PUPIL SPARING 3RD NERVE PALSY

A 45 year old female tailor by occupation came with
c/o headache with dragging sensation in the eyeballs since 3 days

Dropping of eyelid since 1 day

Double vision in the right eye since 1day

Vomitings since 3 days



HOPI: patient was apparently asymptomatic 1 month back.then she had diminision of vision for which she went to a ophthalmologist in nalgonda, they prescribed glasses for her eyesight. Then after using them for few days she got severe headache with dragging sensation in both the eyeballs. She went to a hospital in suryapet and was prescribed by pain killers.

Then next day she developed swelling of right eye, drooping of eyelid, double vision in right eye and vomitings since 3 days which was non bilious, non projectile 



No h/o sudden onset weakness of limbs 

No h/o any dizziness



Not a k/c/o DM, HTN, TB , ASTHMA, CVA, CAD



GENERAL EXAMINATION:



patient is c/c/c

No pallor, no icterus, cyanosis, clubbing,koilonychia lymphadenopathy.



VITALS: 

Temperature: 98.6

Bp:130/90 mmhg

PR:56

RR: 20

Spo2: 99 on RA

Gcs:E4V5M6



CVS : S1 S2 heard 

RS: BAE+

P/A: soft, non tender



CNS EXAMINATION:

Speech normal

Pupils normal 



Cranial nerve -3 

Left : normal

Right: lateral rectus+

           Medial rectus -ve

           Superior rectus -ve 

           Inferior rectus -ve 

Sensory 6th intact

Other cranial nerves - intact



              

Tone : Rt Lt

          UL Normal Normal

          LL Normal Normal



Power: Rt Lt

         UL 5/5 5/5

         LL 5/5 5/5



Relfex:     

                     Rt Lt

            B - +2 +2

            T - +2 +2

            S- +2 +2

            A - +2 +2

            K - +2 +2

            

P- Flexor Flexor 



neck stiffness -ve

Gait - normal 



Investigations:
Diagnosis: pupil sparing 3rd nerve palsy



TREATMENT: 

1. IVF - NS, RL @100ml/hr

2.INJ PAN 40mg IV/OD

3.INJ CIPLOX 200mg IV/BD

4.INJ METROGYL 100ml IV/TID

5.INJ ZOFER 4mg/IV/TID

6.INJ DICLOFENAC 75mg(3cc) IM/BD

7.VITALS MONITORING 4th hrly

8.INFORM SOS



13/5/22

S- no fresh complaints

O- right eye ptosis , mild conjuctival congestion 

H/o lid swelling+, monocular diplopia, retropulsion+

Orbital movements: 

rightt eye- abduction +

Left eye- all movements +

CN-3 no right lid elevation/medial rotation

Vitals:

Temp-afebrile

PR: 65

RR: 18

BP: 100/60



CVS-s1s2+

RS - BAE+

P/A- soft, non tender



A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME



P-  

1. INJ METHYLPREDNISOLONE 1gm /IV OD IN 100ml NS

2.INJ PAN 40mg IV/OD

3VITALS MONITORING 4th hrly

4.INFORM SOS





14/5/22 day 3

S- no fresh complaints

O- right eye ptosis , chemosis resolved 

lid swelling resolved, monocular diplopia, retropulsion+

Orbital movements: 

rightt eye- abduction +

Elevation,depression,adduction,intorsion -absent

Left eye- all movements +

CN-3 no right lid elevation/medial rotation

Vitals:

Temp-afebrile

PR: 58

RR: 18

BP: 110/70



CVS-s1s2+

RS - BAE+

P/A- soft, non tender



A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME



P-  

1. INJ METHYL PREDNISOLONE 1GM in 100 ml NS OD

2.INJ PAN 40mg IV/OD

3.VITALS MONITORING 4th hrly

4.INFORM SOS
15/5/22 day 4

S- no fresh complaints

O- right eye ptosis , chemosis resolved 

lid swelling resolved

Ptosis +

Orbital movements: 

rightt eye- abduction +

Elevation,depression,adduction,intorsion -absent

Left eye- all movements +

Vitals:

Temp-afebrile

PR: 64

RR: 18

BP: 160/80



CVS-s1s2+

RS - BAE+

P/A- soft, non tender



A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME



P-  

1. INJ METHYL PREDNISOLONE 1GM in 100 ml NS OD

2.INJ PAN 40mg IV/OD

3.INJ HAI s/c acc to grbs

4.VITALS MONITORING 4th hrly

5.INFORM SOS





16/5/22 day 5

S- no fresh complaints

O- right eye ptosis , chemosis resolved 

lid swelling resolved

Ptosis +

Orbital movements: 

rightt eye- abduction +

Elevation,depression,adduction,intorsion -absent

Left eye- all movements +

Vitals:

Temp-afebrile

PR: 64

RR: 18

BP: 100/60



CVS-s1s2+

RS - BAE+

P/A- soft, non tender



A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME



P-  

1. TAB METHYL PREDNISOLONE 1MG/KG PO/OD

2.TAB PAN 40mg PO/OD

3.INJ HAI s/c acc to grbs

4.VITALS MONITORING 4th hrly

5.INFORM SOS








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