supranuclear
Supranuclear describes the eye movement control centers that sit above the third, fourth and sixth nerve nuclei in a hierarchy of control.1 The supranuclear centers lie in the cortex and brainstem and direct the actions of the ocular motor nerves.1 For horizontal saccades, the frontal eye fields act through the paramedian pontine reticular formation (PPRF), which excites the sixth nerve nucleus. Vertical saccades start in the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) in the midbrain.1
A supranuclear disorder damages the structures that start, tune or calibrate eye movements, while the nuclei, fascicles and nerves are spared. The eyes usually stay aligned, and the deficit shows as limited, slow or misdirected conjugate gaze with third, fourth and sixth nerve function and the vestibulo-ocular reflex (VOR) intact.2
Complete loss of saccades produces a conjugate gaze palsy.2 Defective pursuit lets the eyes fall behind a moving target, and catch-up saccades then keep the foveae on target, a pattern called saccadic pursuit.2 The VOR can prove that a pursuit or saccadic deficit is supranuclear, because the semicircular canals connect directly to the ocular motor nuclei and enlarge the eye excursions.2
More detail
Horizontal supranuclear gaze disorders tend to localize to the cerebral cortex or pons, and vertical gaze disorders usually localize to the midbrain.2
Sources (8)
- Liu, Volpe and Galetta, Neuro-Ophthalmology: Diagnosis and Management, ch. 15
- Liu, Volpe and Galetta, Neuro-Ophthalmology: Diagnosis and Management, ch. 16
- American Academy of Ophthalmology. 2020. Neuro-Ophthalmology/Orbit: Basic and Clinical Science Course. San Francisco: American Academy of Ophthalmology.
- Brodsky, M.C., Donahue, S.P., Vaphiades, M. and Brandt, T. 2006. Skew deviation revisited. Survey of Ophthalmology, 51(2), pp.105-128.
- Leigh, R.J. and Zee, D.S. 2015. The neurology of eye movements. 5th ed. New York: Oxford University Press.
- Rutstein, R. and Daum, K. 1997. Anomalies of Binocular Vision: Diagnosis & Management. St. Louis: Mosby.
- Rucker, J.C. 2005. Normal and abnormal saccadic eye movements. Neurologic Clinics, 23(4), pp.1123-1147.
- Wong, A.M. 2004. Eye movement disorders. New York: Oxford University Press.
Reviewed October 2026