بسم الله الرحمن الرحيم. orbital region (i) eyelids, lacrimal apparatus and...

الرحيم الرحمن الله بسم

Orbital region (I) ,Eyelidslacrimal apparatus

andorbital muscles

Orbital region (I) Eyelids, lacrimal apparatus

and orbital muscles

College of medicine in Al-AhsaCollege of medicine in Al-Ahsa

King Faisal UniversityKing Faisal University

Dr. Mohammad Bahgat(1431 – 1432 H)

Dr. Mohammad Bahgat (1431 – 1432 H)

ObjectivesBy the end of this lecture, you are expected to:

1- Know the anatomical features of the eyelids.

2- Know the anatomical features of the lacrimal apparatus.

3- Know the anatomical features of the orbital muscles.

4- Use anatomical knowledge to understand and explain

clinical features resulting from

paralysis of the orbital muscles.

Dr. Bahgat

lacus lacrimalisLateral angle

Medial angle

Palpebral fissure

Eyelids The eyelids are placed in front of the eyes to protect them from injury and excessive light. When the eye is opened, the space between the eyelids is called the palpebral fissure. The eyelids meet each other at the medial and lateral angles. The lateral angle of the palpebral fissure is acute and lies in contact with the eyeball. The medial angle is more rounded and is separated from the eyeball by a small space called lacus lacrimalis. The upper eyelid is larger and more mobile than the lower eyelid.

The upper eyelid covers the cornea completely when the eye is closed, and covers its upper margin when the eye is opened.

The lower eyelid lies below the cornea when the eye is opened and

rises only slightly when the eye is closed.

Dr. BahgatConjunctiva3 -Tarsus

2 -Orbicularis oculi muscle

1 -SkinLayers of the eyelid

Dr. Bahgat

Sagittal section of the upper eyelid

I- Skin

II- Orbicularis oculi M

III- TarsusVI- Conjunctiva

Anterior Posterior

The subtarsal sulcus

Layers of the eyelid

Dr. Bahgat


The glands related to the eyelids

1- Sebaceous glands (of Zeis):

open into

the eyelash follicles.

Dr. Bahgat

2 -Ciliary glands (of Moll):

modified sweat glands

open between

the eyelashes.


Dr. Bahgat

modified sebaceous glands

They open onto

the eyelashes

Tarsal glands


Their secretion prevents

the overflow of tears and

makes the closed eyelids airtight.

that pour their oily secretion onto

the margin of the lid.

The lid margin

behind

Eyelids - The eyelids consist of the following layers from superficial to deep aspect: 1- Skin. 2- Orbicularis oculi muscle. 3- Tarsus. 4- Conjunctiva. - The eyelashes are present on the free edge and arranged in double or triple rows at the mucocutaneous junction. - The glands related to the eyelids are: 1- Sebaceous glands (of Zeis): open into the eyelash follicles. 2- Ciliary glands (of Moll): modified sweat glands open between the eyelashes. 3- Tarsal glands: modified sebaceous glands that pour their oily secretion onto the margin of the lid. They open behind the eyelashes. Their secretion prevents the overflow of tears and makes the closed eyelids airtight.

Dr. Bahgat

The superior tarsal plate The tarsi are dense fibrous plates

The lateral ends of the tarsal plates

are attached by

the lateral palpebral ligament

to a bonny tubercle just within the orbital margin

The medial ends of the tarsal plates

the medial palpebral ligament

to the anterior lacrimal crest (frontal process of the maxilla).

The inferior tarsal plate

are attached by

connected to

The aponeurosis of

pierces the orbital septum to reach

the anterior surface of the superior tarsal plate

The tarsal plates

the orbital margin by

the levator palpebrae superioris

fibrous orbital septa the lacrimal sac

Tarsi and palpebral ligaments

- The tarsi are dense fibrous plates connected to the orbital margin by fibrous orbital septum. - The lateral ends of the tarsal plates are attached by the lateral palpebral ligament to a bonny tubercle just within the orbital margin.

- The medial ends of the tarsal plates are attached by the medial palpebral ligament to the anterior lacrimal crest (frontal process of the maxilla).

- The tarsal glands are embedded in the posterior surface of the tarsal plates. - The outer surface of the orbital septum and tarsal plates are covered by

the palpebral fibers of the orbicularis occuli muscle. - The aponeurosis of the levator palpebrae superioris pierces the orbital septum to reach the anterior surface of the superior tarsal plate.

Dr. Bahgat


VI- Conjunctiva

Anterior

Posterior

It is reflected from the eyelid

To form The fornix

The conjunctival sac

to the eyeball

is a thin mucous membrane

that lines the inner surface of the eyelids.

Its epithelium is continuous with

the corneal epithelium.


Dr. Bahgat

Sagittal section of the eye & eyelids

Anterior

Posterior


Palpebral Conjunctiva

is reflected from the eyelid

to the eyeball to form

Bulbar Conjunctiva

The angles between

Palpebral Conjunctiva

And Bulbar Conjunctiva

form Superior fornix

and inferior fornix

Its epithelium is continuous with

the corneal epithelium.

Dr. Bahgat



The conjunctiva thus forms

a potential space called

the conjunctival sac

This sac is closed

when the eye is closed

and it opens through

the palpebral fissure

when the eye is opened

Dr. Bahgat



This sulcus traps small foreign particles

that may enter the conjunctival sac

So it is clinically important

is a groove on the inner surface of the eyelid

parallel and close to

the lid margin

Conjunctiva - The conjunctiva is a thin mucous membrane that lines the inner surface of the eyelids.It is reflected onto the eyeball at the superior and inferior fornices. Its epithelium is continuous with the corneal epithelium. - The conjunctiva thus forms a potential space called the conjunctival sac. This sac is closed when the eye is closed, and it opens through the palpebral fissure when the eye is opened. - The subtarsal sulcus is a groove on the inner surface of the eyelid parallel and close to the lid margin. This sulcus traps small foreign particles that may enter the conjunctival sac

and is thus clinically important.

Dr. Bahgat

lacus lacrimalis

lacrimal caruncle

plica semilunaris

lacrimal papilla

lacrimal punctum

leading to

lacrimal canaliculus

Lateral angle

Medial angle


The conjunctival sac - At the medial angle of the palpebral fissure,

there is a depression called lacus lacrimalis. The lacus lacrimalis contains

a small reddish yellow elevation called lacrimal caruncle

and a reddish semilunar fold called plica semilunaris lying

on the lateral side of the caruncle.

- Near the medial end of the margin of the eyelid,

there is a small elevation called lacrimal papilla.

- On the summit of the papilla,

there is a small hole called lacrimal punctum leading to

a small canal called lacrimal canaliculus.

This canaliculus carries the tears into the lacrimal sac

Dr. Bahgat

Lacrimal apparatus

Lacrimal gland

Lacrimal punctum

lacrimal canaliculus

the lacrimal sac

Nasolacrimal duct

Dr. Bahgat

Lacrimal gland

secretes tears into

the superior fornix

Tears collect in

the lacus lacrimalis

and enter

the lacrimal canaliculi

through the puncta

Canaliculi drain into

the lacrimal sac

Nasolacrimal duct

drains tears into

The inferior meatus of the nasal cavity

Lacrimal apparatus (flow of tears)

Dr. Bahgat

Flow of Tears

12

3 4

57

8

9

1- Lacrimal gland

2 -Excretory ducts

3 -Surface of eye

4 -lacus lacrimalis

5 -Lacrimal punctum

6 -Lacrimal canaliculus

7 -Lacrimal sac

8- Nasolacrimal duct

9 -Nasal cavity

6

Lacrimal apparatus This system consists of: I- Lacrimal gland.I- The lacrimal gland: It lies in the anterolateral part of the roof of the orbit above the eyeball. It consists of large orbital part (superior)

and small palpebral part (inferior) continuous together around the lateral margin of the aponeurosis of the levator palpebrae superioris muscle.The gland has about 8 - 12 ducts. These ducts open into the upper lateral part of the conjunctival sac.II- Lacrimal ducts: 1- Puncta lacrimalia. 2- Lacrimal canaliculi. 3- Lacrimal sac. 4- Nasolacrimal duct.

Lacrimal fluid - The lacrimal gland secretes tears into the conjunctival sac. - The tears circulate across the cornea and accumulate in the lacus lacrimalis.

From here the tears enter the lacrimal canaliculi through the puncta lacrimalia.

-The lacrimal canaliculi pass medially and open into the lacrimal sac. - The lacrimal sac lies in the lacrimal groove

(in the anterior part of the medial wall of the orbit) behind

the medial palpebral ligament. - The lacrimal sac is continuous below with the nasolacrimal duct.

This duct is 0.5 inch long and descends downward, backward and laterally in an osseous canal and opens into the anterior part of the inferior meatus of the nose. This opening is guarded by a fold of mucous membrane known as lacrimal fold. It prevents air from being forced up into the lacrimal sac on blowing the nose.

Parasympathetic supply of the lacrimal gland

Preganglionic fibers the lacrimatory nucleus in the pons

The facial nerve The greater petrosal nerve Unites with

The deep petrosal nerve To form The nerve of pterygoid canal

the pterygopalatine ganglionThen pass to

postganglionic fibers

the maxillary nerve

zygomatic nerve

zygomaticotemporal nerve

Then communication to

lacimal nerve

to reach

the lacrimal gland.

pass to

Dr. Bahgat

Nerve supply of the lacrimal gland


the maxillary nerve

zygomatic nerve

zygomaticotemporal nerve


to reach

the lacrimal gland.

The lacimal nerve

Dr. Bahgat

Lacrimal nerve

Zygomatic nerve

Zygomaticotem

poralNerve supply of the lacrimal gland



Lacrimal gland to reach

Lacrimal apparatusIts parasympathetic supply is derived from

the lacrimal nucleus of the facial nerve (in the pons).

The preganglionic fibers pass along the facial nerve ------- greater petrosal nerve ----------

nerve of pterygoid canal to reach the --------

pterygopalatine ganglion.

The postganglionic fibers

pass along the maxillary nerve ------ zygomatic nerve -------------- ------- zygomaticotemporal nerve ----- then lacimal nerve to reach

the lacrimal gland.

Orbital muscles

Dr. Bahgat

Walls of the OrbitRoof

lateral medial

orbital plate of frontal bone

Lateral wall

lesser wing of sphenoid

Zygomatic bone

Medial wall

greater wing of sphenoid

frontal process of the maxilla lacrimal bone

orbital plate of ethmoid bone

Floor

body of the sphenoid

orbital plate of maxilla Zygomatic bone

Orbital process of palatine bone

Dr. Bahgat

Features of the Orbit

lateral medial

Roof

Lacrimal fossa

Optic canal

Medial wall

Lacrimal groove Anterior ethmoid foramen Posterior ethmoid foramen

Floor Infraorbital groove Infraorbital canal Infraorbital foramen

Superior orbital fissure

Roof

Lateral wall

Inferior orbital fissure

Floor

Dr. Bahgat

The Orbital muscles

2 oblique muscles

The orbital muscles are Levator palpebrae superioris

The 4 recti muscles

superior rectus

inferior rectus

medial rectus

lateral rectus

superior oblique

inferior oblique

medial

lateral

Muscles of the orbitThe orbital muscles are:

1- Levator palpebrae superioris.

2- 4 recti muscles: - superior rectus

- inferior rectus

- medial rectus

- lateral rectus

3- 2 oblique muscles: - superior oblique

- inferior oblique

Dr. Bahgat

Orbital muscles (origin)

The 4 recti muscles

Originate from

the common tendinous ring

Superior Rectus

Medial Rectus

Inferior Rectus

Lateral Rectus (2 heads)

Levator palpebrae superioris

Originates from

From the lower surface of

the lesser wing of sphenoid bone

(posterior part of the roof of the orbit).

Inferior Oblique Originates from

From the anteromedial part of the floor of the orbit

lateral medial

Dr. Bahgat

Orbital muscles (origin)

The 4 recti muscles

Originates from

The common tendinous ring

Originates from

the anteromedial part of the floor of the orbit

Originates from

The body of the sphenoid bone

The superior oblique

The inferior oblique

Dr. Bahgat

Orbital muscles (insertion)

The recti muscles Are inserted into

In front of the equator of the eyeball

The oblique muscles Are inserted into

behind the equator of the eyeball


the sclera

the sclera

Nerve supplyMuscle

Lateral Rectus*

Superior Rectus

Medial Rectus

Inferior Rectus

Inferior Oblique

Superior Oblique*

Nerve supply

CN VI – Abducent

CN III

CN IV - Trochlear

Oculomotor

CN III Levator palpebrae superioris

Inferior division

OculomotorSuperior division

Dr. Bahgat

Cut end (origin)

Cut end (insertion)

)dilator(


Levator palpebrae superioris m. Orbital Roof is removed (seen from above)

Superior rectus

Superior oblique

Dr. Bahgat

Levator palpebrae superioris m.

Dr. Bahgat

Levator palpebrae superioris muscle (origin)

Levator palpebrae superioris Originates from

the lower surface of the lesser wing of sphenoid bone

(posterior part of the roof of the orbit).

lateral medial

Dr. Bahgat

Levator palpebrae superioris Is inserted into

The superior tarsal plate

Dr. Bahgat

Its tendon forms a wide aponeurosis

which splits into two lamellae

The superior lamella

contains striated muscle fibers

To be inserted into

the anterior surface

of the superior tarsal plate

and the skin of the upper eyelid

The inferior lamella

contains smooth muscle fibers

It is inserted into

the upper border of the superior tarsal plate

It pierces the orbital septum

Levator palpebrae superioris muscle (insertion)

Dr. Bahgat

Levator palpebrae superioris muscle (nerve supply)

Nerve supply: Superior lamella by

superior division of

oculomotor nerve

Inferior lamella by

sympathetic fibers derived from

the superior cervical sympathetic ganglion.

Dr. Bahgat

Sagittal section of the eyeAponeurosis of


Action:

Elevation of the upper eyelid

sympathetic stimulation results in

further elevation of the upper eyelid

To open

the palpebral fissure

Levator palpebrae superioris Origin: From the lower surface of the lesser wing of sphenoid bone (posterior part of the roof of the orbit).

Insertion: - Its tendon forms a wide aponeurosis which splits into two lamellae.

- The superior lamella:

(contains striated muscle fibers) is inserted into the anterior surface of the superior tarsal plate and the skin of the upper eyelid.

- The inferior lamella: contains smooth muscle fibers. It is inserted into the upper border of the superior tarsal plate.

Nerve supply:

Superior lamella by superior division of oculomotor nerve.

Inferior lamella by sympathetic fibers derived from the superior cervical

sympathetic ganglion.

Action: - Elevation of the upper eyelid. - sympathetic stimulation results in further elevation of the upper eyelid. - Injury of oculomotor nerve or sympathetic supply leads to dropping of the upper eyelid

(ptosis).

Recti muscles

Dr. Bahgat

Recti muscles (origin)

The 4 recti muscles Originate from

the common tendinous ring

Superior Rectus

Medial Rectus

Inferior Rectus

Lateral Rectus (2 heads)

lateral medial

Dr. Bahgat

Recti muscles (insertion)

The recti muscles Are inserted into

In front of the equator of the eyeball

the sclera

Dr. Bahgat

Nerve supply of recti muscles

superior rectus

Superior division of oculomotor

Medial rectus

inferior division of oculomotorInferior rectus

inferior division of oculomotor

Dr. Bahgat


superior rectus

Superior division of

Medial rectus

inferior division ofInferior rectus

inferior division of

oculomotor nerve

Dr. Bahgat

lateral rectus Abducent nerve


The 4 recti muscles Origin: - They arise from a fibrous ring called

the common tendinous ring. - This rig is a thickening in the periosteum. It surrounds the optic canal and bridges the superior orbital

fissure. - Each rectus muscle arises from a part of the ring corresponding to its name: Superior rectus ---- upper part. Inferior rectus ----- lower part. Medial rectus ------- medial part. Lateral rectus ------ by two heads from the lateral part of the ring.

Insertion: - Each muscle pierces the fascial sheath of the eyeball to be inserted into the sclera about 6 mm behind the corneoscleral junction In front of the equator of the eyeball.

Nerve supply: - The lateral rectus by the abducent nerve.

- The other 3 recti by oculomotor nerve. superior rectus (superior division) medial and inferior recti (inferior division)

Action: - lateral rectus moves the eye laterally. - Medial rectus moves the eye medially. - Superior rectus: moves the eye upward and medially. - Inferior rectus: moves the eye downward and medially.

Oblique muscles

Dr. Bahgat

superior oblique

Inferior oblique

Trochlea

Oblique muscles

lateral view

Dr. Bahgat

superior oblique

Oblique muscles Superior view

Dr. Bahgat

Inferior oblique

Oblique muscles Anterior view

Dr. Bahgat

Oblique muscles (origin)

Superior oblique Originates from

body of the sphenoid bone

Inferior Oblique Originates from

the anteromedial part of the floor of the orbit

lateral medial

Posterior part of

the medial wall of the orbit

at its junction with the roof

Dr. Bahgat

Oblique muscles

The oblique muscles Are inserted into

behind the equator of the eyeball

the sclera

Oblique muscles (insertion) lateral view

Dr. Bahgat

Inferior obliqueAre inserted into the sclera behind

the equator of the eyeball.

&Superior oblique

Superior view

Lateral view

Dr. Bahgat

superior oblique

Nerve supply of oblique muscles

Is supplied by

Trochlear nerve

lateral view

Dr. Bahgat

Nerve supply of oblique muscles

Inferior oblique

Is supplied by

inferior division of

oculomotor nerve

lateral view

The 2 oblique muscles I- Superior oblique: Origin: From the body of the sphenoid bone.

Insertion: - Its rounded belly passes forward and forms a slender tendon which rotates around the trochlea (fibrocartilaginous bulley). - Then the tendon passes downward, backward and

laterally below the superior rectus muscle.

and pierces the fascial sheath of the eyeball to be inserted into the sclera behind the equator of the

eyeball.

Nerve supply: - by the trochlear

nerve.

Action: - It moves the eyeball

downward and laterally.

The 2 oblique muscles II- Inferior oblique: Origin: - From the anterior part of the floor of the

orbit. Insertion: - It passes upward, backward and laterally below the inferior rectus and

pierces the fascial sheah of the eyeball to be inserted into the sclera behind the equator of the eyeball.

Nerve supply: - by the oculomotor nerve (inferior division).

Action: - It moves the eyeball upward and laterally.

Movement of the eyeball around different axes

Dr. Bahgat

elevation

depression

Movement around the axes

Transverse axis

Transverse axis

Dr. Bahgat Adduction

Abduction


Vertical axis

Dr. BahgatIntorsion

Extorsion


Visual axis(Anteroposterior)

Action of

Individual orbital muscles

Dr. Bahgat

medial rectus

lateral rectus

Adduction

Abduction

Dr. Bahgat

superior rectus inferior rectus

Elevation & adduction

Depression & adduction

Dr. Bahgat

superior oblique

inferior obliqueDepression & abduction

Elevation & abduction

lateral rectusmedial rectusinferior rectussuperior obliquesuperior rectusinferior oblique

Looking lateralLooking medialLooking down medialLooking down lateral Looking up medial Looking up lateral

Action of individual muscles

Left lateral rectusRight medial rectus Left medial rectusRight lateral rectus Left inferior rectus & Left superior oblique

Right inferior rectus & Right superior oblique

Left superior rectus & Left inferior oblique

Right superior rectus & Right inferior oblique

Left inferior rectusRight superior obliqueLeft superior obliqueRight inferior rectus Left superior rectusRight inferior obliqueRight superior rectus Left inferior oblique

Looking to left sideLooking to right side Looking downward Looking upward Looking down & rightLooking down & left Looking up & right Looking up & left

Conjugate movement of the two eyes

Dr. Bahgat

M.R.L.R. 1

To right side

L.R.M.R.2

To left side

Both S.R. + I.O.

3 upward

Both I.R.+ S.O.

4 downward

S.R I.O.5

Up & left side

S.R.I.O.6

Up & right side

I.R. S.O.7

Down & left side

S.O. I.R.8

down & right side

Looking to right side Left medial rectusRight lateral rectus Looking to left side Left lateral rectus Right medial rectus Looking upward Left superior rectus & Left inferior oblique

Right superior rectus & Right inferior oblique

Looking downward Left inferior rectus & Left superior oblique

Right inferio rectus & Right r superiorobliqueRight superior rectus Left inferior oblique Looking up & left Left superior rectusRight inferior oblique Looking up & right Left inferior rectusRight superior oblique Looking down & right Left superior obliqueRight inferior rectus Looking down & left

Conjugate movement of the two eyes

Dr. Bahgat

What is this?

Dr. BahgatDr. Bahgat

Case 1 Patient: survived a posterior cerebral aneurysm

ptosis

dilated pupil

left eye is

Conclusion lesion of the oculomotor nerve (CN III) Why?

directed downward

and abducted.

wrinkled forehead

Signs:

Symptoms:

double vision

cannot accommodate

Dr. Bahgat

Case 2 What is the patient’s problem?

Medial Strabismus

Caused by paralysis of lateral rectus

Results in diplopiaResults in diplopia

right eye is directed

Medially (i.e. adducted).

What is the diagnosis

Case 1 Case 2

Dr. Bahgat

What is this?

What is this?

Testing Extraocular Movements

In the setting of an eye movement problem, it can help to check movement in the direction in which

that muscle is the primary mover. This can be assessed as follows: Superior oblique:

Depresses the eye when looking medially Inferior oblique:

Elevates the eye when looking medially Superior rectus:

Elevates the eye when looking laterally Inferior rectus:

Depresses the eye when looking laterally Medial rectus:

Adduction when moving the eye along horizontal plane Lateral rectus:

Abduction when moving the eye along horizontal plane

Testing individual muscles

References

Last’s anatomy Regional and applied )R.M.H. McMinn – (9th edition

Clinical anatomy (Richard S. Snell) – 7th edition

Grey’s anatomy – 39th edition

Good luck

Testing Extraocular Movements

Practically speaking, cranial nerve testing is done such that the examiner can observe eye movements in all directions. The movements should be smooth and coordinated. To assess, proceed as follows:

Stand in front of the patient. Ask them to follow your finger with their eyes while keeping

their head in one position Using your finger, trace an imaginary "H" or rectangular

shape in front of them, making sure that your finger moves far enough out and up so that you're able to see all appropriate eye movements (ie lateral and up, lateral down, medial down, medial up).

At the end, bring your finger directly in towards the patient's nose. This will cause the patient to look cross-eyed and the pupils should constrict, a response referred to as accommodation.

بسم الله الرحمن الرحيم. orbital region (i) eyelids, lacrimal apparatus and...

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