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J OHANNES KEPL ER

UNI VERS I TT L I NZ
Ne t z we r k f r Fo r s c h u n g , L e h r e u n d Pr a x i s
Biomechanical Modelling of the Human Eye
Dissertation
zur Erlangung des akademischen Grades
Doktor der Technischen Wissenschaften
im Doktoratsstudium der technischen Wissenschaften
Angefertigt am Institut fr Anwendungsorientierte Wissensverarbeitung (FAW)
Eingereicht von:
Dipl.-Ing. (FH) Michael Buchberger
Betreuung:
Univ.-Prof. Dipl.-Ing. Dr. Roland Wagner
Beurteilung:
Univ.-Prof. Dipl.-Ing. Dr. Roland Wagner
Univ.-Doz. Dipl.-Ing. Dr. Thomas Haslwanter
Linz, Mrz 2004
Johannes Kepler Universitt
A-4040 Linz Altenbergerstrae 69 Internet: http://www.uni-linz.ac.at DVR 0093696
Eidesstattliche Erklrung
Ich erklre an Eides statt, dass ich die vorliegende Dissertation selbststndig und ohne fremde
Hilfe verfasst, andere als die angegebenen Quellen und Hilfsmittel nicht benutzt bzw. die wrtlich
oder sinngem entnommenen Stellen als solche kenntlich gemacht habe.
Linz, im Mrz 2004 Michael Buchberger
To Bianca and my parents...
Abstract
The goal of this work was the development of a biomechanical model of the human eye. An
interactive software system was implemented, called SEE++ which allows also physicians to
obtain a better understanding of the mechanics of eye movements. This software visualizes and
simulates pathologies and eye muscle surgeries, based on the biomechanics of the eye. It can
be used in preoperative planning, medical training and basic research, and shows how Medical-
Informatics can improve the diagnosis and treatment of patients.
The interdisciplinary nature of the project required contributions from very dierent elds.
Anatomical studies, in cooperation with researchers as well as practicing physicians, provided
data for dening a mathematical representation of human eye movements. The biomechanical
model included a geometrical representation of eye movements, a muscle force prediction model,
and a kinematic model that balances muscle forces by using mathematical optimization meth-
ods. High-resolution magnetic resonance imaging studies were carried out to visualize eye muscle
morphology, and image processing methods used to reconstruct three dimensional approximation
models of human eye muscles. Modern software engineering methods provided the basis for an
extensible object-oriented software design. Three dimensional interactive visualization and a user
interface optimized for medical use were combined into a unique software simulation system for
the clinic and for teaching.
The SEE++ software system is currently the most advanced biomechanical representation
of the human eye, with respect to simulating eye movements and eye muscle surgeries. The
extensive possibilities for parametrization of the human eye model allow interactive simulations
of pathological cases and surgical corrections, and the predictions correspond well with clinical
data. This system is used in various clinical facilities as computer aided decision support for
strabismus (squint) surgeries. In medical training and education, it substantially improves the
functional understanding of human eye movements.
Keywords: Biomechanical Modelling, Eye Surgery, Strabismus, Eye Motility, Medical Decision
Support Systems
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Kurzfassung
Diese Forschungsarbeit hat das Ziel, ein biomechanisches Modell des menschlichen Auges zu
entwickeln. Das implementierte Software System, SEE++, soll es Medizinern ermglichen, ein
besseres Verstndnis der Mechanik der Augenbewegungen zu bekommen. Augenbewegungsst-
rungen und Augenmuskeloperationen werden dabei auf biomechanische Ursachen und Wirkungen
zurckgefhrt. Der erfolgreiche klinische Einsatz dieses Systems zeigt, wie computerbasierte Me-
thoden der Medizin-Informatik die Diagnose und Behandlung von Patienten verbessern knnen.
Die interdisziplinren Anforderungen dieses Projekts erforderten Beitrge aus stark unterschied-
lichen medizinisch-technischen Forschungsbereichen. Anatomische Studien lieferten Grunddaten
fr die Formulierung eines mathematischen Modells der menschlichen Augebewegungen. Biome-
chanische berlegungen fhrten zu einer geometrischen Beschreibung von Augenbewegungen,
einer Muskelkraftsimulation und eines kinematischen Modells. Augenpositionen wurden mit ma-
thematischen Optimierungsmethoden aus dem Krftegleichgewicht der Augenmuskulatur berech-
net. Um die Morphologie der Augenmuskulatur besser zu verstehen, wurden umfangreiche Studien
mit hochausender Magnetresonanztomographie durchgefhrt, und mit Bildverarbeitungsme-
thoden die dreidimensionalen Rekonstruktionen berechnet. Der Einsatz von modernen Methoden
des objektorientierten Software-Engineering bildete die Grundlage fr eine exible Implementie-
rung. Dreidimensionale interaktive Visualisierung und optimiertes Benutzerschnittstellen-Design
wurden in einem einzigartigen Software System kombiniert.
Das biomechanische Simulationssystem SEE++ ist derzeit das weltweit detaillierteste und mo-
dernste Softwaresystem fr die Modellierung und Simulation von Augenbewegungsstrungen. Das
System ermglicht durch umfangreiche Mglichkeiten der Parametrisierung die Simulation von
pathologischen Fllen und deren operative Korrektur. Die Simulationsergebnisse zeigen nach-
weislich eine gute bereinstimmung mit verfgbaren klinischen Vergleichsdaten. Derzeit wird
dieses System fr die computerbasierte Entscheidungsuntersttzung in verschiedenen klinischen
Einrichtungen verwendet. Der Einsatz in der medizinischen Ausbildung verbessert das Verstnd-
nis ber Funktion und Wirkungsweise von menschlichen Augenbewegungen. In der medizinisch-
physiologischen Grundlagenforschung ermglicht das System die Auswertung und Evaluierung
von Messergebnissen, und gibt somit einen detaillierteren Einblick in die komplizierte Struktur
des menschlichen Auges.
Schlsselwrter: Biomechanische Modelle, Augenoperation, Strabismus, Augenmotilitt, Klini-
sche Entscheidungsuntersttzung
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Acknowledgements
Within eight years of research, many people have greatly contributed to this work. First of all, I
would like to express my deepest gratitude, respect and admiration to Prim. Prof. Dr. Siegfried
Priglinger, head of the ophthalmologic department at the convent hospital of the Barmherzigen
Brder in Linz. He did not only start this project, but also greatly contributed to this work as
teacher, mastermind and highly experienced medical expert, always emphasizing improvement in
patient care. His exceptional personality and social engagement inspired me beyond my technical
work.
I would like to thank Univ.-Prof. Dipl.-Ing. Dr. Roland Wagner, head of the Research Institute
for Applied Knowledge Processing (FAW) at the University of Linz for reviewing and supporting
this work.
From the ETH-Zurich, I would like to thank Univ.-Doz. Dipl.-Ing. Dr. Thomas Haslwanter for
explaining medical details and giving valuable advice and guidance throughout the creation of
this thesis. From the medical side, many physicians and researchers have been involved in this
research work. For valuable cooperation I would like to thank Dr. Joel Miller from the Smith
Kettlewell Eye Research Institute. Furthermore, Prim. Univ.-Prof. Dr. Erich Salomonowitz,
Prim. Univ.-Doz. DDr. Armin Ettl and Dr. Jrg Hildebrandt from the hospital St. Plten
supported this work by providing clinical patient data. Additionally, the radiologic department
of the Wagner Jauregg hospital in Linz lead by Prim. Dr. Johannes Trenkler with the help of
Univ.-Doz. Dr. Franz Fellner and Univ.-Doz. DDr. Dipl.-Ing. Mag. Josef Kramer provided
necessary equipment and medical expert knowledge to carry out dierent physiological studies.
For usability testing and evaluation of the software system SEE++ I would like to thank Univ.-
Prof. Dr. Andrea Langmann from the university in Graz for believing in this work. From the
university of Innsbruck I appreciate the help of OA Dr. Eduard Schmid, OA Dr. Ivo Baldissera
and OA Dr. Cornelia Stieldorf. From the hospital of the Barmherzigen Schwestern in Ried I
would like to thank OA Dr. Robert Hrantner for extensively testing the software and providing
valuable feedback.
From the Upper Austrian University of Applied Sciences in Hagenberg I would especially like to
thank Univ.-Prof. Dipl.-Ing. Dr. Witold Jacak for initiating and greatly supporting the SEE-
KID project. Moreover, thanks go to FH-Prof. Dipl.-Ing. Dr. Herwig Mayr, who also supported
the project in its beginnings with his project engineering knowledge.
Many diploma students were involved within this project. First of all, I would like to give
my respect to Dipl.-Ing. (FH) Thomas Kaltofen for extensive implementation work and above-
average participation within this work. Additionally, Dipl.-Ing. (FH) Martin Wiesmair, Dipl.-Ing.
(FH) Franz Pirklbauer, Dipl.-Ing. (FH) Stefan Satzinger and Dipl.-Ing. (FH) Michael Lacher
spent their internship and diploma semester in the eld of the SEE-KID project. I would also
like to thank Dipl.-Ing. (FH) Thomas Kern, Dipl.-Ing. (FH) Johannes Dirnberger, Mag. Michael
Giretzlehner and Dr. Thomas Luckeneder for proof reading this work.
Last but not least, I would like to thank Dipl.-Ing. Dr. Otmar Hglinger from the Upper Austrian
Research GmbH for believing in new technologies and providing a fascinating infrastructure for
application-oriented research in the eld of Medical-Informatics. This work was also supported
by grants from the Austrian Ministry of Science (FFF) and the Upper Austrian government.
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Contents
1 Introduction 1
1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Medical Informatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Clinical Decision Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Eye muscle surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5 SEE-KID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Medical Foundations 9
2.1 Anatomy of the Human Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1.1 Eye Muscle Pulleys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.1.2 Global/Orbital Eye Muscle Layers . . . . . . . . . . . . . . . . . . . . . . 18
2.1.3 Anatomical Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1.4 High Resolution MRI-Imaging of the Orbit . . . . . . . . . . . . . . . . . 21
2.1.5 Human Dissection of the Orbit . . . . . . . . . . . . . . . . . . . . . . . . 24
2.2 Eye Movement Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.2.1 Actions of the Extraocular Muscles . . . . . . . . . . . . . . . . . . . . . . 27
2.2.2 Kinematic Principles of Eye Movements . . . . . . . . . . . . . . . . . . . 29
2.2.2.1 Donders Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.2.2.2 Listings Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.2.3 Sensorimotor Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.2.3.1 Innervation of the Eye Muscles . . . . . . . . . . . . . . . . . . . 34
2.2.3.2 Oculomotor Neurons . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.2.3.3 Neural Signal Encoding . . . . . . . . . . . . . . . . . . . . . . . 36
2.2.3.4 The Superior Colliculus . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.3.5 Brainstem Control of Saccades . . . . . . . . . . . . . . . . . . . 38
2.2.3.6 Control of Smooth-Pursuit Movements . . . . . . . . . . . . . . . 40
2.2.3.7 Herings Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.2.3.8 Sherringtons Law . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.3 Measurement Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.3.1 Eye Movement Measurements . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.3.1.1 Electro-Oculography . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.3.1.2 Infrared-Oculography . . . . . . . . . . . . . . . . . . . . . . . . 43
2.3.1.3 Scleral Search Coils . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.3.1.4 Video-Oculography . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.3.2 Physiologic Muscle Force Measurements . . . . . . . . . . . . . . . . . . . 47
2.3.3 Measurement of Motion in the Orbit . . . . . . . . . . . . . . . . . . . . . 51
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3 Strabismus 53
3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.1.1 Visual Acuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.1.2 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.1.3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.2 Binocular Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.2.1 Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.2.2 Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.3 Ocular Dissociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.4 Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.4.1 Corneal Light Reex Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.4.2 Cover Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.4.3 Subjective Clinical Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.4.4 Hess-Lancaster Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
3.5 Eye Motility Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.5.1 Concomitant Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.5.2 Incomitant Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.5.2.1 Paralytic Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.5.2.2 Duanes Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.5.2.3 Fibrosis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 80
3.5.2.4 Supranuclear Disorders . . . . . . . . . . . . . . . . . . . . . . . 81
3.6 Strabismus Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
3.6.1 Recession Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.6.2 Resection Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
3.6.3 Transposition Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.6.4 Amount of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4 Biomechanical Modelling 89
4.1 Analytical Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
4.2 Structure of Biomechanical Models . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.3 History of Modelling of the Human Eye . . . . . . . . . . . . . . . . . . . . . . . 92
4.4 Ocular Geometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.4.1 Coordinate Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.4.2 Mathematical Description of Eye Rotations . . . . . . . . . . . . . . . . . 96
4.4.2.1 Rotation Matrices . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.4.2.2 Quaternions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.4.2.3 Listings Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.4.2.4 Denition of Eye Positions . . . . . . . . . . . . . . . . . . . . . 104
4.4.3 Geometrical Abstractions . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.4.3.1 Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.4.3.2 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
4.4.3.3 Evaluation of Muscle Action . . . . . . . . . . . . . . . . . . . . 118
4.4.4 Passive Geometrical Changes . . . . . . . . . . . . . . . . . . . . . . . . . 121
4.5 Muscle Force Prediction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
4.5.1 Length-Tension Relationship . . . . . . . . . . . . . . . . . . . . . . . . . 123
4.5.2 Elastic Force Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
4.5.3 Contractile Force Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
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4.5.4 Total Force Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
4.6 Kinematics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4.6.1 Orbital Restoring Force . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4.6.2 Globe Translation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
4.6.3 Balancing Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
4.6.3.1 Solving for Eye Positions . . . . . . . . . . . . . . . . . . . . . . 140
4.6.3.2 Solving for Innervations . . . . . . . . . . . . . . . . . . . . . . . 141
4.7 Brainstem Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
4.7.1 Simulation of Binocular Function . . . . . . . . . . . . . . . . . . . . . . . 143
5 Visualization of Muscle Action 148
5.1 Image Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
5.1.1 Picture Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
5.1.2 Generation of Polyhedron . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
5.2 Surface Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
5.2.1 Calculation of the Muscle Path . . . . . . . . . . . . . . . . . . . . . . . . 156
5.2.1.1 Analyzing Surface Distribution . . . . . . . . . . . . . . . . . . . 159
5.2.2 Approximation of Muscle Surface . . . . . . . . . . . . . . . . . . . . . . . 161
5.2.2.1 Optimized Rendering . . . . . . . . . . . . . . . . . . . . . . . . 162
5.2.3 Interpolation of Muscle Models . . . . . . . . . . . . . . . . . . . . . . . . 164
5.3 Reconstruction Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
5.3.1 Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
6 Software Design and Implementation 169
6.1 Design of the Biomechanical Model . . . . . . . . . . . . . . . . . . . . . . . . . . 171
6.2 Design of the SEE++ Software System . . . . . . . . . . . . . . . . . . . . . . . 176
6.3 The SEE++ Software System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
6.3.1 SEE++ Simulation Task Flow . . . . . . . . . . . . . . . . . . . . . . . 181
6.3.2 Simulation properties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
6.3.2.1 Globe Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
6.3.2.2 Muscle Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
6.3.2.3 Distribution of Innervation . . . . . . . . . . . . . . . . . . . . . 185
6.3.2.4 Gaze Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
6.4 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
6.4.1 Abducens Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
6.4.1.1 Simulation of the Pathology . . . . . . . . . . . . . . . . . . . . . 186
6.4.1.2 Simulation of Surgical Correction . . . . . . . . . . . . . . . . . . 188
6.4.2 Superior Oblique Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
6.4.2.1 Simulation of the Pathology . . . . . . . . . . . . . . . . . . . . . 189
6.4.2.2 Simulation of Surgical Correction . . . . . . . . . . . . . . . . . . 191
6.4.3 Superior Oblique Overaction . . . . . . . . . . . . . . . . . . . . . . . . . 191
6.4.3.1 Simulation of the Pathology . . . . . . . . . . . . . . . . . . . . . 192
6.4.3.2 Simulation of Surgical Correction . . . . . . . . . . . . . . . . . . 193
6.4.4 Heavy-Eye Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
6.4.4.1 Simulation of the Pathology . . . . . . . . . . . . . . . . . . . . . 196
6.4.4.2 Simulation of Surgical Correction . . . . . . . . . . . . . . . . . . 199
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7 Conclusion 201
7.1 Goals Achieved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
7.2 Future Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Literature 205
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List of Figures
1.1 Example Applications Based on Data from the Visual Human Project
r
. . . . . 4
1.2 Classication of Clinical Decision Support Systems . . . . . . . . . . . . . . . . . 5
1.3 SEE++ Virtual Eye Muscle Surgery Software . . . . . . . . . . . . . . . . . . . . 8
2.1 Denition of Anatomical Planes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2 View of the Bony Orbita of a Right Eye . . . . . . . . . . . . . . . . . . . . . . . 11
2.3 Anatomy of the Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4 Anatomy of the Extraocular Eye Muscles . . . . . . . . . . . . . . . . . . . . . . 15
2.5 Extraocular Muscles of a Right Eye from above . . . . . . . . . . . . . . . . . . . 15
2.6 Schematic View of the Extraocular Tissue Architecture . . . . . . . . . . . . . . . 17
2.7 Example of Lateral Rectus Path Inuenced by Pulley . . . . . . . . . . . . . . . . 18
2.8 Dierent Fiber Layers of Rectus Muscles . . . . . . . . . . . . . . . . . . . . . . . 19
2.9 Axial MR Scan, showing Lateral and Medial Rectus of both Eyes . . . . . . . . . 23
2.10 Axial MR Scan using Contrast Agent, showing Lateral and Medial Rectus of both
Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.11 Comparison of MR Scans in dierent Gaze Positions . . . . . . . . . . . . . . . . 24
2.12 Human Dissection of the Orbit showing Medial Rectus Pulley . . . . . . . . . . . 25
2.13 Line of Sight, Vertical and Horizontal Axes; Rotations to Other Eye Positions . . 26
2.14 Binocular Fixation of an Object in Space . . . . . . . . . . . . . . . . . . . . . . 27
2.15 Rotational Directions for both Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.16 Simple Abstraction of Listings Law . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.17 Denition of Listings Law w.r.t. Primary Position . . . . . . . . . . . . . . . . . 32
2.18 Recording of Saccadic Eye Movements . . . . . . . . . . . . . . . . . . . . . . . . 34
2.19 Ocular Motor Neurons and Motor Nuclei . . . . . . . . . . . . . . . . . . . . . . . 35
2.20 Oculomotor Nerve Circuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.21 Location and Distribution of Oculomotor Nerves . . . . . . . . . . . . . . . . . . 37
2.22 Motor Circuit for Horizontal Saccades . . . . . . . . . . . . . . . . . . . . . . . . 39
2.23 EOG Eye Movement Measurement Technique . . . . . . . . . . . . . . . . . . . . 42
2.24 Schematic Overview of Purkinje Corneal Reections . . . . . . . . . . . . . . . . 44
2.25 Purkinje Reections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.26 Electromagnetic Search Coil Eye Position Measurement . . . . . . . . . . . . . . 45
2.27 Insertion Procedure for a Scleral Search Coil Lens . . . . . . . . . . . . . . . . . . 46
2.28 Video-Oculography Pupil Detection . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.29 Chronos VOG System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.30 Dierent Types of Muscle Force Measurement . . . . . . . . . . . . . . . . . . . . 48
2.31 Example of measuring Force with Forceps . . . . . . . . . . . . . . . . . . . . . . 49
2.32 Muscle Force Transducer for Intraoperative Measurements . . . . . . . . . . . . . 50
xii
2.33 Intraconal Tissue Motion around the Optic Nerve . . . . . . . . . . . . . . . . . . 51
3.1 Projection of Objects in Space onto the Retina on an Eye . . . . . . . . . . . . . 57
3.2 Dierent Forms of Binocular Fixation . . . . . . . . . . . . . . . . . . . . . . . . 58
3.3 Example for Inward Squinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.4 Example for Outward Squinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.5 Example for Upward Squinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.6 Example for Downward Squinting . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.7 Pseudo-Esotropia due to wide Bridge and Epicanthal Skin Fold . . . . . . . . . . 62
3.8 Hirschberg Light Reex Test Method . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.9 Krimsky Light Reex Test Method . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.10 Prism-Cover Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.11 Cover Tests for Tropias and Phorias . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.12 Maddox-Wing Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
3.13 Binocular Fixation in the Hess-Lancaster Test . . . . . . . . . . . . . . . . . . . . 67
3.14 Hess-Lancaster Diagram for Right Eye (Left Eye Fixing) . . . . . . . . . . . . . . 68
3.15 Interpretation of Hess-Diagram according to Muscle Actions . . . . . . . . . . . . 68
3.16 Hess-Diagram Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.17 Example of Disturbance of the Binocular Muscular Team . . . . . . . . . . . . . 72
3.18 Example of Abnormal Head Posture, Compensating Esotropia . . . . . . . . . . . 73
3.19 Example of a Right Superior Rectus Palsy . . . . . . . . . . . . . . . . . . . . . . 74
3.20 Hess-Lancaster Chart for Right Superior Rectus Palsy . . . . . . . . . . . . . . . 75
3.21 Example of a Right Superior Oblique Palsy . . . . . . . . . . . . . . . . . . . . . 76
3.22 Hess-Lancaster Chart for Right Superior Oblique Palsy . . . . . . . . . . . . . . . 77
3.23 Example for Duanes Retraction Syndrome Type 3 of a Right Eye . . . . . . . . . 78
3.24 Example for Browns Syndrome of a Right Eye . . . . . . . . . . . . . . . . . . . 79
3.25 Example for an Abducens Gaze Palsy . . . . . . . . . . . . . . . . . . . . . . . . 82
3.26 Schematic Example of Muscle Recession . . . . . . . . . . . . . . . . . . . . . . . 84
3.27 Preparation for Medial Rectus Recession . . . . . . . . . . . . . . . . . . . . . . . 84
3.28 Medial Rectus Recession, continued . . . . . . . . . . . . . . . . . . . . . . . . . . 85
3.29 Medial Rectus Recession, continued . . . . . . . . . . . . . . . . . . . . . . . . . . 85
3.30 Schematic example of Muscle Resection . . . . . . . . . . . . . . . . . . . . . . . 86
3.31 Medial Rectus Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
3.32 Medial Rectus Resection, continued . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4.1 Halles Ophthalmotrope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
4.2 Ruetes Ophthalmotrope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3 Coordinate System of a Left Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.4 Gimbal Systems for describing 3D Eye Position . . . . . . . . . . . . . . . . . . . 95
4.5 Geometrical Abstraction of the Globe . . . . . . . . . . . . . . . . . . . . . . . . 105
4.6 Geometrical Abstraction of an Eye Muscle . . . . . . . . . . . . . . . . . . . . . . 106
4.7 Geometrical String Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.8 Point of Tangency in the String Model . . . . . . . . . . . . . . . . . . . . . . . 108
4.9 Tape Model Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
4.10 Geometrical Tape Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
4.11 Comparison of Conventional vs. Pulley Model . . . . . . . . . . . . . . . . . . . . 112
4.12 Primary Position in Pulley Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
xiii
4.13 Tertiary Position in Pulley Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
4.14 Muscle Action Circles in Pulley Model . . . . . . . . . . . . . . . . . . . . . . . . 116
4.15 Muscle Direction Vector in Pulley Model . . . . . . . . . . . . . . . . . . . . . . . 117
4.16 Muscle Rotation Axis and Action Circle Center in Pulley Model . . . . . . . . . . 118
4.17 Point of Tangency in Pulley Model . . . . . . . . . . . . . . . . . . . . . . . . . . 119
4.18 Muscle Path Comparison using Dierent Geometrical Models . . . . . . . . . . . 119
4.19 Muscle Force Distribution in String and Tape Model . . . . . . . . . . . . . . . . 121
4.20 Muscle Force Distribution in the Pulley Model . . . . . . . . . . . . . . . . . . . 121
4.21 Elastic Force Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
4.22 Contractile Force Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
4.23 Total Force Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
4.24 Apex Coordinate System for measuring Globe Translation . . . . . . . . . . . . . 132
4.25 Torque Error Function for Listing Positions in a Healthy Eye . . . . . . . . . . . 135
4.26 Torque Error Function for Pathological Eye . . . . . . . . . . . . . . . . . . . . . 136
4.27 Torque Error Minimization in solving for Eye Positions . . . . . . . . . . . . . . . 141
4.28 Squint-Angles Diagram for Binocular Fixation . . . . . . . . . . . . . . . . . . . . 143
4.29 Simulation Task Flow for the Hess-Lancaster Test . . . . . . . . . . . . . . . . . . 145
5.1 DXF Model Generation Tasks using Marching Cubes . . . . . . . . . . . . . . . . 149
5.2 Sorting of Color Index Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
5.3 Denition of 2D Polygon for MRI Segmentation . . . . . . . . . . . . . . . . . . . 151
5.4 Threshold Region for MRI Slice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
5.5 Marching Cube Traversal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
5.6 Marching Cubes Standard Classes . . . . . . . . . . . . . . . . . . . . . . . . . . 153
5.7 Surface Reconstruction Tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
5.8 DXF Model with Area Centroids . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
5.9 Approximation of the Muscle Path . . . . . . . . . . . . . . . . . . . . . . . . . . 158
5.10 Angular Measurement of Surface Points . . . . . . . . . . . . . . . . . . . . . . . 159
5.11 Example of Analysis of Variance . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
5.12 NURBS Approximation of Muscle Cross-Section . . . . . . . . . . . . . . . . . . . 162
5.13 Linear Interpolation of NURBS-generated Cross-Section . . . . . . . . . . . . . . 163
5.14 Reconstruction of a Left Medial Rectus Muscle . . . . . . . . . . . . . . . . . . . 166
5.15 Shaded Reconstruction of a Left Medial Rectus Muscle . . . . . . . . . . . . . . . 167
5.16 Morphology of Reconstructed Medial Rectus Muscle . . . . . . . . . . . . . . . . 167
5.17 Shaded Reconstruction of a Left Medial Rectus Muscle with MRI Data . . . . . . 168
6.1 Structure of the SEE++ Software System . . . . . . . . . . . . . . . . . . . . . 170
6.2 Model-View-Controller Structure of the SEE++ Software System . . . . . . . . 171
6.3 Abstraction of Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
6.4 Primary Abstractions for Biomechanical Model . . . . . . . . . . . . . . . . . . . 173
6.5 Extensible Software Design for the Biomechanical Model . . . . . . . . . . . . . . 174
6.6 Optimizer and Related Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
6.7 Structure of the SEE++ Package . . . . . . . . . . . . . . . . . . . . . . . . . . 176
6.8 Structure of the SeeMedic Package . . . . . . . . . . . . . . . . . . . . . . . . . 177
6.9 Structure of the SeeModel Package . . . . . . . . . . . . . . . . . . . . . . . . . 178
6.10 Structure of the SeeView Package . . . . . . . . . . . . . . . . . . . . . . . . . . 179
6.11 Muscle Force Vector Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
xiv
6.12 Simulation Task Flow for using SEE++ . . . . . . . . . . . . . . . . . . . . . . 181
6.13 Default View of the SEE++ Software System . . . . . . . . . . . . . . . . . . . 183
6.14 Globe Data Parameters of the SEE++ System . . . . . . . . . . . . . . . . . . 183
6.15 Muscle Data Parameters of the SEE++ System . . . . . . . . . . . . . . . . . . 184
6.16 Gaze Pattern Dialog of the SEE++ System . . . . . . . . . . . . . . . . . . . . 185
6.17 Muscle Properties for Abducens Palsy Simulation . . . . . . . . . . . . . . . . . . 187
6.18 Hess-Lancaster Test for Abducens Palsy . . . . . . . . . . . . . . . . . . . . . . . 187
6.19 Simulation of Right Lateral Rectus Resection . . . . . . . . . . . . . . . . . . . . 188
6.20 Postoperative Hess-Lancaster Simulation for Abducens Palsy . . . . . . . . . . . 189
6.21 Muscle Properties for Superior Oblique Palsy . . . . . . . . . . . . . . . . . . . . 190
6.22 Hess-Lancaster Simulation of Superior Oblique Palsy . . . . . . . . . . . . . . . . 190
6.23 Postoperative Hess-Lancaster Simulation for Superior Oblique Palsy . . . . . . . 191
6.24 Classication of Superior Oblique Overaction . . . . . . . . . . . . . . . . . . . . 192
6.25 Hess-Lancaster Simulation of Superior Oblique Overaction . . . . . . . . . . . . . 193
6.26 Simulation of Superior Oblique Surgery . . . . . . . . . . . . . . . . . . . . . . . 194
6.27 Hess-Lancaster Simulation of Superior Oblique Surgery . . . . . . . . . . . . . . . 194
6.28 Muscle Displacement as Hypothesis for Heavy-Eye Syndrome . . . . . . . . . . . 195
6.29 Measured Values from Patient with Heavy-Eye Syndrome . . . . . . . . . . . . . 196
6.30 Simulation Results for Resized Globes according to Patient Data . . . . . . . . . 197
6.31 Simulation Attempt using Data suggested by Schroeder and Krzizok . . . . . . . 197
6.32 Superior Oblique Muscle Insertion Transposition in Heavy-Eye Simulation . . . . 198
6.33 Hess-Lancaster Simulation Results of the Heavy-Eye Syndrome . . . . . . . . . . 199
6.34 Muscle Surgery for Heavy-Eye Simulation . . . . . . . . . . . . . . . . . . . . . . 199
6.35 Hess-Lancaster Simulation Results of the Heavy-Eye Surgery . . . . . . . . . . . 200
xv
Chapter 1
Introduction
The research work presented in this document describes a successful combination and application
of interdisciplinary research in the elds of computer science and eye muscle strabismus surgery.
Basic medical research was incorporated in a mathematical model and subsequently realized
as interactive software system for clinical usage. The main goal of this work was application-
oriented research in order to realize a software system that directly aects advancement in patient
treatment.
The goal of this thesis is to prove that software simulation systems can be of valuable assistance
in surgical decision making in the eld of eye muscle strabismus surgery. The combination of
essential diagnostic data of individual surgical cases, its diagnosis and and its possible treatments
into a well designed, clinically applicable computer software system is presented. A new way of
interactive, virtual eye muscle surgery evaluation an preoperative planning method is proposed,
based on a biomechanical model of the human eye in order to predict surgical outcomes on
the basis of objective, anatomically related and measurable data. Additionally, physiologically
meaningful three-dimensional visualization proves to support detailed evaluation and meaningful
interpretation of disorders of the human eye movements. However, it is not intended to replace
common clinical diagnostics, nor surgical expertise, instead, the proposed work should be con-
sidered as a clinical decision support tool to process diagnostic data into possible choices and
amounts of surgery in an objective manner.
1.1 Overview
Due to the extensive medical implication of this work, the rst two Chapters give an overview of
medical foundations within the eld of ophthalmology with special regard to strabismus. In Chap-
ter 2, the basic anatomy of the human eye, its muscles and the orbita are explained. Additionally,
anatomical measurements provide quantitative data based on available literature. Magnetic res-
onance imaging studies and human dissection were performed within the presented research work
that provide detailed data on the anatomy and physiology of the extraocular eye muscles. Results
from magnetic resonance imaging (MRI) studies explained in Sec. 2.1.4 were used to visualize
three dimensional muscle morphology (cf. Ch. 5) which resulted in the most detailed model-based
visualization of human eye muscles currently available.
1
CHAPTER 1. INTRODUCTION 2
Understanding eye movement physiology is very important in order to build a biomechanical
model. Therefore, Chapter 2 contains valuable information on kinematic principles of ocular
movements as well as detailed information on sensorimotor control and neural signal encoding.
Especially important for biomechanical modelling are kinematic and sensory principles that have
been identied as central laws that constrain ocular movements. All these principles need to be
included in a biomechanical model that gives anatomically related predictions.
In order to relate predictions of a simulation model to clinical data, diagnostic methods are needed
to quantify eye motility disorders. These methods are presented in Sec. 2.3 where measurement
results serve as starting point for the simulation of pathological situations. Additionally, physio-
logic muscle force measurements that were carried out by a partner institution (Smith Kettlewell
Eye Research Institute, San Francisco) are introduced in Sec. 2.3.2. These measurements were
included in the biomechanical model in order to simulate muscle forces.
In Chapter 3 of this thesis, the eld of strabismus is introduced. Since the main goal of the
biomechanical model and the software system that are presented in this thesis is the application
in the eld of strabismus, it is essential to understand function and basic medical diagnosis and
treatment in the eld of strabismus. Therefore, Chapter 3 gives an overview of the physiology
of binocular vision and ocular dissociation in Sec. 3.2 and Sec. 3.3. In Sec. 3.4 the clinical
assessment of eye motility disorders is described. Without the use of simulation model, these
mostly subjective measurement methods are currently the only diagnostic basis. In Sec. 3.5,
major categories and examples of important eye motility disorders are explained, whereas Sec. 3.6
describes the most important treatment methods within surgical interventions.
In Chapter 2 as well as in Chapter 3 of this thesis, illustrations of eye muscle anatomy and
examples of major eye muscle disorders were already produced with the biomechanical simulation
system SEE++.
In Chapter 4, the major part of the presented research work is described. In Sec. 4.2, the
structure of a biomechanical model is described which can be split into geometrical, muscle force
and kinematic sub models. In this work, a unique mathematical formulation of ocular geometry
using quaternions is described in Sec. 4.4. Furthermore, the mathematical implementation of
the muscle force prediction model is explained in Sec. 4.5. Another major achievement that
accounts for the stability of simulation predictions is the formulation of the kinematic model,
explained in Sec. 4.6, that connects geometry and muscle forces in order to solve a standard non-
linear minimization problem. Currently, this is the only biomechanical eye model that strictly
dissociates geometry from muscle force and kinematics. Through the application of standard
non-linear numerical minimization methods, the accuracy of simulation predictions with respect
to clinical measurements is unique for this type of medical application.
In Chapter 5 of this thesis, a new approach of three dimensional reconstruction of shape and
morphology of the extraocular muscles is presented. Reconstruction results were incorporated in
the software simulation system SEE++ in order to visualize anatomically related data. Image
analysis and image processing methods were used to generate interpolated muscle models that
were connected to the muscle force simulation of the biomechanical model.
Finally, Chapter 6 gives an overview of the software system design for the biomechanical model as
well as for the software system SEE++ that has been implemented. Modern methods in object
oriented software engineering were used to build a generic extensible and robust software system
CHAPTER 1. INTRODUCTION 3
that provides exibility for further advancements. An additional feature is that the biomechan-
ical model can be seen as autonomous part within the software simulation system SEE++.
While the software system provides user interface, most advanced three dimensional interactive
visualization and representation of biomechanical parameters as anatomically meaningful prop-
erties, the biomechanical model implements and encapsulates the mathematical formulation for
geometric, muscle force and kinematic models. Therefore, in Sec. 6.1, main parts of the software
design of the biomechanical model are explained and in Sec. 6.2, main aspects of the design model
of the SEE++ software system are described.
Additionally, in Chapter 6 the user interface and simulation parameters of the SEE++ software
system are explained in Sec. 6.3. This Chapter then concludes with case studies showing dierent
eye motility disorders that were simulated with the SEE++ system. Currently, SEE++ is
the only simulation system that is able to also simulate complex eye motility disorders as shown
in the Heavy-Eye example in Sec. 6.4.4.
1.2 Medical Informatics
The rapid development of computer systems increasingly enables the use of software systems
within the medical eld. Ecient computers for image processing and 3D-graphics in combination
with specialized systems oer a practical supplement e.g. in medical diagnostics. In building
such systems, interdisciplinary research in the elds of e.g. medicine, mathematics, physics and
informatics is inevitable. Generally, research activities in the described eld can be assigned to the
eld of Medical Informatics, which is dened as the application of computers, communications and
information technology and systems to all elds of medicine - medical care, medical education and
medical research [BM00a]. Therefore, this eld combines medical science with several technologies
and disciplines in the information and computer sciences and provides methodologies by which
these can contribute to better use of the medical knowledge base and ultimately to better medical
care [BM00a].
Medical Informatics range from computer-based patient records to image processing and from
primary care practices to hospitals of health care. Processing information plays a vital role
in health care since the eld of medical knowledge is growing every day, and there needs to
be a way to properly formalize, store, process, and access that knowledge. Diseases and their
diagnosis are being explored more and more so health care professionals have to take advantage
of the information. The number of administrative and legal requirements dealing with processing
information is on the rise. Information technology, if utilized correctly, can improve health care
tremendously which is why health care professionals have to be educated about health and medical
informatics.
The presented research work focuses on simulation software systems providing medical decision
support by using methods and technologies for the elds of mathematics, physics and software
engineering. A substantial criterion for the application of such systems in practice is the reliability
of medically relevant data or results, as well as the scope of interpretation applied to such data.
In the application of virtual reality in connection with surgical interventions, the success of an
operation is substantially inuenced by data obtained from such a system. Detailed graphical
visualization enables the surgeon to preoperatively simulate a disease, and afterwards by means of
CHAPTER 1. INTRODUCTION 4
(a) Segmentation (b) Rendering
Figure 1.1: Example Applications Based on Data from the Visual Human Project
r
, from [Ack02]
interactive virtual surgery, plan, check and possibly even correct a surgical procedure in order to
achieve the best result. Continuous endeavor of current research is associated with the so called
Visual Human Project
r
(Fig. 1.1), an anatomically detailed, three-dimensional representation
of human bodies, in order to use these data in dierent elds of application (e.g. Visible Human
Explorer, Cross Sectional Anatomy, Voxelman
r
, Body Navigator, etc.) [Ack02]. Acquisition
of transverse computed tomography (CT), magnetic resonance (MR) and cryosection images of
representative male and female cadavers has been completed. The male was sectioned at one
millimeter intervals, the female at one-third of a millimeter intervals. The long-term goal of the
Visible Human Project
r
is to produce a system of knowledge structures that will transparently
link visual knowledge forms to symbolic knowledge formats such as the names of body parts.
Another goal of this work is to represent the function of the human body as realistically as possible
by trying to apply well-known relationships from the mechanics to the anatomy of humans.
Complex mathematical models of skeletons, muscles, joints and their graphical, three-dimensional
visualization form the basis of an interactive system. By means of systematic studying of such
systems, new insight can be derived, integrated into the model and subsequently be used to
extend research.
1.3 Clinical Decision Support
In order to improve a patients prognosis, clinicians continuously make decisions on what di-
agnostic procedures they should perform and on what therapeutic actions they should take.
Clinical decision support tools may provide predictions on e.g. the diagnosis of a disease and
potential promising treatment suggestions on the basis of clinical information about a patient.
However, clinical information can be gathered in many dierent ways by using existing informa-
tion technology infrastructure. Clinical decision support tools often make use of dierent sources
of information (Fig. 1.2 [BK03a]) e.g. medical information systems provide electronic medical
patient records or protocol-based systems oer standard algorithms that dene one precise man-
ner in which certain classes of patients should be evaluated or treated. Language coding and
classication systems complement these systems by realizing natural, intuitive interfaces. Com-
munication systems in health care (e.g. workow management tools and electronic transmission
CHAPTER 1. INTRODUCTION 5
of diagnostic ndings) properly arrange selective distribution of medically relevant information.
Figure 1.2: Classication of Clinical Decision Support Systems
Intelligent clinical decision support systems overlap the described technologies for the purpose of
combining medical and administrational data in order to build up clinical useful knowledge within
certain disciplines. Methods and models that operate on this data and are specically designed
for investigations in certain medical elds enable the formulation of predictive conclusions in
order to evaluate diagnosis and treatment options. By means of systematic analysis of patient
data, such systems may support clinicians in their decision-making processes. The development
of predictive decision support tools concentrates on ve main steps [BM00a]:
1. Analysis: In this step, the clinical problem and its specic characteristics must be exam-
ined. This process must be described clearly, including the potential role of the decision
support tool.
2. Outcome: The desired clinical outcome that clinicians consider central for decision making
must be indicated. In most cases, these outcomes are dened in clinically related groups of
diseases or diagnoses.
3. Predictors: This determines the clinical characteristics that might be used as predictors
of the clinical outcome. Predictors directly inuence the way a patient is treated and thus
transitively determine the treatment outcome.
4. Quantication: This step denes a relation between the predictors and the clinical out-
come. The quantication may be provided by expert clinicians who possess the clinical
knowledge and is captured within a mathematical description (e.g. statistical model).
5. Presentation: The predictive decision support tool needs to be presented to the users in
an applicable way. Often, this includes the design and implementation of an interactive
software system, incorporating predictors and quantication relationships.
The research work presented here describes the analysis, design, implementation and application
of a clinical decision support tool in the eld of eye muscle strabismus surgery.
CHAPTER 1. INTRODUCTION 6
1.4 Eye muscle surgery
Surgery of the eye muscles is surgery to weaken, strengthen, or reposition any of the eye muscles
that move the eyeball (the extraocular muscles). The purpose of eye muscle surgery is generally
to align the pair of eyes so that they gaze in the same direction and move together as a team,
either to improve or maintain binocular vision, or to improve the orientation of both eyes. To
achieve binocular vision, corresponding images need to be projected onto corresponding areas of
the retinae of both eyes. In addition, eye muscle surgery can improve eye alignment in people
with other e.g. neurologically caused eye disorders (Nystagmus, Duane Syndrome, etc.).
Depth perception (stereopsis) develops around the age of three months. In case of misaligned
eyes, successful development of binocular vision and the ability to perceive three-dimensionally
is constricted. Surgery should not be postponed past the age of four since immediate sensory
adaptations occur in the early stage of growth.
The six extraocular muscles attach via tendons to the sclera (the white, opaque, outer protective
covering of the eyeball) at dierent places just behind an imaginary equator encircling the top,
bottom, left, and right of one eye. The other end of each of these muscles attaches to a part
of the orbit (the eye socket in the skull). These muscles enable the eyes to move up, down,
to one side or the other, or any angle in between. Modication of one eye muscle also aects
control signals of the brain to the other eye. Normally both eyes move together, receive the
same image on corresponding locations on both retinas, and the brain fuses these images into one
three-dimensional image. The exception is in strabismus which is a disorder where one or both
eyes deviate out of alignment, most often outwardly (exotropia) or toward the nose (esotropia),
sometimes upward (hypertropia) or downward (hypotropia). The brain now receives two dierent
images, and either suppresses one or the person sees double (diplopia). This deviation can, in
most cases, be adjusted by weakening or strengthening the appropriate muscles to move the eyes
toward the center. For example, if an eye deviates upward, the muscle at the bottom of the
eye could be strengthened. Both eyes are controlled by twelve eye muscles (six muscles per eye)
including combined bilateral brain signals that form a highly complex mechanical system. In a
nutshell, the human mechanical eye system seems to work very hard and complicated in order to
give a simple impression.
One main problem in treating eye alignment disorders is, that there is no clinical theory available
that exactly denes surgical treatment consequences based on diagnostic measurements. Up to
now, clinicians use their own practical experience and raw statistical data to derive dose-response
relationships for certain pathological situations [SS00]. This results in repeated surgery, especially
in case of complicated, combined eye alignment disorders. This leads to the establishment of
dierent treatment philosophies without verication of underlying correlation to mechanical
and/or neurological properties. Another issue aects incorporation of patient specic data in
order to adjust accuracy of existing statistical approaches. Moreover, the actions of eye muscles
vary as a function of eye position, thus, eect of eye muscle surgery must be evaluated within a
specic eld of gaze. Realigning both eyes with respect to only one eye position is most often
not sucient to achieve a satisfying result. Many clinical approaches have been undertaken to
dene certain guidelines for eye muscle surgery, however, all of these assumptions are based on
dierent ideas of the mechanical behavior of the human eye system (e.g. [Pri81]). Clinicians
and teachers still legitimate decisions based upon outdated assumptions of the action of the
extraocular muscles. Since the problem of building up fundamental strategies for clinical use, in
CHAPTER 1. INTRODUCTION 7
this case, lies in the lack of denitions for elementary concepts describing the modes of operation
of the human extraocular system, new approaches had to be found.
1.5 SEE-KID
The research work SEE-KID (Software Engineering Environment for Knowledge based Inter-
active Eye motility Diagnostics), described in this work, tries to connect aspects of biomechanical
modelling with methods of modern software engineering [BM00b]. This work is carried out at
the Upper Austrian Research Center at the department for Medical-Informatics in close cooper-
ation with the Upper Austrian University of Applied Sciences in Hagenberg. With international
partners (e.g. ETH-Zrich and Smith Kettlewell Eye Research Institute in San Francisco), this
project started in 1995 and was supported by funding of the Austrian Ministry for Science and
Technology (FFF) within the years 2000 and 2002. Additionally, partners from Austrian hos-
pitals and research centers in Linz, St. Plten, Innsbruck and Graz greatly contributed to this
work as evaluation partners.
Originally, this research project was initiated by Prim. Prof. Dr. Siegfried Priglinger, head of
the department of ophthalmology at the convent hospital of the Barmherzigen Brder in Linz,
Austria. This department has specialized in correcting eye motility disorders, particularly in
infants, by e.g. recession or resection of certain eye muscles. Most of these surgeries must be
performed at an early age. In order to avoid a permanent misalignment and a sensory adaptation
resulting from it, children must be operated according to individual strategies (e.g. brosis syn-
drome) as soon as possible. Prerequisite for such surgeries is an early diagnosis and a conservative
treatment plan that includes e.g. masking (covering the better eye to stimulate the recovery of
the pathological eye).
For the success of an eye muscle surgery, an understanding of the disease mechanism and the
anatomically functioning mechanisms is necessary, in order to avoid wrong or multiple surgical
treatments.
Such model-supported eye muscle operations have been performed at the hospital of the Barm-
herzigen Brder in Linz, Austria, since 1978. Also, new operation techniques and treatment op-
tions have been developed during this time. Particularly complicated surgeries must be planned
in detail and suitable operation steps must be selected. At present, surgical procedures can be
evaluated and improved so far only directly at the patient. In complicated eye motility disorders,
even an experienced surgeon will depend on documented empirical values, which often lead to
multiple treatments until the result is satisfying. The result of this research work is a software
system (SEE++, Fig. 1.3), which enables physicians to simulate eye motility disorders on the
basis of measurements from the patient and to perform all possible surgical treatments inter-
actively. Using a 3D representation of the anatomy of the human eye, the surgeon can model
disorders as deviations from a non-pathological healthy eye. Thus the surgeon can determine
the optimal treatment for the patient and plan its proceeding in detail.
The simulated outcome of a virtual surgery is displayed interactively in the 3D visualization, as
well as through measuring parameters and diagrams familiar to clinicians. In addition, reference
points and measured values are displayed to the surgeon, enabling better orientation while oper-
ating. Moreover, the SEE++ system permits to exchange the model base interactively, therefore,
CHAPTER 1. INTRODUCTION 8
Figure 1.3: SEE++ Virtual Eye Muscle Surgery Software
model predictions can be compared by applying dierent modelling strategies on the y. An-
other benet of this system is that it is capable of simulating binocular highly complex diseases
including neurologically caused pathologies (e.g. nuclear, inter- or supranuclear lesions).
Chapter 2
Medical Foundations
Understanding visual experience has long challenged the best of human minds, from the Ancient
Greeks interest in optics to the study of visual perception by contemporary psychologists and
neuroscientists. Todays scientic study of perception seeks to understand the nature of our
experience in terms of the underlying mechanisms by which it occurs. Understanding the anatomy
and functional behavior of the human eye is causally related to explaining the process of visual
perception.
Ongoing new discoveries implying extensive clinical consequences clearly point out, that the basic
anatomy and physiology of the human eye is still not explored to the full extent. Especially, new
ndings concerning the structure and behavior of eye muscles suggest that the human eye ranks
among the most complex human organs. New radiologic inventions (e.g. MRI, CT, PET and hy-
brid technologies [BWM
+
01]) extend the abilities for diagnostic and scientic exploration. This
also explains why todays fundamental medical research needs interdisciplinary approaches com-
prising collaborations of clinicians, technical engineers, mathematicians and physicists. Without
the invention and incorporation of new technologies, medical research would not emerge that
eectively.
This chapter will give a basic overview of the human eyes anatomy which will be required in
order to fully understand principles and properties of the oculomotor plant that will be described
throughout this thesis. Additionally, physiologic and neurologic principles of oculomotor control
will be explained providing deeper insight into important aspect of the visual system. Moreover,
common measurement techniques are presented, giving new insight into the function of the human
visual system. Especially in research, these methods are essential for the discovery and validation
of various properties of the oculomotor system.
9
CHAPTER 2. MEDICAL FOUNDATIONS 10
Medical professionals and researchers in the medical-technical elds often refer to sections of the
body in terms of anatomical planes (at surfaces). These planes are imaginary lines - vertical
or horizontal - drawn through an upright body. The terms are used to describe a specic body
part. Fig. 2.1 gives an overview of these anatomical naming conventions.
Figure 2.1: Denition of Anatomical Planes
In Tab. 2.1 general anatomical terms and their meanings are listed. The naming for the anatom-
ical planes often dier between coronal plane or frontal plane, sagittal plane or lateral plane and
axial plane or transverse Plane.
Anatomical Terms Direction
Medial Toward the midline of the body
Lateral Away from the midline of the body
Proximal Toward a reference point (extremity)
Distal Away from a reference point (extremity)
Inferior Lower or below
Superior Upper or above
Cephalad or Cranial Head
Caudal or Caudad Tail, tail end
Anterior or Ventral Toward the front
Posterior or Dorsal Toward the back
Table 2.1: Terms of Medical Directions
CHAPTER 2. MEDICAL FOUNDATIONS 11
2.1 Anatomy of the Human Eye
The eyes, the sense of perception , rank among the most important sensory organs of the human
organism. They supply us with a constantly updated picture of the environment. The following
explanations refer to a right eye. The eyeball or globe (lat. bulbus oculi, briey bulbus, approx.
24 mm, approximately spherical [PD01]) lies protected in the orbita, recessed in the head.
Fig. 2.2 shows the bony orbita of a right eye. The human orbita is shaped pyramidal and is
approx. 40-50 mm deep. The back end of the orbita (orbital apex) is situated right next to the
optic canal which acts as passage for the optical nerve and the ophthalmic arteries. Except for
the solid orbital boundary, orbital bones are extremely thin.
(a) Orbital bones (b) Orbital apex with nerves and arteries
Figure 2.2: View of the Bony Orbita of a Right Eye [KJCS99]
Referring to Fig. 2.2(a), the following bone structures can be identied:
(1) Os lacrimale - the lacrimal bone, an irregularly rectangular thin plate, forming part of the
medial orbital wall of the orbit behind the frontal process of the maxilla (the upper jaw
bone).
(2) Os ethmoidale - the ethmoid bone, an irregularly shaped bone lying between the orbital
plates of the frontal and anterior to the sphenoid bone (3).
(3) Os sphenoidale - a bone of most irregular shape occupying the base of the skull.
(4) Os zygomaticum - the zygomatic bone, a quadrilateral bone which forms the prominence
of the cheek.
(5) Os frontale - the frontal bone, a large single bone forming the forehead and the upper
margin and roof of the orbit on either side.
(6) Os maxillare - the maxillary bone or the maxilla, an irregularly shaped bone that with its
fellow forms the upper jaw.
In Fig. 2.2(b), a schematic view of the orbital ssures, consisting of a inferior and superior part.
The inferior orbital ssure is a cleft between the greater wing of the sphenoid and the orbital plate
CHAPTER 2. MEDICAL FOUNDATIONS 12
of the maxilla, through which pass the maxillary division and the orbital branch of the trigeminal
nerve (face nerve) and the infraorbital vessels. The superior orbital ssure is located between the
greater and the lesser wings of the sphenoid establishing a channel of communication between
the middle cranial fossa and the orbit, through which pass the oculomotor and trochlear nerves,
the ophthalmic division of the trigeminal nerve, the abducens nerve, and the ophthalmic veins.
For this work, the area to concentrate on will be the superior orbital ssure, since it provides a
passage for all nerves that control the visual organ.
According to Fig. 2.2(b), the following nerves and vessels can be distinguished:
(1) Vena ophthalmica superior - the superior ophthalmic vein
(2) Nervus lacrimalis - the lacrimal nerve, a branch of the ophthalmic nerve supplying sensory
bres to the lateral part of the upper eyelid, conjunctiva, and lacrimal gland (the gland
that secretes tears).
(3) Nervus frontalis - the frontal nerve, a branch of the ophthalmic nerve which divides within
the orbit into the supratrochlear and the supraorbital nerves.
(4) Nervus trochlearis - the trochlear nerve that controls the superior oblique eye muscle.
(5) Nervus oculomotoris - the oculomotor nerve is responsible for motor innervation of the
upper eyelid muscle, extraocular muscle and pupillary muscle.
(6) Nervus abducens - the abducent nerve, innervates the lateral rectus eye muscle.
(7) Nervus nasociliaris - the nasociliary nerve is a branch of the ophthalmic nerve in the su-
perior orbital ssure, passing through the orbit, giving rise to the communicating branch to
the ciliary ganglion, the long ciliary nerves, the posterior and anterior ethmoidal nerves, and
terminating as the infratrochlear and nasal branches, which supply the mucous membrane
of the nose, the skin of the tip of the nose, and the conjunctiva.
(8) Vena ophthalmica inferior - the inferior ophthalmic vein
(9) Nervus opticus - the optic nerve which is carrying all impulses for the sense of sight.
(10) Arteria ophthalmica - the ophthalmic artery originating from the internal carotid artery
and distributing to the eye, orbit and adjacent facial structures.
The orbita is covered by the periost (or periorbita), a membrane of brous connective tissue which
closely invests all bones except at the articular surfaces. From there, connective tissue and septa
stabilize and cover intraorbital structures (e.g. globe, muscles and vessels). This anatomical
structure is also known as Tenons capsule.
The globe or bulbus (Fig. 2.3) is built bulb at-like, composed of three layers of skin [SS98]:
sclera (leather skin) - outer eye skin,
choroidea (vein skin) - middle eye skin, the middle layer of the globe, between retina and
sclera
CHAPTER 2. MEDICAL FOUNDATIONS 13
retina (retina) - internal eye skin.
Figure 2.3: Anatomy of the Globe [KJCS99]
Like a high sophisticated camera, the eye has multiple discrete parts which must function together
properly to produce a clear vision. To illustrate this, the path of light as it travels through the
eye is discussed, and the various ocular structures are identied.
Cornea: The rst surface encountered by a ray of light is the tear lm. The eyes surface must
be kept moist at all times. To achieve this, glands in and near of the eyelids produce both
tears and a special oil which mix together and coat the eye. This tear lm coats the cornea
which normally is the crystal clear window to the eye. Behind the cornea, the anterior
chamber is situated, which is lled with aqueous uid. The aqueous is usually clear like
water and is responsible for maintaining the pressure of the eye.
Iris: Inside the anterior chamber is the iris. This is the part of the eye which is responsible for
the eye-color perceived from an outside viewer. It acts like the diaphragm of a camera,
dilating and constricting the pupil to allow more or less light into the eye.
Lens: The next structure encounter is the crystalline lens. The lens is responsible for focusing
light onto the retina. It changes shape slightly to allow adaption of focus between objects
that are near and those that are far. During the process of aging, the lens becomes less
exible and able to accommodate or change focus.
Vitreous: This is a jelly-like substance that lls the body of the eye. It is normally clear and
in early life, it is rmly attached to the retina behind it. With age, the vitreous becomes
more water-like and may detach from the retina. Often, little clumps or strands of the jelly
form and cast shadows which are perceived as oaters.
Retina: Finally, light reaches the retina, a thin tissue lining the innermost wall of the eye. The
retina acts much like the lm in a camera. The retina responds to light rays hitting it and
converts them to electrical signals carried by the optic nerve to the brain. The outlying
parts of the retina are responsible for peripheral vision while the center area, called the
CHAPTER 2. MEDICAL FOUNDATIONS 14
macula, is used for ne central vision and color vision. The very center of the macula is
called the fovea. It has a very high concentration of special cells (cones) which make it
the only part of the retina capable of 20/20 vision
1
.
Retinal Layers: Like lm, the retina is composed of several layers with dierent roles. The rst
layer encountered by light is called the nerve ber layer. Here, the nerve cells travel from
all the parts of the retina to the optic nerve. Under this layer, most of the retinal blood
vessels are located. They are responsible for supplying the inner parts of the retina. The
outermost layer is the the photoreceptor layer. The photoreceptor layer, composed of cones
for ne and color vision, and rods for vision in dim light, consists of the cells that actually
convert light into nerve impulses. There are approximately 120 million rods and 6 million
cones in a human retina. Most of the cones are located in the macula. The photoreceptor
cells lie on top of a layer of cells called the retinal pigment epithelium or RPE. The RPE is
responsible for keeping the photoreceptors healthy and functioning well. Under the RPE is
the retinas second set of blood vessels which are in a layer called the choroid. The RPE,
fed by the blood vessels of the choroid, supply the photoreceptors.
Optic Nerve: The optic nerve is the structure which takes the information from the retina as
electrical signals and delivers it to the brain where this information is interpreted as a visual
image. The optic nerve consists of a bundle of about one million nerve bers. The position
in the back of the eye where the nerve enters the globe is corresponds to the blind spot
since there are no rods or cones in these location. Normally, a person does not notice this
blind spot since rapid movements of the eye and processing in the brain compensate for
this absent information.
The globe is tightly suspended within the orbita, surrounded by six extraocular muscles which
are responsible for the movement of the globe. The four straight eye muscles (musculi recti) and
the upper diagonal (superior oblique) eye muscle originate in the posterior part of the orbita.
Only the lower diagonal (inferior oblique) muscle originates from the orbital plate of the maxilla
(see page 11). All eye muscles insert at the leather skin of the globe. Fig. 2.4 shows the muscle
origins in the posterior orbita and their insertions. Each eye muscle aects the eyeball in three
components, whereby the muscle path determines the main direction of pull. The main eect of
each muscle can be derived from its designation [BKP
+
03].
Perpendicular arranged to each other, the musculi recti originate in the anulus of Zinn, a point
at the posterior end of the orbita. Their tendons unite to a circular plate (Zinns ring) and their
insertions lie before the equatorial plane of the globe [Gue86]. In contrast, the musculi obliqui
insert behind the globe equator and pull diagonally forward. The m. obl. sup. is the longest of
all eye muscles. Starting at its insertion, it runs above the globe towards the nasal frontal bone,
pulls through a cartilaginous hole (the trochlea) and runs from there directly to its origin close
at Zinns ring. Obl. inf. originates at the nasal edge of the bony orbita, runs below the globe,
crosses the m. rect. inf. and inserts within the rear range of the eyeball. Within the crossing
area, m. obl. inf. and m. rect. inf. are connected by ligamentum Lockwood [Gue86]. Each
eye muscle consists, apart from the purely muscular portion, also of a tendon which connects the
muscle at the origin on one side, and at the point of insertion on the other side. The overall
1
20/20 vision is a term used to describe normal distance vision. The 20 is a distance of 20 feet, which is a
standard testing distance for eyesight, used by Optometrists and Doctors.
CHAPTER 2. MEDICAL FOUNDATIONS 15
Figure 2.4: Anatomy of the Extraocular Eye Muscles [KJCS99]
length (muscle and tendon) of eye muscles is very dierent. The largest dierences occur in
tendon lengths [Kau95]. The m. obl. inf. has the shortest tendon (0-2 mm) and the m.obl.sup.
the longest (25-30 mm). The actual muscle length lies between 30 mm (mm obliqui) up to 39
mm (m. rect. inf.). Due to the insertion lying before or behind the equator of the globe, each
muscle partially contacts the eyeballs surface. At the point of tangency, the muscle loses contact
to the globe and pulls toward its origin. With each movement of the globe, the relative position
of a muscles insertion changes with respect to the orbita.
Figure 2.5: Extraocular Muscles of a Right Eye from above [uS98]
In referring to Fig. 2.4 and Fig. 2.5, the names and primary directions of action for each muscle
is identied in Tab. 2.2.
Until 1994, eye muscles were assumed to be string like structures that run from the origin straight
to the insertion. At the point where a eye muscle touches the globe (point of tangency), the
muscles were expected to move freely. If the muscles could move freely between insertion and
CHAPTER 2. MEDICAL FOUNDATIONS 16
Fig.Nr. Muscle name Primary action(s)
(1) musculus rectus superior or superior rectus muscle
(upper straight eye muscle)
upward
(2) musculus rectus lateralis or lateral rectus muscle
(outside straight eye muscle)
sideways outward
(3) musculus rectus inferior or inferior rectus muscle
(lower straight eye muscle)
downward
(4) musculus rectus medialis or medial rectus muscle
(internal straight eye muscle)
sideways inward
(5) musculus levator palpebrae or levator muscle
(upper eyelid muscle)
raises the upper eyelid
(6) musculus obliquus superior or oblique superior muscle
(upper diagonal eye muscle)
downward and inside
(7) musculus obliquus inferior or oblique inferior muscle
(lower diagonal eye muscle)
upward and outside
Table 2.2: Eye Muscle Names and Primary Actions
origin during an eye movement (shortest path hypothesis), a shift of the muscle path on the globe
surface would occur, especially in extreme gaze positions. Thus, the muscle path and thus the
direction of pull would change considerably according to the actual eye position (loss of main
direction of pull).
2.1.1 Eye Muscle Pulleys
In order to prevent an eye muscle from slipping away while the globe rotates, connective tissue
surround the globe and stabilizes the muscles within the area of the point of tangency. These
stabilizers are called Pulleys [BM00b][DMP
+
95]. Early radiographic studies in monkeys and
computed tomography studies in human subjects suggested that the bellies of contracted recti
extraocular muscles have paths that are very stable relative to the orbit despite changes in
gaze. Miller and Demer [DMP
+
95] used magnetic resonance imaging (MRI) and manual 3D
image reconstruction to demonstrate the extreme stability of the recti extraocular muscle paths
throughout the normal range of ocular rotations. The result was, that only the anterior parts of
the tendons moved relative to the orbit, as they must, because they are attached to the globe.
Histochemical and Immunohistochemical investigations within this study conrmed the ndings
of the MRI analysis. Fresh orbital specimens were obtained at autopsy from adult cadavers,
dissection and globe enucleation was performed. All specimens were xed in 10% neutral buered
formalin, dehydrated and embedded in paran. The resulting 7 to 10m sections were mounted
on glass slides and chemically colored distinguishing collagen, elastin, cartilage, smooth muscle,
striated muscle and tendon. Smooth muscle is generally involuntary and diers from striated
muscle in the much higher actin/myosin ratio, the absence of conspicuous sarcomeres and the
ability to contract to a much smaller fraction of its resting length.
CHAPTER 2. MEDICAL FOUNDATIONS 17
Figure 2.6: Schematic View of the Extraocular Tissue Architecture from [DMP
+
95]
IR = inferior rectus; LPS = levator palpebrae superioris; LR = lateral rectus; MR = medial rectus; SO = superior
oblique; SR = superior rectus.
In Fig. 2.6, a schematic representation of the orbital tissues with respect to eye muscle pulleys is
shown. The horizontal section shows the lateral and medial rectus muscles (LR, MR) suspended
by broelastic sleeves consisting of collagen and elastin at the posterior part of Tenons capsule,
approx. 10 mm posterior to the muscle insertion. The sleeves itself are coupled to the orbit
by musculobroelastic septae, extending to the periorbita and to adjacent muscle sleeves. The
coronal sections of Fig. 2.6 are represented at the level of the superior rectus tendon (SR tndn),
and the superior oblique tendon (SO tndn).
CHAPTER 2. MEDICAL FOUNDATIONS 18
Figure 2.7: Example of Lateral Rectus Path Inuenced by Pulley
In Fig. 2.7, a left eye elevated by 35

is shown, focusing the left lateral rectus muscle. The gure


shows how the muscle path of the left lateral rectus is inected by the pulley indicated in red.
Since the lateral rectus muscle, in its primary function, pulls the eye outward, away from the nose
(see Tab. 2.2), this main action must be retained, also when the globe rotates to other positions.
Through the inection of the muscle path at the location of the pulley, the main function of the
lateral rectus muscle is preserved and the globe would be rotated laterally in case contraction of
the muscle occurs. Comparing the posterior and anterior part of the muscle with respect to the
pulley location, the anterior part moves with the rotation of the globe, while the posterior part
of the muscle stays stable relative to the point of origin.
2.1.2 Global/Orbital Eye Muscle Layers
Recent anatomic studies of whole orbits conrmed the existence of pulleys (e.g. [Mil89]). Tech-
nical improvements have made it possible to reconstruct orbital histology even more detailed and
without the need to remove the structures from the orbital bones. This leaves the normal spatial
relationships as is, thus providing a better insight in the actions of the dierent muscles. Former
studies on mammals (e.g. [MGGN75]) already suggested that the extraocular muscles consist of
two dierent layers.
Referring to Fig. 2.8, the global layer is continuous from the origin at the annulus of Zinn to the
tendinous scleral insertion on the globe, in contrast to the orbital layer, obviously terminating
posterior to the insertion. Recent studies have shown that the position of the rectus muscle
pulleys change slightly as a function of gaze [DOP00], thus modifying the mechanical properties
of muscle action. Pulley positions were identied by the sharp inections of the muscle path in
dierent gaze positions. A study carried out by Demer et.al [KCD02] showed that for each rectus
muscle, a discrete inection moved signicantly posteriorly during contraction and anteriorly
during relaxation of the muscle. These changes in path inections have been interpreted as
antereoposterior shifts in the rectus muscles pulleys. This so called Active-Pulley hypothesis
CHAPTER 2. MEDICAL FOUNDATIONS 19
Figure 2.8: Dierent Fiber Layers of Rectus Muscles from [DOP00]
is quantitatively supported by recent studies (e.g. [KCD02][DOP00][CJD00]). The resulting
consequence is that human rectus muscle pulleys move to shift the ocular rotation axis in order
to attain commutative behavior of the oculomotor system.
2.1.3 Anatomical Measurements
Around 1869 by A.W. Volkmann [Vol69], a statistic analysis was carried out with several patients.
The results of this study were dened as standard eye, an average eye of humans. Volkmanns
specications referred to the median lines of eye muscle tendinous insertions (i.e. the approxi-
mated center line of a muscle volume), and accuracy was limited due to the seamless transition of
muscle tendon into neighboring tissue. In 1965, Nakagawa used hand dissected slices of cadavers
in order to measure each eye muscles individual cross-section [Nak65]. These clinical results en-
dured as basis for many modelling approaches until studies from Mhlendyck and Miller revised
the data [MR84][MKM84]. With the discovery of Pulleys, new geometrical measurement using
MRI and histologic approaches were denes [CJD00].
CHAPTER 2. MEDICAL FOUNDATIONS 20
Globe Radius: 12.43 mm
Cornea Radius: 5.50 mm
MR LR SR IR SO IO
Origin
x (mm) -17.00 -13.00 -16.00 -16.00 -15.27 -11.10
y (mm) -30.00 -34.00 -31.78 -31.70 8.24 11.34
z (mm) 0.60 0.60 3.80 -2.40 12.25 -15.46
Insertion
x (mm) -9.15 10.44 0.00 0.00 -0.07 6.73
y (mm) 8.42 6.75 7.33 7.65 -8.05 -10.46
z (mm) 0.00 0.00 10.05 -9.80 9.48 0.00
Length (mm) 39.96 49.65 44.05 44.80 22.28 34.03
L0 (mm) 31.60 36.20 33.90 35.00 32.00 29.10
Tendon
Length (mm) 3.80 8.40 5.40 4.80 26.50 1.50
Tendon
Width (mm) 10.30 9.20 10.60 9.80 11.00 9.80
Table 2.3: Muscle Parameters measured by Volkmann from [Gue86]
The geometrical data for muscle length from Tab. 2.3 also includes the tendon of each muscle,
whereas the muscle length (L0) represents only the contractile part of the muscle without its
tendon. These values are dened on the basis of relaxed denervated muscles (muscles which
are not innervated). All coordinates in this table are dened with respect to an oculocentric,
head-xed coordinate system originating in the center of the globe.
Data from Tab. 2.3 data was rened by Miller et.al. due to the discovery of pulleys and new
measurement results for further studies [Mil89][CJD00][KCD02].
CHAPTER 2. MEDICAL FOUNDATIONS 21
Globe Radius: 11.99 mm
Cornea Radius: 5.50 mm
MR LR SR IR SO IO
Origin
x (mm) -17.00 -13.00 -15.00 -17.00 -18.00 -13.00
y (mm) -30.00 -34.00 -31.76 -31.76 -31.50 10.00
z (mm) 1.00 -1.00 3.60 -2.40 5.00 -15.46
Insertion
x (mm) -9.65 10.08 2.76 1.76 2.90 8.00
y (mm) 8.84 6.50 6.46 6.85 -8.00 -9.18
z (mm) 0.00 0.00 10.25 -10.22 8.82 0.00
Pulley
x (mm) -14.00 12.00 -5.16 -5.16 -15.27 -13.00
y (mm) -5.00 -8.00 -10.78 -8.78 11.00 10.00
z (mm) 0.14 0.33 10.00 -12.00 11.75 -15.46
Length (mm) 39.96 49.65 44.05 44.80 22.28 34.03
L0 (mm) 31.92 37.50 33.82 35.60 34.15 30.55
Tendon
Length (mm) 4.91 7.71 5.40 4.80 31.90 1.33
Tendon
Width (mm) 10.50 9.30 10.80 10.00 10.80 8.60
Table 2.4: Revised Muscle Parameters by Miller et.al. [MR84]
In the revised muscle data from from Tab. 2.4, muscle insertions as well as the pulley positions
were measured in three-dimensional space. This means that assuming the globe as geometrical
abstraction using a spherical object, each muscles insertion does not lie exactly on the globe, due
to the fact that in reality, the globe is shaped ellipsoid. This leads to a compromise in choosing
the globe radius as the smallest distance between coordinate system origin and muscle insertion
of all six muscles. The substantial mathematical dierence of these data consists of the fact that
now each muscle rotates its own virtual globe, in turn aecting lever arm and force behavior.
2.1.4 High Resolution MRI-Imaging of the Orbit
Imaging techniques have become an indispensable diagnostic tool in the eld of ophthalmology.
In most hospitals, computed tomography is still the method of choice for orbital imaging because
of its low costs and excellent depiction of bony details. However, resolution of MRI scanners has
improved during the past years providing sucient accuracy to show detailed tiny anatomical
structures. In contrast to CT, MRI allows for multiplanar imaging without the need for reposi-
tioning the patient. Whereas CT uses ionizing radiation, which is known to be harmful to health,
MRI utilizes the nuclear magnetic resonance (MR) eect.
Nuclei with a net magnetic moment, such as hydrogen ions (protons) which occur in living
matter, line up in parallel in a strong magnetic eld and change to a higher energy level when
a radio frequency (RF) impulse is applied at right angles to the static magnetic eld. The
CHAPTER 2. MEDICAL FOUNDATIONS 22
strength of this static magnetic eld in MR scanners ranges between 0.5 to 2 Tesla, whereby one
Tesla corresponds to a unit of magnetic ux. The tesla (symbolized T) is the standard unit of
magnetic ux density. Reduced to base units in the International System of Units, 1 T represents
one kilogram per second squared per ampere (kg/s
2
A). In practice, the tesla is a large unit, and
is used primarily in industrial electromagnetics. Once the RF impulse is turned o, the nuclei
relax to the original energy level and release a RF signal that can be detected by a coil (RF
receiver). Proton density of the examined tissue plays an important role when applying MRI
investigations to in vivo subjects. The nuclear relaxation process depends on the mobility of the
protons in the substance of interest.
These properties are distinguished by T1 (spin-lattice relaxation time) and T2 (spin-spin relax-
ation time) values. T1 is inuenced by molecular rotation time and are lowest in the tissues with
intermediate-sized molecules such as fat. T1 values are dependent upon magnetic eld strength
(increasing eld strength gives increasing T1). T1 values at 1.5 T are around 800 1000 ms for
brain tissue while it is considerably higher (3000 ms) for water and lower (300 ms) for fat. After
the RF signal is applied, energy of the spin system in the examined tissue will be redistributed
and the measurable signal will decay away as the spins. Long T2 relaxation times only occur
in molecules which are tumbling rapidly in solution. More immobile species and solids have
rapid spin-spin relaxation and often produce MR signals which decay away before they can even
be detected in MR imaging. There are several distinct mechanisms occurring at the molecular
level which can contribute to relaxation, but dipole-dipole interactions are the major cause of
T2 relaxation. Additionally, extrinsic factors that are set on the MR scanner inuence image
acquisition. Time of repetition (TR) and time of echo (TE) are the most important values. TR
is the time between the emission of RF pulses, and TE is the time between the excitation of an
RF pulse and the reception of the measured signal. Thus, the relative contribution of any of the
tissue specic factors can be varied by choosing dierent pulse sequences in order to achieve a
weighting of a specic parameter. Hence, in MR imaging, tissues with higher T1 values appear
dark on T1 weighted images and tissues with higher T2 values appear bright on T2 weighted
images. Cortical structures like bones and fast owing blood inside arteries and larger veins give
no signal on MRI scans. Protons of fast owing blood that had been excited by an RF pulse,
have left the imaging slice before their signal can be detected.
Following a study of orbital MR imaging [Ett99], MR signal intensities, with respect to ocular
and orbital tissues, can be identied from Tab. 2.5.
Tissue type T1w T2w
cornea, sclera L L
aqueous, vitreous L H
normal clear lens M L
extraocular muscles M M
orbital fat H M
connective tissue septa M M
nerves M M
Table 2.5: MR Signal Intensities of Ocular and Orbital Tissues on T1-weighted (T1w) and T2-weighted (T2w)
images from [Ett99]. H=high signal, M=medium signal, L=low signal.
CHAPTER 2. MEDICAL FOUNDATIONS 23
Figure 2.9: Axial MR Scan, showing Lateral and Medial Rectus of both Eyes, from [FPBK03].
T1 weighted scan, 1.5 mm slicing, TR: 602 TE: 16
Figure 2.10: Axial MR Scan, showing Lateral and Medial Rectus of both Eyes, from [FPBK03].
T1 weighted scan, 1.5 mm slicing, TR: 602 TE: 16
Within the SEE-KID research work, a MRI study has been carried out in order to visualize the
extraocular eye muscles by using newest MRI scanner equipment and special head coil receptors
[FPBK03]. In this study, three human subjects were scanned using a 1.5 Tesla Siemens Magnetom
Symphony scanner. Coronal and axial scans with T1 and T2 weighting were taken, using a 8
channel head phase array as receptor coil. Image series with approx. 19 images and a slice
thickness of 1.5 mm, 512 416 matrix were taken while the subject was xating reference points
CHAPTER 2. MEDICAL FOUNDATIONS 24
(see Fig. 2.9 and Fig. 2.10). Both eyes were put in local anesthesia using proprietary eye drops.
Additionally, one subject was injected Gadolinium Magnivist 0.2ml/kg radiopaque material. All
subjects were captured focusing dierent stable gaze positions that were indicated by dots in the
scanner tube.
(a) Subject xating straight
ahead
(b) Subject xating to the right (c) Subject xating to the right
bottom
Figure 2.11: Comparison of MR Scans in dierent Gaze Positions [FPBK03]
In Fig. 2.11 dierent gaze positions are compared with respect to the medial rectus muscles of
both eyes. In Fig. 2.11(a), the subject was looking straight ahead, showing the muscles in a rather
low innervated state. Compared to Fig. 2.11(b) and Fig. 2.11(c), where the subject is looking to
the right and to the right bottom respectively, deformation of the physiologic cross-sectional area
(PCSA) can be noticed. In repeating this described process for every slice in each image series,
eye muscle morphology was reconstructed and graphically visualized.
The goal of this study was to show morphology of eye muscles, especially the rectus muscles while
xating dierent reference points. These data was analyzed and reconstructed as 3D dynamic
representation of extraocular eye muscles in dierent gaze positions for later use in the SEE-KID
research project [BK03b].
High resolution MRI enables exact delineation of space occupying orbital processes in relation to
surrounding anatomical structures, thus facilitating planning of surgical procedures, which will
be essential for computer-assisted surgery and treatment planning [Ett99].
2.1.5 Human Dissection of the Orbit
Since the discovery of pulleys, existing surgical procedures need to be revised and checked for me-
chanical consequences that can arise when surgical modication of pulleys and surrounding tissue
occurs. Treatment of strabismus probably aects the action of orbital extraocular muscle layers
on their pulleys, can cause unintended eects, especially when altering relationships between
muscle insertion and pulley positions and should be better understood and perhaps considered
in surgical planning [DOP00].
Human dissection was performed in order to better understand the functional implications of the
newly discovered anatomical structures within eye muscles (Pulleys, global and orbital layers,
etc.) [FAP03]. Compared to striated skeletal muscles, the six extraocular eye muscles show
specic dierences concerning structure, distribution of muscle bers and neural sensitivity to
CHAPTER 2. MEDICAL FOUNDATIONS 25
innervation. Thus, human eye muscles take up a exceptional position among human anatomy
with regard to human skeletal muscles.
Figure 2.12: Human Dissection of the Orbit showing Medial Rectus Pulley [FAP03]
All six extraocular muscles consist of 2 distinct muscle portions, a consistently very thin orbital
muscle layer with a high mitochondrial density in the muscle bers, encircled by a thick C-shaped
global layer. This global muscle layer consists of muscle bers with a variable mitochondrial
density, additionally, average physiologic cross-sectional areas are larger compared to the orbital
muscle layer (see Sec. 2.1.2). Concerning muscle ber types, human extraocular muscles consist
of single innervated twitch bres and multiple innervated non-twitch bres which are usually only
found in skeleton musculature. In Fig. 2.12, the medial rectus muscle of a right eye was dissected,
showing the muscle stretched to indicate the connective tissue structure, encircling parts of the
muscle in order to inect the muscle path and therefore directing muscle force, compared to
the anatomic origin, towards a much more anteriorly located point. The Pulley structure can be
located posterior to the globe equator and is comprised of a dense collagen matrix with alternating
bands of collagen bers precisely arranged at right angles to one another. This three-dimensional
organization most likely gives high tensile strength to the pulley. Connective tissue and smooth
muscle bundles suspend the pulley from the periorbita. Smooth muscle is distributed in small,
discrete bundles attached deeply into the dense pulley tissue. Fine structural observations conrm
the existence and substantial structure of a pulley system in association with the medial rectus
extraocular muscle. The presence of pulleys must be considered in models of the oculomotor
plant. However, the nature of the connective tissue-smooth muscle suspending the pulley system
to the orbit supports the suggestion that the pulley position, and thus the directional force of
the eye muscles, may be adjustable [PPBD96].
CHAPTER 2. MEDICAL FOUNDATIONS 26
2.2 Eye Movement Physiology
The movement of the globe approximately corresponds to a rotation of an object in the three-
dimensional space around a certain axis. The globe center can be regarded as rotation center.
The line of sight is a vector from the globe center through the center of the pupil. Perpendicular
to this vector, the vertical and the horizontal axes are dened, whereby the intersection of these
three axis lies in the globe center Fig. 2.13. Eye positions can be classied by their rotational
properties [Kau95]:
Figure 2.13: Line of Sight, Vertical and Horizontal Axes; Rotations to Other Eye Positions
Primary position: The eye looks straight forward, with the head xed and upright (Fig. 2.13
(a)). It is accepted that in this position all muscles exhibit minimum force. From primary
position, all other eye positions can be reached with as small an energy expenditure as
possible.
Secondary position: From the primary position, a rotation around the horizontal or vertical
axis (Fig. 2.13(b)) is performed. The eye looks to the left or right or upward or down.
Tertiary position: From the primary position a rotation around the horizontal and vertical
axis (Fig. 2.13(c)) is performed. The eye looks e.g. to the left and down. The combination
around two axis can be represented also by a rotation axis, which lies in the plane spanned
by the horizontal and vertical coordinate axes (Fig. 2.13(d)).
Both eyes can be moved only in binocular community with one another, i.e. the movement of
only one eye is usually not possible [Gue86]. Eye muscles are able to reposition the eye accurately
and very fast, moreover they can hold a certain position without exhaustion. The rotation of an
eye around a certain axis results in a certain eye position and thus also realigns the line of sight
to a new gaze direction. The gaze direction designates the orientation of the eye, whereby an eye
position always includes the xation of a target object. Each muscle is dened through its origin,
point of tangency and insertion. The muscle paths from the origin to the insertion at the globe
are however additional held by connective tissues, retaining movements, so called Pulleys. For
spatial perception, both eyes must exactly xate an object of interest. The image of this object
is then projected onto the foveae of both eyes, which provides best visual acuity. A cube xated
with both eyes is projected upside down (like in a camera) and skewed (due to dierent distances
of both eyes) onto the retina. In the brain, both images will be merged in order to perceive one
upright three dimensional cube (fusion) (Fig. 2.14(a)).
As an example, a patient suering from inward squinting (esotropia) of the right eye. According
to this, the right eye fails to xate the cube and misaligns compared to the left eye (Fig. 2.14(b)).
Dierent images are now projected onto the foveae of both eyes, and the brain fails to merge this
CHAPTER 2. MEDICAL FOUNDATIONS 27
(a) (b)
Figure 2.14: Binocular Fixation of an Object in Space [Tho01]
information. The result is, that disturbing (uncrossed) double images are perceived. Especially
in infants, the brain will compensate on these errors by trying to eliminate those images that
originate from the squinting eye. This process leads to a fatal outcome: the squinting eye will
lose visual acuity and will suer from functional deciency.
2.2.1 Actions of the Extraocular Muscles
Basically, the eye can rotate in three dimensions around xed axes of a head-xed coordinate
system. Each extraocular muscle rotates the globe in specic directions, also dependent of the
current position of the eye. Movement of the eye nasally is adduction; temporal movement is
abduction. Elevation and depression of the eye are termed sursumduction and deorsumduction,
respectively. Torsional eye movements rotate the eye around its visual axis, whereby incycloduc-
tion or incyclotorsion (intorsion) is nasal rotation of the vertical meridian and excycloduction or
excyclotorsion (extorsion) is temporal rotation of the vertical meridian.
Referring to Fig. 2.15, the coordinate system used for torsional rotations is dierent in both eyes.
Referring to the gure above, directions of rotation of one eye around the respective axes can be
described as follows:
Rotation around Z-axis
positive angle = adduction (towards the nose)
negative angle = abduction (away from the nose)
Rotation around X-axis
positive angle = elevation or sursumduction (upward)
negative angle = depression or deorsumduction (downward)
CHAPTER 2. MEDICAL FOUNDATIONS 28
Rotation around Y-axis
positive angle = intorsion (inward rolling)
negative angle = extorsion (outward rolling)
Figure 2.15: Rotational Directions for both Eyes [BKP
+
03]
As shown in Fig. 2.15, coordinate axes for ab-/adduction and in-/extorsion point in dierent
directions for both eyes. This provides a uniform denition of the rotation direction by using
consistent designations (e.g. abduction = away from the nose). In both eyes, positive torsion is
dened to rotate the eye inward around the line of sight. If the two axes would not show dierent
signs, then intorsion would roll one eye inward and one outward. The axes for elevation and
depression remain the same in both eyes, since up and down rotations specify the same directions
for both eyes. Additionally, in case of binocular eye movement, abduction of one eye results in
adduction of the other eye, thus eye positions are mirrored for ab-/adduction and in-/extorsion
movements.
The primary muscle that moves an eye in a given direction is known as the agonist. A muscle in
the same eye that moves the eye in the same direction as the agonist is known as the synergist,
while a muscle in the same eye that moves the eye in the opposite direction of the agonist is
the antagonist. For example, in abduction of the right eye, the right lateral rectus muscle is
the agonist, the right superior and inferior oblique muscles are partly synergists, and the right
medial rectus is the antagonists. A muscle that moves the opposite eye in the same direction as
the agonist is the contralateral synergist, whereas a muscle in the opposite eye, that moves the
eye in the opposite direction as the agonist is called contralateral antagonist.
Yoke muscles are the primary muscles in each eye that accomplish a binocular eye movement
(e.g. for right gaze, the right lateral rectus and left medial rectus muscles). Each extraocular
muscle has a yoke muscle in the opposite eye to accomplish movement of both eyes in the same
direction. The primary action of an extraocular muscle is the direction of rotation of the eye
when that muscle contracts. This term also indicates the gaze position in which the eects of a
muscle most easily are demonstrated. Knowledge of primary actions is important as squinting
often increases in the eld of action of a weak eye muscle.
CHAPTER 2. MEDICAL FOUNDATIONS 29
Medial and lateral rectus muscles have only horizontal actions. The medial rectus muscle is the
primary adductor of the eye, and the lateral rectus muscle is the primary abductor of the eye.
Superior and inferior rectus muscles are the primary vertical movers of the eye. The superior
rectus acts as the primary elevator and the inferior rectus acts as the primary depressor of the
eye. This vertical action is greatest with the eye in the abducted position.
The direction of pull of the vertical recti muscles forms a 23

angle relative to the visual axis in


the primary position, giving rise to secondary and tertiary functions. The secondary action of
vertical rectus muscles is torsion. The superior rectus is an incyclotorter, and the inferior rectus
is an excyclotorter. The tertiary action of both muscles is adduction.
Superior and inferior oblique muscles are the primary muscles of torsion. The superior oblique
creates incyclotorsion, and the inferior oblique creates excyclotorsion. As the direction of pull for
both muscles forms a 51

angle (relative to the visual axis in the primary position), secondary


and tertiary actions occur.
The secondary action of the oblique muscles is vertical, and it is best demonstrated when the eye
is adducted with the superior oblique acting as a depressor and the inferior oblique acting as an
elevator of the eye. The tertiary action for each muscle is abduction.
Within the orbita, the eye is surrounded by exible fat pads, which, besides rotation, permit globe
translation up to a certain limit. Usually, this translation is negligibly small, however in some
pathological situations involving co-contraction of muscles (e.g. Duane syndrome), additional
information about globe translation provides an important clue for the estimation and correction
of eye motility disorders. A forward movement of the globe along the Y-axis is denoted as
Protrusion, a backward motion is dened as retraction.
2.2.2 Kinematic Principles of Eye Movements
The main task of the eye movement system is to move the eye quickly from the current gaze
position to a new location, in order to xate an object of interest. Binocular eye movements
are either conjugate (versions) or disconjugate (vergences). Versions are movements of both eyes
in the same direction (e.g. right gaze in which both eyes move to the right). Dextroversion is
movement of both eyes to the right, and levoversion is movement of both eyes to the left. Sur-
sumversion and deorsumversion are elevation and depression of both eyes, respectively. Vergence
movements are movements where both eyes move in opposite horizontal directions to permit the
acquisition of a near or far object. When a subject is Looking at a near object, both eyes move
together slightly to maintain binocular vision of it, as the object recedes away from the subject,
then the two eyes diverge again.
Vision is blurred during an eye movement, so the length of time that the eye is moving must be
minimized. In order to minimize the time during which no clear image is captured on the fovea,
eye movements that move the fovea from one object/point to another are very rapid. These
saccadic eye movements are among the fastest movements the body can make. The eyes can
rotate at over 500 deg/sec, and subjects make well over one hundred thousand of these saccades
daily.
Stabilization movements assure that the image of an object or region in the center of the eld-of-
CHAPTER 2. MEDICAL FOUNDATIONS 30
view is kept over the fovea. Sophisticated mechanisms exist to accomplish this goal in the face of
eye, head, body, and object motion. These eye movements are often grouped into four categories:
The vestibular-ocular reex (VOR) rotates the eyes to compensate for head rotation and
translation. Rotational and linear acceleration are detected by the semicircular canals and
otolith organs in the inner ear. The resultant signals are used to command compensating
eye movements.
The Optokinetic reex stabilizes the retinal image caused by large-eld motion. Retinal slip
induced by eld motion is used to initiate eye movements at the appropriate rate to cancel
out image motion.
Smooth-pursuit eye movements are similar to the optokinetic reex, but allow arbitrarily
sized targets to be stabilized instead of large-eld motion. A moving target is required for
smooth eye movements so that the eyes can move smoothly across a stationary object.
Vergence eye movements counter-rotate the eyes to maintain the images of an object at a
given depth to be maintained at corresponding locations on the two retinae.
In the generation of eye movements, the brain follows certain consistent patterns of behavior
(laws). However, it is important to realize, that the brain only adheres to these laws only when
it suits a given purpose [FHMT97].
2.2.2.1 Donders Law
Donders law states, that the 3D angular position of the eye is always the same for any particular
gaze position [Don48]. If the eye adopts a particular torsional orientation when looking forward
at one instance (e.g. after a rotation from the right), it will adopt the same orientation at all
other instances (e.g. after a rotation from the left) [FHMT97]. Hence, torsional eye position is
not arbitrary, but uniquely determined by the gaze position.
2.2.2.2 Listings Law
Listings Law can be considered as an extension to Donders law, in that it species a specic
torsional value for any particular eye position. It states that, with the head stationary, upright
and the eyes xating a distant object, all rotation axes of the eye lie in the same plane. Listings
law is considered one of the most important principles in eye movement physiology, by which the
brain couples redundant degrees of freedom, in this case by relating the two dimensional space
of target directions relative to the fovea to a 2D manifold of 3D eye positions [FHMT97].
When the eye leaves one target object and xates upon another, it rotates about an axis per-
pendicular to a plane cutting both, the former and the present lines of sight. Applying this
principle in a broader sense, one could say that Listings law is probably the consequence of the
facts that the primary position is the average of all eye positions during the day, that most eye
movements are directed radially from or to the primary position and that rotations about a single
axis are easier to perform than rotation about two axes or about an axis that changes during the
CHAPTER 2. MEDICAL FOUNDATIONS 31
movement. In considering both, horizontal and vertical eye movements, in which case the eye is
treated as if it were a pointer (dened by the line of sight). These two dimensional descriptions of
eye rotations specify the orientation of this pointer in space. Since the eye can also make torsional
movements around the line of sight, a full description of the rotational behavior also requires mea-
surement of torsion. Accounting for all three degrees of freedom of eye rotations leads to some
unique neurological consequences regarding oculomotor organization. Although this subject can
be explained simply, it still causes a lot of confusion. Some of the diculty arise from the need
to dene the kinematics of eye rotations quantitatively, setting up coordinate systems based on
rigorously determined sets of spherical angles. Although this is useful for empirical verication,
it is a poor way to introduce this subject. Rather than describing eye rotations with respect to
a horizontal and vertical angular coordinate system, this explanation will begin intuitively.
(a) (b) (c)
Figure 2.16: Simple Abstraction of Listings Law [Nak83]
A simple physical ball and membrane model of the eye is used [Nak83]. The model consists
of a spherical globe attached to a very tightly stretched elastic membrane, carefully secured to
the end of a cylinder, so that the membrane is equally taut in all directions Fig. 2.16. Because
of the elastic quality of this membrane, there is a natural resting place for the globe. The
stalk that is attached to this globe represents the line of sight. Additionally, a cross is mounted
on top of this stalk to reveal the amount of twist (torsion) of the globe Fig. 2.16(a). The
position of rest is dened as the primary position, and the direction of the line of sight (the
direction the stalk points to) corresponds to the primary gaze direction. The plane spanned by
the membrane of this model in resting position shall correspond to Listings plane for the eye.
It is the fronto-parallel plane passing through the center of the globe. In Fig. 2.16(b), the globe
is rotated with full degrees of rotational freedom. It can be rotated horizontally and vertically
by displacing the stalk and torsionally by twisting the stalk between the ngers. The most
important case is shown in Fig. 2.16(c) where the globe is moved by pushing the stalk with a
smooth rod. Using this technique, the globe can be moved to any desired gaze position and the
model has sucient rotational freedom. Compared to Fig. 2.16(b), only two degrees of freedom
are available to position the globe, since the twist of the globe around its visual axis (the stalk) is
no longer under external control because it cannot be twisted between the ngers. Its orientation
is dictated by the elastic membrane, which ensures that it corresponds to the position having the
CHAPTER 2. MEDICAL FOUNDATIONS 32
lowest potential energy. Thus, each gaze position is associated with exactly one orientation of
the globe.
What is essential to remember is that the behavior of this particular ball and membrane model
is isomorphic with Donders and Listings laws. This phenomenon is also described as pseudoto-
stion, since the eye does not actively rotate around its visual axis, instead, this torsional rotation
is intrinsic to the behavior of the mechanical system of the human eye. The orientation of the
eye can be predicted by assuming that the eye has made a geodesic (shortest path) rotation from
the primary position to any other xation position. The axis of this shortest path rotation is
perpendicular to the intended gaze position and thus lies in Listings plane. For the case of the
rubber membrane model, it means that the axis of the shortest path rotation lies in the plane
spanned by the membrane. The behavior of the model shows a radial or axial symmetry, such
that there is no net torsion of the eye with respect to an axial reference position (the primary
position).
Eye movements from tertiary positions to other tertiary positions do occur, but are less frequent
and do not occur predominantly in down-, up-, right- or left-gaze. During eye movement from one
tertiary to another tertiary position, Listings law is fullled only if the rotation takes place about
an axis that is tilted to Listings plane by half the angle between the momentary tertiary position
and primary position [Hel63]. Hence, an axis that can change during the movement. Using end
points of rotation vectors to plot 3D eye positions, all positions will lie closely scattered along
a plane (Listings Plane). Recordings of eye movements in humans and monkeys show that the
standard deviation of rotation vectors describing eye positions from this plane is only about 0.5-
1.0 deg. The best plane to t these data is called displacement plane [Has95]. The orientation
of this displacement plane also depends on the reference position used to describe eye positions.
In shifting the reference position, the plane describing exactly the same eye positions will only
shift half the angle in the same direction (see Fig. 2.17). In Fig. 2.17(a), the displacement plane is
perpendicular to the reference position, whereas in Fig. 2.17(b), the reference position has shifted
2 deg. forward. Since the displacement plane tilts only degree in Fig. 2.17(b), it is now tilted
deg. backward, with respect to a head xed coordinate system.
(a) Reference position perpendic-
ular to displacement plane
(b) Reference position shifted by
2 deg.
(c) Reference position shifted by
4 deg.
Figure 2.17: Denition of Listings Law w.r.t. Primary Position from [Has95]
For every data-set of arbitrary eye positions, there is one reference position such that the corre-
sponding displacement plane is exactly perpendicular to the reference position. Only in this case,
this position of the eye is termed primary position and the corresponding displacement plane is
termed Listings Plane [Has95]. In Literature it is often preferred to use the term Listings plane
in a broader sense, referring to any plane of rotation vectors. Applying this approach, all planes
CHAPTER 2. MEDICAL FOUNDATIONS 33
in Fig. 2.17 would be termed Listings plane.
2.2.3 Sensorimotor Control
The visual system can be seen as a combination of a high-acuity detector, the eye, with a high-
precision movement system, the oculomotor system [Car00]. Information processing during visual
perception is strongly inuenced by constraints arising from the human oculomotor system. The
oculomotor system is characterized by the interaction between peripheral reexes and central
motor commands of visual origin.
Generally, eye movements fall into three broad classes:
Gaze-stabilization movements - shift the lines-of-sight of the two eyes to precisely compen-
sate for self-motion, stabilizing the visual world on the retina. Gaze-stabilization movements
are accomplished by two partially independent brain systems. The vestibulo-ocular system
employs the inertial velocity sensors attached to the skull (the semi-circular canals) to de-
termine how quickly and in what direction the head is moving and then rotates the eyes an
equal and opposite amount to keep the visual world stable on the retina. The optokinetic
system extracts information from the visual signals of the retina to determine how quickly
and in what direction to rotate the eyes to stabilize the visual world.
Gaze-aligning movements - point a portion of the retina specialized for high resolution (the
fovea) at objects of interest in the visual world. Gaze-aligning movements are also divided
into two broad classes, saccades and smooth pursuit movements. Saccadic eye movements
rapidly shift the lines-of-sight of the two eyes, with regard to the head, from one place in
the visual world to another at rotational velocities up to 5001000 deg /s. Saccades are the
most common eye movements and occur rapidly (e.g. 3 saccades per second). In contrast,
smooth pursuit eye movements rotate the eyes at a velocity and in a direction identical to
those of a moving visual target, stabilizing that moving image on the retina.
Gaze-shifting movements - or vergence movements, operate to shift the lines-of-sight of the
two eyes with regard to each other so that both eyes can remain xated on a visual stimuli
at dierent distances from the head (see Fig. 2.14).
The neural control of gaze in natural conditions requires the interaction between dierent strate-
gies of oculomotor control. In particular, some eye movements are controlled by visual feedback
(e.g. smooth pursuit) whereas others are controlled in open loop with respect to vision (sac-
cades). Indeed, visual tracking of moving targets requires the combination of smooth pursuit
eye movements with catch-up saccades. Only in a small part of the visual eld, i.e. within the
central 2 deg of the eld of vision (the fovea), visual acuity permits the analysis of ne struc-
tured objects. In tracking saccades while a subject is looking at a picture (Fig. 2.18(a)), it can
be shown, how the oculomotor control system directs the sense of perception through a visual
stimulus (Fig. 2.18(b)). The recorded saccadic eye movements from Fig. 2.18 clearly show how
the picture is sketched by discrete point to point eye movements.
Consequently, the brain needs to sample information of complicated scenes by many xations,
e.g. intervals, during which the eyes perform only microscopic movements on dierent parts of
CHAPTER 2. MEDICAL FOUNDATIONS 34
an image (see Fig. 2.18). These xations are separated by rapid eye movements called saccades.
During reading, mean xation durations on words ranges roughly from 200 ms to 300 ms, de-
pending on lexical diculties of the words. These xations are interrupted by saccades with a
mean duration between 20 ms and 40 ms. The brain continuously transforms sensory informa-
tion into meaningful perceptions. The brain also accomplishes visual transformation task, such
as encoding sequences of line points into curves, curves into shapes, and shapes into recognizable
images. Though these processes are mostly visual, they also make use of more general brain
functions, such as information chunking, learning and memory, that are employed by other brain
regions.
(a) (b)
Figure 2.18: Recording of Saccadic Eye Movements from [KSJ00]
2.2.3.1 Innervation of the Eye Muscles
All eye movements are rotations, accomplished by three antagonistic pairs of muscles (see
Sec. 2.2.1). These six muscles are controlled by three brainstem nuclei (Fig. 2.19(b)). These
nuclei contain the cell bodies for all of the motor neurons (Fig. 2.19) which innervate the oculo-
motor muscles and thus serve as a nal common path through which all eye movement control
must be accomplished (Fig. 2.21). Each eye muscle is innervated by approximately 1000 mo-
toneurons. The single motoneurons branch out in the eye muscles and innervate approximately
4 to 40 muscle bers respectively. A motor unit is the aggregation of those muscle bers, which
are connected to one and the same motoneuron (see Fig. 2.19(b)).
The brain uses two dierent possibilities to increase the tractive force of a muscle:
1. It recruits motor units, which were inactive before and
2. it concentrates the activity of those motor units, which have been active before, but which
have not been working to full capacity.
CHAPTER 2. MEDICAL FOUNDATIONS 35
(a) Innervation of a Muscle by a Motoneuron [uS98] (b) The Ocular Motor Nuclei [KSJ00]
Figure 2.19: Ocular Motor Neurons and Motor Nuclei
2.2.3.2 Oculomotor Neurons
The eye muscles are innervated by three cerebral nerves. The nervus oculomotoris (III. cerebral
nerve) innervates the medial rectus muscle, the superior rectus muscle, the inferior rectus muscle
and the inferior oblique muscle (moreover the levator palpebrae muscle as well as - with its
parasympathetic part - the ciliaris muscle and the sphincter pupillae muscle) (see Fig. 2.20).
The nervus trochlearis (IV. cerebral nerve) innervates the superior oblique muscle, the nervus
abducens (VI. cerebral nerve) innervates the lateral rectus muscle.
The cell bodies of the motoneurons lie together in groups and form the so-called nuclei in the
brainstem (Fig. 2.19(b)). The center of both oculomotor nerves lies in the midbrain (Fig. 2.19(b)).
The alignment of those parts of the nuclei, which are associated with the specic eye muscles,
is very complicated and most of the details have been discovered in the last few years. The cell
bodies of the medial rectus muscle, the inferior rectus muscle and the inferior oblique muscle lie
ipsilateral (e.g. for the right eye on the right nucleus-side). Only the cell bodies of the superior
rectus muscle lie contralateral (e.g. for the right eye on the left nucleus-side). The bers of the
nerve of the superior rectus muscle cross in the area of the nucleus oculomotoris to the other
side. The cell bodies of the levator palpebrae muscle lie close to the middle line, both ipsilateral
and contralateral. The two nuclei of the nervus trochlearis also lie in the midbrain, just below
the nucleus oculomotoris. The motoneurons of the nervus trochlearis originate contralateral and
cross behind the aqueduct, below the quadrigeminal bodies, to the other side. The nuclei of the
nervus abducens lie in the bridge and are ipsilateral connected with the respective lateral rectus
muscle (see Fig. 2.20).
CHAPTER 2. MEDICAL FOUNDATIONS 36
(a) (b)
Figure 2.20: Oculomotor Nerve Circuit [KSJ00]
2.2.3.3 Neural Signal Encoding
Engineering models of the eye and its muscles indicate that motor neurons must generate two
classes of muscle forces to accomplish any eye rotation. A pulsatile burst of force that regulates
the velocity of an eye movement and a long-lasting increment or decrement in maintained force
that, after the movement is complete, holds the eye stationary by resisting the elasticity of the
muscles which would slowly draw the eye back to a straight-ahead position [Rob64]. Physiological
experiments have demonstrated that all motor neurons participate in the generation of both of
these two types of forces.
These two forces, in turn, appear to be generated by separable neural circuits. In the 1960s it
was suggested that changes to the long-lasting force required after each eye rotation could be
computed from the pulse-, or velocity-signal by the mathematical operation of integration. In
the 1980s the lesion of a discrete brain area, the nucleus prepositus hypoglossi (Fig. 2.22), was
shown to eliminate from the motor neurons the long-lasting force change required for leftward
and rightward movements without aecting eye velocity during these movements. This, in turn,
suggested that most or all eye movements are specied as velocity commands and that brainstem
circuits involving the nucleus prepositus hypoglossi compute, by integration, the long-lasting
force required by a particular velocity command. More recently, a similar circuit has been iden-
tied that appears to generate the holding force required for upwards, downwards, and torsional
CHAPTER 2. MEDICAL FOUNDATIONS 37
Figure 2.21: Location and Distribution of Oculomotor Nerves [Tho01]
movements.
2.2.3.4 The Superior Colliculus
The superior colliculus is a major visumotor region, integrating visual and motor information
into oculomotor signals for the brainstem (Fig. 2.20(b)). It is a multilayered structure in the
midbrain and can be divided into two functional regions:
1. the supercial layers
2. the intermediate and deep layers.
The three supercial layers of the superior colliculus receive both direct input from the retina
and a projection from striate cortex for the entire contralateral visual hemield. Neurons in the
supercial layers respond to visual stimuli.
In the two intermediate and deep layers cell activity is primarily related to oculomotor actions.
The movement-related cells receive visual information from prestriate, middle temporal, and
parietal cortices and motor information from the frontal eye eld. These layers also contain
representations of the body surface and of the locations of sound in space.
Individual movement-related neurons in the superior colliculus discharge before saccades of spe-
cic amplitudes and directions, just as individual vision-related neurons in the superior colliculus
respond to stimuli at specic distances and direction from the fovea. The movement-related neu-
rons form a map of potential eye movements that is in register with visual and auditory receptive
maps, so that the neurons that control eye movements to a certain target are found in the same
CHAPTER 2. MEDICAL FOUNDATIONS 38
region as the cells excited by the sounds and image of that target. The region of the visual
eld that contains the targets for the saccades controlled by a given movement-related neuron
in the superior colliculus is called the movement eld of that neuron. Electrical stimulation of
the intermediate layers of the superior colliculus evoke saccades into the movement elds of the
neurons at the site of the stimulating electrode. The actual eye movement is encoded by the
entire ensemble of these broadly tuned cells.
Activity in the supercial and intermediate layers of the superior colliculus can occur indepen-
dently. Thus, sensory activity in the supercial layers need not lead to motor output, and motor
output can occur without sensory activity in the supercial layers. In fact, the neurons in the
supercial layers do not have a large, direct projection to the intermediate layers. Lesions of a
small part of the colliculus aect the latency, accuracy, and velocity of saccades, whereas lesions
of the entire colliculus render e.g. a monkey unable to make any contralateral saccades, although
with time, the ability to make contralateral saccades is recovered.
The saccade-related activity of the superior colliculus neurons is shaped by inputs from the poste-
rior parietal cortex, the frontal eye elds, and the substantia nigra pars reticulata (Fig. 2.19(b)).
The posterior parietal cortex is involved in the visual guidance of saccades by shaping the visual
inputs to the superior colliculus. The posterior parietal cortex contains neurons that are modu-
lated by visual attention, i.e., by how behaviorally relevant a visual stimulus is. They respond
more eectively when the stimulus is the target for an eye movement. The frontal eye elds form
an executive center that can selectively activate superior colliculus neurons, playing a role in the
selection and production of voluntary saccades. The activity of frontal eye elds neurons reects
the selection of the visual target for a saccadic eye movement when several potential goals for
movements are available. The frontal eye elds is also involved in suppressing reexive saccades
and generating voluntary, non-visual saccades. The complementary executive control exerted on
saccade generation by the frontal eye elds and the superior colliculus is revealed by the eect of
selective and combined ablation.
Lesions of the superior colliculus prevent the generation of reexive saccades, whereas the genera-
tion of voluntary saccades is disrupted by frontal eye elds lesions. Although saccades can still be
produced after the ablation of either the superior colliculus or the frontal eye elds, a combined
ablation of these two structures results in the complete abolition of saccadic eye movements.
2.2.3.5 Brainstem Control of Saccades
The saccadic system, in order to achieve a precise gaze-shift, must supply the brainstem circuits
with a command that controls the amplitude and direction of a movement. Considerable research
now focusses on how this signal is generated. Current evidence indicates that this command can
originate in either of two brain structures. The superior colliculus of the midbrain or the frontal
eye elds of the neocortex (Fig. 2.19(b)), both containing laminar sheets of neurons that code
all possible saccadic amplitudes and directions in a topographic map-like organization [HM03].
Activation of neurons at a particular location in these maps is associated with a particular
saccade and activation of neurons, adjacent to that location associated with saccades having
adjacent coordinates. Lesion experiments indicate that either of these structures can be removed
without permanently preventing the generation of saccades.
How these signals that topographically encode the amplitude and direction of a saccade are
CHAPTER 2. MEDICAL FOUNDATIONS 39
Figure 2.22: Motor Circuit for Horizontal Saccades [KSJ00]. Excitatory neurons are orange and
inhibitory neurons are gray. The dotted line represents the midline of the brainstem.
translated into a form appropriate for the control of the oculomotor brainstem is not known. One
group of theories proposes that these signals govern a brainstem feedback loop which accelerates
the eye to a high velocity and keeps the eye in motion until the desired eye movement is complete
[Rob75a]. Other theories place this feedback loop outside the brainstem, or generate saccadic
commands without the explicit use of a feedback loop. In any case, it seems clear that the
superior colliculus and frontal eye elds are important sources for these signals because if both of
these structures are removed, no further saccades are possible [STC80]. The superior colliculus
and frontal eye elds, in turn, receive input from many areas within the visual processing streams
including the visual cortex, as well as the basal ganglia and brain structures involved in audition
and somatosensation. These areas are presumed to participate in the processes that must precede
the decision to make a saccade, processes like attention.
As an example, in Fig. 2.22, the motor circuit for horizontal saccades in the brainstem is shown.
CHAPTER 2. MEDICAL FOUNDATIONS 40
The eye velocity component of the motor signal arises from excitatory burst neurons in the
paramedian pontine reticular formation (PPRF) that synapse on motor neurons and interneurons
in the abducens nucleus. The abducens motor neurons, project to the lateral rectus muscles while
the interneurons of the abducens nucleus project to the contralateral medial rectus muscle via
bers that cross the midline and ascend in the medial longitudinal fasciculus (MLF). Excitatory
burst neurons also drive ipsilateral inhibitory burst neurons that inhibit contralateral abducens
and excitatory burst neurons. The medial vestibular nucleus also inhibits contralateral abducens
neurons. Omnipause neurons inhibit excitatory burst neurons and abducens neurons, preventing
unwanted eye movements. The eye position component of the motor signal arises from a neural
integrator comprised of neurons distributed throughout the medial vestibular nuclei and nucleus
prepositus hypoglossi on both sides of the brain stem. These neurons receive velocity signals from
excitatory burst neurons and integrate its velocity signal into a position signal. The position signal
is then transmitted to the ipsilateral abducens neurons.
2.2.3.6 Control of Smooth-Pursuit Movements
In the smooth pursuit system, signals carrying information about target motion are extracted by
motion processing areas in visual cortex and then passed to the dorso-lateral pontine nucleus of
the brainstem. There, neurons have been identied which code either the direction and velocity of
pursuit eye movements, the direction and velocity of visual target motion, or both. These signals
proceed to the cerebellum where neurons have been shown to specically encode the velocity of
pursuit eye movements [SK84]. These neurons, in turn, make connections with cells known to
be upstream of the nucleus prepositus hypoglossi (Fig. 2.22), the integrator of the oculomotor
system for horizontal saccades). As in the saccadic system, the brainstem integrator appears to
compute the long-term holding force from this signal and then to pass the sum of these signals
to the motor neurons.
All eye movement control signals must pass through the ocular motoneurons which serve as a nal
common path. In all cases these neurons carry signals associated both with the instantaneous
velocity of the eye and the holding force required at the end of the movement. Eye movement sys-
tems must provide control signals of this type, presumably by rst specifying a velocity command
from which changes in holding force can be computed. In the case of saccades, this command is
produced by brain structures that topographically map all permissible saccades in amplitude and
direction coordinates. In the case of pursuit, the brain appears to extract target motion and to
use this signal as the oculomotor control input. Together these systems allow humans to redirect
the line-of-sight to stimuli of interest and to stabilize moving objects on the retina for maximum
acuity.
2.2.3.7 Herings Law
Neural processes of binocular vision involve the control of both eyes at the same time. One very
fundamental function of the visual system is to provide information on the location of objects
in space. The left and the right eyes, positioned about 6 cm apart, each capturing an image of
the environment from a slightly dierent point of view, and comparison by the brain of these
two retinal images yields information about distance. As long as the dierence between the
left and right eye image (the binocular disparity) is not too large, the mechanism of stereopsis
CHAPTER 2. MEDICAL FOUNDATIONS 41
(binocular vision) both interprets the disparity as depth and, by means of sensory fusion, causes
the desperate images to be perceived as single impression. Thus, the two eyes must be well
aligned for normal stereopsis to function properly. This implies that both eyes accurately xate
a single point in space.
According to Herings law of equal innervations [Her68], the two eyes are not independently
controlled by the brain. Hering observed that many eye movements are conjugate from birth,
even when one eye is covered. Hering argued that a common innervation must be sent to the
eyes to achieve this conjugacy, implying that the two eyes are controlled as one unit. The means,
that changes of innervation are programmed in one of two modes:
1. for a conjugate eye movement, in which both eyes rotate through the same angle and in
the same direction, or
2. for a disjunctive eye movement, in which both eyes rotate through equal angles but in
opposite directions.
In positioning both eyes with respect to conjugate eye movements, the brain accepts one eye as
the leading or xating eye, from where motor commands are received. The other eye will be
considered as the following eye, and will receive innervations based on those from the xing eye.
By the Hering law, yoke muscles receive equal and simultaneous innervation. The magnitude of
this innervation is determined by the xating eye. Since the magnitude of innervation to yoke
muscles is determined by the xating eye, the angle of deviation between eyes (strabismus) may
vary depending on which eye is xating. The primary deviation is misalignment with the normal
eye xating. If the paretic eye xates, the ensuing secondary deviation is typically larger than
the primary deviation.
2.2.3.8 Sherringtons Law
Rotation of the eyes can be derived from a change in the distribution of active muscle tension
between antagonist muscles, although their sum remains constant. From a stable position (e.g.
primary position), the change of muscle force distribution occurs in phases in order to begin,
carry out, and stop the saccadic or smooth pursuit movement. The distribution is then stabilized
at the new eye position.
Sherringtons law of reciprocal innervation states that increase of innervation and contraction of
a muscle is associated with a reciprocal decrease in innervation of the antagonist muscle [DE73].
2.3 Measurement Techniques
Measurement techniques in the eld of oculomotor physiology can be divided into measurements
of eye movements (positions) and into measurements of the underlying anatomy and physiology
(e.g. neural activity, motion and muscle force). These measurements can be accomplished by the
use of dierent measurement techniques, ranging from minimal invasive methods (e.g. clinical
CHAPTER 2. MEDICAL FOUNDATIONS 42
observations) to methods that need access to the human anatomy. However, in order to under-
stand the fundamental workow of the oculomotor system, all measurement results need to be
considered.
2.3.1 Eye Movement Measurements
Eye movements not only dictate where a subject looks or what a subject sees, they are indis-
pensable for diagnosing ophthalmologic, neurological, and otologic problems. Measurements of
eye movements are used to study how our cortex processes information, what the cerebellum is
doing, and how learning takes place in the brainstem. And they are increasingly used for techni-
cal applications, like monitoring the alertness of drivers or controlling the auto-focus of cameras.
Measurement techniques are comprised of mostly non invasive techniques that monitor moment
of the eyes in two or three dimensions.
2.3.1.1 Electro-Oculography
The electro-oculogram (EOG) is a measurement of bipotentials under two dierent light intensi-
ties (light adapted non-light adapted eye) produced by changes in two constant eye positions. It
is used as a clinical test for retinal dysfunction. The changes of bipotentials in electro-oculography
is also used under constant light intensity for the measurement of dierent eye positions. In the
normal eye, there is a steady potential of approximately 6 to 10 mV between the cornea and the
retina known as the corneal-retinal potential. The corneal-retinal potential can be measured by
placing a single surface electrode directly lateral to each of the orbits of the eye and a reference
electrode to the bridge of the nose.
(a) Application of EOG measurement elec-
trodes
(b) EOG recording: The subject was in-
structed to look to the far left, hold his gaze,
look to the far right, hold his gaze and re-
peat.
Figure 2.23: EOG Eye Movement Measurement Technique [FFG
+
02]
By placing electrodes superior and inferior to the orbit of each eye, and a reference electrode
lateral to the eye of interest, vertical eye movements can also be measured (see Fig. 2.23(a)).
When a test subject is gazing straight ahead, the corneal-retinal dipole is symmetric between the
two electrodes, and measured EOG output is zero. As the subject gazes to the left, the cornea
becomes closer to the left lateral electrode, therefore causing the EOG output to become more
CHAPTER 2. MEDICAL FOUNDATIONS 43
positive (see Fig. 2.23(b)). The inverse of this is true when the subject looks in the right direction.
When measuring the EOG output, there is a fairly linear relationship between the horizontal angle
of gaze and the EOG output. This relationship remains true up to approximately thirty degrees
of arc. Through careful calibration, horizontal eye movements can be measured with a resolution
of approximately one degree of arc. The EOG technique is preferred for recording eye movements
in sleep and dream research.
One specic type of EOG measurements is the electronystagmograhy (ENG). ENG measurements
are used to measure a condition called nystagmus. Measurement of nystagmus, a characteris-
tic pattern of eye movement, is invaluable in the diagnosis of various vestibular and balance
dysfunctions.
The EOG is not a very stable signal and measurements can vary as a result of varying ambient
light conditions. By having a patient carry out eye movements of constant amplitude in the dark
and then in the light, any change in the biopotential would reect a change in the corneal-retinal
potential. In normal eyes, this potential decreases during dark adaptation, and increases during
light adaptation. However, the signal can change when there is no eye movement. It is prone
to drift and giving spurious signals, the state of the contact between the electrodes and the skin
produces and other source of variability. There have been reports that the velocity of the eye as
it moves may itself contribute an extra component to the EOG. It is not a reliable method for
quantitative measurement, particularly of medium and large saccades. However, it is a cheap,
easy and non-invasive method of recording large eye movements, and is still frequently used by
clinicians.
2.3.1.2 Infrared-Oculography
If a xed light source is directed at the eye, the amount of light reected back to a xed detector
will vary with the eyes position. This principle enables the determination of the current eye
position. Infrared light is used as this is invisible to the eye, and doesnt serve as a distraction
to the subject. As infrared detectors are not inuenced to any great extent by other light sources,
the ambient lighting level does not aect measurements. Spatial resolution reaches up to 0.1

,
and temporal resolutions of 1ms can be achieved. It is better for measuring horizontal than
vertical eye movements. Blinks can be a problem, as not only do the lids cover the surface of the
eye, but the eye retracts slightly, altering the amount of light reected for a short time after the
blink. The corneal reection of the light source is measured relative to the location of the pupil
center. Corneal reections are known as the Purkinje reections, or Purkinje images [Cra94].
Due to the construction of the eye, four Purkinje reections are formed (see Fig. 2.24). Video-
based eye trackers typically locate the rst Purkinje image. With appropriate calibration proce-
dures, these eye trackers are capable of measuring a viewers point of regard (POR) on a suitably
positioned (perpendicularly planar) surface on which calibration points are displayed. Two points
of reference on the eye are needed to separate eye movements from head movements. The posi-
tional dierence between the pupil center and corneal reection changes with pure eye rotation,
but remains relatively constant with minor head movements.
Since the infra-red light source is usually placed at some xed position relative to the eye, the
Purkinje image is relatively stable while the eyeball, and hence the pupil, rotates in its orbit
(see Fig. 2.25). So-called generation-V eye trackers also measure the fourth Purkinje image,
CHAPTER 2. MEDICAL FOUNDATIONS 44
Figure 2.24: Schematic Overview of Purkinje Corneal Reections, from [Cra94]
PR, Purkinje reections: 1, reection from front surface of the cornea; 2, reection from rear surface of the
cornea; 3, reection from front surface of the lens; 4, reection from rear surface of the lensalmost the same
size and formed in the same plane as the rst Purkinje image, but due to change in index of refraction at rear
of lens, intensity is less than 1% of that of the rst Purkinje image; IL, incoming light; A, aqueous humor;
C, cornea; S, sclera; V, vitreous humor; I, iris; L, lens; CR, center of rotation; EA, eye axis (line of sight);
a 6mm; b 12.5mm; c 13.5mm; d 24mm; r 7.8mm from [Cra94]
however, due to the anatomical structure of the eye, this reection gives a very weak signal. By
measuring the rst and fourth Purkinje reections, these dual-Purkinje image (DPI) eye trackers
separate translational and rotational eye movements. Both reections move together through
exactly the same distance upon eye translation but the images move through dierent distances,
thus changing their separation, upon eye rotation. Unfortunately, although the DPI eye tracker
is quite precise, head stabilization may be required.
2.3.1.3 Scleral Search Coils
One of the most precise eye movement measurement methods involves attaching a mechanical or
optical reference object mounted on a contact lens which is then worn directly on the eye. This
technique evolved to the use of a modern contact lens to which a mounting stalk is attached (see
Fig. 2.26 and Fig. 2.27). The contact lens is necessarily large, extending over the cornea and sclera
(the lens is subject to slippage if the lens only covers the cornea). Various mechanical or optical
devices have been placed on the stalk attached to the lens: reecting phosphors, line diagrams,
and wire coils have been the most popular implements in magneto-optical congurations.
The principle method employs a wire coil, which is then measured moving through an electro-
magnetic eld. When a search coil (see Fig. 2.26(a) is put into an oscillating magnetic eld, a
voltage is induced in the coil [Has95]. Three orthogonal magnetic elds are emitted by an electro-
magnetic eld frame (see Fig. 2.26(b)). Usually, one contact lens has 2 search coils mounted, one
coil for the measurement along each axis of a two-dimensional coordinate system. The voltages
induced by the electromagnetic eld frame can directly be related to elements of the rotation
matrix that describes the current eye position relative to a reference position where the coils line
CHAPTER 2. MEDICAL FOUNDATIONS 45
Figure 2.25: Purkinje Corneal Reections I. and VI. marked with crosses, from [Kan87]
up with the magnetic elds. The coils commonly used for recording 3D eye positions are dual
search coils (produced by Skalar Instruments, Delft, The Netherlands) which are oriented in such
a way that they are approximately parallel to the axes spanned by the electromagnetic frame.
(a) Scleral Search Coil Lens (b) Electromagnetic Frame for Search Coil
Measurements
Figure 2.26: Electromagnetic Search Coil Eye Position Measurement, from [Ska03]
Problems, like the determination of osets which are frequently superimposed on the induced
voltages have been investigated in detail by Hess et al [HVOS
+
92]. The determination of angular
rotations for a measured eye position also involves consideration of false torsion (see Sec. 2.2.2.2)
and appropriate correction (cf. [Has95]).
Insertion of the contact lens is shown in Fig. 2.27. Although the scleral search coil is the most
precise eye movement measurement method (accurate to about 5-10 arc-seconds over a limited
range of about 5

), it is also the most intrusive method. Insertion of the lens requires care and
practice. Wearing of the lens causes discomfort and therefore is not ideal for clinical application.
CHAPTER 2. MEDICAL FOUNDATIONS 46
Figure 2.27: Insertion Procedure for a Scleral Search Coil Lens, from [Ska03]
2.3.1.4 Video-Oculography
With the development of video and image analysis technology, various methods of automatically
extracting the eye position from images of the eye have been developed. Tracking the relative
movements of these images gives an eye position signal. 3D video-oculography (3D VOG) systems
commonly work on the following principle: rst, the center of the pupil is found. This is achieved
by thresholding the gray-level signal of the image of the eye, nding the pupil, and tting an
ellipse to its outline (see Fig. 2.28). The center of this ellipse determines the horizontal and
vertical eye position. Then, the light-dark distribution of the iris is measured along a circle
around the center of the pupil. Cross-correlating this iris signature with a reference pattern gives
the torsional eye position (cf. [MHCS94] and [Has95]). Up to now, no algorithm exists that
can distinguish between a translation of the camera with respect to the head, and a shift of the
pupil by a rotation of the eye. However, looking at Fig. 2.28, it is obvious that images of the
eye contain more information than just the center of the pupil. Corneal reections, also used in
infrared oculography, patterns of the iris and the shape of the upper and lower eye-lid may give
additional signals to improve the stability of VOG.
Figure 2.28: Video-Oculography Pupil Detection, [SMI]
However, image based methods tend to have temporal resolutions lower than that achieved with
IR techniques. One reason why existing video-oculography (VOG) systems have not lled this
need is the diculty of measuring the rotation of the eye around the line of sight. Techniques for
tracking the horizontal and vertical position of the pupil are straightforward, and a number of
dierent algorithms give acceptable results. But measuring the rotation of the eye around the line
of sight is much more dicult, since it requires not only the detection of the pupil, but also relies
on the resolution of ne details in the structure of the iris (cf. [Has95], [MHCS96] and [SH03]).
Even small displacements between head and camera can cause large measurement artifacts (e.g.
CHAPTER 2. MEDICAL FOUNDATIONS 47
a camera displacement of only 1 mm shifts the center of the pupil by the same amount as a
5

-rotation of the eye). Currently, no published algorithms exist for the automated selection of
suitable landmarks on the iris, which is necessary for automated measurements of ocular torsion.
Such algorithms would dramatically improve the applicability of video-oculography, also to other
scientic and medical applications. However, current system accomplish the 3D measurement of
eye positions, provided that the head is upright and not moving rapidly (see Fig. 2.29).
Figure 2.29: Chronos VOG System, from [Ska03]
The VOG eye tracker shown in Fig. 2.29 consists of a head unit, which is individually adjustable,
and carries the CMOS cameras for recording eye-in-head images. Additionally, this head unit
carries the system unit, which accommodates the custom-designed architecture for the online,
real-time acquisition and pre-processing of image and signal data. This is designed around a
standard Windows PC with a PCI plug-in board. The head unit is connected to the system
unit through high-speed digital data links. These provide the necessary data channels for the
transfer of high bandwidth image and signal data from the head unit to the system unit, and
the command sequences from the system unit to the head unit. The image of the eye is reected
by the dichroic mirror to the optical lens and projected onto the image sensor. An infrared
pass lter is tted in front of the image sensing area in order to exclude sporadic incident light
from the environment. These optical elements and the cameras are arranged on the head unit to
facilitate maximal eld-of-view for the test subject. A eld-of-view approaching 90

horizontal
and +40/ 60

vertical is attained.
Nevertheless, there is an increasing requirement in both the clinical and research elds for non-
invasive precise measurement of three-dimensional eye movement by using 3D VOG systems.
2.3.2 Physiologic Muscle Force Measurements
During the investigation of muscle force, two types of contraction measurements can be dierenti-
ated: isotonic contraction and isometric contraction. An isotonic contraction is the measurement
of the muscle length and length change due to an activation with constant load (Fig. 2.30(A)). In
the case of isometric contraction, the strength and the change of force of the muscle is measured
with the length held constantly (Fig. 2.30(B)). The contraction mechanism takes place on molec-
ular level and is described by the so-called lament sliding theory. Actin and myosin laments
are connected over archings and realize activation-steered shortening, and thus development of
CHAPTER 2. MEDICAL FOUNDATIONS 48
muscle force.
Figure 2.30: Dierent Types of Muscle Force Measurement, from [BKP
+
03]
Generally, static and dynamic characteristics of a muscle can be dierentiated. Static force be-
havior is also called force-length behavior, whereby isometric force measurement is accomplished
as a starting point and, in dependence of the adjusted length, measurement of the produced force
is carried out. Dynamic characteristics of a muscle refers to contraction speed and is analyzed
by using isotonic measurements. In the representation of the static characteristics of a muscle,
active and passive muscle force can be dierentiated. Active muscle force results from activation
(innervation) of a muscle initiated by the brain, while passive forces represent the exible stretch
characteristics of a muscle, which works opposite to the active force. By applying repeated iso-
metric force measurements with dierently adjusted lengths, a force length curve of the muscle
behavior results. In relating these data to the activation potential of a muscle, a three-dimensional
force-length-activation function can be dened. This function can be divided again into its active
and passive forces, receiving an active and a passive force curve, which correspond to the total
force curve of a muscle. The passive force curve describes the exible forces a muscle exerts, if
it is stretched or contracted accordingly. If a detached muscle is suciently stretched, then, at
a certain length, the muscle stops to behave like a non-linear spring, but will get sti very fast,
allowing no further exibility. This is called the leash region and becomes apparent in a drastic
rise of the passive strength with increased stretch length. On the other hand, if a muscle gets
shorter and loses its stretch, then it will get slack and can not exert force anymore. This is called
the slack region of the muscle force function.
Meaningful force measurements of the extraocular muscles are extremely dicult to obtain. How-
ever, there are diculties deriving the physiologic behavior of extraocular muscles from such
measurements. A clinically useful device to measure force was introduced by Scott et al in 1972
(see Fig. 2.31) [SCO72].
Collins described instrumented duction forceps that carried strain gauges to measure force,
and an ultrasonic microphone to measure distance, in conjunction with an ultrasonic sound
source [Col78]. The Collins forceps allowed convenient length-tension measurements on an iso-
lated, disinserted muscle or an intact eye.Others followed with variations of this approach (e.g.
[SCW
+
84]).
CHAPTER 2. MEDICAL FOUNDATIONS 49
Figure 2.31: Example of measuring Force with Forceps
A common clinical diagnostic test is the forced duction, sometimes called passive duction test.
This test is used to identify the cause of the lack of rotation of a muscle from two possible broad
causes. In weakness of the muscle or paresis of the nerve supplying the muscle, the eye does not
rotate as it should because, ultimately, the muscle is not contracting properly. In mechanical
causes of lack of rotation of the eye, the muscle receives input instructing it to contract and rotate
the eye, but mechanical forces are preventing the eye from moving properly. In the exam chair,
it is performed by topically anesthetizing the eye with drops, and then further anesthesia may
be given by soaking an applicator with topical anesthetic and applying it to the intended point
of contact with the eye. Classically, a forceps is used to perform the test, by grabbing the eye
and mechanically rotating it while the patient looks in the direction of gaze being tested, and
seeing if the examiner can rotate the eye for the patient. Free rotation implies that the eye is
not mechanically resisted, which means the rotation problem is a paresis of the nerve supplying
the muscle the impulse to contract. If there is mechanical resistance, often not only does the eye
not fully rotate in the direction being tested, but the examiner may feel the resistance. Some
examiners prefer to do the test by pushing the globe in the intended direction with an applicator,
rather than grabbing the eye with a forceps, but the overall concept is the same (see Fig. 2.31).
According to Miller [MD96], there exist four problems with all isometric measurements:
Relationship of innervation, length, and tension - is not physiologically meaningful dur-
ing isometric measurements, since the eye to be measured is held at a xed position and
moved from there. Normally, when innervation increases, muscle force increases, and the
muscle shortens. When innervation decreases, muscle force also decreases, and the muscle
lengthens. With forced duction, innervation is held constant, thus, muscle force increases
as the muscle is lengthened, and decreases as it is shortened, resulting in the inverse behav-
ior compared to the normal relationship. Isometric measurements also disturb the normal
relationship between length and tension, though not so badly as forced ductions.
Neither forced duction measurements nor isometric measurements can directly predict nor-
mal behavior of the extraocular muscles. The force produced in a suddenly stretched muscle
tends to decay by stress relaxation or yield. Similarly, a sudden increase in load results in
an abrupt initial stretch, followed by a gradual increase in stretch, called creep. Seeking
to avoid yield and creep by pulling and relaxing the muscle quickly does not help, since
CHAPTER 2. MEDICAL FOUNDATIONS 50
increasing stretch velocity increases viscosity, spuriously increasing measured forces dur-
ing the pull and decreasing them during the release. Viscous eects can be minimized by
stretching slowly, but this increases yield and creep.
Methods that require the measured muscle to be disinserted - makes it nearly impos-
sible to measure force at primary position length. Once the cut end of the muscle tendon is
attached to the measuring device, attempts to determine primary position length by abut-
ting it to its severed insertion, while holding the eye in primary position and preventing
globe translation, do not inspire condence. The need to unwrap the muscle from the
globe to take the actual measurement provides another opportunity for error.
Rotating the globe to measure stiness - may be done in an intact eye [CCSJ81] or with
some muscles disinserted. Here the worry is that translation as well as rotational forces are
applied by the duction forceps. There is no way to avoid translating the eye when pulling at
one point on its surface. Translation stretches some muscles and relaxes others, distorting
force measurements in complex ways.
The degree of elastic coupling to surrounding structures - with measurements on disin-
serted muscles is seldom clear and denitely not physiologic.
Figure 2.32: Muscle Force Transducer for Intraoperative Measurements [MD96]
To address these problems, Miller et al developed a method that is related to the method of Collins
[COS75], in that it leaves the eye free to rotate, preserving the physiologic relationship between
muscle tension and length (see Fig. 2.32). The muscle is not disinserted, and its path length
(e.g. degree of stretch in a given eye position) is not signicantly altered. This device lies at on
the muscle tendon, causing little modication of ocular mechanics. Since the measured muscle
remains attached to the globe, primary position muscle length is easily established. Problems of
globe translation do not arise, and musculo-fascial couplings are physiologic. However, signals
are slightly distorted as the transducer rotates under the lids. The method is most useful with
awake patients, but even with anesthetized patients it has the advantage that primary position
forces can be determined.
CHAPTER 2. MEDICAL FOUNDATIONS 51
2.3.3 Measurement of Motion in the Orbit
It has been shown, that the measurement of the motion of orbital tissue can improve the diagnosis
and management of orbital disorders and also give more detailed insight to the kinematics of
orbital movements [DMP
+
95][CJD00][DOP00]. It is easy to measure the motion of the eyes as a
function of gaze, since the eyes are easily observed visually and their motion is readily accessible
for inspection. However, the motion of the orbital tissues behind the globe is eectively hidden
by the orbit, the eye and the eyelids, so that it is very dicult to apply measurements in vivo.
Attempting to measure motion objectively by introducing instruments or devices into the orbit
is not yet an option. The risk of damaging the optic nerve and consequently causing blindness
is simply too large. Additionally, such instruments may inuence the very motion they are
supposed to measure. As an alternative, Abrmo suggested to measure the motion rst by
using MR imaging and then using image analysis techniques to measure the motion objectively
[Abr01]. A suitable image device constructs an image, or a series of images from some regionally
varying physical properties. In this case, an image can be considered as an ordered set of vectors,
where each vector represents the magnitude of one or more of the measured physical properties.
Reconstructing optical ow vector elds in these images gives insight into the motion of the
captured region.
Cine MRI time sequences were obtained using T1-weighted volumes on a 1.5 T MR scanner
and a head-coil (TE 6.9, TR 12, matrix 256x256x46) with an acquisition time of 15 sec. Two
dimensional image sequences were extracted from these volumes on a transversal axis intersecting
both, horizontal rectus muscles and the optic nerve (cf. Sec. 2.1.4).
Figure 2.33: Intraconal Tissue Motion around the Optic Nerve, from [Abr01]
A: ow eld displayed over a static MRI of the left orbit. B: Schematic view of motion as expressed by B.
Because the true motion eld in the orbit is unknown, simulations and measurements of controlled
motion of an object (i.e. a sirloin steak) was used to compare the computed ow elds with the
known motion elds. A sirloin steak was mounted in a transparent box tted with an angle ruler.
A sirloin steak consists of bands of several millimeters width of alternating muscle and fat tissue
that approximates the alternating fat-muscle-brous tissue structure of orbital soft tissue. This
object was rotated 5 degrees per captured frame, and a sequence of 21 frames was obtained by
the MR scanner. Pre-ltering using Gaussian smoothing and nonlinear diusion was performed
on all images.
CHAPTER 2. MEDICAL FOUNDATIONS 52
Optical ow algorithms were used to extract the spatio-temporal patterns of image or signal
intensity to estimate the optical ow eld. In a second stage, the resulting system of equations
is solved to estimate the actual optical ow. The computed ow elds were displayed using a
mapping technique that shows all ow vectors as colored pixels plotted over the original MR image
(see Fig. 2.33). Thus, a multi-modality image is obtained that combines functional (motion) and
anatomical information in a single image.
Chapter 3
Strabismus
Squint (strabismus) is the name given to usually persistent or regularly occurring misalignment
of the eyes. Strabismus is a visual defect in which the eyes are misaligned and point in dierent
directions. One eye may look straight ahead, while the other eye turns inward, outward, upward
or downward. Strabismus is a common condition among children. About 4 percent of all children
suer from strabismus. It can also occur later in life. It occurs in males and females and may
run in families. However, many people with strabismus have no relatives with this problem.
People that have strabismus suer not only from the frequently disguring externally visible
abnormality, the visual impairment associated with squint is an even greater burden. Squint is
not just a blemish but often a severe visual impairment. The earlier a child develops a squint and
the later it can be treated, the worse the visual impairment will be. By the time a child reaches
school age, the prospects of successful treatment decline dramatically. Babies and small children
with strabismus should be treated at the earliest possible moment.
This chapter will give an overview of some important fundamentals in strabismus along with its
various pathological classications. Along with representative examples, basic clinical diagnosis
and treatment will be covered, including the eects of surgery, evaluation of eye motility disorders
or determination of the amount of surgery. However, more detailed information on strabismus
pathology and surgery is well documented and can be found in various literature (e.g. [Kau95],
[DE73], [RSS01], [Kan87] etc.). The goal of this chapter is to give insight into current clinical
practice in the eld of strabismus diagnosis and treatment in order to better understand the
application of a new, computer-aided basis for this medical subject.
53
CHAPTER 3. STRABISMUS 54
3.1 Overview
In order to be able to correctly perceive the environment, both eyes must look in the same
direction. This causes almost identical images to be generated within each eye. These two
images are then fused together in the brain to form a single three-dimensional visual impression.
If a squint is present, the dierence between the two images caused by the misalignment is too
great and the brain is unable to converge and to fuse them. The result is irritating double vision.
The juvenile brain is able to respond to double images by simply suppressing the image arriving
from the deviant eye. This process generally has calamitous consequences as vision in the unused
eye gradually becomes weak (amblyopic). Amblyopia is the term used to describe weak vision
in an otherwise organically healthy eye. In the absence of treatment almost 90% of all children
who suer from a squint develop amblyopia on one side. If this squint-related visual weakness is
not detected and treated within early time, it will remain a lifelong aiction. The child will then
never learn to see with both eyes or even have three-dimensional vision and will be at greater
risk of accidents and restricted in everyday life. Prompt treatment can almost always prevent or
cure amblyopia and sometimes also produce good spatial vision.
3.1.1 Visual Acuity
Babies are able to perceive their environment through their eyes quite soon after birth - but
only indistinctly. Among all human senses, the visual sense develops within shortest time, but
visual acuity still has to be developed through constant exercise. Only a limited period in growth
is available for this purpose. By the time school age is reached, the eyes learning program is
virtually complete. The old adage that what you dont learn as a child, youll never learn as an
adult applies to eyesight, too. In the rst weeks of life a child is still unable to exactly coordinate
the movements of the two eyes. Brief misalignments during this time are no cause for concern.
They may also occur occasionally again in the course of the coming months. The ability to gaze
also has to be learned, but if one eye constantly deviates from the direction of the other, there
is no time to loose. The ophthalmologist can diagnose the problem even in infancy and must
initiate the treatment at the right time.
3.1.2 Symptoms
Children with conspicuous squint have the best prospects because they are taken to the ophthal-
mologist within short time by their parents on account of the blemish. Unfortunately, there
exists a number of barely visible or invisible deviations. They are only detected when one eye is
already amblyopic - such as during the eye test when starting school, when it is generally too late
for an entirely successful treatment. For this reason alone 4% of all people suer from serious
one-sided visual deciency. It is therefore very important to know and to heed all characteristics
that might indicate an impending or existing squint: sensitivity to light, with tears, squeezing one
eye shut, bad mood or irritability, chronic blepharitis, head held to one side and clumsy motion
are alarm signals. Each sign is a valid reason in its own right to obtain an ophthalmologists
opinion immediately.
CHAPTER 3. STRABISMUS 55
3.1.3 Treatment
The primary prerequisite of treatment is to establish an optimum visual acuity for both eyes.
Only then, a squint surgery can yield successful and enduring results. Eyes with total loss of
xation (e.g. blindness) often re-establish squinting after surgical treatment and cannot hold
long-lasting parallel alignment.
Eyeglasses Many squinting children in Europe are farsighted. Exceeding near xation can cause
squinting with these children due to the convergence impulse. Eyeglasses, determined under
full relaxation, using anesthetic, relaxing eye drops, can minimize or even heal a disorder.
Occlusion treatment Occlusion treatment, in which a light restraining plaster is applied over
the squinting and normal eyes in a specic rhythm as instructed by the ophthalmologist,
serves to prevent as well as combat amblyopia. The plaster covering on the normal eye
is intended to have the eect of exercising the squinting eye. Changing over the plaster
alternately prevents weak vision in the normal eye caused by the occlusion. The main pre-
requisite for the success of amblyopia treatment is strict adherence to the treatment/exercise
phases for the squinting eye and the normal eye that have been precisely determined by the
ophthalmologist in every single case. If glasses, occlusion and eye-drops do not result in an
improvement in visual acuity in older pre-school children and younger school children with
amblyopia, a training program prescribed by the ophthalmologist can occasionally provide
further help. The amblyopia check-ups and treatment must generally be continued over a
period of years into the growth phase, in addition to glasses and even after a successful
operation. The skin plaster can, after improval of vision, often be replaced by an occlusion
using blurring spectacle sheets.
Strabismus surgery and subsequent treatment Half of the children with a squint need cor-
rection of the faulty alignment by means of an operation on the extraocular eye muscles.
Sometimes, in a mechanical restriction of eye movements, operative positional correction is
a prerequisite for all other measures. As a general rule, the operation is only carried out
when the child wears glasses reliably, can see more or less equally well in both eyes and
can be adequately examined (normally shortly before starting school). In order to improve
preoperative diagnosis, the wearing of prisms, also for longer time, is useful to determine
the true squint angle. The operation does not eliminate the weak vision, neither does it
produce an immediate improvement in spatial vision. Both generally require further oph-
thalmic treatment. The operation does not eliminate the need for glasses, because they are
the only means of correcting refractive errors. The type of misalignment and the result of
the preliminary treatment determine whether a single operation is sucient. Strabismus
operations are carried out on the children under general anaesthetic by the ophthalmologist.
3.2 Binocular Vision
In vergence disconjugate movement, both eyes move synchronously and symmetrically in opposite
directions, where convergence movements describe the ability to move both eyes inward (to the
nose) and divergence denes the movement of both eyes outward (away from the nose). In
CHAPTER 3. STRABISMUS 56
convergence, voluntary and in voluntary reexes occur, in order to fuse the images of both eyes
to a single stereoscopic picture.
Tonic convergence - describes the tonus of the extraocular muscles (especially the medial recti
muscles) when awake.
Proximal convergence - is the convergence induced by the knowledge of the proximity of an
object and occurs in optical instruments even though they are set for innity.
Fusional convergence - is a reex that ensures the bilateral projection of corresponding areas
onto the retinae of both eyes. This reex occurs without a change in optical refraction and
is stimulated by the perception of double images (diplopia). Thus, fusional convergence
generates compensatory eye movements in order to overcome disparity of the retinal images.
The amplitude of fusion denotes the maximum magnitude of eye movement that resides
from fusional convergence. Fusional amplitudes may be corrected through the application
of prisms and can be measured with a synoptophore. The usual fusional amplitude of
convergence that is measured to the breaking point of diplopia for xation of far targets is
approximately 30 prism dioptres and for near xation approximately more than 35 prism
dioptres, whereas one dioptry corresponds to approximately 0.5 degrees. Generally, fusional
convergence supports to control exophoria (latent divergent strabismus), whereas fusional
divergence helps to compensate for esophoria (latent convergent strabismus).
Accommodative convergence - is convergence induced by accommodation. For each dioptre
is associated with a near linear increasing relationship to the angle of accommodative con-
vergence and results in the so called accommodative convergence/accomodation (AC/A)
ratio. Normally 3 to 5 prism dioptres per dioptre of accommodation. Anomalies in the
AC/A ratio most often indicate a cause for strabismus. A high AC/A ratio due to ac-
commodation for the xation of near objects may induce excessive convergence and result
in esotropia (inward squinting). Thus, a low AC/A ratio may lead to divergence that is
causally related to exotropia (outward squinting) while a subject xates a near object.
Voluntary convergence - is convergence that can be produced at will.
Binocular vision develops within the rst years of life and is additionally accomplished by the
ability to three-dimensionally perceive an image due to stereopsis. Three essential factors are
required for the successful development of binocular vision and stereopsis.
Clear and undisturbed refraction in both eyes,
the ability of dierent areas in the brain to fuse slightly dierent images from both eyes,
and
the ability of exact coordination of eye movements in all possible gaze positions within the
physiologic eld of gaze.
Thus, the ability of fusion strongly depends on the relationship between both retinae.
CHAPTER 3. STRABISMUS 57
3.2.1 Projection
Projection is dened as the interpretation of the position of an object in space on the basis
of corresponding areas that are stimulated on the retina (see Fig. 3.1). Following Fig. 3.1(a),
an object (F) and an additional element (T) are stimulating the right fovea (F) and the right
temporal area of the retina (T), respectively, the brain will perceive the red object (F) as straight
ahead, whereas the black object (T) will be located in the nasal visual eld of the right eye. This
situation corresponds to the normal projection of images onto the retina of an eye. According to
this denition, nasally located elements will project onto temporal areas on the retina, whereas
elements that are located in the upper part of the physiologic eld of gaze are projected onto
lower areas onto the retina, and vice versa.
(a) Right Eye (b) Both Eyes
Figure 3.1: Projection of Objects in Space onto the Retina on an Eye, adapted from [Kan87]
When both eyes are kept open, the red object (F) in Fig. 3.1(b) stimulates the retinae of both
eyes (F), and the black object (T) stimulates temporal areas of the retina in the right eye (T)
as well as nasal areas of the retina in the left eye (N). Accordingly, the right eye projects the
object into temporal areas of the visual eld, and the left eye projects into nasal areas of the
visual eld. Since the stimulated retinal elements both represent the same object, both retinal
points will project to the same location in space and no double images will occur.
According to the implications of retinal projection, a horopter (see Fig. 3.1(b)) represents a
virtual spherical arc that captures all points in space that correspond to diplopia free binocular
vision. Points that are xated beyond or before this horopter will be accompanied by double
images (diplopia) and are the foundation for physiological double vision.
The line of sight or visual axis, corresponds to the line that is virtually drawn from the xation
point in space to the retinal point on the fovea and additionally almost intersects the center of
the pupil. From Fig. 3.1(b) it is easy to see that both red lines of sight intersect at the desired
xation point (F) in order project a single, sharp image onto the foveae. The retinal areas (F)
in both eyes are denoted as corresponding retinal areas.
CHAPTER 3. STRABISMUS 58
(a) (b) (c)
Figure 3.2: Dierent Forms of Binocular Fixation, from [Kan87]
3.2.2 Diplopia
In strabismus, a dissociation of the lines of sight of both eye occurs which can be latent (phoria) or
manifest (tropia). Concerning manifest forms of strabismus there can be two dierent problems
in the alignment of the visual axes, namely confusion and diplopia. In Fig. 3.2(b), a convergent
manifest strabismus of the right eye is shown, so that the fovea of the right eye is stimulated
by a black triangle and the red object is projected onto the left fovea. Confusion results in the
overlapping of these dierent images into the same vertical axis in space.
After that, diplopia results from the stimulation of an excentric retinal area in the fovea of
one eye. In Fig. 3.2(c), the red object in space does not stimulate corresponding retinal areas,
instead, a nasally shifted position on the retina is stimulated in the left eye, whereas the object
is on the fovea of the right eye. In case of convergent strabismus, uncrossed double images
occur (see Fig. 3.2(c)), while in divergent strabismus diplopia is perceived with crossed double
images. Mainly in young children, a mechanism of alternating suppression leads to a temporary
phenomenon in binocular vision, where the misaligned image is actively masked out by the brain.
When the xating eye is covered, the squinting eye takes up the xation and suppression stops
immediately. But in not alternating (monocular) strabismus, amblyopia can be seen as a result
of continuous monocular suppression of the image of the aected eye.
3.3 Ocular Dissociation
The term orthophoria denes the ideal condition of ocular balance wherein the oculomotor system
is in perfect equilibrium so that both eyes retain their normal positional relationship (i.e. both
eyes remain directed upon a xation point or remain parallel). In such a condition, the positions
of both eyes are identical and a correct posture of the eyes is maintained without eort for
all directions of gaze and all physiological distances of a xation point. However, this ideal
equilibrium is rare for distant and seldom existent, especially when xating near objects. Usually,
both eyes are maintained on the xation point only under stress with the aid of corrective
CHAPTER 3. STRABISMUS 59
fusion reexes, originating from the brain. This can be classied as a tendency for deviation
of the eyes from parallelism, which can be prevented by the mechanism of binocular fusion.
This results in a typical deviation of both eyes, when they are dissociated (e.g. one eye is
covered), and binocular vision is mutually prevented on purpose. This common deviation is
called heterophoria and better represents the practical reality compared to the idealized case
of orthophoria. However, functional heterophoria is clinically referred to as a signicant, latent
deviation of the eyes, compared to the unrealized ideal of orthophoria or the physiologically
normal deviations of heterophoria.
Additionally, the time-incidence of the deviation is denoted as follows:
Latent strabismus (Heterophoria) - is referred to as hidden strabismus, which only occurs
when binocular vision is prevented by dissociation of the eyes, usually achieved by covering
and subsequent uncovering of one eye.
Manifest strabismus (constant strabismus, Heterotropia) - is dened as deviation that
occurs all the time, also without dissociation of the eyes.
Variations in the characteristics of deviation of movements of the eye are also distinguished using
the following terms:
Concomitant strabismus - occurs when the deviation remains the same, or approximately
the same, in all position of the eyes and additionally is unaltered no matter which eye is
used for xation of a target object. Thus, both eyes move together in coordination, and
the visual axes, although abnormally directed, retain the same abnormal relationship to
each other throughout the complete physiologic eld of gaze. It is now well known that
so-called concomitant deviations are in fact variable by nature (cf. [RSS01]), and that these
variations can be measured. Therefore the term concomitant is too unspecic, if it has to
signify that the angle of deviation is invariable. Presently, this denition is used if there is
no limitation on duction movements, in spite of an oculomotor disorder, and that there is
an accompanying sensorial disorder to a greater or lesser degree.
Incomitant strabismus - means that the deviation alters with changing the position of the
eyes and varies depending on whether the non-pathological or pathological eye is used for
xation. This usually originates in paretic or paralytic, sometimes spastic problems. In
paralytic strabismus, when the eyes are turned away from a paralyzed muscle, which is thus
not contracted, eye positions may be relatively normal. However, when the eyes move in
the direction of action of the paralyzed muscle, movement becomes limited or even absent
and deviation grows with the angle of excitation.
According to the direction, time-incidence and degree of deviation, heterophoria and heterotropia
are described by using the following terminology [DE73]:
Esophoria and Esotropia (latent and manifest convergent strabismus) - is apparent,
when the deviating eye turns inward, towards the nose (see Fig. 3.3).
CHAPTER 3. STRABISMUS 60
Figure 3.3: Example for Inward Squinting
Exophoria and Exotropia (latent and manifest divergent strabismus) - designates a
outward (away from the nose) deviating eye (see Fig. 3.4).
Figure 3.4: Example for Outward Squinting
Hyperphoria and Hypertropia (latent and manifest vertical strabismus) - occurs
when the eye is deviating upward. Vertical upward deviating strabismus is also often
termed strabismus sursumvergence (see Fig. 3.5).
Figure 3.5: Example for Upward Squinting
Hypophoria and Hypotropia (latent and manifest vertical strabismus) - occurs when
the eye is deviating downward. Vertical downward deviating strabismus is also often termed
strabismus deorsumvergence (see Fig. 3.6).
Figure 3.6: Example for Downward Squinting
In order to denote the aected pathological eye within this terminology, the following terms are
used commonly:
Monocular strabismus - can be denoted as right or left uniocular or monocular strabismus
CHAPTER 3. STRABISMUS 61
that always aects one eye so that the other eye is preferred as the leading xating eye. The
aected eye will then follow the xating eye and deviate according to the actual pathology.
Binocular or alternating strabismus - sometimes aects one eye and sometimes the other,
so that xation can be assumed and maintained by each eye in turn, and when both eyes
are open, each is able to hold xation freely, without any obvious preference for xing with
either eye. Sometimes, however, it is legitimate to retain the term when there is a preference
to take up xation with one eye that is distinctly dominant, despite the absence of an equal
level of vision and the ability of each eye to retain xation of the non-dominating eye after
covering the other eye.
It has to be noted that the mechanism controlling movements of the eyes is variable and struc-
turally determined, but is non-obligatory, non-rigid and physiological in nature although the
oculomotor control system conforms to denite laws within the limits of which it must remain
(see Sec. 2.2.2). It is obvious, however, that a mechanism of such complexity and precise control
must possess the weakness of vulnerability and it is not surprising that disruptions frequently
occur from structural and functional causes, both in its peripheral and central parts. Abnormal-
ities in ocular motility are therefore frequent and, indeed, constitute one of the most common
of ocular disabilities. The essential factor determining the eciency of the oculomotor control
system is the early (in childhood) development of the ability of xation and the fusional reexes
accomplished by the brain.
3.4 Clinical Assessment
In evaluation of ocular alignment a rst decision about the information that is required must
be taken. Measurements can give information on the eye alignment during everyday binocular
viewing, or the maximal deviation of the visual axes under conditions of disrupted binocular
vision, or both of these. Subjective methods are useful for cooperative, communicative older
patients, but objective methods must be used in younger patients or those less cooperative.
Finally, some testing methods are useful only under research laboratory conditions.
Most laboratory tests are objective but depend on the measurement instrument that is used.
The absolute position of the eye in space may be determined by measurement of the quantity
of light reected by the cornea from a deviated eye. The electro-oculogram (see Sec. 2.3.1.1)
is generated by alterations of eye positions and electrodes capture the imbalance of electrical
potentials. Insulated wire placed in a silicone rubber (eye coil) generates response to a magnetic
eld (see Sec. 2.3.1.3) and can be used to exactly determine eye position.
Clinical investigations imply the analysis of atypical head positions that may indicate restrictive
or paralytic strabismus, the presence of a null point in a patient who has nystagmus, or alphabet
pattern strabismus. Usually, a patient places the head in a position that provides comfortable
single binocular vision for the straight ahead view, but occasionally the head is placed to separate
diplopic images maximally. The examiner must dierentiate between head turns, tilts, and
vertical head positions and attempt to quantify these.
In patients who have vertical strabismus, lid asymmetry is often found. If hypotropia is present
and the non xing eye is lower than the xing eye, then the lid position is lower in this non xing
CHAPTER 3. STRABISMUS 62
Figure 3.7: Pseudo-Esotropia due to wide Bridge and Epicanthal Skin Fold, from [Kan87]
eye. This is termed pseudoptosis, if the lid regains normal position when the previously hypotropic
eye xates in primary position. Epicanthal skin folds that extend over the nasal sclera in a small
child may simulate esotropia (see Fig. 3.7). Vertical displacement of an orbit may simulate vertical
strabismus, and an abnormal increase in the interorbital distance may simulate exotropia. The
examiner can declare a patient to be strabismic only after the appropriate alignment testing has
been performed.
Objective clinical methods to determine and measure deviations of the visual axes include corneal
light reex tests, cover tests, and haploscopic tests. These tests do not require any response by
the patient and thus are independent of the patients ability to interpret the testing environment.
3.4.1 Corneal Light Reex Tests
Corneal light reex tests, the oldest testing methods, are suitable for all patients. The angle
kappa (i.e. the angle formed between two imaginary lines: the visual axis and the pupillary axis)
has to be taken into account, and the xation of one eye is required. The Hirschberg method
relies on a pupil size of 4mm and assumes each millimeter of light displacement across the cornea
is equivalent to approximately 7

of deviance. A light reection at the pupillary border signies


a 15

deviation (see Fig. 3.8), at the mid-iris a deviation of 30

and at the limbus a deviation of


45

. The patient shown in Fig. 3.8 has a left esotropia, thus, the corneal light reex of the left
eye is displaced temporally with respect to the pupillary border of the left eye, while the reex
is centered in the pupil of the right eye.
CHAPTER 3. STRABISMUS 63
Figure 3.8: Hirschberg Light Reex Test Method, from [Kan87]
The test should be performed with the light centered in each eyes pupil to detect the presence
of secondary deviations. The disadvantages of this test are the estimations necessary to measure
the eye deviation and the inability to control accommodation when testing at near xation, as
the measuring light serves as the xation target. Distance testing is dicult because the dimness
of the target light is reected in the corneas.
The Krimsky test quanties the light reex displacement using appropriately held prisms. The
original description suggested to place the prism before the aligned, xating eye (see Fig. 3.9),
but most users today nd it easier to hold the prism before the deviating eye. The strength of
a base-out prism over the xing right eye to center the pupillary light reex in the esotropic left
eye is dened as the amount of left esotropia (see Fig. 3.9).
Figure 3.9: Krimsky Light Reex Test Method, from [Kan87]
Prisms must be appropriately handled to yield accurate measurement of strabismus. They deect
light toward their base, but the patient views the light as deected toward the prism apex. The
prism diopter is dened as the strength of prism necessary to deect a light beam 1cm at 1m
distance. Glass prisms are calibrated when positioned with the back surface perpendicular to
the visual axes. Plastic prisms, whether loose or in bar form must be held with the rear surface
in the frontal plane, to approximate closely the position of minimal deviation of light through
the prism. Prisms cannot be stacked base to base as the sum prism strength is much greater
than the sum of each individual prism strength, but they may be stacked with bases 90

apart.
CHAPTER 3. STRABISMUS 64
Large deviations are best neutralized when the prisms are divided between the two eyes. For
measurements when patients view in eccentric gaze positions and for those in the head tilt test,
care is required to ensure the prisms are held in the frontal plane.
3.4.2 Cover Tests
These objective tests detect and measure horizontal and vertical strabismus, but they cannot
measure torsional deviations and detect only some and not all torsional deviations. All cover
tests demand the ability of each eye to look at a xation target at near and distance, and to
move to take up xation upon that target.
Figure 3.10: Prism-Cover Test, from [Kan87]
The monocular cover test detects constant visual axis deviations. The examiner observes the
uncovered eye for movement as its fellow eye is covered with a paddle, the hand or the thumb. A
nasal movement implies exotropia, temporal movement esotropia, upward movement hypotropia,
and downward movement hypertropia of the uncovered eye (see Fig. 3.11). Each eye is covered
in turn. An accommodation-controlling xation target is presented to the patient, who ideally
describes the target. Small toys are suitable for young children, but bright white lights are too
be avoided as the patient cannot accommodate on the contours of a light. Tropias established
by the cover test may be measured using the simultaneous prism and cover test. A prism of
appropriate strength held in the appropriate direction is introduced before one eye as its fellow
is covered (see Fig. 3.10). Prism strength is increased until eye movement ceases and the prism
strength corresponds to the size of the strabismus. The test is then repeated with the prism
before the other eye.
The uncover test requires observation of the covered eye as the cover is removed. If that eye
deviated under cover it may regain xation or may remain deviated. The former implies the
CHAPTER 3. STRABISMUS 65
presence of a phoria, a latent deviation held in check by sensory fusion, or an intermittent tropia;
the latter implies a tropia with xation preference for the fellow eye.
Figure 3.11: Cover Tests for Tropias and Phorias, from [DE93].
(a) For exotropia, covering the right eye drives inward movement of the left eye to take up xation; uncovering the right eye shows recovery
of xation by the right eye and leftward movement of both eyes; covering the left eye discloses no shift of the preferred right eye. (b) For
esotropia, covering the right eye drives outward movement of the left eye to take up xation; uncovering the right eye shows recovery of xation
by the right eye and rightward movement of both eyes; covering the left eye discloses no shift of the preferred right eye. (c) For hypertropia,
covering the right eye drives downward movement of the left eye to take up xation; uncovering the right eye shows recovery of xation by
the right eye and upward movement of both eyes; covering the left eye shows no shift of the preferred right eye. (d) For exophoria, the left
eye deviates outward behind a cover and returns to primary position when the cover is removed. An immediate inward movement denotes a
phoria, a delayed inward movement denotes an intermittent exotropia.
Phorias may be detected more directly using the alternate cover test, in which each eye is occluded
alternately to dissociate the visual axes maximally. Care must be taken to permit time for each
eye to reside behind the cover (the cover must not be fanned before the eyes). Appropriately
held prisms enable quantication of the phoria (see Fig. 3.10). Some patients have poorly dened
end points and a range over which eye movements shift from one direction to the opposite as
prism strength is increased, thus, the strabismus measurement may be estimated as the midpoint
between clearly dened movements in each direction.
If the cause of strabismus is paralytic or restrictive, patients may have greater cover test mea-
surements when the paretic or restricted eye xes in a given gaze position (secondary deviation)
than when the unaected eye xates (primary deviation). This phenomenon arises from Herings
Law (see Sec. 2.2.3.7), which demands equal innervation to yoke muscles, thus, the yoke of a
paralyzed or restricted muscle receives excess innervation when the pathologic eye is xing.
Strabismus should be detected and measured in primary position at distance and near xation,
and in gaze up, down, right, and left 30

from primary position. These nine diagnostic gaze


positions include the above plus up and right, up and left, down and right, and down and left
and are useful to measure cyclovertical muscle palsies. For patients who have oblique muscle
dysfunction, measurements are taken with the head tilted right and left at distance xation.
3.4.3 Subjective Clinical Tests
Subjective clinical methods include diplopia tests and haploscopic tests, which require cooper-
ation, intelligence, and the ability of the patient to communicate the sensory percept to the
CHAPTER 3. STRABISMUS 66
examiner.
Figure 3.12: Maddox-Wing Test, from [YD03]
The Maddox-Rod test dissociates both eyes for near and distance xation and measures het-
erophoria (see Fig. 3.12). A red Maddox rod in a trial frame may be used to evaluate subjective
ocular torsion. The grooves must be aligned with the mark on the rim, as they tend to rotate
within. The red glass requires the patient to alert the examiner when the red light viewed behind
a red lter before the right eye and a white light viewed with the left eye are superimposed or
displaced one from the other. Fusion is disrupted by the red glass and thus horizontal and vertical
phorias are uncovered and measured. The gaze position of maximal image separation is a clue
to the identity of paretic or restricted muscles. This is a useful bedside test, but accommodation
is not controlled.
The Maddox rod consists of closely aligned, powerful glass or plastic cylinders. When illuminated,
these cylinders project a line upon the patients retina perpendicular to the groove orientation.
The line is aligned horizontally to detect and measure horizontal phorias (accommodation cannot
be controlled with this test). Torsion may be detected and quantied using the Maddox rod which
is placed in a trial frame scaled in degrees. It is common to place two Maddox rods of diering
color in each trial frame cell and permit the patient to rotate each to his or her perception of the
horizontal. The torsional position of each eye may be read directly in degrees from the angular
scale used for cylinder axes.
3.4.4 Hess-Lancaster Test
The Hess-Lancaster test is a test for binocular alignment using separated images for both eyes.
Generally, there are many similar testing methods (e.g. Less-Screen, Helmholtz-Test, etc.) that
use the same testing principle as the Hess-Lancaster test. The also exists the so called Hess test,
which uses a dierent coordinate system for measurement, but the basic interpretation of the
results is identical.
During the clinical Hess-Lancaster test the following steps are carried out:
1. The patient wears red-green-glasses with the red lter in front of the e.g. right eye (xing
eye) initially (see Fig. 3.13).
2. The patient gets a green light pointer, the examiner gets a red light pointer.
CHAPTER 3. STRABISMUS 67
3. The examiner projects a red light spot onto the so-called Hess screen and asks the patient to
bring the green light spot (following eye) over the red light spot. Under normal conditions
both light spots overlay in all nine main gaze directions (see Fig. 3.13(a)).
4. Now the red lter is put in front of the other eye and the previous steps are repeated with
the other eye, which is now the xing eye.
If the patient xates with the normal unaected left eye, the xation can be reached with
normal innervation. However, if the right medial rectus muscle is palsied, the patients green
light pointer will point into a direction, which does not correspond to the real location of the
xation point in space (see Fig. 3.13(c)). After the test is nished, the relative positions are
connected with straight lines.
(a) (b) (c)
Figure 3.13: Binocular Fixation in the Hess-Lancaster Test, from [Kan87]
If e.g. the patient suers from a palsy of the lateral rectus muscle on the right eye and also
xates with the right eye (red lter), the normal left medial rectus muscle receives an excessive
innervation (Herings law). As a result, the patients green light pointer will point to a position,
which lies far beyond the correct one (see Fig. 3.13(b)). The results of the Hess-Lancaster test
are in general two diagrams (left eye and right eye xing) with the corresponding gaze positions,
which in turn show the deviation and the squint angle (see Fig. 3.14).
In the Hess-Lancaster diagram from Fig. 3.14, the blue points represent those gaze positions,
which the patient should xate (intended gaze positions) and the red points represent those gaze
positions, which the patient was able to reach with the following eye. The dierence between
the blue and the red points shows the respective deviation of binocular coordination. At the
same time next to each red point (following gaze position) the torsion of the following eye is
shown (as text) in order to get the torsional position of the following eye. The following list gives
an overview of the interpretation of Hess or Hess-Lancaster diagrams for a right medial rectus
muscle palsy:
CHAPTER 3. STRABISMUS 68
Figure 3.14: Hess-Lancaster Diagram for Right Eye (Left Eye Fixing)
1. The two diagrams from Fig. 3.15 (left eye
and right eye xing) are compared.
2. The smaller diagram shows the eye with
the palsied muscle.
3. The larger diagram corresponds to the
eye with the overacting muscle.
4. The smaller diagram shows the biggest
restriction in the main functional direc-
tion of the palsied muscle (in Fig. 3.15(b),
the right medial rectus muscle).
5. The larger diagram shows the biggest ex-
pansion in the main functional direction
of the synergistic muscle (in Fig. 3.15(a),
the left lateral rectus muscle).
(a)
(b)
Figure 3.15: Interpretation of Hess-Diagram
according to Muscle Actions, from [Kan87]
CHAPTER 3. STRABISMUS 69
Figure 3.16: Hess-Diagram
Interpretation, from
[Kan87]
Changes in the Hess diagrams are a prognostic help. A palsy of
the right superior rectus muscle for example will show a restric-
tion of the aected muscle and an overfunction of the synergist
(left inferior oblique muscle) (see Fig. 3.16(a)). As a result of this
signicant incomitant reaction shown in both diagrams, the diag-
nosis can be made directly out of the diagrams. However, when the
palsied muscle has recovered, both diagrams show approximately
normal values again. If the palsy is not corrected, the shapes of
both diagrams change and a secondary contractor of the ipsilat-
eral antagonist (right inferior rectus muscle) develops, which can
be seen as an overfunction in the diagram. This in turn can lead
to a secondary (inhibition) palsy of the left superior oblique mus-
cle, which is represented in the diagram through reduced activity
(see Fig. 3.16(b)) and which gives the false impression that the
left superior oblique muscle is the real cause for the pathological
situation. By-and-by the two diagrams get even more concomitant
up to the point were it is impossible to determine which muscle
was the primary palsied muscle (see Fig. 3.16(c)).
3.5 Eye Motility Disorders
Pathological anomalies in ocular motility are mainly dierentiated in two fundamental types.
The reasons for motility disorders can therefore be a failure in the development of the xation
reexes or a disruption of xation reexes from structural or functional causes. Each of these
categoric disorders will produce dierent symptoms and therefore demand also dierent therapy.
Anomalies in the conjugate xation reex make it impossible to xate objects, since both eyes
cannot move in binocular community. This will result in heterophoria (latent strabismus) when
the xation can be established with stress, and in concomitant, manifest strabismus when xa-
tion is not possible at all. Similarly, the near xation reex may be disrupted, resulting in an
anomaly in convergence. Some structural or neuro-muscular lesion may prohibit the develop-
ment of adequate movements, already from birth on, so that congenital incomitant strabismus is
developed. On the other hand, if a lesion occurs in the peripheral (infranuclear) neuro-muscular
mechanism after the reexes have been established, an acquired incomitant strabismus, resolvable
in terms of individual eye movements results due to some pathological accident. A lesion in the
central (supranuclear) mechanism results in binocular deviation, resolvable in terms of associated
binocular eye movements.
Thus, a supranuclear lesion indicates disorders of movement caused by the destruction or func-
tional impairment of brain structures above the level of the motor neurons, such as the motor
cortex (see Sec. 2.2.3). Furthermore, infranuclear lesions refer to disruptions below a nucleus of
a nerve (e.g. eye muscle palsies), whereas intranuclear lesions aect connections between other
oculomotor nuclei (palsies that aect interneuronal connections, e.g. the medial longitudinal
fasciculus, see Sec. 2.2.3.5).
The fundamental fact about the development of pathological dissociation is, that if the normal
CHAPTER 3. STRABISMUS 70
xation reexes are not attained and to some extent xed by usage in the early months and years
of life and certainly before the age of ve years, while the nervous system is still exible enough
for adaptations, these reexes will never develop.
3.5.1 Concomitant Strabismus
Concomitant strabismus can be classied as congenital, sometimes also acquired, functional eye
motility disorder, caused by common predisposition that lead to a pathological development of eye
movement. Functional eye motility disorders are inuenced by many dierent factors, whereby
three groups of factors can be distinguished and are particularly important [DE73]:
Static anatomical conditions - that produce a faulty position of the eyes relative to each
other,
excessive or abnormal innervations - particularly important in a disharmony of the rela-
tionship between accommodation and convergence, and
decient development of the ability to fuse - due to a unilateral sensory failure or a lack
of central organization.
It is important to notice that it is extremely rare that strabismus is caused by one of these factors
alone. However, generally, all these factors depend on some obstruction to the development of
the binocular xation reexes which coordinate eye movements.
Generally, the following reasons can be responsible for the development of concomitant strabis-
mus:
Hyperopia (long sightedness) - is a very common cause for Esophoria, since a young child
must accommodate in order to get a sharp image, when xating far objects. Unfortu-
nately, accommodation also implies convergence of both eyes and can subsequently lead to
strabismus, when not cured within certain time.
Fusional dysfunction - that can be congenital or acquired (e.g. caused by scarlet fever or
measles). Additionally, concussion or accidents can cause acquired concomitant strabismus.
Unbalanced refraction in both eyes - can hinder fusion due to dierently sized retinal im-
ages that occur when xating objects.
Developmental disorders of eye muscles - can additionally contribute to mechanically
caused concomitant strabismus.
In the great majority of the cases, good fusional reexes can compensate for a mechanical mis-
alignment, and the result is latent strabismus. The common occurrence of divergent strabismus,
wherein, except in most young children, the eyes revert to their divergent resting position after
the development of impaired vision or blindness in one eye. Generally, children tend to convergent
resting positions, whereas adults tend to divergent resting positions of the eyes. This illustrates
the tendency of anatomical conditions to make their inuence felt in the absence of fusion.
CHAPTER 3. STRABISMUS 71
Innervational, particularly accommodational inuences similarly tend to the development of con-
comitant strabismus, but permanent manifest strabismus does not occur if the binocular xation
reexes have not yet been developed and the fusional vergence is good. If the fusional ability is
too weak, concomitant strabismus develops in childhood, before fusion has become stabilized.
A deciency of fusion can also be responsible for the development of concomitant strabismus, espe-
cially when complex neural control mechanisms are labile or unstable. Exhaustion or excitability
and an unstable neuropathic constitution (i.e. a sudden shock or a psychological trauma) leads
to the disruption of the visual system, and strabismus occurs.
Heredity is most frequently an evidence for concomitant strabismus, as relatives of a family in
the same generation show a higher incidence. However, concomitant strabismus does not take
the same form throughout a family, instead it is varying considerably in being uniocular or
alternating. Concerning the incidence and type of amblyopia, variations have even been seen in
monozygotic twins.
3.5.2 Incomitant Strabismus
Incomitant Strabismus can be seen as a dissociation of the ocular movements, wherein the devi-
ation is irregular, varying in an uncoordinated manner, in dierent directions of gaze. This type
of strabismus results of defects in the nal motor path of the binocular reexes. The essential dif-
ference between concomitant and incomitant strabismus is, that in concomitant strabismus, the
central organization of binocular vision functions inadequately or not at all, whereas in incomi-
tant strabismus, the brain is usually able to command movements, but the motor apparatus is
restricted in carrying out these instructions with adequacy. However, this distinction is variable,
since in many forms of incomitant strabismus in early life, disruptions of the sensory stimuli are
established, similar to those typically occurring in concomitant strabismus. Conversely, certain
forms of concomitant strabismus (e.g. accommodative strabismus or hyperopia) do not show any
disruptions of the sensory stimuli, despite the failure to maintain binocular single vision on near
xation. In incomitant strabismus, lesions occur in the lower motor neuron level (the nuclei,
nerves or muscles), and consequently deviations are not resolvable in terms of eye movements,
but in terms of individual muscles. Herein also lies the distinction from conjugate deviations due
to lesions above the motor neuron level, aecting the supranuclear mechanism which concerns
itself with the control of movements and does not take the contraction of individual muscles into
account. Concomitant strabismus, therefore, gives relatively constant deviations in all directions
of gaze, whereas incomitant strabismus may become evident only when the eye is turned into
the eld of action of the aected muscle where deviation always grows proportional to the gaze
position.
Incomitant strabismus may be either paretic or spastic in nature, but most cases show clinically
a simple under- or over-action of a muscle, although this is mostly associated with changes in
activity of other muscles, so that the resulting deviation may be very complicated and may
eventually rapidly assume entirely dierent characteristics.
One way to simplify diagnostics is to divide the symptoms into four distinctive categories [DE73]:
Overaction of the ipsilateral antagonist which, if maintained for longer time, may result in
CHAPTER 3. STRABISMUS 72
permanent contractual changes.
Overaction of the contralateral synergist - which is due to the demand of equal innervation
(Herings law, see Sec. 2.2.3.7) which requires an equal distribution of innervational impulses
between both eyes. The overaction of the contralateral synergist (yoke muscle) becomes
apparent when an attempt is made to move the paretic muscle in the other eye, and may
also result in contractual changes.
Underaction of the antagonist of the contralateral synergist - becomes noticeable
through Sherringtons law (see Sec. 2.2.3.8) of reciprocal innervation. This is due to an
compensatory overaction of the contralateral synergist and results in an inhibitory under-
action of its antagonist, predetermined by the law of reciprocal innervation.
Overaction of the ipsilateral synergist(s) - describes a compensatory reaction that is car-
ried out in an attempt to accomplish the decient movement. This type of overaction
is seldom noticeable, since ipsilateral synergists always have very limited compensatory
actions with respect to an aected muscle.
Figure 3.17: Example of Disturbance of the Binocular Muscular Team
In Fig. 3.17, one example of a disturbance of the binocular muscular team is illustrated. A palsy
of the right lateral rectus muscle results in an overaction of the right medial rectus (the ipsilateral
antagonist). Additionally, this pathological situation produces a compensatory overaction of the
left medial rectus muscle (the contralateral synergist) and an inhibitory underaction of the left
lateral rectus muscle (the ipsilateral antagonist of the contralateral synergist).
If the paretic eye is habitually used for xation, the secondary deviation (deviation when xing
with a pathologic eye) produced by the contralateral synergist becomes accustomed. Conversely,
if the non-paretic eye is constantly used for xation, the primary deviation (deviation when xing
CHAPTER 3. STRABISMUS 73
with a normal, healthy eye) will function against the recovery of the aected, palsied muscle of
the paretic eye, by facilitating the overaction of the ipsilateral antagonist.
It is also possible that a pathological situation (e.g. described in Fig. 3.17) disappears so that the
originally paretic strabismus changes its characteristics and subsequently shows a purely spastic
deviation. However, if the muscle palsy disappears, it leaves permanent changes of the contracture
or stretching in the various muscles involved. Thus, the original incomitant strabismus may
become virtually concomitant.
3.5.2.1 Paralytic Strabismus
Paralytic strabismus means, that one of the muscles attached to the globe is paralyzed and the eye
aected may turn in, out, up or down depending on the muscle involved i.e. the eye movement is
restricted in the direction of the action of the paralyzed muscle. The reasons for paralytic squint
can originate from a breakdown of motor control before or after the binocular xation reexes
have been developed. It may also be caused by certain nerve palsies, which in turn may be caused
by peripheral diseases of the cranial nerves (e.g. meningitis, encephalitis etc.). Clinical progress
and treatment of paretic strabismus therefore diers considerably with respect to its dierent
causes. The following objective signs of paralytic strabismus can be mentioned:
Abnormal deviation of the eyes,
deviation of movements, and
the adoption of compensating postural attitudes (abnormal head posture).
A common symptom for paralytic strabismus is binocular diplopia (double images) that disappear
when either eye is closed. This is caused by a misalignment of the eyes, which can be secondary
to nerve or muscle related disorders. Diplopia can also cause a reduction of reading, driving, and
vocational skills.
Figure 3.18: Example of Abnormal Head Posture compensating Esotropia, from [Kau95]
CHAPTER 3. STRABISMUS 74
Especially abnormal head postures are a noticeable sign for paralytic strabismus. Patients with
early manifest strabismus show abnormal head posture in that the head is tilted to the shoulder
so that xation in excessive adduction of the leading eye can be accomplished at the same time.
The tilt of the head occurs mostly in the direction where the leading eye is situated (see Fig. 3.18).
The head is turned towards the eld of action of the paralyzed muscle, whereas in paralysis of
any of the recti muscles the chin is elevated in paralysis of the elevators of the eye - superior recti
and inferior obliques. It is depressed in paralysis of the depressors of the eye - inferior recti and
superior oblique. The head is tilted towards the normal side in paralysis of the superior oblique.
It is tilted towards the side of the paralyzed muscle in paralysis of the superior and inferior recti,
and the inferior oblique muscle.
In the following, some examples of individual muscle palsies are given along with the respective
clinical signs. In contrast to neurogenic palsies that occur due to lesions in the neural oculomotor
pathway, muscle palsies are restricted to limitations of the function of specic muscles.
Palsy of the Right Superior Rectus Muscle
In primary position, the right superior rectus muscle is mainly an elevator so that the primary
deviation of the aected eye is downwards (see Fig. 3.19(e)), due to an overaction of the right
inferior rectus muscle (the ipsilateral antagonist). The secondary deviation of the unaected eye
during xation with the aected eye is upwards (see Fig. 3.19(f)), due to overaction of the left
inferior oblique and the left superior rectus (the contralateral synergists). Usually, the secondary
deviation is greater than the primary, which complies to the denition of incomitant deviation.
However, if contraction develops in the ipsilateral antagonist (the right inferior rectus muscle), the
primary deviation increases to become approximately equal to the secondary deviation, assuming
concomitant features. Since the right superior rectus muscle is, in its secondary and tertiary
functions also adductor and intorter, the loss of the adducting inuence is of little signicance as
long as the right medial rectus is intact, but there is noticeable extorsion due to an overaction of
the right inferior rectus and the right inferior oblique muscles.
(a) (b) (c)
(d)
(e) Primary Deviation
(f) Secondary Deviation
(g)
(h) (i) (j)
Figure 3.19: Example of a Right Superior Rectus Palsy
CHAPTER 3. STRABISMUS 75
(a) Primary Deviation, Left Eye Fixing (b) Secondary Deviation, Right Eye Fix-
ing
Figure 3.20: Hess-Lancaster Chart for Right Superior Rectus Palsy
Ocular movements show limitations of the palsied eye in an upward and outward direction (see
Fig. 3.19(a)) so that there is an increase of deviation when looking up and to the right using the
unaected eye. Using the right eye to xate, the secondary deviation results in an upshoot of
the unaected left eye, due to an overaction the left inferior oblique (the contralateral synergist)
which is also apparent in right lateral gaze (see Fig. 3.19(d)). A downshoot of the aected right
eye occurs due to an overaction of the right inferior rectus muscle (the ipsilateral antagonist),
or otherwise, a defective downward movement of the unaected left eye, when xating with the
right eye, due to a weakness of the left superior oblique (the antagonist of the contralateral
synergist) which is evident particularly on looking down and to the right (see Fig. 3.19(h)). The
deviation is also evident on upward movement from primary position (see Fig. 3.19(b)), but there
is seldom any defect on downward movement (see Fig. 3.19(i)). The vertical ocular movements
are relatively normal in abduction since the right inferior oblique compensates for the weak right
superior rectus muscle in these positions (see Fig. 3.19(c), Fig. 3.19(g)), although there may be a
slight overaction of the ipsilateral synergist when looking to the left and down (see Fig. 3.19(j)).
There is an increase in extorsion in the aected eye during right gaze, due to overaction of the
right inferior oblique, also in left gaze, due to an overaction of the right inferior rectus muscle.
The compensatory (abnormal) head posture in a right superior rectus palsy is usually a rotation
of the head into the eld of action of the aected muscle. In this case, the head would be turned
up and to the right, and also tilted to the side of the aected eye.
The Hess-charts in Fig. 3.20 show a shrinkage, away from the direction of action of the right
superior rectus muscle with enlargement towards the direction of the right inferior rectus and
the left inferior oblique accompanied by a slight shrinkage away from the action of the left
superior oblique. When xating with the left, unaected eye, the resulting primary deviation
in Fig. 3.20(a) shows the overaction of the ipsilateral antagonist in the right eye through a
CHAPTER 3. STRABISMUS 76
downward movement of the diagram towards the direction of action of the right inferior rectus
muscle. When xating with the aected, right eye, the secondary deviation in Fig. 3.20(b) shows
the overaction of the left superior rectus muscle, which results in a movement of the diagram
towards the direction of action of the left superior rectus muscle.
Palsy of the Right Superior Oblique Muscle
In primary position, the right superior oblique muscle is primarily a depressor, so that the primary
deviation of the aected right eye in this particular situation is an upward movement, due to
an overaction of the right inferior oblique muscle (see Fig. 3.21(e)). The secondary deviation
of the unaected eye during xation with the aected right eye is downward movement due to
overaction of the left inferior rectus muscle (see Fig. 3.21(f)).
(a) (b) (c)
(d)
(e) Primary Deviation
(f) Secondary Deviation
(g)
(h) (i) (j)
Figure 3.21: Example of a Right Superior Oblique Palsy
Since the right superior oblique muscle is also an abductor and intorter, the loss of the abducting
inuence is of little signicance, as long as there is an intact right lateral rectus muscle, but there
is some extorsion due to overactions of the right inferior oblique and the right inferior rectus
muscles, which can easily be seen in Fig. 3.21(f) and Fig. 3.21(e) when looking at the dark (blue)
cross in the pupil.
Ocular movements show limitations of the palsied eye when looking downwards and inwards,
since this is the direction of action of the aected muscle (see Fig. 3.21(j)). This situation is ac-
centuated by an upshoot of the aected right eye, due to an overaction of the right inferior oblique
muscle, which is evident in all positions of left gaze (Fig. 3.21(c), Fig. 3.21(g) and Fig. 3.21(j)).
Particularly, when looking up and to the left, a downshoot of the unaected eye, due to over-
action of the left inferior rectus muscle can be noticed. Restricted downward movement of the
aected right eye is also evident on downward movement (see Fig. 3.21(i)), and to some extent
in upward movement from primary position (see Fig. 3.21(b)). The ocular movements are rather
normal on looking to the palsied side (see Fig. 3.21(a), Fig. 3.21(d) and Fig. 3.21(h)).
The compensatory (abnormal) head posture is usually a rotation of the face to the left and
CHAPTER 3. STRABISMUS 77
(a) Primary Deviation, Left Eye Fixing (b) Secondary Deviation, Right Eye Fix-
ing
Figure 3.22: Hess-Lancaster Chart for Right Superior Oblique Palsy
downwards, accompanied by a tilting of the head to the left. Both, the turning of the face, as
well as the tilting of the head are oriented in the direction of the unaected eye.
The Hess-Lancaster charts shown in Fig. 3.22 show a shrinkage away from the direction of action
of the right superior oblique muscle with a slight enlargement towards the direction of action of
the right inferior oblique (see Fig. 3.22(a)), and an enlargement in the direction of action of the
left inferior rectus muscle with a shrinkage away from the direction of action of the left superior
rectus muscle (see Fig. 3.22(b)).
3.5.2.2 Duanes Syndrome
Duanes syndrome is a congenital ocular motility disorder characterized by limited abduction
and/or limited adduction. The palpebral ssure narrows (the globe retracts) on attempted ad-
duction. Upward or downward deviation may occur with attempted adduction due to a leash
eect. Often associated with this condition is a tether phenomenon consisting of overelevation,
overdepression, or both, in adduction as the retracted globe escapes from its horizontal rectus
restrictions. It is a condition of aberrant innervation that results in co-contraction of the medial
and lateral recti in the aected eye. Thus, Duanes syndrome can be considered to be a congen-
ital miswiring of the medial and the lateral rectus muscles such that globe retraction occurs on
adduction.
Duanes syndrome is often clinically subdivided into three types (1-3). Dierent clinical types
may be present within the same family suggesting that the same genetic defect may produce a
range of clinical presentations.
Duanes syndrome type 1: The ability to move the aected eye outward towards the ear
(abduction) is limited, but the ability to move the aected eye inward towards the nose
CHAPTER 3. STRABISMUS 78
(a) Duanes Retraction Syndrome Type 3 (b) Hess-Lancaster Chart for Duanes Retraction Syn-
drome
Figure 3.23: Example for Duanes Retraction Syndrome Type 3 of a Right Eye
(adduction) is normal or nearly so. The eye opening (palpebral ssure) narrows and the
eyeball retracts into the orbit when looking inward towards the nose (adduction). When
looking outward towards the ear (abduction) the reverse occurs.
Duanes syndrome type 2: The ability to move the aected eye inward towards the nose
(adduction) is limited, whereas the ability to move the eye outward (abduction) is normal
or only slightly limited. The eye opening (palpebral ssure) narrows and the eyeball retracts
into the globe when the aected eye attempts to look inward towards the nose (adduction).
Duanes syndrome type 3: The ability to move the aected eye both inward towards the
nose (adduction) and outward towards the ear (abduction) is limited. The eye opening
(palpebral ssure) narrows and the eyeball retracts when the aected eye attempts to look
inward towards the nose (adduction).
Each of these three types can be further classied into three subgroups designated A, B, and C
to describe the eyes when looking straight (in primary position). In subgroup A the aected eye
is turned inward towards the nose (esotropia). In subgroup B the aected eye is turned outward
towards the ear (exotropia), and in subgroup C the eyes are in a straight primary position.
In Fig. 3.23, Duanes Retraction Syndrome Type 3 for a right eye is illustrated. Due to a co-
contraction of the right medial and right lateral rectus muscles, the aected right eye will show
retraction as indicated in Fig. 3.23(a) when looking to the right. The Hess-Lancaster chart for
the right eye in Fig. 3.23(b) shows the typical restriction in ab/adduction of the right eye, due
to co-innervation of both recti muscles. This results in a shrinkage of the diagram for both sides,
away from the elds of action of the right lateral rectus and the right medial rectus muscles.
CHAPTER 3. STRABISMUS 79
Browns Syndrome
This ocular motility disorder, characterized by an inability to elevate the adducted eye actively or
passively, was rst described by Brown. It has since become recognized that there is a variety of
causes, that the condition may be congenital or acquired, and that the defect can be permanent,
transient, or intermittent.
Browns syndrome is characterized by a deciency of elevation in the adducting position. Im-
proved elevation is usually apparent in the midline, with normal or near-normal elevation in
abduction (see Fig. 3.24). There is occasional widening of the palpebral ssure on attempted
elevation in adduction. With lateral gaze in the opposite direction, the aected eye may depress
in adduction, although no overdepression simulating overaction of the superior oblique muscle
occurs on duction testing. Exodeviation (V pattern) often occurs as the eyes are moved upward
in the midline. Many patients are orthophoric and experience diplopia in the primary position,
although with time hypotropia may develop with a compensatory head posture turn towards the
opposite eye. In some cases, there is discomfort on attempted elevation in adduction, the patient
may feel or even hear a click under the same circumstances, and there may be a palpable mass
or tenderness in the trochlear region. A positive forced duction test is the hallmark of Browns
syndrome.
(a) Primary Deviation, Left Eye xing (b) Secondary Deviation, Right Eye Fix-
ing
Figure 3.24: Example for Browns Syndrome of a Right Eye
From the Hess-Lancaster charts of Browns syndrome in Fig. 3.24, the characteristic V-Pattern
of the primary and secondary deviations can be recognized. The Hess chart for the primary
deviations (xing with the unaected eye) in Fig. 3.24(a) shows a deciency in elevation when
the right eye is in adduction and near normal elevation in abduction. When xing with the
aected eye (see Fig. 3.24(b)), improved elevation of the unaected eye is evident when the
aected right eye looks in adduction.
The anatomical cause of the syndrome is a tight superior oblique tendon. Acquired Brown
CHAPTER 3. STRABISMUS 80
syndrome has been attributed to a variety of causes, including superior oblique surgery, scleral
buckling bands, trauma, focal metastasis to the superior oblique, and following sinus surgery
and inammation in the trochlear region. An identical motility pattern, as seen in Browns
syndrome, can be acquired by patients with juvenile or adult rheumatoid arthritis. It appears
that this form of Browns syndrome shares similar characteristics to inammatory disorders that
aect the tendons of the ngers.
3.5.2.3 Fibrosis Syndrome
This syndrome is characterized by replacement of normal muscle tissue by brous tissue in varying
degrees. The various clinical presentations depend on the number of muscles aected, the degree
of brosis, and whether the involvement is unilateral or bilateral. The condition is congenital,
with males and females equally aected.
Fibrosis Syndrome is characterized encompassing
brosis of the extraocular muscles,
brosis of Tenons capsule,
adhesions between muscles, Tenons capsule, and globe,
inelasticity and fragility of the conjunctiva,
absence of elevation or depression of the eyes,
little or no horizontal movement,
eyes xed 20 to 30 degrees below the horizontal,
chin elevation and
the condition being present at birth.
Congenital brosis of the inferior rectus is probably a variant of the general brosis syndrome.
The inferior rectus alone or together with a levator may be involved, with little or no involvement
of the other extraocular muscles. The condition may be unilateral or bilateral and is commonly
asymmetric. Because patients cannot typically elevate their eyes even to the midline, they adapt
a compensating head posture with their chin up to maintain binocular vision.
Another variant of the general brosis syndrome is strabismus xus, in which the eyes are in a
markedly xed position of esotropia or exotropia. The eyes are so rmly xed that they cannot
be actively or passively moved in a horizontal direction, although vertical movement is usually
possible.
Another possible variation of the general brosis syndrome is the vertical retraction syndrome.
In this condition, horizontal movements are normal, but elevation and depression are reduced,
while the eye is abducted. In addition to the vertical limitation, there is retraction of each eye
during attempted depression, with the eye in the abducted position.
CHAPTER 3. STRABISMUS 81
Congenital brosis of the extraocular muscles (CFEOM) describes a group of rare congenital
(present at birth) eye movement disorders that result from the dysfunction of all or part of the
oculomotor nerve (cranial nerve III) and/or the muscles this cranial nerve innervates. Patients
aected with CFEOM are typically born with ophthalmoplegia (an inability to move the eyes
in certain directions) and ptosis (droopy eyelids). In addition, the eyes are usually xed in an
abnormal position.
3.5.2.4 Supranuclear Disorders
A supranuclear gaze palsy is an inability to look in a particular direction as a result of cerebral
impairment. There is a loss of the voluntary aspect of eye movements, but, as the brainstem is
still intact, all the reex conjugate eye movements are normal.
The type of gaze problem is dependent upon the lesion - thus a right hemisphere lesion, particu-
larly the frontal lobes, leads to a contralateral gaze palsy, i.e. an inability to look away from the
lesion.
As an example for a supranuclear gaze palsy, the abducens gaze palsy will be described in more
detail.
Abducens Gaze Palsy
Cranial nerve VI, also known as the abducens nerve, innervates the ipsilateral lateral rectus (LR),
which functions to abduct the ipsilateral eye.
Patients usually present with horizontal diplopia and an esotropia in primary gaze. The deviation,
as would be expected, is noted to be greater when the patient xates with the paretic eye. Patients
also may present with an abnormal head posture to maintain binocularity and binocular fusion
and to minimize diplopia.
It is rare to nd true congenital sixth nerve palsy. A typical workup of a sixth nerve palsy
involves excluding paresis of other cranial nerves (including VII and VIII), a check of ocular
muscle motility and evaluating pupillary responsiveness. Only the ipsilateral lateral rectus that
is solely innervated by the involved peripheral sixth cranial nerve is aected, therefore, only
deviations in the horizontal plane are produced. In isolated cases of peripheral nerve lesions, no
vertical or torsional deviations are present.
Central nervous system lesions of the abducens nerve tract are localized easily secondary to the
typical ndings associated with each kind of lesion. Damage to the sixth nerve nucleus results
in an ipsilateral gaze palsy. The lack of contralateral adduction defects (see Fig. 3.25) makes it
easy to dierentiate nuclear from a fascicular or non-nuclear lesion (see Sec. 3.5.2.1).
Abducens palsy frequently is seen as a postviral syndrome in younger patients.
CHAPTER 3. STRABISMUS 82
(a) Primary Deviation, Left Eye xing (b) Secondary Deviation, Right Eye Fixing
Figure 3.25: Example for an Abducens Gaze Palsy
Nystagmus
The most primitive fault is a failure in xation, due to anomalies in central vision, in which
case innate attempts to xate cause rapid jumps known as nystagmus. Nystagmus is generally
described as an involuntary movement of the eyes, which reduces vision. The movement is usually
side to side (but can be up and down or circular motion) and can be either jerk or pendular.
Normal (physiological) nystagmus occurs for example when a passenger of a train watches as
telegraph poles pass the window. The eyes will travel one way, and then jump in the opposite
direction to begin watching the next pole. There are over 40 dierent types of nystagmus but
the main division is between congenital and acquired Nystagmus.
Congenital nystagmus - is thought to be present at birth, but is usually not apparent until
the age of ve months.
Acquired nystagmus - occurs later than 6 months of age, and can be caused by a stroke, disease
such as multiple sclerosis, or even a heavy strike to the head. Patients with nystagmus may
suer from the perception of a moving world, known as oscillopsia. The number of people
that suer from congenital nystagmus is much less than those with acquired nystagmus.
This is thought to be because an infant can adapt to the perception of motion better that
an adult that previously had normal vision.
It is not clear whether congenital nystagmus is actually present at birth, or whether it occurs
early in the childs vision development. It is therefore also referred to as early-onset or infantile
nystagmus. Many children with nystagmus have no other vision or brain problems. This is known
CHAPTER 3. STRABISMUS 83
as idiopathic, which means of unknown cause. However, nystagmus is often a symptom of other
conditions such as albinism, aniridia, cataracts, cone dysfunction and many others. Nystagmus
can be present with cerebral palsy, Downs Syndrome and many motor system diseases. A type
of congenital nystagmus is latent nystagmus, and is only present when one eye is covered. This
is not usually noticed until the rst visit to the physician.
3.6 Strabismus Surgery
The goal of surgery of the extraocular muscles is to balance an ocular misalignment in order to
restore binocular alignment. Generally, it is also desirable to reestablish single binocular vision.
Generally, the attainment of peripheral fusion with fusional vergence amplitudes sucient to
maintain alignment of the eyes, comfortable single binocular vision to enable the patient to
perform visual tasks without asthenopia and improved esthetic appearance are the most common
objectives.
Ideal preoperative evaluation of the strabismus surgical patient includes quantication of the
misalignment in primary positions at distance and at near, as well as in the nine diagnostic gaze
positions (see Sec. 3.4). In most patients, the maximal deviation under conditions of complete
dissociation of the visual axes is the deviation for which surgery is to be designed. As indicated,
measurements are taken both with and without the appropriate optical correction. Finally,
duction and version testing and, when appropriate, forced duction testing may be performed.
All surgical methods are accomplished through the modication of the eye muscles since this is the
most eective way to inuence the mechanical properties of the oculomotor system. Basically,
there are three dierent options to modify the mechanical functions of eye movements, when
considering extraocular muscle surgery:
Weakening surgery (recession), in order to reduce the traction of a muscle,
strengthening surgery (resection), in order to raise traction of a muscle,
transposition surgery, in order to inuence the pulling direction of a specic muscle.
Strabismus surgery demands careful planning. Barring unusual circumstances or unusual
anatomy, the surgical plan is prepared before anesthetic is given. It is helpful to keep a de-
scription of the surgical plan, for ready reference before and during surgery. The exact location
and incision technique depends upon the muscles to be operated, pre-existing scarring, and the
patients previous surgical history. Absorbable sutures generally are utilized when vascular heal-
ing of tissues occurs, such as in typical recession and resection techniques. These sutures generally
absorb within 7-10 days if covered with conjunctiva, slightly longer if exposed. Permanent sutures
are utilized if avascular tissue such as the superior oblique tendon is harnessed, as in the superior
oblique tuck or silicone band-lengthening procedure.
CHAPTER 3. STRABISMUS 84
3.6.1 Recession Surgery
Recession surgery aims a transposition of the muscle insertion posterior along the muscles primary
direction of action. This surgical technique can be applied to all six extraocular muscles. In this
procedure (see Fig. 3.26), the surgeon must detach the muscle from the eye and reattach it further
back on the eye, thereby reducing the relative strength of the muscle.
Figure 3.26: Schematic Example of Muscle Recession, from [Kau95]
As an example for the weakening of a extraocular muscle, a medial rectus recession is described
in detail (cf. [YD03]).
To perform a medial rectus recession (Fig. 3.27), the surgeon grasps the eye at the conjunctiva-
Tenons capsule junction with a 0.3mm forceps and rotates the eye into elevation and abduction
(Fig. 3.27(a)). The surgeon then elevates the conjunctiva at the base of the fornix, and incises the
conjunctiva 8mm from the limbus (Fig. 3.27(b)). At this point, all visible conjunctival vessels are
prepared lightly to ensure good visibility during localization of the tendon. The surgeon grasps
the fascia within the conjunctival incision with gentle pressure against the sclera, and elevates it
from the globe (Fig. 3.27(c)). The scissors are then used to incise Tenons capsule at this point,
and expose the sclera (Fig. 3.27(d)). Visualization of the sclera is maintained using the posterior
forceps.
(a) (b) (c) (d) (e)
Figure 3.27: Preparation for Medial Rectus Recession, from [YD03]
A self-retaining muscle hook is then passed behind the medial rectus muscle with no posterior
movement of the hook further than the site of the incision itself (Fig. 3.27(e)). When the medial
rectus is on the hook, the surgeon conrms that the entire tendon is engaged. The posterior
arm of the 0.3mm forceps may be used as a probe to locate the superior pole of the muscle
(Fig. 3.28(a)). The pole is secured using the forceps, and the muscle hook is withdrawn to the
inferior aspect of the tendon (Fig. 3.28(b)). Then, the hook is passed beyond the superior pole
CHAPTER 3. STRABISMUS 85
held by the forceps (Fig. 3.28(c)). This way, it is certain that the full length of the tendon is
secured completely.
A small hook is introduced between the insertion of the tendon and Tenons capsule anterior
and used to dissect carefully the fascia from the surface of the tendon, as it is moved posteriorly
along its long axis (Fig. 3.28(d)). Afterwards, the scissors are used to incise the superior aspect
of Tenons fascia (Fig. 3.28(e)).
(a) (b) (c) (d) (e)
Figure 3.28: Medial Rectus Recession, continued, from [YD03]
Gentle traction, away from the operated muscle, allows the surgeon to control the hook beneath
the tendon and accomplish suture passage at the insertion. The surgeon may then control the
forceps to position optimally and to control the globe. A lock to the edge of the tendon by
applying a suture (Fig. 3.29(a)) is performed. A scissors is used for removal of the tendon
(Fig. 3.29(b)). Visualization of the tendon may be preserved if a dry cotton pledget is passed
between the tendon and globe.
The sutures are then drawn in the direction in which they were passed, to avoid breaking the
sutures out of the sclera. The receded muscle is demonstrated where an attempt is made to
preserve the original orientation of the tendon to the globe at its normal width (Fig. 3.29(c)).
After the tendon has been secured to the globe, a hook is introduced above the superior pole of
the earlier insertion and the fascia is rotated inferiorly (Fig. 3.29(d)) over the operative site. The
incision is closed with a single plain suture (Fig. 3.29(e)).
(a) (b) (c) (d) (e)
Figure 3.29: Medial Rectus Recession, continued, from [YD03]
The principles of recession for the other recti muscles are basically the same as described for the
medial rectus. However, recession of the lateral rectus and vertical recti includes visualization
and preservation of the neighboring oblique muscles before the procedure is performed.
CHAPTER 3. STRABISMUS 86
3.6.2 Resection Surgery
Resection of a muscle is performed in order to strengthen its force. In a muscle resection procedure
shown in Fig. 3.30, the surgeon must detach the muscle from the eye (Fig. 3.30(a)), excise a
portion of the distal end, and reattach the muscle to the eye on the same position (Fig. 3.30(b)).
The shortening of the muscle provides greater pull in the eld of action that the muscle functions.
(a) Resection of Detached Muscle (b) Reinsertion of Muscle
Figure 3.30: Schematic Example of Muscle Resection, from [Kau95]
The preparation procedure in resection surgery is related to the recession surgery in that the
conjunctival vessels are prepared and Tenons fascia is entered. A large muscle hook is passed
beneath the tendon, going no further posteriorly than the insertion itself. The Tenons capsule
beneath the olive tip of the large muscle hook is incised (Fig. 3.31(a)) in order to visualize the
sclera at both poles of the tendon. Two small hooks are passed along the long axis of the tendon
so that the muscular fascia can be exposed for incision (Fig. 3.31(b)). A second large muscle
hook is passed beneath the tendon, and traction is applied between the two muscle hooks, with
the insertion and both hook tips kept parallel. The anterior arm of the caliper is placed on the
midportion of the anterior hook, and the posterior portion delineates the site for needle passage
(Fig. 3.31(c)). A marking pen may be used if it is not desirable to remeasure during suture
passage.
(a) (b) (c) (d) (e)
Figure 3.31: Medial Rectus Resection, from [YD03]
The same technique of suture passage is employed as described earlier for recession. The needle is
passed tangentially to the tendon and globe, and woven through the tendon from its midportion
to the superior pole and then locked upon itself. The needle at the opposite end of the suture
is then passed from the midportion to the inferior pole and once again locked, and the tendon
CHAPTER 3. STRABISMUS 87
secured at the point of desired resection (Fig. 3.31(d)). The tendon is cut ahead of the clamp
(Fig. 3.31(e)), and the resection of the tendon is completed at the original insertion.
(a) (b) (c)
Figure 3.32: Medial Rectus Resection, continued, from [YD03]
Once the surgeon is satised with the location and depth of the scleral pass, the rst suture
throw is placed before the muscle is drawn forward and knotted (Fig. 3.32(a) & Fig. 3.32(b)).
The conjunctiva can be closed with two interrupted plain sutures (Fig. 3.32(c)).
3.6.3 Transposition Surgery
Transposition surgery has the goal to modify that direction of action of the extraocular muscles
in order to correct anomalies of ocular alignment. The vertical transposition surgery of the
horizontal recti muscles is applied to correct symptomatic A- and V-patterns, that arise from
eso- and exotropia, in absence of signicant overaction of the oblique muscles. The eects of
muscle transposition are not completely predictable, and only a few of the many transpositions
with therapeutic potential are attempted by clinicians (cf. [MDR93]).
An A-symptomatic esotropia is treated with a bilateral recession of both horizontal medial
recti muscles in combination with an upward transposition.
An A-symptomatic exotropia is treated with a bilateral recession of both horizontal lateral
recti muscles in combination with a downward transposition.
A V-symptomatic esotropia is treated with a bilateral recession of both horizontal medial
recti muscles in combination with a downward transposition.
A V-symptomatic exotropia is treated with a bilateral recession of both horizontal medial
recti muscles in combination with an upward transposition.
In applying these combined surgical methods, careful preoperative planning is necessary, es-
pecially the consideration of eects that modify lever-arm and unreel-strain of a muscle gives
information about the possible results or complications that may arise and need to be avoided.
3.6.4 Amount of Surgery
The amount of surgery is the main criteria that is to be decided preoperatively on the basis of
diagnosis and measurements. Since the oculomotor systems forms a relatively complex mechanical
CHAPTER 3. STRABISMUS 88
system, these decisions are not trivial. However, it is now generally accepted, that the choice
and amount of surgery are matters of importance on which the end result closely depends (cf.
[RSS01]). From the purely geometric point of view, a 1mm rectus muscle recession, combined
with a 1mm advancement of the ipsilateral antagonist, should result in a 4.7

change of angle
for a globe of 24.5mm diameter, 5

for a globe of 23mm diameter, using the simple spherical


circumference. In reality, however, the result is reduced by the passive forces of the other muscles
and anatomical inuences like pulleys and other movement retaining components. In single-
muscle surgery, the eect is further reduced by the fact that the counter-tension of the antagonistic
muscle remains unchanged. The coecient of surgical eectiveness, or the ratio between the
theoretical geometric eect and the actual result, is close to 1 only when the counter-tension
of the antagonistic muscle is adjusted by an equivalent amount in the opposite direction (in
terms of tension and not of distance). The eect also depends on the muscle that is operated on
and additionally on factors like age, the manner in which surgery is carried out, the eye that is
operated on (aected or unaected), the binocular status and type of the strabismus, concomitant
or incomitant features and a lot of dierent other relations. Finally, there is no linear relationship
between the amount of surgery and the eect of a surgical procedure. All these factors have led
to a wide range of gures being proposed, giving little credibility to establishing the amount of
surgery [RSS01].
Although for some authors the precise amount of surgery is unimportant, or purely
indicative, this attitude is currently unacceptable [RSS01].
From the analysis of their results, some authors have shown that, in spite of variables, it is possible
to measure the amount of surgery to be performed. Postoperative statistical analysis of results
together with known, and in particular mechanical parameters, have, at least for some, provided
the basis for a mean surgical eectiveness chart. Figures and formulae proposed for calculating
the amount of surgery necessary to obtain a certain surgical eect are only valid from 2 to 7 or
8 mm, and are only applicable from the age of 2
1
2
to 3 years. However, diagrams and formulae
provide average values, applicable only when patient data is in this certain eld of tolerance.
Thus, the preoperative process of measurement, diagnosis and planning deals with a certain
amount of tolerance that is intrinsic to every part of this process, since it is unlikely possible to
carry out a surgical procedure with an accuracy of e.g. 1 mm. Additionally, the terminology for
pathologies in the eld of strabismus is dierent in each language and also not clearly separable,
since in some pathological cases, the exact cause is still unknown. Dealing with preoperative
planning and the determination of the amount for eye muscle surgery is somehow the key fact
in this thesis, which proposes an entirely dierent way to describe ocular motility defects. Com-
puter programs that realize and calculate results of formulae that have been based on statistical
result are already used, but do not suciently solve the problem. Instead, this thesis proposes
biomechanical modelling of pathologies in terms of simulation parameters that are conned to
an underlying model of geometry, muscle force and kinematics of the human eye. Essentially
supported by an interactive and clinically applicable computer simulation program, eye motility
disorders can be expressed in their impact on a virtual patient that represents all measured
values from the real patient that should be treated.
Chapter 4
Biomechanical Modelling
Dierent strategies in modelling diagnosis and treatment of strabismus in the eld of medicine
have been proposed over the last years (cf. [C

72], [Jam22], [SS00]). These models had the primary


goal to suggest or predict possible outcomes of a treatment procedure based on measurements
that were acquired from patients. Since many authors proposed new standard values based upon
clinical results, these values dier considerably. It is probable, that these authors did not take the
same amounts of surgery, or even comparable or representative types of strabismus into account.
The problem becomes evident when considering natural variations in the anatomy and physiology
of dierent patients, which makes it nearly impossible to drive a model that is based on clinical
results to exactly the same results, when predicting surgery for comparable patients. This also
expresses the non-linearity of the relationship between surgical dose and postoperative response.
However, a model-driven approach, able to coordinate broad ranges of laboratory research and
clinical experience, can accelerate progress of diagnosis and treatment of strabismus.
This chapter proposes a new approach of predicting surgical results for strabismus surgeries in
that the the human oculomotor system is described by a biomechanical model that incorpo-
rates anatomically related parameters in order to enable the simulation of pathological situations
through the modication of these parameters. Biomechanics is a branch of mechanics and me-
chanics again is a branch of physics. Therefore, biomechanics deals with the mechanical laws
and rules of biological structures and the interaction of these biological structures. Since such
models already existed before (cf. [MR84]), but were used rarely in clinical application, this
thesis proposes a dierent mathematical approach in combination with an interactive, easy to
use software simulation system that enables interactive eye motility simulation and preoperative
planning of surgery.
89
CHAPTER 4. BIOMECHANICAL MODELLING 90
4.1 Analytical Models
Analytical models are mathematical models that have a closed form solution, i.e. the solution to
the equations used to describe changes in a system can be expressed as a mathematical analytic
function. Scientic practice involves the construction, validation and application of scientic
models, thus, an analytical approach implies the invention of hypotheses and theories and the
subsequent eort of validation within the scientic model space. Reapplication of model results
into the real world may support or reject the proposed theories. Further more, models provide
an environment for interactive engagement. Evidence from science education research shows that
signicant gains in knowledge and understanding are achieved within interactive activities. Thus,
it is important that the environment created around a model provides an interactive experience in
order to be valuable for practical use. Working with models can enhance systems thinking abilities
by allowing sensitivity studies to assess how changes in key system variables alter the systems
behavior. Such sensitivity studies can help to identify leverage points of a system to either help to
aect a desired change with a minimum eort, or to help estimate the risks or benets associated
with proposed or accidental changes in a system. Concerning medical application, especially in
the eld of strabismus surgery, there exist dierent model types that aim clinical improvement
on the basis of analytical models.
Medical expert systems model the relationships between symptoms and diseases by using
explicit domain knowledge that is embedded into a model. Such systems use inference
strategies to apply knowledge to the available data (which is often noisy and incomplete)
through heuristic reasoning. As with all expert systems, the design of medical diagnostic
systems raises essential questions:
How to nd a suitable representation of the observed data?
How to dene a suitable representation of the knowledge of the medical domain the
system should work in?
How to obtain measurements that could validate a diagnostic hypothesis?
How to handle inaccuracy and uncertainty of the observed data?
Early systems adopted a sequential data-driven strategy to perform heuristic classi-
cation. Knowledge was encapsulated in production rules in the form of if ... then
statements [CHG00]. Rules are a simple and modular mechanism, but their formalism
is restrictive, and a huge amount of rules are needed to deal with real-life problems.
The application of expert systems can be seen as an eective way to distribute extant
professional expertise, which is specic and also very limited to the domain of appliance.
Conversely, expert systems dont seem to be an adequate model to prove hypothesis or
theories due to their limited generality.
Empirical models are such types of models that generalize empirical knowledge in terms of
surgical dose-response tabular relationship (cf. [MD99]). Whether developed informally
or with computerized databases and statistical techniques, empirical generalizations sum-
marize experience and are therefore models of observations. Empirical generalizations are
probably the basis of professional competence in most elds. However, because these mod-
els are so closely related to experience, they prevent fundamental insight into the causes of
observed patterns.
CHAPTER 4. BIOMECHANICAL MODELLING 91
Homeomorphic models are organized by following the human structure in that these models
are built of comparable physiologic parts found in the domain of interest. All interactions
with a homeomorphic model reect underlying physiological processes. Thus, a homeomor-
phic model can treat arbitrary new situations only so long as they can be expressed using
the models terms.
Biomechanical models are homeomorphic models that try to simulate physiologic functions
of the human body by using parts, properties and parameters that are comparable to the
human example. Moreover, biomechanical models also include constrains and relationships
between the model parts and therefore dene the essential functions that can be evaluated
and modied.
In the following sections, this work presents the formulation of a biomechanical model of the
oculomotor system, based on geometric, force and kinematic principles that have been identied
by studying human subjects (cf. [BKPH03]).
4.2 Structure of Biomechanical Models
Biomechanics, as the name implies, is a branch of mechanics that examines forces acting upon
biological structures and the eects induced by these forces. Thus, for successfully develop-
ing biomechanical models, a good understanding of three dierent areas is required: Biological
structures, mechanical analysis and an understanding of movements [Mil96].
Initially important for creating a biomechanical model is to extract the relevant anatomic struc-
tures of the oculomuscular system (see Sec. 2.1.4) and form proper abstractions that can be
modelled using mathematical methods. Therefore, abstract representations of all six extraocular
eye muscles and the globe need to be dened and used as parts of the overall biomechanical model.
A muscle itself is composed of several other abstract representations. These are for example the
insertion and origin of a muscle which are decomposed again.
However, representing muscles and the globe does not suce in order to form a complete biome-
chanical model. A description of the geometrical interaction between all abstract representations
is also required. This part of a biomechanical model is dened as the geometrical model. It is
desirable to form the geometrical model as autonomous, exchangeable part that interacts with
other biomechanical components in order to preserve system variability. A well formed biome-
chanical model consist of exchangeable components that provide exibility and compatibility for
later modications.
Apart from a geometrical part of the system model, there is also need for a model describing
muscle forces and the inuence of these forces on the ocular geometry. Therefore, a biomechanical
model also requires a muscle force model which simulates and predicts the transformation of
innervations into muscle force and subsequently supplies this muscle force to the ocular geometry,
which resolves forces in terms of eye rotations.
Finally, a biomechanical model also needs to consider kinematics of ocular movements. Adopted
to a kinematic model of the human eye, forward and inverse kinematics can be identied as
CHAPTER 4. BIOMECHANICAL MODELLING 92
predicting eye position on the basis of muscle innervations and predicting muscle innervation on
the basis of eye positions.
Thus, a biomechanical model consists of several abstract representations and sub-models. Ab-
stract representations refer to dierent anatomical parts of the human eye, whereas sub-models
imply the mathematical descriptions of geometrical properties, muscle forces and kinematics
[BKPH03].
4.3 History of Modelling of the Human Eye
One of the rst modelling attempts to get a better understanding about the oculomotor system
was the so called ophthalmotrope, which has been designed and constructed by C.G.T. Ruete
in 1845 [ST90]. An ophthalmotrope is a mechanical model of the eye, usually built out of copper,
and is used to gain better understanding about eye rotations around dierent axes in 3D-space
(see Fig. 4.1).
Figure 4.1: Halles Ophthalmotrope, from [ST90]
In 1848, F.C. Donders made an interesting discovery. If the eye xates an object somewhere in
space, the position of this object also determines the gaze position of the eye. But the position
of the object in space does not specify the amount of torsional rotation, nor is this amount of
torsion arbitrary. In fact, the amount of torsion is clearly specied through the gaze position of
the eye itself.
When the German edition of Donders work appeared, it drew the attention of H. von Helmholtz,
who noticed that Donders had found the existence of pseudotorsion and proposed to call Donders
discovery Donders Law [Hel63]. Pseudotorsion is a problem as it is a measured value of torsion
which does not really exist, but is evoked by the measuring procedure. As Donders did not give
a reason for pseudotorsion, it was von Helmholtz, who gave an explanation for its occurrence.
Pseudotorsion is caused by the fact that, in tertiary positions of gaze, the vertical meridian
CHAPTER 4. BIOMECHANICAL MODELLING 93
through the eye does not coincide with a vertical line in space, nor does the horizontal meridian
coincide with a horizontal line in space. The reason for this discrepancy is that horizontal and
vertical are dened according to the coordinate system used [ST90]. Thus, a solution had to
be found to eliminate the problem of pseudotorsion.
Since pseudotorsion is caused by an unsuitably dened coordinate system, J. B. Listing had the
idea to use polar coordinate systems to overcome this problem. Listing also noticed that in
this coordinate system all tertiary positions of gaze can be reached by a single rotation around
one particular axis. Therefore, when Ruete read about Listings discovery in 1853, he suggested
to call it Listings Law. He also noticed that his rst ophthalmotrope was not correct, as it
violated Listings law, so he developed a new version of the ophthalmotrope, which complied with
Listings law and already included parts for simulating muscles (see Fig. 4.2).
Figure 4.2: Ruetes Ophthalmotrope, from [ST90]
As Donders law and Listings law were published, a consistent sequence of rotations for describing
gaze rotations had to be found. As a consequence, in 1854 A. Fick introduced the so called Fick-
sequence of rotations, where the position of the eye is characterized by rotations around the
vertical, the horizontal and then the torsional axis. Later, in 1863, von Helmholtz suggested a
dierent sequence by exchanging the rst two axes. Therefore, the Helmholtz-sequence describes
rst a rotation around the horizontal, then around the vertical and nally around the torsional
axis [Has95]. Such gimbal systems are a convenient way to describe the sequence of rotations.
In 1869 A. W. Volkmann provided the basis for all future developments in the eld of extraocular
mechanical research, especially for the development of improved models based upon ophthal-
motropes. Volkmann made a statistical analysis of the characteristics of the eyes of numerous
patients and published the data of an average human eye [Vol69].
Using Volkmanns eye data, Krewson [Kre50] published the rst geometrical model of the human
CHAPTER 4. BIOMECHANICAL MODELLING 94
eye called string model. The string model denes muscles as strings which take the shortest
path from the insertion to the origin without considering any orbital connective tissues or muscle
forces. A second attempt for building a geometrical model using Volkmanns data was made by
Robinson [Rob75b]. Robinson named his model tape model and tried to include some sort of
xing structure to reduce muscle side-slip during tertiary positions of gaze. Although this was a
rst step in the right direction, the muscles in the tape model still showed too much side-slip
compared to actual observations of the oculomuscular apparatus. Later, Kusel and Haase [KH77]
tried to improve the tape model and introduced the restricted tape model, but the predictions
of their model were still very close to the original tape model.
Robinson was the rst who noticed that a geometrical model alone is not sucient to successfully
build a realistic model of the human eye. So he also took muscle forces into account and built
the rst biomechanical model. Following Robinsons observation, Gnther [Gue86] extended the
restricted tape model of Kusel and Haase into a biomechanical model. Although the predictions
of these models were better than those of the previous ones, they still were not perfect.
The latest discovery in the eld of extraocular research was the analysis of muscle pulley structures
in 1995. Based on this new research results, Miller and Demer [MD99] started another attempt
to build a biomechanical model of the human eye. Their so called orbit model represents the
latest development in the eld of biomechanical eye motility research.
4.4 Ocular Geometry
The mathematical derivation for the modelling of ocular geometry is comprised of the geometri-
cal denition of eye rotations and the geometrical representation of the extraocular muscles that
cause these rotations. In order to describe the transformation of eye muscle action into respec-
tive angular rotations, the lever-arm of each eye muscle must be dened. This is accomplished
by the geometric interpretation of muscle action, that assumes that each muscle, in its static
behavior, rotates the eye around a specic axis in space. Additionally, geometrical constrains like
the sequence of rotation and conformance to Listings law needs to be taken into account (see
Sec. 2.2.1 and Sec. 2.2.2.2).
4.4.1 Coordinate Systems
In order to describe or measure 3D eye positions, coordinate systems need to be dened, allowing
the exact denition of the orientation the eye. Let {X, Y, Z} denote a cartesian coordinate system
of a left eye (see Fig. 4.3), so that the positive X-axis points to the right, the positive Z-axis points
upward and the negative Y-axis coincides with the line of sight through the center of the pupil
when the eye is in primary position.
For 3D orientation of the eye, Eulers theorem can by applied, which states that for every two
orientations of an object, the object can always move from one position to the other by a single
rotation around a xed axis. This combined rotation is usually decomposed into three consecutive
rotations around well dened, hierarchically nested axes. The sequence of rotation plays an
important role, since the execution of rotations specifying the same angles but in dierent order,
leads to a dierent nal orientation of the rotated object. One important distinction within
CHAPTER 4. BIOMECHANICAL MODELLING 95
Figure 4.3: Coordinate System of a Left Eye
this denition is to consider active and passive rotation behavior. Active rotations are dened
as rotations where the coordinate system is constant and not aected by preceding rotations,
whereas passive rotations change the coordinate system, reorienting the coordinate axes with each
rotation that is applied. Thus, in passive rotations, each rotational modication also changes the
coordinate axes around which successive rotations will be performed. In adopting these properties
to eye rotations, active rotations correspond to rotations in a head-xed coordinate system, and
passive rotations are performed in an eye-xed coordinate system.
(a) Fick Gimbal (b) Helmholtz Gimbal
Figure 4.4: Gimbal Systems for describing 3D Eye Position, adapted from [Has95]
A combination of a horizontal and a vertical rotation of the eye is a well dened sequence,
uniquely characterizing the direction of the line of sight. However, this does not completely
determine the 3D eye position, since the rotation around the line of sight is still unspecied. A
third rotation is needed to completely determine the orientation of the eye. Systems that use
such a combination of three rotations for the description of eye positions generally use passive
rotations, or rotations of the coordinate system. Due to non-commutativity of rotations in 3D
CHAPTER 4. BIOMECHANICAL MODELLING 96
space, it is necessary to use a uniform order of rotations to describe eye positions and to denote
this rotation order along with the denition of eye positions. Such rotations of the coordinate
system can eectively be demonstrated by using gimbal systems, in which the hierarchy of passive
rotations is automatically implemented as intrinsic system property. A coordinate system was
dened by Fick [Fic54], whereby rotations have to be executed rst around the vertical axis, then
around the horizontal and around the torsional axes (see Fig. 4.4(a)). In contrast, Fig. 4.4(b)
shows a rotation sequence dened by Helmholtz, rst around the horizontal, afterwards around
the vertical and torsional axes [Hel63]. Whereas the Fick gimbal system rotates three angular
components {, , } around the coordinate axes {Z, X, Y } respectively, the Helmholtz gimbal
will rotate around the axes {X, Z, Y }. Both systems of rotation describe a gimballed suspension
of the globe with consideration of the respective rotation sequence, where rotations are executed
from the outside to the inside. From the representation of the two systems in Fig. 4.4 it is easy to
recognize that some specied angles of an eye position lead to dierent orientations of the globe
and thus to dierent eye positions when comparing both systems.
4.4.2 Mathematical Description of Eye Rotations
Based on the coordinate system for one eye, depicted in Fig. 4.3, the angular rotations around the
main coordinate axis are described by the Fick sequence of rotations (cf. Sec. 4.4.1). This ensures
that each eye position is expressed by three angular rotations {, , } around the coordinate
axes {Z, X, Y } respectively. There are many dierent ways to represent rotations in three-
dimensional space. In this work, matrices and quaternions will be used to dene rotations and
eye positions for the derivation of the ocular geometry. Eye rotations in three-dimensional space
consist of rotations as well as translations. The discussion here will be restricted to the rotational
components of the total eye movement. Translations of the eye will be treated later in this
document.
First, let a vector

SC(sx, sy, sz) represent a line originating from the center of the eye xed
coordinate system. Next, it will be described how this vector can be rotated according to a given
eye position.
4.4.2.1 Rotation Matrices
In order to specify a rotation matrix that describes an eye position in Fick rotational order, the
standard denition of rotations around the three principle axes are used. The rotation matrices
used in this derivation use passive rotational order.
Generally, elements of a rotation matrix can be indexed in the following row-based form,
R =
_
_
R
11
R
12
R
13
R
21
R
22
R
23
R
31
R
32
R
33
_
_
.
(4.1)
CHAPTER 4. BIOMECHANICAL MODELLING 97
A rotation of radians around the Y-Axis is dened as,
R
Y
() =
_
_
cos() 0 sin()
0 1 0
sin() 0 cos()
_
_
,
(4.2)
a rotation of radians around the X-Axis is dened as,
R
X
() =
_
_
1 0 0
0 cos() sin()
0 sin() cos()
_
_
,
(4.3)
nally, a rotation of radians around the Z-Axis is dened as,
R
Z
() =
_
_
cos() sin() 0
sin() cos() 0
0 0 1
_
_
.
(4.4)
Thus, a generalized rotation matrix that can rotate the eye around each of the principle coordinate
axis in the Fick rotational sequence (Z-X-Y) can be dened using,
R

Fick
(, , ) = R
T
Y
R
T
X
R
T
Z
, (4.5)
which conforms to an active rotation (i.e. a rotation of the object), where
T
denotes matrix
inversion. If rotated in the object space (eye xed coordinate system), the rotation sequence
needs to be inverted to,
R
Fick
(, , ) = R
Z
R
X
R
Y
, (4.6)
and solved for the matrix product, this results in
R
Fick
(, , ) =
_
cos() cos() + sin() sin() sin() sin() cos() sin() sin() cos() cos() sin()
sin() cos() + cos() sin() sin() cos() cos() cos() sin() cos() + sin() sin()
cos() sin() sin() cos() cos()
_
.
Please note that the sequence of rotations from Eqn. 4.5 around the principle axes in world
coordinate space (head-xed) can be rewritten to perform rotation in the objects coordinate
space (eye-xed) by inverting Eqn. 4.5 to Eqn. 4.6.
Given the rotation matrix from Eqn. 4.6, the vector

S can be reoriented to

S

according to the
angular Fick coordinates (, , ) using,

= R
Fick
(, , )

S. (4.7)
Thus, an eye position can be described by reorienting the geometry of the eye according to
Eqn. 4.7. The eye movement can be described by linearly interpolating the rotational angles
(, , ) between two positions, which then describe the shortest path rotation between these
two positions. Moreover, the product of multiple Fick rotation matrices (C
Fick
) describes the
nal eye position that is reached by subsequent execution of each rotation. The nal eye position
of a rotation (, , ) from primary position, followed by a rotation (

) can be described
by,
C
Fick
= R
Fick
(

) R
Fick
(, , ). (4.8)
CHAPTER 4. BIOMECHANICAL MODELLING 98
However, this construction assumes that the eye initially always starts its movement from primary
position (i.e. the position where the line of sight is equal to the Y-Axis of the eye xed coordinate
system). If the shortest path rotation from primary position to a position that is composed of
two or more Fick rotations of the form (4.6) needs to be known, Fick angular coordinates can be
resolved from the compound rotation matrix of the form (4.8).
In order to regain angular coordinates from a Fick rotation matrix of the form (4.1), the following
entities can be used:
tan() =
cos() sin()
cos() cos()
=
R
12
R
22
,
sin() = R
32
, (4.9)
tan() =
cos() sin()
cos() cos()
=
R
31
R
33
.
The presented derivation enables the denition of eye position by using rotation matrices of
the form (4.6) and to determine eye position from given rotation matrices using Eqn. 4.9. When
specifying all entities of the ocular geometry, a new eye position can be described by transforming
each geometric entity using Eqn. 4.7. However, rotation matrices are complicated to handle,
especially when dening rotation around arbitrary axis.
Using the presented method of Euler angles to represent a set of three rotations specied in
successive order may suer from a problem known as gimbal-lock. The problem is that no
matter what the order in which the three rotations are carried out, there will always be a value
for one angle of rotation that yields innite values of the other two angles. For example, Euler
angles are normally represented as yaw, pitch, and roll, in that order. Given that order of rotation,
it is easy to show that when the pitch angle is headed straight up or straight down, the values of
yaw and roll are undened. In a physical gimbal system, this is known as gimbal-lock and refers
to the situation in that two or more principle axis of a coordinate system align, resulting in a
loss of rotational degree of freedom.
The notion of axis-angle denition for rotation represents a more convenient way with respect to
dening eye positions and eye movements, and shall be introduced by using quaternion algebra.
4.4.2.2 Quaternions
Each rotation may be parameterized by a unit vector along the axis of rotation, and the angle
of rotation. Rotations collectively form a three-dimensional space which can be pictured as a
solid 3-sphere with diametrically opposite points of its surface identied. Rotations may also be
parameterized by Euler angles via various combinations of rotations around the X, Y, Z axes (see
Sec. 4.4.2.1). Unfortunately, there are 12 such parameterizations possible, and the use of Euler
angles can give rise to gimbal-lock problems (see Sec. 4.4.1). Using an axis and angle represen-
tation in specifying an arbitrary axis and an angle (positive if in a counterclockwise direction),
this is an ecient way to avoid gimbal-lock. Additionally, axis-angle representations are a more
intuitive and practical oriented method of representing rotations of objects. Quaternion algebra
is a powerful mathematical tool that combines vector notation with rotational operations.
Basically, quaternions are hypercomplex numbers, just as a single complex number, z = x + iy,
CHAPTER 4. BIOMECHANICAL MODELLING 99
can be used to specify a point or vector in a two dimensional space, a single quaternion,
q = a +bI +cJ +dK, (4.10)
can be used to specify a point in a four dimensional space, and a quaternion with a = 0 can be
used to describe vectors in Euclidean 3-space. A quaternion can be rewritten as,
q = (s,

V ), (4.11)
where s = a, and

V = bI +cJ +dK. In this notation, s is called the scalar part of the quaternion,
and

V is the vector part. Additionally,
Scal(q) = s, (4.12)
V ect(q) =

V , (4.13)
extract scalar and vector parts from a quaternion so that Scal(q) results in a real number and
V ect(q) gives the original cartesian three-dimensional vector.
This denition can be extended to include cartesian vector spaces: Let {

E
1
,

E
2
,

E
3
} be a set of
base vectors in a cartesian vector space. Then, a vector

V = (x
1
, x
2
, x
3
) can be represented as:

V = x
1

E
1
+x
2

E
2
+x
3

E
3
.
There exists an isomorphism of a three-dimensional vector space into the four-dimensional vector
space of quaternions.
Let

V = a
1

E
1
+a
2

E
2
+a
3

E
3
,
and
w = a
0
+a
1
I +a
2
J +a
3
K.
w could also be written as: w = a
0
+

V , where a
0
is called the scalar part of the quaternion,
and

V , the vector part. The quantities {I, J, K}, the unit quaternions, stand in relation to
quaternions in the same way that {

E
1
,

E
2
,

E
3
} unit vectors relate to vectors. However, {I, J, K}
do not combine in exactly the same way as the unit vectors, {

E
1
,

E
2
,

E
3
}.
This leads to the denition that a vector

S = (x
1
, x
2
, x
3
) can be represented by a quaternion of
the form,
q = [0, (x
1
, x
2
, x
3
)], (4.14)
where the scalar part is zero and the vector part of the quaternion contains the identical cartesian
vector. The general form of a quaternion is denoted as,
q
s
= [s, (x
1
, x
2
, x
3
)], (4.15)
Given two quaternions according to Eqn. 4.15,
q
1
= [a
0
, (a
1
, a
2
, a
3
)],
q
2
= [b
0
, (b
1
, b
2
, b
3
)],
CHAPTER 4. BIOMECHANICAL MODELLING 100
the following algebraic operations can be dened:
q1 +q2 = [a
0
+b
0
, (a
1
+b
1
, a
2
+b
2
, a
3
+b
3
)], (4.16)
q1 q2 = [a
0
b
0
, (a
1
b
1
, a
2
b
2
, a
3
b
3
)]. (4.17)
According to Eqn. 4.11, q
1
and q
2
can also be written as,
q
1
= [s
1
,

V
1
], (4.18)
q
2
= [s
2
,

V
2
],
where s
1
and s
2
are the scalar parts and

V
1
and

V
2
are the vector parts of the quaternions q
1
and
q
2
respectively. Additionally, a pure quaternion is a quaternion whose sca1ar part is zero,
q
p
= [0,

V ]. (4.19)
Let q
1
and q
2
be in the form of (4.18), then, multiplication of two quaternions can be accomplished
by,
q
1
q
2
= [s
1
s
2


V
1


V
2
, (s
1

V
2
+s
2

V
1
+

V
1


V
2
)], (4.20)
where

V
1


V
2
stands for the vector-cross-product, and

V
1


V
2
stands for the vector-scalar-product.
Two pure quaternions in the form (4.19) can be multiplied using,
q
p1
q
p2
= [

V
1


V
2
, (

V
1


V
2
)]. (4.21)
Multiplication of a quaternion in the form (4.15) or (4.19) by a scalar number n is dened as,
qn = nq = [ns, n

V ] = [nx
0
, (nx
1
, nx
2
, nx
3
)]. (4.22)
In relation to vector operations in cartesian three-dimensional space, the following entities can
be identied when using quaternion algebra:
The conjugate of a quaternion q in the form of (4.11) inverts the vector part in that,
q

= [s,

V ], (4.23)
the absolute value, or magnitude of a quaternion the form of (4.11) can be calculated using,
|q| =
_
s
2
+

V

V , (4.24)
and the norm n of a quaternion is denoted as,
n(q) = (s
2
+

V

V ) = |q|
2
. (4.25)
CHAPTER 4. BIOMECHANICAL MODELLING 101
A very important operation with quaternions, particularly with regard to representing rotations,
is the inverse function,
q
1
= (
1
|q|
2
)[s,

V ] = 1/q =
1
n(q)
q

, (4.26)
whereby the division of two quaternions can be expressed by,
q
3
=
q
1
q
2
= q
1
(q
1
2
) = q
1
q
1
2
. (4.27)
In order to rotate a vector by a quaternion, the vector is multiplied on the right by the quaternion,
and on the left by the inverse of the quaternion.
From (4.19) it follows that a pure quaternion v
p
can be rotated using,
v

p
= Rot(v
p
, q) = q
1
v
p
q. (4.28)
The result v

p
will always be a quaternion with zero scalar component, [0, V ect((v

p
))].
This guarantees that:
Rot(v
p1
, q)Rot(v
p2
, q) = Rot(v
p1
v
p2
, q) (4.29)
which implies that dot and cross products are preserved. This eect is embedded in the quaternion
product.
By using the inverse of a quaternion q = [s,

V ] as q
1
[s,

V ]/ |q|
2
, the eects of magnitude are
divided out so that any scalar multiple of a quaternion gives the same amount of rotation.
When the magnitude of q = 1, these unit-quaternions lie on a sphere of radius 1, q = [w, (x, y, z)]
such that w
2
+x
2
+y
2
+z
2
= 1.
These unit quaternions carry the amount of rotation in w, as cos(/2), while the vector part
(x, y, z) points along the axis of rotation with magnitude sin(/2) and, the axis of rotation is
that line in space which remains unmoved during the rotation.
In referring to Eqn. 4.24, the magnitude of,
q = [cos(/2), sin(/2)(u)] = 1, (4.30)
since cos
2
+sin
2
= 1 and where u denotes the unit-vector of the axis of rotation.
This sphere of unit quaternions spans a 4-dimensional vector space (S4) and forms a sub-group
of the 3-dimensional vector space (S3). This spherical metric of S3 is the same as the angular
metric of S3.
Thus, a quaternion for rotating is stored as,
q
r
= [cos(/2), sin(/2)(u)], (4.31)
where refers to the radian angle of rotation around the unit-vector of the axis of rotation u. A
short (axis-angle) notation of a rotation quaternion can therefor be denoted as:
q
r
= [, (u)]. (4.32)
CHAPTER 4. BIOMECHANICAL MODELLING 102
Rotation quaternions of the form (4.31) can be combined by quaternion multiplication, using
Eqn. 4.29.
An eye position can therefore be represented by a unit-quaternion that describes a rotation from
primary position around a specied rotation axis u with an appropriate angle using Eqn. 4.31.
In order to represent eye movement, interpolation of rotations is conveniently performed using
quaternion algebra.
Let q
a
and q
b
denote two distinct quaternions that describe the start and end position of an eye
movement respectively.
Then the rotation quaternion,
q = q
a
(q
1
a
q
b
)
t
, (4.33)
where the quaternion power operator is dened as,
q
t
= [st,

V ]. (4.34)
This will describe any desired intermediate rotation that lies on the shortest path between the
two eye positions. The time parameter t can be introduced into the angle so that the adjustment
of q varies uniformly over the great arc between q
a
and q
b
.
Eqn. 4.7 can now be rewritten using a rotation quaternion q in the form (4.28) that represents
the current eye position and

= V ect(Rot(

S, q)), (4.35)
represents the rotation of a vector

S into a new position

S

.
Finally, a quaternion can be transformed into a rotation matrix.
Let q be a rotation quaternion in the form of (4.15), then, the corresponding rotation matrix is
dened by,
R =
_
_
1 2x
2
2
2x
3
2
2x
1
x
2
2x
3
S 2x
1
x
3
+ 2x
2
S
2x
1
x
2
+ 2x
3
S 1 2x
1
2
2x
3
2
2x
2
x
3
2x
1
S
2x
1
x
3
2x
2
S 2x
2
x
3
+ 2x
1
S 1 2x
1
2
2x
2
2
_
_
. (4.36)
Further information on quaternions, derivations and proofs can be found in [PW82] or [WP03].
4.4.2.3 Listings Law
In order to generate 3D eye positions based on 2D reference positions, torsional rotation angles
need to be calculated in order to fulll Listings law. Referring to Sec. 2.2.2.2, Listings law can be
derived geometrically. Based on the coordinate system denition from Sec. 2.2.1 and Sec. 4.4.1,
an eye position can be represented by three successive rotations around the coordinate system
axes.
Let {, , } denote three angular rotations around the coordinate axes X, Z and Y respectively,
whereas represents ab-/adduction, elevation or depression and torsional eye movements.
This sequence of rotation corresponds to the denition of the Fick rotation order from Sec. 4.4.1.
Since the Y-Axis represents the line of sight, torsional rotation in accordance with Listings law
needs to be determined as a function of the angles and only.
CHAPTER 4. BIOMECHANICAL MODELLING 103
The torsional rotation of a Point P(x, y, z) around the line of sight results in a new reference
position P

(x

, y

, z

) and can be described using Eqn. 4.37,


x

= xcos() z sin(), (4.37)


y

= y,
z

= z cos() +xsin().
Additionally, P

is rotated around the horizonal X-Axis into position P

(x

, y

, z

) in order to
represent elevation or depression movements using Eqn. 4.38,
x

= x

, (4.38)
y

= y

cos() +z sin(),
z

= z

cos() +y

sin(),
and nally ab-/adduction movement is represented by a rotation of P

around the Z-Axis using


Eqn. 4.39, dening the nal position of P

(x

, y

, z

),
x

= x

cos() +y

sin(), (4.39)
y

= y

cos() x

sin(),
z

= z

.
Substitution of Eqn. 4.37 and Eqn. 4.38 in Eqn. 4.39 gives Eqn. 4.40, a combined rotation around
all three axes of an eye xed coordinate system, obeying the Fick sequence of rotation,
x

= y cos() sin() (z cos() +xsin() sin()) sin() + (4.40)


cos()(xcos() +y sin() sin()),
y

= y cos() cos() xcos() sin() +z sin(),


z

= z cos() cos() + cos()(y cos() sin() +xsin()) +


sin()(xcos() sin() +y sin()).
According to Listings law, Eqn. 4.40 denes a rotation axis in 3D-space, so that any eye position
dened through the angles {, , } can be reached by a single rotation around this axis. Since
this axis stays constant during the rotational movement, it can be found by setting P

= P in
Eqn. 4.40 and subsequently solving for x, y and z. Thus, all points of the rotation axis satisfy
Eqn. 4.41,
x =
y cos() sin() z cos() sin() +y cos() sin() sin()
1 cos() cos() + sin() sin() sin()
, (4.41)
y =
xcos() sin() z sin()
1 + cos() cos()
,
z =
cos()(y cos() sin() +xsin()) + sin()(xcos() sin() +y sin()))
1 + cos() cos()
. (4.42)
Since Listings law also states, that all rotation axes of the eye lie in the fronto-parallel plane
(Listings plane), this constraint needs to be added by using the equation for the X Z plane,
y = 0, (4.43)
CHAPTER 4. BIOMECHANICAL MODELLING 104
constraining all coordinates of the rotation axes from Eqn. 4.41. By replacing Eqn. 4.43 into
Eqn. 4.41, the system of equations can be solved by forward substitution of Eqn. 4.41 in Eqn. 4.42,
resulting in Eqn. 4.44,
z =
z cos() sin()(cos() sin() sin() + cos() sin())
(1 + cos() cos())(1 + cos() cos() sin() sin() sin())
. (4.44)
Solving Eqn. 4.44 for eliminates the last free variable z and expresses the torsional angle of
rotation as a function of and , ensuring that each eye position is assigned a unique torsional
value according to Eqn. 4.45,
(, ) = = cos
1
_
cos() + cos()
1 + cos() cos()
_
. (4.45)
4.4.2.4 Denition of Eye Positions
In describing eye positions with the methods presented in Sec. 4.4.2.1 and Sec. 4.4.2.2, there are
basically two possibilities:
3D eye positions are used to fully specify all three degrees of freedom for a given eye position
in space. This corresponds to the denition of three angular coordinates in Fick rotational
order that specify add-/abduction, elevation/depression and torsion respectively.
2D eye positions are used when specifying ab-/adduction and elevation/depression angles, ex-
cept the torsional rotation angle is calculated as suggested by Listings law and therefore
constrains eye rotation axes to lie in Listings plane (see Sec. 2.2.2.2).
Eye positions that fulll Listings law can therefore be dened by using Eqn. 4.6 in the following
way:
R
Listing
(, ) = R
Fick
(, , (, )), (4.46)
where is substituted by Eqn. 4.45.
Using quaternion notation, 3D eye positions can be dened by considering passive rotation history
of every coordinate system axis. In Fick rotation sequence, rst, the X-axis of the coordinate
system is rotated around the Z-axis by degrees using a quaternion of the form (4.32). Let

XA(1, 0, 0),

Y A(0, 1, 0) and

ZA(0, 0, 1) denote the base vectors of the eye xed coordinate system.
Then, the rotation quaternion,
q
rz
= [, (

ZA)],
denes a rotation of degrees around the base axis

ZA, and,

XA

= V ect(Rot(

XA, q
rx
)),
reorients the original X-axis to a new vector

XA

. Accordingly, the y-Axis of the eye xed


coordinate system is rotated around the Z- and X-axis respectively by using,
q
ry
= [, (

XA

)]q
rz
,

Y A

= V ect(Rot(

Y A, q
ry
)),
CHAPTER 4. BIOMECHANICAL MODELLING 105
resulting in a new Y-Axis

Y A

. The rotation quaternions that rotate around each of the pre-


oriented eye xed axes can now be dened as,
q
ry
= [, (

Y A

)],
q
rx
= [, (

XA

)], (4.47)
q
rz
,
where is given by Eqn. 4.45.
The complete rotation quaternion for dening eye positions according to the Fick sequence of
rotation is given as
q
Listing
= q
ry
q
rx
q
rz
. (4.48)
4.4.3 Geometrical Abstractions
In the derivation of the ocular geometry, geometrical abstractions will serve as modelling ele-
ments that mathematically dene constrains and conditions that represent its human counter-
part. Additionally certain equations can be identied as interfaces to other elements of the overall
biomechanical model.
4.4.3.1 Globe
The rst essential geometrical abstraction is the modelling of the globe. The geometrical object
of a sphere is used to represent the human eyeball and is dened by using the spherical equation,
x
2
+y
2
+z
2
= r
2
, (4.49)
where x, y, z are coordinates that lie on the sphere with radius r.
Figure 4.5: Geometrical Abstraction of the Globe
The illustration in Fig. 4.5 shows that the globe is placed in the center of the eye xed coordinate
system which is identical with the rotation center of the sphere. The line of sight originates from
CHAPTER 4. BIOMECHANICAL MODELLING 106
the center of rotation (C) and intersects the center of the pupil. In primary position, the line of
sight coincides with the Y-axis of the head-xed coordinate system. The orientation of the globe
(i.e. the eye position) is changed according to the rotation of the line of sight using Eqn. 4.35.
Although, this geometrical abstraction assumes that the globe is spherical, further derivations
will show, that the natrual ellipsoid shape of the human eyeball will be considered when dening
the lever-arm of each muscle. Thus, the spherical approximation of the globe was chosen for easier
visualization and can be replaced by a more realistic (i.e. more complex) geometrical structure,
without aecting the models behavior.
4.4.3.2 Muscles
In order to geometrically dene the action of the extraocular muscles, specic landmark-points
that describe the muscle path and the direction of pull are chosen for each muscle. Derivations
will be given starting from older, historic modelling approaches up to the geometrical model used
in this thesis, the so called Pulley model.
Figure 4.6: Geometrical Abstraction of an Eye Muscle
An extraocular muscle can geometrically be approximated by a straight line. Muscle force and
deformation due to contraction or relaxation are not of primary interest in the geometrical model.
These properties will be added by additional models of muscle force and dynamic 3D-visualization.
The geometrical model itself is only responsible for predicting how a muscle can transfer its force
into a rotation axis that aects eye position. Following Fig. 4.6, the requirements for a specic
geometrical model of the extraocular muscles are the calculation of the following entities (cf.
[BKPH03] and [Buc02]):
The origin of each muscle represents the point where a muscle originates in the posterior area
of the orbit (i.e. the anulus of Zinn).
The point of tangency of each extraocular eye muscle is dened as that point where the muscle
rst contacts the globe. This special point is intrinsic to the geometrical denition, since
CHAPTER 4. BIOMECHANICAL MODELLING 107
it changes as a function of gaze and is dened using dierent mathematical formulations in
dierent geometrical models.
The insertion point is that point on the globe where the tendon of the muscle nally inserts
on the globe.
The muscle action circle is dened as that circle that lies on the globe and is dened by the
muscles plane of action.
The arc of contact of a muscle is dened as the circular path between the insertion and the
point of tangency. This path is always part of the muscle action circle.
The muscle rotation axis is dened as a vector that represents an axis around which a specic
muscle rotates the eye. Thus axis is perpendicular to the muscle action circle or the muscles
plane of action.
String Model
The simplest geometrical representation of extraocular muscle action is the string model (see
Fig. 4.7). This model is also known as the shortest path hypothesis (cf. [Kre50]), which means
that muscle strings are assumed to be always tight and therefore take the shortest possible
connection between the insertion and the origin (see Fig. 4.7(a)).
(a) Muscle Path in Primary Position (b) Muscle Path in Secondary Position
Figure 4.7: Geometrical String Model, from [BKPH03]
The denition of the string model can be reduced to specifying the point of tangency as a
function of gaze position (see Fig. 4.8). Let

I be the vector from the center of the coordinate
system C to the insertion point of a muscle from Sec. 2.1.3 and

I

the vector to the insertion


point in the actual eye position, such that,

= V ect(Rot(

I, q)), (4.50)
where the rotation quaternion q in the form (4.32) species the current eye position. Let

O
denote the origin of an eye muscle, according to Sec. 2.1.3 and

R denote a vector with length
r =

that is perpendicular to the vector



O. Then, the right triangle O RC gives l as the
CHAPTER 4. BIOMECHANICAL MODELLING 108
shortest path from origin to insertion by using,
l =
_

2
. (4.51)
From the denition of the right triangle, the angle between

O and

R is dened by,
= cos
1
(l/r). (4.52)
The rotation axis

RM of the muscle can be dened as vector that is perpendicular to the muscle
action plane spanned by the vectors

O and

I

using,

RM =

O

. (4.53)
Finally, the vector

QN, which points along the vector

O with length r needs to be rotated around
the muscle rotation axis

RM by the angle . The vector

QN is denoted as,

QN =

O

r. (4.54)
Using a rotation quaternion of the form (4.32),
r
q
= [, (

RM)], (4.55)
the vector

QN can be rotated into the position of the point of tangency T by,

T = V ect(Rot(

QN, r
q
)). (4.56)
Figure 4.8: Point of Tangency in the String Model
In secondary gaze positions (see Fig. 4.7(b)), the shortest path hypothesis in this model leads to
a displacement of the point of tangency which is known as side-slip. In this model, the muscle
CHAPTER 4. BIOMECHANICAL MODELLING 109
action circle is always a great circle on the globe and its center coincides with the center of the
globe.
However, the predictions of the string model do not correspond to clinical expectations. Par-
ticularly in secondary and tertiary gaze positions, this model gives inadequate results. Only in
primary position, predictions for muscle path and muscle match clinical expectations. Fig. 4.7(a)
shows a left eye with the lateral rectus muscle in primary position, whereas Fig. 4.7(b) shows
an adduction of about 34

(secondary gaze position). It is easy to recognize that the path of


the lateral rectus muscle shifts upwards with a change in gaze position (the lateral rectus muscle
shifts its muscle path with the line of sight), which does not correspond to clinical observations.
This shift results in a drastic change of the muscle path and thus in an abnormal rotation of
the eye (i.e. the lateral rectus now mainly elevates the eye!). The lateral rectus muscle cannot
sustain its mainly abducting eect on the globe, it slips away as the eye turns towards the nose.
Tape Model
Based on the string model, Robinson ([Rob75a]) developed the so called tape model which tries
to reduce the side-slip of the muscles in secondary and tertiary positions. Therefore, Robinson
limited the side-slip of the point of tangency with an empirical value depending on the extent of
the rotation of the eye. This side-slip retaining component is introduced in the tape model via
a reduction of the maximum side-slip angle that is calculated with respect to the string model.
The maximum side-slip angle is determined by measuring the angular displacement of two per-
pendicular vectors with respect to the current eye position in a head-xed coordinate system (see
Fig. 4.9). Let

MP be the vector perpendicular to

I and

O, and let

TP be the tangential vector
with respect to the arc of contact of the muscle such that,

MP =

I

O

I

O

, (4.57)

TP =

MP


MP

. (4.58)
These two base vectors are dened with respect to I, the insertion point in primary position.
Now, these two base vectors are also dened for the current gaze position, using the vector

I

from Eqn. 4.50,

MP

=

I

, (4.59)

TP

=

MP


MP

. (4.60)
The maximum angle of deviance is measured between the vectors

MP and

MP

. However,
since the vector

MP is dened in primary position, it needs to be transformed in the head-xed
coordinate system in order to measure the true angle of deviance. Let q be the quaternion that
CHAPTER 4. BIOMECHANICAL MODELLING 110
Figure 4.9: Tape Model Calculations
denes the current eye position in the form (4.32). Then, q
1
will represent a backward rotation
into the head-xed coordinate space, and,

MP
h
= V ect(Rot(

MP, q
1
)), (4.61)

TP
h
= V ect(Rot(

TP, q
1
))
will transform the vectors

MP and

TP into head-xed vectors

MP
h
and

MP
h
respectively. Now,
the maximum angle of deviation v
max
of the muscle action circles between the primary position
and the current gaze position with respect to the string model is dened as,
v
max
= sgn(

MP


TP
h
) cos
1
(

MP


MP
h
), (4.62)
where the rst part of this equation species the angular direction in terms of the sign of the
deviation angle. The actual deviation angle e with respect to the vector

MP
h
can be calculated
using,
e = cos
1
(

MP
h


O). (4.63)
Finally, the reduced side-slip angle v can be dened as a fraction of the maximum deviation angle
v
max
with respect to the actual excitation angle e using,
v = v
max
|cos(e)| . (4.64)
The angle v now denes the the actual reduced displacement angle for the tape model that is
applied by using a rotation around the axis that is dened by the vector

O based on the point of
tangency from the string model. Thus, the point of tangency T from the string model (4.56)
in primary position is rotated using the following rotation quaternion q
t
of the form (4.32),
q
t
= [v, (

O)], (4.65)
resulting in the denition of the point of tangency TT in the tape model,

TT = V ect(Rot(

T, q
t
)). (4.66)
CHAPTER 4. BIOMECHANICAL MODELLING 111
Because of the modication to the movement of the point of tangency, the center of the muscle
action circle of a specic muscle does no longer coincide with the globe center in secondary and
tertiary positions. Instead, the center of a specic muscle action circle is now dened through a
muscles point of tangency vector

TT and origin vector

O, just like the muscle rotation axis. As
in the string model, the vector perpendicular to the plane spanned through these three points
represents the muscle rotation axis

RM, such that,

RM =

TT

O


TT

O

. (4.67)
The center of the muscle action circle can now be calculated as the intersection point of the
rotation axis with the muscle action plane. Since the muscle rotation axis is perpendicular to the
muscle action plane, and the muscle action plane contains the point of tangency and origin of
a muscle, the center of the muscle action circle lies in the extension of the muscle rotation axis.
Thus, the center of the muscle action circle can be calculated using,

C
c
= (

C

RM)

C

TT

RM

C
. (4.68)
(a) Muscle Path in Primary Position (b) Muscle Path in Secondary Position
Figure 4.10: Geometrical Tape Model, from [BKPH03]
The limitation of the movements of the point of tangency results in a reduced muscle side-slip
in secondary and tertiary positions. Fig. 4.10 shows this eect by comparing an eye in primary
position (Fig. 4.10(a)) and after an adduction of 34

(Fig. 4.10(b)). Although the side-slip is


reduced in the tape model, the model predictions still dier from anatomical ndings. In the
following part of this thesis, a new geometrical pulley model will be described which tries to
overcome this problem and also takes pulleys into account.
CHAPTER 4. BIOMECHANICAL MODELLING 112
Pulley Model
Results of investigations of muscle pulley structures provided the reason why all the conventional
models like the string or tape model where not exact and the predictions of these models did not
compare to clinical ndings (see Sec. 2.1.1). But pulleys did not only inuence existing models.
They also considerably aected existing surgery techniques. Before the discovery of pulleys most
surgeons tended to remove portions of the orbital connective tissues covering the eye muscles,
however, it has been noticed that if too much of the connective tissue is removed, unpredictable
and unwanted results occurred after surgery. With the discovery of pulleys, the reason for this
behavior became clear. When surgeons damaged or even removed pulley structures, they de-
stroyed the functional origin of a muscle and therefore destabilized the muscle and sometimes
even the whole oculomuscular system (see [CJD00]).
In Fig. 4.11, the dierence between conventional models and the pulley model is illustrated.
While conventional models assume that the muscle tendon is coupled tightly to the globe (see
Fig. 4.11(A)), the pulley model introduces an new anatomical structure that lets the muscle slide
through a fascial pulley which is elastically coupled to the orbital wall (see Fig. 4.11(B)). The
functional consequence is obvious in comparing both models when the eye is elevated. While
conventional models tend to dene a constant axis of rotation with respect to dierent gaze
positions (compare Fig. 4.11(A) and Fig. 4.11(B)), the pulley model adapts the axis of rotation
such that the primary direction of action of the muscle is preserved with respect to the current
gaze position (compare Fig. 4.11(C) and Fig. 4.11(D)). This means, that the axis of rotation of
a muscle is expressed according to an eye-xed coordinate system in the pulley model, since the
coordinate system axes are moved as a function of gaze position.
Figure 4.11: Comparison of Conventional vs. Pulley Model, from [MD99]
CHAPTER 4. BIOMECHANICAL MODELLING 113
For the mathematical derivation of the pulley model, a new geometrical pulley point is introduced,
which also serves as functional origin of a muscle. In contrast to other models, the pulley model
redirects a muscles main direction of pull towards the functional pulley point instead of using
the anatomical origin (o) as force directing reference position. This results in a stabilization of
the muscle path in the posterior area of the orbit as well as an adaption of the muscle rotation
axis with respect to the current eye position.
For the calculation of the point of tangency, the muscle action circle must be dened. In primary
position, the muscle action circle of each muscle is a great circle. Therefore, in primary position,
the center of a muscle action circle coincides with C as shown in Fig. 4.12. In secondary and
tertiary positions, the muscle action circle of a specic muscle is no longer a great circle and for
this reason, the center has to be calculated in a dierent way.
Thus, to calculate the center of a muscle action circle in all dierent eye positions, the rst step
is the denition of three vectors {

SX,

SY ,

SZ} based on the insertion in primary position I, the
pulley location P and the center of the globe C.
According to Fig. 4.12, let

SZ denote the unit vector from C to I,

SZ =

I

, (4.69)

SY the vector perpendicular to the plane spanned by the three points C, P and I,

SY =

P

, (4.70)
and

SX be the cross product of

SY and

SZ,

SX =

SY

SZ. (4.71)
In order to calculate the center of a muscle action circle in a secondary or tertiary position the eye
and, consequently, the vectors {

SX,

SY ,

SZ} have to be rotated out of the primary position into
a secondary or tertiary position. Since the orientation of the eye is dened through a rotation
quaternion q of the form (4.32), q is also used for reorienting three vectors {

SX,

SY ,

SZ}, such
that,

TX = V ect(Rot(

SX, q)), (4.72)

TY = V ect(Rot(

SY , q)),

TZ = V ect(Rot(

SZ, q)).
Thus, the resulting vectors {

TX,

TY ,

TZ} dene the three base-vectors {

SX,

SY ,

SZ} in the
current eye position (see Fig. 4.13). Additionally, the insertion point I

is dened as the rotated


insertion point in primary position I according to (4.50).
From Fig. 4.13, it can be seen that the rotated primary position muscle action circle that is dened
by the pulley model is no longer the shortest possible path between the insertion and the origin
CHAPTER 4. BIOMECHANICAL MODELLING 114
Figure 4.12: Primary Position in Pulley Model, from [BKPH03]
on the surface of the bulbus. Therefore, three new vectors {

GX,

GY ,

GZ} are calculated which
form the basis of a new muscle action circle representing the shortest path between the insertion
and the pulley. These vectors are calculated with the same equations shown in (4.69)-(4.71), but
with I replaced by I

, using,

GZ =

I

, (4.73)

GY =

P

GX =

GY

GZ.
There are three dierent muscle action circles which can be determined with a set of given
equations. These circles are the primary position muscle action circle, the rotated primary
position muscle action circle in tertiary and secondary positions (zero side-slip) and the shortest
path muscle action circle in tertiary and secondary positions (full side-slip).
The two dierent muscle action circles in secondary and tertiary positions are important, because
the correct muscle action circle of a specic muscle in secondary and tertiary positions lies
somewhere between these two (see Fig. 4.14). In order to determine the actual muscle action
circle, the full side-slip angle is calculated, which lies between the rotated primary position
muscle action circle and the shortest path muscle action circle measured at the insertion point.
The angle between the two muscle action circles is calculated using,
= tan
1
_


GX

TY


GX

TX
_
. (4.74)
CHAPTER 4. BIOMECHANICAL MODELLING 115
Figure 4.13: Tertiary Position in Pulley Model, from [BKPH03]
However, as already mentioned before, the correct muscle action circle lies somewhere between
the rotated primary position muscle action circle and the shortest path muscle action circle.
Therefore, the angle has to be reduced by an empirical side-slip scaling parameter dened as
. This scaling parameter was tted to comply to other models (i.e. Orbit [MR84]) and describes
the rotational force due to muscle width that tends to rotate the eye around the axis

I

. The
dierent values for of each muscle have been taken from the EyeLab model (cf. [PWD00]) and
are listed in Tab. 4.1.
Muscle Side-slip Scalar ()
medial rectus 0.3443
lateral rectus 0.2909
inferior rectus 0.2954
superior rectus 0.2850
inferior oblique 0.0722
superior oblique 0.1240
Table 4.1: Side-slip Scaling Values for Pulley Model
Using Eqn. 4.74 for calculating and the side-slip scaling parameter , the side-slip angle can
be calculated using,
= tan
1
_

GX

TY

GX

TX
_
. (4.75)
With the side-slip angle and the vectors

TX and

TY , a vector

D can be dened which describes
the direction in which the muscle departs from its insertion (see Fig. 4.15). This vector

D can
CHAPTER 4. BIOMECHANICAL MODELLING 116
Figure 4.14: Muscle Action Circles in Pulley Model, from [Kal02]
be dened as a linear combination of

TX and

TY such that,

D =

TY sin()

TX cos(). (4.76)
To determine the center of the actual muscle action circle in secondary and tertiary gaze positions
a vector

N, which is perpendicular to the actual muscle action circle and represents the axis of
rotation of the globe is dened. However, calculating

N is easy, since I

, P and

D are all lying in
the plane of the muscle action circle and therefore can be used for calculating the perpendicular
vector of the plane spanned by the vector

D and by the vector dened through the points P and
I

(see Fig. 4.16). Consequently, the equation for calculating



N is given by,

N =

D

I

D

I

. (4.77)
Using the vector

N, the calculation of C
c
, the center of the pulley model muscle action circle, is
now possible by using,
C
c
= (

I

N)

N. (4.78)
With the calculation of C
c
, the center of the muscle action circle of a specic muscle in a primary,
secondary or tertiary position is dened. Moreover, the vector

N corresponds to the rotation
axis of a specic muscle. Therefore, the only aspect remaining is the determination of the point
of tangency.
In order to calculate the point of tangency, two vectors {

EX,

EY } are dened, which form the
basis of the pulley model muscle action circle and are shown in Fig. 4.17. These two vectors are
CHAPTER 4. BIOMECHANICAL MODELLING 117
Figure 4.15: Muscle Direction Vector in Pulley Model, from [Kal02]
formed using P, C
c
and

N according to,

EX =

P

C
c

P

C
c

, (4.79)

EY =

N

EX

N

EX

.
With the help of

EX and

EY , the angle which describes the angle between the vector from
C
c
to I

and the vector from C


c
to P, can be dened. The angle is also shown in Fig. 4.17 and
is calculated using,
= tan
1
_


EY


EX
_
. (4.80)
However, in order to determine the point of tangency, the calculation of the angle is necessary
(see Fig. 4.17). Therefore, the radius of the pulley model muscle action circle is required and the
length of the vector from C
c
to P. The radius r of the muscle action circle and the length l of
the vector from the pulley to the center of the muscle action circle can be calculated using,
l =

P

C
c

, (4.81)
r =


C
c

.
Since the angle between the vector from the point of tangency to C
c
and the vector from the
point of tangency to the pulley P must be exactly 90

, implied by the denition of the tangent


CHAPTER 4. BIOMECHANICAL MODELLING 118
Figure 4.16: Muscle Rotation Axis and Action Circle Center in Pulley Model, from [Kal02]
function, the angle can be calculated by,
= 90

sin
1
_
r
l
_
. (4.82)
Thus, the angle between the insertion and the point of tangency at the center of the muscle
action circle is ( ). With this angle, the point of tangency t can be calculated by rotating
the point I

around an axis dened through the vector



N using a rotation quaternion r
q
of the
form (4.32),
r
q
= [ , (

N)]. (4.83)
Next, the rotation quaternion r
q
is used to rotate the point I

in the muscles direction of pull


by ( ) degrees and the resulting quaternion is assigned to the point T,
T = V ect(Rot(

, r
q
)). (4.84)
4.4.3.3 Evaluation of Muscle Action
In order to complete the denition of extraocular geometry, one needs also to consider muscles
and their directions of pull. A muscles geometric description is based on denition of important
reference points, while the muscles direction of pull is determined by the denition of a rotation
axis, around which the muscle would rotate the eye. The geometric description of a muscle is
dened by a muscle path from its origin to its insertion and how this muscle path changes with
dierent gaze positions. The illustration in Fig. 4.18(c) shows the medial rectus muscle dened
by muscle origin, pulley, point of tangency and insertion. The pulley stabilizes the muscle path in
CHAPTER 4. BIOMECHANICAL MODELLING 119
Figure 4.17: Point of Tangency in Pulley Model, from [BKPH03]
the rear orbit. The point of tangency marks that range, at which the muscle path rst contacts
the globe. Reactions of the muscle path to changes in gaze position are dierently represented by
dierent models. Thus, substantial dierences exist in the denition of the muscle path between
string, tape and pulley models. The string model and the tape model use origin, point of
tangency and insertion to dene the muscle path, whereas the pulley model additionally consider
the pulley point.
(a) String Model Path (b) Tape Model Path (c) Pulley Model Path
Figure 4.18: Muscle Path Comparison using Dierent Geometrical Models from [BKP
+
03]
In comparing the muscle path representation of these models (see Fig. 4.18), noticeable dierences
in the movement of the point of tangency occur. In the string model (Fig. 4.18(a)) as well as in
the tape model (Fig. 4.18(b)), the point of tangency and thus also the entire rear muscle path
is pulled downward. This also substantially aects the direction of pull in other gaze positions.
Using the pulley model (Fig. 4.18(c)), stabilization of the direction of pull of the muscle is reached
by introducing a new reference point (pulley), and thus a substantially more realistic result occurs.
To geometrically evaluate the rotational behavior of a muscle according to clinical methods, the
rotation axis can be split into its respective components of action. This results in specifying
normalized rotational magnitudes of rotational action for ab-/adduction, elevation/depression
and in-/extrorsion. These rotational actions are measured within an oblique coordinate system
CHAPTER 4. BIOMECHANICAL MODELLING 120
{

D
1
,

D
2
,

D
3
} where

D
3
denotes the head-xed vertical axis,

D
1
describes the head-xed horizon-
tal axis that is rotated around

D
3
according to ab-/adduction movements and

D
2
corresponds
to the line of sight. Thus, the orientation of this new coordinate system depends only on ab-
/adduction and elevation/depression movements of the globe. In order to measure muscle action
in a certain eye position, the rotation axis of a muscle, dened using string, tape or pulley model
needs to be transformed into the new coordinate system.
Let {, , } denote an eye position according to the Fick rotational sequence and

RA be a
normalized muscle rotation axis according to the string, tape or pulley model (4.53, 4.67 or 4.77).
Using the rotation quaternions q
rx
and q
rz
from (4.47), the rotation quaternion,
q
t
= q
rx
q
rz
, (4.85)
species the rotational transformation of coordinates from head-xed space into the new mea-
surement coordinate system. Therefore, the rotation axis

RA(x, y, z) can be transformed into an
axis

RA

(x

, y

, z

) using,

RA

= V ect(Rot(

RA, q
t
)), (4.86)
where z

represents the ab-/adducting rotational component, x

represents the
elevating/depressing component and y

species the torsional rotation. Since



RA

is a unit
vector, all rotational components lie between 1 and 1.
The muscle force distribution shows this relative rotational components for selected eye muscles
along a horizontal view range (see Fig. 4.19) in a certain elevation/depression level. The ro-
tational components are indicated in standardized values between -1 and 1 for ab-/adduction,
elevation/depression and in-/extorsion. The illustration in Fig. 4.19 show the force distributions
of the lateral rectus muscle in the string and tape models with an elevation of 15

along the
horizontal eld of vision with up to 60

of abduction/adduction of a left eye.


Here, the physiologically incorrect prediction of the string model becomes clearly evident at 36

of adduction. The lateral rectus muscle drastically changes its abducting eect into adduction
(see Fig. 4.19(a)). The comparison with the tape model in Fig. 4.19(b) shows better behavior
for accurately the same scenario due to retention of the main direction of pull of the lateral
rectus. These dierences result from the dierentiated mathematical modelling of the anatom-
ical structures. While in the string model the muscle path within its contact range with the
globe was dened by the shortest path between insertion and origin, the tape model contains
an angle-reducing component, which describes the muscle path by the relative motion of the
point of tangency as a function of gaze position. This allows the simulation of stabilizing connec-
tive tissues, in order to limit the movement of muscles in extreme gaze positions. Graphically,
this simulation results in a bent muscle path between insertion and point of tangency, which
substantially better corresponds to anatomical conditions.
CHAPTER 4. BIOMECHANICAL MODELLING 121
(a) String Model Distribution
(b) Tape Model Distribution
Figure 4.19: Muscle Force Distribution in String and Tape Model from [BKP
+
03]
Figure 4.20: Muscle Force Distribution in the Pulley Model
Only through the introduction of a model that includes pulleys, more detailed simulations and
pathological case studies can be accomplished (see Fig. 4.20). The simulation of pulleys shows
an absolute retention of a muscles main action in the entire physiological eld of vision and is
thus best suitable for being used as geometrical representation.
4.4.4 Passive Geometrical Changes
Passive changes in ocular geometry occur when some muscles move the globe into a dierent
gaze position. Due to the rotation of the globe, muscle length changes in every eye muscle,
since a contracting muscle shortens and an antagonistic muscle lengthens during eye movement.
These geometric variations are very essential to the biomechanical model because muscle length
CHAPTER 4. BIOMECHANICAL MODELLING 122
and length changes are major parameters that aect muscle force prediction. The mathematical
description of muscle length can be split into the sum of the contact arc length and the length
of the posterior muscle part. The length of the contact arc can be calculated as the spherical
distance along the muscle action circle between the insertion point and the point of tangency.
Let

T and

I

be the vectors from the center of the muscle action circle to the insertion and origin
point. Then, the radius of the muscle action circle is dened as,
rad =

, (4.87)
and the angle between the two vectors can be calculated using,
= cos
1
(


T). (4.88)
Using the radius and the angle , the spherical distance on the muscle action circle between
insertion and point of tangency is,
d
arc
= rad . (4.89)
For the pulley model, the length of the posterior part of the muscle is also calculated in two steps.
First, the length from the origin point of the muscle to the pulley point is given by the length of
the vector

PO,
l
1
=


PO

. (4.90)
Then, for the length from the pulley point to the point of tangency, an adapted formula from
(4.51) for the shortest path distance is used,
l
2
=
_

P

P

T
l
, (4.91)
where

P is the vector from the center of the globe to the pulley point,

I

is the vector from the


center of the globe to the insertion point and T
l
denotes the length of the tendon which is given
in Sec. 2.1.3. The subtraction of T
l
is important, since the net muscle length is measured without
the muscle tendon.
For geometrical models that do not use pulleys, the posterior part of the muscle length is simply
calculated using the shortest path distance between origin and point of tangency using,
l =

O

T

T
l
. (4.92)
Finally, the overall muscle length m
l
can be computed using,
m
l
= d
arc
+l
1
+l
2
, (4.93)
for the pulley model, and,
m
l
= d
arc
+l, (4.94)
for any other models that do not use pulleys.
Based upon these calculations, the passive length change with respect to geometrical measure-
ments from Sec. 2.1.3 can be computed. The passive length change d
l
is always measured in
percent, based on the geometrical muscle length in primary position, using,
d
l
=
100 (m
l
L
0
)
L
0
. (4.95)
CHAPTER 4. BIOMECHANICAL MODELLING 123
4.5 Muscle Force Prediction
Besides ocular geometry, muscle force prediction is another essential part of the overall biome-
chanical model. The muscle force prediction model has the function of providing forces for each
muscle, based on muscle length, tension and actual innervation.
For skeletal muscles, many dierent modelling approaches can be found in literature. Most
models are devoted to muscle force prediction in that they only provide models for estimating
the global uniaxial output force of given muscles in dened conditions and experiments (cf.
[MWTT98] and [KS98]). Conversely, other models are concerned with the understanding of the
contractile mechanism, and describe the chemico-mechanical aspects of the contraction process,
but are hardly related to a realistic global output force involving the 3D anatomical and passive
properties of a specic muscle. Only few studies attempt to provide a model of muscles including
anatomical and mechanical, active and passive properties, allowing for a realistic simulation of
its contractile behavior in relation with its deformation and its global output force (cf. [BL99]
and [BCL99]).
However, since all of these studies primarily investigated skeletal muscles, results cannot directly
be related to eye muscles. Further, since the anatomy of human eye muscles is still not fully
explored, models that take ber-types and contraction velocities into account cannot be adapted
to produce accurate results due to currently many unknown properties of human eye muscles.
Therefore, for current proposes, a static model of eye muscle force prediction using the best
available data is preferable. The static muscle force prediction model presented in this thesis
is adapted from studies conducted by Miller and Robinson (cf. [MR84] and [Rob75b]), taking
length-tension-innervation relationships into account.
4.5.1 Length-Tension Relationship
As mentioned before, muscle force depends on muscle length and tension. Tension is a function of
two variables, namely muscle stretch and muscle innervation. The more a muscle is stretched the
higher the tension, the second variable is motor command or innervation. High motor commands
lead to muscle contraction which also increases tension. Based upon measurements that were
carried out by Robinson et al. [ROS69], Collins et al. [CSO69] and Miller (see Sec. 2.3.2), the
length-tension relationship was modelled for a given stretch and motor command by a hyperbola.
This length-tension relationship was modelled according to the following equation,
F
i
(dl
i
, e
i
) =
i
_
k
2
(dl
i
+e
i
) +
_
k
2
4
(dl
i
+e
i
)
2
+a
2
_
. (4.96)
Here k is the asymptotic slope (equal to stiness for large extensions) and a determines the
sharpness of curvature of the transition to the slack state. Miller and Robinson approximated
the values of k = 1.8g and a = 6.24g to t to the measured data. The other parameters in (4.96)
are indexed by muscle number. Changes in muscle length dl is expressed as a percentage of the
length of the muscle in primary position using Eqn. 4.95. Thus, Eqn. 4.96 can be applied to all
muscles with respect to their diering reference lengths (L
0
). The parameter e
i
translates the
whole curve left or right along the length axis. It thus simulates a change in innervation. It
CHAPTER 4. BIOMECHANICAL MODELLING 124
is thought that muscle force is linearly proportional to the average muscle cross sectional area,
accordingly, the parameter
i
is used to scale the lateral rectus muscle length-tension hyperbola.
Therefore, is 1 for the lateral rectus muscle and the scaling parameter for each of the other
ve muscles is taken to be its cross sectional area relative to that of the lateral rectus, shown in
Tab. 4.2.
Muscle
Lateral Rectus 1.00
Medial Rectus 1.07
Superior Rectus 0.80
Inferior Rectus 0.97
Superior Oblique 0.41
Inferior Oblique 0.38
Table 4.2: Cross Sectional Muscle scaling Parameter Values
The remaining parameters dl
i
and e
i
are now used to formulate the muscle force prediction based
upon experimental data. The parameter e
i
slides the force curve along the length axis and
therefore inuences the output force when the length of a muscle does not change. This is related
to a simulation of changing innervation, thus, a mathematical formulation for innervation can be
derived from the parameter e
i
by using,
iv
i
(e
i
) = F
i
(0, e
i
) F(0, e
0
), (4.97)
e
0
= 21.7264.
The rst term in (4.97) describes the total isometric force for zero length change and the second
term describes the passive isometric muscle force for zero length change. The net change in force,
and therefore also innervation can be determined in subtracting the passive isometric force from
the total isometric force. In Eqn. 4.97, e
0
is that constant value of e that ts the passive force
curve from the force data. Thus, changes in e
0
modies default passive force behavior for all
muscles as initial force displacement ratio in units of percent length changes with respect to L
0
from (4.95). Since this mathematical derivation of innervation is based upon the parameter e of
Eqn. 4.96, the units for iv are arbitrary. However, it can be seen that a change in innervation
alters the total force output by the same amount as a numerically equal change of dl.
In using this muscle force prediction model, two fundamental problems arise. When a detached
muscle is stretched suciently it stops behaving like a non linear spring and becomes sti very
quickly. This so called leash region is not incorporated in the length-tension relationship from
Eqn. 4.96. Conversely, if the muscle is shortened suciently it will become slack and exert
no force. However, the hyperbolic nature of Eqn. 4.96 ensures that the tension for muscles
will never become zero. Miller and Robinson addressed these problems by creating three force
surfaces corresponding to elastic (passive), contractile (developed) and their sum total force that
were modied by hand to t experimental data. The relationship between elastic force F
E
and
contractile force F
C
can be dened as,
F
T
(dl, iv) = F
E
(dl) +F
C
(dl, iv), (4.98)
where F represents the total force curve and iv denes innervation according to Eqn. 4.97.
CHAPTER 4. BIOMECHANICAL MODELLING 125
4.5.2 Elastic Force Data
Elastic force is that force that a muscle exhibits when it is stretched or compressed due to its
material properties. Thus, the elastic force data is that part of Eqn. 4.96 that is only sensitive to
length changes dl. The curve consists of static values for passive isometric tension values given
at dierent muscle lengths (cf. Sec. 2.3.2).
Figure 4.21: Elastic Force Data
It is easy to see from Fig. 4.21 that the elastic force function is constant throughout the innervation
axis (iv), thus only depends on the length change of the muscle (dl axis). To incorporate the
leash and slack regions, the dl axis was split into three regions. In the region 17% dl 40%,
elastic force was simply calculated using Eqn. 4.96,
F
E
(dl) = F(dl, e
0
), 17% dl 40%. (4.99)
In the region dl < 17%, muscle force was smoothly tapered by hand to zero in order to reect
the slack region. Similarly for dl > 40%, force was extrapolated to an arbitrarily large value to
model the rapid increase in stiness exhibited in the leash region. From Fig. 4.21 it can be seen
that at a value of dl >= 54, force data stays constant at 82g, which simulates rigid behavior of
the muscle.
Muscle data for the leash and the slack regions are stored as tables that are used for interpolation.
Let,
T
Sd
[x] = (x
1
, x
2
, x
3
, . . . , x
n
), (4.100)
denote the table that stores the dl values of the slack region and,
T
Sf
[y] = (y
1
, y
2
, y
3
, . . . , y
n
), (4.101)
CHAPTER 4. BIOMECHANICAL MODELLING 126
denote the table that stores the force value for each x
i
. Then, any real value x
2
u x
n2
can
be found by using a cubic interpolation for an index i, such that,
x
a
T
Sd
[x
i
] x
b
, 2 a, b n 2. (4.102)
Based on 4 sample points (v
1
, v
2
, v
3
, v
4
) = (T
Sf
[x
i1
], T
Sf
[y
i
], T
Sf
[y
i+1
], T
Sf
[y
i+2
]), the approxi-
mated force value F
Sa
can be calculated using,
a
0
= v
4
v
3
v
1
+v
2
,
a
1
= v
1
v
2
a
0
,
a
2
= v
3
v
1
, (4.103)
a
3
= v
2
,
u

=
1
(x
b
x
a
)
(u x
a
)
F
Sa
(u) = u

3
a
0
+u

2
a
1
+u

a
2
+a
3
.
For the leash region of the elastic muscle data, Eqn. 4.100 - Eqn. 4.103 is used with the respective
table data that extrapolates force values up to 82g, and according to the cubic interpolation, a
function F
La
(u) can be dened in the same manner as Eqn. 4.103.
Using these interpolation values, the elastic force function can be completed in addition to
Eqn. 4.99 as,
F
E
(dl) =
_
_
_
F
Sa
(dl), dl < 17%,
F
La
(dl), dl > 40%,
82, dl 54%.
(4.104)
In order to simulate muscle dysfunction concerning elastic force, F
E
is additionally scaled by an
elastic force scaling factor e
s
such that,
F
E
(dl, e
s
) = F
E
(dl) e
s
, 0 e
s
2. (4.105)
4.5.3 Contractile Force Data
Contractile muscle force can be dened as a function of innervation iv and length change dl.
Based on Eqn. 4.98, the contractile force function F
C
can also be extracted from Eqn. 4.96
with additional manual changes. Compared to force data analysis of human skeletal muscles,
contractile force in eye muscles does not fall o when muscle length increases above normal. This
could be due to the sudden rise of F
E
at large dl. However, it is obvious, that for large dl values,
the total output force is dominated mainly by the elastic force function F
E
. On the other hand,
contractile force F
C
needs to be zero when innervation iv is zero. Thus, the contractile muscle
force function, shown in Fig. 4.22, is calculated in three regions.
In the rst region, where 20% dl 45%, 0g iv 100g, the contractile force is calculated
using Eqn. 4.96 by,
F
C
(dl, iv) = F(dl, iv) F
E
(dl), 20% dl 45%, 0g iv 100g. (4.106)
CHAPTER 4. BIOMECHANICAL MODELLING 127
Figure 4.22: Contractile Force Data
Here, the rst term evaluates the total force using Eqn. 4.96 and the second term uses Eqn. 4.99
to subtract the elastic force to get the contractile output force based on Eqn. 4.98. The second
region is dened as 20% dl 45%, 0g iv > 100g and is interpolated in a manually
generated force data table. To reect saturation of innervation, contractile force is restrained
at a maximum value of approximately 100g for high iv. Bicubic interpolation is used as table
lookup strategy. Let,
T
Cd
[x] = (x
1
, x
2
, x
3
, . . . , x
n
), (4.107)
denote the table that stores the dl values of the interpolation region and,
T
Ci
[y] = (y
1
, y
2
, y
3
, . . . , y
n
), (4.108)
denote the table that stores the innervation values of this region. Then, a two dimensional table
of the form,
T
Cf
[x, y] = (z
1
, z
2
, z
3
, . . . , z
n
), (4.109)
can be dened which stores the force values for each combination of x
i
and y
i
such that for any
real values x
4
< u < x
n4
and y
4
< v < y
n4
, an interpolated force value in the table T
Cf
can be
found by using an average of 16 points, surrounding the closest corresponding value. Therefore,
two indices xi and yi for Eqn. 4.109 can be found for u and v respectively, such that,
x
a
T
Cd
[xi] x
b
,
y
a
T
Ci
[yi] y
b
, 4 a < b n 4.
(4.110)
Using xi and yi as reference point, a weighted sum of force values of 16 surrounding points can
be calculated using,
F
Ca
(u, v) =
2

m=1
2

n=1
T
Cf
[xi +m, yi +n] R(mdx) R(dy n), (4.111)
CHAPTER 4. BIOMECHANICAL MODELLING 128
where dx = T
Cd
[xi] u and dy = T
Cd
[yi] v denote the real dierences between table values
and target coordinates u and v. Finally, R is the cubic weighting function that denes how much
each of the 16 points that are used for interpolation contributes to the nal value,
R(x) =
1
6
[P(x + 2)
3
4P(x + 1)
3
+ 6P(x)
3
4P(x 1)
3
],
P(x) =
_
x, x > 0,
0, x 0.
(4.112)
In the remaining section, where dl > 45%, force in the muscle is taken as that value for dl = 45%,
which has already been dened. Hence, the denition for the contractile force function, can be
completed from Eqn. 4.106 in adding,
F
C
(dl, iv) =
_
F
Ca
(dl, iv), 20% dl 45%, 0g iv > 100g,
F
C
(45, iv), dl > 45%.
(4.113)
In order to simulate muscle dysfunction concerning contractile force, F
C
is additionally scaled by
an contractile force scaling factor c
s
such that,
F
C
(dl, iv, c
s
) = F
C
(dl, iv) c
s
, 0 c
s
2. (4.114)
4.5.4 Total Force Data
The total force of a muscle can be calculated by summing elastic and contractile force data. This
results in a total force function F
T
that depends on innervation iv and length change dl, using
Eqn. 4.105 and Eqn. 4.114 such that,
F
T
(dl, iv, e
s
, c
s
, t
s
) = t
s
(F
E
(dl, e
s
) +F
C
(dl, iv, c
s
)), 0 t
s
2. (4.115)
In Eqn. 4.115, the parameter t
s
indicates the total force scaling parameter, which provides the
simulation of muscle dysfunction that aects all properties of muscle force.
(a) Elastic Force
+
(b) Contractile Force
=
(c) Total Force
Figure 4.23: Total Force Data
In Fig. 4.23, the addition of elastic and contractile force is shown. The resulting total force curve
(Fig. 4.23(c)) shows the dominating elastic leash region (Fig. 4.23(a)) for high values of dl and
CHAPTER 4. BIOMECHANICAL MODELLING 129
innervation dependent muscle force (Fig. 4.23(b)) that is generated with rising iv. In using this
force prediction model, Eqn. 4.115 provides dierent scaling parameters to modify the behavior
of a muscle in pathological situation.
Elastic strength (e
s
) scales the passive force function in order to inuence the elastic properties
of a muscle. A reduction of this value, for example, results in a muscle with a reduced elastic
force when the muscle stretches.
Contractile strength (c
s
) scales the active force function and simulates either overaction or a
muscle palsy in relation to the cerebral innervation. A value of zero would correspond to a
complete muscle palsy (complete loss of the contractile strength).
Muscle strength () scales the total force function (passive and active force). For this value,
default values are used which describe the dierent scaling of all muscles in relation to the
lateral rectus muscle (see Tab. 4.2). If this value is changed, the muscle is strengthened or
weakened relative to the lateral rectus muscle. In order to scale the total force in relation
to the current muscle only, one should change the muscles total strength.
Total strength (t
s
) scales the total force function in relation to the current muscle, but only
after the total muscle force has already been scaled by the factor .
For the simulation of surgeries, the length of a muscle is very important. The length of the muscle
and the tendon also changes the way how the simulation interprets the muscle force curves. As
an example, a rubber band with a length of 10mm (relaxed length L0 = 10mm) is stretched by
10mm, which results in a path length of 20mm and a relative stretch of 100%. Now, if the band
is shortened to 5mm relaxed length, and once again stretched by 10mm, the relative stretch is
now 200%. This would lead to a totally dierent resulting force in the force model and shows,
how the modication of the muscle length can inuence force behavior of a muscle. Referring to
Sec. 4.4.4, the geometrical model oers dierent parameters to modify muscle length.
Muscle length (L0) denes the length of a relaxed, denervated muscle without tendon in mm.
Tendon length (T
l
) denes the additional length of the tendon in mm.
To simulate a resection of the lateral rectus muscle by 5mm, the length of the muscle and/or the
tendon has to be changed. When the insertion of the lateral rectus muscle is disinserted from the
globe, the muscle is shortened by 5mm and afterwards reattached again at the same position. In
carrying out this procedure, 1mm of muscle length is lost during the separation and 1mm during
the xation of the length of the muscle tendon. Since the model cannot predict this condition
automatically, it is necessary to shorten the muscle by 7mm in this situation. Therefore, the
tendon length of the lateral rectus muscle is changed from 8.4 to 1.4mm. If a larger resection
is carried out, it is possible that the muscle loses its tendon (T
l
= 0) and in such a case, the
remaining shortening has to be applied to the muscle length parameter (L0), consequently both
parameters have to be changed.
CHAPTER 4. BIOMECHANICAL MODELLING 130
4.6 Kinematics
Using the orbital geometry from Sec. 4.4.3 and the muscle force prediction from Sec. 4.5, the
kinematics of the biomechanical model can be dened. The goal of the kinematic model is to
relate geometry and muscle force prediction in such a way that eye positions and innervations can
be derived from given parameterizations of one eye. Thus, the kinematic model is responsible for
the correct transformation between muscle simulation and geometrical representation. Starting
point for the derivation of the kinematic model is the complete denition of data for one eye.
This reference data set is given by a geometrical model and the muscle force prediction model for
all 6 eye muscles together with initial values for all parameters. Then, two essential operations
that conform to forward and inverse kinematics, need to be dened.
Forward Kinematics denes the operation that resolves an eye position based upon a given
set of innervations for all eye muscles.
Inverse Kinematics denes the operation that resolves a set of innervations for all eye muscles
that are required to drive the eye into a given position.
To solve the kinematic operations, a mathematical denition of a stable eye position is required.
Such a stable eye position is only reached, when all forces that act on the globe are in an
equilibrium. To measure if an equilibrium is reached, a force balance equation is dened, that
derives a torque imbalance vector based on the current eye position and muscle forces. The
torque imbalance vector

t can therefore be derived using,

t =
6

i=1
F
Ti
(dl
i
, iv
i
, e
si
, c
si
, t
si
) n
i
, (4.116)
where F
Ti
denotes the total output force of a muscle i based on Eqn. 4.115, and the vector n
i
denotes the unit moment vector from Eqn. 4.77. A stable eye position can therefore be dened
as the constraint,

0. (4.117)
It is however not enough to just balance force of the eye muscles to describe a stable eye position.
Additional moments that arise from orbital restoring forces and globe translation that alter forces
and rotational behavior must also be considered.
4.6.1 Orbital Restoring Force
In addition to the torque that is exerted by the muscles as the eye moves further away from
primary position, it encounters resistance from non-muscular elastic tissues in the orbit such as
Tenons Capsule which acts to restore the eye to primary position. This resistance can be dened
by a passive moment vector

P(P

, P

, P

), where the components of the vector correspond to


angular coordinates (, , ) based on the angular coordinates of the current eye position using
Eqn. 4.9. In modelling the orbital restoring force, a simple nonlinear spring model of the form,
K(w, w

) = K
1
w +K
2
w
3
. (4.118)
CHAPTER 4. BIOMECHANICAL MODELLING 131
is used, where K
1
and K
2
denote the spring constants. The torsional restoring force that acts in
the opposite direction of can therefore be denoted as,
P

= K
t
+K

t

3
. (4.119)
In Eqn. 4.119, K
t
and K

t
are the torsional stiness constants, taken from [MR84], as K
t
= 0.5g/

and K

t
= 324g/

3
.
Similarly, the orbital restoring force acting in the opposite direction of and can also be
formulated with respect to Eqn. 4.118,
_
P

_
= K
_

_
+K

(
2
+
2
)
_

_
, (4.120)
where the spring constants K and K

were also taken from [MR84], as K = 0.25g/

and K

=
81g/

.
The orbital restoring torque vector

P needs to be considered when balancing forces
using Eqn. 4.116.
4.6.2 Globe Translation
Globe translation is the anteroposterior movement of the globe during eye movements (see 2.2.1).
Usually the eyes center of rotation remains xed within the head-xed coordinate system. How-
ever, in pathological situations, globe translation can be of great value in diagnosis and treatment,
and therefore it is of interest to the biomechanical model. When the globe translates during ro-
tation, the center of rotation is shifted and thus, the axis of rotation is modied. Additionally,
globe translation alters the relative position to the muscle origin and therefore also the stretch
of each muscle, which in turn modies output force and force balance in Eqn. 4.116.
In order to measure globe translation, a new coordinate system is dened that describes the
orbital cone through the denition of an apex point that lies midway between the origin point
of the superior rectus (O
sr
) and inferior rectus (O
ir
) muscles (see Fig. 4.24). Let {

H
x
,

H
y
,

H
z
}
denote a head-xed coordinate system, and let

V =

O
sr
+

O
ir
2
, denote the apex point in the
posterior region of the orbit. The new apex coordinate system can then be dened by three base
vectors {

A
x
,

A
y
,

A
z
},

A
y
=

V ,

A
x
=

H
z


A
y

A
z
=

A
x


A
y
,
where the base vector

A
y
represents the vector from the origin to the apex point, the vector

A
x
is perpendicular to the head-xed vertical axis and the vector

A
y
and the vector

A
z
is
perpendicular to

A
x
and

A
y
. Then, the rotation quaternions that transform between head-xed
and apex coordinate systems can be formulated using two rotation angles and , such that,
= cos
1
(

A
y


H
y
),
= cos
1
(

A
z


H
z
),
CHAPTER 4. BIOMECHANICAL MODELLING 132
Figure 4.24: Apex Coordinate System for measuring Globe Translation
where denotes the angle between the head-xed axis

E
y
and the apex axis

A
y
, and denotes
the angle between the two vertical axes

E
z
and

A
z
. The forward transformation to the apex
coordinate system can therefore be represented as combined rotation in the form of (4.32), around
the head-xed axes

H
x
and

H
z
,
q
apex
= [, (

H
x
)] [, (

H
z
)]. (4.121)
The reverse transformation into the head xed coordinate system can be formulated using the
inverse rotation of (4.121),
q
head
= q
apex
1
. (4.122)
To measure globe translation, a relationship between the torque imbalance equation (4.116) and
the amount of translation must be dened. This is reached by the introduction of a stiness vector

F
a
= (54, 27, 54), that is linearly related to translation values. Thus, the translation vector

G
trans
can be found by rst transforming the torque imbalance vector

t to the apex coordinate system,
and then restrict the length of this vector using the stiness values

F
a
, which leads to,

G
trans
=
V ect(Rot(

t, q
apex
))
2

F
a
. (4.123)
The amount of globe translation gt along the axis

A
y
for a given eye position can then be dened
as,
gt =


G
trans

, (4.124)
CHAPTER 4. BIOMECHANICAL MODELLING 133
and the translation that aects ocular geometry can be represented by a vector

Trans that is
dened with respect to the head-xed coordinate system using,

Trans = V ect(Rot(

G
trans
, q
head
)). (4.125)
This translation vector

Trans can now be used to modify ocular geometry in order to reect
rotational changes. Therefore, the vector

Trans is used to translate the origin point O and the
pulley point P of each muscle (see Sec. 4.4.3.2) in the opposite direction, prior to calculating the
torque imbalance vector

t, using Eqn. 4.116. Instead of translating the whole ocular geometry,
the pulley and the origin point are translated in the opposite direction, which results in the same
relative eect. In order to formulate this modication, the calculation of the muscle rotation
axis within the ocular geometry is necessary. Therefore, Eqn. 4.53, Eqn. 4.67 and Eqn. 4.77 that
dene the muscle rotation axes in the string, tape and pulley model respectively, need to be
modied, so that each rotation axis is calculated with respect to a displaced pulley and muscle
origin such that,
G
t
(

Trans,

RA) :=

RA

Trans, (4.126)
where

RA denotes any muscle rotation axis from Eqn. 4.53, Eqn. 4.67 or Eqn. 4.77, and the
operator ensures that these rotation axes are calculated with modied pulley and origin data.
4.6.3 Balancing Forces
In order to nd stable eye positions, it is necessary to rene the torque imbalance equation (4.116)
to additionally consider orbital restoring forces and globe translation, since eye muscle are not the
only actors that exert force onto the globe. This leads to the rened torque imbalance equation,

T =

P +
6

i=1
F
Ti
(dl
i
, iv
i
, e
si
, c
si
, t
si
) G
t
(

trans, ra
i
), (4.127)
where the force of each eye muscle is multiplied by the unit moment vector which is calculated
with translated origin and pulley points (G
t
), and

P denotes the orbital restoring force, that
modies the global rotational balance using Eqn. 4.119 and Eqn. 4.120. Each value for the torque
imbalance vector

T in Eqn. 4.127 is mainly determined by six innervations (

iv) and six length


changes (

dl). Each modication to the current eye position results in dierent length change
values and thus also in a dierent torque imbalance vector. Conversely, changing innervations
give dierent force values and therefore also aect torque balance. It can therefore be seen
that dierent eye positions lead to dierent dl values by applying Eqn. 4.95 and that dierent
innervation values lead to dierent values for e, using Eqn. 4.97. Thus, an adequate way to
control the value of

T is to dene an innervation vector

I
v
and an eye position vector

E
p
such
that,

I
v
= {iv
1
, iv
2
, iv
3
, iv
4
, iv
5
, iv
6
}, (4.128)

E
p
= {e
x
, e
y
, e
z
},
where the values {iv
1
, iv
2
, . . . , iv
6
} contain the innervation values for each eye muscle and the
values {e
x
, e
y
, e
z
} contains a rotation vector that describes an eye position based on a rotation
quaternion of the form (4.32),

E
p
=
_
1
2
tan()
_


U, (4.129)
CHAPTER 4. BIOMECHANICAL MODELLING 134
where the orientation vector

U is parallel to the axis of rotation and the length is given by half
the tangens of the rotation angle in radians. In order to transform an eye position

E
p
into a
6-vector of dl values, passive length changes need to be calculated, based on

E
p
by applying the
method described in Sec. 4.4.4.
A rotation vector

E
p
of the form (4.129) can be transformed into a quaternion using,
Q(

E
p
) = [cos(tan
1
(|

E
p
|)), sin(tan
1
(

E
p
))], (4.130)
and,
R(q) = tan(cos
1
(Scal(q)) V ect(q), (4.131)
gives the rotation vector from the quaternion q using Eqn. 4.12.
However, before the minimization can be applied, the degrees of freedom for the innervational
dependency of the objective function needs to be reduced, since the muscles are always working in
pairs according to Sherringtons law described in Sec. 2.2.3.8, Sec. 2.2.1 and Sec. 3.5.2. Assuming
that the innervation vector I
v
has the following form,

v
= {iv
RL
, iv
RM
, iv
RS
, iv
RI
, iv
OS
, iv
OI
}, (4.132)
where agonist muscle innervations correspond to odd, and antagonistic muscle innervations cor-
respond to even vector indices, then, only agonist muscle innervations need to be specied, since
the antagonist muscle innervations can be found by using Sherringtons law of reciprocal innerva-
tions. Thus, the degrees of freedom are reduced from 6 to 3, where antagonist muscle innervations
are dictated by innervations specied for agonist muscles.
Sherringtons law of reciprocal innervations can be applied over

I

v
by,
I
ve
(I
vo
) =
(h +w)
2
I
vo
+w
w, (4.133)
where I
ve
and I
vo
are 3-vectors of even and odd innervations from

I

v
respectively, and w = 7.6, h =
14.3 are constants taken from [Rob75b] and t experimental data. Thus, a new innervation vector

I
v
can be dened as,

I
v
= {I
vo(1)
, I
ve(1)
, I
vo(2)
, I
ve(2)
, I
vo(3)
, I
ve(3)
}, (4.134)
resulting in a 6-vector of innervations that is determined by I
vo
only.
Thus, a stable eye position depends on the parameter vectors

I
v
and

E
p
where the model param-
eters i
x
and e
x
dictate the model function dened in Eqn. 4.127. This can easily be seen when
looking at the muscle force prediction model in Sec. 4.5, where Eqn. 4.96 is a function where the
parameters are non linearly dependent on the function values.
To quantify how well model parameter values in

I
v
and

E
p
approximate a stable eye position,
Eqn. 4.127 can be used such that the squared length L
T
of the vector

T gives information about
kinematic instability,
L
T
(

I
v
,

E
p
) =

P +
6

i=1
F
Ti
(dl
i
, iv
i
, e
si
, c
si
, t
si
) G
t
(

Trans,

RA
i
)

2
, (4.135)
CHAPTER 4. BIOMECHANICAL MODELLING 135
Figure 4.25: Torque Error Function for Listing Positions in a Healthy Eye
where the dl
i
values are calculated from

E
p
using the equations from Sec. 4.4.4.
When plotting 2D eye positions of the form (4.46), the error function (4.135) can be visualized.
Fig. 4.25 shows the torque error function for eye positions between 30

and 30

ab-/adduction
and elevation/depression, where the torsional position is implicitly specied using Listings tor-
sion from Eqn. 4.45. It can be seen that the minimum of this function also species the best
approximation to a stable eye position, thus, the desired goal is a minimization of Eqn. 4.135
which can be reached by nding values for

I
v
and

E
p
such that,
minL
T
(

I
v
,

E
p
). (4.136)
The non linear manner of the error function (4.135) becomes evident when the ocular geometry is
changed to some pathological situation. The curve that is shown in Fig. 4.26 depicts the torque
imbalance function when the lateral rectus muscle has a pathological muscle path (i.e. the muscle
insertion is transposed towards the superior rectus muscle).
In comparing Fig. 4.25 and Fig. 4.26, it can be seen that the shape of the curve changes drastically
with dierent geometrical or muscle force prediction values. Thus, the procedure for nding the
minimum in Eqn. 4.135 needs to be as stable as possible. Additionally, the structure of the
mathematical formulation also guarantees that all components of the biomechanical model can
independently be exchanged by other models without invalidating the model itself. It is therefore
also desirable to use a stable minimization approach in order to provide exibility with respect
to the mathematical model of ocular geometry and muscle force prediction.
CHAPTER 4. BIOMECHANICAL MODELLING 136
Figure 4.26: Torque Error Function for Pathological Eye
However, the minimization algorithm that is used to nd a stable eye position within the torque
imbalance equation is based upon a nonlinear least-squares problem, where Eqn. 4.135 can be
used as objective function. The model is known to have the form L
T
(

I
v
,

E
p
) and the goal is to
choose values for

I
v
or

E
p
that give the best t in order to minimize L
T
. The nonlinear least-
squares problem can be regarded as a general unconstrained minimization problem. In least
squares problems, the objective function f has usually the form,
f(x) =
1
2
m

j=1
r
j
(x)
2
, (4.137)
where each r
j
is a residual and x is a column vector of the free model parameters (x
1
, x
2
, , x
n
).
Using Eqn. 4.137, a residual vector r can be dened such that,
r(x) = (r
1
(x), r
2
(x), , r
m
(x))
T
, (4.138)
where
T
transforms the column vector r(x) into a row-based vector. The rst derivatives of f(x)
is denoted as the Jacobian matrix J of r,
J(x) =
_

_
r
1
x
1
r
2
x
1

r
m
x
1
.
.
.
.
.
.
.
.
.
.
.
.
r
1
x
n
r
2
x
n

r
m
x
n
_

_
. (4.139)
The gradient (f(x)) is given by,
f(x) =
m

j=1
r
j
(x)r
j
(x) = J(x)
T
r(x). (4.140)
CHAPTER 4. BIOMECHANICAL MODELLING 137
The second derivatives of the objective function can be computed in the form of the Hessian
matrix and is described as,

2
f(x) =
m

j=1
r
j
(x)r
j
(x)
T
+
m

j=1
r
j
(x)
2
r
j
(x) = (4.141)
= J(x)
T
J(x) +
m

j=1
r
j
(x)
2
r
j
(x).
The Jacobian matrix can be used to determine the direction of decent for the objective function,
whereas the Hessian matrix gives information whether a current residual vector is a local min-
imum. The goal of minimization is to calculate the gradient in Eqn. 4.140 and the Hessian in
Eqn. 4.141 and use this information to iteratively converge to a minimum of the objective func-
tion. Therefore, the rst part of the Hessian is already known through Eqn. 4.139 as J(x)
T
J(x),
and the second part of the Hessian needs to be calculated as the summation of the second partial
derivatives and the residual values. However, the distinctive feature of least squares problems is
that by knowing the Jacobian and therefore being able to compute the rst part of the Hessian
for free. Moreover, the term J(x)
T
J(x) in Eqn. 4.141 is often more important than the second
summation term in Eqn. 4.141, either because of nearly linear compliance of the model near the
solution when
2
r
j
is very small or because of small residuals r
j
. Most algorithms for minimizing
non linear least squares using equations of the form (4.137) exploit these structural properties
of the Hessian matrix. The simplest of these algorithmic methods is the Gauss-Newton method
(cf. [NW99]) which excludes the second order term in Eqn. 4.141 and therefore approximates
the Hessian matrix and uses a line search strategy to nd a local minimum. The idea of a line
search method is to use the direction of the chosen step, but to control the length, by solving a
one-dimensional problem of minimizing,
() = f(p
k
+x
k
), (4.142)
where is the step size and p
k
is the search direction chosen from the position x
k
. The property,

() = f(p
k
+x
k
)p
k
,
gives the information that if the gradient can be computed, an ecient one-dimensional search
with derivative can be used. The search direction can be evaluated by solving,
J
T
k
J
k
p
k
= J
T
k
r
k
. (4.143)
Typically, an eective line search only looks towards > 0 since a reasonable method should
guarantee that the search direction is a descent direction, which can be expressed as

() < 0.
It is typically not worth the eort to nd an exact minimum of Eqn. 4.142, since the search
direction is rarely exactly the right direction, thus it is enough to move closer. However, each
iterative step in the minimization can be computed using,
x
k+1
= x
k
+
k
p
k
. (4.144)
Most rules for terminating the iterative solver are based on the residual,
r
k
=
2
f(x
k
)p
k
+f(x
k
), (4.145)
CHAPTER 4. BIOMECHANICAL MODELLING 138
and evaluate the relative change of r
k
with respect to each iteration in the minimization procedure.
Therefore, the iterative approach can be terminated by using,
|r
k
|
k
|f(x
k
)| , (4.146)
where
k
could be chosen to be min(0.5, |f(x
k
)|), or any other problem dependent value within
the interval [0; 1]. Additionally, a maximum number of iterations k
max
is often used to limit
non-converging situations.
Using the Gauss-Newton approach, if J(x
k
) is rank-decient for some k, the coecient matrix
in Eqn. 4.143 will become singular. However, the system in Eqn. 4.143 will still have a solution,
in fact, there are innitely many solution for p
k
in this case. To overcome this weakness, the
line search strategy of the Gauss-Newton method is replaced by a trust-region search strategy.
This results in the realization of the Levenberg Marquardt method, which still uses the Hessian
approximation in the same manner as the Gauss-Newton method, but improves convergence by
using a more sophisticated directional search method. Line search and trust-region methods
both generate steps with the help of a quadratic model of the objective function, but they use
this model in dierent ways. The main dierence is that line search methods use the model for
generating a search direction, and subsequently focus on nding a suitable value for the step
length along this direction, whereas trust-region methods dene a region around the current
iterate within which they trust the model to be an adequate representation of the objective
function. The step within trust-region methods is then evaluated as an approximate minimum
within the dened region. In case a step is not acceptable, the size of the region is reduced.
In general, the step direction changes whenever the size of the trust-region is altered. However,
choosing the size of the trust region is crucial with resect to nding a good approximation for a
local minimum. The model function for the trust-region approach can be denoted as,
m
k
(p) = f
k
+f
T
k
p +
1
2
p
T
B
k
p, (4.147)
where f
k
= f(x
k
), f
k
= f
k
(x
k
) and B
k
=
2
f(x
k
). The derivation of Eqn. 4.147 is identical
to the rst two terms of the Taylor-series expansion of f around x
k
due to the fact that,
f(x +p) = f(x) +f(x)
T
p +
1
2
p
T

2
f(x +tp)p, (4.148)
can be solved for some t [0; 1], and is used to study all the points in the immediate vicinity
of f(x
k
) in order to identify a local minimum. In Eqn. 4.147, m(p) approximates the function
values around the current iteration step, thus, the goal is to nd a minimum for p
k
, where

k
is the trust-region radius. Consequently, to obtain each step, a solution of the subproblem,
min
pR
n
m
k
(p) = f
k
+f
T
k
p +
1
2
p
T
B
k
p, (4.149)
is required. Adapted to the current situation, the model function in Eqn. 4.147 can be rewritten
as,
min
pR
n
m
k
(p) =
1
2
|r
k
|
2
+p
T
J
T
k
r
k
+
1
2
p
T
J
T
k
J
k
p. (4.150)
and the subproblem to be solved according to Eqn. 4.149 is stated as,
min
p
1
2
|J
k
p +r
k
|
2
, where |p|
k
. (4.151)
CHAPTER 4. BIOMECHANICAL MODELLING 139
The solution to the subproblem (4.151) can be characterized with respect to comparing the step
direction with a Gauss-Newton approach. When a Gauss-Newton solution (p
GN
k
) of Eqn. 4.143
lies strictly inside the trust-region (that is,

p
GN
k

<
k
), then this step p
GN
k
also solves the
subproblem (4.151). Otherwise, there is a > 0 such that the solution p = p
LM
of Eqn. 4.151
satises |p
k
| =
k
(cf. [NW99]) and,
(J
T
k
J
k
+I)p
LM
k
= J
T
k
r
k
. (4.152)
The vector p
LM
k
is a solution to the trust-region problem (4.151) for some
k
> 0 if and only if
there is a scalar 0 such that,
(J
T
J +I)p
LM
k
= J
T
r,
(
k

p
LM
k

) = 0.
Analytically, the minimization problem of (4.152) becomes,
(J
T
k
J
k
+D
2
k
)p
LM
k
= J
T
k
r
k
, (4.153)
and equivalently solves the linear least squares problem of the form,
min
p
k

_
J
k

D
k
_
p
k
+
_
r
k
0
_

, (4.154)
where the matrix D
k
is a diagonal matrix that is used to scale the step direction p and can change
from iteration to iteration as new information about the typical range of values is gathered.
The trust-region radius
k
is adjusted between iterations according to the agreement between
predicted and actual reduction in the objective function such that,

k
=
f(x
k
) f(x
k
+p
k
)
m
k
(0) m
k
(p
k
)
. (4.155)
For a step to be accepted, the ratio must exceed a small positive number (typically 0.0001). If
this test fails, the trust region is decreased and the step is recalculated. When the ratio is close to
one, the trust region for the next iteration is expanded. The solution of Eqn. 4.154 can be found
by applying matrix factorization methods (e.g. QR factorization) to solve a linear system of
equations. The local convergence behavior of the Levenberg Marquardt method is similar to the
Gauss-Newton method. Near a solution with small residuals, the model function (4.151) will give
an accurate picture of the objective function (4.137). The trust region will eventually become
inactive, and the algorithm will take unit Gauss-Newton steps, giving the rapid linear convergence
rate that is provided by the Gauss-Newton method. Generally, with the determination of in
Eqn. 4.154 the Levenberg Marquardt method changes is preference between a line search and
trust-region strategy with respect to the parameter . However, the introduction of the trust-
region approach for determining is just one possibility among many other strategies including
the direct modication of this value using heuristic approaches (see [NW99]).
The Levenberg Marquardt algorithm for minimizing a n-dimensional non-linear function can be
formulated as follows:
CHAPTER 4. BIOMECHANICAL MODELLING 140
First initial values for x
0
need to be dened and the objective function (4.137) f(x
0
) is evaluated,
the iteration counter k = 0,
0
=

where

is an overall bound on step lengths and =
0
.
(1) Test for convergence: If the condition dened in Eqn. 4.146 is satised, or the maximum
number of iteration is exceeded, the algorithm terminates with x
k
as the solution.
(2) Solve trust-region subproblem This step solves the subproblem Eqn. 4.154 using a trust-
region algorithm. According to Eqn. 4.154, a new vector p
k
is determined that gives the new
search direction for the current iteration. The multiplier
k
is set to zero if the minimum-
norm Gauss-Newton step p
GN
k
is smaller than
k
, otherwise,
k
is chosen such that,

k
= |D
k
p
k
| . (4.156)
(2.1) Evaluate
k
: Using Eqn. 4.155, the ratio
k
gives information on the alternation of the
trust-region radius
k
.
(3) Improve step The next iteration point is updated by,
x
k+1
= x
k
+p
k
. (4.157)
Then, k is increased by 1 and the procedure proceeds by starting again from (1).
A complete implementation and analysis of the Levenberg Marquardt algorithm can be found in
[Fin96]. Details information on dierent methods of the trust-region implementation, proofs and
analysis of convergence can also be found in [PTVF97] and [NW99].
Recalling the torque imbalance equation (4.135), the Levenberg Marquardt method is used to
either nd a stable eye position for constant innervations, or innervations for a constant eye
position.
By using Eqn. 4.135 as objective function for the Levenberg Marquardt minimization method,
stable eye positions can be approximated by minimizing the torque imbalance vector in that
either

I
v
or

E
p
is set constant and Eqn. 4.135 is minimized over the free parameters. Thus, the
solution to the minimization problem,
min
LM
L
T
(

I
v
,

E
p
), (4.158)
gives a stable eye position in terms of balanced muscle and orbital forces.
4.6.3.1 Solving for Eye Positions
Eqn. 4.158 can be used to solve the forward kinematics in that a stable eye position is found
for a given set of innervations. According to Eqn. 4.135, this results in setting I
v
constant and
minimize over E
p
such that,
E
pmin
(

E
p
) = min

E
p
LM
L
T
(

I
v
,

E
p
),

I
v
constant. (4.159)
The resulting eye position E
pmin
in the form of (4.129) can then be regarded as one solution that
satises Eqn. 4.117 for a given constant set of 6 innervations

I
v
.
CHAPTER 4. BIOMECHANICAL MODELLING 141
Figure 4.27: Torque Error Minimization in solving for Eye Positions
In Fig. 4.27, the optimization steps for a pathological situation was rendered. Constant innerva-
tions

I
v
that would hold a normal healthy eye in primary position are given. The indicated
minimum of this function corresponds to a modied primary position, due to the dierent me-
chanical properties of the pathological situation that was modelled according to Fig. 4.26.
However, it must be noticed that each step in the minimization of Eqn. 4.159 modies the vector

E
p
in all 3 components, whereas Fig. 4.27 only shows ab-/adduction and elevation/depression
axis for visualizing eye positions. Thus, the torque error function will change its shape within this
3-dimensional representation, whenever the torsional eye position (that is e
y
of

E
p
) is adjusted by
the minimization procedure. This also explains, why the minimization steps that were rendered
as vectors in Fig. 4.27 do not align with the shape of the function unless the minimum is reached.
4.6.3.2 Solving for Innervations
Using Eqn. 4.158 to solve for innervations is denoted as solving the inverse kinematics problem.
In this case, a given eye position

E
p
will be constant in Eqn. 4.158, and innervations

I
v
need to
be determined. Here, the odd innervation vector I
vo
from Eqn. 4.133 is used in order to reduce
the degrees of freedom, and all 6 innervations are regained by applying Eqn. 4.134. This leads to
CHAPTER 4. BIOMECHANICAL MODELLING 142
a minimization of Eqn. 4.158 over

I
v
such that,
I
vmin
(

I
v
) = min

I
v
LM
L
T
(I
vo
(

I
v
),

E
p
),

E
p
constant. (4.160)
By using Eqn. 4.133, it is possible to reduce the inverse kinematics problem from 6 to 3 degrees of
freedom, thus allowing the optimizer to converge to values for

I
v
that are conned to analytically
formulated laws that are supposed to represent anatomical behavior. However, the goal of this
procedure is to nd meaningful values in terms of innervations that correspond to anatomical
ndings in that innervations of antagonist muscles are dictated by agonist muscle innervations.
4.7 Brainstem Simulation
According to Sec. 2.2.3.1, innervations of the oculomotor system originate in the brainstem nuclei
which are in turn connected to supranuclear brain structures. In order to build a simple inter-
face to controlling these structures in a simulation model, the mathematical representation of
innervations will be used. The presented biomechanical model does not provide an independent
simulation of the brainstem or the supranuclear structures. However, it provides a model of the
distribution of innervations for each eye, which makes it possible to change the percentage of
innervation of the oculomotor nuclei to the respective muscles. If such a distribution of innerva-
tion is changed, all innervations in relation to the aected muscle for the aected eye are scaled.
The maximum allowable innervation of 250% corresponds to the maximum allowable stimulation
which the nucleus shall be able to generate.
If the distribution of innervation is modied, it is possible to simulate either inter- or supranuclear
gaze palsies or even retraction syndromes (see Sec. 3.5.2.2). For simulating a nuclear gaze palsy,
changes to the distribution of innervation of the nervus abducens to the lateral rectus muscle
on the right eye and to the nervus oculomotorius to the medial rectus muscle of the left eye
are required. During an internuclear gaze palsy only one eye would be aected and therefore
also only one eye would require changes to the distribution of innervation. Since the presented
model uses a so-called invisible reference eye (see Sec. 4.7.1), which forms the basis for most of
the calculations, and if the distribution of innervation of this reference eye is changed, only the
following eye would reect these changes in the Hess-Lancaster test. This enables for example
the simulation of a lesion, which is only visible through the following eye alternately depending
whether the left or the right eye is xing.
The mathematical formulation for simulating brainstem control is straight forward, by supplying
a distribution matrix to each eye that scales innervation prior to the application of the muscle
force prediction model (see Sec. 4.5). Therefore, each eye is associated with a matrix D
n
of the
form,
RL RM RS RI OS OI
D
n
=
_

_
s
11
s
12
s
16
.
.
.
.
.
.
.
.
.
.
.
.
s
61
s
62
s
66
_

_
Abducens
Oculo/RM
Oculo/RS
Oculo/RI
Oculo/OS
Oculo/OI
, 0 s
ij
2.5,
(4.161)
where n denotes the corresponding eye (i.e. left, right or reference eye) and the matrix elements
s
ij
correspond to the scaling parameter of a oculomotor nerve i with respect to a muscle j.
CHAPTER 4. BIOMECHANICAL MODELLING 143
Each row in the Matrix of Eqn. 4.161 has the form of (4.132) and each column is ordered by
the respective oculomotor nucleus for each muscle (see Sec. 2.2.3.2). The initial innervation
distribution matrix for an eye is chosen as the identity matrix D
n
= I. In order to scale specic
innervations for one eye, an innervation vector

I

v
of the form (4.132) is multiplied by D
n
such
that,

I
v
= (

I
v

D
n
)
T
, (4.162)
where
T
denotes matrix transposition.
4.7.1 Simulation of Binocular Function
The forward and inverse kinematics solutions from Sec. 4.6.3.1 and Sec. 4.6.3.2 provide two
essential operations to assemble a procedure that aims to simulate behavior of binocular eye
movements. The presented system uses a model for simulating the binocular Hess-Lancaster
test (see Sec. 3.13). The results of the test can be visualized in the form of Hess-diagrams (left
eye and right eye xing) and in the form of a text-based view (squint-angles diagram). The
main dierence between the two visualizations is the declaration of the deviations. While the
Hess-diagram (see Sec. 3.13) oers some visual impression of the pathological situation and can
be calculated for arbitrarily chosen gaze positions, the squint-angles diagram oers a text-based
illustration of deviation values in the nine main gaze directions.
(a) Left Eye (b) Right Eye
Figure 4.28: Squint-Angles Diagram for Binocular Fixation
In the squint-angles diagram from Fig. 4.28, the deviations for each gaze direction for the left and
the right eye xing are shown, whereby HD denotes horizontal deviation and V D denotes vertical
deviation. In the white elds of the diagram, the torsional deviation is given as excyclo or incyclo
(EX or IN) and the protrusion is denoted in mm (PR for negative protrusion = retraction). All
values except for protrusion are given in degrees.
The signs for the horizontal deviations are interpreted as follows:
Positive HD: Towards the nose (adduction)
Negative HD: Away from the nose (abduction)
CHAPTER 4. BIOMECHANICAL MODELLING 144
The signs for the vertical deviations are dened dierently for right eye and left eye xing:
Right eye xing
Positive VD: Deviation downwards (depression)
Negative VD: Deviation upwards (elevation)
Left eye xing
Positive VD: Deviation upwards (elevation)
Negative VD: Deviation downwards (depression)
A gaze pattern is the basis for simulation of the Hess-Lancaster test. At the execution of the
simulation, for every eye position in the gaze pattern, a xation of the particular xing eye is
carried out. The other eye will then, by the description of the simulation, be regarded as following
eye and will deviate from the xing eye, according to some current pathological situation. The
positions of xation specied in the gaze pattern can be assigned to the blue points in a Hess-
Lancaster diagram. The red points depict the resulting deviation points of the following eye (see
Fig. 3.14).
Fig. 6.12 shows a schematic simulation task ow for the Hess-Lancaster test, which is performed
for each gaze position of the xing eye gaze pattern. The goal is the determination of the deviation
of the following eye based on positions of the xing eye. Thereby, the xing and following eye
can be exchanged, i.e. rst the right eye is the xing eye and the left eye the following and vice
versa. This makes it possible to calculate the right resp. left xation. For simplicity, let FP and
FI denote two operations that nd eye positions and innervation respectively of a specic eye,
according to each eyes specic parameters, using Eqn. 4.159 and Eqn. 4.160 such that,
FP
Fix
(

I
v
) = E
pmin
(

I
v
), for the xing eye,
FP
Fol
(

I
v
) = E
pmin
(

I
v
), for the following eye, (4.163)
FP
Ref
(

I
v
) = E
pmin
(

I
v
), for the reference eye,
and,
FI
Fix
(

E
p
) = I
vmin
(

E
p
), for the xing eye,
FI
Fol
(

E
p
) = I
vmin
(

E
p
), for the following eye, (4.164)
FI
Ref
(

E
p
) = I
vmin
(

E
p
), for the reference eye.
Thus, if the left xing eye e.g. looks to an eye position

A(a
x
, a
y
, a
z
) denoted in the form of
(4.129), then,

B = FP
Fol
(FI
Fix
(

A)),
will describe the position of the right, following eye that results from the innervations that are
required to hold the left, xing eye in position

A. Note that the right eye will turn against the
left eye in this case, since the coordinate systems of both eyes are not identical (see Sec. 2.2.1),
and the innervations are applied to the right eye without any modication.
CHAPTER 4. BIOMECHANICAL MODELLING 145
Figure 4.29: Simulation Task Flow for the Hess-Lancaster Test
(A) Starting from a healthy reference eye and a predetermined xation position a complete 3D
eye position is calculated. If a xation position is specied, only the abduction/adduction
and elevation/depression can be chosen freely. The specication of a torsional value is not
possible, since a patient does not explicitly rotate the eye around a specied torsional angle
on command. As a result, the complete position of the xing eye has to be calculated by
generating innervations for eye positions with listing torsion with the help of the reference
eye until the position of the xing eye matches with these innervations and the desired
2D eye position. This is similar to a minimization problem of the form (4.143) using the
objective function,

I
vp
= FI
Ref
(

P),
f(

P,

I
vp
) =

(Z
Ang
(FP
Fix
(

P)), X
Ang
(FP
Fix
(

P))) (Z
Ang
(

P), X
Ang
(

P))

2
,
torsion = Y
Ang
(f(

P,

I
v
)),
(4.165)
where

I
vp
are starting innervations of the reference eye that correspond to the rotation
vector

P of the form (4.129) that describes the 2D eye position in that the torsional rotation
CHAPTER 4. BIOMECHANICAL MODELLING 146
is always 0. f is the objective function that describes the length of the angular dierence
vector between reference eye and xing eye, where X
Ang
, Y
Ang
and Z
Ang
extract the radian
angle from a rotation vector of the form (4.129). A valid 3D eye position is then found,
when the innervations of the reference eye drive the following eye to a 2D position that
matches

P, and f(

P,

I
vp
) 0 holds. The value for torsion will then be the torsional
rotation that expands the 2D eye position

P into a 3D eye position vector

P
Fick
such that,

P
Fick
= (Z
Ang
(

P), X
Ang
(

P), torsion), (4.166)


where

P
Fick
is a 3D eye position of the form (4.6), and the corresponding rotation quaternion
q
p
can be computed by using Eqn. 4.48,
q
p
= q
ry
q
rx
q
rz
, (4.167)
where q
rz
, q
rx
and q
ry
correspond to the quaternions that describe rotation of
angles Z
Ang
(

P
Fick
), X
Ang
(

P
Fick
) and Y
Ang
(

P
Fick
) respectively around each coordinate axis.
(B) Using the xing eye parameters and the 3D eye position p
q
from (A), the innervations for all
six eye muscles are calculated to bring the xing eye in the desired position using Eqn. 4.164,

I
vFix
= (FI
Fix
(R(p
q
)) D
Fix
)
T
, (4.168)
where R transforms the quaternion p
q
into a rotation vector using Eqn. 4.131, and D
Fix
scales the output innervation vector according to the innervation distribution matrix for
the xing eye using Eqn. 4.161.
(C) These innervations are now passed into the reference eye in order to calculate its eye position.
If the xing eye is pathological, the eye position calculated with the reference eye diers from
the previously calculated eye position. The result of this calculation is now the intended
xation position of the xing eye p
Fix
such that,

P
Fix
= FP
Ref
((

I
vFix
D
Ref
)
T
), (4.169)
where the innervation vector

I
vFix
from (B) is scaled by the brainstem matrix D
Ref
from
Eqn. 4.161 with the addition that the columns for the medial rectus and the lateral rectus
muscles are exchanged prior to multiplication using,
RM RL RS RI OS OI
D
Ref
=
_

_
D
22
D
21
D
16
D
12
D
11
D
16
.
.
.
.
.
.
.
.
.
.
.
.
D
62
D
61
D
66
_

_
Abducens
Oculo/RM
Oculo/RS
Oculo/RI
Oculo/OS
Oculo/OI
, 0 D
ij
2.5.
(4.170)
Note that the values D
11
, D
22
and D
21
, D
12
are additionally transposed within the matrix
in order to reect the downward order of the rows that correspond to the oculomotor nuclei.
(D) During this step, the intended xation position of the xing eye is mirrored in order to
get the intended position of the following eye. Since innervations cannot be mirrored (the
contralateral synergist of the right lateral rectus muscle is the left medial rectus muscle,
which may not act in exactly the same way) this indirection of mirroring the eye position
CHAPTER 4. BIOMECHANICAL MODELLING 147
is necessary. Thus, the rotation vector

P
Fix
from (C) is converted into mirrored Fick
rotational angles

P
Fick
such that,

Fick
= (Z
Ang
(

P
Fix
), X
Ang
(

P
Fix
), Y
Ang
(

P
Fix
)), (4.171)
and the corresponding rotation quaternion q
f
can be computed by using Eqn. 4.48.
The mirroring of an eye position is necessary, since abduction/adduction and torsion of
both eyes are dierent for describing the same direction (see Sec. 2.2.1).
(E) Now, innervations are determined, using the reference eye with the mirrored eye position q
f
so that it will be possible to calculate the position of the following eye. These innervations
can be found by applying,

I
vFol
= (FI
Ref
(R(q
f
)). (4.172)
(F) The innervations of the reference eye

I
vFol
now determine the position of the following eye.
This position is one of the red points in the Hess-diagram and can be found by using,

P
Fol
= FP
Fol
((

I
vFol
D
Fol
)
T
), (4.173)
where D
Fol
denotes the innervation distribution matrix for the following eye.
Chapter 5
Visualization of Muscle Action
Besides the path of a muscle, which can be calculated using the methods from Sec. 4.4, the most
important information about a muscle is its volume and the distribution of its volume. In fact,
the distribution of the volume changes with dierent muscle activations. In order to simulate
the deformation process of a given muscle, the initial shape of the muscle at dierent activations
needs to be acquired. To provide this information, a three-dimensional representation of MR
images is used for calculating the basic parameters of the muscle. This data, constructed from a
set of MR images, each representing a slice of the muscle, denes the surface and thus the volume
of the model (see Sec. 2.1.4).
The goal of this chapter is to outline the image processing techniques that were used to reconstruct
a three dimensional representation of the extraocular muscles and additionally make the resulting
model deformable according to underlying MR data and biomechanical predictions. The basic
data was acquired within a study [FPBK03], where MR images were captured in dierent gaze
positions in order to analyze the shape and deformation of the extraocular muscles (see Sec. 2.1.4).
A 3D polygon model was built, and dierent states of innervation of a muscle can interactively
be visualized by interpolating between static reconstructions of MRI data.
The reconstruction procedure consists of two main parts. First, MRI data is segmented by
dening selection polygons on each image slice. These selections are used to scan each slice
and detect muscle boundaries in order to dene a rst basic polygon model. The second step
involves smoothing and interpolation using spline approximation and data variance analysis in
order to render dierent states of innervation. The resulting representation of a muscle is then
incorporated into the biomechanical model and connected to the muscle force prediction model
(see Sec. 4.5) in order to visualize model predictions in terms of muscle deformation.
148
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 149
5.1 Image Analysis
One basic method used for constructing three-dimensional models is the marching cube algorithm.
The idea of this algorithm is to generate a continuous surface by analyzing the relationship of
neighboring points in space. Each point is classied as either inside or outside the volume.
Surfaces are created between points, situated on opposite sides. This process lls an area in
3D-space with a large number of small cubes, determining which corners of the cubes lie inside
or outside of the volume. According to a predened set of rules, this information can be used
to generate a continuous surface, which approximates the surface of the original volume with
an accuracy inversely proportional to the size of the cubes. To achieve this goal, the marching
cube algorithm creates a series of planes, intersecting MRI data. These planes are all aligned in
parallel and are evenly spaced. Then, for each plane, the parts that lie inside and outside of the
traced object are determined. In this case, this is done by assigning one MR image to each plane.
Image pixels of a certain color are dened to be inside, while others are outside. The value of the
points between the planes is assumed to be of the same value as the nearest pixel. The result
of this step is a volume representation, where each pixel represents a small cube (i.e. a voxel),
either (partially) inside or outside of the original object.
set threshold
set threshold
define data volume
sort color table
MR data from imaging
device
define polygons
picture setup
generate polyhedron
use scan-line/marching-
cubes algorithms
generate surface
storage
DXF file
Figure 5.1: DXF Model Generation Tasks using Marching Cubes, from [Sat03]
The overall process of image analysis is depicted in Fig. 5.1. Starting from raw MRI data, each
MR image is modied by the picture setup procedure, where the color index table is sorted, a
segmentation polygon is dened and a threshold for analyzing muscle boundaries is selected.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 150
5.1.1 Picture Setup
The color index table of each MR image le is used to reorder the color values, whereby individual
pixels in the picture refer to the appropriate entry in the color index table. The color index table
is encoded in RGB color scheme, but, due to the grayscale MR images, the respective RGB entries
are always identical (A grayscale color 50 is expressed as RGB(50,50,50)). In MR images, usually
not all of the 256 possible colors are used. Thus, the rst step in this process is to investigate
the picture with respect to the used colors, mark these colors for the subsequent sort procedure
and shift these entries to the end of the color index table. Additionally, unused color entries are
zeroed after sorting. The sorting procedure then orders all used color entries according to their
grayscale values (see Fig. 5.2). The changed color index table is than reapplied to the actual
image in that each pixel reference value is exchanged in order to reference the same color as in
the unsorted color index table.
Figure 5.2: Sorting of Color Index Table
This ensures, that the appearance of the picture is not aected by this action. The reason for
this preprocessing step is that color comparisons can be eciently implemented within a sorted
color index table, in that only the color index of the pixels need to be compared, since higher
color index values directly correspond to higher grayscale colors. This comparison operation will
be used within the next procedure to determine the boundaries of the muscle by thresholding the
color values of the image.
The next step in the picture setup procedure is the denition of 2D polygons to surround the
region of interest for each MRI slice.
In Fig. 5.3, the denition of a image segmentation polygon is shown. The region of interest (the
superior rectus muscle in Fig. 5.3(a)) is surround by a manually dened area in order to use a
scanline approach to rasterize every point within this area (see Fig. 5.3(b)) until the complete
area has been processes, as shown in Fig. 5.3(c). Within this rasterization process, the marching
cubes algorithm, together with color threshold analysis is used to identify boundaries of the
muscle within the region of interest.
In order to decide whether an image pixel lies inside or outside the muscle area, a threshold region
is additionally dened for the color index table of each MRI slice. Fig. 5.4 depicts a threshold
region that is dened within the 256 possible grayscale values and classies an image pixel as
part of the muscle when the pixel index value for the color table is within the interval [8; 134].
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 151
(a) Denition of 2D
Polygon
(b) Scanline Rasteri-
zation
(c) Rasterized Poly-
gon
Figure 5.3: Denition of 2D Polygon for MRI Segmentation, from [Pri01]
Figure 5.4: Threshold Region for MRI Slice, from [Pri01]
Thus, each image of size SIZE(I) = mn can be represented as a table of color index values,
I[i] = {p
1
, p
2
, , p
mn
}, (5.1)
and an index function PI(x, y) can be dened such that,
PI(x, y) = I[x + (y n)], 0 x < m, 0 y < n. (5.2)
Additionally, an image stack I[i] is dened, such that,
I[i] = {PI
1
, PI
2
, , PI
j
} (5.3)
where j MR images are collected, each associated with a 2D polygon denition and a threshold
area such that,
P[i] = (p
1
, p
2
, , p
j
),
T[i] = (t
1
, t
2
, , t
j
),
where P[i] holds the polygon denitions as lists of 2D points p
i
= (P
1
, P
2
, , P
k
) with individual
lengths k
i
, and T[i] stored the threshold regions in the form of a list of intervals t
i
= [t
a
; t
b
] where
0 t
a
t
b
255.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 152
5.1.2 Generation of Polyhedron
In the second stage of the image analysis procedure, a polygon mesh is generated by apply-
ing the surface reconstruction method of marching cubes. Therefore, a series of MR images is
incorporated into a volume data set, based on the denition from (5.3) such that,
V [x, y, z] = {PI
z1
(x, y), PI
z2
(x, y), , PI
j
(x, y)}, (5.4)
where the size of all images is reduced to the size of the largest rectangular boundary of all poly-
gons P[i] for all MRI slices. The scanline algorithm (cf. [Pav94]) is used to generate V according
to Fig. 5.3. This algorithm takes a list of the polygon edges P[i] and performs topological sorting
so that the inner polygon area can be scanned along a horizontal line that is moved from the top
most y-value of the polygon points to the bottom.
Figure 5.5: Marching Cube Traversal, from [BK03b]
Thus, each pixel value within the area of the polygon is visited once. The resulting volume V
then has the following properties:
The data volume is comparable to a cuboid that contains voxels (i.e. 3D pixels) that
encompasses all pixels that are dened by each polygon.
Each image slice contained in V only contains pixels that are situated within the respective
polygon area. Pixels that are outside the polygon edges are set inactive.
All inactive pixels are assigned a color index value that is outside the respective threshold
range (i.e. V [x
o
, y
o
, z
o
] / T[i], where (x
o
, y
o
, z
o
) represents a pixel that is outside a polygon).
All pixel values that are inside the polygon edges are transferred to V without any changes.
To determine the surface of the muscle, the algorithm assigns ags to each possible group of eight
neighboring pixels within two image slices to the corners of a cube (see Fig. 5.5). Every cube can
be generated using,
Q(x, y, z) = (V [x, y, z], V [x + 1, y, z], V [x + 1, y + 1, z], V [x, y + 1, z], (5.5)
V [x, y, z + 1], V [x + 1, y, z + 1], V [x + 1, y + 1, z + 1], V [x, y + 1, z + 1]),
1 x m2, 1 y n 2, 1 z j 2.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 153
Then, for each cube dened by (5.5), a classication function is dened that can determine if a
cube corner is inside or outside the threshold region such that,
C(c, t) =
_
True, t
a
c t
b
,
False, otherwise.
(5.6)
To generate the surface, the algorithm performs the following steps:
1. Determine the state of the corners from the pixel values.
2. Find a transformation T that transforms the actual cube, matching one of the 15 predened
classes (see Fig. 5.6).
3. Build a set of triangles, representing the surface passing through this cube.
4. Transform the triangles using the inverse transformation T
1
from step 2.
5. Add triangles to the set that contains the already constructed surface.
Figure 5.6: Marching Cubes Standard Classes, from [BK03b]
In the rst step, the corners of each marching cube are set such that, 0 = False when the
corner of the cube is outside and 1 = True when the corresponding corner of the cube is inside
the muscle surface according to Eqn. 5.6. Because the cube has eight corners and each corner
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 154
has to be in one of the two states, 2
8
= 256 possible cube congurations exist. Each of these
congurations denes if and how the surface passes through the cube.
Using the cube corner values that dene the points as inside or outside the muscle surface, it
can be shown that by rotation and inversion of the corners, each of the dierent cubes can be
mapped to one out of standard classes (cf. [LC87]), as shown in Fig. 5.6.
The implementation of the marching cubes algorithm performs additional optimization to produce
a smoother surface. It is not only classifying the corners of a cube as inside or outside, but also
determines how far inside or outside each corner is by evaluating the specic color value of each
pixel. Once a specic standard conguration is identied according to Fig. 5.6, the extension of
the triangle along each edge of the cube can be calculated by linear interpolation of the color
values. Let A and B be two corner points of a marching cube, c
a
and c
b
their respective color
values and T[i] = [t
a
; t
b
] the respective threshold interval for a specic slice i. The marching cube
standard classes from Fig. 5.6 dene triangle corners between cube edges where one cube corner
lies inside the muscle area (V [x
o
, y
o
, z
o
] T[i]) and one cube corner lies outside the muscle area
(V [x
o
, y
o
, z
o
] / T[i]). Then, the distance d of one corner point of the triangle within the cube
can be calculated using,
d =
_
_
_
1
tc
b
c
a
c
b
, c
a
> c
b
,
tc
a
c
b
c
a
, c
a
< c
b
,
0.5, c
a
= c
b
,
(5.7)
where t is the lower or upper bound of the threshold interval such that,
t =
_
t
a
, c
a
a c
b
, c
a
c
b
,
t
b
, c
a
b c
b
, c
a
c
b
.
(5.8)
After performing these steps for all cubes in the area of interest, the result is a set of triangles,
describing the surface of the object. It is obvious from the above layout, that for j images of size
mn pixels, the asymptotic runtime of this algorithm is O(j mn). It is therefore desirable
to keep the images as small as possible.
Pixels with color values near a given threshold are assumed to be nearer to the surface then pixel
values far from the threshold. The algorithm is then moving the corner points of the surface
parts inside or outside, depending on the ratio of the distances of the corners of the cube. This
is especially important when the area of the muscle cross section shrinks rapidly from one MR
image to the next.
The resulting list of triangles that is generated by the marching cubes algorithm can be dened
as,
L = {TR
1
, TR
2
, , TR
n
}, (5.9)
TR
i
= {X
1
, X
2
, X
3
},
where L denotes a list of n triangles TR
i
, each consisting of a list of 3 points X
1
to X
3
.
The resulting resolution of the triangle mesh depends on the size of the cubes where image pixels
that would lie between two MR images are linearly interpolated. Output data of this process is
represented using DXF les, storing each triangle as single primitive within the le.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 155
5.2 Surface Reconstruction
Based on the output of the rst stage of the reconstruction process, described in Sec. 5.1, the
polygon model is analyzed and interpolation parameters are dened. The goal of the surface
reconstruction process is to dene a mathematical interpolation model based on the data from
Sec. 5.1.
While output data from the marching cubes algorithm is interchangeable and easy to generate, it
is very insucient in terms of memory usage and rendering speed. Moreover, this data structure
does not contain any connectivity or volume information. Since the last two points are very
important, input data needs to be transformed into a more suitable representation. In Fig. 5.7,
an overview of the main processing steps is depicted.
interpolation between
the two EOM models
spline interpolation
calculate volume and display
surface
import DXF
DXF file from MR
analysis
calculation of gravity line
transform DXF format
calculate area centroids
Figure 5.7: Surface Reconstruction Tasks, from [Sat03]
The rst step is to nd connectivity information. For this purpose a simplied boundary repre-
sentation method is used. Because the surface is built from triangles only, there is no need to
store edge information but only triangles and corners. In order to build a usable data structure,
the input le is transformed into a list of triangles. Corner points of two or more triangles, which
are within a certain limit of spatial proximity, are welded together. This replaces all points that
are to be welded with a new point, which is the geometric average of these points. It can be
shown that, because of the way the marching cube algorithm works, points are either equal to
each other, or have a spatial distance which is higher or equal to
1
2
where is the smallest
distance between two pixels in the stack of images used. Due to this, as long as the threshold for
the welding is smaller than
1
2
, the resulting set of triangles will describe the same (intended)
volume as the triangles in the DXF le.
The boundary representation is then transformed into an indexed triangle list. In this form,
connectivity information can still be gained from the list, but at higher cost. However, this
representation is ideal for current rendering hardware. This list eliminates the references from
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 156
the points to the triangles. Neighboring triangles can still be identied by searching through the
list of triangles and looking for references to the same corner points.
Based on the denition from Eqn. 5.9, the data structure for the list of triangles is modied such
that,
L = {(p
1
, q
1
, r
1
), (p
2
, q
2
, r
2
), , (p
n
, q
n
, r
n
)}, (5.10)
PTS = {PT
1
, PT
2
, , PT
m
},
PT
i
= (x
p
, y
p
, z
p
),
where L denotes a list of n triangles where each list element contains 3 indices p, q, r into a vertex
list PTS. The vertex list holds all corner points PT
i
, where each point contains the coordinates
(x
p
, y
p
, z
p
).
Because the model can be stored using a small amount of memory, and a linear traversal over
the primitives can be used to display them all, this method of storing geometry is widely used in
todays rendering applications. When the input data has been transformed into a data structure
that can eciently be rendered, restoration of the volume information is still needed. Before de-
ciding on how to do this, the transformation of the volume should be taken into account. Fig. 5.7
gives a brief overview of the generation tasks involved in constructing the surface representation
model.
Given two volume models of the same muscle in two dierent activation states, the actual goal
is to generate a new model in an intermediary state, by interpolating between these states. The
two surface representations do however not contain any topological information. The positions of
the triangles of one surface model are not connected in any way with the position of the triangles
on the other surface model. To overcome this aw, the nal model needs to contain topological
data as well as volume information. The following information can be identied as vital for
interpolation:
position and orientation of the muscle in space,
length of the muscle,
activation of the muscle,
volume of the muscle.
It is important to distinguish muscle movement from muscle volume deformation in a set of input
models. This distinction is especially important since the interpolation of position and volume
works in an entirely dierent way. Activation cannot be extracted from the input model itself
but has to be supplied from some external source (e.g. from the physician who acquired the MR
data). The model does not only contain the current volume of a muscle, but also information on
how the volume is distributed along the muscle.
5.2.1 Calculation of the Muscle Path
Based on the data denition from Eqn. 5.10, the approximation of the muscle path (see Fig. 5.28)
can be calculated. This can be done by dening the area centroids on each image slice using all
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 157
triangle corner points that belong to one MR image and were generated by the marching cubes
algorithm.
Let

P(d) be the function that describes the muscle path as approximated curve that connects
all area centroids. To get the path, the muscle is divided into a series of slices along the z-axis.
Because the images PI
i
(x, y) used for generating input data are coronal cuts and the image axes
x and y are mapped to x and y in 3D space respectively, the muscle always has its longest extents
along the z-axis.
Figure 5.8: DXF Model with Area Centroids
A bounding parallelepiped is dened to exactly t the muscle and to nd the longest dimension
of extension. The muscle is then cut into equally spaced slices along this dimension. The area
centroid of each slice is calculated (see Fig. 5.8) and the resulting set of points is approximated
by a series of Hermite splines. An area centroid is calculated such that,
A =
1
2
n1

i=0
(x
i
y
i+1
y
i+1
y
i
), (5.11)
c
x
=
1
nA
n1

i=0
(x
i
+x
i+1
)(x
i
y
i+1
x
i+1
y
i
),
c
y
=
1
nA
n1

i=0
(y
i
+y
i+1
)(x
i
y
i+1
x
i+1
y
i
),
where A denotes the area dened by the polygon of all n points (x
i
, y
i
) on one slice and (c
x
, c
y
)
denotes the area centroid.
The algorithm is generating splines by using cubic regression on the surface points of each slice,
starting with one spline and recursively splitting and adding splines until the whole set of splines
satises a least mean square threshold. The identication of the slices is easy, as a cut can be
performed every units, starting at 0.5 , where delta is the resolution of the marching cubes
(e.g. = 1). This way, each slice contains exactly the points which were dened by one image
in the marching cube algorithm. In the ideal case (i.e. the model contains no noise) these points
form a ring whose borders are two star shaped polygons around the center of gravity.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 158
The best tting spline is calculated using normal cubic regression. The control points are dened
to be equally spaced along the spline. When C
i
, i {0..n} are the area centroids and u
i
, i {0..n}
dene the corresponding locations along the hermite spline curve,
S(u) = au
3
+bu
2
+cu +d, (5.12)
then the error ,
=
n

i=0
(S(u
i
) C
i
)
2
, (5.13)
needs to be minimized. After the regression, the average error

n
is compared to a previously
dened threshold. If the criterion is met, the process stops, otherwise the list of points is split into
two halves and regression is performed on each one. This process is repeated recursively until the
criterion is met on each small spline segment. The process can be proven to stop because when
the amount of points for one spline segment is 4 or less, then the regression produces a spline
where is zero. The complete curve is made continuous by setting the start and end points as
well as the tangents of two consecutive splines equal. In Fig. 5.28 an example of the calculation
of the muscle path is depicted, showing the interpolated curve P(d) with respect to the area
centroids.
Figure 5.9: Approximation of the Muscle Path
Thus, the muscle path can be denoted as function of a set of connected Hermite splines,

P(d) : R R
3
, (5.14)
in order to represent position, orientation and length of the muscle, where the parameter d denotes
the position along the path.
In fact, most of the dened slices consist of too few points to represent a muscle cross-section.
This leads to falsely calculated area centroids, thus resulting in an incorrect muscle path. Hence,
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 159
the slices including too few points have to be identied and lled up with additional points to
represent a better approximation of muscle cross-section. The reason for the existence of such
muscle slices are artifacts in the MRI data and the arbitrarily chosen resolution when applying
the marching cubes algorithm.
5.2.1.1 Analyzing Surface Distribution
The purpose of analyzing the distribution of the surface along the muscle path is to identify cross-
sections which include either too few points or false points. Once identied, the cross-sections
are corrected by using points from the cross-section nearest to the ones with not enough points.
By applying an analysis of variance such that each muscle slice is treated as group of values,
X
i
= {l
1
, l
2
, , l
n
}, (5.15)
where each value l
i
is dened as the angle that is enclosed by a vector from the area centroid
to a surface point and a vector that is parallel to the x-axis of the muscle plane as shown in
Fig. 5.10.
Figure 5.10: Angular Measurement of Surface Points
Then, the arithmetic mean of the angular distribution of the points around the area centroid is
dened as,
x =

n
i=1
l
i
n 1
. (5.16)
The variation with respect to the arithmetic mean can then be calculated using,
s
2
=

n
i=1
(l
i
x)
2
n 1
, (5.17)
where s
2
is dened as variation of angular displacements l
i
and,
v =

s
x
100, (5.18)
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 160
is the variation coecient that relates variation s to the arithmetic mean and provides a better
comparison between dierent groups of data.
An example result of the complete identication process is shown in Fig. 5.11, where all de-
ned cross-sections were analyzed and visualized in a diagram. The x-axis shows the number
of arbitrary chosen cross-sections of one muscle and the y-axis shows the value assigned to each
cross-section by means of analysis of variance. It can be seen that there are sections with low and
high values, but only six of them reach a value which is higher than 80. These six sections with
high values in variance are the cross-sections that consist of points which were derived directly
from the MR images, all others sections lie between the MR images and were approximated by
the marching cubes algorithm, thus not including enough information for further processing.
Hence, the diagram shows which cross-sections have to be edited by adding additional points in
order to smoothen the calculation of the gravity line.
0
20
40
60
80
100
120
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73
number of cross-sections
v
a
r
i
a
n
c
e

Figure 5.11: Example of Analysis of Variance, from [Sat03]


The following steps are performed in order to smoothen the distribution of surface points around
the muscle path:
Iterate over the values received from the analysis of variance.
If a value is below a certain threshold, start searching for a slice which has a better variance.
Find the best variance by searching left and right, take the rst slice found which has
correct points and the shortest distance to the faulty slice.
Add surface points to the faulty slice in order to produce a better distribution around the
area centroid.
Finally, after all slices are corrected, the muscle path

P(d) is recalculated in order to reect
surface modications.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 161
5.2.2 Approximation of Muscle Surface
After the complete path is established, a radius function is dened that describes a NURBS (cf.
[PT97]) interpolated curve that approximates all surface points around the muscle path within
a muscle slice.
Before describing the interpolation itself, it is necessary to determine the input points over which
the approximation should take place. All surface points of one cross-section are split according
to their angular displacement from Eqn. 5.15 into two parts, those having an angle which is
lower than 180 degrees and those whose angle is greater than 180 degrees (see Fig. 5.12). Now,
the partitioned points of each cross-section have to be processed in order to contain only unique
points. The reason why all points of one slice have to be dierent from each other is that in some
cases it is possible that a spline curve is created which has a cusp (visual discontinuity), although
the resulting spline curve is always c1 continuous
1
.
All slices are processed by calculating a NURBS curve for each cross-section, so that this curve
ts exactly between the points used as control points. Thus a control point vector,
Pc = {Pc
1
, Pc
2
, , Pc
n
}, (5.19)
includes all surface points on one cross-section in order to approximate a curve. The NURBS
approximation can be denoted as,
C(u) =
n

i=0
N
i,p
(u)w
i
Pc
i
n

i=0
N
i,p
(u)w
i
, a u b, (5.20)
where the points Pc
i
are the control points, w
i
are the weights that inuence the control points
and N
i,p
are p-degree B-spline functions dened recursively as,
N
i,0
(u) =
_
1 : if u
i
u < u
i+1
0 : otherwise
N
i,p
(u) =
u u
i
u
i+p
N
i,p
(u) +
u
i+p
u
u
i+p+1
u
i+1
N
i+1,p1
(u), (5.21)
where U denotes a knot-vector,
U = {a, . . . , a
. .
p+1
, u
p+1
, . . . , u
mp1
, b, . . . , b
. .
p+1
}. (5.22)
containing values for u at which pieces of the curve join continuously. The knot vector usually
contains internal and external knots, in the form that the values a and b are repeatedly occurring
p + 1 times at the beginning and at the end of the vector. Therefore, any value u for Eqn. 5.20
needs to be within a and b. The spline basis functions N
i,p
only depend on the value of p and the
values of the knot vector, where p is the order of the curve. Increasing the order p also increases
the continuity and smoothness of the curve at the knots, but tends to move the curve away from
its control points. Detailed information on NURBS and B-splines can be found in [PT97]. Within
1
c1 continuous means that the rst derivative is continuous.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 162
the presented research work, partly based on an MRI study described in Sec. 2.1.4, a software
system Visu was implemented which is described in [Pri01], [Lac01] and [Sat03].
In using the NURBS approximation for the muscle surface around the muscle path, two continuous
curves can be approximated for the upper and lower half of the muscle cross-section as shown in
Fig. 5.12.
Figure 5.12: NURBS Approximation of Muscle Cross-Section, from [Sat03]
The next step is to improve the surface also in the length of the model. This has to be done,
because the already calculated shapes of the cross-sections have slightly dierent area centroids
which result in a shift of the sections to each other and thus in a bumpy surface.
5.2.2.1 Optimized Rendering
In order to display the muscle surface and to realize a correct mapping of a texture to the surface
of the muscle, it is vital that all spline points have a constant distance to each other. This leads
to point locations of each cross-section corresponding to points of a consecutive cross-section by
lying in the same plane. This property is, however, not realized after the NURBS interpolation.
The previously calculated splines have to be processed in order to obtain equally spaced points.
Since for all points of a spline the angle from Eqn. 5.15 can be calculated, the idea is to have a
vector

P = P(i) that samples spline points along a circular path, centered at the area centroid.
According to Fig. 5.13, the area centroid of a muscle slice is denoted as M and the vector

P can
be dened as,
P(i) =

M +
_
cos( i)
sin( i)
_
, (5.23)
where =
360

m
and m is the number of points to be generated. Consequently, i needs to be
within the interval [0; m].
The angle i can be used to nd points of the spline curve that t the criteria i < ,
where and dene two vectors

V
1
and

V
2
that point to two consecutive points of the spline
curve. The intermediate spline point X
i
can then be calculated as the intersection point between
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 163

and

V
12
=

V
2


V
1
, where

P

is dened as elongated vector



P such that,

=

P (|

V
1
| +|

M|). (5.24)
Thus, the intersection point can be found by solving,

X
i
=

M +s

P

(5.25)

X
i
=

V
1
+t

V
12
,
for the free variables s and t, resulting in,
t =

M
y
+s

P
y

V
1y

V
12y
(5.26)
s =

M
x

V
12y


M
y

V
12x
+

V
12x

V
1y

V
12y

V
1x

V
12x


P
y

V
12y


P
x
.
The resulting vectors

X
i
(drawn in dashed lines in Figure 5.13) now dene equally spaced, spline
approximated muscle surface points.
Figure 5.13: Linear Interpolation of NURBS-generated Cross-Section, from [Sat03]
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 164
By using the same spline interpolation again on the sum of all spline interpolated cross-sections,
a homogenous surface without disturbances is obtained.
5.2.3 Interpolation of Muscle Models
Once all of the input models are processed, they are assigned values for their activation according
to Sec. 2.1.4. Currently this assignment has to be set manually, as there is no direct way to identify
the activation of a muscle based on pure MRI data. Then, the complete set of input models,
along with their activation values can be used to interpolate the muscle at any given activation
in between.
Both activation and length change whenever interpolation is applied. Due to activation, the
length of a muscle changes. Passive length change is imposed on all other muscles when one is
activated, because of the mechanical properties of the eye. Eye muscles are always working in
pairs, when one muscle contracts, the other muscle is extended and vice versa (see Sec. 2.2.1).
Both, activation and length change of a muscle can be obtained from the biomechanical model
(see Sec. 4.4.4 and Sec. 4.5). The length change and the activation can be handled as separate
problems. First the muscle is interpolated from the input images and the length change is
disregarded. Afterwards the muscle length is adapted and the muscle is scaled with the constraint
to keep its volume constant. The interpolation is done purely on parameter basis.
The process of interpolating the muscle volume without length changes can be split into the
following steps:
1. Identify all input models used for interpolation.
2. Interpolate the muscle path.
3. Interpolate all muscle surface points on each muscle cross-section.
The rst step consists of dening weighting factors for the dierent input models, depending on
their activation relative to the a desired activation A. Let w
M
be the weight associated with an
input model M. Interpolation of nearest neighbors is applied, so the process starts by nding
two models M and N with activations A
M
and A
N
respectively, for which A
M
A A
N
and
there is no model O for which A
M
< A
O
< A
N
. Then a weight is assigned to each of the two
neighbors that depends inversely linear on the distance from the desired activation. The weights
are dened to be,
w
M
= 1
|AM A|
|A
M
A
N
|
(5.27)
w
N
= 1
|AN A|
|A
M
A
N
|
.
The next step is to interpolate the muscle path. Linear interpolation is used for the path. So if
P
M
(d) is the muscle path of model M, according to Eqn. 5.14, and P
N
(d) is the path of model
N, then the resulting interpolated path Pi(d) is can be denoted as,
Pi(d) = P
M
(d) w
M
+P
N
(d) w
N
. (5.28)
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 165
Since two muscle paths may not have an equal number of spline segments, splitting of muscle
paths will be necessary. For this, a splitting operation is dened, such that it is possible to cut
out a new spline from an existing one such that all points of the new spline are also points of
the old spline. This conguration can be achieved by recursively splitting larger splines into two
halves when the corresponding part of the other spline set also consists of multiple splines (cf.
[Lac01]).
The method for interpolating the muscle surface modies the distribution of the volume along
the muscle path. The change of the distribution is given by the input models. Provided that
all input models use the same resolution when dening the muscle surface points on each cross-
section (i.e. parameter m in see Eqn. 5.23), all surface point on a cross-section can directly be
related to surface points within the same cross-section in another model.
From Eqn. 5.25 let,
XM = {XM
1
, XM
2
, , XM
m
}, (5.29)
XN = {XN
1
, XN
2
, , XN
m
},
be the surface points belonging to one cross-section of the model M and N respectively. Then,
for a given activation A, according to Eqn. 5.27, the intermediate muscle surface distribution can
be found by dening a weighting factor w such that,
w =
|A
M
A|
A
M
A
N
, (5.30)
and use this factor to scale the vector that connects source and destination surface points by
using,
XI
i
= (XN
i
XM
i
) w, (5.31)
where XM
i
and XN
i
denote the i
th
surface points on a muscle cross-section and XI
i
gives the
interpolated surface point according to the weighting factor w.
When repeating the conversion process described in Eqn. 5.31, a new list of surface points XI
results that describes an interpolated distribution of the muscle surface according to a given
activation and an interpolated muscle path from Eqn. 5.28.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 166
5.3 Reconstruction Results
In order to reach good matching results, high resolution MR images were taken from a study that
was carried out within this research work, described in Sec. 2.1.4. Therefore, DICOM output
images from the MR scanner were used directly for the reconstruction of the muscle model. The
reconstructed model was rendered using the OpenGL graphics platform. Each of the following
screenshots shows one MR image representing one cross-section of a muscle and is overlapped
with the model at the corresponding location.
In Fig. 5.14, a medial rectus muscle of a left eye was reconstructed, while the patient was looking
in primary position. Underlying MRI data was transparently visualized in order to evaluate
accuracy of the algorithm. The wireframe muscle shown in Fig. 5.14 is the result of the NURBS
approximation described in Sec. 5.2.2.
Figure 5.14: Reconstruction of a Left Medial Rectus Muscle
Additionally, texturing was applied to the wireframe model in order to improve visual quality.
Fig. 5.15 shows a shaded, textured representation of a medial rectus muscle in a left eye.
The screenshots from Fig. 5.16 show a medial rectus muscle in dierent innervation states.
Fig. 5.16(a) shows the muscle model with an innervation of 0, thus corresponding to an initial re-
construction when the patient was looking in primary position. The second static reconstruction
shown in Fig. 5.16(c), which depicts the muscle model that was reconstructed from MRI data,
when the subject was looking in secondary position. An arbitrary innervation of 1 is associated
with Fig. 5.16(c). By using the interpolation methods described in this chapter, it is now possi-
ble to interpolate muscle surface between the two states shown in Fig. 5.16(a) and Fig. 5.16(c).
Therefore, an innervation value of 0.5 is assumed and the resulting interpolated muscle model is
shown in Fig. 5.16(b).
In the case depicted in Fig. 5.16(b), an innervation of 0.5 means that the interpolated mus-
cle model shows a state that is exactly in the middle between the primary and the secondary
positions.
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 167
Figure 5.15: Shaded Reconstruction of a Left Medial Rectus Muscle
(a) Primary Position (b) Interpolated Position (c) Secondary Position
Figure 5.16: Morphology of Reconstructed Medial Rectus Muscle
5.3.1 Validation
Validation of the resulting reconstructions of MRI data concentrates on the evaluation of recon-
struction results with respect to the underlying MRI data. However, validation of the reconstruc-
tion process cannot be realized by simply comparing pictures. Instead, the extracted data has to
be compared with real-life dimensions, which means to use data measured on within data that
is provided by the MR scanner. A possible way is to compare muscle dimension measurements
from the extracted data with muscle dimensions data that can be measured in the MR images.
The standard software Adobe Photoshop was used to measure the pixel dimensions of muscles
in MR images and real dimensions in mm were calculated from DICOM parameters that are
included with each MR image. Since the reconstructed muscle model is dened in a world
coordinate system with units in mm, the measured values from underlying MR data can directly
be compared.
The measured lengths and heights from eleven coronal MRI cross-sections are listed in Tab. 5.1,
whereby the height of the muscle was taken as the longest dimension of the muscle on the current
CHAPTER 5. VISUALIZATION OF MUSCLE ACTION 168
Figure 5.17: Shaded Reconstruction of a Left Medial Rectus Muscle with MRI Data
MR image in vertical direction (the axis that develops vertically within the sagittal plane), and
the width was taken as the longest extension of the muscle in horizontal direction (the axis that
develops horizontally within the coronal plane).
Muscle Image Height Width Length
Cross-Section MR Model MR Model MR Model
1 9.4 8.44 5.1 4.94 0.0 0.0
2 9.4 8.48 4.7 4.14 1.8 1.41
3 9.4 9.07 4.3 4.43 3.6 3.19
4 9.8 9.17 4.7 4.46 5.4 5.43
5 9.8 9.51 4.3 4.35 7.2 6.99
6 10.2 9.70 4.3 4.27 9.0 8.77
7 9.8 9.87 4.3 4.12 10.8 10.84
8 9.8 9.83 3.9 4.00 12.6 12.20
9 9.4 9.77 3.5 3.83 14.4 14.40
10 9.4 9.63 3.9 3.78 16.2 16.17
11 9.4 9.59 3.9 3.96 18.0 17.92
Table 5.1: Comparison of Medial Rectus Muscle Dimension Data in Millimeters, measured form
MR Images and the Model
The inter-slice distance was given by DICOM parameters as 1.8 mm, thus the length of the
muscle that can be displayed according to MRI data is 10 1.8mm = 18mm.
Chapter 6
Software Design and Implementation
The biomechanical model as well as the eye muscle surface reconstruction described in Ch. 4
and Ch. 5 were implemented and incorporated into an interactive simulation software system
SEE++. This system enables the simulation of pathological situations as well as the predic-
tion of surgical interventions by means of graphical three-dimensional visualization of both eyes
including the extraocular muscles.
This chapter gives a short overview of the software design model that was used to implement the
biomechanical model. Additionally, the integration of the biomechanical model into a software
system SEE++ is described. The software design model is structured in a way such that the
biomechanical model is represented as standalone software component that can be integrated into
dierent applications. The software system SEE++ is therefore one possible application that
uses the biomechanical model to simulate eye muscle pathologies and surgeries. Moreover, the
biomechanical model contains exchangeable sub-models (i.e. geometry, muscle force prediction
and kinematics) that provide exibility and scalability for future extensions.
The software system described in this chapter was implemented using the C++ programming
language and the MFC class library framework. Computer-aided Software-Engineering tools (i.e.
Rational Rose, Rational Unied Process) were used to build a design model using the Unied
Modelling Language (UML) within an integrated round-trip engineering approach (cf. [Buc01]).
169
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 170
The basic structure of the software system SEE++ that was implemented within this research
work is depicted in Fig. 6.1. The research work described in this thesis concentrates on results
of the development of a biomechanical model for the human eye within the SEE-KID project,
which subsequently can be split into the development of a mathematical model and a software
system. From Fig. 6.1 it can be seen that the implementation of the biomechanical model is an
autonomous part within the SEE++ software system. The structure of the software system
itself, besides the biomechanical model, consists of a SEE++ and a GUI package. The SEE++
package acts as pure interface to the underlying biomechanical model, whereas the GUI package
contains the application and the user interface.
Figure 6.1: Structure of the SEE++ Software System
Because of the strict division of the software system into biomechanical model and application
components, the SEE++ system provides exchangeable structure such that any other biome-
chanical model could be incorporated as long as it conforms to the SEE++ interface package.
Several tools were used to manage the high complexity of the system design and implementation.
For realizing the software design, Rational Rose 2002 was used (cf. [Cor02b]) and implementa-
tion is based on Microsoft Visual Studio .NET using the MFC (Microsoft Foundation Classes)
framework (cf. [Cor02a]). The graphical three-dimensional visualization within the SEE++
software system was implemented using the OpenGL graphics library. The design is described in
UML notation and consists mainly of class diagrams which are structured in packages.
However, Fig. 6.2 illustrates that the design of the SEE++ system is based on a slightly
modied form of the Model-View-Controller (MVC) concept. The idea behind the MVC concept
is to separate the model, the views and the controller to make the model as independent as
possible. Moreover, the MVC concept enables the use of multiple views onto one shared model
(cf. [GHJV94]).
In the SEE++ system, the See++ package is used by the instancer to provide an interface
between the GUI package and the biomechanical model. Consequently, the GUI package only
uses the classes of the See++ package and the See++ package only uses the instancer to access
data and functionality of the biomechanical model (cf. Fig. 6.2). Since the SEE++ system uses
the MVC concept, all data is stored within the model, thus the views and the controller do not
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 171
Figure 6.2: Model-View-Controller Structure of the SEE++ Software System
store any data on their own.
One of the main goals of the SEE++ system is exibility and reusability. Therefore, dierent
design patterns have been used. The instancer uses the Singleton design pattern, which means
that a global point of access is provided to the other classes and only one instance of the instancer
class can exist at the same time. The instancer also uses the Proxy design pattern. Since most
of the objects required during runtime are managed by the instancer and returned to the See++
package and the GUI package when needed, the usage of the Proxy design pattern has the
consequence that an object is not allocated in memory until it is requested for the rst time. The
advantage of this procedure is that it reduces the start-up time and memory consumption of the
system.
The reason, why the GUI package is placed between the view and the controller section in
Fig. 6.2 is that the GUI package implements the user interface parts of the dierent views of the
SEE++ system, but also handles the mouse and keyboard input, which, according to the MVC
concept, is realized by the controller. Nevertheless, the actual handling of the user input and the
implementation of the views resides in the See++ package, since the GUI package only delegates
these tasks.
6.1 Design of the Biomechanical Model
The structure of the biomechanical model should be easy to extend in order to permit integration
of latest research results. As a consequence, the model design should be able to handle model
extensions and modications to existing parts of the model that do not completely invalidate
current model predictions.
In order to satisfy these requirements, the following design guidelines need to be applied:
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 172
Not every part of the model should be a direct sub-model of the biomechanical model.
Instead, sub-models should use other sub-models, so that the biomechanical model uses
only those parts of the model which are directly required for calculating model predictions.
Sub-models which have a lot in common should not duplicate this shared functionality in
each model. A better approach is to base these models on an abstract base model which
contains all the common functionality, but cannot be instantiated on its own. As a result,
the addition of new models is much easier, since only the model-specic parts have to be
implemented in the new model.
All model data should be stored once in order to avoid redundancies. The biomechanical
model should therefore provide an abstract representation of anatomical parts.
The software design for the biomechanical model starts with nding proper abstractions for the
medical relevant entities of the oculomotor structures. First, all muscles are modelled using an
abstract base class that unites all common operations and additionally aggregates anatomical
subparts like insertion, origin and pulley points (see Fig. 6.3).
Figure 6.3: Abstraction of Muscles
The class diagram shown in Fig. 6.3 treats each geometrical point of a muscle as own class and
therefore provides dierent operations when accessing insertion, origin or pulley of a muscle. This
for example would mean that, when changing the radius of the bulbus, the muscle insertions and
the pulleys are extended, whereas the origin points stays the same.
It is now desirable to incorporate these geometrical abstractions into a design for a complete
biomechanical model, consisting of geometrical, muscle force and kinematic model according to
Sec. 4.2. One possibility is illustrated in Fig. 6.4, which denes one superclass Biomechanical
Eye Model that references all sub-models for modelling geometry, muscle force and kinematics.
Moreover, this superclass also directly accesses the six dierent eye muscle classes and the bulbus
class which hold all data for one eye.
The model structure shown in Fig. 6.4 does however lead to some implementation diculties.
Since the superclass Biomechanical Eye Model directly references dierent geometrical sub-
models like String- or Tape model, common functionality for geometrical calculations cannot be
incorporated into this design. When for example, an additional pulley model needs to be added,
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 173
Figure 6.4: Primary Abstractions for Biomechanical Model
implementation redundancies will occur in that all basic functionality needs to be duplicated
within a new geometrical model. Moreover, external usage of the Biomechanical Eye Model de-
pends on knowing which geometrical models are available and also needs to dierentiate between
dierent access modes of these models. Identical considerations hold for the muscle force model
and the kinematic model.
A conceptual description of a biomechanical model that is very similar to that shown in Fig. 6.4
is suggested in [MD99] and [Gue86]. However, the previously mentioned aws are also present in
these models making them hard to modify and to extend.
In order to provide the necessary exibility and extensibility of the design model, new abstractions
need to be incorporated into the structure from Fig. 6.4. This implies the introduction of abstract
base classes for each of the sub-models for geometry, muscle force and kinematics. This way,
superclasses need to access only one interface in order to be able to use dierent sub-models
within the same functional responsibilities.
Fig. 6.5 shows an extended version of the model structure, where the biomechanical model now
uses only one sub-model, namely the kinematic model. The kinematic model itself uses only the
muscle force model. The muscle force model is an abstract base class with currently one derived
subclass. Derived models are concrete realizations of an abstract base model, where the abstract
base class holds all common functionality. Finally, the muscle force model uses the geometrical
model which is also an abstract base model. The geometrical model has three derived models,
the String-, Tape- and Pulley model, and uses the models of the six extraocular eye muscles and
the bulbus.
The structure for modelling the eye muscles, previously shown in Fig. 6.3 has also been extended
in Fig. 6.5. All muscles are now derivations of one abstract base class and the dierent parts of
a muscle, like insertion, pulley and origin, are now parts of the abstract base model only, so they
need not be added to each individual muscle.
The following properties can be derived from the system design in Fig. 6.5:
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 174
Figure 6.5: Extensible Software Design for the Biomechanical Model
New sub-models can be added to the biomechanical model more easily.
Only parts aected directly by additions have to be validated for their correctness once
again.
Extensions to existing models only inuence parts of the model and not the whole model.
According to the desired structure of a biomechanical model (see Sec. 4.2), the system design
model exposes the Biomechanical Eye Model class on the top of the class hierarchy. This class
references the kinematic model which is responsible to connect geometry and muscle force model,
but the geometrical model is only accessible through the muscle force model.
In the SEE-KID model (cf. Fig. 6.5), the requirements for a specic geometrical model that
are enforced by the abstract base class Geometrical Model are the calculation of the following
entities:
The point of tangency of each extraocular eye muscle,
the rotation axis around which a specic muscle rotates the eye (muscle rotation axis),
the center of the muscle action circle,
and the length of a specic muscle.
The listed requirements are specic to each geometrical model. In the string model, for example,
the center of the muscle action circle is also the center of the bulbus (cf. Sec. 4.8). The muscle
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 175
action circle is dened by the muscle rotation axis and since the muscle rotation axis changes
with nearly every movement of the bulbus, the muscle action circle reacts in the same way.
Apart from containing the bulbus and the muscles, the class GeometricalModel also provides
methods for specifying eye positions, performing eye rotations (using Fick or Helmholtz rota-
tion sequences) and manipulating the properties of the contained bulbus and muscles. These
functionalities are independent of a specic geometrical model and are therefore implemented in
the class GeometricalModel. Thus, the derived models of GeometricalModel do not have to
reimplement this functionality.
Similar conditions can be applied to the muscle force model. The abstract base class Muscle-
Model denes common functionality to load and store muscle force tables. Additionally, methods
for cubic and bicubic data interpolation are provided (cf. Sec. 4.5). Each specic muscle force
prediction model then only implements functionality that is specic to a certain model.
For the kinematic model, the calculation of the forward and inverse kinematics are non-linear
optimization problems and optimization methods have to be used (see Sec. 4.6.3). The SEE-
KID model contains two dierent algorithms for solving kinematics. The Levenberg Marquardt
algorithm, which uses gradients, and the Downhill Simplex algorithm, which only needs function
evaluations to perform function minimization (cf. Sec. 4.6). Concerning convergence speed,
the Levenberg Marquardt algorithm performs much faster since it uses gradients, whereas the
downhill simplex method is slower but much more accurate in nding minimums.
Figure 6.6: Optimizer and Related Classes
In the SEE-KID model, the object-oriented design shown in Fig. 6.6 enables the use of both
algorithms (see Fig. 6.6). Therefore, an abstract base class called Optimizer is introduced
which provides a common interface for solving the non-linear optimization problems. The classes
LevenbergMarquardt and DownhillSimplex are derived from the class Optimizer and imple-
ment the respective algorithms. Moreover, the class Optimizer uses the classes ParamObject
and FunctionObject. The class ParamObject enables the parametrization of the algorithms,
whereas the class FunctionObject is an abstract base class used for dening the objective func-
tion (cf. Eqn. 4.135). Thus, a derived class of FunctionObject implements the specic function
for the optimization and since the forward and inverse kinematics are the problems to be solved,
the kinematic model is derived from FunctionObject.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 176
6.2 Design of the SEE++ Software System
According to Fig. 6.2, the design model for the SEE++ system consists of the GUI and the
SEE++package. These packages hold functionality that provides the user interface and the
interface to the biomechanical model, described in Sec. 6.1. The content of the SEE++ package
is visualized in Fig. 6.7. The main functionality is contained within the packages SeeMedic and
SeeModel.
Figure 6.7: Structure of the SEE++ Package
The packages that are contained within the SEE++ package, according to Fig. 6.7 can be
described as follows:
The SeePoint package provides classes for the dierent kinds of points like insertion points
or points of tangency.
The SeeGeneral package contains the base class SeeObject from which nearly all other
classes of the See++ package are derived.
The SeePatientData package is used for storing and loading data of patients.
The SeeConstraint package describes limits which are applied to most of the user-controlled
values in the GUI package.
The SeeHelp package implements the context sensitive help.
The SeeSurgery package provides dierent surgery techniques in connection with classes of
the SeeView package.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 177
The SeeProjection package prepares data returned by the SeeModel package for use in the
SeeView package.
The basic process of data ow within the SEE++ system starts with loading patient data
(SeePatient package) and distributing these data into classes contained in the SeeMedic package.
Next, simulations are performed using the biomechanical model through the interface of the
SeeModel package, where modications of patient specic data during simulation are checked
for validity by classes that are contained in the SeeConstraint package. Simulation results are
graphically visualized by functionality that is assigned to the SeeProjection and SeeView packages.
Surgical interventions that dene specic methods of how the patient data can be modied in
order to simulate or correct pathological situations are realized within the SeeSurgery package.
Figure 6.8: Structure of the SeeMedic Package
The SeeMedic and the SeeModel packages utilize the Adapter design pattern, which means that
each of the classes of these packages adapts the interface of another class (cf. [GHJV94]). Thus,
the SeeMedic package provides access to the six extraocular eye muscles and their dierent
components, although the classes of the SeeMedic package do not store any values (see Fig. 6.8).
Instead, these values are retrieved from the class SeeDataModel, which is located in the SeeModel
package (see Fig. 6.9). Since the SeeModel package also uses the Adapter design pattern, the
SeeDataModel in turn retrieves the data from the biomechanical model through the instancer.
The other classes in the SeeModel package are adapters of the dierent models contained in the
biomechanical model SEE-KID.
The class SeeMedic is the base class for all medical objects and the class SeeOrbita is used as a
container for the six extraocular eye muscles and the bulbus. Moreover, for the four straight and
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 178
the two oblique muscles, two dierent abstract base classes called SeeRectus and SeeObliquus
have been introduced, both derived from SeeMuscle.
The approach of using the Adapter design pattern in the SeeMedic and the SeeModel packages
may seem too much eort. However, the advantage of this design is that the model stays inde-
pendent from the views, since the views implemented in the SeeView package only use the classes
of the SeeMedic package. On the other hand, the GUI package and the views are independent of
the biomechanical model, which makes it quite easy to exchange either the biomechanical model
or the GUI.
Figure 6.9: Structure of the SeeModel Package
The class SeeModel is the base class for all models in the SeeModel package. The class SeeData-
Model provides access to the data stored in the biomechanical model and the class SeeStateModel
serializes the internal state of the See++ package and the GUI package between dierent execu-
tions of the SEE++ software system.
In order to visualize output data of the SEE++ software system, three dierent types of di-
agrams (views) are supported. The muscle force distribution (MFD) diagram, the muscle force
vector (MFV) diagram and the Hess diagram. The MFD and the MFV diagram represent dier-
ent visualizations of the output data of a geometrical model, whereas the Hess diagram is based
on the output data of the biomechanical model (see Sec. 4.7.1). The implementation of these
diagrams is not part of the SEE-KID model, as they are implemented in the SeeView package,
shown in Fig. 6.10, which is part of the See++ package.
Fig. 6.10 shows the SeeView package which contains the classes of the dierent views that the
SEE++ software system supports. All views are derived from the abstract base class SeeView
and all diagrams are additionally derived from the abstract base class SeeDiagramView. The
classes SeeVText and SeeV3D visualize the dierent properties of the muscles and the bulbus,
either in a textual or in a three-dimensional form. The three diagrams which are all derived from
SeeDiagramView are visualizations of the output data of the biomechanical model.
For the calculation of the MFD diagram, implemented in the class SeeVMFDD, the muscle
rotation axis of a specic muscle is used. It is also possible to calculate one MFD diagram for
several muscles by adding up the diagrams for each muscle. Thus, the MFD diagram visualizes the
force distribution of one or several muscles of one eye in a specic elevation plane (cf. Sec. 4.4.3.3).
Each curve of the diagram shown in Fig. 4.19, represents a dierent rotational component of the
visualized muscle(s) in an arbitrary but xed elevation plane within a specic range.
The MFV diagram and the implementation of this diagram can be found in the class SeeVMFVD.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 179
Figure 6.10: Structure of the SeeView Package
For the calculation of the MFV diagram, shown in Fig. 6.11, arbitrary gaze positions are chosen
which are only constrained by anatomical boundaries. These gaze positions are drawn in a 2D-
diagram where the x-axis represents adduction and abduction and the y-axis represents elevation
and depression in a specic range. Each of the gaze positions is then used for drawing a vector,
whereas the length and the direction of the vector are specied by the force distribution of a
specic muscle along with its particular pulling direction. The MFV diagram, like the MFD
diagram, also supports the visualization of several muscles by adding up the diagrams of each
muscle.
Figure 6.11: Muscle Force Vector Diagram
Fig. 6.11 illustrates a MFV diagram of the lateral rectus muscle of a left eye with a set of gaze
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 180
positions within the 30 degree physiologic eld of vision. These gaze positions are considered as
default gaze positions for a normal human subject.
However, MFD and MFV diagrams themselves cannot be gathered through clinical measure-
ments. For this reason the SEE++ system supports the Hess diagram which can also be
measured clinically (cf. Sec. 3.13).
The Hess diagram is a visualization of combined output data of the kinematic model and is
implemented in the class SeeVHess (see Fig. 6.10). The Hess diagram also depends on arbitrary
gaze positions which must not exceed anatomic boundaries and are plotted in the diagram as
points. These gaze positions are then used as an input for the calculation of the simulation (cf.
Sec. 4.7.1). The axes of the Hess diagram are dened according to the MFV diagram, where the
x-axis represents ab-/adduction and the y-axis represents elevation/depression within a specic
range (see Fig. 3.14). A Hess diagram contains dierent points which represent the specied and
the calculated gaze positions. To improve the visibility of the diagram, points of specied and
calculated gaze positions are drawn using dierent colors and are connected through thin lines.
In addition to the described packages, dierent helper classes for matrix calculations, quaternion
algebra and OpenGL are used. For matrix calculations the NewMat framework was used (see
[Dav03]) and for quaternion and 3D calculations the 3DMath classes (see [Fal99]) were adapted.
6.3 The SEE++ Software System
The SEE++ software is a new simulation system that aims at the forecast of clinical oper-
ation results, as well as the representation of pathological situations in the eld of strabismus
surgery. The system is based on a highly developed mathematical simulation model (biome-
chanical model), which copies the behavior of the human eye realistically and thus provides an
experimental platform for the simulation of pathologies and the evaluation of possible treatments.
SEE++ is a biomechanical system for the interactive three-dimensional simulation and visual-
ization of eye motility disorders and their surgical correction.
The SEE++ software system oers the following functions:
Compact, descriptive and thus well understandable knowledge transfer in teaching and
training,
scientically oriented procedures for practice,
fundamental references and numerous examples,
a basis for individual considerations of diagnostics and operational correction of eye motility
disorders.
The SEE++ software system aims the following target user group:
Ophthalmologists, specialists as well as orthoptics can use SEE++ to support measure-
ments and to archive pathologies and treatment methods.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 181
Researchers in the eld of ophthalmology, strabismology and neurology, pediatrists as well
as researchers in the eld of biophysics use SEE++ as an extensive scientic tool for the
investigation of the mechanics of eye movements.
SEE++ oers a substantial support to teachers through descriptive representation of the
fundamentals for understanding eye movements.
Students have the possibility to interactively deepen their knowledge and to recall and
describe previously studied fundamentals of eye movement and strabismus.
6.3.1 SEE++ Simulation Task Flow
When using SEE++ to model and simulate eye motility disorders, a certain simulation task ow
can be dened in order to perform simulation and evaluation of model predictions. In Fig. 6.12,
this task ow is illustrated as a sequence of simulation steps that can be performed iteratively
within the software system.
Figure 6.12: Simulation Task Flow for using SEE++
1. Parametrization with patient data: One main goal of SEE++ is to give close-to-reality
related predictions of a patient-specic situation. In this rst step of the simulation task
ow, model values will be based directly on the patient. Parameters can be modied such
as globe radius, cornea radius, muscle lengths, insertions, tendons etc. At the same time,
general data are entered like name or description.
2. Simulation of a pathology: During the simulation of a pathology, model parameters are
changed in such a way that the resulting model predictions correspond to measured values
of the patient, as closely as possible. A model prediction is done in SEE++ by the
simulation of a clinical Hess-Lancaster test, whereby the representation for right or left
xation is used. By determination of the Hess-Lancaster data of the patient, these values
can be compared to simulated data to nd whether the simulation corresponds to the
pathology of the patient. Also the 3D representation of the patient oers an additional
support regarding the evaluation of a simulation.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 182
3. Comparison of simulation results with patient data: This comparison refers to the
Hess-Lancaster investigation already mentioned, whereby the process of comparing can
also serve as a verication of the diagnosis posed before. Thus, in this step it is to de-
termine whether the simulation result agrees suciently with the measured patient data.
This, at the same time, oers a basis for a later simulated treatment by interactive virtual
surgery of the modelled pathology.
4. Simulation of surgery: Here the actual operation is simulated by interactively modifying
dierent model parameters using the mouse within the 3D representation. Points of refer-
ence support orientation and the dosage of the surgery performed. Furthermore, dierent
operation techniques are available such as transposition and tangential repositioning of a
muscles insertion. Muscle force and innervation parameters are changed manually in the
program so that they correspond to a comparable surgical procedure. For example, a mus-
cle resection can be accomplished by changing the value of the parameter for muscle length.
The 3D model visualizes these changes immediately after conrmation of entered values.
5. Evaluation of results: According to step 3, a comparison of the simulation results is carried
out again. On the basis of the binocular Hess-Lancaster test, the outcome of a surgery can
be judged regarding to the correction of a pathological situation, and whether it is still
necessary to apply additional changes (simulation trials).
6. Simulation result: The simulation result represents the last condition of all model param-
eters in the task ow of the simulation of a pathology with SEE++. The system enables
the user to assign and archive scenarios to a patient. Thereby the results of dierent sim-
ulations may be compared and e.g. simulation strategies can be developed. Each scenario
stores any step of a treatment of a patient and can later be recalled in textual or graphic
ways.
6.3.2 Simulation properties
When starting the program, the default view depicted in Fig. 6.13 appears. All functions of the
program are accessible through the main menu in a structured manner. At the same time, a
tree representation in the Treeview provides the same functions for direct access. The SEE++
system features four dierent diagram windows, where each diagram can be displayed arbitrarily
within each view window. A xed component of the system is the 3D view, in which the current
simulation is illustrated by a virtual patient. The Toolbar for 3D-View is used in order to
congure this view, i.e. to show or hide muscles, the globe, points of reference, etc.. The Toolbar
for Main Functions allows quick and direct access to the most important features of the main
menu or the Treeview, as well as it allows to switch the current model. Depending on the current
position of the mouse cursor, additional information is displayed in the Status Bar at the bottom
of the main window.
Medical data includes all data necessary for modelling and simulating a virtual patient. When
referring to a patient le, patient data and interactions can be distinguished. Interactions map
simulation and surgeries of the virtual patient through appropriate choice of the simulation
parameters. All values of these simulation parameters, which describe a pathological situation
or simulate a surgical intervention, are centralized into medical data.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 183
Figure 6.13: Default View of the SEE++ Software System
Thus, Medical data includes data for left eye, right eye and a so-called reference eye.
6.3.2.1 Globe Data
Every eye simulated by SEE++ has its own globe data parameters. In this explanation, the
left eye is used as an example. Of course, all details apply similarly to the right eye and the
reference eye.
Figure 6.14: Globe Data Parameters of the SEE++ System
This dialog shown in Fig. 6.14 displays the current patients name if previously entered in the
patients data. The values to be adjusted here are Globe Radius and Cornea Radius, whereby
preset default values depend on the geometric model selected. The globe aects the result of
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 184
the simulation fundamentally, since an enlarged or reduced radius leads to dierent forces of the
muscles acting on the globe. When this value is modied, additionally all points of insertion and
pulleys (functional origins) of all muscles are adapted automatically. Changing the cornea radius
aects only the geometric shape of the globe, but not the result of the simulation.
6.3.2.2 Muscle Data
The muscle data dialog shown in Fig. 6.15 is one of the most important elements of the SEE++
system. Here, the muscle force model can be adapted to pathological conditions with regard to
particular eye muscles. All data in this dialog inuences the development of force of all or of
certain muscles only. Consequently, muscle palsies, overactions or broses can be simulated (cf.
Sec. 3.5). Again, muscle data is present for all eyes simulated by SEE++ (left eye, right eye
and reference eye).
Figure 6.15: Muscle Data Parameters of the SEE++ System
The muscle data dialog also oers the possibility to manually modify some geometric properties
(i.e. origin, pulley and insertion). Modifying these parameters causes alteration of muscle path,
and thus a dierent result of the simulation. All values are dened in primary position, even if
the 3D view depicts a dierent eye position, the muscle dialog, in its geometric values, always
refers to primary position.
Modication of muscle force parameters applies to the muscle force curves (i.e. elastic, contractile
and total force) situated on the right side of the dialog. These curves can be adjusted according
to the simulation parameters dened in Sec. 4.5.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 185
6.3.2.3 Distribution of Innervation
The dialog for modifying the distribution of innervation controls the activation potential of the
muscles on the basis of stimuli generated by motor nuclei of the cranial nerves (cf. Sec. 2.2.3).
Since this distribution is connected to every eye, it represents an abstraction from the actual
anatomical structure (cf. Sec. 2.2.3). Dierent nuclear or supranuclear lesions can be modelled
by appropriate adaptation of the distribution of innervation for the left and/or the right eye. The
distribution of innervation is available for all eyes simulated by SEE++ (left eye, right eye and
reference eye).
6.3.2.4 Gaze Patterns
Additionally, a gaze pattern can be dened for the left and the right eye, each specifying xation
positions for the simulation of the Hess-Lancaster test (cf. Sec. 3.13). The dialog shown in
Fig. 6.16 enables modication and storage of gaze patterns, as well as the possibility to manually
enter measured patient values in order to compare simulation predictions with patient measured
data.
Figure 6.16: Gaze Pattern Dialog of the SEE++ System
Changes concerning medical data are saved as interactions in scenarios that are assigned to a
patient. They are saved along with the patient le as well. By using this scenario concept,
simulation tasks can be retrieved at a later time without loosing the order in which they were
performed.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 186
6.4 Evaluation
In the following sections, dierent examples for the simulation and correction of pathological cases
are described. The rst two examples show common basic cases of pathologies that aect only a
single muscle. In further examples, simulation results are also compared to clinical measurements
acquired pre- and postoperatively from patients that had surgery.
6.4.1 Abducens Palsy
In the rst example, an abducens palsy of the right eye will be simulated. Abducens palsy is an
incomitant form of squinting, i.e. the squint angle increases in the main functional direction of
the muscle concerned - namely the lateral rectus muscle - towards abduction. Clinically, a patient
increasingly shows double images (uncrossed) towards abduction, thus in right gaze positions.
Possible causes for an abducens palsy are, among other things, traumata of the peripheral nerve
(that is the entire nerve without the nucleus) caused for example by a basal skull fracture. As a
result, a damage to the nerve from the nucleus (in the brainstem) up to the insertion can take
place. In case of a damage directly within the area of the nucleus, there is a possibility that also
the interneurons (the connections between the nucleus of the abducens nerve and the conjugated
muscle on the other side, the left medial rectus muscle in this case), which are situated in the
neighborhood, are hurt. This case is not assumed in this example.
6.4.1.1 Simulation of the Pathology
As a consequence of a lesion to the nerve, the contractile strength of the muscle has to be reduced
and furthermore its elastic parts have to be modied. This is the basis for the simulation. In the
SEE++ software system, this force reduction is carried out in the muscle data dialog, shown
in Fig. 6.17.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 187
Figure 6.17: Muscle Properties for Abducens Palsy Simulation
In the eld Total Strength the strength of the muscle can be reduced by changing the value
from 1(%/100) to 0.5(%/100). When the Hess-diagram calculation is displayed, the modications
from the muscle data dialog are immediately taken into account (see Fig. 6.18).
Figure 6.18: Hess-Lancaster Test for Abducens Palsy
In the calculated Hess-diagram shown in Fig. 6.18, for the left eye (right eye xing) the exceeding
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 188
reaction of the following left eye into adduction can be seen. Conversely, in the second Hess-
diagram the restriction of the right eye (left eye xing) in abduction is evident. On the basis
of the results of the simulation, which are represented by the Hess-diagrams in Fig. 6.18, the
simulation of the abducens palsy can be considered as sucient.
6.4.1.2 Simulation of Surgical Correction
For the surgical correction of the simulated abducens palsy, a strengthening of the paretic muscle
is necessary. The surgery is carried out by shortening the aected lateral rectus muscle (resection).
During a resection surgery, the insertion of a muscle is separated from the globe, a piece of the
muscle is cut o or folded in and afterwards, the muscle is xed again at the same position on the
globe. For shortening a muscle in SEE++, the muscle data dialog is used again. The relaxed,
denervated muscle length (L0) of the right lateral rectus muscle is reduced by 4 mm from 37.5
mm to 33.5 mm (see Fig. 6.19).
Figure 6.19: Simulation of Right Lateral Rectus Resection
Now the two Hess-diagrams in Fig. 6.20 show that the target of the surgical correction has been
achieved, namely to get the double image-free zone into the primary position without substantially
weakening adduction.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 189
Figure 6.20: Postoperative Hess-Lancaster Simulation for Abducens Palsy
However, a complete healing of the palsy by modifying the innervational component in the
model is clinically not possible, since a surgical modication of innervation is impossible.
6.4.2 Superior Oblique Palsy
In the second example, a palsy of the superior oblique muscle of the right eye will be simulated.
This palsy is, similar to the abducens palsy, an incomitant form of squint. The vertical deviation
of the palsied eye increases towards adduction and depression, equally, extorsion increases in
abduction. The horizontal component is aected in the sense of a convergent deviation. Again,
similar to the abducens palsy, a possible cause can be a basal skull fracture, since the trochlear
nerve, like the abducens nerve, is vulnerable to traumatic injuries due to its length. Clinically,
the patient usually takes an abnormal head posture (tilt to the left) for balancing extorsion and
for maintenance of binocular vision. Vertically shifted and outward-tilted double images increase
in depression and convergence (in the main functional range of the concerned muscle).
6.4.2.1 Simulation of the Pathology
Similar to the simulation of the abducens palsy (see Sec. 6.4.1), the contractile strength of the
muscle has to be reduced and furthermore, its elastic parts have to be changed (see Fig. 6.21).
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 190
Figure 6.21: Muscle Properties for Superior Oblique Palsy
For successfully simulating a superior oblique palsy, the strength of the superior oblique muscle of
the right eye has to be reduced. In the SEE++ software system, this force reduction is carried
out in the muscle data dialog shown in Fig. 6.21.
In the eld Total Strength the strength of the muscle can be reduced by changing the value
from 1(%/100) to 0.3(%/100).
Figure 6.22: Hess-Lancaster Simulation of Superior Oblique Palsy
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 191
In the calculated Hess-diagram shown in Fig. 6.22, the exceeding reaction of the inferior rectus
muscle of the left eye (right eye xing) can be seen. In the second Hess-diagram, the increasing
incomitant restriction of the superior oblique muscle of the right eye (left eye xing) in adduction
can be clearly seen. On the basis of the results of this simulation, the simulation of the superior
oblique palsy can be considered as sucient.
6.4.2.2 Simulation of Surgical Correction
For the surgical correction of the simulated superior oblique palsy, a strengthening of the paretic
muscle is necessary. The surgery is carried out by shortening the aected superior oblique muscle
(resection). According to Sec. 6.4.1, the relaxed, denervated length (L0) of the muscle (superior
oblique muscle) is reduced by 5 mm from 34.15 mm to 29.15 mm and the simulation results are
shown in Fig. 6.23.
Figure 6.23: Postoperative Hess-Lancaster Simulation for Superior Oblique Palsy
Now, the two Hess-diagrams in Fig. 6.23 show that the target of the surgical correction has
been achieved, namely to get the double image-free zone into the primary position. However,
as explained in Sec. 6.4.1, a complete healing of the palsy, even in extreme adduction and
depression, is clinically not possible, since a surgical modication of the innervation is impossible.
6.4.3 Superior Oblique Overaction
Vertically incomitant squinting is characterized as horizontal misalignment of the eyes in which
the magnitude of the horizontal deviation diers in upgaze when compared to downgaze. Com-
monly, so called A-patterns and V-patterns are seen with respect to the Hess-Lancaster test.
These patterns are named using letters of the alphabet whose shapes have visual similarities to
the ocular motility patterns that they describe.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 192
(a) Increased Divergence in Downgaze (b) Increased Convergence in Upgaze
Figure 6.24: Classication of Superior Oblique Overaction
The term A-pattern designates a vertically incomitant horizontal deviation, shown in Fig. 6.24,
in which there is more convergence in midline upgaze (see Fig. 6.24(b)) and less convergence
(increased divergence) in midline downgaze (see Fig. 6.24(a)). An A-pattern esotropia is an
inward deviation of the visual axes in which there is more inward deviation of the eyes in midline
upgaze than in midline downgaze. An A-pattern exotropia is an outward deviation of the visual
axes in which there is more divergence of the eyes in midline downgaze than in midline upgaze.
With signicant A-patterns, version testing usually reveals superior oblique muscle overaction.
The tertiary abduction eect of the superior oblique muscle is believed to produce the A-pattern.
The abducting force is greatest in downgaze within the superior obliques primary eld of action,
causing an increased relative divergence of the eyes in downgaze.
6.4.3.1 Simulation of the Pathology
In order to simulate superior oblique overaction, clinically measured patient data was used to
compare predictions of the SEE++ software system when adjusting simulation parameters.
The simulated pathology is shown in Fig. 6.25, where the measured patient data is displayed as
green Hess-Lancaster diagram and the simulation results are shown in red.
In order to simulate the pathology, the path of the superior oblique muscle from the trochlea to
the insertion was modied. In the SEE++ software system, this can be done by displacing the
virtual pulley of the superior oblique muscle away from the nose. Thus, the pulley position of
the superior oblique was changed from 15.270/11.000/11.750 to 13.250/11.000/11.750.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 193
Figure 6.25: Hess-Lancaster Simulation of Superior Oblique Overaction
In order to show an overacting superior oblique muscle, the total muscle strength was changed
from 1.00(%/100) to 2.10(%/100), additionally the relaxed, denervated muscle length (L0) was
reduced from 34.150 mm to 32.150 mm. Conversely, the total muscle strength of the inferior
oblique muscle was reduced from 1.00(%/100) to 0.20(%/100) and the muscle length (L0) was
changed from 30.55 mm to 34.55 mm. Thus, the inferior oblique muscle was lengthened, whereas
the superior oblique muscle was shortened. The result of the simulation can be seen in Fig. 6.25.
6.4.3.2 Simulation of Surgical Correction
In order to correct the pathological situation shown in Fig. 6.25, a weakening of the concerned
muscle needs to be carried out. Therefore, the right superior rectus muscle was transposed along
its main direction of action, as shown in Fig. 6.26. This leads to a sucient correction within
horizontal gaze positions.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 194
(a) Recession and Transposition of the Superior
Oblique Muscle
(b) Final Position of the Superior Oblique Muscle
after Surgery
Figure 6.26: Simulation of Superior Oblique Surgery
The complete surgical treatment is characterized by a recession of the right superior oblique
muscle of 8.6 mm followed by a tangential transposition of 4.5 mm (see Fig. 6.26(a)). The
resulting position of the superior oblique muscle can be seen in Fig. 6.26(b).
The simulation results of this operation are shown in Fig. 6.27.
Figure 6.27: Hess-Lancaster Simulation of Superior Oblique Surgery
It can be seen that the results of the simulation predictions correspond to postoperative treatment
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 195
prospects in that within the normal physiologic eld of gaze, binocular function has been restored
to near normal conditions.
6.4.4 Heavy-Eye Syndrome
Motility disorders caused by a myopic globe with high axial length were reported in literature
long ago. Donder reported in 1864 [Don64] frequent divergence in high myope patients whose
elongated globes nd diculty in orientation. The same phenomenon is described in a text book
by Duke Elder (1968) [DE73] in patients with only one myopic eye. A deviation of this type was
called the heavy eye syndrome by Ward (1967) (cf. [Kau95]). Such an eye is frequently limited
in vertical excursions.
For this reason R. Hugonnier and Magnard (1960) suggested the designation the nervous syn-
drome of high myopia, which, because of the muscular aetiology, was changed to myopic myosi-
tis by Hugonnier (1965) [Hug65].
The term heavy eye syndrome is descriptive for hypotrophia. Anatomic studies showed an irreg-
ular path of the extraocular muscle from the origin through the orbit to the point of insertion.
Kaufmann [Kau95] interpreted the heavy eye syndrome with a dislocation of the medial and
lateral rectus muscles into a caudal position. These translocations should cause an overweight
of downward rotating force. Furthermore, Kaufmann reports a shift of the superior and inferior
rectus muscle in nasal direction with the result of adduction overweight. Detailed information
was gathered using MRI analysis of myope patients.
Several publications analyzed the exact muscle path and quantied the translocation of the
aected muscle. Krzizok [KKT97] reported a dislocation of the lateral rectus muscle into the
temporocaudal quadrant by 3.4 mm based on MRI ndings. Furthermore, Krzizok suggested a
xation of the dislocated muscle in the physiological meridian as causal therapy.
In a publication by Schroeder [SKT98], the dislocation of all four rectus muscles is quantied.
Schroeder reported a dislocation of 2.9 mm of the lateral rectus muscle into the lower temporal
quadrant, the path of the superior rectus muscle was altered 1.5 mm medially and the path of
the inferior rectus muscle was shifted 1.3 mm medially, the medial rectus muscle was dislocated
1.3 mm downwards. Before these MRI studies, aetiology of the heavy eye syndrome was unclear.
(a) Lateral Rectus Muscle with Normal Path (b) Displacement of the Lateral Rectus Muscle
into Temporocaudal Quadrant (Base Hypothesis
for Hypotrophy in Heavy-Eye Syndrome)
Figure 6.28: Muscle Displacement as Hypothesis for Heavy-Eye Syndrome
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 196
Fig. 6.28 illustrates the eect of dislocation of the pulley in temporocaudal position. The pulling
direction of the muscle shown in Fig. 6.28(a) is shifted in the same way. Contraction of the
muscle shown in Fig. 6.28(b) causes mainly abduction but also a downward movement. The
biomechanical relevance of these dislocations with the result of downward movement of the eye
was not analyzed up to now.
Dislocations of rectus muscles are reported in a range from 1.3 mm up to 3.4 mm. The operation
is usually performed with permanent sutures or silicon loops. This technique is also known as
guide pulleys, which aims to establish an articial xation and avoid a further side-slip of the
muscle. These guide pulleys xate the muscles to the globe and therefore inuence the natural
pulleys. MRI analysis was not able to clarify mechanical eects which may be responsible for the
heavy eye syndrome.
6.4.4.1 Simulation of the Pathology
The primary aspect for the simulation of the Heavy-Eye Syndrome is the enlargement of the globe
of the aected eye. Due to an oversized globe, the rotational eect of all muscles that act on the
aected eye is much lower compared to a normal eye. Moreover, muscle tension increases, since
the distance from the pulley to the insertion also extents, while muscle length stays constant.
For this simulation, a 48 years old patient with Heavy-Eye Syndrome was measured and compared
with predictions of the SEE++ biomechanical simulation system. The measured values in
Fig. 6.29 are shown in green color.
Figure 6.29: Measured Values from Patient with Heavy-Eye Syndrome
The rst step in the simulation is the modication of the globe radius for both eyes according to
ultrasonic globe measurements of the patient. Thus, the globe radius of the left eye was changed
to 14.00 mm and the globe radius of the right eye was changed to 16.50 mm. The results of the
simulation for these changes can be seen in Fig. 6.30.
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 197
Figure 6.30: Simulation Results for Resized Globes according to Patient Data
The second step is the simulation of the muscle dislocations in order to reproduce the Heavy-Eye
Syndrome according to suggestions from Schroeder and Krzizok. By dislocating the pulleys of all
four rectus muscles, the typical downward overaction of the aected eye could not be reproduced
in the SEE++ system, using the suggested approach, as illustrated by the simulation results in
Fig. 6.31.
Figure 6.31: Simulation Attempt using Data suggested by Schroeder and Krzizok
In contrast to suggestions found in literature, biomechanical simulation of pulley dislocations
using the SEE++ software system barely aects horizontal gaze positions in the Heavy-Eye
Syndrome. Therefore, the oblique muscles obviously contribute to this pathology due to supe-
rior oblique overaction and inferior oblique underaction which in turn inuences horizontal gaze
positions.
In order to simulate the Heavy-Eye Syndrome according to measured patient data, modication
of the oblique muscles was performed as shown in Fig. 6.34, in that the insertion of the superior
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 198
oblique was moved so that both oblique muscle form a steeper angle to the median-sagittal
plane (compare Fig. 6.32(a) and Fig. 6.32(b)). Additionally, the oblique superior muscle was
strengthened, whereas the inferior oblique muscle was weakened. This results in amplication of
the downward movement of the globe.
(a) Normal Insertion Location of
the Superior Oblique Muscle
(b) Transposed Superior Oblique
Insertion
Figure 6.32: Superior Oblique Muscle Insertion Transposition in Heavy-Eye Simulation
The complete values for the simulation parameters that lead to the simulation results shown in
Fig. 6.33 are denoted as follows:
Globe radius of the right eye was changed from 11.90 mm to 16.50 mm.
Globe radius of the left eye was changed from 11.90 mm to 14.00 mm.
The right lateral rectus pulley was displaced 2.90 mm inferiorly.
The right medial rectus pulley was displaced 1.30 mm inferiorly.
The right superior rectus pulley was displaced 1.50 mm medially.
The right inferior rectus pulley was displaced 1.30 mm medially.
The right medial rectus contractile strength was changed from 1.00(%/100) to 2.00(%/100).
The right lateral rectus contractile strength was changed from 1.00(%/100) to 0.50(%/100),
the elastic strength was changed from 1.00(%/100) to 0.20(%/100).
The right superior rectus contractile strength was changed from 1.00(%/100) to 1.10(%/100),
the elastic strength was changed from 1.00(%/100) to 0.50(%/100).
The right inferior rectus total strength was changed from 1.00(%/100) to 1.80(%/100).
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 199
Figure 6.33: Hess-Lancaster Simulation Results of the Heavy-Eye Syndrome
6.4.4.2 Simulation of Surgical Correction
The patient with Heavy-Eye syndrome simulated in Sec. 6.4.4.1 was treated with superior oblique,
medial and lateral rectus surgery. The insertion of the superior oblique muscle was transposed
to the vertical pole (see Fig. 6.34(b). The medial rectus muscle was recessed by 4 mm and
tangentially transposed downward by 4 mm, whereas plication surgery was performed at the
lateral rectus muscle by 7 mm followed by a 4 mm upward tangential transposition.
(a) Directions of Muscle Trans-
positions
(1) Anterior/Posterior Transpo-
sition (2) Tangential Transposi-
tion
(b) Fixation of Muscle to the
Vertical Pole
Figure 6.34: Muscle Surgery for Heavy-Eye Simulation
The same surgery was simulated using the SEE++ software system. The following modications
CHAPTER 6. SOFTWARE DESIGN AND IMPLEMENTATION 200
to simulation parameters were performed:
The right superior oblique muscle was positioned at the vertical pole (see Fig. 6.34(b)),
in that the insertion was moved 13.20 mm horizontally posterior and subsequently moved
-2.90 mm tangentially (see Fig. 6.34(a)).
The insertion of the right medial rectus muscle was moved 4.00 mm horizontal posterior
and subsequently moved -4.00 mm tangentially (see Fig. 6.34(a)).
The insertion of the right lateral rectus muscle was moved 5.00 mm tangentially (see
Fig. 6.34(a)).
The right lateral rectus muscle length (L0) was changed from 37.50 mm to 32.00 mm.
The simulation result is shown in the Hess-Lancaster diagram in Fig. 6.35. The results show
satisfactory reorientation of the lines of sight in primary position. However, full restoration of
ocular motility in case of Heavy-Eye Syndrome is most often not possible due to the diseases
extensive pathological impact.
Figure 6.35: Hess-Lancaster Simulation Results of the Heavy-Eye Surgery
The simulation results from Fig. 6.35 show that the biomechanical model described in this thesis is
also capable of simulating complicated pathological situations as well as their surgical treatment.
Amounts of surgery that were performed on the patient can be used identically or with only small
adjustments within the biomechanical model, which provides proper anatomical conformance in
most cases. This way, the SEE++ software system provides a good approximation for clinical
pre- and postoperative simulation.
Chapter 7
Conclusion
The research work described in this thesis has been inspired by the idea that modern technologies
can also contribute and even advance medical processes, in this case, the eld of strabismus
surgeries. Besides the technical skills in informatics, software engineering and biomechanics,
extensive medical knowledge was needed to create a modern, interactive software system that
supports surgeons in complicated medical decision making and explains students fundamentals
about the way how the oculomotor system works.
One of the most challenging task within this research work was communication with physicians
and medical personnel. Since this research work already started in 1996, almost the rst two
years were spent with gathering medical knowledge and nding common ways to communicate
and talk about medical and technical topics. This common language can be identied as vital
for all further work that was accomplished within this research project.
From the technical point of view, a complex software system needed to be designed that pro-
vides exibility and extensibility, since many state of the art research results within the eld of
extraocular physiology needed to be incorporated successively. Moreover, it was even necessary
to carry out medical studies with partner institutions in order to gain deeper insight in specic
topics of extraocular muscle function and provide the possibility to study pathological situations.
One of these studies is described in Sec. 2.1.4 and Sec. 5, where high resolution MRI studies
were carried out in order to visualize 3D reconstructions of the morphology of the extraocular
muscles in normal human subjects. However, many other research data was needed to develop
a biomechanical model of the human eye. Many other partners provided data about extraocular
muscle force measurements, extraocular geometry and eye motility diagnostics. Without these
medical basis, a mathematical model would never show any relation in its predictions compared
to the human eye.
While developing this model and the software system, it was early realized that the basic un-
derstanding of the function of the oculomotor system is still under heavy discussion. After
implementing and simulating ocular geometry based on the string and tape models (cf. Sec. 4.4),
the pulley hypothesis proposed a very dierent operation mode of the oculomotor system. Inte-
grating pulleys into the biomechanical model also claried how muscle force predictions can be
related to eye positions in a way such that muscle force equilibrium denes a stable eye position.
Nevertheless, these new ndings were incorporated into other biomechanical models before, but
201
CHAPTER 7. CONCLUSION 202
one of the main achievements of this work was that the problem of nding stable eye positions was
reduced to a common non-linear optimization problem, without invalidating model predictions.
Another main feature of the developed software system SEE++ is, that it provides a simple
and easy to use interface which controls biomechanical model parameters in way that is familiar
to medical personnel and physicians. Moreover, one of the goals was that a physician working
with this software system does not need extensive mathematical background knowledge in order
to simulate complex pathological eye motility disorder. In contrast, the user is able to identify
anatomically related parameters and surgical techniques that closely correspond to clinical ex-
perience. Thus, the biomechanical model can be parameterized, using measured patient data
without additional modication.
Concerning the mathematical background of the biomechanical model, implementation was split
into pure modelling of the biomechanics of the oculomotor system and representation of anatomi-
cal abstraction that form an interface to the biomechanical model. This way, maximum exibility
on both ends of the software system was reached. The user interface can be modied without the
need to adapt the biomechanical model. Conversely, the biomechanical model can be modied in
its workow or its behavior that controls model predictions, without modifying the user interface
that controls anatomically related parameters that inuence the model.
One of the most important parts of the system is the interactive 3D representation of a virtual
patient. To provide anatomically relevant models in three dimensions, extensive work has been
carried out in the eld of image analysis and image processing (cf. Sec. 5). Therefore, knowledge
in 3D computer graphics and geometry needed to be incorporated into the software system.
Modern methods for user interface design and interactive control of 3D scene rendering were
implemented to give the user most intuitive control (cf. [Fal99]).
Numerical mathematics, especially algorithms for solving non-linear optimization problems were
used to connect ocular geometry with muscle force simulation and solve forward and inverse
kinematics. Based on these formulations, clinical test methods were investigated and checked for
suitability with respect to integration into the software system. Especially the Hess-Lancaster
test of binocular function (cf. Sec. 3.13) turned out to give valuable information due to its
extensive clinical usage and its relation to other similar measurement methods (cf. Sec. 3.4)
within clinical assessment of eye motility disorders. Therefore, the clinical Hess-Lancaster test
was implemented based on the biomechanical model (cf. Sec. 4.7.1). This abstraction of a
clinical measurement technique also solves the crucial problem of connecting both eyes in order
to transform innervations of one eye to innervations of the fellow eye. Since the horizontal rectus
muscles are mirrored with respect to their locations between both eyes, innervations can be
transformed by using a virtual reference eye that transforms innervations based on mirrored eye
positions. This also provided a basis for simulating neural control of the oculomotor nuclei in
order to also simulate neurological disorders.
Within the last four years, research within this project has been concentrated on rening the
biomechanical model by evaluating dierent pathological cases and comparing model predictions
to clinically measured patient data. Extensive coordination between clinical studies and technical
realization was performed during this time. Dierent partner institutions have been engaged
within this process. The university hospitals of Graz and Innsbruck have contributed to this
work in providing clinical data and studies. The hospital St. Plten and the Wagner Jauregg
hospital in Linz assisted in carrying out anatomical and physiological studies using MRI and
CHAPTER 7. CONCLUSION 203
human dissections. The convent hospital of the Barmherzigen Brder is the primary cooperation
partner within this research work and has been the rst institution to use the SEE++ software
system clinically. Currently, the university hospital of Vienna evaluates the system for educational
purposes. International cooperations supported this work by providing in depth knowledge about
ocular physiology and anatomy. The Smith Kettlewell Eye Research Institute in San Francisco
provided muscle force measurement data (cf. Sec. 2.3.2) and the university hospital of the ETH
Zurich provided measurement data of eye movements.
Besides the eorts of research and software implementation, the most challenging task was the
integration of the software system into the clinical environment. During the last four years, pub-
lications and conference presentations in the eld of strabismus research have been published and
worldwide attention has been gained. In order to convince physicians of the reasonable practical
relevance of such a software system, pure mathematical proofs do not suce. Instead, many
case studies have additionally been presented in order to show clinical compliance of simulation
predictions. The idea was to propose a new way of planning and simulating eye muscle surgeries
and to provide methods to study the functions of the oculomotor system. Currently, a book on
eye motility disorders and computer aided simulation and treatment is being published to give
deeper insight into possibilities and future prospects in using this new methodology.
7.1 Goals Achieved
Within the medical eld, the main goals were to advance the clinical treatment of eye motility
disorders and to provide computer aided teaching support. Within the clinical integration process
of the software system SEE++ these goals were achieved by carrying out clinical trials and
comparisons of patient data. Thus, clinical application of the SEE++ improved patient care
by supporting surgeons in diagnosis and preoperative planning. Often, up to three successive
operations are performed in order to achieve a successful treatment result. Especially in such
cases, the application of computer aided surgical treatment contributes to minimize repeated
surgical treatment which results in benets for the patients and directly reduces treatment costs.
The integration of the biomechanical eye model into the eld of medical training and education
enables students and teachers to interactively explain and study basic functional aspects as
well as surgical methods. Educational trial lessons have shown that the presented software
system supports students in self-studying the function of the oculomotor system and considerably
enhance basic understanding of functional implications of dierent surgical treatment methods.
In basic research, this biomechanical model provides a way of gaining a more detailed under-
standing in principles and processes that aect oculomotor control. In this case, biomechanical
models provides an ecient method for checking hypotheses and verifying experimental data.
Moreover, state of the art research results in anatomy and physiology can be incorporated into
the biomechanical model and subsequently improve simulation predictions.
The SEE++ software system currently implements the worldwide most accurate and up to
date biomechanical model of the human eye. Due to a well structured object oriented design,
this system provides adequate exibility for further improvements. Integration of interactive three
dimensional visualization methods and a user interface that corresponds to anatomical notions
provide an ecient new way for physicians to intuitively handle biomechanical simulations.
CHAPTER 7. CONCLUSION 204
7.2 Future Work
During research, many additional topics and ideas for enhancements and future investigations
have been discovered. Most of the future work that is planned will concentrate on further im-
provements of the biomechanical model and the software system SEE++. However, additional
work will try to use parts of the SEE++ software for the development of new measurement and
clinical diagnostic methods.
One of the next improvements of the biomechanical model will introduce the active pulley hypoth-
esis (cf. Sec. 2.1.2) in that a muscle consists of two distinct layers, one inserting at the pulley
and one on the globe. Additionally, data from Demer et. al. [KCD02] suggests that pulleys
are dislocated as a function of eye position or muscle innervation. Integration of active pulleys
may lead to even more accurate simulation predictions, especially when simulating pathological
situations.
Up to now, a physician that is interested in exploring surgical methods needs to reproduce a
pathological situation in terms of model parameter values before simulation of surgery can be
accomplished. One major extension to the biomechanical model will deal with the automated gen-
eration of pathological simulations based upon measured patient data. Therefore, biomechanical
model parameter values need to be t to actual clinical measurements. Using such functionality
would greatly improve clinical usage.
Currently, the extension of the SEE++ system into a scalable component architecture, realizing
a biomechanical construction kit is evaluated. This construction kit should provide standard
types of elements in order to aggregate and combine new biomechanical models based on a
graphical interactive way of programming.
In order to assign standard cases to specic classes of pathologies, patient data will be - ad-
ditionally to the computation of functional interpretations - stored in a knowledge base. This
enables the system to suggest a suitable surgery for a new pathological case that ts into one of
already stored pathological classes. This practice of evidence-based medicine means integrating
individual clinical expertise with the best available external clinical evidence from systematic
research.
One of the most exciting future development will aim improvements of eye position measurement
methods (cf. Sec. 2.3), especially within ecient objective measurements using video oculography
(cf. Sec. 2.3.1.4). Currently, two techniques exist for the recording of eye positions: scleral search
coils (cf. Sec. 2.3.1.3), and video-oculography (VOG). While scleral search coils have a high
temporal and spatial resolution, they are too expensive and invasive to be used outside the
research laboratory. One part of the future work is the development of new VOG algorithms
that compensate for translations of the camera with respect to the head. Additionally, the
SEE++ software system shall serve as front end for VOG measurements in order to show how
eye movements change after surgery on the extraocular muscles.
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Curriculum Vitae
Michael Buchberger
Address
Bahnhofstr. 63
A-4230 Pregarten
Austria
Phone: +43 664 1651980
Email: Michael.Buchberger@uar.at
Homepage: www.uar-mi.at/sta/mbuchber
Personal Details
Gender: Male
Date of birth: 12th of April, 1974
Place of birth: Linz, Austria
Citizenship: Austrian
Education
20002003 University of Linz, Austria
Doctorate study
Research Project SEE-KID (Software Engineering Environment for Knowl-
edge Based, Interactive Eye Motility Diagnostics)
19941998 Upper Austria University of Applied Sciences, Hagenberg
Study of Software-Engineering
Graduation with honors
Diploma Thesis: Design and Implementation of a Client/Server System for a
Digital Video Archive
19921994 University of Linz, Austria
Study of Informatics for 4 semesters
19881992 Bundes- Oberstufenrealgymnasium Linz/Honauerstr., Austria
High-School with special emphasis on Informatics.
Working Experience
since 01/2003 Upper Austrian Research GmbH, Hagenberg, Austria
Head of the Research Department for Medical-Informatics
20002003 Upper Austrian University of Applied Sciences, Hagenberg, Austria
Research Assistant at the Department for Software-Engineering for Medicine
Project advisor research project SEE-KID (www.see-kid.at), funded by
the Austrian Ministry of Science and Technology (FFF)
Collaboration within the establishment of the research department of the
Upper Austrian University of Applied Sciences (FORTE), Hagenberg
Collaboration within the establishment of an Information Marketplace
Hagenberg, funded by the Austrian Ministry of Science and Technology
(FFF)
03/2002 Consulting for SKI-DATA AG, Salzburg, Austria
Consulting activities in the elds of project engineering and object-oriented
software design using modelling languages (UML).
09/2001 Consulting for Posimis Internet GmbH, Linz, Austria
Consulting in the eld of computer graphics and animation for Internet appli-
cations.
20002001 Upper Austrian University of Applied Sciences, Hagenberg, Austria
Design and Implementation of the Internet presentation of the Polytechnic Uni-
versity in Hagenberg. Implementation of a dynamic scripting language for the
generation of web pages.
19982000 Research Institute for Symbolic Computation (RISC), Hagenberg, Austria
Collaboration within a project for controlling automated transport system
for TMS Voest Alpine, Linz, Austria.
Project manager for the re-engineering of the accounting system for the
Rinderbrse, Linz, Austria.
19941998 AMS-Engineering GmbH, Hagenberg, Austria
Project manager for dierent project in the eld of industry automation
and data analysis.
Project manager for the project Video X-pert, a Client/Server system for
digital video archiving.
19921994 Landesbildstelle Obersterreich, Linz, Austria
Programmer in the eld of computer aided teaching for Geography and English.
Teaching
20022003 Lecturer at the Upper Austrian University of Applied Sciences, Hagenberg,
Austria
Lecturer at the Department for Hardware/Software Systems Engineering, Systems-
Engineering IV.
01/2002 Lecturer at the Upper Austrian University of Applied Sciences, Hagenberg,
Austria
Seminar for object-oriented software design using modelling languages (UML).
20012002 Trainer at WIFI Linz, Austria
WIFI trainer in Linz und Steyr at the WIFI Fachakademie for Informatics.
Courses in C/C++ programming
WEB-Designer course for programming in Javascript
20012002 Lecturer at the Upper Austrian University of Applied Sciences, Hagenberg,
Austria
Lecturer at the Department for Software-Engineering for Medicine, Project-
Engineering Systems-Engineering: Virtual Surgery.
20002001 Lecturer at the Upper Austrian University of Applied Sciences, Hagenberg,
Austria
Lecturer at the Department for Software-Engineering, Project-Engineering: Data
visualization of automation systems using XML.
19992001 Lecturer at the Upper Austrian University of Applied Sciences, Hagenberg,
Austria
Lecturer at the Department for Software-Engineering for Medicine, Project-
Engineering: Simulation Expert for Eyes + diagnosis + transposition surgery
(SEE++).
19992000 Lecturer at the Upper Austrian University of Applied Sciences, Hagenberg,
Austria
Lecturer at the Department for Software-Engineering. Lecture: Introduction
to object-oriented design using modelling languages.
1999 Guest lecturer at the Upper Austrian University of Applied Sciences
Guest lectures in Software-Engineering and C++ programming.
19982001 University of Linz, Austria
Student Tutor for Algorithms and data-structures for technical Mathematics.
Language Knowledge
German native
English near native
French fair
Programming Skills
Visual Studio, MFC, Borland/Inprise C++ Builder, SNIFF++, Oracle De-
signer Tools, Matlab, Mathematica, Labview, GUPTA SQL, ERWin, Rational
Software Suite, Select OMT/UML, Objectdomain, Visual J++, J-Builder, Del-
phi, Borland Turbo Pascal, Borland C++.
.NET, C/C++, Pascal, Java/Java-Script, Modula-2, Oberon, Python, Perl,
SQL, Basic.
Consultations
01/2004 Consultant in the development of the strategic program of the Upper Austrian
government for research and technology transfer Innovatives Obersterreich
2010+.
Listed in Whos Who in Science and Engineering, 7th Edition, 2003-2004.
Publications
Reviewed Publications
M. Buchberger, T. Kaltofen, S. Priglinger, R. Hrantner, Construction and
Application of an Object-Oriented Computer Model for Simulating Ocular Po-
sitioning Defects, Journal of the Austrian Ophthalmologic Society Nr. 17/4,
Springer-Verlag, pp. 151-157, Vienna, Austria, 2003.
R. Hrantner, M. Buchberger, T. Kaltofen, S. Priglinger, Dierentialdiagnose
vertikaler Schielformen bedingt durch schrge Augenmuskeln und Pulleys, Jour-
nal of the Austrian Ophthalmologic Society Nr. 17/4, Springer-Verlag, pp.
158-163, Vienna, Austria, 2003.
M. Buchberger, Ein biomechanisches Modell der Augenmotilitt, Journal of the
Austrian Ophthalmologic Society Nr. 16/4, Springer-Verlag, pp. 176-182, Vi-
enna, Austria, 2002.
Conference Papers
M. Buchberger, T. Kaltofen, An Ophthalmologic Diagnostic Tool Using MR Im-
ages for Biomechanically-Based Muscle Volume Deformation, Proc. of Medical
Imaging 2003, Image Processing; Milan Sonka, Univ. of Iowa (USA); J. Michael
Fitzpatrick, Vanderbilt Univ. (USA), San Diego, USA, 2003.
S. Priglinger, R. Hrantner, M. Buchberger, T. Kaltofen, Functional Topogra-
phy in an Eye Model, Proceedings of Development and Perspectives in Visual
Processing and Eye Movements, The Heidelberg Meeting on Eye Movements,
International Symposium of the German Ophthalmological Society, Heidelberg,
Germany, 2002.
M. Buchberger, Ein dynamisches, volumserhaltendes 3D-Deformationsmodell
von extraokularen Muskeln, basierend auf der Analyse von MRI-Daten, Proc. 1.
Jahrestagung der sterreichischen Wissenschaftlichen Gesellschaft fr Telemedi-
zin, pp. 37, Innsbruck, Austria, 2001.
M. Buchberger, H. Mayr, SEE-KID: Software Engineering Environment for
Knowledge-based Interactive Eye Motility Diagnostics, Proc. International Sym-
posium on Telemedicine, EU Human Potential Programme, pp. 67-79, Gothen-
burg, Sweden, 2000.
Conference Presentations
R. Hrantner, M. Buchberger, T. Kaltofen, S. Priglinger, Myopia Alta, a SEE++
case study, Consilium Strabologicum Austriacum, Innsbruck, Austria, 2003.
M. Buchberger, T. Kaltofen, Ein computeruntersttztes biomechanisches Mod-
ell zur Vorbereitung, Planung und Simulation von Strabismus-Operationen, 44.
Jahrestagung der sterreichischen Ophthalmologischen Gesellschaft, Salzburg,
Austria, 2003.
M. Buchberger, T. Klatofen Computer-based Simulation in Medical Informatics,
Talk at the Brown-Bag Symposium, Smith Kettlewell Eye Research Institute,
San Francisco, USA, 2003.
M. Buchberger, T.Kaltofen, S. Priglinger, R. Hrantner, SEE-KID and EOM-
Modelling, The Heidelberg Meeting on Eye Movements, International Sympo-
sium of the German Ophthalmological Society, Heidelberg, Germany, 2002.
M.Buchberger, J. Hildebrandt, T. Kaltofen MR-Cinematographie der Augen-
motilitt, Consilium Strabologicum Austriacum, St. Plten, Austria, 2001.
References
These persons are familiar with my professional qualications and my character:
Univ.-Prof. Dipl.-Ing. Dr. Roland Wagner
Thesis supervisor Phone: +43 732 2468 8791
FAW-University of Linz Fax: +43 732 2468 9308
Altenberger Strae 69 Email: rrwagner@faw.uni-linz.ac.at
A-4040 Linz, Austria
Univ.-Doz. Dipl.-Ing. Dr. Thomas Haslwanter
Thesis advisor Phone: +41 1 255 3996
Institute for Theoretical Physics, Fax: +41 1 255 4507
ETHZ and Dept. of Neurology
University Hospital Zurich Email: haslwant@neurol.unizh.ch
Frauenklinikstr. 26
8091 Zurich, Switzerland
Univ.-Prof. Dipl.-Ing. Dr. Witold Jacak
Thesis advisor Phone: +43 7236 3888 2000
Upper Austrian University of Applied Sciences Fax: +43 7236 3888 99
Hauptstr. 117 Email: witold.jacak@fh-hagenberg.at
A-4232 Hagenberg, Austria
Prim. Prof. Dr. Siegfried Priglinger
Thesis advisor Phone: +43 732 7897 1300
Convent Hospital of the Barmherzigen Brder Fax: +43 732 7897 1099
Seilersttte 2 Email: Siegfried.Priglinger@bblinz.at
A-4020 Linz, Austria
Prim. Univ.-Doz. DDr. Armin Ettl
Collaborator Phone: +43 2742 300 2869
Hospital St. Plten Fax: +43 2742 300 3285
Propst Fhrer Str. 4 Email: augen2@kh-st-poelten.at
3100 St. Plten, Austria
Univ.-Doz. Dr. Franz Fellner
Collaborator Phone: +43 732 6921 26701
Radiologic Institute of the Wagner Jauregg Hospital Fax: +43 732 6921 26704
Wagner-Jauregg-Weg 15 Email: franz.fellner@gespag.at
A-4020 Linz, Austria

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