A N A T O MY

OF
T HI RD CRANI AL
NERVE

Dr.HASIKA BHIMALA
M.S.OPHTHALMOLOGY ( 1ST YR)
24-3-13
 The cranial nerves 12 in number. Are part of the peripheral nervous
system. The craniocaudal sequence of cranial nerves is as follows
• 1- Olfactory
• 2- Optic
• 3- Oculomotor
• 4- Trochlear
• 5- Trigeminal
• 6- Abducent
• 7- Facial
• 8- Vestibulocochlear
• 9- Glossopharyngeal
• 10- Vagus
• 11- Accessory
• 12- Hypoglossal
 All exit the cranial cavity through foramina or fissures. All originate from
the brain. Contain sensory, motor or both components
1- MOTOR (EFFERENT) PARTS OF
CRANIAL NERVES:
• Ar i se wi t hi n br ai n f r om gr oup of ner ve
cel l s, whi ch const i t ut e t hei r nucl ei of
or i gi n.

• They ar e connect ed wi t h cer ebr al cor t ex

by cor t i conucl ear f i br es, t hese ar i se
f r om cel l s of mot or ar eas of t he
cor t ex, descend chi ef l y i n geni cul ar par t
of i nt er nal capsul e t o br ai nst em, wher e
many but not al l cr oss t he medi an pl ane
and end by ar bor i zi ng r ound nucl ei of
or i gi n of mot or cr ani al ner ves.
 2- SENSORY (AFFERENT) CRANIAL
NERVES:
•Ar i se f r om ner ve cel l s out si de br ai n, t hese ner ve
cel l s may be
gr ouped t o f or m gangl i a on t r unks of t he ner ves, or
may be si t uat ed i n per i pher al sensor y or gans such as
t he nose, eye & ear .

•The cent r al l y di r ect ed pr ocesses of t he cel l s r un

i nt o br ai n & t her e end by ar bor i zi ng ar ound ner ve
cel l s, whi ch ar e gr ouped t o f or m t hei r nucl ei of
t er mi nat i on.

• Fi br es ar i se f r om cel l s of t hese nucl ei and,

The nucl ei of t he
cr ani al ner ves.
The
sensor y nucl ei
ar e i l l ust r at ed
on t he l ef t , and
t he mot or nucl ei
on t he r i ght .
Dorsal aspect of brain stem showing locations
of Afferent cranial N. nuclei (left) , and
Efferent cranial N.nuclei (right) , in which the
same colours have a common embryological
• Thi r d cr ani al ner ve.

• I t i s t he l ar gest of t he ocul ar mot or ner ves.

• I t cont ai ns some 15,000 axons, i ncl udi ng mot or

f i ber s and par asympat het i c mot or f i ber s.

• Ent i r el y mot or i n f unct i on.

• Suppl i es LPS and al l ext r a ocul ar muscl es

except l at er al r ect us and super i or obl i que.

• Al so suppl i es t he i nt r aocul ar muscl es namel y

sphi nct er pupi l l ae and ci l i ar y muscl e
 FUNCTIONAL COMPONENTS
• Somat i c ef f er ent component i s concer ned wi t h
t he movement s of t he eyebal l – mot or suppl y
t o muscl es der i ved f r om head myot omes-LPS,
SR,MR,I R and I O.

• Gener al vi scer al ef f er ent (par asympat het i c)

component of t he ner ve i s meant f or
accommodat i on and cont r act i on of t he pupi l –
mot or suppl y t o ci l i ar i s and sphi nct er
pupi l l ae.

• Gener al somat i c af f er ant component of t he

ner ve i s associ at ed wi t h pr opr i ocept i ve
i mpul ses f r om t he ext r aocul ar muscl es
suppl i ed by t he somat i c ef f er ent component of
OCULOMOTOR NUCLEAR COMPLEX
• Locat ed i n mi dbr ai n at t he l evel of super i or
col l i cul us, i n t he vent r omedi al par t of t he cent r al
gr ey mat t er t hat sur r ounds t he cer ebr al aqueduct .
• I t i s a l ongi t udi nal col umn of about
10mm l engt h.

 RELATIONS:

• Dorsomedial: central grey zone surrounding

aqueduct.
• Ventrolateral: medial longitudinal bundle.
• Superior: approaches floor of third ventricle.
• Inferior: continuous with trochlear nucleus
• The nucl eus of t he t hi r d cr ani al ner ve
i s l ocat ed i n t he i nf er i or
per i aqueduct al gr ay mat t er of t he
mesencephal on.

• I t i s a compl ex of bot h pai r ed and

mi dl i ne mot or cel l s.

• These cel l s ar e f ound f r om t he post er i or

commi ssur e super i or l y t o t he
pont omesencephal i c j unct i on caudal l y i n
t he dor sal mi dbr ai n.
• Cl assi cal l y, t hi s compl ex has been
descr i bed wi t h f our pai r ed subnucl ei
suppl yi ng i nner vat i on t o t he
i nf er i or , medi al , and super i or r ect us
muscl es and t o t he i nf er i or obl i que muscl e.
• Ther e i s a si ngl e caudal , dor sal mi dl i ne
nucl eus pr ovi di ng i nner vat i on t o t he
l evat or muscl e.
• I nner vat i on of t he ext r aocul ar muscl e f r om
t he pai r ed nucl ei i s i psi l at er al f or t he
i nf er i or and medi al r ect us muscl es and t he
i nf er i or obl i que muscl e.
• However , i nner vat i on of t he super i or
r ect us i s cont r al at er al .
• The mot or f i ber s t o t he super i or r ect us
decussat e wi t hi n t he t hi r d ner ve nucl eus
• I n addi t i on t o t he ext r aocul ar muscl e
mot or f i ber s, t he Edi nger -West phal
nucl ei suppl y t he par asympat het i c
pr egangl i oni c neur ons t hat pr oj ect t o
t he ci l i ar y gangl i on.
• These nucl ei ar e posi t i oned dor sal and
medi al t o t he muscl e mot or nucl ei .
• They ar e composed of t wo cel l gr oups,
a medi al unpai r ed col umn and a l at er al
pai r ed col umn.
• Al l evi dence suggest s t hat t hese
f i ber s pr oj ect i psi l at er al l y.
 OCULOMOTOR NERVE NUCLEI:
I ncl ude t wo mot or nucl ei :

 Mai n Mot or Nucl eus:

 Si t e : vent r al par t of cent r al gr ey mat t er

"sur r oundi ng t he cer ebr al aqueduct ", of
mi dbr ai n, at t he l evel of super i or col l i cul us,
cl ose t o medi an pl ane.

 Suppl y : al l ext r i nsi c muscl es of t he eye

except super i or obl i que & l at er al r ect us. The
l evat or pal pebr ae super i or i s muscl es of bot h
si des ar e suppl i ed by si ngl e cent r al gr oup of
cel l s "cent r al caudal nucl eus". The super i or
r ect us muscl e i s suppl i ed by cont r al at er al
ocul omot or nucl eus. The r emai ni ng muscl es ar e
• I t i s composed of subnucl ei suppl yi ng
i ndi vi dual ext r aocul ar muscl es as f ol l ows :

1. Dor sol at er al Nucl eus : I psi l at er al I nf er i or

Rect us
2. I nt er medi al Nucl eus : I psi l at er al I nf er i or
Obl i que
3. Vent r omedi al Nucl eus : I psi l at er al Medi al
Rect us
4. Par amedi al (Scat t er ed) Nucl eus : Cont r al at er al
Super i or Rect us
5. Caudal Cent r al Nucl eus : Bi l at er al Levat or
Pal pebr ae Super i or i s
War wi ck's ar r angement of t he I I I
cr ani al ner ve
subnucl ei , i l l ust r at i ng t he
pat t er n of mot or cel l s i n t he
br ai n st em t hat sends f i ber s t o
 Accessor y par asympat het i c (EDI NGERWESTPHAL)
nucl eus:

 Si t e : i t l i es dor sal t o t he mai n mot or nucl eus.

 Suppl y : t he axons, whi ch ar e pr egangl i oni c

accompany ot her ocul omot or f i br es t o r el ay wi t hi n
ci l i ar y gangl i on i n or bi t and suppl y sphi nct er
pupi l l ae & ci l i ar y muscl es vi a shor t ci l i ar y
ner ves.

 I t consi st s of a medi an and t wo l at er al component s.

 Per haps, t he cr ani al hal f of t he nucl eus i s
concer ned wi t h l i ght r ef l exes and t he caudal hal f
wi t h accommodat i on.
 FASCICLE
• The f asci cul ar por t i on of t he ocul omot or ner ve
descends as i t s moves vent r al l y and l at er al l y
t hr ough t he mesencephal on.

• The f asci cl es pass t hr ough t he medi al l ongi t udi nal

f asci cul us, t he r ed nucl eus, and t he medi al por t i on
of t he cer ebr al peduncl e.

• Dur i ng t he passage t hr ough t he vent r al mi dbr ai n,

t her e appear s t o be t opogr aphi c or gani zat i on of
t he f asci cl es so t hat a di vi si onal par esi s i s
possi bl e even wi t h i nt r i nsi c l esi ons.

• The ocul omot or ner ve exi t s t he br ai n st em i nt o t he

i nt er peduncul ar f ossa as a hor i zont al ar r angement
of mul t i pl e f i ber bundl es t hat r api dl y coal esce t o
 Cr oss-sect i ons of t he br ai n st em. (A) Thr ough super i or
col l i cul us, showi ng cr ani al ner ve I I I nucl ei wi t h
i nt r amedul l ar y f i ber s.
 CONNECTIONS
1. Cer ebr al cor t ex
• Mot or cor t ex (pr ecent r al gyr us) of bot h
si des t hr ough cor t i conucl ear t r act s.
• Vi sual cor t ex t hr ough t he super i or
col l i cul us and t he t act obul bar t r act .
• Fr ont al eye f i el d.
2. Nucl ei of 4t h, 6t h and 8t h cr ani al ner ves
t hr ough t he medi al l ongi t udi nal bundl e.
3. Pr et ect al nucl eus of bot h si des (f or
l i ght r ef l ex)
4. Ver t i cal and t or si onal gaze cent er s
t hr ough t he medi al l ongi t udi nal bundl e.
5. Cer ebel l um t hr ough t he vest i bul ar nucl ei .
 DEEP ORI GI N :
• The ocul omot or f i br es r un f or war ds f r om nucl ear
compl ex passi ng t hr ough MLF, t egment um, r ed nucl eus
& medi al par t of subst ant i a ni gr a, f or mi ng ser i es of
cur ves wi t h l at er al convexi t y.
• They emer ge f r om sul cus ocul omot or i us on medi al
si de of cer ebr al peduncl e.
 SUPERFI CI AL ORI GI N:
• The ner ve emer ges as 10-15 r oot l et s at sul cus
ocul omot or i us cl ose t o upper bor der of pons, near
t er mi nat i on of basi l ar ar t er y.
• As i t emer ges f r om br ai n i t i s i nvest ed by pi amat er &
l i es i n t he subar achnoi d space.
• I t passes bet ween super i or cer ebel l ar & post er i or
cer ebr al ar t er i es.
• Bet ween t he t wo ner ves i s t he post er i or per f or at ed
subst ance (f i g. N4).
 COURS E
AND

DI S T RI BUT I ON
Fasci cul ar

Basi l ar

I nt r acaver nous

I nt r aor bi t al
 The Fascicular part :
• Fasci cul us consi st s of ef f er ent
f i br es whi ch pass f r om t he t hi r d
ner ve nucl eus t hr ough t he r ed nucl eus
and t he medi al aspect of t he cer ebr al
peduncl e

• They t hen emer ge f r om t he mi dbr ai n

and pass i nt o t he i nt er pedencul ar
space
Oculomotor nerve. Axial oblique 0.8-mm-thick SSFP MR image shows the
nerve (small arrows) where it emerges from the interpeduncular cistern
(large arrow), which lies medial to the cerebellar peduncle (p).
 The Basilar part :
• St ar t s as a ser i es of 15-20 r oot l et s i n t he
i nt er peduncul ar f ossa.

• These coal ase t o f or m a l ar ge medi al and a

smal l l at er al r oot , whi ch uni t e t o f or m a
f l at t ened ner ve, whi ch get s t wi st ed br i ngi ng
t he i nf er i or f i br es super i or l y and super i or
f i ber s i nf er i or l y; and t hus t he ner ve becomes a
r ounded cor d.

• The ner ve t hen passes b/w t he post er i or

cer ebr al ar t er y and t he super i or cer ebel l ar
ar t er y and r uns f or war d i n t he i nt er peduncul ar
ci st er n ( r unni ng l at er al t o & par al l el wi t h
t he post er i or communi cat i ng ar t er y) t o r each
Maj or bl ood
vessel s and t hei r
r el at i onshi ps t o
t he ocul ar mot or
ner ves. Not e t he
passage of CN I I I
bet ween t he
super i or
cer ebel l ar ar t er y
bel ow
and post er i or
cer ebr al ar t er y
above. The
vascul ar suppl y t o
CN I I I comes f r om
br anches of f
t he post er i or
communi cat i ng
ar t er y, whi ch i s
i n cl ose
pr oxi mi t y.
Oculomotor nerve. Coronal 0.8-mm-thick SSFP MR image shows the oculomotor
nerve (white arrow) in cross section between the posterior cerebral artery (white
arrowhead) and the superior cerebellar artery (black arrowhead), which are distal
branches of the basilar artery (black arrow).
 The Intracavernous
• part : er s t he caver nous si nus by pi er ci ng t he
The ner ve ent
post er i or par t of i t s r oof on t he l at er al si de of
t he post er i or cl i noi d pr ocess.

• I t t hen descends t o t he l at er al wal l of t he

si nus, wher e i t l i es above t he t r ochl ear ner ve.

• I n t he ant er i or par t of t he caver nous si nus, t he

ner ve di vi des i nt o super i or and i nf er i or di vi si ons
whi ch ent er t he or bi t t hr ough t he mi ddl e par t of t he
super i or or bi t al f i ssur e wi t hi n t he annul us of Zi nn.

• I n t he f i ssur e, t he nasoci l i ar y ner ve l i es i n b/w

t he t wo di vi si ons, whi l e t he abducent ner ve l i es
l nt r acaver nous cour se of t he ocul ar mot or ner ves. CN I I I and CN I V r un
i n t he
l at er al wal l of t he caver nous si nus al ong wi t h CN V di vi si ons VI and
v2. CN VI r uns i n cl ose appr oxi mat i on t o t he car ot i d ar t er y wi t hi n t he
caver nous si nus i t sel f . As t he ner ves cour se t owar d t he ant er i or aspect
of t he caver nous si nus and t he super i or or bi t al f i ssur e, V1
(opht hal mi c) di vi des i nt o 3 br anches: t he l acr i mal , f r on t al , and
nasoci l i ar y ner ves. The l acr i mal and f r ont al ner ves cr oss over t he t op
of CN I I I and CN I V. CN I I I di vi des i nt o super i or and i nf e r i or
The Intraorbital part :
• I n t he or bi t , t he smal l er super i or di vi si on
ascends on t he l at er al si de of opt i c ner ve
& suppl i es t he super i or r ect us and t he LPS
.
• The l ar ger , i nf er i or di vi si on di vi des i nt o
t hr ee br anches :
1. Ner ve To The Medi al Rect us passes i nf er i or
t o t he opt i c ner ve.
2. Ner ve To I nf er i or Rect us passes downwar d
and ent er s t he muscl e on i t s upper
aspect , and
3. Ner ve To I nf er i or Obl i que (l ongest of t he
t hr ee br anches) passes i n b/w t he I R & LR
and suppl i es t he I O f r om i t s post er i or
bor der . I t gi ves of f t he mot or r oot t o t he
 CILIARY GANGLION
• Descr i pt i on : Per i pher al par asympat het i c
gangl i on and i t s const i t uent cel l s ar e
mul t i pol ar .

• Si ze : Smal l , about t he si ze of pi ns head.

• Shape & col or : Fl at & r eddi sh-gr ey.

• Si t e : Near or bi t al apex i n some l oose f at

bet ween opt i c ner ve & l at er al r ect us,
l yi ng usual l y on l at er al si de of
opht hal mi c ar t er y.
 Root s : r eci eves post er i or l y t hr ee
r oot s or r ami

Parasympathetic
(motor) root

Sympathetic
root

Sensory root
 Par asympat het i c (Mot or ) Root :

• Car r i es pr egangl i oni c par asympat het i c

f i br es whi ch ar i se f r om cel l s of
Edi nger -West phal nucl eus and r un
t hr ough ocul omot or ner ve & i t s br anch
t o i nf er i or obl i que t o r each t he
gangl i on.
• These f i br es ar e r el ayed i n t he
gangl i on and post gangl i oni c f i br es
t r avel i n t he shor t ci l i ar y ner ves.
 Sympat het i c Root :

• I s br anch f r om i nt er nal car ot i d pl exus

whi ch ent er t he or bi t t hr ough SOF and
r each t he gangl i on by ei t her : (a) j oi ni ng
i t di r ect l y,
(b) j oi ni ng t he sensor y
r oot , or
(c) t r avel vi a opht hal mi c ner ve

& i t s nasoci l i ar y br anch.

• I t consi st s of post gangl i oni c f i br es
f r om t he SCO whi ch t r aver se t he ci l i ar y
 Sensor y Root :

• cont ai ns sensor y f i br es f r om t he
eyebal l , whi ch r each t he gangl i a vi a
shor t ci l i ar y ner ves and pass t hr ough
i t wi t hout i nt er r upt i on.
• I t l eaves t he gangl i on backwar ds t o
j oi n nasoci l i ar y ner ve near t he poi nt
wher e t hat ner ve ent er s t he or bi t .
Br anches:
• These ar e t he shor t ci l i ar y ner ves, 8-10
del i cat e f i l ament s whi ch emer ge f r om t he
gangl i on.

• They r un f or war ds i n wavy cour se i n

company wi t h shor t ci l i ar y ar t er i es,
above and bel ow t he opt i c ner ve.

• They subdi vi de i nt o 15-20 br anches

whi ch pi er ce scl er a ar ound opt i c ner ve
and pass f or war ds i n del i cat e gr ooves on
• They car r y:

1. Par asympat het i c f i br es: suppl y sphi nct er

pupi l l ae & ci l i ar y muscl es (mor e t han 95%
of t hese f i br es ar e di st r i but ed t o
ci l i ar y muscl e whi ch i s much l ar ger i n
vol ume).

2. Sympat het i c f i br es: di st r i but ed t o bl ood

vessel s of eyebal l and may i ncl ude t he
f i br es whi ch suppl y t he di l at or pupi l l ae
when t hese f i br es do not f ol l ow t hei r
usual cour se i n t he
opht hal mi c, nasoci l i ar y and l ong ci l i ar y
ner ves.
 BLOOD SUPPLY
• The bl ood suppl y t o t he medi al aspect of t he
br ai nst em i s f r om vessel s di r ect l y of f t he Basi l ar
ar t er y.

• Smal l per f or at or s of f ci r cumf l ex ar t er i es (post er i or

cer ebr al , super i or cer ebel l ar ar t er y) may al so suppl y
t he f asci cul ar por t i on of t he t hi r d ner ve as i t
cour ses t hr ough t he vent r al mi dbr ai n.

• The vascul ar suppl y of 3r d ner ve i n subar achnoi d space

i s vi a vascul ar t wi gs f r om t he post . Cer ebr al A., t he
sup. Cer ebel l ar A., and t he t ent or i al and dor sal
meni ngeal br anches of t he meni ngohypophyseal t r unk of
t he I CA.

• I n t he caver nous si nus, t he t ent or i al , dor sal

meni ngeal , and i nf er i or hypophyseal br anches of t he
meni ngohypophyseal t r unk suppl y t he ner ve al ong wi t h
• Al l ner ves ar e suppl i ed wi t h bl ood f r om adj acent vessel s, whi ch ar e
usual l y smal l and var i abl e.

• Such a nut r i ent ar t er y di vi des i nt o ascendi ng and descendi ng

br anches whi ch anast omose i n t he epi neur i um wi t h si mi l ar br anches
f r om ot her s.

• Fr om t hese epi neur al vessel s f i ne br anches penet r at e i nt o t he

per i neur i um, wi t h f ur t her anast omoses, and t hei r t er mi nal
ar t er i ol es ent er f asci cul i t o f or m r i ch l ongi t udi nal capi l l ar y
pl exuses al ong t he f ul l l engt h of t he ner ve.

• These ar e r ei nf or ced by ot her nut r i ent ar t er i es, but no par t of

t he i nt r af asci cul ar pl exus i s domi nat ed by any one ar t er y.

• The bl ood suppl y of t he ocul omot or , t r ochl ear and abducent ner ves
i s si mi l ar l y ar r anged, t he nut r i ent ar t er i es bei ng der i ved f r om any
adj acent smal l er ar t er i es.
CLINICALLY APPLIED
ASPECTS
 ANATOMICAL BASIS OF CLINICAL
FEATURES OF THIRD NERVE PALSY
• A compl et e & a t ot al t hi r d ner ve
pal sy i s of common occur r ence.

• May be congeni t al or acqui r ed.

• Cl i ni cal f eat ur es of compl et e t hi r d

ner ve pal sy i ncl ude :
(b) complete left ptosis;
(a)after manual elevation of
upper left eyelid, we can
observe left exotropia and
hypotropia, and mid-dilated
pupil.
1. Pt osi s - par al ysi s of LPS muscl e.
2. Devi at i on – out , down and i nt or t ed – unopposed
act i on of LR and SO.
3. Ocul ar movement s :
• Adduct i on – MR
• El evat i on – SR and I O
• Depr essi on – I R
• Ext or si on – I R and I O
4. Pupi l i s f i xed and di l at ed – par al ysi s of
sphi nct er pupi l l ae muscl e.
5. Accommodat i on i s compl et el y l ost – par al ysi s of
ci l i ar y muscl e.
6. Cr ossed di pl opi a – par al yt i c
di ver gent squi nt .

7. Head post ur e – i f t he pupi l l ar y ar ea

i s uncover ed, head t akes a post ur e
consi st ent wi t h t he di r ect i ons of
act i ons of t he par al ysed muscl es, i .e.,
head i s t ur ned on t he opposi t e si de,
t i l t ed t owar ds t he same si de and chi n
i s sl i ght l y r ai sed.
 FEATURES AND CAUSES OF THIRD
NERVE LESIONS AT VARIOUS LEVELS
1. Supr anucl ear l esi ons

• Lesi ons of t he cer ebr al cor t ex and

supr anucl ear pat hway pr oduce
conj ugat e par esi s whi ch af f ect bot h
eyes equal l y.
• I n supr anucl ear l esi ons al t hough
posi t i on and movement s of t he eyes
ar e abnor mal , t hey mai nt ai n t hei r
r el at i ve co-or di nat i on and pr oduce
no di pl opi a
2. Nucl ear l esi ons

• Lesi ons i nvol vi ng pur el y t he t hi r d ner ve

nucl eus ar e r el at i vel y uncommon.

• Common causes i ncl ude ; vascul ar

di seases, demyel i nat i on, pr i mar y t umor s and
met ast asi s

• Lesi ons i nvol vi ng ent i r e nucl eus cause an

i psi l at er al t hi r d ner ve pal sy wi t h i psi l at er al
spar i ng and cont r al at er al weakness of
el evat i on.

• Lesi ons i nvol vi ng pai r ed medi al r ect us

subnucl ei (vent r omedi al nucl eus) cause a wal l -
eyed bi l at er al i nt er nucl ear opht hal mopl egi a (
 3. Fasci cul ar l esi ons
• Causes are similar to nuclear lesions.
 Benedikt syndrome involves the fasciculus as it passes
through the red nucleus and is characterised by ipsilateral 3rd
nerve palsy and contralateral extrapyramidal signs such as
hemitremor.

 Weber syndrome involves the fasciculus as it passes through

the cerebral peduncle and is characterised by ipsilateral 3rd
nerve palsy and contralateral hemiparesis.

 Nothangel syndrome involves the fasciculus and the superior

cerebellar peduncle and is characterised by ipsilateral 3rd
nerve palsy and cerebellar ataxia.

 Claude syndrome is a combination of Benedikt and Nothangel

syndromes
Lesion in cerebral peduncle , Weber Syndrome (B)

Lesion in red nucleus , Benedikt Syndrome (C)

4. Lesi ons i nvol vi ng basi l ar par t of t he
ner ve
• As t he ner ve r uns i n t he subar achnoi d space
at t he base of skul l unaccompani ed by any
ot her cr ani al ner ve, i sol at ed t hi r d ner ve
pal si es ar e f r equent l y basi l ar .
• Causes :
1. Aneur ysms at t he post er i or communi cat i ng
ar t er y cause i sol at ed t hi r d ner ve pal sy
wi t h i nvol vement of pupi l .
2. Ext r adur al hemat omas whi ch may cause
t ent or i al pr essur e cone wi t h downwar d
her ni at i on of t he t empor al l obe. Thi s
compr esses t he t hi r d ner ve as i t passes
over t he t ent or i al edge. I ni t i al l y t her e
occur s f i xed, di l at ed pupi l , whi ch i s
f ol l owed by a t ot al t hi r d ner ve pal sy.
rd
5. Lesi ons i nvol vi ng i nt r acaver nous par t of
t he ner ve

• Because of i t s cl ose pr oxi mi t y t o

ot her cr ani al ner ves, i nt r acaver nous
3r d ner ve pal si es ar e usual l y assoc.
wi t h i nv. of t he 4t h and 6t h ner ves, and
t he 1st di vi si on of t r i gemi nal ner ve.

• I n i nt r acaver nous 3r d ner ve

pal sy, pupi l i s spar ed.
Somet i mes, pupi l may be const r i ct ed
owi ng t o i nv of sympat het i cs.
• Causes :

1. Di abet es may cause vascul ar pal sy.

2. Pi t ui t ar y apopl exy – may cause a t hi r d
ner ve pal sy as a r esul t of hemor r hagi c
i nf ar ct i on of a pi t ui t ar y adenoma
(af t er chi l d bi r t h), wi t h l at er al
ext ensi on i nt o caver nous si nus.
3. I nt r acaver nous l esi ons –
aneur ysms, meni ngi omas, car ot i d-
caver nous f i st ul ae and Tol osa-Hunt
syndr ome (gr anul omat ous i nf l ammat i on)
6. Lesi ons of t he i nt r aor bi t al par t
of t he ner ve

• May cause i sol at ed ext r aocul ar muscl e

pal si es or may i nvol ve ei t her
super i or di vi si on or i nf er i or
di vi si on or bot h.

• Causes : or bi t al t umor s, pseudot umor s,

t r auma and vascul ar di seases.
7. Lesi ons of pupi l l omot or f i br es

• B/w t he br ai nst em and t he caver nous

si nus, pupi l l omot or f i br es ar e l ocat ed
super f i ci al l y i n t he super i or medi an
quadr ant of t he ner ve.

• They der i ve t he bl ood suppl y f r om t he

pi al bl ood vessel s wher eas t he mai n
t r unk of t he 3r d ner ve i s suppl i ed by
vasa ner vor um.
• Sur gi cal l esi ons such as aneur ysms,
t r auma and uncal her ni at i on
char act er i st i cal l y i nv t he pupi l by
compr essi ng t he pi al bl ood vessel s and
t he super f i ci al l y l ocat ed pupi l l ar y
f i br es.

• Medi cal l esi ons such as di abet es and

hyper t ensi on usual l y spar e t he pupi l .
Thi s i s because t he mi cr oangi opat hy
assoc. wi t h t hese di seases i nvol ves
t he vasa ner vor um, causi ng i nf ar ct i on
of t he mai n t r unk, but spar i ng t he
 CAUSES OF ISOLATED THIRD
NERVE PALSY
1. I di opat hi c - I n about 25% cases
2. Vascul ar di seases – di abet es and HTN, i s
t he most common cause of pupi l -spar i ng
3r d ner ve pal sy. I n most cases
spont aneous r ecover y occur s wi t hi n 3
mont hs. Di abet i c 3r d ner ve pal sy i s of t en
assoc. wi t h per i or bi t al pai n and may
occasi onal l y be t he pr esent i ng f eat ur e
of di abet es. The pr esence of pai n i s
t her ef or e not hel pf ul i n di f f er ent i at i ng
rd
3. Aneur ysm of t he PCA at i t s j n wi t h t he
I CA i s ver y i mp cause of i sol at ed
pai nf ul 3r d ner ve pal sy wi t h
i nvol vement of pupi l .

4. Tr auma, bot h di r ect and secondar y t o

subdur al hemat oma wi t h uncal
her ni at i on, i s al so a common cause.

5. Mi scel l aneous. Ot her r ar e causes

i ncl ude t umor s, vascul i t i s assoc. wi t h
col l agen vascul ar di sor der s, syphi l i s
T HA NK Y OU
..