Horizontal eye movement

Generated from horizontal gaze center in PPRF which is connected to ipsilateral 6th nerve nucleus. From 6th CN nucleus internuclear neurons cross midline and pass to contralateral MLF to innervate medial rectus in the 3rd nerve complex Stimulation of PPRF on one side causes a conjugate movement of the eyes to the same side.

Vertical eye movements

Generated from vertical gaze center ( rostral interstitial nucleus of the MLF ) which lies in midbrain. rostral interstitial nucleus of medial longitudinal fasciculus (riMLF) is a portion of the medial longitudinal fasciculus which controls vertical gaze.

medial longitudinal fasciculus (MLF)

It yokes the CN nuclei IIIand VI together, and integrates movements directed by the gaze centers (frontal eye field) and information about head movement. t is an integral component of saccadic eye movements as well as vestibulo-ocular and optokinetic reflexes. Lesions of the MLF produce internuclear ophthalmoplegia. Lesions to the MLF are very common manifestations of the disease Multiple sclerosis,where it presents as nystagmus and occasionally diplopia.

 PPRF lesion gives rise to ipsilateral horizontal gaze palsy with inability to look in the direction of lesion. MLF lesion gives rise to INO

Left INO
Straight eyes in primary position. Defective left adduction. Ataxic nystagmus of the right eye in right gaze. Convergence is intact Vertical nystagmus on attempted upgaze.

SUPRANUCLEAR DISORDERS OF EYE MOVEMENT

1. Horizontal gaze palsies
Internuclear ophthalmoplegia Combined internuclear and PPRF (one-and-a-half syndrome)
MLF

2. Vertical gaze palsies

Parinaud dorsal midbrain syndrome Progressive supranuclear palsy

Internuclear ophthalmoplegia
Lesion involving left MLF

Defective left adduction and ataxic nystagmus of right eye

Normal left gaze

Convergence intact if lesion discrete

Important causes

Demylination - usually bilateral Vascular disease Tumours of brainstem

One-and-a-half syndrome
Combined lesion of left MLF and PPRF

Ipsilateral (left) gaze palsy

Defective left adduction Normal right abduction with ataxic nystagmus

Parinaud dorsal midbrain syndrome

Supranuclear upgaze palsy Large pupils with light-near dissociation Lid retracton (Collier sign)

Normal downgaze Convergence weakness Convergence-retraction nystagmus

Important causes

In children: aqueduct stenosis, meningitis and pinealoma In young adults: demylination, trauma and a-v malformations In elderly: vascular accidents and posterior fossa aneurysms

Progressive supranuclear palsy

( Steele-Richardson-Olszewski syndrome )
Affects elderly

Pseudobulbar palsy

Initially involves downgaze

Extrapyramidal rigidity

Gait ataxia

Dementia

Subsequent defective up and horizontal gaze