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Anatomy of Orbit ENT SCHOLAR

Anatomy of Orbit
Otolaryngologist's perspective
February 9, 2013 Rhinology

Author
ProfessorBalasubramanianThiagarajanBalasubramanianThiagarajan

Abstract
AcarefulstudyofanatomyoforbitisveryimportanttoanENTsurgeonbecauseofitsproximitytothe paranasalsinuses.Acomprehensiveknowlegeoforbitalandperiorbitalanatomyisnecessaryto understandthevariousdisordersofthisregionandinitssurgicalmangement.Currentday otolaryngologistsventureintootheruncharteredterritorieslikeorbit,lacrimalsacetc.Anatomical knowledgeofthisareawillhelpotolaryngologiststoavoidcomplicationsduringsurgicalprocedures involvingthisarea.Thisarticleattemptstoexplorethistopicfromotolaryngologistsperspective.

Anatomy of orbit
Introduction: Orbitsupportstheeyeandensuresthatthisorganfunctionsinanoptimalmanner.Italsoprotects thisvitalstructure.Theshapeoftheorbitresemblesafoursidedpyramidtobeginwithbutasone goesposterioritbecomesthreesidedtowardstheapex.Thevolumeoftheorbitalcavityinanadultis roughlyabout30cc.Therimoforbitinanadultmeasuresabout40mmhorizontallyand35mm vertically.Themedialwallsoforbitareroughlyparallelandareabout25mmapartinanadult.The lateralwallsoforbitanglesabout90degreesfromeachother.Thisisactuallyafixedcavitywithno scopeforenlargement,henceasmallincreaseinocularpressurecanleadtodisastrous consequences. Osteology: Sevenbonesjointogethertoformtheorbit1.Theseinclude: 1.Frontalbone 2.Lacrimalbone 3.Zygoma 4.Maxilla 5.Ethmoid 6.Sphenoid 7.Palate Theorbitalrimismoreorlessspiralwithitstwoendsoverlappingmediallyoneithersideoflacrimal fossa.Theinferiororbitalrimisformedbythemaxillarybonemediallyandzygomaticbonelaterally. Thezygomaticboneformsthelateralorbitalrim,whilethefrontalboneformsthesuperiororbitalrim.

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Thesuperiorrimiscommonlyindentedbyasmallnotchknownasthesupraorbitalnotch.Thisnotch isinvariablypresentatthejunctionofmedialandlateral1/3.Thesupraortbitalnerveandarterypass throughthisnotchtoreachtheforehead.

Bonesconstitutingorbit

Themedialportionoftheorbitalrimisformedbythefrontalprocessofmaxillaandthemaxillary portionofthefrontalbones.Adepressionknownasthelacrimalfossaisformedintheinferomedial orbitalrim.Thisfossaisformedbythemaxillaryandlacrimalbones.Thislacrimalfossaisbounded bytwoprojectionsofbonesi.e.theanteriorlacrimalcrestofmaxillaryboneandtheposteriorlacrimal crestoflacrimalbone.Thisfossahousesthenasolacrimalsac.Thisfossaopensintothe nasolacrimalcanalthroughwhichthenasolacrimalducttraverses. Thenasolacrimalductis34mmindiameter,coursesinaninferolateralandslightlyposterior directiontowardstheinferiorturbinateunderwhichitopensintotheinferiormeatus.Thisductis roughly12mmlong.Allthewallsofthelacrimalductexceptitsmedialwallisformedbythemaxillary bone.Themedialwallisformedbythelatealnasalwallinferiorlyandthedescendingprocessof lacrimalbonesuperiorly. Inthefrontalprocessofmaxillajustanteriortothelacrimalfossaafinegrooveknownasthesutura longitudinalisimperfectaofWeber.Thissuturerunsparalleltotheanteriorlacrimalcrest.Small branchesofinfraorbitalarterypassthroughthisgroovetosupplythenasalmucosa.Thepresenceof thesevesselsshouldbeanticipatedinanylacrimalsacsurgerytoavoidunneccessarytroublesome bleeding. Medialwalloforbit: Largestbonycomponentofmedialwallisthequadrangularshapedorbitalplateofethmoidbone. Thisbonycomponentseparatesorbitfromthenasalcavity.Thisplateofbonearticulatessuperiorly withthemedialedgeoforbitalplateoffrontalbone.Thesearticulatingbonystructureshavetwo notches(anteriorandposteriorethmoidalnotches).Thesenotchesintheseboneswhencombined formstheanteriorandposteriorethmoidalcanals.Thesecanalstransmittheethmoidalbranchesof nasociliarynerve(branchofophthalmicdivisionoftrigeminalnerve)andbranchesofopthalmic artery.Thesebranchesfromopthalmicartery(anteriorandposteriorethmoidalarteries)supplynasal

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mucosaandduramateroffrontalbonearea.Thecranialopeningoftheseethmoidalcanalsare relatedtotheanteriorandposteriorlimitsofcribriformplate.Theroofofthenasalcavityispartially formedbythecribriformplateofethmoid.Thesecranialopeningsofethmoidalcanalsdivideanterior skullbaseintofrontal,cribriform,andplanumareas.Ethmoidalcanalsdivideorbitintobulbar, retrobulbarandapicalportions.Thisintricateknowledgeoforbitalanatomyhelpsduringadvanced endoscopicskullbasesurgicalprocedures2. Themedialwalloftheorbitisformedfromanteriortoposteriorby: 1.frontalprocessofmaxilla 2.lacrimalbone 3.ethmoidbone 4.lesserwingofsphenoidbone Thethinnestportionofthemedialwallisthelaminapapyraceawhichseparatestheethmoidal sinusesfromtheorbit.Itisoneofthecomponentsofethmoidbone.Infectionsfromethmoidalsinus caneasilybreachthispaperthinboneandaffecttheorbitalcontents.Themedialwalloftheorbitis thickerposteriorwherethesphenoidboneispresentandanteriorlywheretheposteriorlacrimalcrest ispresent. Thefrontoethmoidalsuturelinemarkstheapproximatelevelofethmoidalsinusroof,henceany dissestionabovethislinemayexposethecranialcavity.Theanteriorandposteriorethmoidal foraminathroughwhichbranchesofophthalmicartery(anteriorandposteriorethmoidalarteries)and branchesofnasociliarynervepassesarepresentinthissuture.Theanteriorethmoidalforamenis locatedatadistanceof24mmfromtheanteriorlacrimalcrest,whiletheposteriorethmoidalforamen islocatedatadistanceof36mmfromtheanteriorlacrimalcrest. Averticalsuturethatrunsbetweentheanteriorandposteriorlacrimalcrestsistheanastomoticarea betweenthemaxillaryandthelacrimalbone.Ifthissutureislocatedmoreanteriorlyitindicatesa predominanceoflacrimalbone,whileamoreposteriorlyplacedsuturelineindicatesapredominance ofmaxillaryboneintheanastomoticrelationship.Thelacrimalboneattheleveloflacrimalfossais prettythin(106micrometer).Thisbonecanbeeasilypenetratedduringdacryocystorhinostomy surgery.Ifthemaxillarycomponentispredominantitbecomesdifficulttoperformtheosteotomyin thisareatoaccessthesacbecausethemaxillaryboneisprettythick.Hencelacrimalbone predominancemakesiteasytoexposethesacduringdacryocystorhinostomy3. Appliedanatomyofmedialwalloforbit: Thiswallisalignedparalleltotheanteroposterioraxisandisveryfragilebecauseofitsproximityto anteriorethmoidalaircells.Disruptionofthiswallduetotraumacauseshypertelorism(Traumatic Hypertelorism).Lateraldisplacementoffrontalprocessofmaxillawillcausetraumatictelecanthus becausethemedialpalpebralligamentisattachedhere.Bothhypertelorismandtelecanthuscanbe causedduetotrauma. Contributionofethmoidbone: Ethmoidboneformsthemedialboundaryoforbit.Itisseparatedfromobitalcontentsbyapaperthin bone(Laminapapyracea).Thisbonecanbebreachedduetodiseasesinvolvingethmoidsorduring nasalsurgeriesallowinginfectionstoreachtheorbitalcavity.Inferiorlyethmoidbonearticulateswith theorbitalplateofmaxilla.Posteriorlytheethmoidbonearticulateswiththebodyofsphenoid

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completingthemedialbonywalloforbitalcavity. Sphenoidbone: Sphenoidbonecontributestotheformationofbonyorbitbyitsgreaterandlesserwings.Thelesser wingsofsphenoidarticulateswithorbitalplateoffrontalbonetoformtheroofoforbit.Thegreater wingsofsphenoidarticulateslaterallywiththeorbitalplateofzygomaformingthelateralwallofbony orbit. Lateralwalloforbit: Understandingthiswalloftheorbitisvitalfromthesurgeonspointofview.Twocomponentsare involvedintheformationofthiswall.Thegreaterwingofsphenoidfacestheorbitonitsexocranial sideanditsendocranialsurfaceformstheanteriorlimitofmiddlecranialfossa.Thezygomaticbone onthecontrarydoesnothavecerebralsurface/endocranialsurface.Itvirtuallyfacestheorbitwhile itsoppositesurfacefromstheanteriorlimitofinfratemporalfossa.Thisanatomicalrelationship provideslateralaccesstotheorbitwithoutresortingtocraniotomy.Inthelateralorbitalapproach,the contentsoftheorbitcanbereachedjustbydisplacingthetemporalboneandperformingzygomatic osteotomy. Therecurrentmeningealbranchofmiddlemeningealarterymaybeseencoursingthrougha forameninthesuturelinebetweenthefrontalandsphenoidbones.Thisarteryformsaanastomosis betweentheexternalandinternalcarotidarterialsystems.Roughly45mmbehindthelateral orbitalrimand1cminferiortothefrontozygomaticsutureisthelateraltubercleofWhitnall.The followingstructuresgetsattachedtothistubercle: 1.Lateralcanthaltendon 2.Lateralrectuscheckligament 3.Suspensoryligamentoflowereyelid(Lockwoodsligament). 4.Orbitalseptum 5.Lacrimalglandfascia. Lateralcanthaltendon: Thepretarsalmusclesjoinlaterallytoformthelateralcanthaltendon.Thistendoninsertsintothe periosteumofWhitnallstubercleabout5mmbehindtheinfraorbitalrim. Lateralrectuscheckligament: Thisisafibrousmembranearisingfromthelateralrectusmuscleandgetsattachedtothezygomatic tubercle,posterioraspectoflateralpalpebralligamentandthelateralconjunctivalfornix. Beingmostproneforinjurythiswalloftheorbithappenstobethethickest.Itisverystrongatthe orbitalmargin.Behindthisthickportionoflateralwallcomesthesomewhatthinnerportion,behind thisthinportionthewallagainbecomesthick.Posteriormostportionofthislateralwallisthin(about1 mm)nearlytranslucent. Thiswallisfurtherweakendbythepresenceofsuperiororbitalfissurebetweenlateralandsuperior wallsoforbit.Thepresenceofinferiororbitalfissurebetweenlateralandinferiorwallsoforbitcreates anotherareaofweakness.

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Diagramshowinglateralwalloforbit:GW(Greaterwingofsphenoid)

Superiororbitalfissure: Thisisalsoknownassphenoidalfissurebecauseitliesbetweenlesserandgreaterwingsof sphenoid.Thisspaceisclosedlaterallybythefrontalbone.Thisfissureliesbetweenthelateralwall androofoforbit.Atitsmedialenditisslightlywider.Atthispointitliesbelowtheopticforamen.This fissuregraduallyreducesinsizeasitreachesitslateralextremity.Superiororbitalfissurehence shouldbeconsideredtohaveanarrowlateralandawidemedialpart.Thisfissureisabout22mm longandisthelargestcommunicationbetweentheorbitandthemiddlecranialfossa.Itstipis situatedabout3040mmfromthefrontozygomaticsutureline.Itsmedialendisseparatedfromoptic foramenbytheposteriorrootoflesserwingofsphenoid.Thisportionofsphenoidbonehasasmall tubercleknownasinfraoptictubercle.TheannulusofZinnfromwhichalltheintraocularmuscles originatespansthesuperiororbitalfissurebetweenitsmedialwideandlateralnarrowportions. AnnulusofZinnsurroundstheopticnerveatitsentranceintotheorbit. ThefollowingstructurespassthroughtheannulusofZinn: 1.Superiordivisionof3rdnerve 2.Nasociliarynerve 3.Sympatheticrootofcervicalganglion 4.Inferiordivisionof3rdnerve 5.6thnerve 6.Opthalmicvein(superioropthalmic) Thisistheroughorderofstructurespassingthroughtheannulusfromabovedownwards. Inferioropthalmicveinpassesbelowtheannulus.

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Lockwoodsligament: Thisligamentactsasahammocksupportingtheglobeinferiorly.Thisisactuallyadense condensationofconnectivetissueengulfinginferiorrectusandinferiorobliquemusclesproviding supporttotheundersurfaceoftheglobe.Thisligamentisattachedtofacialstructuresconnectedto thelowerlid.DamagetoLockwoodsligamentcancauselowereyelidptosiswhichisseeninpatients

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undergoingtotalmaxillectomy.

FigureshowingLockwoodsligamentactingasaHammockholdingtheglobe

Orbitalseptum: Thisisalsoknownaspalpebralligament.Thismembranoussheetactsastheanteriorboundaryof theorbit4.Itextendsfromtheorbitalrimstotheeyelids.Withagethisseptummayweakencausing prolapseoforbitalfatforwards.Blepharoplastyisusuallyperformedtocorrectthisanamoly.Orbital septumhelpsindifferentiatingorbitalcellulitis(behindtheseptum)andperiorbitalcellulitis(infrontof theseptum)5.Thisstructureisusuallypenetratedbyvesselsandnervesthatpassfromtheorbitto faceandscalp. Thefrontalprocessofzygomaticboneandthezygomaticprocessoffrontalbonearethickandthey protecttheglobefromlateraltrauma.Justbehindthisfacialbuttressareatheposteriorzygomatic boneandtheorbitalplateofgreaterwingofsphenoidarethinnerthusmakingthezygomatico sphenoidsutureaconvenientlandmarkforlateralorbitotomy.Thezygomaticofacialandzygomatico temporalnervesandvesselspassthroughthelateralwalloftheorbittoreachthecheekand temporalregions.Posteriorlythelateralwallthickensandmeetsthetemporalbonewhichformsthe lateralwallofthecranialcavity.Whenlateralorbitotomyisbeingdoneonly1213mmseparatethe posterioraspectoflateralorbitotomytothatofthemiddlecranialfossa.Thisdistancecouldstillbe shorterinfemales. Foramenandfissuresoforbit: Thefollowingarethevariousforaminaandfissuresoforbit: 1.Superiororbitalfissure(sphenoidalfissure) 2.Inferiororbitalfissure(sphenomaxillaryfissure) 3.Anteriorandposteriorethmoidalcanals 4.Opticcanal/foramen

Orbitshowingvariouscomponents

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Inferiororbitalfissure: Alsoknownassphenomaxillaryfissure. Thissamecombinationofzygomaticboneandgreaterwingofsphenoidformstheposteriorborderof infraorbitalfissure.Theanteriorborderisformedbyorbitalplateofmaxillaandtheposteromedial partisformedbyorbitalprocessofpalatinebone. Theinferiororbitalfissureliesbetweenthelateralorbitalwallandtheflooroftheorbit.Itisabout20 mmlong.Thisisalsoknownassphenomaxillaryfissure.Itisboundedanteriorlybythemaxillaand theorbitalprocessofpalatinebone,posteriorlybythelowermarginoforbitalsurfaceofgreaterwing ofsphenoid.Thisfissureisnarroweratitscenterwhencomparedtoitsextremities.Theactualwidth ofthisfissureisdependentonthedevelopmentofmaxillarysinus.Thisfissureissomewhatwiderin infantsandchildren.Thisfissureliesneartheopeningsofforamenrotundumandthesphenopalatine foramen. Thefollowingstructurespassthroughthisfissure: 1.Maxillarydivisionoftrigeminalnerve 2.Zygomaticnerve 3.Branchesfromthesphenopalatineganglion 4.Branchesofinferiorophthalmicveinleadingontopterygoidplexus. Themaxillarydivisionoftrigeminalnerveandtheterminalbranchofinternalmaxillaryarteryenterthe infraorbitalgrooveandcanaltobecometheinfraorbitalnerveandartery.Thesestructuresexit throughtheinfraorbitalforamentosupplythelowereyelid,cheek,upperlipandupperanterior gingiva.Theorbitcommunicateswithpterygopalatinefossathroughthemedialmostportionofthis fissureandthroughthisintothenasalcavity.Laterallyinfraorbitalfissureisincontactwithtemporal andinfratemporalfossa.Thislateralaspectofthefissureisfilledwithsmoothmuscleandfattissue makingitasuitableplaceforbonecuts. InlivingpersonsthisfissureisclosedbyperiorbitaltissueandMullersmuscle. Flooroftheorbit: Thisareaisactuallyinterestingbecauseitcanbeinvolvedinpureblowoutfractureswithout involvmentofzygoma.Itismoreorlesstriangularinshapewithroundedcorners.Itisnarrow

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posteriorly.Thisisactuallynothorizontal,butslopesupwardsandmediallyatanangleof45.Itends astheanteriormarginofinferiororbitalfissure.Inthisareathisboneabruptlycurvesdownwards towardstheinfratemporalfossaformingtheposteriorwallofmaxilla. Componentsoftheflooroftheorbit: 1.Orbitalplateofmaxilla(largestcomponent) 2.Orbitalplateofzygomaticbone(anterolateralpart) 3.Orbitalprocessofpalatinebone(formsasmallportionbehindthemaxilla) Theflooroftheorbitistraversedbyinferiororbitalfissure.Thisfissureinfactweakensthefloor.Most ofblowoutfracturesoccurmedialtothisfissure.Fracturelinecancauseentrapmentofinfraorbital nerveleadingontoanesthesiaofcheekareaofthatside.Infraorbitalcanalformedfromthisfissure sinksanteriorlyandopensintotheinfraorbitalforamen. Theroofoftheorbitslopesdownmedially.Infactthisslopecontinuesuptofrontoethmoidalsuture toformtheroofoftheethmoidsinus.Thisisotherwiseknownasfoveaethmoidalis. Theanatomicalrelationshipbetweentheanteriorethmoidalaircellsandthelacrimalfossashouldbe borneinmindtoavoidconfusionbetweentheethmoidandnasalcavitiesduring dacryocystorhinostomysurgery. Ethmoidalforamen: Theseforaminaliebetweentheroofandmedialwalloforbit.Theseforaminainvariablyliewithinthe frontoethmoidalsuturelineorinthefrontalbone.Theseopeningsformcanalsknownasanteriorand posteriorethmoidalcanals.Thesecanalsareformedbyfrontalbonetoagreatextentwithminor contributionsfromethmoids. Anteriorethmoidalcanal: Thiscanalisdirectedbackwardsandlaterally.Thisforamenislocatedabout24mmfromtheanterior lacrimalcrest.Theposteriorborderofthiscanalisnotwelldefinedandiscontinuouswithagroove ontheorbitalplateofethmoid.Thiscanalopensintotheanteriorcranialfossaatthesideofcribriform platetransmittinganteriorethmoidalnerveandartery.

Figureshowinganteriorethmoidalartery

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Posteriorethmoidalcanal: Thiscanallieposteriortoanteriorethmoidalcanal.Thisforamenislocated36mmfromtheanterior lacrimalcrest.Ittransmitsposteriorethmoidalnerveandposteriorethmoidalartery. Opticforamen: Alsoknownasopticcanal.Itbeginsfromthemiddlecranialfossaandextendsuptotheapexofthe orbit.Thisforamenisformedbytworootsofthelesserwingofsphenoid.Thisforamenisdirected laterally,forwardsanddownwards.Thiscanalisfunnelshaped,themouthofthefunnelisitsanterior opening.Thisforamenisovalinshapewiththeverticaldiameterbeingthegreatest.Itsintracranial openingisflattendabovedownwards,whereasitsmiddleportioniscircularinnature.Itslateral borderiswelldefinedandisformedbytheanteriorborderoftheposteriorrootoflesserwingof sphenoid.Itsmedialborderislesswelldefined.Opticcanalisseparatedfromthemedialendof superiororbitalfissurebyabarofbone.Thisbarofbonehasatuberclefortheattachmentof annulustendinous.

Diagramshowingviewofskullafterremovalof lateralwall

Opticnervecanaltransmits: 1.Opticnerve 2.Coveringsofopticnerveincludingduramater,arachnoidmaterandpiamater. 3.Opthalmicarteryliesbelowandlateraltothenerveembeddedintheduralsheath Orbitalindex: Thewidthoftheorbitislargerthanthatofitsheight. Orbitalindexvariesamongvarioushumanraces.Goingbyorbitalindex3typesoforbitshavebeen identified. Orbitalindex=heightoftheorbit _______________X100 Widthoftheorbit Megaseme:Thisisaratherlargeorbitalindex.Heretheorbitalindexcalculatedusingtheformula aboveismorethan89.Thisorbitistheclassicfeatureofyellowraces.

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Mesoseme:Thisisintermediateorbitalindex.Heretheindexrangesbetween8389.Thisis commonlyseeninEuropeanwhites. Microseme:Thisisthesmallestorbitalindex.Thevaluehereislessthan83.Thisorbitistypically seeninblackraces6.Orbitalopeningisrectangular. Orbitalmargin: Thisismadeupofthreebones. Frontal Zygomatic Maxilla Superiororbtialmargin: Thisisentirelyformedbyfrontalbone.Thisportionoffrontalboneisalsoknownasorbitalarch.This marginissharpinlateral2/3androundedinmedialthird.Atthejunctionofthesetwoportionsabout 25mmfrommidlineissituatedthesupraorbitalnotch.Thisnotchtransmitssupraorbitalvesselsand nerves.Thisnotchisconvertedintoaforamenduetoossificationoftheligamentwhichliesinferiorto thisnotch.Thisnotchcaneasilybepalpatedintheliving. Arnoldsnotch: Thisisrarelyseenmedialtosupraorbitalnotch.ThisnotchisalsoknownastheArnoldsnotch.This notchtransmitsthemedialbranchesofsupraorbitalvesselsandnerves. Lateralorbtialmargin: Thismarginisthemostexposedoneandisthestrongestoftheorbitalmargins.Itisformedbythe zygomaticprocessoffrontalboneandzygomaticbone.Thelateralorbitalrimisrecessedto accomodatelacrimalgland.Thisrecessmaybeinvolvedinsegmentalfratureinthisregion.The narrowestandweakespartofthisrimisthefrontozygomaticsutureline.Separationofthissutureline isacommonfeatureoftraumainthisregion. Inferiororbtialmargin: Thismarginisraisedsligthlyabovetheflooroftheorbit.Thismarginisformedbyzygomaticbone andmaxillainequalproportions.Theinfraorbitalmarginisclearlydefinedatitslateralmarginandis easilypalpable.Innerportionoftherimisroundedandisnoteasilypalpable. Medialmargin: Thismarginisformedbyanteriorlacrimalcrestpresentonthefrontalprocessofmaxillaandthe posteriorlacrimalcrestonthelacrimalbone.Themedialmarginishencenotacontinuousridge. Agechangesinorbit: Anatomicalchangesinvolvingorbitdependsonthedevelopmentoffacialskeletonandthe neighbouringparanasalsinuses. Atbirththeorbitalmarginsaresharpandcompletelyossified.Thishelpsinprotectingtheeyesduring thestressfuleventofparturition.Atabouttheageof7theorbitalmarginsbutforthesuperiormargin becomefairlyroundedandlesssharp.Atthisagethesuperomedialandinferolateralanglesarewell

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markedthanotherangles.Thiscausestheorbittobetriangular. Infantsorbitlookmorelaterallythanadults. Orbitalfissuresarelargeinachildwhencomparedwiththatofadults.Thisisbecauseofthenarrow orbtialsurfaceofgreaterwingofsphenoid. Theorbitalindexishigherinachildwhencomparedtoadults.Theverticaldiameteristhesameas thatofhorizontaldiameter.Asgrowthprogressesthetransversediameterincreasesmorethanthe vertical.. Theinterorbitaldistanceisrathersmallinchildren.Thismimikssquint. Theroofoftheorbitismuchlargerthantheflooratbirth. Ininfantsopticcanalisnotacanal.Itisjustaforamen.Astheinfantgrowsthisforamenelongatesto becometheopticcanal. Theperiorbitaisthickerandstrongeratbirththaninadults. Oldagechangesoccuringintheorbitareactuallyduetoboneabsorption.Theroofoftheorbitin elderlypersonmayactuallycontainholeswhichcausesperiorbitatocomeintodirectcontactwith dura.Partsoflacrimalbonetoocanbeabsorbedduetoageingprocess. Softtissuesoforbit: Orbitalseptumistheanteriorsofttissueboundaryoftheorbit.Itactsasaphysicalbarrieragainst pathogens.Thisisathinmultilayeredfibroustissuederivedfromthemesodermallayerofeyelid.This septumiscoveredanteriorlybythepreseptalorbicularisoculimuscle. Periorbita:istheperiostealliningoforbitalwalls.Theperiorbitaisattachedtothesuturelines, fissuresandforaminaoftheorbit.Posteriorlytheperiorbitaiscontinuouswiththeopticnervesheath. Orbitalfat:Adiposetissuepresentintheorbithasacushioningeffectonthecontentsoforbit. Theextraocularmusclesoforbitarisefromtheannulusofzinnandareresponsibleforthe movementoftheglobe.Thesemusclesare: lateralandmedialrectus Superiorandinferiorrectus Superiorandinferioroblique Thefourrectimusclesarisefromtheannulusofzinn.Theannulusofzinnactuallyhastwotendons. Thelowertendonofannulusofzinnisattachedtothemedialendofsuperiororbitalfissureenclosing theopticforamen.Thistendongivesorigintopartsofmedialandlateralrecti.Italsogives attachmentofentireinferiorrectusmuscle.Theuppertendonoftheannulusofzinnalsoknownas tendonofLockwoodarisesfromthebodyofsphenoid.Thistendongivesorigintopartofmedialand lateralrectiandallofthesuperiorrectusmuscle.Theattachmentsofsuperiorandmedialrecti musclesareclosetotheduralsheathofopticnerve.Thisfactexplainsthepaincausedduring extremesofeyemovementsinretrobulbarneuritis. Medialrectus: Thisisthelargestoftheocularmuscles.Itisalsostrongerthanthelateralrectus.Fromitsoriginfrom

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theannulusofZinnitinsertsintotheglobemedially5.5mmfromthelimbus.Itsbloodsupplyis derivedfromtheinferiormuscularbranchofopthalmicarteryandanteriorciliaryarteries.Itderivesits motorinnervationfromthethirdcranialnerveonitslateralsurfaceatthejunctionofmiddleand posteriorthirds.Itisapureadductor. Inferiorrectus: Thisistheshortestofallrectimuscles.Fromitsoriginintheannulusofzinnclosetoopticforamenit insertsintotheglobeinferiorly6.5mmfromthelimbus.Itisalsoattachedtothelowereyelidviaits facialexpansion.Itderivesitsbloodsupplyfromtheinferiormuscularbranchofophthalmicartery, infraorbitalarteryandanteriorciliaryvessels.Itderivesitsmotorinnervationfromtheinferiordivision ofthirdnerveonitsupperaspectatthejunctionofitsmiddleandposteriorthirds.Itmovestheeye downwardsandmedially/rotatesitlaterally(extorsion).Itcanalsodepressthelowereyelidbyits facialslingwhichinsertsintoit.Itsprincipalactionisdepressionofoutturnedeye.Infactitistheonly depressoroftheabductedeye. Lateralrectus: Fromitsoriginfromtheannulusofzinnitisinsertedlaterallyintotheglobeabout6.9mmfromthe limbus.Itreceivesbloodsupplyfromlacrimalartery.Itistheonlyocularmusclewithsinglesourceof bloodsupply.Itisinnervatedbythe6thcranialnerveinitsmedialaspect.Itisapureabductor makingtheeyetolookdirectlylaterally. Superiorrectusmuscle: Arisingfromthesuperiorportionofannulusofzinnitisinsertedintothebulbsuperiorlyabout7.7 mmfromthelimbus.Itreceivesitsbloodsupplyfromthesuperiormuscularbranchofophthalmic arteryandanteriorciliaryarteries.Itisinnervatedbysuperiordivisionofoculomotornerve.Thisnerve enterstheundersurfaceofthemuscleatthejunctionofmiddleandposteriorthirds.Ithelpsin upwardsandmedialrotationoftheeyeandisalsocapableofintortingtheeyeball. Superiorobliquemuscle: Thisisthelongestandthinnestofocularmuscles.Itarisesmedialtotheopticforamenandgets insertedintothetrochleaontheorbitalrim(ontheanterosuperiorportionofthemedialwalloforbit). Itstendongetsinsertedontothetemporalaspectoftheeyebehindtheequator.Thesuperior muscularbranchofopthalmicarteryandciliaryarteriessupplythismuscle.Itmovestheeye downwardsandlaterally.Itistheonlymusclethatcandepresstheeyeinadductedposition.Itis suppliedbythe4thnerve. Inferioroblique: Thisistheonlyextrinsicmuscletotakeoriginfromthefrontoftheorbit.Thismusclearisesfromthe orbitalfloorinadepressionneartheorbitalrim.Someofitsfibresmayalsoarisefromthefascia coveringlacrimalsac.Itisinsertedintotheposteriorinferiortemporalquadrantatthelevelofmacula. Itderivesitsbloodsupplyfromtheinferiorbranchofophthalmicarteryandinfraorbitalartery.Itis innervatedbytheinferiordivisionofoculomotornerve.Thisnerveentersthemusclefromitsupper surface.Thismusclehelpstheeyetolookupwardsandlaterallyandinextorsionoforbit.Thisisthe onlymusclethatelevatestheeyeintheadductedposition. Levatorpalpebraesuperioris: Thisstriatedmuscleelevatestheeyelid.Thismusclearisesfromtheundersurfaceoflesserwingof

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sphenoidjustaboveandinfrontofopticforamen,andusuallyitisblendedwiththeoriginofsuperior rectusmuscle.Fromthisattachmentthisribbonlikemusclepassesforwardsbelowtheroofontopof thesuperiorrectusmuscle.Itgetsinsertedintotheskinoftheuppereyelid,anduppertarsalplate.It receivesitsnervesupplyfromthesuperiordivisonof3rdcranialnerve.Thismusclebyitselevating actionraisestheuppereyelid,thusuncoversthecorneaandportionsofsclera.Theactionofthis muscleisantogonizedbyorbicularisoculimuscleinneravatedbyfacialnerve. Mullersmuscle: Thissmoothmuscleactsasaneyelidelevator.Itarisesfromtheinferioraspectoflevatorpalpebrae. Thismuscleisinsertedintotheupperedgeoftarsalplate.Itisinnervatedbysympatheticfibers.The actionofthismuscleaccountsforthepresenceofupperlidelevationinpatientswith3rdcranialnerve palsy. Thelacrimalsystem: Themainlacrimalglandislocatedinthesuperotemporalportionoforbit.Itliesintheshallowlacrimal fossaofthefrontalbone.Theglandiscomposedofnumeroussecretoryunitsknownasaciniwhich progressivelydrainintosmallandlargerducts.Theglandmeasures20mmby12mm.Afibrous bandincompletelydevidesthelacrimalglandintotwolobesi.e.posteriorlargerorbitallobeanda smalleranteriorpalpebrallobe.26ductsfromtheorbitallobepassthroughthepalpebrallobe joiningwiththeductsfromthepalpebrallobetoform612tubulestoemptyintothesuperiolateral conjunctiva.Hencedamagetothepalpebrallobemayblockdrainagefromtheentiregland.About20 40accessorylacrimalglandsofKrausearelocatedinthesuperiorconjuctivalfornix,abouthalfthis numberislocatedoverthelowerfornix. Thelacrimalglandisinnervatedbybranchesfrom5thand7thcranialnerves,sympatheticsupplyto lacrimalglandisviathenervesfromthesuperiorcervicalganglion.Theparasympatheticfibersare suppliedviathe6thnerve.Sensorysupplyisviathebranchesoftrigeminalnerve.

Diagramillustratingrolesplayedbyvariousmuscles inocularmovement

Thelacrimalexcretorysystembeginsata0.3mmatthemedialendofeacheyelidsknownasthe punctum.Thesepunctaaredirectedposteriorly.Thepunctalopeningwidensintoampulla,whichis perpendiculartotheeyelidmargin.Theampullamakesasharpturntodrainintothecanaliculi.The canaliculimeasures0.51mmindiameterandcoursesparalleltothelidmargins.Thesuperior canaliculusis8mmlongandtheinferiorcanaliculusis10mmlong.Inmajorityofindividualsthe superiorandinferiorcanaliculimergeintoacommoncanaliculibeforedrainingintonasolacrimalsac. Theopeningofcommoncanaliculiintothenasolacrimalsacisknownasthecommoninternal

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punctum.Thereisavalveatthejunctionofcommoncanaliculusandlacrimalsacatthecommon internalpunctumlevel.ThisisknownastheRosenmullervalve.Anothervalveknownasthevalveof Hasnerisfoundatthelowerendofthenasolacrimalductatthelevelofinferiormeatusofnose. IfthisHasnersvalveisimperforateinnewborninfantsitcausescongenitalnasolacrimalobstruction. Thelacrimalsacresidesinthelacrimalfossa.Itmeasuresabout1215mmvertically,and48mm anteroposteriorly.

Diagramshowinglacrimalapparatus

Locationoflacrimalsac: Agoodintranasallandmarkforthelocationoflacrimalsacistheanteriorportionofmiddleturbinate, thesacliesjustlateraltoit.Thelacrimalfossaisboundedbytheanteriorlacrimalcrest,which consistsofthefrontalprocessofthemaxillarybone.Theposteriorlacrimalcrestismadeupofthe lacrimalboneitself.

Figureshowingintranasallandmarkoflacrimalsac

References
1. DoxanasMT,AndersonRL.ClinicalOrbitalAnatomy.Baltimore:Williams&Wilkins1984. 2. C.Martins,A.Yasuda,A.Campero,A.J.Ulm,N.Tanriover,andA.L.RhotonJr.,Microsurgical anatomyoftheduralarteries,OperativeNeurosurgery,vol.56,no.2,pp.141,2005. 3. http://drtbalu.co.in/orbit.html 4. MahmoodF.MafeeGaldinoE.ValvassoriMinervaBecker(10November2004).Imagingofthe headandneck.Thieme.pp.200.ISBN9781588900098.Retrieved16June2010. 5. Cellulitis,Orbital:eMedicineOphthalmology".Retrieved20100616.

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6. NovitM.Facial,upperfacial,andorbitalindexinBatak,Klaten,andFloresstudentsofJember UniversityDentJ.(Maj.Ked.Gigi).200639(3):116119

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