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A 51-year-old woman with binocular diplopia and unilateral ptosis
Digital Journal of Ophthalmology 2019
Volume 25, Number 3
August 18, 2019
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Landon J. Rohowetz, BS | University of Missouri – Kansas City School of Medicine, Kansas City, Missouri
Anjulie K. Quick, MD | Department of Ophthalmology, University of Kansas School of Medicine, Prairie Village, Kansas
Differential Diagnosis
Isolated, pupil-sparing oculomotor nerve palsy is most often due to a microvascular cause, whereas isolated pupil-involving oculomotor nerve palsy is most commonly due to compression from an aneurysm or tumor.(1) Because of the potential for imminent subarachnoid hemorrhage caused by an intracerebral aneurysm, emergent imaging (magnetic resonance angiogram or CTA) is warranted in cases of oculomotor nerve palsy with partial or complete pupil involvement. While our patient’s pupil was dilated, the pupillary light reflex was diminished but not absent. CTA was performed emergently to rule out intracranial aneurysm, followed by MRI, with and without contrast. In a study of 24 patients manifesting similar presentations of relative pupil-sparing oculomotor nerve palsy,(2) Jacobson reported that 10 (42%) had microvascular involvement, 10 (42%) had mass lesions (aneurysm or tumor) compressing the nerve, and 1 (4%) had carcinomatous infiltration (from primary breast cancer). These findings illustrate the importance of the provider’s certainty in non-pupil involvement when deciding to forego imaging studies, a course of action that should only be considered in patients over 50 years of age with atherosclerotic risk factors that increase the probability of microvascular involvement.(3)

When aneurysm was ruled out via imaging in this patient with a history of malignancy and immunosuppression, the differential diagnosis was narrowed to metastatic or infectious processes. As illustrated in our case, these etiologies can be differentiated by lumbar puncture and CSF analysis.