1. Grand Rounds Brooke LW Nesmith, M.D., J.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 7/18/2014

2. Presentation CC: Diplopia x 5 days. CC: Diplopia x 5 days. HPI: 60 year old male presents with onset of binocular diplopia 5 days ago, with subsequent left lid ptosis 2 days later. No other visual acuity changes. HPI: 60 year old male presents with onset of binocular diplopia 5 days ago, with subsequent left lid ptosis 2 days later. No other visual acuity changes.

3. History POH: Proliferative diabetic retinopathy OU s/p panretinal photocoagulation POH: Proliferative diabetic retinopathy OU s/p panretinal photocoagulation PMH:Type II diabetes, hypertension, hyperlipidemia, coronary artery disease PMH:Type II diabetes, hypertension, hyperlipidemia, coronary artery disease Allergies:NKDA Allergies:NKDA

4. Exam VAsc P T VAsc P T 20/25 3  2mm (-) RAPD 20/400 14

5. Exam Findings ODOS Ext/L/Lwnlwnl Conjwnl wnl Kwnlwnl ACwnlwnl Iris/LensPCIOLPCIOL DFE -panretinal photocoagulation-

6. Exam

7. Exam

8. Assessment  60 year old male presents with left pupil-sparing 3 rd nerve palsy. MRI/MRA negative. Observe. Follow-up  3 rd nerve palsy resolved at two month follow-up.

9. 3 rd Nerve Palsy  Anatomy  Causes

10. 3 rd Nerve Pathway

14. 3 rd Nerve Palsy Nuclear Nuclear Fascicle syndromes (brainstem) Fascicle syndromes (brainstem) Uncal herniation Uncal herniation Cavernous Sinus Cavernous Sinus Isolated Isolated –Pupil-involving –Pupil-sparing –Divisional –Younger patients

15. Nuclear 3 rd Nerve Palsy uncommon uncommon

16. Fascicle Syndromes Weber syndrome Weber syndrome – contralateral hemiparesis (cerebral peduncle) Benedikt syndrome Benedikt syndrome - contralateral ataxia or tremor (red nucleus & substantia nigra) Claude syndrome Claude syndrome – contralateral ataxia (superior cerebellar peduncle)

17. Uncal Herniation Uncal herniation Uncal herniation

18. Cavernous Sinus Syndrome Cavernous Sinus – other cranial nerves Cavernous Sinus – other cranial nerves

19. Pupil Involving 3 rd Nerve Palsy Aneurysm at junction of posterior communicating artery and internal carotid artery Aneurysm at junction of posterior communicating artery and internal carotid artery Partial pupil involvement in 25-47% of patients with posterior communicating artery aneurysms Partial pupil involvement in 25-47% of patients with posterior communicating artery aneurysms

20. Pupil Sparing 3 rd Nerve Palsy Microvascular ischemia – most common cause Microvascular ischemia – most common cause –pupillary involvement in up to 20% (typically mild ≤ 1mm anisocoria) –may present with pain –diplopia improves within 3 months Aberrant regeneration Aberrant regeneration –common after trauma or compression by aneurysm or tumor –NOT WITH MICROVASCULAR ISCHEMIA

21. Case Report Grunwald L, Sund NJ, Volpe NJ. Pupillary sparing and aberrant regeneration in chronic third nerve palsy secondary to a posterior communicating aneurysm. BR J Ophthalmol 2008;92:715-716.

22. 3 rd Nerve Palsy Rare causes Rare causes  tumor, inflammation (sarcoid), vasculitis, infection (meningitis), infiltration (lymphoma, carcinoma), trauma (pupil involving) Divisional Divisional –lesion of anterior cavernous sinus or possibly posterior orbit Children Children –ophthalmoplegic migraine – ophthalmoplegia develops days after onset of head pain

23. References Zarbin M, Chu D. The evaluation of isolated third nerve palsy revisited: An update on the evolving role of magnetic resonance, computed tomography, and catheter angiography. Surv Ophthalmol 2002 47:137-157. Zarbin M, Chu D. The evaluation of isolated third nerve palsy revisited: An update on the evolving role of magnetic resonance, computed tomography, and catheter angiography. Surv Ophthalmol 2002 47:137-157. BCSC 2013-2014 Section 5 NeuroOphthalmology. Pages 209-218. BCSC 2013-2014 Section 5 NeuroOphthalmology. Pages 209-218. Jacobson DM. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology 2001 27;56(6):797-8. Jacobson DM. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology 2001 27;56(6):797-8. Sobreira I, Sousa C, Raposo A, Fagundes F, Dias A. Ophthalmoplegic migraine with persistent dilated pupil. J Child Neurol 2013 28:275. Sobreira I, Sousa C, Raposo A, Fagundes F, Dias A. Ophthalmoplegic migraine with persistent dilated pupil. J Child Neurol 2013 28:275.

24. Thank you.