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Extraocular Nerve Palsy
Extraocular Nerve Palsy
Figure 1.
In the Figures 1-4
1. Which eye is abnormal ?
2. What is the abnormality ?
3. Name the cranial nerve involved.
4. Name the muscles supplied by that cranial
nerve
Figure 2.
Figure 4 .
Figure 3.
EXTRAOCULAR MUSCLES
Extraocular muscles
Insertion:
Skin of upper eyelids
Anterior surface of superior tarsus
Muller`s muscle/Superior tarsal
muscle
Superior conjunctival fornix
LEVATOR PALPEBRAE SUPERIORIS
Nerve supply and Actions
Paralysis - PTOSIS
Equator
Optical axis/Axis of Gaze – direction of
sight .Primary position of eye
Axis of movements
Axis of muscles
Movements
•Lateral rectus by 2
heads
–Extra head from
adjoining greater
wing of sphenoid
LEFT EYE
COURSE OF THE 4 RECTI
Muscular cone
Corresponding
wall of orbit
In Adducted eye
Superior oblique – Depression only
Inferior oblique – Elevation only
Nerve Supply of Extraocular Muscles
Superior division of oculomotor:- levator palpebrae superioris, superior rectus
Inferior division of oculomotor:- medial rectus, inferior oblique, inferior rectus
Trochlear nerve - superior oblique
Abducent nerve - lateral rectus
Blood supply
Ophthalmic artery
Extraocular Muscles
Allow accurate positioning of visual axis
Determine the spatial relationship
between the two eyes
Responsible for binocular vision
Have the smallest motor unit among
skeletal muscles – ratio of nerve fibre to
muscle fibre is 1:2(whereas 1:25 in
other skeletal muscles)
-Yoke Muscles: a muscle of one eye is
paired with another muscle of the fellow
eye to produce a cardinal gaze
-Example: Right LR & Left MR
while looking towards right side
They develop from ?
Preotic/preoccipital somitomeres
Fascial expansions of Extraocular muscles
RECTI -Adduct
OBLIQUES – Abduct
SUPERIORS – Intort
INFERIORS -Extort
Clinical Testing
OCCULOMOTOR NERVE PALSY
Ptosis
Loss of accomodation
OPTHALMOPLEGIA / EXTRAOCULAR MUSCLE PALSY
TROCHLEAR NERVE
External squint- Medial rectus paralysis PALSY
The right eye unable to adduct Eyeball turned upwards
and inwards
TROCHLEAR NERVE PALSY
Affected eye rotated up and in.
Attempts to compensate lead to the patient tilting their head to the contralateral side .
ABDUCENS PALSY
Third nerve palsy results in an inability to move
the eye normally in all directions. Injury to the
third nerve can occur anywhere along its path,
from where it originates within the brain to
where it innervates the muscles that move the
eyeball. Third nerve palsy prevents the proper
functioning of the medial, superior, and
inferior recti, and inferior oblique muscles. As
a result, the eye cannot move up, down, or in.
When at rest, the eye tends to look down and
to the side, due to an inequality of muscle
functioning. The muscle responsible for
keeping the upper eyelid open (levator
palpebrae superioris) is also affected, resulting
in a drooping upper eyelid (ptosis
Movements
Elevation
Depression
Adduction
Abduction
Intortion extortion
phthalmoplegia, also called extraocular muscle palsy, paralysis of the
extraocular muscles that control the movements of the eye. Ophthalmoplegia usually involves the third (oculomotor), fourth
(trochlear), or sixth (abducens)cranial nerves. Double vision is the characteristic symptom in all three cases
The optical axis of the eye (the line from the
center of the cornea to the fovea) points
straight ahead during straight-ahead gaze, but
the axis of the orbit points about 23 degrees
laterally. The superior and inferior recti
originate from the back of the orbit, and so
their direction of pulling is not parallel to the
optical axis. As a result, although the superior
rectus primarily elevates the eye, it also has
smaller adducting and intorting effects.
(Similarly, although not indicated in the Þgure,
the inferior rectus primarily depresses but also
adducts and extorts a little.)
The pulling direction of the obliques is not
aligned with either the optical axis or the
orbital axis, and their actions change with the
direction of gaze. The superior oblique inserts
in the posterior half of the eye and pulls
diagonally forward. A, As a result, during
straight-ahead gaze, although it primarily
intorts the eye, it also pulls the back of the eye
a little bit medially and upward (i.e., abducts
and depresses a little). B, During adduction,
the direction of pull is more nearly in line with
the optical axis, and the same muscle
depresses more and intorts less. C, During
abduction, the direction of pull can wind up
perpendicular to the optical axis, and the
action becomes purely intorsion. (Similarly,
although not indicated in the Þgure, the
inferior oblique primarily extorts when the eye
is abducted, but it also elevates and abducts in
other directions of gaze.)