Arielle Bokhour, class of 2017
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1 Arielle Bokhour, class of 2017
2 Objectives 1. Understand the actions and innervation of the extrinsic and intrinsic eye muscles 2. Describe the pathways for pupillary constriction and dilation 3. Understand the Accommodation reflex and its pathway 4. Describe Horner s Syndrome 5. Describe the pathway for conjugate lateral and vertical gaze 6. Understand Internuclear Ophthalmoplegia 7. Understand how lesions may affect visual reflexes
3 Visual Reflexes and Gaze Visual reflexes provide automatic control of 1. the amount of light entering the eye 2. the curvature of the lens They depend upon autonomic control of the intrinsic smooth muscles of the eye. Gaze: Neural pathways automatically move both eyes simultaneously for conjugate gaze.
4 Visual Reflexes Testing visual reflexes has great clinical significance because these reflexes depend upon brainstem centers. Abnormal responses can be a key to recognizing CNS pathology
5 Clinical Examples 1. Your neighbor became unconscious after a fall earlier in the day. On exam, his right eye is dilated compared to the left. When you shine a light into the right eye, there is no change, but the left eye constricts. When you shine the light into the left eye, the left eye constricts, but the right eye is unchanged. 2. A 25-year old woman complained that she sees double when she looks at objects on her left. On exam, her eyes move together normally as they follow your finger up, down, and to her right. When you move your finger to her left, her left eye moves left, but her right looks straight ahead.
6 Overview How does the brain control movement of the eye direction of eye size of pupil we have 2 eyes! voluntary vs reflexive actions
7 Eye Muscles Superior rectus Inferior rectus Medial rectus Inferior oblique Levator palpebrae superior CN III Pupillary constrictor Ciliary muscle
8 Eye Muscles Lateral rectus Superior oblique Pupillary dilator Superior tarsal muscle Cutaneous arteries Sweat glands of face CN VI CN IV Sympathetic
9 Eye Movement
10 Effects of Lesions CN III, IV, VI can be damaged by: head trauma (shearing forces) aneurysms and masses vascular disease, diabetes infections R L If an eye muscle loses its nerve supply, the resting position of the eye will be determined by the remaining active muscles.
11 Check out this web site for a cool demo on how eye muscles work Additional information and animations are found here:
12 Pupil Size Pupillary Constriction and Dilation sphincter contraction makes pupil smaller Radial muscles contraction makes pupil larger
13 Pupillary Constriction Controls the pupillary sphincter to decrease the amount of light entering the eye via parasympathetic fibers. Light shined in one eye causes both eyes to constrict - direct and consensual responses.
14 Pupillary Constriction Reflex: light in one eye causes motor response (contraction) in both eyes. Occulomotor nuc Midbrain contains the reflex center that controls this response: pretectal area and Edinger Westfal nucleus This is a brainstem reflex that can be used in clinical testing.
15 level of pretectal area
16 Pupillary Constriction Brachium of superior colliculus
17 Pupillary Constriction Retina (nasal/temp) Optic N/Chiasm/Tract Brachium Sup Colliculus Pretectal Area (Posterior Commissure) Edinger-Westphal Nuc CN III Ciliary Ganglion Pupillary Constrictor 4-neuron reflex
18 Pupillary Constriction Pretectal Area Axons from pretectal area project bilaterally to the EW Nucleus (cross in posterior commissure). Preganglionic parasympathetic fibers from EW travel in CN III to Ciliary Gang. Postganglionic fibers travel in short ciliary nerves to the pupillary constrictor.
19 Consensual response: Pupillary Constriction 1. Light in 1 eye goes to both sides of midbrain 2. Each pretectal area connects to both EWN Loss of the pup light reflex: 1. Optic nerve lesions 2. CN III lesions
20 Uncal Herniation uncus tentorium CNIII
21 Clinical Importance of Brainstem Reflexes CASE: On returning home from shopping, a wife finds her 59 year-old husband unconscious on the floor. He has no pulse. After calling 911, she begins CPR. When Mr. T arrives in the ED, he is in ventricular fibrillation. Spontaneous circulation is eventually restored, but he remains comatose. After 3 days in coma, his wife asks about her husband s condition and the probability of a good outcome. How assess extent of CNS damage/function in unconscious patient 1. Somatosensory Evoked Potential 2. Corneal reflex 3. Pupillary Light Reflex
22 Accommodation Begins as voluntary action (decision to track an approaching object), but is followed by automatic responses. Voluntary part uses Visual Pathway and cortex to track object. Automatic part uses Midbrain Oculomotor Reflex Center
23 Accommodation Cortical reflex that allows eyes to focus on near objects. Involves 3 actions: 1. Convergence- eyes turn medially 2. Pupillary constriction 3. Lens rounding Reflex parasym control parasympathetic signals in CN III cause contraction of the ciliary muscle which produces an inward, squeezing force. This relaxes tension on the suspensory ligaments, causing the lens to become rounder, with greater ability to focus near objects. retina cortex Midbrain reflex center supraoculomotor nuc near the pretectal area eye
24 Accommodation Information from the retina travels to visual cortex via the optic radiations (geniculocalcarine fibers). Fibers from visual cortex travel back through the optic radiations and enter the midbrain through the brachium of superior colliculus.
25 Brachium fibers synapse in supraoculomotor nuc then bilaterally to oculomotor nuc + Edinger Westfal Accommodation CN III CN III medial rectus pupil constrictor ciliary muscle
26 Argyll-Robertson Pupil pupil Small, irregular pupils that constrict in accommodation but not to direct light. Causes: syphilis, diabetes Probable lesion location pretectal area, but supraoculomotor nuc is intact for accommodation.
27 Pupillary Dilation The pupillary dilator muscle is controlled by the sympathetic nervous system. Sympathetics also control: Superior tarsal muscle Cutaneous arteries Sweat glands of face
28 Sympathetic tone sets the resting tension in the dilator muscle. 1. Reduced ambient light levels relax the constrictor and allow the dilator to be more effective. light, pain, fear, anger 2. Emotional situations cause dilation via the hypothalamus.
29 Pupillary Dilation Hypothalamus Hypothalamospinal fibers [Spinal cord Intermediolateral cell column] Thoracic roots Sympathetic chain to Superior Cervical Gang Carotid plexus/artery Pupillary dilator
30 Pupillary Dilation Brainstem Hypothalamospinal fibers travel near ALS Lesions in lateral areas of brainstem or spinal cord cause Horner s Syn Neighbors with ALS!! ALS
31 Spinal Cord Pupillary Dilation Hypothalamospinal fibers terminate on preganglionic sympathetic neurons in Intermediolateral cell column. Axons enter the sympathetic chain. Intermediolateral cell column T1-L3
32 Pupillary Dilation
33 Horner s Syndrome Results from loss of sympathetic innervation to eye/face Caused by a lesion anywhere along the pathway for pupillary dilation: lateral brainstem, spinal cord, thoracic roots, sympathetic chain, carotid plexus, cavernous sinus, orbit May indicate stroke, tumor or mass in thoracic cavity/neck, trauma to neck, carotid dissection, or cluster headache.
34 Sympathetics control: superior tarsal muscle, dilator muscle, sweat glands, cutaneous arteries. Symptoms: ptosis- drooping eyelid (loss of superior tarsal muscle innervation) miosis- constricted pupil anhidrosis- dryness (loss of sweat gland innervation) affected half of face is warm, flushed (loss of vasoconstrictors) Horner s Syndrome
35 Control of Eye Movements Frontal Eye Fields FEF motor areas Brainstem control centers Brainstem control centers: pons (paramedian pontine reticular formation/horizontal gaze center) superior colliculus Nuclei of CN III, IV, VI Involve voluntary (cortical) and automatic (brainstem) features
36 Sup rectus Inf rectus Sup rectus Inf rectus Conjugate Vertical Gaze Muscles acts in pairs: Sup/Sup; Inf/Inf Requires bilateral coordination via posterior commissure pineal Lesions of Sup Coll/post comm cause paralysis of upward gaze - pinealomas Frontal Eye Field Vertical Gaze Center (midbrain) CN III nuc Superior Colliculus
37 Conjugate Lateral Gaze Horizontal gaze of the 2 eyes requires coordination of medial rectus in 1 eye with lateral rectus in other eye medial rectus lateral rectus III MLF VI PPRF - paramedian pontine reticular formation PPRF MLF - medial longitudinal fasciculus
38 Conjugate Lateral Gaze medial rectus lateral rectus Frontal Eye Field is center for voluntary lateral gaze. It sends axons to the contralateral PPRF. MLF VI III PPRF
39 Conjugate Lateral Gaze FEF to medial rectus MLF III IV VI PPRF to lateral rectus
40 Conjugate Lateral Gaze Activation of FEF in the left hemisphere causes eyes to move to the right. Clinical Implications: Central eye position results from balanced activity in FEF of each side. Seizures (abnormal excitatory activity) involving FEF on one side cause gaze to opposite side. Loss of activity in FEF on one side (eg infarct) causes gaze toward that side. R The eyes look towards a hemisphere lesion (inactivity) L
41 Internuclear Ophthalmoplegia Results from a lesion in the MLF MS, diabetes Disconnects activation of medial rectus from lateral rectus gaze normal INO Cannot turn past mid-position Cannot turn past mid-position
42 Internuclear Ophthalmoplegia medial rectus lateral rectus III MLF VI PPRF
43 Internuclear Ophthalmoplegia But, convergence is normal! Accommodation uses a pathway different from lateral conj gaze, although both ultimately activate CN III/medial rectus. R L lateral rectus CN III CN VI VI accommodation
44 Effects of CN Lesions CN III- Ptosis External Strabismus (eye turned laterally) Dilated Pupil CN IV- CN VI- Difficulty depressing eye when adducted Internal Strabismus (eye turned medially) Diplopia- Double Vision - results from any condition that causes misalignment of eyes (dysconjugate gaze)
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