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Eye Movements
Jason Ryan, MD, MPH
 Eye Movement
Superior
Rectus
Superior
Oblique

Lateral Medial
Rectus AfraTafreeh.com Rectus

Inferior
Oblique
Inferior
Blue = CN III Rectus
CN III
Red = CN IV (Trochlear)
Raise Eyelid
Green = CN VI (Abducens)
Constrict Pupil
LR6SO4
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Eye Nerve Palsies

• Oculomotor (III)
• Trochlear (IV)
• Abducens (VI)
• Many causes: strokes, tumors, aneurysms
Terminology
• Move eye away from nose
• Lateral
• Abduction
• Move eye toward nose
• Medial AfraTafreeh.com
• Adduction
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Diplopia
• Two different images of same object
• Diplopia due to nerve palsies is binocular
• Resolves when one eye is covered
• Monocular diplopia: usually lens problem (astigmatism)

Jonathan Trobe, M.D./Wikipedia

Oculomotor (III)
• Moves eye up and medially
• Up (superior rectus)
• Medial (medial rectus)
• Elevates eyelid (levator palpebrae)
• Pupillary constrictionAfraTafreeh.com
(sphincter pupillae)
• Parasympathetic fibers from Edinger-Westphal nucleus
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Oculomotor Nerve Palsy

• Effected side
• Eye down, out
• Ptosis (eyelid droop)
• Pupil dilated
Rule of the Pupil
• Cranial nerve III lesion: eye down and out
• Pupil dilation: Parasympathetic nerves impacted
• Parasympathetic fibers run on outside of nerve
• Easily compressed by mass (Pcomm aneurysm)
• Absence of pupillaryAfraTafreeh.com
dilation suggests ischemia
• CNIII ischemic nerve damage common in diabetes
• Spares superficial fibers to pupil

Wang Y, Wang XH, Tian MM, Xie CJ, Liu Y, Pan QQ, Lu YN
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Trochlear (IV)
• Superior oblique
• Turns eye down; intorsion
• Reading/stairs
• Palsy symptoms
• Diplopia
• Eye tilted outward
• Unable to look down/in (stairs, reading)
• Head tilting away from affected side (to compensate)
Abducens (VI)
• Lateral rectus
• Affected eye may be pulled medially at rest
• Problems worse on horizontal gaze
• Affected eye can’t move laterally
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Right VI Lesion R L
Rest

R L
Right Gaze
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Estropia
• Type of strabismus (misalignment of the eyes)
• Inward turning of one or both eyes
• Can be seen in CN VI palsy

Kakawere/Wikipedia
Pseudotumor Cerebri
• High intracranial pressure (ICP) can cause CN VI palsy
• Nerve course highly susceptible to pressure forces
• Sometimes bilateral palsy
• May see papilledema on fundoscopy
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• Classic patient:
• Overweight woman
• Childbearing age
• Headaches