The document provides information about the anatomy and development of the orbit and eye. It discusses: - The development of the eye from the optic vesicle, lens placode, and other tissues. - The anatomy of the orbit, including the bones that form it and openings like the optic canal. - The anatomy of the eyeball and its layers like the sclera, choroid, retina. It also discusses the chambers of the eye. - Other structures like the extraocular muscles, blood and nerve supply, and clinical terms like glaucoma and cataracts.

1. ORBIT & EYE
Dr.N.R.K.ANIL KUMAR,
1ST MDS,
DEPARTMENT OF OMFS,
VISHNU DENTAL
COLLEGE.
SEMINAR

2. “I am a camera with its shutter
open, quite passive, recording,
not thinking.”
The human eye
blinks an average of
12 times a min /
4,200,000 times a
year.
All babies are colour
blind when they are
born and do not
produce tears until
the baby is
approximately six to
eight weeks old.
People generally
read 25% slower
from a computer
screen
compared to
paper.
It's
impossible to
sneeze with
your eyes
open.
INTRODUCTION

3. CONTENTS
DEVELOPMENT
ANATOMY OF ORBIT
ANATOMY OF EYE
ANATOMY OF EYELID
LACRIMAL APPARATUS
BLOOD SUPPLY
NERVE SUPPLY
OPTHOLMOLOGICAL EXAMINATION
MAXILLOFACIAL TRAUMA
MAXILLOFACIAL INFECTIONS
CONTENTS

4. DEVELOPMENT
 The eye develops from several types of tissues.
i. Retina & RPE – Neural Ectoderm
ii. Lens – Surface Ectoderm
iii. Sclera &
Anterior Chamber – Migrating Cells.
 Optic Vesicle
 Lens Placode
 Mesenchyme
 Visceral Mesoderm
Mutations in the SHH
gene or inhibition of
protein processing
results in cyclopia. The
phenotype results in a
single eye in the center
of the face.
DEVELOPMENT

5. OPTIC VESICLE
oThe primary optic vesicles
arise as an evagination of
neural tube epithelium.
oThe optic vesicle is
connected to the
procencephalon by the
optic stalk, which will
become the optic nerve.
oIn humans, eye
development isn’t
completed until several
months after birth.
DEVELOPMENT

6. •The lens placode is induced by contact between the
optic vesicle and the overlying ectoderm.
•The optic vesicle infolds, forming a bilayered optic
cup. The inner wall of the optic cup becomes the
neural retina, while the outer wall becomes the
pigment epithelium
•The lens placode then invaginates and pinches off to
form a hollow lens and is subsequently filled with
differentiating primary fiber cells that elongate from the
LENS PLACODEDEVELOPMENT

7. •The surface ectoderm from which the lens vesicle
forms gives rise to the cornea.
•The iris and ciliary body develop at the periphery of
the retina.
•Unlike the other muscles of the body, part of the iris is
derived from the ectodermal layer.
•Migrating mesenchymal tissues form the sclera,
trabecular meshwork, and anterior chamber.
DEVELOPMENT

8. DEVELOPMENT
 At birth, the eye is relatively large in relation to the rest
of the body.
 The eye reaches full size by the age of 8 years.
 The lens continues to enlarge throughout the life.
 The iris has a bluish color due to little or no pigment
on the anterior surface.
 During early infant life, the cornea & sclera can be
stretched by raised IOP → enlargement of the eye.
DEVELOPMENT

9. ANATOMY OF
ORBIT

10. ORBITORBIT
 Orbit / eye socket is
roughly irregular four
sided pyramid located on
either side of root of nose.
 Base - at the orbital
opening
 Apex - at optical canal
 Axis directed posteriorly
and medially
 Medial walls - nearly
parallel
 Medial and lateral walls
makes an angle of 45
25mm

11. ORBITAL CAVITY
CONTRIBUTED BY 7 BONES
 Frontal bone
 Zygomatic bone
 Maxilla
 Ethmoid bone
 Sphenoid bone
 Lacrimal bone
 Palatine bone
ENTRANCE OF THE ORBIT
 Frontal, Zygomatic, Maxillary Bones
ORBIT
ORBIT

12. ROOF
 Orbital plate of frontal bone
 Posteriorly small portion contributed by lesser wing
of sphenoid.
 Anteriomedially frontal sinus is present in the
frontal bone.
 Supra orbital foramen is present at junction of
medial and middle half.
ORBIT

13. FLOOR
 Orbital plate of maxilla
 Anteriolaterally- zygomatic bone
 Posteriomedially- orbital process of palatine bone
 On the lateral side, anteriorly continues with the
lateral wall but separated posteriorly by inferior
orbital fissure.
 It roofs maxillary sinus
 Its thin and is most commonly fractured.
ORBIT

14. MEDIAL WALL
 Orbital plate of ethmoid bone (lamina papyracia)
 Anteriorly – lacrimal bone
 At the apex – body of sphenoid
 Lacrimal bone contains fossa for nasolacrimal sac
ORBIT

15. L ATERAL WALL
 Frontal process of zygomatic bone anteriorly and
the orbital surface of greater wing of sphenoid
posteriorly.
 Thickest wall of the orbit
 Orbital tubercle – lateral palpebral ligament
 Continuous with roof anteriorly and separated
posteriorly by superior orbital fissure
ORBIT

16. COMMUNICATIONSORBITALCAVITY
OPTIC CANAL
 Located between two roots that connect lesser
wing of sphenoid with body of sphenoid
 Connects orbit and middle cranial fossa
 Transmits optic nerve, menengial sheaths,
opthalmic artery

17. COMMUNICATIONSORBITALCAVITY
SUPERIOR ORBITAL FISSURE
 Gap between greater and lesser wings of sphenoid
 Connects orbit and cranial cavity
 Transmits occulomotor, trochlear, opthalmic,
abduscens nerves and opthalmic veins

18. COMMUNICATIONSORBITALCAVITY
INFERIOR ORBITAL FISSURE
 Bounded by
Above – greater wing of sphenoid
Below – maxilla
Laterally – zygomatic bone
 Connects orbit with pterigopalatine and
infratemporal fossa
 Transmits infraorbital, zygomatic branches of
maxillary nerve and vessels, orbital rami of
pterigopalatine ganglion

19. COMMUNICATIONSORBITALCAVITY
 ETHMOIDAL FORAMEN
 At the junction of frontal and ethmoid bones,
anteriorly and posteriorly
 Connects with ethmoid sinuses, anterior cranial
fossa, nasal cavity.
 Openings for Zygomatico temporal and
zygomatico facial nerves
 In the lateral wall on zygomatic surface

20. CONTENTS
ORBITALCAVITY
 Eye ball occupying 1/5th of the orbit
 Extra ocular muscles
 Optic, Occulomotor, Trochlear, Abduscens,
Opthalmic and Maxillary nerves
 Ciliary parasympathetic ganglion
 Opthalmic vessels
 Nasolacrimal apparatus
 Orbital fat and connective tissue

21. EYEBALL

22. EYE BALLEYEBALL
Spherical with 2.3 cms in diameter
Outer coat – 2 spheres of different radii
Anterior segment – smaller sphere, transparent
cornea
Posterior segment – larger sphere, opaque sclera
Middle / vascular coat – Choroid, Ciliary body, Iris
Inner / nervous coat – Retina

23. Cornea and
sclera are
continuous, but
have different
morphology &
function
EYEBALL

24. EYEBALL

25. EYEBALL

26. EYEBALL

27. CONJUNCTIVA
 Mucous membrane with
non keratinized squamous
epithelium and globlet
cells.
 Extends from limbus to
cover interior eyelids.
 Thin, richly vascularized
substantia propria
 Can be divided into three
geographic zones:
◦ Palpebral
◦ Forniceal
◦ Bulbar
EYEBALL

28. CORNEA
• The cornea occupies the center of the
anterior pole of the globe.
• It measures
12 mm horizontally & about 11 vertically.
• The cornea is transparent and highly innervated.
• It is avascular, gets O2 & nutrients from aqueous
humor and outside surface.
• Kept moist by tears.
• Responsible for most of the eye’s ability to refract
and focus light
EYEBALL

29. SCLERAEYEBALL
• The sclera covers the posterior four fifths of the surface
of the globe, with an anterior opening for the cornea
and a posterior opening for the optic nerve
• Composed of dense fibrous connective tissue, almost
avascular
• Maintains shape of the eyeball
• Anteriorly – Corneoscleral junction – limbus
• Posteriorly – fused with dural sheath of optic nerve
• Externally covered by bulbar conjunctiva
• Internally attached to choroid by suprachoroid lamina
• Provides protection to delicate structures,
• Serves as an attachment for the extraocular muscles

30. CHOROID
 The choroid, the posterior portion of the uveal
tract, nourishes the outer portion of the retina. It
averages 0.25 mm in thickness and consists of
three layers of vessels:
 The choriocapillaris, the innermost layer
 A middle layer of small vessels
 An outer layer of large vessels
EYEBALL

31. IRIS
EYEBALL
• Colored structure surrounding the pupil.
• Controls amount of light entering the eye
• Controls the size of the pupil through the sphincter
pupillae (shrinks pupil) and a diffuse dilator pupillae
(enlarges pupil)
• Spongy stroma with melanocytes: faces anterior
chamber
• Pigmented epithelium faces posterior chamber. This
epithelium becomes the ciliary body laterally.
• When it is full open, it is about f/2 and f/3. This
happens at

32. CILIARY BODY
 Triangular in cross section.
 The apex of the ciliary body is directed posteriorly
toward the ora serrata.
 Base gives rise to the iris.
 The ciliary body has three principal functions:
◦ aqueous humor formation: low-protein plasma-
like substance made continuously by the
epithelium of ciliary body. Nourishes cornea, lens,
iris, corneal endothelium, & stroma. Secreted into
posterior chamber, flows around iris through pupil
to “the angle”
◦ It also plays a role in the trabecular and
uveoscleral outflow of aqueous humor
◦ Accommodation
EYEBALL

33. LENS
 The lens is a biconvex structure located directly behind
the posterior chamber and pupil
 Diameter of about 9-10 mm & width of about 6 mm.
 lens fibers: extremely long cells with no nuclei, stretch
anterior to posterior. Cytoplasm filled with crystallin,
arranged in a regular lattice
 Lens capsule: thick basement membrane surrounding
lens. Attachment site for the zonules.
 The lens has certain unusual features. It lacks
innervation and is avascular. Transparent because of
anucleate nature and fibers containing crystalline
proteins.
EYEBALL

34. RETINA
 Photoreceptors: contain photopigment in discs
located within outermost segment. When light
interacts with the photo pigment, conformational
change and neural signal
 Blood supply: central retinal artery enters through
optic disk and ramifies in the inner surface of retina
 Capillary network of the choroid, the
choroicapillaris supplies photoreceptors through
Bruch’s membrane and the RPE
 2 types of photoreceptors:
◦ Rods: sensitive in dim light, not wavelength
sensitive
◦ Cones: sensitive in bright light, differential
sensitivity to wavelength. Three kinds of cones
are - red, green, and blue. These cones work
together to help us see millions of colors.
EYEBALL

35. CHAMBERSEYEBALL
Iris and lens separate eye into three chambers
Vitreous chamber : largest chamber, posterior to
lens, filled with gel like vitreous humour
Anterior chamber : between cornea and iris
Posterior chamber : between iris and lens
Both are filled with aqueous humour, which provides
nourishment to avascular lens and cornea

36. VITREOUS
 The vitreous cavity occupies four fifths of the
volume of the globe
 Important to the metabolism of the intraocular
tissues because it provides a route for
metabolites used by the lens, ciliary body and
retina
 serves as a medium to maintain the path of light
between the lens and the retina
 free from diffusing and absorbing elements
 Its volume is close to 4.0 ml
 Although it has a gel-like structure, the vitreous
is 99% water
 Its viscosity is approximately twice that of water,
mainly because of the presence of the
mucopolysaccharide, hyaluronic acid.
EYEBALL

37. ACCOMMODATION
 The lens changes shape to focus light on the back of the
eye regardless of the distance of the object
 Cornea curvature is fixed, so focus comes from changes
in the lens curvature through the ciliary muscles
 Lens with no tension: would be curved/round
 normal state of lens: flattened by the tension of the
zonules/suspensatory ligaments.
 To curve lens: ciliary muscles contract and ciliary body
moves closer to the lens. Zonules go slack.
 To flatten the lens: ciliary muscles relax, ciliary body
moves away from the lens. Stretches the zonules.
EYEBALL

38. Myopia (Near-sightedness)
 This person can see close objects clearly, but has
trouble seeing distant objects.
 Usually occurs because the distance between the
lens and the retina is too large or because the
cornea-lens combination converges light too
strongly.
 Light from distant objects is brought into focus in
front of the retina.
MYOPIA

39. Hyperopia (Far-sightedness)
• This person had no problem seeing objects in the
distance, but has trouble seeing nearby objects.
• The eye cannot refract light well enough to form an
image on the retina.
• Usually occurs because the distance between the
lens and the retina is too small or because the
cornea-lens combination is too weak. Light from
nearby objects focuses behind the retina.
HYPEROPIA

40.  Even within the cone and rod system, your retina
adjusts its sensitivity in response to the overall light
level
 When you walk into a dark room, you can’t see
anything, but after a few minutes, you adapt and can
start to see things and vice- versa.
 Dark adaptation is a slow process, but allows us to
see in a huge range of light levels
DARKADAPTION CLINICAL CORRELATIONS

41. CLINICAL TERMS
 Glaucoma:
Elevated intraocular pressure from overproduction
of aqueous humor or blockage in drainage. High
pressure in the anterior chamber transduced
through vitreous body, pressure on retina. Can
damage neural retina by impeding blood flow in
reitinal arterioles.
◦ Open angle glaucoma: increased production
◦ Closed angle glaucoma: iris closes the angle,
blocking drainage
 Cataract:
Clouding of the crystalline lens of the eye.In a
normal eye, the crystalline lens is almost
transparent, however injury, age or disease can
cause the lens to eventually lose its clarity.
CLINICALTERMS

42. CLINICAL TERMSCLINICALTERMS
 Hemianopia:
Blindness in one-half of the visual field
 Amblyopia: (lazy eye)
Decreased vision in one eye that leads to the use
of the other eye as the dominant eye. A problem
most commonly associated with children.
 Presbyopia:
Progressive loss of vision which begins in mid-life.
Near vision becomes blurry, making reading
glasses necessary. Over time, the blurriness
extends to intermediate vision, making computer
glasses useful. Bifocals are worn to improve near
vision and distance vision if necessary.
• Diplopia (double vision)
The perception of two images of a single object.

43. CLINICAL TERMSCLINICALTERMS
 Strabismus: (Misaligned eyes / crossed eye)
Condition is the lack of coordination between the eyes,
one eye turns out, down, or up while the other looks
straight ahead.
 Nystagmus:
Rapid and uncontrollable eye movements. an
involuntary, constant, rhythmic movement of the
eyeball that can be congenital or caused by a
neurological injury or drug use
 Anisocoria
A condition in which the pupils are unequal in size. this
condition can be congenital or caused by a head injury,
aneurysm or pathology of the central nervous system

44. CLINICAL TERMSCLINICALTERMS
• Chalazion :
A slowly developing lump that forms due to
blockage and swelling of an oil gland in the eyelid.
• papilledema (chocked disk)
swelling and inflammation of the optic nerve at the
point of entrance into the eye through the optic
disk. this swelling is caused by increased
intracranial pressure and can be due to a tumor
pressing on the optic nerve
• Scotoma (blind spot)
An abnormal area of absent or depressed vision
surrounded by an area of normal vision
• Bitot spots : Raised, silvery white, foamy, triangular

45. CLINICAL TERMSCLINICALTERMS
 Astigmatism:
An eye condition where the eye cannot focus light
uniformly in all directions resulting from an irregular
curvature. Astigmatism results in mild to
moderately blurred vision and/or eyestrain.
 Floaters and Spots:
A generalized term used to describe small specks
moving subtly but noticeably in your field of vision.
A floater or a spot is likely a tiny clump of gel or
cells in the vitreous. Aging, eye injury and
breakdown of the vitreous are the main causes of
floaters and spots.
• Subconjunctival hemorrhage
Bleeding between the conjunctiva and the sclera.

46. CLINICAL TERMSCLINICALTERMS
 Pterygium:
A raised growth on the eye that is most often directly
related to over-exposure to the sun. Dry, dusty
conditions may also contribute to development of these
growths. Protecting your eyes from UV radiation is a
critical preventive measure.
 Blepharitis:
Inflammation of the eyelids. It can have a variety of
causes, such as an allergic reaction, bacterial infection,
or excess oil produced by eyelid glands.
 Dacroadenitis
An inflammation of the lacrimal gland that can be
caused by a bacterial, viral or fungal infection. signs
and symptoms include the sudden severe pain, redness
and pressure in the orbit of the eye
 Keratoconus:
An inherited corneal disease. The cornea gradually
becomes thinner and less able to maintain its shape
against the pressure of the fluids inside the eye.

47. VISUAL PATHWAY
Retina
Optic
nerve
Optic
chiasm
Optic
tract
Lateral
geniculate body
optic
radiation
occipital lobe
optical center

48. VISUAL PATHWAY

49. Oculocardiac Reflex
 Stimulated by:
 Increased pressure on the globe
 Traction of extrinisic eye muscles
 Ocular regional anesthesia techniques
 Results in:
 Cardiac Arrhythmias
 Bradycardia
 Asystole
( and severe increased sphincter tone for
the anesthetist)

50. Oculocardiac Reflex
 Stimulation causes to activation of an Afferent Arc
via CN V, trigeminal.
 Efferent Arc via CN X, vagus.
 Treatment:
 STOP STIMULATION!
 Verify adequate ventilation & oxygenation
 Atropine IVP .01-.02mg/kg (pretx does not always
prevent reflex)
 May also need local anesthetic infiltration
 Via retrobulbular block or peribulbar block.
 Severe Cases: May need to perform CPR.

51. Oculocardiac Reflex
 Reflex usually subsides with repeated
stimulation
 More common in strabismus surgery
with pediatric pts.
 Can occur in all age groups.
 Be vigilant, be prepared.

52. ANATOMY OF EYELID

53. EYELIDEYELID
An eyelid is a thin fold of skin that covers and
protects an eye.

54. THE LID MARGIN
 When eye is open, the upper lid covers about
1/6th of the cornea & the lower lid just touches
the limbus.
 It is About 2mm broad and is divided into two
parts by punctum.
 The medial, lacrimal portion is rounded and
devoid of lashes or glands.
 The lateral, ciliary portion consist of rounded
anterior border, a sharp posterior border and an
inter-marginal strip.
 The medial canthus is about 2mm higher than
the lateral canthus

55. LAYERS OF EYE LIDEYELID
Anterior (cutaneous) to posterior (conjunctiva)
 Skin
 Subcutaneous tissue.
 Striated muscle (orbicularis).
 Submuscular areolar tissue.
 Orbital fat
 Fibrous layer with tarsal plates.
 Mucous membrane or Conjunctiva.

56. 1.SKIN:
It is elastic having fine texture and is the thinnest of the body.
2.THE SUBCUTANEOUS AREOLAR TISSUE:
It is very loose and contain no fat. It is thus readily distended
by oedema or blood.
3.THE LAYER OF STRIATED MUSCLE:-
It consist of orbicularis muscle which comprises three
portions:-
i.The orbital
ii.The palpebral
iii.The lacrimal
It closes the eyelids & is supplied by zygomatic branch of
the facial nerve.

57. 4. SUBMUSCULAR AREOLAR TISSUE:
The layer of loose connective tissue.
 The nerve and vessels lie in this layer.
 Therefore, to anaesthetize lid, injection is given in this plane.
5.FIBROUS LAYER:-consists of central tarsal plate and
peripheral septum orbitale.
a.) Tarsal plate:
There are two plates of dense connective tissue, which give
shape and firmness to the lids.
Both join with each other at medial and lateral canthi and
attached to the orbital margins through medial and lateral
palperable ligaments

58. b.) Septum orbitale
It is thin membrane of connective tissue perforated by
nerves , vessels and LPS muscle, which enter the lids
from the orbit.
6. LAYER OF NON-STRIATED MUSCLE FIBRES:
It consist of the palpebral muscle of muller which lies deep
to the septum orbitale in both the lids.
In the upper lid it arises from the fibres of LPS muscle and in
the lower lid from prolongation of the inferior rectus
muscle; and is inserted on the peripheral margins of the
tarsal plate.
It is supplied by sympathetic fibres.

59. NERVES OF LIDS
 Motor supply
Facial - supplies orbicularis muscle,
Oculomotor - supplies LPS muscle
Sympathetic fibres - supply the muller’s muscle.
 Sensory supply
From branches of the trigeminal nerve.

60. MUSCLES

61. MUSCLESEYEMUSCLES
 Extra-ocular muscles
1. Recti muscles
2. Oblique muscles
3. Levator palpebrea superioris
 Intra-ocular muscles
1. Sphinter pupillae
2. Dilator pupillae

62. RECTI MUSCLES
 Four in number, approximately strap shaped
 Attached to common tendinous ring
 Each rectus passes forwards and attached to
tendinous expansion into the sclera
EYEMUSCLES

63. MUSCLE ACTION
Superior rectus Upwards and medially
Inferior rectus Downards and medially
Medial rectus Medial movement ( adduction )
Lateral rectus Lateral movement ( abduction )
EYEMUSCLES

64. OBLIQUES
 SUPERIOR OBLIQUE
 Fusiform muscle
 Arises from body of sphenoid, passes through
trochlear fossa of frontal bone, attached to sclera
between superior and lateral recti muscles
 Moves the eye laterally and intrudes the eyeball
EYEMUSCLES

65. OBLIQUES
 INFERIOR OBLIQUE
 Lies near anterior margin of floor of orbit
 Inserted into the lateral part of the sclera behind
the equator of eyeball
 Moves eye laterally and causes extorsion
EYEMUSCLES

66. LEVATOR PALPEBRAE
SUPERIORIS
• Thin triangular muscle
• Arises from inferior aspect of lesser wing of
sphenoid
• Ends in wide aponeurosis, some fibers attaches to
anterior end of tarsal plate and others to the skin
of eyelid
• Laterally passes between orbital and palpebral
parts of lacrimal gland and attached to the orbital
tubercle
• Medially continues as loose connective tissue on
medial palpebral ligament
• Innervated by occulomotor nerve
• Elevates upper eyelid
• Linked to superior rectus by check ligament, thus
upper eyelid elevates when eye directed upwards
EYEMUSCLES

67. Intrinsic Eye MusclesEYEMUSCLES

68. BLOOD SUPPLY
BLOODSUPPLY

69. ARTERIAL SYSTEM
Internal carotid artery
Ophthalmic artery
Central retinal A
Short post ciliary A
Long post ciliary A
Anterior ciliary A
Lacrimal A
Superior muscular A
Inferior muscular A
Posterior ethmoidal A
Anterior ethmoidal A
Supraorbital A
Supratrochlear A
BLOODSUPPLY

70. 9lllllllllllllllllllllllllllBLOODSUPPLY

71. Venous system
Central retinal V
Superior vortex V
Superior episcleral plexus
Inferior vortex V
Inferior episcleral plexus
Pterygoid plexus
Superior
ophthalmic V
Cavernous
sinus
Jugular v
BLOODSUPPLY

72. BLOODSUPPLY

73. BLOODSUPPLY

74. NERVE SUPPLY

75. NERVESUPPLY

76. Cranial Nerve III
(Occulomotor)
• It supplies all the extraocular muscles except the
superior oblique and the lateral rectus
• It also carries cholinergic innervation to the
pupillary sphincter and the ciliary muscle
• The CN III nucleus consists of several distinct,
large motor cell
subnuclei, each of which subserves the extraocular
muscle it innervates
• The Edinger-Westphal nucleus provides the
parasympathetic preganglionic efferent innervation
to the ciliary muscle and pupillary sphincter
NERVESUPPLY

77. Cranial Nerve III
 CN III usually divides into superior and inferior
divisions
 The superior division of CN III innervates the
superior rectus and levator palpebrae muscles.
 The larger inferior division splits into three branches
to supply the medial and inferior rectus muscles and
the inferior oblique.
 The parasympathetic fibers enter the inferior
division, and course through the branch that supplies
the inferior oblique muscle and join the ciliary
ganglion.
 They synapse with the postganglionic fibers, which
emerge as many short ciliary nerves.
NERVESUPPLY

78. Cranial Nerve IV (Trochlear)
 Cranial nerve IV has the longest intracranial course
 The CN IV the only cranial nerve that is completely
decussated and the only motor nerve to exit dorsally
from the nervous system.
 CN IV enters the orbit through the superior orbital
fissure outside the annulus of Zinn and runs
superiorly to innervate the superior oblique muscle
NERVESUPPLY

79. Cranial Nerve V (Trigeminal)
 The largest cranial nerve
 Possesses both sensory and motor divisions The
sensory portion subserves the greater part of the
scalp, forehead, face, eyelids, eye, lacrimal gland,
extraocular muscles, ear, dura mater, and tongue
 The motor portion innervates the muscles of
mastication through branches of the mandibular
division
NERVESUPPLY

80. Divisions of Cranial Nerve V
 Ophthalmic
◦ Frontal
◦ Lacrimal
◦ Nasociliary
 Maxillary
 Mandibular
NERVESUPPLY

81. Cranial Nerve VI (Abducens)
 The nucleus of cranial nerve VI is situated in the
floor of the fourth ventricle, beneath the facial
colliculus, in the caudal pons
 CN VI runs below and lateral to the carotid artery
and may transiently carry sympathetic fibers from
the carotid plexus
 It passes through the superior orbital fissure within
the annulus of Zinn and innervates the lateral
rectus muscle on its ocular surface
NERVESUPPLY

82. CILIARYGANGLION
CILIARY GANGLION
 Para sympathetic ganglion which is a
small, flat, reddish grey swelling 1-2 mm
diameter, located near the apex of orbit
medial to superior orbital fissure.
 Three types of nerve fibers run through
the ganglion:
 1. parasympathetic fibers
2.sympathetic fibers
3.sensory fibers
 Only parasympathetic fibers form
synapses in the ganglion and other two
types of nerve fibers simply pass
through.

83. CONNECTIONS
Ciliary nerve innervates two muscles
1.Sphincter pupillae:
constricts the pupil, a movement known as Miosis.
2.Ciliaris muscle:
Releasing tension on the , making the lens more convex, also
known as accommodation
CILIARYGANGLION

84. FASCIAOFORBIT

85. Orbital Fat
 Contains two compartments:
 Central compartment (retrobulbar &
intracone)
 Peripheral compartment (peribulbar &
pericone)
The importance of the orbital fat, is that it
contains the motor & sensory nerves for the
eye.
Therefore regional anesthesia can be injected
into the fat and provide the patient with an
effective block.

86. FASCIAOFORBIT

87. LACRIMAL APPARATUS
LACRIMALAPARATUS
 Lacrimal glands
 Excretory ducts
 Lacrimal punctum
 Lacrimal canals
 Lacrimal sac
 Naso lacrimal duct

88. Lacrimal gland
- orbital part
- palpebral part
Separated by levator palpebrae superioris and are
continuous posteriosuperiorly
LACRIMALAPARATUS

89. LACRIMALAPARATUS

90. Nerve supply
LACRIMALAPARATUS

91. LACRIMALAPARATUS

92. TRAUMA

93. Basic First-Aid Techniques
◦ Specks in the eye
 Do not rub the eye
 Flush the eye with a large amount of water
 See a doctor if the speck does not wash out, or if pain or
redness continues
◦ Cuts, punctures, or objects stuck in the eye
 Do not wash out the eye
 Do not try to remove an object stuck in the eye
 See a doctor at once

94. First-Aid Techniques
◦ Chemical burns
 Flush the eye immediately with water or any
drinkable liquid and continue flushing for at least
15 minutes. For caustic or basic solutions, continue
flushing while
on the way to the doctor.
 Flush the eye even if it has a contact lens. Flushing
over the lens may dislodge it.
◦ Blows to the eye
 Apply a cold compress without pressure.
 Tape a plastic bag containing crushed ice to the
forehead and let it rest gently on the injured eye.
 See a doctor at once in cases of continued pain,
reduced vision, blood in the eye, or discoloration,

95. MAKE EYE SAFETY
•BLOOD SPLASH INJURY
•Disposable surgical masks with full-face visors have been
shown to offer the highest level of protection from blood splash
injury
•The use of masks and visors should be standard practice for all
theatre staff, including assistants, scrub nurses and observers.
•If such an incident occur, a procedure similar to that used for
needle-stick injury may be followed.
•The eye should first be rinsed thoroughly to remove as much of
the fluid as possible.
•Serology should be ordered promptly to obtain a baseline for
future comparisons.
•Hiv screen and acute hepatitis screen are indicated.
•Post-exposure prophylaxis (pep) should be initiated as soon as
practicable unless the patient is known to be HIV, HBV and HCV
negative.

96. EYE EXAMINATION

97. OPHTHALMIC
ASSESSMENT
OPHTHALMICASSESSMENT
 Ophthalmic assessment is mandatory for every
patient who has sustained mid facial trauma severe
enough to cause a fracture.
 HISTORY
- Time, place, nature of injury
- whether glasses were worn at the time of
injury
- antecedent visual status
- whether any squit or other abnormalities
present
before the injury

98. VISUAL ACUITY
OPHTHALMICASSESSMENT
• Measure of resolving power of the eye
• Recorded as a fraction
distance of the patient from the chart
line he / she sees at that distance
PRINCIPLE : Two distinct points appear as separate
only when they subtend an angle of 1 minute at
nodal plane of the eye.
Each test letter is designed as it subtends an angle of
5 minutes at nodal plane of eye.

99. VISUAL ACUITYOPHTHALMICASSESSMENT
• SNELLEN’S CHART
• Patient at 6 mts from snellen’s
chart.
• Test letters are constructed so
that edges subtend a visual
angle of 1min of arc.
• For normal eye with 6/6 vision,
each complete test letter
subtends 5 min of arc at the
eye.
• If patient cant read at 6/6 and
doesn’t have glasses before,
patient is asked to see through
pin hole. If acuity increases

100. VISUAL ACUITY
OPHTHALMICASSESSMENT
 When visual acuity is less and patient cant read ,
then measured by counting fingers.(CF)
 If acuity is still less, then hand movements are
recorded.(HM)
 For patients with polytrauma acuity for near vision
can be measured as snellens letters subtends
same angle at 0.33 mts.

101. VISUAL FIELDS
OPHTHALMICASSESSMENT
 Assessed in patients with sustained severe head
trauma
 CENTRAL VISUAL FUNCTION
 Patient is asked to look at red object and x-ray
illuminator with each eye separately and compare
the color and brightness perceived respectively.
 Color desaturation – traumatic optic neuropathy
 Decreased brightness – optic nerve damage
 Patient is told to look at the examiners nose with
each eye separately and asked whether any part of
face is missing or blurred. This detects paracentral
scotoma (choroidal tear)

102. VISUAL FIELDSOPHTHALMICASSESSMENT
 BINOCULAR VISUAL FIELD TESTING
 Examiner sits opposite to patient at 1mt looking
into his eyes.
 Hands were placed in outer quadrants and asked
to identify the finger movements.
 Patients suspected of left homonymous
hemianopia when left field of vision is defecit.
 CENTRAL VISUAL FIELD TO CONFRONTATION
 Traumatic damage to visual pathways is more
likely to cause impairment of central 30 degrees of
visual field.
 A small red pin is introduced from periphery to
center along the coronal plane and oblique
meridians to check quadrantic field loss.

103. VISUAL FIELDSOPHTHALMICASSESSMENT
 PERIPHERAL VISUAL FIELD
 Examiner introduces large white pin from behind
the patient and moved in an arc of 0.33 mts radius
and peripheral visual field is assessed.
 SUBJECTIVE VISUAL FIELD
 Examiner sits opposite the patient, one eye of
patient and examiner should be closed and fixes
the other eye.
 Red pin is moved in all quadrants adjecent to
examiners eye and noted for color desaturation if
any.
 In traumatic chiasmatic damage, all the other
findings except this are normal.

104. PUPILS
OPHTHALMICASSESSMENT
 DIRECT AND CONSENSUAL PUPILLARY
REFLEXES
 Penlight source is illuminated from below in each
eye twice, first for the direct and next for
consensual reflex

105. PUPILS
OPHTHALMICASSESSMENT
 SWINGING FLASH LIGHT TEST
 Pupils were illuminated in same manner but light
shined in each eye for 2 seconds and then swung
rapidly to illuminate the other eye.
 Afferent pupillary defect, unilateral third nerve palsy

106. RETINA
OPHTHALMICASSESSMENT
 PHOTO STRESS TEST
 Visual acuity is recorded and one eye illuminated
with bright light for 30 sec.
 Visual acuity is again noted observing the recovery
time.
 Normal recovery time is 10 – 30 sec.
 If more than this, retinal damage is suspected.

107. DISPLACEMENT OF GLOBEOPHTHALMICASSESSMENT
 PROPTOSIS (EXOPHTHALMOS)
 Hematoma and swelling of orbital tissue
(commonly resolves spontaneously)
 Subperiosteal hematoma, notably orbital roof
 Inward displacement of orbital bone fragments
(persistent proptosis)
 ENOPHTHALMOS
 Common late sequela, Initially masked by
intraorbital tissue swelling and hematoma
 Expansion of the orbit
 Prolapse of soft tissue through a blow out fracture
 Necrosis of soft tissue and fibrosis
 Sucken upper lid may be present.

108. DISPLACEMENT OF GLOBEOPHTHALMICASSESSMENT
 VERTICAL DISPLACEMENT
 Commonly seen with orbital fractures.
 In acute phase upward displacement due to
hematoma and later phases downward
displacement is commonly seen.
 HORIZANTAL DISPLACEMENT
 Laterally displaced – medial canthal ligament
severed
 Similar to squint
 In both these cases corneal light reflexes are
symmetrical and double vision is not seen.

109. Subconjunctival hemorrhage
 Caused by vascular rupture beneath the bulbar
conjunctiva or by osmotic increase of vascular
wall
 Treatment:
1)find out the cause
2)good explanation

110. Orbital Hematoma
 Poor Vascular perfusion of
the optic nerve and retina
 Early recognition
 “Gray Vision”
 Proptosis
 Ecchymosis
 Subconjunctival
hemorrhage
 Afferent pupil defect
 Hard globe

111. Orbital Hematoma
 Treatment
◦ Lateral Canthotomy
(immediately)
◦ Lateral canthal tendon
lysis (immediately)
◦ IV acetazolamide
500mg
◦ IV mannitol 0.5 g/kg
◦ Surgical
decompression of the
orbit

112. INDIRECT CONSEQUENCESMAXILLOFACIALTRAUMA
 TRAUMATIC RETINAL
ANGIOPATHY
 H/O loss of vision 24 to 48 hrs after injury
 Mostly occurs after severe skull fracture, chest
compression, long bones fractures.
 Multiple discrete, superficial infarcts of retina
accompanied by development of multiple cotton
wool spots adjacent to optic nerve head.
 No specific treatment.
 In most of cases gradual recovery of vision in few
months.

113. INDIRECT CONSEQUENCESMAXILLOFACIALTRAUMA
 FACIAL PALSY
 The degree of cover of cornea is determined.
 Cornea is examined for any ulceration.
 Ointment
 Botulinum toxin into levator palpebrae superioris,
results in complete ptosis for 4 to 6 weeks.
 Tarsorraphy
 PAPILLEDEMA
 Optic nerve heads are to be examined in patients
suspected with raised intra cranial pressure.

114. EYELID TRAUMA
 Types
◦ Blunt
◦ Sharp/penetrating
 classification
◦ lid margin
 not involved
 involved*
◦ canthal involved* *call ophthalmology
◦ canalicula involved*

115. EYE LID INJURIES
MAXILLOFACIALTRAUMA
 Eyelid swelling & hematoma
 Commonly seen following orbital injuries
 Spontaneous resolution in few weeks
 Widening of medial canthus
 Due to disruption of nasoethmoid complex
 Trans nasal wiring

116. EYE LID INJURIES
MAXILLOFACIALTRAUMA
 EYE LID LACERATIONS
 Should be repaired within 72 hrs.
 Surgical repair should be done in layers accurately
 First Margin should be restored with non
absorbable suture passing through the gray line.
 Tarsal plate is repaired with absorbable suture,
only passing through partial thickness.
 Any damage to levator should be carefully
identified and repaired to prevent ptosis.

117. EYE LID INJURIES
MAXILLOFACIALTRAUMA

118. Eyelid Malpositions
 Ectropion
 Entropion
 Blepharoptosis
 Retraction

119. Ectropion
 Outward turning of
lid margin
 Types:
◦ Congenital
◦ Involutional
◦ Paralytic
◦ Cicatricial
◦ Mechanical

120. Entropion
 Inversion of the lid
margin
 Types:
◦ Congenital
◦ Acute-spastic
◦ Involutional
◦ Cicatricial

121. Blepharoptosis
 Drooping or inferior displacement of
the upper lid
 Classification:
◦ Congenital vs acquired
◦ Myogenic, aponeurotic, neurogenic,
mechanical, or traumatic
◦ Iimitators: dermatochalaisis and brow
ptosis
 Evaluation

122. HEMIFACIAL SPASM
 Intermittent contractions of
the entire side of face
 Present during sleep
 Compression of 7th nerve
at the level of the brain
stem
 MRI evaluation

123. 7TH NERVE PALSY
 Location of lesion:
◦ Supranuclear, brain
stem, peripheral
 Cause of paralysis:
◦ Bell’s
◦ Infection
◦ Infarct
◦ Demyelination
◦ Neoplasm
◦ Trauma
◦ Miscellaneous

124. NASO LACRIMAL INJURIES
• Damage to naso lacrimal drainage system results in
EPIPHORA
• Any lacerations of middle third of lower eyelid should
suspect injury to inferior canaliculus.(3/4th of tear
volume evacuated)
• Epiphora following nasal fractures is due to protective
influence of medial canthal ligament.
• Post operative epiphora
- due to malposition of lower eyelid
- due to malposition of bone fragments while
reducing fracture fragments
• Dacrocystorhinostomy
• Canalicular lacerations are to be examined and
addressed.
MAXILLOFACIALTRAUMA

125. ORBITAL FRACTURES
Orbital fractures can be divided into
Anterior section
- sturdy orbital rim
Posterior section
- comparitively thin lateral walls, roof & floor
- these can be blow–in or blow–out
Isolated orbital fractures accounts for 5% of mid facial
fractures.
Most common is the blow – out fracture.
It can occur in the floor, medial and lateral walls.
Commonly floor of the orbit is involved

126. BLOW – OUT FRACTURE

127. PATHOPHYSIOLOGY
Bone conduction theory
“buckling theory”
 Less energy
 Small fractures limited
anterior floor
Hydraulic theory
 More energy
 Larger fracture involving
entire floor and medial
wall
 Should suspect more
extensive orbit
involvement with
associated injuries

128. DIAGNOSIS
HISTORY
 Mechanism of injury
 Double vision, blurry vision
 Epistaxis
 V2 numbness
 Malocclusion
 Nausea and vomiting (especially in
children)
 Forced duction test
 CT Scan (sagittal)

129. Indications for Repair
 Diplopia that persists beyond 7 to 10 days
 Obvious signs of entrapment (positive forced
duction test)
 Relative enophthalmos greater than 2mm
 Fracture that involves greater than 50% of the
orbital floor (most of these will lead to significant
enophthalmos when the edema resolves)
 Entrapment that causes an oculocardiac reflex with
resultant bradycardia and cardiovascular instability
 Progressive V2 numbness

130. Immediate repair
 Nonresolving oculocardiac
reflex with entrapment
◦ Bradycardia, heart block,
nausea, vomiting, syncope
 Early enophthalos or
hypoglobus causing facial
asymmetry
 “White-eyed” floor fracture
with entrapment
 When the criteria have been
met, surgery performed as
soon as possible
 Dulley and fells mentioned
72% of enopthalmas in
patients operated 6 months
after injury and 20% when
operated with in 14 days.

131. Repair Within Two Weeks
 Symptomatic diplopia with positive forced duction
test
 Large floor fracture causing latent enophthalmos
 Significant hypoglobus
 Progressive infraorbital hypesthesia

132. Observation
 Minimal diplopia
◦ Not in primary or downgaze
 Good ocular motility
 No significant enophthalmos
 No significant hypoglobus

133. Trapdoor Fractures
 Trapdoor fractures with entrapment differ in
children and adults
◦ Children repaired within 5 days of injury do
better that those repaired within 6-14 days or
those repaired > 14 days
◦ There is no difference in early timing of adults
(1-5 days or 6-14 days)
◦ Adults repaired less than 14 days from injury
have less long term sequela than those repaired
greater than 14 days from injury

134. TREATMENT
 Reconstruction of orbital floor
 AUTOLOGOUS GRAFT
 Most favoured and high tissue compatibility
 Inner aspect of anterior iliac crest
 Posterior iliac crest
 Calvarial bone
 Lateral mandibular cortex
 Lateral antral wall
 Nasal septum

135. TREATMENT
 ALLOGENIC MATERIAL
 Lypophilised dura, allogenic bone and cartilage
 ALLOPLASTIC MATERIAL
 Polymeric silicone
Polytetrafluoroethylene
 Polyethylene Methyl methacrylate
 Poly vinyl sponge Marlex mesh
 Gelfilm Hydroxyapetite
 0.62 mm threaded steinmann pin
 Titanium flosor plate

136. MEDIAL WALL FRACTURES
 Second most commonly disrupted orbital wall.
 It causes entrapement or damage of medial rectus
muscle and orbital wall.
 Diagnosed consistently by limitation in abduction of
the globe and globe retraction.
 Forced duction test is mandatory
 Axial CT scan is done to evaluate size and extent
of defect

137. MEDIAL WALL FRACTURES
 If amout of orbital tissue loss is minimal, not
necesssary to seal the fracture site
 When the defect is larger, reconstructed with
alloplastic or allogenic materials and secured
 Killian and lynch incision – curvelinear, made along
the lateral wall of nose , 12 mm medial to medial
palpebrea
 Bicoronal flap

138. BLOW IN FRACTURES
 Less common
 Presents with proptosis because of decreased
orbital volume
 Restricted ocular motility
 Dipolpia
 Minimally displaced – no need of treatment
 Immediate decompression with reconstruction

139. Proptosis
 Infection
 Inflammation
 Congenital
 Vascular
 Neural
 Mesenchymal
 Lymphoid
 Secondary
 Lacrimal gland

140. SURGICAL APPROACHES

141. Transconjunctival, Subciliary,
Subtarsal Approaches

142. Transconjunctival Approach
 Transconjunctival
◦ No visible scar
◦ Less incidence of ectropion
and scleral show
◦ Poorer exposure without
lateral canthotomy and
cantholysis
◦ Better access to the medial
orbital wall
◦ Risk of entropion

143. Subciliary Approach
 Subciliary advantages
◦ Easier approach
◦ Scar camouflage
◦ Skin necrosis
◦ Highest incidence of
ectropion
◦ Highest incidence of
scleral show (a) Subciliary incision
(b) Periosteum elevated and
entrapped orbital contents freed
(c) Defect repaired with
synthetic material
(d) Periosteum sutured

144. Subtarsal Approach
 Subtarsal Advantages
◦ Easiest approach
◦ Direct access to floor
◦ Good exposure
◦ Postoperative edema the worst
◦ Visible scar

145. Dissection
 Stay below orbital
septum
 24/12/6mm rule
 Remove entrapped
inferior rectus muscle
 Slightly overcorrect if
possible
 Avoid V2 injury

146. Endoscopic Balloon catheter
repair
 Wide MMA
 Insert Foley and inflate
 Leave in place for 7-10 days
 Best for large trapdoor fractures without
entrapment
 Broad spectrum antibiotics

147. ORBITAL INFECTIONSORBITALINFECTIONS
Anatomical proximity, common blood supply and
lymphatic drainage.
All sinuses share common bony wall with orbit –
prone to infections from sinuses
Thin walls of orbit
Periorbita is loosely attached to bone except at the
rim and apex
Relatively closed compartment

148. CLASSIFICATIONORBITALINFECTIONS
STAGE I Preseptal cellulitis. Infection is confined to the lids and
periocular soft tissue anterior to orbital septum. orbit may be
inflamed secondarily but not directly infected
STAGE II Orbital cellulitis with proptosis, limitations in movements, and
possible optic nerve compromise.
STAGE III Orbital cellulitis with a subperiosteal abscess
STAGE IV Orbital cellulitis with a true orbital abscess within the orbital
fat
STAGE V Retro orbital spread of the infection into the cavernous sinus or
brain

149. INFECTION
 Preseptal Cellulitis
◦ Vision, motility, pupils, disc are
normal
◦ globe itself is not proptotic
 Orbital Cellulitis
◦ 90% secondary to sinus disease
◦ high risk of morbidity and mortality

150. PRESEPTAL CELLULITISORBITALINFECTIONS
 PRIMARY SOURCES
i. Paranasal sinusitis
ii. Upper respiratory tract infection
iii. Direct inoculation
• SIGNS AND SYMPTOMS
• H/O swelling of eyelids
• Spread of infection confined to the lid
• Chemosis may be present
• Proptosis, limitation in eye movements, optic
nerve dysfunction are not present
• CT SCAN to rule out any orbital involvement has
to be done.

151. ORBITAL CELLULITIS & ABSCESSORBITALINFECTIONS
• Infection of retroseptal soft tissue of the orbit
• Serious condition that should be quickly diagnosed
and treated
• Mostly occurs in children and spreads from
sinuses
• Typically begins with painful swelling of the eyelids
and chemosis is seen mostly
• Distuingished from preseptal cellulitis by presence
of proptosis, limitation of ocular movements,
pupillary dysfunction and optic nerve damage
• Should be diagnosed radiographically

152. IMAGING OPTIONS
 Plain films
 CT scan
 MRI
 Ultrasound

153. THANK YOU