Third cranial nerve (oculomotor nerve) palsy in adults
- Andrew G Lee, MD
Andrew G Lee, MD
- Professor of Ophthalmology, Neurology, and Neurological Surgery
- Weill Cornell College 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. 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 in adults will be reviewed here. Third nerve palsy in children and other causes of diplopia, ptosis, and anisocoria are discussed separately. (See "Third cranial nerve (oculomotor nerve) palsy in children" and "Overview of diplopia" and "Overview of ptosis" and "Approach to the patient with anisocoria".)
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. These muscles adduct, depress, and elevate the eye. The superior oblique muscle is innervated by cranial nerve IV and the lateral rectus muscle by cranial nerve VI. 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 that 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 muscleTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bhatti MT, Eisenschenk S, Roper SN, Guy JR. Superior divisional third cranial nerve paresis: clinical and anatomical observations of 2 unique cases. Arch Neurol 2006; 63:771.
- Jacobson DM. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology 2001; 56:797.
- Brazis PW, Lee AG. Binocular vertical diplopia. Mayo Clin Proc 1998; 73:55.
- Jacobson DM, McCanna TD, Layde PM. Risk factors for ischemic ocular motor nerve palsies. Arch Ophthalmol 1994; 112:961.
- Jacobson DM. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy. Arch Ophthalmol 1998; 116:723.
- Nadeau SE, Trobe JD. Pupil sparing in oculomotor palsy: a brief review. Ann Neurol 1983; 13:143.
- Richards BW, Jones FR Jr, Younge BR. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol 1992; 113:489.
- RUCKER CW. Paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1958; 46:787.
- Rucker CW. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1966; 61:1293.
- Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and VI. Cause and prognosis in 1,000 cases. Arch Ophthalmol 1981; 99:76.
- Teuscher AU, Meienberg O. Ischaemic oculomotor nerve palsy. Clinical features and vascular risk factors in 23 patients. J Neurol 1985; 232:144.
- Chou KL, Galetta SL, Liu GT, et al. Acute ocular motor mononeuropathies: prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci 2004; 219:35.
- Carrasco JR, Savino PJ, Bilyk JR. Primary aberrant oculomotor nerve regeneration from a posterior communicating artery aneurysm. Arch Ophthalmol 2002; 120:663.
- Biousse V, Newman NJ. Third nerve palsies. Semin Neurol 2000; 20:55.
- Arle JE, Abrahams JM, Zager EL, et al. Pupil-sparing third nerve palsy with preoperative improvement from a posterior communicating artery aneurysm. Surg Neurol 2002; 57:423.
- Foroozan R, Slamovits TL, Ksiazek SM, Zak R. Spontaneous resolution of aneurysmal third nerve palsy. J Neuroophthalmol 2002; 22:211.
- Lustbader JM, Miller NR. Painless, pupil-sparing but otherwise complete oculomotor nerve paresis caused by basilar artery aneurysm. Case report. Arch Ophthalmol 1988; 106:583.
- Levy J, Marcus M, Shelef I, Lifshitz T. Acute angle-closure glaucoma and pupil-involving complete third nerve palsy as presenting signs of thrombosed cavernous sinus aneurysm. Eye (Lond) 2004; 18:325.
- Satyarthee GD, Mahapatra AK. Unusual neuro-ophthalmic presentation of anterior communicating artery aneurysm with third nerve paresis. J Clin Neurosci 2004; 11:776.
- Ikeda K, Tamura M, Iwasaki Y, Kinoshita M. Relative pupil-sparing third nerve palsy: etiology and clinical variables predictive of a mass. Neurology 2001; 57:1741.
- Keane JR, Ahmadi J. Most diabetic third nerve palsies are peripheral. Neurology 1998; 51:1510.
- Eyster EF, Hoyt WF, Wilson CB. Oculomotor palsy from minor head trauma. An initial sign of basal intracranial tumor. JAMA 1972; 220:1083.
- Levy RL, Geist CE, Miller NR. Isolated oculomotor palsy following minor head trauma. Neurology 2005; 65:169.
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders. Cephalalgia 2004; 24:1.
- Bartleson JD. Transient and persistent neurological manifestations of migraine. Stroke 1984; 15:383.
- Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast-enhanced MR images. AJNR Am J Neuroradiol 1998; 19:1887.
- Lance JW, Zagami AS. Ophthalmoplegic migraine: a recurrent demyelinating neuropathy? Cephalalgia 2001; 21:84.
- O'Hara MA, Anderson RT, Brown D. Magnetic resonance imaging in ophthalmoplegic migraine of children. J AAPOS 2001; 5:307.
- De Silva DA, Siow HC. A case report of ophthalmoplegic migraine: a differential diagnosis of third nerve palsy. Cephalalgia 2005; 25:827.
- Kim JH, Hwang JM, Hwang YS, et al. Childhood ocular myasthenia gravis. Ophthalmology 2003; 110:1458.
- Golnik KC, Pena R, Lee AG, Eggenberger ER. An ice test for the diagnosis of myasthenia gravis. Ophthalmology 1999; 106:1282.
- Sethi KD, Rivner MH, Swift TR. Ice pack test for myasthenia gravis. Neurology 1987; 37:1383.
- Ellis FD, Hoyt CS, Ellis FJ, et al. Extraocular muscle responses to orbital cooling (ice test) for ocular myasthenia gravis diagnosis. J AAPOS 2000; 4:271.
- Jacobson DM, Trobe JD. The emerging role of magnetic resonance angiography in the management of patients with third cranial nerve palsy. Am J Ophthalmol 1999; 128:94.
- Heiserman JE, Dean BL, Hodak JA, et al. Neurologic complications of cerebral angiography. AJNR Am J Neuroradiol 1994; 15:1401.
- Dion JE, Gates PC, Fox AJ, et al. Clinical events following neuroangiography: a prospective study. Stroke 1987; 18:997.
- Bartleson JD, Trautmann JC, Sundt TM Jr. Minimal oculomotor nerve paresis secondary to unruptured intracranial aneurysm. Arch Neurol 1986; 43:1015.
- Elmalem VI, Hudgins PA, Bruce BB, et al. Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol 2011; 31:103.
- Lee SH, Lee SS, Park KY, Han SH. Isolated oculomotor nerve palsy: diagnostic approach using the degree of external and internal dysfunction. Clin Neurol Neurosurg 2002; 104:136.
- Loffredo L, Parrotto S, Violi F. Giant cell arteritis, oculomotor nerve palsy, and acute hearing loss. Scand J Rheumatol 2004; 33:279.
- Day A, Malik N. Giant cell arteritis presenting as painful third nerve palsy. Br J Hosp Med (Lond) 2006; 67:383.
- Yanaka K, Matsumaru Y, Mashiko R, et al. Small unruptured cerebral aneurysms presenting with oculomotor nerve palsy. Neurosurgery 2003; 52:553.
- White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology 2000; 217:361.
- Hashimoto H, Iida J, Hironaka Y, et al. Use of spiral computerized tomography angiography in patients with subarachnoid hemorrhage in whom subtraction angiography did not reveal cerebral aneurysms. J Neurosurg 2000; 92:278.
- Korogi Y, Takahashi M, Katada K, et al. Intracranial aneurysms: detection with three-dimensional CT angiography with volume rendering--comparison with conventional angiographic and surgical findings. Radiology 1999; 211:497.
- Zouaoui A, Sahel M, Marro B, et al. Three-dimensional computed tomographic angiography in detection of cerebral aneurysms in acute subarachnoid hemorrhage. Neurosurgery 1997; 41:125.
- Lee AG, Onan HW, Brazis PW, Prager TC. An imaging guide to the evaluation of third cranial nerve palsies. Strabismus 1999; 7:153.
- Good WV, Barkovich AJ, Nickel BL, Hoyt CS. Bilateral congenital oculomotor nerve palsy in a child with brain anomalies. Am J Ophthalmol 1991; 111:555.
- Gottlob I, Catalano RA, Reinecke RD. Surgical management of oculomotor nerve palsy. Am J Ophthalmol 1991; 111:71.
- Preechawat P, Sukawatcharin P, Poonyathalang A, Lekskul A. Aneurysmal third nerve palsy. J Med Assoc Thai 2004; 87:1332.
- Birchall D, Khangure MS, McAuliffe W. Resolution of third nerve paresis after endovascular management of aneurysms of the posterior communicating artery. AJNR Am J Neuroradiol 1999; 20:411.
- Chen PR, Amin-Hanjani S, Albuquerque FC, et al. Outcome of oculomotor nerve palsy from posterior communicating artery aneurysms: comparison of clipping and coiling. Neurosurgery 2006; 58:1040.
- Inamasu J, Nakamura Y, Saito R, et al. Early resolution of third nerve palsy following endovascular treatment of a posterior communicating artery aneurysm. J Neuroophthalmol 2002; 22:12.
- Dimopoulos VG, Fountas KN, Feltes CH, et al. Literature review regarding the methodology of assessing third nerve paresis associated with non-ruptured posterior communicating artery aneurysms. Neurosurg Rev 2005; 28:256.
- Schumacher-Feero LA, Yoo KW, Solari FM, Biglan AW. Third cranial nerve palsy in children. Am J Ophthalmol 1999; 128:216.
- CLINICAL MANIFESTATIONS
- General features
- - Classification
- Midbrain lesions
- Subarachnoid space
- Cavernous sinus lesions
- Superior orbital fissure/Orbital lesions
- DIFFERENTIAL DIAGNOSIS
- Nonisolated third nerve palsy
- Isolated third nerve palsy
- - Evaluation for intracranial aneurysm
- - Complete external dysfunction with normal internal function (pupil-sparing complete third nerve palsy)
- - Third nerve palsy with complete internal dysfunction (pupil-involved) and complete or incomplete external dysfunction
- - Other patterns of isolated third nerve deficits
- - Isolated third nerve palsy with signs of aberrant regeneration
- TREATMENT AND PROGNOSIS
- Persistent deficits
- SUMMARY AND RECOMMENDATIONS