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GROUP 2 A1
OBJECTIVES
1. 2. 3. 4. Clinical anatomy of extraocular muscles Clinical anatomy of the cranial nerves III,IV,VI Action of extraocular muscles Assessment of ocular deviations: a. Hirschbergs test b. Extraocular movement Cranial nerve palsies ( cause and management) a. Oculomotor nerve palsy b. Trochlear nerve palsy c. Abducent nerve palsy Visual pathway a. Normal visual pathway b. Visual field defects due to lesions along the pathway Normal Pupil light reflex pathway
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EXTRAOCULAR MUSCLES
Consist of 4 recti and 2 oblique muscles. 1. Lateral rectus 2. Medial rectus 3. Inferior rectus 4. Superior rectus 5. Inferior oblique 6. Superior oblique The annulus of Zinn (common tendinous ring) is a ring of fibrous tissue surrounding the optic nerve at its entrance at the apex of the orbit. The extraocular muscles are supplied mainly by branches of the ophthalmic artery.
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MUSCLE
ORIGIN
INSERTION
INNERVATION
MAIN ACTION
Elevates , adducts
Depresses , adducts and Adduct eyeball
Abducent nerve Abduct eyeball Tendon passes Trochlear nerve Depresses, through fibrous ring (CN IV) abducts) (trochlea), inserts into sclera deep to the superior rectus muscle . Sclera deep to lateral rectus muscle.
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Elevates, abducts
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Preganglion axon accompanied the oculomotor fibers then synapse in ciliary ganglion Postganglionic fibers pass through short ciliary nerves to constrictor pupillae of the iris & the ciliary muscles. Received fiber From corticonucleus : accomodation reflex From pretectal nucleus : direct & consensual light reflex.
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Supplies extrinsic muscle of the eye: levator palpebrae superioris, superior rectus, medial and inferior rectus & inferior oblique. Also supplies intrinsic muscles: the constrictor pupillae of the iris & ciliary muscle. Responsible for: Lifting upper eyelid Turning the eye upward, downward & medially Constricting pupil Accommodating the eye
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Midbrain
Decussates contralaterally
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OCULAR DEVIATION
EXTRAOCULAR MOVEMENT
1. Test by asking patient to follow finger movement directed in the full range of the normal muscle movement 2. Ask to look in all directions without moving their head and ask them if they experiences any double vision. 3. Test convergence movements by having the patient fixate on an object as it is moved slowly towards a point right between the patient's eyes. 4. Also, observe the eyes at rest to see if there are any abnormalities such as spontaneous nystagmus or dysconjugate gaze (eyes not both fixated on the same point) resulting in diplopia .
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Fig. 13.25. A patient with third cranial nerve paralysis showing: A, ptosis; B, divergent squint
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CAUSES
Causes of 3rd nerve palsy: Diabetes mellitus type II Atherosclerosis Head injury Aneurysm of the posterior communicating artery Cavernous sinus thrombosis Space occupying lesion especially in the midbrain Multiple sclerosis
PROGNOSIS
Fortunately, nearly all patients undergo spontaneous remission of the palsy, usually within 68 weeks. Medical management is actually watchful waiting, since there is no direct medical treatment that alters the course of the disease.
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MANAGEMENT
Treatment during the symptomatic interval is by alleviating symptoms, mainly pain and diplopia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment of choice for the pain. Diplopia is not a problem when ptosis occludes the involved eye. When diplopia is from large-angle divergence of the visual axes, patching one eye is the only practical short-term solution. When the angle of deviation is smaller, fusion in primary position often can be achieved using horizontal or vertical prism or both.
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Normal
Abnormal
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Normal
Abnormal
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VISUAL PATHWAY
FORMED BY
1) 2) 3) 4) 5) 6) 7) Retina Optic nerves Optic chiasma Optic tracts Lateral geniculate bodies Optic radiations Visual cortex
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1. Optic nerves It is a backward continuation of nerve fiber layer of the retina Consists of axons, afferent fibers Does not regenerate as it is not covered by neurilemma Very fine (about 2-10 um), 47-50 mm in length; Intraocular part (1 mm) passes through sclera as lamina cribrosa and finally appear as optic disc Intraorbital part (30 mm) slightly sinous part as to allow eye movements. From back of the eyeball to the optic foramina. Posteriorly, it is closely surrounded by annulus of zinn and origin of 4 rectus muscles. Some fibers of superior rectus muscle adhere here, which account to painful ocular movement in retrobulbal neuritis.
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Intracanalicular part (6-9 mm) closely related to opthalmic artery. Sphenoid and posterior ethamoid sinuses lie medial to it(separate by thin bony lamina) which account to retrobulbal neuritis secondary to sinusitis. Intracranial part (10 mm) lies above the cavernous sinus
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5. Optic radiation Consist of axon of third order neurons 5. Visual cortex Located at medial aspect of occipital lobe Receives fiber of the radiations
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Light stimulates retinal photoreceptors Afferent Fibers (Optic Nerve) Hemi-decussation (optic chisma)
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