oculomotor palsy

Occulomotor Palsy with Multiple Cranial Nerves Neuropathy

By: Abhimanyu ParasharPharm D Intern

Oculomotor Palsy (3rd Nerve Palsy)

• Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch

• The Oculomotor nerve supplies the majority of the muscles controlling eye movements

• In a complete Oculomotor nerve palsy, the affected eye will normally be in a down and out position relative to the other eye

• The affected eye will also have a ptosis, or drooping of the eyelid, and pupil dilation

Types of Oculomotor Palsy

Congenital Oculomotor Palsy

Acquired Oculomotor palsy

Vascular disorders Lesions or Tumors Inflammation or Infection Trauma Demylenating Disease AIDS Post Operative Neurosurgery

Symptoms Ptosis Downward and

Outward positioning of Eye

Unable to adduct, infraduct, supraduct

Dilated pupil with sluggish reaction

Muscles Innervated by 3rd Cranial Nerve

• 1) Superior Rectus muscle (extraocular muscle)

• 2) Inferior Rectus muscle (extraocular muscle)

• 3) Medial Rectus muscle (extraocular muscle)

• 4) Inferior Oblique (extraocular muscle)

• 5) Levator palpebrae superioris (muscle to upper eye lid)

External Ocular Paralysis

Muscle Direction of pull Result of paralysis Cranial nerve

Medial rectus Medially Lateral III

Superior rectus Upwards Downwards III

Lateral rectus Laterally Medial VI

Inferior rectus Downwards Upwards III

Superior oblique Down and out Up and in IV

Inferior oblique Up and out Down and in III

Pathophysiology lesions at Oculomotor

Nucleus (Midbrain) Lesions at Oculomotor

Nerve Fascicles Lesions at Subarachnoid

place Lesions within

cavernous sinus & Superior orbital fissure

Lesions within Orbit

Differential DiagnosisMyasthenia GravisThyroid associated

orbitopathyInternuclear

ophthalmoplegiaChronic progressive

external ophthalmoplegia

Orbital pseudotumorGiant cell Arteritis

Optic Neuritis• Optic neuritis is an inflammation of the optic nerve• Optic neuritis usually affects one eye, although it may

occur in both eyes simultaneously.• Symptoms:PainVision lossLoss of color visionFlashing lights

Etiology: Multiple Sclerosis (incidence

rate 50%) Neuromylitis Optica Sarcoidosis SLE Infections: Lyme's Disease,

Syphilis, measles, mumps, herpes .

Cranial Arteritis Vasculitis Diabetes Mellitus Drugs (Ethambutol,

Chloramphenicol) Radiation

OP No. 1116060

IP No. 279206

Age 55 Yrs

Sex Male

Weight 86 Kgs

Unit Neurology

OPD Evaluation

c/o Diplopia, Blurring of vision and headache since 1dayNot a k/c/o DM & HTNBP: 160/90 mmHgo/e: Left eye impaired, abduction/ elevation absentLeft third nerve palsy

Imp: Demyelination ? Left 3rd nerve palsyAdv: MRI

MRI BrainOptic Nerve:• Rt Optic nerve: 3.5 mm & Normal.• Lt Optic nerve: 4.0 mm & Enlarged in size and Normal in

outline.• The optic chiasma, the lateral geniculate body, the thalami

and the optic tracts are Normal

Impression: Features S/O Left Optic Neuritis

Neurologist opinion: Left optic Neuritis ? 3rd Nerve PalsyADV: Admit to ward

Day 1

• C/O: Diplopia, painful movement of eye, blurring of vision since 2 days

• H/O headache• No Hx of similar complains in past• Not a k/c/o DM & HTN

Provisional diagnosis: Left optic neuritis

General examination:• CNS: conscious oriented • CN : Lt eye impaired abduction/ elevation/ depression absentMotor system:• Tone: Normal• Power: 5/5 in all limbs• Reflexes: Normal• Plantar: ExtensorSensory/ cerebeller system: Normal

Adv: HIV, VDRL, Rx as per chart

Treatment chart

DRUGS DOSE F R from

Inj. Prednisolone 1 g in 100 ml

1-0-0 IV 16/1

Inj. rabeprazole 20 mg 1-0-0 IV 16/1

Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1

Syp. sucralfate 2 tsp 1-0-1 PO 16/1

T. Paracetamol + Aceclofenac 500 + 50 mg

1-0-1 PO 16/1

T. Amitriptylline + Chlordiazepoxide 25 + 10 mg

0-0-1 PO 16/1

Day 2

BP: 130/80 mmHg Pulse: 76 BPM• O/E Pt feeling slightly better• MRI brain: feature suggestive of left optic neuritis• Left eye ptosis +• Abduction/ elevation impaired

ADV: treatment as per chart, LP CSF, Ophthalmologist opinion, neuro-surgeon opinion for any surgical cause

• 4 PM Lumbar puncture done

HIV Negative

VDRL Negative

FBS 84 mg/dl

PPBS 148 mg/dl

LP - CSF Normal

Ophthalmologists opinion:• Unable to open left eye, sudden in onset• Diplopia only force open the left eye• Pupils dilated• O/E Alternating exotropia• Ptosis – severe• Fundus: WNL• Temporal pallor of disc +• Macula +• IMP: Resolving 3rd cranial nerve palsy• Will be reviewed tomorrow

Treatment chart

DRUGS DOSE F R from

Inj. Prednisolone 1 g in 100 ml

1-0-0 IV 16/1

Inj. rabeprazole 20 mg 1-0-0 IV 16/1

Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1

Syp. sucralfate 2 tsp 1-0-1 PO 16/1

T. Paracetamol + Aceclofenac 500 + 50 mg

1-0-1 PO 16/1

T. Amitriptylline + Chlordiazepoxide 25 + 10 mg

0-0-1 PO 16/1

Day 3BP: 150/80 mmHg Pulse: 84 BPM• O/E: pt symptomatically better• CNS: conscious oriented• CN 3rd : Lt eye ptosis + pupils are reactive to light

abduction decreased• Neurosurgeon opinion:No visual activity symptoms, left 3rd nerve paresisNo active neurological intervention required

• Ophthalmologists opinion: Pupil Sparing 3rd Nerve Paresis ADV: Review after 1 month

Swinging Flashlight Test of Pupillary constriction

Treatment chart

DRUGS DOSE F R from

Inj. Prednisolone 1 g in 100 ml

1-0-0 IV 16/1

Inj. rabeprazole 20 mg 1-0-0 IV 16/1

Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1

Syp. sucralfate 2 tsp 1-0-1 PO 16/1

T. Paracetamol + Aceclofenac 500 + 50 mg

1-0-1 PO 16/1

T. Amitriptylline + Chlordiazepoxide 25 + 10 mg

0-0-1 PO 16/1

T. Aspirin 75 mg 0-1-0 PO 18/1

Day 4

• BP: 150/80 mmHg Pulse: 76 BPM

• O/E: Vital stable• No fresh complains• ADV: treatment as per chart

Treatment chart

DRUGS DOSE F R from

Inj. Prednisolone 1 g in 100 ml

1-0-0 IV 16/1

Inj. rabeprazole 20 mg 1-0-0 IV 16/1

Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1

Syp. sucralfate 2 tsp 1-0-1 PO 16/1

T. Paracetamol + Aceclofenac 500 + 50 mg

1-0-1 PO 16/1

T. Amitriptylline + Chlordiazepoxide 25 + 10 mg

0-0-1 PO 16/1

T. Aspirin 75 mg 0-1-0 PO 18/1

Day 5

• BP: 140/80 mmHg Pulse: 80 BPM

• O/E: Vital stable• No fresh complains• ADV: Discharge

Treatment chart

DRUGS DOSE F R from

inj. Prednisolone 1 g in 100 ml

1-0-0 IV 16/1

Inj. rabeprazole 20 mg 1-0-0 IV 16/1

Inj. Cefoperazone + Sulbactum 1.5 g 1-0-1 IV 16/1

Syp. sucralfate 2 tsp 1-0-1 PO 16/1

T. Paracetamol + Aceclofenac 500 + 50 mg

1-0-1 PO 16/1

T. Amitriptylline + Chlordiazepoxide 25 + 10 mg

0-0-1 PO 16/1

T. Aspirin 75 mg 0-1-0 PO 18/1

Discharge medications

DRUGS DOSE F R

T. Paracetamol + Aceclofenac 500 + 50 mg

1-0-1 PO

T. Amitriptylline + Chlordiazepoxide 25 + 10 mg

0-0-1 PO

T. Aspirin 75 mg 0-1-0 PO

Tab. Prednisolone 40 mg 1-0-0 PO

Tab. Rabeprazole 20 mg 1-0-0 PO

Pharmaceutical Care Plan

Subjective EvidenceDiplopiaBlurred Vision Left eye ImpairedAdduction, Elevation,

Depression AbsentPtosis of Left eyeHeadache Exotropia Left eye

Objective Evidence MRI: Features S/O Left

Optic Neuritis Swinging Flashlight

test: Pupil sparing Oculomotor palsy

Final Diagnosis

Oculomotor Nerve (3rd Cranial Nerve) Palsy with Multiple cranial nerves neuropathy

Goals of Therapy

• To relive presenting signs and symptoms• To rule out the underlying etiology• To prevent further progression and

complication of the disease• To align the eye surgically*• To improve health related quality of life

(*) : Optional

Treatment OptionsPharmacological:• NSAID’s• CorticosteroidsNon Pharmacological:• Patching of Eye• Using Prism Lens SpectaclesSurgical:• Eye muscle surgery (Strabismus Surgery)• Lid lift surgery (Blepharoplasty)• Clipping, Gluing, Coiling, wrapping of Aneurysms*

Goals Achieved

• Patient was started on symptomatic pharmacotherapy

• Patient symptoms improved before he was discharged

Problems Identified

• Use of Cefoperazone + Sulbactum• Use of IV Proton Pump Inhibitor• Untreated indication: Hypertension• Monitoring Error: Lipid Profile not done

Clinical Pharmacy Services Provided

Drug Information: Oral Proton Pump inhibitors Vs. IV Proton Pump InhibitorsIntervention: • Use of IV proton pump inhibitors• Untreated indication – Hypertension

Monitoring Parameters

• MRI• Blood Pressure• Blood Glucose• Lipid Profile• CT Scan*• Fundoscopy• Ophthalmoscopy• Carotid Doppler*

Patient Counseling

About Disease

• What is a third nerve palsy?

• What are the symptoms of third nerve palsy?

• What causes third nerve palsy?

• What can be done to correct third nerve palsy?

About Medications

– Name and purpose

– Dose and frequency

– Medication adherence

– Possible adverse effects

– Missed dose

– Caution with Corticosteroids

About Lifestyle modifications• Patient should avoid driving• Patient should keep an eye patch to cover the affected eye• Using 1 eye will impair 1/3 of the vision and patient may not be

able to judge depth and height so be careful in making any judgment

• Patient should wear prism lenses to avoid Diplopia• Patient Should avoid consuming alcohol as it can precipitate the

ischemic neuropathy• Patient should reduce the salt intake and fatty food in order to

reduce the blood pressure.• Patient should take sufficient rest• Patient should be counseled about cosmetic issues related to

Oculomotor palsy and can be prepared for strabismus surgery*