Surgical Anatomy of Orbit

SURGICAL ANATOMY OF
ORBIT AND ITS CLINICAL
IMPORTANCE
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CONTENTS
• BONY FRAMEWORK
• FORAMINA AND FISSURE
• MUSCLES OF ORBIT
• VASCULAR SUPPLY
• NERVE RELATION
• SURGICAL APPROACH
• CLINICAL IMPORTANCE
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Orbit
• Bilateral structures in the upper half of the face
below the anterior cranial fossa & anterior to
the middle cranial fossa that contains –
– Eyeball
– Optic nerve
– Extraocular muscles
– Lacrimal apparatus
– Adipose tissue
– Fascia , nerve & vessels
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Bony orbit
• 7 bones contribute to the framework of each
orbit –
– Maxilla
– Zygomatic
– Frontal
– Ethmoid
– Lacrimal
– Sphenoid
– Palatine bones
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• Bony orbit is pyramidal in shape, with its wide
base opening anteriorly onto the face & its apex
extending in a posteromedial direction.
• The apex of the pyramidal shaped bony orbit is
the optic foramen, while the base(orbital rim) is
formed –
– Superiorly by the frontal bone
– Medially by the frontal process of the maxilla
– Inferiorly by zygomatic process of the maxilla &
zygomatic bone
– Laterally by zygomatic bone, the frontal process of
zygomatic & the zygomatic process of frontal bone
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Boundaries of Bony Orbit
• Roof (superior wall ) –
made up of orbital part of
frontal bone with a small
contribution from
sphenoid bone.
• This thin plate separates
the contents of the orbit
from the brain in the
anterior cranial fossa.
• Posteriorly the lesser
wing of sphenoid bone
completes the roof.
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• Unique features of the superior wall include:
anteromedially, the possible intrusion of part
of the frontal sinus and the trochlear fovea,
for the attachment of a pulley through which
the superior oblique muscle passes;
• anterolaterally, a depression (the lacrimal
fossa) for the orbital part of the lacrimal
gland.
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• Floor ( inferior
wall ) – which is
also the roof of
maxillary sinus,
consists primarily
of the orbital
surface of maxilla,
with small
contributions from
zygomatic &
palatine bones.

• Thin 0.5mm, ‘S’ shaped concave anteriorly and
convex posteriorly
• Slopes upward and medially at 45o and
posteriorly at 30o
• Then terminates as the anterior margin of
inferior orbital fissure
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• Transversed anteriorly by infraorbital groove and
canal - medial to this blow-out fractures occur
• Posterolateral portion of orbit fracture can cause
late enopthalmos
• HAMMER’S ‘KEY AREA’ – posteromedial and
inferomedial bulge
in the floor
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• Medial wall consists of 4
bones – maxilla ,
lacrimal, ethmoid &
sphenoid bones.
– Largest contributor is
ethmoid bone.
• Parallel to the antero-
posterior axis of the
median plane of skull
• Forms an angle of 45o
with lateral wall

• Lateral wall consists of two bones --
anteriorly the zygomatic bone & posteriorly
the greater wing of sphenoid.
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FORAMINA AND FISSURE
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OPTIC CANAL
• Two bony roots that connect the lesser
wing of the sphenoid with the body of
the sphenoid form the optic canal. The
inferior root separates the optic canal
from the superior orbital fissure and also
is referred to as the optic strut. The
superior root forms the roof of the optic
canal and separates it from the anterior
cranial fossa.
• The body of the sphenoid forms the
medial wall of the canal. From an
anterior view, the entrance to the optic
canal is the most superior and medial
structure in the apex.
• Each optic canal passes posteromedially
at an angle of approximately 35° to the
sagittal and opens posteriorly into the
chiasmatic groove (which terminates
posteriorly at the tuberculum sellae).
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The canal has an intimate relationship to the sphenoid sinus,
and with extensive sinus pneumatization, the optic canal may
become completely surrounded by a posterior ethmoidal Onodi
air cell, the sphenoid sinus, or an aerated anterior clinoid
process.
In adults, the canal is 6.5 mm in diameter and about 8-12 mm in
length. The canal transmits the optic nerve and the ophthalmic
artery. Throughout its intraorbital and intracanalicular course,
the optic nerve is surrounded by pia mater, arachnoid, and dura
mater, giving the nerve a sheath.
Therefore, optic nerve is a white matter tract of the brain and
carries with it meningeal coverings. Within the orbit, the optic
nerve is quite mobile; however, within the canal, the optic nerve
sheath remains adherent to the sphenoid periosteum and thus
is fixed.

Superior orbital fissure
• SOF is situated between the greater and lesser sphenoid wings, with
the optic strut at its superomedial margin. It lies between the roof and
lateral wall of the orbit. The SOF is divided at the spina recti lateralis
by the annulus of Zinn, the common tendinous origin of the recti
muscles.dimension-17.3x20.8x9.5
– Lateral part– SO FATAL
• superior ophthalmic vein
• Frontal , lacrimal & trochlear nerve
• Recurrent br. of ophthalmic artery
– Middle part – TONA
• Two divisions of oculomotor nerve
• Nasociliary nerve
• Abducent nerve
– Medial part – IS
• Inferior ophthalmic vein
• Sympathetic plexus around ICA
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Fig. 1 e Superior orbital fissure measurements
scheme. (a) Maximum
length of the fissure and (b) maximum width of
the fissure.
Fig.
Scheme of measurements determining
location of optic nerve regarding optic
canal and superior orbital fissure with
the types ‘‘a’’ and ‘‘b’’
distinguished. (a) Distance from the optic
nerve centre to the upper margin of
optic canal wall, (b) distance from the
optic nerve centre to the medial pole
of superior orbital fissure, (c) distance
from the optic nerve centre to the lateral
pole of the superior orbital fissure, (d)
distance from the optic nerve
centre to the point determined by the
narrowing of the fissure (type ‘‘a’’) or the
point lying in the middle of line between
lateral and medial pole of the
fissure. (1) Optic nerve, (2) content of
superior orbital fissure, (3) content of
optic canal.

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Fig. 3 e Scheme of
morphological forms of the
superior orbital fissure
with percentage in brackets

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Fig. 7 e Types of arrangement of
nerves and vessels within the orbital
apex. (1) Optic nerve, (2) superior
branch of the oculomotor nerve, (3)
trochlear nerve, (4) frontal nerve, (5)
lacrimal nerve, (6) superior
ophthalmic vein, (7) nasociliary
nerve, (8) abducent nerve, (9) inferior
branch of the oculomotor nerve, (10)
ophthalmic artery.

SUPERIOR ORBITAL FISSURE
SYNDROME
• The syndrome is characterised by retro-orbital paralysis
of extraocular muscles, impairment of the branches of
the 1st division of the trigeminal nerve and frequently
extension to involve the optic nerve.
• Examination shows ophthalmoplegia, ptosis,
decreased corneal sensation, and occasionally visual
loss caused by mechanical optic nerve compression.
• The presence of proptosis, with swelling of eyelids and
chemosis (swelling of ocular surface membranes),
indicates significant mass extension within the orbit.
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Inferior orbital fissure
• A longitudinal opening separating the lateral
wall from the floor of the orbit.
• Its borders are the greater wing of sphenoid,
maxilla, palatine & zygomatic bones.
• Communicates with –
– Orbit & pterygopalatine fossa posteriorly
– Orbit & infratemporal fossa in the middle
– Orbit & temporal fossa anteriorly.
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Contents
• Maxillary branch of V
nerve
• Zygomatic br. of
maxillary nerve
• Infraorbital nerve &
vessels
• An emissary vein
communicating with
pterygoid venous
plexus of veins with
inferior ophthalmic
vein.
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Infraorbital groove and foramen
• Beginning posteriorly an
infraorbital groove is
encountered, continues
anteriorly across the floor of
the orbit.
• This groove connects with
infraorbital canal which
opens onto the face at the
infraorbital foramen.
• Contents – Infraorbital
nerve & vessels.
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Ethmoidal foramen
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DIMENSIONS
HEIGHT-35mm
WIDTH-40mm
DEPTH-45-55 mm

Eyelids
• Upper & lower eyelids are
anterior structures that when
closed protect the surface of the
eyeball.
• Space between the eyelids, when
they are open is the palpebral
fissure.
• Layers of eyelid from anterior to
posterior consists of –
– Skin
– Subcutaneous tissue
– Orbicularis oculi
– Orbital septum
– The tarsus & conjuctiva.
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Orbicularis oculi
• Consists of two parts –
– Orbital part – which
surrounds the orbit
– Palpebral part – which is in
the eyelids.
• Innervated by the facial
nerve & helps in closer of
the eyelids.
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Periorbita
• Periosteal lining of the
bones forming the
orbit.
• Continuous at the
margins of the orbit
with the periosteum on
the outer surface of the
skull & sends extension
into both eyelids as
orbital septa.17-07-2020 16:15:23

Orbital septum
• An extension of periosteum
deep to palpebral part of
orbicularis oculi in both the
upper & lower eyelids from
the margins of the orbit.
• It attaches to the tendon of
levator palpebrae superioris
muscle in the upper eyelid.
• Attaches to tarsus in the
lower eyelid.
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• Aponeurotic connective tissue suspending orbital
contents
• Consists of
– Tenon’s capsule
- sheaths of muscles
- check ligaments
• Function – horizontal support to globe & prevents
spread of infection and haemorrhage from
eyeball to retro-ocular space
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Bulbar sheath
• Tenon’s capsule forms a
thin, loose membranous
sheath around the eyeball,
extending from the optic
nerve posteriorly to the
sclerocorneal junction
anteriorly.
• Eyeball can freely move
within this sheath.
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1. PALBEBRAL LIGAMENTS:
• Formed as fibrous extensions of the tarsal plates
MEDIAL LATERAL
deep head superficial head deep fibres of
(thin) (thick) orbicularis oculi
post. lacrimal ant. lacrimal
crest crest Whitnall’s tubercle
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• Prevent medial and lateral rotation of the eye,
so, a.k.a. ‘CHECK LIGAMENTS’
• Connected inferiorly by thickened fascia –
‘LOCKWOOD’S SUSPENSORY LIGAMENT’
• Functions:
1. Vertical position of the eyeball
2. Prevent loss of orbital substance
3. Prevent gross posterior displacement
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• Lateral check lig. is strong triangular
expansion from the sheath of the lateral
rectus muscle, it is attached to the zygomatic
bone.
• The lower part of tenon’s capsule is thickened
is named suspensory lig. of lockwood formed
by a sling between two rectus muscles.

Tarsus
• Provides major support to each
eyelid.
• These plates of dense
connective tissue are attached
medially to the anterior
lacrimal crest of maxilla by
medial palpebral lig. &
laterally to the orbital tubercle
on the zygomatic bone by the
lateral palpebral lig.
• A large superior tarsus present
in upper eyelid & a smaller
inferior tarsus in lower eyelid.
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Tarsal glands
• Modified sebaceous glands present over
the free margin of each eyelid which
secretes an oily substance that increases
viscosity of tears & decreases the rate of
evaporation of tears from the surface of
eyeball.
• blockage & inflammation of tarsal
glands results in –
– Stye – present on the edge of the
eyelid.
– Chalazion – present on the inner
surface of the eyelid.
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Lacrimal apparatus
• It is involved in production, movement &
drainage of fluid from the surface of the
eyeball.
• Made up of –
– Lacrimal gland & its ducts
– Lacrimal canaliculi
– Lacrimal sac
– Nasolacrimal duct.
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Lacrimal gland
• Lacrimal gland is
anterior in the
superolateral part of
the orbit, divided into
two parts by LPS—
– Larger orbital part –
present in lacrimal fossa
– Smaller palpebral part –
inferior to LPS.
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• Nasolacrimal duct –
12 mm intrabony
canal
• Opens below inferior
turbinate in inferior
meatus
• At opening – mucosal
fold – valve of Hasner
– prevents fluid and
air reflux during high
intranasal pressure
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• Innervation –
–Sensory – lacrimal br. of ophthalmic nerve.
–Parasympathetic –
• facial nerve – GPN --- SPG– maxillary nerve ---
zygomaticotemporal nerve – lacrimal nerve.
–Sympathetic – plexus around ICA containing
fibres from superior cervical ganglion
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Muscles of Eye
• Two group of muscles are
present in the orbit –
– Extraocular muscles –
involved in movements of
eyeball or raising upper
eyelids.
– Intraocular muscles –
control the shape of lens &
size of pupil.
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Extraocular muscles
• 7 in number –
– Levator palpebrae
superioris
– Superior rectus
– Inferior rectus
– Medial rectus
– lateral rectus
– Superior oblique
– Inferior oblique
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Levator palpebrae superioris
• Origin – lesser wing of
sphenoid anterior to optic
canal
• Insertion – anterior surface
of upper tarsal plate
• Supplied by superior br.
Oculomotor nerve.
• Function – elevation of
upper eyelid.
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Superior rectus
• Origin – superior part
of common tendinous
ring
• Insertion – anterior
half of eyeball
superiorly
• Supplied by superior
br. of oculomotor
nerve.
• Function – elevation,
adduction, intortion.
Inferior rectus
• Origin – inferior part of
common tendinous
ring
half of eyeball inferiorly
• Supplied by inferior br.
of oculomotor nerve.
• Function – depression,
adduction, extortion.
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Medial rectus
• Origin – medial part of
common tendinous
ring
half of eyeball medially
• Supplied by inferior br.
of oculomotor nerve.
• Function – adduction
of eyeball.
Lateral rectus
• Origin – lateral part of
common tendinous
ring
half of eyeball laterally
• Supplied by abducent
nerve.
• Function – abduction
of eyeball.
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Superior oblique
• Origin – body of
sphenoid ,superior &
medial to optic canal
• Insertion – outer
posterior quadrant of
eyeball
• Supplied by trochlear
nerve.
• Function – depression,
abduction, intortion.
Inferior oblique
• Origin – medial floor of
orbit posterior to rim
• Insertion – outer
posterior quadrant of
eyeball
• Supplied by inferior br. of
oculomotor nerve.
• Function – elevation,
abduction, extortion.

Eyeball
• Globe shaped structure present in anterior
part of orbit.
• Walls of eyeball – 3 layers
– Outer fibrous layer consists of cornea anteriorly &
sclera posteriorly.
– Middle vascular layer consists of choroid
posteriorly & is continuous with the ciliary body &
iris anteriorly.
– Inner layer consists of optic part of retina
posteriorly & nonvisual retina that covers internal
part of ciliary body & iris anteriorly.
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• Anterior chamber – area directly posterior to
the cornea & anterior to iris.
• Posterior chamber – area posterior to iris &
anterior to lens.
• Aqueous humor is secreted in posterior
chamber ,flows into anterior chamber through
the pupil.
• It supplies nutrients to avascular cornea &
lens & maintains the intraocular pressure.
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Glaucoma
• Intraocular pressure will
rise if the normal cycle of
aqueous humor fluid
production & absorption is
disturbed so that amount
of fluid increases.
• This condition can lead to
blindness which results
from compression of
retina & its blood supply.
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Lens & vitreous humor
• Lens is a transparent,
biconvex elastic disc attached
circumferentially to muscles
associated with outer wall of
eyeball.
• It separates the anterior one-
fifth of eyeball from posterior
four-fifth.
• Posterior four-fifth of the
eyeball, from lens to the
retina, is occupied by vitreous
chamber , filled with
transparent gelatinous fluid
known as viterous humor.
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Optic part of retina
• Consists of 2 layers –
• Outer pigmented layer – firmly attached
to the choroid & continuous anteriorly
over the internal surface of ciliary body
& iris.
• Inner neural layer – further subdivided
into various components , only attached
to the pigmented layer around the optic
nerve.
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Optic disc
• where the optic nerve leaves the retina. It is
lighter than the surrounding retina & branches of
central retinal artery spread from this point
outward to supply the retina.
• No light sensitive cells are presnt in optic disc
(blind spot).
• Lateral to optic disc a small area with yellowish
coloration is macula lutea with its central
depression fovea centralis.
• This is thinnest area of retina & with higher visual
sensitivity.
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Optic nerve
• It is not a true cranial nerve,
but rather an extension of
the brain carrying afferent
fibres from the retina of the
eyeball to visual centers of
brain.
• The optic nerve leaves the
orbit through the optic
canal. It is accompanied in
the optic canal by the
opthalmic artery.
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• Any increase in intracranial
pressure results in increased
pressure in the
subarachnoid space
surrounding the optic nerve.
• This may impede venous
return along the retinal
veins causing papilloedema
which can be seen when
retina is examined using an
ophthalmoscope.

Oculomotor nerve
• The oculomotor nerve [III]
leaves the anterior surface of
the brainstem between the
midbrain and the pons.
• It passes forward in the lateral
wall of the cavernous sinus.
Just before entering the orbit
the oculomotor nerve [III]
divides into superior and
inferior branches .
• These branches enter the orbit
through the superior orbital
fissure, lying within the
common tendinous ring.17-07-2020 16:15:23

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• Superior Branch passes upward on the lateral
side of the optic nerve to innervate the superior
rectus and levator palpebrae superioris muscles.
• The large Inferior branch divides into three
branches:
– one passing below the optic nerve as it passes to the
medial side of the orbit to innervate the medial rectus
muscle;
– a second descending to innervate the inferior rectus
muscle;
– the third descends as it runs forward along the floor of
the orbit to innervate the inferior oblique muscle
• As the third branch descends, it gives off
the branch to the ciliary ganglion. This is the
parasympathetic root to the ciliary ganglion and
carries preganglionic parasympathetic fibers.

LIGHT REFLEX
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Lesion of optic nerve
• Ipsilateral stimulation
– no direct stimulation,
consensual reflex
absent.
• Contralateral
stimulation – both
direct & consensual
reflex are present.
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Lesion of oculomotor nerve
• Ipsilateral stimulation
-- consensual reflex is
preserved, fixed
dilated pupil on same
side.
• Contralateral
stimulation – direct
reflex preserved,
consensual reflex lost.
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Trochlear nerve
• arises from the posterior surface
of the midbrain.
• It passes through the lateral wall
of the cavernous sinus just below
the oculomotor nerve, enters the
orbit through the superior orbital
fissure above the common
tendinous ring.
• In the orbit the trochlear nerve
[IV] ascends and turns medially,
crossing above the levator
palpebrae superioris muscle to
enter the upper border of the
superior oblique muscle .
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Abducent nerve
• The abducent nerve [VI] arises
from the brainstem between
the pons and medulla
• It enters the cavernous sinus
and runs through the sinus
lateral to the internal carotid
artery, enters the orbit
through the superior orbital
fissure within the common
tendinous ring .
• Once in the orbit it passes out
laterally to supply the lateral
rectus muscle.
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Ophthalmic nerve
• It is the smallest and most superior
of the three divisions of the
trigeminal nerve. This purely sensory
nerve receives input from structures
in the orbit and from additional
branches on the face and scalp.
• Leaving the trigeminal ganglion, it
passes forward in the lateral wall of
the cavernous sinus inferior to the
trochlear [IV] and oculomotor [III]
nerves.
• Just before it enters the orbit it
divides into three branches- the
nasociliary, lacrimal, and frontal
nerves.
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Nasociliary nerve
• first branch from the ophthalmic nerve , enters the
orbit within the common tendinous ring between the
superior and inferior branches of the oculomotor nerve.
• Its first branch, the communicating branch with the
ciliary ganglion (sensory root to the ciliary ganglion), is
given off early in its path through the orbit.
• it continues forward along the medial wall of the orbit,
between the superior oblique and the medial rectus
muscles, giving off several branches. These include:
– long ciliary nerves
– posterior ethmoidal nerve
– infratrochlear nerve
– anterior ethmoidal nerve
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Frontal nerve
• It is the largest branch of the ophthalmic nerve
[V1] and receives sensory input from areas
outside the orbit.
• Divides into its two terminal branches-
– the supratrochlear nerve supplies the conjunctiva
and skin of the upper eyelid and the skin on the
lower medial part of the forehead;
– the supra-orbital nerve supplies the upper eyelid
and conjunctiva, the forehead, and as far
posteriorly as the middle of the scalp.
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Lacrimal nerve
• It is the smallest of the three branches of the
ophthalmic nerve . Once in the orbit it passes
forward along the upper border of the lateral
rectus muscle .
• It receives a branch from the
zygomaticotemporal nerve, which carries
parasympathetic and sympathetic
postganglionic fibers for distribution to the
lacrimal gland.
• it supplies the lacrimal gland, conjunctiva, and
lateral part of the upper eyelid.
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Ciliary ganglion
• parasympathetic ganglion of the occulomotor
nerve . It is associated with the nasociliary branch of
the ophthalmic nerve .
• The ciliary ganglion is a very small ganglion, in the
posterior part of the orbit immediately lateral to
the optic nerve and between the optic nerve and
the lateral rectus muscle . It has three roots.
• Parasympathetic root –
– innervate the sphincter pupillae muscle, responsible for
pupillary constriction;
– the ciliary muscle, responsible for accommodation of the
lens of the eye for near vision.
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• Sensory root-- These fibers are responsible for
sensory innervation to all parts of the eyeball.
• Sympathetic root-- these fibers travel up the
internal carotid artery, leave the plexus
surrounding the artery in the cavernous sinus,
and enter the orbit through the common
tendinous ring.
• postganglionic sympathetic fibers reach the
eyeball and innervate the dilator pupillae
muscle.
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Ophthalmic artery
• Branch of cerebral part of
ICA, given off medial to
anterior clinoid process close
to the optic canal.
• Enters the orbit through the
optic canal, lying
inferolateral to the optic
nerve.
• Crosses above the nerve
from lateral to medial side,
then runs along the medial
wall between superior
oblique & medial rectus
muscles.
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Branches
• Central artery of retina
– First branch, lies below
the optic nerve & runs
forwards to reach the
optic disc ,here it
supplies the retina.
– It is an end artery, does
not have effective
anastomosis with other
arteries.
– Occlusion of the artery
leads to Blindness.
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• Branches arising from lacrimal artery
– To the lacrimal gland
– Two zygomatic branches
– Lateral palpebral branch to the eyelid
– A recurrent meningeal branch to middle cranial fossa
– Muscular branches to muscles of orbit
• Branches arising from main trunk
– Posterior ciliary arteries to choroid & iris
– Supratrochlear & supraorbital arteries to scalp
– Anterior & posterior ethmoidal arteries
– Medial palpebral branches
– Dorsal nasal branch to upper part of nose.

Ophthalmic veins
• Superior ophthalmic vein – accompanies the
ophthalmic artery, lies above the optic nerve,
drains into the cavernous sinus.
• Communicates anteriorly with supraorbital &
angular veins.
• Inferior ophthalmic veins – runs below optic
nerve, recieves tributaries from the lacrimal sac,
lower orbital muscles & eyelids , drains into
cavernous sinus.
• Lymphatic drainage – preauricular parotid
lymph nodes.
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Glasgow coma scale
• Eye opening is an important component in
trauma score.
• Score –
–Spontaneous eye opening – 4
–To speech – 3
–To pain – 2
–No eye opening -- 1
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III nerve palsy
• Results in –
– Ptosis – drooping of upper eyelid
– Lateral squint
– Dilatation of the pupil
– Loss of accomodation
– Slight proptosis i.e. forward projection of eye
– Diplopia or double vision
• Weber’s syndrome – midbrain lesion causing
contralateral hemiplegia & ipsilateral paralysis
of III nerve.
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• When trochlear nerve is damaged, diplopia
occurs on looking downwards, vision is single
as long as the eyes look above the horizontal
plane.
• Paralysis of abducent nerve results in –
– medial squint
– diplopia
• VI nerve palsy is one of the commonest false
localizing signs in cases with raised intracranial
pressure.

Ptosis
 Drooping of Upper
Eyelid.
• Loss of function of –
– The levator palpebrae
superioris muscle
– superior tarsal muscle
17-07-2020 16:15:23

Diplopia
 means double vision
• 1). Monocular Diplopia: Seen in lens dislocation & retinal detachment.
Requires ophthalmologic intervention.
2). Binocular Diplopia: 3 basic mechanisms –
a). Edema or hematoma: In peripheral fields of gaze. Diplopia in
primary & downward gaze resolves along with hematoma.
b). Restricted motility: Due to prolapse of periorbital contents or
entrapment of fine suspensory ligamentous system & not the extra-
ocular muscles.
More common in floor fractures.
c). Neurogenic injury: Functional impairment of CN III, IV & VI.
Recover within 6-9 months.17-07-2020 16:15:23

Forced Duction Test
• The forced duction test is performed in
order to determine whether the absence
of movement of the eye is due to a
neurological disorder or a mechanical
restriction.
• The anesthetized conjunctiva is grasped
with forceps and an attempt is made to
move the eye ball in the direction where
the movement is restricted. If a
mechanical restriction is present, it will
not be possible to induce a passive
movement of the eye ball.
17-07-2020 16:15:23

• Is defined as a retro position of the globe in its
three-dimensional relationship in the orbit and
should be assessed in relation to the contra
lateral eye and facial structures
• Etiology:
• Loss or decrease in volume of orbital contents
• Increase in volume of of bony orbit
• Loss of ligament support
• Post traumatic fibrosis,scar contaction and fat
atrophy
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Horner's syndrome
• caused by a lesion in the sympathetic trunk in the neck
that results in sympathetic dysfunction.
• It is characterized by three typical features:
– pupillary constriction due to paralysis
of the dilator pupillae muscle;
– partial ptosis
– Ipsilateral absence of sweating
• Secondary changes may also include:
– ipsilateral vasodilation due to loss of the normal
sympathetic control of the subcutaneous blood vessels;
– Enophthalmos - result from paralysis of the orbitalis
muscle, though this is an uncommon feature of Horner's
syndrome.
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Traumatic changes in pupil
• In testing pupil it is necessary
to use a bright light.
• Most significant changes in
the pupils are progressive
enlargement & loss of
reaction to light, first on
affected side and then on the
other.
• A fixed,dilated pupil is the
sign of oculomotor paralysis.
17-07-2020 16:15:23

CIRCUMORBITAL AND
SUBCONJUCTIVAL ECCHYMOSIS
• Periorbital pre septal tissue-black eye
• Trauma,bleeding from intracranial source
17-07-2020 16:15:23

Traumatic telecanthus
• Displacement and splaying of bones that serve
as attachment for medial canthal ligaments
• Best treated with in 7-10 days
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epiphora
• Initial flow is by
capillary attraction
so that contact of
punctum with the
conjuctiva very
important
• Blockade or
trauma
17-07-2020 16:15:23

17-07-2020 16:15:23
SUPERIOR ORBIT
SUPERIOR RIM
SUPEROLATERAL
LATERAL CANTHOTOMY
LID CREASE
LYNCH
MEDIAL LID CREASE
BICORONAL
INFERIOR ORBIT
INFERIOR RIM
LID CREASE
LATERAL CANTHOTOMY
SUBCILLIARY
TRANSCONJUCTIVAL
VESTIBULAR

• Medial and lateral canthal tendon complexes. Note that the anterior limb of the medial
canthal tendon (AL, MCT) and the posterior limb of the lateral canthal tendon (PL LCT) are
thicker. The thicker anterior portion of the medial canthal tendon attaches to the anterior
lacrimal crest of the maxilla and the frontal process of the maxilla. The thinner posterior limb
of the medial canthal tendon (PL MCT) attaches along the posterior lacrimal crest of the
lacrimal bone. The thick posterior portion of the lateral canthal tendon (PL LCT) attaches to
the orbital (Whitnall’s) tubercle of the zygoma, 3 to 4 mm posterior to the lateral orbital rim.
The thinner anterior fibers course laterally to mingle with the orbicularis oculi muscle fibers
and the periosteum of the lateral orbital rim.17-07-2020 16:15:23

• CENTRAL PLACEMENT
• UPPER AND LOWR
CREASE LINES
• EYE LID HEALS RAPIDLY
• PATHWAY OF LYMPHATIC
DRAINAGE
17-07-2020 16:15:23

SUBCILLIARY INCISION
17-07-2020 16:15:23

• 3. Lateral view of the orbit: (A) tarsal plate,
(B) preseptal orbicularis muscle, (C) orbital
septum, (D) orbital fat, (E) inferior orbital
rim.
17-07-2020 16:15:23
Lateral view of the orbit. The broken line
outlines our
approach to the subtarsal incision and
approach to the orbital rim.

SUBTARSAL APPROACH
17-07-2020 16:15:23

SUPRAORBITAL EYE BROW APPROACH
17-07-2020 16:15:23

UPPER EYE LID APPROACH
17-07-2020 16:15:23

CORONAL APPROACH
17-07-2020 16:15:23

MODIFICATION
17-07-2020 16:15:23

BIBILOGRAPHY
• JOMS
• JOURNAL OF PLASTIC AND RECONSTROUCTIVE
SURGERY
• ROWES AND WILLIAMS
• PRINCEPLES OF OMFS BY PETERSON
• FONSECA TRAUMA
• GRAY ANATOMY
• APPROACH OF FACIAL SKELETON BY ELLIS
17-07-2020 16:15:23

Surgical Anatomy of Orbit

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