Se ha denunciado esta presentación.
Utilizamos tu perfil de LinkedIn y tus datos de actividad para personalizar los anuncios y mostrarte publicidad más relevante. Puedes cambiar tus preferencias de publicidad en cualquier momento.
SUPRANUCLEAR AND
INTERNUCLEAR DISORDERS OF
OCULAR MOTILITY
DR ARPITA
• Extraocular muscles are supplied by 3,4,6 th
cranial nerves which have their nuclei in the
brainstem
• Centres controlli...
• The eyes move in SIX WAYS
FAST EYE
MOVEMENTS
(300°-600°/SEC)
1)SACCADES
2)NYSTAGMUS
SLOW EYE MOVEMENTS
(5°-50°/SEC)
1) S...
SACCADES
• Derived from french word “Saquer” which
means to pull or tug
• REDIRECT eyes from one target to another
• Volun...
• Always conjugate
• Ballistic – once initiated they cannot be stopped
or modified
• Speed of saccade is directly proporti...
Pathways for saccades
CROSSED
PATHWAY
Synthesis of a saccade- “pulse step”
Clinical examination
Thefixation objects should be presented at an angular separation
of about 20 to 30°.
Clinical examination
• SPEED - slowing of saccades can be seen in
AIDS dementia complex , Lipid storage
disorders , PSP , ...
SMOOTH PURSUIT
• Slow eye movements that permits the eyes to
conjugately follow/track a target during
movements of the tar...
• Initiated by a slow moving target across the
fovea
• Visual fixation holds the image of a stationary
object on the fovea
Pathway for pursuit movements
DOUBLE
DECUSSATION
• Parieto – occipito – temporal region is the
confluence of Brodman areas 19, 37 and 39
• A pure occipital lobe lesion wil...
VESTIBULAR REFLEX
• Coordinates eye movements with head
movements, holds image steady during brief
head rotations
• Stimul...
“COWS”
OPTOKINETIC REFLEX
• Stimulus – sustained head rotation
• With sustained head rotation at a constant
velocity , vestibular...
Turning the drum to the right elicits an ipsilateral pursuit movement to the right and a
contralateral saccade to the left.
VERGENCE
• Allows bifoveation of an object moving in Z
axis
• Stimuli –
• Retinal blur – accomodative vergence
• Disparity...
INTERNUCLEAR PATHWAYS
• Vertical saccades require simultaneous
activation of both FEF
• Unilateral activation of the riMLF generates
torsional e...
Supranuclear disorders...
• Affect both eyes
• Do not produce diplopia
• Dolls eye phenomenon and Bells
phenomenon remain ...
DISORDERS OF HORIZONTAL GAZE
A) SACCADIC DISORDERS
• INABILITY TO PRODUCE SACCADES
1) Frontal lobe lesions - Injury
• Cann...
• 2) Congenital ocular motor apraxia (COMA)
• Cannot initiate voluntary horizontal saccades
• Vertical saccades are normal...
• 3) Acquired ocular motor apraxia
• Aka Balints syndrome
• Seen in extensive B/L cerebral disease (parieto
– occipital)
•...
• SLOWING OF SACCADES
1) Progressive supranuclear palsy
• Aka Steel – Richardson – Olszewski syndrome
• Progressive conjug...
• 2) Olivopontocerebellar degeneration
• Presents early in adulthood
• Ataxia , slurred speech and dementia
• Eye movement...
• Dysmetric saccades
• Hypometric saccades are not necessarily
pathological;they can be the product of
inattention or poor...
• UNWANTED SACCADES
• Square wave jerks – named for their
appearance of eye movement recordings
• Sporadic saccades that r...
• Ocular flutter
• Intermittent brief volley of horizontal
oscillations aroud fixation
• No intersaccadic interval unlike ...
• Opsoclonus
• Chaotic saccades occuring randomly in any
direction
• Aka saccadomania
• Causes – cerebellar disease , post...
• Internuclear ophthalmoplegia
• Lesion of the MLF
• INO is named for the side of the MLF lesion
• Posterior INO – convergence is preserved
• Anterior INO – absence of conve...
• One and a half syndrome – PPRF lesion plus
ipsilateral MLF lesion
• Only movement left is contralateral abduction
• “Par...
DISORDERS OF VERTICAL GAZE
• Downgaze palsy –
• Occlusion of posterior thalamo-subthalmic
artery which enters from anterio...
• Dorsal midbrain syndrome
• Aka Parinauds syndrome / Sylvian aqueduct
syndrome
• Paresis of vertical gaze –mainly upward
...
• Skew deviation
• Acquired vertical and torsional deviation
• May be comintant or incomitant
• Due to imbalance of otolit...
• Ocular tilt reaction
• Due to lesion affection central or peripheral
otolithic pathways
• Destructive lesion of INC lead...
• 4th nerve palsy extortion of hypertropic eye
• OTR intortion of hypertropic eye
• Tonic downward deviation of gaze, or forced
downgaze, is associated with medial thalamic
hemorrhage, acute obstructive h...
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Supranuclear disorders of ocular motility
Próxima SlideShare
Cargando en…5
×

Supranuclear disorders of ocular motility

3.914 visualizaciones

Publicado el

Supranuclear disorders of ocular motility

  • Yes you are right. There are many research paper writing services available now. But almost services are fake and illegal. Only a genuine service will treat their customer with quality research papers. ⇒ www.WritePaper.info ⇐
       Responder 
    ¿Estás seguro?    No
    Tu mensaje aparecerá aquí
  • make your breasts bigger without surgery! NO PILLS NO CREAMS 100% NATURAL. FIND out more now! ✤✤✤ https://dwz1.cc/YYZPZbuh
       Responder 
    ¿Estás seguro?    No
    Tu mensaje aparecerá aquí
  • From A Cup To c Cup In 6 Weeks with this... ✱✱✱ https://dwz1.cc/aRWJhQS6
       Responder 
    ¿Estás seguro?    No
    Tu mensaje aparecerá aquí
  • Sex in your area is here: ♥♥♥ http://bit.ly/2Q98JRS ♥♥♥
       Responder 
    ¿Estás seguro?    No
    Tu mensaje aparecerá aquí
  • Dating direct: ❶❶❶ http://bit.ly/2Q98JRS ❶❶❶
       Responder 
    ¿Estás seguro?    No
    Tu mensaje aparecerá aquí

Supranuclear disorders of ocular motility

  1. 1. SUPRANUCLEAR AND INTERNUCLEAR DISORDERS OF OCULAR MOTILITY DR ARPITA
  2. 2. • Extraocular muscles are supplied by 3,4,6 th cranial nerves which have their nuclei in the brainstem • Centres controlling the nuclei – Supranuclear • Pathways connecting the nuclei – Internuclear • Nerves supplying the EOM - Infranuclear
  3. 3. • The eyes move in SIX WAYS FAST EYE MOVEMENTS (300°-600°/SEC) 1)SACCADES 2)NYSTAGMUS SLOW EYE MOVEMENTS (5°-50°/SEC) 1) SMOOTH PURSUIT 2) OPTOKINETIC 3) VESTIBULAR 4) VERGENCE
  4. 4. SACCADES • Derived from french word “Saquer” which means to pull or tug • REDIRECT eyes from one target to another • Voluntary or reflex ( in response to visual , auditory or pain stimulus )
  5. 5. • Always conjugate • Ballistic – once initiated they cannot be stopped or modified • Speed of saccade is directly proportional to size of movement Velocity of a larger saccade is faster than the velocity of a slow saccade , this is known as Main sequence • Visual suppression occurs - even though the visual world is sweeping across retina , there is no sense of a blurred image
  6. 6. Pathways for saccades
  7. 7. CROSSED PATHWAY
  8. 8. Synthesis of a saccade- “pulse step”
  9. 9. Clinical examination Thefixation objects should be presented at an angular separation of about 20 to 30°.
  10. 10. Clinical examination • SPEED - slowing of saccades can be seen in AIDS dementia complex , Lipid storage disorders , PSP , drug intoxications • SMOOTHNESS – affected in cerebellar diseases • ACCURACY – Hypometric or Hypermetric , affected in cerebellar diseases
  11. 11. SMOOTH PURSUIT • Slow eye movements that permits the eyes to conjugately follow/track a target during movements of the target or observer or both • Have the capcity for compensation unlike saccades - when speed of target is varied after initiation of the movement , speed of pursuit can be varied.
  12. 12. • Initiated by a slow moving target across the fovea • Visual fixation holds the image of a stationary object on the fovea
  13. 13. Pathway for pursuit movements DOUBLE DECUSSATION
  14. 14. • Parieto – occipito – temporal region is the confluence of Brodman areas 19, 37 and 39 • A pure occipital lobe lesion will not affect smooth pursuit movements • Deep parietal lobe lesions disrupt smooth pursuit to ipsilateral side
  15. 15. VESTIBULAR REFLEX • Coordinates eye movements with head movements, holds image steady during brief head rotations • Stimulation of Ampulla of horizontal semicircular canal conjuate movement towards contralateral side • Information from anterior and posterior semicircular canals - combination of vertical and torsional eye movements
  16. 16. “COWS”
  17. 17. OPTOKINETIC REFLEX • Stimulus – sustained head rotation • With sustained head rotation at a constant velocity , vestibular response fades and optokinetic response takes over • OKN prevents a continuous blur from relative motion of the moving visual field .
  18. 18. Turning the drum to the right elicits an ipsilateral pursuit movement to the right and a contralateral saccade to the left.
  19. 19. VERGENCE • Allows bifoveation of an object moving in Z axis • Stimuli – • Retinal blur – accomodative vergence • Disparity of location of images- fusional vergence • Pathway : Occipital cortex – midbrain reticular formation – 3rd nerve nucleus
  20. 20. INTERNUCLEAR PATHWAYS
  21. 21. • Vertical saccades require simultaneous activation of both FEF • Unilateral activation of the riMLF generates torsional eye movements • Right riMLF – clockwise movements • Left riMLF – anticlockwise movements
  22. 22. Supranuclear disorders... • Affect both eyes • Do not produce diplopia • Dolls eye phenomenon and Bells phenomenon remain intact
  23. 23. DISORDERS OF HORIZONTAL GAZE A) SACCADIC DISORDERS • INABILITY TO PRODUCE SACCADES 1) Frontal lobe lesions - Injury • Cannot generate contralateral saccades • Preferential gaze to affected side • Pursuit , OKN ,VOR are normal • Recovers after several weeks due to activation of projections from ipsilateral FEF to PPRF
  24. 24. • 2) Congenital ocular motor apraxia (COMA) • Cannot initiate voluntary horizontal saccades • Vertical saccades are normal • “ Head thrusting occurs ” • Becomes less prominent with age
  25. 25. • 3) Acquired ocular motor apraxia • Aka Balints syndrome • Seen in extensive B/L cerebral disease (parieto – occipital) • Simultagnosia – inability to perceive more than one object at a time • Optic ataxia – inaccurate arm pointing • Dementia • Visual field defects
  26. 26. • SLOWING OF SACCADES 1) Progressive supranuclear palsy • Aka Steel – Richardson – Olszewski syndrome • Progressive conjugate paresis of gaze in all directions especially downward • Associated neurological symptoms include dementia , dysarthria , nuchal and axial rigidity • Recurrent falls early in course • Death within several years of diagnosis
  27. 27. • 2) Olivopontocerebellar degeneration • Presents early in adulthood • Ataxia , slurred speech and dementia • Eye movements in all directions are progressively affected • Eventually leads to total ophthalmoplegia
  28. 28. • Dysmetric saccades • Hypometric saccades are not necessarily pathological;they can be the product of inattention or poor cooperation. • Hypermetric saccades on the contrary are always pathological and strongly suggest the presence of a lesion in the cerebellar vermis.
  29. 29. • UNWANTED SACCADES • Square wave jerks – named for their appearance of eye movement recordings • Sporadic saccades that return to fixation within 100-200 msec • Greater than 1 degree = pathologic • Associated with cerebellar disease • Called as “ sed rate of CNS “ as more than 10/min is a non specific indicator of CNS disease
  30. 30. • Ocular flutter • Intermittent brief volley of horizontal oscillations aroud fixation • No intersaccadic interval unlike square wave jerks
  31. 31. • Opsoclonus • Chaotic saccades occuring randomly in any direction • Aka saccadomania • Causes – cerebellar disease , post viral encephalopathy , paraneoplastic sign , drug toxicity
  32. 32. • Internuclear ophthalmoplegia • Lesion of the MLF
  33. 33. • INO is named for the side of the MLF lesion • Posterior INO – convergence is preserved • Anterior INO – absence of convergence • WEBINO – bilateral INO • Myaesthenia can present similarly – pseudo INO
  34. 34. • One and a half syndrome – PPRF lesion plus ipsilateral MLF lesion • Only movement left is contralateral abduction • “Paralytic pontine exotropia”- transient phenomenon seen during first few days of one and a half syndrome – due to unopposed action of contralateral PPRF
  35. 35. DISORDERS OF VERTICAL GAZE • Downgaze palsy – • Occlusion of posterior thalamo-subthalmic artery which enters from anterior part of midbrain (Percheron's artery), • Upgaze palsy – lesion in rostral midbrain (posterior comissure)
  36. 36. • Dorsal midbrain syndrome • Aka Parinauds syndrome / Sylvian aqueduct syndrome • Paresis of vertical gaze –mainly upward • Light near dissociation of pupils • Convergence retraction nystagmus • Lid retraction – Colliers sign • Spasm / paresis of convergence • Spasm / paresis of accomodation
  37. 37. • Skew deviation • Acquired vertical and torsional deviation • May be comintant or incomitant • Due to imbalance of otolithic inputs from utricule and saccule to ocular motor neurons • With lower brainstem lesions the ipsilateral eye tends to be hypotropic , with pontine and midbrain lesions the eye tends to be hypertropic
  38. 38. • Ocular tilt reaction • Due to lesion affection central or peripheral otolithic pathways • Destructive lesion of INC leads to : • Contralateral head tilt • Depression and extorsion of contralateral eye • Elevation and intortion of ipsilateral eye
  39. 39. • 4th nerve palsy extortion of hypertropic eye • OTR intortion of hypertropic eye
  40. 40. • Tonic downward deviation of gaze, or forced downgaze, is associated with medial thalamic hemorrhage, acute obstructive hydrocephalus, severe metabolic or hypoxic encephalopathy, or massive subarachnoid hemorrhage. • When associated with lid retraction, the corneas can be buried below the lower lid (sundowning). • In this setting, elevated intracranial pressure is a major concern.

×