Eye, Orbit, and Vision Lecture Notes

Dr. Siobhán B. Cooke

Study Objectives

This lecture serves as an introduction to the basic structure of the orbit, the eyelids, and the eyeball; how the
eye creates an image; eye musculature and eye movements; how the eye accommodates (adjusts) to see
objects at different distances; and the anatomical causes of common eye problems.

Terms

Anatomical structures optic disc infraorbital nerve (V2)

optic canal fovea centralis maxillary nerve (V2)
superior and inferior orbital macula lutea abducent (CN VI)
fissures refraction facial (CN VII)
infraorbital foramen accommodation pterygopalatine ganglion
lacrimal sac nerve of the pterygoid canal
lacrimal puncta Muscles and associated
lacrimal canaliculae structures Vessels
nasolacrimal canal orbicularis oculi ophthalmic artery
and duct levator palpebrae central artery of the retina
orbital septum superioris superior and inferior
tarsus rectus muscles: ophthalmic veins
tarsal glands superior, inferior, cavernous sinus
ciliary glands lateral, medial
conjunctiva oblique muscles: Clinical terms
sclera superior, inferior cavernous sinus syndrome
cornea trochlea macular degeneration
choroid common tendinous ring glaucoma
ciliary body ciliary muscle papilledema
ciliary processes sphincter pupillae conjunctivitis
iris dilator pupillae cataract
zonular fibers myopia
lens Nerves and ganglia hyperopia
anterior chamber optic (CN II) sty
posterior chamber optic chiasm chalazion
aqueous humor optic tract ptosis
vitreous body oculomotor (CN III)
retina trochlear (CN IV)
ora serrata ophthalmic nerve (V1)
Lecture notes: Eye, orbit, and vision 2

Lecture Part 1

1. Bony Anatomy of the Orbit and Vasculature

a. Bony walls of the orbit
i. Roof – orbital part of frontal and a small contribution of sphenoid.
ii. Medial wall – maxilla, lacrimal, ethmoid, and sphenoid.
iii. Floor – maxilla and a small portion of zygomatic and palatine.
iv. Lateral – zygomatic anteriorly and the greater wing of the sphenoid posteriorly.
b. Orbital foramina
i. Optic canal is found between the body and lesser wing of the sphenoid.
1. Allows passage for the optic nerve [II] and the ophthalmic artery.
ii. Superior orbital fissure is found between the roof and lateral wall of the orbit.
1. Allows passage for the superior and inferior branches of oculomotor nerve [III],
the trochlear nerve [IV], the abducent nerve [VI], the lacrimal, frontal, and
nasociliary branches of the ophthalmic nerve [V1], and the superior ophthalmic
vein.
iii. Inferior orbital fissure is found between the lateral wall and the floor of the orbit.
1. Allows passage for the maxillary nerve [V2] (zygomatic branch), infra-orbital
vessels, inferior ophthalmic vein joining the pterygoid plexus of veins.
iv. Infraorbital foramen arises from the infraorbital groove and canal.
1. The infraorbital nerve (branch of V2) and vessels traverse these structures.
v. Fossa for lacrimal sac – contains the lacrimal sac.
vi. Nasolacrimal canal which give passage to the nasolacrimal duct.

Figs. 8.82 & 8.83 Gray’s Anatomy for Students, 2nd ed.

c. Vasculature
i. Arteries
1. Main blood supply is the ophthalmic artery which gives off branches to muscles
and other structures within the eye.
Lecture notes: Eye, orbit, and vision 3

2. The central artery of the retina (central rentinal artery) is found in the center of
the optic nerve and can be viewed with an opthalmoscope.

ii. Veins
1. Superior and inferior ophthalmic veins communicate with veins from the face
(e.g., angular vein, supraorbital vein) and with the cavernous sinus in the
cranium thus making them a route along which infection can spread.

Clinical Note:
Cavernous sinus syndrome can occur when infection in the “danger zone” of the face spreads to the cavernous
sinus via the ophthalmic veins. The oculomotor nerves may be affected as well as branches of the trigeminal
nerve (V1 and/or V2). There may also be sympathetic or parasympathetic involvement.

2. Lacrimal Apparatus
a. Found in superiolateral aspect of orbit, produces fluid which moves across eye during blinking.
b. Tears drain through the lacrimal puncta into canaliculae then to nasolacrimal duct.
c. Innervation
i. Sensory innervation
1. sensory neurons return to the CNS through the lacrimal branch of ophthalmic
nerve [V1].
ii. Parasympathetic (secretomotor) innervation
1. Parasympathetic fibers stimulate fluid secretion.
2. Preganglionic fibers leave CNS via the facial nerve (VII) → greater petrosal nerve
(VII), which becomes nerve of the pterygoid canal → pterygopalatine ganglion
where fibers synapse on postganglionic parasympathetic fibers → postganglionic
fibers joining maxillary nerve (V2) → zygomatic nerve → zygomaticotemporal
nerve → lacrimal nerve (see image in lecture).
iii. Sympathetic innervation
1. postganglionic fibers originate in cervical ganglion → plexus around internal
carotid → deep petrosal nerve → join parasympathetic fibers in the nerve of the
pterygoid canal and follow parasympathetic pathway.

3. Eyelids
a. Eyelids protect the surface of the eye when closed. The palpebral fissure is the opening
between the upper and lower lid.
b. Anatomy and structures of the eyelid:
i. Layers of the eyelids from anterior to posterior are:
1. Skin
2. subcutaneous tissue
3. voluntary muscle
4. orbital septum
5. tarsus
6. conjunctiva
ii. Musculature
1. Orbicularis oculi (palpebral part) – closes eyelid, innervated by facial nerve (VII).
Lecture notes: Eye, orbit, and vision 4

2. Levator palpebrae superioris – found in upper eyelid and raises lid, innervated
by oculomotor nerve (III).

iii. Orbital septum – extension of periosteum

iv. Tarsus (tarsal plate) – dense
connective tissue that provides
support for the eyelid.
v. Tarsal glands (Meibomian
glands)– modified sebaceous
glands that secrete lipids,
which prevent tears from
spilling over eyelids.
vi. Conjunctiva – thin membrane
covering posterior surface of
eyelid, reflects onto the sclera
of the eyeball.
vii. Ciliary glands (Moll’s glands)–
sebaceous glands associated
with eyelashes that secrete
lipids that add to tear film.

Thieme Atlas of Anatomy, Gilroy 3rd ed.

Clinical Notes:
Ptosis – drooping of eyelid; occurs when function is lost to the levator palpebrea superioris.
Stye – inflammation or blockage of sebaceous glands of eyelash.
Chalazion – inflammation or blockage of tarsal gland.
Lecture notes: Eye, orbit, and vision 5

Lecture Part 2

1. The structure and anatomy of the eyeball

a. There are three layers to the eyeball.
i. Outer fibrous layer
1. Sclera – fibrous white portion of eyeball continuous with cornea.
2. Cornea – transparent layer covering anterior portion of eyeball.
ii. Middle vascular layer
1. Choroid – thin pigmented layer, highly vascularized, found posteriorly.
2. Ciliary body – contains ciliary muscle and processes, forms ring around anterior
portion of eyeball.
3. Iris – projects from the ciliary body anteriorly, the colored part of the eye.
iii. Inner layer
1. Retina – the optic part of retina found posteriorly; and the nonvisual layer of
retina is found anteriorly on the interior surface of the ciliary body. They are
separated by the ora serrata.
a. The optic part of the retina contains a pigmented layer and a neural layer.
2. Optic disc – point of exit of the optic nerve; contains no cone or rod cells and so
is a blind spot.
3. Macula lutea – pigmented area in the center of the retina.
4. Fovea centralis – found in the center of the macula, densely populated with
cone cells.
b. Contents of the eyeball
i. Anterior chamber – posterior to the cornea and anterior to the iris; posterior chamber
–posterior to the iris and anterior to the lens; both contain aqueous humor. The
aqueous humor can flow between the anterior and posterior chambers through the
pupil.
ii. Lens – a biconvex elastic disc which allows light to pass through; focuses light on the
retina; may change shape to focus on objects at different distances. Zonular fibers run
from the lens to the ciliary body to hold the lens in place.
iii. Vitreous body (humor) – fills the posterior aspect of the eyeball; found posterior to the
lens.
c. Intrinsic Muscles of the eyeball
i. Ciliary muscles – smooth muscle fibers that decrease the size of the ring formed by the
ciliary body resulting in relaxation of the zonular fibers (suspensory ligament of the lens)
and allow for the lens to become more rounded.
ii. Sphincter pupillae – found in the iris; contraction of its fibers decrease the size the
pupillary opening; innervation by parasympathetic fibers.
iii. Dilator pupillae – found in iris; contraction of its fibers increase the size the pupillary
opening; innervation by sympathetic fibers.

Clinical Notes:
Glaucoma – high intraocular pressure resulting from an increase amount of aqueous humor.
Cataract – opacity of the lens
Lecture notes: Eye, orbit, and vision 6

Fig. 8.101 Gray’s Anatomy for Students, 2nd ed.

2. Vision and accommodation

a. An image forms by the refraction of light rays entering the eyeball so the rays converge on a
focal point on the retina. If rays converge in front of or behind the retina the image is blurry.
b. Refraction occurs principally at three surfaces of the eye:
i. The air/cornea interface – most refraction occurs here because the difference between
refractive indices of air and cornea is greater than at any other interface.
ii. Anterior surface of the lens – interface between aqueous humor and the lens.
iii. Posterior surface of the lens – interface between the lens and the vitreous body.
c. All ocular structures have a refractive index very close to that of water and much greater than
that of air, explaining the substantial refraction at the air/cornea interface.
d. The lens is unique because it can change shape thus altering its refractive power. The change to
a thicker and more convex lens, which increases refractive power, is called accommodation.
i. The ability to accommodate decreases with age, a condition called presbyopia. It is
thought to be caused by a normal, gradual hardening and loss of elasticity of the lens
and possibly weakening of the ciliary muscle. This leads to difficulty focusing at close
range.
ii. When the ciliary muscle is relaxed, it pulls away from the lens, tightening the zonular
fibers and stretching the lens capsule, which flattens the lens. The exact mechanism
controlling this action is unclear but is thought to be under sympathetic control.
Lecture notes: Eye, orbit, and vision 7

e. The optic nerve (CN II)

i. The optic nerve (CN II) carries afferent fibers from the retina to the visual centers of the
brain, is an extension of the brain, and is surrounded by meninges.
ii. The left and right optic tracts cross at the optic chiasm so that the right optic tract
carries afferent fibers from the right temporal retina and the left nasal retina; the left
optic tract carries fibers from the left temporal retina and the right nasal retina.

Schuenke, Atlas of Anatomy, vol. 3, 2nd ed.,

Fig. 20.466 B

Clinical Note:
Papilledema – swelling of optic disc due to increase in CSF pressure.
Optic nerve lesions – see lecture slides.
Lecture notes: Eye, orbit, and vision 8

Lecture Part 3

1. Extra-ocular (extrinsic) musculature; movement of the eyeball

a. Movements include:
i. Elevation – pupil moves superiorly
ii. Depression – pupil moves inferiorly
iii. Abduction – pupil moves laterally
iv. Adduction – pupil moves medially
v. Internal rotation – rotating pupil medially
vi. External rotation – rotating pupil laterally
b. Muscles
i. Levator palpebrae superioris
1. Raises upper eyelid
2. Innervation – superior branch of oculomotor nerve (III)
ii. Superior rectus muscle
1. Elevates and adducts
2. Superior branch of oculomotor nerve (III)
iii. Inferior rectus muscle
1. Depresses and adducts
2. Inferior branch of oculomotor nerve (III)
iv. Medial rectus muscle
1. Adducts
2. Inferior branch of oculomotor nerve (III)
v. Lateral rectus muscle
1. Abducts
2. Abducent nerve (VI)
vi. Superior oblique
1. Depresses and abducts; is associated with the trochlea – a sling through which it
passes
2. Trochlear nerve (IV)
vii. Inferior oblique
1. Elevates and abducts
2. Inferior branch of oculomotor nerve (III)
viii. The rectus muscles attach to the common tendinous ring (annulus tendinous, annulus
of Zinn) at the posterior aspect of the orbit.
Lecture notes: Eye, orbit, and vision 9

Thieme Atlas of Anatomy, Gilroy 3rd ed.

Fig. 8.94 Gray’s Anatomy for Students, 2nd ed. This image shows the primary movements of the extraocular muscles. For example,
the superior rectus moves the eye superiorly and medially while the inferior oblique moves the eye superiorly and laterally. Be careful
not to confuse this diagram with the H-test diagram.
Lecture notes: Eye, orbit, and vision 10

Clinical Note:

Testing extraocular muscle movement – The “H-test”

The image below outlines the “H-test” which allows you to test the specific muscles of the eye. Isolating the
movements of the medial and lateral rectus is straight forward (have the person look to the right or left –
shown in the second line of pictures), but isolating the superior and inferior rectus and superior and inferior
oblique muscles require adduction or abduction of the eye.

Up and to the right

Looking to the right involves the right lateral rectus (abduction) and the left medial rectus (adduction). When
the right eye is fully abducted it can only be elevated by the superior rectus. Conversely, when the left eye is
fully adducted, it can only be elevated by the inferior oblique. So, to test the right superior rectus have the
person look up and to the right – if the eye cannot be elevated, there is damage to the superior rectus or its
innervation.

Up and to the left

The same principles apply here, just with the opposite eyes.

Down and to the right

When the right eye is fully abducted, it can only be depressed by the inferior rectus. Conversely, when the
left eye is fully adducted it can only be depressed by the superior oblique. So, to test the right inferior
rectus, have the person look down and to the right. If the eye cannot be depressed, there is damage to
the inferior rectus or its innervation.

Down and to the right

The same principles apply here, just with the opposite eyes.

Scheunke’s Thieme Atlas of Anatomy, vol. 3, fig. 5.167E. The labels below each image indicate the muscle that is being tested not the
movement that that muscle makes.