OCULOMOTOR NERVE

Entirely motor in function. Supplies all the extra ocular muscles except lateral rectus & superior oblique.

supplies intraocular muscles- sphincter pupillae &

ciliary muscle.

OCULOMOTOR NUCLEAR COMPLEX

Situated in the midbrain at the level of superior colliculus. Comprised of two nuclei. - Main motor nuclei - Accessory parasympathetic nucleus. (E.W. nucleus)

Main nucleus composed of subnuclei

Dorsolateral Nucleus Intermedial Nucleus Ventromedial Nucleus Paramedial Nucleus Caudate central Nucleus Ipsi IR Ipsi IO Ipsi MR Contra SR B/l LPS

COURSE AND DISTRIBUTION

1) Nuclear portion

2) Fascicular Intraparenchymal midbrain portion

3) Subarchnoid portiopn/ Basilar part. 4) Cavernus sinus portion .

5) Orbital Portion.

COMPLETE 3RD NERVE PALSY :Clinical features

Ptosis Derivation - eyeball is turned down, out & slightly intorted. Adduction, Elevation, Depression and extorsion are restricted. Pupil is fixed & dilated Accomodation lost. Head posture.

Features And Courses of 3rd Nerve Lesions Various Levels.

SUPRANUCLEAR LESIONS :Conjugate paresis which affects both eyes equally . Position and movement of both eyes are abnormal but they maintain Their relative co-ordination and produce no diplopia .

NUCLEAR LESION :
Uncommon . Causes : Vascular diseases , demyelination, primary tumour & metastasis. Ipsilateral third nerve palsy with Ipsilateral sparing and contralatral weakness of elevation. Lesions involving paired medial rectus subnuclei cause WEBINO (defective convergence & adduction )

FASCICULAR LESSIONS:
Causes similar to Nuclear lesions. Benedikts syndrome

(Red Nucleus Inv. )

Ipsilateral 3rd N.palsy - Ipsilateral flapping hand tumors

- Ataxia.
Webers syndrome (Cerebral Peduncle Inv. ) -Ipsilateral 3rd N palsy -Contralateral hemiplegia / hemiparesis

SUBARACHNOID LESIONS:
Basilar

part of the nerve, unaccompanied by any other cranial nerve.

Causes:
- Aneurysms (common) - Extradural haematoma - Diabetes

INTRACAVERNOUS LESION
-- Associated with involvement of 4th ,6th nerve and 1st division of Trigeminal Nerve.
-Pupil is spared

-Causes :
- Pituitary apoplexy/adenoma - Intracavernous lesions . - Aneurysms - Tolosa hunt syndrome - Primary intrasellar mass

- Cavernous sinus syndrome (Diffuse inflammatory lesions with inv. Of 3,4,6,th no. first2 diversion of 5th C.N) - Diabetes

INTRA ORBITAL LESIONS :

Extra ocular muscle palsies . May involve superior/ inferior divisions Causes : Orbital tumours

Pseudo tumours
Trauma Vascular diseases C/F:-Proptosis , lid swelling ,conjunctival injection & chemosis

LESION OF PUPILLOMOTOR FIBRES

Between the brain stem and cavernous sinus the fibres situated in the superior median quadrant of the nerve. Blood supply is from the pial blood vessels. Surgical lesions Pupil involved Medical lesions -Pupil spared.

IMAGING STUDIES.
MRI
* MRI is a more sensitive imaging technique than CT scan for picking out a small intraparenchymal brainstem lesion,such as infarction,small

abscess or tumour.
* Procedure of choice for demostrating meningeal & dural inflammation & infiltration.

* Gives specific information on vascular flow patterns

CT Scan :
CT Scan is more sensitive than MRI to demonstrate

subarachnoid haemorrhage .
CT Scan is better than MRI for demonstrating calcification within lesions .

LUMBAR PUNCTURE
Main purpose is to demonstrate the presence of blood

in cerebrospinal fluid, an inflammatory reaction,

neoplastic infiltration or infection

Meningeal inflammation or infection diagnosed by

bacterial and fungal cultures.

CERBRAL ANGIOGRAPHY
Definitive test for Berry aneurysm in all intracranial locations. Risk of stroke exists.

Indicated in a patient younger than 55-60 yrs. Specially

without a history of longstanding diabetes , hypertension

or both.

MEDICAL CARE
Medical 3rd cranial nerve palsy . Due to ischaemia in the nerve trunk results from insufficiency of vasa nervosa.

Medical management is watchful waiting since there is

no medical Tt that alters the course of disease . Nearly all patients under go spontaneous remission of the palsy ,usually within 6-8 weeks. Treatment during the interval is directed at alleviating

pain and diplopia .

SURGICAL CARE
Includes clipping, glueing or wrapping of the berry aneurysm by a neurosurgeon in the acute stage. Patients who do not recover from 3rd cranial nerve palsy may become candidates for eye muscle resection or recession to create a persistent and stable angle diplopia. Some may require lid lift Surgery for ptosis.

ACTIVITY
Patients who are monocular from either ptosis /ocular patching & patients with Diplopia should not climb high places, drive a vehicle or operate heavy machinery . Must avoid any other activity where limitation of peripheral vision poses danger. Loss of depth perception poses another set of risks .

Most serious complication

Sudden rupture of berry aneurysm with massive subarachnoid haemorrhage leading to devastating neurological deficit and death

PROGNOSIS
Depends on the etiological diagnosis in the individual case. Medical third cranial nerve palsy from presumed ischaemia carries the best prognosis for recovery of nerve function (recovery within weeks ) Patients with identifiable diseases such as infectious / neoplastic infiltration have varying prognosis.