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References
Nolte Chapter 17
Netter: Plates 86 and 114
Related materials from other faculty
Dr. Downing: Histology of the Eye
Dr. Stauffer: Physiology of the Eye
Dr. Trachte: Pharmacology of the Eye
Dr. Hollenhorst: Clinical Ophthalmology
Dr. Meyerson: Neurological Exam
2
Pg. 1
Eye Exam Eyes are the window to the brain!
Visual Acuity: Eye, CN II & beyond in the visual pathway
Visual Fields: Central & Peripheral Vision (retina to cortex)
Ocular Motility: (CN III, IV, VI)
Reflexes
Pupillary Light Reflex (CN II & III)
Accommodation (Near) Reflex
Corneal Reflex (CN V & VII)
Retina including Optic disc: (Increased intracranial
pressure; status of blood vessels reflecting hypertension,
diabetes, etc.)
Visual Pathway: Since it is precisely organized & extends
from the rostral to caudal aspect of the hemispheres, lesions
along the pathway produce specific deficits that can aid in 3
localizing the lesion.
Pg. 1
Learning Objectives
Relationship of bipolar & ganglion cells to the visual pathway
Relationship of retinal quadrants to visual field quadrants
Understanding of monocular vs. binocular visual fields
Importance of corresponding points on the retinae & the Blind spot
Components of the visual pathway; nuclei involved; location of
decussations, etc.
Representation of the visual field within the structures of the visual
pathway. [Upper vs. lower fields; Nasal vs.Temporal fields; Macular vs.
Peripheral fields representation]
Visual field deficits associated with damage along the visual pathway
Components & basis of the:
Direct & consensual pupillary light reflex
Pupillary dilation
Accommodation or near reflex
Definition or description of terms: amblyopia, Argyll Robertson pupil,
diplopia, hemianopsia, heteronymous, homonymous, Horners syndrome,
Meyers loop, quadrantanopsia, retinotopic, scotoma, strabismus
Pg. 2
ON = Optic Nerve
OC = Optic Chiasm
OT = Optic Tract
LGN = Lateral Geniculate Nucleus of Thalamus
VISUAL
CORTEX
5
Beginning of the Pathway
Pg. 2
6
Pg. 2
Bipolar cells
Cells
of the
Rods and Cones
(Receptors) Retina
7
Pg. 2
Object to be seen
Peripheral Retina
Retinal Quadrants
Right retina Left retina
Vertical Meridian
UTQ UNQ UNQ UTQ
nose
LTQ LNQ LNQ LTQ Horizontal Meridian
ON = Optic Nerve
OC = Optic Chiasm
OT = Optic Tract
LGN = Lateral Geniculate Nucleus of Thalamus
VISUAL
CORTEX
10
Visual Fields Pg. 3
Upper Field of
Left Eye
spot.
UTQ UNQ
Mapping of Visual Fields: F F
Confrontational method
Lower Field of
(see Dr. Meyersons
LTQ LNQ
Left Eye
Neurological Exam notes)
Perimetry (Manual or
Automated)
Normal Monocular Visual Normal Monocular Visual
Monocular Visual Fields: Field of Left Eye Field of Right Eye
Blind Spot
Temporal Field of Nasal Field of
15 to the temporal side Left Eye Left Eye
Upper Field of
eye
Left Eye
On the horizontal
meridian F F
Lower Field of
Corresponds to the
Left Eye
location of the optic
nerve head 15 to the
nasal side of the retina of Normal Monocular Visual Normal Monocular Visual
each eye. Field of Left Eye Field of Right Eye
Binocular
F F
Right Visual Field seen by both the left & Monocular Monocular
Crescent of Crescent of
right eyes. Left Eye F Right Eye
Monocular crescent for each eye (blue for Lower Fields
left eye & green for right eye) is only seen by
the nasal retina of the same eye.
Understand the difference between the monocular visual field of the left eye vs. 13
the binocular left visual field and vice versa for the right counterparts.
Temporal Field of Nasal Field of Pg. 3
Visual Fields: Left Eye Left Eye
Binocular
Demonstration of the Binocular
Visual Field & Monocular Crescent: F F
The image of an object in the visual field is inverted and reversed right to left on the retina.
Temporal field of left eye (red & purple) is seen by the nasal retina of the left eye
Nasal field of the left eye (green & yellow) is seen by the temporal retina of the left eye.
Superior field of the left eye (red & green) is seen by the inferior retina of the left eye.
Inferior field of the left eye (purple & yellow) is seen by the superior retina of the left eye.
Similarly, the image is inverted & reversed for the right eye.
Visual Pathway
Left visual field Right visual field
VISUAL FIELDS:
Upper field
Optic Nerve (ON) Lower field
Hatched = binocular
Stippled = monocular
cross
Wilbrands knee may be artifact pretectal
nuclei
Visual Pathway
Left visual field Right visual field
VISUAL FIELDS:
Post-Chiasmatic portion of the pathway: Upper field
Hatched = binocular
From optic tract to visual cortex, each side of the brain Lower field Stippled = monocular
Central area = macula
deals with the contralateral visual field.
17.
Peripheral field representation is in the rostral
Nasal
2/3rds of Area 17. Left retina
ON Right
Tempora Nasal temporal temporal Nasal Tempora
retina
Lesions of Area 17 result in blindness in the l
III
retina
Ciliary
l
OC
contralateral visual field. ganglion
22
Nolte 17-38
Reflex abolished if afferent or efferent is damaged.
Pg. 7
Right Left
Right Left
Afferent
defect
Right Left
Efferent
defect
23
Nolte 17-38
Pg. 7-8
Pupillary Dilation
(Mydriasis)
Decreased light to pupil Cortex, Hypothalamus
? Thalamus & ? Reticular
Severe pain (CNS control center
Hippocampus for ANS) Formation
Strong emotional stimulus
Reticulospinal
fibers
Horners Syndrome
Pupillary Constriction Loss of Sympathetics
Ptosis Lesion can be in CNS or PNS
Flushed & Dry Skin Deficits ipsilateral to lesion
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Pg. 8
26
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
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