1. Speaker:Dr.Ala’ Abu Farsakh
Supervised by:Dr.Amjad Younis

2. Lecture outline
Eyelid anatomy
• Gross anatomy
• Layers of the eyelid
• Eyelid arterial supply
and venus and
lymphatic drainage
• Eyelid nerve supply
Eyelid physiology
• Functions of eyelids
• eyelid movements:
Openning,clouser,bli
nking and
winking,bell’s
-Dynamics of eyelid
openning and
clouser

4. The Eyelids
4
• Each eyelid is divided by a horizontal furrow,
(the superior palpebral sulcus) into:
orbital & a tarsal part.
• The eyelids meet at the medial & lateral
angles or canthi
• The lateral canthus is in direct contact with
the eyeball & forms an angle of 60 when the
eyes are wide open.

5. 5

6. 6
• The medial canthus :
• rounded
• the two eyelids are separated by lacus
lacrimalis, in the centre of which is a small
pinkish elevation; the caruncula lacrimalis. A
semilunar fold called plica semilunaris lies on
lateral side of caruncle.

7. 7

8. 8
• papilla lacrimalis:
• About 5mm from the medial canthusther’s a
small elevation, the
• the punctum lacrimale which varies in size
from 0.4 to 0.8mm in diameter. The punctum
leads to canaliculus lacrimalis.
• The papilla lacrimalis projects into the lacus

9. 9

10. The Eyelashes
10
• 2-3 rows
• those in the upper eyelid(100-150)
• those in the lower lid(50-75)
• life span of 100-150 days.
• The sebaceous glands of Zeis open into each
follicle.
• modified sweat glands, the ciliary glands of Moll,
open into each follicle or into the eyelid margin.

11. 11
• (meibomian glands):
• which number about 20-25 in each lid.
• A gray line or sulcus can be seen running
along the eyelid margin between the
eyelashes & the openings of the tarsal glands.

12. 12

13. Structure of the eyelids
13
1. Skin:
2. Subcutaneous tissue
3. Striated muscle fibers of the orbicularis oculi
4. Orbital septum and tarsal plates
5. Smooth muscle
6. Conjunctiva

14. 14

15. skin
15
• Very thin and easily folds
• stratified squamous epithelium keratenized.
• Skin becomes continuous with conjunctiva at
the posterior edge of the site of the orifices of
the tarsal glands

16. Subcutaneous tissue
16
• very loose and rich in elastic fibers
• Devoid of fat in whites

17. Orbicularis oculi
17
1-Orbital part: extends to the temporal region and
cheek
2-Palpebral part: extends to the eyelids, divided
into preseptal & pretarsal portions
3-Lacrimal part: behind the lacrimal sac
4-Ciliary part: at the lid margin
--Originates from medial palpebral ligament and
neighboring bones… at the lateral angle of the
eye the fibers interlace at the lateral palpebral
raphe

18. 18

19. 19

20. Orbicularis oculi
20
• Nerve supply
Temporal and zygomatic branches of facial nerve
• Action
• Antagonist muscles
Orbital part frontal belly of occipitofrontalis
muscle
Palpebral part levator palpebrae superioris

21. Orbital septum and tarsal plates
21
• Fibrous….
• attached to orbital margin
• Separates eyelids from contents of orbital cavity
• Stonger on lateral side than medial
• Posterior to medial palpebral ligament
• Anterior to lateral palpebral ligament
• Tarsal plate of the upper lid: 10 mm
• the lower lid: 5 mm

22. Orbital septum
22

23. Structures piercing through orbital
septum
23
1. Lacrimal vessels & nerves
2. Supraorbital V. & N.
3. Supratrochlear A. & N.
4. Infratrochlear N.
5. Anastomosing vein bet angular & ophthalmic v.
6. Sup & inf palpebral A.
7. Aponeurosis of levator muscle.
8. Expantion of inf rectus muscle

24. Medial & lateral palpebral ligaments
24
• Medial palpebral ligament:
is anterior to lacrimal sac
• Attaches medial ends of the tarsi to lacrimal
crest and frontal process of maxilla
• Lateral palpebral ligament:
attaches lateral ends of tarsi to marginal
tubercle on the orbital margin formed by
zygomatic bone

25. Smooth muscles
25
• Forms the superior and inferior tarsal
muscles
• Both are innervated by sympathetic nerves
from the superior cervical sympathetic ggl

26. conjunctiva
26
• Subtarsal sulcus: 2 mm from post edge of lid
margin, traps foreign particles
• The area that covers the upper tarsal plate is
strongly bound to it
• That covering the lower tarsla plate is
adherent only to its upper half

27. Levator palpebrae superioris
27
• From inf surface of lesser wing of sphenoid
• Insertion is aponeurosis descending to upper
lid post to the orbital septum
• Nerve supply: occulomotor n.
• Action:

28. Levator palpebrae superioris
28

29. Eyelid Arterial supply
29
• Lat and med palpebral a.
Lateral: lacrimal artery: ophthalmic a.
Medial: ophthalmic a.
• Two arches: marginal and peripheral

30. Lids Venous and lymphatic
drainage
30
Venous:
• Medailly : ophth and angular v.
• Laterally: superficial temporal v.
lymphatic:
Lat 2/3 : superficial parotid LN
Medial: submandibular LN

31. Nerve supply(sensory)
31
• Upper eyelid: infratrochlear +
supratrochlear + supraorbital +
lacrimal nerves(V1)
• Lower lid: infratrochlear +
infraorbital n.

33. Lecture outline
Eyelid anatomy
• Gross anatomy
• Layers of the eyelid
• Eyelid arterial supply
and venus and
lymphatic drainage
• Eyelid nerve supply
Eyelid physiology
• Functions of eyelids
• eyelid movements:
Openning,clouser,bli
nking and
winking,Bell’s phe
-Dynamics of eyelid
openning and
clouser

34. Functions of the Eyelid
1. Reconstitution of the tear film.
2. Maintain the integrity of the corneal
surface.
3. Maintain the proper position of the globe
within the orbital contents.
4. Regulate the amount of light allowed to
enter the eye.
5. Provide protection from airborne particles.
6. Coverage of the eye during sleep.

35. EYELID MOVEMENT

36. • Lid opening
• Lid closure
• Blinking
• Voluntary blinking and winking
• Bell’s phenomenon

37. Lid opening
• Upper lid elevators
• Lower lid retractors

38. Upper lid elevators
• Levator palpebrae superioris (the
primary elevator of the upper eyelid).
• The superior palpebral muscle of Muller’s
• Frontalis (acting as accessory elevator).
Frontalis and Muller’s muscles become important
when the levator is defective.

39. Muscle Attachment Nerve supply
Levator palpebrae
superioris
(main upper lid
retractor)
Lesser wing of the
sphenoid to the
tarsal plate
Superior division of
the oculomotor
nerve (also supplies
the SRM).
Muller’s muscle
(minor upper lid
retractor)
Aponeurosis of the
levator to the upper
border of the tarsal
plate
Sympathetic
Frontalis Scalp to the upper
part of the
orbicularis oculi

40. Eyelid excursion during opening
movements:
• In adults the upper eyelid is raised
some 10-15 mm from extreme
downward gaze to extreme upward
gaze.

41. Tone of levator muscle:
• In upward gaze, tone increases in both
the superior rectus muscle and the
levator, resulting in elevation of the
visual axis and concomitant elevation
and retraction of the upper lid.

42. Lower lid retractors
• NO true counterpart of the levator is
present, and therefore, the opening
movement depends upon several
factors:
1. Traction exerted by the attachment of
the inferior rectus to the inferior tarsus.
2. Inferior palpebral muscle (identical to
Muller’s muscle in the upper lid).

44. Dynamics of opening movement
• Opening of the upper eyelid takes place
against gravity.
• Opening movements of the homolateral
upper and lower eyelids begin in phase,
although the opening movement of the lower
lid is much slower than that of the upper
eyelid due to lack of any direct muscular pull.

45. • During opening movement the upper lid
moves vertically upwards, while the
lower lid moves laterally in a horizontal
direction.

46. • Bilateral coordination and their basis:
• Opening movements of the eyelids are
bilateral, symmetrical, and identical in
direction and amplitude, although they may
be voluntarily inhibited on either side.
• So, the levator muscles of the two upper
eyelids behave as yoke muscles in that they
act as a team or pair, and like extraocular
muscles, obey Hering’s law of equal
innervation.

47. • This implies that the innervational
energy reaching the one levator muscle
is equal to that reaching the other.
• When the levator on one side is weak, as
in unilateral myasthenia gravis or
unilateral congenital ptosis, the lid on
the unaffected side may be retracted in
an unconscious effort (based on Hering’s
law of equal innervation) to elevate the
ptotic lid.

48. Reciprocal innervation pattern
• It exists between the levator muscle and
the orbicularis oculi muscle, i.e. when
levator receives maximum innervation
during opening the orbicularis receives
minimum innervation and vice versa.
Thus, these muscles follow the
Sherrington’s law of reciprocal
innervation.

49. Lid closure

50. Orbicularis oculi controls lid closure and is
supplied by the facial nerve.
It is divided into three main parts:

51. Part Position Function
Pretarsal fibers In front of the
tarsal plate
* Respond in spontaneous blinking
and tactile corneal reflex.
* Close lid and pull lacrimal puncta
medially.
Preseptal fibers In front of the
orbital septum
Respond to voluntary blinking and
sustained activity.
* Pull lacrimal fascia laterally and
create a relative vacuum in lacrimal
sac-improve tear drainage.
Orbital fibers Surrounds the
orbital rims
* Respond in forceful lid closure.

52. Upper lid versus lower lid during closing movements
• Upper lid moves downwards (vertically) while the lower
lid moves medially (horizontally).
• The rate of movement of the upper lid and lower eyelids is
similar during closing movement.
• Closing movements of both upper and lower eyelids occur
in phase, although the movement of the lower eyelid
begins some 10-20 msec. before the movement can be
detected in the upper lid.
• Gravity does not play any role in downward movement of
the upper eyelid during closing movement.(same speed
regardless of the head position).

53. The reciprocal innervation pattern:
• During closing movement the
orbicularis gets maximum
innervation while the levator gets
minimum innervation and relaxes.
(Sherrington’s low ).

54. • Blinking can be divided into
voluntary and involuntary
types.
• The involuntary blinks are
further subdivided into
spontaneous and reflex
blinks.

55. Spontaneous blinking
• It is a common form of blinking that occurs
without any obvious external stimulus or
voluntary willed efforts.

56. • Spontaneous blinking does not occur or is very
infrequent during the first few months of life;
yet the delicate infant cornea does not suffer
from dryness.
• Average rate: 15 times per minute (12-20).
• The blink rate is increased in:
1. Extremely dry conditions.
2. Strong air currents.
3. Certain emotional stress situations (surprise,
anger, or fight).
• A decreased blink rate occurs during times of
visual observations.

57. • Duration: 0.3-0.4 second.
• Present in the blind, hence no retinal
stimulation is required.
• No discontinuity of visual sensation during
blinking.
• The upper lid begins to close with no lower lid
movement.
• It is followed by a zipper-like movement from
the lateral canthus towards the medial
canthus.
• This helps the displacement of the tear film to
the lacrimal puncta which are located on the
medial side of the lids.

58. Mechanism
• The exact stimulus for spontaneous
blinking is unknown.
• Spontaneous blinks occurring
without gaze shifts are triggered by a
timing mechanism probably located
in the brainstem.

59. Course of events:
• Relaxation of the levator
• After about 10 msec of levator relaxation, a train of
high frequency synchronous activity occurs in the
pretarsal portion of the orbicularis at a frequency of
about 180/ sec which lasts some 55 msec.
• As the upper lid moves vertically down, the lower lid
moves medially in a horizontal direction. However,
when the upper eyelid touches the lower eyelid; the
downward movement of the upper lid is also
transmitted to the lower lid, and after contact the
lower lid moves down with the upper lid.

60. • During each blink, the upper eyelid
covers the center of the pupil for a
period of 0.10 sec.
• Due to contraction of the preseptal
fibers, as the upper eyelid reaches the
limit of its downward excursion,
electrical activity in the orbicularis
ceases and concomitantly activity
reappears in the levator.

61. Reflex blinking
•reflexly in a response to a
stimulus.

62. Different stimuli induce a different neurological
pathway.
Blinking
reflex
Examples Afferent Efferent Central
connection
Tactile Corneal touch CNV CNVII Cortical
Dazzle
(optic)
Bright light CNII CNVII Subcortical
Menace
(optic)
Sudden presence of
near object
CNII CNVII Cortical
Auditory Loud noise CNVIII CNVII Subcortical
Orbicularis Stretching of
panorbital structure
(tap/blow)
CNV CNVII Cortical

63. Voluntary blinking and winking
is a willed coordinated closure and
opening movement of the eyelids in both
eyes.
• The voluntary blink is under the control
of the individual (rate and degree of
closure and opening).
• It is produced as a protective gesture.

64. Winking is unilateral voluntary lid closure.
• Part of facial expression.
• It is a learned activity.
• Occasionally, a subject may learn to wink with
one eye but not with the other.
• Minimum periods between winks are 0.3 sec.
• Both are voluntary blinking and winking are
produced by simultaneous contraction of
palpebral and orbital portions of the
orbicularis.

65. BELL’S PHENOMENON
• It is a highly coordinated reflex
between the facial and oculomotor
nuclei, whereby on closure of the
eyelids, the eyeball is rotated
upward and outward.
• This is a protective mechanism

66. • On closure of the eyelids, all the electrical
activities in the levator cease and
concomitantly the activity abruptly rises in
the superior rectus muscle and is inhibited in
the inferior rectus muscle.
• Bell’s phenomenon is NOT present in 10% of
otherwise healthy persons, and therefore its
absence is not necessarily a sign of disease.