Third Cranial Nerve Palsy in Children

LINDA A. SCHUMACHER-FEERO, MD, K. W. YOO, MD, FERNANDO MENDIOLA SOLARI, MD, AND ALBERT W. BIGLAN, MD

PURPOSE: To report the causes and the sensory, motor, and cosmetic results after treatment for oculomotor (third cranial nerve) palsy in children. METHODS: Review of the clinical records of children with a diagnosis of third cranial nerve palsy followed up in a university-based pediatric ophthalmology practice between 1981 and 1996. RESULTS: Forty-nine children with 53 affected eyes were followed up for a mean of 5.5 years. Third cranial nerve palsy was partial in 31 children (32 eyes) and complete in 18 children (21 eyes). The palsy was congenital in 20 eyes and caused by postnatal trauma in 17 eyes. Seventeen eyes had aberrant regeneration and four eyes with partial third cranial nerve palsy had spontaneous resolution. Thirty-six children (38 eyes) were affected before visual maturation (age 8 years), and 25 (27 eyes) had amblyopia. Of the ve amblyopic eyes with quantiable visual acuity, none had measurable improvement of Snellen visual acuity during the follow-up period. Overall, visual acuity was between 6/5 and 6/12 at the last follow-up visit in 31 eyes (58%). Ocular alignment was greatly improved after strabismus procedures, with a mean of 1.5 procedures for patients with partial third cranial nerve palsy and 2.3 procedures for those with complete palsy. Binocular function was difcult to preserve or restore but was achieved for some patients with partial third cranial nerve palsy. CONCLUSIONS: Surgical treatment of third cranial nerve palsy is frequently necessary, especially in cases of complete palsy. Multiple strabismus procedures are often needed to maintain good ocular alignment. Surgery can result in cosmetically acceptable alignment of the eyes, but it rarely results in restoration or achievement of measurable binocular function. Treatment of amblyopia Accepted for publication March 29, 1999. From the Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Drs Schumacher-Ferro and Biglan); Dong A University College of Medicine, Pusan, Korea (Dr Yoo); and Department of Ophthalmology, Hospital del Nino, Lima, Peru (Dr Mendiola Solari). This study was supported in part by a grant from the Childrens Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Dr Biglan). Data from this study were presented at the International Strabismological Association Meeting, Maastricht, The Netherlands, September 11, 1998. Reprint requests to Albert W. Biglan, MD, 3518 Fifth Ave, Pittsburgh, PA 15213; fax: (412) 682-2802.

is effective in maintaining the level of visual acuity present at the onset of the third cranial nerve palsy, but improvement in visual acuity is difcult to achieve. (Am J Ophthalmol 1999;128:216 221. 1999 by Elsevier Science Inc. All rights reserved.)

HIRD CRANIAL NERVE PARESIS OR PALSY OCCURS

uncommonly in children. Miller,1 in a review of more than 3 million records at the Wilmer Eye Institute, identied only 28 patients with this condition who were younger than 20 years. Third cranial nerve palsy in children is often congenital (caused by adverse intrauterine events or a traumatic delivery) or the result of postnatal trauma, infection, or migraine.1 4 The goals of managing third cranial nerve palsy in children are to promote optimal development of visual acuity and binocular function. This requires management of diplopia and prevention of amblyopia, which may frequently develop.5 In one study, nine of 12 children with third cranial nerve palsy had amblyopia.6 In another report of 11 eyes with congenital third cranial nerve palsy, after treatment only ve eyes had a visual acuity of 6/12 or better.4 Amblyopia is challenging to manage because of paresis of the extraocular muscles, dysfunction of the levator palpebrae muscle leading to obstruction of the visual axis, and impairment of accommodation. Results after surgical procedures for strabismus are reported infrequently and usually focus on analysis of the effect achieved by a particular surgical procedure. Gottlob and associates7 treated seven children with a superior oblique transposition procedure, in whom orthotropia in primary gaze was achieved in four. Later, Biglan and Walden8 reported that ocular alignment was achieved in eight of nine patients with third cranial nerve palsy who underwent a modied Knapp procedure. One child, who was 11 years old at the time of surgery, achieved excellent fusion and stereoacuity. Specic guidelines for management and outcomes of treatment of third cranial nerve palsy in children are not available. This report reviews the course of third cranial nerve palsy in patients with partial and complete oculomotor nerve palsy, including the prevalence of amblyopia, good visual acuity, satisfactory ocular alignment, and binocular function. The effectiveness of procedures used to correct strabismus in children with partial and complete
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third cranial nerve paralysis is reviewed. Based on these results, guidelines for management of third cranial nerve palsy in children are provided.

TABLE 1. Causes of Third Cranial Nerve Palsy in 49 Children (53 Eyes)

No. of Patients (No. of Eyes)

PATIENTS AND METHODS

MEDICAL RECORDS OF PATIENTS TREATED BETWEEN 1981

Cause

Partial Palsy

Complete Palsy

Total

and 1996 by members of our university-based pediatric ophthalmology practice were reviewed to identify patients younger than 17 years with a diagnosis of third cranial nerve palsy. The patients gender, age at onset of the palsy, age at initial examination, whether palsy was complete or partial and its cause, the length of patient follow-up, and presence of aberrant regeneration were recorded. All palsies were classied as complete or partial. A palsy was considered complete if no adduction or vertical action of the superior or inferior rectus or the inferior oblique muscle was recorded, the pupil was dilated and unresponsive to light, and blepharoptosis was present. A partial palsy or paresis was characterized by limited adduction and vertical movements of the globe on ductions, a normal or dilated but responsive pupil, and a normal or ptotic eyelid. In each case, best-corrected visual acuity at initial examination and subsequent visits, the methods used to assess visual acuity (selected according to the patients age and level of cooperation or responsiveness), whether amblyopia was present, and, if so, the type and response to treatment were recorded.9 For this study, visual acuity was classied as good if best-corrected Snellen visual acuity was between 6/5 and 6/12, fair if between 6/15 and 6/30, and poor if the best-corrected visual acuity was equal to or worse than 6/60.10 Some children, because of age or mental status, could only be assessed by means of the xation response. For purposes of analysis, central and maintained xation was considered good vision, central but not maintained vision was considered fair, and inability to xate on the target was considered poor vision. The degree of ocular misalignment was assessed in young or nonresponsive patients by means of the Krimsky light reex test. In older, cooperative patients, horizontal and vertical ocular alignment were measured at 6 meters and at a third of a meter by means of the alternate prism and cover test with best optical correction in place. When strabismus surgery was performed, the procedure and alignment achieved in primary gaze at the most recent visit were recorded. Horizontal ocular alignment was considered good if it was 10 prism diopters from orthotropia in primary gaze, fair if horizontal ocular deviation was between 11 and 18 prism diopters, and poor if it was greater than 18 prism diopters. Vertical alignment was considered good if it was within 2 prism diopters of orthotropia in primary gaze, fair if between 3 and 5 prism diopters of orthotropia, and VOL. 128, NO. 2

Congenital Trauma Tumor Vascular Meningitis/encephalitis Idiopathic Total

13 (13) 7 (7) 4 (4) 3 (4) 3 (3) 1 (1) 31 (32)

7 (7) 8 (10) 2 (2) 1 (2) 0 (0) 0 (0) 18 (21)

20 (20) 15 (17) 6 (6) 4 (6) 3 (3) 1 (1) 49 (53)

poor if there was a vertical deviation of greater than 5 prism diopters of hypertropia. All strabismus procedures used have been detailed elsewhere and include horizontal rectus muscle recession/ resection procedures, the modied Knapp procedure, the Hummelsheim procedure, and superior oblique tenotomy.8,1115 Binocular function was assessed with spectacle correction in place. The Worth four-dot test was administered at 6 meters and at a third of a meter. Stereoacuity was measured with the Titmus stereoacuity test at a third of a meter.

RESULTS
A REVIEW OF MORE THAN 65,000 COMPUTER-CODED CLINI-

cal records identied 45 children who had a unilateral third cranial nerve palsy and four who had bilateral third cranial nerve palsies, for a total of 49 patients with 53 affected eyes. Seventeen patients (35%) were female. The onset of third cranial nerve palsy occurred before 8 years of age in 36 patients (38 eyes) and was congenital in 20 children (20 eyes). The mean age at onset was 59 months, with a range of birth to 198 months. The mean age at initial examination was 69.5 months, with a range of 2 weeks to 200 months. Third cranial nerve palsy was partial in 31 patients (32 eyes) and complete in the remaining 18 patients (21 eyes). The mean follow-up period was 5.5 years, with a range of 0 to 19 years. Forty patients (42 eyes) were followed up for a minimum of 6 months, and 22 patients (22 eyes) were followed up for more than 5 years. Clinical signs of aberrant regeneration were present in 17 eyes. Four patients (four eyes) with partial third cranial nerve palsies had complete spontaneous resolution within 1 to 28 months of onset. None of the eyes with complete third cranial nerve palsy showed spontaneous resolution. Third cranial nerve palsy was present at birth in 20 children (20 eyes; Table 1). Postnatal trauma was the cause of the third cranial nerve palsy in 15 patients (17 eyes).
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TABLE 2. Best-corrected Visual Acuity in 53 Eyes by Extent of Third Cranial Nerve Palsy
Initial Evaluation (No. of Eyes) Best-corrected Visual Acuity Partial Palsy (n 32) Complete Palsy (n 21) Most Recent Evaluation (No. of Eyes) Partial Palsy (n 32) Complete Palsy (n 21)

Good (6/56/12) Fair (6/156/30) Poor (6/60 or worse) Unable to assess

17 8 4 3

8 7 4 2

20 6 3 3

11 4 5 1

TABLE 3. Best-corrected Visual Acuity at Most Recent Evaluation in 53 Eyes With Third Cranial Nerve Palsy by Age at Onset
Under 8 yrs (No.) (n 38) 8 yrs and Over (No.) (n 15)

Best-corrected Visual Acuity

Good (6/56/12) Fair (6/156/30) Poor (6/60 or worse) Unable to assess

21 9 5 3

10 1 3 1

The remaining cases were caused by tumors, vascular anomalies, or infection or were idiopathic. Eight eyes had concurrent palsy of at least one other cranial nerve. These cases were caused by trauma (ve eyes), tumor (two eyes), and vascular malformation (one eye). In the six patients (six eyes) in whom third cranial nerve palsy was secondary to a tumor, four had gliomas, one had a lipobroma of the orbit, and one had a nonspecied brainstem tumor. Best-corrected visual acuity at the time of initial examination was considered good in 25 eyes (47%) (Table 2). The xation response was central, steady, and maintained in 13 of these eyes. At the most recent evaluation, 31 eyes (58%) had good best-corrected visual acuity. At the most recent evaluation, best-corrected visual acuity was good in 21 eyes (55%) of children who were visually immature at the time of onset of the third cranial nerve palsy. Among children who were 8 years of age or older at the onset of the third cranial nerve palsy, 10 eyes (67%) had good best-corrected visual acuity (Table 3). Of the 36 children (39 eyes) in whom the diagnosis of third cranial nerve palsy was made before the child was 8 years old, 25 children (27 eyes) were considered to have some degree of amblyopia. Treatment consisted of occlusion therapy for 25 eyes and spectacles alone in two patients with anisometropia. For comparison, the results of amblyopia treatment were evaluated separately for eyes whose best-corrected visual acuity was initially determined by means of the xation response (17 eyes) or measured by Snellen acuity (six eyes). Visual acuity at the initial evaluation was not obtainable for the four remaining eyes. In 17 eyes, visual acuity was determined at the initial 218 AMERICAN JOURNAL
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evaluation by means of the xation response. Eight eyes had central xation at the time of the rst visit but later developed unsteady xation, six eyes had central xation but at least a moderate preference for the uninvolved eye, and the remaining three eyes were not able to xate on a target. At the most recent evaluation of the 14 eyes that initially had central xation, ve eyes had good, two had fair, and one had poor visual acuity. Six maintained or achieved central, steady xation. For the three eyes that initially had no ability to xate, at the most recent evaluation one had fair visual acuity, one had achieved central, steady xation, and the last eye was still unable to xate on a target. In the remaining six eyes treated for amblyopia, Snellen visual acuity was measured at the initial evaluation. Patching resulted in maintenance of the best-corrected visual acuity in three eyes, but two eyes lost 1 or 2 lines of Snellen visual acuity. No follow-up was available for one eye. Among all 27 eyes treated for amblyopia, nine eyes had blepharoptosis severe enough to be considered a risk for inducing deprivation amblyopia. Conditions other than amblyopia accounting for decreased visual acuity, included optic atrophy (two eyes), an optic nerve coloboma (one eye), a macular scar (one eye), and uncorrected incyclotorsion (four eyes). Despite the multiple hindrances to attainment of good visual acuity, 16 (59%) of the 27 eyes had either good Snellen visual acuity or central and steady xation at the most recent evaluation. At the initial evaluation, horizontal alignment was good in only six (12%) of the 49 patients (Table 4). This increased to 30 patients (61%) at the most recent evaluation. The vertical alignment of the eyes was good in 24 (50%) of the 49 patients at the initial evaluation and in 35 (71%) at the most recent evaluation. Among the 31 children (32 eyes) with partial third cranial nerve palsy, 15 patients (15 eyes) did not undergo strabismus surgery. Four of these eyes had complete spontaneous resolution, and the remainder had partial recovery that made surgery unnecessary. The remaining 17 eyes underwent a mean of 1.5 surgical procedures to correct horizontal, vertical, and cyclorotatory alignment. Of the 14 eyes for which an operation for horizontal alignment was performed, the initial operation was a recession/ OPHTHALMOLOGY AUGUST 1999

TABLE 4. Ocular Alignment in 49 Children by Extent of Third Cranial Nerve Palsy

Initial Evaluation (No.) Partial Palsy (n 31) Complete Palsy (n 18) Most Recent Evaluation (No.) Partial Palsy (n 31) Complete Palsy (n 18)

Ocular Alignment

Horizontal Good (010 PD) Fair (1118 PD) Poor (18 PD) Unable to assess Vertical Good (02 PD) Fair (35 PD) Poor (5 PD) Unable to assess PD prism diopters.

5 1 19 6 14 3 11 3

1 0 14 3 10 1 4 3

20 2 4 5 20 0 5 6

10 2 4 2 15 0 2 1

resection procedure in nine eyes and a modied Knapp procedure with vertical transposition of the medial and lateral rectus muscles in ve. Four eyes required a second horizontal rectus muscle recession/resection operation. A surgical procedure to correct vertical alignment was used alone or combined with a horizontal recession/resection procedure in seven eyes. For the 17 eyes with partial third cranial nerve palsy treated with corrective strabismus surgery, the mean time from onset of the palsy to surgery was 29 months (range, 0 to 326 months). Excluding a single eye that underwent strabismus surgery more than 20 years after onset of the third cranial nerve palsy, the mean time to surgery was 12 months. The mean time to reoperation was 60 months (range, 3 to 188 months). Among the 18 patients (21 eyes) with complete third cranial nerve palsy, three patients (three eyes) did not undergo strabismus surgery. One of these eyes underwent phthisis and was enucleated, one had a complex and variable ocular motility pattern secondary to a brainstem malformation, and the last eye was in a patient with bilateral third cranial nerve palsies and a sixth cranial nerve palsy. The remaining 18 eyes underwent a mean of 2.3 alignment procedures. The initial surgical procedure to correct strabismus in 15 eyes was a recession/resection of the horizontal rectus muscles; a second such operation was required in 10 eyes and a third operation was required in ve eyes to obtain good alignment. One eye underwent four recession/resection procedures without obtaining satisfactory alignment. For three eyes the initial surgery was a modied Knapp procedure, and two of these eyes required an additional recession/resection procedure. In addition to surgery on the horizontal rectus muscles, four eyes required separate procedures for vertical alignment (one eye had a VOL. 128, NO. 2

Hummelscheim procedure). Botulinum A toxin was injected into the lateral rectus muscle in three eyes, with limited success. The mean time from onset of palsy to the initial strabismus procedure was 6 months (range, 0 to 11 months). The mean time to a subsequent alignment procedure to treat a complete third cranial nerve palsy was 23 months (range, 2 to 122 months). A fusion response at distance and at near occurred in four of the 31 patients with partial third cranial nerve palsy. Two of these children had spontaneous resolution of their third cranial nerve palsy. None of the children with a complete palsy was able to demonstrate a fusion response at 6 meters. Ten patients were unable to provide a response or were not tested. The remaining patients demonstrated suppression or diplopic responses on testing. Two (6%) of the 31 patients with partial third cranial nerve palsies had stereoacuity better than or equal to 100 seconds of arc. No patient with a complete third cranial nerve palsy was able to demonstrate stereo acuity better than 100 seconds of arc. Half of those tested had no measurable stereo acuity, including seven (22%) of the 31 children with partial third cranial nerve palsy and 11 (61%) of the 18 children with complete third cranial nerve palsies.

DISCUSSION
PALSY OF THE OCULOMOTOR NERVE IS INFREQUENTLY SEEN

in children, and guidelines for its management and outcome are difcult to nd.1113,15 This study was undertaken to examine the outcome of treatment of third cranial nerve palsy in children. Although surgical principles recommended for management of third cranial nerve palsy in adults were used, goals for treating children were to promote or maintain good visual acuity and to achieve optimal development of binocular function. The causes of third cranial nerve palsy in this study are similar to those previously reported. Palsy in this study was most frequently congenital or caused by postnatal trauma. In a series of 28 children reported by Keith,3 third cranial nerve palsy most often resulted from trauma, infection, and idiopathic causes, and in a series of 30 children studied by Miller,1 third cranial nerve palsy was most often congenital or the result of traumatic or inammatory causes. Congenital, traumatic, and infectious causes were also the most frequent causes of third cranial nerve palsy in 38 children studied by Ing and associates4 at the Hospital for Sick Children in Toronto, and Harley2 found that among children at St Christophers Hospital in Philadelphia, the most common causes of third cranial nerve palsy were congenital, traumatic, inammatory, and neoplastic. Hamed16 found that children with congenital third cranial nerve palsy had a high incidence of associated neurologic diseases. However, Kodsi and Younge17 found that of the
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35 children seen at the Mayo Clinic with third cranial nerve palsy, tumors were the single most common cause of the condition, followed by cryptogenic causes. This discrepancy may reect referral bias. In children who have onset of a third cranial nerve palsy before visual maturity, the attainment of good visual acuity may be adversely inuenced by the development of strabismic and deprivation amblyopia as well as the inability to accommodate. Exposure keratitis after blepharoptosis repair also contributes to the disappointing visual prognosis.16 Others have documented the deleterious effects of early-onset third cranial nerve palsy on visual development. Victor6 found a high prevalence of amblyopia among children with congenital third cranial nerve palsy, and the best visual acuity among his patients was 6/21 in the affected eye. Ing and associates4 also found amblyopia to be common among children with third cranial nerve palsy, but more responsive to treatment; visual acuity was 6/12 or better in ve of their 11 cases. In this series, amblyopia was prevalent, occurring in 27 eyes (71%) in children under 8 years of age. This study conrms that visual acuity is likely to be impaired in children with third cranial nerve palsy. The assessment of visual acuity at the initial examination may be difcult, especially in young children or those recovering from an acute episode of infection or trauma. In these situations, the xation response may be the only measure of visual acuity that can be obtained. Because this method was used to measure visual acuity initially in many patients younger than 8 years, it was difcult to obtain a precise quantitative assessment of change in vision from the initial to the nal evaluation. In eyes in which quantitative measures of visual acuity could be obtained, none had an improvement in best-corrected visual acuity during the follow-up period. Overall, the proportion of visually immature children with third cranial nerve palsy and amblyopia who had quantiable visual acuity better than or equal to 6/12 was the same at the nal as at the initial evaluation (50% in each case), despite efforts to improve visual acuity by treating amblyopia. The nding of no alteration in visual acuity from the initial to the nal evaluation seemed to be independent of whether third cranial nerve palsy was partial or complete (Table 2). Overall, 55% of involved eyes of children younger than 8 years at onset compared with 67% of those 8 years of age or older had a nal visual acuity of 6/12 or better (Table 3). We recommend meticulous attention to the prevention and treatment of amblyopia, recognizing that this appears to be effective in maintaining the best-corrected visual acuity but not improving it. Greater success was achieved in treating strabismus than improving visual acuity. Defects of the oculomotor nerve cause an eye to assume a hypotropic and exotropic position. Aberrant regeneration and lack of function of the inferior oblique muscle produces a complex combination of horizontal, vertical, and cyclotorsional strabismus. In this 220 AMERICAN JOURNAL
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study, only six of 49 patients had good horizontal ocular alignment at the initial evaluation and 24 had good vertical alignment. At the most recent evaluation, 30 patients had good horizontal and 35 had good vertical alignment. This success was achieved by multiple surgical procedures. During the 5.5-year follow-up period, a mean of 2.3 procedures were necessary to align the eyes with complete palsy compared with a mean of 1.5 procedures for the eyes with a partial third cranial nerve palsy that underwent surgery. These results were usually achieved by horizontal rectus muscle recession/resection procedures. The modied Knapp procedure or graded supraplacement of the horizontal rectus tendon to elevate the globe was performed along with the recession/resection in cases with hypotropia. Fifteen eyes (47%) with partial third cranial nerve palsy did not require any alignment surgery, because of either spontaneous resolution or partial recovery. After the recession/resection procedure, incyclotorsion caused by unopposed action of the superior oblique muscle was treated with procedures designed to weaken its action. Others have treated third cranial nerve palsy with transposition of the superior oblique tendon to the superior border of the medial rectus muscle.14,18,19 In this series, one eye was treated with this procedure; although the eye was centered, the diplopia and strabismus outside of primary gaze were unacceptable. The only eye in this series treated with a Hummelscheim procedure had disappointing results. This procedure can be expected to have limited success because it transfers the forces of the paretic inferior and superior rectus muscles nasally to correct exotropia. We advocate use of a large recession/resection procedure when third cranial nerve palsy is partial and unilateral, particularly when the medial rectus muscle continues to have some function. If necessary, supplemental injections of botulinum A toxin into the lateral rectus muscle help to further reduce abducting forces and temporarily improve alignment in primary gaze. However, the best results with botulinum toxin occur when the opposing muscle is functional. When third cranial nerve palsy is complete or bilateral, achieving satisfactory alignment is more problematic and requires more surgical procedures. Our preference for the initial surgery is a large horizontal rectus recession/resection procedure designed to cripple the lateral rectus muscle. An augmentative form of this procedure was also used in all of the eyes that required reoperation for horizontal alignment. Five of 11 eyes undergoing a second recession/ resection procedure required a third operation. In some patients, satisfactory alignment could not be achieved in primary gaze despite numerous surgeries. When the cause of third cranial nerve palsy in a child is unknown or there is a reasonable expectation of recovery, we recommend waiting a minimum of 6 months (mean time in this study was just under 9 months) after onset of the palsy before strabismus is surgically corrected. This delay allows time to conrm the cause of the palsy, for OPHTHALMOLOGY AUGUST 1999

recovery to occur, and for the angle of strabismus to stabilize. Aberrant regeneration may occur during this time and lead to an alteration in the surgical plan. During this waiting period, amblyopia may occur. Earlier surgical intervention may be warranted, however, when the third cranial nerve palsy is known to result from such causes as tumor resection with unequivocal and irreparable damage to the third nerve nucleus or its efferent pathways. It is ideal to promote or reestablish binocular function in children with third cranial nerve palsy. Our success in achieving this goal was poor. The probability of achieving good binocular function was notably higher for those with partial third cranial nerve palsy; children with complete palsy are unlikely to achieve either fusion at distance or high levels of stereoacuity. In young children with congenital third cranial nerve palsy, satisfactory alignment that promotes binocular function may not be accomplished before the developmental period for achievement of binocular function has passed. Nevertheless, one child in this study with a congenital third cranial nerve palsy did achieve fusion at distance and near after a single recession/ resection procedure performed at age 8 months. The ndings in this study are limited by the problems inherent in any retrospective review, including examiner bias. To decrease the inuence of this factor, patients were examined by multiple ophthalmologists throughout the follow-up period. A preprinted data recording form to standardize observations of visual acuity, alignment, refraction, and binocular function was used throughout the study period. In addition, photographs were taken of many of the children to document the degree of blepharoptosis and strabismus and were available for review. Because of the relatively short follow-up and the nature of our practice, we are unable to make statements regarding the future needs for additional surgery for ocular alignment and blepharoptosis repair during adulthood. In addition, 12 (44%) of the 27 children with amblyopia were still under the age of 8 years at their most recent visit. With continued treatment, some of these children may show an improvement in their visual acuity beyond the acuity documented at the time of the initial evaluation. This outcome would be encouraging and will require further study as these children pass the age of visual maturity. The results of this study indicate that the visual acuity present shortly after the onset of third cranial nerve palsy in children generally predicts the best-corrected visual acuity 5 or more years later and that Snellen visual acuity will be 6/12 or better in more than half of children (58% in this study). Nevertheless, we recommend persistence in administering occlusion therapy and encourage the use of spectacles, including bifocals, to prevent amblyopia. In this series, these measures were not effective in improving vision but they did prevent further decline in visual acuity. Ocular alignment can be reestablished surgically, with the limited goal that both eyes can be used to xate on VOL. 128, NO. 2

objects in primary gaze and in the reading position. The failure of the children in this study to achieve high levels of binocular function is disappointing and suggests that the benets of surgery may be more cosmetic than functional. Nevertheless, good binocular function was achieved in some children, including one child with a congenital palsy.

REFERENCES
1. Miller N. Solitary oculomotor nerve palsy in childhood. Am J Ophthalmol 1977;83:106 111. 2. Harley RD. Paralytic strabismus in children: etiologic incidence and management of the third, fourth and sixth nerve palsies. Ophthalmology 1980;87:24 43. 3. Keith CG. Oculomotor nerve palsy in childhood. Aust N Z J Ophthalmol 1987;15:181184. 4. Ing EB, Sullivan TJ, Clarke MP, Buncic JR. Oculomotor nerve palsies in children. J Pediatr Ophthalmol Strabismus 1992;29:331336. 5. Mizen TR, Burde RM, Klingele TG. Cryptogenic oculomotor nerve palsies in children. Am J Ophthalmol 1985;100:65 67. 6. Victor DI. The diagnosis of congenital unilateral third nerve palsy. Brain 1976;99:711718. 7. Gottlob I, Catalano RA, Reinecke RD. Surgical management of oculomotor nerve palsy. Am J Ophthalmol 1991; 111:7176. 8. Biglan AW, Walden PG. Results following surgical management of oculomotor nerve palsy with a modied Knapp procedure. Ophthalmic Surg 1985;16:759 764. 9. von Noorden GK. Examination of patient, III: sensory signs, symptoms and adaptations in strabismus. In: von Noorden GK, editor. Binocular vision and ocular motility: theory and management of strabismus, 5th ed. St Louis: Mosby, 1996: 216 223. 10. Biglan AW. Pediatric cataract surgery. In: Albert DM, editor. Ophthalmic surgery: principles and techniques. Malden, Massachusetts: Blackwell Science Inc, 1999:970 1014. 11. Helveston EM. Surgical management of strabismus: an atlas of strabismus surgery, 4th ed. St Louis: Mosby, 1993:502508. 12. Pratt-Johnson JA, Tillson G. Paralytic and paretic strabismus. In: Pratt-Johnson JA, Tillson G, editors. Management of strabismus and amblyopia: a practical guide. New York: Thieme Medical Publishers Inc, 1994:174 177. 13. Buncic JR. Third nerve palsy. In: Good WV, Hoyt CS, editors. Strabismus management. Boston: Butterworth-Heinemann, 1996:287295. 14. Scott AB. Transposition of the superior oblique. Am J Orthop 1977;5:1114. 15. Eggers HM. Oculomotor (third nerve) paralysis. In: Frauenfelder FT, Roy FH, Grove J, editors. Current ocular therapy 4. Philadelphia: WB Saunders Company, 1995:549 550. 16. Hamed LM. Associated neurologic and ophthalmic ndings in congenital oculomotor nerve palsy. Ophthalmology 1991; 98:708 714. 17. Kodsi SR, Younge BR. Acquired oculomotor, trochlear and abducent cranial nerve palsies in pediatric patients. Am J Ophthalmol 1992;114:568 574. 18. Metz HS, Yee D. Third nerve palsy: superior oblique transposition surgery. Ann Ophthalmol 1973;5:215218. 19. Saunders RA, Rogers GL. Superior oblique transposition for third nerve palsy. Ophthalmology 1982;89:310 315.
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