III Oculomotor Nerve

innervates
four of the six
extrinsic
ocular muscles
and the
intrinsic
ocular muscles

© L. Wilson-Pauwels
 III Oculomotor Nerve
CASE HISTORY
Werner is a 54-year-old gentleman whose favorite pastime is working in his garden. One
afternoon, while lifting a heavy potted plant, he experienced a sudden headache. This
headache was the worst he had ever experienced and he started to vomit. Concerned
about the headache’s sudden nature and intensity, he went to the emergency department.
In the emergency department, Werner was drowsy and had a stiff neck, although he
was rousable and able to answer questions and follow commands. When a bright light was
shone into his left eye, his left pupil constricted briskly, but the right pupil remained dilated.
When the light was shone directly into his right eye, his right pupil remained dilated and
his left pupil constricted. Werner also had a droopy right eyelid, and when he was asked
to look straight ahead, his right eye deviated slightly down and to the right. Werner com-
plained of double vision and recalled that he had experienced some sensitivity to light in
his right eye during the two weeks preceding this event. Close examination of Werner’s eye
movements revealed that he could move his left eye in all directions, but had difficulty with
movements of his right eye. With his right eye, Werner was able to look to the right (abduct)
but he could not look to the left (adduct). He was unable to look directly up or down.
Werner’s other cranial nerves were tested and found to be functioning normally.
The emergency physician was concerned that Werner might have experienced a sub-
arachnoid hemorrhage. A computed tomography (CT) scan of his head was done, and this
demonstrated blood in the subarachnoid space. A cerebral angiogram was done, which
demonstrated a dilated aneurysm of the right posterior communicating artery. Werner sub-
sequently underwent neurosurgery to have the aneurysm clipped.

ANATOMY OF THE OCULOMOTOR NERVE

As its name implies, the oculomotor nerve plays a major role in eye movement
(Table III–1). Its somatic motor component innervates four of the six extraocular
(extrinsic) muscles and its visceral motor component innervates the intrinsic ocular
muscles (constrictor pupillae and the ciliary muscle). The nerve also innervates the
levator palpebrae superioris muscle, which elevates the upper eyelid.
The oculomotor nerve emerges from the interpeduncular fossa on the ventral
aspect of the midbrain (Figure III–1). After passing between the posterior cerebral
and superior cerebellar arteries, the nerve courses anteriorly. It pierces the dura and
enters the cavernous sinus (Figure III–2) where it runs along the lateral wall of the
sinus just superior to the trochlear nerve (cranial nerve IV) and then continues for-
ward through the superior orbital fissure. As the oculomotor nerve enters the orbit
through the tendinous ring, it splits into superior and inferior divisions.

50
 Oculomotor Nerve 51

Table III–1 Nerve Fiber Modality and Function of the Oculomotor Nerve

Nerve Fiber Modality Nucleus Function

Somatic motor Oculomotor Innervation of the levator palpebrae

(efferent) superioris, superior, medial, and
inferior recti, and inferior oblique
muscles of the eye
Visceral motor Edinger-Westphal Parasympathetic supply to constrictor
(parasympathetic pupillae and ciliary muscles
efferent)

Levator Oculomotor nerve

palpebrae (CN III)
Superior Edinger-Westphal
superioris nucleus
rectus
muscle Oculomotor
muscle Short ciliary nerves nuclear complex
Ciliary ganglion
Superior division
of CN III

Nerve to
constrictor
muscle
Petrous temporal
Nerve to Inferior division bone (cut)
ciliary of CN III
muscle Nerve to
inferior oblique muscle
(including visceral motor fibers)

© L. Wilson-Pauwels Ciliary ganglion

Nerve to
inferior rectus muscle
Nerve to
medial rectus muscle
Nerve to
inferior oblique muscle

Figure III–1 Overview of the oculomotor nerve.

52 Cranial Nerves

Oculomotor nuclear complex

Cerebral
aqueduct
Internal
carotid artery

CN IV
trochlear
nerve

CN III
oculomotor
nerve

CN VI
abducens nerve

Slice through the

cavernous sinus
(see inset below)

Superior orbital

CN III
parasympathetic
fissure
© L. Wilson-Pauwels
axons (blue)
somatic motor
axons (red)

Slice through the

CN IV cavernous sinus

V1
ophthalmic
division

V2
maxillary Internal carotid
division CN VI artery

Figure III–2 Oculomotor nerve coursing through the area of the right cavernous sinus. The inset demonstrates
the anatomic relationships of the structures coursing through the cavernous sinus. Note in cranial nerve III the
parasympathetic axons are located on the surface of the nerve.

The superior division innervates the superior rectus and the levator palpebrae
superioris muscles. The inferior division innnervates the medial rectus, inferior rec-
tus, and inferior oblique muscles. The visceral motor axons run with the nerve to
the inferior oblique muscle for a short distance, then leave it to terminate in the cil-
iary ganglion. Postganglionic axons leave the ciliary ganglion as eight to ten short
ciliary nerves to enter the eye at the posterior aspect near the exit of the optic nerve
(see Figure III–1).
 Oculomotor Nerve 53

The oculomotor nucleus is situated in the midbrain at the level of the superior
colliculus. Like the other somatic motor nuclei, the oculomotor nucleus is near the
midline. It is located just ventral to the cerebral aqueduct and is bounded laterally
and inferiorly by the medial longitudinal fasciculus. It is generally accepted that sub-
nuclei within the oculomotor complex supply individual muscles (Figure III–3).
The lateral part of the oculomotor complex is formed by the lateral subnuclei,
which, from dorsal to ventral and ipsilaterally, supply the inferior rectus, inferior
oblique, and medial rectus muscles. The medial subnucleus supplies the contralat-
eral superior rectus muscle, and the central subnucleus (a midline mass of cells at
the caudal end of the complex) supplies the levators palpebrae superioris, bilaterally.

Edinger-Westphal nucleus

Lateral subnuclei
Medial subnucleus Dorsal, ipsilateral innervation to inferior rectus muscle
Contralateral innervation to superior rectus muscle Intermediate, ipsilateral innervation to inferior oblique muscle
Ventral, ipsilateral innervation to medial rectus muscle
Central subnucleus
Bilateral innervation to
levator palpebrae superioris muscle Levator palpebrae
superioris muscle

Superior rectus
muscle

Ciliary
ganglia

© L. Wilson-Pauwels
Medial rectus
muscle
Inferior rectus
Inferior oblique muscle
muscle

Figure III–3 Oculomotor nuclear complex and schematic innervation of extraocular muscles (the functions of the Edinger-
Westphal nucleus are discussed with the visceral motor component of cranial nerve III).
54 Cranial Nerves

SOMATIC MOTOR (EFFERENT) COMPONENT

Somatic motor neuron axons leave the oculomotor nuclear complex and course ven-
trally in the tegmentum of the midbrain through the medial portion of the red
nucleus and the medial aspect of the cerebral peduncle to emerge in the interpe-
duncular fossa at the junction between the midbrain and the pons (see Figure III–2).
As the somatic motor axons enter the orbital cavity through the superior orbital
fissure, they branch into superior and inferior divisions (Figure III–4). The superior
division ascends lateral to the optic nerve to supply the superior rectus and levator
palpebrae superioris muscles. The inferior division divides into three branches that
supply the inferior rectus, inferior oblique, and medial rectus muscles. The muscles
are innervated on their ocular surfaces, except for the inferior oblique, whose
branch enters the posterior border of the muscle (Figure III–5).

Red nucleus Superior colliculus

Midbrain Oculomotor nuclear

Posterior complex
communicating
artery
Pons
© L. Wilson-Pauwels Interpeduncular
fossa

Posterior cerebral
artery

Superior cerebellar
artery

Region of the cavernous

sinus

Superior orbital fissure

Superior division of CN III

Levator palpebrae
superioris muscle

Superior rectus muscle

Inferior division of CN III
Inferior rectus
muscle
Medial rectus
muscle

Inferior oblique
muscle

Figure III–4 The somatic motor component of the oculomotor nerve.

 Oculomotor Nerve 55

Table III–2 summarizes the actions of the muscles supplied by cranial nerve III
that move the eye.

Table III–2 Eye Movements Mediated by Cranial Nerve III

Nerve Muscle(s) Primary action(s) Secondary action(s)

CN III Medial rectus Adduction None

Inferior rectus Downward gaze Extorsion
Superior rectus Upward gaze Intorsion
Inferior oblique Upward gaze Abduction and
extorsion

In addition, cranial nerve III innervates the levator palpebrae superioris muscle, which raises the eyelid during
upward gaze (see Figure III–5).

Superior orbital
fissure
Levator palpebrae
Lacrimal gland superioris muscle

Superior oblique
muscle
Superior rectus
muscle
CN IV
CN III (superior division)

Tendinous ring

Medial rectus
muscle
CN VI Optic nerve (CN II)

Central retinal artery

Lateral rectus
muscle CN III (inferior division)

Inferior rectus
Inferior orbital muscle
fissure

Inferior oblique
© L. Wilson-Pauwels
muscle

Figure III–5 Apex of the right orbit, illustrating the tendinous ring and the somatic motor component of cranial
nerve III.
56 Cranial Nerves

The primary action of the medial rectus muscle is to adduct the eye toward the
nose, the inferior rectus muscle turns the eye downward and extorts it, and the supe-
rior rectus muscle rolls the eye upward and intorts it. The inferior oblique muscle
rolls the eye upward and abducts and extorts it. The combinations of these muscles,
plus the superior oblique (cranial nerve IV) and lateral rectus (cranial nerve VI)
muscles, enable eye movement around the three axes of the eye (Figure III–6).

Adduction
Abduction
(toward nose)
(away from nose)
medial rectus muscle CN III
lateral rectus muscle CN VI

"X" AXIS

IS
Upward gaze

AX
superior rectus and

"Z"
inferior oblique muscles CN III

"Y" AXIS
Downward gaze
inferior rectus CN III and
superior oblique muscles CN IV

Extorsion
inferior rectus and inferior oblique muscles CN III

© L. Wilson-Pauwels Intorsion
superior rectus CN III and superior oblique muscles CN IV

Figure III–6 Right eye movements around the “X,” “Y,” and “Z” axes (movements driven by cranial nerve III
are highlighted in pink).

VISCERAL MOTOR
(PARASYMPATHETIC EFFERENT) COMPONENT
The Edinger-Westphal (visceral motor) nucleus is located in the midbrain, dorsal
to the anterior portion of the oculomotor complex (see Figures III–1 and III–3).
Preganglionic visceral motor axons leave the nucleus and course ventrally through
the midbrain with the somatic motor axons. The parasympathetic and somatic
axons together constitute cranial nerve III. The parasympathetic axons are located
on the surface of the nerve. Therefore, when the nerve is compressed, the parasym-
pathetic axons are the first axons to lose their function (see Figure III–2). The
parasympathetic axons branch from the nerve to the inferior oblique muscle and ter-
minate in the ciliary ganglion near the apex of the cone of extraocular muscles (see
Figure III–1).
 Oculomotor Nerve 57

Cerebral
Edinger-Westphal aqueduct
(parasympathetic) Superior colliculus
Oculomotor nuclear complex nucleus

Interpeduncular
fossa

CN III © L. Wilson-Pauwels
Internal carotid
artery

Optic nerve
Middle
cranial fossa
Superior
orbital
fissure Trigeminal
ganglion

Region of the
cavernous sinus
Optic nerve
Ophthalmic nerve (V1)

Inferior division of CN III

Ciliary ganglion

Short ciliary nerves

to constrictor pupillae
and ciliary muscles

Figure III–7 The visceral motor component of the oculomotor nerve travels with the somatic motor axons that form the
inferior division of cranial nerve III (roof of skull and orbit removed).

Postganglionic axons leave the ciliary ganglion as six to ten short ciliary nerves
to enter the eye at its posterior aspect near the origin of the optic nerve. Within the
eyeball, the nerves run forward, between the choroid and the sclera, to terminate in
the ciliary body and the constrictor pupillae muscle (Figure III–7).
The visceral motor fibers control the tone of their target muscles (the constric-
tor pupillae and the ciliary muscles); therefore, they control the size of the pupil and
the shape of the lens.
58 Cranial Nerves

Pupillary Light Reflex

The pupillary light reflex is described in Chapter II. The parasympathetic axons that
form part of the oculomotor nerve are the efferent, or motor limb of this reflex.

Accommodation Reflex
Accommodation is an adaptation of the visual apparatus of the eye for near vision
(Figure III–8). It is accomplished by the following:
• An increase in the curvature of the lens. The suspensory ligament of the lens is
attached to the lens periphery. At rest, the ligament maintains tension on the lens,

Pupillary
Suspensory Ciliary constrictor Ciliary
ligament muscle muscle muscle

Flattened Thickened
lens lens

a. b. a. b.

A B
Oculomotor
nuclear
complex

© L. Wilson-Pauwels
Nerve to medial
rectus in inferior
division of CN III

Medial
rectus
muscles

Figure III–8 A, Eye adjusted for distance vision: large pupil and relaxed ciliary muscle. B, In accommodation
for near vision, the pupillary constrictor muscles contract resulting in a smaller pupil, and the ciliary muscles
contract and the suspensory ligaments relax resulting in a thicker lens. C, The medial recti muscles contract
causing the eyes to converge.
 Oculomotor Nerve 59

keeping it flat (see Figure III–8A). During accommodation, efferent axons from
the Edinger-Westphal nucleus signal the ciliary muscle to contract (shortening
the distance from “a” to “b”), which releases some of the tension of the suspen-
sory ligament of the lens and allows the curvature of the lens to increase (see
Figure III–8B).
• Pupillary constriction. The Edinger-Westphal nucleus also signals the sphincter-
like pupillary constrictor muscle to contract. The resulting smaller pupil helps to
sharpen the image on the retina (see Figure III–8B).
• Convergence of the eyes. The oculomotor nucleus sends signals to both medial
rectus muscles, which cause them to contract. This, in turn, causes the eyes to
converge (see Figure III–8C).

The pathways that mediate these actions are not well understood, but it is clear
that the reflex is initiated by the occipital (visual) cortex that sends signals to the
oculomotor and Edinger-Westphal nuclei via the pretectal region. See Vergence
System, Chapter 13.

CASE HISTORY GUIDING QUESTIONS

1. How did a posterior communicating artery aneurysm cause Werner’s symptoms?
2. What is the significance of the light sensitivity Werner experienced in the two
weeks preceding the subarachnoid hemorrhage?
3. When light was shone into Werner’s right pupil, why did the left pupil con-
strict but not the right?
4. Where else along the course of cranial nerve III could damage occur?
5. How can a third nerve palsy caused by damage to the neuronal cell bodies in
the oculomotor nucleus be differentiated from a third nerve palsy caused by
damage to the axons within the nerve itself?
6. Why did Werner’s right eye deviate downward and outward?

1. How did a posterior communicating artery aneurysm cause Werner’s

symptoms?
The third cranial nerve passes close to the posterior communicating artery (see Figure
III–4). An aneurysm (an expansion of the diameter of a blood vessel) of the posterior
communicating artery can compress cranial nerve III resulting in a lower motor neu-
ron lesion (Figure III–9). In Werner’s case, the aneurysm was compressing the right cra-
nial nerve III causing his double vision and light sensitivity. Rupture of the aneurysm
resulted in a subarachnoid hemorrhage, which caused his sudden, severe headache.
60 Cranial Nerves

Pretectal area
Posterior
Aneurysm of the right commissure
posterior communicating artery
affecting parasympathetic axons
of CN III

Optic tract
Optic disk
Optic nerve Edinger-Westphal
nucleus

CN III
(visceral motor
component)

Inferior
division of
CN III
Ciliary ganglion
Sphincter pupillae
Short ciliary nerve
muscle (constriction)

© L. Wilson-Pauwels
Figure III–9 Efferent pupillary defect. Light shone in Werner’s right eye resulted in left pupillary constriction
(indirect or consensual) with the absence of right pupillary constriction (direct) due to an aneurysm of the posterior
communicating artery.

2. What is the significance of the light sensitivity Werner experienced in the

two weeks preceding the subarachnoid hemorrhage?
The parasympathetic fibers responsible for constriction of the pupil in response to
light lie on the surface of cranial nerve III (see Figure III–2 and Figure III–10).
Initially, the aneurysm was small and, therefore, only the parasympathetic fibers
were compromised. As a result, his right pupil could not constrict as well as usual
in bright light, which caused his light sensitivity.

When the third nerve becomes ischemic, for example, in diabetes or stroke, the
somatic motor axons in the center of the nerve are affected; however, the parasym-
patheic axons on the surface of the nerve are relatively spared. In this case, the
patient has an oculomotor palsy with sparing of the pupillary light reflex—the oppo-
site of Werner’s early dysfunction.
 Oculomotor Nerve 61

Endothelium of
Cavernous cavernous sinus
sinus
CN III
parasympathetic axons (blue)
somatic motor axons (red)
Pituitary
gland

CN IV © L. Wilson-Pauwels
Sphenoidal
air sinus
V1

Internal carotid
artery

V2

CN VI

Dura mater

Figure III–10 Slice through the right cavernous sinus showing the relationship of cranial nerve III to other
structures coursing through the sinus.

3. When light was shone into Werner’s right pupil, why did the left pupil
constrict but not the right?
The aneurysm of the posterior communicating artery compressed the right oculo-
motor nerve but did not affect the optic nerve. When light was shone into the right
eye, the afferent (special sensory) limb of the pupillary light response was intact.
Light shone into either pupil causes signals to be sent along the optic nerve, which
bilaterally innervate the Edinger-Westphal nuclei. Visceral motor signals that arise
from these nuclei are transmitted along the parasympathetic fibers in cranial nerve III.
In Werner’s case, these fibers are intact on the left side but damaged on the right.
Therefore, the left pupil constricted in response to both direct and indirect stimu-
lation, but the right pupil did not constrict in either case (see Figure III–9).
Compare Werner’s efferent pupillary defect (see Figure III–9) with Meredith’s
afferent pupillary defect shown in Chapter II, Figure II–12.

4. Where else along the course of cranial nerve III could damage occur?
Cranial nerve III can be damaged anywhere from the nucleus in the midbrain to the
muscles of innervation.
Cranial nerve III can be damaged at the following sites.
Nucleus of Cranial Nerve III
• Although rare, damage to cells in the nucleus of cranial nerve III may be due to
trauma, ischemia, or demyelination within the midbrain.
62 Cranial Nerves

Peripheral Axons
• Damage to axons in the subarachnoid space may be due to infection, tumor infiltra-
tion, or infarction (loss of blood supply, usually caused by diabetes or hypertension).
• Compression of axons may be due to aneurysms, most typically in the posterior
communicating artery and sometimes in the basilar artery (see Figure III–9).
• Compression of axons may be caused by the uncus of the temporal lobe during
cerebral herniation if there is raised intracranial pressure.
• Compression of axons in the cavernous sinus may be due to tumors, inflamma-
tion, infection, or thrombosis (other nerves that pass through the cavernous sinus
[IV, V1, V2, VI] may also be involved) (see Figure III–10).
• Damage may be caused by trauma to the area where axons pass through the supe-
rior orbital fissure to enter the orbit.

5. How can a third nerve palsy caused by damage to the neuronal cell bodies
in the oculomotor nucleus be differentiated from a third nerve palsy
caused by damage to the axons within the nerve itself?
Because the oculomotor nucleus is close to the midline, it is extremely rare to have
a unilateral nuclear lesion (Figure III–11A). To distinguish a nuclear lesion from an
axonal lesion, a useful indictor is the behavior of the upper eyelid.
In a nuclear lesion, there is
• bilateral innervation of the levator palpebrae superioris muscle by the central sub-
nucleus and, therefore, there is no ptosis;
• ipsilateral innervation of the medial rectus muscle by the lateral subnucleus and,
therefore, ipsilateral weakness of adduction;
• ipsilateral innervation of the inferior rectus muscle by the lateral subnucleus and,
therefore, ipsilateral weakness of downward gaze;
• contralateral innervation of the superior rectus muscle and, therefore, there is no
weakness in upward gaze in the ipsilateral eye; and
• ipsilateral innervation of the pupil by the Edinger-Westphal nucleus resulting in
an ipsilateral dilated unresponsive pupil.
In contrast, when the peripheral part of the third nerve is damaged (axonal dam-
age), innervation of all target muscles is affected and there is ptosis and a dilated
unresponsive pupil on the ipsilateral side (Figure III–11B). Both lesions described
above are lower motor neuron lesions.

6. Why did Werner’s right eye deviate downward and outward?

Werner has a lower motor neuron lesion of the right cranial nerve III (see Introduc-
tion for the general characteristics of a lower motor neuron lesion).
His symptoms include the following:
• strabismus (inability to direct both his eyes toward the same object) and conse-
quent diplopia (double vision);
 Oculomotor Nerve 63

Cerebral aqueduct
Edinger-Westphal nucleus
Lesion
A
Central subnucleus (levator
palpebrae superioris muscle)
Lateral subnuclei

Medial subnucleus

Ipsilateral side Contralateral side

• Weakness of downward gaze • Weakness of upward gaze
• No adduction • No ptosis
• No ptosis • Responsive pupil
• Dilated, unresponsive pupil • Downward gaze intact
• Adduction intact

B © L. Wilson-Pauwels

Ipsilateral side Contralateral side

• Weakness of upward and downward gaze • Normal muscle control
• No adduction • Responsive pupil
• Ptosis • No ptosis
• Dilated, unresponsive pupil

Figure III–11 A, Right unilateral nuclear lower motor neuron lesion of cranial nerve III.
B, Right unilateral peripheral lower motor neuron lesion of cranial nerve III.
64 Cranial Nerves

© L. Wilson-Pauwels

Figure III–12 Right third nerve palsy.

• right-sided ptosis (lid droop) due to inactivation of the levator palpebrae superi-
oris muscle and the subsequent unopposed action of the orbicularis oculi mus-
cle. Werner tries to compensate for ptosis by contracting his frontalis muscle to
raise his eyebrow and attached lid;
• dilation of his right pupil due to decreased tone of the constrictor pupillae muscle;
• downward, abducted right eye postion due to the unopposed action of his right
superior oblique and lateral rectus muscles; and
• inability to accommodate with his right eye.
This combination of symptoms is called a third nerve palsy (Figure III–12).

CLINICAL TESTING
Testing of cranial nerve III involves the assessment of
• eyelid position,
• pupillary response to light,
• extraocular eye movements, and
• accommodation.
(See also Cranial Nerves Examination on CD-ROM.)

Eyelid Position
Elevation of the eyelid results from activation of the levator palpebrae superioris
muscle. Damage to cranial nerve III will result in ipsilateral or bilateral ptosis
(drooping of the eyelid[s]). To assess the function of the muscle, ask the patient to
look directly ahead and note the position of the edge of the upper eyelid relative to
the iris. The eyelid should not droop over the pupil, and the eyelid position should
be symmetric on both sides (Figure III–13).
 Oculomotor Nerve 65

© L. Wilson-Pauwels
Edge of the upper eyelids
Top of the pupil

Figure III–13 Normal eyelid position.

Pupillary Response to Light

The afferent limb of the pupillary light reflex is carried by cranial nerve II—the optic
nerve (Figure III–14). The efferent component of the pupillary light reflex is carried
by parasympathetic fibers that travel on the surface of cranial nerve III (see Figure
III–10). To assess the integrity of the reflex, a beam of focused light is shone directly
into one pupil. In the normal reflex, light shone in the ipsilateral eye causes the ipsi-
lateral pupil to constrict (direct light response). The contralateral pupil also constricts
(indirect or consensual response) (see Figure III–14). If the afferent arm (cranial
nerve II) is intact but the ipsilateral efferent pathway is damaged, the ipsilateral pupil
will not constrict but the contralateral pupil will (see Figure III–9).

Pretectal area

Posterior commissure
Aqueduct

Optic tract

Optic chiasma
Edinger-Westphal
nucleus

Inferior division
of oculomotor nerve

Optic disk
Nerve to inferior
oblique muscle

Pupillary constriction
© L. Wilson-Pauwels
Ciliary ganglion

Short ciliary nerve

Fovea

Figure III–14 Pupillary light reflex. Light shone in either eye (left illustrated ) causes direct (ipsilateral) and indirect
or consensual (contralateral) pupillary constriction.
66 Cranial Nerves

© L. Wilson-Pauwels

Figure III–15 Movements of the right eye and lids controlled by the muscles (colored) innervated by the
oculomotor nerve (cranial nerve III). A, Adduction—medial rectus muscle (cranial nerve III). B, Downward
gaze—inferior rectus muscle (cranial nerve III) aided by the superior oblique muscle (cranial nerve IV). The
tendon of the inferior rectus muscle extends into the lower eyelid, pulling it down during downward gaze.
C, Upward gaze—superior rectus aided by the inferior oblique muscle (cranial nerve III). The upper
eyelid is raised by the levator palpebrae superioris muscle.
 Oculomotor Nerve 67

Extraocular Eye Movements

Cranial nerve III is tested in conjunction with cranial nerves IV and VI through
assessment of extraocular eye movements (see Chapter 13). When testing the
integrity of cranial nerve III, particular attention should be paid to adducting and
vertical eye movements. If a lesion is present, eye adduction may be impaired
because cranial nerve III innervates the medial rectus muscle (Figure III–15A).
Cranial nerve III also innervates the inferior rectus, which controls part of down-
ward gaze (Figure III–15B), and the superior rectus muscle and the inferior oblique
muscle, which are responsible for upward gaze (Figure III–15C). Thus, if a lesion is
present, vertical eye movements may also be impaired.

Accommodation
Accommodation allows the visual apparatus of the eye to focus on a near object. The
observable events in accommodation are convergence and pupillary constriction of
both eyes. Accommodation is tested by asking the patient to follow the examiner’s
finger as it is brought from a distance toward the patient’s nose. As the examiner’s
finger approaches the patient’s nose, the patient’s eyes converge and his or her pupils
constrict (Figure III–16).

Figure III–16 Testing cranial nerve III for accommodation.

ADDITIONAL RESOURCES
Brodal A. Neurological anatomy in relation to clinical medicine. 3rd ed. New York:
Oxford University Press; 1981. p. 532–77.
Glimcher PA. Eye movements. In: Zigmond MJ, Bloom FE, Landis SC, et al, editors.
Fundamental neuroscience. San Diego: Academic Press; 1999. p. 993–1009.
Porter JD. Brainstem terminations of extraocular muscle primary sensory afferent neurons
in the monkey. J Comp Neurol 1986;247:133–43.