the visual and the occulo-motor system netta levin md phd fmri unit,department of neurology hadassah...
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The Visual and the occulo-motor system
Netta Levin MD PhDfMRI unit ,Department of
NeurologyHadassah Hebrew-University
Hospital Jerusalem, Israel
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Visual Neuroanatomy
• Afferent – eye to brain
• Pupillary reflex arc
• Efferents – eye movements
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Visual Neuroanatomy
• Afferent – eye to brain
• Pupillary reflex arc
• Efferents – eye movements
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C.N.Ⅲ,Ⅳ&Ⅵ : Ocular nerves
CN III: Oculomotor nerve CN IV: Trochlear nerve CN VI :Abducens nerve
•Visual inspection: ocular alignment, lids •Smooth pursuits •Saccades •Nystagmus •6 cardinal directions of gaze
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C.N.Ⅲ,Ⅳ&Ⅵ : Ocular nerves
Extraocular movements (H and X)
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Extra-Ocular Muscles
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CN III
• Innervates Levator, inferior oblique & all recti except lateral rectus
• Projects ventrally • Enters cavernous
sinus after crossing PCOM
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CN III Subnuclei
All subnuclei are ipsilateral EXCEPT• Levator subnucleus forms a fused central
nucleus• Superior rectus subnuclei decussate to innervate
contralateral superior rectus muscle
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IS it nuclear or peripheral ?
It must be nuclear if• Bilateral CN III without ptosis• Unilateral CN III with bilateral
ptosisBUT• Complete bilateral CN III• Bilateral ptosisMay be either!
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CN IV
• Nucleus just caudal and dorsal to III
• Innervates Contralateral superior oblique
• Exits brainstem dorsally
• Longest intracranial course
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CN VI
• Origin: ponto-medullary junction• Projects ventrally• Innervates ipsilateral lateral rectus
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Cavernous Sinus
• Site of multiple cranial nerve palsies
• Vascular• Tumor• Idiopathic
– Tolosa-Hunt
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Supranuclear control
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Supranuclear control
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Internuclear Pathways
• PPRF :Paramedian Pontine Reticular Formation
• MLF : Medial longitudinal fasciculus
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Paramedian Pontine Reticular Formation
• Horizontal Gaze center– Initiates horizontal eye movements
• Projects to ipsilateral CN VI nucleus• Lesions of the PPRF cause ipsilateral gaze
palsies
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MLF• Midbrain to cervical spine• Composed of interneurons: ipsilateral CN VI to
contralateral CN III.• fascicle for horizontal gaze and vertical gaze that
connects the VI and III nuclear complexes.
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Damage to the MLF
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Damage to the MLF+PPRF
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Visual Neuroanatomy
• Afferent – eye to brain
• Pupillary reflex arc
• Efferents – eye movements
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• Pupillary function - Light reflex (C.N.Ⅱ&Ⅲ)
• Dim lights • Fix gaze on opposite wall to eliminate effects
of accommodation • Shine bright light obliquely into each pupil • Look for both direct (same eye) and
consensual (opposite eye) reaction • Record pupil size and shape
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PupilsPupils
1st Order – Retina to Pretectal Nucleus in B/S(at level of Superior colliculus)2nd Order – Pretectal nucleus to E/W nucleus(bilateral innervation!)3rd Order – E/W nucleus to Ciliary Ganglion4th Order – Ciliary Ganglion to Sphincterpupillae (via short ciliary nerves)
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• Pupillary function
• Normal pupils are equal in size and shape and are situated in center of iris
• Pupillary size varies with intensity of ambient light, but at average intensity is ~3-4 mm
-Miosis < ~2 mm -Mydriasis > ~5 mm -Anisocoria = pupillary asymmetry
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Constricted (mioisis)• Sympathetic
(pupillodilator) denervation
• DrugsPilocarpineMorphine
Dilated (mydriasis)• Parasympathetic(pupilloconstrictor) denervation
•Lesion of the third CN•DrugsAtropineCocaine
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• Pupillary function
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Visual Neuroanatomy
• Afferent – eye to brain
• Pupillary reflex arc
• Efferents – eye movements
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• Visual acuity • Visual fields • Fundoscopy • Afferent limb of pupillary function
C.N.Ⅱ Optic: vision
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Hold card at comfortable reading distance • Cover 1 eye • Glasses on (looking for optic nerve lesion, not refractive error)
C.N.Ⅱ Optic: vision
• Visual acuity
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C.N.Ⅱ Optic: vision
• Visual fields
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C.N.Ⅱ Optic: vision
• Fundoscopy
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Optic Optic radiationradiation
Occipital Occipital callosalcallosal
Optic Optic tracttract
Optic Optic nervenerve
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How do we divide the visual cortexinto separate areas?
• Retinotopic mapping
• Functional signature
Visual cortex
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How do we divide the visual cortexinto separate areas?
• Retinotopic mapping
• Functional signature
Visual cortex
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Retinotopic organization of visual areas.
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Visual stimuli
Polar stimuli
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Eccentricity mapping: Foveal to Peripheral vision
anterior posterior
V1
Retinotopic mapping
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Eccentricity mapping
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Lesions in the visual pathways
Retinal damage
Macular degeneration
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How do we divide the visual cortexinto separate areas?
• Retinotopic mapping
• Functional signature
Visual cortex
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There are many visual centers Two Visual streams
Functional mapping
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Faces vs. Places processing activationFunctional mapping
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Lesions in the visual pathways
Cortical damage
Prosopagnosia
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Prosopagnostic patient
Activation within face related region
Activation within place related
region
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Visual ImpairmentsVisual Impairments
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• Young man presented with the complaint that he cannot see to the left or the right sides of his visual fields while looking straight ahead.
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Monocular - Binocular
Pre–chiasmatic – monocularChiasmatic / Post-chiasmatic - binocular
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Non-congruent inferior binocular field defects
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Congruent partial hemianopia
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Congruency – Incongruency
Posterior lesions are more congruent
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• 70 Y/O female• Sudden onset – diplopia, dysphagia ->
-> ataxia -> dysarthria -> impaired consciousness
• EXAM – Somnolent, EOM – disconjugate, Gag – decreased, bilateral Babinsky
• Visual Fields?
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Spared binocular macular vision
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• Bilateral PCA stroke (tip of the basilar)
• Macular Sparing
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Localizing the lesionLocalizing the lesion
• Monocular visual field defects indicatelesions anterior to the optic chiasm
• Bitemporal defects are the hallmark ofchiasmal lesions
• Binocular homonymous hemianopia resultfrom lesions in the contralateralpostchiasmal region
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• 18 Y/O male
• Sudden onset of blindness (following argument with girl friend)
• Signs of preserved sight
• Visual fields - tunnel vision
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5 meters
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10 meters
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5 meters
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10 meters
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5 meters
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• 60 y/o • Presenting with confusion• Pt denies neurological deficits• On exam –
–No sensory / motor signs–Confabulations to questions–Visual fields to confrontation – uncooperative
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• 60 y/o • Presenting with confusion• Pt denies neurological deficits• On exam –
– No sensory / motor signs– Confabulations to questions– Visual fields to confrontation –
uncooperative
– Anton Syndrome – •Cortical blindness • Anosognosia
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• 25 y/o female• Headaches for the last month• + Transient visual obscurations
(TVO’s)• + Diplopia (Horizontal? Veritcal?)• + Tinnitus• Referred by Opthalmologist• PMH - Acne
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• 25 y/o female
• Headaches for the last month
• + Transient visual obscurations (TVO’s)
• + Diplopia (Horizontal? Veritcal?)
• + Tinnitus
• Referred by Opthalmologist
Dx ?
Idiopatic Increased Intracranial Hypertension
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• 25 y.o. female
• New onset of reduced visual acuity and pain with eye movement
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• 25 y.o. female
• New onset of reduced visual acuity and pain with eye movement
On examination
• Reduced visual acuity
• Decreased red saturation
• Relative Afferent Pupillary Defect (RAPD)
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RAPDRAPD
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Optic neuritis is a disease of the optic nerve, causing acute visual loss. Optic neuritis can be clinically isolated but more often can arise as one of the manifestations of multiple sclerosis
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VEPVEP
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Thanks!