Medical Subject Headings

Oculomotor Nerve; Aneurysm; Ischemia; Diplopia; Oculormotor Muscles; Visual Fields; Diabetes, Mellitus, Type 2; African Americans; Neuroimaging; Eyelids; Paralysis


Background: Acquired cranial nerve III palsies (CN3P) can be ischemic in nature due to underlying vasculopathy, trauma, or by compressive damage due to aneurysm or tumor. In most cases, neuroimaging is completed to rule out a life-threatening etiology. This case outlines an acute oculomotor palsy due to ischemic microvascular disease with the appropriate diagnostic testing, treatment, and follow-up course.

Case Report: A 67-year-old African American female presented with complaints of a drooping left eyelid and intermittent diagonal diplopia. She had a known diagnosis of type 2 diabetes and hypertension. Entering visual acuity was 20/25-1 in the right eye (OD) and 20/40-1 left eye (OS). No afferent pupillary defect was noted OD or OS, however, a sluggish response to light was noted OS. Entrance testing was unremarkable OD. CVF were restricted superiorly OS due to an incomplete ptosis and EOMs were restricted in all gazes except abduction with the eye in a down-and-out position. The patient was sent to the emergency room to rule out a pupil involving CN3P. All testing was unremarkable and a final diagnosis of an ischemic CN3P was made.

Conclusion: Prompt diagnosis and neuroimaging is essential in the management of acute CN3P. Clinicians must pay close attention to the pupils as it may reveal the etiology. In this case, the pupil response warranted immediate referral to rule out potential life-threatening etiology. Fortunately, the etiology was determined to be ischemia to the oculomotor nerve from her uncontrolled systemic vasculopathies. Such patients should be monitored regularly until resolution.

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This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.

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