Applied Anatomy of

Visual and Olfactory

Organs
by Asisten Anatomi Angkatan 2016
 Eye
and Clinical Correlation

Learning Cataract
and Glaucoma

Objectives Visual Pathway

and Clinical Correlation

Eye Movements
and Clinical Correlation

Olfactory System
and Clinical Correlation
Section 1:
Eye
DS
Anatomy of Eye (External)
Anatomy of Eye (External)
Anatomy of Eye (Internal)
Anatomy of Orbital Cavity
 Orbital Cavity adalah suatu ruangan berbentuk prisma segi empat (quadrangular space)
yang dibatasi oleh apex, basis, dan 4 dinding. Penyusun dari bidang ruangan ini adalah :

 Apex Orbita
• Canalis Opticus (Medial dari Fissura Orbitalis Superior, terletak di Ala Parva Os.
Sphenoidale)

Orbital  Basis Orbita

Cavity • Margo Cavum Orbita (Tepi luar)
• Tempat penempelan Septum Orbitale  Membran Fibrosa yang menempel hingga
Cavum Orbita palpebral
• Pada kasus Sinusitis Maxillaris, efek jangka panjang dari Sinusitis yang dibiarkan
adalah erosi dari dinding medial Orbita

 Dinding Lateral Orbita

• Processus Frontalis Os. Zygomaticus dan Ala Magna Os. Sphenoidale
• Karena rawan trauma, maka dinding lateral lebih kuat dan tebal
  Dinding Medial Orbita
• Dominan oleh Os. Ethmoidale, sisanya diisi oleh bagian kecil dari Os. Frontale, Os.
Lacrimale, dan Os. Sphenoidale
• Terdapat Sulcus Lacrimalis & Fossa Sacci Lacrimalis
• Terdapat Trochlea (Katrol) untuk Tendon dari M. Obliquus Superior
• Sinusitis Ethmoidalis bisa mengikis dinding medial Orbita

Orbital  Dinding Superior Orbita

• Lamina Orbitalis Os. Frontale
Cavity • Memisahkan Cavum Orbita dengan Fossa Cranii Anterior dan Ala Parva Os.
Cavum Orbita Sphenoidale
• Terdapat Fossa Glandula Lacrimale

 Dinding Inferior Orbita

• Dominan oleh Os. Maxilla, dengan kontribusi sedikit Os. Zygomaticus dan Os.
Palatina
• Dinding Inferior dipisahkan dari Dinding Lateral oleh Fissura Orbitalis Inferior
• Terdapat Sulcus et Canalis Infraorbitalis yang dilewati oleh A. et N. Infraorbitalis
Layers of Eyeball
Eyelid
Latin : Palpebra
Terbagi Menjadi :
• Superficial  Cutis
• Profunda  Conjunctiva Palpebralis
• Tarsus  Superior (di Palpebra
Superior) dan Inferior (di Palpebra
Inferior)

Terdapat Kelenjar :
• Glandula Meibomian/Tarsale 
Kelenjar Sebasea, Profunda dari Tarsus
• Glandula Zeis  Kelenjar Sebasea,
Superficial dari Tarsus
• Glandula Moll  Kelenjar Apokrin,
Superfisial dari Tarsus
Eyelid
Latin : Palpebra
1. Cutis
2. Subcutis
3. Otot-otot (M. Orbicularis Oculi)
4. Tarsus & Septum Orbitale
5. Conjunctiva Palpebra
Eyelid
Latin : Palpebra
Tarsus adalah jaringan ikat berbentuk
lempengan yang berada di dalam
palpebral.

Tarsus dalam hal klinis menjadi pembagi

antara hordeolum interna (profunda
tarsus) dan hordeolum eksterna
(superfisial tarsus).

Septum Orbitale/Palpebral Fascia adalah

jaringan ikat yang menghubungkan
tarsus dengan margo orbita dan
berfungsi membatasi penyebaran infeksi
ke area bola mata yang lebih dalam.
Glandula Meibomian Glandula Zeis Glandula Moll
• Terletak profunda dari tarsus, di • Terletak superfisial tarsus, di • Modifikasi kelenjar apokrin
tengah perifer (dekat margo palpebra) • Produksi cairan serosa (keringat)
• Modifikasi glandula sebasea, • Modifikasi kelenjar sebasea yang
berfungsi untuk sekresi lipid berhubungan dengan folikel
• Mencegah perlekatan palpebra rambut cilium
ketika fissura palpebra menutup
• Barrier yang tidak bisa ditembus
oleh cairan lakrimal
Medial Palpebral
Ligament
M. Orbicularis Oculi terdiri atas pars
palpebralis dan pars orbitalis

Perlekatan dari Ligamentum Palpebrale

Medialis adalah :
• Depan  Proc. Frontalis Os. Maxilla
• Belakang  Os. Lacrimale
• Lateral  Tarsus Superior et Inferior
Lacrimal Apparatus
Axis of Orbit and Eyeball
Section 1:
Clinical Correlation
DS
Conjunctivitis
Inflamasi pada Conjunctiva

• Merupakan penyebab tersering mata

merah/ iritasi

• Penyebab paling sering adalah

adenovirus , dengan karakteristik
watery discharge , foreign body
sensation dan photophobia. (apabila
disebabkan oleh bakteri , discharge yg
dikeluarkan mucopurulent)

• Nyeri dan gangguan penglihatannya

minimal
Uveitis
Inflamasi pada Uvea/Tunica
Vasculosa
inflamasi vascular layer
• uveitis anterior : terdiri atas iritis
(mengenai iris) & iridocyclitis (Iritis +
inflamasi Corpus ciliaris)
• uveitis intermediate: mengenai
bagian posterior dari corpus ciliaris.
• uveitis posterior : inflamasi pada uvea
posterior dari vitreous humor.
• panuveitis : uveitis anterior,
intermediate, posterior yg terjadi
bersamaan.
Keratitis
Inflamasi pada Kornea

Bisa Infeksi & Non-infeksi

Gejala & Tandanya antara lain :
• Injeksi siliaris (+)
• Visus turun
• Photophobia
• Nyeri
• Epiphora  Keluar air mata
secara berlebihan
Conjunctival and Ciliary Injection
Conjunctival and Ciliary Injection
Blepharitis
Inflamasi pada Margo Palpebra
Conjunctival vs
Ciliary Injection
• Injeksi konjungtival  Melebarnya
a. conjunctiva posterior (yang
memvaskularisasi conjunctiva
bulbi).

• Injeksi silier  Melebarnya

pembuluh darah perikornea
(a.ciliaris anterior) yang
memvaskularisasi kornea.
Hordeolum
Internum
• Inflamasi & infeksi pada glandula Meibomian
• Nodule terletak di profunda tarsus & tengah
• Tanda inflamasi aktif  Nyeri, kemerahan,
sensasi mengganjal

Hordeolum
Externum
• Inflamasi dan/atau infeksi pada glandula Zeis
& Moll  nodulus terletak di perifer/dekat
margo palpebra
• Nodulus terletak di superfisial tarsus
Hordeolum
• Suatu proses infeksi pada eyelid gland,
menunjukkan tanda-tanda inflamasi akut 
merah, nyeri, suhu meningkat, discharge
• Internum  Meibom.
• Eksternum  Zeis/Moll.

Chalazion
• Inflammasi steril kronis karena terblokadenya
glandula tarsalis (Meibom)
• Nodulus saja, tanpa tanda inflamasi akut
• Dapat berkembang dari hordeolum internum
Dacryoadenitis
Inflamasi dan pembengkakan glandula lakrimalis
• Onset cepat
• Unilateral, nyeri, kemerahan
• Dijumpai di regio supratemporal
(sesuai letak glandula lakrimal)

Dacryocystitis
Obstruksi ductus naolacrimal akibat infeksi
• Onset cepat
• Unilateral, nyeri, kemerahan,
epiphora (keluar air mata terus
menerus)
• Dijumpai di regio inframedial
(sesuai letak ductus
nasolakrimal)
Endopthalmitis
Peradangan struktur internal bola
mata, yaitu jaringan uvea dan retina
yang diikuti dengan terbentuknya
eksudat di dalam aqueous dan
vitreous humor

Panopthalmitis
Peradangan purulent berat
keseluruhan bola mata termasuk
capsula Tenon
Hyphema
Akumulasi darah pada Camera
Oculi Anterior (COA)/ Camera
Anterior Bulbi.

Hypopyon
Akumulasi pus pada Camera Oculi
Anterior (COA)/ Camera Anterior
Bulbi.
Episcleritis
• Inflamasi rekuren jinak dari episclera tanpa
keterlibatan sclera dibawahnya.
• Episclera  terletak tepat di bawah
conjunctiva dan bersebelahan dengan sclera
• ada vasokontriksi ketika diberi tetes mata
simpatomimetik

Scleritis
• Inflamasi kronis dari sclera
• Berhubungan dengan penyakit sistemik
terutama rheumatoid arthritis
• Tidak ada vasokontriksi walaupundiberi tetes
mata simpatomimetik
Coloboma
Palpebra
Hilangnya sebagian kulit mata
atau adnexa mata akibat
kegagalan menyelesaikan
pertumbuhan.
Coloboma Iris
Kelainan kongenital dimana tidak
ditemukannya satu bagian dari
iris.

Aniridia
Kelainan kongenital dimana tidak
ditemukannya seluruh iris.
Pterygium
• Pertumbuhan jaringan jernih, sering
muncul dari pinguecula, tumbuh dari
konjungtiva ekstensi hingga ke kornea.
• Gangguan visus dipengaruhi seberapa
besar pertumbuhan jaringan yang ada

Pinguecula
Suatu nodulus kekuningan pada
konjungtiva bagian medial. Hal ini
disebabkan karena terjadinya perubahan
jaringan normal akibat deposit protein,
lemak, dan kalsium.
Corneal Ulcer
• Etiologi  infeksi, abrasi, contact
lens, topical steroid

• Bisa timbul nyeri, tapi bisa juga jadi

tdk nyeri karena sensasi sensorisnya
hilang, misal pasca herpes zoster
opthalmicus (HZO). Atau bisa juga
karena sensasi sensoris yg hilang
mengakibatkan rawan ulserasi

• Infeksi terus menerus bisa

menyebabkan ulkus kornea ini hingga
menembus membran Descemet
Subconjunctival
Hemorrhage
• Etiologi  Trauma, inflamasi,
hipertensi, gangguan koagulasi

• Ruptur kapiler subconjunctival

• Tidak nyeri, visus normal, bisa sembuh

dengan sendirinya
Ectropion
• Penggulungan margo
palpebra ke arah luar
• Etiologi: Degenerasi, trauma
Entropion Trichiasis
• Penggulungan margo • Tumbuhnya bulu mata ke arah
palpebra ke arah dalam dalam dengan posisi palpebra
• Etiologi: Kongenital, yang normal
trachoma, degenerasi • Tumbuhnya bulu mata ke arah
dalam oleh karena palpebra yang
entropion disebut sebagai
pseudotrichiasis
• Etiologi: Trachoma, blefaritis
ulseratif, hordeolum eksternum
Herpes Zoster
Opthalmicus
• Infeksi unilateral karena reaktivasi
virus Varicella Zoster yang
mengenai teritori N. V1 (n.
ophthalmicus)
• Ruam vesikular dengan dasar
eritema, nyeri, krusta
• Hutchinson sign  adanya ruam
vesikular di ujung nasal
(keterlibatan nervus nasociliaris)
menunjukkan virus sudah masuk
hingga ke intraocular
Enophtalmos
Pergeseran posterior bulbus oculi

Exopthalmos
Penonjolan bulbus oculi keluar
dari orbita  Bisa terjadi di
masalah endokrin seperti
hipertiroidisme

PAMELA  Ptosis, Anhidrosis, Miosis,
Enophthalmos, VasodiLAtasi
Horner’s
Syndrome
• Gangguan jaras simpatis ke mata
dan wajah
• Ptosis : hilangnya inervasi simpatis
ke m.tarsalis superior (otot polos)
• Miosis : hilangnya inervasi simpatis
ke m.dilator pupil
• Anhidrosis: hilangnya inervasi
simpatis ke glandula sudorifera
wajah
• Enophthalmos : hilangnya inervasi
simpatis ke m.orbitalis
• Vasodilatasi : hilangnya inervasi
simpatis ke vasa-vasa di wajah
Sympathetic
Pathways of
Pupillary
Dilatation
Ptosis
• Ptosis : drooping upper eyelid
• Pembukaan fissura palpebra  oleh
otot rangka m. levator palpebra
superioris (n.III) dengan otot polos m.
tarsalis superior (simpatis)
• Penutupan fissura palpebra  oleh
m.orbicularis oculi (n.VII)
• Ptosis terjadi pada:
• Horner syndrome  mild ptosis
• Oculomotor nerve (n.III) palsy 
mild to severe ptosis
• Myasthenia gravis
• Massa orbita
• Lipatan kulit berlebih (pada elderly)
• Lesi n. facialis (n.VII) bisa
melebarkan fissura palpebra salah
satu mata, sehingga mata lainnya
terlihat seperti ptosis
Section 2:
Cataract &
Glaucoma
TY
Senile Cataract
Senile cataract is an age-related,
vision-impairing disease characterized
by gradual progressive clouding and
thickening of the lens of the eye. It is
the world’s leading cause of treatable
blindness.
Review Basic
Anatomy of the
Eye
 Decreased visual acuity
Signs and The most common complaint of patients with senile cataract.
Symptoms Glare
Can range from a decrease in contrast sensitivity in brightly lit environments
or disabling glare during the day to glare with oncoming headlights at night.

Myopic shift
The progression of cataracts frequently increases the anteroposterior (AP)
axis and therefore the dioptric power of the lens, resulting in a mild to
moderate degree of increased myopia or myopic shift.

Monocular diplopia
At times, the nuclear changes are concentrated in the inner layers of the lens,
resulting in a refractile area in the center of the lens, the so called “lens
within a lens” phenomenon, which may lead to monocular diplopia that is not
correctable with spectacles, prisms, or contact lenses.
Classification Based on Its Pathophysiology
Nuclear Cataract
Nuclear cataracts result from excessive
nuclear sclerosis and yellowing, with
consequent formation of a central
lenticular opacity. In some instances,
the nucleus can become very opaque
and brown, termed a brunescent
nuclear cataract.
Cortical Cataract
Changes in the ionic composition
of the lens cortex and the
eventual change in hydration of
the lens fibers produce a cortical
cataract.
Subcapsular Cataract
Formation of granular and
plaquelike opacities in the
posterior subcapsular cortex often
heralds the formation of posterior
subcapsular cataracts.
Classification of
Senile Cataract
Classification of Senile Cataract
Other characteristics
 Hypermature cataract: dense white opacity Immature cataract: This is a cataract
Senile Cataract that obscures the red reflex and contains milky characterized by a variable amount of
Staging fluid within the capsule, a result of degenerated
lens cortex. The capsule if often tense or wrinkled.
opacification, present in certain areas of the
lens. These may include both high- and low-
A morgagnian cataract is a type of density areas, with some clear lens fibers.
based on the appearance
of the lens on slit-lamp hypermature cataract in which the nucleus sinks Incipient cataract: This is a cataract that is
examination within the fluid cortex. seen on slit-lamp examination but is of little
Mature cataract: This is a cataract that is clinical significance.
opaque, totally obscuring the red reflex. It is
either white or brunescent.
Types of Cataract
Other than Senile Cataract
 Surgery: Intracapsular
cataract extraction
It involves extraction of the entire lens, including
the posterior capsule and mechanical or enzymatic
lysis of the zonular support structures.

A number of disadvantages and postoperative

complications accompany ICCE. The larger limbal
incision, often 160°-180°, is associated with the
following risks: delayed healing, delayed visual
rehabilitation, significant against-the-rule
astigmatism, iris incarceration, postoperative wound
leaks, and vitreous incarceration. Corneal edema is a
common postoperative complication.

Although the myriad postoperative complications has

led to the decline in popularity and use of ICCE, it still
can be used when zonular integrity is too severely
impaired to allow successful lens removal and IOL
implantation with an ECCE, particularly carefully
selected posttraumatic and hypermature
cataracts. Furthermore, ICCE can be performed in
remote areas where more sophisticated equipment is
not available.
Surgery : Extracapsular
cataract extraction
ECCE involves the removal of the lens nucleus
through an opening in the anterior capsule with
retention of posterior capsular integrity.
The main requirements for a successful ECCE
and endocapsular IOL implantation are
zonular integrity and an intact posterior
capsule.

ECCE possesses a number of advantages over ICCE,

most of which are related to an intact posterior
capsule, as follows:
- A smaller incision is required in ECCE, and, as
such, less trauma to the corneal endothelium is
expected. Only the diameter of the nucleus must
be accommodated by the opening rather than the
diameter of the entire lens within its capsule.
- Short- and long-term complications of vitreous
adherence to the cornea, iris, and incision are
minimized or eliminated.
- A better anatomical placement of the IOL is
achieved with an intact posterior capsule.
- Etc (look up notes).
Surgery :
Phacoemulsification
Involves extraction of the lens nucleus through an
opening in the anterior capsule; an ultrasonically
driven needle is used to fragment the nucleus of
the cataract; the lens substrate is then aspirated
through a needle port via a small limbal or scleral
incision in a process termed phacoemulsification.

Standard ECCE and phacoemulsification are similar

in that extraction of the lens nucleus is performed
through an opening in the anterior capsule or
anterior capsulotomy. Both techniques also
require mechanisms to irrigate and aspirate fluid
and cortical material during surgery. Finally, both
procedures place the IOL within the capsular bag,
which is far more anatomically correct than
the anteriorly placed IOL.
Surgery : Intraocular
Lens (IOL) Implantation
Intraocular lens (IOL) implantation is
customarily used in combination with each of
these techniques (ICCE, ECCE, and
phacoemulsification), although ECCE and
phacoemulsification allow for more
advantageous anatomical placement of
the IOL than does ICCE.
Glaucoma
Glaucoma is currently defined as a characteristic progressive degeneration of the optic nerve, which
may also lead to specific visual field defects over time. This process can be slowed by adequate
lowering of intraocular pressure (IOP).
Nevertheless, some controversy still exists as to whether IOP should be included in the definition, as
some subsets of patients can exhibit the characteristic optic nerve damage and visual field defects
while having an IOP within the normal range.
Acute Angle-Closure Glaucoma
Angle closure is defined as the apposition of iris to
the trabecular meshwork, which results in
increased intraocular pressure (IOP).
In acute angle closure (AAC), the process occurs
suddenly with a dramatic onset of symptoms,
including blurred vision, red eye, pain, headache,
and nausea and vomiting.
The sudden and severe IOP elevation can quickly
damage the optic nerve, resulting in acute angle-
closure glaucoma (AACG).
Primary Open-Angle Glaucoma
Primary open-angle glaucoma (POAG) is glaucoma in the
presence of open anterior chamber angles. It manifests by
cupping of the optic disc, in the absence of other known
causes of glaucomatous disease.
POAG may develop in the absence of documented
elevated IOP. This condition has been termed normal-
tension or low-tension glaucoma.
POAG is a major worldwide health concern, because of its
usually silent, progressive nature, and because it is one of
the leading preventable causes of blindness in the world.
With appropriate screening and treatment, glaucoma
usually can be identified and its progress arrested before
significant effects on vision occur.
Primary Congenital Glaucoma
Primary congenital glaucoma is restricted to a
developmental abnormality that affects the
trabecular meshwork. This serves to distinguish it
from other childhood glaucomas associated with
other ocular and systemic congenital abnormalities,
as well as childhood glaucomas that may be
secondary to other ocular disorders, such as
inflammation, trauma, and tumors.

The classic triad of manifestations, any one of which

should arouse suspicion of glaucoma in an infant or
young child, includes epiphora, photophobia, and
blepharospasm.
Secondary Glaucoma

Secondary glaucoma is a broad category of problems

usually linked to another eye disease or disorder, like
a very mature cataract, inflammation inside your eye
(uveitis), bleeding, eye tumor, or a previous eye
injury.

In person with diabetes, extra blood vessels can form

inside the eye and block the outflow of fluid. This
severe form of the disease is called neovascular
In photo: Cataract, uveitis, and secondary acute glaucoma glaucoma.
Surgery : Peripheral
Iridotomy
Laser peripheral iridotomy (LPI) is the
preferred procedure for treating angle-
closure glaucoma caused by relative or
absolute pupillary block.
LPI eliminates pupillary block by allowing the
aqueous to pass directly from the posterior
chamber into the anterior chamber,
bypassing the pupil.

LPI can be performed with an argon laser,

with a neodymium:yttrium-aluminum-garnet
(Nd:YAG) laser, or, in certain circumstances,
with both.
Surgery : Peripheral
Iridectomy
A surgical procedure in which a hole is
made in the periphery (outer part) of the
iris by removing a full-thickness piece
from the iris in order to treat a specific
type of glaucoma called narrow-angle
glaucoma (or angle-closure glaucoma).
Surgical iridectomy is commonly indicated
and performed in the following cases:
- Cataract surgery in a glaucoma patient
- Combined procedure for cataract and
glaucoma
- Acute closed-angle glaucoma
- Posterior capsular tears with vitreous loss
- Implantation of anterior chamber IOL.
- Iris trauma
Surgery : Trabeculectomy
Trabeculectomy surgery usually is performed
after MTMT* and ALT* have failed to control
IOP adequately. If IOP is so high that ALT and
SLT are likely to be ineffective in reaching
target IOP, then proceeding from MTMT to
penetrating surgery may be indicated.
A superficial flap of sclera is dissected
anteriorly to the trabecular meshwork, and a
section of trabecular meshwork is removed
underneath the flap..
This alternate outflow pathway is created to
increase passage of aqueous from the
anterior chamber to the subconjunctival
space, creating a filtering bleb and, thereby,
lowering IOP.
*MTMT = Maximum Tolerated Medical Therapy (including
a beta-adrenergic antagonist, a prostaglandin agent, an
alpha-agonist, and a topical carbonic anhydrase inhibitor).
*ALT = Argon Laser Trabeculoplasty.
 Argon laser trabeculoplasty
Argon laser trabeculoplasty (ALT) uses a laser beam focused through a goniolens to treat at the border
Other Surgical between anterior and posterior trabecular meshwork. A full treatment consists of 100 spots placed over the
Cares entire 360 degrees of the trabecular meshwork.
Argon Laser Peripheral Iridoplasty
Argon laser peripheral iridoplasty (ALPI) is a laser surgical technique designed to reduce or eliminate
iridotrabecular contact when laser iridotomy fails to open an appositionally closed angle (ie, a nonpupillary
block mechanism) or when laser iridotomy is not possible.
Drainage implant (ie, seton/tube/shunt) surgery
A tube is placed in the anterior chamber to shunt aqueous to an equatorial reservoir, and then posteriorly
to be absorbed in the subconjunctival space.
Types of implants include Molteno, Baerveldt, Ahmed, and Krupin.
Ciliary body ablation
The ciliary body epithelium can be destroyed by cyclocryotherapy, diathermy, ultrasound, transscleral
Nd:YAG or diode laser (known as cyclophotocoagulation), or a newer endoscopic laser. By destroying a
portion of the nonpigmented ciliary epithelium, aqueous humor production is limited.
Deep sclerectomy/viscocanalostomy/with or without collagen implant
This is probably not as effective as trabeculectomy and is technically more difficult, but it is associated with
less complications.
360-degree suture canaloplasty
An alternative in infants.
Case 3:
Visual Pathway
VW
Visual Pathway
Retina  N. Opticus  Chiasma Optica  Tractus
Opticus  Corpus Geniculatum Lateral (CGL) 
Radiatio Optica / Radiatio Geniculocalcarina 
Cortex Visual Primer (Area Broadmann 17) 
Cortex Visual Sekunder dan Tertier.
Clinical Correlation:
Visual Defect
Clinical Correlation:
Visual Defect
Inervasi Simpatis dan
Parasimpatis
SIMPATIS  midriasis (dilatasi pupil)
Nucleus pre-ganglionik: ciliospinal center (berada di
cornu lateral medulla spinalis C8-T2)
Nucleus post-ganglionik: gg. Cervicalis superior
Efektor: m. dilator pupil

PARASIMPATIS  miosis (konstriksi pupil)

Nucleus pre-ganglionik: nucleus Edinger-Westhpal
Nucleus post-ganglionic: ganglion ciliaris
Efektor: m. sphincter pupil
 SIMPATIS  midriasis (dilatasi pupil)
Inervasi Simpatis Nucleus pre-ganglionik: ciliospinal center (berada di cornu lateral medulla spinalis C8-T2)
Nucleus post-ganglionik: gg. Cervicalis superior
Efektor: m. dilator pupil
Clinical Correlation:
Horner’s Syndrome
- Miosis
- Ptosis
- Enophthalmos
- Anhidrosis
- Vasodilatasi
- Iris Hypochromia
 PARASIMPATIS  miosis (konstriksi pupil)
Nucleus pre-ganglionik: nucleus Edinger-Westhpal
Inervasi Parasimpatis Nucleus post-ganglionic: ganglion ciliaris
Efektor: m. sphincter pupil
Clinical
Correlation:
Clinical Correlation:
Argyll Robertson Pupil

Argyll Robertson Pupil.

(A) Mata dalam keadaan normal.
(B) Pada keadaan terang tidak terjadi konstriksi pupil.
(C) Refleks melihat dekat bekerja dengan baik
Clinical Correlation:
Adie Tonic Pupil
Adie Tonic Pupil pada mata kanan.
(A)Pupil mata kanan berukuran lebih besar.
(B) Refleks cahaya tidak ada atau lamban
Pupillary Light Reflex
Aferen: n. optikus
Nucleus pre-ganglionik: nucleus Edinger-Westhpal
Nucleus post-ganglionic: ganglion ciliaris
Efektor: m. sphincter pupil

Reflex cahaya pupil direct: Penyinaran pada salah satu

mata  Miosis (konstriksi pupil) pupil ipsilateral
penyinaran.
Reflex cahaya pupil indirect / consensual: Penyinaran
pada salah satu mata  Miosis pupil kontralateral
penyinaran.
Clinical Correlation:
Pupillary Light Reflex
Lesi n.opticus kanan:
• reflex pupil direk kanan negatif
• reflex pupil indirek kanan positif
• reflex pupil direk kiri positif
• reflex pupil indirek kiri negatif

Lesi n.oculomotor kanan atau nucleus Edinger-

Westhpal kanan:
• reflex pupil direk kanan negatif
• reflex pupil indirek kanan negatif
• reflex pupil direk kiri positif
• reflex pupil indirek kiri positif
Section 4:
Eye Movements
AM
Extraocular
Muscles

Semua otot berorigo di annulus tendineus communis (annulus Zinn) dan berinsersio di sclera bulbus oculi
Movement of The Eyeball
Innervation of Extraocular Muscles

LR6(SO4)3
Lateral Rectus: N VI
Superior Oblique: N IV
Sisanya: N III
Innervation of Extraocular Muscles
CN III: Nervus Oculomotor
• Serabutnya terbagi dalam 3 divisi:
• Divisi superior: inervasi m. levator palpebrae superior & m. rectus
superior
• Divisi inferior: inervasi m. rectus medial, m. rectus inferior, dan m.
ibliquus inferior
• Serabut preganglionik parasimpatis: m. sphincter pupil & m. ciliaris

• Mempunyai 2 nucleus:
• Nucleus Edinger-Westphal (GVE)
• Nucleus Oculomotor (GSE) yang terbagi menjadi 5 subnucleus:
• Nuc. Dorsal: m. rectus inferior
• Nuc. Intermedia: m. obliquus inferior
• Nuc. Medial: m. rectus superior
• Nuc. Ventral: m. rectus medial
• Nuc. Caudal central: m. levator palpebrae superior
N IV:
Nervus Trochlearis
• Nucleus N IV terletak di bagian caudal mesencephalon
tepatnya di ventral periaqueductal gray matter setinggi
colliculus inferior
• Fasciculus N IV akan menyilang sebelum keluar dari
dorsal mesencephalon
• N IV merupakan satu-satunya nervus cranialis yang keluar
dari bagian dorsal brainstem
N VI: Nervus Abducens
N. Abduces merupakan nervus cranialis yang memiliki
perjalanan terpanjang di dalam spatium subarachnoid
Vascularization of the
Extraocular Muscles
• Artery: vascularized dominantly by r.
muscularis a. ophthalmica

• Vein: v. ophthalmica superior et inferior 

sinus cavernosus.
Eye Movement
Characteristics
Supranuclear
Gaze Control
• Kontrol supranuclear berasal
dari brainstem, cerebellum, dan
cerebrum (terletak lebih atas
dari nucleus N III, IV,dan VI)
yang mempengaruhi output
final dari nucleus N III, IV, dan
VI
• Control Supranuclear
menghasilkan beberapa
gerakan yakni:
• Horizontal Eye Movement
• Vertical Eye Movement
• Vergence Eye Movement
Gaze Control
Center
Horizontal gaze  paramedian pontine reticular
formation (PPRF) ipsilateral to the gaze direction

Vertical gaze  rostral interstitial Medial

Longitudinal Fasciculus (riMLF)

Static tone of horizontal gaze  nuc. Perpositus

hypoglossi

Static tone of vertical gaze  nuc. Interstitial of

Cajal
Horizontal Eye Movement
Section 4:
Clinical Correlation
AM
Strabismus: Phoria X Tropia
Esotropia
• Accomodative
• Non accomodative
• Early Onset/ Congenital
Accommodative
Esotropia
• Most common forms of strabismus
• Strabismus caused by focusing efforts of the eyes as they try to
see clearly
• Refractive esotropia typically are farsighted
Non Accommodative
Esotropia
• If there’s no change of angle of strabismus (esotropia) with glasses, the strabismus is called as
nonaccommodative esotropia.
• Early-onset type: Up to the age of 4 months, infrequent episodes of convergence are normal
but thereafter ocular misalignment is abnormal. Early onset esotropia is an idiopathic
esotropia developing within the first 6 months of life in infants without significant refractive
error or no limitation of ocular movement.
• Others: near esotropia, distance esotropia, acute esotropia, secondary esotropia, consecutive
esotropia, cyclic esotropia, high myopic esotropia.
Exotropia
• Intermittent exotropia noncommitant:
besar sudut penyimpangan berbeda-beda
pada arah pandang yang berbeda-beda.

• Constant exotropia: besar sudut

penyimpangan sama besarnya pada semua
arah pandangan.
Convergence
Insufficiency
• Tidak cukup konvergensi saat melihat
dekat
• Gejala umum: asthenopia, headache,
diplopia, mudah lelah saat membaca dekat
Convergence Paralysis
• Convergence paralysis: In this condition the patient is able to adduct the eyes (monocularly) but
cannot converge (simultaneous adduction) them, thus manifesting symptoms of constant diplopia
at near. Mornal accommodation and pupillary reflexes are present as the patient attempts to
converge.
• This condition usually results from significant closed head trauma, but it also can result from a
lesion in the midbrain, toxic encephalopathy, or encephalitis. It may or may not be associated with
accommodative insufficiency.
Hypertropia
Kondisi yang disebabkan oleh adanya
kelemahan m. rectus inferior (termasuk N IV
palsy) maupun lesi di vertical gaze center
(rostral interstitial Medial Longitudinal
Fasciculus) akibat trauma maupun
penekanan.
External Opthalmoplegia
Merupakan lesi pada otot-otot extraocular
Thyroid Eye
Disease
• Thyroid Eye Disease also known as Graves’
ophthalmopathy. Often associated with
Graves hyperthyroidism.
• Signs: soft tissue swelling and erythema,
eyelid retraction, lid lag, Von Graefe’s sign,
chemosis, exposure keratopathy, proptosis,
optic nerve swelling, choroidal folds,
restrictive myopathy.
• Symptoms: pain, photophobia, lacrimation,
foreign body sensation, diplopia
Section 4:
Eye Movements
PT
 VOR Vestibulo-Ocular Reflex
(VOR)
The vestibulo-ocular reflex (VOR) is a gaze
stabilizing reflex - gaze can be held on an
Rotational Translational object of interest during movements of the
head.

e.g. the ability to fixate our gaze on a dot while

moving our head

Gampangnya  focus ke suatu titik terus kita

Horizontal Vertical Torsional noleh noleh, mata kita tetap terfiksasi padahal
kepala kita gerak
Horizontal VOR
Input :
Canalis semicircularis horizontal → C. N VIII
Center :
Nucl. Vestibularis Medialis
Output :
1. Contralateral Nucl. VI → C. N VI
2. Contralateral Nucl. VI → MLF (named based on targeted nucl. Oculomotor) → nucl. Oculomotor → C. N III

Gampangnya  saat kita ngeliat dua titik
berbeda, mata kita gerak cepat focus dari satu
titik ke titik lainnya.
Saccadic Eye Movement
Saccade is quick movements made by the eye, characterized
by a sudden change from point to point.
Mechanism :
Center : Frontal Eye Field and Superior Colliculus
(Supranuclear structure )
Output : PPRF contra →
1. Nucl. VI → C. N VI
2. Nucl. VI → MLF (named based on targeted nucl.
Oculomotor) → nucl. Oculomotor → C. N III
Smooth Pursuit System
Smooth pursuit movements are much slower movements
of the eyes in order to follow a moving object.
• Smooth pursuit is a conjugate eye movement in
which the two eyes move in the same direction.

Gampangnya  kalau kita ngeliat orang lagi jalan,

mata kita gerak dengan perlahan mengikuti orangnya
Vergence movements
Vergence movements are disconjugate eye movement
which includes either a convergence or divergence.
• Changes in the angle between the eyes to focus on
objects located at different distances from the
observer
• Convergence movement is included in Near Reflex
Triad (reflex to gaze near objects)
1. Convergence  agar bayangan benda jatuh tepat
pada fovea
2. Accommodation of the lens  kerja lensa untuk
memfokuskan bayangan
3. Pupillary constriction  sharpens the image on
the retina Gampangnya  ketika kita lihat bolpen yang
ditempatkan didepan muka lalu kita jauh dekatkan.
Optokinetic Nystagmus (OKN)
In Optokinetic nystagmus, the eyes initially rotate to follow the
moving objects, but beyond a certain point the eyes return to
the primary position.
• combination of smooth pursuit (slow phase) and saccadic
movement (fast phase)

Gampangnya  ketika kita naik mobil sambil melihat keluar

jendela, melihat pohon pohon pass by, mata kita melakukan
smooth pursuit dan saccade secara spontan
Section 4:
Clinical Correlation
PT
Brainstem Lesions : Horizontal Gaze
Abnormalities
Saccadic Dysfunction
• Abnormal latency to initiate eye movements  unable to
initiate saccades or initiated only after a prolonged period.
• Abnormal speed of eye movements (generally slow).
• Abnormal accuracy of eye movements (hypometria or
hypermetria).
Diplopia
• Dysconjugate gaze causes diplopia
• Red glass test
 A red glass is placed in front of one eye( right eye)
 Patient fixates a light source and states whether the red light is to the right, left, above or below the white light
 Normally, white and red images are fused in all positions of gazeC
Occulomotor Nerve Palsy
A complete oculomotor nerve palsy is
easily recognised by a combination of
ptosis, a fixed dilated pupil, and the
affected eye in a “down and out”
position
• Diagonal diplopia, diperberat ketika
melihat ke atas dan medial
Trochlear Nerve Palsy
• Vertical diplopia
• Hipertropia
• Ekstorsi mata
Abducens Nerve Palsy • Abducens nerve palsy, which results in a lateral
rectus muscle paresis and therefore horizontal
diplopia
Cavernous Sinus Syndrome
Nystagmus
Nystagmus is an involuntary, shaking, movement of the eyes.

Early-Onset (Childhood) Nystagmus  any form of nystagmus that presents within the first few months of life, unless precipitated by
a condition causing acquired nystagmus within that time. The three most common forms are
• Latent nystagmus - a form of nystagmus that either only appears when one eye is occluded (latent-latent nystagmus) or worsens
upon occlusion of one eye (manifest-latent nystagmus). E.g. covering the right eye will lead to jerk nystagmus, with both eyes
jerking to the left
• Spasmus nutans - a rare disorder, causing (in combination): a high frequency, low amplitude nystagmus of a disconjugate nature;
irregular head nodding; an abnormal head posture.
• Infantile nystagmus - a constant nystagmus, usually predominantly in the horizontal axis, of similar amplitude in each eye, and at
an average frequency of 2-3 Hz.

Gaze evoked nystagmus  develops because of an inability to maintain fixation in eccentric gaze, caused by dysfunction of the neural
integrator
– For horizontal gaze, the neural integrator includes the nucleus prepositus hypoglossi and the medial vestibular nuclei.
– For vertical gaze, the interstitial nucleus of Cajal serves as the neural integrator. The flocculus and nodulus of the cerebellum also
play a role in maintaining an eccentric position of gaze.

Vestibular nystagmus  the most common type of nystagmus, is caused by dysfunction of the vestibular part of the inner ear, the
nerve, the vestibular nucleus within the brainstem, or parts of the cerebellum that transmit signals to the vestibular nucleus.
Section 5:
Olfactory Organ
SA
Nasus Externus
• Radix nasi
• Dorsum nasi
• Apex nasi
• Nares / aperture nasalis anterior /
nostril
• Septum nasi
• Ala nasi

Skeleton nasi:
Bony part:
• Os. Nasale
• Proc. frontalis os. maxillaris
• Proc. nasalis os. Frontalis
• Spina nasalis

Cartilaginous part:
• 2 cartilago nasi lateralis
• 2 cartilago alaris major : crus lateral et
medial
• 1 cartilago septi nasi
Cavitas Nasi
• Nares  Choana (aperture nasalis
posterior)
• 2 bagian:
- Vestibulum nasi (kulit)  ada
vibrissae
- Cavitas nasi propria (mucosa) 
regio olfaktoria (1/3 superior) +
regio respiratoria (2/3 inferior)

• Batas Cavitas nasi:

- Atap : frontonasalis, os. Ethmoidalis,
os. Sphenoidalis
- Dasar : Palatum durum (proc.
Palatinus maxillaris + lamina
horizontalis os. Palatina)
- Medial : Septum nasi
- Lateral : Concha nasalis (superior,
media, inferior)
 Lamina perpendicularis os. Ethmoidalis

Septum Nasi Os vomer

Cartilago septi nasi

Cartilago alaris major crus mediale

 1. A. ethmoidalis anterior Nasus externa :
2. A. ethmoidalis posterior 1. A. ethmoidalis anterior
Vaskularisasi 3. A. sphenopalatine 2. R. septalis a. labialis superior
4. A. palatina major
5. R. septalis a. labialis superior

Anastomosis pada septum nasi pars anterior

 Plexus Kiesselbach
Sinus Paranasales
1. Sinus Frontalis
• Drainase
Ductus Fronstonasalis  infundibulum
ethmoidalis  hiatus semilunaris  meatus
nasi media
• Vaskularisasi: A. ethmoidalis anterior
• Inervasi: N. supraorbitalis (cabang CN V1)

2. Sinus ethmoidalis
• Drainase:
1. Cellulae ethmoidalis anterior  meatus
nasi media melalui infundibulum
ethmoidalis
2. Cellulae ethmoidales media  meatus
nasi media, membentuk bulla ethmoidalis
3. Cellulae ethmoidales posterior 
meatus nasi superior
• Vaskularisasi: A. ethmoidalis anterior et
posterior
• Inervasi: N. ethmoidalis anterior et posterior
(cabang dari N. nasociliaris / CN V1) + N.
maxillaris via orbital branch
Sinus Paranasales
3. Sinus Sphenoidalis
• Drainase: Recessus sphenoethmoidalis

• Vaskularisasi: A. ethmoidalis posterior

• Inervasi: N. ethmoidalis posterior + N.

maxillaris via orbital branch

4. Sinus Maxillaris (Antrum of Highmore)

• Drainase: ostium maxillaris  meatus nasi
media (hiatus semilunaris)

• Vaskularisasi: A. alveolaris superior (cabang

A.maxillaris), A. palatina major, A.
infraorbitalis

• Inervasi: N. alveolaris superior (anterior,

media, posterior) + N.infraorbitalis
*Vasa lymphatica keempat sinus bermuara
ke Lnn. Cervicalis Profundi
Section 5:
Clinical Correlation
SA
Epistaxis anterior
Sumber perdarahan pada septum nasi bagian
anterior, tepat di ujung posterosuperior dari
vestibulum nasi  Plexus Kiesselbach
Perdarahan bisa juga bersumber dari bagian
depan concha inferior
Sering terjadi pada anak-anak dan biasanya
dapat berhenti sendiri
Tx: Trotter method (kompres es dan menekan
cuping hidung, tampon anterior, kauterisasi
AgNO3
Epistaxis posterior
 Bersumber dari a. sphenopalatine + a.
ethmoidalis posterior = Plexus Woodruff
 Perdarahan hebat dan jarang berhenti spontan 
bisa menyebabkan anemia, hypovolemia, dan
syok.
 Sering ditemukan pada pasien penyakit
kardiovaskular seperti hipertensi dan
arteriosclerosis.
 Tx: Tampon posterior (Tampon Bellocq), kateter
Folley, kauterisasi, ligasi a.maxillaris
CT SCAN - CSF rhinorrhea karena fraktur ethmoid plate
CSF Rhinorrhea
Mengalirnya CSF ke hidung karena
robekan pada meninges  bisa menjadi
pertanda fraktur basis kranii

Causa :
- Trauma = trauma kepala tumpul / tajam
- Iatrogenic = surgery
- Idiopathic / spontan = peningkatan
tekanan intrakranial

Lokasi kebocoran CSF:

- Fossa cranii anteirior
 Lateral lamella of cribiform plate
 Posterior frontal sinus
 Roof of ethmoid sinus

- Fossa cranii media

 Sinus sphenoid

Bisa menyebabkan meningitis dan

pneumocephalus

*Boo hayolo kaget

CSF produced by choroid plexus at lateral ventricles 
3rd ventricle  4th ventricle  subarachnoid space
(through foramen Luschka and Magendie) absorbed by
arachnoid villi

CT SCAN - CSF
rhinorrhea  akumulasi
pada sinus maxillaris
dextra, ethmoid cellulae
dan cavitas nasi
 Fraktur tulang nasal terjadi karena
trauma direk.
Nasal Fracture
Mengakibatkan deformitas hidung
dan diikuti dengan epistaxis
Bisa juga menyebabkan deviasi
hidung atau fraktur pada lamina
cribrosa os ethmoid.
Tx: surgical procedure of open
reduction and/or fixation
 Deviasi ke kiri Setelah Septoplasty

Deviasi septum nasi  jalan napas Menyebabkan:

lubang hidung sebelah semakin kecil - Menurunnya aliran udara
Deviation of Nasal - Obstruksi jalan napas jika deviasi
Septum Causa: Birth injury, trauma hingga dinding lateral hidung
- Memperberat dengkuran

Tx severe deviation : Septoplasty,

rhinoplasty
Section 5:
Olfactory Pathway
SA
Olfactory Pathway
Olfactory Pathway

Brodmann 34
 LATERAL CAVITAS NASI MEDIAL CAVITAS NASI

Anterosuperior Anterosuperior:
Inervasi  N. ethmoidalis anterior et posterior (CN V1)  N. ethmoidalis anterior et posterior (CN V1)

Posteroinferior: Posteroinferior:
 n. palatina major N. nasopalatine (CN V2)
 r. Nasale n. Alveolaris ante et poste, r. Internal n. r. internal n. infraorbitalis
Infraorbital, gg. Palatina (N. V2)
Section 5:
Clinical Correlation
SA
Nasal Cavity Infection
Spreading of infection

Infeksi pada cavitas nasi (e.g. rhinosinusitis)

atau pada bagian nasolabial (e.g. acne)
dapat menyebar infeksinya melalui sinus
cavernosus.

Cavitas nasi :
Plexus venosus submucosa  V.
ophtalmica, V. sphenopalatine, V. Facialis

Nasus externus venous drainage

 V. Facialis

Nasolabial triangle / Danger area of the

face Rute penyebaran infeksi:
V. Facialis  V. ophtalmica superior et 1. Ekstensi langsung
inferior  sinus cavernosus thrombophlebitis, sinus
thrombosis, atau erosi tulang
2. Ekstensi karena anatomis,
trauma, atau defek pasca
operasi
 1. Komplikasi Orbital (biasanya dari acute
ethmoid sinusitis)  periorbital
Komplikasi cellulitis, orbital cellulitis, orbital
rhinosinusitis abscess, subperiosteal abscess,
cavernous sinus thrombosis
2. Mucocele
3. Otitis Media
4. Pott’s Puffy Tumor (osteomyelitis os
frontal karena abses subperiosteal)
5. Komplikasi Intrakranial : Abscess
cerebri, abscess subdural, abscess
epidural

Cerebral abscess karena sinusitis

 Sinus maxillaris yang paling sering
terinfeksi dikarenakan ostiumnya yang
Sinusitis (sinus kecil dan terletak tinggi superomedial.
infection) Sehingga, pada saat terobstruksi akibat
kongesti dari membran mukosa, maka
tidak akan terjadi drainase cairan dari
sinus maxillaris ke cavitas nasal.
Sehingga sinus terisi penuh cairan.
Pemeriksaan fisik yang bisa dilakukan
adalah dengan palpasi dan
transiluminasi sinus.
Inervasi sinus maxillaris = inervasi
gigi molar maxilla = n. alveolaris
superior (cabang CN V2)
Maka:
1. Ketika sinusitis maxilla  gigi
molar maxilla terasa ikut nyeri
2. Infeksi odontogenic pada molar
 bisa menyebar infeksinya ke
sinus maxillaris

Treatmentnya adalah dengan miring ke

arah kontralateral terhadap sinus yang
terinfeksi atau bisa dilakukan kanulasi
melalui ostium sinus maxillaris
Transiluminasi
Sinus
Dilakukan pada ruangan tertutup dan gelap

 Transiluminasi Sinus Frontalis

Jika sinus terdapat kelebihan cairan
atau ada massa atau ada penebalan
mukosa, maka cahayanya akan
berkurang

 Transiluminasi sinus Maxillaris

Nasal Polyp
Dan komplikasinya

Nasal polyp :
Protrusi lokal mucosa nasal atau mucosa
sinus paranasal kareana hipertrofi
glandula mucosa atau edema stroma

Gejala:
-rhinorrhea
-obstruksi jalan nafas
-epistaxis
-anosmia
-postnasal drip

Complication:
- Obstructive sleep apnea
- Asthma flare-ups  karena polyp ada
asosiasi dengan alergi
- Sinus infections  pasien menjadi rentan
terkena sinusitis yang kronis atau rekuren
Gangguan Penghidu (Olfactory disturbance)

Quantitative Qualitative
a.k.a. Dysosmia
1. Anosmia 1. Parosmia
Kehilangan total kemampuan penghidu Mispersepsi penghidu (olfactory illusion)

2. Hyposmia 2. Phantosmia
Kehilangan sebagian kemampuan Persepsi penghidu padahal tidak ada
penghidu bau/aroma (olfactory hallucination)

3. Hyperosmia 3. Cacosmia
Penghidu lebih peka / menyengat dari Persepsi penghidu akan bau busuk padahal
biasanya tidak ada bau/aroma
 Gangguan Penghidu (Olfactory disturbance)
Higher-order loss of olfactory
Olfactory hallucinations and
discrimination (olfactory agnosia)
delusions
• Ditandai dengan Phantosmia AGNOSIA OLFACTORY

• Jika pasien meyakini adanya halusinasi dan Ketidakmampuan untuk mengenali apa
memberi pendapat pribadinya, simptom ini
mengindikasi adanya delusi
yang dihidu, dengan kemampuan
penghidu yang intak
• Adanya gangguan pada grup nucleus Amygdaloid
 halusinasi Terjadi kerusakan di bilateral cortex
• Contohnya pada Delusional type of Olfactory
asosiasi olfactory.
Reference Syndrome