oculomotor palsy
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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*