The extraocular muscles and ocular movements

1. THE EXTRA OCULAR MUSCLES AND
OCULAR MOVEMENTS

2. There are Fourteen Extraocular Muscles, Six Inserted in to each globe which
are responsible for movement of the eyes, and one inserted in to each upper
eyelid, responsible for raising it.
These muscles are :
1. Rectus Muscles
Horizontal recti Lateral rectus (LR)
Medial Recus(MR)
Vertical Recti Superior Rectus(SR)
Inferior Rectus(IR)
2. Oblique Muscles Superior Oblique (SO)
Inferior Oblique (IO)
3. Lid elavator muscles Levator Palpebrae
Superioris (LPS)
ANATOMY
the xtraocular muscles Consist of stiped muscle fibers . The recti muscles
and the superior oblique originate from tendinous ring, the annulus of zinn,
which surrounds the optic foramen at the apex of each orbit. The levator
muscles has its origin just above the annulus of the zinn. The inferior oblique
arises from the orbital floor, just behind the orbital margin and close to the
angle formed, fanning out to form a cone like shap-e ( the muscle cone).

3. In front of the globe. The superior oblique passes forward betweeen the medial
and superior recti until it reaches the trochlea or pulley, a ring of cartilage
situated just inside the orbital margin in the angle formed by the roof and
medial wall. The muscles passes through the pulley and is reflected obliquely
backwards , passing under the superior rectus muscles, to be inserted in to the
posterior superior temporal quadrant of the globe. The inferior oblique passes
obliquely backwards, running running approximately parallel with the superior
oblique, passing between the inferior rectus and the globe to be inserted in to
the posterior inferior temporal quadrant. The levator muscles passes forward
above the superior rectus , just below the orbital roof, and is inserted in to the
skin of the upper eyelid.
NERVE SUPPLY
The extraocular muscles are supplied by the cranial nerves as follows: the
sixth nerve supplies the lateral rectus, the fourth nerve supplies the superior
oblique and the third nerve supplies the medial rectus, inferior rectus and
inferior oblique via its inferior division. The superior division of the third nerve
supplies the superior rectus and the levator muscle. The inferior division also
carries the nerve supply to the sphincter muscle in the iris, which constructs the
the pupil an dto the ciliary muscle, which control accomodation.

4. •Elevation in
adduction
•Adduction
•Depression
in adduction
ACTIONS OF THE EXTRAOCULAR MUSCLES
Movement of the globe is brought about by contraction of the
extraocular muscles. Each muscle has a main action, which increases, in one
position of gaze . When the eyes look ahead, they are in the primary position.
They are maintained in that position by simultaneous contraction of the rectus
and oblique muscles. As the eyes move away from the primary position, one or
more muscles increase their contraction and others relax to allow movement to
take place. The diagnostic position for the right eye shown in fig 1 & fig 2.
elevation
depression
•Elavation in
abducn
•Abduction
•Depresssion
in abduction
Primary position
•Elevation in
abduction
•Abduction
•Depression
in abduction
Fig 1 position of a gaze of the right eye as seen by the
examiner
T
N

5. •Superior
rectus
•Lateral
rectus
•Inferior
rectus
Primary position
•Inferior
oblique
•Medial
rectus
•Isuperior
oblique
Superior
rectus
Inferior
rectus
T N
Fig 2 – the main extra ocular muscles (of right eye) which act in the diagnostic position of
gaze, as seen by the examiner
T -Temporal N- Nasal
Actions of the extraocular muscles
Horizontal recti muscles
Lateral Rectus Abduction (outward movement)
Medial rectus Abduction (inward movent)

6. Muscle Primary Position Adducted Position Abducted Position
Superior rectus
Inferior rectus
Superior oblique
Inferior oblique
Primarily an
elevator also
intorter and
adductor
Primarily a
depressor also
extorter and
adductor
Primarily intorter
also depressor
and abductor
Primarily intorter
also elevator and
abductor
Weaker elevator
better intorter
Weaker depressor
better extorter
Mainly depressor
weaker intorter
Better elevator
Better elevator
weaker intorter
Better depressor
weaker extorter
Better intorter
Better extorter

7. Secondary actions of extraocular muscles
the lateral rectus and the medial rectus have only one action but the
vertically acting muscles have additional secondary action.
There are
1. Abductipon or adduction, suplimenting the actions of the lateral and medial
rectus.
2. Wheel rotation nasally or tempoprally, assessed from the 12’o clock position
on the linbus. Wheel rotation nasally is termed intorsion, wheel rotation
temporally is termed extorsion.
each muscles secondary actions increase when the eye is turned away
from the position of main action. For eg: the main action of the superior
rectus increases when the eye is abducted, its secondary actions increase
when the eye is adducted. As in table below.
OCULAR MOVEMENT
the purpose of ocular movement is to place the image of the object of
interest on the fovea of each eye, so that the best possible vision is obtained
an binocular single vision(BSV) can be maintained in all positions of gaze.
This requires that the two eyes move simultaneously, at the same speed and
in exacly the same direction. Muscles are paired to achieve movements in
the same direction. Paired muscles are termed synergists or yolk muscles.

8. LAWS GOVERNING OCULAR MOVEMENTS
1. Hering’s laws of equal innervation,which states that an increase in
innervation always goes equally to synegistic muscles. Using
the above example, when the right lateral rectus contracts to move the
eyes to the right, an equal amount of innervation goes to the left medial
rectus to bring about coordinated movements.
2. sherrington’s law of reciprocal innervation, which states that an increase
in innervation never takes place simultaneously in antagonistic muscles.
The antagonist of the right lateral rectus is the medial rectus, which has a
directly opposed action. The right lateral rectus cannot contract unless the
antagonistic medial rectus relaxes. Relaxation of the antagonistic muscles
allows smooth movents to the place .
synergistic muscles can be in opposite eyes, termed contralateral
synergistic or in the same eye, termed ipsilaterar synergists. An eg of
contralateral synergists is the right superior rectus and the left inferior
oblique, which work as a pair to bring about movement up and to the right.
An eg. Of ipsi lateral synergists is the right superior rectus and the right
inferior oblique, which act together to move the eye directly up. Contralateral
synergists muscles are shown in the diagnostic position of gaze (fig 3).

9. R
E
RI
O
LS
R
RM
R
LLR
RS
O
LIR
RSR
LIO
RL
R
LM
R
RIR
LSO
T N L
E
LS
R
RI
O
LLR
RM
R
LIR
RSO
LIO
RSR
LM
R
RL
R
LSO
RIO
T
Fig 3 contralateral synergists muscles in the diagnostic positions of
gaze.

10. Ipsilateral synergist are both elevating muscles on looking up, both
depressing muscles on looking down likewise the levator and superior rectus are
synergists. When the superior rectus contracts to elevate the eye,the levator
contracts to r5aise the upper eyelid.When the eye looks down,both the superior
rectus and the levator relax and the eye lid follows the downward movement of
the eye.
Ipsilateral antagonists are muscles in the same eye with directly
opposed main actions.In the right eye these are the lateral and medial rectus, the
superior and inferior recti and the superior and inferior oblique.
VERSIONS
a version is a conjugate all parallell eye movement in which both eyes
move in the same direction. Versions are describe as dextroversions, both eye
move to the right, laevoversion, both eye eyes move to the left, dextroellevation,
both eyes move up end to the right, dextrodepression, both eyes move down and
to the right laevoversion and levodepression are use to describe the movement
up and to the left and down and to the left respectively.
DUCTIONS
a ductionn is a movement of one eye, abduction being outward
movement, adduction inward movent. Supraduction and infraduction apply to
upward and downward movement respectively, but these later terms are rarely
used.

11. VERGENCES
A vergence is a disjugate or non parallel eye movement in which the
eyes moves in oposite direction. These movements are neccesssary to
maintain foveal fixation and BSV as objects approach or recede from the eye.
They comprise :
1. convergence, brought about by contrction of both medical rectus muscles.
2. Divegent , brought about by contraction of both lateral rectus muscles small
amounts of vertical and torsional vergences are also possible and are
used to control vertical or torsional squint.
EXAMINATION OF OCULAR MOVEMENTS
versions are tested routinely by asking the patient to follow a moving target,
controlled by the examiner, in to the diagnostic positions of the gaze,
observing the extent of movement of each eye . Horizontal movements are
always tested first ,followed by vertical movements.
precausions
1. A cover test first should be first performed. The result can help in the
assessment of occular movement. A vertical squint suggest that there may
be a defective vertical movement. A manifest squint influences the method
of resting as described below

12. 2. The patients head must be kept straight. It may be necessary to hold it,
especially when testing a child.
3. The target must be easy to see and small enough to ensure accurate fixation
on it. A small torch is ideal, but must not be too bright.
4. The target should be held about 40cm from the patient’s eyes and should be
kept at level when testing horizontal versions.
5. Both eyes must be visible to the examiner.It may be necessary to raise the
eyelids slightly to see the eyes as they look down,but the eyelid position
must be observed before doing this,because abnormal lid movements are
sometimes seen and must be noted.
6. The target should be moved smoothly at a moderate speed,not too fast for
the patient to follow it.It must be moved to the limits of gaze,otherwise small
defects of movement can be missed.
7. If movement in one eye appears limited,the other eye should be covered and
ductions tested,comparing the amount of movement.This can sometimes
happen with a manifest squint.If for example,there is a large right
exotropia,the right eye will remain divergent when the fixing left ete watches
the target into the left –hand field,so that that the right medial rectus appears
limited. This should be checked with the left eye covered,when it may be
found that adduction is full.Ductions must always be checked when there is
an underaction noted in any position of gaze on versions(compering the
movement with both eyes open and with both eyes open and with the normal
eye covered.

13. REAULT
if both eyes move equally and smoothly in all directions of gaze,
ocular movemen tis full. Abnormal ocular movements comprise.
1. underaction, seen when the eyes are directed into one or more positions
of gaze. For example, if the right lateral rectus underacts or is prevented
from acting mvement of the right eye will stop as the target is
movedfurther to the right, but the left eye will continue to followthe target
to the limit of gaze.
2. Overasction, which is usually the result of underaction in the other eye .
According to Hering’s law , more innervation is send to, for example, th
eright lateral rectus in an effort to improve defective movement: th esame
innervation goes to the normal left medial rectus, which does not need
it,causing it to make an excessive movement. This is best seen by
coveringthe left eye (in the same example) to make the defective eye fix.
As that eye fixes, th eye behind the cover can be observed, making the
overaction more obvious. Underaction may be marked or slight.detection
of slight underation is easier f the movement of the suspect ete is
compared with the same movement in the normal eye. For eg:, abduction
of each eye can be compared by making the patient look at the target
held well to the right , then at target held well to the left. An alternate
cover test is useful in detecting abnormalities of ocular movement and
should performed in all cases, holding the fixation target in each
diagnostic position of gaze inturn while the cover test is performed,

14. position of main action of the defective muscles. This is particularly useful in
suspected superior oblique palsy, which is sometimes obscured by the shape
of the palpebral fissure on looking down and in.
Recording the results
underaction and overaction can be described in relation to the position
of gaze in which they are seen:
- Underaction of the RE on laevodepression, with overaction of the LE.
-Alternatively they can be described in relation tto the muscles involved:
-- underaction of the right superior oblique with overaction with the left
inferior rectus.
-An indication of the amount of limitation of movement should be given,
classed as slight, moderate, marked or no movement.this classification
become easier with experience. This is usually graded from one to four
overaction indicated by (+) sign and underaction indicated by (-) sign.
-Deficits of ocular movement can be recorded diagramatically as shown in
this eg (fig 4 &5)

15. RE
RSR
RLR
RSR
RMR
RIO
RSO
LE
LI
O
LMR
LSO
LSR
LLR
LIR
Fig 4 field of actions of muscles

16. Recording overaction and underatcion
RE LE
Fig 5 (++)overaction –underaction
it is important to record any other abnormalities seen when testing ocular
movement. These sighns can help in the diagnisis. They include nystagmus,
which may be preesnt in certain position gaze, retraction the globe in which the
eye ball is seen to move back into the orbit into one or more position sof gaze,
any changes in the palperal fissure (narrowin gor widening) an dan increase in
the horizontal angle in of squint on looking up or orlookking down.this is quit a
common findings in defects of vertical eye movement.
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