Cranial Nerves Examination
Cranial Name Type Function
Nerve
I Olfactory Sensory Smell
II Optic Sensory Vision
III Oculomotor Motor (plus Eye movement, pupil constriction
PSNS)
IV Trochlear Motor Superior oblique muscle –
downward/inward eye movement
Cranial Nerve I – Olfactory Nerve
Function:
Special sensory: Smell (olfaction)
Anatomy Recap:
Receptors: Nasal olfactory epithelium
Fibers pass through cribriform plate of ethmoid bone
Synapse in olfactory bulb → olfactory tract → limbic system
Examination:
1. Ask about recent changes in smell (history)
2. Make sure patient close eyes before testing
3. Block one nostril at a time.
4. Present a non-irritating odor (coffee, vanilla, soap).
5. Ask patient to identify the smell.
6. Repeat on the other side.
❗ Avoid irritants like ammonia – they stimulate trigeminal nerve, not olfactory.
Clinical Relevance:
Anosmia: Loss of smell (early sign of COVID-19, head trauma, Parkinson’s, aging)
Unilateral anosmia: May suggest olfactory groove meningioma
Test smell only when indicated, but it's often skipped in routine practice unless
there's a concern.
Cranial Nerve II – Optic Nerve
Function:
Special sensory: Vision
Anatomy Recap:
Retina → optic nerve → optic chiasm → optic tract → lateral geniculate body →
visual cortex
Examination Components:
Visual Acuity (Snellen Chart & Jaeger Chart)
🔹 Purpose: Tests central vision (sharpness/clarity of vision) – important in
diagnosing refractive errors, optic nerve damage.
📍 Distance Visual Acuity – Snellen Chart
🔸 How to Perform:
1. Place patient 6 meters (20 feet) from the Snellen chart.
2. Have them cover one eye (without pressing it).
3. Ask them to read the smallest line they can see clearly.
4. Record result as a fraction:
o 6/6: Normal
o 6/18: Patient sees at 6 m what a normal person sees at 18 m
5. Repeat with the other eye.
6. Test with and without corrective glasses.
🔸 Documentation:
Record as: "Visual acuity RE: 6/6, LE: 6/9 with correction"
📍 Near Vision – Jaeger Chart
🔸 How to Perform:
1. Use a Jaeger chart held at 14 inches (35 cm).
2. Ask patient to read the smallest text possible.
3. Helps detect presbyopia or near vision problems.
Visual Fields by Confrontation
🔹 Purpose: Detects peripheral visual field defects (e.g., hemianopia, scotoma).
🔸 How to Perform:
1. Sit or stand at eye level, 1 meter apart.
2. Ask patient to cover their right eye; you cover your left eye (mirror them).
3. Ask the patient to look into your open eye.
4. Move your wriggling fingers from the periphery to the center in each quadrant
(superior, inferior, temporal, nasal).
5. Ask the patient to say when they see the fingers.
6. Repeat for the other eye.
❗ This is a screening test. For accurate mapping, refer for perimetry.
Pupillary Light Reflex (CN II – afferent; CN III –
efferent)
🔹 Purpose: Tests integrity of optic nerve (afferent) and oculomotor nerve
(efferent) pathways.
🔸 How to Perform:
1. Dim the room lights.
2. Ask patient to look at a distant object (prevents accommodation).
3. Shine a pen torch from the side into one eye.
o Observe direct response: the same pupil should constrict.
o Observe consensual response: the opposite pupil should also constrict.
4. Repeat for the other eye.
🔸 Interpretation:
No response = possible optic nerve damage (afferent defect).
Pupil does not constrict on same side = efferent defect (CN III).
Color Vision – Ishihara Plates
🔹 Purpose: Detects red-green color blindness and optic nerve disease.
🔸 How to Perform:
1. Use Ishihara color plates (must be in good natural light).
2. Hold the plate 75 cm from the patient at a right angle.
3. Ask the patient to identify numbers or lines hidden in the colored dots.
4. Test each eye separately.
5. Normal: Can correctly identify 12–14 plates.
🔸 Clinical Tip:
Early optic neuritis (e.g., in MS) may cause color desaturation before visual acuity
loss.
Red Desaturation Test
🔹 Purpose: Simple and sensitive test for early optic nerve dysfunction
(especially in optic neuritis).
🔸 How to Perform:
1. Show the patient a red object (pen cap or target).
2. Ask them to cover one eye and describe the color.
3. Then switch to the other eye.
4. Ask: "Does the red appear less vivid or washed out in either eye?"
🔸 Interpretation:
A duller red or orange tint on one side indicates optic nerve compromise.
Especially useful when visual acuity is normal, but patient complains of visual
symptoms.
Accommodation Reflex
It is a triad of responses that occur when a person shifts their focus from a distant object to
a near object:
🔷 The 3 Components of the Reflex:
1. Accommodation of the lens – lens becomes thicker to increase refractive power
2. Pupillary constriction – to increase depth of focus
3. Convergence of the eyes – medial recti contract to bring both eyes inward
Cranial Nerves Involved:
Step Nerve Involved
Visual stimulus input Optic nerve (CN II)
Lens and pupil control Oculomotor nerve (CN III)
Medial rectus contraction (convergence) CN III (motor to medial rectus)
How to Test the Accommodation Reflex:
1. Ask the patient to look at a distant object (e.g., a wall clock or far corner of the
room).
2. Then hold your finger or pen ~15 cm (6 inches) in front of their eyes.
3. Ask them to shift their gaze and focus on your finger.
4. Observe:
o Pupil constriction
o Convergence of both eyes
o (You can’t directly observe lens shape change, but the other two signs confirm
it)
Clinical:
It tests both visual pathways (CN II) and motor function (CN III).
Useful in diagnosing:
o Argyll Robertson pupil: Accommodation present, but no light reflex (seen in
neurosyphilis)
Parinaud’s syndrome: Pineal Push = Up Can’t Gush”
Pineal tumor
Pushes midbrain
Can’t look up
Pupils don’t react to light but do accommodate
o Early diabetic or compressive third nerve palsies
Cranial Nerve III – Oculomotor Nerve
Function:
Motor to 4 extraocular muscles: SR, MR, IR, IO
Also supplies levator palpebrae superioris (eyelid elevation)
Parasympathetic to sphincter pupillae and ciliary muscle
Examination:
1. Observe eyelids: Ptosis?
2. Check pupils:
o Size, symmetry, shape
o Light reflex (direct and consensual) – afferent CN II, efferent CN III
o Near response (accommodation)
3. Eye movements (test with H-pattern):
o Ask the patient to follow your finger without moving their head.
o Look for restriction or diplopia.
Clinical Relevance:
Third nerve palsy:
o Ptosis
o Dilated pupil (if parasympathetic fibers affected)
o "Down and out" eye position
Common causes: Posterior communicating artery aneurysm, diabetes, head
trauma
Cranial Nerve IV – Trochlear Nerve
Function:
Motor to superior oblique muscle → depresses and intorts the eye (especially in
adduction)
Anatomy Recap:
Only cranial nerve to emerge dorsally from the brainstem
Longest intracranial course – prone to trauma
Examination:
Ask the patient to look inward and downward (e.g., down and toward the nose)
Look for:
o Diplopia on downward gaze (e.g., reading, walking downstairs)
o Head tilt to opposite side (compensatory)
Clinical Relevance:
Trochlear nerve palsy:
o Vertical diplopia
o Difficulty descending stairs
o Common in head trauma, congenital, or diabetes
Documentation Format (SOAP Style):
CN I: Intact / anosmia / decreased sense of smell (R/L)
CN II: Visual acuity 6/6 bilaterally, fields full to confrontation, optic disc normal
CN EOMI (extraocular movements intact), pupils equal and reactive to light and
III: accommodation
CN Intact / vertical diplopia / impaired downward gaze in adduction
IV:
