OCULAR MOTOR DISORDERS IN

CEREBRAL VASCULAR DISEASE

Andradi S.
Examination of Ocular Motor Nerves
(Nn III, IV, VI)

1. Palpebra

2. Pupil

3. Ocular movement
1. Examination of PALPEBRA

Method

1. Eye opening

2. Eye closing
a. Without resistance
b. Against resistance
Disorders of the Palpebra
Ptosis
- N III palsy
- Sympathetic dysfunction (Horners syndrome)

Pseudoptosis
- Blepharospasm, blepharitis etc.

Lagophthalmus
- N VII palsy
2. Examination of PUPIL

Size

Isocoria (equality)

Shape

Pupillary reflexes
1. Pupillary light reflex
2. Accomodation reflex
 Disorders of PUPIL

1. Size
< 2 mm 2 - 5 mm > 5 mm
Miotic Normal Mydriatic
2. Shape
- Normal: round, regular
- Abnormal: oval, irregular, abnormal shape, notching, serration.

3. Isocoria (equality)
Isocor
anisocor Sympathetic or parasympathetic (N III) dysfunction ?

4. Pupil Reflexes
a. Pupillary light reflex: Direct, Indirect, Marcus Gunns sign
b. Accomodation reflex
3. Ocular Movements

1. Four basic movements

2. Six cardinal directions

3. Ocular Movements

a. Four basic movements

Saccades

Persuit

Vergent

Reflex (Oculovestibular)
3. Ocular Movements
Six Cardinal Directions
Examination of Ocular Movements

Method:

1. Eye position

2. Voluntary eye movement

3. Reflex eye movement

 1. Eye Position
Primary position (No 5)
Secondary position (No 6)

1 2 3

4 5 6

7 8 9
2. Voluntary Eye Movements

1. On command

2. On following object (pursuit movement)

3. Cover-uncover test
 Disorders of ocular movements

1. In nuclear and infranuclear lesions.

- Paresis of individual muscle / nerve (III, IV, VI)

- Strabysmus: convergent, divergent, upward, downward. Diplopia

 Disorders of ocular movements
2. In supranuclear lesions
Cerebral lesions (premotor area, area 8)
- Irritative lesion conjugate deviation to contralteral
- Paralytic lesion gaze palsy to contralateral

Midbrain and pons lesions

- Usually paralytic lesion
- FLM
- Superior colliculus
- Periaqueductal gray matter
- Nystagmus
Gaze palsy towards lesion
Internuclear ophthalmoplegia
Upward gaze palsy
Convergence impairment

Cerebellum
- Nystagmus
 Nystagmus
- Type / form : jerky / rhythmic, pendular

- Directions : - horizontal, vertical (upward, downward), oblique, rotatory,

or mixed
- Unidirectional, bidirectional

- Intensity : 1st , 2nd, 3rd degree

- Amplitude : fine, medium, coarse

- Rate / velocity : slow (10-40/min), medium (40-100/min), rapid (>100/min)

Nystagmus in Peripheral vs Central Vestibular lesion !

 3. Reflex Eye Movement

Oculovestibular reflex, oculocephalic reflex, dolls head phenomenon

Method
Sudden passive movement of he head from one side to side, the eyes move
in opposite direction.
 Disorders of Reflex Eye Movement

Absent of oculovestibular reflex

In: - brainstem lesion conjugate gaze palsy
- brainstem death