AUTONOMIC NERVOUS SYSTEM

OF THE EYES
BY
OLULEYE TS
 OCULAR SYMPATHETIC PATHWAYS
• The sympathetic nerve fibers serving the face, eye, and
eyelids originate in the hypothalamus and travel to the C8 -
T2 level of the spinal cord. Second order neurons (Pre-
ganglionic) leave the cord and travel over the lung apex to the
subclavian and carotid arteries. These fibers terminate in the
superior cervical ganglion. Third order neurons (Post-
ganglionic) leave the ganglion and travel with the internal
carotid artery to enter the skull, course through the
cavernous sinus, and the enter the orbit with the ophthalmic
artery and ciliary nerves. These sympathetic fibers allow pupil
dilation and cause and eyelid opening of about 2-3 mm.
SYMPATHETIC PATHWAYS
 DISORDERS OF OCULAR SYMPATHETICS
• HORNER’S SYNDROME-- 1. PTOSIS 2.MIOSIS 3. HYPOCHROMIA 4.
ANHYDROSIS
• CAUSES OF HORNERS SYNDROME
• Pre-ganglionic Causes:
• Lung apex tumor (Pancoast's tumor)
• Mediastinal mass
• Neck lesions such as thyroidectomy or thyroid neoplasm, trauma,
lymphadenopathy
• Post-ganglionic Causes:
• Migraine variants such as Cluster headache, Raeders syndrome
• Cavernous sinus or orbital lesion
• Internal artery dissection
• Carotid-cavernous fistula
• Nasopharyngeal carcinoma
•
 OCULAR PARASYNPATHETIC
SUPPLY
• EDINGER WESTPAL NUCLEUS
• The 3rd cranial nerve originates from the rostral midbrain,
coursing ventrally through the red nucleus and ipsilateral
corticospinal tract. The nerve enters the subarachnoid space,
passes between the posterior cerebral and superior
cerebellar arteries, and lies medial to the posterior
communicating artery. The nerve traverses the superolateral
aspect of the cavernous sinus, and enters the orbit through
the superior orbital fissure, branching into a superior and
inferior branch. Pupillary fibers lie superficially in the nerve,
and thus are subject to dysfunction from compression early.
OCCULOMOTOR NERVE
PATHWAYS
PARASYMPATHETIC PATHWAYS
 DISORDERS OF PARASYMPATHETIC
PATHWAY
• THIRD NERVE PALSY 1. PTOSIS 2.
PARALYSIS OF EXTRAOCULAR MUSCLES—
MED, SUP, INF. RECTI AND INF OBLIQUE 3.
PUPILLARY DILATION 4. CILIARY MUSCLE
PARALYSIS
 CAUSES OF THIRD NERVE PALSY
• In the evaluation of a 3rd cranial nerve palsy, it is important to determine:
• Involvement of the pupil.
• Involvement of other cranial nerves.
• Other neurological problems such as ataxia or hemiparesis.

• Microvascular Infarct:
• (Pupil sparing 3rd nerve palsy) A pupil sparing 3rd nerve palsy in an older patient (over 55) with a history
of diabetes or hypertension is commonly due to ischemic demyelination of the nerve. Headache or pain is
common, and the palsy generally resolves over 3-4 months. MRI is indicated in atypical or non-resolving
cases, or if the pupil becomes involved.
Compressive Lesions:
• (Pupil involving 3rd nerve
palsy, or partial 3rd nerve palsy with some pupil involvement) The 3rd cranial nerve is subject to
compressive injury at a variety of sites along its course:
• subarachnoid Space
– Compression:
– Supratentorial mass with herniation of the uncus - "Hutchinson's Sign" refers to a fixed, dilated pupil in this setting.
– Aneurysm, most commonly of the posterior communication artery. Neurological consultation and urgent neuroimaging are required. MRI,
MRA, and CT may miss aneurysms less than 5mm in diameter, thus arteriography may be appropriate.
– Subarachnoid hemorrhage - often presenting with severe headache and photophobia.
 THIRD NERVE PALSY…..
• Meningeal Inflammation:
• Infectious meningitis
• Sarcoidosis
• Meningeal carcinomatosis
• Lymphoma
–

• 3rd Nerve Palsy with Neurological Findings:

• As the third cranial nerve passes through the brainstem, vascular disease or compression from tumor may lead to
involvement of brainstem structures as well as the 3rd cranial nerve. Specific named syndromes include:
• Weber's Syndrome - ipsilateral 3rd nerve paresis and contralateral hemiparesis due to involvement of the pyramidal tract
• Benedikt's Syndrome - ipsilateral 3rd nerve paresis and contralateral hemitremor, due to involvement of the red nucleus
• Nothnagel's Syndrome - ipsilateral 3rd nerve paresis and cerebellar ataxia, due to involvement of the superior cerebellar
peduncle.

• 3rd Nerve Palsy with Other Cranial Nerve Involvement:

• (Cavernous sinus or orbital causes) The 3rd cranial nerve is accompanied by cranial nerves 4, 5, and 6 as they pass through
the cavernous sinus. Also, the oculosympathetic fibers serving the pupil and eyelids pass through the cavernous sinus on
the carotid artery. Cavernous sinus lesions include:
• Vascular anomalies, such as carotid-cavernous fistulas or aneurysm
• Neoplasms (pituitary, meningioma)
• Inflammatory diseases (Tolosa-Hunt, sarcoidosis, sinus disease)
• Trauma