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Anatomy of the eye muscles The extraocular muscles rotate the eyes about three axes to produce vertical (elevation and depression), horizontal (adduction and abduction), and rotational (intorsion and extorsion) movement. The horizontal recti produce purely horizontal movements; the vertical recti and the obliques have vertical, rotational, and horizontal actions. Their principal effect depends upon the horizontal position of the eye in the orbit, and therefore varies with gaze position.
.Extra ocular muscles anatomy. T. temporal. The cornea (a) is anterior to the iris (b) and pupil (c). nasal. Normal human eye. N. anterior aspect.
Extraocular muscles anatomy Drawing of the upper half of the eye. T. temporal. N. nasal. .
Extraocular muscles anatomy Structures at the orbital apex. showing muscle insertions into the anulus of Zinn and the location of various vessels and nerves. .
.0 mm (lateral). while inferior oblique has its origin at the nasal end of the anterior orbital floor.5 mm (medial) behind the limbus. The recti insert anterior to the equator. 7.5 mm (superior).All four recti and superior oblique have their origin at the apex of the orbit. and 5. at 7.5 mm (inferior). 6.
. the insertion of the superior oblique tendon lies along the lateral border of superior rectus. The superior oblique tendon passes beneath the superior rectus. and the inferior oblique passes beneath the inferior rectus. and the insertion of inferior oblique lies external to the macula. having been reflected through the pulley of the trochlea at the anterior nasal orbital roof.The obliques insert behind the equator.
They have trivial secondary or tertiary actions.PRIMARY AND SECONDARY ACTIONS OF MUSCLES The primary action of the horizontal rectus muscles is 99% horizontal. . and they have secondary torsional and horizontal actions. The primary action of the oblique muscles is 60% cyclorotation (torsion) and they have secondary vertical and horizontal actions. The primary action of the vertical rectus muscles is 75% vertical.
Horizontal movements (adduction and abduction) are produced by contractions of medial rectus (MR) and lateral rectus (LR) muscles .
Torsion The superior rectus and superior oblique act as intortors. .) Lateral rectus by 6th cranial nerve (abducent N.) (LR6SO4)3 Eye movements Horizontal ductions The horizontal recti are mainly responsible for adduction and abduction.Nerve supply of EOM Superior oblique by 4th cranial nerve (trochlear N. and the inferior rectus and inferior oblique act as extortors. ) Others by 3rd cranial nerve (oculomotor N. vertical ductions The vertical recti act as pure elevators and depressors in abduction.
or brainstem pathology. It leads inevitably to loss of binocular single vision. with the visual axes parallel. . muscle. Strabismus (squint): is a failure of the coordination of binocular alignment.Disorders of ocular motility The direction of the visual axis of each eye towards a fixation point is co-ordinated by the action of the extraocular muscles. Primary position Gaze straight ahead. Strabismus may be caused by orbit. motor nerve. Fusion of the two images is replaced either by diplopia or suppression of one image.
and manifest divergent squint as exotropia. i.g. Incomitant(Paralytic) Variable angle of squint. failure of the visual axes to meet at the fixation point when they are dissociated e. . paralytic squint is incomitant.e. failure of the visual axes to meet at the fixation point. Latent convergent and divergent squint are. Concomitant(Non-paralytic) Constant angle of deviation irrespective of the direction of gaze (non-paralytic). Manifest covergent squint is described as esotropia. according to gaze direction. respectively. by monocular occlusion.Heterotropia Manifest deviation i. Heterophoria Latent deviation.e. esophoria and exophoria. Vertical squint is hypertropia and hypotropia.
the paretic muscle is identified by finding the position in which diplopia is maximal. including any compensation which occurred (suppression or abnormal retinal correspondence). Binocular vision: describes the quality of simultaneous perception by the two eyes of an object in visual space. The binocular sensory status. overaction. Two muscles are active in any cardinal position. Muscle imbalance Weakness of any of the 12 EOM causes diplopia which is maximal in the field of action of that muscle. . or restriction has led to ocular motor imbalance.Assessment of ocular motility disorder The extraocular muscle or muscles whose underaction.
.Pseudosquint Pseudo squint =apparent squint as example the Chinese or Japanese because of the epicanthal folds appeared esotropic(eyes inward deviated).
Pseudosquint(apparent squint). Epicanthal folds .
. Nonparalytic( concomitant ) No definite muscle palsy The deviation equal in all direction of gaze.Squint Squint defined as any binocular misalignment 1.
Types of squint 1. Non paralytic=concommitant squint. A. 1-Congenital. non-refractive. B. mixed). 2-Accommodative (refractive. Esodeveation =esotropia=inward deviation. Exodeveation = exotropia =outward deviation 1-Childhood-onset 2-Sensory-deprivation. 3-Convergence-insufficiency .
or strabismus 1. 3. Paralytic Squint :Paralytic (non commitant.Types of Squint 2. incomitant)squint.6th cranial nerve (abducent)=paralysis of lateral rectus muscle .4th cranial nerve .3RD( oculomotor)cranial nerve palsy(all extraocular muscles involved except the lateral rectus & the superior oblique muscle) 2.
Paralytic (non commitant. incomitant)squint. . or strabismus Abducent nerve palsy.
.TYPES OF Non-paralytic (concomitant) 1-Congenital Esotropia Infants with congenital esotropia develop a large angle of esotropia at several months of age. some ophthalmologists prefer to name this condition infantile esotropia. but it is more common in infants with developmental delay and in infants with hydrocephalus. It occurs in otherwise normal infants. Because it is not present at birth. The cause is unknown.
Some also resect one or both lateral rectus muscles for large deviations. depending on the angle of deviation. Most physicians recess each medial rectus muscle a graded amount.Congenital Esotropia The treatment for this condition is surgery. .
.Congenital Esotropia Most agree that surgery should be performed before 2 years of age to enhance the chance for the infant to gain some binocular function. and if proper facilities for safe anesthesia are available. if the child is healthy. if the vision is equal. and most perform surgery any time after the child is 6 months of age.
Esotropia congenital AGE OF ONSET AT BIRTH OR SHORTLY AFTER .
Fundoscopy(exam. optic nerve. use of atropine eye drops for 3 days three times a day. Full cycloplegic refraction measurement of the plus glass Exam. .of the retina. 2.Treatment of accommodative esotropia(inward deviated eye). Under Anasthesia(EUA) 1-Cycloplegic refraction.
CORRECTION OF ACCOMODATIVE SQUINT BY GLASSES & TREATMENT OF AMBLIOPIA BY PATCHING SO BOTH EYE NOW HAVE GOOG VISUAL ACUITY AND NORMAL ALIGNED .
6 months-6 years). about the same time of onset as for accommodative esotropia. The average age of onset is about 2.5 years (range. .EXOTROPIA (OUTWARD DEVEATION) 1-Childhood-onset exotropia is the most common type of exotropia. Many children develop an exotropia that typically begins intermittently .
It is useful to think of this entity as passing through several phases or stages. . It may be weakly hereditary. because few children with this condition have parents or siblings with the same condition.1-Childhood-onset exotropia The cause is unknown.
1-Childhood-Onset Exotropia .
1-Childhood-Onset Exotropia The first phase of this condition is exophoria only-latent deviation not seen until one eye covered-preventing the fusion of the two images into one image. It is rarely seen because it is rarely symptomatic. .
1-Childhood-Onset Exotropia If a child happened to be examined at this time in the evolution of this condition. Testing would reveal a latent deviation. detected only by the cover test. the examiner would find only an exophoria. .
. With fatigue. one of the eyes turns out for several seconds. The child then becomes aware of diplopia and makes some unconscious effort to restore the alignment of the eyes. or inattention and when looking at a distance of several meters or more. the child may progress into the second phase: intermittent exotropia.1-Childhood-Onset Exotropia Several months later. illness.
BOTH EYES NOT COOPERATE TOGETHER TO FORM SINGLE IMAGE(NO BINOCULAR SINGLE VISION-BSV) .EXODEVEATION (EXOTROPIA) ALTERNATING WHEN FIXATE WITH THE RIGHT EYE THE LEFT DEVIATED & VISE VERSA.
The name suggests that the primary etiologic factor is not a motor abnormality but some defect in the afferent or sensory system. especially in adults. If two eyes do not have good binocular function. it is likely that the poorer or .2-Sensory Exotropia This is another common type of exotropia.
EXODEVEATION (EXOTROPIA )SENSORY DEPRIVATION=POOR SEEING EYE .
the eyes are straight at distant fixation and without symptoms. . or tired eyes. called convergence insufficiency. A third type of exotropia is an apparent weakness of convergence.3-Convergence Insufficiency. The entity frequently affects young adults and is a major cause of asthenopia. Students usually suffer from this problem. In this condition. while doing near work in this age group.
The deviation at near viewing is relatively small. at near viewing.3-Convergence Insufficiency However. never larger than 18 prism diopters. sometimes an exophoria or sometimes an intermittent exotropia with transient diplopia. as determined by alternate cover testing. However. there is an exodeviation. even a much smaller deviation can produce .
(lazy eye) Patching of normal eye .Complication of strabismus is Amblyopia Treatment of amblyopic eye.
Myogenic Myasthenia gravis Ocular myopathy Restriction Dysthyroid ophthalmopathy Trauma Inflammation Orbital Orbital mass restricting eye movement .Causes of acquired ocular motility disorder Neurogenic (ocular motor nerve lesion): Vascular (diabetes or hypertention). Inflammatory Compressive (aneurysm or tumour) Trauma or surgery. Demyelinating (multiple sclerosis).
Agnes M.C.9th edition 2003. 3-ABC in ophthalmology.D atlas.References.blackwell publications. Mosby. 4-Basic Ophthalmology 5-Atlas of ophthalmology. Bruce James. Anthony Bron.1st edition. 1-lecture notes in ophthalmology. Chris Chew. . 2-eye movement disorders.2007.Wong.F.
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