Oculomotor Nerve

& Ciliary Ganglion

DR KANIKA SACHDEVA
PROFESSOR ANATOMY
• The oculomotor nerve - Third cranial nerve (CN III).
• It provides motor and parasympathetic innervation to some of the
structures within the bony orbit.
• Functions:
1. Motor – Innervates the majority of the extraocular muscles (levator
palpebrae superioris, superior rectus, inferior rectus, medial rectus
and inferior oblique).
2. Parasympathetic – Supplies the sphincter pupillae and the ciliary
muscles of the eye.
3. Sympathetic – No direct function, but sympathetic fibres run with
the oculomotor nerve to innervate the superior tarsal muscle (helps
to raise the eyelid).
Functional Components of Oculomotor Nerve
1. General Somatic Efferent Fibres/ Somato motor fibres:
• Supply all extraocular muscles except Lateral Rectus (supplied by 6th cranial
nerve) and superior oblique (supplied by 4th cranial nerve).
• The GSE fibres arise from the somatic component of oculomotor nucleus (also
called the somatic motor nucleus).
2. General visceral efferent fibres:
• They supply the sphincter pupillae and ciliaris muscles.
• They arise from the parasympathetic component of oculomotor nucleus (also
called the Edinger–Westphal nucleus).
• These are preganglionic parasympathetic fibres and relay in the ciliary
ganglion.
• The postganglionic parasympathetic fibres arise from the ganglion and supply
the sphincter pupillae and ciliaris muscles.
3. Proprioreceptive Fibres: from most of extra ocular muscles. Cell
bodies of these neurons are located in mesencephalic nucleus of
trigeminal nerve
Functional Components & nuclei of Oculomotor Nerve
Central Connections of Oculomotor Nerve
• The oculomotor nucleus is situated in the ventromedial part of central grey
matter of midbrain at the level of superior colliculus. Ventrolaterally, it is
closely related to the medial longitudinal bundle.
• The nucleus is connected:
1. To the pyramidal tracts of both sides which form the supranuclear pathway
of the nerve.
2. To the pretectal nuclei of both sides for the direct & concensual light reflex.
3. To medial longitudinal fasciculus by which it is connected to the 4th , 6th &
8th for coordination of the eye movements.
4. To the tectobulbar tract by which it is connected to visual cortex through
superior colliculus for visuoprotective reflexes.
5. To mesencephalic nucleus of trigeminal nerve.
Oculomotor Nuclear Complex
• CCN: Caudal Central Nucleus
• DLN: Dorso lateral Nucleus
• EWN: Edinger Westphal Nucleus
• IN: Intermediate Nucleus
• RN: Raphe Nucleus
• VMN: Ventro Median Nucleus
• (IO): Inferior Obliques
• (IR): Inferior Rectus
• (LPS): Levator Palpabrae Superioris
• (MR): Medial Rectus
• (SR): Superior Rectus

• All muscles of eyeball are suppled by ipsilateral

neurons except superior rectus & LPS which
are supplied bilaterally
The nuclear complex includes the following parts

• Dorsolateral—to supply inferior rectus muscle

• Intermediate—to inferior oblique

• Ventromedial—to medial rectus

• Caudal central—to part of levator palpabrae superioris

• Median raphe—to superior rectus

• Edinger-Westphal—to ciliaris and sphincter pupillae muscles.

Course
Superficial Origin of Nerve:
• From Oculomotor nuclear complex, fibres pass forwards forming a series of convex
lateral curves through tegmentum of midbrain, red nucleus & medial part of
substantia nigra
• Fibres form a single nerve trunk which passes through a sulcus on medial side of
cerebral peduncles of midbrain and appears in the interpeduncular fossa.
Course at base of brain & intracranial course:
• Runs forward and laterally in interpeduncular cistern between the posterior
cerebral and superior cerebellar arteries and lateral to the posterior
communicating artery
• Passes through the tentorial notch of tentorium cerebelli to reach the middle
cranial fossa.
• It pierces the dura mater in the oculomotor triangle lying in between the free and
attached margins of tentorium cerebelli in the roof of the cavernous sinus and
enters the lateral wall of the cavernous sinus.
 Relation of Oculomotor nerve and cavernous
sinus
Intracavernous Course:
• Enters cavernous sinus by piercing posterior
part of roof on lateral side of posterior
clinoid process.
• Soon it descends in lateral wall of sinus
where it lies superior to the trochlear,
ophthalmic, and maxillary nerves, and lateral
to the internal carotid artery.
• In the anterior part of the cavernous sinus,
the nerve divides into upper and lower
divisions: small superior & larger lower
rami.
Intracavernous Course
In the Orbit:
• The two divisions enter the orbit through the middle part of superior
orbital fissure within the common tendinous ring/ Annular ring of Zinn.
• The nasociliary nerve intervenes between the two divisions & abducent
nerve lies inferolateral to inferior division.
• The smaller upper division passes above the optic nerve on the inferior
surface of superior rectus (which it supplies), and then passes through the
superior rectus to supply the levator palpebrae superioris
• The larger inferior division of the oculomotor nerve passes below the optic
nerve and immediately gives three branches which supply the medial
rectus, inferior rectus, and inferior oblique muscles.
• The nerve to inferior oblique is longest & gives preganglionic
parasympathetic/motor fibres to the ciliary ganglion
Superior Orbital Fissure
Branches of Oculomotor Nerve
Oculomotor Nerve Palsy
The most common structural causes include:
• Compression by aneurysm of the posterior communicating artery as it
passes between posterior cerebral and superior cerebellar arteries.
• Compression by aneurysm of the internal carotid artery as it passes
through the lateral wall of the cavernous sinus.
• Compression by transtentorial uncal herniation as it passes through the
tentorial notch, Raised intracranial pressure (compresses the nerve against
the temporal bone).
• Cavernous sinus infection or trauma.
• Other pathological causes of oculomotor nerve palsy such as diabetes,
multiple sclerosis, myasthenia gravis and giant cell arteritis
Clinical features of CN III injury are associated with the eye:
• Ptosis (drooping upper eyelid) – due to paralysis of the levator palpabrae superioris and
unopposed activity of the orbicularis oculi muscle.
• Lateral squint/ External Strabismus: ‘Down and out‘ position of the eye at rest – due to
paralysis of the superior, inferior and medial rectus, and the inferior oblique (and therefore
the unopposed activity of the lateral rectus and superior oblique).
The patient is unable to elevate, depress or adduct the eye.
• Dilated pupil – due to the unopposed action of the dilator pupillae muscles due to paralysis
of parasympathetic fibres to sphincter pupillae muscle.
• Loss of accommodation due to paralysis of ciliary muscles
• Slight proptosis, i.e. forward projection of the eye, due to relaxation of the muscles of the
eyeball.
• Diplopia/ double vision occurs on looking medially, inferiorly, and superiorly, due to paraly-
sis of the medial rectus, inferior rectus, and inferior oblique muscles.
• Pupillary light reflex in affected eye is absent : Pupil dilates and becomes fixed to light
• Right oculomotor nerve palsy, characterised by the ‘down and
out’ dilated pupil with ipsilateral ptosis
• A midbrain lesion causing contralateral hemiplegia and ipsilateral
paralysis of the third nerve is known as Weber’s syndrome- due to
interruption of corticospinal tract of cerebral peduncles.
• Supranuclear paralysis of the third nerve causes loss of conjugate
movement of the eyes.
• Compression of III nerve:
Compression of III nerve due to extradural haematoma causes dilatation
of pupil.
Parasympathetic fibres lying superficial get affected first.
Pupil dilates on affected side and there is little response to light.
• Aneurysm/ Periarteritis of posterior cerebral or superior cerebellar
artery, microaneurysm of posterior communicating artery(periarteritis
common in neurosyphilis): compress III nerve as it passes between them
CILIARY GANGLION
• It is a peripheral parasympathetic ganglion
• Topographically it is connected to the nasociliary nerve from
ophthalmic division of the trigeminal
• Functionally it is connected to the oculomotor nerve
• Location:
• It is a minute body (2 mm in diameter)- pin head size, reddish grey in
colour; lying near the apex of orbit between the optic nerve and lateral
rectus muscle.
• It contains multipolar neurons
• Flattened, irregular having 4 angles- anterosuperior, anteroinferior,
posterosuperior and posteroinferior
• Roots: Three roots enter its posterior end- Parasympathetic,
Sympathetic & Sensory
Roots & Distribution of Ciliary Ganglion
Parasympathetic Root: mainly
concerned with focussing
Nerve to Inferior Fibres relay
Edinger Westphal Oblique Muscle
Nucleus Midbrain Postganglionic
Fibres
Preganglionic
Fibres Short Sphincter
Oculomotor Communicating Ciliaris
Nerve Pupillae
Branches Muscle
7%
95%- More
voluminous
Inferior Division muscle
of Oculomotor CILIARY
Nerve GANGLION
Parasympathetic Functions
• There are two structures in the eye that receive parasympathetic
innervation from the oculomotor nerve:
• Sphincter pupillae – constricts the pupil, reducing the amount of light
entering the eye.
• Ciliary muscles – contracts, causes the lens to become more
spherical, and thus more adapted to short range vision.
• The pre-ganglionic parasympathetic fibres travel in the inferior branch
of the oculomotor nerve. Within the orbit, they branch off and
synapse in the ciliary ganglion. The post-ganglionic fibres are carried
to the eye via the short ciliary nerves.
 Postganglionic
Sympathetic Root White Ramus Plexus Around Internal Fibres
Communicantes Carotid Artery
Intermediolateral
Nucleus of T1 Stellate Ganglion
segment of Spinal Communicating Ophthalmic
Cord (Lateral horn) twig to 3rd nerve Nerve
in cavernous
Preganglionic Middle Cervical sinus
Fibres Ganglion
Ventral Root of T1 Nasociliary
Nerve to Inferior Nerve
Superior Cervical Oblique
Ganglion
T1 Spinal Nerve Long Ciliary
Nerves
CILIARY GANGLION
Fibres relay
Blood
Ventral Ramus of T1 Short Ciliary Nerve: Blood vessels Vessels
(95%), Dilator Pupillae (5%)
 Sensory Root Enter communicating
Main Sensory Nucleus &
Nucleus of Spinal Tract of
ramus of ciliary Trigeminal Nerve
Sensory fibres from
ganglion
eyeball (cornea, iris,
choroid)
2nd Order Neurons
Preganglionic Enter Nasociliary cross to opposite side in
Nerve Trigeminal Lemniscus
Fibres Short Ciliary
Nerves
Reach Ventral
Posteromedial Nucleus
Ophthalmic Nerve
CILIARY GANGLION of Thalamus

Fibres donot relay Trigeminal Nerve 3rd Order Neurons pass

to Post Central Gyrus
Branches:
• The ganglion gives off 8 to 10 short ciliary nerves which divide into 15
to 20 branches
• They contain fibres from all the three roots of the ganglion
• They run above and below the optic nerve towards the eyeball
• On reaching the eyeball they pierce the sclera around the attachment
of the optic nerve and pass forwards in the space between the sclera
and choroid to reach the target organs.
Applied Anatomy:
The ciliary ganglion is blocked to produce dilatation of pupil before
cataract extraction.