Cranial Nerves 3 4 6 Handout

CRANIAL NERVES III, IV & VI:
OCULOMOTOR, TROCHLEAR & ABDUCENS

PATHWAY LOCALIZATION AND NEUROLOGICAL EXAMINATION
NICOLE B. ALILING, MD
1 2
Finds
OCULAR Fixates
Focuses
ALIGNMENT
Finds
AND DIPLOPIA
Foveates
3 4
Cranial Nerves 3 4 6 - 13 September 2019

Finds
Fixates
Focuses
Finds
Foveates
PRIMARY GAZE
Suppression of physiologic diplopia
5 6
Duction Duction
Abduction Adduction
7 8

Version Version
9 10
Vergence Vergence
Convergence Divergence
11 12

https://www.youtube.com/watch?v=vd7OOJ7c1q4
13 14
Lateral Rectus
Primary action: Abduction

15 16

Lateral Rectus Lateral Rectus
17 18
Superior Rectus Superior Rectus
Primary action: Elevation Secondary action: Adduction

19 20

Tertiary action: Intorsion

21 22
Primary action: Elevation Primary action: Elevation

Secondary action: Adduction
23 24


Secondary action: Adduction Secondary action: Adduction
Tertiary action: Intorsion Tertiary action: Intorsion
25 26
Superior Rectus: Superior Rectus:

Anatomical Eye Movements Cardinal Position of Gaze
Primary action: Elevation Direction patient should look to

Secondary action: Adduction test the strongest elevating action
27 28

Superior Rectus Superior Rectus:
Cardinal Position of Gaze
Direction patient should look to

Primary action: Elevation test the strongest elevating action
29 30
Inferior Rectus Inferior Rectus
Primary action: Depression
31 32

Inferior Rectus Inferior Rectus
Primary action: Depression Primary action: Depression

Tertiary action: Extorsion
33 34
Inferior Rectus:
Inferior Rectus
Anatomical Eye Movements

Tertiary action: Extorsion Tertiary action: Extorsion
35 36

Inferior Rectus:
Superior & Inferior Oblique Muscles
Direction patient should look to test

the strongest depressing action
37 38
Superior Oblique Superior Oblique
Primary action: Depression
39 40

Superior Oblique Superior Oblique

Secondary action: Abduction Secondary action: Abduction
41 42
Superior Oblique:
Superior Oblique
Anatomical Eye Movements

Tertiary action: Intorsion Tertiary action: Intorsion
43 44

Superior Oblique:
CLINICAL TIP SUPERIOR
OBLIQUE
Direction patient should look to test INTORSION

the strongest depressing action
45 46
Inferior Oblique Inferior Oblique
ORIGINATES
ANTERIORLY
47 48


Secondary action: Abduction
49 50

Tertiary action: Extorsion Tertiary action: Extorsion
51 52

Inferior Oblique: Inferior Oblique:
Anatomical Eye Movements Cardinal Position of Gaze
Primary action: Elevation Direction patient should look to

Secondary action: Abduction test the strongest elevating action
Tertiary action: Extorsion
53 54
55 56

57 58
Muscle Primary Secondary Tertiary Muscle Cranial Nerve
MR Adducts MR III
LR Abducts LR VI
SR Elevates Adducts Intorts SR III
IR Depresses Adducts Extorts IR III
SO Depresses Abducts Intorts SO IV

IO Elevates Abducts Extorts IO III
59 60

Yoking of Ocular Muscles
MNEMONIC
LR 6 SR IO SR
SO 4 LR MR LR
AO 3
IR SO IR
61 62
Yoking of Ocular Muscles

Hering’s Law
SR IO SR
•Equal stimulation of yoke muscles
•Muscles yoked for conjugate eye

movements receive equal stimulation by LR MR LR
the nervous system
•Right lateral rectus and left medial rectus IR SO IR
63 64

Sherrington’s Law
CLINICAL TIP Paralysis of an EOM
•Reciprocal inhibition
causes eye
deviation towards
•Muscles in one eye causing rotation are pull of intact EOMs
actively innervated, antagonists are
inhibited
CN 6 palsy =
•Tonic inhibition at rest
inward deviation
65 66
Initial Inspection:
CLINICAL TESTS Limbus to eyelid
FOR OCULAR
MALALIGNMENT
AND THE RANGE
OF EYE
MOVEMENTS
Abnormal limbus?
67 68

Corneal Light Reflection:
Range of Movement Testing
Hirschberg’s Test
Non-correspondence of reflection?
69 70
Range of Movement Testing Range of Movement Testing
•Prioprioceptive link
•50 cm
•Convergence, then
stations 8 & 9
71 72

73 74
75 76

77 78
79 80

81 82
83 84

85 86
87 88

Range of Movement Testing Ask about
CLINICAL TIP diplopia
You are seeing two
fingers instead of
one, aren’t you?
Do you have diplopia?
Do you see one or

two fingers?
89 90
Ask about
CLINICAL TIP diplopia
You are seeing two COVER-UNCOVER
fingers instead of TEST FOR
one, aren’t you? OCULAR
Do you have diplopia? MALALIGNMENT
Do you see one or
two fingers?
91 92

93 94
95 96

Heterotropia
•Overt
•Non-correspondence of corneal reflection
•Exotropia: Outward
•Esotropia: Inward
•Hypertropia: Upward
•Hypotropia: Downward
97 98
R esotropia L exotropia
L esotropia R hypertropia
99 100

Heterophoria
•Latent, appear when central vision is
blocked an disappear when reestablished
•Virtually always binocular; may be

intermittent
•Exophoria: Outward
•Esophoria: Inward
•Hyperphoria: Upward
•Hypophoria: Downward
101 102
Clinical Classification
of Heterotropia
•Paralytic: Neuromuscular
•Non-paralytic: lesions impairing central

vision
•Refractive errors, cornea or lens

opacification, macular lesions
Intermittent
Right Alternating Alternating right
esotropia esotropia esophoria exotropia
103 104

Primary vs Secondary Deviation Effect of Neuromuscular (Paralytic)
Paresis on Head Position
•Primary: deviation of the eye with the
paretic muscle when the sound eye
•Face turn - horizontal
foveates
•Chin elevation or depression - vertical
•Secondary: deviation of the sound eye

when the eye with the paretic muscle •Head tilt - torsional
foveates
•Moves head toward action of weak muscle

•Always greater: Hering’s Law
105 106
Effect of Neuromuscular (Paralytic) Bielchowsky Park’s Head Tilt Test

Paresis on Head Position
•Superior oblique palsy
•Weak intorsion
•Torticollis: tilt to opposite side, turn face

to same side, depress chin • R SO palsy
• A: Head tilt to L
• B: R hypertropia on head tilt to R
• R upshoot on adduction
107 108

Effect of Neuromuscular Non-paralytic or Concomitant vs
Heterotropia on Vision in Infants: Paralytic or Non-concomitant
Suppression Amblyopia Heterotropia
•Amblyopia ex anopsia
•Concomitant
•Prevent monocular blindness by •Same degree of malalignment in all

intermittently patching sound eye
positions on version, normal range duction
•May also occur in refractive errors, •Equal primary and secondary deviations
opacification of refracting media, or
retinal lesions
109 110
Paralytic Non-paralytic
Laws of Diplopia and the
Non-concomitant Concomitant Clinical Analysis of Diplopia
Ocular deviation changes with eye Full movement when each eye is
movement tested after covering the other • False image
• is always “hazier”
Secondary > primary deviation Secondary = primary deviation

• appears peripheral to true image
(+) Diplopia if occurring

Frequent opacity or severe
after young age refractive error in one eye • projects toward normal direction of pull
of paretic muscle
Often (+) compensatory
head tilt or turn • deviates from true image more when

looking in the direction of pull of paretic
111 112

Summary of Clinical Tests
for Diplopia CASE 1
• Corneal light reflections Double vision looking to the left
• Point of maximum diplopia
Gaze to left causes greatest
• Red glass over R eye separation of images
• Identify eye producing false image
Muscles responsible for left lateral gaze?
• False image = faulty muscle
• Occlude vision alternately

• Reason out muscle responsible
113 114
CASE 1 CASE 1
Right eye occluded: central (true)
Double vision looking to the left
image disappears
Gaze to left causes greatest Left eye occluded: peripheral (false)
separation of images image disappears
Muscles responsible for left lateral gaze? Afflicted eye and muscle?
Right medial rectus, left lateral rectus
115 116

CASE 1 CASE 2
Double vision when looking up
image disappears
Left eye occluded: peripheral (false) Images separate greatest when
image disappears looking up and left
Afflicted eye and muscle? Muscles responsible for gaze?
Left lateral rectus
117 118
CASE 2 CASE 2
Double vision when looking up
image disappears
Images separate greatest when Left eye occluded: peripheral (false)
looking up and left image disappears
Muscles responsible for gaze? Afflicted eye and muscle?
Left superior rectus, right inferior oblique Left superior rectus
119 120

Localization Localization
• Central - long tracts • Central - long tracts

• CN III in midbrain • CN VI in basis pontis
• Ataxia: Dentatorubral tract

• Hemiplegia: basis pontis, CST
• Contralateral tremor: Red nucleus
• Vertical gaze disturbance: RiMLF
• Hemiplegia: midbrain basis, CST
121 122
Localization Localization
• Peripheral nerve • Muscular, systemic

• Cavernous sinus: CN III, IV, VI, V1, V2, • Myasthenia gravis, hyperthyroidism,
carotid sympathetics
botulism, diabetes, arteritides,
• Orbit: CN II plus above nerves aneurysms, inflammation, primary or
metastatic neoplasms
123 124

REFRACTION
AND
ACCOMMODATION
125 126
Accommodation Reflex Myopia and Hyperopia

• Convergence
• Medial recti (skeletal)
• Pupilloconstriction
• Pupilloconstrictor muscle of the iris
(smooth muscle, parasympathetic)
• Lens thickening
• Ciliary muscle (smooth muscle,
parasympathetic)
127 128

Emmetropia Hyperopia
129 130
Hyperopia with Accommodation Myopia
131 132

Myopic Focusing on Near Object
133 134
Hyperopic in infancy
Esophoria
Myopia Epicanthal folds

Exophoria (Also, dystopic canthi)
135 136

Commoner Causes of Blurred Vision
• Various ages
• Malformations, infections, vascular
Presbyopia 42 yo proliferative or occlusive disease,
retinitis pigmentosa and other CNS
Presbyopia hyperope: degenerative diseases, diabetes,
bifocal positive lenses neoplasia, retinal detachment, trauma,
migraine, and toxic (methanol)
137 138
Commoner Causes of Blurred Vision Commoner Causes of Blurred Vision

• Birth through childhood • Later childhood
• Opacities of the media, astigmatism, • 5 to 7 y: increasing myopia, sits closer
refractive errors
to blackboard
• 20/300-400: birth, eyeball too short
• Young adults
• 20/40-60: 1 y
• optic neuritis, Leber hereditary optic

• 20/30: 3 y
neuropathy, and other neuropathies/

• 20/20: 5 y neuritides
139 140

Commoner Causes of Blurred Vision
• 40 to 45 y
• Presbyopia, glaucoma INNERVATION OF
OCULAR
• Older than 50 y MUSCLES
• Cataracts and macular degeneration,
central serous retinopathy, temporal
arteritis and ischemic optic neuropathy
141 142
143 144

MNEMONIC
LR 6
SO 4 EXAMINATION
AO 3 OF THE PUPILS
145 146
Technique of Pupillary Examination Technique of Pupillary Examination

• Inspect at normal illumination, gazing
• Check pupillodilation and dilation lag
at distant point
•Dim room lights and inspect at 5-15 secs
•Pupils black, equal, round, react to light

and accommodation, center or slight •Normal: dilate within 5 secs
inferomedial
•Dilation lag: lack of sympathetic
•Hippus (benign vs metabolic enceph)
innervation (Horner syndrome) or a
myotonic pupil (Adie pupil)
•Kayser-Fleischer ring, arcus senilis
147 148

Technique of Pupillary Examination
CLINICAL TIP “Pupils 3mm, equal,
•Check direct and consensual pupillary centered, react to
reflexes light and in
• Swinging flashlight test accommodation
•Marcus Gunn pupil or relative afferent and dilate promptly
pupillary defect (ie optic neuritis)
in dim light”
•Ophthalmoscopy while room is dimly lit
149 150
PATHWAY FOR
THE PUPILLARY
LIGHT REFLEXES
151 152

CASE CASE
153 154
CASE CASE
Where is the lesion?

Right optic tract
Left CN III
Left optic nerve
155 156

CASE
PHYSIOLOGY AND
PHARMACOLOGY
Where is the lesion? OF THE PUPILS
Right optic tract
Left CN III
Left optic nerve
157 158
Intraocular muscles Pupillodilation (mydriatics)

•Three smooth muscles
•Pupillodilator •Sympathetic/adrenergic agonist or

parasympathetic/muscarinic antagonist
•sympathetic and adrenergic
•Photophobia and blurred vision
•Pupilloconstrictor
•Risk of precipitating glaucoma
•parasympathetic and cholinergic

•Avoid in patients with impaired
•Ciliary consciousness (monitoring pupil size)
•parasympathetic and cholinergic
159 160

Other determinants of pupillary size Other determinants of pupillary size
•Age
•Local disease of eye and iris
•Fetus until 30 to 32 wks: large, non-

•Local ocular or systemic drugs affecting reactive
autonomic nervous system
•Term: small
•Emotionality: SNS > pupillodilation
•Adolescence: large
•Sleep and drowsiness: PNS > constrict

•Elderly: small
161 162
The Syndrome of Parasympathetic

Paralysis of the Eye
(Internal Ophthalmoplegia)
•Pure parasympathetic paralysis: blurring of
near vision (ciliary muscle) and dilated pupil,
not reactive to light or accommodation
(pupilloconstrictor)
•Ischemic CN III lesion, DM, spares pupils
•Aneurysmal CN III involves pupils
163 164

Sympathetic Pathway to the Eye
Hypothalamus > Brainstem tegmentum > GVE of

intermediolateral cell column spinal cord T1 to L2 and L3
Axons to eye from T1 and T2 (ciliospinal center of Budge)
165 166
Sympathetic Pathway to the Eye The Syndrome of Sympathetic

Paralysis of the Eye and Face:
Bernard-Horner or Horner Syndrome
•Ipsilateral ptosis, pupilloconstriction
(cormiosis), anhidrosis, flushing (vasodilation)
•Increase in anisocoria in dim light, dilation lag
ECA > sweat glands of face

ICA > ocular SM + sweat glands forehead
Superior tarsal (extraocular) and pupillodilator (intraocular)
167 168

Clinical Testing:
Horner Syndrome
Faciociliary or Spinociliary Reflex
•Lesion distal to ECA origin from CCA
•Ptosis, cormiosis
•Darkened room, patient focused on distant

•Lesion proximal to ECA
target
•Ptosis, cormiosis, ipsilateral anhidrosis, •Pinch skin over face (CN V) or neck (C2 or C3
vasodilation
afferent) firmly for 5 seconds
•Congenital (Erb brachial plexus injury) may •Both pupils should dilate briskly
have ipsilateral heterochromia (blue gray eye)
169 170
Causes of Horner Syndrome

•Trauma
•Brainstem infarction interrupting descending

axons from hypothalamus
•Neoplasm or inflammatory mass at lung

apex, neck, base of skull or orbit
•Vascular diseases of the carotid artery

(cervicocephalic arterial dissections or
aneurysms)
171 172

Elevation of the Eyelid
•Superior tarsal (Muller’s) muscle
•Carotid sympathetic nerve
•Levator palpebrae
•CN III
•Quick or phasic rise and fall during vertical

eye movements
•Paralysis causes more severe ptosis, and

paralysis of lid elevation during upgaze
CLINICAL EXAMINATION OF PTOSIS
173 174
Causes of Ptosis
Sympathetic
CN III lesion • Central: hypothalamus, brainstem, spinal
pathway lesion
cord
Corectasia / mydriasis Cormiosis •Peripheral: along the course of CN III or

sympathetic nerves
Usually have Pupil reacts to light and

•Neoromyal: nerve-muscle junction
heterotropia accommodation (Myasthenia gravis, Lambert Eaton
syndrome)
Eyelid elevates on •Muscle: myopathic, congenital,

Normal sweating
upward gaze inflammatory, traumatic
•Others: edema, dehiscence of aponeurosis

175 176

Eponymic Conjunction Syndromes of
Causes of Ptosis Ocular Motor Cranial Nerves
•Bell's Palsy (CN VII): corrected by eyelid •Gradenigo: retroorbital pain, CN VI palsy,
lifting test, while it remains in CN III palsy
otitis media
•Cerebral ptosis: in acute strokes, uni- or •Tolosa Hunt: painful opthalmoplegia due to
bilateral ptosis, usually in right hemisphere; idiopathic granulomatous inflammation of the
complete bilateral ptosis may predict brain cavernous sinus or superior orbital fissure
herniation
• Raeder’s Paratrigeminal: severe unilateral
•MG: enhanced ptosis when other lid facial pain and headache V1 division with
elevated, improves with ice pack test ipsilateral oculosympathetic palsy or Horner
syndrome
177 178
Cavernous Sinus CASE
34/F sudden double vision

Unable to adduct, elevate, or depress right eye, but it
did intort when she looked down and left.
Right eyelid did not elevate on volitional upgaze.
Right pupil did not react directly nor consensually.
Left pupil reacted normally. Rest of findings normal.
179 180

CASE CASE
21/F deep pain behind left eye x weeks
Right CN III
Diplopia looking far left. For some weeks her left
eyelid had drooped. Examination showed ptosis that
was corrected on upward gaze, miosis, and mild
R PCom aneurysm weakness of abduction of the left eye; however,

the corneal light reflections remained aligned when
she had her eyes in the primary position.
181 182
CASE CASE
She had no other neurologic abnormalities. At her doctor’s Sympathetic ptosis,

request, the Pt brought in old facial photographs that proved
that the ptosis was new. Does the lesion localize to one minimal lateral rectus palsy (CN VI),
nerve? If not, what nerves are implicated? pain (CN V)
183 184

CASE CASE
The conjunction site of the sympathetic pathway and the VI

Because this Pt had only ptosis and miosis without
nerve is at the cavernous sinus region. This region receives
hemifacial anhidrosis, the lesion must have affected her
its sensory innervation from CrN V. Hence, some lesion was
sympathetic pathway distal to the origin of her external
progressively attacking successive sensory and motor
carotid artery.
nerves at the base of the skull.
185 186
CASE
Thank you for your kind attention
Inspection of the nasopharynx disclosed a soft tissue mass.

For questions:
Radiographs of the skull base showed bony erosion. A biopsy nicole.bernardo@gmail.com
disclosed a nasopharyngeal carcinoma. It had infiltrated the
base of the skull and cavernous sinus and encircled the
internal carotid artery, where it had interrupted the carotid
sympathetic and VI nerves. Painful ophthalmoplegia of this
type is called the Tolosa-Hunt syndrome.
187 188

REFERENCES
Biller J, Gruener G, Brazis P Patten J

DE MYER’S THE NEUROLOGICAL
NEUROLOGIC EXAMINATION DIFFERENTIAL DIAGNOSIS
UP-PGH
Department of Neurosciences
NEURO OSCE VIDEO
https://www.youtube.com/watch?v=ldiNRvLhQ3A
189 190
https://www.youtube.com/watch?v=lWKkHWWDIEI
191

Cranial Nerves 3 4 6 Handout

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cranial Nerves 3 4 6 Handout

Uploaded by

Copyright:

Available Formats

CRANIAL NERVES III, IV & VI:

OCULOMOTOR, TROCHLEAR & ABDUCENS

Cranial Nerves 3 4 6 - 13 September 2019

Suppression of physiologic diplopia

Cranial Nerves 3 4 6 - 13 September 2019

Cranial Nerves 3 4 6 - 13 September 2019

Primary action: Abduction

Cranial Nerves 3 4 6 - 13 September 2019

Superior Rectus Superior Rectus

Primary action: Elevation Secondary action: Adduction

Cranial Nerves 3 4 6 - 13 September 2019

Tertiary action: Intorsion

Superior Rectus Superior Rectus

Primary action: Elevation Primary action: Elevation

Cranial Nerves 3 4 6 - 13 September 2019

Primary action: Elevation Primary action: Elevation

Superior Rectus: Superior Rectus:

Primary action: Elevation Direction patient should look to

Cranial Nerves 3 4 6 - 13 September 2019

Direction patient should look to

Inferior Rectus Inferior Rectus

Primary action: Depression

Cranial Nerves 3 4 6 - 13 September 2019

Primary action: Depression Primary action: Depression

Primary action: Depression Primary action: Depression

Cranial Nerves 3 4 6 - 13 September 2019

Direction patient should look to test

Superior Oblique Superior Oblique

Primary action: Depression

Cranial Nerves 3 4 6 - 13 September 2019

Primary action: Depression Primary action: Depression

Primary action: Depression Primary action: Depression

Cranial Nerves 3 4 6 - 13 September 2019

Direction patient should look to test INTORSION

Inferior Oblique Inferior Oblique

Cranial Nerves 3 4 6 - 13 September 2019

Primary action: Elevation Primary action: Elevation

Inferior Oblique Inferior Oblique

Primary action: Elevation Primary action: Elevation

Cranial Nerves 3 4 6 - 13 September 2019

Primary action: Elevation Direction patient should look to

Cranial Nerves 3 4 6 - 13 September 2019

Muscle Primary Secondary Tertiary Muscle Cranial Nerve

IR Depresses Adducts Extorts IR III

SO Depresses Abducts Intorts SO IV

Cranial Nerves 3 4 6 - 13 September 2019

Yoking of Ocular Muscles

•Muscles yoked for conjugate eye

•Right lateral rectus and left medial rectus IR SO IR

Cranial Nerves 3 4 6 - 13 September 2019

Cranial Nerves 3 4 6 - 13 September 2019

Range of Movement Testing Range of Movement Testing

Cranial Nerves 3 4 6 - 13 September 2019

Range of Movement Testing Range of Movement Testing

Cranial Nerves 3 4 6 - 13 September 2019

Range of Movement Testing Range of Movement Testing

Cranial Nerves 3 4 6 - 13 September 2019

Range of Movement Testing Range of Movement Testing

Cranial Nerves 3 4 6 - 13 September 2019

Range of Movement Testing Range of Movement Testing

Cranial Nerves 3 4 6 - 13 September 2019

Do you have diplopia?

Do you see one or

Cranial Nerves 3 4 6 - 13 September 2019