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Neuro-ophthalmology: part 3, crainial nervesdavid.kinshuck@goodhope.nhs.uk

Ocular cranial nerve problems…main points…can’t discuss all points in time allowed

Present…a few questions as we go

2 tiny quizes

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Anatomy

1. Nuclei of oculomotor nerve 2. Trochlear nucleus 3. Pons 4. Fourth ventricle 5. Abducent nucleus 6. Vestibular nucleus 7. Medial longitudinal

fasciculus

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Anatomy

www.meddean.luc.edu

3rd

4th

5th

6th

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Anatomy cont

a

b

c

d

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Anatomy cont

3rd

4th

5th

6th

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Case 1What is happening?

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Case 1 animation

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3rd nerve palsy

All recti except superior oblique and lateral rectus paralysed

Pupil fixed and dilated

Different types of 3rd nerve palsy..can localise lesion..

Eg elderly patients, diabetic, pupil spared: vascular lesion of nerve itself

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3rd nerve palsy

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Case 2 animation

animation

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Case 2 animation

animation

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Case 2

which eye is affected?

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Case 2 cover test

Which eye is affected?

www.mrcophth.com

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4th nerve palsy

Superior oblique palsy, right: vertical diplopia

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4th nerve palsy

Superior oblique palsy, left: vertical diplopia

www.mrcophth.com

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Case animationanimation

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Case 3

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6th nerve palsyRight Lateral rectus palsy

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6th nerve palsyWhich lateral rectus palsy?

left

www.mrcophth.com

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QuizCases…diff diagnosis and why

1. Age 20, road accident last week, vertical diplopia..diagnosis, & how do you diagnose it?

2. Diplopia…horizontal…as shown here

3. Age 70y, ptosis, diplopia (divergent) pupil OK, sudden onset

www.mrcophth.com

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5th nerve damage

Test

How?

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5th nerve damage

Test

– Sensation in all 3 regions

– motor..clench teeth

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5th nerve damage

Lesion 1•Name?•symptoms

Lesion 2 •Name•symptoms

Lesion 3 •Name•symptoms

Lesion 4•Name?•symptoms

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5th nerve damage

• Vth sensation reduced • Pain and temp opposite

side (vasc or MS or ca)

Lesion 2 •Trigeminal neuralgia…•Vascular compression

Ca …intracranial orNasopharyngeal

Orbital floor fracture (trauma)…numb beneath eye, diplopia

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7th nerve palsy

Try and think, in pairs, 1 minute

Causes

Problems

What is the route of the 7th nerve?

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7th nerve...landmarks?

1…bends round what?

2

3

4

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7th nerve

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7th nerve.. landmarks

Brain stem…Bends round 6th nerve nucleus

Through internal auditory meatus with Vlllth nerve

Through facial canal turns 90o just medial to middle ear …styomastoid foramen

Through parotid

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7th nerve…lesions

6th and 7th lesion..7th supplies both side of face

Vlllth nerve…acoustic neuroma surgery or other SOL

Ear infectionseg. Ramsey Hunt=herpes zoster=rash on ear drum

Parotid tumour..palpate

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7th nerve palsy

lesions

Bells palsy, possibly herpes simplex

Ramsay-Hunt with rash: herpes zoster

Upper motor neurone…forehead symmetrical

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7th nerve palsy

Runs over petrous part of temporal bone…6,7,8th palsy

Herpes zoster: look in ear for vesicles

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7th nerve palsy: eye problems

www.ramsayhunt.org/ images/nik1.jpg

Dry cornea

can ulcerate

Use fluorescein for examination

Lubricate +++

Occasionally suture lids closed.

Serious problem for acoustic neuroma patients

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Questions

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Summary

3rd cranial nerve…aneurysm in young patient(pupils..covered separately)4th cranial nerve…vertical diplopia6th…horizontal diplopia5th ..unsusual but serious7th…common, Bells, Ramsey Hunt, acoustic neuroma surgery, dry eye

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