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Incomitant Strabismus Associated with Instability of Rectus Pulleys

¹ From the Jules Stein Eye Institute Departments of Ophthalmology and ⁴ Neurology, University of California, Los Angeles, California; ² Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and the ³ Southern California Permanente Medical Group, Woodland Hills, California.

PURPOSE. Connective tissue pulleys serve as functional mechanical origins of the extraocular muscles (EOMs) and are normally stable relative to the orbit during gaze shifts. This study evaluated pulley stability in incomitant strabismus.

METHODS. Contiguous 2- or 3-mm thick magnetic resonance images (MRIs) perpendicular to the orbital axis spanned the anteroposterior extents of 12 orbits of six patients with incomitant strabismus. Imaging was performed in central gaze, supraduction, infraduction, abduction, and adduction. Rectus EOM paths were defined by their area centroids and plotted in a normalized, oculocentric coordinate system. Paths of EOMs ran toward the pulleys. Sharp EOM path inflections in secondary gaze indicated pulley locations in three dimensions.

RESULTS. MRI revealed substantial inferior shift of the lateral rectus (LR) pulley of up to 1 mm during vertical gaze shifts in patients with axial high myopia and a posterior shift from abduction to adduction in simulated Brown syndrome. There was substantial LR pulley shift opposite the direction of vertical gaze in a subject with X-pattern exotropia who had undergone repeated LR surgery. The medial rectus (MR) pulley shifted inferiorly with gaze elevation in Marfan syndrome. Pulley instability was associated with significantly increased globe translation during gaze shifts.

CONCLUSIONS. Pulley instability, resulting in EOM sideslip during ductions, occurs in some cases of incomitant strabismus. Resultant patterns of strabismus may depend on static pulley positions, pulley instability, and coexisting globe translation that alters pulley locations relative to the globe. Translational instability of pulleys and the globe could produce abnormalities in actions of otherwise normal EOMs, and connective tissue disorders causing these instabilities should be considered as potential causes of strabismus.

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