Eye lid anatomy for Ophthalmology residents, Oculoplasty fellows.

1. The Eye Lids
Dr. Diwa Hamal
OPAL, Fellow
TIO

2. Early cell division: (A) fertilized ovum, (B)
morula (C) blastula.

3. The facial processes.
• The frontalis muscle arises from the temporal lamina, whereas the orbicularis oculi,
cor- rugator supercilii, and procerus muscles arise from the infraorbital lamina.
• Conjunctival mucous membrane is formed by a surface epithelium resting on a
mesodermal substantia propria.

4. Eyelid development. (A) Eyelid fusion (8 to 10 weeks'
gestation); (B) development of margin structures (3 to 4
months' gestation); eyelid dysjunction (5 to 6 months'
gestation).

5. Abnormalities Of Eyelid Development
• Congenital entropion
• Congenital ectropion

6. Topography of eye lid
A. Sagittal section of Asian eyelid anatomy.B. Sagittal section of
Caucasian eyelid anatomy.

7. Concavity of superior orbital
sulcus after enucleation of right
eye.
Convexity of superior sulcus from
herniated orbital fat.

8. Langer lines (A) as they appear in a diagram and (B)
clinically. These static skin lines are formed by
collagenous, reticular, & elastic fibers in reticular
dermis.

9. Gravitational lines formed by progressive
thinning of relaxed skin.

10. Dynamic lines. Overaction of the procerus & corrugator
superciliaris muscle create these frowns line in this
patient with ocular phemigoid.

11. Structure of eye lid
12
1. Skin & Subcutaneous tissue
2. Muscles of protraction
3. Orbital septum & tarsal plates
4. Orbital fat
5. Muscle of retraction
6. Conjunctiva

12. Skin of eye lid
• Skin of eyelid is thin.
• Fat is absent in pretarsal skin
• In preorbital & preseptal skin subcutaneous fat is sparse
• Pretarsal skin is firmly adherent to the underlying tarsus because of attachments of
levator aponeurosis.
• Clinically, edema collects under loose preorbital & preseptal skin, leaving an
identifiable border at pretarsal skin where there are denser subcutaneous
fibroadipose attachments.

13. Eyelashes
14
• The human eyes are protected and lined by eyelashes
• They are in 2-3 rows
• In upper eyelid(100-150)
• In lower lid(50-75)
• life span of 100-150 days.
• If the eyelash is pulled out or falls off, it will take as
long as seven to eight weeks to grow back.

14. Glands of eye lid
Meibomian glands:
• Present in stroma of tarsal plate
arranged vertically. About 30-40 in
upper & 20-30 in lower lid. They are
modified sebaceous glands & their
ducts opens at lid margin
Glands of zeis:
• Sebaceous glands opens into
eyelashe follicles
Accessory lacrimal glands of Wolfring:
• Present near upper border of tarsal
plate
Glands of Moll:
• Modified sweat gland situated near
hair follicles or into duct’s of Zeis
glands. They do not open directly
into skin surface

15. Orbicularis oculi muscle,(A) Orbital portion; (B)
preseptal portion; (C) pretarsal portion.

16. Protractors
Orbicularis oculi muscle
• Firmly attached to underlying lateral palpebral raphe, medial canthal region,
insertions of upper & lower eyelid retractors, supraorbital ridge, naso-orbital
valley & malar crease
Orbital portion
• Superiorly- to eyebrow, where it interdigitates with frontalis & corrugator
superciliaris
• Medially- extends from supraorbital notch in a curvilinear fashion over side of
nose
• Laterally- extends to temporalis muscle
• Inferiorly- to infraorbital foramen. It continues along infraorbital margin
These thick course fibers play an important role in voluntary lid
closure (winking) & forced eyelid closure.

17. Preseptal Orbicularis Oculi
• It overlies orbital septum & in between is a fibroadipose layer
• If this post orbicularis layer contains a significant amount of fat, ptosis
surgeon may misinterpret it as being preaponeurotic fat.
• Laterally- Whitnall’sl tubercle. Because of fibrous component of this
lateral attachment, Jones misleadingly termed this lateral canthal
tendon rather than lateral canthal ligament.
• Medially- lacrimal sac, its fascia, & lacrimal crests.
• Medial origin
– Deep head or Jones muscle is adherent to lacrimal sac & fascia
– Superficial head arises from anterior rim of medial canthal ligament.
Functionally, the preseptal fibers contribute to voluntary lid
closure (winking) & involuntary lid closure (blinking).

18. Pretarsal Orbicularis Oculi
• It is firmly adherent to underlying tarsus & to superficial insertion of levator
aponeurosis at superior tarsal border.
• The superficial head inserts on anterior lacrimal crest & anterior limb of medial
canthal ligament. Superficial fibers also surround canaliculi.
Contraction shortens canaliculi, forcing lacrimal fluid into lacrimal sac.
Functionally, involuntary lid closure (blinking) is primarily responsibility
of smaller pretarsal orbicularis fibers.

19. Pretarsal Orbicularis Oculi
Medial origin
Deep head, Horner's tensor tarsi muscle arises from 4 mm behind posterior
lacrimal crest & from lacrimal fascia to insert medially on tarsi of upper & lower
eyelids.
It’s contraction pulls eyelid medially & posteriorly, allowing eyelids to follow &
cover, convex globe. In addition, it’s lateral contraction on lacrimal diaphragm
creates a negative pressure in lacrimal sac that draws tears from canaliculi.

20. Orbicularis Oculi
• Horner's & Jones muscles are essential for proper
functioning of lacrimal pump
• Deep fibers medially & posteriorly are responsible for
proper eyelid-to-globe apposition.
• Laterally orbital & preseptal fibers fuse over zygoma to form
lateral palpebral raphe.
• Deep fibers of pretarsal orbicularis joins inferior & superior
crux of lateral canthal ligament, which inserts on Whitnall's
tubercle

21. Medial
attachments of the
Orbicularis Oculi
muscle.

23. Orbicularis Oculi
24
• Nerve supply
Temporal and zygomatic branches of facial nerve
• Antagonist muscles
Orbital part frontal belly of occipitofrontalis muscle
Palpebral part levator palpebrae superioris

24. Orbital Septum
• Discreet, well-defined structure arising from arcus
marginalis
• Deep fascia of overlying orbicularis oculi muscle
• Multilayered structure
• Fibrous septa within submuscular fibroadipose tissue
become contiguous with more compact lamellae of orbital
septum, imparting a multilayered quality to orbital septum.
• Fat within fibroadipose layer anterior to orbital septum may
be mistaken for preaponeurotic fat pad during eyelid
surgery
• Orbital septum & levator aponeurosis joins 2 to 5 mm
above superior tarsal border.
• The orbital septum directly adjoins posterior epimysium of
orbicularis for about 1 to 5 mm before joining levator
aponeurosis.

25. Orbital Septum
• The cross-sectional thickness of orbital septum through its parallel
lamella varies but is less than 1 mm.
• It is thickest at the arcus marginalis laterally and is thinnest in lower
lid medially.
• Medially, posterior orbital septal lamella are carried posteriorly by
pretarsal orbicularis muscle, which inserts on posterior lacrimal crest.
• Superficial orbital septal fibers, as described by whitnall appear to
cross & adhere to lacrimal fascia before reaching anterior lacrimal
crest.
• At lateral canthus, orbital septum is also split; deep fibers insert at
Whitnall's tubercle, whereas superficial fibers join at lateral canthal
raphe, just deep to orbicularis muscle.

26. Orbital Septum
• Variation in septal strength is seen between individuals & varies with
age.
• Clinically, weakness of septum explains medial upper lid bulge
(bourrelet senile) seen in older patients & due to herniation of medial
fat pad through an attenuated septum.
• It also may explain high incidence of orbital invasion of basal cell
carcinoma in medial canthal region.

27. Lower lid Orbital Septa
• Arises from inferior orbital rim as a condensation of periosteum & periorbita.
• Anteriorly & superiorly to a point 4 to 5 mm below inferior tarsus, where it joins with lower
eyelid retractors & as a single structure inserts on lower border of inferior tarsus.
• Medially orbital septum splits & is carried posteriorly by pretarsal orbicularis muscle (Horner's
muscle) & attaches to posterior lacrimal crest.
• Laterally, orbital septum also splits & is carried deep by insertion of orbicularis.
The orbital septa of upper & lower eyelids form an anatomic barrier between preseptal &
orbital structures. Infectious processes anterior to septa are considered to be more
benign than posterior to septa.
• Functionally, suborbicularis oculi fibroadipose layer & multilayered orbital septum change with
movement, enhancing eyelid & eyebrow mobility.

28. Structure piercing orbital septum
• Anastomosis between the angular and ophthalmic veins

29. Orbital fat pad
• Serve as a protective cushion within which eyeball
moves
• Fat within muscle cone is termed central or conal
• Fat outside muscle cone is termed peripheral or
extraconal
• The whitish medial fat pad is more fibrous, whereas
larger central fat pad is more yellow because of a
decreased amount of fibrous tissue
• Larger central fat pad is termed preaponeurotic fat pad.
• Trochlea separates two fat pads.
• Clinically, preaponeurotic fat pad lies directly on the
surface of muscular portion of levator & serves as an
important surgical landmark to levator aponeurosis
immediately beneath it

30. Orbital fat pad
• Preaponeurotic fat pad is less vascular than other fat pads.
• Medial fat pad is more vascular because of location of palpebral arterial arcade,
which serpiginously courses through this pad
• Lateral to preaponeurotic fat pad lies lacrimal gland, which is typically pinker in
appearance, firmer in texture, & distinctly more vascular than preaponeurotic fat
pad
• During removal of orbital fat, eyelid surgeon is careful to avoid injury to laterally
located lacrimal gland.
• In lower eyelid, there exists a smaller temporal fat pad & a larger medial fat pad .
Temporal fat pad lies inferior to lateral canthus. It is separated from larger medial fat
pad by a fibrous extension from periorbita & orbital septum infralaterally, joining with
capsulopalpebral fascia & Lockwood's ligament

32. Orbital fat pad
• The lower eyelid fat pads are in direct communication with deeper
extraconal fat of orbit.
• Clinically, this is important during lower eyelid surgery because
excessive traction may be transmitted deeper into orbit, resulting in
intraoperative or postoperative orbital hemorrhage.
• During transconjunctival lower eyelid blepharoplasty, lateral eyelid fat
pad tends to be more fibrotic & prolapses less easily. Care is also taken
to avoid inferior oblique muscle, which originates just lateral to ostium of
nasolacrimal canal.

33. LPS Origin-
• At the orbital apex from lesser wing of sphenoid bone, superolateral to optic foramen
• At the level of superior tarsal border, fused lamellae of orbital septum & levator aponeurosis
sends connective tissue attachments to secondarily insert onto overlying orbicularis oculi
muscle & subcutaneous tissue.
These attachments result in a sharp upper eyelid crease. Variations in these attachments
result in variations in the location of the upper eyelid crease.
• The levator aponeurosis then sends connective tissue attachments, which insert primarily on
the anterior inferior third of the superior tarsus, with the strongest attachments 3 mm from the
lid margin
It is these tarsal attachments that are more important for proper upper eyelid function.

34. Retractors upper lid
LPS
• Triangular shaped striated muscle. Muscular portion -36 mm. Aponeurosis- 18 mm
• At the level of globe, levator muscle fans out & thins as whitish gray superior
transverse ligament of Whitnall.
• Anteriorly, aponeurosis expands horizontally to insert onto medial & lateral
retinacula as “horns”
• Medial horn of levator attaches to medial canthal ligament.
• lateral horn of levators splits lacrimal gland into larger orbital lobe & smaller
palpebral lobe. It then attaches to lateral orbital tubercle by lateral canthal tendon &
may provide suspensory support for gland.
• Aponeurosis continues anteriorly to a point 2 to 5 mm above the superior tarsal
border, where it joins with fibers orbital septum
• Motor innervation of the levator muscle is the superior division of the oculomotor
nerve (cranial nerve III).

36. Retractors upper lid
Mullers (superior tarsal muscle)
• Müller's muscle takes its origin from underside of levator muscle
22 mm above superior tarsal border where it inserts.
• It is loosely adherent to the conjunctiva & more adherent near tarsus
• Innervated by sympathetic nerve, pierced by peripheral arterial arcade & other
small arteries
Clinically, increased sympathetic stimulation (as seen in Graves' disease) is
thought to be a factor in thyroid eyelid retraction

37. Retractors lower lid
Capsulopalpebral fascia
• Posterior to globe, a fibrous extension arises from inferior rectus muscle
• Collectively termed capsulopalpebral head of inferior rectus muscle that splits to surround
the inferior oblique muscle
It has no inherent innervation but its action mirrors action of inferior rectus muscle, which is
innervated by inferior division of oculomotor nerve.
External portion is termed
capsulopalpebral fascia
Inner counterpart that
contains smooth muscle
is termed inferior tarsal
muscle
The two layers fuse anterior to
inferior oblique muscle to form a
dense fibrous structure termed
Lockwood's suspensory ligament.

38. Retractors lower lid
Inferior tarsal muscle
• It consists of numerous discontinuous smooth muscle bundles &
becomes totally fibrous as the inferior tarsus is approached
• It is sympathetically innervated. Clinically, in Horners' syndrome, the
atonic muscle may allow lower eyelid to elevate as much as 1 mm.
• Conversely, in thyroid eye disease, the lower eyelid may retract from
increased sympathetic tone.
Thyroid lid retraction. Sympathetic stimulation of Müller's muscle & inferior tarsal
muscle is a factor in this patient with Graves' disease.

39. The upper & lower tarsal plates.
• Thickened fibrous connective tissue that provide structural support to
the eyelids.
• Medially and laterally, the tarsal plates are connected to bony orbital
margins by ligamentous fibrous tissue
• Superior tarsal plate is 10 mm in vertical height and 25 to 30 mm in
horizontal dimension. 30 to 40 vertically meibomian glands are
present
• Inferior tarsal plate is 3 to 5 mm in vertical height and measures 25 to
30 mm horizontally. 20 to 30 vertically oriented meibomian glands are
present

40. Suspensory system of the eyelids
• Whitnall's ligament
• Lockwood's ligament
• Lateral canthal ligament
• Medial canthal ligament
• Eyelid margin

41. Suspensory System Of The Eyelids
Superior transverse ligament of Whitnall
• Main suspensory ligament of upper eyelid & as a check ligament for levator
aponeurosis & muscle
• Superior conjunctival fornix suspension assisted by curvature of globe,
• It is suspended from periorbita of orbital roof, extending medially from
trochlea across horizontal dimension of orbit to frontozygomatic suture, 10
mm superior to Whitnall's orbital tubercle
• Laterally, it sends weaker attachments to Whitnall's tubercle
.

42. .
The most significant lateral attachment site of Whitnall's ligament
is at frontozygomatic suture
• Whitnall's ligament is found 15 to 20 mm superior to the superior
border of the tarsus as a white, shiny, glistening structure where the
levator muscle becomes an aponeurosis

43. Suspensory System Of Eyelid
Lockwood's Ligament
• It acts as a suspensory hammock for globe even if all bone inferior to its
attachments at medial & lateral orbital walls are removed.
• Outer fibers of capsulopalpebral fascia fuse with inner fibers of inferior
orbital septum 4 to 5 mm below inferior tarsus & together advance as a
single layer to insert on inferior border of inferior tarsus
• Serves as an anchor for inferior conjunctival fornix
• It is composed of thickened Tenon's capsule, intramuscular septa, check
ligaments, fibers from inferior rectus sheath, lower lid retractors.
• Medially it iattaches to medial canthal ligament and laterally to lateral
canthal ligament.

44. Suspensory System Of Eyelid
Medial Canthal Ligament/tendon-
• Aids in function of lacrimal pump.
• Anterior limb is a broad fibrous structure that attaches eyelids to frontal process of
the maxillary bone & to anterior lacrimal crest. It gives origin to superficial head of
pretarsal orbicularis oculi muscle.
• Posterior limb of medial canthal ligament inserts on posterior lacrimal crest and
lacrimal fascia.
Lateral Canthal Ligament/ tendon-
• Superior crux from superior tarsus & an inferior crux from inferior tarsus they fuse
at the lateral border of tarsal plates to join lateral retinaculum, a condensation of
several anatomic structures that inserts onto lateral orbital tubercle of Whitnall.

46. Anterior limb of medial canthal ligament. In this cadaver
dissection, the anterior limb of the medial canthal ligament
(arrow) is seen originating from the frontal process of the
maxillary bone (pointer). Forceps reflect the medial aspect of the
eyelid.

47. Conjunctiva
• Conjunctiva represents differentiated inner portion of skin fold that forms eyelid. It is
composed of nonkeratinized stratified squamous epithelium with goblet cells.
• Palpebral conjunctiva is loosely adherent, except at tarsus & at superior tarsal
muscle where it is tightly adherent. In lower eyelid, conjunctiva is adherent to lower
tarsus but can be elevated from lower eyelid retractors without difficulty.

48. Arterial Supply
Deep / Intraorbital System
• Lacrimal- Lateral eye lid- LPA
• Supraorbital- Upper eye lid,
Levator, Forehead
• Supratrochlear- Forehead
• Dorsal nasal- MPA
• Zygomatico-orbital branch of
superficial temporal artery

49. Arterial Supply
Superficial / Facial System• Facial artery continewes as angular artery it lies within
orbicularis oculi muscle 6 to 8 mm medial to medial canthus
& 5 mm anterior to lacrimal sac. Anastomose with dorsal
nasal branch of ophthalmic artery.
• Superficial temporal artery (ECA) gives off 3 branches to
supply eye lid.
– Frontal branch- frontalis muscle of forehead & orbicularis
oculi anastomosing with lacrimal & supraorbital arteries
– Zygomatico-orbital- upper eyelid, anterior orbit
– Transverse facial- supply malar region & lateral aspect of
lower eyelid to anastomoses with lacrimal & infraorbital
arteries
• Infraorbital arteries- rich contribution to lower eyelid
(internal maxillary artery)

50. Forehead, eyebrow & upper eyelid
frontal vein
supraorbital vein
deep to orbicularis oculi into
(angular & supraorbital veins) superior ophthalmic v
Leaves orbit near annulus of Zinn by SOF
Inferior ophthalmic vein
begins as a plexus near anterior aspect of orbital floor
receives blood from
lower eyelid, lacrimal sac, IR muscle, IO muscle,
2 inferior vortex veins
Deep venous system
Other branches of deep orbital system…. central retinal vein, anterior ciliary veins, & cavernous
sinuses.
receives venous
drainage from
superior vortex veins
cavernous sinus
pterygoid plexus
by IOF

51. Superficial venous system
superior ophthalmic vein
superficial frontal vein from the forehead
Posterior facial v
common facial vIJV
Superiorly & laterally, venous blood from forehead, eyebrow & eyelid drain from supraorbital
vein into superficial temporal vein, into EJV
EJV

52. FACIAL LYMPHATIC SYSTEM.
Deep parotid
Deep cervical
nodes
IJV

53. • Oculomotor N-
– Sup dev- SR, LPS
– Inf dev- MR,IR,IO,parasym twig to ciliary ganglion
• Trigeminal N-
– Ophthalmic
• Lacrimal- lateral eye lid, forhead
• Frontal- Supra orbita- skin of eye lid, forheadl & supratrochlear medial
commissure, middle of forehead.
• Nasociliary- (1) the long sensory root of the ciliary ganglion; (2) the long
ciliary nerves, (3) the infratrochlear nerve, which is sensory to the medial
canthus(4) the posterior ethmoidal nerve
– Maxillary
• Infraorbital nerve- skin & conjunctiva of lower eyelid,

54. • Facial Nerve
– Temporal
– Zygomatic
– Buccal
orbicularis oculi muscle
procerus
corrugator muscles

55. Sympathetic supply
• Causes vasoconstriction, smooth muscle function, hidrosis, pupillary dilation,
pilomotor and sweat gland function of skin of face.
• Arise from carotid plexus & enter cavernous sinus sheathing intracavernous carotid
artery.
• Within cavernous sinus, sympathetic fibers join nerve branches & arteries entering
the orbit.
• Sympathetic innervation may reach tarsal muscles through a combination of roots:
with (1) levator muscle, (2) marginal vascular arcades, (3) perivascular plexus of
arterioles of muscles, (4) motor nerves of the ocular motor muscles, or (5) sensory
nerves.
• Clinically, interruption of sympathetic nerve fibers may result in Horner's syndrome,
with vascular dilation, ptosis, anhidrosis, miosis, & heterochromia.

56. Forehead
• Transverse elevation of superciliary ridge of frontal bone
• layer consists- skin, subcutaneous connective tissue, muscular layer,
submuscular areolar layer & pericranium
• Skin is thick & mobile contains sebaceous glands
• Subcutaneous tissue layer has more fibrous tissue than fat
• Muscular layer
– Vertical fibers of frontalis
– Horizontal fibers of orbicularis oculi
– Oblique fibers of corrugator supercilii

57. Forhead….
Frontalis
• Origin- Galea aponeurotica
• Insertion- Orbicularis oculi
• Action- Raises eyebraws, wrinkles forehead skin
• Artery- Supraorbital, Supratrochlear
• Nerve- Facial(Temporal)

58. Forehead….
• Corrugator supercilii muscle
– Origin - frontal bone near superomedial orbital margin
– Insertsion- at muscle, skin behind & immediately superior to middle third of
eyebrow
• Procerus muscle
– Origin- from nasal bone & upper nasal cartilage
– Insertion- on medial forehead skin
• Depressor supercilii muscle
– Origin- frontal potion of maxillary bone
– Insertion- on skin superior to medial canthal tendon
• Frontalis muscle & orbicularis interdigitate in eyebrow, a unique feature in
superficial muscle plane of face
Brow muscle force vectors. Open arrows depict
upward muscular force vectors and solid arrows
depict downward muscular force and gravity.

59. Age related changes
• (1) photo-induced aging or ultraviolet (UV) damage, (2) mechanical influences such
as gravity and muscle contraction, and (3) chronologic or intrinsic aging changes.
• Skin changes are characterized clinically by elastosis, irregular pigmentation,
roughness or dryness, teleangiectasia, atrophy, deep wrinkling, and a variety of
neoplasms.
• Mechanical influences from gravity and contraction of the muscles of facial
expression cause a decrease in skin elasticity resulting from constant stretch and
tension.
• Chronologic skin aging is the histologic and physiologic changes seen in sun-
protected skin of most older individuals. Clinical changes seen in the skin are laxity,
dryness, and fine wrinkling.

60. Age related changes
• Eyebrow ptosis
• Synophrys- hypertrophy of eyebrows result in fusion at midline glabellar area
• levator aponeurosis may become infiltrated with fat & disinsert from tarsus
compensatory brow arching
• Involutional lid ptosis
• Horizontal lid laxity- ectropion or entropion
• Telangiectasias, lid thickening, hyperkeratinization & meibomian gland orifice
changes
• Decrease in amplitude & peak velocity of closure phase of both spontaneous &
voluntary blinks. Narrowing of palpebral fissure with age. However, it may also be
partially because of a reduction in dopamine levels with age.

62. References…
• Embryology & Anatomy of the Eyelid. Edward H. Bedrossian, JR.
• Eyebrows, Eyelids, & Face: Structure & Function. Michael s.
Mccracken, Jonathan d. Del Prado, & Don O. Kikkawa.
• Oculoplastic Surgery. Second Edition. Brian Leatherbarrow.
• Smith & Nesi’s Ophthalmic Plastic & Reconstructive Surgery.