Oculomotor nerve palsy or oculomotor neuropathy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. As the name suggests, the

oculomotor nerve The oculomotor nerve, also known as the third cranial nerve, cranial nerve III, or simply CN III, is a cranial nerve that enters the orbit through the superior orbital fissure and innervates extraocular muscles that enable most movements o ...

supplies the majority of the muscles controlling eye movements (four of the six extraocular muscles, excluding only the

lateral rectus The lateral rectus muscle is a muscle on the lateral side of the eye in the orbit. It is one of six extraocular muscles that control the movements of the eye. The lateral rectus muscle is responsible for lateral movement of the eyeball, specifi ...

and superior oblique). Damage to this nerve will result in an inability to move the eye normally. The nerve also supplies the upper eyelid muscle (

levator palpebrae superioris The levator palpebrae superioris () is the muscle in the orbit that elevates the upper eyelid. Structure The levator palpebrae superioris originates from inferior surface of the lesser wing of the sphenoid bone, just above the optic foramen. It ...

) and is accompanied by parasympathetic fibers innervating the muscles responsible for pupil constriction (

sphincter pupillae The iris sphincter muscle (pupillary sphincter, pupillary constrictor, circular muscle of iris, circular fibers) is a muscle in the part of the eye called the iris. It encircles the pupil of the iris, appropriate to its function as a constrictor ...

). The limitations of eye movement resulting from the condition are generally so severe that patients are often unable to maintain normal eye alignment when gazing straight ahead, leading to

strabismus Strabismus is an eye disorder in which the eyes do not properly align with each other when looking at an object. The eye that is pointed at an object can alternate. The condition may be present occasionally or constantly. If present during a ...

and, as a consequence, double vision (

diplopia Diplopia is the simultaneous perception of two images of a single object that may be displaced in relation to each other. Also called double vision, it is a loss of visual focus under regular conditions, and is often voluntary. However, when occ ...

Presentation

A complete oculomotor nerve palsy will result in a characteristic displacement outward ( exotropia) and downward (hypotropia). The outward displacement occurs because the

muscle (innervated by the sixth cranial nerve) maintains muscle tone in comparison to the paralyzed

medial rectus The medial rectus muscle is a muscle in the orbit near the eye. It is one of the extraocular muscles. It originates from the common tendinous ring, and inserts into the anteromedial surface of the eye. It is supplied by the inferior division of th ...

. The downward displacement occurs because the superior oblique muscle (innervated by the fourth cranial or trochlear nerve) is unantagonized by the paralyzed

superior rectus The superior rectus muscle is a muscle in the orbit (anatomy), orbit. It is one of the extraocular muscles. It is innervation, innervated by the superior division of the oculomotor nerve (III). In the primary position (looking straight ahead), its ...

inferior rectus The inferior rectus muscle is a muscle in the orbit near the eye. It is one of the four recti muscles in the group of extraocular muscles. It originates from the common tendinous ring, and inserts into the anteroinferior surface of the eye. It ...

and

inferior oblique The inferior oblique muscle or obliquus oculi inferior is a thin, narrow muscle placed near the anterior margin of the floor of the orbit. The inferior oblique is one of the extraocular muscles, and is attached to the maxillary bone (origin) an ...

. The affected individual will also have a ptosis, or drooping of the

eyelid An eyelid ( ) is a thin fold of skin that covers and protects an eye. The levator palpebrae superioris muscle retracts the eyelid, exposing the cornea to the outside, giving vision. This can be either voluntarily or involuntarily. "Palpebral ...

, and

mydriasis Mydriasis is the Pupillary dilation, dilation of the pupil, usually having a non-physiological cause, or sometimes a physiological pupillary response. Non-physiological causes of mydriasis include disease, Physical trauma, trauma, or the use of c ...

(pupil dilation).

Causes

Oculomotor palsy can arise as a result of a number of different conditions. Non traumatic pupil-sparing oculomotor nerve palsies are often referred to as a "medical third", with those affecting the pupil being known as a "surgical third".

Congenital oculomotor palsy

The origins of the vast majority of congenital oculomotor palsies are

idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin. For some medical conditions, one or more causes are somewhat understood, but in a certain percentage of people with the condition, the cause ...

. There is some evidence of a familial tendency to the condition, particularly to a partial palsy involving the superior division of the nerve with an

autosomal recessive In genetics, dominance is the phenomenon of one variant (allele) of a gene on a chromosome masking or overriding the Phenotype, effect of a different variant of the same gene on Homologous chromosome, the other copy of the chromosome. The firs ...

inheritance. The condition can also result from aplasia or

hypoplasia Hypoplasia (; adjective form ''hypoplastic'') is underdevelopment or incomplete development of a tissue or organ.birth trauma.

Acquired oculomotor palsy

Vascular disorders Vascular can refer to: * blood vessels, the vascular system in animals * vascular tissue Vascular tissue is a complex transporting tissue, formed of more than one cell type, found in vascular plants. The primary components of vascular tissue ...

such as

diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...

heart disease Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina pectoris, angina, myocardial infarction, heart attack), heart failure, ...

atherosclerosis Atherosclerosis is a pattern of the disease arteriosclerosis, characterized by development of abnormalities called lesions in walls of arteries. This is a chronic inflammatory disease involving many different cell types and is driven by eleva ...

and

aneurysm An aneurysm is an outward :wikt:bulge, bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also b ...

, particularly of the

posterior communicating artery In human anatomy, the left and right posterior communicating arteries are small arteries at the base of the brain that form part of the circle of Willis. Anteriorly, it unites with the internal carotid artery (ICA) (prior to the terminal bifurcat ...

# Space occupying lesions or tumours, both malignant and non-malignant #

Inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...

and

infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...

# Trauma # Demyelinating disease (

multiple sclerosis Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...

) #

Autoimmune In immunology, autoimmunity is the system of immune responses of an organism against its own healthy cells, tissues and other normal body constituents. Any disease resulting from this type of immune response is termed an " autoimmune disease" ...

disorders such as

myasthenia gravis Myasthenia gravis (MG) is a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and swallowing. It can result in double vision, ...

# Post-operatively as a complication of

neurosurgery Neurosurgery or neurological surgery, known in common parlance as brain surgery, is the specialty (medicine), medical specialty that focuses on the surgical treatment or rehabilitation of disorders which affect any portion of the nervous system ...

Cavernous sinus thrombosis Cavernous sinus thrombosis (CST) is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart. This is a rare disorder and can be of two types–sept ...

Mechanism

As the pair of oculomotor nerves arises from different subnuclei in the

midbrain The midbrain or mesencephalon is the uppermost portion of the brainstem connecting the diencephalon and cerebrum with the pons. It consists of the cerebral peduncles, tegmentum, and tectum. It is functionally associated with vision, hearing, mo ...

, courses through different structures in the brain and branches into superior and inferior divisions after exiting the

cavernous sinus The cavernous sinus within the human head is one of the dural venous sinuses creating a cavity called the lateral sellar compartment bordered by the temporal bone of the skull and the sphenoid bone, lateral to the sella turcica. Structure The ...

es, any lesions along its path will produce different pathological features of the third nerve palsy. The parasympathetic aspect of the nerve (which constricts pupils and thicken the lens) is located on the nerve surface, supplied by pial blood vessels. The nerve's core contains the main trunk of the oculomotor nerve, supplied by

vasa vasorum Vasa vasorum are networks of small blood vessels that supply the walls of large blood vessels, such as elastic arteries (e.g., the aorta) and large veins (e.g., the venae cavae). The name derives . Occasionally, two different singular forms ar ...

. Thus pathologies affecting the nerve's core without affecting the superficial part of the nerve (thus sparing the pupillary reflex) are known as "medical" oculomotor nerve palsy. The "surgical" type of oculomotor nerve palsy is caused by external structures compressing on the nerve or trauma, which affects the entire nerve, thus affecting pupillary reflex.

Ischemic stroke Stroke is a medical condition in which poor blood flow to a part of the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop ...

selectively affects somatic fibers over

parasympathetic The parasympathetic nervous system (PSNS) is one of the three divisions of the autonomic nervous system, the others being the sympathetic nervous system and the enteric nervous system. The autonomic nervous system is responsible for regulat ...

fibers, while traumatic stroke affects both types more equally. Ischemic stroke affects the vasoneurium, which starts to supply the nerve from outside to inside. As the somatic fibers are located in the inner part of the nerve, these fibres are affected more in the setting of ischemia. A similar mechanism is also accurate for diabetes. Therefore, while almost all forms cause ptosis and impaired movement of the eye, pupillary abnormalities are more commonly associated with trauma and the "surgical third" rather than with ischemia (the "medical third"). A posterior communicating artery aneurysm will generally cause compression of the entire third nerve and will this prevent any nerve signal conduction, affecting the somatic system as well as the autonomic. The compression of the external autonomic fibres renders the pupil nonreactive and leads to the "surgical third" nerve palsy. Oculomotor palsy can be of acute onset over hours with symptoms of headache when associated with diabetes mellitus. Diabetic neuropathy of the oculomotor nerve in a majority of cases does not affect the pupil. The sparing of the pupil is thought to be associated with the microfasciculation of the fibers that control the pupillomotor function located on the outmost aspect of the occulomotor nerve fibres; these fibres are spared because they are outermost and therefore less prone to ischemic damage than are the innermost fibres.

References

External links

{{Eye pathology Disorders of ocular muscles, binocular movement, accommodation and refraction Oculomotor nerve