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Extraocular Muscles -  PARALYSIS OF THIRD NERVE (OCULOMOTOR NERVE) Lecture 29 of 49  NEXT»

This type of paralysis includes ptosis, an inability to rotate the eye upward or inward, a dilated unreactive pupil (iridoplegia), and paralysis of accommodation (cycloplegia).

Extracted table paralysis of third nerve

1. Intracerebral

 A. Lesion of red nucleus (Benedikt syndrome) - homolateral oculomotor paralysis with  contralateral intention tremor
 B. Myasthenia Gravis and Mesencephalic Cavernous Angioma
 C. Nuclear types-pareses of a single or a few extraocular muscles supplied by the oculomotor nerve in one or both eyes; there mayor may not be pupillary disturbances (mydriasis, sluggish pupillary reaction) and paresis of accommodation; in tumors within or near the midbrain (pinealomas), there is a combination of isolated muscle pareses with vertical gaze palsy, possibly a disturbance of convergence, and nystagmus retractorius (Parinaud syndrome, sylvian aqueduct syndrome, pineal syndrome); includes Axenfeld-Schurenberg syndrome (cyclic oculomotor paralysis), Bruns syndrome (postural change syndrome), Claude syndrome (inferior nucleus ruber syndrome), congenital vertical retraction syndrome, and Nothnagel syndrome (ophthalmoplegia-cerebellar ataxia syndrome)
 D. Occlusion of basilar artery-due to emboli especially but also to hemorrhage or aneurysm
 E. Recurrent third nerve palsy secondary to vascular spasm of migraine
 F. Syndrome of cerebral peduncle (Weber syndrome)-homolateral oculomotor paralysis and  cross-hemiplegia
 G. Tumors

2. Intracranial

 A. Amebic dysentery
 B. Aneurysm rupture at base of brain-third nerve paralysis, pain around the face  (fifth nerve), and headache
 C. Botulism
 D. Chickenpox
 E. Craniopharyngioma
 F. Dengue fever
 G. Devic syndrome (optical myelitis)
 H. Diphtheria
 I. Encephalitis, acute
 J. Hepatic failure
 K. Hepatitis
 L. Influenza
 M. Lockjaw (tetanus)
 N. Lymphoma
 O. Malaria
 P. Measles immunization
 Q. Meningococcal meningitis
 R. Multiple sclerosis (disseminated sclerosis)
 S. Ophthalmic migraine
 T. Periarteritis nodosa
 U. Poliomyelitis
 V. Polyneuritis because of toxins such as alcohol, lead, arsenic, and carbon  monoxide; dinitrophenol or carbon disulfide poisoning; or diabetes mellitus,  herpes zoster, or mumps
 W. Rabies
 X. Relapsing polychondritis
 Y. Smallpox vaccination
 Z. Subdural hematoma
 AA. Syphilis (acquired lues)
 BB. Temporal arteritis syndrome (Hutchinson-Horton-Magrath-Brown syndrome)
 CC. Tuberculosis

3. Lesions affecting exit from cranial cavity

 A. Cavernous sinus syndrome-paralysis of third, fourth, and sixth nerves with  proptosis
  (1) Aneurysm (arteriovenous fistula syndrome)
  (2) Carotid-cavernous fistula
  (3) Cavernous sinus thrombosis
  (4) Extension from lateral sinus thrombosis
  (5) Extension of nasopharyngeal tumor
  (6) Pituitary adenoma - lateral extension
  (7) Tolosa-Hunt syndrome (painful ophthalmoplegia)
 B. Superior orbital fissure syndrome-same as for cavernous sinus syndrome  except exophthalmos is less likely to occur and optic nerve involvement and  miotic pupil are more likely
  (1) Aneurysm of internal carotid artery syndrome (foramen lacerum    syndrome)
  (2) Occlusion of superior ophthalmic vein
  (3) Skull fractures or hemorrhage
  (4) Sphenoid sinus suppuration (sphenocavernous syndrome)
  (5) Temporal syndrome (Gradenigo syndrome)
  (6) Tumors, such as sphenoid ridge meningioma (Rochon-Duvigneaud    syndrome), nasopharyngeal tumor, metastatic carcinoma,      rhabdomyosarcoma, chordoma, and sarcoma
 C. Orbital apex-involvement of third, fourth, sixth, and first division of fifth  cranial nerves and optic nerve proptosis is common

4. Other

 A. Alber-Schonberg syndrome (marble bone disease, osteopetrosis)
 B. Associated with aspirin poisoning
 C. Congenital
 D. Hodgkin disease
 E. Lupus erythematosus (Kaposi-Libman-Sacks syndrome)
 F. Myasthenia gravis (masquerade)
 G. Passow syndrome (status dysraphicus syndrome)
 H. Porphyria cutanea tarda
 I. Sarcoid (Schaumann syndrome)

Harrison AR, Wirtschafter JD. Isolated inferior rectus paresis secondary to a mesencaphalic cavernous angioma. Am J Ophthalmol 1999; 127, 5:617-620.

Holmes JM, et al. Pediatric third, fourth, and sixth nerve palsies: a population-based study. Am J Ophthalmol 1999; 127:388-392.

Ing EB, et al. Oculomotor nerve palsies in children. J Pediatr Ophthal Strabismus 1992; 29:331-336.

Purvin V. Third cranial nerve palsy. In: Margo CE, ed. Diagnostic problems in clinical ophthalmology. Philadelphia: WB Saunders, 1994:678.

Roy FH. Ocular syndromes and systemic diseases, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

Childhood Causes of Third Nerve (Oculomotor) Palsy
1. Trauma
2. Neoplasm
3. Undetermined
4. Ophthalmoplegic migraine
5. Postoperative cause
6. Meningitis/encephalitis
7. Subdural hematoma
8. Viral or post-upper respiratory tract infection
9. Varicella-zoster virus
10. Aneurysm
11. Orbital cellulitis
12. Sinus disease
13. Mesencephalic cyst
14. Cyclic oculomotor nerve palsy
15. Poison

Holmes JM, et al. Pediatric third, fourth, and sixth nerve palsies: a population-based study. Am J Ophthalmol 1999; 127:388-392.

Kodsi SR, Younge BR. Acquired oculomotor, trochlear, and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol 1992; 114:568-574

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