9. Complete the following concerning the pupillodilator nerve fibers:

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a. first-order sympathetic nerve fibers

     i. origin, p_____ h_____

posterolateral hypothalamus

     ii. destination, i_____ cell column (_____ to_____)

intermediolateral (C8 to T2)

     iii. neurotransmitter, a_____

acetylcholine (ACh)

b. second-order sympathetic nerve fibers

     i. origin, i_____ cell column

intermediolateral

     ii. destination, s_____ c_____ g_____

superior cervical ganglion

c. third-order sympathetic nerve fibers

     i. origin, s_____ c_____ g_____

superior cervical ganglion

     ii. destination, p_____ m_____ of the eye, l_____ g_____, M_____ m_____

pupillodilator muscle (long ciliary nerves), lacrimal gland, Müller muscle

     iii. neurotransmitter, n_____

norepinephrine

10. How are pupillodilator muscles arranged?

radially

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11. Describe the anatomy of sympathetic outflow to the eye. Hint: hilsc

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a. h_____

hypothalamus

b. i_____ _____ _____

intermediolateral cell column

c. l_____ _____ _____

lateral horn cells

d. c_____ _____

ciliary ganglion Sympathetic summary: first order: posterolateral (a) hypothalamus → descend in midbrain tegmentum uncrossed to pons, medulla, spinal cord (SC) to the (b) intermediolateral cell columns, C8-T2 (ciliospinal center of Budge). → synapse with (c) lateral horn cells acetylcholine (ACh) and give off second-order neurons (a) (preganglionics). Second order: enter sympathetic chain → (b) superior cervical ganglion. Third order: (a) (postganglionics): go up with common (b) carotid artery (CCA) those that mediate sweat to face go up external carotid artery (ECA), the rest go up internal carotid artery (ICA). Some pass: = (d) V1 → ciliary ganglion → (e) pupillodilator norepinephrine (NE)= ICA → (f) ophthalmic artery → (g) lacrimal gland and the Müller muscle.

12. The pupilloconstrictor (parasympathetic) are muscles arranged c_____ as a s_____.

concentric as a sphincter

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13. Describe the parasympathetic outflow to the eyes. Hint: Ect

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a. E_____

Edinger-Westphal

b. c_____

ciliary ganglion

c. t_____

third nerve Parasympathetics summary: Preganglionics arise in the Edinger-Westphal nucleus at the level of the superior colliculus synapse in the ciliary ganglion. Postganglionics travel on the third nerve to (e) innervate sphincter pupillae and ciliary muscle (thickens lens causing accommodation via relaxation).

14. Describe the pupillary light reflex.

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Hint: ropEtcs

a. r_____

retina

b. o_____

optic nerve

c. p_____

pretectal

d. E_____

Edinger-Westphal

e. t_____

third nerve

f. c_____

ciliary ganglion

g. s_____

sphincter light reflex Summary: Mediated by (a) rods and cones of retina. Transmit via axons to (b) optic nerve (ON). Bypass lateral geniculate body (unlike vision) synapse in (c) pretectal nuclear complex. Connect to both (d) Edinger-Westphal nuclei. Preganglionics travel in (e) third nerve to (f) ciliary ganglion, etc. Cornea rods and cones (retina) axons optic nerve bypass lateral geniculate body pretectal nuclear complex Edinger-Westphal nuclei (both preganglionics) to ciliary ganglion. Postganglionics via third nerve to pupillary sphincter. Ciliary muscles thicken (relax) causing accommodation.

15. Complete the following about Argyll Robertson pupil:

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Hint: ALRP = Argyll Robertson

pupil = absent light response pupil

a. Key feature is_____ _____ _____ _____or ALRP.

absent light response pupil

b. It occurs in_____.

syphilis

c. Near light dissociation means the pupil constricts when focusing on an object_____

near

d. but the pupil does not react to_____.

light

16. In which condition do you have light-near dissociation, that is, an Argyll Robertson pupil?

syphilis

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17. Complete the following about Argyll Robertson pupil:

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a. Light-near dissociation refers to pupillary_____

constriction

b. on convergence and_____ of papillary constriction to shining of the light into the eye

absence

c. classically described in_____

syphilis

d. also known as_____ _____ _____

Argyll Robertson pupil

Hint: prostitutes principle, “They accommodate but don’t react.”

18. Does afferent pupillary defect cause anisocoria?

no

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19. Complete the following about anisocoria:

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a. Unequal pupils with an affarent pupillary defect (Marcus-Gunn) means there are_____ _____.

two lesions

b. Physiologic anisocoria occurs in_____% of people.

20%

c. The difference is usually_____ mm.

0.4

d. Sudden onset of anisocoria is usually due to_____.

drugs

e. Sympathomimetics cause_____ to_____ mm of dilation and

1 to 2

f.

     i. parasympatholytics cause_____ mm of dilation and the

8

     ii. eye_____ _____ react to light.

does not

20. Complete the following about Horner syndrome:

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a. The abnormal pupil is_____.

smaller

b. Ptosis is on the side of the_____ pupil.

small

21. With third nerve palsy, if there is ptosis it will be on the side of the_____ pupil.

large

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22. Complete the following about oculomotor neuropathy:

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a. Example is_____

diabetes

b. Usually_____ the pupil

spares

c. Usually resolves in_____ _____

8 weeks

23. Complete the following about third nerve compression:

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a. Example is_____

aneurysm

b. Most common is_____

P-comm

c. Occasionally_____ _____ aneurysm

basilar bifurcation

d. Usually_____ _____ _____ the pupil

does not spare

24. What is the differential diagnosis of anisocoria?

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Hint: u tAp Hat

a. u_____

uncal herniation (also has mental status changes)

b. t_____

trauma (traumatic iridoplegia mydriasis or miosis)

c. A_____

Adie pupil (iris palsy— impaired postganglionic parasympathetics)

d. p_____

physiologic (less than 1 mm difference—20% of population)

e. H_____

Horner syndrome (impaired sympathetics to pupillodilator muscle)

f. a_____

aneurysm (posterior communicating, basilar)

g. t_____

third nerve palsy (pupil sparing-diabetes mellitus [DM 1], ETOH, cavernous aneurysm)

25. What is the differential diagnosis for Marcus-Gunn pupil?

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a. Location of lesion_____

ipsilateral to impaired direct reflex anterior to chiasm

     i. r_____ —d_____ i_____

retina—detachment, infarction

     ii. n_____ —m_____ s_____, v_____, or t_____

nerve—neuritis, multiple sclerosis (MS, viral)—trauma

b. In Marcus Gunn is/are the

     i. third nerve intact?

yes

     ii. parasympathetic nerves intact?

yes

26. Complete the following about Adie pupil:

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a. An Adie pupil is an_____palsy resulting

iris

b. in a_____ pupil, due to

dilated

c. impaired_____ _____.

postganglionic parasympathetics

d. Clinically, patients exhibit_____-_____ _____.

light-near dissociation

e. Typically it occurs in a_____ in her_____.

woman; twenties

27. The patient with an Adie pupil has a

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a. dilated or constricted pupil?

dilated

b. due to impaired preganglionic fibers or postganglionic fibers?

postganglionic

c. thought to be caused by a_____ _____

viral infection

d. of the_____ _____

ciliary ganglion

28. Horner syndrome is caused by interruption of sympathetics to the eye and face anywhere along their path. Name specific causes that affect the following:

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a. first-order neurons (three causes)

     i. i_____

infarction from vascular occlusion (usually posterior inferior cerebellar artery)

     ii. s_____

syringobulbia

     iii. i_____ n_____

intraparenchymal neoplasm

b. second-order neurons (three causes)

     i. l_____ s_____

lateral sympathectomies

     ii. s_____ c_____ t_____

significant chest trauma,

     iii. a_____ p_____ n_____ (P_____ t_____)

apical pulmonary neoplasms(Pancoast tumor)

c. third-order neurons (five causes)

     i. n_____ t_____

neck trauma (e.g., carotid dissections)

     ii. c_____ v_____ d_____

carotid vascular disease

     iii. c_____ b_____ a_____

cervical bony abnormalities

     iv. m_____

migraine

     v. sk_____ -b_____ n_____

skull-base neoplasms

29. The ptosis is due to paralysis of the_____ and _____ _____muscles.

superior and inferior tarsal

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30. Is the ptosis complete or partial?

partial

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31. Enophthalmos is due to paralysis of M_____ muscle, which is or is not involved in Horner syndrome?

Müller muscle; is involved

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32. Trace the third-order neuron in the pupillodilation/sympathetic path. Neurons from the s_____ c_____ g_____ to the p_____ m_____ and M_____ m_____.

superior cervical ganglion to the pupillodilator muscle and Müller muscle

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33. True or False. Answer the following regarding Horner syndrome:

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a. In a patient with Horner syndrome and preserved sweating of the face, the lesion is located

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     i. in the first-order neuron

false

     ii. in the second-order neuron

false

     iii. in the third-order neuron

true (Injured fibers on ICA produce Horner, intact sweat fibers to face on ECA.)

b. This is compatible with a Pancoast tumor.

false (Pancoast tumor would affect the sympathetics between the spinal cord and superior cervical ganglion [i. e., second-order neurons]. The fibers to sweat glands would be damaged because they had not yet separated to travel with the ECA.)

34. Complete the following about Horner syndrome:

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a. What medication is used if diagnosis of Horner syndrome is in doubt?

cocaine

b. How does it work?

cocaine blocks norepinephrine (NE) reuptake

c. Therefore in Horner syndrome the pupil will_____.

not dilate with cocaine (there is no NE release)

d. In a normal patient the pupil will_____.

dilate normally

35. Matching. From the list below identify the cranial nerve that innervates the muscle.

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Nerve:

III; IV; VI Hint: L6 SO4

Muscle:

a. medial rectus

b. inferior rectus

c. inferior oblique

d. superior rectus

e. superior oblique

f. lateral rectus

36. Complete the following regarding the frontal eye field:

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a. True or False. It moves eyes laterally to the opposite side.

true

b. It is located in the Brodmann area_____.

8

c. Its fibers go through the_____ of the_____ _____.

genu of the internal capsule

d. It sends fibers to the ipsilateral_____ _____ _____ nucleus.

paramedian pontine reticular formation (PPRF)

e. It sends fibers to the ipsilateral_____ nucleus

sixth

f. and the contralateral_____ nucleus

third

g. via the_____ _____ _____.

medial longitudinal fasciculus (MLF)

h. The right paramedian pontine reticular formation (PPRF) controls lateral eye movements to the_____.

right

37. Complete the following about the extraocular motor system:

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a. Injury to the medial longitudinal fasciculus (MLF) is called_______.

internuclear ophthalmoplegia (INO)

b. Convergence is_____ _____.

not impaired

c. If the right MLF is injured the right eye will not_____ _____.

move medially (adduct)

d. The left eye on looking laterally shows

     i. w_____ _____ a_____

weakness on abduction

     ii. n_____ or adduction.

nystagmus

e. The most common cause of MLF malfunction is_____ _____.

multiple sclerosis (MS)

38. Name three causes of non-pupil-sparing oculomotor palsy.

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Hint: tau

a. t_____

tumor

b. a_____

aneurysm (posterior communicating artery, basilar tip)

c. u_____

uncal herniation

39. Name seven causes of pupil-sparing oculomotor palsy.

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Hint: mEtDacc

a. m_____

myasthenia gravis

b. E_____

ETOH

c. t_____

temporal arteritis

d. D_____

DM

e. a_____

atherosclerosis

f. c_____ _____ _____

chronic progressive ophthalmoplegia

g. c_____ _____ _____

cavernous sinus lesions

40. Complete the following about trochlear nerve palsy (IV):

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a.

     i. In relation to the aqueduct the trochlear nucleus lies_____

ventral

     ii. At the level of the_____ _____

inferior colliculi

b.

     i. The axons pass_____

dorsally

     ii. Decussate_____

internally

c. It innervates the_____ _____ muscle

superior oblique

d. The superior oblique muscle

     i. Which primarily depresses the_____ eye?

adducted

     ii. In primary gaze it moves the eye_____ and_____.

down and out

41. Complete the following about the unique features of the trochlear nerve:

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a. Nucleus is on the_____ side of the

opposite

b. muscle it goes to:_____ _____ _____.

superior oblique muscle

c. It is the only nerve to decussate_____.

internally

d. It is the only nerve to exit_____ to the brain stem.

posterior

e. True or false. It passes through the annulusof Zinn.

false

f. Palsy results in eye deviation_____ and_____.

up and in

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g. Head is tilted to the_____ the IV palsy.

side opposite

h. Diplopia is exacerbated when looking_____ (i.e.,_____).

down; stairs

42. Name the causes of abducens palsy.

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Hint: abducens

a. a_____

arteritis, aneurysms

b. b_____

sixth nerve palsy

c. d_____

diabetes, Dorello canal (Gradenigo syndrome)

d. u_____

uncontrolled ICP, pseudotumor, trauma, tumor

e. c_____

cavernous sinus lesions, clivus, chordoma, or fracture

f. e_____

eye disease, thyroid, myasthenia gravis

g. n_____

neoplasms

h. s_____

sphenoid sinusitis (Gradenigo syndrome)

43. Matching. Match the syndrome with the nerves involved in multiple extraocular motor involvement.

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Syndrome:

cavernous sinus; superior orbital fissure; orbital apex

Nerves involved:

a. II

b. III

, ,

c. IV

, ,

d. V¹

, ,

e. V²

f. V³

g. VI

, ,

44. Is the ophthalmoplegia painful or painless?

painful

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45. Which nerve(s) is/are involved?

any nerve traversing the cavernous sinus

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46. The pupil is usually_____.

spared

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47. How long do symptoms last?

days to weeks

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48. Can there be spontaneous remission?

yes

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49. Can there be recurrent attacks?

yes

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50. Is there systemic involvement?

no

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51. How is it treated?

systemic steroids = 60 to 80 mg prednisone by mouth daily (slow taper)

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52. The disease is thought to be a_____ _____.

nonspecific inflammation

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53. The inflammation is located at the_____ _____ _____.

superior orbital fissure

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54. Complete the following about Raeder paratrigeminal neuralgia:

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a. Name two components.

     i. u_____ o_____ p_____

unilateral oculosympathetic paresis (think Horner syndrome—anhidrosis ± ptosis)

     ii. h_____ t_____ n_____ i_____

homolateral trigeminal nerve involvement (Horner syndrome and tic-like pain)

b. The pupil is_____

small

c. True or False. The pain is continuous.

false (intermittent, tic-like)

d. The pain is located at the_____.

trigeminal nerve V¹ (ophthalmic division) and sympathetics

55. Complete the following regarding Gradenigo syndrome:

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a. Name the classic triad.

     i. p_____ of_____

palsy; abducens

     ii. p_____ where?_____

pain; retro-orbital

     iii. d_____ e_____

draining ear

b. Pain is located at the p_____ a_____.

petrous apex

56. Complete the following about Gradenigo syndrome:

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a. What is Gradenigo syndrome?

apical petrositis

b. Involves_____ canal

Dorello

c. Features

     i. G_____

Gradenigo

     ii. r_____

retro-orbital pain

     iii. a_____ _____

apical petrositis—abducens palsy

     iv. d_____ _____

draining ear—Dorello canal ear draining

     v. e_____ _____

ear draining

     vi. n_____ _____ _____

neuropathy of VI

     vii. i_____

inflammation

     viii. p_____

petrositis

     ix. o_____ p_____

orbital pain

57. Complete the following about ocular bobbing:

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a. The eyes move_____.

downward

b. How many times per minute?

2 to 12

c. Ocular bobbing is associated with bilateral paralysis of_____ _____.

horizontal gaze

d. It is seen with destruction of the_____ _____.

pontine tegmentum

58. Optic atrophy is due to a_____ lesion.

compressive

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