1. Occulomotor Palsy with Multiple
Cranial Nerves Neuropathy
By: Abhimanyu Parashar
Pharm D Intern

3. Oculomotor Palsy (3rd Nerve Palsy)
• Oculomotor nerve palsy is an eye condition
resulting from damage to the third cranial nerve
or a branch
• The Oculomotor nerve supplies the majority of
the muscles controlling eye movements
• In a complete Oculomotor nerve palsy, the
affected eye will normally be in a down and out
position relative to the other eye
• The affected eye will also have a ptosis, or
drooping of the eyelid, and pupil dilation

4. Types of Oculomotor Palsy
 Congenital Oculomotor
Palsy
 Acquired Oculomotor palsy







Vascular disorders
Lesions or Tumors
Inflammation or Infection
Trauma
Demylenating Disease
AIDS
Post Operative Neurosurgery
Symptoms
 Ptosis
 Downward and
Outward positioning of
Eye
Unable to adduct,
infraduct, supraduct
Dilated pupil with
sluggish reaction

5. Muscles Innervated by 3rd Cranial
Nerve
• 1) Superior Rectus muscle
(extraocular muscle)
• 2) Inferior Rectus muscle
(extraocular muscle)
• 3) Medial Rectus muscle
(extraocular muscle)
• 4) Inferior Oblique
(extraocular muscle)
• 5) Levator palpebrae
superioris (muscle to upper
eye lid)

6. External Ocular Paralysis
Muscle
Direction of pull
Result of paralysis
Cranial nerve
Medial rectus
Medially
Lateral
III
Superior rectus
Upwards
Downwards
III
Lateral rectus
Laterally
Medial
VI
Inferior rectus
Downwards
Upwards
III
Superior oblique
Down and out
Up and in
IV
Inferior oblique
Up and out
Down and in
III

7. 




Pathophysiology
lesions at Oculomotor
Nucleus (Midbrain)
Lesions at Oculomotor
Nerve Fascicles
Lesions at Subarachnoid
place
Lesions within
cavernous sinus &
Superior orbital fissure
Lesions within Orbit
Differential Diagnosis
Myasthenia Gravis
Thyroid associated
orbitopathy
Internuclear
ophthalmoplegia
Chronic progressive
external
ophthalmoplegia
Orbital pseudotumor
Giant cell Arteritis

10. Optic Neuritis
• Optic neuritis is an inflammation of the optic nerve
• Optic neuritis usually affects one eye, although it
may occur in both eyes simultaneously.
• Symptoms:
Pain
Vision loss
Loss of color vision
Flashing lights

11. Etiology:
 Multiple Sclerosis (incidence
rate 50%)
 Neuromylitis Optica
 Sarcoidosis
 SLE
 Infections: Lyme's Disease,
Syphilis, measles, mumps,
herpes .
 Cranial Arteritis
 Vasculitis
 Diabetes Mellitus
 Drugs (Ethambutol,
Chloramphenicol)
 Radiation

12. OP No.
1116060
IP No.
279206
Age
55 Yrs
Sex
Male
Weight
86 Kgs
Unit
Neurology
OPD Evaluation
c/o Diplopia, Blurring of vision and headache since 1day
Not a k/c/o DM & HTN
BP: 160/90 mmHg
o/e: Left eye impaired, abduction/ elevation absent
Left third nerve palsy
Imp: Demyelination ? Left 3rd nerve palsy
Adv: MRI

14. MRI Brain
Optic Nerve:
• Rt Optic nerve: 3.5 mm & Normal.
• Lt Optic nerve: 4.0 mm & Enlarged in size and Normal
in outline.
• The optic chiasma, the lateral geniculate body, the
thalami and the optic tracts are Normal
Impression: Features S/O Left Optic Neuritis
Neurologist opinion: Left optic Neuritis ? 3rd Nerve Palsy
ADV: Admit to ward

15. Day 1
• C/O: Diplopia, painful movement of eye,
blurring of vision since 2 days
• H/O headache
• No Hx of similar complains in past
• Not a k/c/o DM & HTN
Provisional diagnosis: Left optic neuritis

16. General examination:
• CNS: conscious oriented
• CN : Lt eye impaired
abduction/ elevation/ depression absent
Motor system:
• Tone: Normal
• Power: 5/5 in all limbs
• Reflexes: Normal
• Plantar: Extensor
Sensory/ cerebeller system: Normal
Adv: HIV, VDRL, Rx as per chart

17. Treatment chart
DRUGS
DOSE
F
R
from
Inj. Prednisolone
1 g in
100 ml
1-0-0
IV
16/1
Inj. rabeprazole
20 mg
1-0-0
IV
16/1
Inj. Cefoperazone + Sulbactum
1.5 g
1-0-1
IV
16/1
Syp. sucralfate
2 tsp
1-0-1
PO
16/1
T. Paracetamol + Aceclofenac
500 +
50 mg
1-0-1
PO
16/1
T. Amitriptylline + Chlordiazepoxide
25 +
10 mg
0-0-1
PO
16/1

18. Day 2
BP: 130/80 mmHg
Pulse: 76 BPM
• O/E Pt feeling slightly better
• MRI brain: feature suggestive of left optic neuritis
• Left eye ptosis +
• Abduction/ elevation impaired
ADV: treatment as per chart, LP CSF, Ophthalmologist
opinion, neuro-surgeon opinion for any surgical cause
• 4 PM Lumbar puncture done

19. HIV
Negative
VDRL
Negative
FBS
84 mg/dl
PPBS
148 mg/dl
LP - CSF
Normal

20. Ophthalmologists opinion:
• Unable to open left eye, sudden in onset
• Diplopia only force open the left eye
• Pupils dilated
• O/E Alternating exotropia
• Ptosis – severe
• Fundus: WNL
• Temporal pallor of disc +
• Macula +
• IMP: Resolving 3rd cranial nerve palsy
• Will be reviewed tomorrow

21. Treatment chart
DRUGS
DOSE
F
R
from
Inj. Prednisolone
1 g in
100 ml
1-0-0
IV
16/1
Inj. rabeprazole
20 mg
1-0-0
IV
16/1
Inj. Cefoperazone + Sulbactum
1.5 g
1-0-1
IV
16/1
Syp. sucralfate
2 tsp
1-0-1
PO
16/1
T. Paracetamol + Aceclofenac
500 +
50 mg
1-0-1
PO
16/1
T. Amitriptylline + Chlordiazepoxide
25 +
10 mg
0-0-1
PO
16/1

22. Day 3
BP: 150/80 mmHg
Pulse: 84 BPM
• O/E: pt symptomatically better
• CNS: conscious oriented
• CN 3rd : Lt eye ptosis +
pupils are reactive to light
abduction decreased
• Neurosurgeon opinion:
No visual activity symptoms, left 3rd nerve paresis
No active neurological intervention required
• Ophthalmologists opinion:
ADV: Review after 1 month
Pupil Sparing 3rd Nerve Paresis

23. Swinging Flashlight Test of Pupillary constriction

24. Treatment chart
DRUGS
DOSE
F
R
from
Inj. Prednisolone
1 g in
100 ml
1-0-0
IV
16/1
Inj. rabeprazole
20 mg
1-0-0
IV
16/1
Inj. Cefoperazone + Sulbactum
1.5 g
1-0-1
IV
16/1
Syp. sucralfate
2 tsp
1-0-1
PO
16/1
T. Paracetamol + Aceclofenac
500 +
50 mg
1-0-1
PO
16/1
T. Amitriptylline + Chlordiazepoxide
25 +
10 mg
0-0-1
PO
16/1
T. Aspirin
75 mg
0-1-0
PO
18/1

25. Day 4
•
•
•
•
BP: 150/80 mmHg
O/E: Vital stable
No fresh complains
ADV: treatment as per chart
Pulse: 76 BPM

26. Treatment chart
DRUGS
DOSE
F
R
from
Inj. Prednisolone
1 g in
100 ml
1-0-0
IV
16/1
Inj. rabeprazole
20 mg
1-0-0
IV
16/1
Inj. Cefoperazone + Sulbactum
1.5 g
1-0-1
IV
16/1
Syp. sucralfate
2 tsp
1-0-1
PO
16/1
T. Paracetamol + Aceclofenac
500 +
50 mg
1-0-1
PO
16/1
T. Amitriptylline + Chlordiazepoxide
25 +
10 mg
0-0-1
PO
16/1
T. Aspirin
75 mg
0-1-0
PO
18/1

27. Day 5
•
•
•
•
BP: 140/80 mmHg
O/E: Vital stable
No fresh complains
ADV: Discharge
Pulse: 80 BPM

28. Treatment chart
DRUGS
DOSE
F
R
from
inj. Prednisolone
1 g in
100 ml
1-0-0
IV
16/1
Inj. rabeprazole
20 mg
1-0-0
IV
16/1
Inj. Cefoperazone + Sulbactum
1.5 g
1-0-1
IV
16/1
Syp. sucralfate
2 tsp
1-0-1
PO
16/1
T. Paracetamol + Aceclofenac
500 +
50 mg
1-0-1
PO
16/1
T. Amitriptylline + Chlordiazepoxide
25 +
10 mg
0-0-1
PO
16/1
T. Aspirin
75 mg
0-1-0
PO
18/1

29. Discharge medications
DRUGS
DOSE
F
R
T. Paracetamol + Aceclofenac
500 +
50 mg
1-0-1
PO
T. Amitriptylline + Chlordiazepoxide
25 +
10 mg
0-0-1
PO
T. Aspirin
75 mg
0-1-0
PO
Tab. Prednisolone
40 mg
1-0-0
PO
Tab. Rabeprazole
20 mg
1-0-0
PO

30. Pharmaceutical Care Plan
Subjective Evidence
 Diplopia
 Blurred Vision
 Left eye Impaired
 Adduction, Elevation,
Depression Absent
 Ptosis of Left eye
 Headache
 Exotropia Left eye
Objective Evidence
 MRI: Features S/O Left
Optic Neuritis
 Swinging Flashlight test:
Pupil sparing Oculomotor
palsy

31. Final Diagnosis
Oculomotor Nerve (3rd Cranial Nerve) Palsy
with Multiple cranial nerves neuropathy

32. Goals of Therapy
• To relive presenting signs and symptoms
• To rule out the underlying etiology
• To prevent further progression and
complication of the disease
• To align the eye surgically*
• To improve health related quality of life
(*) : Optional

33. Treatment Options
Pharmacological:
• NSAID’s
• Corticosteroids
Non Pharmacological:
• Patching of Eye
• Using Prism Lens Spectacles
Surgical:
• Eye muscle surgery (Strabismus Surgery)
• Lid lift surgery (Blepharoplasty)
• Clipping, Gluing, Coiling, wrapping of Aneurysms*

35. Goals Achieved
• Patient was started on symptomatic
pharmacotherapy
• Patient symptoms improved before he was
discharged

36. Problems Identified
•
•
•
•
Use of Cefoperazone + Sulbactum
Use of IV Proton Pump Inhibitor
Untreated indication: Hypertension
Monitoring Error: Lipid Profile not done
Clinical Pharmacy Services Provided
Drug Information: Oral Proton Pump inhibitors Vs. IV Proton Pump Inhibitors
Intervention:
• Use of IV proton pump inhibitors
• Untreated indication – Hypertension

37. Monitoring Parameters
•
•
•
•
•
•
•
•
MRI
Blood Pressure
Blood Glucose
Lipid Profile
CT Scan*
Fundoscopy
Ophthalmoscopy
Carotid Doppler*

38. Patient Counseling

39. About Disease
• What is a third nerve
palsy?
• What are the symptoms
of third nerve palsy?
• What causes third nerve
palsy?
• What can be done to
correct third nerve
palsy?
About
Medications
– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose
– Caution with
Corticosteroids

40. About Lifestyle modifications
• Patient should avoid driving
• Patient should keep an eye patch to cover the affected eye
• Using 1 eye will impair 1/3 of the vision and patient may not be
able to judge depth and height so be careful in making any
judgment
• Patient should wear prism lenses to avoid Diplopia
• Patient Should avoid consuming alcohol as it can precipitate the
ischemic neuropathy
• Patient should reduce the salt intake and fatty food in order to
reduce the blood pressure.
• Patient should take sufficient rest
• Patient should be counseled about cosmetic issues related to
Oculomotor palsy and can be prepared for strabismus surgery*