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Clinical case: Oculomotor nerve palsy and distal myopathy

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Structure of the eyeball seen in a transverse section.

In this article, we describe a case of a woman who presented with decreased vision, pathological ophthalmoscopic examination, limb paresis, and nervous system lesions. Her final diagnosis is neurofibromatosis type 2 (which caused an oculomotor nerve palsy). Do you want to find out more about it? Stick around to see how the diagnosis was reached, the clinical presentation, and the relevant anatomy.

Key facts
Extraocular muscles Levator palpebrae superioris (elevation of the superior eyelid), superior oblique (outward and downward movement of the eye), superior rectus, medial rectus, lateral rectus, inferior rectus (movements of the eye in the four respective directions, inferior oblique (eye elevation and abduction)
Optic disc swelling An increase in fluid within or surrounding the axons of the optic nerve, seen in ophthalmoscopy.
Hydrocephalus A condition in which there is an excessive accumulation of cerebrospinal fluid (CSF) within the brain.
Tonsillar herniation A condition during which the cerebellar tonsils are displaced inferiorly through the foramen magnum, resulting in compression of the lower brainstem and upper cervical spinal cord.
Cavernous sinus contents Internal carotid artery, oculomotor never, trochlear nerve, ophthalmic nerve, maxillary nerve, abducens nerve.

After reviewing this case you should be able to describe the following:

  • The attachments, function and innervation of the extraocular muscles, especially as they relate to this case.
  • What is meant anatomically by “optic disc swelling;” The clinical significance is of this condition.
  • What is the difference between communicating and non-communicating hydrocephalus, and how they are typically differentiated radiologically.
  • What is meant anatomically by “tonsillar herniation;” the clinical significance of this condition.
  • The locations and contents of the cavernous sinus, and how compression of the sinus could result in some of the ocular signs and symptoms discussed in this case.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

  1. Case description
    1. History
    2. Physical examination
    3. Imaging
    4. Diagnosis
  2. Medical and anatomical considerations
    1. Neurofibromatosis type 2
    2. Pupil Size & Light Reflex
  3. Explanations of objectives
    1. Objectives
    2. Extraocular muscles
    3. Optic disc swelling
    4. Hydrocephalus
    5. Tonsillar herniation
    6. Cavernous sinus
  4. Sources
+ Show all

Case description


The patient was a 23-year-old Malay woman who presented with an eight-year history of drooping of her left eyelid and limited upward movement of that eye. Her right eye had a 20-year history of poor vision and progressive outward deviation. She also had progressive right lower and upper limb paresis that manifested in walking difficulties. The weakness in the upper and lower limbs initially involved the distal muscles, but currently involves both proximal and distal muscles. The patient reported that she has noticed a change in her voice, and a right-sided hearing disturbance for the past two years.

Physical examination

Upon examination, there was mild eyelid retraction in the right eye with exotropia (outward deviation) and hypertropia (upward deviation), whereas the left eye showed mild ptosis (Figure 1).

Figure 1. Photograph of the patient’s eyes showing right exotropia and hypertropia, and left ptosis.

Both pupils were normal in size. The patient had bilateral posterior subcapsular cataracts (cloudiness of posterior surface of lens) and generalized optic disc swelling, with slightly tortuous vessels (Figure 2).

Figure 2. Ophthalmoscopic images of patient showing swollen optic discs and a macular scar on right eye.

A few pedunculated cutaneous lesions were noticed over her body and scalp (Figure 3) and her right thigh had some cafe au lait spots (hyperpigmented skin regions that are usually associated with neurofibromatosis). The patient also had sensorineural deafness and right vocal cord paralysis.

Figure 3. Skin lesion.


MRI showed bilateral acoustic and trigeminal schwannomas with multiple additional tumors (Figure 4).

Figure 4. Contrast enhanced T1 MRI images (A, sagittal, B, axial, coronal) showing multiple enhancing tumors in much of the lower brain and cerebellum. There also is enhancement within the cavernous sinus (B). Also, lateral ventricles are enlarged, indicating obstructive (non-communicating) hydrocephalus (C).

There were also intraspinal lesions and peripheral nerve lesions, likely meningiomas or neurofibromas. Obstructive hydrocephalus resulting in tonsillar herniation was noted.


The patient was diagnosed with neurofibromatosis type 2 with skin, eye, and neural involvement. Craniotomy and tumor debulking by neurosurgical team were planned for this patient, but she declined treatment.

Medical and anatomical considerations

Neurofibromatosis type 2

Neurofibromatosis type 2 is an autosomal dominant disease caused by a mutation in chromosome 22 band q 11- 13.1, called the NF2 gene (neurofibromin 2), which codes for the merlin protein (moesin-ezrin-radixin-like protein). Neurofibromatosis type 2 generally presents with VIIIth nerve symptoms such as hearing loss, tinnitus, and disequilibrium due to vestibular schwannoma, meningioma, glioma, and ependymoma. Pediatric cases are generally diagnosed early by the appearance of skin-related tumors (cafe au lait spots). The most common ocular finding is subcapsular cataract, which was present in our patient. The patient in this case initially had third nerve palsy and only later developed VIIIth nerve symptoms. This is the reverse of typical cases.

Figure 5. Dissection image of the skull base structures, highlighting the cavernous sinus region.

This patient likely had an oculomotor nerve schwannoma or an expansive process in the temporal region close to the cavernous sinus that likely compressed the nerve. The latter is actually more likely than the former because her MRI showed involvement of both cavernous sinuses (Figure 4). Mass effect to the medulla within the foramen magnum (as may have occurred in this patient due to the hydrocephalus) may compress its contents, including the glossopharyngeal, vagus, and spinal root of accessory nerve. However, because of the selective and limited involvement of the recurrent laryngeal nerve in this case, hydrocephalus resulting in nerve compression seems unlikely. Rather, the authors of the case postulated that the right vocal cord palsy was due to a small schwannoma to the vagus nerve somewhere along its course or perhaps directly on the recurrent laryngeal nerve, which may not have been obvious on imaging. Furthermore, peripheral schwannomas, meningiomas, and neurofibromas may cause weakness and numbness, which can progress to hand and foot drop.

Because neurofibromatosis type 2 is an autosomal dominant disease with significant morbidity, patients with family history of neurofibromatosis type 2 should be screened to detect the disease in the early stages, before irreversible damage occurs. Early presentation and intervention, ideally before multiple cranial nerves are involved, will result in a reasonable prognosis for this condition. 

Pupil Size & Light Reflex

The limbs muscle wasting and walking difficulties suggest some of the numerous brain tumors were impinging on brain and/or spinal motor control centers (note also cerebellar involvement in Figure 4). The normal pupil size in this patient suggests that the light reflex is intact meaning that the autonomic fibers that control the pupillary muscles are functioning normally. The parasympathetic fibers that diminish the size of the pupils are part of the oculomotor nerve whereas the dilator pupillae muscle is innervated by sympathetic fibers that arise from the superior cervical ganglion and typically enter the orbit with the nasociliary branch of the ophthalmic nerve.

Finally, although the authors of this case made reasonable conclusions as to the likely compressive effects of tumors on individual nerves, the presence of multiple tumors throughout the brain and brainstem does not allow the ruling out that some of the observed signs were due to upper rather than lower motor neuron injury.

Clinical case: Oculomotor nerve palsy and distal myopathy: want to learn more about it?

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