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Review  |   September 2017
Osteopathic Manipulative Treatment to Manage Ophthalmic Conditions
Author Notes
  • From the St. John Providence Health System in Warren, Michigan (Dr Sherman); the Department of Osteopathic Principles and Practice at Nova Southeastern University College of Osteopathic Medicine in Davie, Florida (Dr Qureshi); and the Bascom Palmer Eye Institute in Miami, Florida (Dr Bach). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Austin Bach, DO, MPH, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136-1119. E-mail: axb1687@med.miami.edu
     
Article Information
Ophthalmology and Otolaryngology / Osteopathic Manipulative Treatment
Review   |   September 2017
Osteopathic Manipulative Treatment to Manage Ophthalmic Conditions
The Journal of the American Osteopathic Association, September 2017, Vol. 117, 568-575. doi:10.7556/jaoa.2017.111
The Journal of the American Osteopathic Association, September 2017, Vol. 117, 568-575. doi:10.7556/jaoa.2017.111
Web of Science® Times Cited: 1
Abstract

Although there is little evidence-based literature regarding osteopathic manipulative treatment for ophthalmic conditions, the general principles and techniques of osteopathic manipulative medicine can be used to manage various ophthalmic pathologic conditions. Additional research to support these treatment options and evaluate the role of OMT as a potential conservative treatment option used by ophthalmologists is needed.

Osteopathic manipulative treatment (OMT) is often used to manage musculoskeletal dysfunctions; however, these techniques may be just as applicable in the management of ophthalmic conditions. This review discusses select ophthalmic conditions (ie, dacryostenosis, dysthyroid orbitopathy, keratoconjunctivitis sicca, cephalgia from asthenopia, and ocular hypertension), their current standard of care, and OMT techniques that could be useful in the management of each condition. 
Dacryostenosis
Congenital or acquired dacryostenosis is an obstruction of the nasolacrimal drainage system. Congenital dacryostenosis is the most common cause of epiphora and ocular discharge in newborns.1 It affects 20% of newborns and results from either misaligned cranial bones or incomplete canalization of the nasolacrimal epithelial cord in utero.1 The most common cause of congenital dacryostenosis in newborns is a noncanalized membrane at the plica lacrimalis (Hasner valve), an anatomic structure that covers the opening to the inferior meatus of the nasal cavity.1 Acquired dacryostenosis is most commonly caused by age-related stenosis of the nasolacrimal duct.2 Other causes include prior nasal or facial bone fractures, sinus operations, inflammatory diseases such as sarcoidosis and granulomatosis with polyangiitis, tumors involving the maxillary or ethmoid sinuses, dacryocystitis, and some medications (particularly chemotherapeutic agents such as 5-fluorouracil, docetaxel, and idoxuridine).2 
The current standard of care for congenital dacryostenosis involves nasolacrimal massage, a noninvasive technique in which pressure is applied over the lacrimal sac to force tears into the nasolacrimal duct and help rupture the membranous plica lacrimalis.1 Most cases resolve without treatment or after the patient's guardian applies massage; however, if symptoms persist beyond age 6 to 12 months, surgical probing of the nasolacrimal duct may become necessary.1 If left untreated, patients with dacryostenosis are at risk for other complications, such as dacryocystitis, orbital cellulitis, or, in the case of congenital dacryostenosis, anisometropia.1 Managing acquired dacryostenosis should focus on addressing the underlying disorder, when possible. If not possible or ineffective, a dacryocystorhinostomy can be performed, in which a passage between the lacrimal sac and nasal cavity is created.2 
Osteopathic manipulative treatment should be considered in the management of dacryostenosis. Cranial bone lift techniques can relieve stress placed on the lacrimal bone by the surrounding maxillary, frontal, sphenoid, zygomatic, palatine, contralateral lacrimal, and ethmoid bones. By decompressing these bony articulations, the nasolacrimal canal may become more patent and drain more easily.1 Several techniques could address muscular restrictions, improve autonomic balance, and aid in realignment and restoration of function of the lacrimal duct. 
The management of dacryostenosis with OMT should include addressing frontal bone restrictions with a frontal lift, assessing the maxillary and zygomatic paired bones for internal or external rotational dysfunctions, and addressing them with extraoral and intraoral OMT techniques, respectively. Techniques can also be applied to muscular restrictions of the palpebral portion of the orbicularis oculi muscle, which contracts to pump tears from the lateral globe through the canaliculus and into the lacrimal sac.3 Cranial bone lift and myofascial techniques applied to the frontalis, procerus, zygomaticus major and minor, orbicularis oculi, and other periorbital muscular and fascial structures can also improve autonomic balance of the orbit. The orbicularis oculi muscle is innervated by the temporal and zygomatic branches of the facial nerve, which exit at the stylomastoid foramen.1 The ophthalmic division of the trigeminal nerve, which provides afferent innervation to the lacrimal gland, exits the skull through the superior orbital fissure.4 The efferent parasympathetic nerves course from the brainstem through the pterygoid canal, nerve fibers synapse at the sphenopalatine ganglion, and postganglionic fibers exit through the inferior orbital fissure.4 Therefore, OMT of bony and myofascial restrictions in these areas may improve autonomic balance. Furthermore, addressing myofascial strains may enhance lymphatic drainage by activating lymphatic stretch reflexes and normalizing sympathetic effects on lymphatic vessels.1 The nasion spread technique (Figure 1) increases motion between the frontal and nasal bones through pressure applied to each bone disarticulating one from the other. This technique can alleviate some of the tension that may be causing the restriction of flow. 
Figure 1.
Nasion spread technique for dacryostenosis. Using gentle contact, the nasion suture is spread by pulling the frontal bone superiorly while pulling the nasal bones inferiorly. The spread is held until a decrease in resistance is felt.
Figure 1.
Nasion spread technique for dacryostenosis. Using gentle contact, the nasion suture is spread by pulling the frontal bone superiorly while pulling the nasal bones inferiorly. The spread is held until a decrease in resistance is felt.
In a case1 of a 9-month-old boy with persistent dacryostenosis and recurrent dacryocystitis who received no relief from standard treatment, a single session of the nasion spread technique resolved his symptoms. Osteopathic structural examination findings included internal rotation somatic dysfunction of the right nasal, frontal, and maxillary bones; bilateral condylar compression; right scalene spasm; and several somatic dysfunctions in the cervical and thoracic spine. The patient was also treated with cranial bone lifts, balanced ligamentous tension of the cervical and upper thoracic regions, condylar decompression, and myofascial release of the cervical spine and thoracic inlet.1 
Dysthyroid Orbitopathy
An autoimmune inflammatory disease of the eye and orbital tissues, dysthyroid orbitopathy is most often associated with dysthyroid states and is the most common disease that affects the orbit.5,6 Dysthyroid orbitopathy is associated with hyperthyroidism in Graves disease, but it may occur in patients with hypothyroidism due to chronic lymphocytic thyroiditis (Hashimoto disease) or in patients with euthyroid.5 Orbital and periorbital tissues are affected by pathologic glycosaminoglycan deposition, infiltration of lymphocytic cells, swelling of peribulbar tissues, fibrosis affecting the extraocular muscles, and adipogenesis in the orbit; however, further studies are needed to understand the exact cause.5,6 Increased volume of the orbital tissues leads to venous outflow impairment and protrusion of the eye, known as proptosis.5 Other ocular manifestations include eyelid retraction, periorbital edema, thickening of extraocular muscles leading to altered ocular motility and consequent diplopia, and decreased vision from optic nerve compression.7 This compressive optic neuropathy results from thickened extraocular muscles or fat at the orbital apex and can produce reduced color vision, visual field loss, and decreased visual acuity.7 
One of the most common symptoms of dysthyroid orbitopathy is dry eyes.6 Treatment for dry eyes is symptomatic and can include artificial tears and punctal plugs. Smoking cessation is encouraged in patients with dysthyroid orbitopathy, as it is the most common modifiable risk factor for congestive orbitopathy.7 Other management methods focus on controlling the inflammatory nature of the disease, such as corticosteroids, external beam radiation, and steroid-sparing immunosuppressive agents. For patients with severe inflammation or compressive optic neuropathy, surgical procedures may be necessary.7 Additionally, it is important to monitor patients with dysthyroid orbitopathy for loss of vision caused by exposure keratopathy and compressive optic neuropathy.7 All of these interventions are aimed at controlling the disease rather than addressing the cause.6 
Although no cure for dysthyroid orbitopathy exists, several OMT techniques may be effective in relieving symptoms. Because dysthyroid orbitopathy can lead to compressive optic neuropathy, techniques that decrease compression in this area may be beneficial. Addressing restrictions of the sphenoid bone through identification and management of cranial strain patterns at the sphenobasilar symphysis can lead to decreased compression of the optic nerve. The nasion spread technique could help decrease congestion and increase drainage in the orbital and periorbital areas as well (written communication, New York Institute of Technology College of Osteopathic Medicine Laboratory, 2013). Similarly, the venous sinus drainage technique (Figure 2) improves intracranial venous drainage, including that of the periorbital region, which can reduce compression of the optic nerve.8 Additionally, head and neck lymphatic OMT techniques can be useful in draining the accumulation of inflammatory mediators in the orbit. Furthermore, addressing cervical, occipitoatlantal joint, and sternocleidomastoid muscle dysfunctions will allow drainage from the venous sinuses through the internal jugular vein and into the thoracic cavity.8 Balanced ligamentous tension can be used to promote ophthalmic vein drainage as well. This technique may be applied to the orbit to assist with orbitopathy-related fascial strains. 
Figure 2.
Venous sinus drainage technique for dysthyroid orbitopathy. Beginning at the most posterior portion of the superior sagittal sinus, the physician crosses his or her thumbs on either side of the sinus and separates the cranial fascia by moving the thumbs away from each other until a release is felt.
Figure 2.
Venous sinus drainage technique for dysthyroid orbitopathy. Beginning at the most posterior portion of the superior sagittal sinus, the physician crosses his or her thumbs on either side of the sinus and separates the cranial fascia by moving the thumbs away from each other until a release is felt.
Keratoconjunctivitis Sicca
One of the most common conditions seen by ophthalmologists is keratoconjunctivitis sicca, or dry eye.9 Symptoms include burning or dryness in the eye, foreign body sensation, decreased vision, and epiphora.7 There are 4 types of lacrimation: reflexive, basal, induced, and psychogenic.4 The reflexive pathway, primarily controlled through parasympathetic innervation of the main lacrimal gland, is most benefited by OMT.4 The preganglionic neurons of the parasympathetic pathway begin in the lacrimal nucleus within the tegmental portion of the pons and then join the nervus intermedius portion of the facial nerve.4 These parasympathetic fibers separate to become the greater superficial petrosal nerve, which then joins the deep petrosal nerve to form the vidian nerve. The vidian nerve passes directly to the sphenopalatine ganglion, where these preganglionic lacrimal axons synapse with postganglionic secretomotor neurons.4 Secretory postganglionic neurons leave the sphenopalatine ganglion and immediately enter the adjacent maxillary division of the trigeminal nerve.4 These parasympathetic nerves induce lacrimation via a cyclic adenosine monophosphate-dependent signal transduction pathway. 
Various treatments are currently recommended for symptomatic relief of keratoconjunctivitis sicca, such as eyelid hygiene, artificial tears, punctal plugs, lubricating ointments, and immunomodulators.7 Eventually, if these options fail, various surgical procedures may be considered.7 Postganglionic fibers from the sphenopalatine ganglion supply parasympathetic innervation to the lacrimal gland and stimulate lacrimation; therefore, an intraoral sphenopalatine release technique that aims to relax the fascia surrounding the sphenopalatine ganglion could be effective in the promotion of tear production. The ganglia are located in the superior, posterior, and lateral area of the pharynx and can be manually released with direct or indirect myofascial release (Figure 3). The sphenopalatine release technique usually promotes immediate tear production.10 Because the sphenopalatine ganglia receive parasympathetic innervation from the facial nerve and contain sensory fibers from the trigeminal nerve, release of the fascia near the ganglia normalizes parasympathetic activity and sensory components of the trigeminal nerve.10 As a result, the technique can stimulate the reflexive tear secretion pathway, causing the lacrimal gland to produce tears. 
Figure 3.
Sphenopalatine ganglion release technique for keratoconjunctivitis sicca. Using the fifth digit, the physician manually massages and stimulates the sphenopalatine ganglion located in the superior, posterior, and lateral areas of the pharynx.
Figure 3.
Sphenopalatine ganglion release technique for keratoconjunctivitis sicca. Using the fifth digit, the physician manually massages and stimulates the sphenopalatine ganglion located in the superior, posterior, and lateral areas of the pharynx.
Cephalgia From Asthenopia
Asthenopia, or eye strain, describes nonspecific symptoms that occur after extended use of the eyes.11 Common causes include prolonged reading or computer use, inadequate or excessive lighting, dry eye, presbyopia, and uncorrected refractive errors.11 Use of computers, tablets, and mobile devices has become essential in everyday work, study, and leisure activities.12 Continuous attention to these screens is closely related to a decreased blink rate and increased accommodation and convergence, which leads to eye dryness and asthenopia.11 The symptoms that result from asthenopia include blurred vision, eye irritation or burning, dry eye, epiphora, eye redness, headache, diplopia, and photophobia.12 
Current recommendations to manage asthenopia include adjusting the distance from the patient's eyes to the computer screen or reading material, adjusting the brightness and contrast of monitors, conscious frequent blinking, and interrupting long sessions of focusing the eyes.13 Many patients with headache use over-the-counter pain relievers to alleviate symptoms. 
To avoid unnecessary use of pain relievers, which can have adverse effects, OMT techniques such as occipital condylar decompression (Figure 4) can be an effective alternative to manage the symptoms of cephalgia in general.14,15 To manage the symptoms of cephalgia caused by asthenopia, balanced ligamentous tension could help loosen taut fascial connections in the strained extraocular musculature (Figure 5). The viscoelastic nature of fascia gives it both permanent (viscous) and temporary (elastic) deformation characteristics.16 
Ocular Hypertension
Defined as an intraocular pressure (IOP) greater than 21 mm Hg, ocular hypertension does not exhibit changes typical of glaucoma, such as glaucomatous changes of the optic disc and visual field defects.17 However, elevated IOP is one of the most common risk factors for glaucoma, which is a leading cause of irreversible blindness.17 It is crucial to monitor ocular hypertension closely to decrease the risk of optic nerve damage and vision loss.7 
Figure 4.
Occipital condylar decompression technique for cephalgia. The physician cradles the occiput in both hands, with the tips of the middle digit contacting the most inferior aspect of the occiput in the midline, the second digits toward the occipital condyle, and the thumbs on the mastoid processes. Postero superior traction is applied to slightly adjust the level of cranial tension.
Figure 4.
Occipital condylar decompression technique for cephalgia. The physician cradles the occiput in both hands, with the tips of the middle digit contacting the most inferior aspect of the occiput in the midline, the second digits toward the occipital condyle, and the thumbs on the mastoid processes. Postero superior traction is applied to slightly adjust the level of cranial tension.
Figure 5.
Balanced ligamentous tension technique of the orbit for cephalgia caused by asthenopia. Balance or midpoint of motion is assessed for when displacing the fascia over the eyelid in the following directions: medial/lateral, superior/inferior, and clockwise/counterclockwise. The specific positions are stacked and held until a release is felt.
Figure 5.
Balanced ligamentous tension technique of the orbit for cephalgia caused by asthenopia. Balance or midpoint of motion is assessed for when displacing the fascia over the eyelid in the following directions: medial/lateral, superior/inferior, and clockwise/counterclockwise. The specific positions are stacked and held until a release is felt.
The current management protocol involves IOP-lowering eye drops and laser trabeculoplasty.7 In 2002, Kass et al18 demonstrated that topical ocular hypotensive medication was effective in delaying or preventing the onset of primary open-angle glaucoma in people with ocular hypertension. Although the authors did not suggest that all patients with borderline or elevated IOP should receive medication, they did recommend that physicians should initiate treatment for patients with ocular hypertension who are at moderate or high risk for developing primary open-angle glaucoma.18 
Although there is little research on the benefit of OMT for ocular hypertension and glaucoma, theories regarding its potential usefulness have been postulated for many years. In 1988, William Garner Sutherland, DO, stated, “In the case of glaucoma, one may reason that the accumulation of fluid points to a condition somewhere back along the intracranial membranous wall of the cavernous sinus, or in the walls of the petrosal sinus, to a membranous restriction affecting the venous return.”19 Osteopathic manipulative treatment techniques should be focused on improving osseous, muscular, membranous, sympathetic, and parasympathetic dysfunctions to improve the microcirculation of the eye.19 Constriction of the superior orbital fissure, intracranial venous congestion, dysfunction of the cavernous sinus, and craniocervical or cervicothoracic tension can impair blood flow through the superior ophthalmic veins, whereas congestion in the pterygoid plexus can impair the flow through the inferior ophthalmic veins.19 Improving microcirculation in the retina and optic nerve is crucial for balancing fluctuations of IOP; therefore, treatment aimed at these areas of restriction may decrease IOP.19 Studies20-22 have shown a significant decrease in IOP after myofascial techniques to the cervical and upper thoracic areas are performed in patients with glaucoma. In addition to the aforementioned OMT techniques that reduce venous congestion, the Cant Hook and the Ruddy techniques can also be used. 
The Cant Hook technique (Figure 6) can be used to release the superior orbital fissure to improve flow of the superior ophthalmic vein.23 This technique operates by means of leverage and can be applied to various cranial sutures. Because the superior orbital fissure boundaries are made up of the sphenoid and frontal bones, releasing the sphenofrontal suture (Figure 6A) can open the foramen, thus, improving the flow of the superior ophthalmic vein that passes through it.24 The technique involves disengaging the complex of the body of the sphenoid and lesser wings from the complex of the greater wings and pterygoid process (Figure 6B) until the point of balanced membranous tension is reached between the complex of the body of the sphenoid and lesser wings from the complex of the greater wings and pterygoid process.24 
Figure 6.
Cant Hook technique for ocular hypertension includes (A) freeing the sphenofrontal suture and (B) releasing the complex of the body of the sphenoid and lesser wings from the complex of the greater wings and pterygoid process.
Figure 6.
Cant Hook technique for ocular hypertension includes (A) freeing the sphenofrontal suture and (B) releasing the complex of the body of the sphenoid and lesser wings from the complex of the greater wings and pterygoid process.
The Ruddy technique (Figure 7) can also be useful, as it improves fluctuation of the aqueous humor.23 This technique involves the physician offering resistance to the patient's active movement while the patient moves at a rate of 60 excursions per minute, or equal to the patient's heart rate.25 The purpose of this quick and repetitive contraction is to use the surrounding muscle tissue to effect motion and circulation of blood, lymph, and tissue fluids into dysfunctional areas. Several research teams have independently confirmed a marked improvement in IOP from 6 minutes to 1 hour after treatment.24 
Figure 7.
Ruddy technique for ocular hypertension. The index finger of one hand is used to perform a gentle tapotement on the index finger of the other hand, which is pointed in a lateral to medial direction, resting on the patient's closed eye.
Figure 7.
Ruddy technique for ocular hypertension. The index finger of one hand is used to perform a gentle tapotement on the index finger of the other hand, which is pointed in a lateral to medial direction, resting on the patient's closed eye.
Conclusion
All disease processes have numerous management options, but osteopathic physicians have the additional tool of OMT. One of the tenets of osteopathic medicine is that the body was built with the ability to heal and self-regulate, so the management of somatic dysfunctions using OMT should always be thought of as a first-line treatment when feasible.26 Although there is little evidence-based literature on the effects of OMT on ophthalmic conditions, the general principles of osteopathic medicine can be applicable to the eye. Additional research is needed to support these treatment options and evaluate the role of OMT as a potential conservative treatment option used by ophthalmologists. 
References
Apoznanski TE, Abu-Sbaih R, Terzella MJ, Yao S. Resolution of dacryostenosis after osteopathic manipulative treatment. J Am Osteopath Assoc. 2015;115(2):110-114. doi: 10.7556/jaoa.2015.022 [PubMed]
Cantor LB, Rapuano CJ, Cioffi GA. Part III lacrimal system: 13 abnormalities of the lacrimal secretory and drainage systems. In: Holds JB, ed. Basic and Clinical Science Course: Section 7: Orbit, Eyelids, and Lacrimal System. San Fransicso, CA: American Academy of Ophthalmology; 2014:249-278.
Shinohara H, Kominami R, Yasutaka S, Taniquchi Y. The anatomy of the lacrimal portion of the orbicularis oculi muscle (tensor tarsi or Horner's muscle). Okajimas Folia Anat Jpn. . 2001;77(6):225-232. [CrossRef] [PubMed]
Sharpe JA, Wong AM. Anatomy and physiology of normal lacrimal function. In: Miller N, Newman N, Biousse V, Kerrison J, eds. Walsh & Hoyt's Clinical Neuro-Ophthalmology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:700-708.
Szczapa-Jagustyn J, Gotz-Wleckowska A, Kociecki J. An update on thyroid-associated ophthalmopathy in children and adolescents. J Pediatr Endocrinol Metab. 2016;29(10):1115-1122. doi: 10.1515/jpem-2016-0122 [CrossRef] [PubMed]
Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthalmol. 2012;60(2):87-93. doi: 10.4103/0301-4738.94048 [CrossRef] [PubMed]
Gerstenblith AT, Rabinoqitz MP, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed. Philadelphia, PA: Lippincott Williams & WIlkins; 2012:59-60, 154-157, 204-213.
DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:575-576.
Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clin Ophthalmol. 2009;3:405-412. [CrossRef] [PubMed]
Campbell SM, Winkelmann RR, Walkowski S. Osteopathic manipulative treatment: novel application to dermatological disease. J Clin Aesthet Dermatol. 2012;5(10):24-32. [PubMed]
Park CY, Gu N, Lim CY et al The effect of Vaccinium uliginosum extract on tablet computer-induced asthenopia: randomized placebo-controlled study. BMC Complement Altern Med. 2016;16:296. doi: 10.1186/s12906-016-1283-x [CrossRef] [PubMed]
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Figure 1.
Nasion spread technique for dacryostenosis. Using gentle contact, the nasion suture is spread by pulling the frontal bone superiorly while pulling the nasal bones inferiorly. The spread is held until a decrease in resistance is felt.
Figure 1.
Nasion spread technique for dacryostenosis. Using gentle contact, the nasion suture is spread by pulling the frontal bone superiorly while pulling the nasal bones inferiorly. The spread is held until a decrease in resistance is felt.
Figure 2.
Venous sinus drainage technique for dysthyroid orbitopathy. Beginning at the most posterior portion of the superior sagittal sinus, the physician crosses his or her thumbs on either side of the sinus and separates the cranial fascia by moving the thumbs away from each other until a release is felt.
Figure 2.
Venous sinus drainage technique for dysthyroid orbitopathy. Beginning at the most posterior portion of the superior sagittal sinus, the physician crosses his or her thumbs on either side of the sinus and separates the cranial fascia by moving the thumbs away from each other until a release is felt.
Figure 3.
Sphenopalatine ganglion release technique for keratoconjunctivitis sicca. Using the fifth digit, the physician manually massages and stimulates the sphenopalatine ganglion located in the superior, posterior, and lateral areas of the pharynx.
Figure 3.
Sphenopalatine ganglion release technique for keratoconjunctivitis sicca. Using the fifth digit, the physician manually massages and stimulates the sphenopalatine ganglion located in the superior, posterior, and lateral areas of the pharynx.
Figure 4.
Occipital condylar decompression technique for cephalgia. The physician cradles the occiput in both hands, with the tips of the middle digit contacting the most inferior aspect of the occiput in the midline, the second digits toward the occipital condyle, and the thumbs on the mastoid processes. Postero superior traction is applied to slightly adjust the level of cranial tension.
Figure 4.
Occipital condylar decompression technique for cephalgia. The physician cradles the occiput in both hands, with the tips of the middle digit contacting the most inferior aspect of the occiput in the midline, the second digits toward the occipital condyle, and the thumbs on the mastoid processes. Postero superior traction is applied to slightly adjust the level of cranial tension.
Figure 5.
Balanced ligamentous tension technique of the orbit for cephalgia caused by asthenopia. Balance or midpoint of motion is assessed for when displacing the fascia over the eyelid in the following directions: medial/lateral, superior/inferior, and clockwise/counterclockwise. The specific positions are stacked and held until a release is felt.
Figure 5.
Balanced ligamentous tension technique of the orbit for cephalgia caused by asthenopia. Balance or midpoint of motion is assessed for when displacing the fascia over the eyelid in the following directions: medial/lateral, superior/inferior, and clockwise/counterclockwise. The specific positions are stacked and held until a release is felt.
Figure 6.
Cant Hook technique for ocular hypertension includes (A) freeing the sphenofrontal suture and (B) releasing the complex of the body of the sphenoid and lesser wings from the complex of the greater wings and pterygoid process.
Figure 6.
Cant Hook technique for ocular hypertension includes (A) freeing the sphenofrontal suture and (B) releasing the complex of the body of the sphenoid and lesser wings from the complex of the greater wings and pterygoid process.
Figure 7.
Ruddy technique for ocular hypertension. The index finger of one hand is used to perform a gentle tapotement on the index finger of the other hand, which is pointed in a lateral to medial direction, resting on the patient's closed eye.
Figure 7.
Ruddy technique for ocular hypertension. The index finger of one hand is used to perform a gentle tapotement on the index finger of the other hand, which is pointed in a lateral to medial direction, resting on the patient's closed eye.