3rd,4th, 6th nerves
Extraocular muscles
How to examine for ocular motility
Ophthalmoplegia
Diplopia and related disorders
Gaze pathway
How to examine for gaze
Gaze palsy
Types of eye movements
How to examine for EM
Nystagmus and non nystagmus ocular oscillation
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Ocular motility and gaze
1. Amr Hassan, MD, FEBN
Associate professor of Neurology - Cairo
University
Ocular motility, gaze,and
Nystagmus
2. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
3. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
5. • The oculomotor nerve originates from 3 nuclei:
Motor neurons arise from the oculomotor
nucleus
Parasympathetic fibers arise from Edinger-
Westphal nucleus.
Perlia nuclei in the midbrain.
Oculomotor nerve
9. • The nucleus of origin of
the oculomotor nerve.
1. Posterior dorsal
nucleus.
1’. Posterior ventral
nucleus.
2. Anterior dorsal nucleus.
2’. Anterior ventral
nucleus.
3. Central nucleus.
4. Nucleus of Edinger and
Westphal.
5. Antero-internal
nucleus.
6. Antero-external
nucleus.
8. Crossed fibers.
9. Trochlear nerve, with
9’, its nucleus of origin,
and 9", its decussation.
10. Third ventricle.
M, M. Median line.
Oculomotor nerve
10. Oculomotor nerve
• The nerve passes through the superior orbital fissure to reach
the orbit.
• The motor component of the nerve divides into a superior
and inferior division:
– The superior division supplies the levator palpebrae
superioris and superior rectus muscles.
– The inferior division supplies the medial rectus,
inferior rectus and inferior oblique muscles.
12. Oculomotor nerve
The parasympathetic component of the oculomotor nerve
travels with inferior division to innervate
Ciliary muscle
Constrictor pupillae muscle
14. • The trochlear nerve has only a
somatic motor component which
innervates the superior oblique
muscle of the contralateral orbit.
• The nucleus of this nerve lies in
the lower part of the midbrain.
Trochlear nerve
17. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
26. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
27.
28.
29.
30. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
31. Lesions of the oculomotor nerve
• External ophthalmoplegia
• Internal ophthalmoplegia
NB:
compression: early mydriasis and lost
light reflex
infarction: pupillary reflex intact
Lesions of the oculomotor nerve
33. O C D
Distribution: Uni/Bilateral.
Symm/Asymmetrical
Simultaneous/ Sequential
Partial / complete
Painful or not.
Limitation of ocular motility( double vision)
Diminution of vision.
Local eye manifestations: (photophobia,
lacrimation, exophthalmos, red eye)
Ptosis
34. (A) Asymmetrical ptosis (B) application of ice; (C) improvement of ptosis
Positive ice test in myasthenia gravis.
46. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
47. Assessment of the Patient with Diplopia
History
■ Define symptoms.
■ Effect of covering either eye?
■ Horizontal or vertical separation of
the images?
■ Monocular?
■ Effect of distance of target (worse
at near or far)?
■ Effect of gaze direction?
■ Tilting of one image?
Observation
■ Head tilt or turn? (“FAT scan”)
■ Ptosis (fatigue)?
■ Pupil size?
■ Proptosis?
■ Spontaneous eye movements?
Eye Examination
■ Visual acuity (each eye separately,
and binocularly if primary
position nystagmus present)
■ Versions (pursuit, saccades)
■ Convergence (does miosis occur?)
■ Ductions
■ Ocular alignment (muscle balance)
in the “forced primary position”
■ Pupils
■ Lids (examine palpebral fissures,
levator function, fatigue)
■ Vestibulo-ocular reflexes (doll’s eye
reflex)
■ Bell phenomenon
■ Optokinetic nystagmus
48. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
49. The ability of the eyes to move symmetrically and
synchronously in the same direction, horizontally
or vertically is termed “ cojugate” gaze.
Gaze
59. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
64. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
65. It is the inability to move both eyes
simultaneously either horizontally or vertically.
Types of Gaze palsy:
1. Horizontal gaze palsy
2. Vertical gaze palsy
Gaze palsy
66. Looking to RIGHT
Nystagmus on abducting eye Failure of adduction with NORMAL III
Cr.N
:
INO: Internuclear Ophthalmoplegia
73. Signs:
• Upward gaze palsy.
• Defective convergence.
• Large pupils light-near dissociation.
• Lid retraction (Collier sign).
• Convergence-retraction nystagmus.
Causes:
a In children: aqueduct stenosis, meningitis and pineal body tumer
b In young adults: demyelination, trauma and arteriovenous
malformations.
c In the elderly: midbrain vascular accidents, mass lesions involving the
periaqueductal grey matter (pineal body tumer )and posterior fossa
aneurysms.
Parinaud (dorsal midbrain) syndrome
74. MR sagittal view shows a pinealoma and a dilated 3rd ventricle
Parinaud (dorsal midbrain) syndrome
75. • Supranuclear gaze palsy, which initially
primarily affects downgaze.
• As the disease progresses, upgaze is also
affected.
• Horizontal movements subsequently
become impaired and eventually global gaze
palsy develops.
• Pseudobulbar palsy.
• Extrapyramidal rigidity, gait ataxia and
dementia.
PSP
76. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
79. • Saccades are rapid, brief conjugate eye
movements that are characterized by their
ballistic nature and high velocity (400–800°/s).
• These redirect our line of gaze while trying to
acquire a new object of interest.
Saccades
80. • Latency: the length of time between the onset
of target to the onset of saccade.
• Gain: ratio of the initial saccade amplitude to
the final target saccade amplitude
• Peak velocity
• Final eye position.
Saccades metrics
82. Frontal eye field
Para-Pontine Reticular Formation (PPRF)
Ocular Motor Nuclei
Cr.N III, IV, VI
Posterior eye field
Superior
Colliculus
Caudate
Substantia Nigra
Pathway of voluntary saccades
83. • Executed following an internal decision to look
in a particular direction like glancing at the
clock on the wall after a long tiring day at
work.
• Voluntary saccades are further divided into
memory-guided, predictive, endogenous
saccades, and antisaccades
Voluntary saccades
88. Anatomical scheme for smooth Pursuit eye movement
Striate Cortex (LGB)
Extra-Striate Visual Areas
MT: middle temporal, MST:medial sup.temporal,
PP: posterior parietal cortex
Dorso-Lateral PONTINE NUCLEI
CEREBELLUM: Flocculus& Dorsal vermis
Vestibular Nuclei
Ocular Motor Nuclei
Cr.N III, IV, VI
89. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation
91. AGENDA
• 3rd,4th, 6th nerves
• Extraocular muscles
• How to examine for ocular motility
• Ophthalmoplegia
• Diplopia and related disorders
• Gaze pathway
• How to examine for gaze
• Gaze palsy
• Types of eye movements
• How to examine for EM
• Nystagmus and non nystagmus ocular oscillation