BLUK017-Tjandra September 12, 2005 8:37
Textbook of Surgery
Edited by Joe J. Tjandra, Gordon J.A. Clunie, Andrew H. Kaye & Julian A. Smith
80 Double vision
J. E. K. Galbraith
Anatomy
The elucidation of double vision depends on knowledge
of the anatomy of the extra-ocular muscles and their
actions.
The extra-ocular muscles are divided into two
groups. The first group arises from the apex of the orbit
to attach to the sclera anterior to the equator of the eye.
Included in this group are the rectus muscles: medial,
lateral, superior and inferior.
The second group consists of the oblique muscles.
The superior oblique arises from the apex of the orbit
and is deviated through a pulley in the anterior orbit so
that it passes backwards and laterally above the globe
to attach to the postero-lateral area of the upper surface
of the eye. The inferior oblique arises in the anterior or-
bit and passes backwards and laterally under the globe
to attach to the postero-lateral quadrant of the eye in-
feriorly.
Nerve supply
The extra-ocular muscles are supplied by three cranial
nerves. The third cranial nerve passes forward in the
lateral wall of the cavernous sinus and divides ante-
riorly into the superior and inferior divisions, which
enter the orbit through the superior orbital fissure. The
superior division supplies the levator and superior rec-
tus, while the inferior division supplies the medial and
the inferior rectus and the inferior oblique.
The fourth cranial nerve supplies the superior
oblique muscle, and the sixth cranial nerve supplies the
lateral rectus.
Actions
The medial and lateral rectus pass forward from the
apex of the orbit to the globe, and their actions are
© 2006 by Blackwell Publishing Ltd
not influenced by the position of the globe. The medial
rectus only adducts the eye, that is turns it towards the
nose and the lateral rectus only abducts the eye, turning
it outwards away from the nose.
The remaining rectus muscles have three actions de-
pending on the direction of gaze. Clinically one need
only consider the action of a muscle when the eye is
directed along the axis of that muscle.
Thus, when the eye is abducted, the superior or in-
ferior rectus each has only one action – the superior
elevates the eye and the inferior depresses the eye.
When the eye is adducted to look along the line of
action of the superior oblique, it has one action, to de-
press the eye. Its antagonist, the inferior oblique, when
the eye is adducted, elevates the eye. The actions can
be simply represented diagramatically (see Fig. 80.1).
The superior and the inferior oblique muscles also
rotate the eye around an antero-posterior axis. When
the 12 o’clock meridian is rotated towards the nose it
is called intorsion. Rotation of the 12 o’clock meridian
away from the nose is extorsion. The oblique muscles
have no torsional effect when the eye is adducted, but
when the eye is abducted the torsional effect is maxi-
mal. The superior oblique intorts the eye, the inferior
oblique extorts the eye.
SR IO SR
LR MR L R
IR
SO
IR
Fig. 80.1 Actions of ocular muscles.
677
BLUK017-Tjandra September 12, 2005 8:37
678 Problem Solving
Diplopia
Pathology
Diplopia results when the visual axes are not paral-
lel. Very occasionally, it is due to abnormalities in the
refracting surfaces of the eye. The commonest cause
of diplopia is palsy of the third, fourth or sixth cra-
nial nerves resulting from vascular accidents, cerebral
aneurysm, giant cell arteritis, multiple sclerosis, dia-
betes or trauma. Muscular causes are myositis, myas-
thenia gravis, thyroid eye disease and trauma, particu-
larly a blowout fracture of the orbital floor (see Chapter
37).
When a patient complains of sudden onset of painful
diplopia, one should always think of cerebral aneurysm
or diabetes. Diabetes causes occlusion of the small ves-
sels supplying the fourth or sixth nerve causing pain
due to ischaemia.
Diagnosis
The key to the diagnosis of diplopia is the fact that the
eye muscles work in pairs (see Fig. 80.1). When the eye
turns to the left, the left lateral rectus and the right me-
dial rectus combine to produce the movement. When
the eyes look down to the left the movement is pro-
duced by the left inferior rectus and the right superior
oblique.
When the patient complains of diplopia the first
question to ask is, “In which direction is the double
vision maximal?” This then isolates the cause to the
two muscles involved in turning the eye in that direc-
tion.
Because the image in the eye is inverted, the next
step is to cover one eye to determine which eye gives
rise to the image that is furthest away (image inversion
dictates that the eye that moves least has the maximum
displacement of the image). This indicates the muscle
responsible for the diplopia.
Lateral rectus palsy
If the patient complains of double vision looking to the
left, the left lateral rectus or the right medial rectus is
responsible for the diplopia. Covering one eye elicits
the information that the furthest image comes from the
left eye and thus the cause of diplopia is the left lateral
rectus – a lesion of the sixth cranial nerve. Furthermore,
the medial rectus is one of four muscles supplied by the
third nerve, and if the other muscles are acting normally
it is unlikely that one of the four would be defective in
the presence of three healthy muscles.
Fourth cranial nerve palsy
It is easy to diagnose a fourth nerve palsy because this is
the muscle which takes the eye down in adduction. That
is it is the muscle used in reading. Thus a person with
a fourth nerve palsy will complain of double vision, a
line of print will be double, with the second line below
the line being read, and that line will be tilted, while
the other remains level. Again, covering one eye will
enable the diagnosis to be made, as the eye with the
tilted image (due to the unopposed action of the inferior
oblique) will be the eye at fault.
In unilateral fourth nerve palsy, one line is tilted; in a
bilateral fourth nerve palsy both lines of print are tilted
in opposite directions.
The sequelae of muscle palsy
The action of the eye muscles is not as simple as de-
tailed here because in every eye movement all the extra-
ocular muscles are involved, some contracting and oth-
ers relaxing. When one extra-ocular muscle is paretic,
changes occur in all the muscles.
The direct antagonist of the paretic muscle undergoes
contracture because it is opposed by a weaker muscle.
In a right lateral rectus palsy the right medial rectus
undergoes contracture. This tends to increase the sep-
aration of the two images.
The contralateral synergist of the paretic muscle
over-acts. In the case of a right lateral rectus palsy, the
left medial rectus will overact, increasing the separation
of the images. This is due to the paretic muscle receiv-
ing an increased innervation in an attempt to increase
its range of movement: because the contralateral syn-
ergist, in this case the medial rectus, receives the same
innervation it over-acts. Finally, to allow this muscle
to overact, there must be an inhibitional palsy of its
antagonist (in the example this will be the left lateral
rectus).
Another example – a patient with a right superior
oblique palsy suffers a contracture of the right inferior
oblique, over-action of the left inferior rectus and a
secondary palsy of the left superior rectus.
This increases the deviation – this is of value to the
sufferer, as the further apart the images, the easier it is
for one to be suppressed.
BLUK017-Tjandra September 12, 2005 8:37
Fig. 80.2 This patient has a right third
cranial nerve palsy. In the upper picture
he is attempting to look up. The right
eye fails to elevate. In the lower picture
when he attempts to look down the
upper lid elevates owing to
misdirection of nerve fibers. In this case
fibers intended for the inferior rectus
are innervating the levator muscle of
the upper lid.
Sometimes the secondary effects of the paretic muscle
do not recover when the paresis recovers. Surgery to the
overacting, but healthy, muscle may then be necessary
to weaken it.
Aberrant regeneration
Aberrant regeneration is commonly seen after a third
nerve palsy resulting usually from head trauma. When
the nerve recovers, some fibers will be misdirected. Typ-
ically, when the patient converges the eyes, the upper
eyelid elevates because fibers to the medial rectus have
reinnervated the levator of the upper lid. (See Fig. 80.2).
Aberrant regeneration is untreatable.
Surgery of diplopia
The principles of the surgery of double vision are:
r to strengthen weak muscles by lengthening them,
r to weaken overacting muscles by shortening them.
A muscle is strengthened by excising some of the
tendon and then resuturing it to its original insertion.
A muscle is weakened by removing it from the globe
and re-attaching it closer to its origin.
A paretic muscle may be strengthened by excising
a small portion (usually 3–6 mm) and its direct an-
tagonist weakened by recessing its attachment to the
globe. If this is insufficient to correct the double vision
one next proceeds to the contralateral synergist. The
patient who has a weak lateral rectus would have an
excision of a small length of the tendon of that muscle,
a recession of the medial rectus on the same side ini-
tially, followed later by recession of the opposite medial
rectus if required.
Surgery for diplopia never completely cures the pa-
tient because five muscles cannot do the work of six.
Rather, the intention is to move the double vision away
80: Double vision 679
from the straight-ahead position to the extremes of oc-
ular movement where it is less troublesome.
A patient with a completely paralysed extra-ocular
muscle will always have intractable double vision in
some direction of gaze. In such cases, surgery is disap-
pointing. Often single vision can be secured in straight-
ahead gaze, but not elsewhere.
MCQs
Select the single correct answer to each question.
1 With reference to the actions of the extra-ocular
muscles, which of the following is correct?
a in adduction, the superior oblique elevates the eye.
b in abduction, the inferior rectus depresses the eye.
c in adduction, the inferior oblique muscle intorts the eye.
d in abduction, the inferior oblique muscle intorts the
eye.
2 The muscle most employed in reading is:
a the medial rectus.
b the lateral rectus.
c the superior oblique.
d the inferior oblique.
3 When investigating a case of diplopia, a helpful sign is:
a the patient prefers to fixate on a target with the eye
with the paretic muscle.
b the image from the eye with the paretic muscle is
displaced most.
c the paralysis of one extra-ocular muscle has no effect
on the other muscles.
d the patient prefers to fixate on a target with the eye
with healthy muscles.