Extraocular connective tissues: a role in human eye movements?

PURPOSE This study presents a detailed anatomic analysis of the undisturbed connective tissues that surround the horizontal extraocular muscles (EOMs) of humans. Emphasis is placed on those EOM orbital side tissues that, in previous MRI studies, were assumed to couple the muscle to the pulley. METHODS Serial 5-mum sections were prepared from paraffin-embedded blocks of the lateral and medial rectus muscles and their surrounding connective tissues. The sections were treated with Masson's trichrome stain for light microscopic examination of muscle fibers (red) and surrounding connective tissues (blue). RESULTS Rectus muscle sections demonstrated the orbital connective tissues to be a collagenous bridge between the distal third of the muscle and the orbital periosteum (i.e., check ligament [CL]). The CL attaches to the muscle by investing itself around orbital muscle fibers whereas, at the point of attachment, those fibers remain aligned with the remainder of the muscle. The CL on the orbital side and the reflected bulbar fascia on the global side of the muscle constitute a tubelike sheath. The posterior border of the sheath insinuates into the muscle belly and its anterior aspect blends into the sides of the portal through Tenon's capsule. CONCLUSIONS All rectus EOM fibers participate in eye rotation. The CL is the band of tissue present on the MRI images, but was previously described as the orbital layer insertion for the active pulley hypothesis (APH). The APH should now be questioned. Alternate theories incorporating accepted neurophysiological, anatomic, and ophthalmological principles of EOM movement are discussed.