Chapter 12 - Nuclear, internuclear, and supranuclear ocular motor disorders
Introduction
Eye movement commands originate in diverse cerebral hemispheric areas for saccades, smooth pursuit, and convergence, or in the labyrinths for the vestibular ocular reflex. They are carried out in the brainstem by the immediate premotor (supranuclear and internuclear) structures and the ocular motor nuclei (see Chapter 2). Conjugate lateral eye movements are mainly organized in the pons, and vertical eye movements and convergence in the midbrain. In this chapter we will see the main types of eye movement paralysis resulting from brainstem lesions. Such types of abnormality are easily detected at the bedside by studying four main types of eye movement: (1) saccades, i.e., rapid eye movements made towards a visual target (such as the examiner's finger); (2) smooth pursuit, elicited by a small visual target moving slowly in front of the subject's eyes; (3) the vestibulo-ocular reflex (VOR), tested using oculocephalic movement, by passive movement of the subject's head; and (4) convergence, elicited by a small object moving slowly towards the subject's nose. Since the pathways of lateral and vertical eye movements are separate in the brainstem, these two types of eye movement will be reviewed successively. More details about the anatomy of these pathways may be found in Chapter 2.
Section snippets
Final common pathway: structures
The final common pathway of conjugate lateral eye movements begins in the abducens nucleus, located in the paramedian dorsal part of the lower pontine tegmentum (see Chapter 2). The abducens nucleus contains (Fig. 12.1, Fig. 12.2; see Fig. 2.4): (1) the motoneurons of the abducens nerve, which originate in the nucleus, first form the abducens nerve fascicles, coursing anteriorly through the lower part of the paramedian pontine reticular formation (PPRF) in the lower medial pontine tegmentum and
Final common pathway: structures
The final common pathway of vertical eye movements is formed by the oculomotor and trochlear nuclei and nerves. The motor neurons of the trochlear nerve decussate in the brainstem, as do those innervating the superior rectus muscle in the oculomotor nucleus, which originate in one oculomotor nucleus, cross the midline, and then pass through the contralateral oculomotor nucleus and nerve (Warwick, 1953). More details about the anatomical pathways serving vertical gaze may be found in Chapter 2.
References (85)
- et al.
Skew deviation revisited
Surv Ophthalmol
(2006) - et al.
Contralateral trochlear nerve paresis and ipsilateral Horner's syndrome
Am J Ophthalmol
(1989) - et al.
Transient upbeat nystagmus due to unilateral focal pontine infarction
J Clin Neurosci
(2009) - et al.
Hemi-seesaw nystagmus
Rev Neurol
(2006) - et al.
New insights into the upward vestibulo-ocular pathways in the human brainstem
Prog Brain Res
(2008) - et al.
Whipple's disease mimicking progressive supranuclear palsy: the diagnostic value of eye movement recording
J Neurol Neurosurg Psychiatry
(1999) - et al.
Anatomical connections of the prepositus and abducens nuclei in the squirrel monkey
J Comp Neurol
(1988) - et al.
A hypothetical scheme for the brainstem control and vertical gaze
Neurology
(2000) Syndromes oculomoteurs résultant de lesions mésencéphaliques chez l'homme
Rev Neurol
(1989)- et al.
Upgaze palsy and monocular paresis of downward gaze from ipsilateral thalamo-mesencephalic infarction: a vertical one-and-a-half syndrome
J Neurol
(1984)
Internuclear ophthalmoplegia, prenuclear paresis of contralateral superior rectus, and bilateral ptosis
J Neurol
The reticular formation
Vertical gaze paralysis and the rostral interstitial nucleus of the medial longitudinal fasciculus
Brain
Raphe nucleus of the pons containing omnipause neurons of the oculomotor system in the monkey, and its homologue in man
J Comp Neurol
Ptosis and supranuclear downgaze paralysis
Neurology
Loss of the neural integrator of the oculomotor system from brain stem lesions in monkey
J Neurophysiol
Wall-eyed bilateral internuclear ophthalmoplegia from lesions at different levels of the brainstem
J Neuroophthalmol
The clinical syndrome and etiological mechanism of infarction involving the nucleus prepositus hypoglossi
Cerebrovasc Dis
Contribution of y-group of vestibular nuclei and dentate nucleus of cerebellum to generation of vertical smooth eye movements
J Neurophysiol
Dissociated ipsilateral horizontal gaze palsy in one-and-a-half syndrome: a clinico-pathologic study
Neurology
Impairment of smooth pursuit in pontine lesions: functional topography based on MRI and neuropathologic findings
Acta Neurol Belg
Some neuro-ophthalmological observations
J Neurol Neurosurg Psychiatry
Quantitative oculographic characterization of INO in MS
J Neurol Neurosurg Psychiatry
The medial longitudinal fasciculus in ocular motor physiology
Neurology
Neuronal activity related to vertical eye movement in the region of interstitial nucleus of Cajal in alert cats
Exp Brain Res
Smooth pursuit eye movement disorders after pontine nuclei lesions in man
J Neurol Neurosurg Psychiatry
Jerk-waveform see-saw nystagmus due to unilateral mesencephalic lesion
Brain
Selective saccadic palsy caused by pontine lesions: clinical, physiological and pathological correlations
Ann Neurol
Deficits in vertical and torsional eye movements after uni- or bilateral muscimol activation of the interstitial nucleus of Cajal of the rhesus monkey
Exp Brain Res
Deficits in vertical and torsional eye movements after uni- and bilateral muscimol inactivation of the interstitial nucleus of Cajal of the alert monkey
Exp Brain Res
Localizing value of torsional nystagmus in small midbrain lesions
Neurology
Premotor neurons for vertical eye movements in the rostral mesencephalon of monkey and human: histologic identification byparvalbumin immunostaining
J Comp Neurol
Saccadic premotor neurons in the brainstem: functional neuroanatomy and clinical implications
Neuroophthalmology
Monocular elevation paresis caused by a central nervous system lesion
Arch Ophthalmol
Sparing of the vestibulo-ocular reflex with lesions of the paramedian pontine reticular formation
Neurology
Convergence nystagmus and vertical gaze palsy of vascular origin
Rev Neurol
Mesencephalic cholinergic nuclei in progressive supranuclear palsy
Neurology
Eye movement deficits after ibotenic acid lesions of the nucleus prepositus hypoglossi in monkeys
I. Saccades and fixation. J Neurophysiol
Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients
Arch Neurol
Oculomotor nerve nuclear complex syndrome
A case with clinicopathlogical correlation. Neuroophthalmology
Unilateral lesion of the paramedian pontine reticular formation
Neuroophthalmology
Eye movements in parkinsonism: it's saccadic speed that counts
Neurology
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Eye motor manifestations in children with neurometabolic disorders
2022, Journal of the Formosan Medical AssociationCitation Excerpt :Typical presentation in patients with bilateral vestibular failure is oscillopsia only during head and body movements.11 From an anatomic perspective, the eye movement control can be approached as infranuclear, nuclear, internuclear, and supranuclear.12,13 The supranuclear ocular motor dysfunction, accounting for about 10% of eye movement problems, deserves special attention that a substantial number of neurometabolic diseases have supranuclear ocular motor problems.14
Nonvestibular Dizziness
2021, Otolaryngologic Clinics of North AmericaCitation Excerpt :The MLF links the horizontal gaze centers in the pons (sixth cranial nerve nucleus and the paramedian pontine reticular formation) and the third cranial nerve nucleus in the midbrain (including the medial rectus subnucleus).16 In the normal state, horizontal gaze in one direction is triggered by the ipsilateral pons, and signals are transmitted through decussating fibers to the contralateral MLF, and in turn, the contralateral 3rd cranial nerve nucleus in the midbrain, allowing for the contraction of the ipsilateral lateral rectus muscle and contralateral medial rectus muscle, thus facilitating conjugate horizontal gaze.17 A lesion of the MLF can cause disruption of this pathway, resulting in an INO—defined as an abnormality of adduction (slowed adduction, limited range of adduction, or complete failure of adduction) during horizontal gaze (Video 2).
Half and half syndrome as a presentation of multiple sclerosis
2021, NeurologiaSaccadic delay in multiple sclerosis: A quantitative description
2020, Vision ResearchCitation Excerpt :They can result in visual complaints and are associated with greater general disability in MS. Hitherto, many studies described the extensive range of abnormalities based on clinical examinations. ( Coric, Nij Bijvank, van Rijn, Petzold, & Balk, 2018; Downey et al., 2002; Frohman, Frohman, Zee, McColl, & Galetta, 2005; Nerrant & Tilikete, 2017; Pierrot-Deseilligny, 2011; Prasad & Galetta, 2010). However, the clinical diagnosis can be challenging, especially when subtle abnormalities are involved (Frohman, Frohman, & O'Suilleabhain, 2003).
Convergence-Retraction Nystagmus in a Dog With Presumptive Ischemic Encephalopathy Following Acute Cervicothoracic Myelopathy
2020, Topics in Companion Animal MedicineCitation Excerpt :Venus infarction of the brain is rare, and usually it is accompanied by hemorrhage;53 thus we hypothesized that our case represented an arterial infarction. Accepting the hypothesis of relation between the brain infarct and a presumptive spinal cord infarct, an embolus might have traveled from the cervicothoracic spinal cord arteries, through the ventral spinal artery which becomes basilar artery, following the basilar bifurcation and either the caudal perforating artery or the paramedian branches of the proximal portion of the caudal cerebral artery, and reaching dorsal midbrain.6,54 In humans, the pathway of the embolus after the basilar artery follows the posterior thalamo-subthalamic paramedian artery causing infarction in the rostral interstitial nucleus of medial longitudinal fasciculus and thus dorsal midbrain syndrome.55,56
Eye Movement Disorders: Conjugate Gaze Abnormalities
2018, Liu, Volpe, and Galetta's Neuro-Ophthalmology: Diagnosis and Management