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LETTER TO THE EDITOR
Year : 2019  |  Volume : 57  |  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 Submission11-Oct-2019
Date of Acceptance12-Nov-2019
Date of Web Publication26-Dec-2019

Correspondence Address:
Prof. Krishnamurthy Ilango
Department of Ophthalmology, Velammal Medical College Hospital and Research Institute, Ring Road, Anupanadi, Madurai - 625 009, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_88_19

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How to cite this article:
Ilango K. Importance of pupil in isolated oculomotor nerve palsy. TNOA J Ophthalmic Sci Res 2019;57:338-9

How to cite this URL:
Ilango K. Importance of pupil in isolated oculomotor nerve palsy. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2020 Jul 14];57:338-9. Available from: http://www.tnoajosr.com/text.asp?2019/57/4/338/273988



Dear Editor,

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.[1]

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.
Figure 1: Posterior communicating artery aneurysm

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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.[2] 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.[3]

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.[4] 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.[5]

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Caignard A, Leruez S, Milea D. Neuro-ophthalmic emergencies. J Fr Ophtalmol 2016;39:716-28.  Back to cited text no. 1
    
2.
Motoyama Y, Nonaka J, Hironaka Y, Park YS, Nakase H. Pupil-sparing oculomotor nerve palsy caused by upward compression of a large posterior communicating artery aneurysm. Case report. Neurol Med Chir (Tokyo) 2012;52:202-5.  Back to cited text no. 2
    
3.
Soni SR. Aneurysms of the posterior communicating artery and oculomotor paresis. J Neurol Neurosurg Psychiatry 1974;37:475-84.  Back to cited text no. 3
    
4.
Kwan ES, Laucella M, Hedges TR 3rd, Wolpert SM. A cliniconeuroradiologic approach to third cranial nerve palsies. AJNR Am J Neuroradiol 1987;8:459-68.  Back to cited text no. 4
    
5.
Zacharia BE, Hickman ZL, Grobelny BT, DeRosa P, Kotchetkov I, Ducruet AF, et al. Epidemiology of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010;21:221-33.  Back to cited text no. 5
    


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