Search

The differential diagnosis of congenital superior oblique paresis (strabismus sursoadductorius), acquired superior oblique paresis and inferior oblique overaction are discussed. In this study the purpose of the graphic description of a lever arm, “equal-line”, crossing points of equal lines, “functional pole”, in primary position (functional topography), are described. The efficacy of functional and mechanical guidelines for oblique muscle surgery are discussed. The pattern of motility disorders (clinical measurements of three patients), congenital oblique paresis (strabismus sursoadductorius SSA), aquired superior oblique paresis (SOP) and inferior oblique overaction (IOO) are compared with the mechanical situation (functional topography) of eye-motility. In a mechanical eye model SSA can be created as a concomitant vertical pattern of movement disorder with excyclorotation by a sagittalisation of the functional inferior oblique muscle origin (pulley-displacement). SOP with normal functional origin and insertion of superior and inferior oblique muscle can be created only by weakening (less muscle strength) the superior oblique muscle. IOO is constructed by a sagittalisation of muscle insertion of inferior oblique muscle and desagittalisation of insertion of superior oblique muscle. An ideal insertion line of the oblique muscles can be created at the surface of the eyeball by connecting points of the same main function. There are crossing points (areas) of this equal line projected at the “functional pole” at different gaze positions. At this equal-line the oblique muscle has to be fixed in recession or reforcing surgery to get a normal eye function. The findings of Bielschowskys’ strabismus sursoadductorius as a vertical motility disorder with its own typical clinical appearance as well as SOP and IOO are confirmed by the clinical and vectorial results. In oblique muscle surgery a functional topography helps to prevent errors in eye muscle surgery. In dieser Studie wird die Differentialdiagnose der kongenitalen m.obliquus superior-Parese (strabismus sursoadductorius, SSA), der erworbenen m.obl.superior-Parese (SOP) und der m.obliquus inferior-Überfunktion (IOO) erläutert. Dem Zweck der Beschreibung und graphischen Darstellung von idealen Ansatzlinien in Primärposition und deren Kreuzungspunkte — „funktionelle Pole“ (funktionelle Topographie) wird nachgegangen. Die Bedeutung dieser Richtlinien für die Chirurgie der schrägen Augenmuskeln wird aufgezeigt. Die Motilitätsmuster klinischer Messungen eines SSA, einer SOP und einer IOO werden mit Mustern eines mechanischen Augenmodells verglichen. Der SSA als konkomitante vertikale Abweichung mit typischer Excyclorotation kann in unserem mechanischem Augenmodell nur durch Sagittalisation des funktionellenUrsprungs(pulley displacement) des m.obl.inferior, geringer des m.obl.superior nachempfunden werden. Die SOP wird allein durch geringere Muskelstärke (Gewichtung) bei normalen Ursprungs- und Ansatzverhältnissen dargestellt. Die IOO ist durch Sagittalisation (steiler Ansatzwinkel) des m.ob.inferior-Ansatzes, Desagittalisation (weniger steiler Ansatz) des m.obl.superior-Ansatzeszu simulieren. Eine ideale Ansatzlinie der schrägen Augenmuskeln läßt sich durch Vereinigung aller jener Punkte gleicher Wirkung (keine Buchstabensymptomatik) auf die Augenoberfläche projezieren. Der Schnittpunkt dieser Linie ohne Buchstabensymptomatik — „funktioneller Pol“ in den Blickrichtungen lässt sich festlegen. Bei der Rücklagerung oder der stärkenden Operation muss der schräge Augenmuskel in Richtung funktionellem Pol verlagert werden um eine normale Augenfunktion zu erreichen. Die Erkenntnisse Bielschowskys der SSA sei eine vertikale Augenmotilitätsstörung mit eigenem typischem Erscheinungsbild, deutlich von der SOP und IOO abgrenzbar, lässt sich klinisch und mechanisch nachweisen. Eine „funktionelle Topographie“ hilft bei der obliquus-Chirurgie Fehler zu vermeiden.

Abstract:  We recorded three-dimensional eye and head movements during circular, horizontal, vertical, and torsional head shaking in six human subjects with normal vestibular function. With circular head shaking, the stimulation of the canals by the termination of the head movement is similar to that following a step in velocity about the naso-occipital axis. A large torsional nystagmus with slow phase eye velocity of about 20/s was observed upon cessation of circular head shaking. The three-dimensional eye movements expected from stimulation of the semicircular canals by the head-shaking maneuvers were calculated. The predicted activation of the canals was determined by projecting the head velocity (in head coordinates) into the canal planes and then processing the signal with the transfer function of the canals. The torsional eye velocity components predicted by the stimulation of the canals matched the recorded ones. We observed small horizontal eye velocities that could not be predicted by the stimulation of the canals alone. No eye movements were observed after the end of head shaking about a fixed horizontal or vertical axis. The eye velocities following the termination of head oscillations in the roll plane were small. The analysis methods developed for this study may be useful in the investigation of eye movements elicited by other types of three-dimensional head movements.

Horizontal and vertical smooth pursuit was compared with otolith-ocular responses in 11 patients with cerebellar ataxia and 21 normal subjects using three-dimensional magnetic search coil eye movement recordings. Otolith-ocular responses were investigated during off-vertical axis rotation. This stimulus induces nystagmus consisting of the exponentially decaying canalicular response, and an eye-velocity modulation and offset which arise from the excitation of the otoliths by the gravity vector, which lasts as long as the rotation continues. Otolith-ocular reflexes are intimately interrelated with visual tracking when real targets are viewed during linear motion. The responses of both the translational vestibulo-ocular reflex and the pursuit system have been shown to be linearly dependent on the inverse of the viewing distance, so that a common central pathway for the two systems has been suggested, probably travelling through the cerebellum. Thus, the aim of the study was to evaluate to what extent these reflexes are disturbed in cerebellar disease. The results confirm the earlier notion that in normal subjects pursuit performance is better for horizontal than for vertical tracking, and that it is better for upward than for downward tracking. This pattern is also found in patients. In addition, smooth pursuit performance is clearly degraded in patients, but the modulation of eye-velocity during off-vertical axis rotation is enhanced. Since the amount of this enhancement does not correlate with the amount of pursuit impairment, degradation of smooth pursuit and pathological enhancement of otolith-ocular responses seem to be independent effects of cerebellar degeneration. Thus, the increase in the otolith-ocular response in patients cannot be attributed to adaptational mechanisms trying to overcome the smooth pursuit deficiency; it is more likely to represent pathological disinhibition of otolith derived responses. The absence of compensatory eye-velocity offset during off-vertical axis rotation may reflect the fact that in patients the otolith signals are not utilized in computations thought to be important for spatial orientation mechanisms arising from the interaction of vestibular, visual and somatosensory signals.Keywords:cerebellar ataxia; otolith-canal interaction; smooth pursuit; off-vertical axis rotation; three-dimensional eye movements

Abstract:  Dual search coils were used to record horizontal, vertical and torsional eye movement components of one eye during nystagmus caused by off-center yaw rotation (yaw centrifugation). Both normal healthy human subjects (n=7) and patients with only one functioning labyrinth (n=12) were studied in order to clarify how the concomitant linear acceleration affected the nystagmus response. Each subject was seated with head erect on the arm of a fixed-chair human centrifuge, 1 m away from the center of the rotation, and positioned to be facing along a radius; either towards (facing-in) or away from (facing-out) the center of rotation. Both yaw right and yaw left angular accelerations of 10°s–2 from 0 to 200°/s were studied. During rotation a centripetal linear acceleration (increasing from 0 to 1.24×g units) was directed along the subject’s naso-occipital axis resulting in a shift of the resultant angle of the gravitoinertial acceleration (GIA) of 51° in the subject’s pitch plane and an increase in the total GIA magnitude from 1.0 to 1.59×g. In normal subjects during the angular acceleration off-center there were, in addition to the horizontal eye velocity components, torsional and vertical eye velocities present. The magnitude of these additional components, although small, was larger than observed during similar experiments with on-center angular acceleration (Haslwanter et al. 1996), and the change in these components is attributed to the additional effect of the linear acceleration stimulation. In the pitch plane the average size of the shift of the axis of eye velocity (AEV) during the acceleration was about 8° for a 51° shift of the GIA (around 16% of the GIA shift) so that the AEV-GIA alignment was inadequate. There was a very marked difference in the size of the AEV shift depending on whether the person was facing-in [AEV shift forward (i.e. non-compensatory) of about 4°] or facing-out [AEV shift forward (i.e. compensatory) of around 12°]. The linear acceleration decreased the time constant of decay of the horizontal component of the post-rotatory nystagmus: from an average of 24.8°/s facing-in to an average of 11.3°/s facing-out. The linear acceleration dumps torsional eye velocity in an manner analogous to, but independent of, the dumping of horizontal eye velocity. Patients with UVD had dramatically reduced torsional eye velocities for both facing-in and facing-out headings, and there was little if any shift of the AEV in UVD patients. The relatively small effects of linear acceleration on human canal-induced nystagmus found here confirms other recent studies in humans (Fetter et al. 1996) in contrast to evidence from monkeys and emphasizes the large and important differences between humans and monkeys in otolith-canal interaction. Our results confirm the vestibular control of the axis of eye velocity of humans is essentially head-referenced whereas in monkeys that control is essentially space-referenced.

We recorded three-dimensional eye movements during angular acceleration steps from 0 to 250°/s at 20°/s2 about an earth-vertical axis. Experiments were performed on 27 normal subjects and on 19 patients who had recovered well from unilateral vestibular deafferentation on the right or left side. In addition to compensatory horizontal eye movements, significant vertical and torsional eye movement components were elicited. These vertical and torsional eye velocity traces led to a shift of the axis of eye velocity away from the axis of head velocity. Horizontal, vertical, and torsional velocity components showed clear differences between normals and patients with unilateral vestibular deafferentation. In normals, the axis of eye velocity tilted backward and slightly away from the axis of head velocity. Patients showed similar, but more pronounced, shifts during rotations toward the intact ear and shifts in the opposite direction for rotations toward the operated ear. Eye velocity traces were analyzed with special consideration given to the orientation of the axis of eye velocity. We speculate that the vertical and torsional velocity components may be due to the effects of Listing's plane, as well as the contributions of the otolith signals.

The parameters characterizing Listing's plane have been determined in a group of normal subjects, and in patients who have had unilateral vestibular deafferentation on the right or left side. All patients were well compensated. There was no statistically significant difference in the orientation of Listing's plane between either of these groups: Listing's plane was approximately perpendicular to the horizontal stereotaxic plane and showed a systematic temporal tilt, i.e., it tilted right for the right eye, and left for the left eye. We also found a considerable intersubject variability in the orientation of Listing's plane. The effect of this variability on the interpretation of three-dimensional eye position and velocity data is discussed.

1. The kinematics of the human angular vestibuloocular reflex (VOR) in three dimensions was investigated in 12 normal subjects during high-acceleration head rotations (head "impulses"). A head impulse is a passive, unpredictable, high-acceleration (3,000-4,000 degrees/s2) head rotation of approximately 10-20 degrees in roll, pitch, or yaw, delivered with the subject in the upright position and focusing on a fixation target. Head and eye rotations were measured with dual search coils and expressed as rotation vectors. The first of these two papers describes a vector analysis of the three-dimensional input-output kinematics of the VOR as two indexes in the time domain: magnitude and direction. 2. Magnitude is expressed as speed gain (G) and direction as misalignment angle (delta). G is defined as the ratio of eye velocity magnitude (eye speed) to head velocity magnitude (head speed). delta is defined as the instantaneous angle by which the eye rotation axis deviates from perfect alignment with the head rotation axis in three dimensions. When the eye rotation axis aligns perfectly with the head rotation axis and when eye velocity is in a direction opposite to head velocity, delta = 0. The orientation of misalignment between the head and the eye rotation axes is characterized by two spatial misalignment angles, which are the projections of delta onto two orthogonal coordinate planes that intersect at the head rotation axis. 3. Time series of G were calculated for head impulses in roll, pitch, and yaw. At 80 ms after the onset of an impulse (i.e., near peak head velocity), values of G were 0.72 +/- 0.07 (counterclockwise) and 0.75 +/- 0.07 (clockwise) for roll impulses, 0.97 +/- 0.05 (up) and 1.10 +/- 0.09 (down) for pitch impulses, and 0.95 +/- 0.06 (right) and 1.01 +/- 0.07 (left) for yaw impulses (mean +/- 95% confidence intervals). 4. The eye rotation axis was well aligned with head rotation axis during roll, pitch, and yaw impulses: delta remained almost constant at approximately 5-10 degrees, so that the spatial misalignment angles were < or = 5 degrees. delta was 9.6 +/- 3.1 (counterclockwise) and 9.0 +/- 2.6 (clockwise) for roll impulses, 5.7 +/- 1.6 (up) and 6.1 +/- 1.9 (down) for pitch impulses, and 6.2 +/- 2.2 (right) and 7.9 +/- 1.5 (left) for yaw impulses (mean +/- 95% confidence intervals). 5. VOR gain (gamma) is the product of G and cos(delta). Because delta is small in normal subjects, gamma is not significantly different from G. At 80 ms after the onset of an impulse, gamma was 0.70 +/- 0.08 (counterclockwise) and 0.74 +/- 0.07 (clockwise) for roll impulses, 0.97 +/- 0.05 (up) and 1.09 +/- 0.09 (down) for pitch impulses, and 0.94 +/- 0.06 (right) and 1.00 +/- 0.07 (left) for yaw impulses (mean +/- 95% confidence intervals). 6. VOR latencies, estimated with a latency shift method, were 10.3 +/- 1.9 (SD) ms for roll impulses, 7.6 +/- 2.8 (SD) ms for pitch impulses, and 7.5 +/- 2.9 (SD) ms for yaw impulses. 7. We conclude that the normal VOR produces eye rotations that are almost perfectly compensatory in direction as well as in speed, but only during yaw and pitch impulses. During roll impulses, eye rotations are well aligned in direction, but are approximately 30% slower in speed.

1. We studied the three-dimensional input-output human vestibuloocular reflex (VOR) kinematics after selective loss of semicircular canal (SCC) function either through total unilateral vestibular deafferentation (uVD) or through single posterior SCC occlusion (uPCO), and showed large deficits in magnitude and direction in response to high-acceleration head rotations (head "impulses"). 2. A head impulse is a passive, unpredictable, high-acceleration (3,000-4,000 degrees/s2) head rotation through an amplitude of 10-20 degrees in roll, pitch, or yaw. The subjects were tested while seated in the upright position and focusing on a fixation target. Head and eye rotations were measured with the use of dual search coils, and were expressed as rotation vectors. A three-dimensional vector analysis was performed on the input-output VOR kinematics after uVD, to produce two indexes in the time domain: magnitude and direction. Magnitude is expressed as speed gain (G) and direction as misalignment angle (delta). 3. G. after uVD, was significantly lower than normal in both directions of head rotation during roll, pitch, and yaw impulses, and were much lower during ipsilesional than during contralesional roll and yaw impulses. At 80 ms from the onset of an impulse (i.e., near peak head velocity), G was 0.23 +/- 0.08 (SE) (ipsilesional) and 0.56 +/- 0.08 (contralesional) for roll impulses, 0.61 +/- 0.09 (up) and 0.72 +/- 0.10 (down) for pitch impulses, and 0.36 +/- 0.06 (ipsilesional) and 0.76 +/- 0.09 (contralesional) for yaw impulses (mean +/- 95% confidence intervals). 4. delta, after uVD, was significantly different from normal during ipsilesional roll and yaw impulses and during pitch-up and pitch-down impulses. delta was normal during contralesional roll and yaw impulses. At 80 ms from the onset of the impulse, delta was 30.6 +/- 4.5 (ipsilesional) and 13.4 +/- 5.0 (contralesional) for roll impulses, 23.7 +/- 3.7 (up) and 31.6 +/- 4.4 (down) for pitch impulses, and 68.7 +/- 13.2 (ipsilesional) and 11.0 +/- 3.3 (contralesional) for yaw impulses (mean +/- 95% confidence intervals). 5. VOR gain (gamma), after uVD, were significantly lower than normal for both directions of roll, pitch, and yaw impulses and much lower during ipsilesional than during contralesional roll and yaw impulses. At 80 ms from the onset of the head impulse, the gamma was 0.22 +/- 0.08 (ipsilesional) and 0.54 +/- 0.09 (contralesional) for roll impulses, 0.55 +/- 0.09 (up) and 0.61 +/- 0.09 (down) for pitch impulses, and 0.14 +/- 0.10 (ipsilesional) and 0.74 +/- 0.06 (contralesional) for yaw impulses (mean +/- 95% confidence intervals). Because gamma is equal to [G*cos (delta)], it is significantly different from its corresponding G during ipsilesional roll and yaw, and during all pitch impulses, but not during contralesional roll and yaw impulses. 6. After uPCO, pitch-vertical gamma during pitch-up impulses was reduced to the same extent as after uVD; roll-torsional gamma during ipsilesional roll impulses was significantly lower than normal but significantly higher than after uVD. At 80 ms from the onset of the head impulse, gamma was 0.32 +/- 0.13 (ipsilesional) and 0.55 +/- 0.16 (contralesional) for roll impulses, 0.51 +/- 0.12 (up) and 0.91 +/- 0.14 (down) for pitch impulses, and 0.76 +/- 0.06 (ipsilesional) and 0.73 +/- 0.09 (contralesional) for yaw impulses (mean +/- 95% confidence intervals). 7. The eye rotation axis, after uVD, deviates in the yaw plane, away from the normal interaural axis, toward the nasooccipital axis, during all pitch impulses. After uPCO, the eye rotation axis deviates in same direction as after uVD during pitch-up impulses, but is well aligned with the head rotation axis during pitch-down impulses.

Using dual torsion scleral search coils we have recorded 3-dimensional eye position during yaw angular accelerations of 20°/s2 about an earth vertical axis in healthy subjects and in patients with unilateral vestibular deafferentation (UVD). These experiments produced two interesting results: i) even in healthy subjects, the axis of eye velocity did not coincide with the (earth vertical) stimulus axis during centred rotation; ii) Patients with UVD had torsional eye velocity components that were systematically different from those in normal subjects. While in normals the direction of the torsional component of the eye velocity depended on the direction of rotation and was on average approximately symmetric for CW and CCW yaw rotation, there was a clear asymmetry in patients, which was distinctly different for left and right UVD.