Clinical Measurement of the Angle of Ocular Movements in the Nine Cardinal Positions of Gaze

doi:10.1016/j.ophtha.2013.11.019

Ophthalmology

Volume 121, Issue 4, April 2014, Pages 870-876

https://doi.org/10.1016/j.ophtha.2013.11.019 Get rights and content

Purpose

To measure the maximum angle of ocular versions using photographs of the 9 cardinal positions and a modified limbus test.

Design

An evaluation of diagnostic technology; a prospective observational study.

Participants

We enrolled 104 healthy subjects, 20 to 40 years of age.

Methods

Photographs were obtained in the 9 cardinal positions of gaze and the images were processed using Photoshop. The images were analyzed using the Image J program to measure the angle of version. The maximum angle of the 9 cardinal positions was quantified using a modified limbus test.

Main Outcome Measures

We measured the maximum angle of ocular versions in the 9 cardinal positions of gaze. We also compared the results for males and females.

Results

The mean angles of maximum version were adduction 47.4°, abduction 46.4°, elevation 31.8°, depression 47.8°, elevation in adduction 39.7°, elevation in abduction 40.7°, depression in adduction 52.7°, and depression in abduction 49.2°. The mean angle of maximum elevation was significantly smaller than that of depression (P <0.001). There were no correlations between the angle of maximum version and age, spherical equivalents, or axial length. The angle of maximum version for males was significantly greater than that for females, except for inferior gaze.

Conclusions

A modified limbus test using photographs of the 9 cardinal positions is an objective and reproducible tool for quantifying ocular movement. Considering its simplicity, ease of use, and low cost, it has clear applications in clinical practice.

Section snippets

Study Design and Participants

This prospective study included a total of 104 healthy subjects (20–40 years of age; 57 male, 47 female). The age for participation was limited to 20 to 40 years to obtain accurate ocular movement measurements and good cooperation. Inclusion criteria consisted of the absence of strabismus, orbital diseases, neurologic diseases, ocular motility dysfunction, diabetes, and previous ocular or periocular surgery as well as a corrected visual acuity >20/50 in each eye. The study protocol complied

Results

One hundred four subjects were included in this study: 57 males and 47 females (age range, 20–40 years; mean, 27.2 years). Subject demographics and characteristics are shown in Table 1. The mean age ± standard deviation was 27.1±4.1 in males and 27.3±5.1 in females. The mean spherical equivalent was −2.97±2.39 diopters (D) (range, −9.85 to 3.25 D), with the men tending to be more myopic than the women (−3.18 vs −2.71 D; P = 0.156). Axial length for the entire study population had a mean value

Discussion

In our study, we described a photographic method for measuring ocular versions using a limbus test, which is quantitative, simple, and uses photographs of the cardinal gaze positions. This study demonstrated that the modified limbus test using photographs can objectively measure the angle of version and is the first to establish baseline normative values of maximum versions in the 9 cardinal positions of gaze. The fact that our method requires minimal operator interpretation makes this test

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Extent of foveal fixation with eye rotation in emmetropes and myopes
2022, Journal of Optometry
Citation Excerpt :
Monocular eye movements (ductions) are achieved with the help of six extraocular muscles. A normal healthy individual aged between 20–40 can rotate their eye up to 47° nasally and 46° temporally2 and the maximum ability to rotate the eye tend to decrease with increasing age.3 Although many studies have reported the extent of eye rotation,2–7 there is very limited literature on what extent eyes can foveate an object (henceforth referred to as foveation) by keeping the head stationary in a primary and fixed position.
This pilot study aimed to investigate the maximum extension of foveal fixation in the horizontal direction among young adults in both emmetropes and myopes.
35 participants (28 emmetropes and 7 myopes) were included. Participants with restricted extra-ocular mobility, end gaze nystagmus, and/or any other ocular pathology were excluded. Visual acuity (VA) was used as a surrogate measure of foveal fixation. VA was determined using a staircase procedure with 8 reversals. The average of the last 5 reversals was taken as the thresholds. VA acuity was measured at different gaze eccentricities along nasal and temporal visual field meridian. The eccentricity at which VA drops significantly was taken as the maximum extent of foveal fixation. A bilinear fit regression model was used to investigate the drop in the VA in both nasal and the temporal direction.
Emmetropes can foveate up to 35 ± 2° in nasal and 40 ± 3° in temporal direction and myopes can foveate up to 38° in both nasal and temporal directions. Paired student t-test showed a significant difference in foveal fixation between nasal and temporal direction for emmetropes (P<0.001) but not in myopes (P = 0.168). An unpaired student t-test showed a significant difference in foveal fixation for nasal direction between myopes and emmetropes (P = 0.01). However, no statistically significant difference was found in foveal fixation for temporal direction between myopes and emmetropes (P = 0.792).
The eye rotation does not necessarily match with the extent of foveal fixation at extreme eye rotation. Eyes can fixate only up to 35° nasally and 40° temporally maintaing their maximum visual acuity.
Influence of eye movement on lens dose and optic nerve target coverage during craniospinal irradiation
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For lenses and optic discs, the latter considered as the most peripheral part of the optic nerve, mean movement amplitudes of all 10 volunteers in our study ranged between±3 mm to±7 mm, with overall largest amplitudes, of even > 9 mm, in the caudal gaze direction. This is comparable to eye movement studies, where largest displacement angles were measured with caudal gaze [20,21]. Ocular biometry- or MRI-based studies found that during gaze shifts, the axial length of the eyeball changes slightly - with largest elongation in downward gaze [22], and the posterior segment of the eye shows more displacement from the anterior segment during vertical than during horizontal displacements [18].
Optic nerves are part of the craniospinal irradiation (CSI) target volume. Modern radiotherapy techniques achieve highly conformal target doses while avoiding organs-at-risk such as the lens. The magnitude of eye movement and its influence on CSI target- and avoidance volumes are unclear. We aimed to evaluate the movement-range of lenses and optic nerves and its influence on dose distribution of several planning techniques.
Ten volunteers underwent MRI scans in various gaze directions (neutral, left, right, cranial, caudal). Lenses, orbital optic nerves, optic discs and CSI target volumes were delineated. 36-Gy cranial irradiation plans were constructed on synthetic CT images in neutral gaze, with Volumetric Modulated Arc Therapy, pencil-beam scanning proton therapy, and 3D-conventional photons. Movement-amplitudes of lenses and optic discs were analyzed, and influence of gaze direction on lens and orbital optic nerve dose distribution.
Mean eye structures’ shift from neutral position was greatest in caudal gaze; −5.8±1.2 mm (±SD) for lenses and 7.0±2.0 mm for optic discs. In 3D-conventional plans, caudal gaze decreased Mean Lens Dose (MLD). In VMAT and proton plans, eye movements mainly increased MLD and diminished D98 orbital optic nerve (D98_OON) coverage; mean MLD increased up to 5.5 Gy [total ΔMLD range −8.1 to 10.0 Gy], and mean D98_OON decreased up to 3.3 Gy [total ΔD98_OON range −13.6 to 1.2 Gy]. VMAT plans optimized for optic disc Internal Target Volume and lens Planning organ-at-Risk Volume resulted in higher MLD over gaze directions. D98_OON became ≥95% of prescribed dose over 95/100 evaluated gaze directions, while all-gaze bilateral D98_OON significantly changed in 1 of 10 volunteers.
With modern CSI techniques, eye movements result in higher lens doses and a mean detriment for orbital optic nerve dose coverage of <10% of prescribed dose.
Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves’ orbitopathy: A randomized prospective comparative study
2021, Clinics
Citation Excerpt :
The photographs included a 12-mm circular sticker for digital calibration (Figure 1). Digital images were processed and analyzed by a single researcher using the method proposed by Lim et al. (16). Using Photoshop software (Adobe, San Jose, CA, USA, version 19.1.9), semitransparent photographs of the patient's versions were successively juxtaposed on a photograph in the primary gaze position (Figure 2A).
To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities.
Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964.
Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002).
IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.
Novel compact device for clinically measuring extraocular muscle (EOM) tension
2020, Journal of Biomechanics
Accurate knowledge of extraocular muscle (EOM) tension is important for the diagnosis of and surgical planning for strabismus, such as choosing which eye to operate or determining the amount of muscle displacement. Previous evaluations of passive EOM tension have relied extensively on the experience and skill of ophthalmic surgeons, who generally perform such evaluations by gripping the eyeball and then pushing and pulling it. This methodology, named the forced duction test, has the significant limitation that the tension is felt subjectively via the forceps, with the results therefore not being quantifiable. Previous quantitative analyses have utilized several different types of equipment with implanted force transducers or have involved connecting the muscle tendon to a strain gauge. However, the associated equipment setups and recording systems are highly complex and rarely used outside research settings. This situation prompted the present study to develop a novel compact, quantifiable and clinically applicable device for measuring the passive tension in human EOMs for use in clinical practice. The device employs locking forceps and a tilting sensor to rule out effects of the gripping force and to compensate for changes in the force due to tilting, which improves the measurement accuracy. The performance of the device was investigated in 60 eyes of 30 consecutive anaesthetized patients immediately prior to ophthalmic surgery. The results showed that the measured EOM tension in each rectus muscles agreed with previous findings: 48.3 ± 14.5 g (0.82 ± 0.28 g/deg, mean ± SD) for the lateral rectus, 45.6 ± 13.2 g (0.82 ± 0.23 g/deg) for the medial rectus, 48.6 ± 14.7 g (0.71 ± 0.21 g/deg) for the inferior rectus and 53.4 ± 13.7 g (0.77 ± 0.25 g/deg) for the superior rectus.
Vestibular and oculomotor function in children with CP: Descriptive study
2019, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
After obtaining consent and assent, a short interview that included demographic questions and medical history was given. All participants completed a vision screening that included: 1) eye alignment using the modified Thorington test [18], 2) accommodation amplitude using the Push up test [18], 3) Convergence using the Near Point of Convergence test [18], 4) Depth perception using Randot Stereotest [19], and 5) Cardinal Positions of gaze [20]. See Appendix A for detailed description of these tests.
We aimed to describe vestibular/oculomotor function of 7–12-year-old children with CP, Gross Motor Function Classification System (GMFCS) levels (I-III), in comparison to an age-matched control group to understand the effect of the vestibular system on activities and participation of children with CP.
Vestibular, oculomotor and balance function were tested in children with CP. Central and peripheral vestibular function was examined using an enclosed rotary chair and infrared video goggles (100 Hz) that measured eye movements. Oculomotor tests included smooth pursuit and optokinetic nystagmus (OKN). Vestibulo-Ocular Reflex (VOR) tests, done in complete darkness, included step rotation (STEP), sinusoidal harmonic acceleration (SHA) test, VOR cancellation and enhancement, and subjective visual vertical and horizontal (SVV/SVH). The integrity of the saccule was tested with the Cervical Vestibular Evoked Myogenic Potential. If able, the participants' balance abilities were examined using the Sensory Organization Test (SOT) to determine ability to maintain standing balance during six conditions that challenged the visual, somatosensory and vestibular systems. Independent t-tests and Mann-Whitney U tests were used to compare results between groups.
Forty-one children with CP (mean age = 9.44 years, SD = 1.66; 23F/18M; Gross Motor Function Classification System levels: I (n = 19), II (n = 7), III (n = 15) and thirty-three typically developing (TD) children (mean age = 10.16 years, SD = 1.6; 13F/20M) were recruited from the Birmingham, AL community. There was no significant difference between children with CP and TD children in saccular function (i.e. C-VEMP test), and peripheral vestibular end organ (i.e. SHA test and STEP test), VOR enhancement, or OKN gain. Velocity gain for horizontal smooth pursuit was significantly worse in children with CP (p = 0.009), compared to TD children. Poor mediation of central vestibular function were that evident with significantly higher VOR cancellation gain in children with CP (p < 0.0001), compared to TD children and significantly higher SVV variance (p = 0.002), SVH mean (p = 0.001), and SVH variance (p < 0.0001) in children with CP compared to TD children. Compromised balance abilities in children with CP was evident with significantly lower composite scores (p < 0.0001), vestibular ratio (p < 0.0001), and visual ratio (p = 0.021). The somatosensory ratio (p = 0.798) of children with CP was similar to children with TD.
Although peripheral vestibular function was intact, children with CP had difficulty coupling eye and head movement (VOR cancellation), using the vestibular system for postural control (SOT), demonstrated poor perception of upright (SVV/SVH), and had difficulty following a slow moving target (smooth pursuit eye movement). These results implicate a central vestibular and oculomotor function impairment the severity of which corresponded with severity of the level of CP.
Quantitative assessment of inferior oblique muscle overaction using photographs of the cardinal positions of gaze
2014, American Journal of Ophthalmology
To report a novel method for measuring the degree of inferior oblique muscle overaction and to investigate the correlation with other factors.
Cross-sectional diagnostic study.
One hundred and forty-two eyes (120 patients) were enrolled in this study. Subjects underwent a full orthoptic examination and photographs were obtained in the cardinal positions of gaze. The images were processed using Photoshop and analyzed using the ImageJ program to measure the degree of inferior oblique muscle overaction. Reproducibility or interobserver variability was assessed by Bland-Altman plots and by calculation of the intraclass correlation coefficient (ICC). The correlation between the degree of inferior oblique muscle overaction and the associated factors was estimated with linear regression analysis.
The mean angle of inferior oblique muscle overaction was 17.8 ± 10.1 degrees (range, 1.8–54.1 degrees). The 95% limit of agreement of interobserver variability for the degree of inferior oblique muscle overaction was ±1.76 degrees, and ICC was 0.98. The angle of inferior oblique muscle overaction showed significant correlation with the clinical grading scale (R = 0.549, P < .001) and with hypertropia in the adducted position (R = 0.300, P = .001). The mean angles of inferior oblique muscle overaction classified into grades 1, 2, 3, and 4 according to the clinical grading scale were 10.5 ± 9.1 degrees, 16.8 ± 7.8 degrees, 24.3 ± 8.8 degrees, and 40.0 ± 12.2 degrees, respectively (P < .001).
We describe a new method for measuring the degree of inferior oblique muscle overaction using photographs of the cardinal positions. It has the potential to be a diagnostic tool that measures inferior oblique muscle overaction with minimal observer dependency.

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: Financial Disclosures: The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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Original articleClinical Measurement of the Angle of Ocular Movements in the Nine Cardinal Positions of Gaze

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Study Design and Participants

Results

Discussion

Am J Ophthalmol

J AAPOS

Ophthalmology

Am J Ophthalmol

Ophthalmology

Vision Res

Med Hypotheses

Binocular Vision and Ocular Motility: Theory and Management of Strabismus

Diagnosis and Management of Ocular Motility Disorders

Clinical Methods of Neuro-ophthalmologic Examination

Original article
Clinical Measurement of the Angle of Ocular Movements in the Nine Cardinal Positions of Gaze