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pyramid that becomes three-sided near the apex (Fig. 1). The bony orbit has
a volume of approximately 30 cc. The adult orbital margin is approximately
rectangular with a horizontal dimension of 40 mm and a vertical dimension
of 35 mm. The widest dimension of the orbit is 1 cm behind the anterior
orbital rim. The medial walls are separated by 25 mm in the average adult
and are roughly parallel.1 The length of the medial orbital wall from the
anterior lacrimal crest is 45 to 50 mm, whereas the lateral wall from the rim
to the superior orbital fissure measures 40 mm. The adult lateral orbital
walls are angled 90 degrees from each other, or 45 degrees in the
anteroposterior direction. The divergent axis of each orbit thus becomes half
of 45 degrees or 22.5 degrees (Fig. 2). The eyes tend to diverge in
accordance with their bony surroundings, as seen in persons with acquired
visual loss, under general anesthesia, or in death. Because of the continuous
need for torsion of the globe away from the orbital axis, it is not surprising
to find that the medial is the thickest of the rectus muscles. The lateral
orbital rim is approximately at the level of the equator of the globe.
Fig. 1 Anterior view of the orbit. The walls are made up of seven bones; the
roof consists of the sphenoid (S) and the frontal bone (F); the lateral wall
consists of the sphenoid (S) and zygomatic bones (Z); the floor consists of
the maxilla (M), the palatine (P), and zygomatic bones (Z); the medial wall
consists of the sphenoid (S), maxilla (M), ethmoid (E), lacrimal bones (L),
and supraorbital notch (SON).
The intraorbital optic nerve measures 25 mm, on the average, between the
back of the globe and the entrance into the optic foramen, but the distance
between these structures is only 18 mm. This 7 mm of slack in the optic
nerve results in a gentle curve with a convexity directed inferotemporally in
the orbit. This degree of play in the nerve allows free eye movement and
40 mm
35 mm
Volume
30 cc
4555 mm
18 mm
25 mm
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ORBITAL RIM
The zygomatic bone forms the lateral orbital margin. It serves as an orbital
protector or facial buttress that can withstand significant trauma without
fracturing. When fractured, steps may be palpable inferiorly at the
zygomaticomaxillary suture and superolaterally at the zygomaticofrontal
suture. The frontal bone comprises the superior orbital margin and extends
both laterally and medially to form portions of those borders (see Fig. 1). In
the newborn, the supraorbital rim is sharp; it remains so in the female but
becomes rounded with development in the male. In most skulls, the superior
rim at the junction of its medial one-third is indented by a supraorbital
notch, where the supraorbital nerve and artery pass to innervate the forehead
and frontal sinus. In approximately 25% of skulls, the frontal bone covers
these structures, forming a foramen.
The medial orbital rim is formed anteriorly by the maxillary bone rising to
meet the maxillary process of the frontal bone. The lacrimal sac fossa
complicates the medial rim by indenting the bone and forming anterior
(maxillary bone) and posterior (lacrimal bone) crests. Thus, Whitnall2
likened the definable orbital rim to a single coil of an undulating spiral. The
inferior orbital rim is comprised of the maxillary and zygomatic bones, and
inferior to the rim exits the infraorbital nerve and artery.
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ORBITAL WALLS
The orbital walls are embryologically derived from neural crest cells.
Ossification of the orbital walls is completed by birth, except at the orbital
apex. The lesser wing of the sphenoid is initially cartilaginous, unlike the
greater wing of the sphenoid and other orbital intramembranous bones.
The walls are made up of seven bones (see Fig. 1).
The orbital roof is principally comprised of the frontal bone. Its progressive
concavity with growth reflects molding of the globe. Posteriorly, the roof
remains flat and receives a 1.5-cm contribution from the lesser wing of the
sphenoid bone as the roof tapers into the anterior clinoid process of the
lesser sphenoid. At an angle of about 45 degrees from the midline, the optic
nerve enters the optic foramen located in the lesser wing of the sphenoid at
the orbital apex. Anteromedially, the small trochlear fossa is found, and the
large lacrimal gland fossa is seen laterally. The roof is usually strong, and
only rarely will blunt ocular trauma disrupt it, in contrast to the commonly
seen orbital floor fracture.
The lateral orbital wall is bordered by the superior and inferior orbital
fissures. The anterior borders are formed by the frontozygomatic and the
zygomaticomaxillary sutures. Posteriorly, the greater wing of the sphenoid is
alone in forming the lateral wall but is met anteriorly by the zygoma and the
lateral angular (zygomatic) process of the frontal bone. Near the suture
between the frontal and sphenoid bones, a meningeal foramen conducting
the recurrent meningeal artery off the middle meningeal artery may be
found. This artery anastomoses the external carotid circulation with the
internal carotid system via the lacrimal artery from the ophthalmic artery.
Approximately 4 to 5 mm behind the lateral orbital rim at its midpoint,
approximately 1cm inferior to the frontozygomatic suture, is the lateral
orbital tubercle of Whitnall.3 The lateral canthal ligament, the lateral rectus
check ligament, the lateral horn of the levator aponeurosis, the suspensory
ligament of the lower lid (Lockwood's ligament), the orbital septum, and the
lacrimal gland fascia attach at Whitnall's tubercle. Whitnall's tubercle is
usually the location for reattachment during the lateral tarsal strip or other
lateral canthal procedures. The zygoma thickens inferiorly and forms the
anterior loop of the inferior orbital fissure. This thicker zygoma also
separates the orbit from the buccal fat-pad.
Posterior and lateral to the lateral orbital wall lies the temporalis muscle,
which is firmly adherent to the bony temporal fossa. The frontal process of
the zygomatic bone and the zygomatic process of the frontal bone are quite
thick and protect the globe from lateral trauma. Behind this facial buttress
area, the posterior zygomatic bone and the orbital plate of the greater wing
of the sphenoid is thinner, making the zygomaticosphenoid suture a
convenient breaking point for bone removal during lateral orbitotomy. The
The floor is the shortest of the orbital walls and is shaped like an equilateral
triangle. A line passing through the axis of the inferior orbital fissure forms
the lateral border (see Fig. 1). The medial border can be defined with
anterior and posterior extensions of the maxillary-ethmoidal suture. The
orbital plate of the maxillary bone comprises nearly the entire floor with
small contributions from the palatine bone posteriorly and from the zygoma
anterolaterally. The posterior infraorbital groove becomes a canal anteriorly
as the nerve passes through the infraorbital foramen (see Fig. 1). In
childhood the infraorbital foramen is found immediately below the orbital
margin, but as the face grows into adult size, the foramen migrates 6 to 10
mm below the orbital rim. The floor remains strong lateral to the infraorbital
nerve but becomes thin medially with maxillary sinus expansion. This
unsupported dome of maxillary sinus is where the floor usually fractures
with trauma, often causing hypesthesia of the infraorbital skin, the lateral tip
of the nose, and the anterior superior gingiva. The nasolacrimal duct lies at
the anteromedial orbital floor and travels inferiorly and posteriorly 2 cm
along the lateral wall of the nose before exiting into the inferior meatus.
The medial orbital wall is composed, from anterior to posterior, by the
frontal process of the maxilla, the lacrimal bone, the ethmoid bone, and the
lesser wing of the sphenoid bone. The thinnest portion of the medial wall is
the lamina papyracea, which covers the ethmoid sinuses posterior to the
maxillary bone (see Fig. 1). It can be breached by inflammatory and
neoplastic disease that originates in the ethmoid air cells as well as by
dissection during surgery. In children, infections of the ethmoid sinuses
commonly extend through the lamina papyracea as a result of dehiscences or
venous channels to cause orbital cellulitis and proptosis. The medial wall
becomes thicker posteriorly at the body of the sphenoid and again anteriorly
at both the posterior lacrimal crest of the lacrimal bone and the anterior
lacrimal crest of the maxillary bone. The many bullae of ethmoid
pneumatization appears as a honeycomb pattern beneath the ethmoidal
orbital plate. This supportive structure, in part, explains why the medial wall
fractures less often than the thicker orbital floor. The frontoethmoidal suture
is important in orbital bony decompression or medial exploration because it
marks the roof of the ethmoid sinus, and bony dissection superior to this
suture line may expose the dura of the frontal lobe. The anterior and
posterior ethmoidal foramina conveying branches of the ophthalmic artery
and the nasociliary nerve are located at the frontoethmoidal suture 24 mm
and 35 mm posterior to the anterior lacrimal crest, respectively (see Fig. 1).
The location of these foramina is important when the surgeon gives an
anterior ethmoidal nerve block for local anesthesia during medial
orbitotomy.
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NASAL AND PARANASAL SINUSES
Knowledge of nasal and paranasal sinus anatomy improves our
understanding of surgical relationships to the orbit, as well as endonasal
anatomy. Furthermore, when lacrimal surgery is performed using the
endonasal approach, the surgeon must be familiar with this anatomy.
Each paranasal sinus is named for the bone into which it originally
invaginates during fetal life. The bones forming the orbital floor, roof, and
medial wall are pneumatized by air sinuses arising from and maintaining
communication with the nasal cavity. Ethmoid bullae are particularly
exuberant in their expansion and may pneumatize the orbital plate of the
frontal bone, and even develop as frontal sinuses. The maxillary processes
contribute the maxillary bone portion of the lateral nasal wall and the
majority of the nasal floor, the posterior or secondary palate. The ethmoid
box, derived from the embryologic nasal frontal process, spans the roof of
the nasal cavity, arching from the superior lateral nasal walls (see Fig. 4).
The nasal cavity is bisected anteriorly by the cartilage and septum, which
joins the vomer, a bony vertical plate of ethmoid, posteriorly. Laterally, the
nasal wall is thrown into three or more horizontal ridges termed turbinates,
with spaces below each with corresponding names (Fig. 5). The inferior
turbinate is the largest ridge, whereas the progressively smaller and more
posterior middle, superior, and supreme turbinates (sometimes present) are
outcroppings of the ethmoid bone. The large cartilaginous anterior dilatation
of the nose is the nasal vestibule. When the exterior nares are dilated by a
nasal speculum, the inferior turbinate and inferior meatus can be seen by
tilting the blades to look along the nasal floor. The middle turbinate and
nasal atrium are seen, if the examiner does not forcibly rotate the blades.
Because the atrium wall is convex medially, an external
dacryocystorhinostomy site located at the anterior or inferior tip of the
middle turbinate may not be directly visualized. A dacryocystorhinostomy
achieved by the endoscopic laserassisted approach is usually more inferior
and posterior to the routine external site.5 The nasolacrimal duct drains under
the inferior turbinate, whereas the frontonasal duct from the frontal sinus
drains into the anterior middle meatus. Within the middle meatus posterior to
the atrium lies a curvilinear ridge, the uncinate process, with the hiatus
semilunaris depression behind, which houses the ostium of the maxillary
sinus (see Fig. 5).6
Fig. 5 Endonasal sagittal view. Each meatal space is named for the turbinate
that lies immediately above. (ST, superior turbinate; OM, ostium of
maxillary sinus; MT, middle turbinate; NV, nasal vestibule; IT, inferior
turbinate; ONLD, ostium of nasal lacrimal duct; BE, bulla ethmoidalis; S,
sphenoid sinus; HS, hiatus semilunaris; F, frontal sinus; UP, uncinate
process; EO, ethmoid ostia)
The paranasal sinuses more than double the nasal chamber volume. The
The sphenoid sinus also continues to grow until adulthood with varying
degrees of pneumatization. It drains into the sphenoethmoid recess under the
superior turbinate. In the instance where the sphenoid body is fully
pneumatized, only sinus mucoperiosteum, a thin layer of bone, and
periosteum separate the respiratory tract from the overlying internal carotid
artery, the cavernous sinus, and branches of the trigeminal nerve.
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ORBITAL APEX: SUPERIOR ORBITAL FISSURE, INFERIOR ORBITAL
FISSURE
The orbital apex contains a plethora of vital structures. A large number of
arteries, veins, and nerves pass through several significant foramina. The
superior orbital fissure is a transverse notch between the greater and lesser
wings of the sphenoid bone that descends medially (see Fig. 1). Although
the shape of the superior orbital fissure is variable, the superior portion is
usually narrower where the lacrimal, frontal, and trochlear nerves pass (Fig.
6). The middle meningeal artery anastomosis with the ophthalmic artery
may enter here, if not through its own foramen, more anteriorly in the roof.
Most of the venous drainage from the orbit and the globe flow through the
superior orbital fissure to the cavernous sinus. Other structures passing
through the superior orbital fissure within the annulus of Zinn include the
superior and inferior divisions of the third cranial nerve, the sixth cranial
nerve, and the nasociliary branch of the ophthalmic trigeminal nerve (Fig.
6).
Fig. 6 Orbital apex with nerves coursing through foramina. (LN, lacrimal
nerve; NCN, nasociliary nerve; FN, frontal nerve; VI, abducens nerve; IV,
trochlear nerve; INF III, inferior division of cranial nerve III; SOV, superior
ophthalmic vein; II, cranial nerve II; SUP III, superior division of cranial
nerve III; IOV, inferior ophthalmic vein; ZN, zygomatic nerve; V2, V2
nerve; SGB, sphenopalatine ganglion branches)
infraorbital nerve and artery, which then traverse the infraorbital canal and
foramen to carry sensation to the lower lid, cheek, upper lip, and upper
anterior gingiva. It is important to identify this neurovascular bundle during
midface suborbicularis oculi fat lifts to avoid inadvertent injury.
The inferior orbital fissure extends more anteriorly than the superior orbital
fissure, ending about 20 mm from the anterior orbital rim. This structure
serves as a posterior landmark in the surgical subperiosteal dissection along
the orbital floor. Immediately beneath the infraorbital fissure lies the
pterygoid space with the temporalis fossa laterally; blunt trauma to the
temporalis muscle can result in orbital hemorrhage via this connection (see
Fig. 3).
Orbital Soft Tissues
The soft tissues contained within the bony walls of the orbit and limited
anteriorly by the orbital septum are discussed in this section in the following
order: orbital septum, periorbita, orbital fascia, orbital fat, lacrimal gland,
extraocular muscles, levator palpebrae superioris, Mller's muscle, optic
nerve and meninges, globe, orbital nerves, orbital vessels, and orbital
lymphatic drainage.
Orbital Septum
The orbital septum is the anterior soft tissue boundary of the orbit and acts
as a physical barrier against pathogens and maintains the normal posterior
position of the orbital fat-pads. It is a thin, multilayered sheet of fibrous
tissue derived from the mesodermal layer of the embryonic eyelid. The
septum is covered by a thin layer of preseptal orbicularis and skin and
originates from the superior and inferior orbital rims at a thick, white fibrous
line called the arcus marginalis to insert onto the eyelid retractors. Medially,
the septum covers the posterior aspect of Horner's muscle as it inserts along
the posterior lacrimal crest. Laterally, the septum fuses with the lateral
canthal tendon and lateral horn of the levator aponeurosis to attach to the
lateral orbital rim11 (see Fig. 7).
Fig. 7 Anterior view of orbital septum and related structures. The medial
deep orbital insertion of the orbicularis muscle carries the orbital septum
behind it. The septal attachments to the levator aponeurosis in the upper lid
and inferior tarsus in the lower lid are also demonstrated, as well as the
anatomic relationships to the structures of the upper lid. (AE, arcuate
expansion of the inferior oblique; CFP, central fat-pad; IO, inferior oblique
muscle; LA, levator aponeurosis; LCT, lateral canthal tendon; LFP, lateral
fat-pad; LGO, lacrimal gland orbital lobe; LGP, lacrimal gland palpebral
lobe; LLR, lower lid retractors; MCT, medial canthal tendon; MFP, medial
fat-pad; OS, orbital septum; STA, supratrochlear artery, nerve, vein; SOA,
supraorbital artery, nerve, vein; TP, tarsal plate; Tr, trochlea; WL, Whitnall's
ligament)
In the lower eyelid, the septum inserts onto the inferior border of tarsus after
joining with the lower lid retractors 4 to 5 mm below the tarsus. The
superior orbital septum does not insert onto the superior tarsal plate because
of the intervening levator aponeurosis; rather it inserts on the aponeurosis
about 10 mm above the superior eyelid margin, or 2 to 5 mm above the
superior tarsal border in non-Asians11 (see Fig. 8). In Asian lids, the orbital
septum fuses to the levator aponeurosis at a level below the superior tarsus,
allowing preaponeurotic fat to prolapse inferior and anterior to tarsus; in the
lower lid, it may fuse directly to the inferior tarsal border rather than joining
with the retractors. An absent or lower lid crease in Asian eyelids may be
due to this fat protrusion and other subcutaneous fat tissue that inhibits
levator fibers from inserting into the subdermal skin.12
The septum may attenuate with age allowing orbital fat to herniate forward,
requiring blepharoplasty. In performing levator surgery or blepharoplasty the
The periorbita is extensively vascularized on both its bone and soft tissue
sides. These vessels are interconnected so that the periosteum does not serve
as a vascular barrier area.14 It is supplied by twigs from regional branches of
the sensory intraorbital trigeminal nerve. The periorbita has a dense layer
adjacent to bone and a more loosely packed layer next to the orbital
contents. It serves as a membrane that can restrain periosteal hematomas and
temporally provide resistance to the spread of infections and tumors from
the sinuses and bones into the orbit. However, the periorbita can be
eventually dissolved by these processes. In children, granulocytic sarcoma
has a predilection for the periosteum and bones of the orbit.10 The periorbita
can often be the only separation between the orbital contents and dermoids
or mucoceles. The potential space between the periorbita and orbital bones
provides a convenient plane of dissection to many orbital tumors or for
removal of soft tissues in an exenteration.
Orbital Fascia
The fibrous tissue organization within the orbit may be divided into three
parts: the fascia covering the globe, the coverings of the extraocular
muscles, and the check ligament extensions of the extraocular muscle fascia
that extend to the surrounding bone and eyelids. Extensive work by
Koornneef,15 using a thick serial section technique has shown the orbital
fascia to be complex and highly organized.
Tenon's capsule, the fascia bulbi, is a fibrous membrane that extends from
the posterior aspect of the globe to fuse anteriorly with the conjunctiva
slightly posterior to the corneoscleral junction. It is thinnest at the entrance
of the optic nerve. It is closely applied to the globe but may be lifted some
distance from it to reveal a fine netlike character. The resultant space
between these structures is termed Tenon's space. Externally, Tenon's
capsule is joined to the network of fibrous septa dividing the lobules of
orbital fat. Thus, the globe is loosely related to the surrounding orbital fat,
and freedom of movement is afforded by elasticity in the septa and fat.
Tunnel-like openings in Tenon's fascia allow the extraocular muscles to pass
from the orbital fat into the Tenon's space to insert onto the sclera (see Fig.
10). In the areas of these openings, Tenon's capsule fuses with the
intermuscular septal fascia. Orbital implants used after enucleation are
placed either within this fibrous Tenon's capsule or posterior to it within the
muscle cone. Inflammatory pseudotumor may involve Tenon's capsule and
cause a tenonitis that can produce proptosis. B-scan ultrasonography can
help identify this type of periocular inflammation. Posterior geographic
scleritis and intense choroiditis may also cause secondary inflammations of
Tenon's capsule.10
Fig. 10 Tenon's fascia, anterior view. Tenon's capsule covers the globe and
extends onto the muscular fascia. Tenon's fascia is denser between the
muscles and thinner toward the posterior aspect of the globe. The
intermuscular septal fascia connecting the muscular sheaths is demonstrated
beneath the reflected Tenon's fascia. (IMF, intermuscular fascia; LGO,
lacrimal gland orbital lobe; LL, Lockwood's ligament; LPA, levator
palpebrae aponeurosis; MRC, medial rectus check ligament; MS, muscular
sheath; TF, Tenon's fascia; Tr, trochlea; WL,
Whitnall's ligament)
The fused inferior rectus and inferior oblique muscle sheaths send fascial
connections to the inferior periorbita, which may also have some checking
function.
Fig. 11 Superior view of the orbit. Whitnall's ligament fuses medially with
the trochlea of the superior oblique muscle and fuses laterally with the
lacrimal gland. The medial horn of the levator aponeurosis lies directly on
top of the superior oblique reflected tendon. The lateral horn of the levator
aponeurosis splits the palpebral and orbital lobe of the lacrimal gland. The
lateral rectus check ligament attaches to Whitnall's tubercle and is slightly
denser than the medial rectus ligament. (WL, Whitnall's ligament; OLG,
orbital lobe of lacrimal gland; SOT, superior oblique tendon; PAFP,
preaponeurotic fat-pad; LM, levator palpebrae superioris muscle; WT,
Whitnall's tubercle; MRM, medial rectus muscle; LRM, lateral rectus
muscle; SRM, superior rectus muscle)
The trabeculae of orbital fat are also part of this extensive fascial connective
tissue system of the orbit and globe. In Graves' disease as well as early
pseudotumor, the trabeculae of the orbital fat thicken, giving the fat a rough
texture.10
Nodular fasciitis is a reactive pseudosarcomatous proliferation of the fascial
connective tissues of the orbit and globe. It usually presents as a rapidly
developing nodule situated in the epibulbar region of the anterior
aponeurosis of the extraocular muscles. Although the histologic features can
be disturbing, the condition is benign.
Orbital Fat
The orbital structures are surrounded by orbital fat, which provides a
resilient cushion to support the globe. Anteriorly in the orbit, the fat is
fibrous, whereas the larger lobules are found posteriorly (see Fig. 13). In the
upper eyelid, the orbital septum covers a central preaponeurotic fat-pad and
a smaller medial fat-pad separated by the trochlea (see Figs. 7 and 8). The
medial fat-pad of the upper eyelid is firmer and whiter in color. The
infratrochlear nerve and the medial palpebral artery branch of the
ophthalmic artery courses through the medial fat. Clinically, there exist three
areas in the inferior orbit from which fat may protrude.22 The lateral fat pad
is divided from the central third by the lateral arcuate expansion fascial
attachments of the inferior oblique passing to the floor inferotemporally. The
medial and central fat-pads of the lower lid are separated by the inferior
oblique muscle (see Fig. 14). When excising fat during blepharoplasty,
excessive anterior traction on the fat may pull the muscle forward and lead
to its inadvertent injury.
As the fascial layers in the orbit thin with age, the orbital fat sometimes
prolapses through the weakened orbital septum into the lids. Asians may be
more predisposed to involutional entropion than whites due to a more
anterior and superior position of orbital fat within the lower eyelid.23 The
orbital fat in Asians appears to protrude anterior to the inferior orbital rim
and up to the inferior tarsus due to differences in orbital septum insertion
with the capsulopalpebral fascia.
It is quite rare to find a primary tumor of the orbital fat. Prolapse of the
orbital fat must be distinguished from lipomas. Liposarcoma of the orbit is
rare and originates from primitive mesenchymal cells related to the orbital
fascia rather than from a lipoma or preexistent adipose tissue. More
commonly, inflammatory pseudotumor may involve orbital fat to some
degree. The fat cells degenerate and release their lipid content, which further
augments the inflammatory process. Eventually, fibrosis and a sclerosing
lipogranuloma occurs. Trauma to the orbit can also cause fat necrosis and an
orbital lipogranuloma. An orbital abscess within the orbital fat can lead to fat
liquefaction. All types of chronic granulomatous disease, either infectious,
such as fungal infections, or noninfectious, such as Wegener's
granulomatosis, may involve the orbital fat.
Since the orbital fat fills most of the retrobulbar space, infections and
metastatic tumors may expand at its expense. Rare parasitic conditions, such
as hydatid cyst (Echinococcus granulosus) and cysticercosis, as well as
metastatic carcinoma and lymphoma are found in the retrobulbar fat.10
Lacrimal Gland
The main lacrimal gland resides in the superotemporal orbit in a shallow
lacrimal fossa of the frontal bone. The gland measures 20 mm by 12 mm by
5 mm and is divided by the lateral horn of the levator aponeurosis into a
larger orbital lobe and a lesser palpebral lobe as shown (see Figs. 7 and 11).
Division is not complete, since a posterior connection of parenchyma
persists between the lobes. The superior orbital lobe is bound anteriorly by
the orbital septum and the preaponeurotic fat-pad, behind by orbital fat, and
laterally by bone. The palpebral lobe lies underneath the levator aponeurosis
in the subaponeurotic Jones' space and is separated from conjunctiva
medially, where the superior tarsal muscle intervenes. Pleomorphic
adenomas typically involve the orbital lobe.
Secretory ducts from the palpebral lobe drain into the superotemporal
conjunctival fornix, as do those from the orbital lobe. The ducts of the
orbital lobe pass through the palpebral lobe, or on its surface, so that damage
to the latter structure may block the drainage of the entire lacrimal gland.
The scarring of the superotemporal conjunctiva may also close the ducts of
an otherwise healthy gland.
Arterial blood to the lacrimal gland is supplied by the lacrimal branch of the
ophthalmic artery, often with contributions from the recurrent meningeal
artery (which may join the lacrimal artery or enter the gland independently)
and by a branch of the infraorbital artery. The lacrimal artery then passes
through the gland and provides the blood supply to the temporal upper and
lower eyelids as the lateral palpebral arteries and subsequent arterial arcades.
The lacrimal vein follows approximately the same intraorbital course of the
artery and drains into the superior ophthalmic vein. Both artery and vein
communicate with the gland on its posterior surface.
The lacrimal gland receives innervation from cranial nerves V and VII as
well as from the sympathetics of the superior cervical ganglion. The lacrimal
nerve branch of the ophthalmic trigeminal nerve travels superotemporally in
the orbit just underneath the periorbita to enter the gland with the vessels.
Like the artery, the lacrimal nerve continues through the gland to supply
more superficial eyelid structures. Sympathetic nerves arrive with the
lacrimal artery and along with parasympathetics in the zygomatic nerve. The
zygomatic branch of the maxillary trigeminal nerve enters the orbit 5 mm
behind the anterior limit of the inferior orbital fissure and may indent the
medial canthal tendon. The puncta are 2 mm in height, the canaliculi are 8
mm in length, and the sac is 12 to 14 mm in height, with its fundus
extending slightly above the medial canthal tendon. The nasolacrimal duct
then travels inferolaterally and slightly posteriorly in its bony course to the
inferior turbinate. The valve of Rosenmuller is located at the junction of the
common canaliculus and sac, the valve of Krause between the sac and duct,
and the valve of Hasner at the ostium to the inferior meatus. The entry in an
external dacryocystorhinostomy is at the anterior middle meatus.
Extraocular Muscles
Except for the inferior oblique, the extraocular muscles all arise from the
orbital apex. The four recti muscles originate from the thick fibrous annulus
of Zinn, which surrounds the optic foramen at the orbital apex and divides
the superior orbital fissure into intraconal and extraconal spaces (see Fig. 6).
The levator and the superior oblique muscles arise more superiorly and
medially on the lesser wing of the sphenoid. The annulus of Zinn is
connected posteriorly to the dura and medially and laterally to the lesser and
greater wings of the sphenoid, respectively. Passing through the annulus of
Zinn are the oculomotor nerve divisions, the optic, the nasociliary and
abducen nerves, and the ophthalmic artery (see Fig. 6). Passing through the
superior orbital fissure outside the annulus are the trochlear, lacrimal, frontal
nerves, and the superior ophthalmic vein.
The horizontal recti muscles attain a length (excluding the tendon) of about
40.5 mm, whereas the superior rectus muscle is slightly longer and the
inferior rectus muscle shorter. The medial rectus muscle has the greatest
mass, and the superior rectus muscle has the least. The four recti muscles
course through the orbital fat and define the muscle cone. The muscles then
pass through openings in Tenon's fascia to insert on the anterior portion of
the globe in a configuration called the spiral of Tillaux (see Fig. 15). The
medial rectus inserts nearest at 5.5 mm posterior to the limbus, and the
superior rectus inserts farthest from the limbus at 7.7 mm. The relationship
of the muscle insertions and the ora serrata is clinically important. A
misdirected bridle suture passed through the insertion of the superior rectus
muscle could perforate the retina. The medial and inferior recti and inferior
oblique are supplied by the inferior division of the oculomotor nerve, the
superior rectus by the superior oculomotor division, and the lateral rectus by
the abducens nerve. Each enters the muscle on the ocular surface at the
junction of the posterior third with the anterior two-thirds (see Fig. 19).
Fig. 15 Anterior view of the right globe. The spiral of Tillaux is shown with
superimposed location of the ora serrata.
The inferior rectus muscle lies juxtaposed to the orbital floor posteriorly in
the region of the palatine bone but elevates from it more anteriorly. A series
of fibrous septa radiate to the inferior periorbita, suggesting that
incarceration of this tissue alone in a floor fracture may yield restriction of
the muscle. The inferior oblique muscle courses posterolaterally underneath
the inferior rectus muscle, and their conjoined fascias form the suspensory
ligament of Lockwood (see Fig. 12). The large inferior oculomotor nerve
division to the inferior oblique muscle travels anteriorly along, and is bound
to, the lateral border of the inferior rectus muscle.
The medial rectus remains close to the medial orbital wall until the anterior
third of its course when it angles laterally to insert on the eye. Just above the
medial rectus lie terminal branches of the nasociliary nerve and ophthalmic
artery. The lateral rectus muscle is separated from the optic nerve by the
ciliary ganglion, nasociliary nerve, and the ophthalmic artery, which are
embedded in the loose intraconal orbital fat (see Fig. 6).
Having arisen from the same mesoblastic mass, the superior rectus and
levator palpebrae superioris muscles remain fused at their medial borders.
The nasociliary nerve and ophthalmic artery leave the lateral orbit to cross
beneath the superior rectus.
The superior oblique, the roundest of extraocular muscles, arises from the
superomedial annulus of Zinn and courses anteriorly and superiorly for 40
mm from its origin, closely applied to the superior medial orbital wall.
Beneath it, and separating it from the medial rectus muscle, are the
ethmoidal branches of the nasociliary nerve and ophthalmic artery. The
superior oblique becomes tendinous just before it passes through the trochlea
located 5 to 10 mm posterior to the orbital rim. The tendon then makes a 54degree angle to continue posteriorly, laterally, and inferiorly to the eye. The
28-mm reflected tendon passes underneath the superior rectus and fans out
to insert on the globe in a broad-based attachment that extends to the
posterior pole. The distance between the temporal borders of the superior
rectus and superior oblique tendon averages 4.7 mm.29 The superior oblique
muscle depresses, intorts, and abducts the eye (see Fig. 11).
The trochlea is situated in a shallow fossa bearing its name on the
The inferior oblique muscle arises from a shallow depression in the orbital
plate of the maxilla at the anteromedial corner of the orbital floor just lateral
to the lacrimal excretory fossa. This muscle travels in a course similar to that
of the reflected superior oblique tendon. As noted before, the fascia of the
inferior rectus divides to encircle the inferior oblique, and their joined fascia
just anterior to the oblique forms the suspensory ligament of the globe
before continuing as the capsulopalpebral fascia and lower lid retractor
complex. The 37-mm inferior oblique muscle remains muscular until its
insertion on the globe, where a tendon several millimeters in length or the
muscle fibers themselves may enter into the sclera. The insertion is 2.2 mm
inferior and lateral to the macula and may be found 9.5 mm posterior to the
lateral rectus insertion. The nerve enters the middle of the muscle at the
lateral border of the inferior rectus muscle. Blood supply for the extraocular
muscles is from the medial and lateral muscular branches of the ophthalmic
artery, the lacrimal artery, and the infraorbital artery. Except for the lateral
rectus, each muscle receives two anterior ciliary arteries that communicate
with the major arteriole circle of the ciliary body. The lateral rectus is
supplied by a single vessel derived from the lacrimal artery.32
where the peripheral arterial arcade is found between the overlying levator
aponeurosis and Mller's muscle (see Fig. 8). In Horner's syndrome,
sympathetic denervation results in 2 mm of upper lid ptosis. The analog of
Mller's smooth muscle in the lower lid is inferred in Horner's syndrome
from the way the lower lid rides up on the cornea, suggesting atonia
secondary to loss of sympathetic innervation. This inferior tarsal muscle is
less well developed but found posterior to the capsulopalpebral fascia and
firmly adherent to the underlying conjunctiva. The exact sympathetic nerve
course to these smooth muscles is unknown.42 An inverse Horner's syndrome
refers to an irritative instead of ablative effect on normal sympathetic
innervation in which one sees lid retraction; a lung tumor, for example, can
irritate sympathetic fibers destined for Mller's muscle. Mller's muscle
infiltration and scarring occurs invariably in thyroid eye retraction and,
therefore, this muscle may be excised or recessed in conjunction with levator
aponeurosis recession.43
The Globe
The globe is located in the anterior orbit situated slightly superiorly and
laterally. The superior, medial, and inferior orbital rims extend anteriorly to
be on about the same frontal plane as the front of the eye. The lateral rim is
recessed 12 to 18 mm behind the cornea as measured by exophthalmometry.
Attached to the eye are the six extraocular muscles, the optic nerve, the long
and short posterior ciliary nerves, the anterior and posterior ciliary arteries,
and the vortex veins (Fig. 17). The globe is covered behind the corneal
limbus by Tenon's fascia and is supported in the orbit by Lockwood's
ligament. The average volume of the eye is about 6.5 cc compared to the
orbital volume, which is about 29.7 cc.2 The shape is not truly spheric; rather
it is formed by the union of two spheres, being that of the cornea and the
sclera, with radius of curvatures equal to 8 and 12 mm, respectively.
Fig. 17 Posterior view of the right globe after enucleation. (SRM, superior
rectus muscle; VV, vortex veins; SOT, superior oblique tendon; II, cranial
nerve II; LRM, lateral rectus muscle; SPCA & N, short posterior ciliary
artery and nerve; LPCA & N, long posterior ciliary artery and nerve; MRM,
medial rectus muscle; IRM, inferior rectus muscle; IOM, inferior oblique
muscle)
The average adult and newborn infant globe dimensions are given in Table
2.
Adult
Anterior-posterior
24 mm
Vertical
23 mm
Horizontal
23.5 mm
Newborn Infant
Anterior-posterior
16.4 mm
Vertical
16 mm
Horizontal
15.4 mm
Orbital Nerves
Entering the orbit are the optic (cranial nerve II), the oculomotor (cranial
nerve III), the trochlear (cranial nerve IV), the abducens (cranial nerve VI),
the first and second divisions of the trigeminal (cranial nerve V), the
sympathetics, and the parasympathetics of the third and fifth cranial nerves.
The nerves crowd together along with the ophthalmic artery to enter the
orbit at its apex, whereas the orbital venous blood drains via the superior and
inferior ophthalmic veins into the cavernous sinus (see Fig. 6). Obviously,
single lesions in this crowded area can result in multiple deficits often
termed orbital apex syndromes. The intraorbital courses of the nerves are
discussed in the order in which they are mentioned previously.
Optic Nerve (II)
The optic nerve represents peripherally extended nerve tracts of the brain.
Unlike other cranial nerves, they contain supporting neuroglial cells and are
bathed by cerebrospinal fluid within investing layers continuous with brain
coverings. The course and lengths of the visual fibers are intraocular (1
mm), intraorbital (25 mm), intracanalicular (5 to 9 mm), intracranial (16
mm), chiasmatic, optic tract, ganglionic, optic radiation, and occipital
cortex.
The axons of the optic nerve arise from the ganglion cell layer of the retina
and course through the scleral lamina cribrosa to join in forming the massive
optic nerve. The nerve is 1.5 mm in diameter within the eye but expands to 3
to 4 mm at the back of the eye because of an increase in supporting
neuroglial cells and the onset of myelination.44 Its exit is about 3 mm medial
and 1 mm below the posterior pole of the eye.
The intraorbital optic nerve is surrounded and cushioned by large lobules of
intraconal fat, which allow freedom of movement to the structure. The
intraorbital portion runs a sinusoidal course because it is longer than the 18
mm from the posterior globe to the optic canal, which allows for some
leeway in proptosis before nerve compromise. The nerve is covered by dura
that thickens near the optic canal, where it becomes continuous with the
posterior periosteum. Cerebrospinal fluid within the subarachnoid space
around the nerve communicates freely with the fluid bathing the midbrain,
explaining instances of sudden respiratory arrest following retrobulbar
injection.
Oculomotor Nerve (III)
Within the anterior cavernous sinus, several millimeters behind the annulus
of Zinn, cranial nerve III divides into a superior and inferior division. The
branches are separated by the nasociliary nerve. The superior branch rises
within the muscle cone to reach the superior rectus on its inferior side 15
mm from the orbital apex. Fibers then terminate above in the levator
palpebrae superioris by passing medial to the superior rectus (90%) or
through it (10%) (Fig. 18).
The inferior branch of the oculomotor nerve travels underneath the optic
nerve to innervate the medial and inferior rectus muscles. Its large terminal
branch to the inferior oblique muscle continues anteriorly, intimately
associated with the lateral border of the inferior rectus. This inferior oblique
branch gives off a vertical parasympathetic twig to the ciliary ganglion
above, to eventually innervate the ciliary body and iris sphincter.
Trochlear Nerve (IV)
At the superior orbital fissure, the thin trochlear nerve crosses over the third
nerve to enter the orbit temporal to Zinn's annulus and medial to the frontal
nerve. Its course is outside the muscle cone, thus the superior oblique may
continue to function after a retrobulbar block (see Fig. 6). The nerve travels
anteriorly from lateral to medial orbit to insert into the lateral border of the
superior oblique muscle at the posterior one-third of the muscle belly.
Abducens Nerve (VI)
The abducens nerve enters the orbit through the intraconal section of the
superior orbital fissure to lie between the optic nerve and the lateral rectus
muscle. It travels along the lateral rectus muscle belly before inserting into
the inner surface of the muscle, where the posterior third meets the anterior
two-thirds.
Trigeminal Nerve (V)
The ophthalmic and maxillary divisions of the sensory trigeminal nerve
enter the orbit and pass through to supply the superior two-thirds of the face
(Figs. 19 and 20) . The ophthalmic division enters the orbit through the
superior orbital fissure as three branches: the lacrimal, frontal, and
nasociliary. The lacrimal nerve is the smallest branch, and it passes into the
orbit through the lateral end of the extraconal superior orbital fissure (see
Figs. 6 and 19). It joins the lacrimal artery to reach the posterior aspect of
the lacrimal gland. Here, it forms superior and inferior branches; the former
supplies the gland, conjunctiva, and the lateral upper eyelid. The inferior
branch anastomoses with the zygomaticotemporal branch of the maxillary
trigeminal nerve, where it picks up parasympathetic secretory fibers to the
gland. The frontal branch passes just beneath the periorbita, where it divides
anteriorly in the orbit to form the supratrochlear and larger supraorbital
branch, which supply sensation to the medial canthus, upper lid, and brow
areas (see Fig. 19). The supraorbital nerve should be identified and spared
during dissection of the supraorbital rim, transcoronal forehead orbital
approaches, or during forehead lifts. The nasociliary branch of the
ophthalmic division is the only one to pass through Zinn's annulus. It passes
over the optic nerve with the ophthalmic artery to lie between the superior
oblique and medial rectus muscles. The nasociliary nerve gives off a sensory
route to the ciliary ganglion, two or three long ciliary nerves to the globe, the
anterior and posterior ethmoidal nerves to supply the nasal mucosa, and the
terminal infratrochlear branch to supply the tip of the nose (Fig. 21).
Involvement of this terminal infratrochlear branch of the nasociliary nerve in
herpes zoster ophthalmicus is termed Hutchinson's sign.