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OCULAR MOTOR NERVE PALSIES PowerPoint PPT Presentation


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OCULAR MOTOR NERVE PALSIES. 1. Third nerve. 2. Fourth nerve. 3. Sixth nerve. Anatomy of third nerve. Oculomotor nucleus. Pituitary gland. Red nucleus. Carotid artery. Cavernous sinus. Pons. III nerve. Post cerebral artery. Clivus. Basilar artery.

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OCULAR MOTOR NERVE PALSIES

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OCULAR MOTOR NERVE PALSIES

1. Third nerve

2. Fourth nerve

3. Sixth nerve


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Anatomy of third nerve

Oculomotor nucleus

Pituitary gland

Red nucleus

Carotid artery

Cavernous sinus

Pons

III nerve

Post cerebral artery

Clivus

Basilar artery


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Applied anatomy of pupillomotor nerve fibres

Blood vessels on pia mater supply surface

of the nerve including pupillary

fibres ( damaged by

compressive lesions )

Vasa nervorum supply part

of nerve but not pupillary

fibres ( damaged by medical

lesions )

Pupillary fibres lie dorsal and peripheral


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Signs of right third nerve palsy

  • Ptosis, mydriasis and cycloplegia

  • Abduction in primary position

  • Normal abduction

  • Intorsion on attempted

  • downgaze

  • Limited adduction

  • Limited depression

  • Limited elevation


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Hess chart of right third nerve palsy

  • Contraction of right chart and expansion of left

  • Right chart - underactions of all muscles except lateral rectus and superior oblique

  • Left chart - overactions of all muscles except medial rectus and inferior oblique


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Important causes of isolated third nerve palsy

Idiopathic - about 25%

Vascular disease - hypertension, diabetes

Trauma

Posterior communicating aneurysm

Extradural

haematoma

Aneurysm

Chiasm

Midbrain

pushed

across

Edge of

tentorium

Prolapsing

temporal

lobe

Posterior cerebral

artery

Third nerve


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Internal carotid artery

Postr. communicating

artery

III

VI

Postr.cerebral artery

Supr.cerebellar artery

Basilar artery

IV

  • Only cranial nerve to emerge dorsally

  • Crossed cranial nerve

  • Very long and slender

Anatomy of fourth nerve


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Signs of right fourth nerve palsy

  • Right hyperdeviation in primary

  • position when left eye fixating

  • Excyclotorsion

  • Right underaction on depression

  • in adduction

  • Vertical diplopia

  • Right overaction on left gaze


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Positive Bielschowsky test in right fourth nerve palsy

Absence of right

hyperdeviation on

contralateral head tilt

Increase in right

hyperdeviation on ipsilateral

head tilt


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Hess chart of right fourth nerve palsy

  • No significant difference in chart size

  • Upward deviation of right fixation spot on inner chart (hypertropia)

  • Downward deviation of left fixation spot on inner chart

  • Right chart - underaction of superior oblique and overaction of inferior oblique

  • Left chart - overaction of inferior rectus and underaction of superior rectus


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Anatomy of sixth nerve

Basilar artery

Pituitary gland

Medial

lemniscus

Carotid artery

4th ventricle

Cavernous sinus

Petroclinoid

ligament

Clivus

Vestibular

nucleus

VI nerve

Pyramidal tract


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Recent right sixth nerve palsy

Right esotropia in primary position due to

unopposed action of right medial rectus

Marked limitation of right abduction due to

right lateral rectus weakness


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Hess chart of recent right sixth nerve palsy

  • Contraction of right chart and expansion of left

  • Right chart - marked underaction of lateral rectus and mild overaction of medial rectus

  • Left chart - marked overaction of medial rectus


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Old right sixth nerve palsy

Straight in primary position due to partial

recovery

Limitation of right abduction and

horizontal diplopia

Normal right adduction


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Important causes of isolated sixth nerve palsy

Vascular - hypertension, diabetes

Raised intracranial pressure

Acoustic neuroma

Dilated

ventricles

Petrous

tip

Brainstem pushed downwards


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