P.

08 ANATOMY OF THE EYEBALL, EXTRA-OCULAR MUSCLES,

EYELID AND LACRIMAL APPARATUS THE ORBIT
Dr. Sison| August 30, 2020
Dr. Batcagan| August 31, 2020

OUTLINE
I. THE EYE BALL (Dr. Sison)
A. Conjunctiva
B. Cornea
C. Sclera
D. Uveal Tract
E. Iris
F. Ciliary body
G. Choroid
H. Lens
I. Vitreous
J. Retina
II. THE EXTRA-OCULAR MUSCLES (Dr. Sison)
A. Recti Muscles
B. Oblique Muscles
C. Levator Palpebrae Superioris
III. NERVES IN THE ORBIT (Dr. Sison)
Figure 2. Right orbit (Frontal)
IV. BLOOD SUPPLY TO THE ORBIT AND EYE (Dr. Sison)
V. LANDMARKS OF THE EYE (Dr. Batcagan)  The bones contributing to the orbit include the following:
VI. EMBRYOLOGY (Dr. Batcagan) o Frontal (orbital surface)
VII. GROSS ANATOMY OF THE EYELID (Dr. Batcagan) o Maxillary (orbital surface)
A. The Eyelid o Zygomatic (orbital surface)
B. Skin/ Subcutaneous Tissue
o Sphenoid
C. Orbicularis Oculi Muscle
D. Orbital Orbicularis
o Palatine (orbital plate)
E. Orbital Septum o Ethmoid (orbital plate)
F. Orbital Fat o Lacrimal
G. Eyelid Retractors
H. Tarsus  The back of the orbit has three large openings that include
I. Conjunctiva the following:
VIII. VASCULAR SUPPLY TO THE EYELID (Dr. Batcagan)  Superior orbital fissure – CN III, IV, VI, and V1 (frontal,
IX. VENOUS DRAINAGE OF THE EYELID (Dr. Batcagan)
X. LYMPHATIC DRAINAGE (Dr. Batcagan)
lacrimal and nasociliary nerves) pass through the fissure
XI. INNERVATION (Dr. Batcagan) along with the ophthalmic vein
XII. LACRIMAL APPARATUS (Dr. Batcagan)  Inferior orbital fissure – CN, V2 and infraorbital vessels
A. Development of the Lacrimal Secretory System pass through this fissure
B. Blood Supply & Lymphatics  Optic canal – CN II and the ophthalmic artery pass through
C. Innervation this canal
D. Lacrimal Pump
E. Theories of Lacrimal Pump A. CONJUNCTIVA
 Thin membrane that lines the inner aspect of the eyelids and
I. THE EYEBALL reflects onto the sclera, ending at the scleral-corneal
 Measures about 25mm in diameter junction
 Tethered in the bony orbit by six (6) extraocular muscles  Important: mucus membrane which covers the sclera
that moves the globe
 Cushioned by fat that surrounds the posterior two-thirds of  Parts:
the globe o Anterior surface of sclera( Bulbar)
 Contains three (3) chambers: Vitreous chamber, Anteror - loosely attaches to the globe
Chamber, Posterior Chamber. - Extends to form a fold called the
fornix
o Posterior surface of the lids (Palpebral)
- adheres tightly to the eyelids
o Forniceal conjunctiva
o Semilunar fold or Plica Semilunaris
o Thickened fold of bulbar conjunctiva
located in the medial frontal area
o Corresponds to nictitating membrane of
some lower animals
o Caruncle – Small fleshy epidermoid structure
attached superficially at the most medial portion of
the semilunar fold
o Transition zone which contains both
cutaneous and mucous membrane
elements (transition zone)

Figure 1. Structures of the Eyeball

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 o Continuous to the mucocutaneous junction and
corneal epithelium at the limbus
o Non keratinized squamous epithelium
o Accessory glands:
o Glands of Krause
o Glands of Wolfring
o Glands of Henle
o Glands of Manz
SUBCONJUNCTIVAL FASCIA-Holds the globe
 Tenon’s Capsule
- Anterior: fuses with conjunctiva behind the limbus
- Posterior: separates orbital fat from muscles and globe
- suspends the structures of the orbit
 Intermuscular Septum
- extension of the Tenon’s
- connects muscles
 Check ligaments
- connect muscles to overlying Tenon’s
- inserts on orbital walls to support globe
-suspends the eyeball to the orbit
 Lockwood’s Ligament
- fusion of sheaths of inferior rectus and inferior oblique
- attaches to medial and lateral retinacula and supports
LIMBUS
 (anterior) termination of Descemet’s and Bowman’s
B. CORNEA
membranes
 most anterior coat of the eyeball
o (posterior) line between iris root and Schlemm’s
 Occupies about 1/6 of the circumference of the globe and is
canal
continuous with the opaque sclera
 Transparent part of outer layer; very sensitive to pain
 Schlemm’s canal- circular venous space at the
 Avascular and transparent
corneoscleral junction/ limbus; it communicates with
 Major refractive medium of the eye and protective window
the scleral veins and with the aqueous humor
o Central Cornea Thickness (CTT)
o Transition zone between cornea and sclera (1-
o Varies between individuals
2mm wide)
 Continues posteriorly to blend with the sclera
o Conjunctiva and Tenon’s are fused in this area
 Key determinant of the intraocular pressure (OP) in
Contains:
Goldmann Tonometry
o Corneal epithelial stem cells
 Due to avascularity, it receives nourishment from:
o Goblet cells lymphoid cells
o Aqueous
o Langerhans’cells
o Tears from precorneal tear film
o Mast cells
o Blood vessels at the libmal area
 Sensory innervation - OPHTHALMIC DIVISION OF
C. SCLERA
TRIGEMINAL NERVE, Long Ciliary Nerve (CN V1)
 White fibrous protective coating of the eyeball
 composed of 5 layers: from external going posterior
 Consist almost entirely of collagen fibers that is continuous
o Epithelium - continuous to epithelium of bulbar
to the cornea anteriorly & dural sheath of the optic nerve
conjunctiva
posteriorly
o Bowman’s layer - clear and acellular
 The anterior and posterior chamber is filled with Aqueous
o Stroma - 90% of corneal thickness; collagen fibrils
(secreted by the non-pigmented epithelium of the ciliary
arranged parallel to the cornea
processes)
o Descemet’s membrane - basal lamina of the
o provides nutrition to the lens and cornea
innermost layer
o responsible for maintaining intra-ocular pressure
o Endothelium - single layer of cell responsible for
 Anterior chamber – chamber between the cornea and the
maintaining the relative hydrated state or
iris; filled with aqueous humor
deturgescence of the stroma.
 Posterior chamber – space between the iris and lens;
filled with aqueous humor
 *Aqueous humor – produced by the ciliary body and
circulates from the posterior chamber, through the pupil,
and into the anterior chamber, where it is absorbed by the
trabecular meshwork into the scleral venous sinus (canal of
Schlemm) at the angle of the cornea and iris
 Supports eye shape
 Protects delicate internal structures
 Extrinsic muscle attachment site
Layers:
o Episcleral
o Sclera proper
o Lamina fuscia

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D. UVEAL TRACT
 VASCULAR PIGMENTED COAT
 Middle vascular layer of the eye
 Protected by the cornea and sclera
 Contributes to the blood supply of retina
3 parts:
o Iris
o Ciliary body
o Choroid - contributes to the blood supply of the
retina
E. IRIS
 Shallow cone pointing anteriorly containing the pupil both
function to moderate the amount of light entering the eye
 Anterior extension of the ciliary body
 contractile diaphragm with central aperture (pupil)
 regulates the amount of light to reach the retina
 referred to as a “curtain” It divides the space between the
lens and the cornea into:
o anterior chamber
o posterior chamber
Figure 3. Anterior and Posterior Chambers of the Eyeball
 Within the stroma of the iris are the Sphincter pupillae
muscles along the pupillary border and are innervated by
the 3rd Cranial Nerve
 short ciliary nerves
 Dilator pupillae muscles (Sympathetic) – Innerveted by
the sympathetic arising from the superior cervical ganglion
 long ciliary nerves
F. CILIARY BODY
 Contains ciliary muscles for accommodation
 The muscles allow one to focus in real time, distant objects
and near objects
 Contains layer of non-pigmented cells that produces
Aqueous humor
 vascular and muscular extension of choroid anteriorly
 “dangerous area” of the eye
 continuous posteriorly with the choroid and anteriorly, it lies
behind the peripheral margin of the iris
 Functions:
o Produces aqueous humor
o maintains intraocular pressure
o contains ciliary muscle for accommodation: focus lens
when you are looking at a near object
 Composition:
o Ciliary Ring - is the posterior part of the body, and its
surface has shallow grooves, the ciliary striae
[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL]
o Ciliary Processes - are radially arranged folds, or
ridges, to the posterior surfaces of which are connected
to the suspensory ligament of the lens
o Ciliary Muscle- is composed of meridianal and circular
fibers of smooth muscle
 INNERVATION
Parasympathetic Fibers from the oculomotor nerve
-After synapsing in the ciliary ganglion, the postganglionic
fibers pass forward to the eyeball in the short ciliary nerves
Oppressed Myopia – lens loses their elasticity due to
aging
G. CHOROID
 middle vascular layer located between the retina and sclera
 most posterior portion of uveal tract
 supplies the blood supply of the outer half of the retina
H. LENS
 located behind the iris pupil diaphragm
 transparent lens supported in capsule by zonular fibers
 suspended by zonules of zinn to the ciliary body
 Sole purpose: TO FOCUS LIGHT INTO THE (FOVEA OF
THE) RETINA
 Accomodation: The ciliary body contains smooth muscle
arranged in a circular fashion like a sphincter. When relaxed,
it pulls a set of zonular fibers attached to the elastic lens
taut and flattens the lens for viewing objects at some
distance from the eye. When focusing on near objects, the
sphincter-like ciliary muscle (parasympathetically innervated
by CN III) contracts and constricts closer to the lens,
relaxing the zonular fibers and allowing the elastic lens to
round up for accommodation (near vision).
I. VITREOUS
 clear visco-elastic gel avascular gelatinous body behind the
lens
 comprises ⅔(75%) of the total eye volume
 maintains the shape of the eye as well as its structural
stability
 Vitreous chamber – large chamber behind the lens; filled
with gel-like substance called vitreous humor (helps cushion
and protect the fragile retina during rapid eye movements)
J. RETINA
 thin, semi-transparent layer of nerve tissue
 Innermost coat of the eye
 Optically receptive part of the optic nerve (optic retina);
contains Rods (dim light vision) and Cones (color vision)
 “window” into the brain
 contains photoreceptors that convert light to electrical
impulses
 covers the ciliary processes and the back of the iris
 Its anterior edge forms a wavy ring, the ora serrata,
 Where nervous tissues end
MECULA LUTAE
- oval, yellowish area at the center of the posterior part of
the retina
FOVEA CENTRALIS
-central depression, the inner nuclear layer and ganglion cell
layer are displaced
- Area of macula with the most acute vision; contains only
cones and is the center of the visual axis (ideal focus point)
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OPTIC DISC  Inferior Rectus
- medial side of the macula lutea o Depresses and ADducts
- about 3 mm to the optic disc the optic nerve leaves the o concerned with EXTORSION
retina about 3 mm B. OBLIQUE MUSCLES
- is slightly depressed at its center pierced by the central  Superior Oblique
artery of the retina - longest and thinnest EOM
-Complete absence of rods and cones so that it is insensitive - moves the eye laterally and inferiorly
to light and is referred to as the “blind spot” lateral - responsible for INTORSION
-Non-receptive area (blind spot) where retinal ganglion cell  Inferior Oblique
nerve axons leave the retina in the optic nerve and pass to - moves the eye superiorly and laterally
the brain - responsible for EXTORSION
C. LEVATOR PALPEBRAE SUPERIORIS
 Origin: Lesser Wing of Sphenoid
REFRACTIVE MEDIA  Insertion : Superior Tarsal Plate
 Light rays focused by the cornea, aqueous humor, lens, and  Action: Elevates Superior Eyelid and maintain this
vitreous humor position
 Innervated by : Oculomotor Nerve (3rd Cranial Nerve)
II. EXTRA-OCULAR MUSCLES  Blood Supply: Ophthalmic and Supraorbital artery
 responsible for the movement of the eyes
 there 6 extraocular muscles:
o 4 Recti
o 2 Oblique
 3rd Cranial nerve (III) innervates
o Medial Rectus (MR)
o Inferior Rectus (IR)
o Superior Rectus (SR)
o Inferior Oblique (IO)
 6th Cranial Nerve (VI) innervates
o Lateral Rectus (LR)
 4th cranial nerve (IV) innervates
o Superior oblique (SO)
The innervation of these muscles aid neurologists in localizing any
neurologic diseases resulting from loss or decrease of muscle
movement.

Figure 5. Extrinsic Eye Muscles

Figure 4. Extraocular muscles

A. RECTI MUSCLES
 originate from Annulus of Zinn
 named after the sites of insertion e.g. Medial Rectus inserts INTRINSIC MUSCLES
medial to the Cornea; Lateral Rectus inserts temporal/lateral  Sphincter pupillae-around the pupil margin
to the cornea - circular rotation
 Medial and Lateral rectus only have a single action - constricts the pupil
o Adduction - moving the eye medially (MR) - nasal  Dilator Pupillae
o Abduction - moving the eye laterally (LR) - temporal - Radial Rotation
Inferior and Superior rectus have : - Dilates Pupil
o Primary Action  Ciliary muscle-deeper
o Secondary Action - longitudinal fibers
 Superior Rectus - circular fibers
o Elevates and ADducts - radial fibers
o concerned with INTORSION - for accommodation (pupil dilates, lens thickens, then
convergence)
-Control how the lens adapts to focusing

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III. NERVES IN THE ORBIT
Three cranial nerves innervate the extraocular skeletal muscles:
 CN II (Optic nerve): cranial nerve that mediates the
special sense of sight; brain tract that conveys sensory
information from the retina, via the ganglion axons, to the
brain
 CN V1 (Opthalmic nerve): cranial nerve that conveys
general sensory information from the orbit and eye; its
branches include:
o Frontal – runs on the superior aspect of the
levator palpebrae superioris muscle and ends as
the supratrochlear and supraorbital nerves;
sensory to the forehead, scalp, frontal sinus, and
upper eyelid
o Lacrimal – courses laterally on the superior
aspect of the lateral rectus muscle to the lacrimal
gland; sensory to conjunctiva and skin of the
upper eyelid
o Nasociliary – gives rise to short and long ciliary
nerves, posterior and anterior ethmoidal nerves,
and infratrochlear nerve; sensory to iris and
cornea, sphenoid and ethmoid sinuses, lower
eyelid, lacrimal sac, and skin of the nose

 CN III (Oculomotor nerve): provides parasympathetic

fibers in which they exhibit the following features:
o They arise centrally from the nucleus of Edinger-
Westphal (preganglionic fibers), and course along
the CN III and its inferior division to synapse in
the ciliary ganglion on post ganglionic
parasympathetic neurons
o Postganglionic fibers then course via short ciliary
nerves to the eyeball
o These fibers innervate the sphincter muscle of the
pupil (sphincter pupillae) and the ciliary muscle for
accommodation
 Sympathetic innervation to the eyeball is arranged as
follows:
 It arises from the upper thoracic
intermediolateral cell column of the
spinal cord (T1-T2) and sends
preganglionic fibers into the sympathetic
trunk, where they ascend to synapse in
the superior cervical ganglion (SCG)
 Postganglionic fibers course along the
internal carotid artery, enter the orbit on
the ophthalmic artery, and pass through
the ciliary ganglion or along the long
and short ciliary nerves to the eyeball
 They innervate the dilator muscle of the
pupil (dilator pupillae) and the superior
tarsal muscle of the upper eyelid
Figure 6. Nerves of the Orbit
IV. BLOOD SUPPLY TO THE ORBIT AND EYE
 The ophthalmic artery arises from the internal carotid
artery just as it exits the cavernous sinus, and it supplies the
orbit and the eye by the following branches:
a. Central artery of the retina: travels in the optic
nerve; occlusion leads to blindness
b. Short and long posterior ciliary arteries:
pierce the sclera and supply the ciliary body, iris,
and choroid
c. Lacrimal arteries: supply the gland, conjunctiva,
and the eyelids
d. Ethmoidal arteries: supply the ethmoid and
frontal sinuses, nasal cavity, and external nose
e. Medial palpebrae arteries: supply the eyelids
f. Muscular arteries: supply skeletal muscles of
the orbit and smooth muscles of the eyeball
g. Supraorbital artery: passes through supraorbital
notch and supplies the forehead and scalp
h. Supratrochlear artery: supplies the forehead
and the scalp
 The venous drainage is by the superior and inferior
ophthalmic veins, which connections to the cavernous sinus
posteriorly (principal drainage), the pterygoid plexus
inferiorly, and the facial vein anteriorly.

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 VI. EMBRYOLOGY

Facial processes from brachial

arch:
[1] Frontonasal= Upper eyelid
[2] Medial nasal
1st week of Development of the [3] Lateral nasal
gestation five Pharyngeal arches [4] Maxillary= Lower eyelid
[5] Mandibular

Incomplete development leads to:

6th to 7th week Eyelid folds mark [1] Ablepharon
(completed at the beginning of [2] Cryptophthalmos
10th week) eyelid development [3] Microblepharon
Figure 7. Branches of the Ophthalmic Artery

Eyelid Development Stages

Failure:
8th to 10th 1. Eyelid fusion Colobomas of lid margin

2. Development of
3rd to 4th month Congenital ptosis
eyelid structures

[1] Ankyblepharon
5th to 6th month 3. Eyelid dysjunction [2] Blepharophimosis
[3] Epicanthus Euryblepharon

VII. GROSS ANATOMY OF THE EYELIDS

Extent and Position of the Eyelid

o Upper Lid
- Eyebrows to the superior boundary of the palpebral
border
o Lower Lid
- Inferior border palpebral fissure to the cheeks.
o In the Primary Position
V. LANDMARKS OF THE EYE
o The upper lid covers the upper 1/6th of
the upper part of cornea
o The lower lid just touches the cornea

Figure 9. Normal eyelid v. Ptosis

* If more than 1/6th = sign of ptosis
*Scleral show at inferior position = exophthalmos/thyroid related
eye disease

 Lid Creases and Folds

- Outline the underlying structures that serve as
landmarks that assist in clionical evaluation which can
help plan surgical procedures involving the area

Figure 8. Landmarks of the Eye

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 Clinical Application
Hordeolum Chalazion
Infection of sterile, chronic inflammation
the tarsal gland (of Meibom) of thethat results from
eyelid (redness, acutely tender) blocked meibomian
gland (hard, non-tender)
Internal – Meibomian gland May develop from an internal
External (STYE) – Gland of Zeis or hordeolum
Moll

Figure 10. Location of Lid Creases and Folds

o Superior lid crease

- represents cutaneous insertion of the levator
aponeurosis to the preseptal orbicularis oculi
o 8-12 mm above the upper lid margin in
Caucasians
o 2-5 mm above the lid margin in Asians Figure 11. Stye v. Chalazion
- Lower in Asians since the orbital septum and levator  Gray Line
aponeurosis is fused at a lower level - Outline of the Muscle of Riolan or Pars Ciliaris
- Constructive/aesthetic surgery: adjusting or retaining - Located posterior the lash line and is anterior to the
the position will result to creating a lid crease or fuller tarsus
lid - Represent the pretarsal Orbicularis on the eyelid margin
o Inferior lid crease - Posterior the gray line demarcates the anterior and
o Lid Folds posterior lamellae
o Nasojugal and Malar Creases Functions:
1. Meibomian gland discharge
 Canthi – The angles to which the upper and lower lids meet 2. Blinking
o Lateral Canthus – Directly in contact with the globe 3. Positioning of eyelashed
o Medial Canthus - Separated with the globe by a tear  Lacrimal Puncta
lake - opening near the medial canthus
Structures nearby: - Represents the opening from the lid margin into the
o Caruncle - Modified skin with sebaceous glands ampulla and canaliculi (lacrimal drainage apparatus)
o Plica semilunaris - Vestigial structure analogous to  Palpebral Fissure
the nictitating membrane of animals o The opening of the lid
- Space between the upper and lower lid, provides
 Eyelid Free Lid Margin opening for the globe
- 20-30 mm long, about 2 mm wide - At birth: 20 mm wide x 8 mm height
- Divided by the mucocutaneous junction (gray line) - Adults: 30 mm wide x 10 mm height
50% have the lateral canthus higher by 2 mm than the medial
Anterior Margin canthus
 Lash line (Eye lashes) A. THE EYELIDS
- Most anterior part of the lid margin  Modified skin folds to protect the anterior part of the eye
- They arise from hair follicles on the anterior side of the  Each eyelid contains a tarsal plate of dense connective tissue
tarsus and project outward and anterior to the lid  Each eyelid contains:
margins o Tarsal plate- consist of dense
- 100-150 cilia in the upper lid Connective tissue
- 50-70 cilia in the lower lid o Tarsal glands- secrete an oily mixture
2 Glands: into the tears
The glands secrete lipid to cover the outer part of o Smooth muscle- a.k.a superior tarsal
the tear film to prevent evaporation (Müller’s) muscle; attaches to the tarsal
o Glands of Zeis plate along with the levator palpebrae
- Small modified sebaceous glands that open into superioris muscle
the hair follicles at the base of the eyelashes  Functions:
o Glands of Moll Primary
- Modified ciliary sweat glands that open in a row
o Protection from injury and
near the base of the eyelashes excessive light
o Voluntary or Involuntary closure
Posterior Margin - In close contact with the globe and along this o Keeps the corneas moist
margin are two small orificies of modified sebaceous glands Secondary
 Meibomian or Tarsal Glands o Tear Production and
o Holocrine glands Drainage
o Meibium (oils) o Blink Reflex
o Approximately 50 glands upper lid and 25 glands lower o Stabilization of Precorneal Tear
lid Film

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B. SKIN/ SUBCUTANEOUS TISSUE Functions:
- Differs from the skin of most other areas o Voluntary: winking
- Thin and Loosely adherent to the orbicularis muscle o Involuntary: Blinking
- Elastic  Orbital Orbicularis
- Few hair follicles o Surrounds the orbital aperture
o Outermost and largest segment
- No subcutaneous fat
Functions:
2 LAYERS
o Forcible eyelid closure
 Epidermis
o Voluntary eyelid closure
- Keratin
Origin:
- Granular Cell Layer
o MCT
- Prickle Cell Layer
o Frontal bone
- Basal Cell Layer
 Dermis o Maxillary bone
- The skin of the upper lid is thinner than the lower lid
Insertion: Below the origin

Figure 12. Epithelial layers of the eyelid skin

Figure 13. Location of the Orbicularis Orbital Muscle
o Eyelid skin is composed of
keratinized stratified epithelium D. ORBITAL SEPTUM
that covers the surface  Thin, multilayered fibrous sheath
o Pilosebaceous elements are  Arises from the periosteal lining at the arcus marginalis
conspicuous in the dermis and a  Separates the eyelids from the orbit
few blood vessels and sweat glands * Important anatomic barrier from infection, edema and
hemorrhage
C. ORBICULARIS OCULI MUSCLE
*From the arcus marginalis, the septum spans the anterior
 Thin sheet of concentrically arranged muscle orbit in a plane deep to the orbicularis oculi muscle and
fibers covering the eyelids and periorbital region ultimately fuses with the eyelid retractors or tarsus.
 Although it is a skeletal muscle, it has  Upper Eyelid - The orbital septum adjoins the
voluntary and reflex actions orbicularis then fuses with the levator aponeurosis.
 Innervated by CN VII o 2-3 mm above the tarsal border
 Functions: o 10 mm above the lashline
o Main protector of the eyelids  Lower Eyelid - The septum arises from the inferior orbital
o Narrows the palpebral fissure rim as a condensation of the periorbita and periosteum then
and closure of the eyelids it continues anteriorly until it joins with the lower eyelid
o Plays a role in the lacrimal pump retractors as a single unit at 4-5mm below the inferior
system
tarsus. It then inserts on the lower border of the tarsus.
ANATOMIC PARTS:
 Pretarsal Orbicularis  Medially - OS + pretarsal orbicularis muscles attaches
o Anterior and overlies the tarsus posterior lacrimal crest (w/ anterior lacrimal crest)
o Functions for horizontal movement of  Laterally - OS attaches to the deep insertion of the
the eyelid which is important in the pretarsal orbicularis muscle + lateral orbital tubercle
lacrimal pump Figure 14. Location of the Orbital Septum
o Assist mainly in involuntary blinking
Origin:
- Superficial: Medial canthal tendon
- Deep: Post lacrimal crest
- Horner’s muscle (Pars lacrimalis)
Insertion: Lateral Canthan Tendon
Contraction of which draws the eyelids medially and posteriorly then
the resulting lateral pull creates a negative pressure in the lacrimal sac
and draws the tears form the canaliculli into the sac.
 Preseptal Orbicularis
o Overlies the orbital septum
Origin: MCT
Insertion: LCT

[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL] Page 8 of 14

E. ORBITAL FAT - Provides ~2 mm elevation of the upper lid
 Posterior to the orbital septum - Attaches the tarsal plate
 Anterior to the levator aponeurosis (upper) or - Firmly attached to the palpebral
capsulopalpebral fascia (lower) conjunctiva
 Surrounded by thin fibrous sheets that are the continuation - Origin: levator aponeurosis (12-14 mm
of the anterior orbital system above the tarsal margin)
 Fat Pads - Innervation: sympathetic nervous system
o Upper (2 pockets formed): - If innervation is interrupted, may cause:
Nasal Mild ptosis
Central Horner’s Syndrome
o Lower (3 pockets formed): - Ptosis – drooping of upper eyelid
Medial - Miosis – constriction of pupil
Central - Anhidrosis – absence of sweating of the face
Lateral o Enophthalmos – sinking of eyeball
Central orbital fat pad is an important landmark in: into bony cavity that protects the eye
o Elective eyelid surgery *In the third cranial nerve dysfunction, ptosis is due to paralysis
o Lid laceration repair of the striated muscle of the levator palpebrae superioris

 Lower Eyelid
F. EYELID RETRACTORS
a. Capsulopalpebral Fascia
Responsible for opening the eyelids and formed by a musculofascial
complex with both striated and smooth muscle components known as - Analogous to the levator aponeurosis
the Levator Complex and the Capsulopalpebral fascia in the lower lid. - Fuses to the sheath of the inferior oblique
 Upper Eyelid muscle
a. Levator Palpebrae Superioris - 2 heads then fuse anterior to the inferior oblique
- Origin: Apex of the orbit and extends inferiorly to form to form the Lockwood suspensory ligament
the lateral and medial horns - Origin: terminal fibers of the inferior rectus
- Periobital of the lesser wing of the sphenoid, above - Insertion: inferior tarsal border after it fuses with the
the Annulus of Zinn orbital septum
- Muscular portion: 40mm b. Inferior Tarsal Muscle
- Levator Aponeurosis: 14-20mm; passes through - Analogous to the Muller’s muscle
orbital septum forward then downward to the tarsal - Poorly developed; inferior tarsal muscle runs
plates and widens to two major attachments. posterior to the capsulopalpebral fascia
o Lateral Horn
 Divides the lacrimal gland to G. TARSUS
orbital and palpebral lobes
o Medial Horn  Gives the structural framework of the eyelid
 Disinsertion results in loss of  Made of fibrous and elastic tissue (NOT cartilage)
eyelid crease  Contains meibomian glands
- Insertion:  Measurement
o Anterior fibers - 3mm above the lid margin o Length: 20-30 mm long
(pretarsal skin, orbicularis muscles and o Thickness: 1 mm thick
septa) o Height: 9-10 mm (superior tarsus) and 4-5 mm
o Posterior fibers - 2-3mm superior the tarsus (inferior tarsus)
o Lateral Horn – Inserts to the lateral orbital  Both anchored to the bone by the MCT and LCT
tubercle
o Medial Horn - Inserts to posterior lacrimal  Tarsal Surfaces
crest o Anterior: attachment of the Orbital Septum
- Disinsertion, dehiscence or rarefaction after and Retractors
trauma/surgery may give rise to ptosis o Posterior: Conjunctiva

Superior Transverse Ligament H. MEIBOMIAN GLANDS

- AKA Whitnall’s ligament
- Vertically oriented
- Located in the transition of the levators and - Oil secreting glands
levator aponeurosis o Orifices
- Functions as a support for the upper eyelid and - Posterior the grey line
the superior orbital tissues
- Anterior to the mucocutaneous junction
- Analogue in the lower eyelid is the Lockwood
o Distribution
ligament
- Upper: ~30 MB glands
- Acts as a fulcrum for the levator muscle - Lower: ~20 MB glands
o To transfer the vector force from
anterior-posterior to superior-inferior Factors to loss of horizontal stability:
direction o Aging
o Atrophy
b. Muller’s Muscle o Laxity of the attachments
- AKA Superior Tarsal Muscle o Decreased orbicularis tone
- Smooth muscle
- Originates at the undersurface of the levator
aponeurosis at the level of whitnall’s ligament, 12-
14mm above the tarsal margin

[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL] Page 9 of 14

 VIII. VASCULAR SUPPLY OF THE EYELID
Network of vessels derived from 2 major sources:
 Internal Carotid
o Ophthalmic Artery
o Supraorbital Artery
o Lacrimal Artery
 External Carotid
o Angular Artery
o Temporal Artery
 Collateral Circulation
o Marginal Artery
o Peripheral Arcad

Figure 15. Meibomian glands

I. CONJUNCTIVA
 Composed of Non-keratinized squamous epithelium
 Forms the posterior layer of the eyelids
 Lining from eyelid margin to the corneal scleral limbus
 Transparent mucus membrane lining the eye socket
from the eyelid margin into the corneal-scleral limbus
2 Parts
 Bulbar conjunctiva
o Loosely attaches to the globe
 Palpebral conjunctiva
o Adheres tightly to the eyelids

Figure 18. Vascular Supply of the Eyelid

Collateralization b/n the internal and external systems contribute to the
rapid wound healing and low incidence of infection following eyelid
surgeries. As the vessels approach the eyelids, branches of the
ophthalmic artery from the internal carotid arterty, and branches of
the facial artery of the maxillary branch of the external carotid artery
form the marginal and peripheral arcades of the eyelids.
X. VENOUS DRAINAGE OF THE EYELID
Composed of:
Figure 16. Location of the Bulbar conjunctiva  Pretarsal drainage
and the Palpebral conjuctiva o Medial: Angular vein
o Temporal: Superficial temporal vein laterally
Accessory glands- helps with tears production to the jugular vein
o Glands of Krause
 Post-tarsal drainage
o Glands of Wolfring
o Orbital veins out to the cavernous sinus
o Glands of Henl
o Deeper branches of the anterior facial vein
o Glands of Manz
o Pterygoid Plexus
 Aqueous producing glands of Krause and Wolfring are
histologically identical with main lacrimal gland
 Mucous secreting goblet cells
 Scattered around the conjunctiva but concentrated
at the Crypts of Henle

Figure 17. Diagrammatic illustration of the location of Figure 19. Veins Surrounding the Eyelid
the accessory glands

[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL] Page 10 of 14

XI. LYMPHATIC DRAINAGE OF THE EYELID
 Lymphatic vessels serving the Medial side of the eyelid
drain to the Submandibular Lymphatic Node
 Lymphatic vessels serving the Lateral side of the eyelid
drain to the Superficial Preauricular Lymphatic Node
Figure 20. Lymphatic Drainage of the Eyelid
XI. INNERVATION
 Sensory
o V1 – forehead and lateral periocular region
o V2 – lower lid and cheek
 Motor
o CN III – for eyelid opening
o CN VII – for eyelid closing + Sympathetic
Nerves
XII. LACRIMAL APPARATUS
 Network where tears are produced, transported and flows to
an outlet
 Tears: contain albumins, lactoferrin, lysozyme, lipids,
metabolites, and electrolytes
 Components of the Lacrimal Apparatus
o Secretory
o Osteology
o Excretory
o Tear Film
o Lacrimal Pump - concerned with tear production
and transport
Lacrimal pathway
Lacrimal gland > Conjunctival Sac > Lacrimal Puncta > Lacrimal
Canaliculi > Lacrimal Sac > Nasolacrimal Duct
Figure 21. Structures of the Lacrimal Apparatus
[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL]
A. DEVELOPMENT OF LACRIMAL SECRETORY SYSTEM
 Develop from multiple solid ectodermal
buds (anterior superolateral orbit)
 Lacrimal glands are small and do not function fully until
6th week after birth
 Morphogenesis is divided in 3 stages
Glandular Stage
o Thickening of superior conjunctival fornix
epithelium
o Condensing of the surrounding
mesenchyme
o ~2 weeks
Bud Stage
o Initial sign of glandular formation
o Development of nodular structures and
lumina within epithelial buds
Glandular Maturity
o Week 9-16
o Begins to mirror the adult gland
Secretory Component: Lacrima Glands & Accessory Glands
 Lacrimal Gland
- Secretes most components of the tear film that
moisturizes, lubricates and helps protect the eyes
o Location: Superotemporal area beneath the eyebrow
o Lobes (2): Anterior and Posterior
o Divided by tendon of the LPS muscle (aponeurosis)
o Has 8-12 ductules
o Innervations: facial nerve parasympathetics
Lacrimal glands receive secretomotor parasympathetic fibers from the
facial nerve (CN VII) that originate in the superior salivatory nucleus;
travel in the greater petrosal and vidian (nerve of the pterygoid canal)
nerves; synapse in the pterygoidpalatine ganglion; and send post
ganglionic fibers via the maxillary, zygomatic, and lacrimal nerves to
the lacrimal gland
In the clinical area, biopsies are done and when doing this from the
lacrimal gland, a portion from the orbital part is taken. This is to
prevent damage from the ductules of the lacrimal gland.
 Exocrine glands producing aqueous secretion
 Body of each gland contain 2 cell types
o Acinar Cells/Acini - Lining the lumen
o Myoepithelial Cells
- Surround the parenchyma and are covered by a
basement membrane
 The connective tissues surrounding the acinar contain blood
vessels of the microvasculature and intra & inter globular
ducts converging at excretory ducts that empty into the
superior conjunctival fornix between the upper eyelid and
the eye
B. BLOOD SUPPLY AND LYMPHATIC DRAINAGE
 Lacrimal Artery (Zygomatic branch)
- Branch of the Ophthalmic Artery
 The vein that drains glands joins the ophthalmic vein.
 The lymphatic drainage joins the conjucntival
lymphatics to drain into the pre-auricular
lymph nodes.
Figure 22. Blood Supply and Lymphatic
Drainage of the Lacrimal Apparatus
Page 11 of 14
C. INNERVATION
 Irritation of the cornea or conjunctiva stimulates the afferent
nerves
 The impulses are carried along the lacrimal nerve to the
ophthalmic nerve though the ophthalmic division of the
trigeminal nerve and to the sensory nucleus in the trigeminal
ganglion.
 The trigeminal ganglion is connected to the lacrimal nucleus
of the facial nerve and the pons by internuncial neurons
 Impulses are then directed by the trigeminal ganglia to the
lacrimal nucleus
In humans there’s is a connection b/n the hypothalamus and the
lacrimal nucleus causing emotional tears;
There’s also a connection in the olfactory system and lacrimal
nucleus causing “Wasabi tears”
*The lacrimal nerve is the smallest of the ophthalmic nerve.
 Afferent (Sensory Innervation)
o Lacrimal Nerve (CN V1 Ophthalmic Branch of
Trigeminal Nerve) – smallest branch of the ophthalmic
nerve
o The sympathetic post ganglionic nerve fibers arise
from the cranial cervical sympathetic ganglion which is
the upper most ganglion of the ganglionic trunk and
travels into the plexus of nerves around the internal
carotid artery and they join the maxillary nerve,
zygomatic nerve, zygomatico-temporal nerve and
finally the lacrimal nerve
o Sympathetic simulation increases tear secretion by
affecting the vascular supply to the lacrimal gland as
well as activating a G-protein pathway

Figure 25. Diagram of the Sympathetic Innervation

Accessory Glands
Figure 23. Diagram of the Lacrimal Gland Innervation  Glands of Krause
- Subconjunctival connective tissue of the superior
Lacrimal Gland Innervation fornix
 Efferent (Parasympathetic or  Glands of Wolfring
Secretomotor) - AKA Glands of Claccio
o Facial Nerve (CN VII): originate in the superior  Both glands are histologically identical to the lacrimal gland
salivatory nucleus
o The efferent post ganglionic parasympathetic impulses
are transmitted via the spheno-palatine nerve to the
zygomatic nerve, which is a branch of the maxillary
division of the trigeminal nerve then passes into the
zygomatic temporal nerve which reaches the lacrimal
gland
o The zygomatic temporal nerve also gives off recurrent
branch to the lacrimal nerve from which the efferent
fibers terminate in the lacrimal gland

Figure 26. Accesspry Glands of the Lacrimal Gland

D. OSTEOLOGY

Figure 24. Diagram of the Sympathetic Innervation

Figure 27. Structures in the Lacrimal Sac Fossa

[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL] Page 12 of 14

 Tear Film
Lacrimal Sac Fossa Composition:
- A depression in the inferomedial orbital rim  Oily Outer Layer/Lipid Layer
- Formed by the maxillary and lacrimal bones o Meibomian Glands
Boundaries o Reduces evaporation of underlying aqueous layer
o Anterior Lacrimal Crest (Maxillary Bone) o Prevent aqueous layer from drying
o Dry eye syndrome
o Posterior Lacrimal Crest (Lacrimal Bone)
 Aqueous Layer (90% of pre-corneal tear film)
Measurement
o Main and accessory lacrimal glands
o 16 mm high
o 10% evaporated; goes up to 20% when aging
o 4-9 mm wide
o 2 mm deep o Basal secretion: Accessory glands
o Reflex: Main Lacrimal
Excretory Component  Mucin Layer or Mucous Layer
 Punctum o Goblet cells found in conjunctiva and tarsus
o Surrounded by the ampulla o Distribute tears to entire ocular surface
o ~0.3 mm in diameter o To adhere with ocular surface
o From the medial canthus
 Inferior punctum is 6.5 mm
 Superior punctum is 6 mm
 Canaliculi - collect tears into openings on the lid called the
puncta, and convey them to the lacrimal sacs
Path
 From ampulla, it travels vertically 2mm > turns 90°
>travels horizontally 8-10mm>Then attaches to the
lacrimal sac
 The upper and lower canaliculi can connect to the lacrimal
sac in three ways:
o Type A: Connection where there is a common
canaliculus
o Type B: Attachment of both upper and lower
canaliculi at a common opening Figure 24. Layers of the Tear Film
o Type C: The canaliculi enter the lacrimal sac D. LACRIMAL PUMP
separately  Responsible for draining out tears in the eyes; lacrimal tear
 90% of the population form a common canaliculus (the pump works by blinking mechanism
rest insert to the lacrimal sac separately)  When the lids close, the pretarsal oribucalirus contracts and
Valve of Rosenmuller compresses the ampulla. It shortens the canaliculus and
 Mucosal fold located between the common canaliculus moves the punctum medially. The lacrimal sac then expands
and lacrimal sac and creates negative pressure, drawing fluid from the
 Prevents tear reflux from the sac back to the canaliculi canaliculus into the sac. When the lids open, the muscle
 1-way valve then relaxes and the lacrimal sac collapses. The tears are
Lacrimal Sac then forced into the nose and then the punctum moves
 Found in the anterior medial orbit laterally and the tears enter the canaliculus.
 10-15 mm long  Tears flow
 Collect tears and release them into the nasolacrimal duct o The upp
when one blinks (contraction of the orbicularis oculi muscle) canaliculi
 Lies within the lacrimal fossa
o Capillarity and suction
 Pretarsal portion of the orbicularis oculi - causes the
 Eyes Close
compression of the sac
o Pretarsal orbicularis compress the ampullae and
Nasolacrimal Duct
shortens and compresses the canaliculae and puncta
- convey tears from lacrimal sacs to the inferior meatus of the nasal
medially
cavity
o 2 Parts: o Lacrimal part of the orbicularis contracts tears >
- Intraosseous: 12 mm nasolacrimal duct > nose
 Eyes Open
- Meatal: 5 mm
o Muscles relax > canaliculi and sac expand (negative
o Opens into the ostium under the inferior turbinate
(inferior meatus) pressure) + capillarity = tears into the sac
o Ostium E. THEORIES OF THE LACRIMAL PUMP
- Located anterior to the inferior nasal meatus, ~2.5 cm  Jones Theory
posterior the nares o Eyelid closure causes negative pressure inside the
- Covered by mucosal fold called the Valve of Hasner lacrimal sac
o Valve of Hasner  Rosengen-Doane’s Theory
- Opens 3-4 weeks of life o Eyelid opening causes negative pressure inside the
- Can be delayed 6-9 months to a year lacrimal sac
- Clinical significance: Epiphora-excessive tears  Tricompartment Theory of Becker
o Eyelid closure causes negative pressure in the superior
aspect of the lacrimal sac

[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL] Page 13 of 14

CHECKPOINT!
1. Chambers of the eyeball which contain aqueous humor
2. Space which communicates with the scleral veins and aqueous humor
3. Structure which provides blood supply to the retina
4. Longest and thinnest extraocular muscle
5. Structures responsible for the production of aqueous humor
6. Meeting point of the upper and lower lids
7. 2 glands that prevent evaporation of the tear film
8. Important landmark in lid laceration repair
9. Condition where the eyeball sinks into the orbit
10. Medial lymphatic drainage of the eyelid
11. True / False: Surgeries or wounds involving the eyelids heal rapidly

11. True
10. Submandibular Lymph Node
9. Enophthalmos
8. Central orbital fat pad
7. Glands of Zeis; Glands of Moll
6. Canthi
5. Ciliary Body
4. Superior rectus
3. Choroid
2. Schlemm’s canal
1. Anterior and Posterior chambers o

[CORPUZ, TOMAS, TABANGCURA, GARALDE, RABBON, RAMIL] Page 14 of 14