Third Cranial (Oculomotor) Nerve Disorders

ByMichael Rubin, MDCM, New York Presbyterian Hospital-Cornell Medical Center
Reviewed/Revised Nov 2023
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Third cranial nerve disorders can impair ocular motility, pupillary function, or both. Symptoms and signs include diplopia, ptosis, and paresis of eye adduction and of upward and downward gaze. If the pupil is affected, it is dilated, and light reflexes are impaired. If the pupil is affected and patients are increasingly unresponsive, neuroimaging is done as soon as possible to check for transtentorial herniation.

(See also Overview of Neuro-ophthalmologic and Cranial Nerve Disorders.)

Etiology of Third Cranial Nerve Disorders

Third cranial (oculomotor) nerve disorders that cause palsies and affect the pupil commonly result from

  • Aneurysms (especially of the posterior communicating artery)

  • Transtentorial brain herniation

  • Less commonly, meningitis affecting the brain stem (eg, tuberculosis meningitis)

The most common cause of palsies that spare the pupil, particularly partial palsies, is

Occasionally, a posterior communicating artery aneurysm causes oculomotor palsy and spares the pupil.

Symptoms and Signs of Third Cranial Nerve Disorders

Diplopia and ptosis (drooping of the upper eyelid) occur. The affected eye may deviate slightly out and down in straight-ahead gaze; adduction is slow and may not proceed past the midline. Upward gaze is impaired. When downward gaze is attempted, the superior oblique muscle causes the eye to adduct slightly and rotate.

The pupil may be normal or dilated; its response to direct and to consensual light may be sluggish or absent (efferent defect). Mydriasis (pupil dilation) may be an early sign.

Patients with oculomotor palsy with pupil dilation due to intracranial aneurysm or early transtentorial brain herniation can have severe headache, and mental status may deteriorate rapidly.

Diagnosis of Third Cranial Nerve Disorders

  • Clinical evaluation

  • CT or MRI

Differential diagnosis for third cranial nerve disorders includes

  • Midbrain lesions that disrupt the oculomotor fascicle (Claude syndrome, Benedict syndrome)

  • Leptomeningeal tumor or infection

  • Cavernous sinus disease (giant carotid aneurysm, fistula, or thrombosis)

  • Intraorbital structural lesions (eg, orbital mucormycosis) that restrict ocular motility

  • Ocular myopathies (eg, due to hyperthyroidism or mitochondrial disorders)

  • Disorders of the neuromuscular junction (eg, due to myasthenia gravis or botulism)

Differentiation may be clinical. Exophthalmos or enophthalmos, a history of severe orbital trauma, or an obviously inflamed orbit suggests an intraorbital structural disorder. Graves orbitopathy (ophthalmopathy) should be considered in patients with bilateral ocular paresis, paresis of upward gaze or abduction, exophthalmos, lid retraction, lid lag during downward gaze (Graefe sign), and a normal pupil.

CT or MRI is required. If a patient has a dilated pupil and a sudden, severe headache (suggesting ruptured aneurysm) or is increasingly unresponsive (suggesting herniation), neuroimaging (CT or, if available, MRI) is done immediately. If a ruptured aneurysm is suspected and CT (or MRI) does not show blood or is not available rapidly, other tests, such as lumbar puncture, magnetic resonance angiography, CT angiography, or cerebral angiography, are indicated. Cavernous sinus disease and orbital mucormycosis require immediate MRI imaging for timely treatment.

Treatment of Third Cranial Nerve Disorders

  • Various, depending on the cause

Treatment of a third cranial nerve disorder depends on the cause.

Key Points

  • Symptoms and signs include diplopia, ptosis, and impaired adduction and upward and downward gaze.

  • If the pupil is affected, consider aneurysms and transtentorial herniation; if the pupil is spared, consider ischemia of the nerve (usually secondary to diabetes or hypertension).

  • Exclude other possible causes based on clinical evaluation and neuroimaging; if patients have a severe headache or become increasingly unresponsive, do CT or MRI immediately.

  • Treat the disorder causing the palsy.

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