2. OBJECTIVES
• To know the process of development of lid
structures and the associated developmental
defects.
• To understand the anatomical features and related
clinical aspects of eyelid.
• To have the overview of the physiological aspect of
lid structures.
4. Introduction
• The eyelids are the mobile tissue in front of the
eyeballs. (ocular appendages)
• Upper and lower eyelid
Functions:
Act as shutters protecting eyes from injuries and
excessive light
Spread the tear film over the cornea and conjunctiva
Contribute to the facial feature
Information regarding the state of wakefulness and attention
5. EMBRYOLOGY OF EYELID
Develops from folds of surface ectoderm above and below
the developing cornea.
• The folds enlarge and fuse with each other by 3rd month
• A closed space, conjunctival sac is formed in front of the
cornea
• The lid separation starts by 5th month and completes by
7th month of intrauterine life
7. Connective tissue and tarsal plate : from mesenchymal
core.
Orbicularis oculi muscle:
From mesenchyme of 2nd
Pharyngeal arch.
(12wks)
8. Eyelashes develop as epithelial buds from surface
ectoderm. [ 1st arise in upper lid]
Glands of Moll and Zeis : from ciliary follicles.
Meibomian glands : from columns of ectodermal cells in
lid margin.
9. Gross Anatomy
• Extent
• Position of eyelids
• Parts of eyelids
• Canthi
• Eyelids Margin
• Eyelashes
• Palpebral Aperture
10. Extent:
Upper lid: eyebrows to the free margin
Lower lid: merges to skin of the cheek below
Position of the eyelids:
Upper lid covers about
1/6th of the cornea (1.5-2
mm below superior
corneal limbus)
Lower lid margin just
touches the cornea
11. Parts of eyelids:
Orbital part
horizontal sulcus(or forrow).
Tarsal part
• Additional folds in
lower lid- nasojugal
fold medially and the
malar fold laterally.
These folds limit the spread
of blood downward from
eyelids to cheek.
12. Canthi (sing. canthus)
• The upper and lower lids meet at an angle of about 60˚
medially and laterally forming canthus.
• lateral canthus: 5-7 mm medial to the orbit
13. • Medial canthus: separated from globe by lacus
lacrimalis.
In the center is small pinkish elevation – caruncula
lacrimalis.
Lateral to it is semilunar fold called plica
semilunaris.
Racial variation- Mongoloid slant and antimongoloid
slant
14. Eyelid Margin:
• 2 mm wide
• Covered by cutaneous epithelium
• Lacrimal papillae (at the center of which is lacrimal
punctum) divides the margin into medial 1/6th and lateral
5/6th part
15. Eyelid margin contd..
Lacrimal part: medial to punctum
rounded
devoid of lashes and glands
contains lacrimal canaliculi
Ciliary part: lateral to punctum
rounded anterior and sharp posterior border
16. Grey line:
Represents the line of demarcation
between the anterior portion of the
eyelid formed by the skin and
orbicularis muscle (ant. lamina) and
the posterior formed by the tarsus and
conjunctiva (post lamina).
Histologically corresponds to most
superficial portion of orbicularis
oculi , muscle of Riolan , and to the
avascular plane of lid.
Surgically Important: For splitting of
eyelid with minimal scarring.
17. Palpebral fissure or aperture
• Space between upper and
lower eyelid margin
Birth (mm) Adult (mm)
horizontal 18-21 28-30
vertical 8 9-11
18. Eyelashes:
2-3 rows
Upper lid: 100-150 (forward,
upward and backward)
Lower lid 50-75 (forward,
downward and backward)
Lifespan: 3-4 months
19. • Trichiasis: Acquired misdirection
of eyelashes
• Pseudotrichiasis: Seen in
entropion
• Madarosis: Decrease in number
of eyelashes.
• Lash Poliosis: Premature graying
of the lashes
• Trichomegaly: Excessive eyelash
growth
22. • Euryblepharon: vertical
shortening and
horizontal lengthening
of eyelids.
• Epiblepharon: lower lid
pretarsal muscle and
skin ride above the
lower lid margin to form
a horizontal fold of
tissue
23. • Ankyloblepharon:
partial or complete
fusion of eyelids by
webs of skin.
Symblepharon: adhesion
of lid to the gobe.
24. • Distichiasis : extra rows
of eyelashes
• Epicanthus: medial
canthal fold
31. Orbicularis oculi
Origin Insertion
Orbital part Anterior limb of medial canthal
tendon
Orbital process of frontal bone.
Frontal process of maxillary
bone infront of anterior lacrimal
crest
Forms continuous
eclipse and inserts just
below the point of
origin.
Pretarsal part Deep origin : medially posterior
lacrimal crest (forms Horners
muscle.)
Superficial origin : anterior limb
of medial canthal tendon
Lateral canthal tendon
Preseptal part Upper and lower border of medial
canthal tendon
Lateral palpebral raphe
32. Palpebral portion
Pretarsal part
Preseptal part
Functions for both involuntary and voluntary eyelid
movements (blink).
Deep heads of pretarsal orbicularis muscle fuse to form a
prominent bundle of fibres, near the common canaliculus
known as Horner muscle
Play a role in drainage of tears (pumping mechanism).
33. Orbital portion
Primarily involved in forced eyelid
closure
Orbicularis fiber extends to lid margin
, where there is a small bundle of
straited muscle called muscle of
Riolan. (forms gray line, play role in
meiomian gland discharge, blinking
and position of eyelashes).
34. Nerve supply :
Temporal and zygomatic branch of facial nerve.
APPLIED :
Paralysis of the orbicularis oculi muscle leads to :
Lagopthalmous - inadequate closure of lids.
35. Orbital Septum
• thin, fibrous framework,
membranous sheet
• begins anatomically at the
arcus marginalis along the
orbital rim
• Separates the eyelid from
the contents of orbital cavity
36. Perforated by:
Nerves and vessels that exit form the orbital cavity
Aponeurosis of levator muscle in upper lid
Expansion of the inferior rectus in the lower lid
37. Functions:
Holds the orbital fat in position
Barrier function- prevent the transmission of infection
from lids to orbital cavity and viceversa
During the normal ageing process the thining of the
septum and the laxity of the orbicularis muscle causes
the anterior herniation of the orbital fat.
38. Orbital Fat
• Upper lid : 2 fat pockets
• Lower lid : 3 fat pockets
• Landmark for elective eyelid surgery and lid
laceration surgery
39. Retractors
• Upper lid: Levator palpebrae superioris along with
Mullers muscle
• Lower lid: Capsulopalpebral fascia
40. Levator Palpebrae Superioris
Origin: apex of the orbit, just above the annulus of
Zinn.
Extends as aponeurosis, in upper lid posterior to
orbital septum and inserts into anterior surface of
tarsus.
Muscle = 40mm, Aponeurosis = 14-20mm.
Medial and lateral expansion of aponeurosis forms
horns.
Thin sheet of smooth muscle arise from its inferior
surface – superior tarsal muscle / Muller muscle.
41. Insertion :
Lateral horn: lateral orbital tubercle.
Medial horn : posterior lacrimal crest.
In center, aponeurosis continues towards the tarsus
and divides into an anterior and posterior portion.
(Anterior portion inserts into septa between pretarsal
orbicularis and skin – forming upper lid crease.)
42. Whitnall’s ligament (superior transverse
ligament)
• Sleeve of elastic fibers around the LPS muscle
located in the area of transition from levator muscle
to levator aponeurosis.
Functions of whitnall’s ligament:
• Primarily as a suspensory support for the upper
eyelid and the superior orbital tissues.
• Also act as a fulcrum for the levator
43. Muller muscle :
• Originates from under-surface of LPS aponeurosis
approx. at the level of Whitnall ligament.
• 12-14mm
• Inserts in superior tarsal margin of upper eyelid.
• Provides 2mm elevation of upper eye lid.
44. Action of LPS: raises upper lid
Nerve supply :
LPS : superior branch of oculomotor
Superior tarsal : sympathetic nerves from cervical
ganglion
APPLIED:
• Fear and excitement causes contraction of superior
tarsal leading to further elevation of eyelid.
45. Applied anatomy
• Disinsertion of lower lid retractors from
tarsus may lead to spastic entropion.
• Paralysis of LPS [ 3rd nerve palsy,
myasthenia]:
Ptosis
Loss of superior palpebral fold and
Horizontal furrows
46. contd…
• Paralysis of superior tarsal muscle [ lesion of
cervical sympathetic ganglion]:
Mild ptosis
When associated with miosis , anhydrosis –
Horner’s syndrome.
47. RETRACTORS OF LOWER
EYELID
• Capsulopalpebral fascia :
• Originates from terminal
muscle fiber of inferior
rectus muscle.
• Forms lockwood
ligament.
48. Tarsal plate:
Dense fibrous tissue.
Gives shape and firmness
to eyelid.
In upper lid – larger
-- crescentic
--11mm in center
--Orbital septum and smooth muscle
fiber of LPS attached to its upper edge.
49. In lower lid –smaller
--4mm at centre
--Orbital septum
attached to its lower edge.
Medially , MPL attaches it to
lacrimal crest and frontal
process of maxilla.
Laterally , LPL attaches it to
marginal tubercle on orbital
margin formed by zygomatic
bone.
50. Conjunctiva
Thin mucous membrane lining the eyelids(posterior
layer of lids).
Composed of non keratinizing squamous epithelium
• Contains - 1. goblet cells
2. accessary lacrimal glands ( Wolfring
and Krause )
At the margin of eyelid – continues into skin along
posterior margin of tarsal gland.
51. Subtarsal sulcus : shallow
groove on the back of the
lid, 2mm from posterior
edge of lid margin.
• APPLIED : site for FB impaction.
52. GLANDS
1. Tarsal or meibomian
glands
2. Ciliary glands of Moll
3. Sebaceous glands of
Zeis
53. Tarsal ( meibomian ) gland
modified holocrine sebaceous glands.
lies within the tarsal plates; single row
Upper eyelid (30-40); Lower eyelid (20-
30).
Vertically parallel to each other.
The orifice lies just infront of the posterior
edge of the lid margin---marks the junction
between the skin and conjunctiva.
54. Applied anatomy:
a)Meibomian gland dysfunction: dry eye.
b)Chalazion or tarsal cyst:
-chronic non infectious inflammatory
granuloma of meibomian gland.
c)Internal hordeolum:
-suppurative inflammation of meibomian gland
secondary to infection of chalazion
55. Glands of moll
modified sweat glands
lie in the lid margin between the cilia.
more numerous in lower lid.
the duct opens between cilia
into ciliary follicles or into the
glands of Zeis.
56. Gland of zeis
modified sebaceous gland.
Consists 2-3 lobules.
discharge directly into the eyelash follicles.
Its secretion (sebum) prevents the lashes from becoming
dry and brittle.
Applied anatomy:
External hordeolum / Stye:
Suppurative inflammation of Zeis gland
or lash follicle.
57. Accessory glands of wolfring
Present along upper border of superior tarsus
and lower border of inferior tarsus.
2-5 in upper lid
2-3 in lower lid
59. BLOOD SUPPLY
1. Internal carotid artery:
By ophthalmic artery and its branches (supraorbital and
lacrimal)
2. External carotid artery:
By arteries of the face (angular and temporal)
60. • LATERAL PALPREBRL ARTERY (branch of
lacrimal artery)
• MEDIAL PALPREBRAL ARTERY (direct branch of
ophthalmic artery)
• Each artery divides into 2 branch --- forming 2
arches in upper eyelid:
• Peripheral arterial arcade
• Marginal arterial arcade.
• In lower eyelid :
• Only single arterial arch
64. Lymphatic Drainage
• Lower lid and medial portion
drains into submandibular lymph
node.
• Upper lid and lateral portion
drains into superficial
preauricular lymph node
Deeper cervical nodes.
65.
66. Nerve Supply of Eyelids
Motor Nerve Supply:
• Orbicularis oculi muscle - facial nerve (temporal &
zygomatic branches)
• Levator palpebrae superioris - superior division of
oculomotor nerve
Autonomic Nerve Supply:
• Superior and inferior tarsal muscle - sympathetic
nerve fibers from superior cervical ganglion.
67. upper eyelid -
supraorbital,
supratrochlear &
lacrimal nerves
(ophthalmic division)
lateral portion of
upper eyelid &
temple -
zygomaticotempor
al branch of the
maxillary nerve
extreme
medial
portion of
both upper &
lower eyelid -
infratrochlea
r nerve
lower eyelid -
infraorbital nerve
(maxillary
division)
lateral portion
of lower eyelid -
zygomaticofacia
l branch of the
maxillary nerve
Sensory supply:
70. OPENING
MOVEMENTS:
In upper lid:
1. LPS : primary
elevator
2. Frontalis : accessory
elevator
3. Superior palpebral
muscle of Muller’s :
long term adjustment
of upper lid in
position.
In lower lid :
1. Elastic recoil of lower
eyelid tissue
2. Traction exerted by
attachment of inferior
rectus to inferior
tarsus.
3. Inferior palpebral
muscle.
71. CLOSING MOVEMENTS:
Orbicularis oculi
1. Pretarsal fibres : spontaneous blinking and tactile
corneal reflex.
2. Preseptal fibres : voluntary blinking and sustained
activity.
3. Orbital fibres : forceful closure of eyelid in
association with all other fibres.
• Blepherospasm: involuntary sustained and forcible
eyelid closure.
72. PEERING :
Act of looking at some object with great interest.
Can be voluntarily inhibited.
Upper lid moves 2.5mm down and lower lid moves
2.5mm down and 1mm medially.
73. BLINKING :
Co – ordinated closing and opening movements of
eyelids.
2 types :
i. Voluntary
ii. Involuntary
spontaneous
Reflex blink
74. 1. Voluntary Blinking
Coordinated closure and opening of eyelids, carried out
as a willed act in both eyes.
- Produced by simultaneous contraction of palpebral
and orbital part of orbicularis muscle.
75. 2. Spontaneous blinking:
Occurs without any obvious stimulus.
Occurs at frequent interval
Infrequent during first few months of life.
Rate: 12-20 /minute, duration: 130 msec
76. • Events :
Relaxation of levator.
Contraction of preseptal fibers of orbicularis against minimal
resistance.
Synchronous activity occurs in pretarsal and upper lid
reaches the limit of its downward excursion.
Electrical activity ceases in orbicularis and the concomitant
action starts in levator.
77. As the upper lid move vertically
downward, the lower lid moves
medially in horizontal direction.
When upper lid touches the lower lid,
the downward movement of upper lid
is transmitted to lower lid.
After contact, the lower lid moves
downward with upper lid.
Pupil moves upward just before the
upper lid reaches the center of pupil {
Bell’s phenomenon}.
78. 3. Reflex blinking:
Co –ordinated closing and opening movements of
eyelid in response to some direct stimulus.
Types :
1. Tactile
2. Optic
3. Auditory
4. Stretch reflex blinking.
79. Hering’s law
• Law of equal innervation.
• States “ levator of two eyes act as yoke muscle i. e.
get equal innevation during contraction” .
• Causes symmetric opening movements.
80. Sherrington’s law
• Law of reciprocal innervation.
• Levator and orbicularis oculi get reciprocal
innervation during eyelid movement.
• i. e. opening movement of levator gets maximum
innervation while orbicularis is inhibited and gets
minimum innervation and vice versa.
81. Bell’s phenomenon
Co ordinated reflex between facial and oculomotor
nuclei , thus on closure of eyelids , eyeball rotates
upward and outward.
Inverse Bell’s phenomenon – when eyeball rotates
downward and outward on eyelid closure.
82. During sleep
• Tonic muscular activity in the orbicularis
combined with a simultaneous inhibition of
tonus in the levator
83.
84. References
• Fundamentals and principals of ophthalmology, AAO, 2016-2017
• Clinical anatomy of eye , Richard S. Snell , Michaell A. Lemp [2nd edition]
• Wolff’s Anatomy of eye and orbit , eighth edition
• Clinical Opthalmology – Jack J Kanski and Brad bowling , seventh
edition
• Anatomy and Physiology of Eye, A. K. Khurana, 3rd edition
• Parson’s Diseases of the Eye ,22nd edition
• Internet sources
Editor's Notes
Eyelids develops from the surface ectoderm
The folds enlarge and fuse with each other by 3rd month
A closed space, conjunctival sac is formed in front of the cornea
The lid separation starts by 5th month and completes by 7th month of intrauterine life
Connective tissue tarsal plate and orbicularis oculi are of mesenchymal origin
Whereas eyelashes, glands of moll and zeis and the meibomian glands are derived from the ectodermal cells
Upper eyelid: From eyebrow to end in the free margin forming the superior boundary of palpebral fissure
Lower eyelid: Forms the inferior margin of palpebral fissure and below it merge to the skin of cheek
Superior lid fold lies 4mm above the edge of eyelid and is formed by fibrous slips arising from the tendon of levator which pass towards between the muscle bundles fo orbicularis to insert into the skin thereby drawing it posteriorly and forming a fold fo variable depth.
Inferior lid fold is formed by fibrous slips that arise from the fascia surrounding the inferior rectus muscle and are inserted into the skin.
(lateral canthus is more acute than medial )
In Caucasians the x-axis (line joining the lateral and medial canthual angle) of fissure is horizontal in half of population, in the remaining half lateral canthal angle is slightly higher than the medial
Greater elevation of lateral canthus results in mongoloid slant to the fissure; a lateral canthus placed lower than the medial produces an antimongoloid slant.
Margin is divided into medial 1/6th and lateral 5/6th part by the lacrimal papillae, at the centre of which is the lacrimal punctum
Divides the intermarginal strip into anterior part with lashes and posterior parts with openings of meibomian glands
The sebaceous glands of Zeis and glands of Moll empty into the infundibulum of each ciliary canal.
Coloboma is a embryologic cleft, usually isolated anomaly if in medial upper eyelid (lower lid: Goldenhar syndrome)
Cryptophthalmus : partially developed adnexa are fused to anterior segment of globe
Congenital ectropion : caused by the vertical insufficiency of anterior lamella of eyelid
a/w blepherophimosis syndrome
Congenital entropion: due to lower lid retractor dysgenesis, structural defect in the tarsal plate and relative shortening of posterior lamellae
(tarsal kink: tarsal plate of upper euelid is folded resulting in entropion)
Epiblepharon:that causes the cilia to assume a vertical position
Besides this we have :
Microblepharon: abnormally small eyelids
Epiblepharon: lower lid pretarsal muscle and skin ride above the lower lid margin to form a horizontal fold of tissue
Distichiasis: an extra row of eyelashes is present in place of the orifices of the meibomian glands; occurs when embryonic pilosebaceous untis improperly differentiate into hair follicles
Medial canthal tendon: d/t immature midfacial bones or a fold of skin or subcutaneous tissue
Skin and subcutaneous tissue
Muslcle of protraction
Orbital septum f
Orbital fat
Muscle of retraction
Tarsus
conjunctiva
Nasal part of skin is smooth, shining and greasy than temporal part which may contain fine hairepidermis:
stratified squamous with stratum corneum, granulosum, spinosum, basale(melanocytes)
dermis : this connective tissue. Vessels, lymphatics, nerves and macrophages fibroblasts.
The contour of eyelid skin is defined by the eyelid crease and the eyelid fold
Racial variation: Asian: low upper eyelid crease coz orbital septum fuses with levator aponeurosis between eyelid margin and superior border of tarsus
Caucasian: levator aponeurosis attaches near the superior border of tarsus
Surrounding the orbital margin
Medially, Orbital septum lies posterior to the medial palpebral ligament but on the lateral side,it lies posterior to the lateral rapheof the orbicularis oculi but anterior to the lateral palpebral ligament
Lacrimal vessels and nerves; Supraorbital vessels and nerves; Supra trochlear vessels and nerves; Infratrochlear nerve; Dorsal nasal artery
Superior and inferior medial palpebral arteries
Aponeurosis of LPS in upper lid
Expansion of IR in lower lid
apex of the orbit, from periorbita of lesser wing of sphenoid bone, just above the annulus of Zinn.
Extends as aponeurosis, in upper lid posterior to orbital septum and inserts into anterior surface of tarsus.
Muscle = 40mm, Aponeurosis = 14-20mm.
4 mm vertically
Functions:
oily marginal tear strip prevents overflow of tears across lid margin.
ensures air – tight closure of eyelids.
after blinking leaves the oily layer of the tear film over cornea preventing evaporation.
In Upper lid marginal arcade lies 2mm superior to the margin, near the follicles of cilia and anterior to the tarsal plate
Peripheral arcade lies superior to the tarsus between the levator aponeurosis and muller muscle (pretarsal space)
Most of the nerves of the eyelids are arranged in the submuscular plane ie in between the orbicularis and the tarsal plate; therefore to anesthesize the lid injection should be made in this compartment…. From here the branches pass forward to supply orbicularis and skin and backward to supply tarsal structures and conjunctiva
Purpose :
Redistribute tear film
Protection
Provide rest for ocular muscle.
Course of events occurring in spontaneous blinking
When the levator in 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 to elevate the ptotic lid
Bells phenomenon is not present in 10% of otherwise healthy person so its absence is not necessarily a sign of disease
When inverse bells phenomenon is associated with lagophthalmos severe corneal drying and ulceration (exposure keratitis) may occur