Evidence supporting extraocular muscle pulleys: refuting the platygean view of extraocular muscle mechanics.

BACKGROUND: Late in the 20th century, it was recognized that connective tissue structures in the orbit influence the paths of the extraocular muscles and constitute their functional origins. Targeted investigations of these connective tissue "pulleys" led to the formulation of the active pulley hypothesis, which proposes that pulling directions of the rectus extraocular muscles are actively controlled via connective tissues.
PURPOSE: This review rebuts a series of criticisms of the active pulley hypothesis published by Jampel, and Jampel and Shi, in which these authors have disputed the existence and function of the pulleys.
METHODS: This article reviews published evidence for the existence of orbital pulleys, the active pulley hypothesis, and physiological tests of the active pulley hypothesis. Magnetic resonance imaging in a living subject and histological examination of a human cadaver directly illustrate the relationship of pulleys to extraocular muscles.
RESULTS: Strong scientific evidence is cited that supports the existence of orbital pulleys and their role in ocular motility. The criticisms of the hypothesis have ignored mathematical truisms and strong scientific evidence.
CONCLUSIONS: Actively control led orbital pulleys play a fundamental role in ocular motility. Pulleys profoundly influence the neural commands required to control eye movements and binocular alignment. Familiarity with the anatomy and physiology of the pulleys is requisite for a rational approach to diagnosing and treating strabismus using emerging methods. Conversely, approaches that deny or ignore the pulleys risk the sorts of errors that arise in geography and navigation from incorrect assumptions such as those of a flat ("platygean") earth.