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Neuro-ophthalmology: part 3, crainial [email protected]
Ocular cranial nerve problems…main points…can’t discuss all points in time allowed
Present…a few questions as we go
2 tiny quizes
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Anatomy
1. Nuclei of oculomotor nerve 2. Trochlear nucleus 3. Pons 4. Fourth ventricle 5. Abducent nucleus 6. Vestibular nucleus 7. Medial longitudinal
fasciculus
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Anatomy
www.meddean.luc.edu
3rd
4th
5th
6th
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Anatomy cont
a
b
c
d
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Anatomy cont
3rd
4th
5th
6th
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Case 1What 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 animationanimation
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Case 3
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6th nerve palsyRight Lateral rectus palsy
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6th nerve palsyWhich lateral rectus palsy?
left
www.mrcophth.com
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QuizCases…diff diagnosis and why
1. Age 20, road accident last week, vertical diplopia..diagnosis, & how do you diagnose it?
2. Diplopia…horizontal…as shown here
3. 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 1•Name?•symptoms
Lesion 2 •Name•symptoms
Lesion 3 •Name•symptoms
Lesion 4•Name?•symptoms
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5th nerve damage
• Vth sensation reduced • Pain and temp opposite
side (vasc or MS or ca)
Lesion 2 •Trigeminal neuralgia…•Vascular compression
Ca …intracranial orNasopharyngeal
Orbital floor fracture (trauma)…numb beneath eye, diplopia
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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?
1…bends round what?
2
3
4
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7th nerve
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7th nerve.. landmarks
Brain stem…Bends round 6th nerve nucleus
Through internal auditory meatus with Vlllth nerve
Through facial canal turns 90o just medial to middle ear …styomastoid foramen
Through parotid
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7th nerve…lesions
6th and 7th lesion..7th supplies both side of face
Vlllth nerve…acoustic neuroma surgery or other SOL
Ear infectionseg. Ramsey Hunt=herpes zoster=rash on ear drum
Parotid tumour..palpate
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7th nerve palsy
lesions
Bells palsy, possibly herpes simplex
Ramsay-Hunt with rash: herpes zoster
Upper motor neurone…forehead 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 nerve…aneurysm in young patient(pupils..covered separately)4th cranial nerve…vertical diplopia6th…horizontal diplopia5th ..unsusual but serious7th…common, Bells, Ramsey Hunt, acoustic neuroma surgery, dry eye
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