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The bony orbit is a pear-shaped structure closely resembling a four-sided

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).

Fig. 2 Diagram of horizontal section through orbits. Medial walls are


roughly parallel and lateral walls diverge 45 degrees. Thus, the orbital axis
diverges 22.5 degrees away from midline.

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

affords a margin of safety in proptotic states. Approximate measurements of


the adult orbit are outlined in Table 1.

TABLE 1. Adult Orbital Dimensions

Horizontal entrance width

40 mm

Vertical entrance height

35 mm

Volume

30 cc

Orbital depth (measured from rim to the optic strut)

4555 mm

Distance from back of globe to optic foramen

18 mm

Orbital segment of optic nerve

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

zygomaticofacial and the zygomaticotemporal canals transmit like-named


branches of the zygomatic nerve and vessels through the lateral orbital wall
to terminate in the cheek and temporalis region, respectively. These vessels
are often encountered as the surgeon dissects the temporalis muscle during a
lateral orbitotomy. Posterior to the thin zygomaticosphenoid suture the
lateral orbital wall again begins to thicken. At this point it meets the
temporal bone, which forms the lateral wall of the cranium (Fig. 3). When
performing a lateral orbitotomy, the surgeon must be aware that a distance of
approximately 12 to 13 mm separates the posterior aspect of the osteotomy
from the middle cranial fossa. In females, however, this distance may be 5 to
6 mm shorter.4

Fig. 3 Posterior lateral view of temporalis fossa showing the thin


zygomaticosphenoid suture, which is a convenient breaking point in a
lateral orbitotomy. Also shown are the zygomaticofacial (ZF) and the
zygomaticotemporal (ZT) canals, which transmit like-named branches of the
zygomatic nerve and vessels.

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).

Fig. 4 Axial computed tomography demonstrating the ethmoid (E) and


sphenoid (S) sinuses. (Courtesy of June M. Unger, MD, University of
Wisconsin.)

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

vascular mucoperiosteum of the nose is carried into the sinuses, where


densely populated cilia rhythmically beat mucus toward the ostium. Acute
inflammation of the nasal and paranasal mucoperiosteum can result in
swelling severe enough to occlude the sinus ostia, and thus purulent sinusitis
may result. Chronic sinusitis may lead to permanent occlusion of the ostia,
which can result in mucocele formation.
The maxillary sinus is the largest of the paranasal sinuses (15 cc). This sinus
roof is the orbital floor that declines from the medial wall to the lateral wall
at an angle of approximately 30 degrees. Like the medial sinus roof, the
lateral wall of the sinus is also thin and subject to fracture with zygomatic
displacement. The maxillary sinus drains into the middle meatus through an
ostium located near the level of the orbital floor, thus orbital tissues that are
displaced in surgery or trauma may obstruct the ostium. The pterygoidpalatine space lies posterior to the maxillary sinus with the internal
maxillary artery intimately related to the posterior sinus wall.
As mentioned previously, the ethmoidals are the most exuberant growing
sinuses and may pneumatize the frontal, sphenoid, palatine, and lacrimal
bones. The ethmoid sinuses are shaped like a box slightly wider posteriorly
where it articulates with the sphenoid (see Fig. 4). The anterior and middle
ethmoidals drain into the middle meatus, whereas the posterior cells may
drain into the superior meatus. The roof of the orbit slopes down as it travels
medially, and this slope continues at the frontoethmoidal suture to become
the ethmoid roof (fovea ethmoidalis), and finally to overlie the nasal cavity
as the cribriform plate. The crista galli bisects the cribriform plate above and
continues below as the vertical nasal plate (vomer). Three to fifteen air cells
expand from each lateral border to the cribriform plate, and the air cell
masses convolute medially to form the middle, superior, and supreme (if
present) turbinates. The surgeon should be aware of the anatomic
relationship of anterior ethmoid air cells to the lacrimal sac fossa when
performing external dacryocystorhinostomy. Blaylock7 evaluated computed
tomographic scans of 190 orbits with normal ethmoid anatomy and found
that in 93% of the orbits, the cells extended anterior to the posterior lacrimal
crest, with 40% entering the frontal process of the maxilla.
The frontal sinus is not well developed or radiographically evident until
about the 6th year of life. Frontal sinus expansion continues until early
adulthood and attains greater proportions in the male. The frontal sinus lies
deep to the superior orbital rim and drains into the middle meatus via the
frontonasal duct. Each sinus is a single chamber with intrasinus septae,
which give it a scalloped appearance radiologically. The frontal sinus is a
common site for mucocele development.

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)

Radiographic enlargement of the superior orbital fissure may accompany


pathologic processes, such as aneurysm, meningioma, chordoma, pituitary
adenoma, or tumors of the orbital apex.8 When idiopathic inflammation
preferentially involves the superior orbital fissure, the Tolosa-Hunt
syndrome (painful ophthalmoplegia) results. The nerves to the extraocular
muscles may be affected by the inflammation as they pass through the
superior orbital fissure. The pain in this syndrome results from the

inflammatory involvement of the first division of the trigeminal nerve.


Interference with venous drainage through the inflamed fissure can cause
stasis edema of the lids and orbits.
Medial to the superior orbital fissure lies the optic foramen (see Fig. 1)
within the lesser wing of the sphenoid, which conveys the optic nerve and
the ophthalmic artery. The optic canal attains adult dimensions by age 3 and
is symmetric in most persons. Because of the shift in the position of the
ophthalmic artery relative to the optic nerve, the canal is horizontally oval
posteriorly and more vertically oval anteriorly. In the adult the optic canal is
8 to 10 mm long and 5 to 7 mm wide, and the optic foramen normally
measures 6.5 mm in diameter. Optic foramen enlargement is commonly seen
with optic nerve gliomas. A foramen that measures 7 mm in diameter is
usually abnormal. Among young children whose optic canals have not yet
reached adult dimensions, the size of both foramina should be compared. In
these patients, a foramen that is 6.5 mm in diameter and at least 1 mm larger
than the contralateral foramen is considered abnormal. The optic canal is
separated from the superior orbital fissure by the bony optic strut, the
inferior root of the lesser wing of the sphenoid bone (see Fig. 1). It joins the
body of the sphenoid to its lesser wing and separates the optic foramen from
the superior orbital fissure. This thin optic strut forming the lateral and
inferior borders of the optic canal is subject to deformation by optic nerve
gliomas, infraclinoid aneurysms, or intracanalicular spread of an intracranial
chiasmal tumor.9 An optic neuritis that is progressive over months or years
should suggest an intracanalicular meningioma.10
Other orbital diseases may cause enlargement of the optic canal. Benign
arachnoidal hyperplasia extending beyond the tumoral glial tissue can
enlarge the optic foramen. Rarely, a fungal infection, such as aspergilloma,
or a bacterial infection, such as a syphilitic gumma or tuberculoma, can
settle in the optic canal and mimic a neoplasm. Enlargement of the canal can
also occur in sarcoidosis, neurofibroma, arachnoidal cyst, and chronic
hydrocephalus. Fibrous dysplasia and ossifying fibromas of the sphenoid
bone can involve the canal and narrow its dimensions.10
The infraorbital fissure is a 20-mm bony defect bounded by the sphenoid,
zygomatic, maxillary, and palatine bones, and lies between the lateral orbital
wall and orbital floor (see Fig. 1). It transmits the second (maxillary)
division of the fifth cranial nerve, the zygomatic nerve, small branches from
the sphenopalatine ganglion, and branches of the inferior ophthalmic vein
leading to the pterygoid plexus (see Figs. 1, 6, and 19). Posterior to the
inferior orbital fissure, the foramen rotundum pierces the greater sphenoid
wing carrying the maxillary division of the trigeminal nerve forward to the
orbit. Arriving with the maxillary nerve is the terminal branch of the internal
maxillary artery. The structures enter the infraorbital sulcus to become the

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

Fig. 8 Parasagittal section to show anterior orbital structures. (F, frontal


sinus; SRM, superior rectus muscle; FM, frontalis muscle; MM, Mller's
muscle; BFP, brow fat-pad; T, tarsus: POF, postorbicularis fascia; OM,
orbicularis muscle; OS, orbital septum; LSL, Lockwood's suspensory
ligament; PAFP, preaponeurotic fat-pad; IOM, inferior oblique muscle; WL,
Whitnall's ligament; IRM, inferior rectus muscle; LA,
levator aponeurosis)

The septum may attenuate with age allowing orbital fat to herniate forward,
requiring blepharoplasty. In performing levator surgery or blepharoplasty the

preaponeurotic fat is encountered just posterior to the septum. Loose areolar


tissue, termed the suborbicularis fascia, lies immediately anterior to the
septum13 and shares the same plane as the eyebrow retro-orbicularis oculi fat
and malar fat-pads further from the eyelid margins.
Periorbita
The periorbita is the periosteal covering of the orbital bones. The periorbita
is firmly attached at the suture lines, the foramina, the fissures, the arcus
marginalis, and at the posterior lacrimal crest. Elsewhere, it is loosely
adherent to the bone and may be easily separated from the bone by the
surgeon or by accumulations of blood or pus. Posteriorly, the periorbita is
continuous with the dura of the optic nerve, where the dura is fused to the
optic canal. Likewise, the superior orbital fissure is bound by thickened
periorbita, which also blends with intracranial dura. Anteriorly, the periorbita
is continuous with the orbital septum, which partitions the lids from the
anterior orbital tissues. The periorbita is continuous with the frontal,
zygomatic, malar, and nasal periostea, and is also continuous with the bones
of the sphenopalatine and temporal fossa through the inferior orbital fissure.
The periorbita lines the lacrimal fossa, and an extensionthe lacrimal fascia
covers the lacrimal sac between the anterior and posterior lacrimal crest
(Fig. 9).

Fig. 9 Shaded areas demonstrate dense attachment sites for


the periorbita.

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 muscular fascia ensheathes the extraocular muscles and extends


between them. These muscle fascial sheaths are thin posteriorly but become
much denser anteriorly. The muscular sheaths connect from their extraconal
surface to the orbital walls and from their intraconal surface to the fibrous
septae dividing the intraconal fat lobules.16 The bulbar side of the muscular
sheath is thinner than the external aspect that forms the check ligaments, yet
it is thicker than the posterior portion of Tenon's capsule.17 Smooth muscle
fibers are scattered throughout the membrane and are innervated by the
sympathetic nervous system.2
The muscles are connected to the surrounding fascia throughout the anterior
one-third of their lengths, especially where they insert onto the globe, which
prevents their retraction far posteriorly in the orbit if lost during strabismus
operation (unless the muscle has been dissected free). These attachments
account, in part, for the persistent movement of the eye socket after
enucleation when muscles have not been specifically sewn to the implant. As
noted above, each extraocular muscle sheath sends extensions to the orbital
walls. Anteriorly, they are especially prominent and are called check
ligaments. The most developed check ligaments are those of the medial and
lateral rectus muscles (see Figs. 10 and 11). The lateral check ligament is the
strongest and inserts primarily on the posterior aspect of Whitnall's lateral
orbital tubercle with lesser extensions to the lateral conjunctival fornix and
lateral orbital septum. The medial check ligament inserts on the bone behind
the posterior lacrimal crest and to the medial orbital septum, caruncle, and
plica semilunaris. The superior rectus muscle sheath is joined anteriorly with
that of the levator palpebrae superioris by means of an intermuscular
fascia.18 The superior transverse Whitnall's ligament may serve as a superior
check ligament to limit elevation by the upper eyelid19 (see Figs. 10 and 11).

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)

Lockwood20 described a hammock-like structure extending from the lateral


orbital tubercle to the medial canthal tendon comprised of the fused fascia of
the inferior rectus and inferior oblique muscles. The retractor complex of the
lower eyelid is composed of aponeurotic expansions of the inferior rectus.
These expansions form the capsulopalpebral head, which divides to extend
anteriorly around the inferior oblique muscle and then fuses into
Lockwood's ligament in front of the inferior oblique to form the
capsulopalpebral fascia.21 This fascia connects Lockwood's ligament to the
inferior fornix, to the inferior border of the tarsus, and to the preseptal
orbicularis muscle and skin at the level of the lid crease (see Fig. 12). It also
contains the adrenergic smooth muscle fibers of the inferior tarsal muscle,
which are more diffusely distributed than in Mller's muscle and do not
insert directly onto the tarsus. Lockwood's suspensory ligament is strongest
immediately anterior to the inferior oblique muscle and may help support the
globe after removal of the orbital floor. However, globe ptosis can occur
after orbital decompression for thyroid eye disease.

Fig. 12 Normal lower lid anatomy in cross section. (CPF, capsulopalpebral


fascia; CPH, capsulopalpebral head; IOM, inferior oblique muscle; IRM,
inferior rectus muscle; LL, Lockwood's ligament; MF, malar fat; OF, orbital
fat; OM, orbicularis muscle; OML, orbitomalar ligament; OS, orbital
septum; T, tarsus)

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.

Fig. 13 Anatomic section demonstrating orbital septa 1.4 mm from behind


the surface of the eye. Diameters vertically, 2.4 cm; transversally, 2.7 cm.
Enlargement is approximately 3.5. (ON, optic nerve; SOV, superior

ophthalmic vein; SLP, superior levator palpebrae muscle; SRM, superior


rectus muscle; LRM, lateral rectus muscle; IRM, inferior rectus muscle;
MRM, medial rectus muscle; SOM, superior oblique muscle; *, connective
tissue septa; ATC, adipose tissue compartment; IOA + IN, infraorbital artery
and nerve; MM, Mller's muscle) (From Koornneef L: Spatial aspects of
orbital musculofibrous tissue in man: A new anatomical and histological
approach. Amsterdam: Swets en Zeitlinger, 1976)

Fig. 14 Anterior view of deep dissection of orbital fat-pads to show trochlea


dividing fat-pads in the upper eyelid. The inferior oblique muscle divides
the medial from the central fat, and the arcuate expansion fascia of the
inferior oblique divides the central from the lateral fat pads in the lower
eyelid. (FP, fat pad; T, trochlea; IOM, inferior oblique
muscle)

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

zygomatic bone (zygomatic groove) on its anterosuperior course. The


zygomatic nerve gives off the lacrimal branch before dividing into
zygomaticotemporal and zygomaticofacial branches. This lacrimal branch
anastomoses with the lacrimal nerve of the ophthalmic trigeminal nerve or
travels along the periorbita to independently enter the gland at its posterior
lateral aspect.
The lacrimal nerve is sensory, although it may carry some sympathetic fibers
gained while traversing the cavernous sinus. The parasympathetic VII nerve
supply to the lacrimal gland (via the zygomatic nerve of V2) provides the
main secretory motor function. The exact role of sympathetic innervation in
the control of lacrimal secretion is unknown.24,25
In addition to the lacrimal gland itself, there are approximately 20 accessory
glands of Krause in the superior fornix, and, perhaps, half that number are in
the inferior fornix. There are also accessory glands of Wolfring above the
tarsus. Removal of the lacrimal gland can produce keratitis sicca, despite
normally functioning accessory lacrimal glands.26 Parasympatholytic drugs
may reduce lacrimal secretion. Damage to the sphenopalatine ganglion as
well as brain tumors impinging the efferent supply to the lacrimal gland may
cause hyposecretion. Hyposecretion in central autonomic dysfunction states,
such as Riley-Day syndrome, can lead to corneal damage.27 Hyposecretion
also occurs as a consequence of lacrimal gland parenchymal loss in older
persons in conditions such as age-related atrophy, Sjgren's syndrome,
sarcoidosis, and benign lymphoepithelial lesion (seen often in
postmenopausal women). Chronic inflammation and periductal fibrosis were
the most common changes seen in a light microscopic study of lacrimal
glands removed at autopsy.28
Hypersecretion is seen in cases of reflex stimulation, such as ocular trauma
or inflammation of any etiology. Damage to the facial nerve in the vicinity
of the geniculate ganglion can cause aberrant regeneration resulting in
crocodile tears in which the patient tears while masticating. This is thought
to be due to aberrant regeneration of afferent taste fibers of the nervus
intermedius into the nearby efferent parasympathetic fibers to the lacrimal
gland. A related phenomenon can be caused by an acoustic neuroma, and the
patient with this reflex may have ipsilateral hearing loss. Tumors of the
lacrimal gland can be benign or malignant and are discussed in detail
elsewhere.
The tears drain through the superior and inferior puncta and canaliculi and
are pumped into the nasolacrimal sac by the orbicularis muscle sphincter
action. The nasolacrimal sac lies in a fossa between the anterior lacrimal
crest of the maxillary bone and the posterior lacrimal crest of the lacrimal
bone, and is wrapped by the thick anterior and thinner posterior limbs of 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

anteromedial orbital roof. Crescent-shaped cartilage is suspended from the


periorbita on either end by the fibrous pillars. The central fibers of the
reflected tendon exhibit few adhesions to the neighboring fibers, whereas
those peripheral in the tendon are connected in a loose fashion to the fibers
of the tendon. Located between the cartilage and the tendon is a bursalike
structure, presumably to reduce friction.30 The cartilage is a U-shaped ring
with a grooved flange that supports the reflected tendon posteriorly and
laterally from the front of the trochlea (Fig. 16).31 The periorbita to which
the trochlea is attached can be carefully elevated from the bone by the
surgeon and replaced, if needed, although injury to the tissues surrounding
the trochlea can cause scarring and possible superior oblique restriction or
Brown's syndrome.

Fig. 16 Schematic drawing of the right trochlea. Tendon is supported by a


layer of cartilage suspended by fibrous supports from the periorbita. Central
fibers of the tendon are strong with dense unconnected fibers. Peripheral
tendon shows loose interconnected fibers. (SOT, superior oblique tendon)
(Adapted from Helveston EM, et al: The trochlea: A study of the anatomy
and physiology. Ophthalmology 1982:89:124)

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

Levator Palpebrae Superioris


Arising from the lesser wing of the sphenoid above Zinn's annulus, the
levator origin is lateral to the superior oblique muscle and above the superior
rectus muscle (see Fig. 6). The levator extends arteriorly in the superior orbit
with a thin layer of fat, the supraorbital artery, frontal nerve, and the
trochlear nerve separating it from the orbital roof. The levator rests upon the
superior rectus, and these muscles are attached by a fascial sheath along
their medial borders (see Fig. 11). Both muscles are innervated by the
superior division of the oculomotor nerve, which enters at the posterior onethird of the muscles from the inferior surface.
The muscle sheath of the levator is thin, like the other extraocular muscle
sheaths, except on the medial edge, where it joins with the superior rectus.
The muscular portion of the levator is approximately 40 mm in length, in
contrast to its aponeurosis, which is 14 to 20 mm from Whitnall's ligament
to the anterior inferior tarsus border.33 Immediately behind the superior
orbital rim, a transverse fibrous condensation attaches superiorly to the
widening levator, termed the superior transverse Whitnall's ligament (see
Fig. 11).19 Whitnall's ligament is a thick condensation of elastic fibers of the
anterior sheath of the levator, located at the transition from fleshy levator
muscle to fibrous aponeurosis. Whitnall's ligament acts as a suspensory
ligament for the upper lid as well as a fulcrum for the levator muscle to
change vector force from an anterior-posterior direction to a superiorinferior direction.34 The ligament terminates medially in the fascia
surrounding the trochlea. Laterally, Whitnall's ligament forms septa through
the lacrimal gland before attaching to the inner lateral orbital wall, up to 10
mm superior to the lateral orbital tubercle. In the older person, Whitnall's
ligament or the levator aponeurosis becomes attenuated, leading to upper
eyelid ptosis. External repair of aponeurogenic blepharoptosis involves
incising the septum to reach the levator, dissecting superiorly towards the
musculoaponeurotic junction, releasing the inferior aspect of the levator
aponeurosis from the tarsus and underlying Muller's muscle, and then
suturing tarsus to a higher position on the levator to achieve the desired lid
height. The numerous techniques of levator repair include posterior
approaches and small-incision repairs.35 Ptosis of the medial eyelid has been
suggested to result from medial disinsertion of the ligament.36
As the aponeurosis approaches tarsus, it splits into an anterior layer that
inserts into the pretarsal orbicularis bundles and skin, and a posterior layer
that inserts onto the inferior half of the anterior tarsus. In his description of
the levator aponeurosis,37 Whitnall gives a length of 7 mm from the
aponeurosis origin to the orbicularis and cutaneous insertions (see Fig. 8).
The upper lid crease is created by these anterior insertions of the
aponeurosis. A light and electron microscopic study by Stasior38 revealed an

elastic attachment system for the levator palpebrae superioris muscle


complex that forms an intricate insertion into the upper eyelid. As the levator
aponeurosis approaches the mid-tarsal level, approximately two-thirds of the
aponeurotic elastic fibers radiated away from the tarsus to fuse onto the
pretarsal orbicularis muscle bundles. The remaining one-third of the
aponeurotic elastic fibers is inserted onto the anterior surface of the inferior
tarsus. It is this complex elastic fiber network that degenerates with age,
rather than the aponeurosis itself.
In addition to the palpebral insertions, the levator aponeurosis expands into a
broad, fibrous sheath to insert into the orbital rims behind the medial and
lateral commissures of the eye as medial and lateral horns of the levator.
Confusion between the lateral horns below and the ends of the superior
transverse suspensory ligament above should be avoided. The lateral horn is
a strong, fibrous band incompletely dividing the lacrimal gland into two
lobes and continuing inferiorly to insert on the lateral orbital tubercle and the
lateral canthal tendon. The medial horn, in contrast, becomes filmy as it
passes over the reflected superior oblique tendon to insert onto the posterior
medial canthal tendon and posterior lacrimal crest (see Fig. 11).
Histologic sections studying lateral canthal anatomy demonstrated that the
lateral canthal ligament is formed by fibrous extensions of the upper and
lower tarsal plates and orbicularis muscle that unite into a common ligament
1 mm in thickness and 3 mm wide.39 As the lateral canthal ligament
approaches the orbital rim, it widens to 6 to 7 mm as the lateral horn of the
levator aponeurosis, the check ligament of the lateral rectus muscle, and
Lockwood's ligament fuse with it before its bony insertion into the lateral
orbital tubercle of Whitnall located 5 mm inside the orbital rim. Knowledge
of lateral canthal ligament anatomy is important when reconstructing the
lateral canthal angle and taking a periosteal bite inside the orbital rim to
simulate the normal anatomic insertion. Elevating a short periosteal flap
based inside the lateral orbital wall, to which the lateral lid tissues are
secured, may provide a more correct and secure anatomic reapposition of the
lax lid well inside the lateral wall. This periosteal flap technique may be
performed through small incisions without lateral canthotomy and
cantholysis and has been suggested for ectropion repair and as lateral canthal
advancement in repair of exophthalmic lid retraction.3941
Mller's Muscle
Arising from the underside of the striated levator muscle approximately 15
mm above the superior tarsal border is the smooth superior tarsal muscle of
Mller. It is firmly attached to the levator only at its origin and may be easily
separated from the latter below to form the postaponeurotic space described
by Jones. The superior tarsal muscle inserts at the upper border of the tarsus,

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.

TABLE 2. Average Globe Dimensions

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).

Fig. 18 Nerves to the extraocular muscles. The superior and inferior


divisions of the oculomotor nerve are separated by the nasociliary nerve
within the superior orbital fissure. The superior division supplies the
superior rectus and the levator palpebrae superioris muscles. The inferior
division supplies the inferior and the medial rectus muscles and the inferior
oblique muscle. The trochlear nerve supplies the superior oblique muscle,
whereas the abducens nerve innervates the lateral rectus muscle. (III, cranial
nerve III; IV, cranial nerve IV; VI, cranial nerve VI; SUPIII, superior
division of cranial nerve III; INFIII, inferior division of
cranial nerve III)

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.

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