CHAPTER XVI. Law of Projection

LAW OF PROJECTION

The movements of the eye are designed primarily to effect fixation—that is, to bring upon the macula the image of the object that we wish to look at. When this has been accomplished, we know as a result of long experience, the direction of the object looked at and also direction of other neighboring objects. This knowledge is doubtless afforded us, in part, by our muscle sense. Thus we know that an object, A, is straight in front of us because we can see it sharply without moving either the head or the eyes from the position of rest or equilibrium; and we know that an object, B, is on the right of us because to see it sharply we have to move either the head or the eyes to the right, thus altering the muscular condition from one of rest to one of tension. But without moving either head or eye, we also know, while still looking at A, that B is to the right, for the image of B is then formed on a portion of the retina situated to the left of the macula. From long experience we also know that an image so situated means an object placed on our right. Moreover, the farther to the left of the macula the image B is, the farther to the right do we judge B itself to be.

Similarly, if B is so placed that its image falls below the macula, we then know B itself is really above A, which forms its image on the macula; and if the image of B is above the macula, we know that B itself is below A.

The table on page 116 is suggested as a guide in cases of muscular imbalance:

SUPPRESSION OF IMAGE

All deviations should be and probably are primarily associated with diplopia. Yet in the great majority of cases of established squint, especially convergent squint, there is no double vision. This is due to the mental suppression of the image by the squinting eye. In such cases all attempts to evoke diplopia by our tests may be futile, the patient not appreciating the presence of double images even when they are widely separated by prisms. Moreover, this suppression usually persists after the squint is cured, so that even though there are two retinal images of the same object, the mind perceives but one and ignores the other, just as though it were not present. In this case there is no true stereoscopic, or solid, vision.

MONOCULAR DIPLOPIA

Binocular diplopia, due to deviation of the eyes or to prisms, must be distinguished from monocular diplopia, or the condition in which the patient sees double with one eye alone. This occurs as the result of astigmatism, plus spherical aberration and other conditions found occasionally in squint. It can readily be differentiated by the fact that binocular diplopia disappears when the patient shuts either eye; while monocular diplopia, of course, does not.

TABLE OF DIPLOPIA

==================+===========+=====================================+ | Image of | | | right eye | CAUSED BY | |as compared+-------------------+-----------------+ Name of |with that | |(2) Artificially | diplopia | of the | (1) By a natural | by a prism | | left is | deviation of | placed, base | ------------------+-----------+-------------------+-----------------+ {Homonymous | On the |Either eye inward |In before either | { | right | (esophoria, | eye. | Lat-{ | | esotropia.) | | eral{ | | | | {Heteronymous| On the |Either eye outward |Out before either| {(or crossed)| left | (exophoria, | eye. | | | exotropia.) | | ------------------+-----------+-------------------+-----------------+ {Right | Below |Right eye up |Up before right | { | | or left eye down | eye, down before| Vert-{ | |(right hyperphoria,| left eye. | ical{ | | right hypertropia,| | { | | left hypotropia.) | | { | | | | {Left | Above |Right eye down |Down before right| | | or left up |eye, up before | | |(left hyperphoria, | left | | | left hypertropia, | | | | right hypotropia.)| | ==================+===========+===================+=================+ | Image of | | | right eye | CORRECTED BY | |as compared+-------------------+-----------------+ Name of |with that | | | diplopia | of the | (1) Turning |(2) Prism placed | | left is | | with base | ------------------+-----------+-------------------+-----------------+ {Homonymous | On the |Both eyes outward |Out before either| { | right | (divergence.) | eye. | Lat-{ | | | | eral{Heteronymous| On the |Both eyes inward |In before either | {(or crossed)| left | (convergence.) | eye. | | | | | ------------------+-----------+-------------------+-----------------+ {Right | Below |Right eye down |Down before right| Vert-{ | | and left eye up | eye or up before| ical{ | | (left | left eye. | { | | supravergence.) | | { | | | | {Left | Above |Right eye up and |Up before right | | | left eye down | eye or down | | | (right | before left. | | | supravergence.) | | ==================+===========+===================+=================+

MOVEMENT OF EACH EYE SINGLY

The movements of each eye individually are effected as follows:

The external rectus moves the eye directly outward; the internal rectus, directly inward.

The primary action of the superior rectus is to raise the eye. Because of the way in which the muscles run, obliquely from within outward, its lifting action increases when the eye is abducted and diminishes to little or nothing when the eye is adducted.

The inferior rectus carries the eye down. Owing to the oblique direction of the muscle, its depressing action increases as the eye is abducted and decreases to zero as the eye is adducted.

The inferior oblique is inserted back of the equator of the eye. Hence it pulls the back part of the eye down and consequently throws the front part up. It is thus an elevator of the eye, reinforcing the action of the superior rectus. Owing to the way in which it runs, from the front backward and outward, its elevating action is greatest when the eye is adducted, and diminishes to little or nothing when the eye is abducted.

The superior oblique, so far as its action on the eyeball is concerned, may be regarded as arising from the trochlea. From this point it runs backward and outward and is inserted back of the equator of the eye. It there pulls up the back part of the eye and consequently throws the front part down. It is thus a depressor, reinforcing the action of the inferior rectus. Owing to the oblique way in which it runs, its depressing action is greatest when the eye is adducted, and diminishes to little or nothing when the eye is abducted.

SUBSIDIARY ACTIONS

Besides these actions, rightly regarded as the main action of the ocular muscles, there are various subsidiary actions, due to the oblique way in which the superior and inferior recti and the two obliques run. Thus, both the superior and inferior recti adduct the eye, their action being most pronounced when the eye is already adducted. The two obliques, on the other hand, abduct the eye and do so most effectively when the eye is already abducted.

The superior rectus and superior oblique rotate the top of the vertical meridian of the eye inward (intorsion); while the inferior oblique and inferior rectus rotate it outward (extorsion). The superior and inferior recti act thus on the vertical meridian mainly when the eye is adducted; the oblique, on the other hand, when the eye is abducted.

Hence the eye is adducted by the internal rectus, assisted toward the end of its course by the superior and inferior recti. It is abducted by the external rectus, assisted toward the end of its course by the two obliques. It is carried straight up by the superior rectus and inferior oblique, up and out by the superior rectus and external rectus (the inferior oblique helping to carry it out, but not up; and in, mainly by the inferior oblique and internal rectus). The superior rectus assists in carrying it in, but hardly up at all.

The eye is likewise carried straight down by the inferior rectus and the superior oblique; down and out by the inferior and external recti, and down and in by the superior oblique and internal recti.

FIELD OF ACTION OF MUSCLES

As will be seen, each muscle acts most energetically in some special direction of the gaze, termed field of action of that particular muscle; thus the external rectus acts most powerfully when the eye is directed outward, and acts little or not at all when the eye is directed inward, except by purely passive traction. Likewise the superior rectus acts mainly when the eye is directed down. Furthermore, its action is limited to the upper and outer field; for in the upper and inner field elevation is performed chiefly by the inferior oblique.

This is also true of all the other muscles.

DIRECTION OF THE GAZE

There are six cardinal directions of the gaze, each corresponding to the field of action of one of the six ocular muscles as follows:

CARDINAL DIRECTION: MUSCLES SPECIALLY ACTIVE:

Straight out External rectus Straight in Internal rectus Up and out Superior rectus (as an elevator) Up and in Inferior oblique (as an elevator) Down and out Inferior rectus (as a depressor) Down and in Superior oblique (as a depressor)

It is to be noted that the action of each muscle does not absolutely stop at the middle line, but extends somewhat beyond it. Thus the action of the right externus extends not only throughout the whole right half of the field of vision, but also some fifteen to twenty degrees to the left of the median line; and that of the superior rectus extends not only above the horizontal plane but also somewhat below.

PRIMARY POSITION—FIELD OF FIXATION

Under normal conditions, when the head is erect and the eye is directed straight forward—that is, when its line of sight is perpendicular to the line joining the centres of rotation of the two eyes in the horizontal plane—the muscles are all balanced. This is called “the position of equilibrium” or the primary position. It is this position which must be assumed by the patient in conducting tests for balance of the muscles.

From the primary position, the eye may make excursions in every direction so that the patient can look at a whole series of objects in succession without moving the head. This portion of space, occupied by all the objects that may thus be seen directly by moving the eye without moving the head, is called “the field of fixation.”

BINOCULAR MOVEMENTS

While either eye alone may move in all possible directions, one cannot move independently of the other eye. Under ordinary circumstances, those movements only are possible which are regularly required to subserve binocular vision, hence, binocular single vision, as well. These movements are as follows:

PARALLEL MOVEMENTS

When one eye looks at a distant object the other is also directed to it, so that the lines of sight of the two eyes are parallel; if the distant object is moved about, the lines remain parallel, one moving as fast and as far as the other. These parallel movements of the two eyes are executed with considerable freedom in all directions, either eye being able to move readily to the right, left, up, down, or obliquely, provided the other eye moves precisely with it.

In executing any parallel movement, each eye is acted upon by at least three and sometimes by as many as five muscles. At times, but one of these muscles is required to produce any great movement of the eye, the others simply serving to steady it in its course. Thus when we look up to the right, although there are five muscles really acting upon each eye, the right eye is moved mainly by the external rectus and the left eye by the internal rectus.

Similarly, when we look up and to the right, although other muscles take part, the superior rectus is the chief muscle that moves the right eye up, and the external rectus the chief one that moves it to the right; while for the left eye the inferior oblique and the internal rectus are the efficient muscles.

A careful study of the action of the individual muscles will make it clear that these facts hold good for each of the cardinal directions of the gaze.

Furthermore, if we attentively consider the action of the twelve muscles moving the two eyes, we see that they may be divided into three groups, viz.; four lateral rotators, four elevators and four depressors.

LATERAL ROTATORS Right rotators } { Left rotators L. Internal rectus } to { R. Internal rectus R. External rectus } { L. External rectus

ELEVATORS Right-handed elevators } { Left-handed elevators (acting mainly when the } { (acting mainly when the eyes are directed to the } to { eyes are directed to the right) } { left) R. Superior rectus } { R. Inferior oblique L. Inferior oblique } { L. Superior rectus

DEPRESSORS Right-handed depressors } { Left-handed depressors (acting mainly when the } { (acting mainly when the eyes are directed to the } { eyes are directed to the right) } to { left) R. Inferior oblique } { R. Superior oblique L. Superior oblique } { L. Inferior rectus.

Each group, it will be seen, comprises two pairs of muscles; one pair acting solely when the eyes are directed to the right, the other when they are directed to the left. It will further be noted that of the two muscles constituting any one pair, one is situated in the right eye, the other in the left.

EYE ASSOCIATES

The muscles forming any one pair are called associates. Any two associates acting together will move their respective eyes in precisely the same direction and to the same extent. Thus the right superior rectus moves the eye up to the left and rotates its vertical meridian to the left; and its associate, the left inferior oblique, moves its eye up to the left and rotates its vertical meridian to the left. This likewise applies to each of the other five groups of associates.

If one eye fails to keep pace with the other in executing parallel movements, diplopia ensues. If the eyes are moved in all directions and the point noted where the patient just begins to see double, we delimit the field of binocular single vision.

Normally, however, the two eyes maintain parallelism to the very limit of their excursion, so that diplopia occurs only at the extreme periphery of the field of vision, if at all. In fact, the field of binocular single vision usually extends not less than 40 degrees from the primary position in every direction.

Each of the various parallel movements of the eye appear to be governed by a distinct nerve mechanism, there being one centre for movements to the right, one for movements to the left, one for movements up, etc.

MOVEMENTS OF CONVERGENCE

In order to see an object at a nearby point, the eyes have to converge—a movement affected by a simultaneous and equal contraction of both internal recti. This movement may be combined with a vertical, lateral or oblique parallel movement. Thus, when we wish to look at a near object situated twenty degrees to our right, we first turn both eyes twenty degrees to the right, then converge both equally, turning the left a little more to the right and the right a little back toward the left.

Convergence is governed by a distinct mechanism of the nerves, the source of which has not been determined.

MOVEMENTS OF DIVERGENCE

In passing from a position of convergence to a position of parallelism, the lines of sight separate or diverge. This movement of divergence is a simultaneous, equal contraction of both externi; or, probably, of both actions combined. The eyes may even diverge somewhat beyond parallelism, as in overcoming prisms, base in, when looking at a distant object.

VERTICAL DIVERGENCE

The amount by which the lines of sight can separate in a vertical direction is very limited—at most but one or two degrees.

ORTHOPHORIA

The term orthophoria is used to denote an absolutely normal balance of the extrinsic muscles, just as the term emmetropia denotes a normal refractive condition. They are equally rare.

HETEROPHORIA

The term heterophoria includes all those conditions in which there is a tendency to depart from normal balance, but which nature is able to compensate for; while the term also includes the conditions in which nature has been unequal to the task and an actual turning or squint has occurred.

SUBDIVISIONS

The subdivisions of these terms at first reading appear complicated, but prove simple enough on closer study, indicating only the direction of the turning or tendency to turn. For instance:

Esophoria signifies inward tendency. Exophoria signifies outward tendency. Hyperphoria signifies upward tendency. Hypophoria signifies downward tendency. Cyclophoria signifies tendency to torsion. Esotropia signifies inward turning. Exotropia signifies outward turning. Hypertropia signifies upward turning. Hypotropia signifies downward turning. Cyclotropia signifies actual torsion.

Combinations are describable in similar terms. A tendency of the right eye to turn up and inward, is a “right hyperesophoria”; the left eye to turn down and out, a “left hyperexophoria,” etc. Tendencies of both eyes together are denoted by the terms which follow:

Anaphoria signifies an upward tendency. Kataphoria signifies a downward tendency. Dextrophoria signifies a right tendency. Laevophoria signifies a left tendency.