ABDUCENT NERVE

DR. Nirmal Jayadev

Final year PG student (MS Ophthalmology)
MKCG Medical College
Berhampur
Odisha
INTRODUCTION
 NUCLEUS

• Situated near the midline

in the tegmentum of the
pons ventral to the
colliculus facialis

• colliculus facialis is an
elevation in the floor of
the 4th ventricle ,
produced by the genu of
facial . N
Spi nucleus
of eminaln. Medial
1o·lkinal
bund

.... I

¡' I
Abducentnucleus
/
._
_v I
I

Facialnerve '
Facialnucleus

hemetoshowthecourseoftbefibresofthefacialnervethroughthe poos,
and theformation ofthe facialcolliculus.
The medial longitudinal bundle is
ventromedial

• Partly intermingled with these larger neurons

are more numerous small multipolar cells
which form the so-called nucleus para
abducens
 CONNECTIONS

OCULOMOTOR
NUCLEUS

ABDUCENT MEDIAL TROCHLEAR

NERVE NUCLEUS LONGITUDINAL NUCLEUS
BUNDLE

VESTIBULAR
NUCLEUS
 PARA PONTINE RETICULAR
FORMATION (PPRF)

• The gaze motor command involves specialized

areas of the reticular formation of the brain
stem which receive a variety of supra nuclear
inputs.

The main region for horizontal gaze is the

paramedian pontine reticular formation
(PPRF)
 I

Fo i le
illard-Gubler syndro
syndrome 7th ne

6th nerve
Pyramidal Paramedian pontine
,.. +.. •
PPRF MLF
IPSILATERAL CONTRALATERAL
ABDUCENT OCULOMOTOR
NUCLEUS NERVE
ANATOMICAL LANDMARKS
 SUPERFICIAL EMERGENCE
• Emerges between lower
border of the pons &
lateral part of the
pyramid

• Emerge as seven or
eight rootlets
 COURSE
• Passes upwards & anterolaterally in
subarachnoid space of posterior cranial fossa

• Pierces the arachnoid & dura lateral to the

dorsum sellae
• Ascends between the layers of dura on the
posterior surface of the petrous bone near its
apex

• Turns anteriorly to traverse the cavernous

sinus
• Enters the orbit through the superior orbital
fissure within the annular tendon to supply
the lateral rectus muscle
COURSE OF ABDUCENT. N
RELATIONS OF ABDUCENT .N
 1.AT EMERGENCE
• Abducent nerves are
about 1 cm apart

 Between them is the

Basilary . A at its
formation from the 2
vertebral . A

• Lateral to each abducent

is the emergence of the
facial. N at the lateral
side of the olive
 2.POSTERIOR CRANIAL FOSSA
Just after its emergence , the nerve is crossed
by the ANTERIOR INFERIOR CEREBELLAR. A

• Usually the artery is ventral , but it may be

dorsal or pass between the abducent rootlets.
• Sleeved by the piamater
, it ascends
anterolaterally in the
cisterna pontis of the
subarachnoid space
between pons &
occipital bone
 -
Basilar
1-- _..:--- - Cribrifonnplate-Eth 'd artery Pituiary
Cristagalli - bonmeio Medial gland
Sphenoi lemniscus
dbone Opticcanal t Caroidartery

Selaturcica
Foramenovale

Jugularformaen
•1'
/·
n
l temal ···· P
acoustci meatus etroclinoidli
Clivusgament
Vestibular 6thnerve
Parietalbone- ,_;_ nucleus
Pyramd
i al
Occipitalbone ract
Foramenmagnum
, 1.10 a al ie o hecourseof he6thner e
• At the upper border of the bone, it turns forward
at a right – angle under the Petro sphenoidal
ligament ( Gruber’s ligament )

• Thus passing through a canal called the Dorello’s

canal – to enter the cavernous sinus with the
inferior petrosal sinus

• Often the nerve pierces the inferior sinus,

entering the cavernous sinus within the inferior
petrosal sinus
 Basilar
artery Pituiary
dial gland
lemniscus
Caroidartery
th

••
,; Petroclinoid
··\· ligament

Clivus
Vestibula 6thnerve
rnucleus
Pyramid
;nI alrae
tr
1JO aeal ie o hecourseof he6thner e
1

1
 3.CAVERNOUS SINUS
• Here the nerve
lies within the
cavernous sinus
Nerve is inferolateral to the horizontal portion
of the internal carotid artery with its
sympathetic plexus , which may communicate
with the nerve
• In the lateral wall of the
sinus , in descending
order are

• Oculomotor .N
• Trochlear . N
• Ophthalmic. N
• Maxillary. N

 Abducent .N is usually in
the sinus, with a separate
sheath
 4.SUPERIOR ORBITAL FISSURE
 Traverses the fissure
within the annulus of
Zinn

• At 1st below the division

of oculomotor.N

• Then between them &

lateral to nasociliary
nerve
 5.IN THE ORBIT

• Nerve divides into 3 or

4 filaments which enter
the ocular surface of
lateral rectus muscle
behind its midpoint
 CLINICAL ASPECTS

PONTOMEDULLARY
JUNCTION

AT FASCICULUS
BASILAR
COURSE

IN
AT NUCLEUS LESIONS CAVERNOUS
SINUS
 1. At the level of nucleus

• ipsilateral weakness of
abduction
• failure of horizontal
gaze towards the side of
lesion
• ipsilateral LMN palsy of
facial nerve
AN ISOLATED 6TH NERVE PALSY IS THEREFORE
NEVER NUCLEAR IN ORIGIN
2.PONTINE SYNDROMES – AT THE
LEVEL OF FASCICULUS
• MILLARD GUBLER SYNDROME
M

• RAYMOND CESTON SYNDROME

R

•FOVILLE SYNDROME
F
 A. Foville syndrome

 Involves fasciculus as it
passes through PPRF
 5th nerve – facial
anaesthesia
 6th nerve + gaze palsy
 7th nerve – facial
weakness
 8th nerve - deafness
 B. Millard – Gubler syndrome
 Involves fasciculus as it
passes through the
pyramidal tract
 Ipsilateral 6th nerve
palsy
 Contralateral
hemiplegia
 C. Raymond – Ceston syndrome
Due to tumor of cerebral peduncles
Red nucleus – speech & gait disorder
Paralysis of lateral conjugate gaze
Ipsilateral 6th N palsy
5th nerve – facial anaesthesia
Contralateral hemiparesis
 3. At the pontomedullary junction:

 ACOUSTIC NEUROMA:
• 1ST symptom – hearing
loss
• 1st sign - ↓ corneal
sensitivity
It is very important to test hearing &
corneal sensation in all patients with
6th nerve palsy
 4. In the basilar course

 A. ↑ intracranial
tension:
• - downward
displacement of
brainstem
• - stretching of 6th nerve
over petrous tip
• b/l 6th nerve palsy –
false localizing sign
 B. nasopharyngeal
tumors

 C. base of skull fractures

 D. Gradenigo’s
syndrome:
• Mastoiditis/Petrositis
• - damage to 6th nerve at
the Dorello’s canal
• Facial weakness
• Pain
• Hearing difficulties
 5. INTRACAVERNOUS PART
• Situated close to the
internal carotid A
• More prone to damage
than other cranial
nerves
 Intra cavernous 6th
nerve palsy is
accompanied by a
postganglionic Horner’s
syndrome
 CLINICAL PRESENTATION
• HISTORY:
– Esotropia
– Head-turn
– Binocular diplopia (worse at distance)
– Vision loss
– Pain
– Hearing loss
– Symptoms of vasculitis, particularly giant cell arteritis
– Trauma
 PHYSICAL FINDINGS
• An eso deviation that ↑
on ipsilateral gaze
• An isolated abduction
deficit
• Slowed ipsilateral
saccades
• Papilloedema
• Nystagmus
• Otitis media
• Orbital wall fracture
• Tender , non pulsatile
temporal arteries
 CAUSES OF 6TH NERVE PALSY

ELEVATED INTRACRANIAL NEOPLASM

TENSION

SUBARACHNOID SPACE CONGENITAL ABSENCE

LESIONS
VASCULAR TRAUMATIC

METABOLIC POST LUMBAR TAP

DEMYELINATING DISEASE INFECTIONS

Classic teaching in pediatric ophthalmology
held that isolated sixth nerve palsies in
childhood should be considered the result of a
PONTINE GLIOMA until proven otherwise
 DIFFERENTIAL DIAGNOSIS
1. myasthenia gravis
2. restrictive thyroid myopathy
3. medial orbital wall blow out fracture
4. orbital myositis
5. duane syndrome
6. convergence spasm
7. divergence paralysis
8. early onset esotropia
 WORK UP
• LAB TESTS:
• CBC
• Glucose levels
• HbA1C
• ESR/C – reactive protein
• Rapid plasma reagin tests
• Fluorescent treponemal antibody – absorption test
• Lyme titre
• Anti nuclear antibody test
• IMAGING STUDIES
 IMAGING STUDIES

• CT
• MRI
• CEREBRAL ANGIOGRAPHY
 Indications of MRI
• Age < 45 years
• Associated pain or neurologic abnormality
• History of cancer
• Bilateral 6th nerve palsy
• Papilloedema
• In the event no marked improvement is seen
or other nerves become involved
 OTHER TESTS

• Lumbar puncture
• Thyroid function tests
• Otoscopic examination
• Temporal artery biopsy
 MANAGEMENT
• Medical Care

• Truly isolated cases often are benign.

• They can be followed with a serial

examination, at least every 6 weeks, over a 6-
month period to note decreasing symptoms
(diplopia) and resolution of the paretic lateral
rectus (increasing motility)
• Children : Amblyopia treatment

• Older patients in whom giant cell arteritis is a

consideration should start the standard
treatment with prednisone or intravenous
methylprednisolone as soon as possible.
 SURGICAL CARE
• INDICATION:

• If after 6 months of follow up care the

remaining deviation is still unacceptable & is
too large to be corrected with prisms
 residual function exists

graded recession/resection
little or no residual function

transposition procedure
( weakening of antagonist
ipsilateral medial rectus
in appropiate patients )
THANK YOU