LESIONS OF 3rd ,4th and 6th CRANIAL NERVES

1.Oculomotor (3rd) nerve

A complete Oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. The eye will be displaced outward and displaced downward; outward because the lateral rectus (innervated by the sixth cranial nerve) maintains muscle tone in comparison to the paralyzed medial rectus. The eye will be displaced downward, because the superior oblique (innervated by the fourth cranial or trochlear nerve), is unantagonized by the paralyzed superior rectus, inferior rectus and inferior oblique. The affected individual will also have a ptosis, or drooping of the eyelid, and mydriasis (pupil dilation). Lesion in oculomotor nerve fibers results in : 1.Diplopia, external strabismus 2.Loss of parallel gaze 3.Ptosis 4.Dilated pupil, loss of light reflex 5.Loss of near response, blurred vision Oculomotor palsy can arise as a result of a number of different conditions. Congenital Oculomotor Palsy The origins of the vast majority of congenital oculomotor palsies are unknown, or idiopathic to use the medical term. There is some evidence of a familial tendency to the condition, particularly to a partial palsy involving the superior division of the nerve with an autosomal recessive inheritance. The condition can also result from aplasia or hypoplasia of one or more of the muscles supplied by the oculomotor nerve. It can also occur as a consequence of severe birth trauma. Acquired oculomotor palsy 1. Vascular disorders such as diabetes, heart disease, atherosclerosis and aneurysm, particularly of the posterior communicating artery 2. Space occupying lesions or tumours, both malignant and non-malignant 3. Inflammation and Infection 4. Trauma 5. Demyelinating disease (Multiple sclerosis)

6. Autoimmune disorders such as Myasthenia gravis 7. Post operatively as a complication of neurosurgery 8. Cavernous sinus thrombosis Oculomotor palsy can be of acute onset over hours with symptoms of headache when associated with diabetes Mellitus. Diabetic neuropathy of the oculomotor nerve in a majority of cases does not effect the pupil. The sparing of the pupil is thought to be associated with the microfasciculation of the edge fibers which control the pupillomotor fibers, which control the pupil.

2.Trochlear (4th) nerve

The sole function of the trochlear nerve is innervation of the superior oblique muscle, which is one of the six muscles of eye movement. Fourth nerve palsy or trochlear nerve palsy is a neurological defect resulting from dysfunction of the fourth cranial nerve. Double vision, also known as diplopia, may occur because of the inability of the eyes to maintain proper alignment. Lesion in Trochlear nerve results in : 1.Weakness looking down with adducted eye 2.Trouble going downstairs/ reading 3.Head tilt away from lesioned side

Causes of fourth nerve palsy can be broadly classified as congenital or acquired. Isolated congenital palsies may be heralded by head-tilting to the opposite side of the affected nerve in early childhood. In others a congenital palsy may go unnoticed because of a compensatory mechanism allowing for alignment of the eyes when focusing on an image. Isolated acquired trochlear nerve palsies can be the result of numerous disorders. Most commonly an underlying cause cannot be found and this is known as an idiopathic palsy following severe head trauma.Aneurysms or brain tumors may directly compress or result in an increase of intracranial pressure (the pressure within the skull) resulting in nerve palsies.Myasthenia gravis, diabetes, meningitis, microvascular disease is another caose.

3.Abducens (6th) nerve

Sixth cranial nerve palsy is weakness of the nerve that innervates the lateral rectus muscle. The lateral rectus muscle pulls the eye away from the nose and when the lateral rectus muscle is weak, the eye crosses inward toward the nose (esotropia). The esotropia is larger on distance fixation and on gaze to the same side as the affected lateral rectus muscle. Lesion results in : 1.diplopia,internal strabismus 2.Loss of parallel gaze, pseudoptosis 3.amblyopia in children The most common causes of 6th cranial nerve palsy are stroke, trauma, viral illness, brain tumor, inflammation, infection, migraine headache and elevated pressure inside the brain. The condition can be present at birth; however, the most common cause in children is trauma. In older persons, a small stroke is the most common cause. Sometimes the cause of the palsy is never determined despite extensive investigation.

Myasthenia gravis

Strabismus

Myasthenia gravis with ptosis