1. Neuro-ophthalmology: part 3, crainial nerves david. kinshuck@goodhope
Neuro-ophthalmology: part 3, crainial nerves
Ocular cranial nerve problems…main points
…can’t discuss all points in time allowed
Present…a few questions as we go
2 tiny quizes
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2. Anatomy Nuclei of oculomotor nerve Trochlear nucleus Pons
Fourth ventricle
Abducent nucleus
Vestibular nucleus
Medial longitudinal fasciculus
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3. Anatomy
5th
3rd
6th
4th
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4. Anatomy cont a c b d
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5. Anatomy cont
3rd
5th
4th
6th
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6. Case 1
What is happening?
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7. Case 1 animation
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8. 3rd nerve palsy
All recti except superior oblique and lateral rectus paralysed
Pupil fixed and dilated
Different types of 3rd nerve palsy..can localise lesion..
Eg elderly patients, diabetic, pupil spared: vascular lesion of nerve itself
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9. 3rd nerve palsy
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10. Case 2 animation
animation
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11. Case 2 animation
animation
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12. Case 2
which eye is affected?
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13. Case 2 cover test
Which eye is affected?
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14. 4th nerve palsy Superior oblique palsy, right: vertical diplopia
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15. 4th nerve palsy Superior oblique palsy, left: vertical diplopia
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16. Case animation
animation
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17. Case 3
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18. 6th nerve palsy
Right Lateral rectus palsy
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19. 6th nerve palsy Which lateral rectus palsy? left www.mrcophth.com
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20. Quiz Cases…diff diagnosis and why
Age 20, road accident last week, vertical diplopia..diagnosis, & how do you diagnose it?
Diplopia…horizontal…as shown here
Age 70y, ptosis, diplopia (divergent) pupil OK, sudden onset
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21.                                            
5th nerve damage
Test
How?
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22. 5th nerve damage Test Sensation in all 3 regions motor..clench teeth
                                           
5th nerve damage
Test
Sensation in all 3 regions
motor..clench teeth
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23. 5th nerve damage Lesion 4 Name? symptoms Lesion 1 Name? symptoms
                                           
5th nerve damage
Lesion 4
Name?
symptoms
Lesion 1
Name?
symptoms
Lesion 3
Name
symptoms
Lesion 2
Name
symptoms
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24.                                            
5th nerve damage
Orbital floor fracture (trauma)…numb beneath eye, diplopia
Vth sensation reduced
Pain and temp opposite side (vasc or MS or ca)
Lesion 2
Trigeminal neuralgia…
Vascular compression
Ca …intracranial or
Nasopharyngeal
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25. 7th nerve palsy Try and think, in pairs, 1 minute Causes Problems
What is the route of the 7th nerve?
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26. 7th nerve...landmarks?
1…bends round what? 3 4 2
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27. 7th nerve
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28. 7th nerve.. landmarks Brain stem… Bends round 6th nerve nucleus
Through facial canal turns 90o just medial to middle ear …styomastoid foramen
Brain stem…
Bends round 6th nerve nucleus
Through parotid
Through internal auditory meatus with Vlllth nerve
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29. 7th nerve…lesions Ear infections eg. Ramsey Hunt =herpes zoster
=rash on ear drum
6th and 7th lesion..
7th supplies both side of face
Parotid tumour..palpate
Vlllth nerve…acoustic neuroma surgery or other SOL
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30. 7th nerve palsy lesions Bells palsy, possibly herpes simplex
Ramsay-Hunt with rash: herpes zoster
Upper motor neurone…forehead symmetrical
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31. 7th nerve palsy Runs over petrous part of temporal bone… 6,7,8th palsy
Herpes zoster: look in ear for vesicles
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32. 7th nerve palsy: eye problems
images/nik1.jpg
Dry cornea
can ulcerate
Use fluorescein for examination
Lubricate +++
Occasionally suture lids closed.
Serious problem for acoustic neuroma patients
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33. Questions
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34. Summary 3rd cranial nerve…aneurysm in young patient
(pupils..covered separately)
4th cranial nerve…vertical diplopia
6th…horizontal diplopia
5th ..unsusual but serious
7th…common, Bells, Ramsey Hunt, acoustic neuroma surgery, dry eye
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35. 23/11/2018