Neuro-ophthalmology: Case fifteen

Figure 1

Figure 2

This 70 year-old man developed the above appearance and headache.

a. What is the diagnosis?

A medical left third nerve palsy.

The pictures show a complete left ptosis with the left globe turning down and out. The pupils are equal in sizes suggesting that this is a medical third nerve palsy. This patient had diabetes mellitus and hypertension. The palsy resulted from microvascular infarction of the third nerve.

b. Is he likely to develop aberrant regeneration?

No. Aberrant regeneration occurs with compressive third nerve palsy (surgical third nerve palsy) such as tumour or aneurysms. It does not occur with medical nerve palsy.

c. What is the management?

The management is conservative as medical third nerve palsy tends to improve with time. The complete ptosis abolishes the diplopia which he may otherwise experience. If the ptosis improved before the muscle palsy, he may experience diplopia. In which case occlusion of the left eye is useful or alternatively prism may be tried. Surgery is not usually needed as the majority resolves spontaneously.
Click here for the questions Click here for the main page Click here for MRCOphth/ FRCS tutorials