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Chapter 7: Ocular Motor System

Valentin Dragoi, Ph.D., Department of Neurobiology and Anatomy, McGovern Medical School

Last Review 20 Oct 2020

7.1 Introduction
The simplicity of the motor systems involved in controlling eye musculature make them ideal for illustrating the mechanisms and principals you have
been studying in the preceding material on motor systems. They involve the action of few muscles and of well defined neural circuits.

We use our eyes to monitor our external environment and depend on our ocular motor systems to protect and guide our eyes. The ocular motor
systems control eye lid closure, the amount of light that enters the eye, the refractive properties of the eye, and eye movements. The visual system
provides afferent input to ocular motor circuits that use visual stimuli to initiate and guide the motor responses. Neuromuscular systems control the
muscles within the eye (intraocular muscles); the muscles attached to the eye (extraocular muscles) and the muscles in the eyelid. Ocular motor
responses include ocular reflexes and voluntary motor responses to visual and other stimuli. The complexity of the circuitry (the chain or network of
neurons) controlling a ocular motor response increases with the level of processing involved in initiating, monitoring, and guiding the response.

In this chapter we will start at the level of reflex responses and move onto more complex voluntary responses in the following lecture. The eye blink
reflex is the simplest response and does not require the involvement of cortical structures. In contrast, voluntary eye movements (i.e., visual tracking of
a moving object) involve multiple areas of the cerebral cortex as well as basal ganglion, brain stem and cerebellar structures.

7.2 Ocular Reflex Responses

The ocular reflexes are the simplest ocular motor responses. Ocular reflexes compensate for the condition of the cornea and for changes in the visual
stimulus. For example, the eye blink reflex protects the cornea from drying out and from contact with foreign objects. The pupillary light reflex
compensates for changes in illumination level, whereas the accommodation responses compensate for changes in eye-to-object-viewed distance.
Note that reflex responses are initiated by sensory stimuli that activate afferent neurons (e.g., somatosensory stimuli for the eye blink reflex and visual
stimuli for the pupillary light reflex and accommodation responses).

In general, ocular reflexes are consensual (i.e., the response is bilateral involving both eyes). Consequently, a light directed in one eye elicits
responses, pupillary constriction, in both eyes. In this chapter you will learn of the structures normally involved in performing these ocular responses
and the disorders that result from damage to components of neural circuit controlling these responses.

A. The Eye Blink Reflex

Tactile stimulation of the cornea results in an irritating sensation that normally evokes eyelid closure (an eye blink). The response is consensual (i.e.,
bilateral) - involving automatic eyelid closure at both eyes.

The corneal eye blink reflex neural circuit: This neural circuit (Figure 7.1) is relatively simple, consisting of the

trigeminal1° afferent (free nerve endings in the cornea, trigeminal nerve, ganglion, root, and spinal trigeminal tract), which end on
trigeminal 2° afferent in the spinal trigeminal nucleus, some of which send their axons to
reticular formation interneurons, which send their axons bilaterally to
facial motor neurons in the facial nucleus, which send their axons in the facial nerve to
orbicularis oculi, which functions to lower the eyelid

Figure 7.1
The corneal eye blink reflex is initiated by the free nerve endings in the
cornea and involves the trigeminal nerve and ganglion, the spinal
trigeminal tract and nucleus, interneurons in the reticular formation,
motor neurons in the facial nucleus and nerve, and the orbicularis oculi.
As the afferent information from each cornea is distributed bilaterally to
facial motor neurons by the reticular formation interneurons, the eye
blink response is consensual, that is, both eye lids will close to
stimulation of the cornea of either eye.

B. Pupillary Light Reflex

The pupillary light reflex involves adjustments in pupil size with changes in light levels.

The reflex is consensual: Normally light that is directed in one eye produces pupil constriction in both eyes.
The direct response is the change in pupil size in the eye to which the light is directed (e.g., if the light is shone in the right eye, the right pupil
constricts).
The consensual response is the change in pupil size in the eye opposite to the eye to which the light is directed (e.g., if the light is shone in the
right eye, the left pupil also constricts consensually).

The pupillary light reflex allows the eye to adjust the amount of light reaching the retina and protects the photoreceptors from bright lights. The iris
contains two sets of smooth muscles that control the size of the pupil (Figure 7.2).

The sphincter muscle fibers form a ring at the pupil margin so that when the sphincter contracts, it decreases (constricts) pupil size.
The dilator muscle fibers radiate from the pupil aperture so that when the dilator contracts, it increases (dilates) pupil size.

Both muscles act to control the amount of light entering the eye and the depth of field of the eye1.

The iris sphincter is controlled by the parasympathetic system, whereas the iris dilator is controlled by the sympathetic system.
The action of the dilator is antagonistic to that of the sphincter and the dilator must relax to allow the sphincter to decrease pupil size.

Normally the sphincter action dominates during the pupillary light reflex.

Dilato r mus c le
Iris
o f iris

S phinc te r
mus c le
o f iris

Pupil

CONTRACT

DILATE

c 2000 UTHS CH

Figure 7.2
Iris dilator and sphincter muscles and their actions.

The pupillary light reflex neural circuit: The pathway controlling pupillary light reflex (Figure 7.3) involves the

retina, optic nerve, optic chiasm, and the optic tract fibers that join the
brachium of the superior colliculus, which terminate in the
pretectal area of the midbrain, which sends most of its axons bilaterally in the posterior commissure to terminate in the
Edinger-Westphal nucleus of the oculomotor complex, which contains parasympathetic preganglionic neurons and sends its axons in the
oculomotor nerve to terminate in the
ciliary ganglion, which sends its parasympathetic postganglionic axons in the
short ciliary nerve, which ends on the
iris sphincter

RIGHT LEFT
Brac hium o f the
s upe rio r c o llic ulus
Po s te rio r
Pre te c tal c o mmis s ure Pre te c tal
are a are a

Eding e r-we s tphal Eding e r-we s tphal

nuc le us nuc le us

Oc ulo mo to r
ne rve Optic
Optic trac t
c hias m
Optic
ne rve

Ciliary Ciliary
g ang lio n g ang lio n

S ho rt c iliary
c 2000 UTHS CH ne rve

Figure 7.3
The pupillary light reflex pathway. The lines ending with an arrow
indicate axons terminating in the structure at the tip of the arrow. The
lines beginning with a dot indicate axons originating in the structure
containing the dot. Bilateral damage to pretectal area neurons (e.g., in
neurosyphilis) will produce Argyll-Robertson pupils (non-reactive to light,
active during accommodation).

Recall that the optic tract carries visual information from both eyes and the pretectal area projects bilaterally to both Edinger-Westphal nuclei:
Consequently, the normal pupillary response to light is consensual. That is, a light directed in one eye results in constriction of the pupils of both eyes.

C. Pupillary Dark Response

The pupils normally dilate (increase in size) when it is dark (i.e., when light is removed). This response involves the relaxation of the iris sphincter and
contraction of the iris dilator. The iris dilator is controlled by the sympathetic nervous system.

The pupillary dark reflex neural circuit: The pathway controlling pupil dilation involves the

retina and the optic tract fibers terminating on neurons in the hypothalamus and the
axons of the hypothalamic neurons that descend to the spinal cord to end on the
sympathetic preganglionic neurons in the lateral horn of spinal cord segments T1 to T3, which send their axons out the spinal cord to end on the
sympathetic neurons in the superior cervical ganglion, which send their
sympathetic postganglionic axons in the long ciliary nerve to the
iris dilator.

Axons from the superior cervical ganglion also innervate the face vasculature, sweat and lachrymal glands and the eyelid tarsal muscles. When the
superior cervical ganglion or its axons are damaged, a constellation of symptoms, known as Horner's syndrome, result. This syndrome is
characterized by miosis (pupil constriction), anhidrosis (loss of sweating), pseudoptosis (mild eyelid droop), enopthalmosis (sunken eye) and flushing
of the face.

D. The Accommodation Response

The accommodation response is elicited when the viewer directs his eyes from a distant (greater than 30 ft. away) object to a nearby object (Nolte,
Figure 17-40, Pg. 447). The stimulus is an “out-of-focus” image. The accommodation (near point) response is consensual (i.e., it involves the actions of
the muscles of both eyes). The accommodation response involves three actions:

Pupil accommodation: The action of the iris sphincter was covered in the section on the pupillary light reflex. During accommodation, pupil constriction
utilizes the "pin-hole" effect and increases the depth of focus of the eye by blocking the light scattered by the periphery of the cornea (Nolte, Figure 17-
39, Pg. 447). The iris sphincter is innervated by the postganglionic parasympathetic axons (short ciliary nerve fibers) of the ciliary ganglion (Figure 7.3).

Lens accommodation: Lens accommodation increases the curvature of the lens, which increases its refractive (focusing) power. The ciliary muscles
are responsible for the lens accommodation response. They control the tension on the zonules, which are attached to the elastic lens capsule at one
end and anchored to the ciliary body at the other end (Figure 7.4).

Canal o f Co rne a
Trabe c ular s c hle mm
me s hwo rk

Limbus Ante rio r

c hambe r

Iris Ante rio r

le ns
c aps ule

S c le ra

Ciliary
mus c le

Zo nule s
Po s te rio r
Ciliary bo dy c hambe r
Po s te rio r le ns
c 2000 UTHS CH c aps ule

Figure 7.4
The ciliary muscles, which control the position of the ciliary processes and the tension on the zonule, control the shape of the lens. The
ciliary muscles function as a sphincter and when contracted pull the ciliary body toward the lens to decrease tension on the zonules
(see Figure 7.5). The decreased tension allows the lens to increase its curvature and refractive (focusing) power. When the ciliary
muscle is relaxed, the ciliary body is not pulled toward the lens, and the tension on the zonules is higher. High tension on the zonules
pulls radially on the lens capsule and flattens the lens for distance vision. The ciliary muscles are innervated by the postganglionic
parasympathetic axons (short ciliary nerve fibers) of the ciliary ganglion

c 2000 UTHS CH
PLAY
Ciliary mus c le s
re laxe d

Figure 7.5
The accommodation response of the lens:
comparing the lens shape during near vision
(contraction of the ciliary muscle during
accommodation) with lens shape during distance
vision (relaxation of the ciliary muscle).

Convergence in accommodation: When shifting one's view from a distant object to a nearby object, the eyes converge (are directed nasally) to keep
the object's image focused on the foveae of the two eyes. This action involves the contraction of the medial rectus muscles of the two eyes and
relaxation of the lateral rectus muscles. The medial rectus attaches to the medial aspect of the eye and its contraction directs the eye nasally (adducts
the eye). The medial rectus is innervated by motor neurons in the oculomotor nucleus and nerve.

The accommodation neural circuit: The circuitry of the accommodation response is more complex than that of the pupillary light reflex (Figure 7.6).

The afferent limb of the circuit includes the

retina (with the retinal ganglion axons in the optic nerve, chiasm and tract),
lateral geniculate body (with axons in the optic radiations), and
visual cortex.

Ocular motor control neurons are interposed between the afferent and efferent limbs of this circuit and include the

visual association cortex, which

determines the image is "out-of-focus"
sends corrective signals via the internal capsule and crus cerebri to the
supraoculomotor nuclei, which
is located immediately superior to the oculomotor nuclei
generates motor control signals that initiate the accommodation response
sends these control signals bilaterally to the oculomotor complex.

The efferent limb of this system has two components: the

Edinger-Westphal nucleus, which

sends its axons in the oculomotor nerve to
control the ciliary ganglion, which
sends it axons in the short ciliary nerve to
control the iris sphincter and the ciliary muscle/zonules/lens of the eye
oculomotor neurons, which
sends its axons in the oculomotor nerve to
control the medial rectus
converge the two eyes.

RIGHT LEFT c 2000 UTHS CH

VIS UAL AS S OCIATION VIS UAL AS S OCIATION

CORTEX CORTEX

Exc ite d
c o rtic o te c tal
fibe rs

S UPRAOCULOMOTOR S UPRAOCULOMOTOR
AREA Exc ite d AREA
pre g ang lio nic
paras ympathe tic
axo n
EDINGER- EDINGER-
WES TPHAL WES TPHAL
NUCLEUS OCULOMOTOR Exc ite d OCULOMOTOR NUCLEUS
NUCLEUS o c ulo mo to r NUCLEUS
axo ns to
me dial re c tus

EXCITED
ABDUCENS Une xc ite d Une xc ite d ABDUCENS
S ho rt Ciliary
MOTOR abduc e ns abduc e ns MOTOR
Ne rve s
NEURONS ne rve to ne rve to NEURONS
late ral re c tus late ral re c tus

Figure 7.6
The accommodation pathway includes the afferent limb, which consists of the entire visual pathway; the higher motor control
structures, which includes an area in the visual association cortex and the supraoculomotor area; and the efferent limb, which
includes the oculomotor nuclei and ciliary ganglion. The lines ending with an arrow indicate axons terminating in the structure at the
tip of the arrow. The lines beginning with a dot indicate axons originating in the structure containing the dot. During accommodation
three motor responses occur: convergence (medial rectus contracts to direct the eye nasally), pupil constriction (iris sphincter
contracts to decrease the iris aperture) and lens accommodation (ciliary muscles contract to decrease tension on the zonules).

7.3 Clinical Examples

An excellent way to test your knowledge of the material presented thus far is by examining the effects of damage to structures within the ocular motor
pathways. The observed motor loss(s) provide clues to the pathway(s) affected; and the muscle(s) and eye affected provide clues to the level of the
damage.

Cranial nerve damage: Damage to cranial nerves may result in sensory and motor symptoms. The sensory losses would involve those sensations the
cranial nerve normally conveys (e.g., taste from the anterior two thirds of the tongue and somatic sensations from the skin of the ear - if facial nerve is
damaged). The motor losses may be severe (i.e., a lower motor neuron loss that produces total paralysis) if the cranial nerve contains all of the motor
axons controlling the muscles of the normally innervated area.

The cranial nerves involved in the eye blink response and pupillary response are the optic, oculomotor, trigeminal and facial nerves.

The optic nerve carries visual information from the eye.

The oculomotor nerve contains
lower motor axons innervating
extraocular muscles: the medial, superior and inferior rectus muscles, the inferior oblique muscle,
eyelid muscle: the superior levator palpebrae,
as well as parasympathetic preganglionic axons to the ciliary ganglion.
The trigeminal nerve contains
the 1° somatosensory afferents for the face, dura, oral and nasal cavities
the lower motor axons for the jaw muscles.
The facial nerve contains
the lower motor neurons innervating the superficial muscles of the face,
the 1° gustatory afferents to the anterior tongue
the parasympathetic preganglionic axons to parasympathetic ganglia for the lachrymal and salivary glands.

7.4 Clinical Example #1

Symptoms. The patient, who appears with a bloodshot left eye, complains of an inability to close his left eye. When asked to rise his eyebrows, he can
only elevate the right eyebrow. When asked to close both eyes, the right eyelid closes but the left eyelid is only partially closed. Touching the right or
left cornea with a wisp of cotton elicits the eye blink reflex in the right eye, but not the left eye (Figure 7.7). However, the patient reports he can feel the
cotton when it touches either eye. He can smile, whistle and show his teeth, which indicates his lower facial muscles are functioning normally. Physical
examination determines that touch, vibration, position and pain sensations are normal over the entire the body and face. There are no other motor
symptoms.

Figure 7.7
Observe the reaction to a wisp
of cotton touching the patient's
Rig ht Le ft left and right cornea.

PLAY PLAY PLAY

Rig ht c o rne a Clo s e e ye s Le ft c o rne a
to uc h to uc h
c 2000 UTHS CH

Observation: You observe that the patient

has not lost cutaneous sensation in the upper left face area
does not blink when his left cornea is touched
cannot close his left eye voluntarily

You conclude that his left eye's functional loss is

not sensory
a lower motor neuron dysfunction

Pathway(s) affected: You conclude that structures in the following motor pathway have been affected

the eye blink pathway (Figure 7.8)

S pinal
trig e minal
trac t
Fac ial Abduc e ns
ne rve nuc le us
g e nu
Figure 7.8
Trig e minal The eye blink pathway
ne rve involves the trigeminal
nerve, spinal trigeminal
tract and nucleus, the
reticular formation, and
the facial motor nucleus
S pinal and nerve.
trig e minal
nuc le us
Fac ial
nuc le us Fac ial ne rve ro o t

c 2000 UTHS CH

Side & Level of damage: As the eye blink loss involves

only motor function

both reflex and voluntary motor functions
the upper part of the face
only one eye lid
eyelid closure

Conclusion: You conclude that the damage involves

the facial nerve

a branch of the nerve innervating the upper face
a lower motor neuron paralysis of the left orbicularis oculi
motor innervation on the left side (i.e., the symptoms are ipsilesional)

When lower motor neurons are damaged, there is a flaccid paralysis of the muscle normally innervated. The action of the muscle will be weakened or
lost depending on the extent of the damage. There will be a weakened or no reflex response and the muscle will be flaccid and may atrophy with time.

The Facial Nerve. Section of the facial nerve on one side will result in paralysis of the muscles of facial expression on the ipsilesional side of the face.
There will be an inability to close the denervated eyelid voluntarily and reflexively. The eyelids may have some mobility if the oculomotor innervation to
the levator is unaffected.

7.5 Clinical Example #2

Symptoms. The patient complains of a badly infected left eye. When he is asked to close both eyes, both eyelids close. Touching the right cornea with
a wisp of cotton elicits the eye blink reflex in the both eyes (Figure 7.9, Right). However, touching the left cornea with a wisp of cotton does not elicit the
eye blink reflex in the either eye (Figure 7.9, Left). The patient cannot detect pinpricks to his left forehead. However, he reports that pinpricks to rest of
his face are painful. He can blink, wrinkle his brows, smile, and whistle and show his teeth, which indicates his facial muscles are functioning normally.
Physical examination determines that touch, vibration, position and pain sensations are normal over the entire the body and over the lower left and
right side of his face.

Figure 7.9
Observe the reaction to a wisp
of cotton touching the patient's
Rig ht Le ft left and right cornea.

PLAY PLAY PLAY

Rig ht c o rne a Clo s e e ye s Le ft c o rne a
to uc h to uc h
c 2000 UTHS CH

Observation: You observe that the patient

responds with direct and consensual eye blink when his right cornea is touched
can close his left eye voluntarily
has lost cutaneous sensation in the upper left face area
does not blink when his left cornea is touched

You conclude that his left eye's functional loss is

not motor
sensory

Pathway(s) affected: You conclude that structures in the following reflex pathway have been affected

the eye blink pathway (Figure 7.8)

Side & Level of damage: As the eye blink loss involves

only one eye

a sensory loss
the upper part of the face

Conclusion: You conclude that the damage involves

a loss of the afferent limb of the eye blink response

the trigeminal nerve
a branch of the nerve innervating the upper face
the innervation of the left side (i.e., the symptoms are ipsilesional)

The Trigeminal Nerve. Section of the trigeminal nerve will eliminate somatosensory sensation from the face and the eye blink reflex (e.g., with section
of the left trigeminal nerve, light touch of the left cornea will not produce an eye blink in the left or right eye). However, light touch of the right cornea will
elicit a bilateral eye blink. The effect of sectioning the trigeminal nerve is to remove the afferent input for the eye blink reflex.

7.6 Clinical Example #3

Symptoms. The patient complains of pain in her left eye. Her left pupil appears dilated and is not reactive to light directed at either the left or right eye
(Figure 7.10). The right pupil appears normal in size and reacts to light when it is directed in the right or left eye. Both eyelids can be elevated and
lowered and both eyes exhibit normal movement. Touch, vibration, position and pain sensations are normal over the entire the body and face. There
are no other motor symptoms.

Figure 7.10
Observe the reaction of the
patient's pupils to light directed
in the left or right eye.
Rig ht Le ft

PLAY RES ET PLAY

Lig ht rig ht e ye Lig ht le ft e ye
c 2000 UTHS CH

Observation: You observe that the patient has

a left pupil that does not react to light directly or consensually

a right pupil that reacts to light directly and consensually
normal eye movements

You conclude that his left eye's functional loss is

not sensory (the right pupil reacts to light directed at the left eye)
a motor dysfunction

Pathway(s) affected: You conclude that structures in the following motor pathway have been affected

the pupillary light reflex pathway (Figure 7.11)

S ho rt c iliary ne rve

Ciliary g ang lio n

Optic trac t Oc ulo mo to r ne rve

O
O
O
O
O

O
O
O O
O
O

O
O
O
O
O
O
Figure 7.11
The pupillary light reflex
O O O O O
O O O O
O O O O O O
O O O O O O
O O O
O O
O
O O

pathway involves the

Late ral
optic nerve and the
g e nic ulate
oculomotor nerve and
bo dy
nuclei.

Brac hium Eding e r-

o f the we s tphal
s upe rio r nuc le us
c o llic ulus
Po s te rio r
Pre te c tal
c o mmis s ure
are a

c 2000 UTHS CH

Side & Level of damage: As the pupillary light reflex loss

involves only one eye

involves only motor function
does not involve eyelid or ocular motility
is limited to pupil constriction in the left eye

Conclusion: You conclude that the damage

involves the motor innervation of the left iris sphincter2

involves structures peripheral to the oculomotor nucleus (i.e., eye movement unaffected)
does not involve the oculomotor nerve
involves the ciliary ganglion or the short ciliary nerve
is on the left side (i.e., the symptoms are ipsilesional)

Parasympathetic Innervation of the Eye. Section of the parasympathetic preganglionic (oculomotor nerve) or postganglionic (short ciliary nerve)
innervation to one eye will result in a loss (motor) of both the direct and consensual pupillary light responses of the denervated eye. Section of the left
short ciliary nerve or a benign lesion in the left ciliary ganglion will result in no direct response to light in the left eye and no consensual response in the
left eye when light is directed on the right eye (a.k.a., tonic pupil). When the damage is limited to the ciliary ganglion or the short ciliary nerve, eyelid
and ocular mobility are unaffected.

7.7 Clinical Example #4

Symptoms. The patient presents with a left eye characterized by ptosis, lateral strabismus, and dilated pupil. When asked to rise his eyelids, he can
only raise the lid of the right eye. When asked to close both eyes, both eyelids close fully. His left pupil does not react to light directly or consensually
(Figure 7.12). When asked to look to his right, his left eye moves to a central position, but no further. The right eye is fully mobile. When the patient is
asked to look straight ahead, you note his left eye remains directed to the left and depressed. Physical examination determines that touch, vibration,
position and pain sensations are normal over the entire the body and face. There are no other motor symptoms.

Figure 7.12
The patient presents with a left
eye characterized by ptosis,
lateral strabismus and dilated
pupil. Observe the reaction of
Rig ht Le ft the patient's pupils to light
directed in the left or right eye.
PLAY RES ET PLAY
Lig ht rig ht e ye Lig ht le ft e ye
c 2000 UTHS CH

Observation: You observe that the patient

has not lost cutaneous sensation in the face area

has a left ptosis
cannot adduct his left eye (i.e., move it toward the nose)
has a left dilated pupil that is non reactive to light in either eye

You conclude that his left eye's functional loss is

not sensory
a lower motor neuron dysfunction
involving an autonomic dysfunction

Pathway(s) affected: You conclude that structures in the following motor pathway have been affected

the pupillary/oculomotor pathway (Figure 7.11)

Side & Level of damage: As the ocular loss involves

only motor function

both reflex and voluntary motor functions
both somatic and autonomic functions
only the left eye

Conclusion: You conclude that the damage

involves the oculomotor nerve

is a lower motor neuron paralysis of the superior levator palpebrae
is a lower motor neuron paralysis of the medial, superior & inferior rectus muscles and inferior oblique muscles of the eye
is an autonomic disorder involving the axons of the Edinger-Westphal nucleus
is on the left side (i.e., the symptoms are ipsilesional)

The Oculomotor Nerve. Section of the oculomotor nerve produces a non-reactive pupil in the ipsilesional side as well as other symptoms related to
oculomotor nerve damage (e.g., ptosis and lateral strabismus). Section of the oculomotor nerve on one side will result in paralysis of the superior
levator palpebrae, which normally elevates the eyelid. It will also paralyze the medial, superior & inferior rectus muscles and the inferior oblique, which
will allow the lateral rectus to deviate the eye laterally and the superior oblique to depress the eye. The parasympathetic preganglionic axons of the
Edinger-Westphal nucleus, which normally travel in the oculomotor nerve, will be cut off from the ciliary ganglion, disrupting the circuit normally used to
control the iris sphincter response to light.

7.8 Clinical Example #5

Symptoms. The patient complains of reduced vision in the left eye. Pupil size in both eyes appears normal. However, both pupils do not appear to
constrict as rapidly and strongly when light is directed into his left eye (Figure 7.13). That is, compared to the response to light in the left eye, light in
the right eye produces a more rapid constriction and smaller pupil in both eyes. Physical examination determines that touch, vibration, position and
pain sensations are normal over the entire the body and over the lower left and right side of his face.

Figure 7.13
Observe the reaction of the
patient's pupils to light directed
in the left or right eye.
Rig ht
Rig ht LeLe
ftft

PLAY RES ET PLAY

Lig ht rig ht e ye Lig ht le ft e ye
c 2000 UTHS CH

Observation: You observe that the patient's pupils

respond when light is directed into either eye

has weaker direct and consensual responses to light directed in the left eye

You conclude that his left eye's functional loss is

not motor
sensory (because the responses in both eyes are weaker when light is directed in the left eye)

Pathway(s) affected: You conclude that structures in the following motor pathway have been affected

the pupillary light reflex pathway (Figure 7.11)

Side & Level of damage: As the pupillary light response deficit involves

only stimulation of one eye

a sensory loss
the left eye

Conclusion: You conclude that the damage

is in the afferent limb of the pupillary light response

involves the optic nerve or retina
is on the left side (i.e., the symptoms are ipsilesional)
produced a left pupillary afferent defect

The Optic Nerve. Partial damage of the retina or optic nerve reduces the afferent component of the pupillary reflex circuit. The reduced afferent input to
the pretectal areas is reflected in weakened direct and consensual pupillary reflex responses in both eyes (a.k.a., a relative afferent pupillary defect).

Section of one optic nerve will result in the complete loss of the direct pupillary light reflex but not the consensual reflex of the blinded eye. That is, if
the left optic nerve is sectioned, light directed on the left (blind) eye will not elicit a pupillary response in the left eye (direct reflex) or the right eye
(consensual response). However, light directed in the right eye will elicit pupillary responses in the right eye and the left (blind) eye. The effect of
sectioning one optic nerve is to remove the afferent input for the direct reflex of the blinded eye and the afferent input for the consensual reflex of the
normal eye. Section of one optic tract will not eliminate the direct or consensual reflex of either eye as the surviving optic tract contains optic nerve
fibers from both eyes. However, the responses to light in both eyes may be weaker because of the reduced afferent input to the ipsilesional pretectal
area.

7.9 Clinical Example #6

Symptoms. A patient who is suffering from the late stages of syphilis is sent to you for a neuro-ophthalmological work-up. His vision is normal when
corrected for refractive errors. He has normal ocular mobility and his eyelids can be elevated and depressed at will. Examination of his pupillary
responses indicates a loss of the pupillary light reflex (no pupil constriction to light in either eye) but normal pupillary accommodation response (pupil
constricts when the patient's eyes are directed from a distant object to one nearby).

Observation: You observe that the patient has normal vision but that his pupils

do not respond when light is directed into the either of his eyes
do respond during accommodation

You conclude that his eye's functional loss is

not sensory (his vision is normal)

motor (the pupillary light responses in both eyes are absent)
higher-order motor (because he has a normal pupillary accommodation response)

Pathway(s) affected: You conclude that structure(s) in the

accommodation pathway have not been damaged (Figure 7.14)

pupillary light reflex pathway have been damaged (Figure 7.11)

Side & Level of damage: As the pupillary response deficit

does not involve a sensory loss

does not involve the pupil accommodation response
involves only the pupillary light reflex response

Conclusion: You conclude that the damage

involves the pretectal area bilaterally

spared the supraoculomotor area
produced the Argyll Robertson response

S ho rt c iliary ne rve c 2000 UTHS CH

Ciliary g ang lio n

Optic trac t Oc ulo mo to r ne rve Figure 7.14

The accommodation pathway
includes the supraoculomotor
area, which functions as a
O

Vis ual as s o c iatio n c o rte x

O O
O O O
O O O O O
O O
O O O O
O O O O O
O O O O
O O O O O O
O O O O O O
O O O

c o rtic o te c tal fibe rs "higher-order" motor control

O O
O
O O

Late ral stage controlling the motor

g e nic ulate neurons and parasympathetic
nuc le us Optic radiatio n neurons (i.e., the Edinger-
to s triate c o rte x Westphal neurons) of the
oculomotor nucleus. This area
was spared by syphilis.
Eding e r-
Oc ulo mo to r we s tphal
nuc le us nuc le us

S uprao c ulo mo to r
are a

In the Argyll Robertson response, there is an absence of the pupillary light reflex with a normal pupillary accommodation response. The Argyll
Robertson response is attributed to bilateral damage to pretectal areas (which control the pupillary light reflex) with sparing of the supraoculomotor
area (which controls the pupillary accommodation reflex).

The accommodation response involves many of the structures involved in the pupillary light response and, with the exception of the pretectal area and
supraoculomotor area, damage to either pathway will produce common the symptoms. The most common complaint involving the accommodation
response is its loss with aging (i.e., presbyopia). Recall that presbyopia most commonly results from structural changes in the lens which impedes the
lens accommodation response.

7.10 Summary

This chapter described three types of ocular motor responses (the eye blink, pupillary light and accommodation responses) and reviewed the nature of
the responses and the effectors, efferent neurons, higher-order motor control neurons (if any), and afferent neurons normally involved in performing
these ocular responses. Table I summarizes these structures and the function(s) of these ocular motor responses. Readers should understand the
anatomical basis for disorders that result from damage to components of neural circuit controlling these responses.

Table I
Classification of Consensual Ocular Responses & Their Motor Control Structures
Ocular Responses Function Afferent Input* & Motor Control Structures

Free Nerve Endings in cornea that are afferent endings of the Trigeminal Nerve, Ganglion, Root
& Spinal Trigeminal Tract*

Spinal Trigeminal Nucleus*

Protects cornea
Eye Blink Reflex from contact with
Reticular Formation (bilaterally to)
foreign objects
Facial Motor Nuclei & Facial Nerves

Orbicularis Oculi

Retina, Optic Nerve, Chiasm & Tracts and Brachium of Superior Colliculus*

Decreases pupil Pretectal Areas of Midbrain (bilaterally to)

size (constriction) –
Pupillary Light
reduces the Edinger-Westphal Nuclei & Oculomotor Nerves
Reflex
amount of light that
enters the eye. Ciliary Ganglia & Short Ciliary Nerves

Iris Sphincters

Visual System* including Visual Association Cortex

Increases depth of
Pupillary focus of eye lens Supraoculomotor Nuclei (bilaterally to)
Accommodation system
Edinger-Westphal Nuclei & Nerve III
Lens Increases
Accommodation refractive power of Ciliary Ganglia & Short Ciliary Nerves
lens
Iris Sphincters & Ciliary Muscles

Visual System* including Visual Association Cortex

Eyes directed Supraoculomotor Nuclei (bilaterally to)

Convergence nasally during
accommodation Oculomotor Nuclei

Medial Rectus Muscles

* Afferent structures proving sensory input.

Test Your Knowledge

Question 1 A B C D E

A patient is capable of pupillary constriction during accommodation but not in response to a light directed to either eye.
The lesion is most likely present in the...

A. optic nerve

B. abducens nucleus

C. Edinger-Westphal nucleus

D. pretectal areas

E. supraoculomotor nucleus

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