A patient presents with vertical double vision. What is your diagnosis?
Do you think this is:
- Sixth (CN VI) nerve palsy
- Fourth (CN IV) nerve palsy
- Inferior rectus entrapment post blowout fracture
- Third (CN III) nerve palsy
Analysis
Please watch this 20-second video clip to see the patient's motility examination.
The patient had ptosis and was using her finger to elevate her paralyzed lid. On examination, there was limited eye movement in supraduction, infraduction and adduction. Abduction was normal but no torsion on the Double Maddox rod test was noted.
The patient was imaged with an MRI and a diagnosis of an isolated third nerve palsy due to a ruptured aneurysm located at the posterior communicating artery.
In this 7-minute video from Dr. Paul Freund, you will review:
- The hallmark position of the eye when a CN III palsy is present
- The implications of a torsional component in the presence of a CN III palsy
- Important intracranial landmarks that can cause a CN III palsy
Neuro Coach Tip
In a patient with a third nerve palsy who also has a torsional element, a cavernous sinus lesion must be ruled out.
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