CILIARY GANGLION. MUK.pptx

The ciliary ganglion is one of four parasympathetic ganglia of the head and neck. It receives preganglionic parasympathetic fibers from the EWN via the CN III.
It supplies the eye via short ciliary nerves not only with parasympathetic fibers, but also with sensory and sympathetic fibers that pass through the ganglion. 

Gross anatomy
Shape: Flat/lenticular
Size: 2 mm*1mm (smallest)
Location: posterolaterally in the intra-conal space of the orbit between the optic nerve and the LR muscle. 10 mm from Zinn, 15-20 mm from posterior pole
It is just lateral to the ophthalmic artery as it crosses the optic nerve  from lateral to medial
Sympathetic root
from the ICA (from the superior cervical ganglion) via the nasociliary nerve, a branch of the trigeminal nerve
fibers pass through the ganglion without synapsing.

Roots
Parasympathetic root (motor)
from the Edinger-Westphal nucleus of the CN III via the inferior division; nerve to the IO muscle.
fibers synapse in the ganglion
Roots
Parasympathetic root (motor)
from the Edinger-Westphal nucleus of the CN III via the inferior division; nerve to the IO muscle.
fibers synapse in the ganglion
Sensory root 
via the small communicating branch of the ciliary ganglion (from CN V1)
fibers pass through the ganglion without synapsing

1. CILIARY GANGLION PRESENTER: DR. MLALUKO, MD MODERATOR: DR. NTENDE JACOB (CONSULTANT OPHTHALMOLOGIST-MULAGO NRH) 11/23/2023 Mlaluko MD 1

2. Outlines Introduction Embryology and Anatomy Clinical importances 11/23/2023 Mlaluko MD 2

3. Introduction The  ciliary ganglion  is one of four  parasympathetic ganglia of the head and neck. It receives preganglionic parasympathetic fibers from the  EWN via the  CN III. It supplies the eye via short ciliary nerves not only with parasympathetic fibers, but also with sensory and sympathetic fibers that pass through the ganglion.  11/23/2023 Mlaluko MD 3

4. Embryology Neural crest cells arising from both the caudal half of the midbrain and the rostral hindbrain contribute to the ciliary as well as the trigeminal ganglion . 6-7 weeks Precursors to both ganglia have overlapping migration patterns; moving first ventrolaterally and then rostrally toward the optic vesicle. At the level of the midbrain/forebrain junction, precursors to the ciliary ganglion separate from the main migratory stream, turn ventromedially , and condense in the vicinity of the rostral aorta and Rathke's pouch. 11/23/2023 Mlaluko MD 4

5. Anatomy Gross anatomy Shape: Flat/lenticular Size : 2 mm*1mm (smallest) Location : posterolaterally in the intra- conal space of the orbit between the optic nerve and the LR muscle. 10 mm from Zinn , 15-20 mm from posterior pole It is just lateral to the ophthalmic artery as it crosses the optic nerve  from lateral to medial 11/23/2023 Mlaluko MD 5

6. Cont… 11/23/2023 Mlaluko MD 6

7. Cont… Roots Parasympathetic root (motor) from the  Edinger-Westphal nucleus of the  CN III via the inferior division; nerve to the IO muscle. fibers synapse in the ganglion 11/23/2023 Mlaluko MD 7

8. Cont… S ympathetic root from the ICA (from the superior cervical ganglion) via the nasociliary nerve, a branch of the trigeminal nerve fibers pass through the ganglion without synapsing S ensory root  via the  small communicating branch of the ciliary ganglion  (from the nasociliary nerve, a branch of the trigeminal nerve) fibers pass through the ganglion without synapsing 11/23/2023 Mlaluko MD 8

9. Cont… Branches Short ciliary nerve 12 or more branches, termed  Each contains elements from all 3 roots , and pierce the back of the sclera around the attachment of the optic nerve to supply the globe. 11/23/2023 Mlaluko MD 9

10. Cont… B oth long ciliary nerves (branches of the nasociliary nerve) and short ciliary nerves contain sensory/sympathetic supply to the cornea, iris, and ciliary body. O nly the short ciliary nerves are involved in pupillary constriction and accommodation. Fibers for accommodation are 30 times than that for pupillary constriction. 11/23/2023 Mlaluko MD 10

11. Cont… 11/23/2023 Mlaluko MD 11

12. Cont… 11/23/2023 Mlaluko MD 12

13. Blood supply and drainage Arterial supply Posterior lateral ciliary artery Trunk of lateral muscular artery Branches of central retinal artery Special branch from ophthalmic artery Vascular network of optic nerve head 11/23/2023 Mlaluko MD 13

14. Cont… The branches PLCA supply blood to the anterior half, running backwards and frequently bifurcating into two branches, one each for its medial and lateral surface. The branches originating from the muscular trunk most frequently enter the ganglion on its lateral aspect , while those of the central artery of the retina enter more often on its medial aspect . 11/23/2023 Mlaluko MD 14

15. Cont… 11/23/2023 Mlaluko MD 15

16. Cont… Venous drainage Two to four veins leave the ciliary ganglion  muscular branches LR and IR , venous network in the coats of the optic nerve , and central retinal vein  inferior ophthalmic vein. 11/23/2023 Mlaluko MD 16

17. Clinical importance Pupillary and accommodation reflex Adie tonic pupil 11/23/2023 Mlaluko MD 17

18. Cont.. Adie’s tonic pupil Idiopathic, sudden onset de-innervation of CM and PS. R einnervation ( aberrant); fibers intended for the ciliary body may end up targeted to the pupil and upregulation of the postsynaptic receptors occurs, a process known as denervation supersensitivity . P atients develop Light-Near dissociation of the pupil by which the near accommodation produces more miosis compared to response to light, the reaction which is tonic. 11/23/2023 Mlaluko MD 18

19. Cont… The tonic reaction is the result of the iris sphincter supersensitivity to acetylcholine . Roughly 80% of cases are unilateral but can become bilateral. Most cases of the tonic pupil are idiopathic and referred to as the Adie tonic pupil. 11/23/2023 Mlaluko MD 19

20. Cont… However, a tonic pupil can also be caused by viral infection, trauma, vasospasm due to migraine, orbital surgery , retrobulbar alcohol , RD surgery, IO muscle surgery , transconjunctival cryotherapy and tumors , among other potential causes. The ciliary ganglion can also be affected in other systemic autonomic or peripheral neuropathies to result in the tonic pupil such as  Ross syndrome and Harlequin syndrome. 11/23/2023 Mlaluko MD 20

21. Cont… Diagnosis Slit lamp examination of the pupil often shows sectoral palsy of the iris sphincter, with vermiform movements of the pupillary margin. To correctly form a diagnosis, it is important to examine the degree of anisocoria in the light and in the dark and to examine the pupillary reaction to light and to accommodation. 11/23/2023 Mlaluko MD 21

22. Cont… Examination reveals anisocoria greater in the light compared to in the dark indicating dysfunction of the parasympathetic fibers. Adie tonic pupil will demonstrate increased pupillary constriction to accommodation compared to light, also known as the light-near dissociation. Pupil re-dilate slowly in dark 11/23/2023 Mlaluko MD 22

23. Cont… Diagnosis Dilute pilocarpine (0.125 or 0.1 percent) can be made by diluting readily available commercial 1% solution with sterile saline. After 30-60 minutes the affected pupil will constrict more than the normal pupil. This test, however, is not specific for the Adie tonic pupil where there is postganglionic parasympathetic denervation. 11/23/2023 Mlaluko MD 23

24. Cont… Adie’s tonic pupil: Rule out Orbital trauma Orbital tumor and choroidal tumors Intracranial hemorrhage/stroke with third nerve palsy Varicella- zoste (CN V1) Syphilis (Argyll Robertson pupil, generally bilateral, small, brisk redilation ) Diabetes Chronic alcoholism Multiple sclerosis Neurosarcoidosis GCA VHKS Migraine headache 11/23/2023 Mlaluko MD 24

25. References Wolf’s anatomy, 8 th edition AAO, 2022/23 UpToDate https://eyewiki.aao.org/Adie_Pupil https://www.uptodate.com/contents/tonic-pupil/print#:~:text=The%20tonic%20pupil%20is%20a,variety%20(Adie%20tonic%20pupil) . 11/23/2023 Mlaluko MD 25