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A Conflicting Case of Ophthalmoparesis

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 37-year-old Asian nonsmoking man with no known medical or drug history presented with an insidious onset of left-eye ptosis (only brought to attention by his friends on review of recent photographs) and subsequent painless vertical diplopia for 1 year. He did not complain of headaches, facial numbness, dysarthria, facial droop, dysphagia, or limb weakness or numbness. There was no history of joint pain or constitutional symptoms.

Neurological examination revealed a nonfatigable partial left-eyelid ptosis, left-eye hypotropia at primary position, and impaired left eye supraduction (Figure 1) with a nonreactive left pupil on direct and consensual light reflexes. There were no other cranial nerve deficits. Limb reflexes, motor testing, and sensory testing results were normal, and the plantar responses were flexor.

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D. Neurovascular conflict of the oculomotor nerve

Further detailed MRI constructive interference in steady-state sequence with fine cuts of the midbrain was performed, which revealed that the left posterior cerebral artery (PCA) and left superior cerebellar artery (SCA) were indenting the oculomotor nerve with resultant displacement (Figure 2). No intracranial aneurysms were demonstrated.

An oculomotor nerve palsy with pupil involvement is often due to extrinsic compression by posterior communicating artery (PCoA) aneurysms.1 This is because when the nerve exits the midbrain, its cisternal course2 passes between the PCA and SCA and is accompanied by the PCoA before running in an anteromedial-lateral direction to reach the cavernous sinus. The dilated pupil occurs as external compression affects the pial vessels, which then compromise the parasympathetic fibers and results in paralysis of the sphincter pupillae.

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Article Information

Corresponding Author: Newman Cheng, MBBS (S’pore), MRCP (UK), MRCP(UK) (Neurology), National Neuroscience Institute (SGH Campus), 20 College Rd, Academia, Singapore S169856 (newman.cheng@gmail.com).

Published Online: October 3, 2022. doi:10.1001/jamaneurol.2022.3149

Correction: This article was corrected on November 14, 2022, to fix a typographical error in the figure 2 caption.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Tsai  TH , Demer  JL .  Nonaneurysmal cranial nerve compression as cause of neuropathic strabismus: evidence from high-resolution magnetic resonance imaging.   Am J Ophthalmol. 2011;152(6):1067-1073.e2. doi:10.1016/j.ajo.2011.05.031PubMedGoogle ScholarCrossref
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Leal  PR , Hermier  M , Souza  MA , Cristino-Filho  G , Froment  JC , Sindou  M .  Visualization of vascular compression of the trigeminal nerve with high-resolution 3T MRI: a prospective study comparing preoperative imaging analysis to surgical findings in 40 consecutive patients who underwent microvascular decompression for trigeminal neuralgia.   Neurosurgery. 2011;69(1):15-25. doi:10.1227/NEU.0b013e318212bafaPubMedGoogle ScholarCrossref
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Kheshaifati  H , Al-Otaibi  F , Alhejji  M ,  Microvascular decompression for oculomotor nerve palsy: a case report and literature review.   World Neurosurg. 2016;88(695) e1-e3. doi:10.1016/j.wneu.2015.12.083Google ScholarCrossref
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Fang  C , Leavitt  JA , Hodge  DO , Holmes  JM , Mohney  BG , Chen  JJ .  Incidence and etiologies of acquired third nerve palsy using a population-based method.   JAMA Ophthalmol. 2017;135(1):23-28. doi:10.1001/jamaophthalmol.2016.4456PubMedGoogle ScholarCrossref
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Belotti  F , Zanin  L , Fontanella  MM , Panciani  PP .  The oculomotor neurovascular conflict: Literature review and proposal of management.   Clin Neurol Neurosurg. 2020;195:105920. doi:10.1016/j.clineuro.2020.105920PubMedGoogle ScholarCrossref
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