AVein ofGalenTransversesinusCavernoussinusTrigeminalganglionInternal carotid arteryPituitarystalkN. XIIN. XN. IXN. VIIIN. VIIN. VIN. IVN. IIIV3V2V1Oculomotor N.Optic chiasmInternal carotidarteryHypophysisSella turcicaDiaphragmasellaDuramaterSphenoidsinusNasopharynxTrochlear N.Ophthalmic N. (V1)Maxillary N. (V2)Abducens N.B
Figure 13-5. The cavernous sinus and its relation to the cranial nerves. A. Base of the skull; the cavernous sinus has been removed on the right. B. The cavernous sinus and its contents viewed in the coronal plane.
SUP. RECT.INF. RECT.SUP. RECT.INF. RECT.INF. OBL.SUP. OBL.INF. OBL.SUP. OBL.
Figure 13-6. Muscles chiefly responsible for vertical movements of the eyes in different positions of gaze. (Adapted by permission from Cogan DG: Neurology of the Ocular Muscles, 2nd ed. Springfield, IL, Charles C Thomas, 1956.)
Upward gazeLeft gazeRight gazeDownward gazeRt. lat. rectusARt. med. rectusBRt. inf. rectusCRt. sup. rectusDRt. sup. obl.ERt. inf. obl.F
Figure 13-7. Diplopia fields with individual muscle paralysis. The red Maddox rod is in front of the right eye and gives rise to the straight line image, and the fields are projected as the patient sees the images. A. Paralysis of right lateral rectus. Characteristic: right eye does not move to the right. Field: the vertical red line is displaced to the right and the separation of images increases on looking to the right. B. Paralysis of right medial rectus. Characteristic: right eye does not move to the left. Field: horizontal crossed diplopia increasing on looking to the left. C. Paralysis of right inferior rectus. Characteristic: right eye does not move downward when eyes are turned to the right. Field: vertical diplopia (with the red line, seen by the right eye, displaced inferiorly) increasing on looking to the right and down. D. Paralysis of right superior rectus. Characteristic: right eye does not move upward when eyes are turned to the right. Field: vertical diplopia (with red line displaced superiorly) increasing on looking to the right and up. E. Paralysis of right superior oblique. Characteristic: right eye does not move downward when eyes are turned to the left. Field: vertical diplopia (with red line displaced inferiorly) increasing on looking to the left and down. F. Paralysis of right inferior oblique. Characteristic: right eye does not move upward when eyes are turned to the left. Field: vertical diplopia (with red line displaced superiorly) increasing on looking to the left and up.
Source: Adapted by permission from Leigh and Zee.
Figure 13-8. MRI of orbital pseudotumor showing bilateral swelling of the extraocular muscles and adjacent orbital contents. A “streaming” appearance of the fat as shown in the right retro-orbital compartment is characteristic. The process in this patient responded to corticosteroids.
Figure 13-9. Diagram of the pathways subserving the pupillary light reflex. (Redrawn with permission from Bradford CA [ed]: Basic Ophthalmology, 7th ed. San Francisco, American Academy of Ophthalmology, 1975.)
Figure 13-10. Congenital Horner syndrome on the patient’s left. In addition to the miosis and ptosis, the patient’s left iris is gray in color and the right, brown.