Single Ocular Motor Cranial Nerve Palsies With Accompanying Abnormalities

    • Single ocular motor cranial nerve palsy with other pertinent neurologic or systemic abnormalities (“ocular motor nerve palsy plus”)
    • Third nerve palsy + congestive orbitopathy = carotid-cavernous fistula
    • Third nerve palsy + bitemporal hemianopia = sellar lesion
    • Third nerve palsy + contralateral hemiparesis = midbrain lesion (Weber syndrome)
    • Third nerve palsy + ipsilateral afferent pupil defect = orbital apex/superior orbital fissure lesion
    • Third nerve palsy + tremor = tegmental midbrain lesion
    • Fourth nerve palsy + convergence retraction eye movements = dorsal midbrain lesion
    • Sixth nerve palsy + history of cancer = clival or meningeal metastasis
    • Sixth nerve palsy + papilledema = increased intracranial pressure causing stretch damage of sixth nerve (“false-localizing sixth nerve palsy”)
    • Sixth nerve palsy + lumbar dural puncture = intracranial hypotension
    • Sixth nerve palsy + ipsilateral trigeminal sensory loss = cerebellopontine angle or Meckel’s cave lesion
    • Sixth nerve palsy + gaze palsy + seventh nerve palsy = pontine lesion
    • Graves disease
    • Genetic extraocular myopathy
    • Orbital myositis, tumor, trauma
    • Myasthenia gravis
    • Look beyond the single neuro-ophthalmic abnormality for other pertinent neuro-ophthalmic, neurologic, or systemic abnormalities
    • Order brain MRI and other relevant imaging studies
    • If unrevealing, order lumbar puncture
    • Order catheter cerebral angiogram if you suspect carotid-cavernous fistula for which endovascular closure is needed
    • Testing usually reveals a complex disorder
    • Outcome depends on the nature of the disorder

    Non-isolated Ocular Motor Cranial Nerve Disorders

    Single Ocular Motor Cranial Nerve Palsies With Accompanying Abnormalities Multiple Ocular Motor Cranial Nerve Palsies Carotid-Cavernous Fistula