Figure 12-15. Nonarteritic anterior ischemic optic neuropathy (NAION) related to hypertension and diabetes. There is diffuse disc swelling from infarction that extends into the retina as a milky edema. The veins are engorged. “Cotton-wool” infarcts can be seen to the left of the disc and a “flame” hemorrhage extends from the right disc margin.
Chapter  12    Disturbances of Vision
Disorders of Ocular Movement and Pupillary Function
Ocular movement and vision are virtually inseparable. A moving object automatically evokes movement of the eyes and almost simultaneously enhances attention and perception. To visually search, that is, to peer, requires coordinated eye movements interspersed with periods of stable fixation of the visual image on the center of the two retinas. One might say that the ocular muscles are at the service of vision.
Abnormalities of ocular movement are of three basic types. One category can be traced to a lesion of the extraocular muscles themselves, the neuromuscular junction, or to the cranial nerves that supply them (nuclear or infranuclear palsy). The second type is a derangement in the highly specialized neural mechanisms that enable the eyes to move together (supranuclear and internuclear palsies). This distinction, in keeping with the general concept of upper and lower motor neuron paralysis, hardly portrays the complexity of the neural mechanisms governing ocular motility. Perhaps more common but not primarily neurologic is a third group of disorders, congenital strabismus, in which there is an imbalance of the yoked muscles of extraocular movement. This early ocular misalignment is one cause of a developmental reduction in monocular vision (amblyopia), as discussed at the end of the previous chapter.
In no aspect of human anatomy and physiology is the sensory guidance of muscle activity more instructively revealed than in the neural control of coordinated ocular movement. Moreover, the entirely predictable and “hard-wired” nature of the central and peripheral oculomotor apparatus allows for a very precise localization of lesions within these pathways. To focus the eyes voluntarily, to stabilize objects for scrutiny when one is moving, to bring into sharp focus near and far objects—all require the perfect coordination of six sets of extraocular muscles and three sets of intrinsic muscles (ciliary muscles, sphincters, and dilators of the iris). The neural mechanisms that govern these functions reside mainly in the midbrain and pons, but are greatly influenced by centers in the medulla, cerebellum, basal ganglia, and the frontal, parietal, and occipital lobes of the brain. Most of the nuclear structures and pathways concerned with fixation and stable ocular movements are now known and much has been learned of their physiology both from clinical-pathologic correlations in humans and from experiments in monkeys.
Accurate binocular vision is actually achieved by the associated action of all the ocular muscles. Several terms are used, somewhat interchangeably but with different specific meanings to describe these movements. The term duction denotes the movement of one eye in a single direction. The synchronous movement of both eyes is a version. The commonly used term, conjugate gaze, simply indicates that the eyes are aligned and move in the same direction. Therefore, the simultaneous movement of the eyes in opposing directions is dysconjugate, or disjunctive. Dysconjugate movements are either convergent or divergent. Convergent movements are required when one looks at a near object. At the same time, the pupils constrict and the ciliary muscles relax to thicken the lens and allow near vision (the accommodative-near reflex, or triad). Divergence is required for distant vision.