphery is also
filled with glial tissue
Disc is normal in size and
shape with well defined
disc margins.CDR-
0.3.Peripapillary area
normal.Vessels arising
from the centre of the disc
and branching
dichotomously with AV
ratio of 2:3.Macula
normal.Periphery-normal

19. INVESTIGATIONS
MRI BRAIN-PRE OP OF 22MARCH 2019
Well defined T1 isointense ,T2 mildly
hyperintense lesion is seen in intraconal portion
of optic nerve extending till optic
canal.Widening of optic canal noted. Lesion
appears to closely abut medial rectus,lateral
rectus and superior rectus.Right SOV is
prominent.There is evidence of cerebellar
dysplasia
IMPRESSION-Features suggestive of right optic
nerve sheath meningioma
Left cerebellar dysplasia

20. MRI REPORT OF 14.01.2022-Increase in right
optic nerve sheath tumor likely meningioma
HISTOPATHOLOGY REPORT-
-Meningothelial meningioma,CNS WHO Grade
I,Right optic nerve sheath

21. MRI BRAIN AND ORBIT-POST OP ON
23/07/2022
Intensely enhancing soft tissue noted in right
retrobulbar region ,near the orbit apex-residual
meningioma likely.

22. SUMMARY
A 38 Years old female patient presented with
complaints of drooping of upper eyelid of RE
for the past 8 months following a
neurosurgery.On examination ,grade2
limitation in elevation ,grade 1 limitation in
depression and adduction in RE. Visual acuity is
PL+ and PR inaccurate. Pupil non reacting to
both direct and indirect light reflex in RE,and
indirect reflex sluggish in LE.The amount of
ptosis in RE is 4mm.Fundus examination shows
ill defined disc with glial tissue and
chorioretinal atrophy in RE

23. DIAGNOSIS
PUPIL INVOLVING TOTAL 3rd NERVE PALSY(RE)
POST NEURITIC OPTIC ATROPHY (RE)