Muscular insertion

Ocular Motility Medial rectus 5.5mm away

from sclera (nearest)
Dr. Rivadillo
Superior rectus 8mm away
from sclera (farthest)

Transcribed by: Ruzzlle Anne C. Delos Santos 3-C Medicine

Approximate distances of the rectus muscles from the limbus, and the approximate lengths of tendons.

Oblique Muscles
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The two oblique muscles control primarily torsional movement and, to a lesser extent, upward and downw
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movement of the globe (see Chapter 12).

The superior oblique is the longest and thinnest of the ocular muscles. It originates above and medial to
foramen and partially overlaps the origin of the levator palpebrae superioris muscle. The superior oblique h
fusiform belly (40 mm long) and passes anteriorly in the form of a tendon to its trochlea, or pulley. It is th
backward and downward to attach in a fan shape to the sclera beneath the superior rectus. The trochlea is
cartilaginous structure attached to the frontal bone 3 mm behind the orbital rim. The superior oblique tend
enclosed in a synovial sheath as it passes through the trochlea.

The inferior oblique muscle originates from the nasal side of the orbital wall just behind the inferior orbit
lateral to the nasolacrimal duct. It passes beneath the inferior rectus and then under the lateral rectus mu
onto the sclera with a short tendon. The insertion is into the posterotemporal segment of the globe and ju
macular area. The muscle is 37 mm long.

In the primary position, the muscle plane of the superior and inferior oblique muscles forms an angle of 51
degrees with the optic axis.

Fascia

Ocular movements
All the extraocular muscles are ensheathed by fascia. Near the points of insertion of these muscles, the fas
continuous with Tenon's capsule, and fascial condensations to adjacent orbital structures (check ligaments

Extraocular movements
functional origins of the extraocular muscles (Figures 1!19 and 1!20).

Figure 1!19.

Duction

Primary Secondary Tertiary
Muscles
Movement Movement movements Monocular movement
Superior Rectus Elevation (upward gaze) Adduction Intorsion (incycloduction)
Adduction
Inferior Rectus Depression (downward gaze) Adduction Extorsion (excycloduction)
Infraduction
Lateral Rectus Abduction
Abduction
Medial Rectus Adduction
Supraduction
Superior Oblique Depression (downward gaze) Abduction Intorsion (incycloduction)
Active muscles will have increase innervation
and tonicity
Inferior Oblique Elevation (upward gaze) Abduction Extorsion (excycloduction)

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Ex. Adduction (MRM) , Abduction (LRM)
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Ocular movements Yoke Muscles in Cardinal Positions

Version
Binocular movement, Conjugate movement Eyes up & right RSR & LIO

Supraversion Eyes up & left LSR & RIO

Dextroversion (Right) Eyes right RLR & LMR

Levoversion (Left) Eyes left LLR & RMR
Infraversion
Eyes down & right RIR & LSO
Follows Herrings law of equal innervation -
simultaneous innervation of yoke muscle Eyes down & left LIR & RSO
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 Ocular movements Ocular movements
Vergence

Vergence Convergence - can be voluntary or reflex, If reflex there

are 4 components:

Binocular movement, disconjugate movement Tonic - inherent innervation of MRM

Convergence Proximal - Psychological awareness that there are

nearby objects

Divergence Fusional - Optometer reflex, ensuring that images

are projected to specific retinal area.
Accomodative - initiated by accomodation by
synkinetic reflex (AC/A (Normal) = 3-5 prism
diopter

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Strabismus Strabismus
Manifestation
Under normal condition the two eyes are Deviation - Heterotropia/tropia
parallel to each other to perceive an image
as one, termed as Fusion, landing the 2 Eso - goes to nasal area
images in the fovea centralis simultaneously Exo - lateral

Fusion is supported by 2 phenomenon: Hyper - vertical deviation (up)

Hypo - Vertical deviation (down) -
Ability of eye to land the image at the rarely used
fovea centralis In some instances it is not manifested,
termed as heterophoria /phoria - appears
Ability of EOM to make eyes parallel only if the fusion is interrupted(cover one
anatomically eye with opaque material)
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Strabismus
Classification
Strabismus
Intermittent - Deviation is present sometimes
Constant - Persistent deviation is present Consequences
Monocular - Only one eye is involved Confusion - Simultaneous appreciation of
Alternating - Deviation shifts from one eye to the different stimulus coming from each eye.
other
Diplopia - Simultaneous appreciation of an
Comitant - Non-paralytic, EOM are normal no image but one lands in the fovea the
weakness nor paralysis
other does not
Non-comitant - Paralytic, not same in all
direction of gaze
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 Strabismus Strabismus
Adaptation (usually for childrens eye) Adaptation (usually for childrens eye)

Sensory Motor
Horizontal deviation - you will notice a head
Suppression - sensory suppression of turn in the patient (Ex. RMR paralysis - Lateral
the other image, may lead to amblyopia deviation - Exotropia - patient turns to left)

Abnormal retinal correspondence - Vertical deviation - abnormal position of the

positive sensory response better than
suppression, allows binocular vision
with limited fusion seen in small degree
of deviation (Isotropia)
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chin
Torsional deviation - paralysis of the muscles
(inferior/superior rectus) - patient in sideview
position or head is turned to the opposite side
of the deviation.
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Orthophoria Amblyopia
Condition wherein there is deviation in
Not a subtype of heterophoria visual acuity, in the absence of ocular
pathology or absence of lesions in the
Ideal occular alignment (Normal) visual pathway
Without effort This condition is most often unilateral
Without stimulus of fusion Depending on degree of amblyopia this can
be reversed sometimes

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Amblyopia
Amblyopia
Classification Classification
Strabismic - abnormal ocular deviation, due Stimulus deprivation - a disorder in one of
to suppression the media of the eye, normal image
formation is disrupted
Anisometropic - difference in the refraction Iso-ametropic - Presence of error of
of the two eyes - one of the image is not
refraction, bilateral - large degree of
clear, or difference in size of the image
error, hyperopia, myopia
Meridional - pertains to astigmatism
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 Amblyopia
Treatment
Diagnosis
Visual acuity - a difference of two lines or more in
the visual acuity of 2 eyes can be indicative of amblyopia
Ex. 20/20 - R 20/40 -L Do a pinhole test - if not
improved amblyopia --- examine further --- rule out
other conditions first
Neutral density filter - check if abnormality is
caused by organic lesion or not
Amblyopia
Occlusion - occlude the better seeing eye so you will
force the amblyotic eye to improve (3 days to 1 week
depends on age of patient) then recheck the visual acuity, be
sure not to induce amblyopia on the normal eye , if it is
improving patch again then check again then continue till
stabilization of improvement occurs (if youre patching
youre patient for 6 months then it is not improving then
that condition is different - not amblyopia
Isometropic deviation - 11-12 years duration of occlusion

Ex. 20/20 -R place a filter = decrease if 20/40 -L - place
filter - Decrease more - pathologic not amblyopia -
amblyopia should not have significant drop
Strabismic deviation - 7-8 years duration of occlusion
Not all patients can tolerate occlusion (especially
children)

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Amblyopia Clinical Evaluation

History
Treatment Ocular examination
Penalization - if patient cant tolerate Visual acuity
occlusion Ocular motility
Not as fast and as effective as occlusion Fusion and binocularity
Maddox rod
This involves placing atropine drugs to Titmus fly test
paralyze the muscle of the abnormal eye
Worth four dot test
Ocular alignment test
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Clinical Evaluation
Clinical Evaluation Ocular Examination
Do Visual acuity (First) and Ocular motility
Do examination of external and internal eye
History
Visual Acuity

Look before you leap - before history observe the For Pre-verbal children
patients eye alignment (or deviation), and abnormal Occlusion of one eye (child cries when you occlude the better
head position seeing eye)
Fixation test
Check age of the patient so you will have an idea of
Hundreds and thousands
possible problems in the patient
Rotation test
Family history - almost always positive, inquire Preferential looking
treatment that are being done and results Pattern visually evoked potential

Medical and Neurological history - in cases of cerebral

Optokinetic nystagmus
palsy, almost always there will be deviation. Ocular motility
6 cardinal gaze (Big - H test)
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 Clinical Evaluation Clinical Evaluation
Binocularity & Fusion
Binocularity & Fusion Aligned vision is a must
Aligned vision is a must Titmus Fly Test

Maddox Rod Touch the fly for depth perception, with the use of
special lenses (Imax - like)
A red lens composed of parallel series
of strong cylinders through which a
point of light is viewed as a red lines
used to measure phorias. (from Vaughan
& Asbury)
can have vertical or horizontal striations
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Clinical Evaluation Clinical Evaluation

Ocular Alignment
Binocularity & Fusion to check what kind and where the deviation
Aligned vision is a must is


Worth four dot test
You have a lens, a red (R) and green(L), a flash light with
TEST:
little bulbs of 2 green, 1 red, 1 white.
Cover test
The eye with red lens perceive the red color but not the
green due to wavelength absorption - wear lens.... if
normal all are seen, If 2 reds 3 greens - check either
cover/uncover test
simultaneously or one after the other - Simultaneously, if
5 lights (diplopia) - check if image is crossed then there alternate cover test
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is exodeviation - if one eye after the other (alternating
deviation) prism cover test
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Clinical Evaluation Clinical Evaluation

Ocular Alignment
Ocular Alignment
Corneal light reflex test - check also COVER TEST
deviation present
Interrupt process of fusion
Hirschberg method - 1mm decentation The eye with deviation is covered then observe the
(7 deg. 15 PD) movement of the eye after you remove the cover

Modified Krimsky
(check if exophoric, esophoric)
in Tropia - used to check if you have monocular
Major amblyoscope (chance for amblyopia) or binocular deviation - you
should have a target check if patient has ability to
Disimilar image test focus on the subject (may have alternating type of
deviation) will not develop amblyopia because the
Dissimilar target test eye problem interchange
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 Clinical Evaluation Clinical Evaluation
CORNEAL LIGHT
REFLEX TEST
Ocular Alignment
Hirschberg -
CORNEAL LIGHT REFLEX TEST decentration - if within
pupillary border 15
In normal eye, the reflection of the light deg , if center of iris -
is in the center, Pupil
30 deg, if it is in the
In abnormal eye , not in the middle , if limbal area - deviation
of 45 deg , frequently
towards temporal ESO if towards nasal
EXO used for children to
check angle of deviation
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Esotropia
Clinical Evaluation
CORNEAL LIGHT REFLEX TEST
Most common type of strabismus
Krimsky - also check light in cornea
but uses prism to determine angle
of deviation (number on base of
Non-accomodative
prism - represents diopter (ex. 40
prism diopters) prism - deviates the
Onset at birth
light) - lowest 2 highest 50 (prism
diopter) - observe reflection of the
familial
light then put prism on the fixated Up to 50 prism diopter of deviation
eye then use prism to center the
light then note the number presence of cross fixation
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Esotropia Esotropia
Accomodative
Combined accomodative/non-
Refractive - large degree of error of accomodative
refraction. Increase to see objects in high
degrees of hyperopia also needs Increase after neglected accomodative
accommodation & increase convergence) esotropia,
non refractive - abnormality of synkinetic
familial
reflex
age of onset - between 2-3 years of age abnormal accomodative mechanism
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 Exotropia Exotropia
Exophoria ---> intermittent exotrophia --->constant TREATMENT:
exotropia
Non surgical
Aqcuired exotropia - after surgery for so tropia
spectacles (corrective lenses) - to correct deviating
Accomodative Exotropia eye, if you suspect the amblyopia - do occlusion and
penalizing therapy before giving corrective lens
onset 5 years
Prisms - incorporated with spectacles
familial
Drugs - anti-cholinesterase - miotics - used if
uncorrected myopia (clear vision of near object, patient has correction spectacles but still with
blurred vision of far objects)- no use for certain degree of deviation --- this drugs improve
convergence accommodation and convergence.

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Exotropia Pseudostrabismus
TREATMENT: Eyes appear crossed to the observer but they are actually
parallel.
Surgical (if non surgical does not work) Causes:

recession-weakening procedure - muscle Presence of epicanthus (excessive fold in the skin near
the nasal area)
is removed form anatomical insertion
then resuture it farther, lessens tonicity A broad flat nose
of the muscles Eyes that are exceptionally closed together

resection - strengthening procedure - Oval shaped palpebral fissure

shortening the muscle
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Pseudostrabismus
Causes:
Angle kappa - difference between the visual and
anatomical axis of the eye when assessed with a
penlight
Positive (exodeviation/ pseudoexodeviation) -
visual axis is extremely below the anatomical axis
Negative (esodeviation/pseudoesodeviation) -
visual axis is extremely above the anatomical
axis
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End
Please double check everything because
majority of the notes are just based on what I
heard during lecture & according to my
seatmates they cant hear a thing ... so its
either:
A) I have sonic hearing (,)
B) Everything in this HO is wrong (T.T)
Transcribed by: Ruzzlle Anne C. Delos Santos - 3C
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