Picture quiz: Surgical or medical third nerve palsy?
A 76 year old woman presented to the eye department with a one week history of left eye pain and drooping eyelid. She had a history of hypertension and atrial fibrillation controlled with drugs. On examination visual acuity was normal at 6/9 in each eye. There was complete ptosis and ophthalmoplegia of four of the six extraocular muscles of the left eye. In primary position the left eye was depressed (that is, “down”) and abducted (that is, “out”). One week later she presented with increasing left eye pain and pupil involvement. Magnetic resonance imaging and angiography was normal. Subsequent cerebral angiography was also normal. Within three months all symptoms and signs had resolved with full recovery of ocular movements.
The most common cause of a third nerve palsy is ischaemia in patients with vasculopathic risk factors such as diabetes or hypertension.12 The pupil should be checked in the first week