• Description: Autoimmune orbital inflammation linked with thyroid dysfunction. Symptoms include proptosis, lid retraction, diplopia, and exposure keratopathy.

• Treatment: Control thyroid function, artificial tears, selenium, systemic steroids, orbital decompression, or strabismus surgery in severe cases.

• Emergency?: Yes, if optic neuropathy or corneal ulceration occurs.

• Helpful Testing: Thyroid panel blood testing, exophthalmometry.

• Differential Diagnoses: Orbital pseudotumor, orbital cellulitis, cavernous sinus disease, lymphoma.

Notes:

Werner Classification of Eye Findings in Graves: “NOSPECS”:

• No signs or symptoms

• Only signs

• Soft tissue involvement (signs and symptoms)

• Proptosis

• EOM involvement

• Corneal involvement

• Sight loss

• Description: Oculomotor nerve palsy characterized by ptosis, “down and out” eye, and dilated pupil; suggests a compressive lesion like an aneurysm.

• Treatment: Immediate neuroimaging (MRI/MRA or CT angiography); neurosurgical intervention if aneurysm is found.

• Emergency?: Yes, this is a neurosurgical emergency.

• Helpful Testing: MRI/MRA, CT angiography, blood work, neurological exam.

• Differential Diagnoses: Microvascular third nerve palsy (pupil-sparing), myasthenia gravis, orbital mass, cavernous sinus lesion.

Notes:

• Fascicular CN3 palsy can be due to Benedikt's, Nothnagel's, Claude's, and Weber's syndromes.

• Causes include subarachnoid CN3 palsy (aneurysms), trauma, or uncal herniation.

• Intracavernous CN3 palsy may be caused by various factors, associated with CN4, 5, 6 findings.

• Description: Dysfunction of the trochlear nerve causes vertical diplopia, especially when looking down, often compensated by head tilt.

• Treatment: Generally no treatment required unless due to trauma/systemic disease; prism glasses or surgery for persistent cases.

• Emergency?: No, but further investigation may be necessary for underlying causes.

• Helpful Testing: MRI/MRA, CT angiography, blood work, neurological exam. 

• Differential Diagnoses: Myasthenia gravis, third nerve palsy, skew deviation, vestibular disorders.

Notes:

Complete recovery is common with microvascular palsies. 

• Description: Abducens nerve palsy leads to horizontal diplopia, often inability to abduct one eye; potentially caused by pontine glioma in children or brainstem lesions in adults.

• Treatment: Neuroimaging (MRI) for diagnosis; potential surgery/radiation for glioma.

• Emergency?: Yes, requires urgent neuroimaging and evaluation.

• Helpful Testing: MRI/MRA, CT angiography, blood work, neurological exam. 

• Differential Diagnoses: Myasthenia gravis, Miller-Fisher syndrome, diabetes, trauma.

Notes:

Age-related causes vary significantly; microvascular palsies generally resolve within 3 months.