Oculomotor system
Foveate – align each eye so as to the central light rays
fall in the fovea, primary fixation fixed forward, eyes
must be continually foveate as it moves in any direction
Foveation – promotoes visual acuity and a single fused
mental image secures advantages
Visual axes during distant vision – achieve by looking
straight, from infinity to the fovea centralis of one eye,
to the center, defines visual axis, coverge eyes, eyes
adducted and central ight ray remains in max acuity
Determine dominant eye: fixate object across the room,
put index finger 10-20cm from eye, wink the right eye
then the left eye as you fixate on the distant object
Produce physiologic diplopoa, both eyes open, fixate on
imaginary object, fixate strongly on your fingertop but
secondarily attend to the doorknob
-alternate focusing strongly on one target while attend
to the other target
-doubling of finger and doorknow
-object shifts from one another, changed from
angulation of the visual axes when eyes fix on near to
distant point
-fall off fovea and macula
Self production of pathologic diplopoa, place tip of your
right index finger on your right
While fixating press very gently on your right eyelid just
above the canthus with your right index finger
-by changing the pressure, you should change the
diplopia
-the distance between diplpoc images inreases
True image- visual iamge of aligned eye and false image
is the image of misaligned
True images vs false – nondisplaced eye receives the
central rays from the visual target directly on the cones,
the site of the sharpest vision
SO – originates lesser wing just above annulus and
branch through the cochlea which is attached to rim of
bony orbit
-list down the extra ocular muscles and site their origin
and insertion and demonstrate action
EOM recti – originate from annulus oxin
SO – lesser wing of sphenoid
???
MR – adduction
LR – abduction
All other muscles have secondary and tertiary actions
Test the EOMS
-start from the midline
-test the horizontal, index horizontal and vertical use
vertical index
-for convention use right hand
Range of movement of your eye
Examine for mal alignment, cover uncover test, place
the right hand on the head, thumb is the labellar area
so you can easily move the thumb to cover left eye and
right eye
-see if the corneal reflections is equal, center of the eye
-don’t tell them that banlag sila
Heterotropia
Exotropia – deviates outward
Esotropia – eye deviates inward
Hypertorpia – upward
Hypotropia – downward
Mononuclear heterotropia, right esotropia
Alternating heterotropia, 2 esotropia
Heteroforia, alternating esotropia
Heteroforia, intermittent right esotropia
Refraction and Accomodation
Prism – bends light rays to its base
Prism with two bases together – the light will converge,
positive converging lens
Prims with two apex together – diverge, negative
Pinhole can also focus this because central
nonrefractive rays and block the peripheral rays
Accommodation reflex
Convergence – medial recti skeletal
Pupilloconstriction – iris smooth muscle parasympa
Lens thickening ciliary muscle – smooth muscle
parasympathetic
Thicken – ciliary muscle parasympa
-three vents, convergence, constriction and thickening
Myopia, hyperopia
Emotropic eye – parallel rays focus without
accommodation
Hyperopia – too short eyeball so lense need to thicken
to bring parallel rays focus on the retina, distant objects
more clear than nearer object, far sighted
Myopia – diameter of eyes too long, blurred vision for
distant but sharp on close, near sighted
Myopic people – matigas na ung lens, able to read near
objects just by removing lenses,
Cranial nerve 3, 4, 6 carotid sympathetic nerve, 2 motor
and 2 sensory, afferent nerve come to cranial nerve 2
and cranial nerve 5
2 of somato motor nerves serve only 1 EOM – CN6 LR
CN4 SO
CN3 – serves remaining EOMS, and 2 of 3 intraocular
muscles, conveys para sympathetic fibers, pupillary
constrictor and ciliary
Carotid = pupilidilator, carotid artery at level of carotid
sinus orbital fissure
Examination of pupils: technique of pupillary
examination
Normal illumination of the room
No direct sunglight
Ask patient to gaze at a distant point to avoid
pupilloconstriction from the accommodation
Technique of upillary exam
Pupils black, equal size, round and react to light and
accommodation
Normal pupils appears almost exactly centered in the
iris
A nonblack pupil indicates opacification of the cornea or
lens
Record pupillary sizes in millimeters
Fayser Fleischer ring – pathonomic sign of willsons
disease, pathoreticular degeneration
Technique of pupillary examination
Dim the lights and inspect the pupuls immediately and
after 5-15s
Normal pupils dilate promptly with 5 s of dimming light
Myotonic pupil if there is lac
Check the direct and consensual pupillary light reflexes
Observe whether pipults constrict proimptlky and
equally
Direct light reflex and consensual light reflex
Don’t shine directly in front, liliit dahil accommodation
and might cause discomfort
Watch the equal reaction
Artral Robertson – bilateral pathonomic of syphilis, no
dilation, kunan ng CSF, lumbar puncture to confirm
diagnosis
AD tonic syndrome – both pupils, atonic pupil
malcoretasia, unilateral anisocira??, slow pupilarry
dilation, no reaction seen, benign disorder,
Pathways of pupillary light reflex, contraletral course of
axon and optic chiasm from multipolar neurons of
ganglion cell layer, parasympathetic nucleus CNIII
edener westpal nucleus
Stimulate light in one eye, distributed bilaterally, pupils
in both eyes will constrict, effector axons travel both
eyes via both cn III
Parasympa of ciliary and epescleral ganglion near the
end organs
Ganglion of sympathetic system is located near the neck
Physiology and pharmacology of the pupils:
The eyeballs contain three intraocular muscles, all
smooth muscles
Pupillodilator and pupilloconstrictor muscles of iris
adjust the diameter of the pupil
Parasymn cholinergic – constrictor
Sym adrenergic – dilator
Parasympathetic paralysis of eye
Msucles of general visceral effecrent para sym CNIII
intraocular and smooth muscle, only efferent pathway
for active pupilloconstrictor
Dilatation: ischemia, aneurysm of ciclke of willis,
neoplasm or inflammation
Ischemia of the III nerve spares the pupil, find out why
this happens, nerves for pupil located near the cover
the nerves for the movement located medially, ischemia
will not affect the puil, it affects the inner portion of the
nerve
Inner portion vulnerable to ischemia
Outer portion where axons to pupillary constriction
vulnerable to pressure
Compression of aneurysm – pupillary constnriction is
affected
Sympathetic pathway to the eye, upper motor pathway
begins in the thalamus, brainstem to spinal cord, lower
motor neurons of intermediate cell, L1 L2 L3 but eye
uses axons T1-T2, second order synapse in
paravertebral ganglion,
Parasympathetic smooth muscles sweat glans to face,
internal carotid sweat glands forehead
Sympathetic axons innervate two ocular muscles
superior tarsal and pupillodilator
Case: 21 years old stab wound of neck
List of signs? Ipsilateral ptosis, pupilloconstriction
anhuidrosis, flushing (Bernard horner syndrome)
Sympaatehtic pathway
If the lesions interrupts the sympathetic pathway distal
to the origin of the common carotid artery, only
sympathetic denervation
Causes of horner syndrome
Direct trauma
Brainstem infarction
Neoplastic inflammatory masses in lung apex, TB, base
of skull, orbit
Vascular disease of the carotid artery
Ptosis – two muscle elevate eyelid
Superior tarsal muscle, levator palpebrae muscle
Smooth muscle acts tonmically to elevate, levetaory
palpebrae severe tasal ptosis, allows the eyelid
automatic elevate eye in the presence of sympathetic
ptosis
Other causes of ptosis
Myasthenia gravis, myopathic ptosis in muscular
dystrophies, injury or inflammation, congenital
CN – conjunction syndrome, base of the forebrain and
pituiotary fosssam region of cavernous isnus, 2,3,4,5,6,
carotid sympathetic cnerve, carotid sinus infection can
cause ptosis, reflect
Pain numbness in ophthalmic division of CN V
Gradenigo syndrome abducen nerve paralysis
Tolosa hunt syndrome – retroorbital pain, ocular motor
weakness, diminished facial sensation
Examination – central ocular motor system
Control movement they have two speeds, fast and slow
Saccades – physiologic fast eye movements, indued by
caloric stimuli
Slow eyemovement – smooth pursiutm, vergences and
deviation phase of vestibvular and optokinetic
nystagmus
Corrective phase is saccades
Five eye movement systems tested by neurologic
-sacadic, fixation ,smooth pursiot, counter rolling
Saccade: to jerk or rein in
Eye movemnts by icnrements or jerks, all voluntary
mvoements require saccades one cannot move ones
eye smoothly voluntarily
Fronto-tegmental corticobulbar pathways
Fixation – hold eyes on the target and promote fusion
of both retinal images into one sharp image
Breaking away form chosen target requires generation
of another saccade
Fixation reflexes tend to keep the eyes on target whjen
head moves
Retino-geniculo ioccipitopareiot frontal tegmental
pathways
Smooth pursiot – keeps eyes on target when target
moves, drug intoxication causes irregular jerky rather
than smooth pursuit
Vergence system – converge or diversge of eyes to
insure of suion gof the two retinal images and
prpopriate regraction when persons looks at near or
distanct visual target,
Counter rolling – reflexively moves eyes against
direction of head to maintain fixation on the chosen
visual target
Two system collaborate:
Ocular fixation and proprioceptive system. Counter rolls
the eyes an action callerd vestibule ocular reflex
Coticopointine pathway for voluntary conjugate
horizontal eye movements