The most important questions when confronted with an oculomotor (III) palsy are 1) Is the pupil spared? 2) Is it complete aside from pupil sparing? and 3) Is it in isolation? A “no” answer to any makes a benign, ischemic III palsy less likely.1 In the presence of a III palsy, the traditional method of testing the trochlear nerve (IV) at the bedside by asking the patient to depress the adducted eye cannot be performed. Instead, the patient should be instructed to abduct the eye and then look down; if IV is intact, there will be intorsion.2 Confirming that IV is intact in the presence of a III palsy is important because the combination of an oculomotor and trochlear palsy suggests a lesion in the cavernous sinus. A 56-year-old man presented with a complete, pupil-sparing right oculomotor palsy (video E-1). The evaluation was negative, and the palsy resolved within 1 month.
ACKNOWLEDGMENT
The author thanks Dr. Neil Miller for assistance.
Footnotes
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Disclosure: The author reports no conflicts of interest.
Series editor: Mitchell S.V. Elkind MD, MS, Section Editor
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