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CLINICAL NEURO-OPHTHALMOLOGY

ANATOMY AND PHYSIOLOGY OF NORMAL LACRIMAL FUNCTION

ANATOMY OF TEAR SECRETION BY THE
LACRIMAL GLANDS
The lacrimal gland is situated in the superior lateral corner
of the orbit, immediately behind the orbital rim within the
lacrimal fossa of the frontal bone (Fig. 14.39). Inferiorly, it
is in contact with the globe. Anteriorly, it is divided into an
upper (orbital) and lower (palpebral) lobe by the lateral horn
of the levator aponeurosis. The upper or superior lobe is
bean-shaped, with its medial extremity lying on the levator
and its lateral extremity lying on the lateral rectus muscle.
The lower or inferior lobe, about half the size of the superior
lobe, is situated underneath the levator aponeurosis and connects to the lateral superior conjunctival fornix by a series
of excretory ducts. These ducts, about 12 in number, open
into the conjunctival sac 45 mm above the upper border
of the tarsus.
The lacrimal gland is a typical tubuloalveolar exocrine
gland composed of small lobules made up of many fine tubules. Each tubule is composed of a layer of cylindrical cells
lining the lumen and a layer of flat basal cells lying on a
basement membrane. The basal cells are myoepithelial and
contractile. The cylindrical cells contain granular cytoplasmic inclusions that histochemically differentiate these

cells by their role in tear secretion. The collecting channels

are initially intralobular, but later become extralobular, and
finally empty into fine ducts. These ducts are lined with a
double layer of epithelium. The ultrastructure of the human
lacrimal gland has been described by several investigators
(433435).
The fluid produced within the acini of the primary lacrimal gland and secreted by the gland contains water, electrolytes, and protein. The concentrations of these components
are then modified by cells of the duct system (436). Parasympathetic and sympathetic nerves innervate the acinar cells,
duct cells, and blood vessels of the gland. The parasympathetic nerves contain acetylcholine and VIP. Norepinephrine
is contained in the sympathetic nerves, whereas the sensory
nerves contain substance P and possibly calcitonin generelated peptide (CGRP).
Aqueous tear secretion occurs not only from the primary
lacrimal gland but also from the accessory lacrimal glands
of Krause and Wolfring. These small glands are similar in
structure to the main lacrimal gland but are much smaller.
The glands of Krause are located in the upper fornix; the
glands of Wolfring are situated further down on the eyelid,
above the tarsus (Fig. 14.39). It has generally been accepted

Figure 14.39. Partial schematic representation of secretory tear system. Note locations of
primary and accessory lacrimal glands. (Redrawn from Jones LT, Reeh MJ, Wirtschafter
JD. Manual of Ophthalmic Anatomy. Rochester, MN, American Academy of Ophthalmology
and Otolaryngology, 1970.)

ANATOMY AND PHYSIOLOGY OF THE AUTONOMIC NERVOUS SYSTEM

that the main lacrimal gland, having an efferent, parasympathetic innervation, functions primarily during reflex tear secretion, whereas the accessory lacrimal glands provide nonreflex, basal tear secretion (437441) (see also Chapter 15).
Afferent stimuli causing discharge of the brain stem lacrimal secretory neurons arise from peripheral sensory nerve
endings, usually from the trigeminal nerve, but occasionally
from the retina. There are two neural pathways by which
impulses from the lacrimal nucleus eventually reach the lacrimal gland to induce tear secretion. The parasympathetic
pathway is primarily responsible for the gross production of
reflex and continuous tears, but the role of the sympathetic
system remains controversial.
PARASYMPATHETIC PATHWAY FOR
LACRIMATION
The cell bodies of the preganglionic neurons responsible
for parasympathetic lacrimal secretion are located in the lacrimal nucleus within the tegmental portion of the pons in a
small area dorsal to the superior salivary nucleus (442). After
traversing the facial nucleus, the preganglionic axons join
the sensory root of the seventh nerve (the nervus intermedius) that emerges from the lateral portion of the pons between the facial and auditory nerves (Figs. 14.40). The ner-

701

vus intermedius passes through the cistern of the pontine

angle and then joins with the rest of the facial nerve, occupying an anterior superior position within the combined nerve
as it courses laterally (443) (Fig. 14.41). The surgical anatomy of the nervus intermedius is important because it can
be injured during the resection of vestibular schwannomas
and other procedures in this area. Symptoms of such injuries
include crocodile tears (the gustolacrimal reflex), reduced
or absent tear production, and taste abnormalities. These
symptoms reflect the sensory and parasympathetic components of the nervus intermedius (444).
After joining the nervus intermedius, the facial nerve enters the internal auditory meatus within the petrous pyramid
of the temporal bone (445448). From here, the meatal segments of the facial nerve enter the labyrinthine segment of
the facial canal, having pierced the meninges. After coursing
above the vestibule of the inner ear and laterally 2.56 mm,
the facial nerve trunk turns posteriorly at the geniculate ganglion (Fig. 14.42). The parasympathetic fibers destined for
the lacrimal gland pass through the ganglion without synapsing and then separate anteriorly at the apex of the ganglion
to become the greater superficial petrosal nerve (Figs. 14.42
and 14.43). The close relationship of the origin of the greater
superficial petrosal nerve to the apex of the geniculate gan-

Figure 14.40. Relationships between nervus intermedius, facial nerve trunk, vestibulocochlear nerve trunk, and the superior
cerebellar and anterior inferior cerebellar arteries. Nervus intermedius (VII N.I.) exits from the brain stem between the facial
nerve trunk (VII) and the cochlear (VIII Co.) and superior vestibular (VIII S.V.) nerve trunks. Note relationships of the rostral
(Ro. Tr.) and caudal (Ca. Tr.) trunks of the anterior inferior cerebellar artery (A.I.C.A) to the facial-vestibulocochlear nerve
complex. V, trigeminal nerve; S.C.A., superior cerebellar artery; R.P.A., recurrent perforating artery; I.A.A., internal auditory
artery; Mea. Seg., meatal segment. (From Martin RG, Grant JL, Peace D, et al. Microsurgical relationships of the anterior
inferior cerebellar artery and the facial-vestibulocochlear nerve complex. Neurosurgery 1980;6:483507.)