ANATOMY of Cranial Nerve III,

IV, & VI (Oculomotor, Trochlear,

and Abducens)
Dhita Dewi Alviane, dr.
 Contents
• Cranial Nerve III (Oculomotor) • Cranial Nerve IV (Trochlear)
• Location of Nuclei • Cranial Nerve VI (Abducens)
• Pathway
• Pathway & Clinical correlation
• Pathways for the Pupil Reflexes
• Light Reflex
• Near Reflex
Oculomotor Nerve
(3rd Cranial Nerve)
 Oculomotor Nerve (3rd Cranial Nerve)
Position and Location of Nuclei
• Contains only 2400 fibers
• CN III arises from complex group of cells in
the rostral midbrain, or mesencephalon, at
the level of the superior colliculus.
• Has 2 nucleis (motor and somatofiber /
parasymphathetic)
• Motor nuclei : Supplies all extraocular
muscles except superior oblique (trochlear
nrv) and lateral rectus (abducens nrv)
• Parasymphatetic nuclei : Provides
parasympathetic cholinergic innervation to
the pupillary sphincter and the ciliary muscle
(Edinger westphal nuclei)
 Oculomotor Nerve (3rd Cranial Nerve)
Position and Location of Nuclei
• Consist of several sub nuclei (which
is large motor cell and distinct to
each other subnuclei), that are
innervate :
• ipsilateral inferior rectus muscle
• ipsilateral inferior oblique muscle
• ipsilateral medial rectus muscle
• contralateral superior rectus muscle
• Except for a single central, caudal
subnucleus that serves both
levator palpebrae superioris
muscles, the cell groups are paired
(shared innervation – Hering’s law
of equal innervation)
Oculomotor Nerve (3rd Cranial Nerve)
Pathway
Pathway
Oculomotor Nerve (3rd Cranial Nerve)
Pathway
 Oculomotor Nerve (3rd Cranial Nerve)
Pathway
• CN III may divide within the anterior cavernous sinus.
• CN III usually separates into superior and inferior divisions after
passing through the annulus of Zinn in the orbit (Fig 3-17).
• CN III superior division innervates :
• superior rectus
• levator palpebrae superioris muscles.
• The larger inferior division splits into 3 branches, innervates :
• medial rectus
• inferior rectus
• inferior oblique muscles.
• The parasympathetic fibers (from Edinger Westphal nuclei) wind
around the periphery of CNIII  enter the inferior division and
course through the branch that supplies the inferior oblique muscle 
join ciliary ganglion (where they synapse with the postganglionic
fibers)  emerge as many short ciliary nerves pierce the sclera 
travel through the choroid (innervate the pupillary sphincter and the
ciliary muscle)
• The superficial (more superficial than motor nerve) location of these
fibers makes them more vulnerable to compression, such as from an
aneurysm, than to ischemia.
Oculomotor Nerve (3rd Cranial Nerve)
Pathway
 Oculomotor Nerve (3rd Cranial Nerve)
Pathway & clinical correlation

• The nerve maintains a topographic

organization even in the midbrain,
so lesions almost anywhere along
its course may cause a divisional
nerve palsy
• +/- 20% of patients with PCoA
aneurysms have isolated
oculomotor nerve palsy on
presentation,
• +/- 80% of aneurysms occurring
with CN III palsy were located in
the PCoA— usually at the junction
of the PCoA and the ICA.
 Oculomotor Nerve (3rd Cranial Nerve)
Pathway & clinical correlation
Oculomotor Nerve (3rd Cranial Nerve)
Pathway & clinical correlation
 Oculomotor Nerve (3rd Cranial Nerve)
Pathway & clinical correlation
Radioanatomy

CN3
Pathway
 Oculomotor Nerve (3rd Cranial Nerve)
Pathway For the Pupil Reflexes
Light Reflex
• The light reflex (also called pupillary light reflex,
pupillary reflex) consists of a simultaneous and
equal constriction of the pupils in response to
illumination of one eye or the other
• Preganglionic parasympathetic fibers leave each
Edinger- Westphal nucleus  run on the
superficial surface of the oculomotor nerve (CN
III)  leaves the brainstem  spiral downward
to lie medially in the nerve at the level of the
petroclinoid ligament  spiraling inferiorly in
the inferior division of CN III as it enters the orbit
• Inside Orbit : These fibers synapse in the ciliary
ganglion (Fig 3-19)  give rise to postganglionic
myelinated short ciliary nerves (approximately
3%–5% of which are Pupillomotor)  The rest
are designated for the ciliary muscle and are
concerned with the near reflex.
 Oculomotor Nerve (3rd Cranial Nerve)
Near Reflex

• The near reflex (also called near

synkinesis, near triad), is a reflex that
assist in the redirection of gaze from
a distant to a nearby object.
(simultaneously)
• This reflex includes the triad of
accommodation of the lens, pupil
constriction, and convergence.
 Oculomotor Nerve (3rd Cranial Nerve)
Near Reflex
• Pupillary accommodation/ constriction reflex
• Afferent pathway (For the three reflexes)
Input from the retina  sent to the lateral geniculate nucleus  via the
optic tract  project to the visual cortex.
• Efferent Pathway
efferent parasympathetic fibers from the E-W nucleus  via the
oculomotor nerve  project to ciliary ganglion + short ciliary nerves 
innervate iris sphincter muscle  pupillary constriction.

• Lens accommodation reflex

• Efferent pathway
Efferent parasympathetic fibers from the E-W nucleus  via the
oculomotor nerve  project to the ciliary ganglion + short ciliary nerves
 innervate the ciliary muscle  cause ciliary muscle contraction 
allows the lens zonular fibers to relax  lens become more round
(increasing its refractive power)

• Convergence reflex
• Efferent pathway for convergence
Efferent fibers from the medial rectus subnucleus of the oculomotor
complex in the midbrain innervate the bilateral medial rectus muscles
to cause convergence.

https://eyewiki.aao.org
 Trochlear Nerve
(4th Cranial Nerve)
 Trochlear Nerve (4th Cranial Nerve)
• Contains the fewest nerve fibers
(approximately 3400) of any CN
• The longest intracranial course (75
mm)
• Nerve nucleus is located in the
caudal midbrain at the level of the
inferior colliculus near the
periaqueductal gray matter, ventral
to the aqueduct of Sylvius.
• CN IV is the only CN that is
completely decussated
• the only CN to exit the dorsal
surface of the brainstem
 Trochlear Nerve (4th Cranial Nerve)
Nerve bundle of CN IV curve dorsocaudally around the
periaqueductal gray matter  completely decussate
(menyilang) in the superior medullary velum  exit the
brainstem beneath the inferior colliculus  As it
curves around the brainstem in the ambient cistern  runs
beneath the free edge of
the tentorium  passes between the posterior cerebral and
superior cerebellar arteries (like
CN III, but more laterally)  pierces the duramater  enter
the cavernous sinus 
 Trochlear Nerve (4th Cranial Nerve)

 CN IV travels beneath CN III

and above the ophthalmic division
of CN V in the lateral wall of the
cavernous sinus 
 Trochlear Nerve (4th Cranial Nerve)
 It enters the orbit through the
superior orbital fissure outside the
annulus of Zinn  runs superiorly
to innervate the superior oblique
muscle.
• Because of its location outside
the muscle cone, CN IV is usually
not affected by injection of
retrobulbar anesthetics (see Fig
3-17).
 AbducensNerve
(6th Cranial Nerve)
 Abducens Nerve (6th Cranial Nerve)
• The nucleus of the abducens
nerve (CN VI) is situated in the
floor of the fourth ventricle,
beneath the facial colliculus in
the caudal pons.
 Abducens Nerve (6th Cranial Nerve)
• Nerve fiber of CN VI runs ventrally
through the paramedian pontine
reticular formation and the
pyramidal tract  leaves the
brainstem in the pontomedullary
junction  CN VI then takes a
vertical course along the ventral
face of the pons and  crossed by
the anterior inferior cerebellar
artery  continues through the
subarachnoid space along the
surface of the clivus 
 Abducens Nerve (6th Cranial Nerve)
perforate the dura mater below the petrous apex,
approximately 2 cm below the posterior clinoid
process  passes intradurally through or around
the inferior petrosal sinus and beneath the
petroclinoid (Gruber) ligament through the Dorello
canal,  becomes extradural and enters the
cavernous sinus. In the cavernous sinus, CN VI
runs below and lateral to the ICA and may
transiently carry sympathetic fibers from the
carotid plexus  passes through the superior
orbital fissure within the annulus of Zinn  enter
the medial surface of the lateral rectus muscle,
which it innervates.

• This long route (especially along the surface of the

clivus and beneath the petroclinoid ligament) is
responsible for this nerve’s susceptibility to stretch
injury leading to paresis in the context of increased
intracranial pressure.
Abducens Nerve (6th Cranial Nerve)