Extraocular muscles

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Extraocular muscles
MRI of human eye.jpg
Details
System Visual system
Origin Common tendinous ring, maxillary and sphenoid bone
Insertion Tarsal plate of upper eyelid, eye
Artery Ophthalmic artery, lacrimal artery, infraorbital artery, anterior ciliary arteries,
superior and inferior orbital veins
Nerve Oculomotor, trochlear and abducens nerve
Actions See table
Identifiers
Latin musculi externi bulbi oculi
MeSH D009801
TA98 A04.1.01.001
TA2 2041
FMA 49033
Anatomical terms of muscle

The extraocular muscles, or extrinsic ocular muscles, are the seven extrinsic muscles of the human eye. [1] Six of the extraocular muscles, the four recti muscles, and the superior and inferior oblique muscles, control movement of the eye. The other muscle, the levator palpebrae superioris, controls eyelid elevation. The actions of the six muscles responsible for eye movement depend on the position of the eye at the time of muscle contraction. [2]

Contents

Structure

Lateral and anterior views of the extraocular muscles also showing common tendinous ring origin and trochlea 1412 Extraocular Muscles.jpg
Lateral and anterior views of the extraocular muscles also showing common tendinous ring origin and trochlea

Since only a small part of the eye called the fovea provides sharp vision, the eye must move to follow a target. Eye movements must be precise and fast. This is seen in scenarios like reading, where the reader must shift gaze constantly. Although under voluntary control, most eye movement is accomplished without conscious effort. Precisely how the integration between voluntary and involuntary control of the eye occurs is a subject of continuing research. [3] It is known, however, that the vestibulo-ocular reflex plays an important role in the involuntary movement of the eye.

The levator palpebrae superioris is responsible for raising the upper eyelid, and this can be a voluntary or involuntary action. The other six extraocular muscles are involved in movements of the eye; these are the four recti (straight) muscles, and two oblique muscles.

Recti muscles

The four recti muscles are named according to their relative positions of attachment – the superior rectus muscle, lateral rectus muscle, medial rectus muscle, and inferior rectus muscle. The recti muscles are all of almost equal length of around 40 mm but the lengths of their associated tendons differ. [4]

Oblique muscles

The two oblique muscles are the inferior oblique muscle and the superior oblique muscle.

Pulley system

Extraocular muscles are shown in this image of the left eye (lateral view). Click on the structures for more information. Lateral orbit nerves.jpg Lateral rectusSuperior obliqueSuperior obliqueSuperior rectusSuperior rectusSuperior rectusInferior obliqueInferior rectusInferior rectusMedial rectusMedial rectusMedial rectusIrisAnterior chamberLateral rectusSuperior obliqueSuperior obliqueMedial rectusOrbitOrbitOrbit
Extraocular muscles are shown in this image of the left eye (lateral view). Click on the structures for more information.

The movements of the extraocular muscles take place under the influence of a system of extraocular muscle pulleys, soft tissue pulleys in the orbit. The extraocular muscle pulley system is fundamental to the movement of the eye muscles, in particular also to ensure conformity to Listing's law. Certain diseases of the pulleys (heterotopy, instability, and hindrance of the pulleys) cause particular patterns of incomitant strabismus. Defective pulley functions can be improved by surgical interventions. [5] [6]

Origins and insertions

Four of the extraocular muscles have their origin in the back of the orbit in a fibrous ring called the common tendinous ring: the four recti muscles. The four recti muscles attach directly to the front half of the eye (anterior to the eye's equator), and are named after their straight paths. [3]

Medial and lateral are relative terms. Medial indicates near the midline, and lateral describes a position away from the midline. Thus, the medial rectus is the muscle closest to the nose. The superior and inferior recti do not pull straight back on the eye, because both muscles also pull slightly medially. This posterior medial angle causes the eye to roll with contraction of either the superior rectus muscle or the inferior rectus muscle. The extent of rolling in the recti is less than the oblique, and opposite from it. [3]

The superior oblique muscle originates at the back of the orbit (a little closer to the medial rectus, though medial to it), getting rounder as it [3] courses forward to a rigid, cartilaginous pulley, called the trochlea, on the upper, nasal wall of the orbit. The muscle becomes tendinous about 10mm before it passes through the pulley, turning sharply across the orbit, and inserts on the lateral, posterior part of the globe. Thus, the superior oblique travels posteriorly for the last part of its path, going over the top of the eye. Due to its unique path, the superior oblique, when activated, pulls the eye downward and laterally. [7]

The last muscle is the inferior oblique, which originates at the lower front of the nasal orbital wall, passes inferiorly over the inferior rectus muscle on its path laterally and posteriorly, and inserts under the lateral rectus muscle on the lateral, posterior part of the globe. Thus, the inferior oblique pulls the eye upward and laterally. [7] [8] [9]

Blood supply

The extraocular muscles are supplied mainly by branches of the ophthalmic artery. This is done either directly or indirectly, as in the lateral rectus muscle, via the lacrimal artery, a main branch of the ophthalmic artery. Additional branches of the ophthalmic artery include the ciliary arteries, which branch into the anterior ciliary arteries. Each rectus muscle receives blood from two anterior ciliary arteries, except for the lateral rectus muscle, which receives blood from only one. The exact number and arrangement of these ciliary arteries may vary. Branches of the infraorbital artery supply the inferior rectus and inferior oblique muscles.

Nerve supply

Cranial nerveMuscle
Oculomotor nerve
(N. III)
Superior rectus muscle

Inferior rectus muscle

Medial rectus muscle

Inferior oblique muscle

Levator palpebrae superioris muscle
Trochlear nerve
(N. IV)
Superior oblique muscle
Abducens nerve
(N. VI)
Lateral rectus muscle

The nuclei or bodies of these nerves are found in the brain stem. The nuclei of the abducens and oculomotor nerves are connected. This is important in coordinating the motion of the lateral rectus in one eye and the medial action on the other. In one eye, in two antagonistic muscles, like the lateral and medial recti, contraction of one leads to inhibition of the other. Muscles show small degrees of activity even when resting, keeping the muscles taut. This "tonic" activity is brought on by discharges of the motor nerve to the muscle. [3]

Development

The extraocular muscles develop along with Tenon's capsule (part of the ligaments) and the fatty tissue of the eye socket (orbit). There are three centers of growth that are important in the development of the eye, and each is associated with a nerve. Hence the subsequent nerve supply (innervation) of the eye muscles is from three cranial nerves. The development of the extraocular muscles is dependent on the normal development of the eye socket, while the formation of the ligament is fully independent.

Function

Eye movement

The vestibulo-ocular reflex. A rotation of the head is detected, which triggers an inhibitory signal to the extraocular muscles on one side and an excitatory signal to the muscles on the other side. The result is a compensatory movement of the eyes. Simple vestibulo-ocular reflex.PNG
The vestibulo-ocular reflex. A rotation of the head is detected, which triggers an inhibitory signal to the extraocular muscles on one side and an excitatory signal to the muscles on the other side. The result is a compensatory movement of the eyes.

The oculomotor nerve (III), trochlear nerve (IV) and abducens nerve (VI) coordinate eye movement. The oculomotor nerve controls all muscles of the eye except for the superior oblique muscle controlled by the trochlear nerve (IV), and the lateral rectus muscle controlled by the abducens nerve (VI). This means the ability of the eye to look down and inwards is controlled by the trochlear nerve (IV), the ability to look outwards is controlled by the abducens nerve (VI), and all other movements are controlled by the oculomotor nerve (III). [10]

Movement coordination

Intermediate directions are controlled by simultaneous actions of multiple muscles. When one shifts the gaze horizontally, one eye will move laterally (toward the side) and the other will move medially (toward the midline). This may be neurally coordinated by the central nervous system, to make the eyes move together and almost involuntarily. This is a key factor in the study of strabismus, namely, the inability of the eyes to be directed to one point.

There are two main kinds of movement: conjugate movement (the eyes move in the same direction) and disjunctive (opposite directions). The former is typical when shifting gaze right or left, the latter is convergence of the two eyes on a near object. Disjunction can be performed voluntarily, but is usually triggered by the nearness of the target object. A "see-saw" movement, namely, one eye looking up and the other down, is possible, but not voluntarily; this effect is brought on by putting a prism in front of one eye, so the relevant image is apparently displaced. To avoid double vision from non-corresponding points, the eye with the prism must move up or down, following the image passing through the prism. Likewise conjugate torsion (rolling) on the anteroposterior axis (from the front to the back) can occur naturally, such as when one tips one's head to one shoulder; the torsion, in the opposite direction, keeps the image vertical.

The muscles show little inertia - a shutdown of one muscle is not due to checking of the antagonist, so the motion is not ballistic. [3]

Compensatory movements

The vestibulo-ocular reflex is a reflex that stabilizes gaze when the head is moved. The reflex involves compensatory eye movements driven by inhibitory and excitatory signals.

Table

Below is a table of each extraocular muscle and their innervation, origins and insertions, and the primary actions of the muscles (the secondary and tertiary actions are also included, where applicable). [11]

Muscle Innervation OriginInsertionPrimary actionSecondary actionTertiary action
Medial rectus Oculomotor nerve
(inferior branch)
Common tendinous ring Eye
(anterior, medial surface)
Adduction
Lateral rectus Abducens nerve Common tendinous ring Eye
(anterior, lateral surface)
Abduction
Superior rectus Oculomotor nerve
(superior branch)
Common tendinous ring Eye
(anterior, superior surface)
Elevation Incyclotorsion Adduction
Inferior rectus Oculomotor nerve
(inferior branch)
Common tendinous ring Eye
(anterior, inferior surface)
Depression Excyclotorsion Adduction
Superior oblique Trochlear nerve Sphenoid bone
via the Trochlea
Eye
(posterior, superior, lateral surface)
Incyclotorsion Depression Abduction
Inferior oblique Oculomotor nerve
(inferior branch)
Maxillary bone Eye
(posterior, inferior, lateral surface)
Excyclotorsion Elevation Abduction
Levator palpebrae superioris Oculomotor nerve Sphenoid bone Tarsal plate of upper eyelid Elevation/retraction

of the upper eyelid

Clinical significance

The oculomotor (III), troclear (IV) and abducens (VI) nerves supply the muscle of the eye. Damage will affect the movement of the eye in various ways, shown here. Lawrence 1960 14.13.png
The oculomotor (III), troclear (IV) and abducens (VI) nerves supply the muscle of the eye. Damage will affect the movement of the eye in various ways, shown here.

Damage to the cranial nerves may affect the movement of the eye. Damage may result in double vision (diplopia) because the movements of the eyes are not synchronized. Abnormalities of visual movement may also be seen on examination, such as jittering (nystagmus). [12]

Damage to the oculomotor nerve (III) can cause double vision and inability to coordinate the movements of both eyes (strabismus), also eyelid drooping (ptosis) and pupil dilation (mydriasis). [13] Lesions may also lead to inability to open the eye due to paralysis of the levator palpebrae muscle. Individuals suffering from a lesion to the oculomotor nerve may compensate by tilting their heads to alleviate symptoms due to paralysis of one or more of the eye muscles it controls. [12]

Damage to the trochlear nerve (IV) can also cause double vision with the eye adducted and elevated. [13] The result will be an eye which can not move downwards properly (especially downwards when in an inward position). This is due to impairment in the superior oblique muscle. [12]

Damage to the abducens nerve (VI) can also result in double vision. [13] This is due to impairment in the lateral rectus muscle, supplied by the abducens nerve. [12]

Amblyopia also known as lazy eye is a condition of diminshed sight in one eye.

Ophthalmoparesis is weakness or paralysis of one or more extraocular muscles.

Examination

The initial clinical examination of the extraoccular eye muscles is done by examining the movement of the globe of the eye through the six cardinal eye movements. When the eye is turned out (temporally) and horizontally, the function of the lateral rectus muscle is tested. When the eye is turned in (nasally) and horizontally, the function of the medial rectus muscle is being tested. When turning the eye down and in, the inferior rectus is contracting. When turning it up and in the superior rectus is contracting. Paradoxically, turning the eye up and out uses the inferior oblique muscle, and turning it down and out uses the superior oblique. All of these six movements can be tested by drawing a large "H" in the air with a finger or other object in front of a patient's face and having them follow the tip of the finger or object with their eyes without moving their head. Having them focus on the object as it is moved in toward their face in the midline will test convergence, or the eyes' ability to turn inward simultaneously to focus on a near object.

To evaluate for weakness or imbalance of the muscles, a penlight is shone directly on the corneas. Expected normal results of the corneal light reflex is when the penlight's reflection is located in the centre of both corneas, equally. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Abducens nerve</span> Cranial nerve VI, for eye movements

The abducens nerve or abducent nerve, also known as the sixth cranial nerve, cranial nerve VI, or simply CN VI, is a cranial nerve in humans and various other animals that controls the movement of the lateral rectus muscle, one of the extraocular muscles responsible for outward gaze. It is a somatic efferent nerve.

<span class="mw-page-title-main">Oculomotor nerve</span> Cranial nerve III, for eye movements

The oculomotor nerve, also known as the third cranial nerve, cranial nerve III, or simply CN III, is a cranial nerve that enters the orbit through the superior orbital fissure and innervates extraocular muscles that enable most movements of the eye and that raise the eyelid. The nerve also contains fibers that innervate the intrinsic eye muscles that enable pupillary constriction and accommodation. The oculomotor nerve is derived from the basal plate of the embryonic midbrain. Cranial nerves IV and VI also participate in control of eye movement.

<span class="mw-page-title-main">Trochlear nerve</span> Cranial nerve IV, for eye movements

The trochlear nerve, also known as the fourth cranial nerve, cranial nerve IV, or CN IV, is a cranial nerve that innervates a single muscle - the superior oblique muscle of the eye. Unlike most other cranial nerves, the trochlear nerve is exclusively a motor nerve.

<span class="mw-page-title-main">Orbit (anatomy)</span> Cavity or socket of the skull in which the eye and its appendages are situated

In anatomy, the orbit is the cavity or socket/hole of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents. In the adult human, the volume of the orbit is 30 millilitres, of which the eye occupies 6.5 ml. The orbital contents comprise the eye, the orbital and retrobulbar fascia, extraocular muscles, cranial nerves II, III, IV, V, and VI, blood vessels, fat, the lacrimal gland with its sac and duct, the eyelids, medial and lateral palpebral ligaments, cheek ligaments, the suspensory ligament, septum, ciliary ganglion and short ciliary nerves.

<span class="mw-page-title-main">Superior oblique muscle</span> Part of the eye

The superior oblique muscle or obliquus oculi superior is a fusiform muscle originating in the upper, medial side of the orbit which abducts, depresses and internally rotates the eye. It is the only extraocular muscle innervated by the trochlear nerve.

<span class="mw-page-title-main">Eye movement</span> Movement of the eyes

Eye movement includes the voluntary or involuntary movement of the eyes. Eye movements are used by a number of organisms to fixate, inspect and track visual objects of interests. A special type of eye movement, rapid eye movement, occurs during REM sleep.

<span class="mw-page-title-main">Superior rectus muscle</span> Extraocular muscle that elevates the eye

The superior rectus muscle is a muscle in the orbit. It is one of the extraocular muscles. It is innervated by the superior division of the oculomotor nerve (III). In the primary position, its primary function is elevation, although it also contributes to intorsion and adduction. It is associated with a number of medical conditions, and may be weak, paralysed, overreactive, or even congenitally absent in some people.

<span class="mw-page-title-main">Inferior rectus muscle</span>

The inferior rectus muscle is a muscle in the orbit near the eye. It is one of the four recti muscles in the group of extraocular muscles. It originates from the common tendinous ring, and inserts into the anteroinferior surface of the eye. It depresses the eye (downwards).

<span class="mw-page-title-main">Lateral rectus muscle</span> Muscle on lateral side of the eye

The lateral rectus muscle is a muscle on the lateral side of the eye in the orbit. It is one of six extraocular muscles that control the movements of the eye. The lateral rectus muscle is responsible for lateral movement of the eyeball, specifically abduction. Abduction describes the movement of the eye away from the midline, allowing the eyeball to move horizontally in the lateral direction, bringing the pupil away from the midline of the body.

<span class="mw-page-title-main">Medial rectus muscle</span> Extraocular muscle that rotates the eye medially

The medial rectus muscle is a muscle in the orbit near the eye. It is one of the extraocular muscles. It originates from the common tendinous ring, and inserts into the anteromedial surface of the eye. It is supplied by the inferior division of the oculomotor nerve (III). It rotates the eye medially (adduction).

<span class="mw-page-title-main">Inferior oblique muscle</span> Part of the eye

The inferior oblique muscle or obliquus oculi inferior is a thin, narrow muscle placed near the anterior margin of the floor of the orbit. The inferior oblique is one of the extraocular muscles, and is attached to the maxillary bone (origin) and the posterior, inferior, lateral surface of the eye (insertion). The inferior oblique is innervated by the inferior branch of the oculomotor nerve.

<span class="mw-page-title-main">Abducens nucleus</span>

The abducens nucleus is the originating nucleus from which the abducens nerve (VI) emerges—a cranial nerve nucleus. This nucleus is located beneath the fourth ventricle in the caudal portion of the pons near the midline, medial to the sulcus limitans.

<span class="mw-page-title-main">Ophthalmoparesis</span> Weakness or paralysis of extraocular muscles

Ophthalmoparesis refers to weakness (-paresis) or paralysis (-plegia) of one or more extraocular muscles which are responsible for eye movements. It is a physical finding in certain neurologic, ophthalmologic, and endocrine disease.

<span class="mw-page-title-main">Common tendinous ring</span> Ring of fibrous tissue around optic nerve at its entrance to the eye

The common tendinous ring, also known as the annulus of Zinn or annular tendon, is a ring of fibrous tissue surrounding the optic nerve at its entrance at the apex of the orbit. It is the common origin of the four recti muscles of the group of extraocular muscles.

<span class="mw-page-title-main">Nasociliary nerve</span> Branch of the ophthalmic nerve

The nasociliary nerve is a branch of the ophthalmic nerve (CN V1) (which is in turn a branch of the trigeminal nerve (CN V)). It is intermediate in size between the other two branches of the ophthalmic nerve, the frontal nerve and lacrimal nerve.

<span class="mw-page-title-main">Sixth nerve palsy</span> Medical condition

Sixth nerve palsy, or abducens nerve palsy, is a disorder associated with dysfunction of cranial nerve VI, which is responsible for causing contraction of the lateral rectus muscle to abduct the eye. The inability of an eye to turn outward, results in a convergent strabismus or esotropia of which the primary symptom is diplopia in which the two images appear side-by-side. Thus, the diplopia is horizontal and worse in the distance. Diplopia is also increased on looking to the affected side and is partly caused by overaction of the medial rectus on the unaffected side as it tries to provide the extra innervation to the affected lateral rectus. These two muscles are synergists or "yoke muscles" as both attempt to move the eye over to the left or right. The condition is commonly unilateral but can also occur bilaterally.

<span class="mw-page-title-main">Cranial nerve examination</span> Type of neurological examination

The cranial nerve exam is a type of neurological examination. It is used to identify problems with the cranial nerves by physical examination. It has nine components. Each test is designed to assess the status of one or more of the twelve cranial nerves (I-XII). These components correspond to testing the sense of smell (I), visual fields and acuity (II), eye movements and pupils, sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing and balance, taste, pharyngeal movement and reflex, tongue movements (XII).

<span class="mw-page-title-main">Oculomotor nerve palsy</span> Medical condition

Oculomotor nerve palsy or oculomotor neuropathy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. As the name suggests, the oculomotor nerve supplies the majority of the muscles controlling eye movements. Damage to this nerve will result in an inability to move the eye normally. The nerve also supplies the upper eyelid muscle and is accompanied by parasympathetic fibers innervating the muscles responsible for pupil constriction. The limitations of eye movement resulting from the condition are generally so severe that patients are often unable to maintain normal eye alignment when gazing straight ahead, leading to strabismus and, as a consequence, double vision (diplopia).

The term gaze is frequently used in physiology to describe coordinated motion of the eyes and neck. The lateral gaze is controlled by the paramedian pontine reticular formation (PPRF). The vertical gaze is controlled by the rostral interstitial nucleus of medial longitudinal fasciculus and the interstitial nucleus of Cajal.

<span class="mw-page-title-main">Corticomesencephalic tract</span>

In neuroanatomy, corticomesencephalic tract is a descending nerve tract that originates in the frontal eye field and terminate in the midbrain. Its fibers mediate conjugate eye movement.

References

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Further reading