Monosymptomatic oculomotor paralyses during childhood are uncommon. One half of pediatric third nerve pa-reses are congenital, and are often associated with signs of aberrancy (synkinesis). In individual cases, the cause usu ally remains unknown. Frequently, a congenital oculomotor paralysis will have recurrent periods of spasms lasting about one minute, usually recurring with a regular frequency (cyclical oculomotor paralysis).
The most striking sign is seen at the onset of a cycle, with a vertical twitching of the ptotic upper lid. The lid then lifts and the mydriatic pupil constricts. Shortly after that, the signs will fade and disappear in an order that reverses their onset.
Acquired oculomotor pareses in childhood are mostly traumatic, the consequence of frequent migraine episodes, associated with tumors, or in the context of acute meningitis. Aneurysms as a cause of oculomotor paresis are a rarity in children. An acquired, nontraumatic paresis in a child requires an MRI study with contrast enhancement. If meningitis is suspected, a lumbar puncture is indicated. Depending on the child's age, evaluation to rule out or treat amblyopia in the affected eye is necessary
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