ANATOMY

Eyelids

The skin consists of the epidermis, dermis and hypodermis,

comprising a wide range of cell types capable of proliferation and
neoplastic transformation.

The range of cutaneous tumours is thus very extensive, ranging

from common papillomas and basal cell carcinomas to much rarer
skin appendage and soft tissue tumours in the dermis.

Both benign and malignant tumours are classified according to their

cell of origin as well as to their location in the epidermis, dermis or
one of the skin appendages.

Eyelid skin (A) Normal skin is composed of keratinized stratified

epithelium that covers the surface; pilosebaceous elements are
conspicuous in the dermis and a few blood vessels and sweat glands
are also seen; (B) dysplasia with loss of cell polarity; (C) dyskeratosis
a non-surface epithelial cell producing keratin; (D) parakeratosis
retention of cell nuclei into the surface keratin layer

Eyelids
Epidermis
The epidermis consists of four layers of keratin-producing cells
(keratinocytes). It also contains melanocytes, Langerhans cells and
Merkel cells.

From superficial to deep, the layers of the epidermis are:

1. Keratin layer is very thin and consists of flat cells devoid of nuclei.
2. Granular cell layer consists of one or two layers of diamondshaped or flattened cells containing keratohyaline granules.

Eyelids
Epidermis

3. Stratum spinosum layer is approximately five cells in thickness.

The cells are polygonal and have abundant eosinophilic cytoplasm.
Their free borders are united by intercellular bridges (desmosomes),
hence the alternative term prickle cell layer.
4. Basal cell layer comprises a single row of columnar-shaped cells
that give rise to more superficial cells. Basal cells contain melanin
derived from adjacent melanocytes.

Eyelids
Dermis

The dermis is much thicker than the epidermis.

It is composed of connective tissue and contains blood vessels,

lymphatics and nerve fibres in addition to fibroblasts, macrophages
and mast cells.

Upward dermal projections (papillae interdigitate) with downward

epidermal projections (rete ridges).

In the eyelid the dermis lies on the orbicularis muscle.

Eyelids
Dermis

Skin appendages (adnexae) lie deep in the dermis or within the

tarsal plates:

1. Sebaceous glands are located in the caruncle and within

eyebrow hairs.

2. Meibomian glands are modified sebaceous glands located in the

tarsal plates. They empty through a single row of about 30 openings
on each lid. A gland consists of a central duct with multiple acini, the
cells of which synthesize lipids (meibum) that pass into the duct and
form the outer layer of the precorneal tear film.

3. Glands of Zeis are modified sebaceous glands that are

associated with lash follicles.

Eyelids
Dermis

4. Glands of Moll are modified apocrine sweat glands which open

either into a lash follicle or directly onto the anterior lid margin
between the lashes. They are more numerous in the lower lid.

5. Eccrine sweat glands are distributed throughout the eyelid skin

and are not confined to the lid margin, unlike glands of Moll.

6. Pilosebaceous units comprise hair follicles together with their

sebaceous glands.

Lacrimal drainage system

1. The puncta are located at the

posterior edge of the lid margin, at the
junction of the lash-bearing lateral fivesixths (pars ciliaris) and the medial
non-ciliated one-sixth (pars lacrimalis).

Normally they face slightly posteriorly

and can be inspected by everting the
medial aspect of the lids.

Treatment of watering caused by

punctal stenosis or malposition is
relatively straightforward.

Lacrimal drainage system

2. The canaliculi pass vertically from the lid margin for about 2 mm
(ampullae).

They then turn medially and run horizontally for about 8 mm to reach
the lacrimal sac.

The superior and inferior canaliculi most frequently unite to form the
common canaliculus, which opens into the lateral wall of the lacrimal
sac. In some individuals, each canaliculus opens separately.

A small flap of mucosa

(valve of Rosenmller) overhangs the junction
of the common canaliculus and the lacrimal
sac and prevents reflux of tears into the canaliculi.

Treatment of canalicular obstruction

is often complicated.

Lacrimal drainage system

3. The lacrimal sac is about 1012 mm long and lies in the lacrimal
fossa between the anterior and posterior lacrimal crests.

The lacrimal bone and the frontal process of the maxilla separate
the lacrimal sac from the middle meatus of the nasal cavity.

In a dacryocystorhinostomy (DCR) an anastomosis is created

between the sac and the nasal mucosa to bypass an obstruction in
the nasolacrimal duct.

Lacrimal drainage system

4. The nasolacrimal duct is 1218 mm long and is the inferior

continuation of the lacrimal sac.

It descends and angles slightly laterally and posteriorly to open into

the inferior nasal meatus, lateral to and below the inferior turbinate.

The opening of the duct is partially covered by a mucosal fold (valve

of Hasner). Obstruction of the duct may cause a secondary
distension of the sac.

Lacrimal drainage system

Physiology
Tears secreted by the main and accessory lacrimal glands pass
across the ocular surface.
A variable amount of the aqueous component of the tear film is lost
by evaporation. This is related to the size of the palpebral aperture,
the blink rate, ambient temperature and humidity. The remainder of
the tears drain as follows:

Lacrimal drainage system

a. Tears flow along the upper and lower marginal strips (A) and enter the
upper and lower canaliculi by capillarity and also possibly by suction.

b. With each blink, the pretarsal orbicularis oculi compresses the ampullae,
shortens and compresses the horizontal canaliculi and moves the puncta
medially. Simultaneously, the lacrimal part of the orbicularis oculi, which is
attached to the fascia of the lacrimal sac, contracts and compresses the
sac, thereby creating a positive pressure which forces the tears down the
nasolacrimal duct and into the nose (B and C).

c. When the eyes open the muscles relax, the canaliculi and sac expand
creating a negative pressure which, assisted by capillarity, draws the tears
from the eye into the empty sac.

Conjunctiva

The conjunctiva is a transparent mucous membrane lining the inner

surface of the eyelids and the surface of the globe as far as the
limbus.

It is richly vascular, supplied by the anterior ciliary and palpebral

arteries.

There is a dense lymphatic network, with drainage to the

preauricular and submandibular nodes corresponding to that of the
eyelids.

It has a key protective role, mediating both passive and active

immunity.

Conjunctiva

Anatomically, it is subdivided into the following:

1. The palpebral conjunctiva starts at the mucocutaneous junction
of the lid margins and is firmly attached to the posterior tarsal plates.
The underlying tarsal blood vessels can be seen passing vertically
from the lid margin and fornix.

2. The forniceal conjunctiva is loose and redundant and may be

thrown into folds.

3. The bulbar conjunctiva covers the anterior sclera and is

continuous with the corneal epithelium at the limbus. Radial ridges
at the limbus form the palisades of Vogt. The stroma is loosely
attached to the underlying Tenon capsule, except at the limbus,
where the two layers fuse. A plica semilunaris (semilunar fold) is
present nasally, medial to which lies a fleshy nodule (caruncle)
consisting of modified cutaneous tissue containing hair follicles,
accessory lacrimal glands, sweat glands and sebaceous glands.

Conjunctiva

Histology of the conjunctiva

Cornea

The cornea is a complex structure which, as well as having a

protective role, is responsible for about three-quarters of the optical
power of the eye.

The normal cornea is free of blood vessels; nutrients are supplied

and metabolic products removed mainly via the aqueous humour
posteriorly and the tears anteriorly, with a downhill anteriorposterior
oxygen gradient.

The cornea is the most densely innervated tissue in the body, with a
subepithelial and a deeper stromal plexus, both supplied by the 1st
division of the trigeminal nerve.

For this reason corneal abrasions and disease processes such as

bullous keratopathy are associated with pain, photophobia and
reflex lacrimation.

Cornea

Dimensions
The average corneal diameter is 11.5 mm vertically and 12 mm
horizontally.

It is 540 m thick centrally on average, and thicker towards the

periphery.

Central corneal thickness varies between individuals and is a key

determinant of the conventionally-measured intraocular pressure
level.

Cornea
The cornea consists of the following layers, each of which is critical
to normal function:
1. The epithelium is stratified squamous and non-keratinized, and
is composed of the following:
A single layer of columnar basal cells attached by
hemidesmosomes to an underlying basement membrane.
Two to three strata of wing cells.
Two layers of squamous surface cells.
The surface area of the outermost cells is
increased by microplicae and microvilli that
facilitate the attachment of the tear film and
mucin. After a lifespan of a few days
superficial cells are shed into the tear film.

Cornea

2. Bowman layer is the acellular superficial

layer of the stroma formed from collagen
fibres.

3. The stroma makes up 90% of corneal

thickness. It is arranged in regularly orientated
layers of collagen fibrils whose spacing is
maintained by proteoglycan ground substance
(chondroitin sulphate and keratan sulphate)
with interspersed modified fibroblasts
(keratocytes). Maintenance of the regular
arrangement and spacing of the collagen is
critical to optical clarity. The stroma cannot
regenerate following damage.

Cornea

4. Descemet membrane is a discrete sheet

composed of a fine latticework of collagen fibrils
that are distinct from the collagen of the stroma. It
has regenerative potential.

5. The endothelium consists of a monolayer of

polygonal cells. Endothelial cells maintain corneal
deturgescence throughout life by pumping excess
fluid out of the stroma. The adult cell density is
about 2500 cells/mm2. The number of cells
decreases at about 0.6% per year and
neighbouring cells enlarge to fill the space; the
cells cannot regenerate. At a cell density of about
500 cells/mm2 corneal oedema develops and
transparency is reduced.

Sclera

The scleral stroma is composed of collagen bundles of varying size

and shape that are not as uniformly orientated as in the cornea.

The inner layer of the sclera (lamina fusca) blends with the
suprachoroidal and supraciliary lamellae of the uveal tract.

Anteriorly the episclera consists of a dense, vascular connective

tissue which lies between the superficial scleral stroma and Tenon
capsule.

Sclera

The three vascular layers that cover the anterior sclera are as
follows:
1. The conjunctival vessels are the most superficial; arteries are
tortuous and veins straight.

2. The superficial episcleral plexus vessels are straight with a

radial configuration.
In episcleritis, maximal congestion occurs within this vascular
plexus. Tenon capsule and the episclera are infiltrated with
inflammatory cells, but the sclera itself is not swollen.
Instillation of topical phenylephrine
will cause blanching of the conjunctival and
to a certain extent the superficial episcleral
vessels, allowing visualization of the underlying
sclera.

Episcleritis with maximal vascular congestion of

the superficial episcleral plexus

Sclera

3. The deep vascular plexus lies in the superficial part of the sclera
and shows maximal congestion in scleritis.

There is also inevitably some engorgement of the superficial

vessels, but this should be ignored.

Examination in daylight is important to localize the level of maximal

injection; scleritis often has a purplish hue.

scleritis with scleral thickening and maximal

vascular congestion of the deep vascular plexus

Uvea

Vascular layer under sclera

Richly pigmented membrane, highly vascularized - nutritional
membrane of the eye
Three components:
- iris
- ciliary body
- choroid

Uvea

Iris
The anterior portion of the uvea, located behind the
cornea and in front of the lens

The shape of a diaphragm with a central hole called the pupil (1.5 - 9 mm)

Front face provided with radial depressions (crypts)

- peripheral area ciliary part
- the central area - pupillary
part, collar pigmented area

Colour - the amount of cromatofore stroma cells

Uvea

Iris functions:

aperture: adjust the size of the pupil amount of light

reaching the retina

protector of the retina: the absorption of light rays that

penetrate the cornea

the absorption of aqueous humor

Uvea

Ciliary body middle part of the uveea,

extends from iris root until orra serrata, with a

width of 6-7 mm

2 parts:
- anterior part - pars plicata contains ciliary
processes and ciliary valleys (ciliary processes
produce aqueous humour)
- posterior part - pars plana
Smooth muscle fibres ciliary muscle

Functional role:
- aqueous humor secretion
- accommodative role - changes the refractive
power of the lens by traction on the zonula
of Zinn

Uvea

Choroid

Posterior portion of the uvea, stretching

from orra serrata to the papilla of the optic
nerve
In relation to the sclera outside and retina
inside
Intensely pigmented and vascularized

Functional role
- nutrition: vascularized
- mechanical protection
- darkroom of the eye: rich in melanin
pigment

Aqueous secretion

Aqueous humour is produced in two steps:

Formation of a plasma filtrate within the stroma of the

ciliary body.

Formation of aqueous from this filtrate across the

blood-aqueous barrier.

Aqueous secretion

Two mechanisms are involved:

1. Active secretion by the non-pigmented ciliary epithelium
accounts for the vast majority, and involves a metabolic process that
depends on several enzyme systems, especially the Na+/K++
ATPase pump which secretes sodium ions into the posterior
chamber.

2. Passive secretion by ultrafiltration and diffusion, which are

dependent on the capillary hydrostatic pressure, oncotic pressure
(colloid osmotic pressure exerted by proteins in blood plasma) and
the level of IOP, is thought to play a minor role in the genesis of
aqueous humour under normal conditions.

Aqueous secretion

Aqueous outflow
Anatomy

Scanning electron micrograph of the

trabecular meshwork

Anatomy of outflow channels. (A) Uveal meshwork; (B) corneoscleral meshwork; (C)
Schwalbe line; (D) Schlemm canal; (E) connector channels; (F) longitudinal muscle of
the ciliary body; (G) scleral spur

Aqueous secretion

1. The trabecular meshwork (trabeculum) is a sieve-like structure at the

angle of the anterior chamber, through which 90% of the aqueous humour
leaves the eye. It is made up of the following three portions:

a. The uveal meshwork is the innermost portion and consists of cord-like

endothelial cell-covered strands arising from the iris and ciliary body
stroma, and extending from the root of the iris to Schwalbe line.

b. The corneoscleral meshwork forms the larger middle portion which

extends from the scleral spur to Schwalbe line. The layers are sheet-like
and composed of connective tissue strands also with overlying
endothelial-type cells.

c. The juxtacanalicular (cribriform)

meshwork is the outer part of the trabeculum,
and links the corneoscleral meshwork with the
endothelium of the inner wall of the Schlemm canal.

Aqueous secretion

2. Schlemm canal (D) is a

circumferential channel in the perilimbal
sclera, bridged by septa.

The inner wall is lined by irregular

spindle-shaped endothelial cells
containing infoldings (giant vacuoles)
which are thought to convey aqueous
via the formation of transcellular pores.

The outer wall is lined by smooth flat

cells and contains the openings of the
collector channels which leave the canal
at oblique angles and connect directly or
indirectly with episcleral veins.

Aqueous secretion

Physiology
Aqueous flows from the posterior chamber via the pupil into the anterior
chamber, from where it exits the eye by two different routes :

1. Trabecular (conventional) route accounts for approximately 90% of

aqueous outflow. The aqueous flows through the trabeculum into the
Schlemm canal and is then drained by the episcleral veins. This is a bulk
flow pressure-sensitive route so that increasing the pressure head will
increase outflow. Trabecular outflow can be increased by drugs (miotics,
sympathomimetics), laser trabeculoplasty and filtration surgery.

Routes of aqueous outflow.

(A) Trabecular; (B) uveoscleral;
(C) iris

Aqueous secretion

2. Uveoscleral (unconventional) route accounts for the remaining

10% in which aqueous passes across the face of the ciliary body
into the suprachoroidal space and is drained by the venous
circulation in the ciliary body, choroid and sclera. Uveoscleral
outflow is decreased by miotics and increased by atropine,
sympathomimetics and prostaglandin analogues.
3. Some aqueous also drains via the iris.

Routes of aqueous outflow. (A) Trabecular;

(B) uveoscleral; (C) iris

Lens

The lens is a transparent structure

shaped - biconvex lens
iris anterior
vitreous posterior
suspended to ciliary body by a ligament (zonula of Zinn) which
transmits ciliary muscle contraction to the lens, thus making
accommodation phenomenon
Has two faces, two poles and an equator
Histologically - layers
- capsule (anterior crystalloid)
- epithelium
- lens mass, nucleus
- capsule (posterior crystalloid)

Vitreous

The vitreous is a transparent extracellular gel, with a complicated

structural framework consisting of collagen, soluble proteins,
hyaluronic acid and a water content of 99%.

Its total volume is approximately 4.0 mL.

The few cells normally present in the gel are located predominantly
in the cortex and consist of hyalocytes, astrocytes and glial cells.

Vitreous

The vitreous provides structural support to the

globe while providing a clear path for light to
reach the retina. It also hinders the forward
diffusion of oxygen from the retinal blood supply
to the anterior segment.

Once liquefied or surgically removed it does not

reform.

Vitreous opacities may be caused by

developmental abnormalities, trauma or disease
(malignant cells, parasitic cysts and hereditary
vitreoretinopathies).

Retina

1. The macula is a round area at the posterior pole, lying inside the
temporal vascular arcades. It measures between 5 and 6 mm in diameter,
and subserves the central 1520 of the visual field.

Histologically, it shows more than one layer of ganglion cells, in contrast to

the single ganglion cell layer of the peripheral retina.

The inner layers of the macula contain the yellow xanthophyll carotenoid
pigments lutein and zeaxanthin in far higher concentrations than the
peripheral retina (hence the full name macula lutea yellow plaque).

(A) Normal foveal light reflex

Retina

2. The fovea is a depression in the retinal surface at the centre of

the macula, with a diameter of 1.5 mm, about the same as the optic
disc.

(B) OCT shows the foveal

depression

Cross-section of the fovea

Retina

3. The foveola forms the central floor of the fovea and has a
diameter of 0.35 mm. It is the thinnest part of the retina and is
devoid of ganglion cells, consisting only of a high density of cone
photoreceptors and their nuclei, together with Mller cells.

4. The umbo is a depression in the very centre of the foveola which

corresponds to the foveolar light reflex, loss of which may be an
early sign of damage.

5. The foveal avascular zone (FAZ), a central area containing no

blood vessels but surrounded by a continuous network of
capillaries, is located within the fovea but extends beyond the
foveola. The exact diameter varies with age and in disease, and its
limits can be determined with accuracy only by fluorescein
angiography (FA); an average is 0.6 mm.
(C) fovea (yellow circle); foveal avascular
zone-approximate (red circle); foveola (lilac
circle); umbo (central white spot)

Retinal pigment epithelium

1. Structure
The retinal pigment epithelium (RPE) is composed of a single layer
of cells, hexagonal in cross-section. The cells consist of an outer
non-pigmented basal element containing the nucleus, and an inner
pigmented apical section containing abundant melanosomes.

The cell base is in contact with Bruch membrane, and at the cell
apices multiple thread-like villous processes extend between the
outer segments of the photoreceptors.

At the posterior pole, particularly at the fovea, RPE cells are taller
and thinner, more regular in shape and contain more numerous and
larger melanosomes than in the periphery.

Retina

2. Functions
RPE cells and intervening tight junctional complexes (zonula
occludentes) constitute the outer bloodretinal barrier, preventing
extracellular fluid leaking into the subretinal space from the
choriocapillaris, and actively pump ions and water out of the
subretinal space.
Its integrity, and that of Bruch membrane, is important for
continued adhesion between the two, thought to be due to a
combination of osmotic and hydrostatic forces, possibly with the aid
of hemidesmosomal attachments.

Retina

2. Functions

Facilitation of photoreceptor turnover by the phagocytosis and

lysosomal degradation of outer segments following shedding.

Maintenance of the outer bloodretinal barrier is a key factor, as

are the inward transport of metabolites (mainly small molecules such
as amino acids and glucose) and the outward transport of metabolic
waste products.

Storage, metabolism, and transport of vitamin A in the visual cycle.

Retina
Bruch membrane
1. Structure
Bruch membrane separates the RPE from the
choriocapillaris and on electron microscopy
consists of five distinct elements:
The basal lamina of the RPE.
An inner collagenous layer.
A thicker band of elastic fibres.
An outer collagenous layer.
The basal lamina of the inner layer
of the choriocapillaris.

Retina

2. Function

The RPE utilizes Bruch membrane as a route for the transport of

metabolic waste products out of the retinal environment.

Changes in its structure are thought to be important in the

pathogenesis of many macular disorders for example, its integrity
may be important in the suppression of choroidal neovascularization
(CNV).

Optic Nerve Head

Optic disc size

Optic disc size is important in deciding if a
cup-disc (C/D) ratio is normal. Normal
median vertical diameter for nonglaucomatous discs is 1.50 mm in a
Caucasian population.
Cupdisc ratio C/D ratio
The C/D ratio indicates the diameter of the
cup expressed as a fraction of the diameter
of the disc; the vertical rather than the
horizontal ratio is generally used in clinical
practice. The NRR occupies a relatively
similar cross-sectional area in different eyes.

Optic Nerve Head

Neuroretinal rim
The neuroretinal rim (NRR) is the tissue between the outer edge of
the cup and the optic disc margin. The normal rim has an orange or
pink colour and a characteristic configuration in most healthy eyes:
the inferior rim is the broadest followed by the superior, nasal and
temporal (the ISNT rule).

Optic Nerve Head

Small discs have small cups with a median C/D ratio of about 0.35
Large discs have large cups with a median C/D ratio of about 0.55
Only 2% of the population have a C/D ratio greater than 0.7.
In any individual, asymmetry of 0.2 or more between the eyes
should also be regarded with suspicion, though it is critical to
exclude a difference in overall disc size.

Normal discs. (A) Small disc with a low C/D ratio; (B) large disc with
a higher C/D ratio

Bibliography

Kanski Jack J. Clinical Ophthalmology: a

systematic approach 7th ed.
Butterworth-Heinemann International
Editions 2011