NERVII OCULOMOTOR,

TROCHLEARIS, DAN ABDUCENT

ANATOMICAL STRUCTURE AND
CLNICAL APPROACH
• Overview anatomy nerves III, IV, and VI
• overview clinical examination
• overview dysfunction of the nerve
ANATOMICAL
STRUCTURE
 NERVII CRANIALES
• SENSORIC
N. I, II, VIII
• MOTORIC
N. III, IV, VI, XI, XII
• SENSORIC-MOTORIC
N. V, VII, IX, X
ANATOMY N. OCULOMOTOR
NUCLEUS N. OCULOMOTOR CONSISTS OF:
• MAIN NUCLEUS
• ACCESORY NUCLEUS OF EDINGER WESTPHAL

• 24000 FIBERS
NOTATION

M.Lev. Palp. Sup. Supplied by a single

central caudal nucleus

M. Rec. Superior is supplied by contralateral

nucleus oculomotor

Remaining muscles are supplied ipsilaterally

DIVIDED INTO:
• PARS SUPERIOR (SMALLER BUNDLE OF FIBERS)
• PARS INFERIOR (LARGER BUNDLE OF FIBERS)

NOTATION:
• SMALL ELEVATION IN INFERIOR PART CAUSED BY
FIBER OF CILIAR MUSCLE THAT CONTAINS
PARASYMPHATETIC FIBER.
• FIBERS THEN JOIN THE CILIARY GANGLION.
 ANATOMY N.TROCHLEAR
• THE MOST SLENDER CRANIAL NERVE (3400
FIBERS)
• THE ONE AND ONLY CRANIAL NERVE COMES
OUT FROM THE DORSAL PART OF MID BRAIN
(75 MM).
• IMMEDIATELY DECUSSATES WITH THE NERVE
OF THE OPPOSITE SIDE
ANATOMY N. ABDUCENT
• RECEIVED SYMPHATETIC FIBERS OF INTERNAL
CAROTID PLEXUS TRANSIENTLY. THOSE FIBERS
LATER LEAVE THE ABDUCENT NERVE TO JOIN
OPHTALMIC NERVE.
 Extraocular Muscles
Horizontal Rectus
Muscles:
-MR
-LR

Vertical Rectus Muscles:

-SR
-IR

Oblique Muscles:
-SO
-IO
 Action of the Extraocular Muscles
from Primary Position
Actions of the Extraocular Muscles from Primary Position
Muscles Primary Secondary Tertiary
Medial Rectus Adduction - -
Lateral rectus Abduction - -
Inferior Rectus Deppression Extorsion Adduction
Superior Rectus Elevation intorsion Adduction
Inferior Oblique Extorsion Elevation Abduction
Superior Oblique Intorsion Depression Abduction
 Positions of Gaze
• Primary position is the position of the eyes
when fixating straight ahead.
• Secondary positions are straight up, straight
down, right gaze, left gaze
• Tertiary positions are the 4 oblique positions
of gaze: up and right, up and left,down and
right, down and left.
• Cardinal positions are up and right, up and
left, right, left, down and right, down and left
 CLINICAL
EXAMINATION
 Evaluation of Eye Movements
STEPS :
1. Sit facing the patient. Hold your finger or a
small fixation target at eye level. Distance : 10-
14 inch. Patient looking in primary position
(straight ahead).

2. Ask the patient to follow the target as you

move into 6 cardinal fields and then up and
down the midline.
Elevate the upper eyelid with a finger on your
free hand to abserve movements in down gaze.
Evaluation of Eye Movements

Figure: Primary position and cardinal positions. (Duane`s Opthalmology.

Volume 1. Chapter 2 : Eye Movements and Positions)
 Evaluation of Eye Movements
STEPS :

3. Note whether the amplitude of

eye movement is normal/abnormal.
Record the underaction or
overaction.
Note: 0 = normal, -1 to -4 =
underactions, +1 to +4 = overaction.
 COVER TEST

• Make sure that the patient`s usual refractive

correction is in place.
1
• Have the patient look at a distance fixation
target (20 feet/6 m), and position yourself
directly opposite the patient, w/in arms
2 reach w/o obstructing patient view.
 COVER TEST
• Swiftly cover the fixating eye with an
occluder or your hand, and observe the
other eye for any movement. Carefully note
3 its direction.

• Uncover the eye and allow about 3 seconds

for both eyes to be uncovered
4
 COVER TEST
• Swiftly cover the other eye and
observe its fellow eye for any
5 movement.

• Ensure that the patient is

maintaining fixation on the same
6 point as established for step 1.
 COVER TEST
• Note the results but do not
record them until other cover
7 testing is completed.

• Repeat the test for near, using a

near fixation point (13
8 inches/33cm).
 Three Step Test

• To adress 3 question:
1. Is there any left or right hypertropia in
primary position?
2. Does the deviation increase in right gaze or
left gaze?
3. Does it increase with the head tilt to the right
or to the left?
 Three Step Test
8 cyclovertically acting muscles:

4 work as depressors 4 work as elevators

(2 in each eye) (2 in each eye)
• inferior rectus (IR) • superior rectus (SR)
• superior oblique • inferior oblique (IO)
(SO)
 Step 1

• Determine which eye is hypertropic by using

the cover·uncover test
• Narrows the number of possible underacting
muscles from 8 to 4.
 Step 2

• Determine whether the vertical deviation is

greater in right gaze or in left gaze.
• Draw an oval around the 4 vertically acting
muscles that are used in right or left gaze.
 Step 3

• Known as the Bielschowsky head· tilt test

• Tilting the head to the right and then to the
left during distance fixation.
• Head tilt to the right stimulates intorsion of
the right eye (RSR, RSO) and extorsion of the
left eye (LIR, LIO).
• Head tilt to the left stimulates extorsion of the
right eye (RIR, RIO) and intorsion of the left
eye (LSR, LSO).
Three Step Test
DYSFUNCTION OF
THE NERVES
CN III PALSY
 Nuclear complex
• Levator subnucleus
• Superior rectus subnuclei
• Medial rectus, inferior rectus, inferior oblique
subnuclei
 Fasciculus
Lesions in the fasciculus can cause these
syndromes :
1. Benedikt :
2. Weber
3. Nothnagel
4. Claude
Basilar
 Intracavernous
1. Diabetes
2. Pituitary apoplexy
3. Intracavernous
 Intraorbital
• Superior division
• Inferior division
 Pupillomotor fibers
• Surgical lesions
• Medical lesions
 DIAGNOSIS
• Signs :
– Profound ptosis
– Abducted in primary position
– Intorsion of eye at rest
– Normal abduction
– Limited adduction
– Limited elevation
– Limited depression
– Dilated pupil  defective accomodation
• Abberant regeneration

Regrow of nerve fibers

↓
Misrouting
↓
Synkinetic phenomena
 Causes of isolated CN III palsy
• Idiopathic
• Vascular
• Aneurysm
• Trauma
• Miscellaneous
 Treatment
• Non-surgical :
– Fresnel prisms
– Uniocular occlusion
– Botulinum toxin injection
• Surgical
 FOURTH NERVE PALSY
Causes of isolated CN IV palsy :
1. Congenital
2. Trauma
3. Vascular
 Signs
If left CN IV palsy :
• Left hypertropia in primary position; and
increase on right gaze
• Left limitation in depression an adduction
• Exyclotorsion
• Diplopia  vertical, torsionl, and worse on
looking down
Abnormal head posture
 Bilateral involvement
• Right hypertropia in left gaze and vice versa
• > 10 degrees of cyclodeviation on double
Maddox rod testing
• “V” pattern esotropia
• Bilaterally (+) Bielschowsky test
 Special tests
1. Parks three step tests
2. Double Maddox rod testing
 Symptoms

• Horizontal
diplopia, that
worswn on
ipsilateral gaze
• Esotropia in
primary gaze
 Causes
• Ischaemic mononeuropathy (most common)
• Lesion of CPA (acoustic neuroma or meningioma)
• Chronic inflammation of petrous bone (Gradenigo syndrome)
• Meningeal/skull-based processes (meningioma, nasopharingeal
Ca, chordoma, chondrosarcoma)
• Head trauma/increased ICP
• Collagen vascular disease (sarcoidosis/syphilis)
• Neuromuscular junction disease (MG)
• Leukimia/brain glioma (children)
• Multiple sclerosis
 Work-up
• A typical workup of a sixth nerve palsy
involves excluding paresis of other cranial
nerves (including VII and VIII)
• checking ocular muscle motility
• evaluating pupillary responsiveness
• checking deep tendon reflexes (DTRs) and
motor function to exclude corticospinal tract
involvement also is important.
• MRI is indicated for any brainstem findings to
exclude pontine glioma in children (most have
papilledema and nystagmus without other
cranial nerve involvement) and in adults who
show no improvement.
 Goal of Treatment
• identify and treat the cause of the condition
• to relieve the patient's symptoms (if possibl)
• In children, who rarely appreciate diplopia,
the aim will be to maintain binocular vision
and, thus, promote proper visual
development.