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Eyelid Anatomy
Author: Bhupendra Patel, MD, FRCS; Chief Editor: Arlen D Meyers, MD, MBA more...
Updated: Jun 17, 2013
Overview
The eyelids act to protect the anterior surface of the globe from local injury. Additionally, they aid in regulation of
light reaching the eye; in tear film maintenance, by distributing the protective and optically important tear film over
the cornea during blinking; and in tear flow, by their pumping action on the conjunctival sac and lacrimal sac.
Structures that must be considered in a description of lid anatomy are the skin and subcutaneous tissue; the
orbicularis oculi muscle (shown below); the submuscular areolar tissue; the fibrous layer, consisting of the tarsi
and the orbital septum; the lid retractors of the upper and lower eyelids; the retroseptal fat pads; and the
conjunctiva.
Orbicularis oculi muscle anatomy. (A) Frontalis, (B) corrugator superciliaris, (C) procerus, (D) orbital orbicularis, (E) preseptal orbicularis,
(F) pretarsal orbicularis.
The anatomy of the lid is best approached initially by reviewing a sagittal cross section of the eyelid. The exact
number of tissue layers and the relationship between the many layers are modified significantly by the level of the
lid examined. The orbital septum represents the anatomic boundary between the lid tissue and the orbital tissue,
but an assessment of eyelid function and preparation for lid surgery requires knowledge of these postseptal
structures. The upper and lower lids may be considered analogous structures, with differences mainly in the lid
retractor arrangement.[1]
In eyelid reconstruction, it is more practical to consider the repair of the anterior and posterior lamellae, with the
anterior lamella being the skin and orbicularis, and the posterior lamella being the tarsus and conjunctiva.
For patient education information, see the Eye and Vision Center, as well as Anatomy of the Eye.
Surface Anatomy
The upper eyelid extends superiorly to the eyebrow, which separates it from the forehead. The lower lid extends
below the inferior orbital rim to join the cheek, forming folds where the loose connective tissue of the eyelid is
juxtaposed with the denser tissue of the cheek. (See the images below.)
The upper eyelid skin crease (superior palpebral sulcus) is approximately 8-11 mm superior to the eyelid margin
and is formed by the attachment of the superficial insertion of levator aponeurotic fibers (8-9 mm in men and 9-11
mm in women). The inferior eyelid fold (inferior palpebral sulcus), which is seen more frequently in children, runs
from 3 mm inferior to the medial lower lid margin to 5 mm inferior to the lateral lid margin.
The nasojugal fold runs inferiorly and laterally from the inner canthal region along the depression of separation of
the orbicularis oculi and the levator labii superioris, forming the tear trough. The malar fold runs inferiorly and
medially from the outer canthus toward the inferior aspect of the nasojugal fold.
The open eye presents the palpebral fissure, a fusiform space between the lid margins that is 28-30 mm in length
and about 9 mm in maximal height. The natural curvature of the upper lid is a function of the static shape of the
tarsus combined with adaptation of the lid to the curvature of the globe.
In the normal adult fissure, the highest point of the upper lid is just nasal to the center of the pupil, while the lowest
point of the lower lid is just temporal to the center of the pupil. In youths, the upper lid margin rests at the upper
limbus, while in adults, it rests 1.5 mm below the limbus. The lower eyelid margin rests at the level of the lower
limbus. The lateral canthal angle is 2 mm higher than the medial canthal angle in Europeans; it is 3 mm higher in
Asians. The distance from the medial canthus to the midline of the nose is approximately 15 mm. (See the image
below.)
Medial canthus.
The palpebral fissure presents the lateral canthus (an angle of 30-40 approximately 5 mm from the lateral orbital
rim), the medial canthus (forming the medial angle of the fissure, with the upper border passing inferomedially and
the lower border passing horizontally), and the lacrimal papillae, which rest on the free lid margin, with the
punctum lacrimale serving as an opening to the canaliculus.
Tarsal plates
The tarsal plates are composed of dense fibrous tissue and are responsible for the structural integrity of the lids.
Each tarsus is approximately 29 mm long and 1 mm thick. The crescentic superior tarsus is 10 mm in vertical
height centrally, narrowing medially and laterally. The lower border of the superior tarsus forms the posterior lid
margin. The rectangular inferior tarsus is 3.5-5 mm high at the eyelid center. The posterior surfaces of the tarsi
adhere to conjunctivae.
Each tarsus encloses about 25 sebaceous meibomian glands, which span the vertical height of the tarsus. Their
ducts open at the lid margin posterior to the grey line and just anterior to the mucocutaneous junction. The medial
and lateral ends of the tarsi are attached to the orbital rims by the medial and lateral palpebral ligaments.
surgical release of the tarsal strap, the lateral canthus is elevated easily.
Orbital septum
The orbital septum is a connective tissue structure that attaches peripherally at the periosteum of the orbital
margin (the arcus marginalis); it centrally fuses with the lid retractor structures near the lid margins, thus acting as
a diaphragm (that has been reported to retain orbital contents). Although usually depicted diagrammatically as a
discrete layer immediately posterior to the orbicularis oculi muscle, the orbital septum is a multilaminated
structure that is part of the anterior orbital connective tissue framework. The septum has a laxity consistent with
the mobility of the eyelids.
Laterally, the septum is attached to the orbital margin, 1.5 mm in front of the lateral orbital tubercle attachment of
the lateral palpebral ligament. The Eisler fat pocket separates the lateral palpebral ligament from the orbital
septum. From there, the septum continues along the superior orbital rim at the arcus marginalis. Superomedially,
the septum bridges the supraorbital groove, passes inferomedially anterior to the trochlea, and then follows the
posterior lacrimal crest. As it runs down the posterior lacrimal crest, it lies anterior to the medial check ligament
and posterior to the Horner muscle (and hence, behind the lacrimal sac).
The line of attachment crosses the lacrimal sac fascia to reach the anterior lacrimal crest at the level of the
lacrimal tubercle. From there, it passes inferiorly down the anterior lacrimal crest and laterally along the inferior
orbital rim. A few millimeters lateral to the zygomaticomaxillary suture, the attachment leaves the rim and lies
several millimeters from it on the facial aspect of the zygomatic bone, thus forming the fat-filled premarginal recess
of Eisler. The line of attachment then continues to again reach the lateral orbital rim, just below the level of the
Whitnall ligament.
Reid et al proposed the existence of a septal extension, from the line of fusion of the orbital septum to the levator
aponeurosis, extending caudally to cover the tarsal plate up to the ciliary margin.[4] The septal extension acts as
an adjunct to the levator aponeurosis; recognition of this structure may be important to avoid relapse or
complications in ptosis repair and blepharoplasty.
Eyelid Retractors
Upper lid retractors
The levator palpebra superioris (LPS) arises at the orbital apex from the undersurface of the lesser wing of the
sphenoid bone. The levator muscle and superior rectus muscle share a developmental origin and are connected by
fibrous attachments. The LPS proceeds anteriorly for 40 mm and ends in an aponeurosis approximately 10 mm
behind the orbital septum. The levator complex changes direction from a horizontal to a more vertical direction at
the superior transverse ligament (Whitnall ligament).
The superior transverse ligament lies near the junction of the muscular and aponeurotic levator and represents an
orbital fascial condensation spanning the anterosuperior orbit between the trochlea and the lacrimal gland fascia.
Variations in thickness and adherence to the levator complex are evident. Thin fascial attachments lie between the
Fat Pads
Upper eyelid preaponeurotic fat is found immediately posterior to the orbital septum and anterior to the levator
aponeurosis. A central fat pad and a medial fat pad are described in the upper lid, while the lacrimal gland
occupies the lateral compartment. The medial fat pad usually is pale yellow or white and lies anterior to the levator
aponeurosis extending superomedial to the medial horn of the levator.
The central fat pad is yellow and broad. A portion of the lateral end of this pad surrounds the medial aspect of the
lacrimal gland. The lacrimal gland has a firm, pinkish, lobulated structure, in contrast to the soft, yellow intraorbital
fat. The lacrimal gland's anterior border is normally just behind the orbital margin, but involutional changes may
lead to prolapse anteroinferiorly, which is prominent on external lid examination.
Three retroseptal fat pads are associated with the lower eyelid. The medial and central fat pads are separated by
the inferior oblique. However, an isthmus of fat generally lies anterior to the muscle belly. The inferior oblique
muscle takes a bony origin from a shallow depression on the anteromedial orbital floor, directly posterior to the
orbital margin and lateral to the nasolacrimal canal.
The inferior oblique muscle courses posterolaterally, passing inferior to the inferior rectus muscle, penetrating the
Tenon capsule, and inserting onto the globe near the macula. Its course makes it susceptible to injury during
surgical dissection of the surrounding fat pads.
The medial and lateral fat pads are separated by the arcuate expansion, a fascial band extending from the
capsulopalpebral fascia to the inferolateral orbital rim. Notably, the inferolateral orbital septum inserts 2 mm
outside the orbital rim, creating the recess of Eisner, allowing the lateral fat pad to just spill over the orbital rim.
Conjunctiva
The conjunctiva is a smooth, translucent mucous membrane. Palpebral conjunctiva lines the posterior surface of
the lids as tarsal conjunctiva (from the mucocutaneous junction of the lid margin to the tarsal plate border) and
continues as orbital palpebral conjunctiva into the fornix. Tarsal conjunctiva is adherent to the tarsus, while a
submucosal lamina propria underlies orbital palpebral conjunctiva and allows dissection from the vascular Mller
muscle. At the depths of the fornices, the conjunctiva reflects anteriorly onto the globe as bulbar conjunctiva.
Nerves
Sensory innervation of the eyelids is subserved by terminal branches of the ophthalmic (cranial nerve [CN] V1) and
maxillary (CN V2) divisions of the trigeminal nerve (CN V). Within the superior orbit, the frontal branch of the
ophthalmic division of the trigeminal nerve travels anteriorly between the periorbita of the roof and the levator
muscle. Midway along the roof, it divides into a larger supraorbital nerve and a smaller supratrochlear nerve.
Terminal branches of these nerves supply sensation to the upper eyelid and forehead.
The supraorbital nerve exits the orbit through the supraorbital notch or supraorbital foramen. It subserves sensation
to the upper eyelid and forehead skin, except for a midline vertical strip, which is supplied by the supratrochlear
nerve. The supratrochlear nerve exits the orbit just lateral to the bony origin of the corrugator supercilii muscle,
enters this muscle, and divides into its terminal sensory branches.
The infratrochlear nerve, a terminal branch of the nasociliary nerve (CN V1), supplies the skin and conjunctiva of
the medial canthus, the most medial aspect of the eyelids, and the nasolacrimal sac. The sensory supply of the
remaining lower eyelid is provided by the infraorbital nerve (CN V2) and the zygomaticofacial nerve (CN V2). The
zygomaticofacial nerve supplies skin to the lateral lower eyelid, while the palpebral branch of the infraorbital nerve
supplies the central lower eyelid skin and conjunctiva.
Branches of the facial nerve innervate the muscles of facial expression. The frontal and zygomatic branches of CN
VII innervate the orbicularis oculi muscle; the frontal branch of CN VII innervates the forehead muscles.
The orbicularis oculi is innervated by multiple motor branches from the branches of CN VII; in the lower eyelid, they
enter the inferior edge of the orbicularis oculi, with branches lateral and medial to the lateral limbus, and there is
no single dominant branch for the supply. Thus, in resection of the orbicularis oculi in lower lid surgery, preserving
the pretarsal portion alone may not sufficiently support the lower lid. Conversely, if one single branch is injured, the
adjacent branches are able to reinnervate the muscle by sprouting.[7]
The levator palpebra superioris is innervated by the superior branch of the oculomotor nerve, entering the muscle
from its inferior surface in its posterior third. Mller muscle (and the inferior tarsal muscle) requires sympathetic
innervation. Postganglionic sympathetic fibers arise from the superior cervical ganglion and travel superiorly in the
neck as a plexus with the internal carotid artery. The fibers take an intracranial course to the cavernous sinus,
where they travel through the superior orbital fissure into the orbit via CN branches.
Within the orbit, the exact pathways for sympathetic innervation of the superior and inferior tarsal muscles is
unknown, but some evidence suggests that sympathetic fibers travel with the extraocular muscle motor nerves
before termination on the target muscles.
Lymphatic drainage
The eyelids and conjunctiva have a rich lymphatic drainage. The drainage of most of the upper lid and the lateral
half of the lower lid is to the preauricular lymph nodes. The medial portion of the upper lid and the medial half of the
lower lid drain into the submandibular nodes by way of vessels that follow the angular and facial vessels.