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Anatomy of the eyelids


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anatomy of the eye lids. by Dr.Vaibhav.K
post graduate in ophthalmology
navodaya medical college raichur

Published in: Health & Medicine
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Anatomy of the eyelids

  1. 1. By Dr.Vaibhav k Moderator : Dr.Anupama.T
  2. 2. Introduction
  3. 3. Embryology  Formed by reduplication of surface ectoderm above and below the cornea during second month of gestation.  The folds enlarge and their margins meet and fuse with each other  The lids cut off a space called conjunctival sac.  The folds thus formed contain some mesoderm for development of muscles of lid and tarsal plates.  Lids seperate after 7th month of intrauterine life
  4. 4. 1) Extent 2) Lid folds 3) Position of eyelids 4) Canthi 5) Eyelid Margins 6) Eyelashes 7) Palpebral aperture or fissure Gross Anatomy
  5. 5. Extent  Upper eyelid  From eyebrow downward to end in a free margin  Superior boundary of palpebral fissure  Lower eyelid  Merge into skin of cheek, where nasojugal,malar sulci limit it.
  6. 6. Lid folds  Superior lid fold  Orbital & tarsal portion  Formed by fibrous slips, from tendon of levator  Inferior lid fold  On skin of lower eyelids  Fibrous slips from fascia of inferior rectus
  7. 7. Position of eyelids  In primary position of gaze Upper eyelid covers 1/6th of cornea Lower eyelid just touches the cornea
  8. 8. Canthi
  9. 9.  the two eyelids are separated by lacus lacrimalis, in the centre of which is a small pinkish elevation;  the caruncula is a small area of tissue derieved from skin,contains large modified sweat glands and sebaceous glands.  A semilunar fold called plica semilunaris lies on lateral side of caruncle.Represnts the third eye lid of other vertebrae.
  10. 10. Eyelid Margins
  11. 11.  Lid margin vascularity increases with age,particularly in women.
  12. 12. Eyelashes  2-3 rows  When lids close eyelashes do not interlace  Upper lid : 100-150  Lower lid : 50-75  Cilia  20 – 120 microns  Taper & end in fine point  Lifespan 5 months.  Replacement is fully grown in 10 wks.  Darker than other hairs and remain so except in alopecia areata.  Glands of Zeis & Moll- empty into infundibulum of each piliary gland
  13. 13. Ciliary follicles:  Cilia have no erector muscles set obliquely,anterior to palpebral muscle reach the tarsal plate, have a sensory innervation.
  14. 14. Palpebral aperture  Elliptical space b/w upper & lower lid margins  At Birth  Horizontally– 18 to 21 mm  Vertically -- 8mm  In Adults  28 to 3o mm (hor)  9 to 11 mm (ver)
  15. 15. Structure  From without inwards, each lid has following layers: 1) Skin 2) Layer of subcutaneous areolar tissue 3) Layer of striated muscles(orbicularis oculi) 4) Sub muscular areolar tissue 5) Fibrous layer and tarsal plate. 6) Septum orbitale 7) Layer of non-striated muscle fibres 8) Conjunctiva
  16. 16. Skin  Elastic , fine texture, thinnest in the body(<1mm)  Almost transparent.  The skin of medial part of eye lid differs from temporal .more oily,few rudimentary hairs,sebaceous glands,plentiful unicellular sebaceous glands in basal epidermis.
  17. 17. Epidermis 6-7 layers , stratified squamous epithelium Basal layer- unicellular sebaceous glands, sweat glands Dermis Thin layer , dense connective tissue Rich network : BV, elastic fibers, lymphatics, nerve Variable no. of melanocytes
  18. 18.  The mucocutaneous junction is just behind openings of tarsal glands,i.e. junction of wettable and non wettable surfaces, representing ant limit of of marginal strip of tear fluid.
  19. 19. Subcutaneous areolar tissue  Beneath the skin  No fat  Readily distended by blood/ oedema  Nonexistent  Near ciliary margin  At lid folds  Medial & lateral angles
  20. 20. Layer of striated muscle  Orbicularis muscle , thin oval sheet across eyelids  Upper eyelid- also has levator muscle
  21. 21. Orbicularis oculi muscle
  22. 22. Orbital part  From anterior part of the medial palpebral ligament & adjacent bones  Cover orbital margins , large ellipse , meet at lateral palpebral raphe  Intermingle with frontalis
  23. 23. Palpebral part of orbicularis  Preseptal fibres  Pretarsal fibres
  24. 24. Preseptal fibres  Deep head & superficial head  From lacrimal fascia, posterior lacrimal crest, MPL  Pass superiorly & inf. In front of orbital septum  Unite at lateral palpebral raphe
  25. 25. Pretarsal fibres  Deep head  From lacrimal fascia & post. Lacrimal crest  Superficial head  From medial palpebral ligament  Overlying upper & lower tarsus  Join laterally to form lateral canthal tendon  It is inserted over lateral orbital tubercle of WHITNALL  Pars lacrimalis (Horner’s muscle)  Pars ciliaris (muscle of Riolan)
  26. 26. Function of orbicularis oculi  Orbital part  Forced closure of eyelids  Thus pull eyebrows downwards  Palpebral part  Helps in gentle closure during blinking, sleep, soft voluntary closure  Entire muscle supplied by branches of 7th nerve
  27. 27. Levator palpebrae superioris  Origin  Course & attachments  Superior transverse ligament of Whitnall  Nerve supply & action
  28. 28. Origin of LPS  At apex of orbit from the Under surface of lesser wing of sphenoid above Annulus of Zinn by a Short tendon whuch is Blended with origin of SR
  29. 29. Course & attachments  Ribbon like belly  Axis slightly nasal  Medial & lateral horns  Aponeurosis passes through septum orbitale  LPS inserted – pretarsal skin of lid forming the sup.lid fold  Thickened posterior part- ant tarsal surface  Few fibrous slips from post.LPS insert into sup.conj. Fornix
  30. 30. Sup. Transverse lig. Of Whitnall  Thickened band of orbital fascia extending From trochlear pulley to the capsule of orbital lobe of lacrimal gland.  Formed by condensation of superior sheath of levator muscle joined medially by the sheath of reflected tendon of superior oblique muscle
  31. 31.  Severing of this ligament during ptosis surgery can lead to failure of levator function.
  32. 32. Nerve supply & action of LPS Branch of superior division of 3rd nerve  Acts as Elevator of upper lid.
  33. 33. Submuscular areolar tissue Layer of loose connective tissue  b/w orbicularis muscle & fibrous layer  Nerves & vessels lie in this layer  Splits lid into anterior & posterior lamina  Superiorly communicates with subaponeurotic layer of scalp
  34. 34.  Lower lid – submuscular tissue is a single space behind orbicularis  Upper lid- levator muscle- divides into 2 spaces › Pretarsal space- has peripheral arcade › Bounded anteriorly by levator tendon,orbicularis,posteriorly by tarsal plate,palpebral muscle. › Limited by origin of this muscle from levator,below by attachment of levator to tarsal plate. › Preseptal space- triangular, bounded in front by Orbicularis, behind by septum orbitale
  35. 35. Fibrous layer  Framework of the lids  Central thick part- tarsal plate  Peripheral thin part- septum orbitale/ palpebral fascia
  36. 36. Tarsal plates  Dense fibrous tissue, skeleton of lids  Extend from a point 7mm from lateral orbital tubercle to lacrimal puncta,9mm from anterior lacrimal crest.  29mm long, 1mm thick  Superior tarsus is transversely cresentric  Inferior tarsus is oblong.  Surfaces: anterior and posterior  Tarsal glands embedded in substance of tarsal plates
  37. 37. Capsulopalpebral fascia:  i. Origin: as capsulopalpebral head from delicate attachments to inferior rectus muscle  ii. Extends anteriorly and splits into two and surrounds the inferior oblique muscle  iii. Again rejoins to form the Lockwood’s ligament and fascial tissue anterior to this forms the capsule palpebral fascia  iv. Insertion: on the inferior fornix along with inferior tarsal muscle and on inferior border of tarsus
  38. 38. Septum orbitale(palpebral fascia) Thin , floating membrane of connective tissue  Takes part in all movements of lids  Thick & strong on lateral side,in upper lid than lower lid.
  39. 39.  Peripherally attached to orbital margins called arcus marginale formed by periorbita when it continues with periosteum of facial bones.  Centrally it becomes continuous with tarsal plates except where pierced by fibres of levator in upper lid.  Weak areas in septum orbitale determines the site of herniation of fat(orbital)
  40. 40. Relations  Upper lid: • In contact with orbital fat which seperates it from larimal gland ,levator,tendon of sup oblique muscle. • Medially contact with orbital fat between trochlea,medial palpebral ligament.  Lower lid: • Contact with orbital fat,expansions of inf and superior rectus.
  41. 41. Structures piercing orbital septum Lacrimal vessels & nerves  Supraorbital vessels & nerves  Supratrochlear artery & nerve  Infratrochlear nerve  Anastomosing vein b/w angular & ophthalmic  Superior & inferior palpebral arteries  Aponeurosis of levator muscle in upperlid  Expansion of inferior rectus in lower lid
  42. 42.  Triangular band of connective tissue  Attached to frontal process of maxilla  From ant. Lacrimal crest  To suture line of frontal process with nasal bone  Divided into 2 parts › Ant. part of MPL › Post. part of MPL
  43. 43. Lateral palpebral ligament  Thin band  Lateral- whitnall’s tubercle  Medially attached to lateral ends of upper,lower tarsal plates.  Anterior surface- related to lat.palpebral raphe  Posterior surface- check ligament of LR  Upper border- aponeurosis of levator muscle  Lower border- IO ,IR
  44. 44. 6. Layer of non striated muscle:  Consists of smooth muscle fibres of muller, which lie deep to septum orbitale.  Origin: arise from the inferior terminal striated fibres in upper lid,from expansion of inf rectus in lower lid.  Supplied by sympathetic nerve fibres.  So sympathetic irritation leads to retraction of lids, paralysis leads to horners syndrome.
  45. 45. 7. Conjunctiva  It is the posterior most layer of eyelidwhich extends from m ucocutaneous junction at lid margin to conjunctival fornix.  It is firmly adherent to posterior surface of tarsal plate,mullers muscle.
  46. 46. Glands of Eyelids
  47. 47. The tarsal glands
  48. 48. Glands of Zeis  Modified sebaceous glands  Structure  Microscopy  epithelium on basement membrane  Cuboidal cells actively dividing  Secretion  Sebum, prevents lashes becoming dry  Oily layer of tear film
  49. 49. Glands of Moll  Modified sweat gland  Gross structure  Unbranched spiral shape  Fundus, body, ampullary portion & neck  Duct passes through dermis,epidermis,terminate between 2 lashes  Microscopic structure  Secretory part- cylindrical cell  b/w cells & bm – myoepithelial cells  Ducts lined by one/two layers of cells
  50. 50. Acessory lacrimal glands of wolfring  Microscopic accessory lacrimal glands present along upper border of superior tarsus, along lower tarsus inferior border.  2-5 in upper lid  2-3 in lower lid
  51. 51. Arterial supply  Mainly by medial & lateral palpebral arteries  Marginal Arterial arcades  Medial palpebral + lateral palpebral  Superior or peripheral arterial arcade  Superior branches of medial palpebral artery  Tarsal arcades  Superficial temporal artery  Transverse facial artery  Infraorbital artery
  52. 52. Venous drainage  Pretarsal Venous Plexus  Superficial to the tarsus  Angular vein– Internal jugular vein ,  sup. temporal, lacrimal vein  External jugular vein  Post-tarsal venous plexus  Structures posterior to tarsal plate  Ophthalmic veins
  53. 53. Nerve supply
  54. 54. Contd.  Sympathetic nerves  Supply Muller’s muscle  Vessels & glands of skin  Arrangement of Nerves  Submuscular to anesthetise lid,inj is given in this compartment  From here branches pass Forward for orbicularis & skin  Backward to tarsal structures & conjunctiva
  55. 55. Lymphatics
  57. 57.  Lid opening  Lid closure  Blinking  Voluntary blinking and winking  Bell’s phenomenon
  58. 58. Lid opening Upper lid elevators Lower lid retractors
  59. 59. Upper lid elevators  Levator palpebrae superioris (the primary elevator of the upper eyelid).  The superior palpebral muscle of Muller’s  Frontalis (acting as accessory elevator). Frontalis and Muller’s muscles become important when the levator is defective.
  60. 60. Muscle Attachment Nerve supply Levator palpebrae superioris (main upper lid retractor) Lesser wing of the sphenoid to the tarsal plate Superior division of the oculomotor nerve (also supplies the SRM). Muller’s muscle (minor upper lid retractor) Aponeurosis of the levator to the upper border of the tarsal plate Sympathetic Frontalis Scalp to the upper part of the orbicularis oculi
  61. 61. Eyelid excursion during opening movements:  In adults the upper eyelid is raised some 10-15 mm from extreme downward gaze to extreme upward gaze.
  62. 62. Tone of levator muscle:  In upward gaze, tone increases in both the superior rectus muscle and the levator, resulting in elevation of the visual axis and concomitant elevation and retraction of the upper lid.
  63. 63. Lower lid retractors  NO true counterpart of the levator is present, and therefore, the opening movement depends upon several factors: 1. Traction exerted by the attachment of the inferior rectus to the inferior tarsus. 2. Inferior palpebral muscle (identical to Muller’s muscle in the upper lid).
  64. 64. Dynamics of opening movement  Opening of the upper eyelid takes place against gravity.  Opening movements of the homolateral upper and lower eyelids begin in phase, although the opening movement of the lower lid is much slower than that of the upper eyelid due to lack of any direct muscular pull.
  65. 65.  During opening movement the upper lid moves vertically upwards, while the lower lid moves laterally in a horizontal direction.
  66. 66.  Bilateral coordination and their basis:  Opening movements of the eyelids are bilateral, symmetrical, and identical in direction and amplitude, although they may be voluntarily inhibited on either side.  So, the levator muscles of the two upper eyelids behave as yoke muscles in that they act as a team or pair, and like extraocular muscles, obey Hering’s law of equal innervation.
  67. 67.  This implies that the innervational energy reaching the one levator muscle is equal to that reaching the other.  When the levator on one side is weak, as in unilateral myasthenia gravis or unilateral congenital ptosis, the lid on the unaffected side may be retracted in an unconscious effort (based on Hering’s law of equal innervation) to elevate the ptotic lid.
  68. 68. Reciprocal innervation pattern  It exists between the levator muscle and the orbicularis oculi muscle, i.e. when levator receives maximum innervation during opening the orbicularis receives minimum innervation and vice versa. Thus, these muscles follow the Sherrington’s law of reciprocal innervation.
  69. 69. Lid closure
  70. 70. Orbicularis oculi controls lid closure and is supplied by the facial nerve. It is divided into three main parts:
  71. 71. Part Position Function Pretarsal fibers In front of the tarsal plate * Respond in spontaneous blinking and tactile corneal reflex. * Close lid and pull lacrimal puncta medially. Preseptal fibers In front of the orbital septum Respond to voluntary blinking and sustained activity. * Pull lacrimal fascia laterally and create a relative vacuum in lacrimal sac-improve tear drainage. Orbital fibers Surrounds the orbital rims * Respond in forceful lid closure.
  72. 72. Blinking can be divided into voluntary and involuntary types. The involuntary blinks are further subdivided into spontaneous and reflex blinks.
  73. 73. Spontaneous blinking  It is a common form of blinking that occurs without any obvious external stimulus or voluntary willed efforts.
  74. 74.  Spontaneous blinking does not occur or is very infrequent during the first few months of life; yet the delicate infant cornea does not suffer from dryness.  Average rate: 15 times per minute (12-20).  The blink rate is increased in: 1. Extremely dry conditions. 2. Strong air currents. 3. Certain emotional stress situations (surprise, anger, or fight).  A decreased blink rate occurs during times of visual observations.
  75. 75.  Duration: 0.3-0.4 second.  Present in the blind, hence no retinal stimulation is required.  No discontinuity of visual sensation during blinking.  The upper lid begins to close with no lower lid movement.  It is followed by a zipper-like movement from the lateral canthus towards the medial canthus.  This helps the displacement of the tear film to the lacrimal puncta which are located on the medial side of the lids.
  76. 76. Mechanism  The exact stimulus for spontaneous blinking is unknown.  Spontaneous blinks occurring without gaze shifts are triggered by a timing mechanism probably located in the brainstem.
  77. 77.  During each blink, the upper eyelid covers the center of the pupil for a period of 0.10 sec.  Due to contraction of the preseptal fibers, as the upper eyelid reaches the limit of its downward excursion, electrical activity in the orbicularis ceases and concomitantly activity reappears in the levator.
  78. 78. Reflex blinking reflexly in a response to a stimulus.
  79. 79. Different stimuli induce a different neurological pathway. Blinking reflex Examples Afferent Efferent Central connection Tactile Corneal touch CNV CNVII Cortical Dazzle (optic) Bright light CNII CNVII Subcortical Menace (optic) Sudden presence of near object CNII CNVII Cortical Auditory Loud noise CNVIII CNVII Subcortical Orbicularis Stretching of panorbital structure (tap/blow) CNV CNVII Cortical
  80. 80. Voluntary blinking and winking is a willed coordinated closure and opening movement of the eyelids in both eyes.  The voluntary blink is under the control of the individual (rate and degree of closure and opening).  It is produced as a protective gesture.
  81. 81. Winking is unilateral voluntary lid closure.  Part of facial expression.  It is a learned activity.  Occasionally, a subject may learn to wink with one eye but not with the other.  Minimum periods between winks are 0.3 sec.  Both are voluntary blinking and winking are produced by simultaneous contraction of palpebral and orbital portions of the orbicularis.
  82. 82. BELL’S PHENOMENON  It is a highly coordinated reflex between the facial and oculomotor nuclei, whereby on closure of the eyelids, the eyeball is rotated upward and outward.  This is a protective mechanism
  83. 83.  On closure of the eyelids, all the electrical activities in the levator cease and concomitantly the activity abruptly rises in the superior rectus muscle and is inhibited in the inferior rectus muscle.  Bell’s phenomenon is NOT present in 10% of otherwise healthy persons, and therefore its absence is not necessarily a sign of disease.
  84. 84. Applied aspects  Congenital anamolies:  Congenital ptosis  Coloboma: characterised by full thckness triangular gap in tissues of lids.  Involves nasal side.more common in upper lid.  Cryptophthalmos:lids fail to develop and skin passes continuously over the eye balls.
  85. 85.  Microblepharon: abnormally small eye lids.associated with microphthalmos or anophthalmos.  Ablepharon: ocasionally lids may be virtually absent
  86. 86. Inflammatory disorders of eye lids  Blepharitis : subacute or chronic inflammation of eye lids. • Seborrhoeic blepharitis • Ulcerative blepharitis  Posterior blepharitis. • Chronic meibominitis • Acute meibominitis.
  87. 87.  External hodeolum: • Acute suppurative inflammation of gland of zeiss or moll.  Chalazion : tarsal or meibomian cyst.chronic non infective granulomatous inflammation of meibomian gland.
  88. 88.  Internal hordeolum: suppurative inflamation of meibomian gland asso with blockage of duct.  Molluscum contagiosum: viral infection of lids caused by a pox virus.  Waxy,umbilicated,multiple swellings scattred over skin near lid margin
  89. 89. Anamolies in position of lashes and margin  Trichiasis : inward misdirection of cilia with normal position of lid margin.  The inward turning of lid margin and lashes is called pseudo trichiasis.  Entropion :inturning of lid margin. • Congenital • Cicatrical • Spastic • Senile • mechanical
  90. 90.  Ectropion : out rolling or outward turning of lid margin. 1. Senile 2. Cicatrical 3. Paralytic 4. Mechanical 5. spastic
  91. 91.  Symblepharon :  Condition in which lids become adherent with the eye ball as a result of adhesions between palpebral and bulbar tissue.  Ankyloblepharon:  Refers to adhesions between margins of upper and lower lids.  Congenital or acquired.  Complete or incomplete.
  92. 92.  Blepharophimosis:  The extent of palpebral fissure is appears contracted at outer canthus.  Lagophthalmos:  condition characterised by inability to close the eye lids voluntarily.
  93. 93.  Ptosis :  Abnormal drooping of upper eye lid.  If more than 16 th of cornea is covered i.e. >2mm  Congenital 1. Simple congenital 2. Asso with weakness of superior rectus 3. Part of blepharophimosis syndrome 4. Congenital synkinetic ptosis.
  94. 94.  Acquired :  Neurogenic  Myogenic  Aponeurotic  Mechanical ptosis.
  95. 95.  Thank you.