If contributory signs have appeared, body imaging and lumbar puncture must be considered. The 3 rd cranial nerve innervates the levator palpebrae superioris, medial rectus, superior rectus and inferior rectus muscles, which are all affected in this patient. (IR) Inferior rectus infraducts the eye and contributes to extorsion. Exp Neurol 1968;21(4):455-66. It can present in different ways causing somatic extraocular muscle dysfunction (superior, inferior, and medial recti; inferior oblique; and levator palpebrae superioris) and autonomic (pupillary sphincter and ciliary) muscles. Jpn J Ophthalmol 2002;46(5):540-7. Neurosurgery 2006;58(6):1040-6. 89. Why does a complete unilateral nuclear 3rd nerve palsy have bilateral elevation deficits? (definitely not if the pupil is involved) Is the third nerve palsy isolated, or not? Temporal arteritis is an uncommon but important cause of a third nerve palsy and should be suspected in patients 55 or older who present with diplopia accompanied by headache, jaw claudication, scalp tenderness, or elevated serum markers (64). For profound palsies, eye muscle surgery is rarely effective in relieving diplopia; the combination of eye muscle and lid lifting surgery may restore a more cosmetic appearance and pave the way for the use of an opaque contact lens (36; 03; 37; 17). Surv Ophthalmol 2002a;41(2):137-57. 2017;135:23. Levy J, Marcus M, Shelef I, Lifshitz T. Acute angle-closure glaucoma and pupil-involving complete third nerve palsy as presenting signs of thrombosed cavernous sinus aneurysm. Thurtell MJ, Longmuir RA. On the other hand, the prognosis of ruptured aneurysms is poor, with a high, acute mortality rate. It has numerous possible etiologies which can be divided according to which portion of the nerve is affected: dorsal midbrain (nuclear lesions): usually due to small regions of infarction; often no other neurological symptoms, ventral midbrain (fascicular): Benedikt syndrome and Weber syndrome, rapidly enlarging with or without SAHis the most common cause, and usually involves only the oculomotor nerve, ischemic involvement of the nerve will usually be pupil sparing whereas aneurysmal compression usually involves the pupil, basal meningeal processes including infection, neoplastic infiltration, and inflammatory lesions (e.g. 86. It can be divided into a partial or complete palsy. Neurosurgery 2015;76(6):687-94. The information below is from Neuro-ophthalmology Illustrated-2nd Edition. Mathew MR, Teasdale E, McFadzean RM. Lesions at the Red Nucleus and superior cerebellar peduncle (Claude Syndrome) presents with ipsilateral 3rd nerve palsy, contralateral ataxia, asynergy and tremor. Neuroimaging of Isolated and Non-Isolated Third Nerve Palsies. A unilateral nuclear lesion of the 3rd nerve affects the single central caudal subnucleus which serves both levator palpebrae muscles. A partial palsy can be associated with the development of binocular vision. Searching for Brain Aneurism in Third Cranial Nerve Palsy. [1]. Although tumors are the most common causes of lesions in this area, vascular processes can also produce damage. CT and CTA are preferred over MRI and MRA because of accessibility. Davies GE, Shakir RA. Residual diplopia can be quite bothersome for some patients. Prompt recognition allows emergent diagnosis and treatment before the aneurysm ruptures. The majority of complete or incomplete CN III palsies without pupil involvement are secondary to an ischemic process. Gray LG, Galetta SL, Hershey B, Winkelman AC, Wulc A. Aug;18(9):836-40. If symptoms do not go away, medicines, surgery, or other treatments might be helpful as well. Know what to expect if you do not take the medicine or have the test or procedure. The third cranial nerve also controls constriction of the pupil, the position of the upper eyelid, and the ability of the eye to focus. Approach to a patient with diplopia in the emergency department. The appropriate management requires recognition of the underlying cause. Please fill out this brief <5 minute survey to guide WikEM's development of pediatric emergency resources: https://redcapynh.ynhh.org/surveys/?s=Y7J7DDHRTNNLFFPX. Activation of the iris sphincter induces pupillary constriction in response to light; activation of the ciliary muscles causes relaxation of the lens zonules and an increase in lens curvature, allowing for increased refractive power, and the accommodation necessary to focus targets viewed at reading distance (14). Amblyopia may develop in children with strabismus or ptosis due to third nerve palsy. Lesions of Oculomotor Nerve Fascicles (Leaving the 3rd nerve nucleus), Lesions within the Cavernous Sinus and Superior Orbital Fissure, Miller, N and Newman, N. Clinical neuro-ophthalmology 5th edition. Preda L, Gaetani P, Rodriguez y Baena R, et al. Oculomotor nerve palsies, or third nerve palsies , result in weakness of the muscles supplied by the oculomotor nerve, namely the superior rectus, inferior rectus, medial rectus, inferior oblique, and levator palpebrae superioris muscles. Diagnosis is made by physical examination. Flanders M, Hasan J, Al-Mujaini A. 85. What is the most likely diagnosis? Supported by Lesions at the Red Nucleus (Benedikt's Syndrome) are characterized byipsilateral 3rd nerve palsy and contralateral involuntary movement. What is meant by a pupil-sparing 3rd nerve palsy? Very rarely, aneurysms of the anterior communicating artery will produce a third nerve palsy (54; 68). Complete ipsilateral 3rd nerve palsy with pupil involvement. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations. An acquired third nerve palsy may resolve, depending on the cause. When interpreted by experienced neuroradiologists, CTA and magnetic resonance angiography (MRA) are very sensitive, especially for aneurysms measuring at least 3 to 5mm. Cranial neuropathy can develop for many different reasons. Surg Neurol 2002;57(6):423-6. Bhatt, VR. [1] . Third nerve ophthalmoplegia can be associated with trochlear and abducens nerve palsies. The most common cause of an isolated pupil-sparing third-nerve palsy is believed to be microvascular ischemia, frequently associated with diabetes mellitus or other vascular risk factors. Bothersome diplopia can be averted by blocking the image from being seen by 1 eye. Know why a new medicine or treatment is prescribed, and how it will help you. Inexperienced radiologists may overlook aneurysms (16). The third nerve runs in close proximity to the posterior communicating artery in this location (58), and until proven otherwise, an isolated pupil-involving third nerve palsy should be presumed to be due to aneurysm. This can cause partial oculomotor nerve palsies. Why does a complete unilateral nuclear 3rd nerve palsy have bilateral ptosis? Giant cell arteritis may cause a third nerve palsy, but it more commonly causes ischemia to the extraocular muscles that mimics a palsy. Rucker CW. Such palsies almost always derive from lesions of the extra-axial, precavernous portion of the nerve, where it is away from neurologic traffic. Fourth nerve palsy is often a congenital birth defect, which means that a baby is born with it. This content does not have an English version. The majority of third nerve palsies will resolve over weeks to months, particularly if the underlying cause is addressed. Asian J Neurosurg 2013;8(3):117-24. Ophthalmol Clin No Amer 2001;14(1):169-85. Multiple surgeries may be required to achieve good ocular alignment in straight-ahead gaze, and surgery on the uninvolved eye may be necessary. Oculomotor nerve palsy. Exceptionally, individual nuclei can be affected by a lesion, explaining the rare central partial third nerve palsies (in which not all extraocular muscles innervated by the third nerve are affected).Each extraocular muscle innervated by the third nerve is subserved by an individual subnucleus located in the midbrain third nerve nuclear complex. The inferior oblique, inferior rectus, and medial rectus muscles are subserved by their ipsilateral subnuclei. The superior rectus muscle is subserved by the contralateral subnucleus (fibers cross the midline). Both levator palpebrae muscles are subserved by one single subnucleus (the central caudal nucleus). The pupillary constrictor and accommodation muscles are under the control of a parasympathetic pathway subserved by an ipsilateral subnucleus (EdingerWestphal nucleus).Because of these anatomical characteristics of the third nerve nuclear complex, specific clinical syndromes can be observed when there is a lesion at the level of the midbrain (Fig. An abnormal head posture may allow binocular vision. Complete with pupillary involvement 2. (IO) Inferior oblique supraducts the eye when the eye is a (SR) Paired subnuclei of the superior recti, which are activated here. Introduction and importance: Aneurysm, diabetes mellitus, central nervous system (CNS) infections, pituitary tumors, and ischemia alterations are all potential causes of unilateral oculomotor nerve palsy, a common clinical disease. A complete third nerve palsy causes ptosis, a fixed and dilated pupil, paralysis of accommodation, and an abducted eye that has no supraduction, infraduction, or adduction. Controlling diabetes and high blood pressure can sometimes help. The sudden onset of a painful third nerve palsy with associated meningeal signs suggests subarachnoid hemorrhage from aneurysmal rupture. Patching may be necessary for several years, sometimes until age 12 years. 13.94). Although most isolated third nerve palsies in adults can be attributed to microvascular ischemia, clinical features do not permit exclusion of aneurysm (04; 18). What tests should be done when a patient over age 50 presents with an isolated incomplete 3rd nerve palsy and the pupil is involved? Jo YS, Kim SK, Kim DH, Kim JH, Na SJ. Sudden onset is a medical emergency. Also write down any new instructions your provider gives you. If the palsy worsens or does not resolve, or if contributory manifestations appear, reimaging is indicated. Nevertheless, compressive masses or aneurysm can also cause it. Continuum 2014;20(4):942-65. J Fr Ophtalmol 2012;35(10):818.e1-4. If a droopy eyelid (ptosis) covers the pupil, diplopia may not be noticeable. The sixth cranial nerve can be damaged by infection, a stroke or tumor, increased pressure in the brain, and even migraines. 2023 Stanford School of Medicine | Terms of Use | In some cases, the precise site of the lesion is clear, whereas in others, the location of the lesion is speculative. Differentiating between lesions at the cavernous sinus versus the superior orbital fissure can be challenging and sometimes the literature describes it as sphenocavernous syndrome. 3. Kupersmith MJ, Heller G, Cox TA. Reference article, Radiopaedia.org (Accessed on 30 Jun 2023) https://doi.org/10.53347/rID-1761. [1] For this reason, they are less susceptible to ischemia.. Evaluation and management will vary according to patients systemic illnesses, age, and associated symptoms. It is a result of persistent partial oculomotor nerve dysfunction after failure to completely recover from disruption of the nerve due to any cause. In confirmed cases, the cause of the third nerve palsy was determined. An acquired oculomotor nerve palsy (OMP) results from damage to the third cranial nerve. Know how you can contact your provider if you have questions. Chen PR, Amin-Hanjani S, Albuquerque FC, McDougall C, Zabramski JM, Spetzler RF. Aberrant regeneration of the oculomotor nerve: implications for neurosurgeons. These patients must be observed closely (daily) for the next week for evidence of pupillary involvement. This likely reflects the true etiologic incidences because it was a population-based study and therefore does not suffer from inherent referral bias," says Dr. Chen. CTA or MRA are 96% sensitive to cerebral aneurysms of at least 7 mm diameter, the size needed to cause third nerve palsy (66; 65; 45; 49; 29; 69; 35; 44). Dinkin M. Diagnostic approach to diplopia. Lesions of the red nucleus lead to contralateral tremor (Claude syndrome); lesions of the superior cerebellar peduncle lead to contralateral ataxia (Benedikt syndrome); lesions of the cerebral peduncle lead to contralateral hemiparesis (Weber syndrome). J Neurol Neurosurg Psychiatry 1990;53(7):549-53. What is the definition of a partial 3rd nerve palsy? The presenting signs depend on the affected area of 3rd nerve track. Clinical clues to an orbital process are proptosis, lid swelling, resistance to retropulsion, and conjunctival hyperemia. Even excluding third cranial nerve palsies from this cohort (as the majority of third cranial nerve palsy patients will undergo neuroimaging regardless of the presence of vasculopathic risk factors), the incidence of other causes for fourth and sixth cranial nerve palsies was 13.5% (five of 37). Computerized tomography angiography in isolated third nerve palsies. In several small series, clipped patients recovered more often than coiled patients, although 1 series reported no difference in outcome (10; 33; 48; 62). Acquired oculomotor nerve palsy evaluation depends on signs and symptoms, patients age and systemic diseases. In a series of patients with aneurysms treated with endovascular coiling or neurosurgical clipping, older age, diabetes, delayed interventions, and complete third nerve palsy at presentation were associated with a worse prognosis for recovery of the palsy (01). An isolated third cranial nerve palsy may cause variable ipsilateral involvement of the superior, inferior, and medial recti muscles and/or inferior oblique muscle. What is the most common cause of an isolated "pupil-sparing 3rd nerve palsy"? The evaluation of isolated third nerve palsy revisited: an update on the evolving role of magnetic resonance, computed tomography, and catheter angiography. In children, a negative imaging study allows the presumption of a viral or postviral cause and deferral of further investigations. CN III palsy with fixed dilated pupil, it is important to recall that pupillary fibers occupy a peripheral location and receive more collateral blood supply that the main trunk of the nerve. Jacobson DM, Trobe JD. Interpretation of these tests is difficult; the clinician must communicate with the interpreting radiologist, who should know that an aneurysm is suspected, and who should be aware of the patients clinical presentation. 79. What should be done when a patient over age 50 presents with an isolated complete 3rd nerve palsy and the pupil is Not involved? A challenging diagnosis in systemic lupus erythematosus. Reducing your risk factors for stroke and head injury, managing your diabetes well, and lowering high blood pressure can all be helpful in preventing neuropathy. MRI/MRA is preferred in children to avoid radiation exposure. Ophthalmology 2013;120(11):2264-9. Bondenson J, Asman P. Giant cell arteritis presenting with oculomotor nerve palsy. The sixth cranial nerve can . Exactly how your body and your movement are affected depends on where in the body the damaged nerves are located. Treatment for third nerve palsy in diabetes depends on the severity of the condition and the underlying cause. J Emerg Med 2018;54(6):799-806. Before your visit, write down questions you want answered. The terms third nerve palsy and oculomotor nerve palsy are essentially interchangeable. Microvascular 3rd nerve palsies are sometimes quite painful. The annual incidence in patients older than 60 was greater than patients younger than 60, predominantly due to a large increase in microvascular third nerve palsies in older adults. Anan M, Nagai Y, Fudaba H, et al. Because ischemic and nonischemic causes cannot be confidently distinguished by clinical criteria, all patients with isolated third nerve palsies should undergo prompt neuroimaging aimed at identifying a responsible aneurysm, regardless of whether the pupil is spared or involved. At the time the article was created Frank Gaillard had no recorded disclosures. Appenzeller S, Veilleux, M. Clarke, A. Lupus. Acute 3rd nerve palsies are true neuro-ophthalmic emergencies, especially painful ones. Paralysis of the third, fourth, and sixth cranial nerves. What are the findings when there is a unilateral lesion of the entire 3rd nerve nucleus? 1. Gresir E, Schuss P, Setzer M, Platz J, Seifert V, Vatter H. Posterior communicating artery aneurysm related oculomotor nerve palsy: the influence of surgical and endovascular treatment on recovery. 77. Orbital lesions can give rise to ocular ductional deficits that resemble a third nerve palsy, but the damage is to the extraocular muscles and levator, not to the third nerve. leukemia), toxic (e.g. J Neurol Neurosurg Psychiatry 2002;72:485-90. At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. J AAPOS 1999;3:2-8. All other aspects of the ophthalmic and neurologic examination were normal. How long does it usually take for a microvascular 3rd nerve palsy to resolve? Neuropathy is a disorder that causes nerve damage and affects your ability to feel and move. But it may also be caused by a head injury or an infection. Other causes of isolated third nerve palsy are severe head trauma, infection, inflammation, neoplastic invasion of the meninges, and most urgently, aneurysms located at the junction of the internal carotid and posterior communicating arteries internal and basilar artery apex. In some cases, the precise site of the lesion is clear, whereas in others, the location of the lesion is speculative. 75. A partial third nerve palsy affects, to varying degrees, any of the functions controlled by the third cranial nerve. Note that the axons originating in the superior rectus subnuclei decussate and travel through the contralateral paired subnucleus before innervating the contra Pupillary fibers within the oculomotor nerve. John J. Chen, M.D., Ph.D., Chengbo Fang, M.D., David O. Hodge, Jonathan M. Holmes, M.D., Jacqueline A. Leavitt, M.D., and Brian G. Mohney, M.D., at Mayo Clinic's campuses in Rochester, Minnesota, and Jacksonville, Florida, turned to the Rochester Epidemiology Project (REP) database to help determine the population-based incidence and etiologies of acquired third nerve palsies. This is why in most of the cases patients have diabetes mellitus, systemic hypertension, atherosclerosis and in some cases migraine. The most common ocular complaint is diplopia secondary to somatic extraocular muscle dysfunction, but pain and ptosis can also me present. Spiral CT angiography and surgical considerations in the evaluation of intracranial aneurysms. The emerging role of magnetic resonance imaging in the management of patients with third cranial nerve palsy. The neurons in this subnucleus are present on both sides of the midline, so that a caudal central nuclear lesion will cause bilateral ptosis. How long does it usually take for a microvascular 3rd nerve palsy to resolve? Multidetector computed tomographic angiography in isolated third nerve palsy. J Neuroophthalmol 2015;35(1):37-40. Moreover, skew deviation is usually associated with ataxia or other brainstem dysfunction (Walter and Trobe 2020). Treatment of aneurysm is aimed at isolating the pouch from the circulation, typically achieved by clipping or coiling with or without stenting. Bring someone with you to help you ask questions and remember what your provider tells you. A complete third nerve palsy presents with complete ptosis, with the eye positioned downward and outward with the inability to adduct, infraduct, or supraduct, as well as a dilated pupil with sluggish reaction. Causes of headache with anisocoria include Horner syndrome and trigeminal autonomic cephalgias, including cluster headache, carotid dissection wiht Horner syndrome, some oculomotor palsies (both. Risk factors and prognosis of isolated ischemic third, fourth, or sixth cranial nerve palsies in the Korean population. Given that reduced perfusion of the extra-axial third nerve is responsible for the preponderance of third nerve palsies in adults, control of conventional arteriosclerotic risk factors ought to be preventive. Kim T, Nam K, Kwon B. A patient without a history of trauma has signs of aberrant regeneration of the 3rd nerve. Tips to help you get the most from a visit to your healthcare provider: Types of Muscular Dystrophy and Neuromuscular Diseases, Neuro-Visual and Vestibular Disorders Center. Aneurysms that cause third nerve palsy typically have a minimal cross-sectional diameter of at least 7 mm and are found at the junction of the carotid and posterior communicating arteries (63; 56). Aug;18(9):836-40. An isolated third cranial nerve palsy may cause variable ipsilateral involvement of the superior, inferior, and medial recti muscles and/or inferior oblique muscle. Rathke cleft cyst presenting as unilateral progressive oculomotor nerve palsy. Scand J Rheumatol 1997;26(4):327-8. Lesions at these zones can produce an isolated CN III palsy, but it is most commonly associated with other cranial nerves dysfunctions. Know why a test or procedure is recommended and what the results could mean. PearlsMicrovascular third nerve palsies are most often nonarteritic, but giant cell arteritis should always be considered. A disorder affecting the brain, such as an aneurysm or brain tumor, may also cause third nerve palsy. Common symptoms can include weakness or loss of sensation in part of the face, or changes in vision. CT/CTA is preferred in adults because of accessibility (Vaphiades et al 2008). Symptoms depend on the location of the lesion. Historical features and risk factors can help distinguish the cause of third nerve palsy. https://eyewiki.org/w/index.php?title=Acquired_Oculomotor_Nerve_Palsy&oldid=90950, Chronic progressive external ophthalmoplegia, Kline, Lanning B. Neuro-Opthalmology. Cranial arteritis. The most common causes of acquired third nerve palsy were: Ten patients (17 percent) with microvascular third nerve palsies had pupil involvement, while pupil involvement was seen in 16 patients (64 percent) with compressive third nerve palsies. Occlusion can be accomplished with a pirate patch, an occluder placed on the spectacle, or by an opaque contact lens. Gresir E, Schuss P, Seifert V, Vatter H. Oculomotor nerve palsy by posterior communicating artery aneurysms: influence of surgical strategy on recovery. Continuum (Minneap Minn) 2014;20(4):966-80. et al Imaging of Intracranial Aneurysms Causing Isolated Third Nerve Palsy. Cureus. Aoki K, Sakaue T, Kubota N, Maruo T. Outcome of surgery for bilateral third nerve palsy. Nearly 3,000 illustrations, including video clips of neurologic disorders. Multiple cranial nerve palsies might indicate lesions of the brainstem, cavernous sinus, skull base, or a more generalized peripheral nerve process such as Miller Fisher Syndrome. Management depends on the presented scenarios. All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias. Br J Neurosurg 2014;28(4):483-7. Powered by Higher Logic. Pupil-Sparing Third Nerve PalsyIschemia of the nerve usually involves only the very central part of the nerve itself, at the most distal end of the circulation. J Neuroophthalmol 2011;31(2):103-9. Aneurysmal clipping appears to lead to complete recovery from the palsy in 50% or more of patients, whereas coiling leads to complete recovery in about 33%, but the approach to the aneurysm must be based on what is safest and most effective in dealing with the aneurysm. The causes of cranial neuropathies include poorly controlled diabetes or high blood pressure, head injuries, infections, strokes, and brain tumors. 73. Chaudhary,N. The distinction becomes very important in management (to be discussed). 13.99). Similarly, but less commonly, adduction may cause constriction of the pupil. For small misalignments, press-on or ground-in prism on the spectacles is often successful in alleviating diplopia. However, brain imaging with noninvasive vascular imaging (CTA or MRA) is always obtained in patients with third nerve palsies. sarcoidosis) often involve additional cranial nerves, neoplasms, most commonly pituitary macroadenomas extending into the sinus, meningiomas of the sella or sinus and any other sinus mass (e.g. The Massachusetts eye and ear infirmary Illustrated manual of Ophthalmology. This article includes discussion of isolated and nonisolated third nerve (oculomotor) palsies. JAMA Ophthalmology. Microvascular extra-axial third nerve palsies should resolve completely within 3 months of onset. Click here to view our credit card processing security policy. 2023 AAPOS, All Rights Reserved. J AAPOS 2013;17(6):648-9. 91. Extraocular muscles governed by the third nerve. A 60-year-old man with hypertension and diabetes presented with acute, binocular oblique diplopia and severe headache. Causes of a third nerve palsy include: Poor blood supply to the third nerve caused by a combination of factors such as high blood pressure, diabetes, high cholesterol and smoking. Leigh RJ, Zee DS. If the symptoms do not go away on their own, your healthcare team might recommend physical therapy, occupational therapy, or other options to help with them. Bienfang DC. Cornblath WT. Complete oculomotor nerve palsy caused by direct compression of the posterior cerebral artery. Kushner BJ. Third nerve palsy produces some combination of ipsilateral ptosis, mydriasis, and ophthalmoplegia. A complete third nerve palsy causes a completely closed eyelid and deviation of the eye outward and downward. Third nerve palsy as the initial manifestation of giant cell arteritis. 13.91, and Fig. The most common causes of acquired third nerve palsy were presumed microvascular (42%), trauma (12%), compression from neoplasm (11%), postneurosurgery (10%), and compression from aneurysm (6%). Painless, pupil-sparing, but otherwise complete oculomotor paresis caused by basilar artery aneurysm. You should also prevent head injury. Third cranial (oculomotor) nerve disorders that cause palsies and affect the pupil commonly result from Aneurysms (especially of the posterior communicating artery) Transtentorial brain herniation Less commonly, meningitis affecting the brain stem (eg, tuberculosis meningitis) Parasympathetic nerve fibers originating from the Edinger-Westphal nucleus travel circumferentially with CN III to the pupil. The classic presenting symptoms of a patient with a third nerve palsy are binocular vertical and horizontal diplopia, droopy lid, or, less frequently, awareness of an enlarged pupil or blurred monocular vision at near. 3rd ed. The third cranial nerve controls the actions of four external eye muscles. Both levator palpebrae superioris are innervated by one subnucleus (central caudal nucleus); therefore a central caudal nuclear lesion would produce bilateral ptosis. Gunter K. von Noorden Young Investigator Award. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Why does a complete unilateral nuclear 3rd nerve palsy have bilateral ptosis? Mudgil AV, Repka MX. Another common cause is from poor blood flow related to diabetes. 6th edition. [2] A partial third nerve palsy may be more common, and can present with variable duction limitation of the affected extraocular muscles and with variable degrees of ptosis and/or pupillary dysfunction. Arch Ophthalmol 2011;129(3):301-5. The pupils may be equal in size and constrict equally to direct light, or the ipsilateral pupil may be relatively dilated and poorly constrictive to light. Arch Ophthalmol 1998;116(6):798. If imaging is negative, further investigation, including lumbar puncture, should be considered. They will likely advise you to call if your symptoms get worse or if you develop new symptoms such as pain, numbness, weakness, or changes in vision. Infarction of the third cranial nerve is the most common cause and often occurs in patients with diabetes, hypertension, or atherosclerosis. J Neuro-ophthalmol 2002;22(1):12-4. no financial relationships to ineligible companies to disclose. Diplopia due to ocular motor cranial neuropathies. Ptosis of the eyelid or an enlarged pupil may be the first sign of a third nerve palsy. Giant cell arteritis presenting as oculomotor nerve palsy with pupillary dilatation. The third cranial nerve controls the movement of four of the six eye muscles.