EXAMINATION OF CN
3,4 AND 6
BY DR JITENDRA KUMAR
More attention:
Nuclei of the cranial nerves
Cranial nerve Site of nucleus
1st, 2nd directly go to the
cerebral cortex
3rd, 4th midbrain
5th, 6th, 7th, 8th pons
9th,10th,11th,12th medulla oblongata
The oculomotor, trochlear and abducent
nerve
• There are 3 pairs of cranial nerves which supply ocular movement.
• The 3rd cranial nerves are called oculomotor nerve.
• The 4th, trochlear nerve.
• The 6th, abducent nerve.
THE OCULOMOTOR NERVE
• The oculomotor, or third cranial nerve (CN III),arises from the oculomotor nuclear complex in the
midbrain and conveys motor fibers to extraocular muscles, plus parasympathetic fibers to the
pupil and ciliary body
• CN III has a superior and an inferior division. The superior division supplies the levator palpebrae
superioris and superior rectus muscles. The inferior division supplies the medial and inferior recti,
the inferior oblique, and the pupil
• The Edinger-Westphal (EW) nuclei are part of the craniosacral, or parasympathetic,division of the
autonomic nervous [Link] EW subnucleus is a single structure that provides
parasympathetic innervation to both sides.
• The nerve exits from the interpeduncular fossa on the anterior surface of the midbrain just above
the pons
• It runs forward parallel to the posterior communicating artery. Third nerve palsy is a classic and
important sign of posterior communicating aneurysm
• In its course toward the cavernous sinus, it lies on the free edge of the tentorium cerebelli,
medial to the temporal lobe. Here it is at risk of compression due to uncal herniation.
• CN III separates into its superior and inferior divisions in the anterior cavernous sinus, then enters
the orbit through the superior orbital fissure and passes through the annulus of Zinn.
• It sends a short root to the ciliary ganglion, from which postganglionic fibers go as the short
ciliary nerves to supply the ciliary muscle and the sphincter pupillae
The actions of
extraocular muscles
The right eye
The 3rd nerve: oculomotor nerve
• Its nucleus lies in the midbrain.
• It supplies levator palpebrae superioris,
medial rectus, superior rectus, inferior rectus
and inferior oblique.
• The oculomotor nerve also contains
parasympathetic fibers. They supply
intraocular muscles
The 4th nerve: The 6th nerve:
trochlear nerve abducent nerve
• Its nucleus also lies in the midbrain. • Its nucleus lies in the pons.
• It supplies superior oblique muscle. • It supplies lateral rectus muscle.
THE TROCHLEAR NERVE
• The trochlear, or fourth cranial nerve (CN IV), is the smallest CN. It arises from the trochlear
nucleus located just anterior to the aqueduct in the gray matter of the lower mesencephalon at
the level of the inferior colliculus, immediately above the pons and caudal to the lateral nucleus
of CN III
• The nerve filaments curve posteriorly around the aqueduct, decussate in the anterior medullary
velum, and exit through the tectum. It is the only CN to exit from the brainstem posteriorly
• The nerve circles the brainstem, then turns and runs forward, passing between the posterior
cerebral and superior cerebellar arteries
• It penetrates the dura just behind and lateral to the posterior clinoid processes and enters the
cavernous sinus in proximity to CN III.
• Leaving the cavernous sinus,it traverses the superior orbital fissure, enters the orbit,
THE ABDUCENS NERVE
• The nucleus of the abducens, or sixth cranial nerve(CN VI), lies in the mid to lower pons, in the
gray matter of the dorsal pontine tegmentum in the floor of the fourth ventricle, encircled by the
looping fibers of the facial nerve
• The nerve exits anteriorly at the pontomedullary junction, crosses the internal auditory artery,
and then ascends the clivus in the prepontine cistern
• It enters the orbit through the superior orbital fissure and the annulus of Zinn to innervate the
lateral rectus.
3rd cranial nerve paralysis
• Ptosis: paralysis of levator palpebrae superioris.
Drooping of eyelid
Palpebral fissure
3rd cranial nerve paralysis
• The eye ball is deviated laterally.
• The eye ball cannot move medially, upwards and downwards.
• Pupil is dilated.
• Diplopia
3rd cranial nerve 4 cranial nerve
th
paralysis
• Etiology
paralysis
• Diabetes mellitus • 4th cranial nerve lesion, namely
• Pupil is usually not affected.
trochlear nerve lesion, can cause
• Aneurysm of PoCA
paralysis of the superior oblique.
• Midbrain lesion
• Weber syndrome
• Unilateral oculomotor paralysis
• Contralateral hemiplegia
• Cavernous sinus thrombosis
• oculomotor paralysis
• 4th, 6th cranial nerves are also involved.
6th cranial nerve paralysis
• 6th cranial nerve injury results in paralysis of the
lateral rectus (cannot move laterally) and the eye ball
is deviated medially.
• In pontine lesion, if 6th cranial nerve is involved, there
will be crossed hemiplegia ， that is 6th cranial nerve
paralysis on one side and hemiplegia on the opposite
side.
Internuclear ophthalmoplegia
• Symptom
• When patient is asked to look quickly to
each side, such as to left, there is nystagmus
of that eye (left eye) and the opposite eye
cannot move medially.
• But accommodation reflex is normal. Look
at a distant object and then look at his nose.
There will be convergence of eyes.
• The lesion is in the medial longitudinal
fasciculus (MLF).
• Examination of the eyes begins with inspection—looking for any obvious ocular malalignment,
abnormal lid position, or abnormalities of the position of the globe within the orbit.
Exophthalmos and Enophthalmos-The globe may be abnormally positioned within the
orbit so that it protrudes (exophthalmos, proptosis) or recedes (enophthalmos)
The Eyelids-Patients may couch the complaint of ptosis (blepharoptosis) in ways other than
droopy eyelid (e.g.,eye has shrunk). Fluctuating ptosis may suggest myasthenia gravis (MG),
although many varieties of ptosis, as in Horner’s syndrome, may get worse when the patient is
fatigued.
Lid Retraction-Lid position is abnormal if there is a rim of sclera
showing above the limbus, indicating either lid retraction
or lid lag. exa(posterior commissure lesion,midbrain lesion,parkinson’s disease)
The Pupillary Reflexes
• The principal pupillary reflex responses assessed on examination are
the light response and the near response (“accommodation”). The
normal pupil constricts promptly in response to light. Pupillary
constriction also occurs as part of the near response,along with
convergence and rounding up of the lens for efficient near vision.
Normally, the light and near responses are of the same magnitude.
The Light Reflex
• The pupillary light reaction is mediated by the macula,optic nerve, chiasm, and optic tract
• The pupillary light reflex (PLR) or photopupillary reflex is a reflex that controls the diameter of the
pupil, in response to the intensity (luminance) of light that falls on the retinal ganglion cells of the
retina in the back of the eye, thereby assisting in adaptation of vision to various levels of
lightness/darkness. A greater intensity of light causes the pupil to constrict (miosis/myosis;
thereby allowing less light in), whereas a lower intensity of light causes the pupil to dilate
(mydriasis, expansion; thereby allowing more light in). Thus, the pupillary light reflex regulates
the intensity of light entering the eye. Light shone into one eye will cause both pupils to constrict.
• Type- direct light reflex
indirect light reflex
•➢ Reduce illumination of room & vision should focus on a far
object
•➢ A bright beam of light is shone from the side of one eye
•➢ Repeat on the other side
• [the pupil should constrict briskly]
•➢ Shield one eye & perform test on the other & see for
consensual reaction
The Accommodation Reflex
• The reflex, controlled by the parasympathetic nervous system, involves three responses: pupil
constriction, lens accommodation, and convergence.
• The accommodation reflex (or accommodation-convergence reflex) is a reflex action of the eye,
in response to focusing on a near object, then looking at a distant object (and vice versa),
comprising coordinated changes in vergence, lens shape (accommodation) and pupil size. It is
dependent on cranial nerve II (afferent limb of reflex), superior centers (interneuron) and cranial
nerve III (efferent limb of reflex). The change in the shape of the lens is controlled by ciliary
muscles inside the eye. Changes in contraction of the ciliary muscles alter the focal distance of
the eye, causing nearer or farther images to come into focus on the retina; this process is known
as accommodation
• When moving focus from a distant to a near object, the eyes converge. The ciliary muscle
constricts making the lens thicker, shortening its focal length. The pupil constricts in order to
prevent strongly diverging light rays hitting the periphery of the cornea and the lens from
entering the eye and creating a blurred image
• Reaction to convergence & accommodation for near vision
•➢ Fix vision on a distant object & instruct to look in a near object
•➢ Place finger tip in front of the bridge of the nose (22 cm)
•➢ Then return to the far object
•➢ Observe pupillary reaction in both
Other Pupillary Reflexes
• The ciliospinal reflex -consists of dilation of the pupil on painful stimulation of
the skin of the ipsilateral [Link] cutaneous stimulation (e.g., scratching the
neck),activates sympathetics through connections with the ciliospinal center at
C8–T2 that cause the ipsilateral pupil to dilate. An intact ciliospinal refl ex is
evidence of brainstem integrity when evaluating a comatose patient
• The oculosensory or oculopupillary reflex- consists of either constriction of
the pupil or dilation followed by constriction in response to painful stimulation of
the eye or its adnexa.
DISORDERS OF THE PUPIL
• Large Pupils- The two conditions most commonly causing a
unilaterally large pupil are third CN palsy and Adie tonic pupil .The
patient presenting with Adie (Holmes-Adie) tonic pupil is typically a
young woman who suddenly notes a unilaterally enlarged pupil, with
no other symptoms. The pupillary reaction to light may appear
absent, although prolonged illumination may provoke a slow
constriction.
The pathology in Adie pupil lies in the ciliary ganglion or short ciliary
nerves,or both; its precise nature remains unknown
• Small Pupils-
HORNER’S SYNDROME-
ptosis, miosis, and anhidrosis, enophthalmos and loss of the ciliospinal
reflex,
Argyll Robertson Pupil-
Argyll Robertson pupils are the classic eye finding of neurosyphilis and
when present they mandate appropriate serologic testing. The lesion
lies in the periaqueductal region, pretectal area,and rostral midbrain
dorsal to the EW nuclei
Rules governing analysis of diplopia
•➢ Separation of image is greatest in the direction in which the
weak muscle has its purest action
•➢ False image is displaced farthest in the direction in which the
weak muscle should move the eye
Analyzing nystagmus
•➢ Watch the patients eye while talking
•➢ Ask to look at a definite point & move the point from left to
right & up to down
•➢ Hold each end position for 5 sec & assess nystagmus
(direction, rate amplitude)