What medical care is indicated in the treatment of third cranial nerve palsy (oculomotor cranial nerve palsy)?

Updated: Oct 08, 2018
  • Author: James Goodwin, MD; Chief Editor: Andrew G Lee, MD  more...
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Third cranial nerve palsy from ischemia in the nerve trunk is believed to result from insufficiency of the vasa nervosa or small vessels that supply the nerve. [30]

Third cranial nerve palsy is most frequent in persons older than 60 years and in those with prominent or long-standing atherosclerotic risk factors, such as diabetes or hypertension. [31, 32] The key finding in these patients is relative sparing of the pupillary sphincter with complete or near-complete palsy of the extraocular muscles innervated by the third cranial nerve, including levator palpebrae. [33, 31, 34] Ironically, these patients may have very severe pain in the eye or orbit ipsilateral to the involved nerve. The pathogenesis of this pain is not understood, but it is common in patients with medical palsy and does not in itself suggest aneurysm as the cause.

Medical management is actually watchful waiting, since there is no direct medical treatment that alters the course of the disease. Fortunately, nearly all patients undergo spontaneous remission of the palsy, usually within 6-8 weeks. Treatment during the symptomatic interval is directed at alleviating symptoms, mainly pain and diplopia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment of choice for the pain. Diplopia is not a problem when ptosis occludes the involved eye. When diplopia is from large-angle divergence of the visual axis, patching one eye is the only practical short-term solution. When the angle of deviation is smaller, fusion in primary position often can be achieved using horizontal or vertical prism or both.

Since the condition is expected to resolve spontaneously within a few weeks, most physicians would prescribe a Fresnel paste on prism.

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