Eye movements are produced by six extraocular muscles for each eye, which are controlled by the third, fourth and sixth cranial nerves, their nuclei, and specialized populations of neurons in the medulla, pons, midbrain, cerebellum and cerebral hemispheres. Together, these neurons allow the eyes to move quickly together to an object of interest (saccades), follow a moving target (pursuit), maintain ocular alignment (conjugate gaze), and converge on a close target (vergence). Vestibular inputs allow vision to remain fixed on an object despite head movement, whereas their suppression helps the eyes and head follow a moving object together. A lesion in the pathways subserving eye movements leads to characteristic abnormalities that can often be localised upon careful clinical examination. Understanding the anatomy of these pathways and common diseases that affect them facilitates accurate diagnosis and appropriate treatment.
Key Concepts:
The third, fourth, and sixth cranial nerves are the final common pathway for all eye movements.
Binocular diplopia (that resolves with either eye covered) is the cardinal clinical symptom of misalignment of the eyes.
Saccades are fast conjugate eye movements that direct the eyes to a point of interest and originate with signals in the cortex.
Pursuits are slower conjugate eye movements that allow the eyes to follow a moving point of interest.
Abnormalities of conjugate horizontal eye movements may localise to the pons, where saccadic eye movements are controlled by neurons of the paramedian pontine reticular formation (PPRF) and maintained by neurons of the nucleus prepositus hypoglossus.
Abnormalities of conjugate vertical eye movements may localise to the midbrain, where saccadic eye movements are controlled by neurons of the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) and maintained by neurons of the interstitial nucleus of Cajal (inC).
Head and eye movements are coordinated by information from the semicircular canals and otolith organs and their specialized connections with the ocular motor nuclei.
The medial longitudinal fasciculus (MLF) is a highly myelinated fibre tract connecting the abducens nuclei and contralateral oculomotor nuclei, serving to facilitate rapid coordinated horizontal eye movements and maintain conjugate gaze.
Nystagmus (back and forth oscillations of the eyes) primarily results from abnormalities of the slow eye movement systems and gaze‐holding mechanisms.