Neuro-ophthalmology: part 3, crainial nerves david. kinshuck@goodhope Neuro-ophthalmology: part 3, crainial nerves david.kinshuck@goodhope.nhs.uk Ocular cranial nerve problems…main points …can’t discuss all points in time allowed Present…a few questions as we go 2 tiny quizes 23/11/2018

Anatomy Nuclei of oculomotor nerve Trochlear nucleus Pons Fourth ventricle Abducent nucleus Vestibular nucleus Medial longitudinal fasciculus 23/11/2018

Anatomy 5th 3rd 6th www.meddean.luc.edu 4th 23/11/2018

Anatomy cont a c b d 23/11/2018

Anatomy cont 3rd 5th 4th 6th 23/11/2018

Case 1 What is happening? 23/11/2018

Case 1 animation 23/11/2018

3rd nerve palsy All recti except superior oblique and lateral rectus paralysed Pupil fixed and dilated Different types of 3rd nerve palsy..can localise lesion.. Eg elderly patients, diabetic, pupil spared: vascular lesion of nerve itself 23/11/2018

3rd nerve palsy 23/11/2018

Case 2 animation animation 23/11/2018

Case 2 animation animation 23/11/2018

Case 2 which eye is affected? 23/11/2018

Case 2 cover test Which eye is affected? www.mrcophth.com 23/11/2018

4th nerve palsy Superior oblique palsy, right: vertical diplopia 23/11/2018

4th nerve palsy Superior oblique palsy, left: vertical diplopia www.mrcophth.com 23/11/2018

Case animation animation 23/11/2018

Case 3 23/11/2018

6th nerve palsy Right Lateral rectus palsy 23/11/2018

6th nerve palsy Which lateral rectus palsy? left www.mrcophth.com 23/11/2018

Quiz Cases…diff diagnosis and why Age 20, road accident last week, vertical diplopia..diagnosis, & how do you diagnose it? Diplopia…horizontal…as shown here Age 70y, ptosis, diplopia (divergent) pupil OK, sudden onset www.mrcophth.com 23/11/2018

                                            5th nerve damage Test How? 23/11/2018

5th nerve damage Test Sensation in all 3 regions motor..clench teeth                                             5th nerve damage Test Sensation in all 3 regions motor..clench teeth 23/11/2018

5th nerve damage Lesion 4 Name? symptoms Lesion 1 Name? symptoms                                             5th nerve damage Lesion 4 Name? symptoms Lesion 1 Name? symptoms Lesion 3 Name symptoms Lesion 2 Name symptoms 23/11/2018

                                            5th nerve damage Orbital floor fracture (trauma)…numb beneath eye, diplopia Vth sensation reduced Pain and temp opposite side (vasc or MS or ca) Lesion 2 Trigeminal neuralgia… Vascular compression Ca …intracranial or Nasopharyngeal 23/11/2018

7th nerve palsy Try and think, in pairs, 1 minute Causes Problems What is the route of the 7th nerve? 23/11/2018

7th nerve...landmarks? 1…bends round what? 3 4 2 23/11/2018

7th nerve 23/11/2018

7th nerve.. landmarks Brain stem… Bends round 6th nerve nucleus Through facial canal turns 90o just medial to middle ear …styomastoid foramen Brain stem… Bends round 6th nerve nucleus Through parotid Through internal auditory meatus with Vlllth nerve 23/11/2018

7th nerve…lesions Ear infections eg. Ramsey Hunt =herpes zoster =rash on ear drum 6th and 7th lesion.. 7th supplies both side of face Parotid tumour..palpate Vlllth nerve…acoustic neuroma surgery or other SOL 23/11/2018

7th nerve palsy lesions Bells palsy, possibly herpes simplex Ramsay-Hunt with rash: herpes zoster Upper motor neurone…forehead symmetrical 23/11/2018

7th nerve palsy Runs over petrous part of temporal bone… 6,7,8th palsy Herpes zoster: look in ear for vesicles 23/11/2018

7th nerve palsy: eye problems www.ramsayhunt.org/ images/nik1.jpg Dry cornea can ulcerate Use fluorescein for examination Lubricate +++ Occasionally suture lids closed. Serious problem for acoustic neuroma patients 23/11/2018

Questions 23/11/2018

Summary 3rd cranial nerve…aneurysm in young patient (pupils..covered separately) 4th cranial nerve…vertical diplopia 6th…horizontal diplopia 5th ..unsusual but serious 7th…common, Bells, Ramsey Hunt, acoustic neuroma surgery, dry eye 23/11/2018

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