Neuro-ophthalmology: part 3, crainial nerve

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Neuro-ophthalmology part 3, crainial
nervesdavid.kinshuck_at_goodhope.nhs.uk
Ocular cranial nerve problemsmain points cant
discuss all points in time allowed Presenta few
questions as we go 2 tiny quizes
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Anatomy

• Nuclei of oculomotor nerve
• Trochlear nucleus
• Pons
• Fourth ventricle
• Abducent nucleus
• Vestibular nucleus
• Medial longitudinal fasciculus

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Anatomy
5th
3rd
6th
www.meddean.luc.edu
4th
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Anatomy cont
a
c
b
d
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Anatomy cont
3rd
5th
4th
6th
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Case 1
What is happening?
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Case 1 animation
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3rd nerve palsy
All recti except superior oblique and lateral
rectus paralysed Pupil fixed and
dilated Different types of 3rd nerve palsy..can
localise lesion.. Eg elderly patients, diabetic,
pupil spared vascular lesion of nerve itself
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3rd nerve palsy
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Case 2 animation
animation
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Case 2 animation
animation
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Case 2

• which eye is affected?

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Case 2 cover test

• Which eye is affected?

www.mrcophth.com
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4th nerve palsy

• Superior oblique palsy, right vertical diplopia

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4th nerve palsy

• Superior oblique palsy, left vertical diplopia

www.mrcophth.com
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Case animation

• animation

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Case 3
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6th nerve palsy

• Right Lateral rectus palsy

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6th nerve palsy

• Which lateral rectus palsy?

left
www.mrcophth.com
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Quiz

• Casesdiff diagnosis and why
• Age 20, road accident last week, vertical
  diplopia..diagnosis, how do you diagnose it?
• Diplopiahorizontalas shown here
• Age 70y, ptosis, diplopia (divergent) pupil OK,
  sudden onset

www.mrcophth.com
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5th nerve damage

• Test
• How?

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5th nerve damage

• Test
• Sensation in all 3 regions
• motor..clench teeth

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5th nerve damage

• Lesion 4
• Name?
• symptoms

• Lesion 1
• Name?
• symptoms

• Lesion 2
• Name
• symptoms

• Lesion 3
• Name
• symptoms

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5th nerve damage

• Orbital floor fracture (trauma)numb beneath eye,
  diplopia

• Vth sensation reduced
• Pain and temp opposite side (vasc or MS or ca)

• Lesion 2
• Trigeminal neuralgia
• Vascular compression

• Ca intracranial or
• Nasopharyngeal

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7th nerve palsy

• Try and think, in pairs, 1 minute
• Causes
• Problems
• What is the route of the 7th nerve?

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7th nerve...landmarks?
1bends round what?
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4
2
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7th nerve
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7th nerve.. landmarks
Through facial canal turns 90o just medial to
middle ear styomastoid foramen
Brain stem Bends round 6th nerve nucleus
Through parotid
Through internal auditory meatus with Vlllth nerve
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7th nervelesions
Ear infectionseg. Ramsey Huntherpes
zoster rash on ear drum
6th and 7th lesion.. 7th supplies both side of
face
Parotid tumour..palpate
Vlllth nerveacoustic neuroma surgery or other SOL
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7th nerve palsy

• lesions
• Bells palsy, possibly herpes simplex
• Ramsay-Hunt with rash herpes zoster
• Upper motor neuroneforehead symmetrical

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7th nerve palsy
Runs over petrous part of temporal bone 6,7,8th
palsy
Herpes zoster look in ear for vesicles
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7th nerve palsy eye problems

• www.ramsayhunt.org/ images/nik1.jpg

• Dry cornea
• can ulcerate
• Use fluorescein for examination
• Lubricate
• Occasionally suture lids closed.
• Serious problem for acoustic neuroma patients

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Questions
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Summary

• 3rd cranial nerveaneurysm in young patient
• (pupils..covered separately)
• 4th cranial nervevertical diplopia
• 6thhorizontal diplopia
• 5th ..unsusual but serious
• 7thcommon, Bells, Ramsey Hunt, acoustic neuroma
  surgery, dry eye

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