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)
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2. Outlines
• Introduction
• Embryology and Anatomy
• Clinical importances
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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.
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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.
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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
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6. Cont…
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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
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8. Cont…
• 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
• Sensory 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
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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.
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10. Cont…
• Both long ciliary nerves (branches of
the nasociliary nerve) and short ciliary nerves
contain sensory/sympathetic supply to the
cornea, iris, and ciliary body.
• Only the short ciliary nerves are involved in
pupillary constriction and accommodation.
• Fibers for accommodation are 30 times than
that for pupillary constriction.
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11. Cont…
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12. Cont…
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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
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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.
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15. Cont…
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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.
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17. Clinical importance
• Pupillary and accommodation reflex
• Adie tonic pupil
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18. Cont..
Adie’s tonic pupil
• Idiopathic, sudden onset de-innervation of CM
and PS.
• Reinnervation (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. Patients 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.
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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.
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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.
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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.
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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
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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.
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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
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25. References
• Wolf’s anatomy, 8th edition
• AAO, 2022/23
• UpToDate
• https://eyewiki.aao.org/Adie_Pupil
• https://www.uptodate.com/contents/tonic-
pupil/print#:~:text=The%20tonic%20pupil%20
is%20a,variety%20(Adie%20tonic%20pupil).
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