Third nerve palsy
The annual incidence of third nerve palsy is estimated at approximately 4 per 100 000. It is most common in people over age 60. Infarction of the third cranial nerve is the most common cause and often occurs in patients with diabetes, hypertension, or atherosclerosis.
Palsy from infarction presents more acutely. Patients with ischemic third nerve palsies usually do not have pupillary dysfunction. In 20% of patients, the third nerve palsy is due to compression of the oculomotor nerve by tumors (eg, meningioma), herniation, or a brain aneurysm. If nerve dysfunction is caused by external compression (eg, from a tumor), pupil dilation may also occur due to the peripheral location of these nerve fibers. If the third nerve palsy is caused by compression from a tumor, symptoms are usually subacute in onset and gradually progressive. Other common causes include trauma and neurosurgical procedures.
Treatment is primarily aimed at the underlying cause. Most patients with a third nerve palsy require emergent evaluation and neuroimaging to evaluate for compressive lesions, including aneurysms.
H49.00 – Third [oculomotor] nerve plasy, unspecified eye
388980004 – Third cranial nerve weakness
Differential Diagnosis & Pitfalls
- Internuclear ophthalmoplegia
- Thyroid ophthalmopathy (see Graves ophthalmopathy)
- Migraine headache
- Miller-Fisher syndrome
- Carotid-cavernous fistula
- Dural arteriovenous malformations
- Cavernous sinus thrombosis
- Cerebral aneurysm
- Ischemic stroke
- Ophthalmoplegic migraine
- Tolosa-Hunt syndrome
- Pituitary apoplexy
- Giant cell arteritis
- Orbital trauma
- Orbital pseudotumor
- Herpes zoster