OCULAR

MOTILITY/STRABISMUS
 EXTRA OCULAR
MUSCLES
• The eye is moved chiefly by 6
extrinsic muscles: 4 recti and 2
oblique muscles .
4 Recti :
• Orgin: Tendinous ring surrounding
the optic canal and a part of superior
orbital fissure.
• Insertion: Anterior portion of the • Medial rectus: 5.5mm from limbus
sclera, 6-8 mm posterior to the • Inferior rectus: 6.5mm from limbus
sclerocorneal junction (limbus) at
different distances. • Lateral rectus: 6.9mm from limbus
• Superior rectus: 7.7mm from limbus
2 Obliques
1. Superior oblique muscle
• Origin : sphenoid bone above and medial to optic foramen
• Insertion: upper and outer part of sclera behind the equator
2. Inferior oblique muscle
• Origin: Rounded tendon from the orbital plate of maxilla lateral to orifice of
nasolacrimal duct
• Insertion: lower and outer part of sclera behind the equator
 NERVE SUPPLY AND ACTIONS OF EOMS

NERVE SUPPLY
• All the extra ocular muscles are supplied by 3rd nerve i.e Oculomotor nerve except
• Superior oblique : Trochlear nerve (4th nerve)
• Lateral rectus: Abducent nerve (6th nerve)
• Mnemonic: SO-4, LR-6
ACTION
• Abduction
• Adduction
• Elevation
• Depression
• Intorsion
• Extorsion
Agonist: Primary muscle moving the eye in any one direction.
Synerist: Muscle that acts together with agonist.
Antagonist: Muscle acting in opposite direction to agonist
Yoke muscle: pair of muscle one from each eye that contracts simultaneously to move
the two eyes in the same direction
Eg: Dextro version( right LR left MR)
 DIAGNOSTIC POSITION
OF GAZE
9 cardinal positions:
1 primary
4 secondary
4 tertiary

PRIMARY POSITION OF GAZE:

Position assumed by the eye when fixating a
distant object
Eg: straight ahead with erect head posture
SECONDARY POSITIONS OF GAZE:
• Dextro version
• Levo version
• Supra version
• Infra version

TERTIARY POSITION OF GAZE: Combination of vertical and horizontal movements

• Dextro elevation
• Dextro depression
• Levo elevation
• Levo depression
 LAWS GOVERNING THE OCULAR
MOVEMENTS
A ． Herrings law: Equal and
simultaneous innervation flows
from brain to a pair of muscle (yoke
muscle) that contract
simultaneously in binocular
movements.
B ． Sherrington’ s law of reciprocal
innervation: When the agonist
contracts antagonist relaxes
 STRABISMUS
DEFINITION: Misalignment of visual axis of two eyes is called strabismus or squint
PSEUDOSTRABISMUS: Visual axis are parallel but eye seem to have squint.
Types :
1. Pseudoesotropia/ apparent convergent squint
Associated with: Prominent epicanthal
2. Pseudoexotropia/ apparent divergent squint
Associated with: Hypertelorism (wide IPD, wide separated eyes)
 RISK OF STRABISMUS
Family history- If relatives have strabismus, a person is more likely to develop it.

Refractive errors -Hypermetropia can develop strabismus due to the amount of eye focusing
necessary to keep vision clear.

Medical conditions-Down syndrome, Cerebral palsy and people who have suffered a stroke or
head injury are at higher risk for developing strabismus
 TYPES
Congenital-
• Developing during infancy;
• 50% of children with strabismus are born with it
Acquired-
• Developing in adulthood;
• can also develop as a result of lack of treatment
during childhood
1. Apparent squint - It is a pseudosquint.
2. Latent squint (phoria) - Squint is manifested only if fusion is broken otherwise
eyes are aligned normally.
Based on the tendency for deviation, latent squint is of following types
• Exophoria – the tendency for an outward deviation
• Esophoria – the tendency for an inward deviation
• Hyperphoria – the tendency for an upward deviation
• Hypophoria – the tendency for a downward deviation
3. Manifest squint (Tropia) - Squint is manifested all the time.
Based on deviation, tropia is of following types
1. Exotropia – outward deviation
2. Esotropia – inward deviation
3. Hypertropia – upward deviation
4. Hypotropia – downward deviation
Manifest squint could also be divided as
．
A Concomitant - Here the angle of deviation is same in all the directions of gaze
5. Uniocular
6. Alternate
．
B Incomitant or paralytic - Here angle of deviation changes with change in the direction
of gaze.
 EXAMINATION OF SQUINT
• History taking: Age of onset, symptoms, birth history, family history, h/o spectacles
• Preliminary examination:
Assessment of vision by Cardiff vision chart/ Gardiner chat
Pupillary reaction
Head posture
Fundus examination
• Measurement of deviation
A ． Hirschberg test
A．Krimsky test: increasing power of prisms in front fixating eye until corneal reflex is
symmetrical in both eyes
B． Cover uncover test:

Cover test Uncover test

A． Alternating cover test: one eye is occluded for several seconds then quickly shifted to
opposite eye for 2 seconds and then back and forth several times.
B． Prism cover test: It combines the alternate cover test with prisms.
C． Maddox wing: The Maddox wing dissociates the eyes for near fixation (1/3 m) and
:

measures heterophoria.
D． Maddox rod:The Maddox rod consists of a series of fused cylindrical red glass rods
which convert the appearance of a white spot of light into a red streak
 Treatment of squint
1. Prism:The base of the prism is kept opposite to the direction of deviation
2. Occlusion: If there is amblyopia, the eye with good vision is occluded and the child is
forced to use the amblyopic eye to get the maximum stimulus.
3. Vision therapy : Vision therapy is like physiotherapy to the eyes and brain to improve
visual skills.
• It includes the use of
lenses, prisms, filters, computer-assisted visual activities, balance boards,
metronomes and non-computerized visual instruments.
1. Surgery:
．
A Recession: Recession weakens a muscle by moving it away from its insertion.
• Rectus muscle recession
• The muscle is exposed and two absorbable sutures are tied through the outer quarters
of the tendon.
• The tendon is disinserted from the sclera, and the amount of recession is measured
and marked on the sclera with callipers.
• The detached end of the muscle is sutured to the sclera at the measured distance
behind its original insertion (Fig. 15.18).
 ．
A Resection strengthens by shortening a muscle to enhance its effective pull. It is suitable
only for a rectus muscle and involves the following steps:
• The muscle is exposed and two absorbable sutures tied into the muscle at a measured the
distance behind its insertion.
• The muscle is disinserted and part of the muscle anterior to the sutures is excised and the
cut end is reattached to the original insertion (Fig. 15.19).

Resection
In medial rectus and lateral rectus is needed to weaken medial
rectus and strengthen lateral rectus. As opposed to this in medial rectus
and lateral rectus is needed to strengthen medial rectus and weakens lateral rectus.