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CLINICAL ANATOMY

and

PHYSIOLOGYof the

VISUAL SYSTEM

FOURTH EDITION
 Fourth Edition

CLINICAL ANATOMY

and
PHYSIOLOGYof the

VISUAL SYSTEM

LEE ANN REMINGTON, OD, MS, FAAO DENISE GOODWIN, OD, FAAO

Professor Emerita Professor of Optometr y

Pacic University College of Optometr y Pacic University College of Optometr y

Forest Grove, Oregon Forest Grove, Oregon

3251 Riverport Lane

St. Louis, Missouri 63043

CLINICAL ANATOMY AND PHYSIOLO GY OF THE VISUAL SYSTEM,

FOURTH EDITION ISBN: 978-0-323-71168-5

Copyright © 2022 by Elsevier, Inc. All rights reser ved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,

including photocopying, recording, or any information storage and retrieval system, without permission in writing

from the publisher. Details on how to seek permission, further information about the Publisher's permissions poli-

cies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing

Agency, can be found on our website: http://www.elsevier.com/permissions

is book and the individual contributions contained in it are protected under copyright by the Publisher (other

than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using

any information, methods, compounds or experiments described herein. Because of rapid advances in the medi-

cal sciences, in particular, independent verication of diagnoses and drug dosages should be made. To the fullest

extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injur y and/

or damage to persons or property as a matter of products liability, negligence or other wise, or from any use or

operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2012, 2005, and 1998

Librar y of Congress Number : 2021936357

Senior Content Strategist: Kayla Wolfe

Content Development Specialist: Kristen Helm

Publishing Services Manager: Shereen Jameel

Project Manager: Aparna Venkatachalam

Design Direction: Brian Salisbur y

Printed in Canada

Last digit is the print number : 9 8 7 6 5 4 3 2 1

 To Dan for his encouragement and support.

L AR

To Spencer who supports me in all my crazy endeavors, and to Bob

whostartedme writing.

DG
 P R E F A C E

Clinical Anatomy and Physiolog y of the Visual System was writ- e branches of the internal and the external carotid arteries

ten to provide optometr y, ophthalmolog y, and visual science that supply the globe and adnexa are identied in Chapter 12.

students, as well as clinicians, with a single text that describes e cranial ner ve supply to orbital structures, including both

the embr yolog y, anatomy, histolog y, physiolog y, blood supply, sensor y and motor pathways, is claried in Chapter 13, with an

and inner vation of the globe and ocular adnexa. e visual and emphasis on the clinical relevance and implications of interrup-

pupillar y pathways are covered as well. e text is fully refer- tions along the pathways. Chapter 14 presents the autonomic

enced, and information gathered from historical and current pathways to the smooth muscles of the orbit and to the lacrimal

literature is well documented. An over view of the visual system, gland. e pupillar y pathway is included in this chapter, as is

as well as a short review of histolog y and physiolog y, is provided a discussion of the more common pupillar y abnormalities and

in the introductor y chapter. ereaer, detailed discussions and the relation between the pathway and the clinical presentation.

images help illustrate anatomy and physiolog y concepts related Some of the common pharmaceutical agents and their actions

to the visual system. and pupillar y eects are covered as well. e nal chapter has

Chapters are roug hly ar ranged anatomically, st ar t ing ante- signicant detail on the relationship between the structures of

r iorly and moving p oster iorly. Chapter 2 det ai ls e yelid st r uc- the visual pathway and neighboring structures and on the ori-

ture and histolog y, including t he roles t hat t he mus cles and entation of the bers as they course through the cranium en

g lands have in te ar  lm s ecretion and drainage. Chapters 3 route to the striate cortex. Examples are given of characteristic

t hroug h 8 include t he anatomy, det ai led histolog y, and visual eld defects associated with injur y to various regions of

physiolog y of t he str uc tures constituting t he g lob e. E ach of the pathway.

t he t hree coats of t he e ye—t he cor ne a and s clera, uve a, and In the format used in the text, terms and names of struc-

retina—is covered in s eparate chapters. Included in e ach is tures are noted in bold print when they are rst described or

an emphasis on simi lar ities and dierences b etween regions explained. e name for a structure that is more common in

wit hin e ach coat and not ations ab out layers t hat are cont inu- usage is presented rst, followed by other terms by which that

ous b etween str uc tures and regions. Chapters 6 covers t he structure is also known. Current nomenclature tends to use the

chamb ers inside t he g lob e and t he pro duc t ion and comp osi- more descriptive name rather than proper nouns when identify-

tion of t he mater ial t hat o cc upies t hos e sp aces, and Chapter 7 ing structures, but that is not always the case, especially when

des cr ib es t he cr yst alline lens. the proper name of an individual has been linked so closely his-

In our experience, students can more easily grasp the intri- torically (e.g., Schwalbe line and Schlemm canal). When proper

cacies of ocular development aer gaining a comprehensive names are used, we have followed the example of major journals,

understanding of the composition of the structures; there- which are phasing out the use of the possessive form of the name.

fore ocular embr yolog y is covered in Chapter 9. e tissue Experienced clinicians know that the knowledge of struc-

and structures associated with and surrounding the globe are ture and function provides a good foundation for recognizing

described in the next two chapters. Chapter 10 is a review of and understanding clinical situations, conditions, diseases, and

the bones and important foramina of the entire skull, as well treatments. For this reason, “Clinical Comments” are included

as the detail regarding the orbital bones and connective tis- throughout the book to emphasize common clinical problems,

sue. Chapter 11 explains the extraocular muscles and describes disease processes, or abnormalities that have a basis in anatomy

movements that result from contraction of the muscles with or physiolog y.

the eye in various positions of gaze; an explanation of the clini-

cal assessment of extraocular muscle function based on the Lee Ann Remington, OD, MS

anatomy is included. Denise Goodwin, OD, FAAO

vii
 A C K N O W L E D G M E N T S

We have had the pleasure of interacting with many bright, to Dean Jennifer Coyle and Dean Fraser Horn for the constant

engaging students while teaching at Pacic University College level of support they have provided and to the optometr y faculty

of Optometr y. eir questions, corrections, suggestions, and for their warm encouragement and help during this process.

enthusiasm motivate us to continually improve and update the Kristen Helm, our Content Development Specialist at

understanding of the process we call vision. We are grateful for Elsevier, championed the project and guided us with kind-

their kindness; they make our days richer. ness and tact throughout the entire process, and for that we are

We are also fortunate to work with an extraordinar y group grateful. Kayla Wolfe, our Content Strategist at Elsevier, compe-

of colleagues, the faculty at Pacic, who create an enjoyable tently combined the text and gures into a cohesive whole. We

environment conducive to academic growth. We are grateful appreciate her thoughtful suggestions.

ix
 C O N T E N T S

Preface, vii
8 Retina, 111

Acknowledgments, ix

9 Ocular Embryology, 140

10 Bones of the Skull and Orbit, 159

1 Introduction to the Visual System, 1

11 Extraocular Muscles, 175

2 Ocular Adnexa and Lacrimal System, 10

12 Orbital Blood Supply, 193

3 Cornea, 30

13 Cranial Nerve Innervation of Ocular Structures, 208

4 Sclera, Conjunctiva, and Limbus, 53

14 Autonomic Innervation of Ocular Structures, 222

5 Uvea, 62

15 Visual Pathway, 239

6 Aqueous and Vitreous Humors, 82

7 Crystalline Lens, 97
Index, 257

xi
CLINICAL ANATOMY

and

PHYSIOLOGYof the

VISUAL SYSTEM

FOURTH EDITION
 1

Introduction to the Visual System

e visual system takes in information from the environment in from the same embryonic germ cell layer. e iris is the most

the form of light and analyzes and interprets the data. is pro- anterior portion of the uvea, acting as a diaphragm to regulate the

cess of sight and visual perception involves a complex system of amount of light entering the pupil. Two iris muscles control the

structures, each of which is designed for a specic purpose. e shape and diameter of the pupil and are supplied by the autonomic

organization of each structure enables it to perform its intended nervous system. Continuous with the iris at its root is the ciliary

function. body, which produces the components of the aqueous humor and

e eye houses the elements that take in light rays and change contains the muscle that controls the shape of the lens. e pos-

the light to a neural signal. It is protected by the surrounding terior part of the uvea, the choroid, is an anastomosing network

bone and connective tissue of the orbit. e eyelids cover and of blood vessels with a dense capillary network. e choroid sur-

protect the anterior surface of the eye and contain glands that rounds the retina and supplies nutrients to the outer retinal layers.

produce the lubricating tear lm. Muscles that attach to the e neural tissue of the retina, by complex biochemical pro-

outer coat of the eye control and direct the globe’s movement, cesses, changes light energ y into a signal that can be transmitted

and the muscles of both eyes are coordinated to provide bin- along a neural pathway. e signal passes through the retina,

ocular vision. A network of blood vessels supplies nutrients, exits the eye through the optic ner ve, and is transmitted to vari-

and a complex system of ner ves provides sensor y, motor, and ous parts of the brain for processing.

autonomic inner vation to the eye and surrounding structures. Within the globe are three spaces: the anterior chamber, pos-

e neural signal that carries visual information passes through terior chamber, and vitreous chamber. e anterior chamber is

a complex and intricately designed pathway within the central bounded in front by the cornea and posteriorly by the iris and

ner vous system, enabling an accurate view of the surrounding anterior surface of the lens. e posterior chamber lies behind

environment. is information, evaluated by a process called the iris. e lens lies within the posterior chamber, and the outer

visual perception, inuences a myriad of decisions and activities. border of the posterior chamber is the ciliar y body. e anterior

is book examines the macroscopic and microscopic anat- and posterior chambers are continuous with one another through

omy and physiolog y of the components in this complex system, the pupil, and both contain the aqueous humor, which is pro-

as well as the supporting structures. duced by the ciliar y body. e aqueous humor provides nourish-

ment for the surrounding structures, particularly the cornea and

lens. e vitreous chamber, which is the largest space, lies adja-

ANATOMIC FEATURES OF THE EYE

cent to the inner retinal layer and is bounded in front by the lens.

e eye, also called the globe, is a special sense organ made up is chamber contains a gel-like substance, the vitreous humor.

of three coats, or tunics (Fig. 1.1): e cr ystalline lens is located in the area of the posterior

1. e outer brous layer of connective tissue forms the cornea chamber and provides additional refractive power for accurately

and sclera. focusing images onto the retina. e lens must change shape to

2. e middle vascular layer is composed of the iris, ciliar y view an object that is close to the eye through the mechanism of

body, and choroid. accommodation.

3. e inner neural layer is the retina.

e outer dense connective tissue of the eye oers protec-

ANATOMIC DIRECTIONS AND PLANES

tion for the structures within, maintains the shape of the globe,

and provides resistance to the pressure of the uids inside. e Anatomy is an exacting science, and specic terminolog y is

sclera is the opaque white area of the eye and is covered by a basic to its discussion. e following anatomic directions should

transparent tissue, the conjunctiva. e transparent cornea, at be familiar (Fig. 1.2):

the anterior part of the globe, allows light rays to enter the globe • Anterior, or ventral: toward the front

and, by refraction, helps bring these light rays into focus on the • Posterior, or dorsal: toward the back

retina. e region at which the cornea transitions to sclera and • Superior, or cranial: toward the head

conjunctiva is the limbus • Inferior, or caudal: away from the head

Inner to the sclera and cornea is a vascular layer of the eye, the • Medial: toward the midline

uvea. e uvea is made up of three structures, each having a sepa- • Lateral: away from the midline

rate but interconnected function. Some of the histological layers • Proximal: near the point of origin

are continuous throughout all three structures and are derived • Distal: away from the point of origin

1
2 CHAPTER 1 Introduction to the Visual System

Iris
Cor nea

Anterior chamber

Exter nal scleral sulcus

Cor neoscleral border

Bulbar conjunctiva

Ciliar y muscle

Ora

serrata

Pars plicata

Ciliar y body

Pars plana

Medial

rectus

Lateral

rectus

Retina

Choroid

Fovea

Sclera

Lamina cribrosa

Dural sheath

Long posterior ciliar y

ar ter y

Optic ner ve

Shor t posterior ciliar y ar teries

Fig. 1.1 Horizontal section of the globe showing major components.

e following planes are used in describing anatomic struc- B ecause the globe is a spherical structure, references to loca-

tures (Fig. 1.3): tions can sometimes be confusing. In references to anterior and

• Sagittal: vertical plane running from anterior to posterior posterior locations of the globe, the anterior pole (i.e., center

locations, dividing the structure into right and le sides. of the cornea) is the reference point. For example, the pupil is

• Midsagittal: sagittal plane through the midline, dividing the anterior to the ciliar y body (see Fig. 1.1). When layers or struc-

structure into right and le halves. tures are referred to as inner or outer, the reference is to the

• C orona l or f ront a l: ver t ica l plane r unning f rom side to entire globe unless specied other wise. e point of reference

side, dividing t he st r uc ture into anter ior and p oster ior is the center of the globe, which would lie within the vitreous.

p ar ts. For example, the retina is inner to the sclera (see Fig. 1.1). In

• Axial or transverse: horizontal plane, dividing the structure addition, the term sclerad is used to mean toward the sclera,

into superior and inferior parts. and vitread is used to mean toward the vitreous.
 CHAPTER 1 Introduction to the Visual System 3

Sagittal (median)

plane

Coronal (frontal)

plane

Posterior

Superior

Inferior

Anterior

Axial

(horizontal)

plane

Lateral

Medial

Proximal

Distal

Fig. 1.3 Anatomic planes. (From Palastanga N, Field D, Soames

R. Anatomy and Human Movement. Oxford, UK: Butter worth-

Heinemann; 1989.)

lens and cornea are too strong or, more likely, the eyeball is too

long, causing parallel light rays to focus in front of the retina

Fig. 1.2 Anatomic directions. (From Palastanga N, Field D, So-

ames R. Anatomy and Human Movement. Oxford, UK: Butter- (Fig. 1.4C). Myopia can be corrected by placing a concave lens

worth-Heinemann; 1989.) in front of the eye, causing the incoming light rays to diverge.

OPHTHALMIC INSTRUMENTATION

REFRACTIVE CONDITIONS
Various instruments are used to assess the health and function

If the refractive power of the optical components of the eye, of elements of the visual pathway and the supporting structures.

primarily the cornea and lens, correlates with the distances is section briey describes some of these instruments and the

between the cornea, lens, and retina so that incoming parallel structures examined.

light rays come into focus on the retina, a clear image will be e cur vature of the cornea is one of the factors that deter-

seen. is condition is called emmetropia (Fig. 1.4A). No cor- mine the corneal refractive power. A keratometer measures the

rection, such as glasses or contact lenses, is necessar y for clear cur vature of the central 3 to 4 mm of the anterior corneal surface

distance vision. In hyperopia (farsightedness), the distance and provides information about the power and the dierence in

from the cornea to the retina is too short for the refractive power cur vature between the principle meridians at that location. An

of the cornea and lens, thereby causing images to focus behind automated corneal topographer maps the corneal surface and

the retina (Fig. 1.4B). Hyperopia can be corrected by placing a gives an indication of the corneal cur vature at selected points.

convex lens in front of the eye to increase the convergence of is instrument is an important adjunct in the tting of contact

the incoming light rays. In myopia (nearsightedness), either the lenses in dicult cases.
4 CHAPTER 1 Introduction to the Visual System

retinal layers. OCT angiography detects motion of blood and

uses this to produce high resolution images of the retinal and

choroidal vasculature. is does not require the use of injectable

dyes, and the images can be obtained within seconds. Additional

instrumentation can allow visualization of corneal layers, cells,

and ner ves and can aid in the dierentiation of bacterial, viral,

parasitic, and fungal infection in corneal tissue.

A
e visual eld is the area that a person sees, including those

areas seen in the peripher y. A perimeter is used to test the extent,

sensitivity, and completeness of this visual eld. Computerized

perimeters provide extremely detailed maps of the visual eld,

as well as statistical information on the reliability of the test and

the probabilities of any defects.

Neuroimaging techniques, such as magnetic resonance

imaging and computed tomography, allow increasingly detailed

imaging of the globe, orbit, and visual pathway anatomy. ese

B

images provide physiological and pathological information

never before available. Having a basic understanding of the nor-

mal anatomical appearance will aid in detecting patholog y.

BASIC HISTOLOGICAL FEATURES

Because many of the anatomical structures are discussed in this

book at the histological level, this section briey reviews basic

C
human histolog y. Other details of tissues are addressed in the

pertinent chapters.
Fig. 1.4 Refractive conditions. A, Emmetropia, in which paral-

All body structures are made up of one or more of the four

lel light comes to a focus on the retina. B, Hyperopia, in which

parallel light comes to a focus behind the retina (dotted lines). basic tissues: epithelial, connective, muscle, and ner vous tissue.

A convex lens is used to correct the condition and bring the A tissue is dened as a collection of similar cells that are special-

light rays into focus on the retina. C, Myopia, in which parallel

ized to perform a common function.

light comes to a focus in front of retina (dotted lines). A concave

lens is used to correct the condition and bring the light rays into
Epithelial Tissue

focus on the retina. (Courtesy Karl Citek, O.D., Pacic Universit y

Epithelial tissue oen takes the form of sheets of epithelial cells

College of Optometr y, Forest Grove, Ore.)

that either cover the external surface of a structure or that line a

cavity. Epithelial cells lie on a basement membrane that attaches

e inside portion of the eye surrounding the vitreous cham- them to underlying connective tissue. e basement membrane

ber is called the fundus. is is examined using an ophthalmo- can be divided into two parts: the basal lamina, secreted by the

scope, which illuminates the interior of the eye with a bright light. epithelial cell, and the reticular lamina, a product of the under-

e retina, optic nerve head, and blood vessels can be assessed lying connective tissue layer. e free surface of the epithelial cell

and information about ocular and systemic health obtained. is is the apical surface, whereas the surface that faces underlying

is the only place in the body in which blood vessels can be viewed tissue or rests on the basement membrane is the basal surface.

directly and noninvasively. Various systemic diseases, such as dia- Epithelial cells are classied according to shape (Fig. 1.5).

betes, hypertension, and arteriosclerosis, can alter ocular vessels. Squamous cells are at and platelike, cuboidal cells are of equal

To obtain a more complete view of the inside of the eye, topical height and width, and columnar cells are higher than wide.

drugs are administered to inuence the iris muscles, causing the Epithelium consisting of a single layer of cells is referred to as

pupil to become enlarged, or mydriatic. A binocular indirect oph- simple: simple squamous, simple cuboidal, or simple columnar.

thalmoscope allows stereoscopic viewing of the fundus. Endothelium is the special name given to the simple squamous

e outside of the globe and the eyelids can be assessed with layer that lines certain cavities. Epithelium consisting of several

a biomicroscope. is combination of an illumination system layers is referred to as stratied and is described by the shape of

and a binocular microscope allows stereoscopic views of various the cells in the surface layer. Only the basal or deepest layer of

parts of the eye. Particularly benecial is the view of the trans- cells is in contact with the basement membrane, and this layer

parent ocular structures, such as the cornea and lens. A number usually consists of columnar cells.

of auxiliar y instruments can be used with the biomicroscope to Keratinized, stratied squamous epithelium has a surface layer

measure intraocular pressure and to view the interior of the eye. of squamous cells with cytoplasm that has been transformed into

Optical coherence tomography (OCT) uses light waves to a substance called keratin, a tough protective material relatively

noninvasively obtain a cross-sectional image of optical struc- resistant to mechanical injur y, bacterial invasion, and water loss.

tures. It provides three-dimensional mapping of the retina and ese keratinized surface cells constantly are sloughed o and

the optic ner ve head and can measure the thickness of specic are replaced from the layers below where cell division takes place.
 CHAPTER 1 Introduction to the Visual System 5

Simple

Squamous Cuboidal Columnar

Stratified

Squamous nonkeratinized
Cuboidal

Keratinized Columnar

Fig. 1.5 Types of epithelia. (From Gartner LP, Hiatt JL. Color Textbook of Histology. 3rd ed. Phila-

delphia: Saunders; 20 07, p 87.)

Many epithelial cells are adapted for secretion and, when (Fig. 1.6). Glands can also be named according to the composi-

gathered into groups, are referred to as glands. Glands can be tion of their secretion: mucous, serous, or sebaceous.

classied according to the manner of secretion—exocrine glands

Connective Tissue
secrete through a duct onto the epithelial surface, whereas

endocrine glands secrete directly into the bloodstream. Glands Connective tissue provides structure and support and lls the

can also be classied according to the process of secretion pro- space not occupied by other tissue. Types of connective tissue

duction—holocrine glands secrete complete cells laden with the include bone, muscle, tendons, blood, lymph, and adipose

secretor y material; apocrine glands secrete part of the cell cyto- tissue. Connective tissue consists of cells, bers, and ground

plasm in the secretion; and the secretion of merocrine glands substance. A combination of insoluble protein bers within the

is a product of the cell without loss of any cellular components ground substance is called the extracellular matrix. Connective

A B C

Secretion

Disintegrating

cell and its

contents
Intact cell

(secretion)

New cell

Pinched off

portion of cell

(secretion)

Fig. 1.6 Modes of glandular secretion. A, Holocrine. B, Merocrine. C, Apocrine. (From Gartner

LP, Hiatt JL. Color Textbook of Histology. 3rd ed. Philadelphia: Saunders; 2007, p 105.)
6 CHAPTER 1 Introduction to the Visual System

tissue can be classied as loose or dense. Loose connective tis- myelinated or unmyelinated. Myelinization improves impulse

sue has relatively fewer cells and bers per area than dense con- conduction speed. Astroc ytes have a number of functions,

nective tissue, in which the cells and bers are tightly packed. including providing physical and metabolic support, maintain-

Dense connective tissue can be characterized as regular or irreg- ing extracellular homeostasis, and participating in the blood

ular on the basis of ber arrangement. brain barrier. Microglial cells mediate the immune response in

Among the cells that may be found in connective tissue are the central ner vous system. ey possess phagocytic properties

broblasts (attened cells that produce and maintain the bers and increase in number in areas of damage or disease.

and ground substance), macrophages (phagocytic cells), mast cells

(which contain heparin and histamine), and fat cells. Connective

BRIEF REVIEW OF HUMAN CELLULAR

tissue composed primarily of fat cells is called adipose tissue.

PHYSIOLOGY

e bers found in connective tissue include exible collagen

bers with high tensile strength, delicate reticular bers, and A cell membrane surrounds each cell and is composed of a

elastic bers, which can undergo extensive stretching. Collagen double layer of hydrophilic lipids surrounding a hydrophobic

bers are a major component of much of the eye’s connective intermediate area (Fig. 1.7). e two hydrophilic phospholipid

tissue. ese bers are composed of protein macromolecules layers face the aqueous solutions on both the inside (intracel-

of tropocollagen that have a coiled helix of three polypeptide lular area) and outside (extracellular area) of the cell. A hydro-

chains. e individual polypeptide chains can dier in their phobic fatty acid chain extending from each phospholipid layer

amino acid sequences, and the tropocollagen has a banded pat- projects toward the center of the membrane. Cholesterol mol-

tern because of the sequence dierences. Collagen is separated ecules found in the central fatty acid portion decrease the mem-

into various types on the basis of such dierences, and several brane’s permeability to water soluble molecules. Carbohydrates

types are components of ocular connective tissue structures. may form a glycocalyx coating on the extracellular cell mem-

e amorphous ground substance, in which the cells and brane. Protein molecules may be embedded in both surfaces of

bers are embedded, consists of water bound to glycosamino- the lipid bilayer, and membrane-spanning proteins have por-

glycans, proteoglycans, and glycoproteins. tions both inside and outside the cell.

e cellular c ytoplasm (cytosol) contains various protein

Muscle Tissue
bers. Microtubules are the largest and are composed of the pro-

Muscle tissue is contractile tissue. It can be classied as striated tein tubulin. Other bers may be tissue specic: keratin bers in

or smooth and may be under voluntar y or involuntar y control. epithelium, microlaments of actin and myosin bers in the sar-

Striated muscle has a regular pattern of light and dark bands coplasm of muscles, and neurolaments in neurons. e c yto-

and is subdivided into skeletal and cardiac muscle. Skeletal skeleton is a three-dimensional scaolding within the cytoplasm

muscle is under voluntar y control, whereas cardiac muscle is that gives the cell structure and support and provides intra-

controlled involuntarily. e structure of skeletal muscle and cellular transport. e nucleus, the control center for the cell,

the mechanism of its contraction are discussed in Chapter 11. directs cellular function and contains most of the genetic mate-

e smooth muscle ber is an elongated, slender cell with a rial within its deoxyribonucleic acid (DNA), which is organized

single centrally located nucleus. is tissue is under the invol- into chromosomes. e genes within the chromosomes are the

untar y control of the autonomic ner vous system. genome. Ribosomes, granules of ribonucleic acid and proteins

within the cytoplasm, manufacture proteins as directed by the

Nerve Tissue
cellular DNA. e endoplasmic reticulum within the cytoplasm

Nerve tissue encompasses two types of cells: neurons, which provides sites for protein and lipid synthesis. Smooth endoplas-

are specialized cells that react to a stimulus and conduct a nerve mic reticulum does not have embedded ribosomes. It is involved

impulse, and neuroglia, which are cells that provide structure and in steroid and lipid synthesis. Rough endoplasmic reticulum

metabolic support to the neurons. e neuron cell body, called houses ribosomes and is involved in producing proteins. e

the soma, has several cytoplasmic projections. e projections Golgi apparatus modies and packages proteins. Mitochondria,

that conduct impulses to the cell body are dendrites, and the pro- the powerhouse of the cell, produce the cell’s supply of energy

jection that conducts impulses away from the cell body is an axon in the form of adenosine triphosphate (ATP). e inner wall of

A ner ve impulse, in the form of an action potential, passes the double-walled mitochondria is folded into cisternae. is is

between ner ves at a specialized junction, a synapse. As the where biochemical processes occur that result in the production

action potential reaches the presynaptic membrane of the rst of ATP. Lysosomes, intracellular digestive systems containing

axon, a neurotransmitter is released into the synaptic gap, trig- powerful enzymes, take up bacteria or old organelles and break

gering an excitator y or an inhibitor y response in the postsynap- them down into component molecules that are reused or reab-

tic membrane of the second neuron. sorbed into the cytoplasm and transported out of the cell.

Neuroglia in the central ner vous system include oligodendro- Fluid and solute transport across a cell membrane can occur

cytes, astrocytes, and microglial cells. Schwann cells are the only passively either by diusion down a concentration gradient or by

neuroglial cell in the peripheral ner vous system. Cytoplasmic facilitated diusion using membrane transport proteins (Fig. 1.8).

extensions of Schwann cells in the peripheral ner vous system Molecules can be transported against the concentration gradient

encircle ner ve bers to form a myelin sheath, and oligodendro- with the use of active transport, which requires energy. Diusion

c ytes do the same in the central ner vous system (including form- occurs when molecules pass from a higher to a lower concentra-

ing the myelin for the optic ner ve). Ner ve bers thus are either tion and no energy is expended. Facilitated diusion may occur
 CHAPTER 1 Introduction to the Visual System 7

Extracellular space

Glycoprotein
Glycolipid

Outer

leaflet

Inner
Cholesterol

leaflet

Fatty acid

Integral

tails

Peripheral protein

Channel

protein

Polar head

Cytoplasm

Fig. 1.7 Model of the cell membrane. (From Gartner LP, Hiatt JL. Color Textbook of Histology.

3rd ed. Philadelphia: Saunders; 20 07, p 16.)

through channel proteins or carrier proteins. Channel proteins cellular metabolism and are regulated by signals f rom either

within the cell membrane create water-lled passages linking the inside or outside the cell. Integrins are membrane-spanning

intracellular and extracellular spaces. ese channels facilitate proteins that can carr y information f rom the extracellular

ion movement across the lipid bilayer and move ions without the matrix into the cell and activate intracellular enzymes that

expenditure of energy. e channels control entrance into the cell then inuence cellular processes. Energ y for metabolic pro-

using gates. Voltage-gated channels open with depolarization. cesses is supplied by ATP molecules, produced either through

Ligand-gated channels open when a signaling molecule, such as aerobic or anaerobic metabolism. Aerobic metabolism is more

a neurotransmitter or a nucleotide like cyclic guanosine mono- ecient, with 36 to 38 molecules of ATP produced per mol-

phosphate, binds to the channel. Mechanical-gated channels open ecule of glucose. Anaerobic glycolysis yields two ATP per

with physical contact like cilia deformation. Some channels are molecule.

not gated, such as potassium (K ) channels or aquaporins, and are

always open. Transport across a cell membrane using carrier pro-

INTERCELLULAR JUNCTIONS

teins requires internal binding sites for the ion or molecule being

transferred. e carrier proteins never form a direct connection Intercellular junctions join epithelial cells to one another

between the intracellular and extracellular environments. is and to adjacent tissue. ere are three main types of junc-

method is slower and selective but can carry larger molecules. tions. Tight junctions, which form fused connections between

Molecules, such as glucose and amino acids, are moved in this membranes of adjoining cells, include zonula occludens and

way. Carrier proteins can function passively (facilitated diusion) macula occludens. Z onula adherens, macula adherens (des-

or with the use of energy (active transport). e most well-known mosomes), and hemidesmosomes form anchoring junctions

+ +

active transport pump is the Na /K ATPase pump. Here, trans- between adjacent cells or between the cell and the basal lamina.

porters and cotransporters move substances against the concen- Gap junctions allow communication between adjacent cells

tration gradient and need a steady supply of ATP. Transporting by permitting passage of ions and small molecules between

epithelia are polarized and the apical and basal membranes have cells. Physical changes, such as pressure and biochemical or

diering properties. Both oen contain ion channels; however, pharmaceutical factors, can modulate junctions and alter the

+ +

the Na /K ATPase pumps are generally located in the basolateral junctional proteins. is allows changes in the extracellular

membranes. Aquaporins are bidirectional channels composed environment to be relayed to the interior cell and may aect

of major intrinsic proteins that specically allow water passage intracellular processes.

but may not allow other materials to pass through the channel. With tight (occluding) junctions, the outer leaet of the cell

Aquaporins are numerous in ocular tissues, including the cornea, membrane of one cell comes into direct contact with its neigh-

lens, ciliary body epithelia, and retina. bor. Ridgelike elevations on the surface of the cell membrane

C ellular metabolic functions are complex activities that fuse with complementar y ridges on the surface of a neighbor-

maintain the viability of the cell. Amino acids, carbohydrates, ing cell. As the paired strands meet, the neighboring cell mem-

and lipids are used as building blocks in the construction of branes are fused. e bers of tight junctions are connected to

cellular components or are broken down as a source of energ y. the cytoskeleton within the cell. is forms an impermeable

A myriad of biochemical pathways and processes function in barrier that prevents passage of unwanted material between
8 CHAPTER 1 Introduction to the Visual System

Passive Transport

Extracellular space

Plasma
Uniport

membrane

Simple diffusion Ion channel-mediated Carrier-mediated

of lipids diffusion diffusion

Facilitated diffusion

Cytoplasm

Active Transport

Extracellular space

Symport Antiport

Cytoplasm Coupled transport

Fig. 1.8 Types of transport. A, Passive transport that does not require the input of energy.

B, Active transport is an energy requiring mechanism. (From Gartner LP, Hiatt JL. Color Textbook

of Histology. 3rd ed. Philadelphia: Saunders; 2007, p 18.)

adjacent cells. Zonula occludens forms a belt-like zone of tight a l lows subst ances to p ass b et we en a dj ac ent cel ls d espite

junctions around the entire apical portion of the cell, joining it rel at ively f ir m ad hes i ons . Adj ace nt to t he a d her ing junc t i ons

with each of the adjacent cells (Fig. 1.9). In these zones, row on are f ine microf i l aments t hat extend f rom a pl aqu e just i ns id e

row of intertwining ridges eectively occlude the intercellular t he membrane to f i l aments of t he c yto skele ton , cont r ibut i ng

space. A substance cannot pass through a sheet of epithelium to c el l st abi l it y. In ge n e r a l, z onu l a a d h eren s e nc i rcl e s t he

whose cells are joined by zonula occludens by passing between e nt i re c el l ju st b as a l to t he z onu l a o c clu d e ns w h i ch lies ne ar-

the cells. Instead the substance must pass through the cell. In e st t he cel l ap ex (s e e Fig . 1.9B). Mac u l a ad herens ( d esmo -

stratied epithelia, where the surface layer is constantly being s ome) is a st rong , sp ot li ke att achment b e t we en cel ls (s ee Fig .

sloughed and replaced from below, zonula occludens, if present, 1.9A). A dens e dis c or pl aque is pre s ent w it hin t he c ytopl as m

will be located in the surface layer. e components of the tight adj acent to t he pl as ma me mbr ane at t he site of t he ad her-

junction are found in increasing numbers as a cell moves from ence. Hair pin lo ops of c y topl asm ic f i l ament s c a l le d tonof i l a -

its origin in the basal layer until, nally, when the cell reaches ments extend f rom t he d is c into t he c y topl as m and l in k to

the surface, its occluding junction is complete. e complex kerat in f i l aments in t he c y toskeleton, cont r ibut ing to c el l st a -

formed by the junctional proteins in the zonula occludens aids bi lit y. O t her f i l aments , t ransmembrane lin kers , or c ad he r ins

in forming the blood-retinal and blood-aqueous barrier. e extend f rom t he pl aque across t he interc el lu l ar sp ac e, hold-

tight junction can be aected in some diseases, causing dys- ing t he cel l membranes toget her and for m ing a st rong b ond.

function of the barrier function. A macula occludens junction The intercel lu l ar sp ace cont ains an ac i d - r ich muc oprote in

has a rounded shape. t hat ac ts as a st rong ad hes ive.

Z onu l a ad herens and mac u l a ad herens are anchor ing Hemidesmosomes provide a strong connection between

junc t ions t hat bind cel ls toget her. T he adj ac e nt pl as ma me m- the cell and its basement membrane and underlying connec-

branes are s ep arate d, le av i ng a nar row i nterc el lu l ar sp ac e tive tissue. ey contain similar components to desmosomes.

t hat cont ains a g lycoprotei n mater i a l. T his ar range me nt e protein complex extends through the cell membrane to
 CHAPTER 1 Introduction to the Visual System 9

ZO

ZA
ZO

ZA

DESM

Connexin

MO

Connexon

HEMI-DESM

Cell 1 Cell 2

BM
“Gap” between cells (~2nm)

A C

Fig. 1.9 Intercellular junctional complexes. A, The lateral cell membranes of adjacent cells.

Zonula occludens joins cells with no intercellular space present. Zonula adherens joins cells without

fusing the membranes. Macula adherens (desmosome) forms strong, spot-like junctions with bers

extending into the cytoplasm. Hemidesmosomes form strong junctions that join the basal aspect of

the cell to its basement membrane. B, Zonula occludens and zonula adherens generally lie adjacent

to one another at the apex of the cell. C, Gap junctions joining two cells. Six proteins (connexins)

surround the central channel (connexon). BM, Basal membrane; DESM, desmosome; HEMI-DESM,

hemidesmosomes; MO, macula occludens; ZA, zonula adherens; ZO, zonula occludens.

attach to keratin in the basement membrane. Bundles of la- with connexins of a neighboring cell forming a channel called

ments join the intracellular plaque to the underlying connec- a connexon (see Fig. 1.9C). ese narrow channels allow rapid

tive tissue matrix, oen attaching to a plaque embedded in the cell-to-cell communication, that is, passage of small molecules

connective tissue. and ions from one cell to another. A group of cells with such

Gap junctions are formed by a group of (usually six) pro- connections act like a syncytium, that is, a single cell with mul-

teins, called connexins, that span the cell membrane and unite tiple nuclei.
 2

Ocular Adnexa and Lacrimal System

e ocular adnexa includes the structures situated in proximity nasal bone and inserts into the medial side of the frontalis. It

to the globe. is chapter discusses the eyebrows, the structures pulls the medial portion of the eyebrow inferiorly and pro-

of the eyelids, the palpebral conjunctiva, and the lacrimal sys- duces horizontal furrows over the bridge of the nose. e orbi-

tem, which consists of a secretor y system for tear production cularis oculi (described in more detail later) lowers the entire

and an excretor y system for tear drainage. brow. e bers of these muscles blend with one another

and are dicult to separate. All are inner vated by the facial

ner ve—cranial ner ve VII.

EYEBROW FEATURES

e eyebrows consist of thick skin covered by characteristic

EXTERNAL FEATURES OF THE EYELIDS

short, prominent hairs extending across the superior orbital

margin, usually arching slightly but sometimes merely running e eyelids, or palpebrae, are folds of skin and tissue that, when

horizontally. In general, in men the brows run along the orbital closed, cover the globe. e eyelids have four major functions:

margin, whereas in women the brows run above the margin. (1) they cover the globe for protection, (2) they contain struc-

e rst body hairs produced during embr yological develop- tures that produce the tear lm, (3) on opening, they spread the

ment are those of the eyebrow. tear lm over the anterior surface of the eye, and (4) on closure,

e muscles located in the forehead—the f rontalis, pro- they move the tears toward drainage areas at the medial canthus.

cerus, corrugator superciliaris, and orbicularis oculi— On closure, the upper eyelid moves down to cover the cornea,

produce eyebrow movements, an impor tant element in facial whereas the lower eyelid rises only slightly. When the eyes are

expression (Fig. 2.1). e frontalis muscle originates high on closed gently, the eyelids should cover the entire globe.

the scalp and inserts into connective tissue near the superior

Palpebral Fissure
orbital rim. e bers are oriented ver tically and raise the eye-

brow, causing a look of surprise or attention. e corr ugator e palp ebral ssure is the area between the open eyelids.

originates on the inferomedial frontal bone and inserts into e average vertical palpebral ssure height is approximately

3 4

skin superior to the medial eyebrow. It is characterized as the 11 mm in Caucasians and 8.5 mm in Asians. Although

muscle of trouble or concentration, and its bers are oriented numerous variations exist in the positional relationship of the

obliquely. It moves the brow down and medially, toward the eyelid margins to the limbus (the junction of the cornea and

nose, creating vertical furrows between the brows. e pro- sclera), generally the upper eyelid covers the superior limbus

cer us, the muscle of menace or aggression, originates on the by 1.5 to 2 mm when the eyes are open and looking straight

ahead. e distance between the corneal reex and the upper

eyelid margin while the patient is in primar y gaze, known

as the margin to reex distance, is approximately 5 mm in

Frontalis

Caucasians, 4.5 mm in African Americans and L atinos, and

Orbital portion
4 mm in Asians. e lower eyelid position is more variable,

7–9
of orbicularis
usually lying within 1 mm of the inferior limbus.

Procerus
e upper and lower eyelids meet at the corners of the palpe-

bral ssure in the lateral and medial canthi. e lateral canthus

Palpebral portion
Corrugator is located approximately 5 to 7 mm medial to the bony orbital

of orbicularis
9

margin and is in contact with the globe. e medial canthus is

at the medial orbital margin but is separated from the globe by a

reser voir for the pooling of tears, the lacrimal lake. At the oor

of the lacrimal lake is the plica semilunaris (Fig. 2.2). is nar-

row, crescent-shaped fold of conjunctiva, located in the medial

canthus allows for lateral movement of the eye without stretch-

ing the bulbar conjunctiva. e caruncle is a small, pink mass of

modied skin located just medial to the plica semilunaris. It is

Fig. 2.1 Forehead muscles that control the eyebrows. These

covered with epithelium that contains goblet cells, as well as ne

are called the muscles of expression. hairs and their associated sweat and sebaceous glands.

10
 CHAPTER 2 Ocular Adnexa and Lacrimal System 11

Plica semilunaris

Caruncle

Lacrimal punctum

Papilla

Cilia

Fig. 2.2 Structures located in left medial canthus.

the orbital septum and orbicularis muscle descends lower into the

CLINICAL COMMENT: Lagophthalmos

10 1 11–15

eyelid eliminating the superior palpebral sulcus.

Lagophthalmos refers to an incomplete closure of the eyelids (Fig. 2.3). Its cause

In the lower eyelid, the inferior palpebral sulcus, which

may be physiological, mechanical (e.g., scarring), or paralytic. Lagophthalmos

separates the lower lid into tarsal and orbital parts, is oen not
is most evident during sleep, when drying of the inferior cornea may result.

ver y distinct. e tarsal portion rests against the globe, and the
Scratchy, irritated eyes are evident on awakening, and punctate keratitis can

orbital portion extends from the lower border of the tarsus onto
occur. Clinical assessment of the inferior cornea will show varying degrees of

epithelial disruption, manifesting as staining with uorescein dye. the cheek, extending just past the inferior orbital margin to the

nasojugal and malar sulci (see Fig. 2.4). ese furrows occur at

the attachment of the skin to the underlying connective tissue

Eyelid Topography

and become more prominent with age.

e upper eyelid extends to the eyebrow and is divided into tarsal

and orbital or preseptal parts. e tarsal portion lies closest to the

Eyelid Margin

lid margin, rests on the globe, and contains the tarsal plate. e

e eyelid margin rests against the globe and contains the eye-

skin is thin, and the underlying loose connective tissue is devoid

lashes and the pores of the meibomian glands. e cilia (eye-

of adipose tissue. e orbital portion extends from the tarsus to

lashes) are arranged at the lid margin in a double or triple row,

the eyebrow, and a furrow—the superior palpebral sulcus—

with approximately 150 in the upper eyelid and 75 in the lower

separates the tarsal portion from the orbital portion (Fig. 2.4). is
16

eyelid. e lashes curl upward on the upper and downward on

sulcus separates the pretarsal skin, which is tightly adherent to the

the lower lid. Replacement lashes grow to full size in approxi-

underlying tissue, from the preseptal skin, which is only loosely

mately 10 weeks, and each lash is replaced approximately ever y

adherent to its underlying tissue and may contain a cushion of

9

5 months. e eyelashes are richly supplied with ner ves, caus-

fat. In eyelids of those of Eastern Asian descent, the fat between

ing them to be sensitive to even the slightest unexpected touch,

which will elicit a protective response—a blink.

CLINICAL COMMENT: Conditions Affecting the Cilia

Various epithelial diseases can cause madarosis (loss of eyelashes) or trichi-

asis (misdirected growth of eyelashes, in which the eyelashes grow toward

rather than away from the palpebral ssure). Contact between the eyelashes

and cornea can cause irritation and painful abrasions and can lead to corneal

ulceration. The problem lashes can be removed by epilation.

Receptors for prostaglandin analogs have been found in the bulb and stem

17

of eyelash follicles. When these receptors are inuenced by prostaglandin

analogs, increased growth and pigmentation of eyelashes occur. Prostaglandin

analogs are a type of medication commonly used to treat glaucoma.

e pores of the meibomian glands are located posterior to

the cilia (Fig. 2.5A), and the transition from skin to conjunc-
Fig. 2.3 Lagophthalmos of the left eye. The eyelids do not fully

close. tiva, the mucocutaneous junction (line of Marx), occurs just

12 CHAPTER 2 Ocular Adnexa and Lacrimal System

Orbital portion of eyelid

Superior palpebral sulcus

Malar sulcus

Tarsal portion of eyelid

Nasojugal sulcus

Fig. 2.4 Surface anatomy of the eyelids.

A B

Fig. 2.5 Eyelid margin. A, Meibomian gland orices; B, mucocutaneous junction stained with lis-

samine green. (Courtesy Tracy Doll, O.D., Pacic University College of Optometr y, Forest Grove, Ore.)

posterior to these openings (Fig. 2.5B). A groove called the gray

GROSS ANATOMY OF THE EYELID

line runs along the eyelid margin between the cilia insertions and

Orbicularis Oculi Muscle

the pores of the meibomian glands. is groove is the location of

a surgical plane that divides the eyelid into anterior and posterior e striated bers of the orbicularis oculi muscle are located

portions. below the subcutaneous connective tissue layer. e muscle

e eyelid margin can be divided into two parts: the medial encircles the palpebral ssure and extends from the eyelid

one-sixth is the lacrimal portion, and the lateral ve-sixths is

the ciliar y portion. e division occurs at the lacrimal papilla,

a small elevation containing the lacrimal punctum, the open-

ing that carries the tears into the nasolacrimal drainage system

(see Fig. 2.2). Usually, no cilia or meibomian pores are found

medial to the punctum, along the lacrimal portion of the eyelid

margin.

CLINICAL COMMENT: Epicanthus

Epicanthus, or an epicanthal fold, is a vertical fold of skin at the nasal canthus

arising in the medial area of the upper eyelid and terminating in the nasal can-

thal area (Fig. 2.6). It is common in newborns and may cause the appearance

of esotropia. A parent of an infant with an epicanthal fold might worry that the

child's eyes are crossed; however, a cover test will identify a true esotropia.

As the bridge of the nose develops, the epicanthal fold gradually disappears.

An epicanthal fold is common in those of Asian descent because there is no

Fig. 2.6 Epicanthal fold may gi ve rise to pseudoesotropia.

connection between the upper and lower preseptal portions of the palpebral

18
(From Kanski JJ, Nischal KK. Ophthalmology: Clinical Signs and

orbicularis muscle.

Differential Diagnosis. St Louis: Mosby; 1999.)

 CHAPTER 2 Ocular Adnexa and Lacrimal System 13

Fig. 2.7 Medial canthal structures. The orbicularis oculi muscle

is composed of semicircles of muscle bers originating at the me- Fig. 2.8 Involutional ectropion.

dial orbital margin and medial canthal tendon. The bers attach

laterally to the lateral canthal tendon. (From Most SP, Mobley SR,

the globe and, unless relieved, can cause a corneal abrasion. Scarring of the
Larrabee WF. Anatomy of the eyelids [review]. 2005;13:488.)

eyelid after trauma or disease may also cause entropion. Both ectropion and

entropion are more common in the lower eyelid and can be corrected surgi-

margin to overlap onto the orbital margin. It is xed to the

cally, if necessary. The anatomic relationship of the muscular and connec-

orbital bones by the orbicularis retaining ligament. e muscle

tive tissue components is an important consideration when repair is done.

can be divided into two regions: palpebral and orbital.

Palpebral Portion of the Orbicularis Muscle Orbital Portion of the Orbicularis Muscle

e palpebral portion of the orbicularis oculi muscle occupies the e orbital portion of the orbicularis oculi muscle is attached

area of the eyelid that rests on the globe and is closest to the eyelid superiorly to the orbital margin, just medial to the supraorbital

margin. It is divided further into pretarsal and preseptal parts, notch (see Fig. 10.7). e concentric circular bers encircle the

named for the structures that the divisions overlie. e palpebral area outer to the palpebral portion and attach inferiorly at the

portion is composed of semicircles of muscle bers originating at orbital margin, medial to the infraorbital foramen.

the medial orbital margin and medial canthal tendon (Fig. 2.7)

19
Orbicularis Action
and attaching to the lateral canthal tendon laterally. e supe-

20–22

rior and inferior muscle bers fuse with one another laterally. e orbicularis oculi muscle is inner vated by cranial ner ve

Deep palpebral orbicularis bers arise from attachments on VII (the facial ner ve). Contraction of the palpebral portion of

23 24

the posterior lacrimal crest and medial orbital wall. is sec- the orbicularis closes the eyelid gently. In addition, the palpe-

tion of the palpebral part of the orbicularis, Horner muscle, bral orbicularis is the muscle of action in an involuntar y blink

25

encircles the lacrimal canaliculi. Contraction of this portion and a voluntar y wink. Relaxation of the levator muscle occurs

28

of the orbicularis assists in moving tears through the canaliculi concurrently. Spontaneous involuntar y blinking renews the

26

into the nasolacrimal drainage system. Horner muscle, along

with the medial rectus muscle pulley and check ligament, sup-

24

port the medial aspect of the tarsal plate.

Another section of the palpebral orbicularis, Riolan muscle, lies

near the lid margin on both sides of the meibomian gland openings.

It maintains the eyelid margins close to the globe and may aid in

21 27

regulation of meibum expression from the meibomian glands.

CLINICAL COMMENT: Ectropion and Entropion

Abnormal eversion of the eyelid margin away from the globe is called ectro-

pion (Fig. 2.8). A common cause of this is loss of orbicularis muscle tone, a

normal occurrence in the aging process. As the eyelid margin falls away from

its position against the globe, the lacrimal punctum is no longer in position to

drain the tears from the lacrimal lake. Epiphora, an overow of tears onto the

cheek, may occur, causing irritation of the delicate skin in this area.

Inversion of the eyelid margin, called entropion, may result from spasm of

Fig. 2.9 Involutional entropion. (From Kanski JJ. Clinical Ophthal-

the orbicularis oculi muscle causing the lid margin to turn inward (Fig. 2.9).

mology: A Systematic Approach. ed 5, Oxford, UK: Butter worth-

This inward turning of the eyelid margin puts the eyelashes in contact with

Heinemann; 2003.)
14 CHAPTER 2 Ocular Adnexa and Lacrimal System

precorneal tear lm. A reex blink is protective and may be elic- ese ligaments form brous bands that span the anterior supe-

ited by a number of stimuli—a loud noise; corneal, conjunctival, rior orbit from the trochlea to the lateral orbital wall. ey pro-

or cilial touch; or the sudden approach of an object. vide support for the upper eyelid and orbital structures as well

When the orbital portion of the orbicularis contracts, the eye as acting as a pulley for the levator. ey are located at the point

34

closes tightly, and the areas surrounding the lids—the forehead, where the levator muscle bers end and the aponeurosis begins.

temple, and cheek—are involved in the contraction. Such eyelid

Levator Aponeurosis
closure is oen a protective mechanism against ocular pain or aer

injury and is called reex blepharospasm. If the lids are closed As it enters the eyelid, the levator becomes a fan-shaped ten-

tightly in a strong contraction, forces compressing the orbital dinous expansion, the levator aponeurosis. Unlike a typical

29

contents can signicantly increase the intraocular pressure. tendon, the aponeurosis spreads out into an extensive sheet

e antagonist to the palpebral portion of the orbicularis beginning posterior to the orbital septum. e bers of the

muscle is the levator muscle. e antagonist to the orbital por- aponeurosis penetrate the orbital septum and extend into the

tion of the orbicularis muscle is the frontalis muscle. upper lid, fanning out across its entire width. ese tendinous

bers pass through the submuscular connective tissue. en, the

Superior Palpebral Levator Muscle

posterior bers insert into the lower third of the anterior sur-

e superior palpebral levator muscle, the retractor of the face of the tarsal plate, and the anterior bers run between the

upper eyelid, is located within the orbit above the globe and muscle bundles of the orbicularis to insert primarily into the

extends into the upper eyelid. It originates on the lesser wing of skin of the eyelid, although some insert into the intermuscular

35

the sphenoid bone above and in front of the optic foramen, and septa of the orbicularis (see Fig. 2.10). e attachments between

its sheath blends with the sheath of the superior rectus muscle. the levator aponeurosis, skin, and orbicularis anchor the skin

As the levator approaches the eyelid from its posterior origin at to the underlying tissue in the pretarsal area of the eyelid and cre-

35

the orbital apex, two ligaments, the superior transverse liga- ate the upper eyelid crease. In those of Eastern Asian descent,

ment (Whitnall ligament), found above the levator, and the the aponeurotic bers do not attach as extensively to the cutane-

1,11,35

intermuscular transverse ligament, found below the levator, ous tissue causing an absent or lowered eyelid crease.

form a sleeve around the levator which changes the anteroposte- e two side extensions of the aponeurosis are referred to as

10 12 30–33

rior direction of the levator to superoinferior (Fig. 2.10). horns. e lateral horn helps to support the lacrimal gland by hold-

ing it against the orbital roof, dividing the gland into orbital and

Superior transverse
palpebral lobes (Fig. 2.11). e lateral horn then attaches to the lat-

ligament Frontal bone

eral canthal tendon and lateral orbital tubercle. e medial horn is

attached to the medial canthal tendon and posterior lacrimal crest.

Levator
Adipose tissue

muscle

Levator Action

Contraction of the levator muscle causes elevation of the eyelid.

e connection between the sheath of the levator and sheath

of the superior rectus muscle coordinates eyelid position with

Orbital

septum globe position so that as the eye is elevated, the lid is raised. e

Intermuscular levator is inner vated by the superior division of the oculomotor

transverse
ner ve, cranial ner ve III.

ligament
Orbicularis
e eyelids are closed by relaxation of the levator and con-

muscle

traction of the orbicularis oculi muscles. e tonic activity of

Tarsal muscle

the levator and the relaxation of the orbicularis hold the eyelid
of Müller

open. In a blink, tonic activity of the levator is suspended, and

with a burst of activity, the orbicularis rapidly lowers the lid fol-
Tarsal

plate lowed by a cessation of orbicularis activity and resumption of

36

levator tonicity.

Retractor of the Lower Eyelid

Tendon

e retractor of the lower eyelid is the capsulopalpebral fascia

of levator

37

(lower eyelid aponeurosis). is is analogous to the levator apo-

muscle

neurosis in the upper eyelid. e capsulopalpebral fascia, an ante-

rior extension from the sheath of the inferior rectus muscle and

the suspensory ligament, inserts into the inferior edge of the tarsal

37

plate. is insertion coordinates lid position with globe move-

ment. e lower eyelid is depressed on globe depression, and the

lower eyelid elevates slightly on upward movement of the globe.

e capsulopalpebral fascia also fuses with the orbital septum and

sends some bers to insert into the inferior fornix (the junction

37

Fig. 2.10 Sagittal section of upper eyelid. between the palpebral and bulbar conjunctiva). In contrast to the
 CHAPTER 2 Ocular Adnexa and Lacrimal System 15

Levator

Orbital
aponeurosis

portion of

lacrimal gland Superior

Tarsal muscle

tarsal plate

Palpebral of Müller

portion of

lacrimal gland

Medial

canthal

tendon

Lateral

canthal

tendon

Inferior

tarsal

plate

Fig. 2.11 Orbital area viewed from the front, with skin, subcutaneous tissue, and orbital septum

removed. The levator tendon is sectioned before its insertion on the tarsal plate. The origin and inser-

tion of Müller muscle are evident.

levator aponeurosis, there are few attachments to the skin of the lower border of the tarsal plate, although investigators disagree

lower lid. is results in a poorly formed lower lid crease. about whether the inferior tarsal muscle actually inserts into the

1 9 29 32 38

tarsal plate or inserts into the tissue below the tarsal plate.

Tarsal Muscle of Müller

Both the superior and inferior tarsal muscles are inner vated by

e superior tarsal muscle (Müller muscle) is composed of sympathetic bers that widen the palpebral ssure when acti-

smooth muscle and originates on the posteroinferior aspect of the vated (as in situations associated with fear or surprise).

levator muscle. ese smooth muscle bers begin to appear within

the striated muscle at the point at which the muscle becomes apo-
CLINICAL COMMENT: Ptosis

neurotic. e superior tarsal muscle inserts on the superior edge Ptosis is a condition in which the upper eyelid droops or sags. It can be caused

of the tarsal plate (see Figs. 2.10 and 2.11). Contraction of Müller by weakness or paralysis of either the levator or Müller muscle. If Müller mus-

10
cle alone is affected, a less noticeable form of ptosis occurs than when the
muscle can provide 2 mm of additional lid elevation.

levator is involved (Fig. 2.12). An individual with ptosis might attempt to raise
A similar smooth muscle, the inferior tarsal muscle, is found

the lid by using the frontalis muscle, which results in elevation of the eyebrow

in the lower eyelid. It arises from the inferior rectus muscle sheath

and wrinkling of the forehead.

and inserts into the lower palpebral conjunctiva and possibly the

A B

Fig. 2.12 A, Mild ptosis of the right eyelid associated with Horner syndrome. B, Severe ptosis of

the right eyelid following a cranial ner ve III palsy. Note the elevation of the ipsilateral eyebrow in

both cases, indicating use of the front alis muscle to aid in raising the eyelid.
16 CHAPTER 2 Ocular Adnexa and Lacrimal System

Orbital Septum
The upp er b orders of b ot h t he me di a l and l atera l c ant ha l

e orbital septum is a thin sheet of brous connective tis- tendons are j oine d to t he exp ansion of t he l e vator tend on ,

sue that concentrically encircles the orbit. It acts as a barrier and t heir lower b ord ers are j oine d to an ex p ans ion of t he

to separate the orbital contents from the eyelid structures. e ligament of L o ckwo o d.

orbital septum extends from the superior orbital rim to insert

Glands of the Eyelids

into the levator aponeurosis 3.7 to 4.4 mm above the tarsal plate

14 19

(see Fig. 2.10). e orbital septum extends from the inferior e meibomian glands (tarsal glands) are sebaceous glands

orbital rim to insert into the tarsal plate of the inferior eyelid. embedded in the tarsal plate. ese long, multilobed glands

Although the superior tarsal plate height is shorter in Asians, resemble a large bunch of grapes and are arranged vertically

there is no appreciable dierence in the insertion site of the such that their openings are located in a row along the eyelid

14 15

orbital septum in relation to the tarsal plate in dierent races. margin posterior to the cilia (Fig. 2.13). Approximately 25 to

40 meibomian glands are found in the upper eyelid, and 20 to

27
Tarsal Plate
30 meibomian glands are found in the lower eyelid. e

Each eyelid contains a tarsal plate (tarsus) that gives the eyelid length of a gland is approximately 5.5 mm in the upper lid and

27

rigidity and structure and shapes it to the cur vature of the globe. 2 mm in the lower lid. On eyelid eversion the vertical rows of

In those of Asian descent, the superior tarsal plate is 8 mm high the meibomian glands can sometimes be seen as yellow streaks

15 39

compared with 10 mm high in Caucasians. e inferior tar- through the palpebral conjunctiva. ese glands secrete the

sal plate is approximately 5 mm high in both Caucasians and outer lipid layer of the tear lm.

15 39

Asians. e anterior surface of the tarsal plate is adjacent

to the submuscular connective tissue. e posterior surface is

CLINICAL COMMENT: Contact Lens Wear

adherent to the palpebral conjunctiva. e orbital border of

Some studies have identied a loss in both the number and the length of mei-

the superior tarsus is attached to the Müller muscle, whereas bomian glands in contact lens wearers (Fig. 2.14). Loss does not appear to

the marginal border lies at the eyelid margin. e lateral aspect be dependent on the type of lens but rather on the duration of wear and is

41

speculated to be caused by chronic irritation.

of the tarsal plate is attached to the orbital margin by the lat-

eral canthal tendon. Recent studies have shown that the medial

aspect of the tarsal plate is attached to the orbital margin by the

23 24

Horner muscle and the medial rectus capsulopalpebral fascia. e sebaceous Zeis glands secrete sebum into the hair fol-

e medial rectus capsulopalpebral fascia consists of the medial licle of the cilia, coating the eyelash sha to keep it from becom-

rectus muscle pulley, the medial check ligament, and bers ing brittle.

attaching to the lacrimal caruncle and tarsal plate. e dense e Moll glands have been called modied sweat glands but

42

connective tissue structures connecting the tarsal plates to the are more accurately described as specialized apocrine glands.

orbital rim hold the tarsal plates in position against the globe ey are located near the eyelid margin and their ducts empty

during eye and lid movements. into the hair follicle, into the Zeis gland duct, or directly onto

the lid margin. Similar glands found in the axillae are scent

9 16

organs, but that is likely not the function of the Moll gland.

CLINICAL COMMENT: Eyelid Eversion e accessory lacrimal glands of Krause are located in the

When attempting to evert the upper eyelid, one should place a cotton-tipped stroma of the conjunctival fornix, and the accessory lacrimal

applicator or ngertip above the superior edge of the tarsal plate. The novice
glands of Wolfring are located along the orbital border of the tar-

experiences difculty in everting the eyelid if the applicator is placed in the

sal plate (see Fig. 2.13). ese glands are oval and display numer-

middle of the tarsal plate.

ous acini. In the upper fornix, 20 to 40 glands of Krause are found,

although only six to eight such glands appear in the lower fornix.

e glands of Wolfring are less numerous. e secretion of the

Canthal Tendons
accessory lacrimal glands appears similar to that of the main lac-

e canthal tendons, previously known as palpebral ligaments, rimal gland and contributes to the aqueous layer of the tear lm.

are the insertion points of the orbicularis muscle. e medial

canthal tendon occupies a signicant area in the medial canthal

HISTOLOGICAL FEATURES OF THE EYELID

region. It was thought to divide into two limbs, but recent studies

Skin
have shown only one limb that attaches to the anterior lacrimal

24

crest. Because of this, Horner muscle is now thought to play a e skin of the eyelid contains many ne hairs, sebaceous glands,

greater role in stabilizing the tarsal plate medially. e medial and sweat glands. It is the thinnest skin in the body, easily forms

canthal tendon lies anterior to the orbital septum (see Fig. 10.22). folds and wrinkles, and is almost transparent in the very young.

e lateral canthal tendon is located posterior to the orbital e epidermal layer of the skin consists of a basal germinal layer,

septum and attaches the lateral edges of the tarsal plates to a granular layer, and a supercial layer that is keratinized. e

the lateral orbital margin at the lateral orbital tubercle (see underlying dermis is abundant in elastic bers. A very sparse are-

Fig. 10.22). Fibrous connections between the lateral canthal olar connective tissue layer, the subcutaneous tissue, lies below

tendon and the check ligament for the lateral rectus muscle the dermis. is thin layer is devoid of adipose tissue in the tarsal

allow a slight lateral displacement of the lateral canthus with portion. A pad of fat is oen located in this region in the orbital

40 9

extreme abduction. portion that separates the orbicularis from the skin.
 CHAPTER 2 Ocular Adnexa and Lacrimal System 17

Accessor y lacrimal

gland (of Krause)

Orbicularis

oculi muscle

Superior tarsal

Subcutaneous
muscle (of Müller)

connective tissue

Accessor y lacrimal

gland (of Wolfring)

Epider mis

of skin
Palpebral

Aponeurosis of
conjunctiva

levator muscle

Tarsal

plate

Submuscular

areolar layer

Meibomian

glands

Gland of Moll

Zeis gland

Riolan

muscle

Hair follicle

Pore of

meibomian gland

Fig. 2.13 Sagittal section of the eyelid illustrating palpebral muscles and glands.

A B

C1 C2 C3 C4

Grade 1 Grade 2 Grade 3 Grade 4

Fig. 2.14 Infrared digital photography of meibomian glands. A, Normal meibomian glands of

the upper eyelid. B, Normal meibomian glands of the lower eyelid. C, Grading scale for meibomian

gland loss. (Courtesy Patrick Caroline, C.O.T., Pacic Universit y College of Optometr y, Forest

Grove, Ore.)
18 CHAPTER 2 Ocular Adnexa and Lacrimal System

the skin so rmly in the tarsal portion of the eyelid. e smooth

CLINICAL COMMENT: Fluid Accumulation in the Eyelid

muscle bers of the superior tarsal muscle are located above

The loose connective tissue layer of the eyelid can be separated easily from

the superior tarsal plate and insert into its upper edge.

the underlying tissue and is the site for the accumulation of blood or edema

in injuries or the accumulation of exudates in inammatory conditions. The

Tarsal Plates

thinness of the skin and the ne underlying adjacent tissue allow this area

e tarsal plates are composed of dense connective tissue. e

to be greatly distensible, as evidenced in patients with periorbital cellulitis or

collagen brils of this tissue are of uniform size and r un both

ecchymosis (a black eye). This skin recovers rapidly after distention because

of the elasticity of the dermis. With advancing age, however, the skin loses its vertically and horizontally to surround the meibomian glands.

elasticity, and stretching will cause exaggerated skin folds.

Palpebral Conjunctiva

e palpebral conjunctiva lines the inner surface of the eyelid

Muscles
and at the fornix transitions into bulbar conjunctiva, which covers

e orbicularis oculi lies deep to the subcutaneous layer. ese the sclera. At the mucocutaneous junction of the lid margin, the

striated muscle bundles run throughout the eyelid. In a sagit- epithelial layer of the conjunctiva is continuous with the epithe-

tal section of the lid prepared for microscopic examination, the lium of the skin (see Fig. 2.15). As the conjunctiva lines the eyelid,

orbicularis bundles are cut in cross-section (Fig. 2.15). Along squamous cells of the skin are replaced by cuboidal and columnar

the lid margin, small muscle bundles located on both sides of cells of the conjunctiva, forming a stratied columnar mucoepi-

the meibomian glands represent a specic part of the orbicu- thelial layer, and the granular and keratinized layers of the skin are

43

laris, the ciliar y part (Riolan muscle), which holds the eyelid discontinued.

margin against the globe (see Fig. 2.15). e epithelial layer of the conjunctiva thickens at the muco-

Posterior to the orbicularis lies another layer of loose con- cutaneous junction (see Fig. 2.15) and may be a location for stem

44

nective tissue, the submuscular areolar layer, which separates cells that repopulate the palpebral conjunctival epithelium. e

the muscle from the tarsal plate. B etween this layer and the tar- mucocutaneous junction transitions to the lid wiper region at

sal plate is a potential space, the pretarsal space, that contains the conjunctival edge of the upper and lower eyelids. is thick-

the vessels of the palpebral arcades. An analogous preseptal ened area of palpebral conjunctiva, 0.3 to 1.5 mm in height, is

space is located between the orbicularis and the orbital septum. held tightly against the eye by the Riolan muscle and is the part

43

Tendinous bers of the levator aponeurosis run through the of the eyelid that makes contact with the globe. It is responsible

submuscular tissue layer between the orbicularis and the supe- for spreading tears during the blink. In the lid wiper region there

rior tarsal muscle to insert into the tarsal plate and the skin of are large stratied cuboidal and columnar cells interspersed with

45

the eyelid (see Fig. 2.13). It is this insertion of bers that anchors goblet cells that secrete mucin onto the ocular surface.

Epidermis
Levator aponeurosis

Orbicularis muscle

Palpebral conjunctiva

Gland of Moll

Meibomian glands

Hair follicle for eyelash

Riolan muscle

Zeiss gland

Mucocutaneou s

junction

Fig. 2.15 Light micrograph of the upper eyelid.

 CHAPTER 2 Ocular Adnexa and Lacrimal System 19

with advancing age and increases in inammator y conditions.

e goblet cell produces mucin droplets that accumulate, caus-

ing the cell to swell and become goblet shaped. e surface of

the cell nally ruptures, releasing mucus into the tear layers.

Parasympathetic and sympathetic ner ves have been associ-

49

ated with goblet cells and may play a role in their secretion.

Invaginations of conjunctival epithelium, oen located near

the fornix, are called cr ypts of Henle. Goblet cells release their

mucus into the cavity formed by these invaginations, and the

mucus may become trapped if the opening to the cr ypt is narrow.

e surface of the supercial conjunctival cell contains

microvilli and microplicae and is covered with a glycocalyx

50 51

similar to that found on the corneal surface. Subsurface ves-

icles, found below the outer membrane of the supercial con-

junctival cell, may be an additional source of mucous material.

As these vesicles fuse with the epithelial cell membrane, chains

extend outward to form a chemical bond with the mucous layer

Fig. 2.16 Lid wiper epitheliopathy along the lower eyelid

margin. (Courtesy Tracy Doll, O.D., Pacic Universit y College of secreted by the goblet cells. ese chains increase the adherence

Optometr y, Forest Grove, Ore.) of the tear lm. ese vesicle membranes may also contribute to

52

the microvilli present on the surface of the epithelial cell.

CLINICAL COMMENT: Lid Wiper Epitheliopathy

CLINICAL COMMENT: Vitamin A Deciency

Lid wiper epitheliopathy occurs when there is alteration of the conjunctival

Vitamin A deciency has been associated with a loss of goblet cells. In dry-eye
epithelium along the eyelid margin because of increased friction between the

46
disorders showing a decrease in the number of goblet cells, treatment with
eyelid and the ocular surface or contact lens surface (Fig. 2.16). Tear instabil-

53 54

vitamin A therapy can induce the reappearance of goblet cells. In acute

ity or eyelid anatomy that causes greater pressure between the lid and cornea

47
disease, cellular proteins may be activated causing keratinization of the sur-
can contribute to this condition.

55

face epithelia.

Goblet cells, which produce, store, and secrete the innermost

mucous layer of the tear lm, are scattered throughout the strati- e submucosa (stroma, substantia propria) of the palpe-

ed columnar conjunctival epithelium (Fig. 2.17). ese cells are bral conjunctiva is ver y thin in the tarsal portion of the eyelid but

most numerous in the plica semilunaris followed by the inferior becomes increasingly thick in the orbital portion. It is composed

48

nasal aspect of the tarsal conjunctiva. eir number decreases of loose, vascularized connective tissue that can be subdivided

into an outer lymphoid layer and a deep brous layer. In addition

to the normal connective tissue components (collagen brils,

broblasts, ground substance, and a few ne elastic bers), the

lymphoid layer contains macrophages, mast cells, polymorpho-

nuclear leukocytes, eosinophils, accumulations of lymphocytes,

56

and occasional Langerhans cells. Immunoglobulin A is found

in the lymphoid layer, making the conjunctiva an immunologi-

57,58

cally active tissue. More lymphoid tissue is found in palpe-

59

bral conjunctiva than in bulbar conjunctiva.

e deep brous layer connects the conjunctiva to under-

lying str uctures and contains a random network of collagen

brils and numerous broblasts, blo o d vess els, ner ves, and

accessor y lacrimal glands. is brous layer merges and is

continuous with the dens e connective tissue of the tarsal plate.

e conjunctiva is so richly supplied with blo o d vess els that a

pale palp ebral conjunctiva may be a clinical sign of anemia.

CLINICAL COMMENT: Conjunctival Concretions

Conjunctival concretions are small, yellow-white nodules about the size of a

pinhead and are most often located in the tarsal conjunctiva (Fig. 2.18). They

are composed of ne granular material and membranous debris, products of

cellular degeneration. These nodules are hardened but contain no calcium

60

deposits. Concretions are found more often in elderly patients and can be

Fig. 2.17 Light micrograph of the conjunctival palpe-

removed if they produce foreign body irritation.

bral epithelium showing goblet cells.

20 CHAPTER 2 Ocular Adnexa and Lacrimal System

move centrally in the acini, become large and polyhedral, and

27 63

begin to synthesize lipids and ll with lipid droplets. As each

meibocyte degenerates, the nucleus begins to diminish in size,

and the cell membrane disintegrates.

Cells in var ying stages of decomposition pack each saccule.

Decomposed cells move down the duct toward the opening.

During a blink, the surrounding Riolan muscle compresses the

tarsal plate releasing meibum into the tear lm, at which point

the secretion (lipid droplets and cell debris) forms the outer-

most lipid layer of the tear lm. e predominant inner vation of

meibomian glands is parasympathetic and may act to alter the

27 64 65

lipid production or cause cell rupture.

e oily secretion of the meibomian glands has been called

meibum to distinguish it from sebum secreted by the sebaceous

glands of the skin and hair follicles. Meibum is much more vis-

cous than sebum; sebum is more polar and if mixed with the

66

tear lm will contaminate and disrupt it.

Fig. 2.18 Concretions on the inferior palpebral conjuncti va.

Histologically, the sebaceous Zeis glands are similar to the

meibomian glands. e Zeis glands, however, are composed of

Glands
just one or two acini and are associated with the eyelash follicle

e meibomian glands are large sebaceous glands occupying (Fig. 2.20). In general, two Zeis glands are present per follicle.

the length of the tarsal plate. Each consists of 10 to 15 lobes or ey release sebum into the follicle, thereby preventing the cilia

27 61 62 61

secretor y acini attached to a large central duct. e duct is from becoming dr y and brittle.

arranged vertically such that the opening is located at the edge Moll glands, modied apocrine glands, are also located near

of the tarsal plate corresponding to the eyelid margin (Fig. 2.19). the eyelash follicle. ey consist of a spiral that begins as a large

Meibomian glands are holocrine glands. eir secretion is cavity, the neck of which becomes narrow as it forms a duct. e

produced by the decomposition of the entire cell. Each acinus large lumen oen appears empty and is surrounded by a layer of

is surrounded by a layer of myoepithelial cells and is lled with cuboidal to columnar secretor y cells (Fig. 2.21). Myoepithelial

actively dividing cells. e daughter cells, called meibocytes, cells surround the secretor y cells. Because the Moll gland is an

Meibomian

gland

Riolan

muscle

Mucocutaneous

junction

Meibomian

gland

duct

Riolan

muscle

Zeis gland

Fig. 2.19 Light micrograph of the meibomian glands embedded in the tar sal plate. The duct

and pore are shown.

 CHAPTER 2 Ocular Adnexa and Lacrimal System 21

Zeis gland Hair follicle Zeis

with duct for cilia gland

Fig. 2.20 Light micrograph of the eyelid margin. A Zeis gland is located next to a hair follicle.

The duct is evident.

apocrine gland, its secretion is composed not of the whole cell

that suggest a role in immune defense protecting the lash sha

42 67
but of parts of cellular cytoplasm. e duct might empty into
and ocular surface.

the duct of a Zeis gland, or it might open directly onto the eye-
Accessor y lacrimal glands are groups of secretor y cells with

lid margin between cilia. Histochemical studies have identied

a truncated-pyramid shape arranged in an oval pattern around a

antimicrobial peptides and proteins in Moll gland secretions

central lumen (Fig. 2.22). e acini are surrounded, sometimes

Accessor y lacrimal
Moll gland

gland

Meibomian gland

Hair follicle

Fig. 2.22 Light micrograph of a lower eyelid. An accessor y

Fig. 2.21 Light micrograph of a hair follicle of a cilia. Two Moll lacrimal gland is seen near the tarsal plate, within which houses

glands are seen. a meibomian gland.

22 CHAPTER 2 Ocular Adnexa and Lacrimal System

incompletely, by a row of myoepithelial cells. ese are merocrine

glands—that is, the cell remains intact and secretes a product—

and these glands have the same histological makeup as the main

68

lacrimal gland. e secretion contains antibacterial agents,

69

lysozyme, lactoferrin, and immunoglubulins. e accessor y

lacrimal glands are densely inner vated, as is the main lacrimal

70

gland. Animal studies suggest that the ducts of Wolfring glands

68

have a tortuous course and open onto the palpebral conjunctiva.

CLINICAL COMMENT: Common Eyelid Conditions

A hordeolum is an acute inammation of an eyelid gland, usually caused by

71

staphylococci. An infected Zeis or Moll gland is called an external hordeo-

lum, or common stye, and usually comes to a head on the skin of the eyelid

(Fig. 2.23). A localized infection of a meibomian gland usually drains from the

inside surface of the eyelid and thus is called an internal hordeolum (Fig. 2.24).

Mild cases usually resolve with warm compress treatment, but more severe

cases might require antibiotic treatment.

A chalazion is a localized, noninfectious, and sometimes painless swelling of

a meibomian gland, often caused by an obstructed duct (Fig. 2.25). The gland

may extrude its secretion into surrounding tissue, setting up a granulomatous

Fig. 2.24 Internal hordeolum.

inammation. Medical or surgical therapy sometimes is necessary.

Blepharitis is an inammatory disease of either the eyelid skin and lashes infratrochlear branch of the ophthalmic ner ve and the zygo-

(anterior blepharitis) or meibomian glands (posterior blepharitis). It is often

maticofacial and infraorbital ner ves, branches of the maxillar y

caused by a disruption of the microora on the lid margin with increased pres-
division of the trigeminal ner ve (Fig. 2.27). Motor control of

72

ence of Staphylococcus aureus In addition, Demodex parasites increase with

the orbicularis muscle is through the temporal and zygomatic

age and can cause blepharitis involving either the lashes or the meibomian

branches of the facial ner ve, and that of the levator muscle is

73 74

glands. Clinical presentation includes crusting or translucent debris sur-

through the superior division of the oculomotor ner ve. e tarsal

rounding the lash base, erythema of the lid margin, or plugging of the meibo-

smooth muscles are inner vated by sympathetic bers from the

mian glands (Fig. 2.26). Blepharitis is typically a chronic condition that requires

superior cer vical ganglion.

periodic treatments with warm compresses, lid hygiene, and antibiotic or an-

tiparasitic agents to aid in restoring normal microora. Long-term blepharitis

can lead to loss of eyelashes, hyperkeratinization and brosis of the meibo-

72 75 BLOOD SUPPLY OF THE EYELIDS

mian glands, and hyperemia, telangiectasia, and scarring of the lid margin.

e blood vessels are located in a series of arcades or arches in

each eyelid. e marginal palpebral arcade lies near the eyelid

INNERVATION OF THE EYELIDS

margin, and the peripheral palpebral arcade lies near the orbital

e ophthalmic and maxillar y divisions of the trigeminal edge of the tarsal plate (Fig. 2.28). e vessels forming these

ner ve provide sensor y inner vation of the eyelids. e upper arcades are anastomosing branches from the medial and lateral

lid is supplied by the supraorbital, supratrochlear, infratroch- palpebral arteries. e medial palpebral arteries branch from

lear, and lacrimal ner ves, branches of the ophthalmic division either the ophthalmic arter y or from the dorsonasal arter y. e

of the trigeminal ner ve. Inner vation to the lower lid is from the lateral palpebral arteries are branches of the lacrimal arter y.

Fig. 2.23 External hordeolum. Fig. 2.25 Painless chalazion.

 CHAPTER 2 Ocular Adnexa and Lacrimal System 23

A B

Fig. 2.26 Inammation of Eyelids. A, Anterior blepharitis showing translucent debris surround-

ing the base of the eyelash. B, Plugged meibomian gland.

Normal variations occur in the blood supply, and the most debris and helps remove sloughed epithelial cells and debris; (3)

common variation is a lack of the peripheral arcade in the it is the primar y source of atmospheric oxygen for the cornea;

lower lid. (4) it provides a smooth refractive surface necessar y for opti-

mum optical function; (5) it contains antibacterial substances

(lysozyme, beta-lysin, lactoferrin, and immunoglobulins) to

76

help protect against infection; (6) it helps to maintain corneal

LACRIMAL SYSTEM

hydration through changes in tonicity that occur with evapora-

e lacrimal system consists of the lacrimal and ancillary glands, tion; and (7) it contains various growth factors and peptides that

69

tear lm, puncta, canaliculi, and nasolacrimal duct. ese structures can regulate ocular surface wound repair.

work together to balance the inow and outow of the tears while Traditionally, the tear lm is described as having three layers;

providing appropriate moisture to the cornea and conjunctiva. however, there is no clear distinction between the aqueous and

77

mucin layers (Fig. 2.29). e outermost layer is a lipid layer

Tear Film
containing waxy esters, cholesterol, and free fatty acids, primar-

e tear lm, which covers the anterior surface of the globe, has ily produced by the meibomian glands. e lipid layer retards

several functions: (1) it keeps the surface of the eye moist and evaporation, provides lubrication for smooth eyelid movement,

ser ves as a lubricant between the globe and eyelids; (2) it traps and stabilizes the tear lm by lowering surface tension, keeping

Levator palpebrae Supraorbital ar ter y, Supratrochlear

Superior tarsus superioris tendon vein, and ner ve ar ter y, vein, and ner ve

Lateral palpebral

ar ter y
Infratrochlear

ar ter y, vein, and ner ve

Lacrimal ner ve

Superior palpebral arcade

Lacrimal ar ter y

Medial palpebral ar ter y

Lateral canthal

Medial canthal tendon

tendon

Lateral palpebral

ar ter y

Inferior palpebral

arcade

Angular ar ter y and vein

Orbital septum

Inferior tarsus

Infraorbital

Transverse facial ar ter y and ner ve

ar ter y

Fig. 2.27 Palpebral innervation. (From Klonisch T, Hombach-Klonisch S. Sobotta. Clinical Atlas of

Human Anatomy. Elsevier 2019.)

24 CHAPTER 2 Ocular Adnexa and Lacrimal System

Peripheral Marginal Lateral

Lipid layer

palpebral palpebral palpebral

Superficial temporal

arcade arcade arteries

artery Aqueous layer

Supraorbital artery

Mucin layer

Epithelium – glycolcalyx

Supratrochlear

Fig. 2.29 Schematic representation of the tear lm.

artery

Middle palpebral

arteries

Lacrimal Secretory System

e lacrimal secretor y system includes the main lacrimal gland,

Angular artery

the accessor y lacrimal glands, the meibomian glands, and the

conjunctival goblet cells.

e main lacrimal gland is located in a fossa on the tempo-

Dorsal nasal artery

ral side of the orbital plate of the frontal bone, just posterior to

Infraorbital
the superior orbital margin. e lacrimal gland is divided into

artery
two portions, palpebral and orbital, by the aponeurosis of the

levator muscle (see Fig. 2.11). e superior orbital portion is

larger and almond shaped. e superior surface lies against the

periorbita of the lacrimal fossa, the inferior surface rests against

the aponeurosis, the medial edge lies against the levator, and the

lateral edge lies on the lateral rectus muscle. e palpebral lobe

Facial artery

is one-third to one-half the size of the orbital lobe and is subdi-

Fig. 2.28 Palpebral blood supply. (Adapted from: Lemke BN,

Lucarelli MJ. Anatomy of the ocular adnexa, orbit, and related fa- vided into two or three sections. If the upper lid is everted, the

cial structures. In: Nesi FA, Lisman RD, Levine MR, eds: Smith’s
lacrimal gland can be seen above the edge of the upper tarsal

Ophthalmic Plastic and Reconstructive Surger y. 2nd ed. St Louis:

plate. Ducts from both portions of the gland exit through the

1998; Mosby.)
palpebral lobe.

e lacrimal gland consists of lobules made up of numer-

27

tears from overowing onto the cheeks. e middle or aque- ous acini. Each acinus is an irregular arrangement of secretor y

ous layer contains inorganic salts, glucose, urea, enzymes, pro- cells around a central lumen surrounded by an incomplete

teins, glycoproteins, and antibacterial substances. It is secreted layer of myoepithelial cells. A network of ducts connects the

by the main and accessor y lacrimal glands. e innermost or acini and drains into one of the main excretor y ducts. ere

mucin layer acts as an interface that facilitates adhesion of the are approximately 12 of these ducts, which empty into the con-

aqueous layer of the tears to the ocular surface and provides a junctival sac in the superior fornix. e secretion is composed

78

coating which reduces friction between the eyelid and cornea. of water, electrolytes, and antibacterial agents, including lyso-

e mucin layer is composed of the glycocalyx secretion from zyme, lactoferrin, and immunoglobulins. e accessor y glands

the surface epithelia and mucin produced and secreted by the are located in the subconjunctival tissue between the fornix

conjunctival goblet cells. Mucins can also bind and entrap bac- area and the tarsal plate. Histologically, the accessor y lacrimal

teria and viruses blocking binding sites on microbes and pre- glands are identical to the main lacrimal gland. Basic secretion

69

venting them from penetrating the ocular surface. maintains the normal volume of the aqueous portion of the

According to some sources, the tear lm is 4 to 8 μm thick, tears, and reex secretion increases the volume in response to

9 79–81

with the aqueous layer accounting for 90% of the thickness. a stimulus. B oth main and accessor y glands play a role in basic

82

e lipid layer is approximately 53 nm thick. and reex secretion.

e lacrimal gland is supplied by the lacrimal arter y, a

branch of the ophthalmic arter y. Sensor y inner vation is through

the lacrimal ner ve, a branch of the ophthalmic division of the

CLINICAL COMMENT: Tear Film Assessment

trigeminal ner ve. Vasomotor sympathetic inner vation causes

Various clinical procedures are used to assess the extent of tear abnormalities.

decreased lacrimal secretion and secretomotor parasympa-

In one method, uorescein dye is instilled into the lower cul-de-sac, and it

spreads throughout the tear lm. After a blink, the thin lipid upper layer begins thetic inner vation results in increased lacrimation. Reex tear-

to break down, and dry spots appear. The time between the completion of the ing occurs when branches of the ophthalmic ner ve within the

blink and the rst appearance of a dry spot is termed the tear lm breakup time
cornea or conjunctiva are stimulated or in response to external

(TBUT) and gives an indirect measure of the evaporative rate. Normally the
stimuli, such as intense light. e aerent pathway for reex

83 84

TBUT is greater than 10 seconds and longer than the time between blinks.
tearing is through the trigeminal ner ve, and the eerent path-

A short TBUT can occur if irregularities or disturbances in the corneal surface

way is through the parasympathetic bers of the facial ner ve.

prevent complete tear lm adherence or if abnormalities exist in the lipid layer

Although it was thought that accessor y glands provided

causing increased evaporation.

the water y component of tear secretion and the main lacrimal

 CHAPTER 2 Ocular Adnexa and Lacrimal System 25

gland was primarily active during reex or psychogenic stimu-

85

lation, it is now thought that all lacrimal glands work together

to produce the aqueous layer and that production is stimulus

77 86

driven. e rate of production ranges from low levels in sleep

69 87

to high levels under conditions of stimulation.

CLINICAL COMMENT: Dry Eye

Alteration in any layer of the tear lm or in eyelid anatomy or lid closure can

result in depletion of the tear lm and cause dry eye, one of the most common

disorders seen in clinical eye care practice.

Dry eye syndrome, also known as keratoconjunctivitis sicca, has a complex

etiology and may be caused by a deciency of any of the layers of the tear

lm or a change in the interaction between the layers. Aqueous deciency,

often resulting in tear hyperosmolarity and ocular surface inammation, is

common, and normal aging can cause a decrease of aqueous tear produc-

tion. Autoimmune diseases, such as Sjögren syndrome, rheumatoid arthritis,

Fig. 2.30 The tear lm is seen as a green uorescence through

and systemic lupus erythematosus, can affect the lacrimal gland causing a

a cobalt blue lter.

deciency in the aqueous layer. Increased meibum viscosity can cause ob-

struction of the meibomian glands resulting in meibomian gland dysfunction

27

and evaporative dry eye. Loss of lipid secretion can lead to alterations in

Puncta and Canaliculi

the lipid layer, allowing increased evaporation of the tear lm and leading

to dry eye symptoms and corneal epithelial compromise. Conditions with

A small aperture, the lacrimal punctum, is located in a slight

decient secretion of the mucin layer are associated with reduced goblet tissue elevation, the lacrimal papilla, at the junction of the lac-

cell populations, such as chemical burns, Stevens-Johnson syndrome, and

rimal and ciliar y portions of the eyelid margin (see Fig. 2.2).

ocular pemphigoid. Complaints associated with dry eye include scratchiness

Both upper and lower lids have a single punctum which drains

and foreign body sensation.

the tears into the upper and lower canaliculi, respectively. e

88 89

width of the lower punctum varies between 0.1 and 0.9 mm.
The tear lm can be augmented by the application of ocular lubricants, con-

sisting of articial tears during the day and ointments at night. More serious
e puncta are turned toward the globe and normally can be

dry eye problems can be treated with procedures that decrease tear drain- seen only if the eyelid edge is everted slightly.

age. Punctual plugs are a temporary solution, and electrocautery can produce
e canaliculi are tubes in the upper and lower eyelids that

permanent closure of the punctum. Ocular surface inammation contributing

join the puncta to the lacrimal sac. e walls of the canaliculi

to dry eye may be successfully treated with topical antiinammatory agents,

contain elastic tissue and are surrounded by bers from the lac-

78

such as cyclosporin or litegrast eye drops.

rimal portion of the orbicularis muscle (Horner muscle). e

rst portion of the canaliculus is vertical and extends approxi-

mately 2 mm; a slight dilation, the ampulla, is at the base of

Tear Film Distribution

e lacrimal gland uid is secreted into the lateral part of the

upper fornix and descends across the anterior surface of the

globe. Contraction of the orbicularis forces meibum out of

the pores and eyelid motion spreads the thin lipid layer across

Canaliculus (8 mm)

the surface. Each blink reforms the tear lm, spreading it over the

ocular surface.

At the posterior edge of both upper and lower eyelid margins,

there is a meniscus of tear uid (Fig. 2.30). e meniscus at the

Nasolacrimal

lower lid is more easily seen. e upper tear meniscus is continu-

sac (10 mm)

ous with the lower meniscus at the lateral canthus whereas at the

medial canthus the tear menisci lead directly to the puncta and
Canaliculus (2 mm) Nasolacrimal

duct (12 mm)

drain into them. e lacrimal lake, a tear reser voir, is located in

the medial canthus. e plica semilunaris makes up the oor of

Common canaliculus
Valve of Hasner

the lake and the caruncle is located at its medial side.

Nasolacrimal Drainage System

Some tear uid is lost by evaporation and some by reabsorption

through conjunctival tissue, but approximately 75% passes through

76

the nasolacrimal drainage system. e nasolacrimal drainage sys-

Fig. 2.31 Anatomy of the lacrimal drainage system. (From

tem consists of the puncta, canaliculi, lacrimal sac, and nasolacri- Kanski JJ. Clinical Ophthalmology. Ed 3, Oxford, UK: Butter worth-

Heinemann; 1995.)
mal duct, which empties into the nasal cavity (Fig. 2.31).
26 CHAPTER 2 Ocular Adnexa and Lacrimal System

90

the vertical portion of the canaliculus. e canaliculus then t he blin k. O t her stud i es supp or t t he l ack of volume change

94 , 95

turns horizontally to run along the lid margin for approxi- w it hin t he l acr ima l s ac.

mately 8 mm (see Fig. 2.31). e canaliculi join to form a single Most of the tears are absorbed by the mucosal lining of

common canaliculus that pierces the periorbita covering the the duct before the remaining tears enter the inferior meatus.

lacrimal sac and enters the lateral aspect of the sac. e angle Absorption through mucous membranes is ver y rapid and so

at which the canaliculus enters the sac produces a physiologic substances, such as drugs, that are present in tears may enter the

96

valve that prevents reux. blood stream of the body.

Lacrimal Sac and Nasolacrimal Duct

AGING CHANGES IN THE EYELIDS AND

e lacrimal sac lies within the lacrimal fossa in the anterior

LACRIMAL SYSTEM

portion of the medial orbital wall. is fossa is formed by the

frontal process of the maxillar y bone and the lacrimal bone. e aging process is apparent in the eyelids as tissue atrophies,

e sac is surrounded by fascia, continuous with the periorbita, the skin loses elasticity, and wrinkles appear. With age the dis-

which runs from the anterior to the posterior lacrimal crests. tance between the center of the pupil and the lower eyelid mar-

e lacrimal sac is surrounded by the medial canthal tendon gin increases caused by sagging of the lower lid; this change

97

anteriorly and Horner muscle posteriorly. e orbital septum is greater in males than females. More pronounced changes

and the check ligament of the medial rectus muscle also lie in eyelid margin position, including ectropion and entropion

behind the lacrimal sac (see Fig. 10.22). (previously described), increase in incidence with age-related

e lacrimal sac empties into the nasolacrimal duct just as changes in the orbicularis muscle tone, and elongation of the

it enters the nasolacrimal canal in the maxillar y bone. e duct levator aponeurosis. e orbital septum weakens with age

is approximately 15 mm long and terminates in the inferior allowing orbital fat to prolapse anteriorly.

meatus of the nose. At this point, the valve of Hasner is found. Tearing may be caused by eversion of the lower punctum

is fold of mucosal tissue prevents retrograde movement of because of eyelid position or by stenosis of the passages in

uid up the duct from the nasal cavity. the lacrimal drainage system. B oth occur more frequently in

elderly persons. Some studies nd that the basal rate of tear

Tear Drainage
secretion diminishes aer age 40 years, contributing to dr y

98,99

During closure, the eyelids meet rst at the temporal canthus. eye, the incidence of which increases with age. Others have

100

Closure then moves toward the medial canthus where the tears determined that tear reex secretion decreases. e goblet

pool in the lacrimal lake. e tear menisci are pushed toward cell population may decrease over age 80 years, and a decrease

100

the lacrimal puncta into which they drain. Capillar y attraction in lysozyme and lactoferrin is noted. With age, meibomian

plays a role in moving tears into the puncta and down into the glands atrophy resulting in decreased overall gland secretion

76 27,101,102

canaliculi between blinks. and ocular dr yness. Causative factors include loss of

e underlying mechanism of tear drainage is not completely glandular tissue and a change in composition of the meibo-

understood. One theor y involves compression of the canaliculi mian secretion forming a more viscous material that does not

41,103

and expansion of the lacrimal sac with eyelid closure. When the ow as easily. e incidence of vascular engorgement at the

eyes are closed, Horner muscle contracts shortening the cana- lid margin and plugged meibomian gland pores also increases

91 103

liculi. en, upon eyelid opening Horner muscle relaxes, and with age.

the canaliculi expand pulling uid in from the puncta. In addi-

tion, because Horner muscle shares fascia with the lacrimal sac,

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56. Steuhl KP, Sitz U, Knorr M, et al. Age-dependent distribution of 78. Clayton JA. Dr y eye. N Engl J Med. 2018;378:2212–2223.

Langerhans cells within human conjunctival epithelium. German 79. Hosaka E, Kawamorita T, Ogasawara Y, etal. Interferometr y in

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57. A l lensmit h MR , Grei ner JV, B ai rd RS. Numb er of i n f l am- Ophthalmol. 2011;151:18–23. e1.

mator y cel ls in t he nor ma l c onjunc t iva . Am J O phthalmol. 80. Werkmeister RM, Alex A, Kaya S, etal. Measurement of tear

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 CHAPTER 2 Ocular Adnexa and Lacrimal System 29

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 3

Cornea

e outer connective tissue coat of the eye has the appearance

CORNEAL ANATOMY AND HISTOLOGY

of two joined spheres. e smaller, anterior transparent sphere

is the cornea and has a radius of cur vature of approximately e cornea is the principal refracting component of the eye. Its

8 mm. e larger, posterior opaque sphere is the sclera, which transparency and avascularity provide optimal light transmit-

has a radius of approximately 12 mm (Fig. 3.1A). e cornea and tance. e anterior surface of the cornea is covered by the tear

sclera merge at the limbus. e approximate diameters of the lm, and the posterior surface borders the aqueous-lled ante-

globe are 24.5 mm anteroposterior, 24 mm vertical, and 24 mm rior chamber. At its peripher y, the cornea is continuous with the

1–3

horizontal; these do not change much beyond age 1 year. conjunctiva and the sclera. From anterior to posterior, the ve

layers that compose the cornea are epithelium, Bowman layer,

stroma, Descemet membrane, and endothelium (Fig. 3.3).

CORNEAL DIMENSIONS

Epithelium
e transparent cornea appears from the front to be oval, as

the sclera encroaches on the superior and inferior aspects. e e outermost corneal layer is stratied corneal epithelium of

9 10

anterior horizontal diameter is 12 mm, and the anterior vertical ve to seven cells thick and measuring approximately 50 µm.

1 2 4

diameter is 11 mm (Fig. 3.1B). If viewed from behind, the It is further broken down into surface squamous cells, wing cells,

cornea appears circular, with horizontal and vertical diameters and basal columnar cells. e epithelium thickens in the periphery

of 11.7 mm. and is continuous with the conjunctival epithelium at the limbus.

In prole, the cornea has an elliptic rather than a spheri- e surface squamous cell layer of corneal epithelium is

cal shape, the cur vature being steeper in the center and at- two cells thick and displays a ver y smooth anterior surface.

ter near the peripher y. e radius of cur vature of the central It consists of nonkeratinized squamous cells, each of which

cornea at the anterior surface is 7.8 mm and at the posterior contains a attened nucleus and fewer cellular organelles than

1 5 6

surface is 6.5 mm. e central corneal thickness is 535 to deeper cells. Cell size varies but a supercial cell can be 50 μm

11

555 μm, whereas the corneal peripher y is 640 to 670 μm thick in diameter and 5 μm in height. e plasma membrane of the

7–9

(Fig. 3.1C). surface epithelial cells secretes a glycocalyx component that

adjoins the mucin layer of the tear lm. Loss of the glycocalyx

will result in poor tear stability. Many projections located on

CLINICAL COMMENT: Astigmatism

the apical surface of the outermost cells increase the surface

Astigmatism is a condition in which light rays coming from a point source are

area, also enhancing the stability of the tear lm. e nger-

not imaged as a single point. This results from unequal refraction of light by

different meridians of the refracting element, each meridian having a different like projections are microvilli, and the ridgelike projections are

radius of curvature. The cornea, which refracts light and helps focus light rays microplicae (Fig. 3.4)

onto the retina, contributes to astigmatism of the eye because the surface is
Tight junctions (zonula occludens) join the surface cells

12
generally not spherical. The radius of curvature of the corneal surface can be
along their lateral walls, near the apical surface. ese junc-

determined clinically by keratometry or topography measurements. These will

tures provide a barrier to intercellular movement of substances

give an approximation of the corneal contribution to astigmatism.

from the tear layer and prevent the uptake of excess uid from

Regular astigmatism occurs when the longest radius of curvature and short- the tear lm. A highly eective, semipermeable membrane is

est radius of curvature lie 90 degrees apart. The most common presenta- produced, allowing passage of uid and molecules through the

tion occurs when the radius of curvature of the vertical meridian differs from
cells but not between them. Additional adhesion between the

that of the horizontal meridian. With-the-rule astigmatism (Fig. 3.2A), occurs

cells is provided by numerous desmosomes.

when the steepest curvature lies in the vertical meridian. Thus the vertical

meridian has the shortest radius of curvature. Against-the-rule astigmatism

(Fig. 3.2B) occurs when the horizontal meridian is the steepest; the greatest
CLINICAL COMMENT: Evaluation of Corneal Surface

refractive power is found in the horizontal meridian. If the meridians that

Fluorescein dye can be used to evaluate the barrier function of the surface

contain the greatest differences are not along the 180- and 90-degree axes
layer. When instilled in the tear lm, it will not penetrate the epithelial tissue

(±30 degrees), but lie along the 45- and 135-degree axes (±15 degrees), the
as long as the zonula occludens are intact. If the tight junctions are disrupted,

astigmatism is called oblique. Irregular astigmatism is a less common nd-

the dye can pass easily through Bowman layer and into the anterior stroma. An

ing in which the meridians corresponding to the greatest differences are not
epithelial defect will usually appear a vivid green uorescence when viewed

90 degrees apart.
with the cobalt blue lter of the slit lamp (Fig. 3.5).

30
 CHAPTER 3 Cornea 31

cells (Fig. 3.6). e diameter of a wing cell is approximately

mm
11

20 μm. D esmos omes and gap junc tions join wing cells to

21
e ach ot her, and desmos omes join wing cells to sur face and

13

bas al cells.

The inner most b as a l c el l l ayer of t he cor ne a l epit helium is

a sing le l ayer of columnar c el ls, w it h d i ameters r ang ing f rom

11
8 mm
8 to 10 μm (Fig . 3.7). Thes e cel ls cont ain ova l- shap e d nucl ei

displ ace d toward t he ap ex and or ie nte d at r ig ht ang les to t he

sur face. The round e d, api c a l sur face of e a ch c el l l i es adj a-

cent to t he w ing cel ls , and t he b as a l su r fa ce att aches to t he

underly ing b as ement membrane ( b as a l l ami na) . A lt houg h

less numerous here t han in t he w ing cel l l ayer, d esmos omes

and gap junc t ions j oi n t he c olumnar cel ls . Interd i g it at ions

A
and desmos omes con ne c t t he b as a l cel ls w it h t he adj ac e nt

l ayer of w ing cel ls.

e basal cells secrete the basement membrane, which

mm

attaches the cells to the underlying tissue by hemidesmosomes.

1

From the hemidesmosomes, anchoring brils form a complex

1

branching network that runs from the basal epithelial cells,

12 mm

14

through Bowman layer to penetrate into the anterior stroma.

If the basement membrane is damaged, healing of the epithe-

15

lium can take up to 6 weeks.

CLINICAL COMMENT: Recurrent Corneal Erosion

Recurrent corneal erosion is a condition in which the hemidesmosomes or

anchoring brils are abnormal causing the corneal epithelium to periodi-

cally slough off. There is poor attachment between the epithelium and its

basement membrane or the basement membrane and underlying stromal

tissue. Recurrent corneal erosion can occur after incomplete healing of a

supercial abrasion or it may be caused by an epithelial basement mem-

brane dystrophy. Matrix metalloproteinases, which normally maintain the

extracellular matrix by causing degradation and remodeling, are upregulated

in recurrent corneal erosion and may cause this break down of the epithelial

16

attachments.

Age-related changes can play a role in recurrent corneal erosion. The corneal

535 to 555 µm
epithelium continues to secrete the basement membrane throughout life. The

thickness of the basement membrane doubles by 60 years of age. In addition,

17

reduplication in focal areas of the membrane can occur with aging. As the

basement membrane thickens or as reduplication occurs, the thickness of the

membrane can exceed the length of the anchoring brils, allowing sloughing

of epithelial layers.

640 to 670 µm
Corneal erosions are very painful because the dense network of sensory

nerve endings in the epithelium is disrupted. A number of treatments may

be used. Ointment at night can help prevent the eyelid from adhering to the

corneal epithelium as the tear lm thins overnight. Acute cases may require

antibiotic ointment to protect from opportunistic infection. Bandage soft

C
contact lenses are applied to alleviate pain while allowing healing of the

surface without the shearing effect from opening and closing the eyelids.
Fig. 3.1 Corneal dimensions. A, Radius of curvature of cornea and

For cases in which the suspected cause is a defective basement membrane,

sclera. B, View from the front of the eye. The sclera encroaches on

treatment might include debridement of the faulty tissue to enhance adhe-

the corneal periphery inferiorly and superiorly. Dotted lines show the

sion between the basal epithelial cells and basement membrane or corneal
extent of the cornea in the vertical dimension posteriorly. C, Sagittal

puncture in which multiple perforations are made through the epithelial

section of cornea showing central and peripheral thickness.

layers to induce adhesion by producing subepithelial scar tissue (Fig. 3.8).

Oral tetracycline or topical steroids may reduce breakdown of the bonds

e middle layer of t he cor ne al epit helium is made up of

between the epithelium and basement membrane by inhibiting matrix me-

two to t hree layers of w ing cel ls. es e cells have wing-li ke

talloproteinases. Autologous serum supplies bronectin which promotes

lateral pro cess es, are p oly hedral, and have convex anter ior

epithelial attachment.

sur faces and concave p oster ior sur faces t hat t over t he bas al
32 CHAPTER 3 Cornea

A B

Fig. 3.2 Corneal topography showing a map of the corneal surface curvature. Colors of longer

wavelength (i.e., red) indicate areas of steeper corneal cur vature, whereas the shorter wavelength

colors indicate a atter corneal cur vature. A, Corneal topography demonstrating with-the-rule

corneal astigmatism. B, Corneal topography demonstrating against-the-rule corneal astigmatism.

(Courtesy Patrick Caroline, C.O.T., Pacic University College of Optometr y, Forest Grove, OR.)

Bowman Layer
the stroma rather than a true membrane. It diers from the

e second layer of the cornea is approximately 8 to 19 μm stroma in that it is acellular and contains collagen brils of a

8–10

thick (Fig. 3.9). Bowman layer (anterior limiting lamina) is smaller diameter. e pattern of the anterior surface is irregu-

a dense, brous sheet of inter woven collagen brils randomly lar and reects the contour of the bases of the basal cells of the

arranged in a mucoprotein ground substance. e brils have epithelium. Posteriorly, as the layer transitions into stroma, the

a diameter of 20 to 25 nm, run in various directions, and are brils gradually adopt a more orderly arrangement and begin

not ordered into bundles. B owman layer sometimes is referred to merge into bundles that intermingle with those of the stroma

18

to as a membrane, but it is more correctly a transition layer to (Fig. 3.10). e posterior surface is not clearly dened.

Cor neal epithelium

Bowman layer

Cor neal stroma

Descemet membrane

Cor neal endothelium

Anterior chamber

Fig. 3.3 Light micrograph of corneal layer s.

 CHAPTER 3 Cornea 33

CROSS-SECTIONAL VIEW OF THE CORNEAL EPITHELIAL CELL LAYER

tear film

glycocalyx layer

apical microvilli

superficial

cells

wing cells

basal cells

basement

membrane hemidesmosomes tight junctions

Fig. 3.4 Cross-sectional view of the corneal epithelial cell layer. (From Farjo A, Mc Dermott

M, Soong HK. Corneal Anatomy, Physiology, and Wound healing . In: Yanoff M, Duker JS, eds.

rd

Ophthalmology, 3 ed. St Louis, MO: Mosby; 20 08, Figure 4.1.1).

B owman layer is produced prenatally by the epithelium layer and whether it is necessar y to maintain corneal function.

and is not believed to regenerate. erefore if injured, the No long-term eects have been documented in patients with

layer usually is replaced by epithelial cells or stromal scar tis- B owman layer removed by photorefractive keratectomy, a pro-

19

sue. However, B owman layer is ver y resistant to damage by cedure performed since the late 1980s.

shearing, penetration, or infection. Although B owman layer is Corneal ner ves passing through B owman layer typically

thought to provide biomechanical rigidity and shape to the cor- lose their Schwann cell covering and pass into the epithelium

nea, speculation continues regarding the function of B owman as naked ner ves (see Fig. 3.6). Bowman layer tapers and ends at

the corneal peripher y and does not have a counterpart in either

the conjunctiva or the sclera.

Stroma

e middle layer of the cornea is approximately 450 to 500 μm

9,11,20

thick, or about 90% of the total corneal thickness (see Fig. 3.3).

e corneal stroma (substantia propria) is composed of collagen

brils, keratocytes, and extracellular ground substance.

e collagen brils have a uniform 25- to 35-nm diameter and

18

run parallel to one another, forming at bundles called lamellae.

e 200 to 300 lamellae are stacked throughout the stroma and lie

parallel to the corneal surface. Adjacent lamellae lie at angles to one

another, but with signicant interweaving, particularly in the ante-

21,22

rior cornea (Fig. 3.11). Each lamellae contains uniformly straight

collagen brils, running in the same direction and arranged with

regular spacing because of the surrounding proteoglycans and gly-

cosaminoglycans (Fig. 3.12). Each lamella extends across the entire

cornea, and each bril runs from limbus to limbus. Near the limbus
Fig. 3.5 Following a paper cut to the cornea, uorescein dye is

the collagen bril diameter increases and anchoring lamellae run

instilled and an epithelial defect is seen as green uorescence

21

circumferentially between the sclera and cornea.

through a cobalt blue lter.
34 CHAPTER 3 Cornea

Fig. 3.6 Three-dimensional drawing of the corneal epithelium showing  ve layer s of cells.

The polygonal shape of the basal and surface cells and their relative size are apparent. W ing cell

processes ll the spaces formed by the dome-shaped apical surface of basal cells. Turnover time

for these cells is 7 days, and during this time the columnar basal cell gradually is transformed into

a wing cell and then into a thin, at surface cell. During this transition, cytoplasm changes and

Golgi apparatus becomes more prominent. Numerous vesicles develop in the supercial wing

and surface layers, and glycogen appears in surface cells. The intercellular space separating the

outermost surface cells is closed by zonula occludens, forming a barrier that prevents passage of

the precorneal tear lm into the corneal stroma. The cell surface shows an extensive net of micro-

plicae (a) and microvilli that are involved in retention of the precorneal tear lm. A corneal ner ve

(b) passes through Bowman layer (c); the ner ve loses its Schwann cell sheath near the basement

membrane (d) of the basal epithelium. It then passes as a naked ner ve bet ween the epithelial

cells toward the supercial layers. A lymphocyte (e) is seen between two basal epithelial cells.

The basement membrane is seen at (f). Some of the most supercial corneal stromal lamellae (g)

are seen cur ving for ward to merge with Bowman layer. The regular arrangement of the corneal

stromal collagen differs from the random disposition in Bowman layer. (From Hogan MJ, Alvarado

JA, Weddell JE. Histology of the Human Eye. Philadelphia: Saunders; 1971.)

18

e arrangement of the lamellae varies slightly within the wide and 1–2.5 μm thick). e anterior cornea has a higher

stroma. In the anterior one-third of the stroma, the lamellae incidence of cross-linking and is more rigid, helping to main-

24

are thin (0.5–30 μm wide and 0.2–1.2 μm thick), and they tain the corneal cur vature. is arrangement is the reason

18 23

branch and inter weave more than in the deeper layers. In that stromal swelling is directed posteriorly. is swelling

the posterior two-thirds of the stroma, the arrangement is causes Descemet membrane to fold, which can be seen clini-

15

more regular, and the lamellae become larger (100–200 μm cally as striae.
 CHAPTER 3 Cornea 35

Surface cells

Wing cells

Basal cells Bowman layer

Bowman layer

Anterior stroma

Stromal keratocyte

Fig. 3.10 Light micrograph of corneal epithelium, Bowman

layer, and anterior stroma. There is a change in the direction

of the supercial lamellae as they cur ve for ward to merge with

Bowman layer (arrows).

Fig. 3.7 Light micrograph of corneal epithelium showing co-

lumnar basal cells, wing cells, and squamous surface cells of the

e collagen brils of the innermost layers of the corneal

cornea. Bowman layer and the anterior stroma are also evident.

stroma, adjacent to Descemet membrane, become ver y com-

pact with a random arrangement similar to what is found in

25–27

Bowman layer. e brils interlace with the anterior zone

of Descemet membrane and add strength to the cornea. When

injecting air into the corneal tissue, as is done in lamellar kera-

toplasty, this area (8–15 μm) of posterior stroma separates and

21 26 27

stays attached to Descemet membrane.

Keratoc ytes (corneal broblasts) are attened cells that lie

28

between and occasionally within the lamellae (see Fig. 3.7).

e cells are not distributed randomly, their density is higher

24

in the anterior stroma. Keratocytes have extensive branching

processes joined by gap junctions along the lateral extensions,

29 30

as well as the anteroposterior branches. ese cells become

active when there is injur y to the corneal tissue. Other wise, they

maintain the stroma by slowly synthesizing collagen and extra-

cellular matrix components, including glycosaminoglycans and

matrix metalloproteinases. Other cells may be found between

lamellae, including white blood cells, lymphocytes, macro-

phages, and polymorphonuclear leukocytes, which can increase

in number in pathological conditions.

Ground substance lls the areas between brils, lamellae, and

Fig. 3.8 In recurrent corneal erosion, defective adhesion of

cells. It contains proteoglycans, macromolecules consisting of a

the epithelium and basement membrane complex to underly-

core protein with one or more attached glycosaminoglycan side

ing stroma exists. One treatment option involves passing a hy-

chain. ere are four main proteoglycans in the normal human

podermic needle through the epithelium and anterior stroma to

cornea. Decorin (molecules that contain chondroitin and derma-

create focal areas of scarring that help to cause “spot welds.
”

(From Krachmer JH, Palay DA. Cornea Color Atlas. St Louis: tan sulfate) is more abundant in the anterior stroma. e other

Mosby; 1995.) three proteoglycans, lumican, keratocan, and mimican, contain

Tear film

Epithelium

Bowman layer

Stroma

Descemet membrane

and endothelium

Fig. 3.9 Anterior segment optical coherence tomography demonstrating the layers of the cornea.
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 BRICK HORIZONS

Here the old map a woodland marks,

With rivers winding through the hills;
And prints remain of spacious parks,
And gabled farms and watermills.

But now we see no fields to reap,

No flowers to welcome sun and rain:
The hillside is a cinder heap,
The river is an inky drain.

The modern town of red brick streets,

Row beyond row, and shelf on shelf,
On one side spreads until it meets
A town as dreary as itself;
And on the other side its arms
Of road and tramway are out-thrust,
And mutilate the fields and farms,
And shame the woods with noise and dust.

Here, from the scenes we love remote,

Dwell half the toilers of the land,—
The soul we think of as a vote,
The heart we speak of as a hand.

Dull sons of a mechanic age

Who claim but miss the rights of man,—
They have no dreams beyond their cage,
They know not of the haunts of Pan.

Here, wandering through mills and mines

And dreary streets each like the last,
Enclosed by brick horizon lines,
I found an island of the past.
A few sad fields, a few old trees,
In that new world of grime and smoke
Told me the time was springtime; these
Alone remembered and awoke.

And in the grass were stars and bells,

The immemorial blossomings
That spring to greet us from the wells
Of Beauty at the heart of things.

A lark sang overhead, its note

Had the same joy with which it fills
The morning, when we hear it float
Through crystal air on thymy hills.

We mar the earth, our modern toil

Defaces old and lovely things;
We soil the stream, we cannot soil
The brightness of Life’s fountain springs.

Here where man’s last progressive aim

Has stamped the green earth with the brand
Of want and greed, and put to shame
Her beauty, and we see the land

With mine and factory and street

Deformed, and filled with dreary lives,—
Here, too, Life’s fountain springs are sweet:
Our venture fails, God’s hope survives.

And in the heart of every child

Born in this brick horizon ring
The flowers of wonderland grow wild,
The birds of El Dorado sing.
 FIRST PATHWAYS

Where were the pathways that your childhood knew?—

In mountain glens? or by the ocean strands?
Or where, beyond the ripening harvest land,
The distant hills were blue?

Where evening sunlight threw a golden haze

Over a mellow city’s walls and towers?
Or where the fields and lanes were bright with flowers,
In quiet woodland ways?

And whether here or there, or east or west,

That place you dwelt in first was holy ground;
Its shelter was the kindest you have found,
Its pathways were the best.

And even in the city’s smoke and mire

I doubt not that a golden light was shed
On those first paths, and that they also led
To lands of heart’s desire.

And where the children in dark alleys penned,

Heard the caged lark sing of the April hills,
Or where they dammed the muddy gutter rills,
Or made a dog their friend;
Or where they gathered, dancing hand in hand,
About the organ man, for them, too, lay
Beyond the dismal alley’s entrance way,
The gates of wonderland.

For ’tis my faith that Earth’s first words are sweet

To all her children,—never a rebuff;
And that we only saw, where ways were rough,
The flowers about our feet.
 HIDDEN PATHS

You see a house of weathered stone,

A pillared gate, a courtyard wide,
And ancient trees that almost hide
The garden wild and overgrown;
You see the sheltering screen of pines
Beyond the farmyard and the fold,
And upland cornfields waving gold
Against the blue horizon lines;
But we of every field and wall
And room are now so much a part,
We seem to touch a living heart
And rather feel than see it all.

You pass the broken arch that spanned

The garden walk,—you note the weeds,
But miss our secret path that leads
To hidden nooks of wonderland;
And, where the faded rooms you mark,
You know not of the ancient spell
That o’er them in the firelight fell
When all the world outside was dark.

Elsewhere is your enchanted ground,

Your secret path, your treasure store;
And those who sojourned here before
Saw marvels we have never found.
For Earth is full of hidden ways
More wondrous than the ways it shows,
And treasures that outnumber those
For which men labour all their days.
 THE PATHS OF THE INFINITE

Have we not marked Earth’s limits, followed its long ways round,
Charted our island world, and seen how the measureless deep
Sunders it, holds it remote, that still in our hearts we keep
A faith in a path that links our shores with a shore unfound?

No quest the venturer waits, no world have we to explore;

But still the voices that called us far over the lands and seas
Whisper of stranger countries and lonelier deeps than these,
In the wind on the hill, and the reeds on the lake, and the wave on the shore.

Never beyond our Earth shall the venturer find a guide:

From the golden light of the stars, but not from the stars, a clue
May fall to the Earth; and the rose of eve and the noonday blue
Veil with celestial beauty the fathomless deeps they hide.

They have their bounds those deeps, and the ways that end are long;
But the soul seeks not for an end,—its infinite paths are near;
Over its unknown seas by the light of a dream we steer,
Through its enchanted isles we sail on an ancient song.

Here, where a man and a maid in the dusk of the evening meet,
Here, where a grave is green and the larks are singing above,
The secret of life everlasting is held in a name that we love,
And the paths of the infinite gleam through the flowers that grow at our
feet.
 A DESERTED HOME

Here where the fields lie lonely and untended,

Once stood the old house grey among the trees,
Once to the hills rolled the waves of the cornland—
Long waves and golden, softer than the sea’s.

Long, long ago has the ploughshare rusted,

Long has the barn stood roofless and forlorn;
But oh! far away are some who still remember
The songs of the young girls binding up the corn.

Here where the windows shone across the darkness,

Here where the stars once watched above the fold,
Still watch the stars, but the sheepfold is empty;
Falls now the rain where the hearth glowed of old.

Here where the leagues of melancholy loughsedge

Moan in the wind round the grey forsaken shore,
Once waved the corn in the mid-month of autumn,
Once sped the dance when the corn was on the floor.
 BEYOND THE FARTHEST HORIZON

We have dreamed dreams beyond our comprehending,

Visions too beautiful to be untrue;
We have seen mysteries that yield no clue,
And sought our goals on ways that have no ending.
We, creatures of the earth,
The lowly born, the mortal, the foredoomed
To spend our fleeting moments on the spot
Wherein to-morrow we shall be entombed,
And hideously rot,—
We have seen loveliness that shall not pass;
We have beheld immortal destinies;
We have seen Heaven and Hell and joined their strife;
Ay, we whose flesh shall perish as the grass
Have flung the passion of the heart that dies
Into the hope of everlasting life.

Oh, miracle of human sight!

That leaps beyond our earthly prison bars
To wander in the pathways of the stars
Across the lone abysses of the night.
Oh, miracle of thought! that still outsweeps
Our vision, and beyond its range surveys
The vistas of interminable ways,
The chasms of unfathomable deeps,
Renewed forevermore, until at last
The endless and the ended alike seem
Impossible, and all becomes a dream;
And from their crazy watch-tower in the vast
Those wild-winged thoughts again to earth descend
To hide from the unfathomed and unknown,
And seek the shelter love has made our own
On homely paths that in a graveyard end.
Oh, miracles of sight and thought and dream!
Y d b t l d t f th t
You do but lead us to a farther gate,
A higher window in the prison wall
That bounds our mortal state:
However far you lift us we must fall.
But lo! remains the miracle supreme,—
That we, whom Death and Change have shown our fate,
We, the chance progeny of Earth and Time,
Should ask for more than Earth and Time create,
And, goalless and without the strength to climb,
Should dare to climb where we were born to grope;
That we the lowly could conceive the great,
Dream in our dust of destinies sublime,
And link our moments to immortal hope.

No lesson of the brain can teach the soul

That ’twas not born to share
A nobler purpose, a sublimer care
Than those which end in paths without a goal;
No disenchantment turn it from the quest
Of something unfulfilled and unpossessed
O’er which no waters of oblivion roll.
But not in flight of thought beyond the stars
Can we escape our mortal prison bars:
There the unfathomable depths remain
Blind alleys of the brain:
The sources of those sudden gleams of light
That merge our finite in the infinite,
We look for there in vain;
For not upon the pathways that are barred
But those left open,—not where the unknown quest
Dismays the soul, but where it offers rest,
Are set those lights that point us heavenward.

So, let us turn to the unfinished task

That earth demands, strive for one hour to keep
A watch with God, nor watching fall asleep,
Before immortal destinies we ask.
Before we seek to share
A larger purpose, a sublimer care,
Let us o’ercome the bondage of our fears,
And fit ourselves to bear
The burden of our few and sinful years.
Ere we would claim a right to comprehend
The meaning of the life that has no end
Let us be faithful to our passing hours,
And read their beauty, and that light pursue
Which gives the dawn its rose, the noon its blue,
And tells its secret to the wayside flowers.

Our eyes that roam the heavens are too dim,

Our faithless hearts too cumbered with our cares
To reach that light; but whoso sees and dares
To follow, we must also follow him.
Our heroes have beheld it and our seers,
Who in the darkest hours foretold the dawn.
It flashes on the sword for freedom drawn:
It makes a rainbow of a people’s tears.
The vast, the infinite, no more appal
Him who on homely ways has seen it fall:
He trusts the far, he dowers the unknown
With all the love that Earth has made our own,
And all the beauty that his dreams recall:
For him the loneliest deeps of night it cheers;
It gathers in its fold the countless spheres,
And makes a constant homelight for them all.
 A HALT ON THE WAY

A pause, a halt upon the way!

A time for dreaming and recalling;
We bore the burden of the day,
And now the autumn night is falling.

A halt in life! a little while

In which to be but a beholder,
And think not of the coming mile
And feel not, “I am growing older.”

A stern old man with wrinkled brow,

Urging us on with beckoning finger,
Time seems no longer—rather now
A sweetheart who would make us linger.

Old times are with us,—long ago;

Upon the wall familiar shadows;
We find again the haunts we know,
The pleasant pathways through the meadows.

And as we turn and look ahead,

Seeking beyond for things departed,
And dream of pathways we must tread
In days to come through lands uncharted,

Old faiths still light us on our way,

Old love and laughter, hope and sorrow,—
As evening of the Northern day
Becomes the morning of to-morrow.
 OLD LANDMARKS

The log flames, as they leap and fall,

Cast ancient shadows on the wall;
Again I hear the south-west blow
About the house, as long ago
We heard it, when we gathered round
The hearth made homelier by the sound
That in the chimney caverns keened
And told of things the darkness screened.
Dim in their panels round the room
The old unchanging faces loom;
And soft upon the crimson robe,
The hand that rests upon a globe,
The dusky frames, the faded tints,
The flicker of the hearth-light glints.
Out in the yard familiar tones
Of voices reach me; on the stones
A waggon rumbles, and a bark
Welcomes an inmate from the dark.
It might be twenty years ago,
So much of all we used to know
Remains unchanged; and yet I feel
Some want that makes it half unreal.
For we who long ago were part
Of all we knew, the very heart
Of all we loved, let somewhere slip
The bonds of that old comradeship.
The past awakes; but while I muse
Here in the same old scenes, I lose
The paths to which we once had clues.
Along familiar ways we went
All day, at every turn intent
To mark where Time had made a theft,
Or undisturbed our treasure left.
H ld d d h
Here an old tree was down, and there
A roof had fallen, a hearth was bare,
Where once we saw amid the smoke
The glowing turf, the kindly folk.
Here one we had watched beside the plough
Stride with his horses, hobbled now;
And here there strode a full-grown man
Where once a bare-legged urchin ran.
And where was now that girl whose feet
Once made yon mountain path so sweet?
Whose shyness flushed her cheek, the while
The mischief hidden in her smile
Belied it? I behold the spot
Where once she passed but now is not,
The grey rocks, where the mountain breeze
Fluttered the skirts about her knees.
We passed beside the wheelwright’s door
Where, as it used to be, the floor
Was piled with shavings, and a haze
Of dusty motes made dim the rays
Of sunlight, and the air was sweet
With smell of new-sawn wood and peat.
We heard the smithy anvil clink,
And saw the fire grow bright and sink
In answer to the bellows’ wheeze,
While, as of old, between his knees
The smith a horse’s fetlocks drew,
And rasped the hoof and nailed the shoe.
Here, and at every place of call,
The welcome that we had from all,
The pleasant sound of names outgrown
By which in boyhood we were known,
Quick springing to their lips, a look
That backward to old meetings took
Our thoughts, a word that brought to mind
Something for ever left behind,—
All, though they blessed us, touched the springs
Of tears at the deep heart of things.
O tea s at t e deep ea t o t gs.

We saw the mountains far away,

Beyond whose blue horizons lay
The wonderlands of which we dreamed
Of old; and still their barrier seemed
To tell us of the pilgrim quest,
And things remote and unpossessed,—
Not of that world which on our hearts
Had marked its bounds and graved its charts.
They told us of that unknown shore
That none can find; but where, before,
They called us o’er the world to roam,
They now seemed sheltering walls of home.
And those old paths whose ends we sought
Were dearer for themselves than ought
Their ends foretold: no truth could harm
Their beauty or undo their charm;
No disillusions of the far
Could touch their homeliness, or mar
The love that made them what they are.

Here we were children: here in turn

Our children in the same paths learn
The secrets of the woods and flowers,
And dream the dreams that once were ours.
Their vision keen renews our own,
Their certainties our doubts atone,
And, sharing in their joys, we weave
The years we find with those we leave.
A little weary, glad of rest
Ourselves, our hearts are in their quest.
Pilgrims of life, whose steps have slowed,
We love to linger on the road,
Or reach the welcome stage, while they
Are eager for the unknown way.
Some time to come their thoughts will turn
To these wild winter nights, and yearn
For something lost and left behind
For something lost and left behind,
As now I turn.—I hear the wind
Keen in the chimney as of old,
And darkness falls on field and fold;—
I catch the clue, on scenes that were
I look not backward,—I am there!
The men are gone, the gates are barred,
We steal across the empty yard,
The cattle drowse within their stalls,
The shelter of our homestead walls
Is round us, and the ways without
Are filled with mystery and doubt.
Over the hidden forest sweeps
The wind, and all its haunted deeps
Are calling, and we do not dare
Farther beyond our walls to fare
Than o’er one field, the sheds to gain
Where, sheltered from the wind and rain,
The watchful shepherd and his dogs
Still tarry, and a fire of logs,
A lantern’s light, a friendly bark,
Make us an outpost in the dark.
I miss the way! I drop the clues!
Through mists of years again I lose
My childhood, and alone I sit
And watch the shadows leap and flit
Above the hearth. The world that lies
Beyond our homely boundaries
I know, and in the darkness dwell
No hidden foes, no wizard spell.
But still the starry deeps are crossed
By lonelier paths than those we lost;
Still the old wonder and the fear
Of what we know not, makes more dear
The ways we know; and still, no less
Than in my childhood’s days, I bless
The shelter of their homeliness.

A id th b dl d k
Amid the boundless and unknown
Each calls some guarded spot his own;
A shelter from the vast we win
In homely hearths, and make therein
The glow of light, the sound of mirth,
That bind all children of the earth
In brotherhood; and when the rain
Beats loud upon the window-pane,
And shadows of the firelight fall
Across the floor and on the wall,
And all without is wild and lone
On lands and seas and worlds unknown,—
We know that countless hearthlights burn
In darkened places, and discern,
Inwoven with the troubled plan
Of worlds and ways unknown to man,
The shelter at the heart of life,
The refuge beyond doubt and strife,
The rest for every soul outcast,
The homely hidden in the vast;
And doubt not that whatever fate
May lie beyond us, soon or late,
However far afield we roam,
The unknown way will lead us home.

THE END

Printed by R. & R. Clark, Limited, Edinburgh.

By SIDNEY ROYSE LYSAGHT

Crown 8vo. 4s. 6d. net.
POEMS OF THE UNKNOWN WAY
 ATHENÆUM.—“The series of poems under the general heading, ‘The
Undiscovered Shore,’ contains some exquisite renderings of the moods and
impressions of one who goes down, literally as well as tropically, into the
great waters. They are full of melody, full of sadness—the harvest of an eye
quick to catch the beauty of external circumstance and of an ear open to the
calling of the highways of the seas and the highways of life.... Mr. Lysaght
puts an exceptional sense of rhythm at the service of sincere thinking and
fine feeling.”
DAILY CHRONICLE.—“Mr. Lysaght has an admirable style and an
almost Swinburnian command of metre.”
LITERARY WORLD.—“Here is stuff with the right ring; with an accent
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enjoyed our tour among Mr. Lysaght’s perplexities in no half-hearted
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MORNING POST.—“A most remarkable book, and no one on the look-
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interesting, and every individual is alive and appealing.”
ACADEMY.—“To find fault with Her Majesty’s Rebels is difficult, and to
praise it worthily is not easy; few Irish books of such good parts have come
into our hands since Carleton’s days.”
STANDARD.—“The story is tremendously absorbing and poignant.”
SPECTATOR.—“A very striking story.”
DAILY CHRONICLE.—“An able book, certainly one of the ablest of the
year.”
MACMILLAN AND CO., Ltd., LONDON.

By SIDNEY ROYSE LYSAGHT

Crown 8vo. 3s. 6d. each.
ONE OF THE GRENVILLES
 DAILY TELEGRAPH.—“Bound to be discussed by any one who reads it,
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want to urge on the writer a more frequent exercise of his powers.”
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