Extraocular Motility

Walter Huang, OD Yuanpei University Department of Optometry

Extraocular Muscles
Purpose

To control the movement of the globe

Extraocular Muscles
Rectus muscles

Superior rectus muscle (SR) Inferior rectus muscle (IR) Medial rectus muscle (MR) Lateral rectus muscle (LR) Superior oblique muscle (SO) Inferior oblique muscle (IO)

Oblique muscles

Anterior View of Right Eye

Superior View of Right Orbit

Action of muscles affected by globe position in the ocular orbit and muscle orientations

Posterior View of Right Eye

Medial Rectus
Along the medial aspect of the eyeball, the medial rectus muscle inserts at a point 5.5mm of the limbus It is controlled by the oculomotor nerve (cranial nerve III) Contraction of this muscle causes adduction of the eye

Medial Rectus
Adduction

Lateral Rectus
Along the lateral aspect of the eyeball, the lateral rectus muscle inserts at a point 7.0mm of the limbus It is controlled by the abducens nerve (cranial nerve VI) Contraction of this muscle causes abduction of the eye

Lateral Rectus
Abduction

Inferior Rectus
Along the inferior aspect of the eyeball, the inferior rectus muscle inserts at a point 6.5mm of the limbus It is controlled by the oculomotor nerve (cranial nerve III)

Inferior Rectus
When the eyeball is positioned 23 degrees outward in the orbit with respect to primary gaze, contraction of this muscle causes depression of the eye When the eyeball is positioned 67 degrees inward in the orbit with respect to primary gaze, contraction of this muscle causes excycloduction of the eye

Inferior Rectus
When the eyeball is positioned straight ahead in the orbit with respect to primary gaze, contraction of this muscle causes adduction of the eye Contraction of this muscle causes depression, excycloduction, and adduction of the eye

Position of IR and SR

Primary Action of IR
Depression

Secondary Action of IR
Excycloduction

Tertiary Action of IR
Adduction

Superior Rectus
Along the superior aspect of the eyeball, the superior rectus muscle inserts at a point 7.5mm of the limbus It is controlled by the oculomotor nerve (cranial nerve III)

Superior Rectus
When the eyeball is positioned 23 degrees outward in the orbit with respect to primary gaze, contraction of this muscle causes elevation of the eye When the eyeball is positioned 67 degrees inward in the orbit with respect to primary gaze, contraction of this muscle causes incycloduction of the eye

Superior Rectus
When the eyeball is positioned straight ahead in the orbit with respect to the primary gaze, contraction of this muscle causes adduction of the eye Contraction of this muscle causes elevation, incycloduction, and adduction of the eye

Primary Action of SR
Elevation

Secondary Action of SR
Incycloduction

Tertiary Action of SR
Adduction

Superior Oblique
The superior oblique muscle passes through the trochlea and its insertion on the eyeball below the superior rectus muscle is at 51 degrees with respect to primary gaze It is controlled by the trochlear nerve (cranial nerve IV)

Superior Oblique
When the eyeball is positioned 39 degrees outward in the orbit with respect to primary gaze, contraction of this muscle causes incycloduction of the eye When the eyeball is positioned 51 degrees inward in the orbit with respect to primary gaze, contraction of this muscle causes depression of the eye

Superior Oblique
When the eyeball is positioned straight ahead in the orbit with respect to the primary gaze, contraction of this muscle causes abduction Contraction of this muscle causes incycloduction, depression, and abduction of the eye

Position of SO and IO

Primary Action of SO
Incycloduction

Secondary Action of SO
Depression

Tertiary Action of SO
Abduction

Inferior Oblique
The insertion of the inferior oblique muscle is on the eyeball below the lateral rectus muscle at 51 degrees with respect to primary gaze It is controlled by the oculomotor nerve (cranial nerve III)

Inferior Oblique
When the eyeball is positioned 39 degrees outward in the orbit with respect to primary gaze, contraction of this muscle causes excycloduction of the eye When the eyeball is positioned 51 degrees inward in the orbit with respect to primary gaze, contraction of this muscle causes elevation of the eye

Inferior Oblique
When the eyeball is positioned straight ahead in the orbit with respect to the primary gaze, contraction of this muscle causes abduction Contraction of this muscle causes excycloduction, elevation, and abduction of the eye

Primary Action of IO
Excycloduction

Secondary Action of IO
Elevation

Tertiary Action of IO
Abduction

Functions of Extraocular Muscles

Muscle MR LR Primary Action Adduction Abduction Secondary Action Tertiary Action

IR

Depression

Excyclo duction

Adduction

Functions of Extraocular Muscles

Muscle Primary Action Secondary Action Tertiary Action

SR
SO IO

Elevation
Incyclo duction Excyclo duction

Incyclo duction
Depression Elevation

Adduction
Abduction Abduction

Terminology
Duction: describes movement of one eye

Abduction Adduction Supraduction or elevation Infraduction or depression Incycloduction or intorsion Excycloduction or extorsion

Terminology
Version: describes movement of two eyes in the same direction

Dextroversion Levoversion Supraversion Infraversion

Terminology
Vergence: describes movement of two eyes in opposite directions

Convergence Divergence

Version and Vergence

Near Point of Convergence

Maximum convergence ability or NPC is measured by as part of confrontational testing NPC = point of intersection of line of sight when eyes are maximally converged Theoretically, NPC should be measured from center of rotation of eyes Clinically, NPC is measured from the facial plane

Near Point of Convergence

NPC break point (target becomes double) greater than 7cm is considered abnormal Average NPC is approximately 5cm The recovery point (target becomes single) is expected to be within 10cm

Near Point of Convergence

A patient with reduced NPC

Convergence insufficiency Some presbyopes Symptoms

Diplopia, frontal headache, asthenopia, fatigue, and reduced reading ability

The patient may benefit from vision therapy or prism in reading Rx

Object Tracking Movements

Saccade: fast, step-like eye movement (up to 1000 deg/sec) that places image of the target on the fovea

Reading Looking from point A to B Fixating on a stationary target

Object Tracking Movements

Pursuit: slow, smooth-following movement (up to 30 deg/sec) that maintains image of the target on the fovea

Following a moving target

Extraocular Motility Testing

The most common test for extraocular motility is the broad H test EOM testing is also part of confrontational testing

Extraocular Motility Testing

Purpose

To investigate the integrity of the extraocular muscles and their nerves To assess the patients ability to perform version eye movements To determine if strabismus is comitant (i.e., deviation does not change with direction of gaze)

Broad H Test
A pursuit test done binocularly with penlight at a test distance of 30 to 40cm It tests 9 positions of action, starting with primary position

Broad H Test

Broad H Test
It tests fields of action of the 6 extraocular muscles Field of action = direction where a particular muscle has the greatest action

Broad H Test
Examples of fields of action

Right LR: field of action is the right-hand field Right MR: field of action is the left-hand field This is opposite for left LR and left MR

Position of SR and IR

Action of SR and IR
SR and IR lie in a muscle plane that makes a 23 degree angle with the straight ahead position When the eye turns out 23 degrees, SR acts as a pure elevator, and IR acts as a pure depressor

Position of SO and IO

Action of SO and IO
SO and IO lie in a muscle plane that makes a 51 degree angle with the straight ahead direction When the eye turns in 51 degrees, SO acts as a pure depressor, and IO acts as a pure elevator

Broad H Test
It is not necessary to direct the patients gaze exactly 23 degrees or 51 degrees during the broad H test 40 degrees to the right or left is enough to detect any limitation of movement

Muscles and their Fields of Action

Right-hand elevator: muscle that turns the eye upward when the eye is already looking to the right (RSR and LIO) Right-hand depressor: muscle that turns the eye downward when the eye is already looking to the right (RIR and LSO)

Muscles and their Fields of Action

Left-hand elevator: muscle that turns the eye upward when the eye is already looking to the left (LSR and RIO) Left-hand depressor: muscle that turns the eye downward when the eye is already looking to the left (LIR and RSO)

Muscles and their Fields of Action

Example: A patient is asked to direct gaze 23 degrees to the right and up, any limitation in movement of OD is due to problem with RSR

Muscles and Their Fields of Action

Broad H Test
Look for lags or overshoots at various diagnostic positions of gaze Look for smooth and accurate pursuit movements Look for any gaze restrictions or overactions of muscle in the 9 positions Look for comitancy

Comitancy
When deviation of the visual axes remains constant in all fields of gaze, there is comitancy When deviation of the visual axes changes with field of gaze, there is noncomitancy

Comitancy
Check for comitancy by moving the target to different positions of gaze, while keeping the patient steady In general, a patient with EOM paresis is incomitant

Gaze Restriction

Overaction of Muscle

Saccade Test
Test set-up is the same as for the broad H test Direct patient to look quickly from positions 8 to 2, and then back to 8 Repeat rapid shifts of gaze from positions 6 to 5, and then back to 6 Look for accuracy of movement (i.e., overshoots and undershoots)

Saccade Test

Recording

Expected Findings
SAFE

Smooth Accurate Full Extensive