Ocular Motility

Dr. Tracy Crnic

Panhandle Eye Group and Texas Tech
Department of Ophthalmology
Pediatric Ophthalmology and Adult
Strabismus

Basics
Primary Position
Eyes pointed straight ahead
Tonic muscle action and orbital contents hold in place
Without tonic action resting place of the eye is
divergent

Duction movement of one eye irrespective of

the other
Supraduction, infraduction, adduction, abduction,
incycloduction, excycloduction (in or extorsion)

Versions movements of eyes together

Movement of Eye
Six Extraocular Muscles
Superior, Inferior, Medial and Lateral Recti
Superior and Inferior Obliques

Primary, Secondary, and Tertiary functions

Movement from Contraction of one or
more muscles with coincident relaxation of
others

Origin of Muscles
Important for function of muscle where
contraction of muscle pulls toward
Annulus of Zinn

Muscular circle behind globe

All recti muscles (sup, inf, med, lat)
About where bony orbit begins

Just above this at orbital apex is superior

oblique origin
Orbital floor near nose is inferior oblique origin

Insertion of Muscle on Eye

Spiral of Tillaux musc create a spiral around
corneal edge

Medial Rectus 5.5 mm from limbus

Inferior Rectus 6.5 mm
Lateral Rectus 7.0 mm
Superior Rectus 8.0 mm

Superior Oblique spread out under Superior

Rectus (first bending through troclea)
Inferior Oblique close to the macula (back of
eye)

Angle of Insertion
Horizontal Rectus muscles - medial and lateral
insert parallel to each other in a horseshoe
shape
Vertical Rectus muscles superior and inferior
insert 23 degrees temporal to the visual axis
Oblique muscles insert 50 degrees nasal to
visual axis
Allows for primary, secondary and tertiary
actions

Laws of Motion
Sherringtons Law
One muscle (agonist) contracts as another
muscle on the same eye relaxes

Herings Law you cant move one eye at

a time
Each eye muscle has a yoke muscle in the
other eye that contracts at the same time so
both eyes move the same direction with the
same force
Exception convergence and divergence

Neural Input
Cranial Nerve 3 (Oculomotor Nerve)

Superior Rectus
Medial Rectus
Inferior Rectus
Inferior Oblique
Pupil and Eyelid

Cranial Nerve 4 (Troclear Nerve)

Superior Oblique

Cranial Nerve 6 (Abducens Nerve)

Lateral Rectus

Alignment
Normal alignment is Orthotropia
Any abnormality in alignment is Strabismus
Manifest strabismus is Heterotropia
Hidden strabismus is Heterophoria
Controlled by fusion, 2 foveas point same direction
prevents deviation

Constant and Intermittent

Prefixes describe direction
Eso, Exo, Hyper, Hypo, Cyclo

Abbreviations
Eso E
Exo X
Hyper/ Hypo H
by convention H is hyper unless written out hypo
side refers to eye that is higher so RHT is same as
LHypoT

Tropia T (ex. Esotropia = ET)

Phoria letter alone (ex. Esophoria = E)
Intermittency parenthesis (ex. E(T))
To indicate deviation at near use apostrophe
(ex. ET)

Measurements
Prism Diopters abbreviated with Delta or
^(up arrow)
Is a factor using millimeters of deviation from
midline
Measured with Prisms bend light traveling
through them at a certain angle
Used to describe strabismus and guide
treatment
Ex. 30^ ET
Also can be abbreviated PD

Examination of Motility
Visual Acuity important
Dont assume binocularity
Ability to fixate on object needed for many steps

Movement of eye in all 9 positions of gaze

Primary, up, down, right, left, 4 corners

Each has primary acting muscle
Overaction and Underaction (ab. + or 1-4)

Test both eyes individually (ductions) and

together (versions)
Palsy versus Paresis versus Restriction results
in Strabismus

Red Reflex
Helpful for evaluation of alignment and
fixation
Easily misinterpreted
Abnormal in Strabismus, Refractive Error,
and opacity
Bruckner
Corneal Light Reflex should be centered
in pupil

Examination of Alignment
Use smallest target patient can discern
Not big E or penlight, can alter angle

Cover and Uncover

Alternate Cover
Tests that estimate angle without requiring
fixation
Hirshberg based on where light reflex exists relative
to pupil
Krimsky Centers light reflex inside pupil using
prisms

Cover and Uncover

Place Occluder over right eye- then
uncover right eye and evaluate for
refixation movement without covering
other eye
Repeat for left eye
Evaluates for presence of Tropia or
Manifest deviation

Alternate Cover
Perform after above, breakage of fusion may
alter numbers
First cover right eye then slowly move to left eye
while uncovering right
Repeat in opposite direction
Evaluates for presence of Phoria plus Tropia
(manifest and latent deviation)
Most accurate way to evaluate angle of
Strabismus
Not useful if fixation not possible with one or
both eyes

Where do you put the Prism?

Point the prism apex toward the direction
of the deviation
So to correct an esodeviation point the
apex toward the nose
OR think of the light as bending toward the
base of the prism so the image moves
toward the direction of the deviated fovea
(not cornea) this is the more confusing of
the two if you ask me.

How much prism?

Continue adding prism (1-50 in most sets)
until the eyes quit moving back and forth
Called Neutralization of the angle
Prisms can be stacked but only if in
different directions.. To get measurement
of angle greater than 50PD must add
prism to other eye.. Air interface gives
incorrect result.

What if you have more than one

direction of deviation?
Many patients will have in and up.
So you use prisms in different directions
simultaneously
Ex. Pt. with esotropia and hypertropia
Place prism over one eye with base out and
other eye with base up or down
May require another set of hands

Simultaneous Prism Cover

Used to measure tropia only component of
tropia/phoria mix
Place prism and occulder simultaneously
over opposite eyes
Estimate angle of deviation first with
corneal light reflex
Difficult to interpret

Common pitfalls to strabismus

measurement
Target not small enough
Variable working distance or direction (of target)
Fusion not suspended (keeping other eye covered
prism bars help) cant tell whats phoria or tropia
Fixation not attained (you cant neutralize a stare)
Refixation movements (patient may overshoot..)
Dont assume comitance (deviation may vary with gaze)
Poor vision (inability to fixate) wear refractive correction
but not prismatic correction
Nystagmus if the patients eyes are moving for other
reasons than strabismus, must measure with blur not
occlusion
Fatigue (the patients) breakdown of angle can occur

So I have a primary deviation measured,

now what?
Remember those nine cardinal gaze positions?.... You
guessed it, repeat all that testing for each one.yep all 9
and dont forget head tilt
And you have to do it again for near (important that near
is always 1/3 meter because distance can alter the
amount of deviation our old friend accommodation)
Variable measurements in different directions of gaze is
Incomitance occurs with over/underaction
This is how you determine which muscle is causing the
problem

What about Torsion?

Measurement of Rotation of the
eye
Done with Maddox Rod
Patient moves to align two
straight lines to parallel position

How do you determine if the

problem is a weakness or tightness
of a muscle?
Easiest way is to test forced duction or
generation.
Using forceps in numb eye rotate eye in
variable directions
Typically done at time of surgery

So now we have a diagnosis, or do

we?
Ok ready, cut
Hold on, first we have to figure out what
caused our problem.
Surgery isnt always the best treatment
. Just kidding right?
NOPE

Esotropia
Congenital or Infantile
Accommodative
Divergence insufficiency
Sensory Esotropia
Duanes Syndrome
Congenital Fibrosis Syndrome
Sixth nerve palsy
Myasthenia Gravis
Pseudoesotropia
Thyroid Ophthalmopathy

Exotropia
Intermittent Exotropia
Convergence insufficiency
Sensory Exotropia
Congenital Exotropia
Restrictive (entrapped muscle)
Thyroid

Then there are neurological causes

Yea.. The syndromes
Downs, Duanes, Mobius, Browns
And Craniosynostosis.. The ever popular
but politically incorrect FLK.

Dissociated what?
Dissociated vertical and horizontal
deviations.
Drifting that occurs under the cover
Can be surgically corrected but isnt
usually necessary
Controlled with fusion

Now we know why, what do we do?

Ohh Boy, we finally get to cut?
Maybe
First..
Correct refractive errors
Treat underlying conditions (amblyopia, thyroid,
stroke, cataract)
Wait (depending on cause) for stable angle up to 6
months and multiple measurements needed
Dont forget PRISM glasses in appropriate cases

Finally we get to OPERATE!

Recession weakens a muscle by moving it closer to
the origin of the muscle
Resection strengthens a muscle by shortening it (takes
a piece out)
Transposition changes the angle of contact with the
eye (moves a horizontal muscle up or down) altering its
primary function
Tuck shortens a muscle without taking the piece out
Myotomy taking a muscle off and not putting it back on
(also known as loosing a muscle) ha
Faden procedure attaching the muscle to the sclera in
an additional place
Can do all above with part of or entire muscle

More surgery
Tendon expanders- primarily on superior oblique
for Browns syndrome
Advancement the undoing of a recession
Botulinum toxin partially paralyzes muscle that
is overacting
Orbital procedures to remove masses, fix
fractures, or make more space (orbitotomy)
Remove the Buckle, move the glaucoma implant

Important things your patients should

know about strabismus surgery
20-25% of anyone who needs eye muscle surgery will
require more than one in their lifetime
Double vision is common after surgery but usually
resolves
The eyes will be RED for a few weeks and may drain
bloody tears for a day or so
We dont take the eye out to operate on it
It is not done with laser, incisions are going to be made
and stitches used
Surgery does not improve vision but can prevent vision
loss
Youre never too old or too young for eye surgery or
examination

There is no such thing as a

stupid question!
Not from a patient or from you!
THANK YOU for your
attention!

References
American Academy of Ophthalmology, Basic Clinical
Science Course Section 5: Neuro-Ophthalmology, 20052006 ed., San Francisco, CA.
American Academy of Ophthalmology, Basic Clinical
Science Course Section 6: Pediatric Ophthalmology and
Strabismus, 2005-2006 ed., San Francisco, CA.
Kenneth W. Wright and Peter Spiegel, Pediatric
Ophthalmology and Strabismus, 2nd ed., Elservier, Inc.,
2003.
Duanes Ophthalmology On CD-rom, Lippincott Williams
and Wilkins, 2002.