![]() Update on the clinical assessment and management of thyroid eye disease. A new era in the treatment of thyroid eye disease. The other Babinski sign in hemifacial spasm. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: report of the guideline development subcommittee of the American Academy of Neurology. Simpson DM, Hallett M, Ashman EJ, Comella CL, Green MW, Gronseth GS, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Narayanaswami P, Sanders DB, Wolfe G, Benatar M, Cea G, Evoli A, et al. Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies. Evaluation of Horner syndrome in the MRI era. Treatment of ptosis using brimonidine tartrate for anterior laminectomy-induced Horner syndrome. Or, if your patient has anisocoria and/or ptosis and you do not know where to start and do not have the time to read through the individual sections, begin with the “Help me now!” tables for a symptom (or sign)-based approach. This chapter covers each of these anatomic regions individually, first with an emphasis on the focused history and examination, followed by a case-based approach to the most common disorders. Therefore, the clinician must be able to recognize the most dangerous etiologies, but also those benign etiologies that may only require reassurance. There's more to see - the rest of this topic is available only to subscribers.Patients presenting with disorders affecting the pupils, eyelids, or orbits may have a relatively benign etiology (e.g., tonic pupil, levator dehiscence, mild thyroid eye disease), or symptoms/signs may signify a potentially life-threatening disorder (e.g., aneurysmal third nerve palsy, Horner’s syndrome from carotid artery dissection, aggressive orbital fungal infection). Can also see in neurofibromatosis, ophthalmologic migraine with recurrent CN III palsy, and spontaneous intracranial hypotension. ![]() Trauma is the most common cause of acquired oculomotor nerve palsies:.Congenital etiologies are often unknown but some with familial tendency.Idiopathic intracranial hypertension (IIH).Intracranial hemorrhage (nonaneurysmal).Aneurysm (esp posterior communicating artery).Incomplete CN III palsy originates here as the nerve divides into superior and inferior divisions.Lesions in the orbit are associated with visual loss (CN II), ophthalmoplegia (CN III, IV, VI), and proptosis and caused by trauma, mass, inflammation:.Lesions in the cavernous sinus and superior orbital fissure can cause isolated CN III palsy, but often are associated with CN IV, CN VI, and maxillary division of CN V dysfunctions.Lesions in the subarachnoid space cause complete palsy with pupil involvement (compressive aneurysms) or complete palsy with pupil sparing (ischemia due to risk factors).Lesions leaving CN III nucleus are often associated with other neurologic findings such as hemiplegia or ataxia (Weber syndrome, Benedikt syndrome).Midbrain lesions of the oculomotor nucleus leads to bilateral CN III palsy (ischemia of the basilar artery).Pathophysiology of oculomotor nerve palsy:.Most often caused by ischemia of vasa vasorum.Incomplete oculomotor nerve palsy (more common):.Often benign and fully resolves in 3 mo.Ischemic injuries often spare the pupil because the outer parasympathetics are not affected.Almost always ischemic from microvascular disease due to underlying diabetes, hypertension, and/or hyperlipidemia.Pupil-sparing complete oculomotor nerve palsy:.Mydriasis is often first symptom of compression.Parasympathetic fibers sit peripherally in CN III.95–97% of compressive lesions involve the pupil.Most often caused by compressive lesions.Eye “down and out,” ptosis, pupil dilated.Oculomotor nerve palsy results from damage to CN III or a branch thereof resulting in abnormal eye movements, lid ptosis, and/or changes to the pupil:.Depression and slight abduction (lateral rotation).Innervated by parasympathetic fibers of CN III.Iris sphincter pupillae and ciliary muscles.Extorsion – rotates top of eye away from nose.Intorsion – rotates top of eye toward nose.Adduction – moves eye medially toward nose.CN III, or oculomotor nerve, innervates 4 of the 6 eye muscles and also innervates the lid and pupil:.There are six muscles that control eye movement innervated by three cranial nerves (CN):.
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