Evidence for fibromuscular pulleys of the recti extraocular muscles.

PURPOSE: Magnetic resonance imaging (MRI) shows that the paths of recti extraocular muscle (EOM) bellies remain fixed in the orbit during large ocular rotations and across large surgical transpositions of their insertions. These findings imply that recti EOMs pass through pulleys coupled to the orbit and anterior to the muscle bellies, because the insertions must move with the globe. The present study was conducted to locate anatomically and to characterize histologically the pulley tissues. METHODS: High-resolution MRI images were collected from volunteers, using multiple gaze directions to infer the locations of, and occasionally to visualize, recti EOM pulleys. Fresh cadaver orbits were exenterated and dissected to evaluate mechanical and structural properties of the orbital connective tissues. Lipid was cleared from whole specimens to reveal tissue relationships. Other specimens were selectively step- and serial-sectioned for histochemical and immunohistochemical staining. RESULTS: Magnetic resonance imaging demonstrated dense connective tissue structures within posterior Tenon's fascia near the equator of the globe adjacent to the recti EOMs. Histochemistry showed these structures to be pulleys--fibroelastic EOM sleeves consisting of dense bands of collagen and elastin, suspended from the orbit and adjacent EOM sleeves by bands of similar composition. A monoclonal antibody to human smooth muscle alpha-actin demonstrated substantial smooth muscle in the pulley suspensions and in posterior Tenon's fascia. Tenon's fascia itself was seen to be suspended at its periphery from the orbital walls like a drumhead. CONCLUSIONS: The human orbit contains specialized musculofibroelastic tissues in and just posterior to Tenon's fascia that serve as compliant pulleys and determine the pulling directions of recti EOMs. In this sense, the pulleys are the functional origins of the recti EOMs and are determinants of ocular motility.