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2nd Shifting / September 25, 2008
Goldi and Her Playful Dogs

Optic Pathway
 patient complains of either seeing spots in
the center of field of vision (scotoma) or his
 Commonly called the optic nerve peripheral field is contracted
 ocular pain is present
 Consists of: optic nerve, optic chiasm, optic tract,
lateral geniculate body, optic radiation, and  management is similar to that of papillitis
visual center
Papilledema or choked disc
 (optic nerve itself)Has intraocular portion known as
optic disc and retrobulbar portion divided into orbirtal,  optic disk swelling due to raised intracranial pressure
canalicular, and intracranial segments  due to some interference of optic nerve circulation,
 Starts as axons of ganglion cells located in the particularly the venous drainage
superficial layer of the retina  no visual disturbances if macula is spared
 visual field is normal except for an occasional enlarged
 These axons converge at the opening of the blind spot
eyeball transverse by a sieve-like membrane  associated with increased ICP as in brain tumor,
(lamina cribrosa) to form the optic disc abscess, meningitis, and intracranial hemorrhage
 At the floor of the third ventricle, behind the  orbital tumors and hypertension are also known causes
sphenoidal bone, above the sella turcica and  treatment is towards the etiology
in between the two internal carotid arteries,
the optic nerve from the two sides fuse to Optic atrophy
form the optic chiasm  when nerve fibers are destroyed, they are replaced by
 Axons from lateral geniculate body of each neuroglial tissues and the finer blood vessels close
side pass backwards through the internal  ophthalmoscopic picture is pale disc
capsule to reach the visual cortex  visual acuity is poor and visual field is contracted
(Brodmann’s area 17)
 primary optic atrophy – occurs on a previously normal
 The nerve composing the optic pathway is a disc
sensory nerve with no neurolemal sheath  secondary optic atrophy: blurred disc margin, hazy
(Schwann) lamina cribrosa, retinal perivascular sheathing
 The main function of the optic pathway is vision which  management: corticosteroids, vasodilators, carbon
consists of two parts: dioxide inhalation; sclera or extraocular muscle
surgical transplantation
 central (cone) – visual acuity and color
Optic chiasm to Visual centers
 peripheral (rods) – visual field and dark
 chiasmal lesions – caused by pituitary tumors and
adaptation; also performs as apparent arm of
craniophryngioma - bitemporal hemianopsia
papillary reflex
 increased ICP and internal carotid artery sclerosis -
Optic Nerve binasal hemianopsia

Optic neuritis  optic tract lesions – incongruous homonymous
 inflammation of the optic nerve can be localized in the hemianopsia
optic disc (papillitis) or behind the globe (retrobulbar  lateral geniculate lesions – congruous homonymous
neuritis) hemianopsia
 Papillitis
 suspected when patients complain of sudden
 upper portion of optic radiation lesions – inferior
blurring of vision commonly in one eye congruous homonymous quadranopsia
 Ophthalmoscopic exam – hyperemic disc with  lower portion of optic radiation (temporal lobe tumors
blurred margins and dilated blood vessel; disc may and otitic abscesses) – superior congruous
be elevated but seldom becomes more than +2 D homonymous quadranopsia
 Macular star – radiating streaks produced by
edema accumulating in the macula (if surrounding
 visual centers are generally affected by intracranial
retina is involved) injuries – congruous homonymous scotoma
 Most of the causes are unknown
Oculomotor, Trochlear, and Abducens Nerve (3,4,and
 Systemic steroids and anti-inflammatory drugs are 6)
given to hasten the recovery and minimize the
 purely motor nerves that govern ocular movements of
 If left untreated, atrophic changes begins to show the eye
in 8-18 months
 Retrobulbar neuritis  oculomotor nerve –
 no abnormal ophthalmoscopic finding  elevates the upper lid, constricts the pupil,
and incites accommodation

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 Lesions of the third nerve nucleus typically o enters the orbit with the third and fourth
affect the ipsilateral medial and inferior rectus nerves to supply the lateral rectus muscle
and inferior oblique muscles, both levator o Abducens Nerve Palsy –
muscles, and both superior rectus muscles
 most common single extraocular
 Bilateral ptosis and bilateral limitation of muscle palsy
elevation as well as limitation of adduction  Abduction of the eye is reduced
and depression ipsilaterally or absent
 Oculomotor Synkinesis (Aberrant  esotropia is present in the
primary position and increases
Regeneration of the Third Nerve) - This
with distance fixation and upon
phenomenon is characterized by
gaze to the affected side
inappropriate activation of muscles
innervated by the oculomotor nerve, including  Ischemia (arteriosclerosis,
(1) lid dyskinesias due to inappropriate diabetes, migraine, and
activation of levator palpebrae superioris hypertension) is a common
either on horizontal gaze (eyelid elevates on cause
attempted adduction) or on vertical gaze  Arnold-Chiari malformation
(eyelid elevates on attempted depression (congenital downward
("pseudo-Graefe's sign"); (3) adduction or displacement of the cerebellar
retraction on attempted upgaze due to tonsils) can produce sixth nerve
inappropriate activation of medial rectus or palsy due to traction but can
inferior rectus; (4) pupillary constriction on also produce a distance
attempted adduction or depression; and (5) a esotropia without limitation of
monocular vertical optokinetic nystagmus abduction due to cerebellar
response (due to coactivation of superior dysfunction
rectus, inferior oblique and inferior rectus o Duane’s syndrome
muscles fixing the involved eye, allowing only  stationary, nearly always
the normal eye to respond to the moving unilateral condition consisting of
target). deficient horizontal ocular
motility characterized by
complete or partial deficiency of
- Trochlear Nerve (IV) – abduction
o unique among the cranial nerves in o Gradenigo's Syndrome
arising from the dorsal brainstem  characterized by pain in the face
o travels near the third nerve along the (from irritation of the trigeminal
wall of the cavernous sinus to the orbit, nerve) and abducens palsy
where it supplies the superior oblique  syndrome is produced by
muscle meningeal inflammation at the
o Trochlear Palsy – tip of the petrous bone and most
often occurs as a rare
 Congenital trochlear palsy is complication of otitis media with
probably not usually neurogenic mastoiditis or petrous bone
in origin but due to tumors
developmental anomaly within
the orbit Syndromes Affecting Cranial Nerves III, IV, & VI
 It may present in childhood with
an abnormal head posture or in - Superior Orbital Fissure Syndrome
childhood or adult life with
eyestrain or diplopia due to o All the ocular motor nerves pass through
reduced ability to overcome the the superior orbital fissure and can be
vertical ocular deviation involved by trauma or by tumor
(decompensation) encroaching on the fissure
- Orbital Apex Syndrome
 Acquired trochlear palsy is
o This syndrome is similar to the superior
commonly traumatic
orbital fissure syndrome with the addition
 The nerve is vulnerable to injury of optic nerve signs and usually greater
at the site of exit from the dorsal proptosis
aspect of the brainstem o It may be caused by tumor, inflammation,
 Both nerves may be damaged or trauma
by severe trauma as they - Sudden Complete Ophthalmoplegia
decussate in the anterior o Complete ophthalmoplegia of sudden
medullary velum, resulting in onset can be due to extensive brainstem
bilateral superior oblique palsies vascular disease, Wernicke's
o Superior oblique palsy results in upward encephalopathy, Fisher's syndrome,
deviation (hypertropia) of the eye, which bulbar poliomyelitis, pituitary apoplexy,
increases when the patient looks down basilar aneurysm, meningitis, diphtheria,
and to the opposite side botulism, or myasthenic crisis

- Abducens Nerve (VI) – Trigeminal Nerve
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 Both a sensory and a motor nerve
 Stimulation of the sympathetic system induces
papillary dilation
 Sensory nerve to the region of the face and the nasal
 Destruction of the sympathetic causes miosis as in
and buccal mucosa
Horner’s syndrome (miosis, ptosis, enopthalmos)
 Motor nerve to muscles of mastication
 Certain drugs may localize the lesion along this
 The nucleus of the sensory portion is in the lateral side pathway
of the pons. It receives fibers from the semilunar
(Gasserian) ganglion Pharmacologic test in location of lesion in Horner’s
 Semilunar ganglion receives three main branches: syndrome (Mydriasis)
ophthalmic, maxillary, and mandibular
 Ophthalmic branch: Drug Normal Central Pre-gang Postgang
 Frontal branch terminates as the Cocaine 10% + impaired _ _
supratrochlear and supraorbital nerves to Epinephrine 1:100 - - Moderate Dramatic
supply forehead, scalp, and medial part of the Phenylephrine 1% Slight Slight Moderate Dramatic
upper lid Phenylephrine 10% Dramatic + + +
 Lacrimal branch supplies the lacrimal Hydroxyamphetamine + + + _
glandand the lateral aspect of the upper and
lower lids Fin
 Nasociliary branch is the sole sensory nerve of
the globe supplying the long and short ciliary Mga tsong, galing lang to’ sa buk ng
nerves and also supplies the lower part of the
nose and medial aspect of lids as the infra- ophtha.. d namin nahingi ung lec

trochlear nerve
Maxillary branch supplies the meninges of middle
cranial fossa

Mandibular brancc supplies the lower jaw
Testing the function of CN V: corneal reflex, blinking
- Pornstars –
reflex, and sensation of touch, pain, and temperature
in the lids
 Lesions affecting this nerve is frequently with the
ophthalmic branch (herpes zoster); in tic doulourex the
mandibular is affected
 Peripheral lesions affect the branches individually

Facial Nerve

 Motor nerve to the facial muscles
 Sensory functions to the anterior 2/3 of the tongue
(taste) and external ear (general sensation)
 Main ocular function is closing of the lids through the
orbicularis oculi
 If lesions affect the lower neuron (nucleus or facial
nerve), the entire half of the face is paralyzed
 If lesions affect the upper neuron (cortico-bulbar
pathway), the upper facial muscles are spared because
the forehead receives innervations from both sides

Acoustic Nerve

 Two divisions: cochlear (hearing) and vestibular
 Examination of the oculo-vestibular connections is
done by studying the character of the nystagmus
 Vestibular nystagmus has a fast and slow component,
without which, it cannot be of vestibular origin
 Direction of the nystagmus id based on the direction of
the fast component
 Spontaneous nystagmus of a vertical or oblique nature
is generally central in origin; horizontal nystagmus
may be peripheral or central
 Direction of the fast component is towards the
opposite side of the vestibular apparatus that is
 Tumors produce a hypofunctioning vestibular
apparatus; hemorrhages produces stimulating effect

Sympathetic System
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