occulomotor nerves
DESCRIPTION
ocular motor cranial nervesTRANSCRIPT
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Dr. Ravi Thanage
Third Year MD Resident
27th June , 2014
Dept. of Medicine
Seth GSMC & KEMH
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Scheme of the seminar
Anatomy
Etiologies
localisation on basis of clinical features
Pupillary abnormalities
Gaze palsies
Conclusion
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Motor supply of extraocular and intraocular muscles.
Oculomotor nerve (Third CN)
Trochlear nerve (Fourth CN)
Abducent nerve (Sixth CN)
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Oculomotor nerve
Nucleus lies in midbrain at the level of superior colliculus anterior to cerebral aqueduct.
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Anatomy of oculomotor nucleus
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Bilateral innervation
1) Edinger Westphalnucleus
2) Superior rectus
3) Levator palpebraesuperioris
Unilateral innervation
1) Medial rectus
2) Inferior rectus
3) Inferior oblique
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Complete third nerve palsy Complete ptosis
Dilated pupil
Sluggishly reacting to light
Eye deviated lateral and downward
C/L eye partial ptosis with occasional associated superior rectus palsy
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Nucleus:
Ipsilateral complete third nerve palsy
C/L ptosis and superior rectus palsy
Isolated levator subnucleus- isolated bilateral ptosis
Etiology: Infarction/Hemorrhage
Tumor
Multiple Sclerosis
Trauma
Infection
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Fascicle Isolated fascicle-ipsilateral third nerve palsy
Weber’s syndrome: Fascicle + cerebral peduncleipsilateral third nerve and C/L hemiplegia
Nothnagel syndrome: Fascicle + cerebellar peduncle(dentatorubralfibres)ipsilateral third nerve and C/L ataxia
Benedikt syndrome: Fascicle + red nucleus/substantia nigraipsilateral third nerve and C/L choreiform movement
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Claude’s syndrome:
fascicle + cerebellar peduncles + red nucleus
ipsilateral third nerve palsy, ipsilateral ataxia and contralateral tremors
Additional Etiologies: Osmotic demyelination
Ophthalmoplegic Migraine
(MRI may show enhancement of nerve at exit of midbrain)
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Subarachnoid space
It is supero-medial to trochlear nerve and infero-lateral and parallel to PCA
It pierce the dura b/w free and attached margin of tentorium, to reach the cavernous sinus.
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Ipsilateral complete third nerve palsy
Etiology :
1)Aneurysm of posterior cerebral, superior cerebellar or posterior communicating artery.
2)AV malformation.
3)Ophthalmoplegic migraine
4)Inflammatory Sarcoidosis, Wegener’s, Sjogren’s
5)Nerve infarction in DM, SLE and Temporal arteritis
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Cavernous sinus
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Palsy of all three nerves+
Painful – lateral lesions
(from temporal lobe abscess)
painless – Cavernous sinus thrombosis,
Tolosa Hunt syndrome
Mucormycosis
Arterial-venous fistula
Sphenoid sinus mucocele
Pitutary apoplexy, Adenoma
With Horner syndrome- likely forth nerve involvement
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Orbit
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Proptosis and isolated muscle involvement favours orbital pathology
Etiology: Granulomatous lesion
Pseudotumor cerebri
Inflammatory disorders
Metastases
Dural AVM
Trauma
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Trochlear nerve 1. It is purely motor nerve, Supplies to Sup. Oblique
muscle.
2. The nerve is named for the trochlea, the fibrous pulley through which the tendon of the superior oblique muscle passes.
3. It is crossed, most slender, smallest nerve and has longest intra cranial course (7.5cm) of all cranial nerves.
4. It is only cranial nerve to emerge from dorsal aspect of brain
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Nucleus Trochlear nucleus situated at
the level of sup. border of inferior colliculus.
It is in the dorsum of tegmentum of mid brain, ventrolateral to the cerebral aqueduct.
Dorsal to the medial longitudinal fasciculus.
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At lower border of inf. Colliculus they turn medially to decussate in superior medullaryvelum.
Hence each Sup. Oblique is supplied from contralateral trochlearnucleus.
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Affected eye is in upward gaze.
Unopposed inferior oblique action.
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Abducent nerve Entirely motor nerve, supplies to lateral rectus muscle.
Most vulnerable cranial nerve, to be damaged in traumas and raised ICT, it crosses many bony prominences.
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Nucleus Abducent nucleus is Small mass of large multipolar
cells, in floor of fourth ventricle, ventral to facial colliculus, where it is closely related to the horizontal gaze centre(PPRF).
fasciculus of the 7th nerve curves around the abducentnucleus.
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Course and relation
Efferent fibres start from nucleus, traverse through tegmentum, Parapontineraticular formation(PPRF) and pyramidal tract .
Then leave the brainstem at pontomedullaryjunction, just lateral to pyramidal prominence.
Lateral to each abducentthere is the emergence of facial nerve.
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Abducent nerve
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Millard-gublersyndrome
ipsilateral sixth nerve
contralateral hemiplegia
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Foville syndrome:
Extensive infarction involving sixth, seventh nerve nuclei and MLF and corticospinal tract
Sixth and V2 –nasopharyngeal carcinoma.
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Gradenigo’s syndrome:
1. Acute apical petrositis
2. Ipsilateral sixth nerve palsy
3. Retro-bulbar pain ( trigeminal ganglion )
4. Deafness and ear discharge
Etiology: Middle ear infection, trauma, inferior petrosalsinus thrombosis.
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Pupil Aperture of the diaphragm of eye (iris) that allows
light to enter the retina
FUNCTION
Controls amount of light entering the eye – influence of autonomic nervous system
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Pupils are controlled by 2 muscles of ectodermalorigin –
1. Sphincter pupillae
2. Dilator pupillae
Normal size 3-5 mm
<3mm constricted
>5mm dilated
<1mm pin point pupils
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Points to be kept in mind during examining pupils
Illumination of examination room should be low.
Patient should look into the distance.
Light used should be focused & bright.
Note the size, shape & contour of the pupil then test for reflexes.
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Pupillary reflexes
Light reflexes
direct
indirect
Near reflex
Psychosensory reflex
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Light reflex
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DIRECT & INDIRECT
When light is shone in one eye, both the pupils constrict..
Constriction of pupil to which light is shone is directlight reflex and that of other is consensual ( indirect )light reflex.
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If both optic nerves are intact, both pupils will be tightly constricted
(direct’ magnitude = consensual)
If one optic nerve damaged, both pupils dilate on showing the light to the diseased eye.
on swinging back to normal side, both pupils constrict
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The dilatation or escape that occurs is called MARCUS GUNN PUPIL or RELATED AFFERENT PUPILLARY DEFECT (RAPD)
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Near reflex
Convergence
Pupillary constriction
Accomodation
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Accomodation Frontal eye field area
Nucleus of perlia (small set of neuron in medial rectus nuclei
Contraction of ciliary muscles
Increase in anterior curvature of lens
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Psychosensory reflex
Refers to the dilatation of pupil in response to sensory and psychic stimuli.
Complex, mechanism still not elucidated.
e.g - Ciliospinal reflex
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Anisocoria= unequal pupils
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ANISOCORIA
Dilated pupil Constricted pupil
Well appreciated in bright light
Causes1)Pharmacological
2)Adie’s pupil
3)Third nerve palsy
4)RAPD
Well appreciated in dim light
Causes
1)Horner’s syndrome
2)Argyll Robertson pupil
3)Pharmacological
4) Pin point- opc, opiates, pontine
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ANISOCORIA
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HORNER’S SYNDROME
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HORNER’S Syndrome
Miosis
Partial ptosis
Inverse ptosis
Enophthalmos (apparent)
Anhidrosis
Loss of ciliospinal reflex
Dilatation lag
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Etiologies of Horner SyndromeCentral
Lat. Medullary syndrome
Anterior spinal artery thrombosis
Syphilis
Hypothalamic lesions
Sarcoidosis
Demyelination
Mutli system atrophy
Peripheral
Lung cancer
Cervical rib
Birth trauma(Klumpke’s)
Cavernous sinus
Diabetic autonomic neuropathy
High chest tube insertion.
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Horner’s pupil
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Congenital Horner Syndrome
Heterochromia irides
Low IOP
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COCAINE TEST
Normal pupil dilates.
Horner pupil does not dilate.
Mechanism- prevents re-uptake of norepinephrine
1% HYDROXY AMPHETAMINE TEST
In PREGANGLIONIC lesions pupil will Dilates
Mechanism- releases the norepinephrine
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Roots of ciliary ganglon:
1. Sensory root: comes from nasocilliary nerve
2. Parasympathetic root: arise from nerve to inf. Oblique muscle.
3. Sympathetic root: is a branch from int. carotid plexus.
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Adie’s pupil
Large unilaterally dilated pupil
Absent or poor light response
Near slow tonic contraction
Absence of deep tendon reflex- Holme’s Adie’s syndrome.
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Ciliary ganglion
Denervation super-sensitivity
Responds to very small doses of pilocarpine(0.125%)
Indicate postganglionic lesion
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Adie’s pupil
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Argyll Robertson Pupil Pupil slightly smaller in size
Near reflex present but Light reflex absent i.e there is light -near dissociation
Both pupils are involved, dilate poorly with mydraiatics
Hallmark of tertiary syphilis (neurosyphilis)
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Etiology:
Encephalitis
Wernicke’s encephalopathy
Demyelination
Pineal tumour
Vasculitic disease.
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Hutchison’s pupil
Lesions compressing nerve from outside causes dilatation of pupil before external ophthalmoplegia
e.g. Uncal herniation
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Location of Pupillary fibres
Part of oculomotornerve which lies between brainstem and cavernous sinus, the pupillaryparasympathetic fibres are located superficially
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Oculomotor nerve gets blood supply from various branches from basilar artery (in brain stem) and int & ext carotid artery
Pupillomotor fibres derive their blood supply from the pial blood vessels, whereas the main trunk is supplied by vasa nervosum
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Medical third nerve palsy
DM, vasulitis affect vasanervosum, results in third nerve palsy with pupillary sparing.
Surgical third nerve palsy
Raised ICT , rupture of aneurysm affect pialblood vessels, results in pupillary involvement without ophthalmoplegia.
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Hippus Alternate contraction dilatation of pupils
Creuzfeldt –Jacob Disease- Correspond to periodic sharp wave complexes (PSWC) on EEG associated with myoclonus
Aortic regugitation- Landolfi’s sign.
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Ptosis and pupil
Ptosis wth dilated pupil - third nerve palsy
Ptosis with constricted pupil - Horner’s
Ptosis with normal sized pupil-
1)Neuromuscular causes: Myasthenia,
Snake bite
Botulism
2)Myotonia dystrophica
3) Infarction of nerve in vasculitis, DM
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Gaze palsy
Gaze palsy
Conjugate Non-conjugate
Horizontal Vertical Horizontal Vertical
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Horizontal conjugate gaze:
Toward lesion gaze preference-FEF, parietal lobe
Away from lesion- brainstem infarct
Vertical conjugate gaze:
dorsal midbrain syndrome
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Non-conjugate horizontal gaze palsy:
Internuclear ophthalmoplegia
Non-conjugate vertical gaze palsy:
Progressive supranuclear palsy
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Internuclear ophthamoplegiaMLF Syndrome -it is due to lesion of medial longitudinal fasciculus in pons -it connects 3rd ,4th & 6th nerve nuclei with vestibular nuclei
If left MLF having lesion –
- Vertical gaze unaffected
- Loss of left eye adduction
- Nystagmus in right eye on looking to right
- Convergence normal
- Also called as half syndrome
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MLF Syndrome
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One & Half Syndrome
single unilateral lesion of the paramedian pontine reticular formation and the ipsilateral medial longitudinal fasciculus
An alternative anatomical cause is a lesion of the abducent nucleus (VI) on one side(resulting in a failure of abduction of the ipsilateral eye and adduction of the contralateral eye = conjugate gaze palsy towards affected side), with lesion of the ipsilateral medial longitudinal fasciculus
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Only movement present is contralateral eye abduction
Convergence unaffected
Vertical gaze unaffected
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