|LETTER TO THE EDITOR
|Year : 2019 | Volume
| Issue : 4 | Page : 338-339
Importance of pupil in isolated oculomotor nerve palsy
Department of Ophthalmology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
|Date of Submission||11-Oct-2019|
|Date of Acceptance||12-Nov-2019|
|Date of Web Publication||26-Dec-2019|
Prof. Krishnamurthy Ilango
Department of Ophthalmology, Velammal Medical College Hospital and Research Institute, Ring Road, Anupanadi, Madurai - 625 009, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ilango K. Importance of pupil in isolated oculomotor nerve palsy. TNOA J Ophthalmic Sci Res 2019;57:338-9
I read with interest the discussion of the article (photo image) of a posterior communicating artery aneurysm presenting with ipsilateral oculomotor nerve palsy by Reddy Ravikanth and Kanakasabai Kamala Sekar in the April–June 2019 issue of TNOA.
I appreciate the authors for reporting such a rare case of clinical interest. Though it is mentioned that spontaneous unilateral oculomotor nerve palsy is the most common presentation related to a posterior communicating artery aneurysm in this communication, I wanted to emphasize the importance of the examination of pupils. Neuro-ophthalmic emergencies can cause life-threatening complication. Diplopia related to oculomotor nerve palsy with pupillary involvement may reveal an intracranial aneurysm.
We had a similar case presenting to our ophthalmology department. The patient was a 52-year-old woman with the only presenting symptom of headache with pain around the right orbit. On ocular examination, she had a complete ptosis of the right eyelid for 3 weeks. On examination of ocular movement's elevation, adduction and depression were restricted. Light reaction showed a sluggishly reacting pupil which was dilated. The left eye was normal on examination. Vision was 6/24 improving to 6/6 with refractive correction. She had diplopia binocularly on lifting the eye lid to the right gaze. Color vision and field examination were normal.
A plain computed tomography (CT) scan of the brain without arteriography done elsewhere before presenting to us did not show any abnormality. The patient had the clinical features of aneurysm. Magnetic resonance imaging angiogram was done which confirmed the clinical diagnosis. [Figure 1] shows the aneurysm at the posterior communicating artery.
The patient was promptly referred to a neurosurgeon, and she underwent an endovascular coiling of the aneurysm. A timely intervention resulted in the recovery of oculomotor palsy, and her diplopia resolved.
To summarize the important clinical points, whenever a patient presents with isolated oculomotor palsy, it is important to examine whether his/her pupil is involved or not to suspect aneurysm. However, there are case reports with aneurysm presenting with pupil-sparing oculomotor palsy. Hence, a proper clinical history and correlation of findings is mandatory.
Second, posterior communicating artery aneurysms occur four times more often in women than men, and 34% are associated with oculomotor paralysis.
Third, in patients presenting with isolated oculomotor nerve palsy, CT yield is low (30%). Carotid angiography is indicated in all patients if the ophthalmoplegia is accompanied by any pupillomotor dysfunction. Last but not the least is a prompt referral to a neurosurgeon is urgent as ruptured intracranial aneurysm accounts for approximately 75%–80% of spontaneous subarachnoid hemorrhage.
The purpose of this communication is to emphasize the importance of pupil examination in an isolated oculomotor nerve palsy keeping in mind the ophthalmology residents.
Declaration of patient consent
The author certifies that he had obtained all appropriate patient consent forms. In the form, the patient has given her consent for the image and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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