Diagnosis and management of third nerve palsy

To provide clinically relevant information regarding the diagnosis, etiology, work-up and treatment of third cranial nerve palsies, while incorporating information from current publications and providing our opinions on these studies.

In the past year, an important study focused on the confirmation of current neuro-imaging guidelines for third cranial nerve palsies. Recent case reports have highlighted etiologies such as giant cell arteritis, trauma, neuro-syphilis and demyelination secondary to infliximab and multiple sclerosis. Surgically, newer studies have focused on globe-tethering procedures for correcting strabismus and the use of frontalis suspension for correcting ptosis. Improved imaging technology with high-resolution magnetic resonance imaging (hr-MRI) allows for direct visualization of the entire nerve path and the affected muscles.

Management of a third nerve palsy depends upon localization of the causative lesion and determination of the underlying etiology. Once these issues are addressed, strabismus surgery can be both challenging and rewarding in these complex patients.