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Surat Tanprawate, MD, MSc(London), FRCP(T) Neurology Unit, Department of Medicine Chiang Mai University
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Ptosis
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Ptosis Anisocoria
Oculomotor pathway
Supranuclear(UMN)
FEF: horizontal conjugate gaze Diffuse frontal and occipital: vertical conjugate gaze
Infranuclear(LMN)
Faciculus Cranial nerve NMJ muscle
Diplopia is the simultaneous perception of the two images of a single object that may be displaced horizontally, vertically, diagonally caused by impair EOMs functions
Diplopia
Monocular diplopia Binocular diplopia
Repetitive images
Ghosting image
Nuclear control
Infranuclear control
Internuclear control
- CN III - CN IV - CN VI
Key features
Wednesday, October 31, 2012
Internuclear lesion specic syndrome; Internuclear Ophthalmoplegia (INO), WEBINO, One and a half syndrome
NMJ lesion: fatiguability, not consistent with CN lesion, sign of myasthenia gravis Muscle lesion: not consistent with CN lesion: not consistent with CN lesion, sign of myopathy
CN III
CN IV
CN VI
facial nerve wraps around the nucleus of cranial nerve VI within the pons
Left LR palsy
Wednesday, October 31, 2012
Left LR palsy
Dx. Left CN VI palsy from ischemic neuropathy
Wednesday, October 31, 2012
19
Wednesday, October 31, 2012
CN 3, 4, 6, V1
20
Wednesday, October 31, 2012
21
Wednesday, October 31, 2012
A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
A patient with diplopia for 1 week with gait ataxia and areexia
2 weeks
2 months
Interneuclear lesion
Interneuclear ophthalmoplegia (INO): MLF lesion Bilateral INO : Bilateral MLF lesion One and a half syndrome: PPRF lesion + MLF lesion
b. Left impaired adduction on right gaze and horizontal nystagmus of the right eye
d. Normal convergence
WIBINO
Wednesday, October 31, 2012
Infranuclear lesion ;
disease of ocular muscle disease of NMJ
Upper eyelid
Levator palpebral superioris(CN 3) Muller muscle (sympathetic) Frontalis muscle(CN 7)
Lower eyelid
Capsulopalpebral fascia (inferior rectus) Inferior tarsal muscle (sympathetic)
Ptosis
Non-neurogenic(mechanical) ptosis
Neurologic ptosis
Congenital ptosis
Uni-bilateral Partial-complete
Horners syndrome
Ptosis from Cranial nerve III lesion - complete or near complete ptosis - EOM involvement - Pupil dilatation
Nystagmus
Nystagmus
Wednesday, October 31, 2012
Ancient Greek (nustagmos (Ancient Greek,"nodding, be sleepy") Involuntary biphasic rhythmic ocular oscillation in which one or both phase are slow The slow phase is responsible for the initiation and generation of the nystagmus, whereas the fast (saccadic) phase i a corrective movement bringing the fovea back on target Type: jerk (direction to fast phase) ; pendular nystagmus
Mechanism
Nystagmus may result from dysfunction
of the vestibular ending organ, vestibular nerve, brainstem, cerebellum, or cerebral centers for ocular pursuit
(B) an accelerating velocity exponential slow phase jerk nystagmus (CN) (C) a decelerating exponential slow phase jerk nystagmus (MLN) (D) a linear or constant velocity slow phase jerk nystagmus (MLN)
In (A) a slow phase is followed by a slow phase while in (B)(D) a slow phase is followed by a fast phase
Wednesday, October 31, 2012
Mechanism
Pendular nystagmus: is central (brainstem/cerebellum) Jerk nystagmus:
linear (constant velocity) slow phase: peripheral vestibular dysfunction slow phase has decreasing velocity exponential: brainstem neural integrator slow phase has increasing velocity exponential: central in origin (usual form of congenital nystagmus)
vestibular nystagmus
Wednesday, October 31, 2012
Conclusion
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Conclusion
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Conclusion
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Conclusion
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Ptosis
Conclusion
Oculomotor system
conjugate eye movement Saccadic system Pursuit system Vergence system Counter rolling system: VOR, Ocular xation system
Eyelids Pupils
Ptosis Anisocoria