Third Nerve Palsy (Oculomotor Nerve Palsy) Treatment & Management

Updated: Oct 08, 2018
  • Author: James Goodwin, MD; Chief Editor: Andrew G Lee, MD  more...
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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. [30]

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. [31, 32] 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. [33, 31, 34] 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 axis, 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 a Fresnel paste on prism.


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. [35]

Patients who do not recover from third cranial nerve palsy after 6-12 months may become candidates for strabismus surgery (eye muscle resection or recession) to treat persistent and stable-angle deviation. [36] 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. [37] Also, total third cranial nerve palsy has less recovery potential than partial palsy. [38, 39]



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 nasal 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.