At the 2025 American Academy of Optometry annual meeting, Anne Tasaki, OD, FAAO, and Jennifer Fisher, OD, FAAO, FOVDR, presented “Congenital Cranial Nerve Palsy Impersonators: A Diagnostic Challenge,” highlighting the importance of distinguishing true cranial nerve palsies from their many mimickers in children. The lecture occurred October 8.
Classic Features
True cranial nerve palsies (III, IV, VI) are rare in pediatric patients—just 7.6 per 100,000—but their clinical presentations can be deceptive. In fact, during this lecture, Dr. Fisher reviewed the classic features of pediatric third, fourth, and sixth nerve palsies, stressing the importance of neuroimaging when etiology is unclear or when multiple cranial nerves are involved. She also noted that congenital cases often present with distinctive compensatory head postures or aberrant regeneration patterns.
Common Masqueraders
Meanwhile, Dr. Tasaki focused on common masqueraders, including Brown syndrome, Duane syndrome, Mobius syndrome, Marcus Gunn jaw-winking syndrome, and congenital fibrosis of the extraocular muscles.
Specifically, through case examples, she demonstrated how versions, ductions, and careful motility assessment can help differentiate mechanical or dysinnervation disorders from neurogenic palsy.
Case in Point
One highlighted case showed Duane syndrome mimicking sixth-nerve palsy, and a third highlighted Marcus Gunn jaw-winking syndrome, which can be confused with third-nerve palsy but carries a high risk of amblyopia.
The presenters emphasized that optometrists are often the first to detect these conditions. Specifically, careful examination, awareness of systemic associations, and prompt referral when sudden or progressive symptoms occur are essential for protecting pediatric visual outcomes.
"Cranial nerve palsy impersonators can closely mimic true neuropathies, posing a diagnostic challenge,” Dr. Fisher told Optometric Management. “For optometrists, recognizing these masqueraders is critical for appropriate management and timely referral." OM