EXTRINSIC OCULAR MUSCULATURE PALSY: A CASE REPORT

Resumo

Introduction: The third cranial nerve (oculomotor) does the innervation of four of the six extraocular muscles responsible for the eyes movements, whereas the IV nerve (trochlear) innervates the superior oblique muscle. The oculomotor also innervates the elevator muscle of the eyelid and the muscles constrictors of the pupil and ciliary. Objective: The purpose of this case report is to show the consequences suffered by the pacient victim of cerebrovascular accident which presented only paresis of the III and IV cranial nerves. Description of the case: A 56-years-old male patient started on April 5, 2017 with vertigo and was medicated with beta-thistine and cinarizine having no improvement. It evolved with incomplete paresis of the III and IV cranial nerves, with look to the right deviation. At physical examination the patient presented good general condition, good nutrition, eupneic, afebrile, acyanotic, anicteric, hydrated; rhythmic normo-phonemic sounds in two times without blow, FC: 84 bpm, PA 130x80mmHg; universal physiological vesicular murmur without adventitious noise, FR: 18 IRPM. Neurological examination: Glasgow 15, strength V degree in the four limbs, without rhyme deviation; left ptosis, with difficulty of adduction and elevation of the left eye, left nystagmus; preserved sensitivity, other preserved eye movements, preserved visual field; absence of cerebellar signals. Surveys were performed to discover the etiology and location of the lesion. In the examination of nuclear magnetic resonance of the skull, the presence of paramedian mesencephalic hyperaurudic ischemia was detected on the left, and a mesencephalic ischemic stroke was diagnosed. The patient was maintained on a mild hyposodic diet and given ASA 100mg, clexane ® 40mg and losartan potassium 50mg if PA> or = 160 / 100mmhg. The patient was discharged on April 7, 2017 with guidelines to schedule the return to the medical clinic from Santa Casa Hospital, Campo Grande - MS. Discussion: Mesencephalic ischemic lesion that reaches cranial nerve nucleus can be difficult to diagnose. Except when there is total paralysis of the III nerve, the paresis of the extrinsic musculature will only be detected with a thorough neurological examination. The patient with third nerve injury may present mydriatic pupil and lateral deviation of the ocular globe, already in the lesion of the fourth nerve presenting with vertical diplopia.