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Picture quiz: Surgical or medical third nerve palsy?

BMJ 2008; 337 doi: (Published 01 October 2008) Cite this as: BMJ 2008;337:0810371
  1. Yap Yew Chong, senior house officer1,
  2. Evelyn Mensah, consultant ophthalmologist1
  1. 1Deptartment of Ophthalmology, Watford General Hospital, Watford WD18 0HB

A 76 year old woman presented to the eye department with a one week history of left eye pain and drooping eyelid. She had a history of hypertension and atrial fibrillation controlled with drugs. On examination visual acuity was normal at 6/9 in each eye. There was complete ptosis and ophthalmoplegia of four of the six extraocular muscles of the left eye. In primary position the left eye was depressed (that is, “down”) and abducted (that is, “out”). One week later she presented with increasing left eye pain and pupil involvement. Magnetic resonance imaging and angiography was normal. Subsequent cerebral angiography was also normal. Within three months all symptoms and signs had resolved with full recovery of ocular movements.


  • (1) From figs 1 to 4 which eye movements are absent?

  • (2) From figs 1 to 4 what position of gaze and which cranial nerve is intact?

  • (3) From figs 5 and 6 what other ophthalmic abnormalities are noticeable?

  • (4) …

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