Examination of Cranial Nerves Allison Mae T.

Mangabat 1BMD
Patient Name: Hannah P. Clemente Age: 24 Sex: Female

CRANIAL NERVE II

VISUAL ACUITY
DISTANT VISION (SNELLEN’S CHART)
RIGHT EYE 20/13(-2) LEFT EYE 20/13(-1)
FIELD OF VISION
SUPERIOR INFERIOR MEDIAL LATERAL
RIGHT EYE + + + +
LEFT EYE + + + +
COLOR VISION RIGHT EYE 15/15 LEFT EYE 15/15

CRANIAL NERVE III, IV, VI

PUPILS
RIGHT EYE LEFT EYE
DIRECT LIGHT REFLEX + +
INDIRECT LIGHT REFLEX + +
ACCOMMODATION REFLEX + +

*Size is seen superficially to be normal

QUESTIONS

1. List the effects of various lesions in the visual pathway.

Optic tract lesion

Incongruous homonymous hemianopia: a defect pattern associated with an optic tract lesion, there is a temporal hemianopic defect in the field of the
contralateral eye and a nasal hemianopic defect in the field of the ipsilateral eye. Incomplete homonymous hemianopias tend to be dissimilar in
extent in the two eyes ("incongruous") when lesions are in the optic tract, but relatively similar in extent in the two eyes ("congruous") when lesions
are in the lateral geniculate body, optic radiations, or visual cortex.

Optic Nerve lesion

Central scotoma: The visual field defect in the left eye. It is generated by an optic nerve or foveal lesion. (The visual field of the right eye is normal.)
Common causes of this defect shape are inflammatory, compressive, toxic, hereditary, nutritional, and mitochondrial disorders.

Cecocentral scotoma: This visual field defect is also in the left eye. The defect extends from fixation toward the physiologic blind spot (the "ceco"
means "blind" in Greek). Common causes of this defect pattern are toxic, hereditary, and nutritional optic nerve disorders.

Arcuate scotoma: This is also a defect in the left eye. Note that the defect fans out from the physiologic blind spot into the nasal field and abuts on
the horizontal meridian. Common causes of this defect pattern are glaucoma, ischemic optic neuropathy, and compression of the optic nerve by
tumor.

Temporal wedge scotoma: The visual field defect in the left eye is a temporal wedge scotoma. It is a relatively rare defect generated by an optic
nerve lesion. The defect fans out radially from the physiologic spot into the temporal field. Common causes are congenital optic nerve dysplasia and
glaucoma.

Chiasmal lesion
Bitemporal hemianopia: The defects in the two eyes involve only the temporal fields and that their borders are aligned to the vertical meridian
passing through fixation. The temporal fields are lost because the ganglion cell axons that originate in the nasal retina and cross in the optic chiasm
are selectively vulnerable to compression by mass lesions in this neighborhood: pituitary tumor, craniopharnygioma, astrocytoma, sphenoid
meningioma, and carotid artery aneurysm.
 Examination of Cranial Nerves Allison Mae T. Mangabat 1BMD
Occipital lesion
Congruous homonymous hemianopia: is a defect pattern associated with an optic radiation or visual cortex lesion. As with any lesion affecting the
visual pathway behind the optic chiasm, there is a temporal hemianopic defect in the field of the contralateral eye and a nasal hemianopic defect in
the field of the ipsilateral eye. The combination of these defects is called a "homonymous hemianopia." If the retrochiasmal lesion does not destroy
all the visual pathway, the homonymous hemianopia will be incomplete, as it is here. Unlike incomplete homonymous hemianopic defects associated
with optic tract lesions, those associated with lesions of the optic radiations and visual cortex are similar in extent, or "congruous."

2. What is color blindness? What are the types of the color blindness? How is it transmitted
in man?
Color blindness is not a form of blindness at all, but a deficiency in the way you see color. With this vision problem, you have difficulty distinguishing
certain colors, such as blue and yellow or red and green. Color blindness (or, more accurately, color vision deficiency) is an inherited condition that
affects males more frequently than females. Red-green color deficiency is the most common form of color blindness.

3. How are supranuclear (UMN) and infranuclear (LMN) lesions of IIIrd, IVth, and VI cranial nerves differentiated?
Supranuclear lesion is involved when there is loss of conjugate movements of the eyes, skew deviation of eyes, and nystagmus.
Infranuclear lesion is involved when there is paralysis of individual muscles of CN III if there is ptosis or drooping of the eyelid wherein the eyball is
displaced downward. The pupil is dilated and there is loss of accommodation.
Paralysis of CN IV shows impaird downward movement. Eyeball is rotated outwards due to unopposed action of inferior rectus when attempting to
look downwards and diplopia below the horizontal plane. Paralysis of CN VI is when there is inability to move the eye outwards and diplopia is seen
on looking in that direction. Convergent squint is due sometimes to unopposed action of medial rectus.

4. Describe Argyll Robertson pupil.

Argyll Robertson pupils (AR pupils or, colloquially, "prostitute's pupils") are bilateral small pupils that reduce in size on a near object (i.e., they
accommodate), but do not constrict when exposed to bright light (i.e., they do not react to light). They are a highly specific sign of neurosyphilis;
however, Argyll Robertson pupils may also be a sign of diabetic neuropathy.

5. What is Horner’s syndrome?

Horner syndrome is a combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one
side of the body. Typically, Horner syndrome results in a decreased pupil size, a drooping eyelid and decreased sweating on the affected side of
your face.

6. What are the receptors involved in color vision?

The cones are not as sensitive to light as the rods. However, cones are most sensitive to one of three different colors (green, red or blue). Signals
from the cones are sent to the brain which then translates these messages into the perception of color. Cones, however, work only in bright light.
That's why you cannot see color very well in dark places. So, the cones are used for color vision and are better suited for detecting fine details.
There are about 6 million cones in the human retina. people Some people cannot tell some colors from others - these people are "color blind."

7. Define visual acquity and visual field. How is it tested?

Visual acuity (VA) commonly refers to the clarity of vision. Visual acuity is dependent on optical and neural factors, i.e., (i) the sharpness of the
retinal focus within the eye, (ii) the health and functioning of the retina, and (iii) the sensitivity of the interpretative faculty of the brain. The Visual
Acuity Test is used to determine the smallest letters you can read on a standardized chart (Snellen chart) or a card held 20 feet (6 meters) away.

The Visual Field refers to the total area in which objects can be seen in the side (peripheral) vision as you focus your eyes on a central point. Visual
Field Testing: Many eye and brain disorders can cause peripheral vision loss and other visual field abnormalities. Visual field tests are performed by
eye care professionals to detect blind spots (scotomas) and other visual field defects, which can be an early sign of these problems.

8. What are the tests for color vision?

Ishihara 38 Plates CVD Test. Ishihara Color Blindness Test
Farnsworth-Munsell 100 Hue Color Vision Test. F-M 100 Hue Color Vision Test
Color Arrangement Test. D-15 Color Arrangement Test
RGB Anomaloscope

9. What is blind spot?

Anatomy. a small area on the retina that is insensitive to light due to the interruption, where the optic nerve joins the retina, of the normal pattern of
light-sensitive rods and cones.
A blind spot, scotoma, is an obscuration of the visual field. A particular blind spot known as the physiological blind spot, "blind point", or punctum
caecum in medical literature, is the place in the visual field that corresponds to the lack of light-detecting photoreceptor cells on the optic disc of the
retina where the optic nerve passes through the optic disc.[2] Because there are no cells to detect light on the optic disc, the corresponding part of
the field of vision is invisible.
 Examination of Cranial Nerves Allison Mae T. Mangabat 1BMD
10. What is the cause for indirect light reflex?
The pupillary light reflex (PLR) or photopupillary reflex is a reflex that controls the diameter of the pupil, in response to the intensity (luminance) of
light that falls on the retinal ganglion cells of the retina in the back of the eye, thereby assisting in adaptation to various levels of lightness/darkness.
In short, the pupillary light reflex (PLR) is the constriction of the pupil that is elicited by an increase in illumination of the retina.
A greater intensity of light causes the pupil to constrict (miosis/myosis; thereby allowing less light in), whereas a lower intensity of light causes the
pupil to dilate (mydriasis, expansion; thereby allowing more light in). Thus, the pupillary light reflex regulates the intensity of light entering the eye.[1]
Light shone into one eye will cause both pupils to constrict.

11. What is squint/strabismus?

The medical name for squint is strabismus. It is a condition where the eyes do not look in the same direction. Whilst one eye looks forwards to focus
on an object, the other eye turns either inwards, outwards, upwards or downwards.

12. What is cataract?

A cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. Cataracts are very common in older people. By
age 80, more than half of all Americans either have a cataract or have had cataract surgery. A cataract can occur in either or both eyes.

13. What are the manifestations of vitamin ‘A’ deficiency?

Vitamin A deficiency (VAD) or hypovitaminosis A is a lack of vitamin A in blood and tissues. Nyctalopia (night blindness) is one of the first signs of
VAD. Xerophthalmia, keratomalacia, and complete blindness can also occur since vitamin A has a major role in phototransduction.

14. Which cranial nerve is commonly affected by increase in intracranial pressure?

Increased intracranial pressure can produce pressure on the Optic Nerve (CN II), damaging the nerve. It also causes a lesion on Abducens
Nerve(CN VI) which is the sixth cranial nerve, somatic efferent nerve that, in humans, controls the movement of a single muscle, the lateral rectus
muscle to abduct (i.e., turn out) the eye.That when damaged, showing signs of a convergent strabismus or esotropia of which the primary symptom
is diplopia (commonly known as double vision) in which the two images appear side-by-side. The condition is commonly unilateral but can also occur
bilaterally.

15. What is glaucoma, types and how is it tested?

Glaucoma is an eye disease that is often associated with elevated intraocular pressure, in which damage to the eye (optic) nerve can lead to loss of
vision and even blindness.Glaucoma is the leading cause of irreversible blindness in the world.Glaucoma usually causes no symptoms early in its
course, at which time it can only be diagnosed by regular eye examinations (screenings with the frequency of examination based on age and the
presence of other risk factors).
There are many different types of glaucoma. Most, however, can be classified as either open-angle glaucomas, which are usually conditions of long
duration (chronic), or angle-closure (closed angle) glaucomas, which include conditions occurring both suddenly (acute) and over a long period of
time (chronic).

Open-angle glaucoma
Primary open-angle glaucoma (POAG) is by far the most common type of glaucoma. This increase in incidence occurs because the drainage
mechanism gradually may become clogged secondary to aging, even though the drainage angle is open. As a consequence, the aqueous fluid does
not drain from the eye properly. The pressure within the eye, therefore, builds up painlessly and without symptoms. This type of glaucoma is said to
be primary because its cause cannot be attributed to any discernable structural changes within the eye.

Normal tension (pressure) glaucoma or low tension glaucoma are variants of primary chronic open-angle glaucoma is thought to be due to
decreased blood flow to the optic nerve. This condition is characterized by progressive optic-nerve damage and loss of peripheral vision (visual field)
despite intraocular pressures in the normal range or even below normal. This can be diagnosed by repeated examinations by the eye doctor to
detect the nerve damage or the visual field loss.

Congenital (infantile) glaucoma is a relatively rare, inherited type of open-angle glaucoma. In this condition, the drainage area is not properly
developed before birth. This results in increased pressure in the eye that can lead to the loss of vision from optic-nerve damage and also to an
enlarged eye. The eye of a young child enlarges in response to increased intraocular pressure because it is more pliable than the eye of an adult.
Early diagnosis and treatment with medication and/or surgery are critical in these infants and children to preserve their sight.

Secondary open-angle glaucoma is another type of open-angle glaucoma. It can result from an eye (ocular) injury, even one that occurred many
years ago. Other causes of secondary glaucoma are inflammation in the iris of the eye (iritis), diabetes, cataracts, or in steroid- susceptible
individuals, the use of topical (drops) or systemic (oral or injected) steroids (cortisone). It can also be associated with a retinal detachment or retinal
vein occlusion or blockage. The treatments for the secondary open-angle glaucomas vary, depending on the cause.

Pigmentary glaucoma is a type of secondary glaucoma that is more common in younger men. In this condition, granules of pigment detach from the
iris, which is the colored part of the eye. These granules then may block the trabecular meshwork, which, as noted above, is a key element in the
drainage system of the eye. Finally, the blocked drainage system leads to elevated intraocular pressure, which results in damage to the optic nerve.
 Examination of Cranial Nerves Allison Mae T. Mangabat 1BMD

Exfoliative glaucoma (pseudoexfoliation or PXE) is another type of glaucoma that can occur with either open or closed angles. This type of glaucoma
is characterized by deposits of flaky material on the front surface of the lens (anterior capsule) and in the angle of the eye. The accumulation of this
material in the angle is believed to block the drainage system of the eye and raise the eye pressure. While this type of glaucoma can occur in any
population, it is more prevalent in older people and people of Scandinavian descent. It has recently been shown to often be associated with hearing
loss in older people.

Angle-closure glaucoma
Angle-closure glaucoma is a less common form of glaucoma in the Western world but is extremely common in Asia. Angle-closure glaucoma may be
acute or chronic. The common element in both is that a portion of or the entire drainage angle becomes anatomically closed, so that the aqueous
fluid within the eye cannot reach all or part of the trabecular meshwork. Thus, the problem in angle-closure glaucoma is the difficulty with access of
the eye fluid to the drainage system (trabecular meshwork). In chronic open-angle glaucoma, portions of the drainage angle remain closed over a
long period of time and damage the drainage system which is usually relieved by eye surgery.

Which test is used to diagnose glaucoma?

A Comprehensive Glaucoma Exam

Examining... Name of Test

The inner eye pressure Tonometry
The shape and color of the optic nerve Ophthalmoscopy (dilated eye exam)
The complete field of vision Perimetry (visual field test)
The angle in the eye where the iris meets the cornea Gonioscopy

16. What is the afferent and efferent nerve for corneal reflex?
The reflex is mediated by:
the nasociliary branch of the ophthalmic branch (V1) of the 5th cranial nerve (trigeminal nerve) sensing the stimulus on the cornea only (afferent
fiber). The temporal and zygomatic branches of the 7th cranial nerve (Facial nerve) initiating the motor response (efferent fiber).