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THE ORBIT

Pyramidal-shaped cavity with its base opening in front & its apex behind, and contains lacrimal apparatus & eyeball. 4 walls: Roof is formed by frontal bone & lesser wing of sphenoid. Floor is formed by the orbital plate maxilla & and palatine (posteriorly). Lat. Wall is formed by the processes of the frontal and zygomatic bone & greater wing of sphenoid. Med. Wall is formed by frontal process of maxilla & lacrimal bone & orbital plate of the ethmoid & body of sphenoid.

Openings of the orbit: Orbital opening: lies anteriorly. About one sixth of the eye is exposed; the
remainder is protected by the walls of the orbit.

Optic canal:

1- located posteriorly 2- in the lesser wing of sphenoid 3- It communicates with the middle cranial fossa 4-transmits optic nerve & the ophthalmic artery

Superior orbital fissure:


1-located posteriorly between the greater and lesser wings of sphenoid 2-transmits 4 nerves & 1 vein
4nerves are: 1. ophthalmic by its 3 branches ( frontal, lacrimal, nasociliary)
2. Trochlear nerve 3. Oculomotor nerve (upper and lower divisions) 4. Abducent nerve 1 vein: superior ophthalmic vein

3- it also communicates with the middle cranial fossa

Inferior orbital fissure


located posteriorly between the maxilla and greater wing of sphenoid. transmits maxillary nerve with its zygomatic branch & inferior ophthalmic vein. It communicates with the pterygopalatine fossa

Supraorbital notch:
Situated on sup. orbital margin transmits supraorbital nerve and blood vessels

Infraorbital foramen
Located in the orbital plate of the maxilla extension of infra orbital groove and canal it transmit the infraorbital nerve and blood vessels

Nasolacrimal duct:
anteromedially in lacrimal bone Opens in inferior Meatus of the nose It transmits the nasolacrimal duct

Zygomaticotemporal & zygomaticofacial Foramina


2 small openings on lat. wall Transmit Zygomaticotemporal & zygomaticofacial nerves, they are branches of maxillary of trigeminal.

Ant. & Post. Ethmoidal foramina:


on medial wall Transmit Ant. & Post. Ethmoidal arteries and nerves

Muscles of the Orbit


Those we call them orbital muscles because they are in the orbital cavity, and other name is extraocular muscles because they are outside the eyeball. Actually we have seven muscles: Six of them are eyeball muscles means that are related to the eyeball. The remaining one is eyelid muscle because it relates to the eyelid and it moves the upper eyelid allows you to elevate your upper lid. It is called levator palpebrae superioris. And it originates form: lesser wing of sphenoid bone, and insert: in skin of superior eyelid. Note: we have two muscles related to the eye lid; orbicularis oculi which is a muscle of facial expression and this allows you to close your eyes. And the other muscle that allows you to open your eyes is the levator palpebrae superioris. the lower eye lid is open by relaxation of orbicularis oculi and action of gravity.

Eyeball muscles: they are 4 recti and 2 opliques. Recti: means that it goes in a straight direction. From the posterior wall of the orbit to the eyeball. 1. The one that reaches the eye ball from superior is the superior rectus. 2. And the one from inferior is called inferior rectus. 3. The one medially medial rectus. 4. The one that come from the lateral side of the eyeball is the lateral rectus. The two oblique the come from the posterior wall of the orbit then they turn in an oblique direction. The one above is superior oblique and the one below is inferior oblique. The superior oblique comes from the body of sphenoid bone all the way then it gets inside a trochlea pulley which is a fibrous ring that is attached to the

medial angle of the orbit <frontal bone>. So the sup. oblique muscle enters this trochlea and turns obliquely and attach superiorly to the eye ball. The inferior oblique, it comes from the medial wall of the orbit all the way to the inferior surface of the eyeball in an oblique direction

This is the trochlea why we name the nerves and arteries supratrochlear and infratrochlear. If the artery or the nerve passes above the trochlea or sup.oblique muscle then we call it

Innervation of Orbital Muscles


Simply by CN III which is the oculomotor nerve. Except this formula SO4 LR6. SO4 LR6. What does it mean!!!
SO4 means superior oblique is innervated by cranial nerve IV, trochlear nerve. LR6 means lateral rectus is innervated by cranial nerve VI, abducent nerve. Note Oculomotor nerve (CNIII) is named like this because it is motor to the ocular muscles.except SO4LR6 Trochlear nerve (CN IV) is named like this because it innervates the muscle above the trochlea. And this nerve is the smallest nerve. Abducent nerve (CN VI) is named like this because when it is activated it will lead to contraction of the lateral rectus which abducts the eyeball.

Levator palpebrae Superioris : Is innervated by oculomotor Function: elevates upper eye lid. It comes from the posterior wall of the orbit all the way to insert in the upper eyelid. However some fibers in the inferior deep part of Levator owever palpebrae are made of smooth muscles. Means that they are involuntary. And these fibers are innervated by nd sympathetic trunk. And to distinguish Have you ever had your them we call them the superior tarsal eyelid contracting alone?? muscles. They are important in fright situation. During fright situstion Why? sympathetic nervous system is stimul stimulated and it goes to these fibers and so it helps the Levator palpebrae to contract more so you are opening your eyelid much more and this allow for a better vision and more carefull to be. because there is activation for the superior tarsal muscles ,which are involuntary muscles as we said

Recti muscles
When we look to the orbit, and as we said it is pyramidal in shape.but this pyramidal doesnt mean that it is symmetric. Because we have the nasal cavity and the wall from this side is straight while laterally it is oblique. So when the muscles comes from the apexfrom the optic canal, its apex comes medial to the eye ball. So when the recti go to the eye ball they go in somehow an oblique direction and they are inserted in the medial side of the eyeball. So there is an angulation in the muscles and this angle is nearly 23 degree. So here we draw the long axis of the eyeball the superior and inferior rectus are not parallel to the long axis. They are angulated about 23 degree medial. So when they contract they 1. Elevate the eyeball 2. Moves the eye ball medially.

The long axis of the muscles is angulated 23 degree medial to the long axis of the eyeball. The action of superior rectus is to move the eyeball superior and medial. The action of inferior rectus is to move the eye ball inferior and medial.

But for the horizontal plane it doesnt make a difference.


The action of medial rectus is to move the eyeball medially. = adduction The action of lateral rectus is to move the eyeball laterally. = abduction

Usually these muscles work together in a cooperative manner. so when you move your eye; you dont contract only one muscle. At least you move 2 to 3 muscles. Those cooperate to move the eye. But what we listed above is the action for each single muscle.

Superior oblique & inferior oblique muscles.


Superior oblique will go all the way to enter the trochlea in a tendon and go in an oblique direction but this time it goes to the posterior half of the eyeball from above. This indicates that when this muscle contracts the eyeball moves down. And since the tendon comes from the medial side it will move the eyeball laterally.
So Superior oblique muscle will contract superior and medial moving the eyeball in the opposite direction inferior and lateral. Inferior oblique muscle will contract inferior and medial moving the eyeball in the opposite direction superior and lateral.

Now!

Whats happening when you want to elevate your eyeball just in the midline equatorial superiorly?

Two muscles will work together to balance themselves the superior rectus because it moves the eyeball above and medial and the inferior oblique moves the eye ball superior and lateral. So when these two muscles contracts the eyeball elevated in the middle.

Which muscles will work to depress your eyeball in the middle? The superior oblique & inferior rectus

Clinical: Testing for the actions of extrinsic eyeball Muscles


To test which is the muscle that is paralysed or injured. How? We need to separate between the actions of these muscles. Means that you have to take the single action of each muscle. And where it predominates. That means where is the optimum position when that muscle only contracts the eyeball will move in that direction. In other words the long axis of the eyeball and the long axis of the muscle must be parallel to each other.
Optimum position for the muscle means that the long axis of the muscle & the long axis of the eyeball must be parallel to each other.

How to get these axes together? Since we can only move the eyeball. So first ask the patient to close one eye. Second ask him to look outside; by this we move the cornea outside, now the long axis of eyeball become parallel to the long axis of superior rectus. So if you want to move the eyeball superiorly which muscle will work now?
Only the superior rectus.

And if you want tom move the eyeball inferiorly which muscle will work?
Only the inferior rectus.

Testing the recti. At the horizontal plane there is no problem. ( medial and lateral rectus) so when you ask the patient to move his eyes laterally it is the action of?? Lateral rectus. Then ask him to look upward it will be the action of?? Superior rectus. And then ask him to look down it will be the action of?? Inferior rectus. Testing the oplique muscles. Now we go back to middle and ask the patient to look medially. This will be the action of?? Medial rectus. Now by this position the long axis of the eyeball is parallel to the long axis of the oblique muscles. Now ask the patient to look up. this will be the action of inf.oblique. The ask him to look down it will be the action of sup. Oblique

This test is called H. test close one eye!! laterally then up and down. Back. Then medially and up and down.

Sup. Rectus: lateral


then superior

Sup. Oblique: medial


then inf.

Inf. Rectus:

lateral then inferior

Inf. Oblique: medial


then sup.

The nerves in the orbit 3 motor


CN III, oculomotor CN IV, trochlear CN VI, abducent

3sensory
Branches of the ophthalmic a. Lacrimal, the smallest above the lateral rectus b. Frontal, the largest. It goes to the frontal bone above levator palbebrae superiorus. This will further branch into supra orbital and supratrochlear.

1 special sensory
optic nerve CN I

These are for the 7 muscles of the orbit

c. Nasociliary it is related to the eyeball


and the nose. And it is intermediate in size between the frontal and lacrimal. Within the orbit it usually gives five branches. ( continue below with the story of nasociliary nerve )

The story of the nasociliary nerve:

It is intermediate in size between frontal and lacrimal and it arises from the ophthalmic division of the trigeminal nerve. Within the orbit when you look to the nasociliary nerve you see that it is crossing over the superior surface optic nerve from lateral to medial side of the orbit. As it passing there it will give its branches then it will continue medially along the medial wall of the orbit, between superior oblique and medial rectus muscle. The nasociliary gives 5 important branches: 1. Communicating branch with ciliary ganglion (general sensory nerve): This branch is sensory. It is carrying general sensation from the eyeball itself. 2. Long ciliary nerves: Those are usually two or three in number from each side, across the eyeball all the way to the corneoscleral junction. When it is inserted there to the anterior part of the eyeball. They are carrying sympathetic innervations to a muscle there called dilator pupillae muscle. This muscle when it contracts it makes dilatation in the pupil to increase the amount of light entering the eye and have a better vision. Thats why this muscle is under sympethetic control.

3. Posterior ethmoidal nerve. It enters through posterior ethmoidal foramen. And it supplies the posterior & middle ethmoidal air cells & sphenoidal air sinus.
**Then the nasociliary nerve will terminate into two branches**

4. Infratrochlear nerve: pass forward below the trochlea (pulley) that attaches the superior oblique. it supply the medial side of the upper eyelid. 5. Anterior ethmoidal nerve: once it leaves through anterior Ethmoidal foramen and enter the anterior cranial fossa on the upper surface of the cribriform plate of the ethmoid all the way to the crista galli in the middle. Now beside crista galli there is a small fissure (slit ) ,through this slit close to the crista galli the ant. Ethmoidal nerve will descend through it to the nasal cavity. And there it provides general sensation to the anterior part of the nasal cavity. Innervation in the nasal cavity mainly the maxillary but the anterior part ophthalmic by its ant. Ethmoidal branch. Then the nerve will leave the nasal cavity between the nasal bones and upper lateral cartilages of the nose it will go to outside and supplies the skin of the nose down as far as the tip. And become the external nasal nerve.

Ophthalmic artery:

It is a branch from the internal carotid artery; it is passing through optic canal. Along with the optic nerve. It is usually located inferior and lateral to the optic nerve within the optic canal. Within the orbit ophthalmic artery arises from below the optic nerve, and then the ophthalmic a. turns up the optic nerve from lateral to medial. And any arterial branch within the orbit is from the ophthalmic artery. Branches: - CRA (central retinal artery): it runs in the substance of the optic nerve and enters the
eyeball at the center of the optic disc

- Muscular a. - Ciliary a. - lacrimal a. - ant. & post. ethmoidal - supratrochlear & supraorbital

Veins in the orbital cavity:


Superior ophthalmic vein: pass through superior orbital fissure and go to

cavernous sinus
inferior ophthalmic vein: pass through inferior orbital fissure drain to

pterygoid venous plexus ADDITIONAL NOTE: Lymph vessels:


No lymph vessels or nodes are present in the orbital cavity.

The eyeball
It is embedded within orbital fat except the cornea which is the exposed part of the eyeball and it is 1/6 of the eyeball.

The eyeball consist of 3 coats 1. Fibrous coat 2. Vascular pigmented coat 3. Nervous coat

1)

Fibrous coat: this is the external one, it is rigid and it is for protection
mainly. It is made of a posterior opaque (white, tough collagenous fiber) part the sclera & an anterior transparent part, the cornea. *Why the anterior part is transparent? To allow the light to pass through it. But when you look carefully to it, the cornea, it is more convex than the sclera. Why?! To provide its main function to refract the light rays. by this it will pass through the pupil. Be careful refract (not reflex) * The sclera which is the hard part located posteriorly made of white dense connective tissue, has mainly two functions: 1. Protection of the inner part of the eyeball (the vascular coat, and the nervous coat). 2. It has to be rigid, to allow the extraocular muscles to attach to it. *at specific area more medial to the equatorial plane (23 degrees) all the nerves in the retina will join together to form the optic nerve that pierce the sclera in lamina cribrosa. Lamina cribrosa: is the area of the sclera where the optic nerve fibers leave through. And it is also called the blind spot.

2)

Vascular pigmented coat: it is deep to the fibrous coat and it contains the
arteries and veins related to the eyeball. It consists, from behind forward, of the choroid, the ciliary body, and the iris.

a. CHOROID (G, SKIN): it is like skin because it is pigmented, it contains melanin, and it is more brownish in color. It continues anteriorly with the ciliary body, Also it is a highly vascular layer. -Whats the function of melanin?? It absorbs the bad rays, and the scattered light rays. To allow for a sharp and clear image in the eyeball. b. CILIARY BODY: it consists of two parts Ciliary muscle. Its smooth muscle and its function is accommodation (meaning that focusing he vision). How? If you look to a far object you have to get the rays more close to the retina. So for the lens to make refraction in the light rays

and reach the vision area, the ciliary muscle must relax to be more flat.

** Accommodation the Vision** By increasing the convexity or reducing it of the lens and this by contraction and relaxation of the ciliary muscle.
* focusing vision for near objects: The ciliary muscle contracts it goes forward, once it goes forward the suspensory ligaments relax so the lens will be more convex and in this case you see near objects more clear. **focusing vision for far objects: The ciliary muscles relax and go posteriorly. Once it goes posteriorly it tenses the ligaments and the lens become more flat. Ciliary processes those are folds/elevations from the ciliary body and they have two functions. First, they are there because the suspensory ligaments are going from these processes to attach the lens so the suspense the lens/fix the lens in its position. The second function, these processes secrete fluid this will be distributed in the anterior part of the eyeball. This fluid is called the Aqueous Humor. The Aqueous Humor, which is clear plasma fluid filtrated within the ciliary processes, is very important because it nourishes and provides nutrients to two avascular structures in the eyeball, the cornea & the lens. This fluid can enter to the cornea and lens through the canal of schlemm, and the obstruction to the draining of the aqueous humor results in a rise in intraocular pressure called glaucoma.

c. IRIS (L, RAINBOW): it is simply two smooth muscles and it is suspended in the aqueous humor between the cornea and the lens,

and they are covered by a pigmented membrane. This membrane contains epithelial cells filled with melanin. And the amount of melanin will reflect the color of the iris. As the amount of melanin increases the color of the iris will be darker (more black). And as the amount of melanin reduces the color of the iris will be more bluish. Black eyes containing more melanin than brown eyes and brown eyes containing more melanin than green and the latter containing more melanin than blue eyes. The blue eyes contain no melanin The function of melanin again is to absorb the scattered light rays. When we remove the pigmented membrane we can see the two important involuntary muscles in the iris. The inner circle is the pupil. The circular sphincter pupillae: The circular fibers. Function: once it contracts it will close/reduce the size of the pupil. Dilator pupillae: this is the one from outside with radial fibers. Once it contracts it will dilate the pupil. **SUMMARY** this is iris: dilator pupillae from outside and the sphincter pupillae from inside. And it is covered with pigmented membrane. It is located between cornea anteriorly and the lens posteriorly. So it divides the anterior aspect of the eyeball into anterior chamber (between cornea & iris) and posterior chamber (between iris & lens). The parasympathetic innervations control sphincter pupillae to contract it. The sympathetic innervations control the dilator pupillae so when it contracts it dilates the pupil to allow more light to enter and to see much more in dangerous situations.

3)

Nervous coat: for nerves, receptors of vision. Consist of the retina.

Note: Hyperopia

it usually happens with old aged people, what happens here that the lens with age will contain more collagen fibers, so when the muscles contract the ligaments will relax and the lens because it is containing more fibers it will remain flat. Since the lens stay more fibrous and flat, old aged people can still see far objects but when they want to see near objects they cant.

Myopia

It happens usually in youth, because they have less sympathetic innervations and higher parasympathetic innervations so the muscles will be more contracted, and the lens more convex, so the one can see near objects but not the far ones.

The End. Note: in this script you might find some additional notes that the Dr didnt mention in the lecture, but it is here for your benefit. We are sorry if there is any mistake. Hope you all the best of luck in the final exams.

Done by: Sawsan

Jwaied Nasrawi

Corrected by: Yousef