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Immediate features of paralysis

Authoring team

The acute features of oculomotor nerve palsy may include:

  • divergent strabismus:
    • the paralysed eye is rotated outwards and downwards when the normal eye fixates - due to intact actions of lateral rectus and superior oblique muscles
    • concurrent trochlear nerve palsy is indicated by absence of intorsion on attempted down-gaze

  • only lateral movement is possible

  • pupil may be fixed and dilated, and accommodation lost:
    • however the pupil is spared in 75% of cases due to diabetes since the inner pupillary fibres are more affected than the outer ones

  • ptosis of the upper eyelid - may cover the pupil due to loss of action of levator palpebrae superioris

  • ipsilateral oculomotor nerve palsy may feature as part of Benedikt or Weber syndromes

  • there may be a mild proptosis arising from loss of tone of three of the four recti muscles

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