Ocular Motor Mononeuropathies in Diabetes Mellitus: A Brief
                    Review

Dimitrios Pantazopoulos; Evanthia Gouveri; Dimitrios Papazoglou; Nikolaos Papanas

doi:10.1055/a-2463-7075

Experimental and Clinical Endocrinology & Diabetes, Table of Contents

Exp Clin Endocrinol Diabetes 2025; 133(02): 73-77
DOI: 10.1055/a-2463-7075

Mini-Review

Ocular Motor Mononeuropathies in Diabetes Mellitus: A Brief Review

Authors

Dimitrios Pantazopoulos

¹Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece (Ringgold ID: RIN112220)
Evanthia Gouveri

¹Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece (Ringgold ID: RIN112220)
Dimitrios Papazoglou

¹Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece (Ringgold ID: RIN112220)
Nikolaos Papanas

¹Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece (Ringgold ID: RIN112220)

Abstract

Ocular motor mononeuropathies affect cranial nerves III, IV and VI and are more frequent in diabetes mellitus, with oculomotor nerve involvement being predominant. This narrative brief review discusses the clinical manifestations, diagnosis and management of ocular motor mononeuropathies in subjects with diabetes. Clinical manifestations often include ptosis, diplopia, and periorbital pain. Pupillary sparing is a characteristic of third nerve palsy. Differential diagnosis may be challenging due to overlapping symptoms with nerve palsies of other aetiologies. Treatment includes optimised glycaemic control and management of vascular risk factors. Neuroprotective agents, mainly alpha-lipoic acid and botulinum toxin A have been occasionally used, as well. Spontaneous recovery is seen in many cases.

Keywords

cranial nerve - diabetes mellitus - diabetic neuropathy - mononeuropathy - oculomotor

Full Text

References

References
1 Feldman EL, Callaghan BC, Pop-Busui R. et al. Diabetic neuropathy. Nat Rev Dis Primers 2019; 5: 41
2 Stamatiou I, Papachristou S, Papanas N. Diabetes mellitus and Bell’s palsy. Curr Diabetes Rev 2023; 19: e080322201913
3 Watanabe K, Hagura R, Akanuma Y. et al. Characteristics of cranial nerve palsies in diabetic patients. Diabetes Res Clin Pract 1990; 10: 19-27
4 Boulton AJ, Arezzo JC, Lamik RA. et al. Diabetic somatic neuropathies. Diabetes Care 2004; 27: 1458-1486
5 Modi P, Arsiwalla T. Cranial Nerve III Palsy. In: StatPearls. Treasure island (FL): StatPearls Publishing; 2023
6 Smith BE. Focal and entrapment neuropathies. Handb Clin Neurol 2014; 126: 31-43
7 Abdelhady A, Patel BC. Anatomy, Head and Neck: Eye Superior Tarsal Muscle (Muller Muscle). In: StatPearls. Treasure island (FL): StatPearls Publishing; September 12 2022
8 Khanam S, Sood G. Trochlear nerve palsy. In: StatPearls. Treasure island (FL): StatPearls Publishing; February 27 2023
9 Graham C, Gurnani B, Mohseni M. Abducens nerve palsy. In: StatPearls. Treasure island (FL): StatPearls Publishing; August 24 2023
10 Hanewinckel R, Ikram MA, Van Doorn PA. Peripheral neuropathies. Handb Clin Neurol 2016; 138: 263-282
11 AlZailaie AK, Aseeri AM, Algahtany AM. et al. Prevalence of and risk factors for cranial neuropathy in diabetic and non-diabetic patients. Eur Rev Med Pharmacol Sci 2023; 27: 4990-4997
12 Greco D, Gambina F, Pisciotta M. et al. Clinical characteristics and associated comorbidities in diabetic patients with cranial nerve palsies. J Endocrinol Invest 2012; 35: 146-149
13 Al Kahtani ES, Khandekar R, Al-Rubeaan K. et al. Assessment of the prevalence and risk factors of ophthalmoplegia among diabetic patients in a large national diabetes registry cohort. BMC Ophthalmol 2016; 16: 118
14 Hörner R, Kassubek J, Dreyhaupt J. et al. The spectrum and differential diagnosis of acquired ocular motor nerve palsies: A clinical study of 502 patients. J Neurol 2022; 269: 2140-2148
15 Zhao B, Bhatti MT, Fang C. et al. Vascular risk factors in isolated microvascular ischemic third nerve palsy: A population-based study. J Neuroophthalmol 2023; 43: 248-253
16 Patel SV, Mutyala S, Leske DA. et al. Incidence, associations, and evaluation of sixth nerve palsy using a population-based method. Ophthalmology 2004; 111: 369-375
17 Keane JR. Third nerve palsy: Analysis of 1400 personally-examined inpatients. Can J Neurol Sci 2010; 37: 662-670
18 Billerot E, Nguyen TH, Sedira N. et al. Ocular motor nerve palsy in patients with diabetes: High-resolution MR imaging of nerve enhancement. J Fr Ophtalmol 2023; 46: 726-736
19 Patel SV, Holmes JM, Hodge DO. et al. Diabetes and hypertension in isolated sixth nerve palsy: A population-based study. Ophthalmology 2005; 112: 760-763
20 Lajmi H, Hmaied W, Ben Jalel W. et al. Oculomotor palsy in diabetics. J Fr Ophtalmol 2018; 41: 45-49
21 Bell DSH. Diabetic mononeuropathies and diabetic amyotrophy. Diabetes Ther 2022; 13: 1715-1722
22 Wilker SC, Rucker JC, Newman NJ. et al. Pain in ischaemic ocular motor cranial nerve palsies. Br J Ophthalmol 2009; 93: 1657-1659
23 Acaroglu G, Akinci A, Zilelioglu O. Retinopathy in patients with diabetic ophthalmoplegia. Ophthalmologica 2008; 222: 225-228
24 Samakidou G, Eleftheriadou I, Tentolouris A. et al. Rare diabetic neuropathies: It is not only distal symmetrical polyneuropathy. Diabetes Res Clin Pract 2021; 177: 108932
25 Chen H, Wang X, Yao S. et al. The aetiologies of unilateral oculomotor nerve palsy: A clinical analysis on 121 patients. Somatosens Mot Res 2019; 36: 102-108
26 Jacobson DM. Pupil involvement in patients with diabetes-associated oculomotor nerve palsy. Arch Ophthalmol 1998; 116: 723-727
27 Smith BE. Focal and entrapment neuropathies. Handb Clin Neurol 2014; 126: 31-43
28 Dhume KU, Paul KE. Incidence of pupillary involvement, course of anisocoria and ophthalmoplegia in diabetic oculomotor nerve palsy. Indian J Ophthalmol 2013; 61: 13-17
29 Meliksetyan G, Bourdain F, Rodesch G. et al. Pupilsparing painful oculomotor neuropathy due to a caroticocavernous aneurysm. Rev Neurol 2006; 162: 378-381
30 Motoyama Y, Nonaka J, Hironaka Y. et al. Pupil-sparing oculomotor nerve palsy caused by upward compression of a large posterior communicating artery aneurysm. Case report. Neurol Med Chir 2012; 52: 202-205
31 Hegde V, Coutinho CM, Mitchell JD. Dissection of the intracranial internal carotid artery producing isolated oculomotor nerve palsy with sparing of pupil. Acta Neurol Scand 2002; 105: 330-332
32 Yang HK, Kim JH, Hwang J-M. Teaching neuroimages: pupil-sparing oculomotor nerve palsy with posterior communicating artery aneurysm. Neurology 2020; 95: e1443-e1444
33 Chou PY, Wu KH, Huang P. Ptosis as the only manifestation of diabetic superior division oculomotor nerve palsy: A case report. Medicine 2017; 96: e8739
34 Chauhan S, Sachdev A, Bali J. et al. Simulataneous bilateral occulomotor nerve paralysis: An unusual manifestation of diabetes mellitus. Singapore Med J 2006; 47: 1006-1007
35 Erdal Y, Gunes T, Emre U. Isolated abducens nerve palsy: Comparison of microvascular and other causes. North Clin Istanb 2022; 9: 353-357
36 Trigler L, Siatkowski RM, Oster AS. et al. Retinopathy in patients with diabetic ophthalmoplegia. Ophthalmology 2003; 110: 1545-1550
37 Morillon P, Bremner F. Trochlear nerve palsy. Br J Hosp Med 2017; 78: C38-C40
38 Said G. Diabetic neuropathy--a review. Nat Clin Pract Neurol 2007; 3: 331-340
39 Papanas N, Heliopoulos I, Piperidou H. et al. Simultaneous, painless, homolateral oculomotor and trochlear nerve palsies in a patient with type 2 diabetes mellitus. Neuropathy or brainstem infarction?. Acta Diabetol 2006; 43: 19-21
40 Hoi CP, Chen YT, Fuh JL. et al. Increased risk of stroke in patients with isolated third, fourth, or sixth cranial nerve palsies: A nationwide cohort study. Cerebrovasc Dis 2016; 41: 273-282
41 Park SJ, Yang HK, Byun SJ. et al. Risk of ischemic stroke after third, fourth, and sixth cranial nerve palsies in type 2 diabetes. J Diabetes 2019; 11: 379-385
42 Chou KL, Galetta SL, Liu GT. et al. Acute ocular motor mononeuropathies: Prospective study of the roles of neuroimaging and clinical assessment. J Neurol Sci 2004; 219: 35-39
43 Tamhankar MA, Biousse V, Ying GS. et al. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: A prospective study. Ophthalmology 2013; 120: 2264-2269
44 Venkatesan PE, Gnanashanmugam G, Parimalam N. et al. Diabetes plus third nerve palsy not always diabetic third nerve palsy. J Postgrad Med 2015; 61: 50-52
45 Chakraborty PP, Patra S, Barman H. et al. Cranial neuropathies in uncontrolled diabetes: May not always be due to diabetic microangiopathy. BMJ Case Rep 2017; 2017: bcr2017220054
46 Khaku A, Patel V, Zacharia T. et al. Guidelines for radiographic imaging of cranial neuropathies. Ear Nose Throat J 2017; 96: E23-E39
47 Yanovitch T, Buckley E. Diagnosis and management of third nerve palsy. Curr Opin Ophthalmol 2007; 18: 373-378
48 Raza HK, Chen H, Chansysouphanthong T. et al. The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature. Somatosens Mot Res 2018; 35: 229-239
49 Ziegler D, Papanas N, Schnell O. et al. Current concepts in the management of diabetic polyneuropathy. J Diabetes Investig 2021; 12: 464-475
50 Stino AM, Rumora AE, Kim B. et al. Evolving concepts on the role of dyslipidemia, bioenergetics, and inflammation in the pathogenesis and treatment of diabetic peripheral neuropathy. J Peripher Nerv Syst 2020; 25: 76-84
51 Feldman EL, Callaghan BC, Pop-Busui R. et al. Diabetic neuropathy. Nat Rev Dis Primers 2019; 5: 41
52 Cernea S, Raz I. Management of diabetic neuropathy. Metabolism 2021; 123: 154867
53 Tankova T, Cherninkova S, Koev D. Treatment for diabetic mononeuropathy with alpha-lipoic acid. Int J Clin Pract 2005; 59: 645-650
54 Ganesh S, Anilkumar SE, Narendran K. Botulinum toxin A in the early treatment of sixth nerve palsy in type 2 diabetes. Indian J Ophthalmol 2019; 67: 1133-1136
55 Stamatiou I, Ntoga M, Papanas N. Peroneal nerve entrapment in diabetes mellitus. Exp Clin Endocrinol Diabetes. 2024 Jul 25. Online ahead of print.
56 Apergi K, Papanas N. Dietary and nutritional supplementation for painful diabetic neuropathy: A narrative review. Exp Clin Endocrinol Diabetes 2023; 131: 646-655