OCEAN MEDICAL CENTER

STROKE SERIES

AWARENESS OF VISUAL SEQUELLA OF STROKES

NORMAN P EINHORN OD MS FAAO

Diplomate American Board of OptometryNational & International Lecturer NORPast AOA Membership Chair SVSPast NJSOP Board MemberPast Chair NJSOP Rehabilitation SectionSenior member Vision Panel NJ MVCExecutive Committee Belmar Business PartnershipStaff Consulting Privileges 5 Acute Rehab Hosptals

Visual Deficits Post CVAto watch for

1. Field Loss or Visual Inattention2. Diplopia or Binocular Deficits3. Spatial Deficits4. Dry eye caused by poor lid closure,

partial CN7 or CN 5 Ophthalmic Branch loss

5. Inability to read or scan

RETINA

STRUCTUREFUNCTION

RETINAL STRUCTURE

GANGLION CELS

THREE PARALLEL PATHWAYS

BASE OF BRAIN

AFFERENT PAHTWAY

RETINO GENICULATE CALCARINE PATHWAY

RETINO GENICULO CALCARINE PATHWAY

OPTIC TRACTS AND LATERAL GENICULATE

GANGLION CELL INPUT TO LGN LAYERS

THALMUS &

LATERAL GENICULATE

• Specific relay nuclei• VA ventral anterior (motor)• VL ventral lateral (motor)(somatosensory) • VPM ventral posteromedial (trigeminal)• MG medial geniculate (body) nucleus (auditory)• LG lateral geniculate (body) nucleus (vision)• Association nuclei• DM dorsomedial nucleus (prefrontal cortex)• AN anterior nucleus (limbic lobe)• P pulvinar (visual cortex) • LP lateral posterior (parietal lobe)• Nonspecific nuclei• IL intralaminar

OPTIC RADIATIONS

PRIMARY CORTEX – VISUAL ORGANIZATION

THREE PARALLEL PATHWAYS

PRIMARY CORTEX – VISUAL ORGANIZATION

Territories Supplied by the Cerebral Arteries

SHORT ASSOCIATION FIBERS

LONG ASSOCIATION FIBERS

AFFERENT PATHWAY

EXTRA GENICULATE PATHWAYMagno cellular

EXTRA GENICULATE PAHTWAY

EXTRA GENICULATE PATH

Although this figure again illustrates the optic

radiation and the lateral geniculate nucleus

[a nucleus with six layers], the focus is now on the synaptic terminations of

other visual fibers.Some of the visual

information is relayed to the superior colliculus for

visual reflex responses. Other fibers relay in the

pre-tectal region which is the locus for the pupillary

light reflex. The oculomotor nucleus (including the

parasympathetic component) is not shown

here.

RETINO SUPERIOR COLLICULUS

SUPERIOR COLLICULUS FIBERS AND MOTOR FIBERS

AFFERENT PATHWAY

RETINO HYPOTHALAMIC PATHWAY

AFFERENT PATHWAY

PRE TECTAL PATHWAY

Visual Field Loss By

Deficit Areas

Review

EFFERENT

EYE MOVEMENT

CLASSES OF HUMAN EYE MOVEMENT

VESTIBULAR- HOLDS IMAGES OF THE SEEN WORLD STEADY ON THE RETINADURING BRIEF HEAD ROTATIONS

VISUAL FIXATION- HOLDS THE IMAGE OF A STATIONARY OBJECT ON THE FOVEA

OPTOKINETIC- HOLDS AN IMAGE OF THE SEEN WORLDSTEADY ON THE RETINADURING SUSTAINED HEAD ROTATION

CLASSES OF HUMAN EYE MOVEMENT

SMOOTH PURSUIT- HOLDS AN IMAGE OF A SMALL MOVING TARGET ON THE FOVEA; OR HOLDS THE IMAGE OF A NEAR TARGET ON THE RETINA DURINGLINEAR SELF MOTION

NYSTAGMUS QUICK PHASE- RESET THE EYES DURING PROLOGED ROTATION AND DIRECT GAZE TOWARD THE ONCOMING VISUAL SCENE

CLASSES OF HUMAN EYE MOVEMENT

SACCADES- BRINGS IMAGES OF OBJECTS OF INTEREST ONTO THE FOVEA

VERGENCE- MOVES THE EYES IN OPPOSITE DIRECTIONSSO THAT IMAGES OF A SINGLE OBJECTARE PLACED OR HELD SIMULTANIOUSLY ON BOTH FOVEAS.

SMOOTH PURSUITS

SACCADES

VESTIBULAR

VERGENCE EYE MOVEMENT

SUPRA AND INFRA NUCLEAR PATHWAYS

VENTRAL BRAIN STEM• This photographic

view of the brainstem is shown as a parallel to the illustration shown in the previous illustration - the same structures are indicated.

• Various cranial nerves (CN)

• are still attached. The

• cerebellum, with its characteristic folia, is still attached.

DORSAL BRAIN STEM

• The brainstem is shown from the dorsal (posterior) perspective, with the cerebellum removed (and the middle cerebellar peduncles have been cut).

• In particular, one should note the colliculi (superior and inferior) of the midbrain, the sensory relay nuclei (cuneatus and gracilis) of the medulla, the fourth ventricle, and the emerging cranial nerves that can be seen from this perspective.

CN 3,4,6 IN PONTINE REGION

CN 3,4.6 TRACTS THROUGH BRAIN

EOM ACTIONS

Visual Deficits Post CVAto watch for

1. Field Loss or Visual Inattention2. Diplopia or Binocular Deficits3. Spatial Deficits4. Dry eye caused by poor lid closure,

partial CN7 or CN 5 Ophthalmic Branch loss

5. Inability to read or scan

NO MAS