Speaker:Dr.

Ala’ Abu Farsakh

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

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• 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.

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• 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

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The Eyelashes
• 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.

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• (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.

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

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 skin
• 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

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

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 Orbicularis oculi
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

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 Orbicularis oculi
• Nerve supply
Temporal and zygomatic branches of facial nerve

• Action

• Antagonist muscles
Orbital part frontal belly of occipitofrontalis
muscle
Palpebral part levator palpebrae superioris
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 Orbital septum and tarsal plates
• 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
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Orbital septum

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 Structures piercing through orbital
septum
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
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Medial & lateral palpebral ligaments
• 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
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 Smooth muscles
• Forms the superior and inferior tarsal
muscles
• Both are innervated by sympathetic nerves
from the superior cervical sympathetic ggl

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 conjunctiva
• 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

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 Levator palpebrae superioris
• 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:

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Levator palpebrae superioris

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

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Lids Venous and lymphatic
drainage
Venous:
• Medailly : ophth and angular v.
• Laterally: superficial temporal v.

lymphatic:
Lat 2/3 : superficial parotid LN
Medial: submandibular LN

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

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 Lecture outline
Eyelid anatomy Eyelid physiology
• Gross anatomy • Functions of eyelids
• Layers of the eyelid • eyelid movements:
• Eyelid arterial supply
and venus and Openning,clouser,bli
lymphatic drainage nking and
• Eyelid nerve supply winking,Bell’s phe
-Dynamics of eyelid
openning and
clouser
 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.
EYELID MOVEMENT
• Lid opening
• Lid closure
• Blinking
• Voluntary blinking and winking
• Bell’s phenomenon
 Lid opening

• Upper lid elevators

• Lower lid retractors
 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.
Muscle Attachment Nerve supply
Levator palpebrae Lesser wing of the Superior division of
superioris sphenoid to the the oculomotor
(main upper lid tarsal plate nerve (also supplies
retractor) the SRM).

Muller’s muscle Aponeurosis of the Sympathetic

(minor upper lid levator to the upper
retractor) border of the tarsal
plate
Frontalis Scalp to the upper
part of the
orbicularis oculi
 Eyelid excursion during opening
movements:

• In adults the upper eyelid is raised

some 10-15 mm from extreme
downward gaze to extreme upward
gaze.
 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.
 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).
 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.
• During opening movement the upper lid
moves vertically upwards, while the
lower lid moves laterally in a horizontal
direction.
• 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.
• 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.
 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.
Lid closure
Orbicularis oculi controls lid closure and is
supplied by the facial nerve.
It is divided into three main parts:
 Part Position Function

Pretarsal fibers In front of the * Respond in spontaneous blinking

tarsal plate and tactile corneal reflex.
* Close lid and pull lacrimal puncta
medially.

Preseptal fibers In front of the Respond to voluntary blinking and

orbital septum sustained activity.
* Pull lacrimal fascia laterally and
create a relative vacuum in lacrimal
sac-improve tear drainage.

Orbital fibers Surrounds the * Respond in forceful lid closure.

orbital rims
 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).
The reciprocal innervation pattern:

• During closing movement the

orbicularis gets maximum
innervation while the levator gets
minimum innervation and relaxes.
(Sherrington’s low ).
• Blinking can be divided into
voluntary and involuntary
types.
• The involuntary blinks are
further subdivided into
spontaneous and reflex
blinks.
 Spontaneous blinking
• It is a common form of blinking that occurs
without any obvious external stimulus or
voluntary willed efforts.
• 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.
• 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.
 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.
 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.
• 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.
 Reflex blinking

• reflexly in a response to a
stimulus.
 Different stimuli induce a different neurological
pathway.
Blinking Examples Afferent Efferent Central
reflex connection
Tactile Corneal touch CNV CNVII Cortical

Dazzle Bright light CNII CNVII Subcortical

(optic)
Menace Sudden presence of CNII CNVII Cortical
(optic) near object
Auditory Loud noise CNVIII CNVII Subcortical

Orbicularis Stretching of CNV CNVII Cortical

panorbital structure
(tap/blow)
 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.
 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.
 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
• 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.