THE ORBIT AND EYE

The Orbit Seven bones contribute to the framework of each orbit. These are the maxilla, zygomatic, frontal, ethmoid, lacrimal, sphenoid, and palatine bones. Together they give the bony orbit the shape of a pyramid with its base in front and its apex behind. The apex of the pyramidal-shaped bony orbit is the optic foramen, while the base is the orbital rim/margin. The orbital margin is formed above by the frontal bone, the lateral margin is formed by the processes of the frontal and zygomatic bones, the inferior margin is formed by the zygomatic bone and the maxilla, and the medial margin is formed by the processes of the maxilla and the frontal bone. The orbital fascia is the periosteum of the bones that form the walls of the orbit. It is loosely attached to the bones and is continuous through the foramina and fissures. The orbital walls The roof (superior wall) of the bony orbit is made up of the orbital part of the frontal bone with a small contribution from the sphenoid bone. This thin plate of bone separates the contents of the orbit from the brain in the anterior cranial fossa. Unique features of the superior wall include: anteromedially, the possible intrusion of part of the frontal sinus and the trochlear fovea, for the attachment of a pulley through which the superior oblique muscle passes; anterolaterally, a depression (the lacrimal fossa) for the orbital part of the lacrimal gland. The medial walls of the paired bony orbits are parallel to each other and each consists of four bones-the maxilla, lacrimal, ethmoid, and sphenoid bones. The largest contributor to the medial wall is the orbital plate of the ethmoid bone. This part of the ethmoid bone contains collections of ethmoid air cells, which are clearly visible in a dried skull. Also visible, at the junction between the roof and the medial wall are the anterior and posterior ethmoidal foramina that transmit the respective nerves and vessels. The floor (inferior wall) of the bony orbit, which is also the roof of the maxillary sinus, consists primarily of the orbital surface of the maxilla, with small contributions from the zygomatic and palatine bones. The lateral wall of the bony orbit consists of contributions from two bones, the zygomatic and the greater wing of the sphenoid bones.

Openings Into the Orbital Cavity.

Orbital opening: Lies anteriorly. About one-sixth of the eye is exposed; the remainder is protected by the walls of the orbit. Supraorbital notch (Foramen): The supraorbital notch is situated on the superior orbital margin. It transmits the supraorbital nerve and blood vessels. Infraorbital groove and canal: Situated on the floor of the orbit in the orbital plate of the maxilla; they transmit the infraorbital nerve and blood vessels. Nasolacrimal canal: Located anteriorly on the medial wall; it communicates with the inferior meatus of the nose. It transmits the nasolacrimal duct. Inferior orbital fissure: Located posteriorly between the maxilla and the greater wing of the sphenoid; it communicates with the pterygopalatine fossa. It transmits the maxillary nerve and its zygomatic branch, the inferior ophthalmic vein, and sympathetic nerves. Superior orbital fissure: Located posteriorly between the greater and lesser wings of the sphenoid; it communicates with the middle cranial fossa. It transmits the lacrimal nerve, the frontal nerve, the trochlear nerve, the oculomotor nerve (upper and lower divisions), the abducent nerve, the nasociliary nerve, and the superior ophthalmic vein. Optic canal: Located posteriorly in the lesser wing of the sphenoid; it communicates with the middle cranial fossa. It transmits the optic nerve and the ophthalmic artery.

Blood Vessels of the Orbit Ophthalmic Artery The ophthalmic artery is a branch of the internal carotid artery.
Acquaint yourself with branches of the ophthalmic artery.

Ophthalmic Veins The superior ophthalmic vein communicates in front with the facial vein. The inferior ophthalmic vein communicates through the inferior orbital fissure with the pterygoid venous plexus. Both veins pass backward thru the superior orbital fissure to the cavernous sinus.
No lymph vessels or nodes are present in the orbital cavity.

Nerves of the orbit 1. Optic nerve 2. Lacrimal nerve (ophthalmic division of Trigeminal nerve) 3. Frontal (ophthalmic division of Trigeminal nerve) 4. Trochlear nerve 5. Oculomotor nerve 6. Nasociliary nerve (ophthalmic division of Trigeminal nerve) 7. Abducent nerve 8. Ciliary ganglion
Acquaint yourself with branches of these nerves and what they innervate.

Muscles Eyeball movements and muscles The centre of the cornea or pupil is used as the anatomic anterior pole of the eye. The eyeball can move in horizontal, vertical and saggital planes. Movements then are; elevation, depression, adduction and abduction. Rotary movements of the eyeball use the upper rim of the cornea or pupil as the marker. The eye rotates either medially or laterally

Additionally, the axis of each orbit is directed slightly laterally from back to front, while each eyeball is directed anteriorly. Therefore, the pull of some muscles has multiple effects on the movement of the eyeball, while that of others has single effects.

There are two groups of muscles within the orbit:

extrinsic muscles of eyeball (extra-ocular muscles) involved in movements of the eyeball or raising upper eyelids;

intrinsic muscles within the eyeball, which control the shape of the lens and size of the pupil. The 3 intrinsic muscles include ciliary muscle, sphincter pupillae, and dilator pupillae.

Intrinsic Muscles of Eyeball (Smooth Muscle) Sphincter Parasympathetic via Constricts pupil pupillae of iris oculomotor nerve Dilator pupillae Sympathetic Dilates pupil of iris Ciliary muscle Parasympathetic via Controls shape of lens; in oculomotor nerve accommodation, makes lens more globular

Extrinsic (extra-ocular) muscles Muscle Levator palpebrae superioris Origin Insertion Innervation Oculomotor nerve Function Elevation of upper eyelid

Lesser wing of Tarsal plate sphenoid and skin of anterior to optic upper eyelid canal Superior part of Anterior half common of eyeball tendinous ring superiorly Inferior part of common tendinous ring Medial part of common tendinous ring Lateral part of common tendinous ring Anterior half of eyeball inferiorly Anterior half of eyeball medially Anterior half of eyeball laterally

Superior rectus

Oculomotor Elevation, nerve [III]adduction, medial superior branch rotation of eyeball Oculomotor nerve Depression, adduction, lateral rotation of eyeball Adducts eyeball

Inferior rectus

Medial rectus

Oculomotor nerve

Lateral rectus

Abducent nerve Abducts eyeball

Superior oblique

Body of Sclera deep sphenoid bone to superior rectus Anterior part of Sclera deep floor of orbit to lateral rectus

Trochlear nerve Depression, abduction, medial rotation of eyeball Oculomotor nerve Elevation, abduction, lateral rotation of eyeball

Inferior oblique

A unique feature of levator palpebrae superioris is that a collection of smooth muscle fibers passes from its inferior surface to the upper edge of the superior tarsus. This group of smooth muscle fibers (the superior tarsal muscle) help maintain eyelid elevation.
Loss of oculomotor nerve function results in complete ptosis or drooping of the superior eyelid, whereas loss of sympathetic innervation to the superior tarsal muscle results in partial ptosis.

The lacrimal apparatus The lacrimal apparatus is involved in the production, movement, and drainage of fluid from the surface of the eyeball. It is made up of the lacrimal gland and its ducts, the lacrimal canaliculi, the lacrimal sac, and the nasolacrimal duct. The lacrimal gland is anterior in the superolateral region of the orbit and is divided into two parts by the levator palpebrae superioris; the larger orbital part is in a depression, the lacrimal fossa in the frontal bone; the smaller palpebral part in the superolateral part of the eyelid. Numerous ducts empty the glandular secretions into the lateral part of the superior fornix of the conjunctiva. Fluid is continually being secreted by the lacrimal gland and moved across the surface of the eyeball as the eyelids blink. The fluid accumulates medially in the lacrimal lake and is drained from the lake by the lacrimal canaliculi, (one associated with each eyelid). The lacrimal punctum is the opening through which fluid enters each canaliculus. Passing medially, the lacrimal canaliculi eventually join together to enter the lacrimal sac posterior to the medial palpebral ligament and anterior to the lacrimal part of the orbicularis oculi muscle. When the orbicularis oculi muscle contracts during 'blinking', the small lacrimal part of the muscle compresses the lacrimal sac forcing fluid into the nasolacrimal duct. Nasolacrimal duct This is about 1.3cm long and emerges from the lower end of the lacrimal sac. The duct descends downward, backward and laterally in a bony canal and drains into the inferior meatus of the nasal cavity.
The opening is guarded by a fold of mucous membrane called the lacrimal fold. This prevents air from being forced up the duct into the lacrimal sac on blowing the nose.

Eyelids The upper and lower eyelids are anterior structures that, when closed protect the eye from injury and excessive light. The eyelids also keep the cornea moist by spreading the lacrimal fluid. The upper eyelid is larger and more mobile than the lower. The two lids meet at the medial and lateral angles (canthi). The space between the eyelids, when they are open, is the palpebral fissure and is the entrance into the conjuctival sac. When the eye is closed, the upper lid completely covers the cornea of the eye. The lower lid lies just below the cornea when the eye is open and rises only slightly when closed. The layers of the eyelids, from anterior to posterior, consist of skin, subcutaneous tissue, muscle, the orbital septum, the tarsus, and conjunctiva. The upper and lower eyelids are basically similar in structure except for the 5

addition of muscles in the upper eyelid. Skin and subcutaneous tissue The skin of the eyelids is thin and loose, only a thin layer of connective tissue separates the skin from the underlying muscle layer.
The thin layer of connective tissue and its loose arrangement account for the accumulation of fluid (blood) when an injury occurs.

Eyelashes The eyelashes are curved hairs on the free edges of the skin of eyelids. They are arranged in double or triple rows at the mucocutaneous junction. The eyelashes are associated with large sebaceous glands (glands of Zeis) and Ciliary glands (modified sweat glands, glands of Moll). Orbicularis oculi The muscle fibers encountered next in an anteroposterior direction through the eyelid belong to the palpebral part of orbicularis oculi. This muscle is part of the larger orbicularis oculi muscle, which consists primarily of two parts-an orbital part, which surrounds the orbit, and the palpebral part, which is in the eyelids. Orbicularis oculi Origin: medial orbital margin, medial palpebral ligament and lacrimal bone. Insertion: skin around orbital margin and tarsal plate. Action: closes the eyelids.
A third part of the orbicularis oculi muscle that can be identified consists of fibers on the medial border, which pass deeply to attach to the posterior lacrimal crest. These fibers form the lacrimal part of the orbicularis oculi, involved in the drainage of tears.

Orbital septum The framework of the eyelids is formed by a fibrous sheet, the orbital septum. This is attached to the periosteum at the orbital margins. The orbital septum is thickened at the margins of the lids to form the superior and inferior tarsal plates. Tarsus and levator palpebrae superioris Providing major support for each eyelid is the tarsus, form the skeleton of the eyelid. There is a large superior tarsus in the upper eyelid and a smaller inferior tarsus in the lower eyelid. These plates of dense connective tissue are attached medially to the maxilla by the medial palpebral ligament and laterally to the zygomatic bone by the lateral palpebral ligament.

Embedded in the tarsal plates are tarsal glands, which empty onto the free margin of each eyelid. These glands are modified sebaceous glands and secrete an oily substance; 1. That increases the viscosity of the tears and decreases the rate of evaporation of tears from the surface of the eyeball. 2. It lubricates the edges of the eyelids and prevents them from sticking together when they close. Although the tarsal plates in the upper and lower eyelids are generally similar in structure and function, there is one unique difference. Associated with the tarsus in the upper eyelid is the levator palpebrae superioris muscle, which raises the eyelid. In companion with the levator palpebrae superioris muscle is a collection of smooth muscle fibers passing from the inferior surface of the levator to the upper edge of the superior tarsus, this muscle is the superior tarsal muscle.
Loss of function of either the levator palpebrae superioris muscle or the superior tarsal muscle results in a ptosis (drooping of the upper eyelid).

Conjunctiva The structure of the eyelid is completed by a mucous membrane, the conjunctiva. The palpebral conjunctiva covers the inner surface of each eyelid. This membrane covers the full extent of the eyelid before reflecting onto the sclera as the bulbar conjunctiva. The bulbar conjunctiva is loose and wrinkled over the sclera where it contains small blood vessels, and is adherent to the periphery of the cornea at the corneoscleral junction. With this membrane in place, a conjunctival sac is formed. The upper and lower extensions of this sac are the superior and inferior conjunctival fornices.
The upper lateral part of the superior fornix is pierced by the ducts of the lacrimal gland.

Vessels: Medial and lateral palpebral arteries. The palbebral conjunctiva is very vascular (pink color) while the bulbar is slightly vascular and is transparent. Venous drainage is to the ophthalmic and angular veins. Lymphatic drainage is primarily to the parotid nodes, with some drainage from the medial third to submandibular nodes. Innervation of the eyelids includes both sensory and motor components.

A stye is an infection of the sebaceous glands of Zeis, or of the sweat glands of Moll. A chalazion/meibomian gland lipogranuloma, is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland, usually on the upper eyelid. Hyperemia of the conjuctiva: the bulbar conjuctiva is colorless, except when its vessels are dilated and congested blood shot eyes. This is usually due to local irritation. Conjunctivitis (pink eye) is a common contagious infection of the eye. xxSubconjuctival hemorrhages The Eyeball The globe-shaped eyeball occupies the anterior part of the orbit. The eyeball is embedded in the orbital fat but is separated from it by the fascial sheath of the eyeball. The fascial sheath surrounds the eyeball from the optic nerve to the corneoscleral junction. It separates the eyeball from the orbital fat and provides it with a socket for free movement. The fascial sheath is thickened medially and laterally to contribute to formation of the medial and lateral suspensory ligaments that suspend the eye from lateral and medial walls of the orbit.

Posterior to the cornea and in order from front to back are; the anterior chamber, iris and pupil, posterior chamber, lens, postrenal (vitreous) chamber, and the retina. The eyeball consists of 3 coats; 1. Outer fibrous coat 2. Vascular pigmented coat 3. Inner coat Fibrous coat: this is made up of a posterior sclera and anterior cornea. Sclera (white of the eye) The sclera is the opaque part of the fibrous coat. The anterior part of the sclera is visible through the transparent bulbar conjuctiva as the white of the eye. Posteriorly it is pierced by the optic nerve fibres at a point known as lamina cribrosa. The sclera is also pierced by ciliary arteries, nerves and choroid veins (venae vorticosae). It provides attachment for the various muscles involved in eyeball movement. The sclera is continuous in front with the cornea at the corneoscleral junction/limbus. At this junction there is an important venous structure, scleral venous sinus (canal of Schlemm). The sclera is loosely attached to the choroid.

Cornea The cornea is transparent and responsible for refraction of light entering the eye. It is continuous with the sclera anteriorly and covers the anterior 1/6th of the eyeball. It is in contact with the aqueous humor posteriorly. The cornea is avascular and devoid of lympatics, thus can be transplanted. It is nourished by diffusion from the aqueous humor and capillaries at its edge.. It is innervated by the short (mainly) and long ciliary nerve. The tear film maintains the normal environment for the corneal epithelium. Vascular Pigmented Coat/uveal tract The vascular pigmented coat consists, from behind to forward; the choroid, the ciliary body, and the iris. The Choroid The choroid is composed of an outer pigmented layer and an inner, highly vascular layer. It represents about 2/3rds of the vascular layer. The smaller vessels are adjacent to the retina while the larger vessels are more peripheral. It is firmly attached to the pigment layer of the retina and loosely attached to the sclera (can easily be stripped from sclera). The Ciliary Body The ciliary body is triangular-shaped structure that lies between the choroid posteriorly and iris anteriorly. It forms a complete ring around the eyeball. It is composed of ciliary processes, and ciliary muscle. -the ciliary processes are longitudinally arranged folds/ridges which are connected to the lens by the suspensory ligaments. The epithelium of the ciliary processes secretes the aqueous humor. -The ciliary muscle is composed of longitudinal, circular and radial fibers of smooth muscle. Action: Contraction of the ciliary muscle relieves the tension in the suspensory ligament, and the elastic lens becomes more convex. This increases the refractive power of the lens. The Iris and Pupil The iris is a thin, contractile, pigmented/colored diaphragm with a central aperture called the pupil. Controlling the size of the pupil are smooth muscle fibres within the iris. The iris is suspended in the aqueous humor between the cornea and the lens. The periphery of the iris is attached to the anterior surface of the ciliary body. It divides the space between the lens and the cornea into an anterior and a posterior chamber. The muscle fibers of the iris are involuntary and consist of circular and radiating fibers. The circular fibers form the sphincter pupillae and are arranged around the margin of the pupil. The radial fibers form the dilator pupillae and consist of a thin

sheet of radial fibers that lie close to the posterior surface. Action: The sphincter pupillae constricts the pupil in the presence of bright light and during accommodation. The dilator pupillae dilates the pupil in the presence of light of low intensity or in the presence of excessive sympathetic activity such as occurs in fright. Inner layer of the eyeball Retina The inner layer of the eyeball is the retina. It consists of two parts. 1. Posteriorly and laterally is the optic part of the retina, which is sensitive to light. 2. Anteriorly is the nonvisual part. This is nonphoto receptive and consists merely of the pigmented layer of cells. It covers the internal surface of the ciliary body and the iris. The junction between the optic and non optic parts is a wavy line, the ora serrata (formed by the anterior edge of optic part). Optic part of the retina The optic part of the retina consists of two layers. An outer pigmented layer and an inner neural layer:

The pigmented layer is firmly attached to the choroid and continues anteriorly on the non-visual part. It consists of a single layer of cells that reinforces the light absorbing property of the choroid in reducing the scattering of light in the eye. The neural layer, which can be further subdivided into its various neural components, is only attached to the pigmented layer around the optic nerve and at the ora serrata.

It is the neural layer that separates in the case of a detached retina. Several obvious features are visible on the fundus/posterior surface of the optic part of the retina. The optic disc is where the optic nerve leaves the retina. The branches of the central retinal artery spread from its centre to supply the retina. As there are no light-sensitive receptors cells in the optic disc it is referred to as a blind spot in the retina. On ophthalmoscopic examination, the optic disc is seen to be pale pink in color, much paler than the surrounding retina.

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Lateral to the optic disc a small area with a yellowish coloration, the macula lutea (yellow spot) with its central depression the fovea centralis. The maculae lutea is the thinnest area of the retina and visual sensitivity here is higher than elsewhere in the retina because it has fewer rods (light-sensitive receptor cells that function in dim light and are insensitive to color) and more cones (lightsensitive receptor cells that respond to bright light and are sensitive to color). Macula lutea - specialised for acuity. Fovea centralis - most acute vision. The retina is supplied by the central artery a branch of ophthalmic artery. The rods and cones are supplied by the choriocapillaries. The refractive media of the eye On their way to retina, light waves pass through the refractive media of the eye as it includes; cornea, aqueous humor, lens and vitreous humor. Most of the refraction of light takes place at the junction of air and corneal epithelium. Aqueous Humor The aqueous humor is a clear fluid that fills the anterior and posterior chambers of the eyeball. The anterior chamber of the eye is the larger space between the cornea and iris. The posterior camber of the eye is the space between the iris and lens & ciliary body. The aqueous humor is a secretion from the ciliary processes, from where it enters the posterior chamber. It then flows into the anterior chamber through the pupil and is drained away into the canal of Schlemm. Obstruction to the draining of the aqueous humor results in a rise in intraocular pressure called glaucoma. This can produce degenerative changes in the retina, with consequent blindness. The functions of the aqueous humor include; 1. support the wall of the eyeball by exerting internal pressure and thus maintaining its optical shape. 2. It also nourishes the cornea and the lens and removes the products of metabolism; ( cornea and the lens do not possess a blood supply). Vitreous humor The vitreous humor is a watery fluid enclosed in the meshes of the vitreous body (fills the eyeball behind the lens and is a transparent jelly-like substance). In addition to transmitting light, it supports the lens and assists in holding the neural part of the retina against the pigmented part of the retina. Unlike the aqueous humor, the vitreous humor can not be replaced.

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The Lens The lens is a transparent, biconvex structure enclosed in a transparent capsule. The lens separates the anterior one-fifth of the eyeball from the posterior 4/5th It is situated behind the iris and in front of the vitreous body. It is connected to the ciliary body by the suspensory ligaments. The lens fibers make up the bulk of the lens. The convexity of the lens esp its anterior surface, constantly varies to focus near or distant objects on the retina. The ciliary muscle changes the shape of the lens. Opacity of the lens is known as cataract. With increasing age and in certain disease states the lens of the eye becomes opaque. Increasing opacity results in increasing visual impairment. A common operation is excision of the 'cloudy' lens and replacement with a new manmade lens.
Arterial supply to the eyeball - read about retinal and ciliary circulations

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