What Causes Muscle Paralysis After An Accident?

Brief Answer:
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Detailed Answer:
I read your question carefully and I understand your concern. I also read your last couple of exchanges.

I am afraid there are a couple of things which are hard to explain:

It is unclear who stated there was a paresis of those three nerves, if it was a neurologist noticing that, how can he say it's not neurological....or do you mean to say he says he doesn't notice a paresis at all, but that you believe that to be the case?
Also the 3, 4 and 6 on which side.
What type of diplopia, is it horizontal (seeing one object as two objects side by side) or vertical (one upon the other).
Also what about the pupils, were they equal in size and responsive to light (it is important to know as pupil size is related to 3rd cranial nerve)?
Is there any other symptom, involvement of other cranial nerves.
How was the symptom onset, abrupt or gradual.
Have they been constant, or constantly progressive or fluctuate (if fluctuating during the day, more marked in the evening?)
Any other conditions apart from the mentioned ones such as diabetes, thyroid dysfunction?

I agree with Dr Misra, but with the limited info at his disposal he could only conclude there was diplopia due to muscle paresis and I guess you knew that yourself.

As for whether symptoms can manifest months later after a trauma that is unlikely, usually manifest rightaway.

I remain at your disposal for other questions possibly with the above mentioned information.

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Brief Answer:
Diabetes is a probable cause

Detailed Answer:
Thank you for that additional information. I am still not clear who said that there was involvement of all 3 nerves and on which side. It is not common for them to be affected all at the same time, usually it's one of them. If all seem to be affected and on both sides I would consider a neuromuscular disorder like myasthenia gravis as a possible cause.

If the bony spurs are in the outer margins of the orbit then they shouldn't cause nerve compression. Even if they were more inwardly still compression would have been evidenced by the MRI that you mention to have had.

Generally speaking when faced with a normal MRI which doesn't show brainstem lesions or traumatic compression a peripheral disorder or metabolic disorder is considered. As I said myasthenia gravis would be one possible peripheral cause, characteristically causing weakness of different oculomotor muscles, often bilaterally, which might not correspond to individual nerves and can fluctuate during the day being more severe in the evening.

The other possibility to be considered would be nerve damage from a metabolic disorder like diabetes. Looking at those blood glucose levels you mention they are pretty high and wouldn't be surprised if you have had high values for months and years (a test called HbA1c would show the average for the last 2-3 months). For that reason right now I would put nerve damage due to diabetes as the main most probable hypothesis for your diplopia. Treatment of diabetes is the mainstay of management, diplopia should improve gradually.

I hope to have been of help.

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Detailed Answer:
No there is not blurring of the vision. Blurring of the vision happens because of diabetic retinopathy, damage of the retina.
Damage to the oculomotor nerves (either 3, 4 or 6 - diabetes can affect any nerve in the body) doesn't affect vision, those nerves merely control eye bulbi movements but play no role in vision itself.

So to resume. Double vision, diplopia, can have many causes, like nerve damage from trauma, stroke, tumors, infections causes which are excluded by MRI, metabolic damage of the nerve from diabetic isolated neuropathy, or muscular issues like myasthenia, thyroid dysfunction etc. At times the cause may remain unknown even after all tests have been done. In this case though there is one potential cause like diabetes.

From what I understand the neurologist says he doesn't notice any paresis at all. Since I can't examine you myself I can't say whether he's wrong or right, but I have to assume that it is a mild paresis which while enough to cause diplopia is not noticeable by outside viewer (and for the cause remains the above reasoning).
It's either that or I then assume that there is no true diplopia at all and it's just your impression, a psychological issue.
I am inclined to believe you that there is some diplopia though due to the fact you say it disappears when you close one eye which is typical for true diplopia.

Wishing you good health

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Brief Answer:
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Detailed Answer:
You seem to think that you can have diplopia but that since the neurologist and the hospital said so you have no muscle paresis. If you have true diplopia though I maintain there is a paresis, even though very discreet to be seen by neurologist. Since you see well with each eye separately it is not a question of the eye bulbi itself, vision is preserved, the fact that the issue is present only when using both eyes confirms that it is due to a muscle paresis leading to the eyes not moving in full synchronization. Otherwise there is no plausible explanation really (traumatic nerve damage would cause muscle paresis as well), if vision is unaffected and eye movements as well then we go back to it not being true diplopia.

You sure seem also to walk into a lot of trouble I must say as the list of your injuries mounts....just kidding :). Anyway the previous reasoning regarding trauma remains, if the issue was due to old direct traumatic nerve compression it should have manifested before at the time and if due to later developing bony spurs there should be some compression on MRI/CT.

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Detailed Answer:
Hello again!

The reason the diplopia is worse for near object is because for that the eyes have to converge, so it seems that the rotation of the eyes towards the nose is involved. When you look far away convergence is not necessary, the muscles mediating it are not used, so there is no asynchrony between the eyes, no diplopia.

Same principle applies to looking down, apparently the eyes involved in rotating eyeball downwards are involved (or the nerve which commands them). When you look upwards those muscles are not used so again no asynchrony, no diplopia.

So paresis involves muscles used for downward and inward movement such as the superior oblique, innervated by 4th nerve.

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Brief Answer:
Now.

Detailed Answer:
Lol, that was an unexpected question. It's 5 minutes past midnight where I live so I am just about to go to sleep actually.

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