Oculomotor nerve palsy (1)

August 7, 2012  |  Neurology Study

We had two female patients with oculomotor nerve palsy hospitalized in two consecutive days. I made a comparison between their conditions and found it very interesting.

Patient #1 (Let’s call her Mary): Mary is 60 years old, and she was admitted to hospital because of recurrent headache for two months and right ptosis for 10 days.

Two months ago, Mary got a headache in a sudden after using her full strength to lift a heavy object. Her headache came with throbbing pain on the top right side of head. She said she can hardly bear it. She also had a blurred vision and felt dizzy and sick although she didn’t want vomit. The doctor in a local clinic gave her some infusion therapy (unknown) and her headache was relieved in two hours. However, after some time she had the same symptoms, which repeated every 1 to 2 hours. She said it became more severe when she got up, exposed to intensive sunshine or coughed. Taking painkillers cannot make her relieved with the headache. About one month ago, Mary had a head CT scan and the result was normal. About 10 days ago, she suddenly had right ptosis and diplopia in the horizontal direction.

Our neurologic examination revealed that Mary’s right eyelid was drooping and completely covered the right eyeball, and right eye movement was limited when it moves towards left, upper and lower directions. Also, she had diplopia when her eyes moved to the left. In addition, her right pupil was 5 mm in size and had poor light reflex. The size and light reflex of her left eye were normal. (One day before the examination, Mary hit her head onto the edge of a table, so she had ecchymosis on her periorbital skin.)

Mary’s pupils are like the picture below:

Mary's pupils


The eye movements of Mary are presented as below:

Mary's eye movements


Patient #2 (Let’s call her Linda): Linda is 61 years old. She was admitted to hospital because of vertigo and headache for eight days and left ptosis for 6 days.

Eight days before her presentation, Linda suddenly got vertigo and blurred vision after doing some manual labor work. Her vertigo came with a headache (presented as throbbing pain) and nausea. She didn’t feel like vomiting and felt better when she lay down and rested for a while. The next day she got a gradual onset of weakness of her left eyelid, and 2 days later she found it was difficult to open her left eye.

Our neurologic examination revealed her left eyelid was drooping and completely covered the left eyeball, and her left eye movement was limited when it moved towards the right and upper directions. In addition, her bilateral pupils were 3 mm in size and had good light reflex.

Linda’s pupils are like the picture below:

Linda's pupils


The eye movements of Linda were presented as below (she was not very cooperative when we took photos of her eyes, so you may see her normal eye (right eye) is not in place in some directions):

Linda's eye movements


I will review details about the causes of their diseases with you in the future.

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