--- title: A 60-year-old female complains of double vision when looking straight ahead description: It's Double Vision Quiz Time with Med-Challenger! image: https://challengercme.com/hubfs/image%20(64).png --- [![Med-Challenger-green-logo-1024x244](https://challengercme.com/hubfs/Med-Challenger-green-logo-1024x244.webp) ](https://challengercme.com/) - [SHOP EXAM PREP & CME ](https://challengercme.com/blog/a-60-year-old-female-complains-of-double-vision-when-looking-straight-ahead#) ### [EMERGENCY MEDICINE](https://challengercme.com/emergency-medicine-exam-review-cme-course) [ABEM exam prep](https://challengercme.com/emergency-medicine-exam-review-cme-course), [MyEMCert](https://challengercme.com/emergency-medicine-myemcert-exam-review-course), etc. ### [FAMILY MEDICINE](https://challengercme.com/family-medicine-exam-review-cme-course) [ABFM exam prep](https://challengercme.com/family-medicine-exam-review-cme-course), [ABFM KSA](https://challengercme.com/family-medicine-moc-ksa-course), etc. ### [INTERNAL MEDICINE ABIM exam prep, MOC points, etc.](https://challengercme.com/internal-medicine-exam-review-cme-course) ### [OBGYN ABOG exam prep, CREOG, etc.](https://challengercme.com/obgyn-exam-review-cme-course) ### [PEDIATRICS ABP exam prep, MOCA-PEDS, etc.](https://challengercme.com/pediatric-medicine-exam-review-cme-course) ### [PEDIATRIC EM](https://challengercme.com/pediatric-emergency-medicine-3rd-edition) [ABP/ABEM exam prep Ed.3](https://challengercme.com/pediatric-emergency-medicine-3rd-edition), [Ed.2](https://challengercme.com/pediatric-emergency-medicine-pack2), etc. ### [SPECIAL PURPOSE / SPEX FSMB exam prep, etc.](https://challengercme.com/special-purpose-exam-review-spex-exam-preparation-course) ### [PHYSICIAN ASSISTANT](https://challengercme.com/physician-assistant-exam-review-cme-course) [PANCE / PANRE](https://challengercme.com/physician-assistant-exam-review-cme-course), [CAQ-EM](https://challengercme.com/pa-caq-em-review-course), etc ### [NURSE PRACTITIONER](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course) [FNP](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course), [ENP](https://challengercme.com/emergency-nurse-practitioner-exam-review-cne-course), [AGNP](https://challengercme.com/adult-gerontology-nurse-practitioner-exam-review-cne-course), [PNCB/CPNP](https://challengercme.com/pediatric-nurse-practitioner-exam-review-cne-course), etc. ### [NURSING / NCLEX NCLEX, CNE, etc.](https://challengercme.com/nursing-certification-nclex-exam-review-cne-courses) ### [STATE-REQUIRED CME / CE State CME requirements, etc.](https://challengercme.com/state-required-cme) ### [JOINT COMMISSION CME](https://challengercme.com/stroke-center-ce-review-course) [Stroke](https://challengercme.com/stroke-center-ce-review-course), [Cardiac](https://challengercme.com/cardiac-center-ce-review-course), [Trauma](https://challengercme.com/trauma-center-ce-review-course), [ALS](https://challengercme.com/advanced-life-support-and-resuscitation-center-ce-review-course), etc. ### [PROFESSIONALISM CME Professionalism review with CME](https://challengercme.com/professionalism-review-course) ### [DERMATOLOGY CME Dermatology review with CME](https://challengercme.com/dermatology-review-course) ### [USMLE STEP 2CK / STEP 3 USMLE exam prep, etc.](https://challengercme.com/usmle-certification-exam-review-clerkship-exams-shelf-exam-review) - [INSTITUTIONS ](https://challengercme.com/atlas-pro-inst) - [BLOG ](https://challengercme.com/blog) - [SUPPORT ](https://support.challengercme.com/knowledge) [SIGN IN ](https://fuse.challengercme.com/sign-in?redirectURL=%2Fuserdash) family medicine # A 60-year-old female complains of double vision when looking straight ahead It's Double Vision Quiz Time with Med-Challenger! [ Med-Challenger ](https://challengercme.com/blog/author/med-challenger) Jan 18, 2025 [family medicine](https://challengercme.com/blog/tag/family-medicine) [Personal Education](https://challengercme.com/blog/tag/personal-education) [Question of the Week](https://challengercme.com/blog/tag/question-of-the-week) [quick quiz](https://challengercme.com/blog/tag/quick-quiz) ### < [All Posts](https://challengercme.com/blog) ABFM Exam Prep + CME Med-Challenger Family Medicine Pass-guaranteed ABFM exam review with CME built-in. Try it for free. On sale now. 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This started 10 days prior after a brief left, retro-orbital headache. The headache has since resolved. She has a history of type 2 diabetes. She has no history of any injury. Her left pupil was dilated and during normal gaze, there was a slight ptosis on the left side (not visible below) ![image (64)](https://challengercme.com/hs-fs/hubfs/image%20(64).png?width=240&height=242&name=image%20(64).png) Which of this patient's cranial nerves is malfunctioning: - Right CN III - Left CN III - Right CN VI - Left CN VI The correct answer is: Left CN III   **Educational Objective:** Identify the clinical presentation of oculomotor nerve palsy. **Key Point:** Isolated oculomotor nerve palsy may occur in patients at risk for microvascular disease, and presents with diplopia and a somewhat “down-and-out” gaze of the affected eye (intensity of the down-and-out position of the affected pupil varies; it may be nearly midline, but unable to cross the midline). **Explanation:** This patient demonstrates a left cranial nerve III (oculomotor) palsy with the eye in a lateral and down position during frontal gaze and a dilated pupil on the affected side. The oculomotor nerve innervates the medial rectus muscle (adduction), the superior rectus muscle (elevation), inferior rectus muscle (depression), and inferior oblique muscle (excytotorsion and elevation in adduction). The precipitating event could have been from pressure on the oculomotor nerve from an aneurysm. Often, however, there is no recognized event before the diploplia develops. Isolated oculomotor nerve palsy typically occurs in older patients with vascular risk factors such as diabetes and hypertension. It usually presents with diplopia and lateral gaze to the affected side, ipsilateral pupillary dilation and ptosis, and a “down and out” appearance on extra-ocular movement testing. It is important to remember that diabetic neuropathies can affect any nerve in the body, and therefore can present as an infinite number of clinical syndromes. The following photo collage (image 1) shows the effects of a right-sided CN III palsy (different from the above patient, who has a left-sided CN III) during extra-ocular movement testing: ![image (65)](https://challengercme.com/hs-fs/hubfs/image%20(65).png?width=1002&height=540&name=image%20(65).png) ![image (66)](https://challengercme.com/hs-fs/hubfs/image%20(66).png?width=1046&height=1170&name=image%20(66).png) ![image (67)](https://challengercme.com/hs-fs/hubfs/image%20(67).png?width=1322&height=980&name=image%20(67).png) **Reference:** Guluma K. “Diplopia.” Rosen’s Emergency Medicine: Concepts and Clinical Practice, 9th Ed. Elsevier 2018: 160-168.   This question appears in [Med-Challenger Family Medicine Exam Review with CME](https://challengercme.com/family-medicine-exam-review-cme-course) [Try for free and save](https://fuse.challengercme.com/fulltrial/198). Ace your exams and meet your CME/MOC requirements for just $35 a month! 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All rights reserved [Privacy Policy](https://support.challengercme.com/knowledge/what-are-your-terms-of-service-privacy-policy-user-agreement) ```json { "@context" : "https://schema.org", "@id" : "https://challengercme.com/blog#webpage", "@type" : "WebPage", "description" : "The Challenger Medical Education Blog offers informative patient cases, medical certification exam preparation courses and board exam review tips.", "inLanguage" : "en", "isPartOf" : { "@type" : "WebSite", "name" : "Med-Challenger", "url" : "https://challengercme.com/" }, "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog", "@type" : "WebPage" }, "name" : "Challenger Medical Education Blog", "primaryImageOfPage" : { "@type" : "ImageObject", "url" : "https://challengercme.com/hubfs/Webpage%20Featured%20Images/Medical%20Education%20Blog%20-%20Free%20CME%20resources%2c%20certification%20exam%20tips%2c%20clinical%20challenge%20questions%20and%20more.png" }, "publisher" : { "@type" : "Organization", "name" : "Challenger Corporation", "url" : "https://challengercme.com/" }, "url" : "https://challengercme.com/blog" } ``` ```json { "@context" : "https://schema.org", "@type" : "Article", "about" : [ "oculomotor nerve palsy", "diplopia", "cranial nerve III", "ptosis", "pupillary dilation", "diabetic microvascular neuropathy", "exam preparation", "family medicine board review" ], "articleSection" : "Medical Education", "author" : { "@type" : "Organization", "name" : "Challenger Corporation" }, "dateModified" : "2025-01-18T15:30:01.101Z", "datePublished" : "2025-01-18T15:30:00.000Z", "description" : "It's Double Vision Quiz Time with Med-Challenger! A brief clinical vignette of a 60-year-old woman with new-onset diplopia, a transient left retro-orbital headache, diabetes, left pupil dilation and mild left ptosis — used for medical education and exam preparation.", "headline" : "A 60-year-old female complains of double vision when looking straight ahead", "image" : [ { "@type" : "ImageObject", "caption" : "Extra-ocular movement testing showing CN III palsy appearance", "description" : "Photo collage demonstrating the effects of a right-sided CN III palsy on extra-ocular movement testing (article case describes a left CN III palsy)." } ], "inLanguage" : "en-US", "keywords" : [ "double vision", "diplopia", "CN III palsy", "oculomotor nerve", "diabetes", "microvascular disease", "ptosis", "down-and-out gaze", "Med-Challenger", "medical education" ], "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog/a-60-year-old-female-complains-of-double-vision-when-looking-straight-ahead", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "url" : "https://challengercme.com/logo.png" }, "name" : "Challenger Corporation" } } ``` ```json { "@context" : "https://schema.org", "@type" : "QAPage", "mainEntity" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Left cranial nerve III (oculomotor) palsy. The affected eye is lateral and down on frontal gaze, with ipsilateral pupillary dilation and ptosis, consistent with CN III dysfunction; isolated CN III palsy can occur in older patients with vascular risk factors such as diabetes." }, "name" : "Which of this patient's cranial nerves is malfunctioning?", "text" : "A 60-year-old female presents with 10 days of diplopia that began after a brief left retro-orbital headache. She has type 2 diabetes. On exam the left pupil is dilated and there is slight left ptosis; on frontal gaze the left eye is lateral and down. Which of this patient's cranial nerves is malfunctioning? (Right CN III; Left CN III; Right CN VI; Left CN VI)" } } ``` ```json { "@context" : "https://schema.org", "@type" : "ItemList", "description" : "Exam-style review questions based on this article’s teaching points.", "itemListElement" : [ { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Left cranial nerve III (oculomotor) palsy, as indicated by the left eye being lateral and down on frontal gaze with a dilated pupil and mild ptosis." }, "name" : "Which cranial nerve is affected in the vignette?" }, "position" : 1 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "The oculomotor nerve innervates the medial rectus, superior rectus, inferior rectus, and inferior oblique muscles (contributing to adduction, elevation, depression, and elevation in adduction/excyclotorsion)." }, "name" : "Which extraocular muscles are innervated by the oculomotor nerve?" }, "position" : 2 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Diplopia, a ‘down-and-out’ appearance of the affected eye on extra-ocular movement testing, ipsilateral pupillary dilation, and ptosis; presentation intensity can vary." }, "name" : "What are common clinical features of isolated oculomotor nerve palsy?" }, "position" : 3 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Older patients with vascular risk factors such as diabetes and hypertension (microvascular disease) are at risk; compression from an aneurysm is a possible precipitant though often no recognized event occurs before diplopia develops." }, "name" : "What common risk factors or causes are associated with isolated CN III palsy in this article?" }, "position" : 4 } ], "name" : "Practice Questions", "numberOfItems" : 4 } ```