Oculomotor Nerve Palsy Case File

https://medical-phd.blogspot.com/2021/03/oculomotor-nerve-palsy-case-file.html

Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo Papasakelariou, MD,
FACOG

CASE 42
A 38-year-old male presents to the emergency room with complaints of a persistent headache and
problems with his left eye. He has no known medical problems, and his headache is slightly
improved with ibuprofen. He denies having any previous vision problems. Examination reveals
ptosis, dilated pupil, and displacement “down and out” in his left eye The remainder of the exam is
normal. An MRI shows an aneurysm of the circle of Willis.

⯈ Given the physical exam, what ocular muscles are likely to have been unaffected?
⯈ Which nerve is likely to have been affected?

ANSWER TO CASE 42:

Oculomotor Nerve Palsy
Summary: A 38-year-old healthy male with recent-onset left eye findings of ptosis, dilated pupil,
and displacement of eye “down and out.”

• Ocular muscles not involved: Superior oblique and lateral rectus

• Nerve affected: Oculomotor nerve (CN III)

CLINICAL CORRELATION
Findings of ptosis, dilated pupil, and down-and-out eye displacement are most consistent with
oculomotor nerve palsy. The oculomotor nerve is the third of 12 paired cranial nerves and
originates from the midbrain. It controls most eye movements, constriction of the pupil, and eyelid
position. Down-and-out displacement of the eye occurs from the unopposed action of the lateral
rectus and superior oblique. The superior oblique muscle is innervated by the trochlear nerve (CN
IV), and the lateral rectus muscle is innervated by the abducens nerve (CN VI). An oculomotor
nerve palsy may be caused by an aneurysm, compression, infection, infarction, or tumor.

APPROACH TO:
Extraocular Muscles of the Orbit

OBJECTIVES
1. Be able to name the seven extraocular eye muscles of each orbit, and also their attachments,
actions, and innervation
2. Be able to describe how each of these muscles is optimally tested in a clinical setting
3. Be able to describe the presentation of a patient with injury to each nerve that innervates these
muscles

DEFINITIONS
PTOSIS: Drooping or partial closure of the upper eyelid

NERVE PALSY: Partial or incomplete paralysis

ANEURYSM: Dilatation of the wall of an artery due to an acquired or congenital condition