Right-sided ischemic pupil-sparing cranial nerve III palsy DISCUSSION Etiology/EpidemiologyĪcquired third nerve palsy, often presenting with ptosis and the eye in a "down and out" position, has a wide differential diagnosis including microvascular damage, tumors, aneurysms, post-neurosurgery, and trauma. He was encouraged to discuss diabetes and hypertension management with his primary care provider, and to continue to follow with ophthalmology regarding PDR management.įigure 3: External 5-gaze photographs taken at the follow-up appointment four months after onset of symptoms demonstrating full extraocular motility and no ptosis bilaterally. At the return visit three months later, the right upper eyelid ptosis and motility deficits had completely resolved. It was determined that the third nerve palsy was ischemic in nature, and he was given strict return precautions, such as progression of symptoms or involvement of the pupil. The previous work-up by neurology four months prior was negative for a mass, aneurysm, or stroke. The presentation was consistent with a right pupil-sparing third nerve palsy secondary to poorly controlled hypertension and diabetes. Giant cell arteritis (or other types of vasculitis).Microvascular ischemia secondary to diabetes.Chronic progressive external ophthalmoplegia.Macula: No clinically significant macular edema.Vessels: No major occlusions, attenuated.Macula: Diabetic macular edema (DME) present but none within one disc diameter of the fovea.Disc: Normal, regressed neovascularization of the disc (NVD), gliosis.Vitreous: Dexamethasone (Ozurdex®) implant inferiorly.Lens: Posterior chamber intraocular lens (PCIOL).OS: 3 mm (dark) → 2 mm (light) with no RAPDįigure 1: External photograph demonstrating right upper eyelid ptosis.įigure 2: External 5-gaze photographs demonstrating the decreased motility of the right eye in all directions except for abduction.OD: 3 mm (dark) → 2 mm (light) with no relative afferent pupillary defect (RAPD).OCULAR EXAMINATION Visual Acuity with correction (Snellen) The patient specifically denied weight loss, jaw claudication, scalp tenderness, and fatigue. Negative except as listed in the history of present illness. Tobacco: 2.5 pack year smoking history, quit smoking in the early 2000s.Mother and brother with history of type 2 diabetes.Sitagliptin 100 mg 1 tablet daily by mouth.Metformin 500 mg 3 tablets daily by mouth.Insulin glargine 100 unit/mL inject 30 units at bedtime subcutaneously.Insulin detemir 100 unit/mL inject 30 units at bedtime subcutaneously.Type 2 diabetes mellitus for more than 10 years with PDR in addition to peripheral neuropathy and left foot amputation due to a non-healing ulcer.Avastin intravitreal injections since 2012.Ozurdex OU (7 weeks OD and 15 weeks OS since last implantation) since 2017.PDR requiring laser indirect ophthalmoscopy OD and pars plana vitrectomy with endolaser PRP of the left eye (OS) in 2017.Cataract surgery both eyes (OU) in 2010.The laboratory work-up, including ESR and CRP, was unremarkable. The remainder of his physical exam was otherwise unremarkable. Examination showed limited extraocular motility of his right eye (OD) in all directions that appeared worse than the prior presentation. He also developed headaches due to tonic contraction of the frontalis muscle in an attempt to raise his right upper eyelid. The patient presented to his ophthalmologist approximately four months later with binocular diplopia and noted that his right eye symptoms were affecting his ability to read and drive. He was diagnosed with an ischemic partial third nerve palsy and discharged with instructions to follow-up with his primary care provider and a retina specialist An inpatient stroke evaluation by the neurology service revealed an unremarkable computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain, and magnetic resonance angiogram (MRA) of the head and neck. Examination was remarkable for bilateral PDR and a right adduction motility deficit. Approximately four months prior to developing his droopy right upper eyelid, he presented to the emergency department (ED) because he could not move his right eye inward. He had a history of proliferative diabetic retinopathy (PDR) with recurrent vitreous hemorrhage despite intravitreal Avastin therapy and panretinal photocoagulation (PRP) of both eyes 5 years prior. Right upper eyelid ptosis and binocular double vision History of Present IllnessĪ 62-year-old man with a history of hypertension, hyperlipidemia, and poorly controlled type 2 diabetes mellitus was referred to the University of Iowa Hospitals and Clinics oculoplastics service for evaluation of a drooping right upper eyelid.
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