Third cranial nerve (oculomotor nerve) palsy in children
- Andrew G Lee, MD
Andrew G Lee, MD
- Professor of Ophthalmology, Neurology, and Neurological Surgery
- Weill Cornell College of Medicine
- Paul W Brazis, MD
Paul W Brazis, MD
- Section Editor — Neuroophthalmology
- Professor of Neurology, Department of Ophthalmology
- Mayo Clinic College of Medicine
- Section Editors
- Evelyn A Paysse, MD
Evelyn A Paysse, MD
- Section Editor — Pediatric Ophthalmology
- Professor of Ophthalmology and Pediatrics
- Baylor College of Medicine
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Chief of Neurology
- Children’s Hospital Los Angeles
- Vice Chair of Neurology
- USC Keck School of Medicine
Dysfunction of the third cranial nerve (oculomotor nerve) can result from lesions anywhere along its path between the oculomotor nucleus in the midbrain and the extraocular muscles within the orbit. Third nerve palsy may herald a life-threatening intracranial process (eg, tumor, aneurysm). The diagnosis and management of third nerve palsy varies according to the age of the patient, characteristics of the third nerve palsy, and the presence of associated signs and symptoms.
The manifestations and diagnosis of third nerve palsy will be reviewed here. Palsies of the fourth and sixth cranial nerves are considered separately. (See "Fourth cranial nerve (trochlear nerve) palsy in children" and "Sixth cranial nerve (abducens nerve) palsy in children".)
The third cranial nerve supplies the levator muscle of the eyelid and four extraocular muscles: the medial rectus, superior rectus, inferior rectus, and inferior oblique. The superior oblique muscle is innervated by cranial nerve IV and the lateral rectus muscle by cranial nerve VI (table 1). In addition, the third cranial nerve constricts the pupil through its parasympathetic fibers that supply the smooth muscle of the ciliary body and the sphincter of the iris.
The third nerve begins as a nucleus in the midbrain. It consists of several subnuclei that innervate the individual extraocular muscles, the eyelids, and the pupils. Each subnucleus, except the superior rectus subnucleus, supplies the ipsilateral muscle.
●The superior rectus subnucleus innervates the contralateral superior rectus.
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- CLINICAL MANIFESTATIONS
- Eye examination
- - General findings
- - Nuclear lesions
- - Extra-axial lesions
- - Cavernous sinus lesions
- - Orbital lesions
- DIFFERENTIAL DIAGNOSIS
- RADIOLOGIC EVALUATION
- Overview of imaging strategy
- Isolated third nerve palsies
- - Congenital or long-standing third nerve palsy
- - Complete third nerve palsy with pupillary sparing
- - Partial third nerve palsy and pupillary sparing
- - Third nerve palsy with impaired pupillary function
- Non-isolated third nerve palsies
- SUMMARY AND RECOMMENDATIONS