2. Overview of the Presentation
A. Fundamentals of Extra-ocular movements
B. Anatomy of cortical and brainstem centers
C. Basic binocular eye movements and their pathways
D. Step-wise evaluation of EOMs
E. Lesions of Supranuclear Pathways
4. FUNDAMENTAL PRINCIPLES OF
OCULAR MOTOR CONTROL
• Detect objects
• Spatial resolution
AFFERENT
visual
system
• Clear and stable vision
• Binocular single vision
EFFERENT
visual
system
5. FUNDAMENTAL PRINCIPLES OF
OCULAR MOTOR CONTROL
Efferent ocular motor system
- Supranuclear pathways : Affect both eyes
simultaneously
- Infranuclear pathways : Affect eyes differently
7. HIERARCHY OF OCULAR MOTOR
CONTROL
Cortical
Control, BG,
SC, thalamus,
VA, Cerebellum
Brainstem, Ocular
Motor Cranial Nerve
Nuclei
Ocular motor nerves and Extra-
ocular muscles
LEVEL 1:
SUPRANUCLEAR
LEVEL 2:NUCLEAR
LEVEL 3:
INFRANUCLEAR
13. ROLE OF CEREBELLUM
Cerebellum plays an important role in fine tuning all
eye movements, including modulation and adaptation
of vestibulo-ocular responses, saccades, pursuit, and
vergence.
14. ROLE OF CEREBELLUM
Two distinct parts of the cerebellum contribute to
ocular motor control:
(1) the vestibulocerebellum (flocculus, paraflocculus,
nodulus, and ventral uvula) and
(2) the dorsal vermis of the posterior lobe and fastigial
nuclei. The vestibulocerebellum deals with
stabilization of sight during motion, whereas the
dorsal vermis and fastigial nuclei influence voluntary
gaze-shifting (i.e., saccades, pursuit and vergence).
17. EYE MOVEMENTS
CLASS MAIN FUNCTION
Vestibular Holds retinal image steady during brief head rotation or
translation
Optokinetic Holds images steady on the retina during sustained head
rotation
Smooth pursuit Holds target image steady during linear movement of
object or self
Saccades Rapidly bring object of interest to focus on fovea
Vergences Moves the eye in opposite directions so a single image is
simultaneously held on each fovea
18. 1. SACCADES
Rapid movement to bring object of interest on fovea
Clinical exam to
Check saccades
19. SACCADIC SYSTEM
STIMULUS
Visually reflexive – Parietal lobe Contralateral
Memory guided or volitional – Frontal lobe
Contralateral
CENTRE
Horizontal Saccades -> PPRF -> Pons
Vertical Saccades -> riMLF & PC -> Midbrain
21. VERTICAL SACCADE PATHWAY
riMLF : upward and
downward eye movements
and for ipsilateral torsional
saccades.
Projects to motoneurons of
elevator muscles bilaterally
but projects to motoneurons
of depressor muscles only
ipsilaterally
The INC projects by way of
the posterior commissure to
motoneurons of the
contralateral nuclei of the
third and fourth cranial
nerves and the contralateral
INC
23. SACCADIC SYSTEM – Features of a
saccade
Latency : duration of stimulus to movement
Accuracy : arrival of eyes on target
Velocity and conjugacy : degree to which 2 eyes move
together
Hypometric saccades : saccade that falls short of
intended target
Hypermetric saccades : overshoots the target
24. SACCADIC DYSFUNCTION
CLINICAL FEATURE SITE OF LESION
Prolonged Latency Degenerative disorders
Hypometric saccades PPRF lesion
Slow saccades in horizontal plane Pons
Slow saccades in vertical plane Midbrain
Hypermetric saccades Cerebellar lesions
25. 2. SMOOTH PURSUIT
Saccade and pursuit have common neural pathway
Cortical centres Middle Temporal & Medial Superior
Temporal
Ipsilateral cortical control
27. PURSUIT SYSTEM
Relatively slow moving target <30 degress per second
Initiation of pursuit - latency
Gain of eye movements = output/input
28. PURSUIT DYSFUNCTION
Low gain -> saccadic pursuit
Poor initiation -> Frontal / parietal lobe lesions
Deficits found usually in both vertical and horizontal
planes
30. OKN DYSFUNCTION
Parietal or temporal lobe lesions -> abnormal OKN
towards the side of lesion
Locate and define extent of cerebral lesions
31. 4. VESTIBULAR OCULAR REFLEX
Brief, high frequency rotation of the head
SCC – angular movements
Otoliths of utricle & saccule – linear acceleration
Centre: Vestibular nuclei
Efferent: fibres carried via MLF to cranial nerve nuclei
Velocity Storage mechanism
34. VESTIBULAR OCULAR REFLEX
Examination for VOR dysfunction
- Spontaneous nystagmus
- Horizontal head shaking
VOR gain = Amplitude of eye rotation/ Amplitude of
head rotation
Bilateral VOR dysfunction
- dynamic visual acuity
35. 5. VERGENCES
Vergence eye movements drive the eyes in
opposite directions to maintain the image of an
object on the fovea of both eyes as the object moves
toward or away from the observer.
Vergence eye movements are driven primarily by
a disparity in the relative location of im· ages on
the retinas.
36. 5. VERGENCES
Convergence centre : Pretectal area (mesencephalic
reticular formation, just dorsal to the third nerve
nuclei )
Inputs from bilateral cerebral hemispheres give inputs
to the centre and from there to both 3rd nerve nuclei.
38. EVALUATION OF EOMs
Q1. Is there a manifest strabismus?
How to check – Hirschberg, PBCT
What to look for – Comitant or incomitant strabismus
Generally a feature of infra-nuclear lesions
Q2. Is there limitation of range of movement? If yes, is
it horizontal, vertical or both?
How to check – Ductions and versions
What to look for – uniocular/binocular limitation,
conjugate limitation
Conjugate limitation: supra-nuclear lesion
Diplopia and limitation of ductions: infra-nuclear lesions
39. EVALUATION OF EOMs
Q3. Is there impairment of latency, accuracy or velocity
of voluntary saccade?
How to check - saccades 20 - 30° on either side of
primary position
What to look for –
Full range of movement with slow saccades: supra-nuclear
lesion
Limited range of movement with slow saccades: infra-nuclear
lesions
Limited range of movement with normal saccades in the
movement range allowed: myasthenia gravis
Difference in saccadic velocity of both eyes
40. EVALUATION OF EOMs
Q4. Is their impairment of latency or velocity of
smooth pursuit?
How to check – Follow a small target smoothly 20° on
either side of primary position
What to look for – Catch up saccades
Cortical lesions causing latency in pursuits: patient has catch
up saccades for foveation
Q5. Is their impairment of OKN?
How to check – OKN drum or scanning a newspaper in
front of the patient’s eye
What to look for – impaired or absent OKN
Localises lesion to the cortex. OKN is also a good method for
checking visual acuity in children
41. EVALUATION OF EOMs
Q6. Is there impairment of VOR?
How to check – doll’s head or oculocephalic maneuvers
What to look for – Corrective saccades, jerk nystagmus
on rapid head movement
Spontaneous jerk nystagmus on head shaking: VOR
dysfunction
Corrective saccades after head rotation: due loss of velocity
storage mechanism of VOR
Q7. Is there impairment of VOR suppression?
How to check - watching if the patient can keep their
gaze fixed on the thumb of their outstretched hand
while oscillating or being oscillated en bloc.
What to look for – quick phases in direction of head
42. EVALUATION OF EOMs
Q7. Is there impairment of VOR suppression?
How to check - watching if the patient can keep their
gaze fixed on the thumb of their outstretched hand
while oscillating or being oscillated en bloc.
What to look for – quick phases in direction of head
movement
Normally the patient should be able to maintain gaze on the
thumb of outstretched hand when swilled in a chair
Spontaneous nystagmus indicates a VOR dysfunction
43. EVALUATION OF EOMs
Q8. Is there impairment of vergence?
How to check – Moving object towards bridge of the
nose
What to look for – pupillary constriction present or not,
adduction present or not
Light near dissociation is a feature of dorsal midbrain
syndrome: Here the pretectal area is affected leading to
damage of pupillary light reflex centres. But since the
convergence centre lies ventral to it, accomodation reflex is
spared leading to miosis on convergence.
In cases of horizontal gaze palsy, there is limitation of
adduction due to MLF lesion. But the convergence centre
remains intact in midbrain, hence the patient can have
adduction on convergence.
44. EVALUATION OF EOMs
Q9. Is there involvement of other cranial nerves?
How to check – Cranial nerve examination
What to look for – 2nd nerve important, other CN
involvement helps in localisation
Other cranial nerve involvement can help localise the site of
lesion
Eg: PPRF lesion and VI n Nu. Lesion present with similar gaze
palsy. If there is associated VII n palsy, that helps localising
the lesion to VI n as the VII nerve fibres loop around the VI n
nucleas forming the facial colliculus.
45. EVALUATION OF EOMs
Q10. Is the limitation mechanical?
How to check – FDT, FGT
What to look for – Restriction vs Paralytic
Q11. Is there any spontaneous or inducible involuntary
eye movement, ocular oscillation, or nystagmus?
46. SUMMARY
Supranuclear lesions- BE involvement
Saccade – Contralateral frontal lobe control
Pursuit – Ipsilateral parietal control
Horizontal movements – PPRF, MLF – Pons
Vertical movements – riMLF & PC – midbrain
VOR – Brief, high frequency rotations
Ocular stability dysfunction – Saccadic intrusions
48. GAZE PALSY
Symmetric limitation of movement of both eyes in the
same direction.
Conjugate ophthalmoplegia
49. HORIZONTAL GAZE PALSY
Congenital – Mobius Syndrome
Acquired – Pontine lesions
- Disrupt eye movements towards the side of the
lesion.
Acquired – FEF lesions
- Disrupt eye movements towards side of lesion
63. References
Neuro- Ophthalmology, American Academy of Ophthalmology,
2010-2011. 5th edition.
Walsh & Hoyt’s. Clinical Neuro- ophthalmology. 6th edition
Khurana AK. Anatomy and Physiology of eye. 2nd edition
Kanski. Clinical Ophthalmology, 7th edition
Yanoff and Duker. 6th edition
Peter Their, Uwe J. The neural basis of smooth pursuit eye
movements. Current opinion in neurology 2005,15:645-652
David L sparks, Ellen J Barton. Neural control of saccadic eye
movements. Current opinion in neurobiology 1993,3:966-972
Chen,Chien Ming, Lin, Sung Hsuing. Wall eyed bilateral
internuclear ophthalmoplegia. Journal of Neuroophthalmology
2007,1:9-15
The combined influence of the pulse and step signal that contributes to the genera- tion of a saccadic eye movement. This schematic shows the coordination among omnipause cells (P), burst cells (B), and the cells of the neural integrator (N/) in the generation of a sac- cade. The NI performs an integration of the amount of neural activity required to execute an eye movement over the duration of time ddt). The omnipause cells cease their discharge just before the onset of a saccade. At the same time, the burst ce lls create the pu lse that initiates the saccade. This pulse is received by the NI, which determines the appropriate step needed to maintain the eccentric position of the eyes. The pulse and step alter the firing of the ocular motoneurons (OMN) that activate an extraocular muscle to execute an eye movement. The lower right trace (E) represents the shift in eye position from baseline to a sustained eccentric position. Vertical lines represent individual discharges of neurons. Underneath each schema- tized neural (spike) discharge are plots of discharge rate versus time. (Reproduced with permission from Leigh RJ, Zee DS. The Neurology of Eye Movements. 3rd ed Concemporary Neurology Series. New York: Oxford University Press; 1999.)
Brainstem control of vertical gaze. The rostral interstitial nucleus of the LF (riMLF) on each side contains excitatory burst neurons for upward and downward saccades and ipsitorsional saccades. Projections from riMLF onto motoneurons of the depressor muscles subnuclei— inferior rectus (ir) and superior oblique (so)—are mainly ipsilateral, whereas projections onto the elevator muscles subnuclei are bilateral. Note that the interstitial nucleus of Cajal (INC) decussates extensively in the posterior commissure, whereas riMLF decussates ventrally to the aqueduct. For details, see text. III = the oculomotor nucleus; IV = the trochlear nucleus; sr = superior rectus; io = inferior oblique; dotted line = midline.
Longer period of influence over longer periods of head rotation
MINOR COMPONENTS
Spasm/paresis of convergence
Spasm/paresis of accomodation
Pseudoabducens palsy (thalamic esotropia)
Associated Ocular Motility Deficits
Skew deviation
Third nerve palsy
Internuclear ophthalmoplegia
See-saw nystagmus
MINOR COMPONENTS
Spasm/paresis of convergence
Spasm/paresis of accomodation
Pseudoabducens palsy (thalamic esotropia)
Associated Ocular Motility Deficits
Skew deviation
Third nerve palsy
Internuclear ophthalmoplegia
See-saw nystagmus
Dorsal midbrain (Parinaud) syndrome. Upgaze palsy (A) with normal downgaze and horizontal movement. Pupils mid-dilated and fixed to light (B) but react to near-effort (C).
Argyll Robertson pupils
Aberrant regeneration of the third nerve
Diabetes
Tonic pupil
Deafferention
Argyll Robertson pupils
Aberrant regeneration of the third nerve
Diabetes
Tonic pupil
Deafferention
Limited upgaze in elderly patients
Progressive supranuclear palsy
Niemann-pick disease
Whipple’s disease