General Anatomy 2

THE ORBIT

TROCHLEAR FOVEA
ORBIT
→ attachment of a pulley
→ bilateral structures → superior oblique muscle passes
→ it contains the: → possible intrusion of part of the frontal sinus
✓ Eyeball
✓ Optic nerve LACRIMAL FOSSA
✓ Extra-ocular muscles → depression
✓ Lacrimal apparatus → for the orbital part of the lacrimal gland
✓ Adipose tissue
✓ Fascia
✓ Nerves and vessels

BONY ORBIT
→pyramid-shaped
→consists of 7 bones
✓ Maxilla
✓ Zygomatic
✓ Frontal
✓ Ethmoid
✓ Lacrimal
✓ Sphenoid
✓ Palatine bones

Apex
- optic foramen
Base
- orbital rim
ORBITAL RIM
Superiorly ✓ Frontal bone
Medially ✓ Frontal process of the MEDIAL WALLS
maxilla →consists of 4 bones
✓ Zygomatic process of the ✓ Maxilla
Inferiorly maxilla ✓ Lacrimal
✓ Zygomatic bone ✓ Ethmoid
✓ Zygomatic bone ✓ Sphenoid
✓ Frontal process of the
Laterally zygomatic bone ORBITAL PLATE OF THE ETHMOID BONE
✓ Zygomatic process of the → largest contributor
frontal bone → contains collection of ethmoidal cells

ROOF Ethmoidal cells

(SUPERIOR WALL) - clearly visible in a dried skull
→thin plate of bone
→separates the contents of the orbit from the ANTERIOR AND POSTERIOR ETHMOIDAL FORAMINA
brain in the anterior cranial fossa → visible at the junction between the roof and the
✓ Orbital part of the frontal bone medial wall
✓ Small contribution from the sphenoid bone → associated with the frontoethmoidal suture
→ where the anterior and posterior ethmoidal
UNIQUE FEATURES OF THE ROOF: nerves and vessels pass when they leave the orbit
Anteromedially Trochlear Fovea
Anterolaterally Lacrimal Fossa
Posteriorly Lesser wing of the sphenoid
 LACRIMAL GROOVE ORBITAL FRACTURE
→ contains the lacrimal sac →not uncommon
→formed by the small lacrimal bone, and the →may involve in the orbital margins with
frontal process of the maxilla extension into the maxilla, frontal, and zygomatic
→bounded by: bones
✓ Posterior lacrimal crest →often part of the complex facial fractures
- Part of the lacrimal bone →frequently occur within the floor and the medial
✓ Anterior lacrimal crest wall
- Part of the maxilla
INFERIOR ORBITAL FLOOR FRACTURE
SMALL LACRIMAL BONE →commonest types of injuries
→anterior to the ethmoid bone →may drag the inferior oblique muscle and
associated tissues into the fracture line
FRONTAL PROCESS OF THE MAXILLA ✓ Upward gaze failure in the affected eye
→anterior part of the medial wall
MEDIAL WALL FRACTURE
SMALL PART OF THE SPHENOID BONE →air within the orbit
→posterior to the ethmoid bone →due to the fracture of the ethmoidal labyrinth
→completes the medial wall ✓ Patients may feel full sensation within the orbit
when blowing the nose
FLOOR
(INFERIOR WALL) EYELIDS
→roof of the maxillary sinus →anterior structure
✓ Orbital surface of the maxilla →protects the surface of the eyeball when closed
✓ Small contributions from the zygomatic and Layers of the eyelids:
palatine bones ✓ Skin
✓ Subcutaneous tissue
INFERIOR ORBITAL FISSURE ✓ Voluntary muscle
→posterior ✓ Orbital septum
→continuing along the lateral boundary of the ✓ Tarsus
floor of the bony orbit ✓ Conjunctiva

ZYGOMATIC BONE ❖ The upper and lower eyelids have similar

→beyond the anterior end of the fissure structures
→completes the floor of the bony orbit ❖ There is an addition of 2 muscles in the upper
eyelid
ORBITAL PROCESS OF THE PALATINE BONE
→makes a small contribution to the floor of the Palpebral fissure
bony orbit - space between the eyelids
→near the junction of the maxilla, ethmoid, and
sphenoid bones

LATERAL WALL
IT CONSISTS OF:
Anteriorly ✓ Zygomatic bone
Posteriorly ✓ Greater wing of the
sphenoid bone

SUPERIOR ORBITAL FISSURE

→between the greater wing of the sphenoid and
the lesser wing of the sphenoid
→forms part of the roof

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 SKIN AND SUBSUTANEOUS TISSUE
→the skin is not particularly substantial
→a thin layer of connective tissue separates the
skin from the underlying voluntary muscle layer

The thin layer of connective tissue and its loose

arrangement account for the accumulation of
fluid (blood) when an injury occurs

ORBICULARIS OCULI
ORBITAL PART
→surrounds the orbit

PALPEBRAL PART
→muscle fibers encountered in an anteroposterior
direction through the eyelid
→in the eyelids
TARSUS AND LEVATOR PALPEBRAE SUPERIORIS
→thin
TARSUS
o Facial nerve
→provides major support for each eyelid
Medial Palpebral Ligament
→plates of dense connective tissue
- Anchors the palpebral part medially
Lateral Palpebral Ligament
Medial palpebral ligament
- Laterally blends the palpebral part with fibers
- Attaches the tarsus medially to the anterior
from the muscle in the lower eyelid
lacrimal crest of the maxilla
LACRIMAL PART
Lateral palpebral ligament
→consists of fibers on the medial border - Attaches the tarsus laterally to the orbital
→may be involved in the drainage of tears
tubercle on the zygomatic bone

SUPERIOR TARSUS
→large
→in the upper eyelid

INFERIOR TARSUS
→smaller
→in the lower eyelid

ORBITAL SEPTUM
→deep to the palpebral part of the orbicularis
oculi
→extension of periosteum
→extends downward into the upper eyelid
→continuous with the periosteum
→attaches to the tendon of levator palpebrae
muscle in the upper eyelid
→attaches to the tarsus in the lower eyelid

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 LEVATOR PALPEBRAE SUPERIORIS MUSCLE VESSELS
→in the upper eyelid ✓ Supratrochlear
→raises the eyelid ✓ Supra-orbital
→posterior part of the roof of the orbit ✓ Lacrimal
o Oculomotor nerve (III) ✓ Dorsal
✓ Nasal arteries from the ophthalmic artery
SUPERIOR TARSAL MUSCLE ✓ Angular artery from the facial artery
→collection of smooth muscle fibers ✓ Transverse facial artery from the superficial
o Postganglionic sympathetic fibers temporal artery
from the superior cervical ganglion ✓ Branches from the superficial temporal artery

Loss of function of either the levator palpebrae External pattern

superioris muscle or the superior tarsal muscle - Through veins associated with the various
results in ptosis or dropping of the upper eyelid arteries
Internal pattern
CONJUNCTIVA - Moving into orbit through connections with the
→thin membrane that completes the structure of ophthalmic veins
the eyelid PAROTID NODES
→covers the posterior surface of each eyelid →primary lymphatic drainage
→covers the full extent of the posterior surface of
each eyelid SUBMANDIBULAR NODES
→attaches to the eyeball at the junction between →medial corner of the eye along lymphatic vessels
the sclera and the cornea associated with angular and facial arteries

SCLERA
→outer surface of the eyeball

CONJUNCTIVAL SAC
→formed when the eyelids are closed

Superior and Inferior conjunctival fornices

- Upper and lower extensions of the conjunctival
sac

GLANDS
TARSAL GLANDS
→embedded in the tarsal plates
→empty onto the free margin of each eyelid INNERVATION
→modified sebaceous glands ✓ Sensory
→secrete an oily substance ✓ Motor
→increases the viscosity of the tears SENSORY
→decreases the rate of evaporation of tears from o Trigeminal nerve
the surface of the eyeball Palpebral branches arise from:
✓ Supra-orbital
CHALAZION ✓ Supratrochlear
→blockage and inflammation of a tarsal gland ✓ Infratrochlear
→on the inner surface of the eyelid ✓ Lacrimal branches of the ophthalmic nerve
(V1)
SEBACEOUS AND SWEAT GLANDS ✓ Infra-orbital branch of the maxillary nerve (V2)
→associated with the eyelash follicles MOTOR
Facial nerve (VII) Palpebral part of the
STYE orbicularis oculi
→blockage and inflammation of either the Oculomotor nerve (III) Levator palpebrae
superioris
sebaceous or sweat glands
Sympathetic fibers Superior tarsal muscle
→on the edge of the eyelid

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 Orbitalis muscle
- Helps maintain the forward position of orbital
contents

SURGICALLY INDUCED HORNER’S SYNDROME

→necessary for patients who suffer sever
hyperhidrosis (sweating)
→small incision is made in the intercostal space
on the appropriate side
→surgically induced pneumothorax is created

LACRIMAL APPARATUS
→production
→movement
→drainage of fluid from the surface of the eyeball

Made up of:
Loss of innervation of the orbicularis oculi by ✓ Lacrimal gland and its ducts
the facial nerve causes an inability to close the ✓ Lacrimal canaliculi
eyelids tightly and the lower eyelid droops away, ✓ Lacrimal sac
resulting in a spillage of tears ✓ Nasolacrimal ducts

Loss of innervation of the levator palpebrae

superioris muscle by the oculomotor nerve
causes an inability to open the superior eyelid
voluntarily, producing a complete ptosis

Loss of innervation of the superior tarsal

muscle by sympathetic fibers causes a constant
partial ptosis

HORNER’S SYNDROME
→caused by any lesion
→loss of sympathetic function in the head
→commonest cause is a tumor eroding the LACRIMAL GLAND
cervicothoracic ganglion, which is an apical lung - Anterior in the superolateral region of the orbit
tumor - Divided into two parts by the levator
TYPICAL FEATURES: palpebrae superioris
1 Pupillary constriction due to paralysis of
the dilator pupillae muscle ORBITAL PART
Partial ptosis (drooping of the upper →larger
2 eyelid) due to the paralysis of the →in a depression (lacrimal fossa)
superior tarsal muscle
Absence of sweating on the ipsilateral PALPEBRAL PART
3 side of the face and neck due to →smaller
absence of innervation of the sweat →inferior to the levator palpebrae superioris
glands
Superior fornix of the conjunctiva
SECONDARY CHANGES - Numerous ducts empty the glandular
1 Ipsilateral vasodilation due to loss of secretions into the lateral part
the normal sympathetic control of the
subcutaneous blood vessels
2 Enophthalmos (sinking of the eye)-
believed to result from paralysis of the
orbitalis muscle, this is an uncommon
feature of Horner’s syndrome

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 SENSORY INNERVATION
→sensory neurons from the lacrimal gland return
to the CNS through the lacrimal branch of the
ophthalmic nerve (V1)

SECRETOMOTOR (PARASYMPATHETIC INNERVATION)

→secretomotor fibers from the parasympathetic
part of the autonomic division of the PNS stimulate
fluid secretion from the lacrimal gland
→leave the CNS in the facial nerve (VII)
→enter the greater petrosal nerve
→it becomes the nerve of the pterygoid canal

Nerve of the pterygoid canal

→eventually joins the pterygopalatine ganglion
LACRIMAL LAKE →preganglionic sympathetic neurons synapse on
→where fluid accumulates medially postganglionic parasympathetic neurons

LACRIMAL CANALICULI Postganglionic neurons

→where fluid is drained from the lake →join the maxillary nerve (V2)
→continues until the zygomatic nerve branches
✓ Contraction of orbicularis oculi during →gives off the zygomaticotemporal nerve
blinking, the small lacrimal part of the muscle
may dilate the lacrimal sac and draw tears Zygomaticotemporal nerve
into it through the canaliculi from the →distributes postganglionic parasympathetic
conjunctival sac fibers in a small branch that joins the lacrimal
nerve

SYMPATHETIC INNERVATION
→follows a similar path as the parasympathetic
innervation
LACRIMAL PUNCTUM
→opening Postganglionic sympathetic fibers
→where fluid enters each canaliculus →from the superior cervical ganglion
→travel along the plexus surrounding the internal
INNERVATION carotid artery
→involves three different components →leaves the plexus as the deep petrosal nerve
✓ Sensory innervation →joins the parasympathetic fibers in the nerve of
✓ Secretomotor (parasympathetic) innervation the pterygoid canal
✓ Sympathetic innervation →as it passes the pterygopalatine canal, it follows
the path of the parasympathetic fibers to the
lacrimal gland

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 INFERIOR ORBITAL FISSURE
→separates the lateral wall of the orbit from the
floor of the orbit
→longitudinal opening

Borders of the fissure:

✓ Greater wing of the sphenoid
✓ Maxilla
✓ Palatine
✓ Zygomatic bones

VESSELS
ARTERIAL SUPPLY
→branches from the ophthalmic artery

VENOUS DRAINAGE
→ophthalmic veins

FISSURES AND FORAMINA

OPTIC CANAL
→round opening at the apex of the pyramidal-
shaped orbit
→seen when the orbit is viewed from an
anterolateral position IT ALLOWS COMMUNICATION BETWEEN:
→opens into the middle cranial fossa Posteriorly ✓ Orbit
✓ Pterygopalatine fossa
BOUNDARIES Middle ✓ Orbit
Medially Body of the sphenoid ✓ Infratemporal fossa
Laterally Lesser wing of the sphenoid Posterolaterally ✓ Orbit
✓ Temporal fossa
Nerves that pass through:
o Optic nerve Nerves that pass through:
o Ophthalmic artery o Maxillary nerve (V2) and its
Zygomatic branch
o Infra-orbital vessels
SUPERIOR ORBITAL FISSURE
o Vein communicating with the
→lateral to the optic canal
pterygoid plexus of veins
→between the roof and lateral wall of the bony
orbit
→triangular-shaped gap
→allows structures to pass between the orbit and
the middle cranial fossa

Nerves that pass through:

o Superior and Inferior branches of the
oculomotor nerve (III)
o Trochlear nerve (IV)
o Abducent nerve (VI)
o Lacrimal
o Frontal
o Nasociliary branches of the
ophthalmic nerve (V1)
o Superior ophthalmic vein

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 INFRA-ORBITAL FORAMEN
→begins posteriorly
→crossing about two-thirds of the inferior orbital
fissure
→connects with the infra-orbital canal
→opens onto the face at the infra-orbital
foramen

Nerves that pass through:

o Infra-orbital nerve
o Part of the maxillary nerve (V2) FASCIAL SHEATH OF THE EYEBALL
o Vessels →bulbar sheath
OTHER OPENINGS →layer of fascia
ANTERIOR AND POSTERIOR ETHMOIDAL FORAMINA →encloses a major part of the eyeball
→junction between the superior and medial walls
→provide exits from the orbit into the ethmoid Posteriorly:
bone for the: • Firmly attached to the sclera
o Anterior and posterior ethmoidal • Around the point of entrance of the optic
nerves and vessels nerve into the eyeball
DEPRESSION FOR THE LACRIMAL SAC SCLERA
→clearly visible →white part of the eyeball
→formed by the lacrimal bone and the frontal
process of the maxilla Anteriorly:
→continuous with the nasolacrimal canal • Firmly attached to the sclera near the edge of
→leads into the inferior acoustic meatus the cornea
→contains the nasolacrimal duct CORNEA
NASOLACRIMAL DUCT →clear part of the eyeball
→part of the lacrimal apparatus
Additionally:
FASCIAL SPECIALIZATIONS ✓ The investing fascia surrounding each muscle
PREORBITA blends with the fascial sheath of the eyeball as
→periosteum lining of the bones the muscle pass through and continue to their
point of attachment
→forms the orbit
SUSPENSORY LIGAMENT
→continuous at the margins of the orbit with the
periosteum →sling-like structure
→sends extensions into the upper and lower →specialized lower part of the fascial sheath of
eyelids (orbital septa) the eyeball
→continuous with the periosteal layer of dura →supports the eyeball
mater
→point of origin of the four rectus muscles It is made up of:
→the common tendinous ring • Fascial sheath of the eyeball
• Two inferior ocular muscles
In the posterior part of the orbit: • Medial and lateral ocular muscles
→it thickens around the optic canal and the
central part of the superior orbital fissure

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 CHECK LIGAMENTS OF THE MEDIAL AND MUSCLES
LATERAL RECTUS MUSCLES • Extrinsic muscles
CHECK LIGAMENTS • Intrinsic muscles
→other fascial specialization in the orbit
→expansions of the investing fascia covering the EXTRINSIC MUSCLES
medial and lateral rectus muscles
(EXTRA-OCULAR MUSCLES)
→attach to the medial and lateral walls of the
→involved in movements of the eyeball
bony orbit
→raising upper eyelids

• Levator palpebrae superioris

• Superior rectus
• Inferior rectus
• Medial rectus
• Lateral rectus
• Superior oblique
• Inferior oblique

MOVEMENTS OF THE EYEBALL:

Elevation Superiorly
MEDIAL CHECK LIGAMENT Depression Inferiorly
→extension from the fascia covering the medial Abduction Laterally
rectus muscle Adduction Medially
→attaches immediately posterior to the posterior Internal Upper part of the pupil
lacrimal crest of the lacrimal bone Rotation medially (toward the nose)
External Upper part of the pupil
LATERAL CHECK LIGAMENT Rotation laterally (toward the temple)
→extension from the fascia covering the lateral
rectus muscle
→attached to the orbital tubercle of the zygomatic
bone

• Their positions restrict the medial and lateral

rectus muscles

Axis of each orbit

→directed slightly laterally from back to front
→pull of some muscles has multiple effects on the
movement of the eyeball

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 LEVATOR PALPEBRAE SUPERIORIS SUPERIOR RECTUS
→raises the upper eyelid →elevates, adducts, and medially rotates the
→most superior muscle in the orbit eyeball
→collection of smooth muscle fibers passes from
its inferior surface to the upper edge of the - Superior part of the
superior tarsus ORIGIN common tendinous ring
above the optic canal
ORIGIN - Lesser wing of the sphenoid INSERTION - Anterior half of eyeball
anterior to optic canal superiorly
- Anterior surface of tarsal
INSERTION plate o Superior branch of the oculomotor
- (Few fibers) to skin and nerve (III)
superior conjunctival fornix
o Superior branch of the oculomotor Moving the finger downward tests the superior
nerve (III) rectus muscle
Loss of oculomotor nerve (III) function results in
INFERIOR RECTUS
complete ptosis or drooping of the superior
eyelid →originates from the inferior part of the common
tendinous ring below the optic canal
→depression, adduction, and laterally rotates the
SUPERIOR TARSAL MUSCLE
eyeball
→group of smooth muscle fibers
→help maintain eyelid elevation
- Inferior part of the common
o Postganglionic sympathetic fibers
ORIGIN tendinous ring below the
from the superior cervical region
optic canal
Loss of sympathetic innervation to the superior INSERTION - Anterior half of eyeball
tarsal muscle results in partial ptosis inferiorly

RECTUS MUSCLES Moving the finger upward tests the inferior

→four muscles rectus muscle
→occupy medial, lateral, inferior, and superior
positions o Inferior branch of the oculomotor
→originate as a group from a common tendinous nerve (III)
ring at the apex of the orbit
→form a cone of muscles as they pass forward to • These muscles are directed laterally as they
their attachment on the eyeball pass forward in the orbit to attach to the
anterior half of the eyeball

SUPERIOR AND INFERIOR RECTUS MUSCLES

→have complicated actions
→its origin is medial to the central axis of the
eyeball when looking directly forward

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 MEDIAL AND LATERAL RECTUS MUSCLES OBLIQUE MUSCLES
→orientation and actions are more →in the superior and inferior parts of the orbit
straightforward →they do not originate from the common
→pass forward and attach to the anterior half of tendinous ring
the eyeball →angular
→attach to the posterior half of the eyeball
MEDIAL RECTUS
→adduction of eyeball SUPERIOR OBLIQUE
→directs the pupil down and out
- Medial part of the common →depression, abduction, internal rotation of
ORIGIN tendinous ring below the eyeball
optic canal
INSERTION - Anterior half of eyeball - Body of sphenoid
medially ORIGIN - Superior and medial to optic
canal
o Inferior branch of the oculomotor INSERTION - Outer posterior quadrant of
nerve (III) eyeball (superior surface)

LATERAL RECTUS o Trochlear nerve (IV)

→abduction of eyeball Tracking the finger medially to bring the axis of
the tendon of the muscle into alignment, then
- Lateral part of the common looking down tests the superior oblique muscles
ORIGIN tendinous ring below the
optic canal Trochlea
INSERTION - Anterior half of eyeball - fibrocartilaginous pulley
laterally - attached to the trochlear fovea of the frontal
bone
o Abducent nerve (VI) INFERIOR OBLIQUE

Moving the finger medially and laterally tests →only extrinsic muscle that does not take origin
the medial and lateral rectus muscles from the posterior part of the orbit
→elevation, abduction, external rotation of eyeball

- Medial floor of orbit

ORIGIN posterior to rim
- Maxilla lateral to
nasolacrimal groove
INSERTION - Outer posterior quadrant of
eyeball (inferior surface)

o Inferior branch of the Oculomotor

nerve (III)
Tracking the finger medially to bring the axis of
the tendon of the muscle into alignment, then
looking up tests the inferior oblique muscles

EXTRINSIC MUSCLES AND EYEBALL

MOVEMENTS
→ 6 of the extrinsic muscles are directly involved
in movements of the eyeball

✓ Medial rectus
✓ Lateral rectus
✓ Inferior rectus
✓ Superior rectus
✓ Superior oblique
✓ Inferior oblique

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→these muscles do not act in isolation LOSS OF INNERVATION OF THE MUSCLES
→they work as teams of muscles in the AROUND THE EYE
coordinated movement of the eyeball
LOSS OF INNERVATION OF THE ORBICULARIS OCULI BY
INTRINSIC MUSCLES THE FACIAL NERVE (VII)
→within the eyeball →causes inability to close the eyelids tightly
→control shape of the lens and size of the pupil →drooping of the lower eyelid
→spillage of tears
• Ciliary muscle
• Sphincter pupillae • Loss of tears allows drying of conjunctiva
• Dilator pupillae • May ulcerate, allowing secondary infection

EXAMINATION OF THE EYE

→assessment of the visual capabilities LOSS OF INNERVATION OF THE LEVATOR PALPEBRAE
SUPERIORIS BY OCULOMOTOR NERVE (III)
• Tests for visual acuity →inability of the superior eyelid to elevate
• Astigmatism →complete ptosis
• Visual fields →usually caused by severe head injury
• Color interpretation
LOSS OF INNERVATION OF THE SUPERIOR TARSAL
It includes assessment of: MUSCLE BY SYMPATHETIC FIBERS
• Retina →causes constant partial ptosis
• Optic nerve and its coverings →may be caused by any lesion along the
• Lens sympathetic trunk
• Cornea
• Apical pulmonary malignancy should always
→the extrinsic muscles work synergistically to be suspected
provide appropriate and conjugate eye • The ptosis may be part of Horner’s syndrome
movement:
H-TEST
Lateral rectus “LR6SO4 and all the rest are 3“
o Abducent nerve (VI) • Lateral rectus (VI)
Superior oblique • Superior oblique (IV)
o Trochlear nerve (IV) • All the rest including levator palpebrae
Remainder superioris are (III)
o Oculomotor nerve (III)
→”H” pattern
DIABETES MELLITUS →starting from the midline between the two eyes
→typically affects the eye

It may cause:
• Cataracts
• Macular diseases
• Retinal hemorrhage
• Impairing vision

BRAINSTEM INJURY OR DIRECT NERVE INJURY

→causes unilateral paralysis of the extra-ocular
muscles
→may be associated with tumor compression or
trauma

PARALYSIS OF A MUSCLE
→double vision (diplopia)

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 VESSELS ANTERIOR ETHMOIDAL ARTERY
ARTERIES →supplies the septum and lateral wall
• Ophthalmic artery →exits the orbit through the anterior ethmoidal
- Branch of the internal carotid artery foramen
- Passes the orbit through the optic canal →enters the cranial cavity giving off the anterior
- Lies inferior and lateral to the optic nerve meningeal branch
→ends as the dorsal nasal artery
LACRIMAL ARTERY
→From the ophthalmic artery on the lateral side of MEDIAL PALPEBRAL ARTERIES
the optic nerve →supplies the medial area of the upper and lower
eyelids
It supplies the: →small branches
✓ Lacrimal gland
✓ Muscles DORSAL NASAL ARTERY
✓ Anterior ciliary branch to the eyeball
→supplies the upper surface of the nose
✓ Lateral sides of the eyelid
→first terminal branch of the ophthalmic artery
CENTRAL RETINAL ARTERY
SUPRATROCHLEAR ARTERY
→enters the optic nerve
→clearly seen when viewing the retina with an →supplies the forehead
ophthalmoscope →another terminal branch of the ophthalmic
artery
• Occlusion of this vessel or of the parent artery
leads to blindness

LONG AND SHORT POSTERIOR CILIARY ARTERIES

→branches that enter the eyeball posteriorly
→pierces the sclera
→supplies structures inside the eyeball:

• Muscular arteries
• Supra-orbital artery
• Posterior ethmoidal artery
• Anterior ethmoidal artery
• Medial palpebral arteries
• Dorsal nasal artery
• Supratrochlear artery

MUSCULAR ARTERIES
→supplies the intrinsic muscles of the eyeball
VEINS
SUPRA-ORBITAL ARTERY
• Superior ophthalmic vein
→supplies the forehead and scalp • Inferior ophthalmic vein
→arises from the ophthalmic artery
→exits the orbit through the supra-orbital SUPERIOR OPHTHALMIC VEIN
foramen →in the anterior area of the orbit
→begins as connecting veins from the supra-
POSTERIOR ETHMOIDAL ARTERY orbital vein and the angular vein
→supplies the ethmoidal cells and nasal cavity →receives tributaries from the companion veins to
→exits the orbit through the posterior ethmoidal the branches of the ophthalmic artery and veins
foramen →drains the posterior part of the eyeball
→leaves the orbit through the superior orbital
fissure

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 INFERIOR OPHTHALMIC VEIN OCULOMOTOR NERVE
→smaller →leaves the anterior surface of the brainstem
→passes across the inferior part of the orbit between the midbrain and the pons
→receives various tributaries: →passes forward in the lateral wall of the
✓ From the muscles cavernous sinus
✓ Posterior part of the eyeball →divides into:
• Superior branch
Leaves the orbit posteriorly by: • Inferior branch
• Joining with the superior ophthalmic vein →these branches leave the orbit through the
• Pass through the superior orbital fissure and superior orbital fissure
joins the cavernous sinus
• Pass through the inferior orbital fissure and Innervates the:
joins the pterygoid plexus of veins in the ✓ Superior rectus
infratemporal fossa ✓ Levator palpebrae superioris muscles
Because the ophthalmic veins communicate
with the cavernous sinus, they act as a route by
which infections can spread from outside to
inside the cranial cavity

3 BRANCHES OF THE LARGE INFERIOR BRANCH:

- One passing below the optic nerve
- Passes to the medial side of the orbit to
innervate the medial rectus muscle
- Descending
- Innervate the inferior rectus muscle
- Runs forward along the floor of the orbit
- Innervate the inferior oblique muscle
INNERVATION
• Optic nerve (II) THIRD BRANCH
• Oculomotor nerve (III) →gives off the branch to the ciliary ganglion
• Trochlear nerve (IV) →parasympathetic root to the ciliary ganglion
• Abducent nerve (VI) →carries preganglionic parasympathetic fibers
• Autonomic nerves
• Ophthalmic nerve SHORT CILIARY NERVES
→distributes the postganglionic parasympathetic
OPTIC NERVE fibers to the eyeball
→not a true cranial nerve
→extension of the brain Innervates the:
→carry afferent fibers from the retina of the ✓ Sphincter pupillae
eyeball to the visual centers of the brain ✓ Ciliary muscles
→surrounded by cranial meninges
→leaves the optic canal with the ophthalmic
artery
Increase intracranial pressure results in
increased pressure in the subarachnoid space
surrounding the optic nerve. This may impede
venous return along the retinal veins, causing
edema of the optic disc (papilledema).

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 TROCHLEAR NERVE OPHTHALMIC NERVE (V1)
→arises from the posterior surface of the midbrain →smallest
→passes around the midbrain to enter the edge of →most superior of the three divisions of the
the tentorium cerebelli trigeminal nerve
→continues on an intradural path →purely sensory nerve
→enters the orbit through the superior orbital →receives input from structures in the orbit and
fissure above the common tendinous ring from additional branches on the face and scalp
→crosses above the levator palpebrae superioris →it divides into three branches before it enters the
muscle orbit:
✓ Nasociliary
ABDUCENT NERVE ✓ Lacrimal
→arises from the brainstem between the pons ✓ Frontal nerves
and medulla
→enters the dura covering the clivus • Enter the superior orbital fissure with the
→continues in a dural canal until it reaches the frontal and lacrimal nerves outside the
cavernous sinus common tendinous ring and the nasociliary
→enters the orbit through the superior orbital nerve within the common tendinous ring
fissure within the common tendinous ring
→supplies the lateral rectus muscle

PREGANGLIONIC SYMPATHETIC FIBERS

→arise from the upper segments of the thoracic
spinal cord (T1)
→enter the sympathetic chain through the white
rami communicantes
→ascend to the superior cervical ganglion

SUPERIOR CERVICAL GANGLION

→where they synapse with postganglionic
sympathetic fibers

POSTGANGLIONIC FIBERS
→distributed along the internal carotid artery and
its branches
→destined for the orbit
→travels with the ophthalmic artery LACRIMAL NERVE
→innervates the dilator pupillae muscle →smallest of the three branches of the
ophthalmic nerve
Fibers are distributed to the eyeball by: →receives a branch from the zygomaticotemporal
• Passing through the ciliary ganglion and nerve, which carries parasympathetic and
joining the short ciliary nerves sympathetic postganglionic fibers
• Passing through long ciliary nerves to reach
the eyeball It supplies the:
✓ Lacrimal gland
✓ Conjunctiva
✓ Lateral part of the upper eyelid

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 FRONTAL NERVE NASOCILIARY NERVE
→largest branch →intermediate in size
→receives sensory input from areas outside the →between the frontal and lacrimal nerves
orbit →first branch from the ophthalmic nerve
→exits the superior orbital fissure →most deeply placed in the orbit
→passes forward between the levator palpebrae →passes in a medial direction below the superior
superioris and the preorbita rectus muscle
→continues forward along the medial wall of the
It divides into 2 terminal branches: orbit, between the superior oblique and medial
• Supra-orbital rectus muscles
• Supratrochlear nerves →gives off several branches:
• Long ciliary nerves
SUPRATROCHLEAR NERVE • Posterior ethmoidal nerve
→continues forward in an anteromedial direction • Infratrochlear nerve
→exits the orbit medial to the supra-orbital • Anterior ethmoidal nerve
foramen
Communicating branch with the ciliary ganglion
It supplies the: (sensory root to the ciliary ganglion)
✓ Conjunctiva - First branch
✓ Skin of the upper eyelid
LONG CILIARY NERVES
✓ Skin on the lower medial part of the forehead
→sensory to the eyeball
SUPRA-ORBITAL NERVE →may also contain sympathetic fibers for
→larger pupillary dilation
→passes between the levator palpebrae superioris
muscle and the preorbita POSTERIOR ETHMOIDAL NERVE
→covers the roof of the orbit →exits the orbit through the posterior ethmoidal
Exits the orbit through the supra-orbital notch foramen

It supplies the: Supplies the:

✓ Upper eyelid ✓ Posterior ethmoidal cells
✓ Conjunctiva ✓ Sphenoidal sinus
✓ Forehead
✓ Middle of the scalp INFRATROCHLEAR NERVE
Distributes to the:
• Medial part of the upper and lower eyelids
• Lacrimal sac
• Skin of the upper half of the nose

ANTERIOR ETHMOIDAL NERVE

→exits the orbit through the anterior ethmoidal
foramen

Supplies the:
✓ Anterior cranial fossa
✓ Nasal cavity
✓ Skin of the lower half of the nose

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 It innervates:
✓ Sphincter pupillae
✓ Ciliary muscle

SPHINCTER PUPILLAE MUSCLE

→responsible for pupillary constriction

CILIARY MUSCLE
→accommodation of the lens of the eye for near
vision

SENSORY ROOT
→second branch
→passes from the nasociliary nerve to the
ganglion
→enters the posterosuperior aspect of the
ganglion
→carries sensory fibers
→these fibers are responsible for sensory
innervation to all parts of the eyeball
CILIARY GANGLION
SYMPATHETIC ROOT
→parasympathetic ganglion of the oculomotor
nerve (III) →third branch
→associated with the nasociliary branch of the →most variable
ophthalmic nerve (V1) →contains postganglionic sympathetic fibers from
→site where preganglionic and postganglionic the superior cervical ganglion
parasympathetic neurons synapse as fibers →enter the orbit through the common tendinous
→traversed by postganglionic sympathetic fibers ring
and sensory fibers →they enter the posterior aspect of the ciliary
→very small ganglion ganglion, cross the ganglion, and continue along
→in the posterior part of the orbit, lateral to the the short ciliary nerves
optic nerve
→between the optic nerve and the lateral rectus Postganglionic sympathetic fibers innervate:
muscle • Dilator pupillae muscle
→receives atleast two (or three) branches or roots
from other nerves in the orbit EYEBALL
→globe-shaped
→occupies the anterior part of the orbit
→bulges outward

ANTERIOR CHAMBER
→area directly posterior to the cornea
→anterior to the iris

✓ Iris
✓ Pupil

IRIS
→colored part of the eye
PARASYMPATHETIC ROOT
→carries preganglionic sympathetic fibers PUPIL
→enters the ganglion and synapse with →central opening in the iris
postganglionic parasympathetic fibers within the
ganglion
→leave the ganglion through the short ciliary
nerves

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 POSTERIOR CHAMBER POSTREMAL (VETROUS) CHAMBER
→anterior to the lens →occupies the posterior four-fifths of the eyeball
✓ Lens from the lens to the retina
✓ Postremal (vitreous) chamber →it is filled by the vitreous body
✓ Retina
VITREOUS BODY
• The anterior and posterior chambers are →transparent
continuous with each other through the →gelatinous substance
pupillary opening →it cannot be replaced
• They are filled with aqueous humor
WALLS OF THE EYEBALL
AQUEOUS HUMOR →surround the internal components of the eyeball
→fluid
→secreted into the posterior chamber It consists of three layers:
→flows into the anterior chamber through the • Outer fibrous layer
pupil • Middle vascular layer
→supplies nutrients to the avascular cornea and • Inner retinal layer
lens
→maintains the intra-ocular pressure OUTER FIBROUS LAYER
If the normal cycle of its production and • consists of the sclera, posteriorly
absorption is disturbed, the amount of fluid • consists of the cornea, anteriorly
increases and intra-ocular pressure will
increase. It can lead to variety of visual MIDDLE VASCULAR LAYER
problems (glaucoma) • choroid, posteriorly
• continuous with the ciliary body and iris,
SCLERAL VENOUS SINUS anteriorly
(canal of Schlemm)
→where the aqueous humor is absorbed INNER RETINAL LAYER
→circular venous channel • optic part of the retina, posteriorly
→at the junction between the cornea and the iris • nonvisual retina, anteriorly

NONVISUAL RETINA
→covers the internal surface of the ciliary body
and iris

VESSELS
ARTERIAL SUPPLY
• Short posterior ciliary arteries
• Long posterior ciliary arteries
• Anterior ciliary arteries
• Central retinal artery

SHORT POSTERIOR CILIARY ARTERIES

LENS AND VITREOUS HUMOR →branches from the ophthalmic artery
LENS
→pierce the sclera around the optic nerve and
→separates the anterior one-fifth of the eyeball enter the choroid layer
from the posterior four-fifths
→transparent LONG POSTERIOR CILIARY ARTERIES
→biconvex elastic disc
→attached to muscles associated with the outer →enter the sclera on the medial and lateral sides
wall of the eyeball of the optic nerve
→its attachment provides its ability to change its →proceed anteriorly in the choroid layer
refractive ability to maintain visual acuity →anastomose with the anterior ciliary arteries

The clinical term for opacity of the lens is a

cataract

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ANTERIOR CILIARY ARTERIES
→branches of the arteries supplying the muscles
→anastomose with the long posterior ciliary
arteries in the choroid layer

CENTRAL RETINAL LAYER

→traversed the optic nerve
→enters the area of the retina at the optic discs

VENOUS DRAINAGE
→related to the drainage of the choroid layer
→four large veins (vorticose veins) are involved in
this process
→exit through the sclera from each of the
posterior quadrants of the eyeball SCLERA
→enter the superior and inferior ophthalmic veins →covers the posterior and lateral parts of the
→central retinal vein also accompanies the eyeball
central retinal artery →five-sixths of the surface
→opaque layer of dense connective tissue
GLAUCOMA →can be seen through its conjunctival sac
→rise of intraocular pressure → “white of the eye”
→normal cycle of aqueous humor fluid production →pierced by numerous vessels and nerves
and absorption is disturbed o Optic nerve
→amount of fluid increases →provides attachment for various muscles
→compression of retina and its blood supply involved in eyeball movement

• It can also lead to a variety of visual problems Fascial sheath

including blindness - Covers the surface of the sclera externally
- From the entrance of the optic nerve to the
CATARACTS corneoscleral junction
→lens of the eye becomes opaque
→increasing opacity results in increasing visual Choroid of the vascular layer
impairment - Where the surface of the sclera is attached
→common operation is excision of the cloudy lens loosely (internally)
and replacement with a new man-made lens
CORNEA
OPHTHALMOSCOPY →covers the anterior part
→direct visualization of the postremal (vitreous) →continuous with the sclera
chamber →transparent
→small battery-operated light with a tiny lens →covers the anterior one-sixth of the eyeball
→allows direct visualization of the postremal →allows light to enter the eyeball
chamber and the posterior wall of the eye through
the pupil and lens VASCULAR LAYER OF THE EYEBALL
• Choroid
What is seen: • Ciliary body
✓ Optic nerve • Iris
✓ Optic disc
✓ Four branches of the central retinal artery CHOROID
✓ Fovea →posterior
→represents two-thirds of the vascular layer
FIBROUS LAYER OF THE EYEBALL →thin
• Sclera →highly vascular
• Cornea →pigmented layer
→contains smaller vessels adjacent to the retina
→contains larger vessels more peripherally

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Internally: IRIS
• Firmly attached to the retina →anterior
Externally: →circular structure
• Loosely attached to the sclera →projects outward
→colored part of the eye
CILIARY BODY
→extending from the anterior border of the Pupil
choroid - central opening
→triangular-shaped
→between the choroid and iris Sphincter pupillae
→forms a complete ring around the eyeball - smooth muscle fibers
- controls the size of the pupil
Components:
• Ciliary muscle Dilator pupillae
• Ciliary process - myoepithelial cells

CILIARY MUSCLE SPHINCTER PUPILLAE

→smooth muscle fibers →fibers arranged in a circular pattern
→decrease the size of the ring formed by the →decreases or constricts the pupillary opening
ciliary body o Parasympathetics
→arranged longitudinally, circularly, and radially
→controlled by parasympathetics traveling to the DILATOR PUPILLAE
orbit →contractile fibers
o Oculomotor nerve (III) →arranged in a radial pattern
• Its contraction reduces tension on the →increases or dilates the pupillary opening
suspensory ligament of the lens o Sympathetics
• Lens becomes more rounded (relaxed)
• Accommodation of lens for near vision INNER LAYER OF THE EYEBALL
→retina
CILIARY PROCESS
→It consists of:
→longitudinal ridges • Optic part of the retina
→projecting from the inner surface of the ciliary • Nonvisual part
body
→contributes to the formation of the aqueous Ora serrata
humor - Junction between the two parts
- Irregular line
Zonular Fibers
- attached to the lens of the eyeball OPTIC PART OF THE RETINA
- extending from the ciliary process →sensitive to light
- suspend the lens in its proper position →on the posterior and lateral side
- collectively form the suspensory ligament of
the lens It consists of two layers:
• Outer pigmented layer
• Inner neural layer

OUTER PIGMENTED LAYER

→firmly attached to the choroid
→continues anteriorly over the internal surface of
the ciliary body and iris

INNER NEURAL LAYER

→only attached to the pigmented layer around
the optic nerve and at the ora serrata
The neural later separates in the case of a
detached retina

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Features visible on the posterior surface of the
optic part of the retina:
• Optic disc
• Macula lutea
• Fovea centralis

OPTIC DISC
→where the optic nerve leaves the retina
→branches of central retinal artery spread from
this point outward to supply the retina
→no light sensitive receptor cells
→blind spot in the retina

MACULA LUTEA
→lateral to the optic disc
→yellowish coloration

FOVEA CENTRALIS
→central depression
→thinnest area of the retina
→visual sensitivity is higher because it has fewer
rods and more cones

Rods
- Light-sensitive receptor cells
- Function in dim light
- Insensitive to color

Cones
- Light-sensitive receptor cells
- Respond to bright light
- Sensitive to color

HIGH-DEFINITION OPTICAL COHERENCE

TOMOGRAPHY
→procedure used to obtain surface images of
translucent or opaque materials
→similar to ultrasound
→uses light instead of sound to produce high-
resolution cross-sectional images
→useful in diagnosis and management of optic
nerve and retinal diseases

EPIRETINAL MEMBRANE
→thin sheet of fibrous tissue
→develops on the surface of the retina in the area
of macula
→can cause visual problems
→surgical removal of the membrane may be
necessary if visual problems are significant

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