Management Of Third Nerve Palsy Research Articles

The use of lyophilized bovine pericardium (Tutopatch®) in the management of third nerve palsy following prior conventional strabismus surgery – a case series

ABSTRACT To study the secondary management of strabismus due to third nerve palsy using bovine pericardium (Tutopatch®) when previous conventional surgical therapy had failed. Review of our clinic records of selected patients with third nerve palsy, in whom residual deviation had been managed using Tutopatch® after previous surgical correction. The squint angle was measured preoperatively, and at 1 day, 3 months, and if possible 6 months postoperatively. Nine patients were enrolled in this study. One patient had mainly residual vertical deviation and was corrected with tendon elongation of the contralateral superior rectus. Three patients were operated on with tendon elongation of the lateral rectus muscle with or without medial rectus muscle resection and/or advancement (Group 1). Lateral rectus splitting after tendon elongation in addition to the resection and/or advancement of the medial rectus was performed in five patients with complete third nerve palsy (Group 2). In Group 1, the preoperative median squint angle was −20° (range −17° to −25°), which improved postoperatively to −4.5° (range −12° to +3°). In Group 2, the preoperative horizontal and vertical median squint angles were −27° (range −20° to −40°) and 0.5° (range 0° and 20°), respectively. Postoperatively, they had improved to −12.5° (range–2° to −25°), and 1.5° (range 0° to 7°), respectively. Two patients of Group 2 were re-operated due to residual exotropia. No postoperative complications were observed in any patient. In this small series several complex re-do situations of patients with third nerve palsy were evaluated in which Tutopatch® markedly improved outcomes after an initially ineffective surgical management. For better evaluation of its usefulness a study with more patients is recommended.

Surgical management of third nerve palsy

Third nerve paralysis has been known to be associated with a wide spectrum of presentation and other associated factors such as the presence of ptosis, pupillary involvement, amblyopia, aberrant regeneration, poor bell's phenomenon, superior oblique (SO) overaction, and lateral rectus (LR) contracture. Correction of strabismus due to third nerve palsy can be complex as four out of the six extraocular muscles are involved and therefore should be approached differently. Third nerve palsy can be congenital or acquired. The common causes of isolated third nerve palsy in children are congenital (43%), trauma (20%), inflammation (13%), aneurysm (7%), and ophthalmoplegic migraine. Whereas, in adult population, common etiologies are vasculopathic disorders (diabetes mellitus, hypertension), aneurysm, and trauma. Treatment can be both nonsurgical and surgical. As nonsurgical modalities are not of much help, surgery remains the main-stay of treatment. Surgical strategies are different for complete and partial third nerve palsy. Surgery for complete third nerve palsy may involve supra-maximal recession - resection of the recti. This may be combined with SO transposition and augmented by surgery on the other eye. For partial third nerve, palsy surgery is determined according to nature and extent of involvement of extraocular muscles.

Evaluation of Third Nerve Palsy in the Emergency Department

Third nerve palsy is an uncommon condition that carries significant risk of serious disease due to both the variability of its presentation and its association with intracranial aneurysms. In this article, we review the existing literature on the pathophysiology, diagnosis, and management of third nerve palsy presenting to the Emergency Department.

Diagnosis and management of third nerve palsy

To provide clinically relevant information regarding the diagnosis, etiology, work-up and treatment of third cranial nerve palsies, while incorporating information from current publications and providing our opinions on these studies. In the past year, an important study focused on the confirmation of current neuro-imaging guidelines for third cranial nerve palsies. Recent case reports have highlighted etiologies such as giant cell arteritis, trauma, neuro-syphilis and demyelination secondary to infliximab and multiple sclerosis. Surgically, newer studies have focused on globe-tethering procedures for correcting strabismus and the use of frontalis suspension for correcting ptosis. Improved imaging technology with high-resolution magnetic resonance imaging (hr-MRI) allows for direct visualization of the entire nerve path and the affected muscles. Management of a third nerve palsy depends upon localization of the causative lesion and determination of the underlying etiology. Once these issues are addressed, strabismus surgery can be both challenging and rewarding in these complex patients.