Managing the patient with oculomotor nerve palsy

Surgical management of oculomotor nerve palsy - a review of the literature

We aim to review the surgical management techniques available for patients with oculomotor nerve (OMN) palsy, compare and contrast the approaches and subsequent outcomes. A search of the literature was carried out to yield all papers relevant to the topic, and a wide spectrum of surgical techniques were identified. These included: muscle shortening and lengthening procedures, muscle transposition, globe fixation and ptosis surgery. Patients often require a synergistic combination of these techniques. Strabismus surgery for OMN palsy can be approached through a variety of different techniques to improve the quality of life, independence and aesthetics for the patient.

Acupuncture therapy for isolated ischemic oculomotor nerve palsy: A case report

BACKGROUND

Isolated ischemic oculomotor nerve palsy as a type of ophthalmic disease is rarely observed in clinical practice. Quality of life is frequently impacted by isolated ischemic oculomotor nerve palsy due to its lack of treatment options and long-term visual impairment. We describe an acupuncture-treated instance of isolated ischemic oculomotor paralysis.

METHODS

Acupoints including Jingming (BL 1), Chengqi (ST 1), Cuanzhu (BL 2), and Sizhukong (TE 23) on the right side, and bilateral Fengchi (GB 20), Waiguan (TE 5), Hegu (LI 4), and Zulinqi (GB 41) were selected for needling. Each treatment lasted for 30 minutes, once every other day. Acupuncture treatment was administered for a total of 11 times.

RESULTS

Acupuncture is a promising treatment option for isolated ischemic oculomotor nerve palsy.

CONCLUSIONS

Ischemic oculomotor nerve paralysis can affect the quality of life of patients. Acupuncture intervention can promote the recovery of the disease is a very effective treatment measure.

The profiles and clinical significance of extraocular muscle-expressed lncRNAs and mRNAs in oculomotor nerve palsy

Introduction

Oculomotor nerve palsy (ONP) arises from primary abnormalities in the central neural pathways that control the extraocular muscles (EOMs). Long non-coding RNAs (lncRNAs) have been found to be involved in the pathogenesis of various neuroparalytic diseases. However, little is known about the role of lncRNAs in ONP.

Methods

We collected medial rectus muscle tissue from ONP and constant exotropia (CXT) patients during strabismus surgeries for RNA sequencing analysis. Differentially expressed mRNAs and lncRNAs were revealed and included in the functional enrichment analysis. Co-expression analysis was conducted between these differentially expressed mRNAs and lncRNAs, followed by target gene prediction of differentially expressed lncRNAs. In addition, lncRNA-microRNA and lncRNA-transcription factor-mRNA interaction networks were constructed to further elaborate the pathological changes in medial rectus muscle of ONP. Furthermore, RT-qPCR was applied to further validate the expression levels of important lncRNAs and mRNAs, whose clinical significance was examined by receiver operating characteristic (ROC) curve analysis.

Results

A total of 618 differentially expressed lncRNAs and 322 differentially expressed mRNAs were identified. The up-regulated mRNAs were significantly related to cholinergic synaptic transmission (such as CHRM3 and CHRND) and the components and metabolism of extracellular matrix (such as CHI3L1 and COL19A1), while the down-regulated mRNAs were significantly correlated with the composition (such as MYH7 and MYL3) and contraction force (such as MYH7 and TNNT1) of muscle fibers. Co-expression analysis and target gene prediction revealed the strong correlation between MYH7 and NR_126491.1 as well as MYOD1 and ENST00000524479. Moreover, the differential expressions of lncRNAs (XR_001739409.1, NR_024160.1 and XR_001738373.1) and mRNAs (CDKN1A, MYOG, MYOD1, MYBPH, TMEM64, STATH, and MYL3) were validated by RT-qPCR. ROC curve analysis showed that lncRNAs (XR_001739409.1, NR_024160.1, and NR_002766.2) and mRNAs (CDKN1A, MYOG, MYOD1, MYBPH, TMEM64, and STATH) might be promising biomarkers of ONP.

Conclusions

These results may shed light on the molecular biology of EOMs of ONP, as well as the possible correlation of lncRNAs and mRNAs with clinical practice.

CD24 in Head and Neck Malignancies-An Uprising Biomarker?

INTRODUCTION

CD24 is often overexpressed in human tumors as a regulator of cell migration, invasion and proliferation. It has been associated with poor prognosis and chemoresistance in laryngeal cancer. In oral cavity tumors, it was correlated with better overall survival. In this study, we aimed to evaluate the role of CD24 in peripheral blood leukocytes (PBLs) as a potential marker for head and neck malignancies.

MATERIALS AND METHODS

CD24/CD11b expression in peripheral blood leukocytes (PBLs) of head and neck cancer patients and matched healthy controls was analyzed via flow cytometry. Tumors and healthy tissues were immune-stained for CD24 expression and the intensity of stain was ranked. Clinical data including tumor site, size, locoregional or metastatic spread, histopathological characteristics and recurrence events were analyzed.

RESULTS

CD24 expression in PBLs was significantly higher in a cohort of 101 head and neck cancer patients compared with 101 matched healthy controls (26.9 ± 12.9 vs. 22.4 ± 13.8; p = 0.02). No significant differences in CD24 levels in PBLs were found between different head and neck subsites involved with malignancy. Higher CD24 levels did not correlate with any adverse feature, i.e., perineural invasion or lymphovascular invasion, advanced T stage or regional spread. Immunohistochemistry analysis demonstrated that CD24 was highly expressed in tumor tissue in comparison to healthy surrounding tissue.

CONCLUSIONS

CD24 is a possible uprising marker for tumor identification, overexpressed in PBLs and is intensely stained in tumor tissue and pre-malignant lesions. Tumor-PBLs should be further studied.

Immediate effects of electroacupuncture in oculomotor nerve palsy following brainstem infarction: A case report

INTRODUCTION

Research has demonstrated that electroacupuncture (EA) stimulation of paralyzed muscles significantly improves nerve regeneration and functional recovery.

DESCRIPTION

An 81-year-old man with no history of diabetes mellitus or hypertension presented with a history of brainstem infarction. Initially, the patient had medial rectus palsy in the left eye and diplopia to the right in both eyes, which almost returned to normal after six sessions of EA.

METHODS

The CARE guidelines informed the case study report. The patient was diagnosed with oculomotor nerve palsy (ONP) and photographed to document ONP recovery after treatment. The selected acupuncture points and surgical methods are listed in the table.

DISCUSSION

Pharmacological treatment of oculomotor palsy is not ideal, and its long-term use has side effects. Although acupuncture is a promising treatment for ONP, existing treatments involve many acupuncture points and long cycles, resulting in poor patient compliance. We chose an innovative modality, electrical stimulation of paralyzed muscles, which may be an effective and safe complementary alternative therapy for ONP.

Identification and characterization of differentially expressed circular RNAs in extraocular muscle of oculomotor nerve palsy

BACKGROUND

Oculomotor nerve palsy (ONP) is a neuroparalytic disorder resulting in dysfunction of innervating extraocular muscles (EOMs), of which the pathological characteristics remain underexplored.

METHODS

In this study, medial rectus muscle tissue samples from four ONP patients and four constant exotropia (CXT) patients were collected for RNA sequencing. Differentially expressed circular RNAs (circRNAs) were identified and included in functional enrichment analysis, followed by interaction analysis with microRNAs and mRNAs as well as RNA binding proteins. Furthermore, RT-qPCR was used to validate the expression level of the differentially expressed circRNAs.

RESULTS

A total of 84 differentially expressed circRNAs were identified from 10,504 predicted circRNAs. Functional enrichment analysis indicated that the differentially expressed circRNAs significantly correlated with skeletal muscle contraction. In addition, interaction analyses showed that up-regulated circRNA_03628 was significantly interacted with RNA binding protein AGO2 and EIF4A3 as well as microRNA hsa-miR-188-5p and hsa-miR-4529-5p. The up-regulation of circRNA_03628 was validated by RT-qPCR, followed by further elaboration of the expression, location and clinical significance of circRNA_03628 in EOMs of ONP.

CONCLUSIONS

Our study may shed light on the role of differentially expressed circRNAs, especially circRNA_03628, in the pathological changes of EOMs in ONP.

Traumatic oculomotor nerve palsy treated with transnasal endoscopic decompression through the optic strut

Objective

To present a surgical treatment regimen of transnasal endoscopic decompression through the optic strut for traumatic oculomotor nerve palsy based on the anatomical study of the superior orbital fissure and the oculomotor nerve fissure segment.

Methods

The bone structure of the oculomotor nerve fissure segment and the important bone anatomical landmarks of the lateral wall of the sphenoidal sinus were identified on a dried skull and a cadaveric head, respectively, using a nasal endoscope, and a surgical plan was determined. Decompression was conducted on the orbital apex, the superior orbital fissure, the optic canal and the optic strut of the two patients in sequence, after which the degree and range of decompression were identified by three-dimensional (3D) computed tomography (CT).

Results

The oculomotor nerve had a close correlation with the lateral surface of the optic strut. The transnasal endoscope was employed to identify the lateral optic-carotid recess (LOCR), as well as the positions of the optic nerve, internal carotid artery (ICA), and superior orbital fissure, collectively called the "optic strut triangle". The surgical plans for decompression of the orbital apex, superior orbital fissure, optic canal, and optic strut and the necessity of optic strut drilling were determined, and the surgical procedures for safe drilling of the optic strut were elaborated. After surgery, the two patients had significantly improved symptoms, without complications. In addition, their postoperative CT showed that the medial margin of the superior orbital fissure was fully decompressed.

Conclusion

The optic strut triangle is a crucial anatomical landmark in the decompression of the oculomotor nerve, and optic strut drilling is necessary for such decompression. For patients with traumatic oculomotor nerve palsy and fractures of the medial wall of the superior orbital fissure on CT, the oculomotor nerve fissure segment can be decompressed in an effective, complete and safe manner as per the surgical plan of decompressing the orbital apex, superior orbital fissure, optic canal and optic strut in turn under a transnasal endoscope, conducive to the recovery of neurological function of patients.

Oculomotor Cranial Neuropathies: Diagnosis and Management

Ocular nerve palsies are among the most common cranial neuropathies in neurological practice. Nerves can get affected anywhere along their path from the brainstem to the orbit. There can be isolated involvement of multiple cranial nerves together. The etiologies differ according to the type of presentation. The steps toward the diagnosis need to be strategically planned and must be based on clinical localization. It is crucial to make proper localization to plan further investigations and thus treatment of the etiology. This review covers the approach toward the diagnosis, etiologies involved, and management of ocular cranial neuropathies.

Larger Than Larger: Huge Amounts of Recession-Resection Surgery for Third Nerve Palsy

PURPOSE

To describe the characteristics and management outcomes of strabismus surgery in patients with third cranial nerve palsy and identify factors associated with long-term outcomes.

METHODS

A 10-year retrospective study of patients with third cranial nerve palsy who underwent strabismus surgery was performed at Zhongshan Ophthalmic Center, Sun Yat-sen University, China, between August 2010 and January 2021. Clinical characteristics and factors associated with long-term outcomes were evaluated. Success of surgery was defined as esotropia of 15 prism diopters (PD) or less at postoperative day 1 (POD1) or any deviation of 10 PD or less at postoperative month 2 (POM2) or later.

RESULTS

A total of 91 patients were included, with a mean age of 24.02 ± 15.38 years (range: 2 to 64 years). Forty-one patients (45.1%) were diagnosed as having complete palsy. Congenital palsy accounted for 40.7% (n = 37). Mean follow-up time was 2.50 ± 1.78 years (range: 8 months to 8 years). One-step surgery was performed in 78.0% of cases (n = 71), a staging procedure in 7.7% (n = 7), and reoperations in 14.3% (n = 13). Most patients had supra-maximal recession and resection of the horizontal rectus muscle with additional techniques, including horizontal rectus transposition, superior oblique transposition, traction sutures, and fixation of the globe. The mean surgical dosage performed on the horizontal rectus muscle was 18.52 ± 5.69 mm (range: 8 to 35 mm). Success rates at postoperative month 8 (POM8) were 69.0% (49 of 71) in the one-step surgery group, 57.1% (4 of 7) in the staging surgery group, and 46.2% (6 of 13) in the reoperation group. Preoperative horizontal deviation (odds ratio [OR]: 1.07, 95% CI: 1.02 to 1.13, P = .011), horizontal deviation at POD1 (OR: 0.86, 95% CI: 0.76 to 0.97, P = .016), and horizontal deviation at POM2 (OR: 1.53, 95% CI: 1.18 to 1.98, P = .001) were associated with the outcomes at POM8. Patients with partial palsy had a higher success rate than those with complete palsy (76.0% vs 51.2%, P = .014).

CONCLUSIONS

Supra-maximal recession and resection with additional techniques yields satisfying surgical results in patients with third nerve palsy when a larger surgical dose is performed for an initial overcorrection for 15 to 25 PD at POD1. The cases with complete palsy showing a larger deviation were prone to failure. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

[Management of ptosis]

Ptosis is defined as a drooping of the upper eyelid. It often results in functional and/or aesthetic impairment. Although often benign, ptosis may be the first symptom of a life-threatening condition (carotid dissection, intracranial aneurism, generalized myasthenia). Only a rigorous, systematic and clinical examination will allow the physician to distinguish "benign ptosis" from "urgent ptosis". The history should attempt to detect a daily variation in the ptosis, suggesting myasthenia gravis. Pupillary examination should rule out myosis, which would suggest Claude Bernard-Horner's syndrome (secondary to an internal carotid dissection until proven otherwise), or mydriasis, suggesting an intracranial aneurism. Once an emergency has been ruled out, the clinical examination should assess the levator muscle strength (helpful for determining the underlying etiology) and the Bell's phenomenon (the lack of which is predictive of postoperative corneal exposure). The amount of ptosis is not related to its etiology. At the conclusion of the examination, the physician must be able to classify the ptosis as either pseudoptosis, aponeurotic ptosis, neurogenic ptosis, myogenic ptosis, or junctional ptosis (myasthenia). Except for "urgent ptosis", requiring multidisciplinary medical treatment, surgery is the mainstay of treatment. The surgical technique is based on the etiology of the ptosis, the strength of the levator muscle and the phenylephrine test.

Long term outcomes of strabismus surgery for third nerve palsy

PURPOSE

To report long-term outcomes of strabismus surgery for treatment of third nerve palsy.

METHODS

We performed a 15-year retrospective study of patients who had undergone surgery. We analyzed preoperative mean deviation (at 6 months, 1 year after surgery, and at the end of follow-up), type of surgery, and factors predicting outcomes. A final deviation <10 prism diopters (pd) was considered a good esthetic outcome, and no diplopia in the primary position at the end of follow-up was considered a good functional outcome.

RESULTS

Surgery was performed in 31 cases. Mean age was 36.27 years (women, 51.6%). Total and complete third nerve palsy was recorded in 22.6% and acquired palsy in 80.6%. Mean preoperative horizontal deviation (HD) in primary position was 40.24pd (near) and 44.29 (distance) and 14.33pd in vertical deviation (VD). Mean final HD was 8.94pd (near) and 11.35pd (distance), and mean final VD was 6.13. One surgery was performed in 68.9%. A favorable esthetic outcome was obtained in 64.5% and a successful functional outcome in 72.2%. Statistically significant differences were found between near HD (p=0.019) and distance HD (p=0.035) at 1 year compared with the end of follow-up and between VD at 6 months and 1 year after surgery (p=0.03). Mean follow-up was 6.05 years. No specific factors predicted a successful outcome.

CONCLUSIONS

Esthetic and functional results were similar. No predictors of successful outcome were identified. HD was better 1 year after surgery, and VD improved during follow-up.

Guidelines for radiographic imaging of cranial neuropathies

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Oculomotor palsy as a single presenting sign of midbrain hemorrhage

We report a case presenting with bilateral oculomotor nerve palsy (ONP) resulting from a midbrain hemorrhage. The patient visited the ophthalmological clinic due to the sudden onset of horizontal diplopia for a week. Bilateral ONP spared the left eye levator and bilateral pupils were found while the remaining results of examinations were unremarkable. Cerebral magnetic resonance imaging revealed a midbrain hemorrhage. Mono-ocular occlusion was arranged, and the patient was referred to a neurologist for further management. No further ophthalmic signs developed, but the patient became bedridden due to brainstem hemorrhage and died of aspiration pneumonia 9 months after the onset of the oculomotor signs. It is advocated that midbrain hemorrhage should be included in the differential diagnosis once diplopia develops and that careful neurological investigation of the origin of diplopia is warranted.

Transposition of Both Oblique Muscles Combined With Lateral Rectus Botulinum Toxin Injection and Globe Fixation Suture in the Treatment of Congenital Cranial Nerve III Palsy

The authors report a new technique to treat complete cranial nerve III palsy. A 15-year-old girl underwent botulinum toxin injection into the lateral rectus muscle, nasal transposition of both the superior and inferior oblique muscles to the medial rectus insertion, and absorbable suture globe fixation to the nasal orbital periosteum. Six months postoperatively, her primary position eye deviation was within 12 prism diopters of orthotropia with limitation of ductions in all directions. [J Pediatr Ophthalmol Strabismus. 2017;54:e13-e17].

Triptans and third nerve paresis: a case series of three patients

PurposeThe aim of this report is to increase awareness of a possible association between cranial nerve paresis and the use of sumatriptan in migraine sufferers, particularly in patients who have additional vascular risk factors.Patients and methodsWe describe a series of three cases where third nerve paresis developed in patients who were treated with the oral form of sumatriptan. All of the patients had a clear history of repetitive migraine headache and none of them had previous third nerve paresis.ConclusionAmong a variety of medications for the treatment of migraine, there are some drugs with vasoconstrictive effects, particularly triptans. These drugs may be a contributing factor for microvascular damage of the cranial nerves and other organs.

Isolated oculomotor nerve palsy resulting from acute traumatic tentorial subdural hematoma

Acute subdural hematoma (SDH) resulting from head trauma is a potentially life-threatening condition that requires expedient diagnosis and intervention to ensure optimal patient outcomes. Rapidly expanding or large hematomas, elevated intracranial pressure, and associated complications of brain herniation are associated with high mortality rates and poor recovery of neurological function. However, smaller bleeds (clot thickness <10 mm) or hematomas occurring in infrequent locations, such as the tentorium cerebelli, may be difficult to recognize and patients may present with unusual or subtle signs and symptoms, including isolated cranial nerve palsies. Knowledge of neuroanatomy supported by modern neuroimaging can greatly aid in recognition and diagnosis of such lesions. In this report, we present a case of isolated oculomotor nerve palsy resulting from compressive tentorial SDH following blunt head trauma, review the literature concerning similar cases, and make recommendations regarding the diagnosis of SDH in patients presenting with isolated cranial nerve palsies.

Acute isolated partial oculomotor nerve palsy due to Lyme neuroborreliosis in a 5 year old girl

Lyme neuroborreliosis is a frequent cause of facial nerve palsy in children, isolated oculomotor nerve palsy due to Borrelia-associated nervous system infection however is rarely seen. Here we report a case of isolated oculomotor nerve palsy due to a nervous system infection with Borrelia burgdorferi in childhood and restitutio in integrum after intravenous antibiotic therapy.

Superior Oblique Anterior Transposition with Horizontal Recti Recession-Resection for Total Third-Nerve Palsy

Aims. To report the results of lateral rectus muscle recession, medial rectus muscle resection, and superior oblique muscle transposition in the restoration and maintenance of ocular alignment in primary position for patients with total third-nerve palsy. Methods. The medical records of patients who underwent surgery between March 2007 and September 2011 for total third-nerve palsy were reviewed. All patients underwent a preoperative assessment, including a detailed ophthalmologic examination. Results. A total of 6 patients (age range, 14–45 years) were included. The median preoperative horizontal deviation was 67.5 Prism Diopter (PD) (interquartile range [IQR] 57.5–70) and vertical deviation was 13.5 PD (IQR 10–20). The median postoperative horizontal residual exodeviation was 8.0 PD (IQR 1–16), and the vertical deviation was 0 PD (IQR 0–4). The median correction of hypotropia following superior oblique transposition was 13.5 ± 2.9 PD (range, 10–16). All cases were vertically aligned within 5 PD. Four of the six cases were aligned within 10 PD of the horizontal deviation. Adduction and head posture were improved in all patients. All patients gained new area of binocular single vision in the primary position after the operation. Conclusion. Lateral rectus recession, medial rectus resection, and superior oblique transposition may be used to achieve satisfactory cosmetic and functional results in total third-nerve palsy.

Severe cranial neuropathies caused by falls from heights in children

PURPOSE

Falls from heights are the most common traumatic event associated with emergency department visits in children. This study investigated the incidence and clinical course of cranial neuropathies caused by falls from heights in children.

METHODS

The computerized records of a tertiary pediatric medical center were searched for all patients admitted to the emergency department in 2004-2014 with a head injury caused by falling from a height. Those with cranial neuropathies involving optic and eye-motility disturbances were identified, and their clinical, imaging, and outcome data were evaluated.

RESULTS

Of the estimated 61,968 patients who presented to the emergency department during the study period because of a fall, 18,758 (30.3 %) had head trauma. Only 12 (seven boys, five girls, average age 6.7 years) had a visual disturbance. Eight were diagnosed with traumatic optic neuropathy, one after a 6-month delay, including two with accompanying cranial nerve (CN) III injuries. Five patients had anisocoria or an abnormal pupillary response to light at presentation, one patient had CN VI paralysis and temporary vision loss, and one patient had an isolated CN III injury diagnosed on follow-up. Visual improvement varied among the patients.

CONCLUSION

Cranial neuropathies due to falls from heights are rare in children and are associated with high visual morbidity. Vision or ocular motility impairment, especially monocular vision loss, may be missed during acute intake to the emergency department, and a high index of suspicion is needed. Assessment of the pupillary response to light is essential.

Strabismus

Defining the type of strabismus creates a framework for work-up and management. Comitant esotropia is most commonly a childhood condition treated with glasses and surgery. Comitant exotropia is often a childhood condition that may require surgical correction. Microvascular disease is the most common cause of ocular cranial nerve palsies in adult patients.

A 1-Year Review of Amblyopia and Strabismus Research

PURPOSE

This current review highlights some of the literature published in the past year from April 2013 to May 2014.

DESIGN

Literature Review.

METHODS

The present review is based on an extended search for pertinent articles on amblyopia and strabismus published during the specified period.

RESULTS

Many articles are often not very comparable to one another because of a lack of randomized clinical trials with most of the studies being retrospective in nature. There is often disagreement on some terminology. Typically, the definition of binocular vision is rarely related to the tests used for evaluating it.

CONCLUSIONS

The authors conclude that adult strabismus patients seem to gain benefits from corrective surgery not only for their ocular misalignment, but also for social anxiety levels that may be associated with improvements in their quality of life and disability levels.

Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms

Pupillary dysfunction, a concerning finding in the neurologic examination of the patient with an acute traumatic brain injury often dictates the subsequent treatment paradigm. Patients were monitored closely with an infrared pupillometer, with NPi technology, for acute changes in pupillary function. NPi technology applies a scalar value to pupillary function. A retrospective chart review was performed of traumatic brain injury patients with acute unilateral pupillary dilation, admitted to Legacy Emanuel Medical Center’s NeuroTrauma Unit, Portland, OR, and followed as outpatients, between January 2012 and December 2013. Clinical exam findings of pupillary size, NPi scores, and brain Magnetic Resonance Imaging and Computed Tomography images were analyzed. Five traumatic brain injury patients were identified with unilateral pupillary dysfunction with long-term follow-up after the initial injury. Each patient was monitored closely in the trauma bay for neurological deterioration with a pupillometer and the clinical exam. Two patients underwent subsequent intracranial pressure monitoring based on a deteriorating clinical scenario, including consistent abnormal unilateral NPi scores. One patient with consistent abnormal NPi scores and an improved clinical exam did not undergo invasive interventions. Two patients showed early improvement in NPi scores correlating with the normalization of their pupillary reactivity. Anisocoria improved in all patients despite concurrent abnormal NPi scores. Magnetic Resonance Imaging and Computed Tomography imaging studies, with a focus on the third nerve, revealed focal abnormalities consistent with the clinical findings. A unilateral blown pupil and abnormal NPi score in a traumatic brain injury patient are not necessarily indicative of intracranial pressure issues, and must be correlated with the entire clinical scenario, to determine the etiology of the third nerve injury and direct potential therapeutic interventions. Early NPi score normalization suggests pupillary function may improve. We found that NPi scores, as a component of the clinical exam, provide a sensitive, noninvasive and quantitative means of following pupillary function acutely and chronically after a traumatic brain injury.