Anatomy and Physiology of Extra

ocular Muscles
 Table of Content
• Anatomy of Extra ocular muscles

• Innervation & Blood supply

• Physiology of ocular movements

• Center of rotation

• Laws of ocular motility

• Sherrington’s law and Herring’s law

• Binocular movements
 Extraocular Muscles
• Extraocular muscles are also referred to as the extrinsic (arising externally)
or muscles of the orbit.
• There are 6 of these extraocular muscles that control eye movement (cows only
have 4 of these), and one muscle that controls eyelid elevation.
• The position of the eye at the time of muscle contraction is what determines how
the 6 muscles of the orbit are engaged.
• Four of the 6 extraocular muscles controls movement in the cardinal directions:
north, east, south, west (or up, right, down, left).
• The other 2 of 6 extraocular muscles are responsible for counteracting head
movements and adjusting eye movement accordingly.
• There is orbital fat that surrounds the sides and back of the eye which cushions it,
allows it to move more freely, and functions to protect blood vessels and nerves as
they pass through the rear of the orbit.
 Extraocular Muscle Anatomy
The 7 Extraocular Muscles
 4 RECTUS MUSCLES
• Superior rectus
• Inferior rectus
• Medial rectus
• Lateral rectus
 2 OBLIQUE MUSCLES
• Superior oblique
• Inferior oblique
1 EYELID MUSCLE
• Levator palpebrae superioris
Extraocular Muscle Insertions
• The 4 rectus muscles do not insert at the same distance from the limbus; the
medial rectus inserts closest to the limbus, with the inferior rectus, lateral rectus,
and superior rectus muscles progressively inserting farther away, resulting in an
imaginary spiral termed the spiral of Tillaux.
 Conti…
• Spiral of Tillaux, right eye.
• Note that the insertion distances, given in millimeters, are maximum values.
Insertion distances vary in individuals.
• Image credit: Illustration by Christine Gralapp. American Academy of
Ophthalmology. Used with permission for educational purposes.
• Here the values expressed in a table format:
 CLINICAL SIGNIFICANCE

• These measurements need to be memorized because of surgical considerations:

• Knowing these measurements are important when performing any surgery
involving the conjunctiva, sclera, or extraocular muscles. Some examples include:
 Glaucoma surgeries (especially tubes and trabeculectomies)
 Scleral surgeries
 Retinal surgeries (especially scleral buckle surgery)
 Trauma repair (extraocular muscle exploration, scleral exploration)
 Strabismus surgeries
• Because the ora serrata (the boundary between the retina and pars plana of the
ciliary body) lies between 5.75 mm (nasal) and 6.50 mm (temporal) posterior to
Schwalbe line (which conceptually forms the anterior-most border of the limbus),
sutures passing too deeply at or behind the extraocular muscle insertions are at
risk for perforating the retina, resulting in retinal holes and tears.
 Medial Rectus
• The medial rectus is the only rectus muscle that does not have an oblique muscle
running tangential to it.There is no point of reference for finding the muscle if it is
lost/slipped.
• Of the rectus muscles, the medial rectus has shortest tendon (4.5 mm); the
inferior oblique muscle has the shortest tendon overall (1 mm).
 Lateral Rectus
• Of the rectus muscles, the lateral rectus has the broadest arc of contact (12 mm);
the inferior oblique muscle has the broadest arc of contact overall (15 mm).
• The lateral rectus muscle is the only extraocular muscle supplied by the lacrimal
artery (also receives supply from the lateral/superior muscular branch of the
ophthalmic artery).
• The lateral rectus muscle is connected to the inferior oblique muscle by a
frenulum of the intermuscular septum.
 This must be disconnected with lateral rectus muscle surgery or the inferior
oblique muscle may be inadvertently advanced with. the lateral rectus muscle.
• The lateral rectus muscle is the thinnest extraocular muscle (9.2 mm wide).
 Superior Rectus
• The superior rectus muscle is loosely attached to the levator palpebrae superioris
muscle.
• When the eye is hypotropic, a pseudoptosis may be present because the
upper eyelid will follow the superior rectus muscle.
• With resection of the superior rectus muscle, the eyelid may be pulled
downward (typically is not retracted upward with recessions).
• The superior rectus muscle is connected to the superior oblique
muscle by a frenulum of the intermuscular septum.
 Inferior Rectus
• Along with the inferior oblique muscle, the inferior rectus muscle receives partial
arterial supply from the infraorbital artery (also receives supply from the
medial/inferior muscular branch of the ophthalmic artery).
• The inferior rectus muscle is strongly attached to the lower eyelid retractors.
 Recession of the inferior rectus muscle results in lower eyelid retraction (eyelid
moves down).
 Resection of the inferior rectus muscle results in lower lid narrowing (eyelid
moves up).
 Superior Oblique
• The superior oblique muscle has the longest tendon of all the extraocular muscles
(26 mm).
• The functional origin of the superior oblique tendon is the trochlea (though the
muscle itself arises from the periosteum of the sphenoid bone body), which
redirects the superior oblique to allow for its primary action of incyclotorsion.
• The superior oblique muscle is connected to the superior rectus muscle by a
frenulum of the intermuscular septum.
 Levator Palpebrae Superioris

• The levator palpebrae superioris (LPS) is the only muscle involved in raising the
superior eyelid. A small portion of this muscle contains a collection of smooth
muscle fibres – known as the superior tarsal muscle. In contrast to the LPS, the
superior tarsal muscle is innervated by the sympathetic nervous system.
• Attachments: Originates from the lesser wing of the sphenoid bone, immediately
above the optic foramen. It attaches to the superior tarsal plate of the upper eyelid
(a thick plate of connective tissue).
• Actions: Elevates the upper eyelid.
• Innervation: The levator palpebrae superioris is innervated by the oculomotor
nerve (CN III). The superior tarsal muscle (located within the LPS) is innervated by
the sympathetic nervous system.
 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
• 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 .
Extraocular Muscle Actions
• Here are a few take-home points and helpful hints:
• Excyclotorsion is seen in superior oblique/CN IV palsy because there is
unopposed contraction of the inferior oblique.
• The oblique muscles abduct the eye (“abduction is an oblique crime”).
• The inferior muscles (inferior rectus and inferior oblique muscles) excyclotort
the eye (“extortion is an inferior crime”)
• Depending on the horizontal position of the eye (adducted or abducted), the
primary action of the vertical muscles may change:
 For example, in adduction the inferior oblique is the primary elevator of
the eye and the superior oblique is the primary depressor; in abduction
the superior rectus is the primary elevator and the inferior rectus muscle is
the depressor.
 Motility diagrams reflect this relationship between the various actions of
the extraocular muscles:
Conti..
 Key terms

• Elevation: eye looks up

• Depression: eye looks down
• ABduction: eye looks away from the nose
• ADduction: eye looks towards the nose
• Intorsion: top of the eye twists in towards the nose (e.g. while looking at R eye, it
appears to turn clockwise)
• Extorsion: top of the eye twists away from the nose (e.g. while looking at R eye, it
appears to turn counterclockwise)
Pearls to memorize (once you finish the article and understand why these occur)
• Both superior muscles INtort (superior rectus and superior oblique)
• Both inferior muscles EXtort (inferior rectus and inferior oblique)
• Both oblique muscles ABduct (superior oblique and inferior oblique), and the
corresponding vertical recti ADduct (superior rectus and inferior rectus)
 Fundamental concepts

• There are three fundamental concepts about EOM anatomy/function you must
understand to master all of the EOMs:
1) Attachment on anterior vs. posterior half of eye: The four recti (medial, lateral,
inferior, and superior recti) attach on the anterior half of the eye. In contrast, the
superior and inferior oblique attach on the posterior half of the eye.
 Conti..
2) 3 possible axis of rotations: The eye can rotate around three different axes – a
horizontal axis (x axis), an anterior/posterior axis (y axis) AND a vertical axis (z axis).
 Conti..
3) Axis of globe vs. axis of orbit: The axis of the globe is NOT aligned with the axis of the
orbit: When the eye is in primary position (i.e. looking straight ahead), the axis of the
orbit actually runs about 23 degrees offset from the globe.

• Since the superior, inferior, medial, and lateral recti originate from the annulus of Zinn
at the apex of the orbit, they attach to the eye at an offset angle and don’t run
straight anterior/posterior.
• This is why the superior and inferior recti don’t ONLY elevate or depress the eye. The
force vectors that occur when these recti muscles contract run backwards AND
nasally.
 Lateral and medial recti

• These are the most straightforward. If you look at the path of these two muscles
from the front, you can see that they travel in the same horizontal plane as their
origin at the annulus, so there are no superior or inferior force vectors. Therefore,
these only cause the eye to rotate around the vertical z axis. This is why these each
only have one primary action and no secondary/tertiary actions.
– Lateral rectus: The posterior force vector pulls the lateral portion of the globe
back, which rotates around the z axis and causes ABduction.
– Medial rectus: The posterior force vector pulls the medial portion the globe back,
which rotates around the z axis and causes ADduction
 Superior rectus

• The superior rectus runs from the annulus of Zinn to the superior, anterior portion
of the globe. As it pulls, the force vector runs not only posteriorly, but also medially
and inferiorly.
• Think of how the force vectors will act on each of the 3 possible axes of rotations
independently:

1) X axis: The posterior force vector pulls the top of the eye back. This rotates the front
of the eye up by rotating around the x axis, causing elevation (primary function).

2) Y axis: The combined medial and inferior force vectors pull the top of the eye
medially and downwards, rotating around the y axis and causing intorsion (secondary
function).

3) Z axis: The medial force vector pulls the front of the eye medially, rotating around
the z axis, causing ADduction (tertiary function).
 Inferior rectus

• The inferior rectus runs from the annulus of Zinn to the inferior, anterior portion of
the globe. As it pulls, the force vector runs not only posteriorly, but also medially
and superiorly.
• Again, consider the force vectors and their action on each of the 3 possible axes of
rotation:

1) X axis: The posterior force vector pulls the bottom of the eye back. This rotates the
front of the eye down by rotating around the x axis, causing depression (primary
function).

2) Y axis: The combined medial and superior force vectors pull the bottom of the eye
medially and upwards, rotating around the y axis and causing extorsion (secondary
function).

3) Z axis: Like the superior rectus, the medial force vector pulls the front of the eye
medially, rotating around the z axis, causing ADduction (tertiary function).
Conti..
 Superior oblique:

• This is where things start to get a little weird. Remember that although the
superior oblique begins roughly at the annulus of Zinn (technically it actually
begins on sphenoid bone very close to the annulus), it runs through the trochlea
and then courses posteriorly prior to attaching to the globe. Additionally, in
contrast to the four rectus muscles which attach to the anterior half of the globe,
both the superior and inferior obliques attach at the posterior half of the globe.
Therefore, the force vector that is created when the superior oblique contracts
runs anteriorly, medially and superiorly.
• 1) X axis: The anterior/superior force vector pulls the back of the eye up, causing
the front of the eye to go down, leading to depression (secondary function).
2) Y axis: The medial force pulls the top of the eye towards the nose, rotating
around the Y axis, causing intorsion (primary function).
3) Z axis: The medial force also pulls the back of the eye towards the nose, rotating
the front of the eye around the Z axis, causing ABduction (tertiary function).
 Inferior oblique:

• The inferior oblique is just like the superior oblique, but on the inferior portion of
the eye. The force vectors are similar because the inferior oblique’s origin on the
medial floor of the orbit is analogous to the superior oblique running through the
trochlea.
• Therefore, the force vector runs anteriorly, medially, and inferiorly

1) X axis: The anterior/inferior force vector pulls the back of the eye down, causing the
front of the eye to go up, leading to elevation (secondary function).

2) Y axis: The medial force vector pulls the bottom of the eye towards the nose,
rotating around the Y axis, causing extorsion (primary function).

3) Z axis: The medial force vector also pulls the back of the eye towards the nose,
rotating the front of the eye around the Z axis, causing ABduction (tertiary function).
Conti..