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Anatomy of eyelids

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Anatomy of eyelids and clinical significance of the various structures.

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Anatomy of eyelids

  1. 1. ANATOMY OF EYELIDS -DR. SHIBASHIS DEB 1st Year PGT, Ophthalmology. Silchar Medical College.
  2. 2. The Eyelids: The eyelids are thin folds of skin, on either side, that covers and protects the human eyes. They act as a shutter mechanism and play very important role in protection of the eyeballs from trauma and excessive light, maintaining the tear film, blink reflex and in cosmetic beauty of the eye.
  3. 3. GROSS ANATOMY OF EYELIDS: The eyelids are mobile folds of tissue which are placed in front of the eyeballs. The gross anatomy of the eyelids is as follows: 1. Extent: The upper eyelid extends from the eyebrows, in a downward direction, to end in a free margin. This forms the superior border of the palpebral fissure. The lower eyelid extends from a free margin, the lower border of the palpebral fissure, proceeds downwards and merges with skin of the cheek. IN the primary gaze position, the upper eyelids cover 1/6th of the cornea(2mm from upper corneal margin) and the lower eyelids just touches the cornea.
  4. 4. 2. Lid Folds: The skin of the eyelids are not smooth and have folds on them, known as the lid folds. The superior lid fold is present in the upper eyelid. It is formed by the insertion of a few fibers of the levator palpebrae superioris which retracts the skin. It divides the upper eyelid into the - orbital part and tarsal part. The inferior lid folds are less distinctly marked and is formed due to the fibrous slips of fascia around inferior rectus, which are inserted into the skin. There are 2 other folds: a. Naso-jugal skin fold. b. Malar skin fold.
  5. 5. 3. Canthi: The canthi are the two angular area where the upper and the lower eyelids meet. They are called the medial and lateral canthi respectively. The lateral canthus is in touch with the eyeball. In the position of primary gaze, it has angle of 30◦ and an angle of 60◦ in eyes wide gaze. The medial canthus is rounded and separated from the globe by the lacus lacrimalis. The medial canthus contains the caruncle and plica semilunaris.
  6. 6. 4. Lid Margins: The eyelid margins are 2mm in width and are nearly flat. The lid margins have several important structures associated with it. The most important is the lacrimal papilla which has the lacrimal puncta at its centre. This medially situated elevation in the lid margin divides it into 2 parts : - a. The medial lacrimal portion. This portion is devoid of eyelashes and glands. b. The lateral ciliary portion. This has a rounded anterior portion, a sharp posterior border and an intermarginal strip. This strip contains the a grey line, the junction between skin and conjunctiva.
  7. 7. 5. Eyelashes: The eyelashes are arranged in the ciliary portion of the eyelid margin, in 2-3 rows. The upper eyelashes are 100-150 in number and the lower lashes are 50-75 in number. They do not interlace when the eyelids appose. Each cilium has a lifespan of 3-4 months. The lashes lack errectores and are embedded in the the fibrous tissue that binds the the ciliary margin of tarsus to the overlying skin. Each follicle is surrounded by dense plexus of vessels and nerves. The modified sebaceous glands of Zeis and sweat gland of Moll empty into the infundibulum of each ciliary canal.
  8. 8. 6. Palpebral aperture: It is the elliptical space between the upper and lower eyelid margins. Dimensions: Horizontal Vertical At birth 18-21 mm 8 mm At adult 28-30 mm 9-11 mm Anatomical variation: The lateral canthus maybe is slightly (<2mm) higher then the medial canthus. The greater elevation of lateral canthus results in a mongoloid slant. A lower level of lateral canthus results in a antimongloid slant.
  9. 9. Structural Anatomy : The eyelids consists of the following layers from outside to inside: 1. Skin 2. Subcutaneous areolar tissue layer. 3. Striated muscle layer. 4. Submuscular areolar tissue layer. 5. Fibrinous layer. 6. Non-striated muscle fibre layer. 7. Conjunctiva.
  10. 10. 1. Skin: • It is elastic and thinnest in the body (thickness 0.05mm). Nasal part is smooth while temporal part has fine hairs. • The epidermis is well-formed with 6-7 layers of stratified squamous epithelium. • The basal layer contains numerous unicellular sebaceous glands and typical eccrine sweat glands. • The dermis is composed of dense connective tissue of elastic fibres, blood vessels, lymphatics and nerves. 2. Subcutaneous areolar tissue: • Does not containing fat. • Non-existent near the ciliary margin, lid folds and at medial and lateral angles.
  11. 11. 3. Striated muscle layer: This layer consists of the following muscles: a. Orbicularis oculi – both upper and lower lid. b. Levator palpebrae superiors – upper lid. Orbicularis oculi: This muscle is divided into two distinct parts – the orbital (peripheral) part and palpebral (central) part. Orbital part : Origin (Medial) Insertion (Lateral) Function 1. Medial palpebral lig. 2. Upper orbital margin medial to supraorbital notch. 3. Maxillary process of frontal bone. 4. Lower orbital margin medial to infraorbital foramen. 1. Lateral palpebral raphae. 2. Superiorly, skin of eyebrows. 1. Forced closure of eyelids. 2. Pulls eyebrows downwards.
  12. 12. Palpebral part: It is subdivided into – preseptal and pretarsal fibres. Preseptal fibres: Pretarsal fibres: Origin Insertion 1. Medial palpebral lig. (ant.) 2. Lacrimal fascia 3. Posterior lacrimal crest. 1. Lateral palpebral raphae. Origin Insertion 1. Medial palpebral lig. (ant.) 2. Lacrimal fascia 3. Posterior lacrimal crest 1. Lateral canthal tendon, inserted over Lateral orbital tubercle of Whitnall.
  13. 13. Muscle of Horner (tensor tarsi) Muscle of Riolan It plays an important part in drainage of tear secretion via lacrimal pump system. It helps in maintaining a close relation of the eyelids with the globe (Lamination effect).
  14. 14. LEVATOR PALPEBRAE SUPERIORS: The LPS, present in the upper eyelids, is the major muscle for elevating them. It is a striated muscle which lies beneath the subcutaneous areolar tissue, and acts as the primary elevator of the eyelids along with – Frontalis (accessory elevator in extreme upgaze) and Muller’s muscle (1st 2mm elevation and long term adjustments). Gross Anatomy: The LPS muscle has 2 parts – a. the fleshy part b. the tendinous aponeurosis Fleshy Part Tendinous Part • 40 mm long. • Runs horizontally. • From origin of LPS upto Superior Transverse Lig. Of Whitnall. • 15mm long annd 30mm wide. • Runs vertically. • From Lig. Of Whitnall to insetion of LPS.
  15. 15. Origin: • At the Apex of the orbit • From the under-surface of the Lesser wing of Sphenoid. • Above the Annulus of Zinn, by a tendinous process, that merges with the belly.
  16. 16. Course of LPS: Fleshy part: a. Runs forwards between the Roof of Orbit and Superior Rectus. b. Widens as it proceeds and on reaching the Superior Transverse Lig. Of Whitnall, it descends vertically posterior to orbital fat wedge. Tendinous part: a. As the LPS approaches the Septum Orbitale it fans out into LPS aponeurosis, and tapers into medial and lateral horns. b. The medial horn passes over the reflected head of superior oblique and fuses with medial canthal tendon. c. The lateral horn passes though the lacrimal gland and divides it into – orbital (larger) and palpebral parts and inserts into lateral canthal tendon.
  17. 17. Fig: Course of LPS and its relation with Whitnall’s lig. and Lacrimal gland.
  18. 18. Insertion of LPS: The aponeurosis of LPS passes through the septum orbitale and then forwards and downwards till the tarsal plates. It widens into 2 major attachments. 1. The anterior collagen fibers attach to the septa between the orbicularis muscle fibers, at the level of upper border of tarsal plate. Few fibers insert into the pre-tarsal skin. 2. The posterior part attach to the anterior surface of tarsus, 3-4mm below its superior border. 3. A few fibers attach posteriorly into the superior conjunctival fornix.
  19. 19. Superior Transverse Lig. Of Whitnall: • The function of LPS depends on the integrity of this ligament. • It extends from trochlear pulley system (medially) to the capsule of orbital part of lacrimal gland (laterally). • This is formed fibrous sheath farms from the condensation of superior sheath of LPS and reflected head of Superior Oblique. • At the level of this lig. the LPS bends and moves downwards from its horizontal direction.
  20. 20. 4. Submuscular areolar tissue 1. It is a layer of loose connective tissue present between the orbicularis muscle and the fibrous layer. 2. It splits the eyelid into – anterior lamina and posterior lamina. 3. In upper eyelid it is traversed by the LPS which divides it into two spaces – a. pretarsal space. b. preseptal space. Clinical importance: 1. The nerves and vessels of the lids lie in this layer, so anaesthesia for lids is given in this plane. 2. In upper eyelid, it is connected superiorly with subaponeurotic startum of scalp – dangerous area of scalp.
  21. 21. Pretarsal space: 1. It is a small space which appears fusiform in a vertical section. 2. Bounded by – LPS (anteriorly) and Tarsal plate (posteriorly). Clinical significance – The peripheral arterial arcade is present here. Preseptal space: 1. It appears triangular is vertical section. 2. Bounded by – Orbicularis oculi (anteriorly) and Orbital septum (posteriorly). Preseptal cushion of fat: 1. It is crescent-shaped pad of fat. 2. Bounded by – Orbicularis oculi (anteriorly); to which it is firmly adherent; and Orbital septum (posteriorly).
  22. 22. Fig: Submuscular areolar space with its spaces.
  23. 23. 5. Fibrous layer: The fibrous layer consists of – Tarsal plate (centrally) and Septum Orbitale (peripherally). It also includes the medial and lateral palpebral ligaments. Tarsal Plate: Tarsi are firm plates of dense fibrous tissue that form the skeleton of the eyelids giving them shape and firmness. Size: The tarsi 29mm long and 1mm thick. The upper tarsus is 10mm in height and lower tarsus is 4-5mm. Borders: The free border are straight while the attached borders are convex. Superior border of upper tarsus gives attachment to– Septum orbitale and Muller’s muscle. Inferior border of lower tarsus gives attachment to – Orbital septum, Capsulopalpebral fascia and inferior palpebral muscle.
  24. 24. Surfaces: The tarsal plates have 2 surfaces. Anterior surface, it is convex and seperated from orbicularis muscle by loose areolar tissue. In the upper eyelid, the LPS gets attached to the anterior surface 3-4mm from the upper border. This area of 3- 4mm is the potential pretarsal space. Posterior surface, is concave and is lined by firmly adherent conjunctiva. Extremities: The lateral ends of the tarsi are attached to the Whitnall’s tubercle by the lateral palpebral lig. and the medial ends are attached to the Anterior Lacrimal crest and frontal process of Maxilla by the medial palpebral lig. The tarsal plate contains the Meibomian glands embedded within its substance.
  25. 25. Fig: Tarsal plates and the attached structures.
  26. 26. SEPTUM ORBITALE It is a thin, floating membrane of connective tissue which takes part in the movements of the eyeball. Attachments: Centrally, it becomes continuous with the convex borders of the tarsi. Peripherally, it is attached to the orbital margins at a thickening called Arcus marginale. Structures piercing through septum orbitale: The septum orbitale is important as several structures pierce through it including blood vessels and nerves. From medial to lateral: 1. Superior and inferior palpebral arteries. 2. Infratrochlear N. and Dorsal nasal A. (upper septum) 3. Supratrochlear N. and A. (upper septum) 4. Supraorbital N. and A. (upper septum) 5. Lacrimal N. and A. (upper septum) 6. Expansion of inferior rectus (lower septum)
  27. 27. Fig: Structures passing through the Septum Orbitale.
  28. 28. Clinical Importance of Septum Orbitale: The Septum Orbitale forms a barrier against spread of infection to the deeper structures of the eye. An infection, which is in front of the septum, preseptal cellulitis, has better prognosis then a deeper infection and is associated with less number of complications.
  29. 29. 6. Layer of Non-Striated Muscle fibres: This layer consists of smooth muscle fibres of Muller. Origin: Upper eyelid – Inferior terminal striated fibres of LPS. Lower eyelid – Expansion of the inferior rectus. Insertion: The Muller’s muscles get inserted in the orbital margin of the tarsal plate. Nerve supply: Supplied by sympathetic nerve fibres. 7. Conjunctiva: The posterior-most layer of the eyelid is formed by the palpebral conjunctiva. It extends from the mucocutaneos junction at the lid margin to the conjunctival fornix. It is firmly adherent to the posterior surface of the tarsal plate and Muller’s muscle.
  30. 30. Fig: Muller’s muscle and Palpebral conjunctiva. (upper lid)
  31. 31. Gland Location Opening Secretion Meibomian gland. Stroma of tarsal plate. Arranged vertically parallel to each other, 20-30 in each lid. Single row on the lid margin between posterior border and grey-line. Oily in nature (sebum). Gland of Zeis. Follicles of cilia, eyelid and caruncle. Opens directly into the eyelash follicle. Usually 2 per cilium. Oily in nature. Gland of Moll. Eyelids, between the cilia. Unbranched spiral in shape. Terminate seperately between 2 lashes or into the ducts of Zeis gland. Sweat. Glands of Wolfring. Upper border of superior tarsus Lower border of inferior tarsus. Into inner surface of eyelid Aqueous. (contribute to tear film) Glands of the Eyelid:
  32. 32. Vessels and Nerves of the Eyelid: Arterial Supply: Upper eyelid, supplied by 2 arterial arcades – a. Marginal arterial arcade, formed by anastomosis of the medial and lateral palpebral arteries. b. Superior arterial arcade, formed by the superior branches of the medial palpebral artery. Lower eyelid, has a single marginal arterial arcade formed similar to the upper eyelid. Venous Supply: The venous drainage of eyelids are arranged in 2 sets of venous plexus: a. Pretarsal venous plexus: Drains mainly into subcutaneous veins – Angluar vein -> Internal jugular vein medially and Superficial temporal V. and Lacrimal V. -> External jugular vein laterally. b. Post-tarsal venous plexus: Drains mainly into the Ophthalmic veins.
  33. 33. Lymphatic drainage of the eyelids: Lymphatic Vessels Medial Group Superficial medial channel Superficial Submandibular L.N. Deep medial channel Deep Submadibular L.N. Lateral Group Deep lateral channel Deep Parotid L.N. Superficial lateral channel Superficial Parotid and Preauricular L.N.
  34. 34. Lymphatic Drainage: Medial Group : A. Superficial : i) Medial ½ of lower lid, ii) Medial ¼ of upper lid and iii) medial commissure. B. Deep : i) Medial 2/3rd of conjunctiva of lower lid and ii) caruncle. Lateral Group : A. Superficial : i) Lateral ½ of lower lid and ii) Lateral ¾ of upper lid. B. Deep : i) Lateral 1/3rd of conjunctiva of lower lid and ii) entire conjunctiva of upper lid.
  35. 35. Fig: Schematic diagram of lymphatic drainage of eyelids.
  36. 36. Nerve Supply: Motor Nerve: 1. Zygomatic branch of Facial N. – Orbicularis muscle. 2. Oculomotor N. – Levator Palpebrae Superioris. Sensory Nerve: Derived from branches of the 1st and 2nd divisions of the Trigeminal N. Upper lid: supraorbital, supratrochlear, infratrochlear and lacrimal branches. Lower lid: infraorbital, infratrochlear and orbital branches. Sympathetic Nerve: supply Muller’s muscle, the vessels and the glands of the skin. Arrangement: The nerves are arranged in the submuscular plane (between orbicularis and the tarsal plates). This is the plane of anaesthesia of eyelids.
  37. 37. Embryology of the eyelids: • Reduplication of surface ectoderm • 2nd month of gestation. • Contain mesoderm – gives rise to muscles. • Lids are fused at 2nd trimester and separate at 7th month of IUL. • Molecular biology and genetics: • cell migration – FGF10, TGF-α, Activin B and HB-EGF modulate downstream BMP4 signaling, ERK cascade and JNK/c-JUN. •Wnt/β-catenin – inhibit and regulate eyelid fusion.
  38. 38. Congenital Anomalies of the Eyelid: Condition Description Treatment Epicanthal folds Vertical folds of skin over the canthal area. Utilize the excess horizontal skin to make up the vertical deficit. Telecanthus Increased distance between medial canthi (>30mm) Shortening of medial canthi by transnasal wiring with transposition of flaps. Epiblepharon Excess of skin of medial part of eyelids with vertical eyelashes Excision of redundant skin with adjacent orbicularis. Blepharophimosis Horizontal and vertical size of palpebral fissure is reduced Mustarde’s procedure. Euryblepharon Incresed horizontal palpebral fissure, downward dispalcement of lateral canthus, ectropion of lateral 1/3rd of lid Canthoplasty Coloboma of lid Full-thickness lid margin defect due to absence of fusion. Tanzel procedure – large defect Cutler-Beard procedure – severe cases Hughe procedure – lower lid defect Ankyloblepharon Variable portions of the lids are fused together Lateral side – Canthoplasty Medial side – lacrimal app reconstruction Cryptophthalmos Failure of seperation of lids at 4th to 6th week IUL As anterior segment agenesis is a rule, no treatment for restoration.
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Anatomy of eyelids and clinical significance of the various structures.

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