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Cranial Nerve Palsies

Cranial Nerve Palsies


Cranial mononeuropathy III - compression type

Cranial mononeuropathy III is a problem with the function of the third cranial nerve, which is located behind the eye.

Causes

Cranial mononeuropathy III - compression type is a mononeuropathy, which means that only one nerve is affected. It affects the third cranial (oculomotor) nerve, one of the cranial nerves that controls eye movement. Local tumors or swelling can press down on and damage the nerve.

Causes may include:

  • Brain aneurysms
  • Disorders such as mononeuritis multiplex
  • Infections
  • Poorly formed blood vessels (vascular malformations)
  • Sinus thrombosis
  • Tissue damage from loss of blood flow (infarction)
  • Trauma (from head injury or caused accidentally during surgery)
  • Tumors or other lesions (especially tumors at the base of the brain and pituitary gland)

Rarely, people with migraine headaches may have a temporary problem with the oculomotor nerve. This is probably due to a spasm of the blood vessels. In some cases, no cause can be found.

Symptoms

  • Double vision
  • Drooping of one eyelid
  • Headache or eye pain

Other symptoms may occur if the cause is a tumor or trauma. Decreasing consciousness is a serious sign, because it could indicate brain damage or death.

Exams and Tests

An eye examination may show:

  • Enlarged (dilated) pupil of the affected eye
  • Eye movement abnormalities
  • Eyes that are not aligned (dysconjugate gaze)

A complete medical and nervous system (neurological) examination can show whether any other parts of the body are affected.

Other tests may include:

  • Blood tests
  • CT angiogram
  • CT scan
  • MRI
  • Spinal tap (lumbar puncture)

Treatment

Some cases may get better without treatment. Treating the cause (if it can be found) may relieve the symptoms in many cases.

Treatment may include:

  • Corticosteroid medications to reduce swelling and relieve pressure on the nerve
  • Surgery to treat eyelid drooping or eyes that are not aligned
  • Wearing an eye patch or prisms

Outlook (Prognosis)

Some cranial nerve dysfunctions will respond to treatment. A few cases result in some permanent loss of function. If the problem is caused by brain swelling due to a tumor or stroke, those conditions may be life-threatening.

Possible Complications

  • Permanent eyelid drooping
  • Permanent vision changes

When to Contact a Medical Professional

Call the local emergency number (such as 911) or go to the emergency room if you have:

  • Double vision
  • No feeling in or control over parts of your body
  • Signs of changed consciousness
  • Unusual headache

Prevention

Quickly treating disorders that could press down on the nerve may reduce the risk of developing cranial mononeuropathy III.


Cranial mononeuropathy III - diabetic type

Cranial mononeuropathy III is a complication of diabetes that involves double vision and eyelid drooping.

Causes

Cranial mononeuropathy III - diabetic type is a mononeuropathy, which means that only one nerve is damaged. It involves the third cranial (oculomotor) nerve, which is one of the cranial nerves that controls eye movement. This type of damage usually occurs with diabetic neuropathy.

Cranial mononeuropathy III is the most common cranial nerve disorder in people with diabetes.

Symptoms

  • Double vision that comes on quickly
  • Drooping of one eyelid
  • Pain in head or behind eye

Exams and Tests

An examination of the eyes will determine whether only the third nerve is affected or if other nerves have also been damaged. Signs may include:

  • Eyes that are not aligned (dysconjugate gaze)
  • Normal or abnormal pupil reaction

In some cases, it may not be clear if the nerve damage is due to diabetes or some other cause, such as an aneurysm. Tests to rule out other causes may include:

  • Computed tomography (CT) angiogram
  • Lumbar puncture
  • Magnetic resonance angiography (MRA)

Treatment

There is no specific treatment to correct the nerve injury.

Treatments may include:

  • Close control of blood sugar levels
  • Eye patch or prisms to reduce double vision
  • Pain medications (analgesics)
  • Surgery to correct eyelid drooping or eyes that are not aligned
  • Some people may recover without treatment.

Outlook (Prognosis)

Many patients get better over time, although some have permanent eye muscle weakness.

Possible Complications

  • Permanent eyelid drooping
  • Permanent vision changes

When to Contact a Medical Professional

Call your health care provider if you have double vision and it doesn't go away in a few minutes, especially if you also have eyelid drooping.

Prevention

Control of blood sugar levels in people with diabetes may reduce the risk of developing this disorder.


Cranial Nerves Fourth and Sixth Palsies

Fourth (VI) nerve palsy

The fourth cranial nerve supplies the superior oblique muscle, which is the eye muscle responsible for lower the eye and tilting the eye in when the head is tilted.

Causes

Causes of a fourth nerve palsy include:

  • poor blood flow from diabetes or high blood pressure
  • inflammation
  • trauma to the eye socket
  • congenital (present since birth or childhood)

Symptoms

  • double vision where objects appear vertically separated and where objects may appear to be tilted
  • eye strain
  • difficulty focusing

Exams and Tests

An eye examination specifically for eye misalignment and motility is required. Other tests may be ordered, such as:

  • CT scan
  • MRI
  • bloodwork that may be pertinent if a particular cause is suspected on examination

Treatment

Depending on the cause of the fourth nerve palsy, treatments may include:

  • observation with eye muscle exercises
  • close control of blood sugar and blood pressure
  • eye patch or prisms to reduce double vision
  • eye muscle surgery

Outlook (Prognosis)

The underlying cause must be treated. The time to recovery will depend on the cause.

Sixth (VI) nerve palsy

The sixth nerve supplies the lateral rectus muscle, which is the eye muscle responsible for turning the eye out when looking to the side.

Symptoms

Symptoms of a sixth nerve palsy include:

  • double vision with objects horizontally separated, generally more when looking far away than when looking up close
  • inability to turn the eye out
  • appearance of “crossed eyes” or “eyes turning in”

Causes, examination, treatment, and prognosis are similar to fourth nerve palsy.

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