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ORBIT

a pear shaped structure with the optic nerve as its

stem. 30 cc in volume in adults and the eye occupies 20 % of the space and the muscles and fat accounts for the rest. is limited anteriorly by the orbital septum, which serves as a barrier between the eyelid and the orbit. related to the frontal sinus above, maxillary sinus below and the ethmoid and sphenoid sinuses medially.

Orbital Walls 1. Roof : frontal bone, sphenoid bone 2. Lateral wall : sphenoid bone, zygomatic bone 3. Floor : maxillary bone, zygomatic bone 4. Medial wall : ethmoid, lacrimal bone, frontal bone, maxillary bone

Orbital Apex The orbital apex is the entry site of all the nerves and blood vessels to the eye and all the extraocular muscles except the inferior oblique

Blood Supply
A. Arterial Supply : Ophthalmic Artery (branch of internal carotid artery) 1. Central retinal artery the first intraorbital branch 2. Lacrimal artery supplies lacrimal gland and upper eyelid 3. Muscular branches to the muscles continue to form the anterior ciliary arteries and supply the sclera, episclera, limbus and conjunctiva and contribute to the major arterial circle of the iris.

4. Long posterior ciliary arteries supplies the ciliary

body. The 2 long posterior ciliary arteries anastomose with each other and with the anterior ciliary arteries to form the major arterial circle of the iris. 5. Short posterior ciliary arteries supply choroid and part of the optic nerve 6. Medial palpebral arteries to both eyelids

B. Venous Drainage : Superior and inferior ophthalmic veins, into which drains the vortex veins, anterior ciliary veins and the central retinal vein. The ophthalmic veins communicate with the cavernous sinus. The skin of the periorbital region drain to the angular vein, and to the supraorbital and supratrochlear vein branches of the superior ophthalmic vein. This provides a direct communication between the skin of the face and the cavernous sinus.

CONJUNCTIVA
The conjunctiva is a thin transparent mucous membrane consisting of 2 parts 1. Palpebral conjunctiva lines the posterior surface of the eyelid and is adherent to the tarsus. 2. Bulbar conjuctiva is loosely attached to the orbital septum in the fornices and is folded many times. This allows the eye to move and enlarge the secretory conjunctival surface. The semilunar fold is a thickened fold of bulbar conjunctival at the inner canthus and corresponds to the nictitating membrane of lower animals.

The conjunctiva has the following layers: 1. Conjunctival epithelium consists of 2-5 layers of stratified columnar epethelial cells.
The superficial epithelial cells consists of mucous

secreting goblet cells. The basal epithelial cells are deeper and may contain pigments near the limbus.

2. Conjuctival stroma has an adenoid (superficial) layer

and a fibrous (deep) layer.


The adenoid layer contains lymphoid tissue and follicle-

like structures without germinal centers and develops after the 2nd or 3rd month of life. The fibrous layer is composed of connective tissue that attaches to the tarsus and is loosely arranged over the globe.

The accessory lacrimal glands (glands of Krause and

Wolfring) located in the stroma resemble the lacrimal gland in structure and function.

The conjunctival arteries are derived from the anterior

ciliary and palpebral arteries and anastomose freely. Conjuctival veins follow the arterial pattern. The conjuctival lymphatics with the lymphatics of the eyelids form a rich lymphatic plexus. The conjunctiva is innervated by the ophthalmic (first) division of the trigeminal nerve.

TENONS CAPSULE (Fascia Bulbi)


The Tenons capsule is a fibrous membrane covering

the globe from the limbus to the optic nerve. At the limbus, the conjuctiva, Tenons capsule and the episclera are fused together. Posteriorly the inner surface of the Tenons capsule lies against the sclera and the outer aspect lies in contact with the orbital fat and structures within the extraocular muscle cone.

At the point where Tenons capsule is pierced by the

tendons of the extraocular muscles, it sends out tubular reflections around each of the muscles. These fascial reflections become continuous with the fascia of the muscles and the fused fascia send out expansions to the surrounding structures and to the orbital bones called check ligaments. Inferiorly, the Tenons capsule fuse with the fascia of the inferior rectus and inferior oblique to form the suspensory ligament of Lockwood, upon which the globe rests.

SCLERA AND EPISCLERA


The sclera is the fibrous outer layer of the eye

consisting mainly of collagen. It is dense and white and continuous with the cornea anteriorly and the optic nerve dural sheath posteriorly. It is thinnest at the insertion of the recti mucles (0.3 mm); elsewhere it is 0.6 mm thick. The outer layer of the anterior sclera is covered with a thin layer of fine elastic tissue, the episclera, which contains blood vessels that nourish the sclera.

CORNEA
The cornea is a transparent tissue inserted to the sclera

at the limbus. It is thicker at the periphery (0.65 mm) than at the center (0.52 mm). Its horizontal diameter (11.75 mm) is slightly bigger than its vertical diameter (10.6 mm)

There are 5 layers of the cornea : 1. Epithelium : 5-6 layers of cells, continuous with the epithelium of the bulbar conjunctiva 2. Bowmans membrane : clear acellular layer, a modified portion of the stroma. 3. Stroma : 90 % of corneal thickness; composed of intertwining lamellae of collagen fibrils that run parallel to the surface of the cornea and because of their size and proximity are optically clear. The lamellae run within the ground substance of hydarated polyglycans in association with the keratocytes that produce the collagen and ground substance.

4. Descemets membrane : basal lamina of corneal

endothelium 5. Endothelium : single layer of cells ; responsible for maintaining the deturgescence of the cornea and failure of function leads to corneal edema. Cell loss occurs with age and injury. Endothelial repair occurs with cell enlargement and sliding of existing cells with minimal capacity for cell division.

The cornea gets its nutrition from the vessels of the

limbus, the aqueous and the tears. The superficial cornea gets most of its oxygen from the tears. The sensory nerves of the cornea is from the ophthalmic division of the trigeminal nerve. The transparency of the cornea is due to its uniform structure, avascularity, and deturgescence.

A. IRIS
Is a flat surface with a central opening, the pupil. The

iris lies in contiguity with the anterior surface of the lens, dividing the anterior chamber from the posterior chamber, both of which contains aqueous humor. Within the stroma of the iris are the sphincter and dilator muscles. The 2 pigmented posterior layers of the iris represent anterior extensions of the neuroretina and the retinal pigment epithelium (RPE). The blood supply of the iris is from the major circle of the iris. The iris capillaries are non fenestrated. Sensory supply is from fibers of the ciliary nerve.

The pupil controls the light entering the eye. The

pupillary size is determined by the balance between constriction due to parasympathetic activity via the oculomotor nerve and dilation due to sympathetic activity.

B. CILIARY BODY
The ciliary body consists of 2 zones 1. Pars plicata : 2 mm wide; ciliary processes arise from this zone. The ciliary processes are composed mainly of large fenestrated capillaries and veins that drain to the vortex veins. The 2 layers of the ciliary epithelium are the internal non pigmented layer (representing the anterior extension of the neuroretina) and the external pigmented layer (representing the RPE). The ciliary processes produce the aqueous. 2. Pars plana 4 mm ; flattened posterior zone

The ciliary muscle is composed of longitudinal, circular and radial fibers. 1. Circular fibers: contraction and relaxation of the zonular fibers alters the capsule of the lens thus giving variable focus for far and near objects of fixation. 2. Longitudinal fibers : insert to the trabecular meshwork, influencing its pore size 3. Radial fibers
The blood supply of the ciliary body is from the major

circle of the iris and the nerve supply is from the ciliary nerves.

C. CHOROID
The choroid is the posterior

portion of the uveal tract, located between the retina and the sclera. The internal portion of the choroidal vessels is called the choriocapillaries. Blood from the choroidal vessels drain via 4 vortex veins, one in each posterior quadrant. The choroid nourishes the outer portion of the retina.

LENS
The lens is a biconvex, avascular clear structure, 4 mm

thick and 9 mm in diameter. It is suspended behind the iris by the zonules which connects it with the ciliary body. Anterior to the lens is the aqueous and posterior to it is the vitreous. The lens capsule is a semi-permeable membrane (to water and electrolytes). A subcapsular epithelium is present anteriorly. The lens nucleus is harder than the cortex. With age, the subepithelial lamellar fibers are continuously produced, gradually making the lens larger and less elastic.

The lens consists of 65 %

water and 35% protein and minerals. There are no blood vessels, pain fibers of nerves in the lens.

AQUEOUS
The aqueous is a clear fluid that fills the anterior and

posterior chambers of the eye. Its volume is about 230 L and its rate of production which is subject to diurnal variation is 2.5 L/ min. Its composition is similar to plasma except for higher concentration of ascorbate, pyruvate and lactate and lower concentrations of protein, urea and glucose. Aqueous is produced by the ciliary epithelium. From the posterior chamber, the aqueous pass through the pupil to go to the anterior chamber and then to the trabecular meshwork, to the Schelemms canal and into the venous system. Some aqueous passes between the bundles of the ciliary body and through the sclera (uveoscleral pathway).

ANTERIOR CHAMBER ANGLE


The anterior chamber

angle lies at the junction of the periphearal cornea and the root of the iris. Its main anatomic features are Schwalbes line, trabecular meshwork ( which overlies the Schlemmss canal) and the scleral spur.

The Schwalbes line corresponds to the termination of

the corneal endothelium. The trabecular meshwork is triangular in cross section with the base directed to the ciliary body. It is composed of perforated sheets of collagen and elastic tissue with decreasing pore size as the canal of Schlemm is approached. The longitudinal muscles of the ciliary body insert into the trabecular meshwork. The scleral spur is an inward extension of the sclera between the ciliary body and the Schlemms canal, to which the ciliary body and the iris are attached.

RETINA
The retina is a thin, semi-transparent, multilayered

sheet of neural tissue that lines the inner aspect of the posterior 2/3 of the wall of the eye. It extends anteriorly as the ora serrata. The outer surface of the retina is apposed to the retinal pigment epithelium (RPE). Except at the disc and the ora serrata, the retina and RPE are easily separated to form a subretinal space, such as occurs in retinal detachment. The inner layer of the retina is apposed to the vitreous

The 10 layers of the retina, from the inner aspect are the following: 1. internal limiting membrane 2. nerve fiber layer ganglion cell axons passing to the optic nerve 3. ganglion cell layer 4. inner plexiform layer connections of the ganglion cells with the amacrine and bipolar cells 5. inner nuclear layer cell bodies of the bipolar, amacrine and horizontal cells 6. outer plexiform layer connections of the bipolar and horizontal cells with the photoreceptors 7. outer nuclear layer cell nuclei of photoreceptors 8. external limiting membrane 9. phototreceptor layer rod and cones inner and outer segments 10. retinal pigment epithelium (RPE) The inner layer of the Bruchs membranes is actually the basement membrane of the RPE

The retina is 0.1 mm thick at the ora serrata and 0.56 mm

thick at the posterior pole. In the center of the posterior retina is the macula. It is clinically seen as a 3 mm area of yellowish pigmentation (due to xanthophylls pigments) and bounded by the temporal vascular arcades. In the center of the macula is the fovea, clinically seen as a depression and corresponds to the foveal reflex. It corresponds to the retinal avascular zone of fluorescein angiography.

Histologically, the fovea is characterized by thinning of

the outer nuclear layer and the absence of the other parenchymal layers. The foveola is the most central portion of the fovea, in which the photoreceptors are all cones, and the thinnest part of the retina. All these histologic features provide for fine visual discrimination. The normally empty extracellular space of the retina is potentially greatest at the macula, and diseases that can lead to accumulation of fluid causes thickening of this area.

The retina receives its blood supply from 1. choriocapillaries supply outer third of retina, from outer plexiform layer to RPE 2. central retinal artery supply the inner 2/3 of the retina

The fovea is supplied entirely by the choriocapillaries

and is susceptible to irreparable damage when the macula is detached. The retinal blood vessels have a nonfenestrated endothelium, which forms the inner blood-retinal barrier. The endothelium of the choroidal vessels is fenestrated. The outer bloodretinal barrier lies at the level of the RPE.

VITREOUS
The vitreous is a clear, avascular body, comprising 2/3

of the volume and weight of the eye. It fills the space bounded by the lens, retina and optic disc. The hyaloid membrane, the outer surface of the vitreous is in contact with the posterior lens capsule, zonules, pars plana epithelium, retina and optic nerve head. The base of the vitreous maintains a firm attachment through out life with the pars plana epithelium and the retina immediately behing the ora serrata. The attachment to the lens capsule and the optic nerve head is firm early in life but soon disappears. The vitreous is 99% water. Collagen and hyaluronic acid makes the vitreous gel like because of their ability to bind large amounts of water.

EXTRAOCULAR MUSCLES
The 4 recti muscles originate from the annulus of Zinn

at the apex of the orbit and are named after their insertion at the sclera on the medial, lateral, superior and inferior aspect of the eye. The superior oblique is the longest and thinnest of the extraocular muscles. The inferior oblique originates from the nasal side of the orbital wall and is the only extraocular muscle that does not originate from the apex of the orbit

EYEBROWS
The eyebrows are folds of thickened skin covered with

hair. The glabella is the hairless prominence in between the eyebrows

EYELIDS
The upper and lower lids (palpebrae) are folds of skin that can close to protect the anterior portion of the eye. Blinking helps spread the tear film, keeping the cornea and conjunctiva wet. Layers of the eyelids 1. Skin thin, loose, elastic, few hair follicles and no subcutaneous fat. 2. Orbicularis oculi muscle Circular muscle fibers surround the palpebral fissure which functions to close the eyelids. It is innervated by the facial nerve. 3. Areolar tissue under the orbicularis oculi, communicates with the subaponeurotic layer of the scalp. 4. Tarsal plates dense fibrous tissue layer ; main support of the eyelids 5. Palpebral conjunctiva adheres firmly to tarsal plate

Lid Margin free lid margin is 25-30 mm long and 2 mm wide. It is divided by the gray line (mucocutaneous junction) into anterior and posterior margin. 1. Anterior margin
a. Eyelashes
b. Glands of Zeis modified sebaceous glands ; open onto

hair follicles at the base of eyelashes c. Glands of Moll modifies sweat glands ; open in a row near the base of the eyelashes

2. Posterior margin in close contact with the globe ; along

margins are the small orifices of the meobomian glands (modified sebaceous glands) 3. Lacrimal punctum at the medial end of posterior margin of the lid ; small elevation with a central opening ; carry tears through the canaliculus to the lacrimal sac.

ORBITAL SEPTUM
The orbital septum is the fascia behind the portion of

the orbicularis muscle that lies between the orbital rim and the tarsus. It serves as a barrier between the lid and the orbit

LID RETRACTORS
The lid retractors are responsible for opening the eyelids; have striated and smooth muscle components A. Upper lid
1. Levator palpebrae superioris 2. Mullers muscle (superior tarsal muscle)

B. Lower lid 1. Inferior rectus muscle 2. Inferior tarsal muscle

LACRIMAL COMPLEX
A. Lacrimal gland ; has orbital portion and palpebral

portion B. Accessory lacrimal glands of Krause and Wolfring located in the sustantia propria of palpebral conjunctiva C. Canaliculi D. Lacrimal sac E. Nasolacrimal duct- drains out to the nasal cavity

Blood supply of the lacrimal gland is from the lacrimal artery and venous blood drain to ophthalmic vein. Lymphatics drain into preauricular lymph nodes. Nerve supply to the lacrimal gland is by a. lacrimal nerve (sensory), a branch of the trigeminal first division b. great superficial petrosal nerve (secretory) c. sympathetic nerves

OPTIC NERVE
The trunk of the optic nerve consists of about 1 million axons arising from the ganglion cells of the retina a. intraocular portion optic nerve head ; 1.5 mm in diameter b. orbital portion 3 mm in diameter, 25-30 mm long, located within the muscle cone c. intracanalicular portion 4-9 mm long d. intracranial portion- 10 mm long, and with the opposite optic nerve joins to from optic chiasm

Fibers of the optic nerve consist of a. visual fibers 80%, synapse in the lateral geniculate body on neurons whose axons terminate in the visual cortex of the occipital lobe b. pupillary fibers 20% , bypass the geniculate body en route to the pretectal area.
The ganglion cells of the retina and their axons are part

of the central nervous system and as such, do not regenerate if severed. The optic nerve sheath is continuous with the meninges.

Cross-section

The surface layer of the optic

disc receives blood from the branches of the retinal arterioles. The rest of the nerve in front of the lamina cribrosa is from the peripapillary choroidal vessels. At the region of the lamina cribrosa, the blood supply is from the short posterior ciliary arteries. Retrolaminar nerve receive blood from branches of the central retinal artery. The rest of the introrbital portion, intracnalicular and intracranial portions are supplied by pial vessels from branches of ophthalmic artery and other branches of the internal carotid artery.