Ophthalmology
Neuro-Ophtha
Optic Pathway
 Commonly called the optic nerve
 Consists of: optic nerve, optic chiasm, optic tract,
lateral geniculate body, optic radiation, and
visual center
 (optic nerve itself)Has intraocular portion known as
optic disc and retrobulbar portion divided into orbirtal,
canalicular, and intracranial segments
 Starts as axons of ganglion cells located in the
superficial layer of the retina
 These axons converge at the opening of the
eyeball transverse by a sieve-like membrane
(lamina cribrosa) to form the optic disc
 At the floor of the third ventricle, behind the
sphenoidal bone, above the sella turcica and
in between the two internal carotid arteries,
the optic nerve from the two sides fuse to
form the optic chiasm
 Axons from lateral geniculate body of each
side pass backwards through the internal
capsule to reach the visual cortex
(Brodmann’s area 17)
 The nerve composing the optic pathway is a
sensory nerve with no neurolemal sheath
(Schwann)
 The main function of the optic pathway is vision which
consists of two parts:
 central (cone) – visual acuity and color
perception
 peripheral (rods) – visual field and dark
adaptation; also performs as apparent arm of
papillary reflex
Optic Nerve
Optic neuritis
 inflammation of the optic nerve can be localized in the
optic disc (papillitis) or behind the globe (retrobulbar
neuritis)
 Papillitis
 suspected when patients complain of sudden
blurring of vision commonly in one eye
 Ophthalmoscopic exam – hyperemic disc with
blurred margins and dilated blood vessel; disc may
be elevated but seldom becomes more than +2 D
 Macular star – radiating streaks produced by
edema accumulating in the macula (if surrounding
retina is involved)
 Most of the causes are unknown
 Systemic steroids and anti-inflammatory drugs are
given to hasten the recovery and minimize the
complications
 If left untreated, atrophic changes begins to show
in 8-18 months
 Retrobulbar neuritis
 no abnormal ophthalmoscopic finding
MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
Doc.
2nd Shifting / September 25, 2008
Goldi and Her Playful Dogs
 patient complains of either seeing spots in
the center of field of vision (scotoma) or his
peripheral field is contracted
 ocular pain is present
 management is similar to that of papillitis
Papilledema or choked disc
 optic disk swelling due to raised intracranial pressure
 due to some interference of optic nerve circulation,
particularly the venous drainage
 no visual disturbances if macula is spared
 visual field is normal except for an occasional enlarged
blind spot
 associated with increased ICP as in brain tumor,
abscess, meningitis, and intracranial hemorrhage
 orbital tumors and hypertension are also known causes
 treatment is towards the etiology
Optic atrophy
 when nerve fibers are destroyed, they are replaced by
neuroglial tissues and the finer blood vessels close
 ophthalmoscopic picture is pale disc
 visual acuity is poor and visual field is contracted
 primary optic atrophy – occurs on a previously normal
disc
 secondary optic atrophy: blurred disc margin, hazy
lamina cribrosa, retinal perivascular sheathing
 management: corticosteroids, vasodilators, carbon
dioxide inhalation; sclera or extraocular muscle
surgical transplantation
Optic chiasm to Visual centers
 chiasmal lesions – caused by pituitary tumors and
craniophryngioma - bitemporal hemianopsia
 increased ICP and internal carotid artery sclerosis -
binasal hemianopsia
 optic tract lesions – incongruous homonymous
hemianopsia
 lateral geniculate lesions – congruous homonymous
hemianopsia
 upper portion of optic radiation lesions – inferior
congruous homonymous quadranopsia
 lower portion of optic radiation (temporal lobe tumors
and otitic abscesses) – superior congruous
homonymous quadranopsia
 visual centers are generally affected by intracranial
injuries – congruous homonymous scotoma
Oculomotor, Trochlear, and Abducens Nerve (3,4,and
6)
 purely motor nerves that govern ocular movements of
the eye
 oculomotor nerve –
 elevates the upper lid, constricts the pupil,
and incites accommodation

 Lesions of the third nerve nucleus typically
affect the ipsilateral medial and inferior rectus
and inferior oblique muscles, both levator
muscles, and both superior rectus muscles
 Bilateral ptosis and bilateral limitation of
elevation as well as limitation of adduction
and depression ipsilaterally
 Oculomotor Synkinesis (Aberrant
Regeneration of the Third Nerve) - This
phenomenon is characterized by
inappropriate activation of muscles
innervated by the oculomotor nerve, including
(1) lid dyskinesias due to inappropriate
activation of levator palpebrae superioris
either on horizontal gaze (eyelid elevates on
attempted adduction) or on vertical gaze
(eyelid elevates on attempted depression
("pseudo-Graefe's sign"); (3) adduction or
retraction on attempted upgaze due to
inappropriate activation of medial rectus or
inferior rectus; (4) pupillary constriction on
attempted adduction or depression; and (5) a
monocular vertical optokinetic nystagmus
response (due to coactivation of superior
rectus, inferior oblique and inferior rectus
muscles fixing the involved eye, allowing only
the normal eye to respond to the moving
target).
- Trochlear Nerve (IV) –
o unique among the cranial nerves in
arising from the dorsal brainstem
o travels near the third nerve along the
wall of the cavernous sinus to the orbit,
where it supplies the superior oblique
muscle
o Trochlear Palsy –
 Congenital trochlear palsy is
probably not usually neurogenic
in origin but due to
developmental anomaly within
the orbit
 It may present in childhood with
an abnormal head posture or in
childhood or adult life with
eyestrain or diplopia due to
reduced ability to overcome the
vertical ocular deviation
(decompensation)
 Acquired trochlear palsy is
commonly traumatic
 The nerve is vulnerable to injury
at the site of exit from the dorsal
aspect of the brainstem
 Both nerves may be damaged
by severe trauma as they
decussate in the anterior
medullary velum, resulting in
bilateral superior oblique palsies
o Superior oblique palsy results in upward
deviation (hypertropia) of the eye, which
increases when the patient looks down
and to the opposite side
- Abducens Nerve (VI) –
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o enters the orbit with the third and fourth
nerves to supply the lateral rectus muscle
o Abducens Nerve Palsy –
 most common single extraocular
muscle palsy
 Abduction of the eye is reduced
or absent
 esotropia is present in the
primary position and increases
with distance fixation and upon
gaze to the affected side
 Ischemia (arteriosclerosis,
diabetes, migraine, and
hypertension) is a common
cause
 Arnold-Chiari malformation
(congenital downward
displacement of the cerebellar
tonsils) can produce sixth nerve
palsy due to traction but can
also produce a distance
esotropia without limitation of
abduction due to cerebellar
dysfunction
o Duane’s syndrome
 stationary, nearly always
unilateral condition consisting of
deficient horizontal ocular
motility characterized by
complete or partial deficiency of
abduction
o Gradenigo's Syndrome
 characterized by pain in the face
(from irritation of the trigeminal
nerve) and abducens palsy
 syndrome is produced by
meningeal inflammation at the
tip of the petrous bone and most
often occurs as a rare
complication of otitis media with
mastoiditis or petrous bone
tumors
Syndromes Affecting Cranial Nerves III, IV, & VI
- Superior Orbital Fissure Syndrome
o All the ocular motor nerves pass through
the superior orbital fissure and can be
involved by trauma or by tumor
encroaching on the fissure
- Orbital Apex Syndrome
o This syndrome is similar to the superior
orbital fissure syndrome with the addition
of optic nerve signs and usually greater
proptosis
o It may be caused by tumor, inflammation,
or trauma
- Sudden Complete Ophthalmoplegia
o Complete ophthalmoplegia of sudden
onset can be due to extensive brainstem
vascular disease, Wernicke's
encephalopathy, Fisher's syndrome,
bulbar poliomyelitis, pituitary apoplexy,
basilar aneurysm, meningitis, diphtheria,
botulism, or myasthenic crisis
Trigeminal Nerve
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 Both a sensory and a motor nerve

 Stimulation of the sympathetic system induces
papillary dilation
 Sensory nerve to the region of the face and the nasal
 Destruction of the sympathetic causes miosis as in
and buccal mucosa
Horner’s syndrome (miosis, ptosis, enopthalmos)
 Motor nerve to muscles of mastication
 Certain drugs may localize the lesion along this
 The nucleus of the sensory portion is in the lateral side pathway
of the pons. It receives fibers from the semilunar
(Gasserian) ganglion Pharmacologic test in location of lesion in Horner’s
 Semilunar ganglion receives three main branches: syndrome (Mydriasis)
ophthalmic, maxillary, and mandibular
 Ophthalmic branch: Drug Normal Central Pre-gang Postgang
 Frontal branch terminates as the Cocaine 10% + impaired _ _
supratrochlear and supraorbital nerves to Epinephrine 1:100 - - Moderate Dramatic
supply forehead, scalp, and medial part of the Phenylephrine 1% Slight Slight Moderate Dramatic
upper lid Phenylephrine 10% Dramatic + + +
 Lacrimal branch supplies the lacrimal Hydroxyamphetamine + + + _
1%
glandand the lateral aspect of the upper and
lower lids Fin
______________________________________________________
 Nasociliary branch is the sole sensory nerve of
the globe supplying the long and short ciliary Mga tsong, galing lang to’ sa buk ng
nerves and also supplies the lower part of the
nose and medial aspect of lids as the infra- ophtha.. d namin nahingi ung lec

trochlear nerve
Maxillary branch supplies the meninges of middle
eh..
cranial fossa


Mandibular brancc supplies the lower jaw
Testing the function of CN V: corneal reflex, blinking
- Pornstars –
reflex, and sensation of touch, pain, and temperature
in the lids
 Lesions affecting this nerve is frequently with the
ophthalmic branch (herpes zoster); in tic doulourex the
mandibular is affected
 Peripheral lesions affect the branches individually

Facial Nerve

 Motor nerve to the facial muscles

 Sensory functions to the anterior 2/3 of the tongue
(taste) and external ear (general sensation)
 Main ocular function is closing of the lids through the
orbicularis oculi
 If lesions affect the lower neuron (nucleus or facial
nerve), the entire half of the face is paralyzed
 If lesions affect the upper neuron (cortico-bulbar
pathway), the upper facial muscles are spared because
the forehead receives innervations from both sides

Acoustic Nerve

 Two divisions: cochlear (hearing) and vestibular

(equilibrium)
 Examination of the oculo-vestibular connections is
done by studying the character of the nystagmus
 Vestibular nystagmus has a fast and slow component,
without which, it cannot be of vestibular origin
 Direction of the nystagmus id based on the direction of
the fast component
 Spontaneous nystagmus of a vertical or oblique nature
is generally central in origin; horizontal nystagmus
may be peripheral or central
 Direction of the fast component is towards the
opposite side of the vestibular apparatus that is
hypofunctional
 Tumors produce a hypofunctioning vestibular
apparatus; hemorrhages produces stimulating effect

Sympathetic System
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