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Oculomotor Nerve Palsy Treatment & Management

  • Author: James Goodwin, MD; Chief Editor: Andrew G Lee, MD  more...
Updated: Mar 18, 2016

Medical Care

Medical third cranial nerve palsy

Third cranial nerve palsy from ischemia in the nerve trunk is believed to result from insufficiency of the vasa nervosa or small vessels that supply the nerve.[12]

Third cranial nerve palsy is most frequent in persons older than 60 years and in those with prominent or long-standing atherosclerotic risk factors, such as diabetes or hypertension.[13, 14] The key finding in these patients is relative sparing of the pupillary sphincter with complete or near-complete palsy of the extraocular muscles innervated by the third cranial nerve, including levator palpebrae.[15, 13, 16] Ironically, these patients may have very severe pain in the eye or orbit ipsilateral to the involved nerve. The pathogenesis of this pain is not understood, but it is common in patients with medical palsy and does not in itself suggest aneurysm as the cause.

Medical management is actually watchful waiting, since there is no direct medical treatment that alters the course of the disease. Fortunately, nearly all patients undergo spontaneous remission of the palsy, usually within 6-8 weeks. Treatment during the symptomatic interval is directed at alleviating symptoms, mainly pain and diplopia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment of choice for the pain. Diplopia is not a problem when ptosis occludes the involved eye. When diplopia is from large-angle divergence of the visual axes, patching one eye is the only practical short-term solution. When the angle of deviation is smaller, fusion in primary position often can be achieved using horizontal or vertical prism or both.

Since the condition is expected to resolve spontaneously within a few weeks, most physicians would prescribe the prism as Fresnel paste on.


Surgical Care

For practical purposes, surgical care of third cranial nerve palsy includes clipping, gluing, coiling, or wrapping of the berry aneurysm by a neurosurgeon in the acute stage.[17]

Patients who do not recover from third cranial nerve palsy after 6-12 months may become candidates for eye muscle resection or recession to treat persistent and stable-angle diplopia.[18] Some of these patients also may require some form of lid-lift surgery for persistent ptosis that restricts vision or is cosmetically unacceptable to the patient.

Comparison of third cranial nerve palsy recovery following surgical intervention shows that aneurysm clipping is more likely to result in resolution than coiling since the latter does not reliably remove the mass effect of the aneurysm on the nerve. Also, total third cranial nerve palsy has less recovery potential than partial palsy.[19, 20]



Internal medicine

Initial workup of pupil-sparing, third cranial nerve palsy without any other evidence of aneurysm involves medical evaluation for arteriosclerotic risk factors, including diabetes and hypertension.

Certain patients may require screening for collagen vascular disease, systemic vasculitis, sarcoidosis, or other granulomatous systemic diseases.

If carcinomatous meningitis is diagnosed on cerebrospinal fluid workup, then a search for systemic metastatic disease, an occult primary carcinoma, lymphoma, or leukemia is warranted.


Third cranial nerve palsy due to berry aneurysm, with or without concomitant subarachnoid hemorrhage, requires neurosurgical management in most cases.


The ophthalmologist provides symptomatic treatment for diplopia using occlusion, prism, or eye muscle surgery, and various lid-lift procedures for ptosis.



Patients who are monocular from either ptosis or ocular patching and patients with diplopia should not climb on high places, drive a vehicle, or operate heavy machinery.

Patients should avoid any other activity where limitation of peripheral vision poses danger.

The monocular temporal crescent is lost when one eye is occluded, which effectively shrinks the field by some 20-30° on the side of the closed eye. Loss of depth perception with one eye poses another set of potential risks for activities that depend on accurate assessment of depth.

Contributor Information and Disclosures

James Goodwin, MD Associate Professor, Departments of Neurology and Ophthalmology, University of Illinois College of Medicine; Director, Neuro-Ophthalmology Service, University of Illinois Eye and Ear Infirmary

James Goodwin, MD is a member of the following medical societies: American Academy of Neurology, Illinois State Medical Society, North American Neuro-Ophthalmology Society, Royal Society of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Andrew G Lee, MD Chair, Department of Ophthalmology, Houston Methodist Hospital; Clinical Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch; Clinical Professor, Department of Surgery, Division of Head and Neck Surgery, University of Texas MD Anderson Cancer Center; Professor of Ophthalmology, Neurology, and Neurological Surgery, Weill Medical College of Cornell University; Clinical Associate Professor, University of Buffalo, State University of New York School of Medicine

Andrew G Lee, MD is a member of the following medical societies: American Academy of Ophthalmology, Association of University Professors of Ophthalmology, American Geriatrics Society, Houston Neurological Society, Houston Ophthalmological Society, International Council of Ophthalmology, North American Neuro-Ophthalmology Society, Pan-American Association of Ophthalmology, Texas Ophthalmological Association

Disclosure: Received ownership interest from Credential Protection for other.

Additional Contributors

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.


Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

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Angiography anteroposterior and lateral views, left posterior communicating artery aneurysm, indicated by red arrow. Courtesy of James Goodwin, MD.
Patient with left posterior communicating artery aneurysm and third cranial nerve palsy. Courtesy of James Goodwin, MD.
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