Oculomotor Synkinesis Following Traumatic Head Injury

A 50-year-old woman was referred to the oculoplastics service for ptosis evaluation following severe head trauma 2 years prior. Her examination findings were classic for aberrant regeneration of the third cranial nerve—also known as oculomotor synkinesis—secondary to traumatic injury of the oculomotor nerve. In primary gaze (panel A), the patient had ptosis of the right upper eyelid due to oculomotor nerve trauma. In down gaze (panel B), there was decreased downward excursion of the right upper eyelid compared with the left upper eyelid (i.e., pseudo-Graefe sign)—a result of aberrant third cranial nerve regeneration between the inferior rectus and levator palpebrae superioris muscles. In left gaze (panel C), there was a retraction of the right upper eyelid secondary to aberrant regeneration between the medial rectus and levator palpebrae superior muscles (i.e., horizontal gaze-eyelid synkinesis). In attempted up gaze (panel D), there was adduction of the right eye (instead of supraduction) secondary to aberrant regeneration between the medial rectus and superior rectus muscles. Approximately 1 in 6 patients sustaining traumatic oculomotor nerve palsy will go on to develop oculomotor synkinesis. When it does occur, post-traumatic oculomotor synkinesis is usually noted on the scale of weeks to months following initial trauma to the oculomotor nerve. Our patient desired ptosis repair, a challenging surgery in the setting of oculomotor synkinesis. We successfully treated our patient’s traumatic neurogenic ptosis by performing levator advancement via an external approach. Müller muscle–conjunctival resection may alternatively be employed in patients with traumatic injury to the sympathetic fibers innervating Müller muscle.