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CASE 38: Traumatic third nerve palsy with misdirection after successful horizontal alignment
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Clinical picture
A, Primary position alignment with 3 mm ptosis of the left upper lid. B, The left palpebral fissure widens on right gaze. C, The left palpebral fissure narrows on left gaze. D, The left eye does not elevate. E, The left eye does not depress and the left upper lid retracts from aberrant regeneration during attempted downgaze.
History
This 36-year-old woman was involved in a motor vehicle accident 2 years earlier. She was comatose for 14 days. When she regained consciousness, she had constant double vision. She is also bothered by generalized left-side weakness. She has difficulty walking, has slurred speech, cries easily, and has difficulty with memory. Aleft lateral rectus recession of 9 mm and a left medial rectus resection of 10 mm with one-half muscle width upshift was done 4 months ago.
Examination
The patient has visual acuity of OD 20/30 and OS 20/20. The 30 prism diopters of left exotropia and 15 prism diopters of left hypotropia that had been present in the primary position before recent surgery has been nearly eliminated, leaving 5 prism diopters of exotropia resulting in satisfactory appearance. The left pupil is dilated to 6 mm and is nonreactive to light or accommodation. The left eye has nearly full adduction but neither elevates nor depresses more than a few degrees. During dextroversion of the left eye, the left upper lid elevates. This lid is photic on gaze to the left. On attempted downgaze, the left eye remains near the primary position but the left upper lid retracts. The remainder of the eye examination is unremarkable.
Diagnosis
Traumatic third nerve palsy with aberrant regeneration after recess-resect of the horizontal recti with upshift.
Treatment/Surgery
Recession of the left lateral rectus 9 mm, resection of the left medial rectus 10 mm with upshift of the insertion of both horizontal recti one half muscle width.
Comment
In cases of unilateral palsy of the third nerve with aberrant regeneration, such as this, a recession/resection procedure with upshift of both muscles can be effective in straightening the eyes in the primary position. There is no effective way to deal surgically with the aberrant regeneration. Since the ptosis in this patient is only moderate, possibly a result of the effects of the aberrant regeneration, no treatment is required. Patients with third nerve palsy will always see double in nearly every direction unless they are successful in suppressing one image, usually from the paretic eye. Aberrant regeneration occurs in approximately two-thirds of patients with third nerve palsy, congenital or traumatic. |
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