Case of the week 45 (
March 2012
) Combined Third and Fourth nerve palsy
25 years old young man complains of
the dropped Rt eye lid . He uses the frontalis ms to
just expose the pupil . Old
photos show that the condition started shortly after
birth . Neurologically , he is fine , no history of
trauma , no history of general illness .
During Ocular examination findings more than
blepharoptosis are discovered .
See video of this patient
The Striking Findings
in thid patient are :
1. Paralytic blepharoptosis .
2. Loss of Bell's phenomenon .
2. Right XT and Hypertropia .
The right hypertropia is greater on looking left and
on head tilt to the right ( Rt SO palsy ) . The
right XT and LPS palsy are remnants signs of
regenerated 3rd nerve palsy .
Combined ocular motor palsies are present when eye
muscle weakness indicates dysfunction of more than
one ocular motor nerve. These may be unilateral or
bilateral. They should be distinguished from
supranuclear disorders of ocular motility and from
diffuse disorders of the muscles or neuromuscular
junction ( Graves ophthalmopathy,
myasthenia gravis
) .
When multiple nerves are
affected, this is usually a combination of
horizontal and vertical deviations .
Ptosis is also common, as the third nerve is
frequently a component of multiple nerve palsies.
Although surgical correction of the SO has no effect
on this paralytic strabismus , my plan for this
patient has two sessions , first to do Rt. LR
recession and IO myotomy and second to do guarded
frontalis sling operation .
Post operative
See video of this patient post
operative
الموقع المصري للحول
وامراض الجهاز الحركي للعين
The Egyptian Site of
Strabismus & Oculomotor Disorders
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