EYELIDS: Layers,Nerve Supply,Vascular Supply & Clinical Correlations

1. Moderator
Dr. Sanjeev Bhattarai
Presented by:
Sarmila Acharya
Santosh Pandit
2nd year
EYELIDS:
Layers, Nerve Supply,
Vascular Supply,Functions
&
Clinical Correlation

2. Presentation Layout
• Introduction
• Embryology
• Anatomy
Layers of Eyelids
Glands of Eyelids
• Functions
• Nerve Supply
• Vascular Supply
• Drainage System
• Clinical Correlations

3. Introduction
• An eyelid is a mobile, flexible, multilamellar
structure that covers globe anteriorly.
• Assist in distribution of tears over the
anterior surface of the eyeball.
• Provide protection from excessive light,
desiccation and air borne foreign matter.

4. Embryology
• Derived from surface ectoderm
• Starts as a proliferation in the region future outer canthus
at 4-5 weeks gestation
• Mesodermal mesencyhme infiltration during 2nd month
• Fusion at 10 weeks gestation
• Orbicularis condensation at 12 weeks gestation
• Eyelid adhesions break down during 5-6th month

5. Clinical Sig…
Cryptophthalmos coloboma
Microblepharon

6. The Anatomy Of The Eyelids:
• Extention:
– eyebrow superiorly
– cheek inferiorly
• Eyelid folds/sulcus:
Upper eyelid: orbital part , tarsal part
Formed by the insertion of the aponeurotic
fibers of LPS into the skin
Lower eyelid - less obvious
Formed by few connections between the skin
and the orbicularis oculi muscle.
(with age, Nasojugal sulcus & Malar sulcus are formed)

7. • Canthi
– Eyelids meet at medial and lateral canthi
• Medial canthus: Rounded,
-separated from globe by
Lacus lacrimalis (tear lake)
• Lateral canthus:
- 5-7mm from lateral orbital margin,
-60 deg with eyes wide open,
-30-40 deg with eyes open in a normal way
-About 2 mm above the medial canthus
Epicanthus –dermal fold across the medial
canthus

8. • Eyelid Margins
- 2mm wide, round anterior border & sharp
posterior border

9. contd…
• Eyelid margin is divided into 2 portion by lacrimal
papilla.
1) Lacrimal portion:
-medial portion of the eyelid margin
-extending from the punctum medially to medial
canthal angle.
-Round & devoid of lashes and glands
2) Ciliary portion:
-From punctum to lateral canthal angle
-Contains lashes at anterior border & sharp posterior
border

10. contd…
 Gray line
-Correspond histologicaly to the muscle of Riolan
- relatively avascular area
- Gray
- Eyelashes emerge anteriorly
- Posteriorly opening of meibomian gland (just
anterior to mucocutaneous junction)

11. cont…
• Interpalpebral Fissure:
- the exposed zone between the upper and lower
eyelid
- 8 to 11 mm vertically
- 27 to 30 mm horizontally
- Width of the palpebral fissure is determined by
the level of tonic activity in the levator palpebrae
superioris and the sympathetically innervated
Muller’s Muscle
• Position:
In primary position
– Upper eyelid margin is at 1.5-2mm below the
superior corneal limbus
– Lower eyelid margin is at inferior corneal limbus

12. • Eyelashes
– Arranged in 2 to 3 rows.
– Upper lid: 100-150 in number and directed upward,
forward and backward
– Lower lid : 50-75 in number and directed forward,
downwards and backward
– Taper throughout the length to end in a fine sharp
point
– Life span : 3 to 4 months
(cilia have no erector muscle)

13. Layers Of The Eyelids:
(From front to back)
• Skin
• Subcutaneous Areolar Tissue
• Layers of Striated Muscles
• Submuscular Areolar Tissue
• Fibrous Layer
• Non Striated Muscles Fibres
• Conjunctiva

14. 1. Skin:
• Palpebral skin is thinnest in body (<1 mm)
• Elastic & folds easily contributing to speed of
mobility of upper eyelid
• Nasal skin:
– Smoother and more oily
– Few rudimentary hairs
– Many unicellular sebaceous glands (hence
Xanthelasma develops on the nasal side)
• Lateral skin:
– Numerous sweat gland

15. Contd…
• Epidermis
– Consists of 6-7 layers of stratified squamous
epithelium
– Unicellular sebaceous glands & sweat glands
• Dermis
– Dense connective tissue
– Rich network of elastic fibers, blood vessels,
lymphatics & nerves

16. 2.Subcutaneous Areolar Tissue:
• Loose connective tissue arrangement
• No fat
• Applied anatomy:
– Fluid from oedema or haemorrhage rapidly
engorges into the loose subcutaneous eyelid
tissue & produce swelling of eyelids

17. 3. Layers Of Striated Muscles:
• Consists of
–Orbicularis oculi (forms thin oval sheet over
eyelid)
–Upper eyelid also contains LPS

18. The Orbicularis Oculi Muscle:
• Complex striated muscle sheet
• Divided anatomically into;
-Orbital
-Palpebral
Pretarsal Preseptal

19. a) Orbital Orbicularis:
• Origin :
- Most peripheral fibers which arise from anterior part
of the medial palpebral ligament & adjacent bones viz.
o Upper orbital margin medial to supraorbital notch
o Maxillary process of frontal bone
o Frontal process of maxilla
o Lower orbital margin medial to the infraorbital
foramen

20. Orbital Orbicularis Cont:
• Muscles fibres sweeps superiorly & inferiorly,
covering the orbital margins in the form of ellipse &
meet at the lateral palpebral raphe
 Superior fibres called Musculus Superciliaris get
inserted into the skin of eyebrows
 Inferior fibres called Musculs Malaris attached to
skin of cheeks
• Functions:
Help in forceful closure of eyelids & pull eyebrow
downwards

21. b) Palpebral Orbicularis:
• Overlies the mobile eyelid from the orbital rims to the
eyelid margins
• subdivided into:
- preseptal
-pretarsal
• Function:
In gentle closing of eyelid (during blinking , sleep
and soft voluntary closure)

22. Preseptal fibres:
– Arise from
• Lacrimal fascia
• Posterior lacrimal crest
• Anterior part of medial palpebral ligament
 Fibers pass superiorly & inferiorly in front of the
orbital septum and unite at the lateral palpebral
raphe

23. Pretarsal fibers:
– Arise from
• Deep head (lacrimal fascia & posterior lacrimal
crest)
• And superficial head (medial palpebral ligament)
 Fibers pass laterally above & below, overlying the
upper & lower tarsus respectively and join at lateral
canthal tendon which is inserted over lateral orbital
tubercule of whitnall.

24. Horner’s Muscle:
• Prominent bundle of fibers, formed by fusion of the
deep heads of the pretarsal orbicularis
• Runs just behind the posterior limb of the canthal
tendon
• insertion – posterior lacrimal crest
• Functions :
- helps to maintain the posterior position of the
canthal angle
-tightens the eyelids against the globe during eyelid
closure
-aids in the lacrimal pump mechanism

25. • Muscle of Riolan
– Small bundle of striated muscle fibers at the eyelid
margin
– Extension of pretarsal portion of orbicularis oculi
fibers
• Function:
– Keep the lids in close apposition to the globe

26. The eyelid retractors
• Upper lid
1) Levator palpabrae superioris
2) Muller’s muscle
• Lower lid
1) Capsulopalpebral fascia

27. Levator palpebrae superioris
• Major eyelid retractor
• Origin:
- At the apex of orbit from the under Surface of lesser
wing of the sphenoid above annulus of zinn
• Course and attachment:
-Passes forward below the roof of the orbit, above
the superior rectus
-At septum orbitale,it fans out into white tendon
called aponeurosis of LPS and forms medial and
lateral horns

28. • Lateral horn: Divides the lacrimal gland into orbital &
palpebral parts and inserts into superior edge of
lacrimal canthal tendon
• Medial horn: Passes over reflected tendon of
superior oblique and fuses with medial canthal
tendon
 Together, the two horns serve to distribute the forces
of the levator muscle along the aponeurosis and the
tarsal plate

29. Muller’s Muscle
• Sympathetic accessory retractor of upper eyelid
• Modulates the position of the upper and lower
eyelid when the eye is open
• Origin –From undersurface of the LPS
• Insertion – orbital margin of the tarsal plate
• Applied Anatomy:
- Horner’s Syndrome
(triad of ptosis, miosis & anhidrosis)

30. Capsulopalpebral Fascia
• Fibrous sheet in the lower eyelid, that arises from
the Lockwood’s ligament
• Fuses with fibers of
the orbital septum,
forms a common
fascial sheet &
inserts onto the
lower border of
the tarsal plate

31. • Fine fibrous slips pass forward from this fascial sheet
to the inferior conjunctival fornix , so forming the
lower eyelid crease
• Applied Anatomy:
– Spastic Entropian
(Due to disinsertion of the
lower eyelid retractors from
the tarsus)

32. 4) Submuscular Areolar Tissue
• Present between orbicularis muscle & fibrous layer
• Superiorly communicates with the subaponeurotic
stratum of the scalp
• This plane can be entered by incision at the gray line
• The nerves & vessels of the eyelids also lie in this
layer, and so to anaesthetise the lid, injection is
made in this plane

33. 5) Fibrous Layer
• Framework of lid
• Consists of:
-Central thick part Tarsal Plate
-Peripheral thin part of the Septum Orbitale

34. Tarsal Plates
• Dense fibrous tissue
• Form skeleton of
eyelids (gives shape
and firmness)
• Lateral end of tarsi attached to Whitnall’s tubercle
by lateral palbebral ligament
• Meibomian glands are embedded in tarsal plates

35. Cont..
• Medial end of tarsi attached to anterior lacrimal
crest and frontal process of maxilla by medial
palpebral ligament
• Orbital septum & Muller’s muscle are attached at
superior border of upper tarsus
• Orbital septum, capsulopalpebral fascia & inferior
palpebral muscle are attached to inferior border
of lower tarsus

36. Septum Orbitale
• Thin, floating membrane of connective tissue
• Takes part in all movements of eyelids
• Thick & strong on lateral side than medial side
and upper eyelid than lower eyelid
• Applied Anatomy:
-Barrier to extravasation of blood / spread of infection
-With age, orbitale septum weakens orbital fat
herniates Dermatochalasis

37. The Orbital Fat:
• Lies in between Orbital Septum & Levator
aponeurosis(Upper Eyelid) / Capsulopalpebral
Fascia (Lower Eyelid)
• In the upper eyelid - medial & central fat pockets
• In the lower eyelid - medial, central & lateral fat
pockets
• Applied Anatomy - surgically important landmark

38. 6) Non Striated MusclesFibres
• Consists of smooth muscles fibres of Muller’s
muscles which lie just deep to septum orbitale in
upper & lower lid
• Origin:
-From the inferior terminal striated fibres of LPS
in Upper Eye Lid & expansion of inferior rectus
in the Lower Eye Lid
-Runs vertically & gets inserted in the orbital
margin of the tarsal plate
• Supplied by sympathetic nerves

39. 7. Conjunctiva
• Transparent vascularised membrane covered by a
non keratinized epithelium that lines the posterior
surface of the eyelids (palpebral conjuntiva) and the
anterior surface of the globe (bulbar conjunctiva)
• Firmly adherent to the tarsus
• Small accessory lacrimal glands (Gland Of Krause &
Wolfring) are located within the submucous
connective tissue

40. Plica Semilunaris:
• Pinkish crescentric fold of conjunctiva present in
medial canthus
• Highly vascularized & rich in goblet cells
• Resemles the nictitating membrane (3rd eyelid) as in
lower vertebrates

41. Caruncle:
• Pinkish mass situated in inner canthus , just
medial to Plica Semilunaris
• Covered by non-keratinized stratified squamous
epithelium
• Actually a part of margin of lower lid which gets
cut off due to development of inferior canaliculi
• Contains sebaceous glands & sweat glands

42. Glands Of Eyelids:
• Tarsal / Meibomian Glands
• Gland of Zeis
• Gland of Moll

43.  Tarsal / Meibomian Glands
• Modified sebaceous gland
• Present on the posterior part of stroma of
tarsal plate
• 30 -40 no. in upper eyelid & 20-30 no. in
lower eyelid
• Oily secretion

44. Cont…
• Functions:
– Forms hydrophobic barrier at the margin of the
eyelid,preventing spillage of tears at the lid margin
– Forms oily layer of tear film over cornea &bulbar
conjunctiva
Retards evaporation of tears.

45. Gland of Zeis
• Modified sebaceous glands
• Attached to eyelash follicles (usually two glands with
each cilium)
• Sebum secretion
• Functions: Prevents eyelashes from being dry &
brittle

46. Gland of Moll
• Modified sweat gland
• Lies between cilia
• Numerous in lower lid than upper lid

47. Functions Of Eyelids:
I. Act to protect the anterior surface of the globe
from local injury.
II. Aid in regulation of light reaching the eye.
III. Tear film maintenance by distributing the
protective optically important tear film over the
cornea during blinking.
IV. Tear flow by their pumping action on the
conjunctival sac and lacrimal sac.

48. Nerve Supply To the Eyelids:
Motor Nerve Supply:
motor nerves to the orbicularis oculi muscle - facial
nerve (temporal & zygomatic branches)
motor nerve to the levator palpebrae superioris -
superior division of oculomotor nerve
motor nerve to the Müller muscle - sympathetic
nervous system

50. –Sensory Nerve Supply: ophthalmic & maxillary
divisions of the trigeminal nerve
• upper eyelid - supraorbital, supratrochlear & lacrimal
nerves (ophthalmic division)
• lateral portion of upper eyelid & zygomaticotemporal
branch of the maxillary nerve
• extreme medial portion of both upper & lower eyelid
- infratrochlear nerve

51. –Sensory Nerve Supply:
• lower eyelid - infraorbital nerve (maxillary division)
• lateral portion of lower eyelid - zygomaticofacial
branch of the maxillary nerve

53. Vascular supply of Eyelids
Upper eyelid
• Marginal Arcade – 2-3 mm from the eyelid margin;
either between the tarsal plate & the orbicularis or
within the tarsus
Peripheral Arcade - along the upper border of tarsal
between the levator aponeurosis & Müller muscle
supplied by superior medial palpebral vessel
• (the terminal ophthalmic artery and superior lateral
palprebal Vessel from lacrimal artery)

54. • Lower eyelid:
• By medial and lateral palpebral vessel

55. Venous Drainage System:
• not well defined
• can be divided into two portions: a superficial,
or pretarsal system & a deep, or posttarsal
system
• mainly into several large vessels of the facial
system

57. Lymphatic Drainage
Two systems- superficial and deep system.
 Superficial system- drains skin and orbicularis oculi.
 Deep system- drain tarsi and conjunctiva.
 Upper lid, lateral 1/3 of lower lid and lateral canthus->
preauricular Lymph Node and deep parotid nodes-> deep
cervical Lymph Node.
 Medial part of Upper lid, medial 2/3 of Lower Lid and
medial canthus-> submandibular Lymph Node-> internal
jugular vein.

59. Clinical corelations of eyelids
Hordeolum Externum (Stye)
Localized suppurative inflammation of gland of
zeis at lid margin at ciliary follicle.

60. Hordeolum Internum
• Hordeolum Internum is a suppurative
inflammation of meibomian gland associated with
the blockage of the duct.

61. Chalazion
• Chalazion is chronic inflammatory granuloma of
meibomian gland

62. Blepharitis
• Blepharitis is chronic inflammation of lid
margin occurring as true inflammation.

63. Meibomitis (posteriorBlepharitis)
inflammation and obstruction of meibomian
glands. Characterized by diffuse thickening of
posterior border of lid margin which becomes
rounded.

64. • Entropion
Inward rolling and rotation of lid
margin toward globe.

65. • Ectropion
out rolling or outward turning of lid
margin.

66. Lagophthalmos
• Incomplete closure of the palpabral
aperture when attempt is made to close
the eyes.

67. Ptosis
Drooping of upper lid usually due to paralysis
or defective development of the levator
palpebrae superioris (LPS)

68. Blepharospasm
• It is the involuntary, sustained and forceful
closure of the eyelids.

69. Symblepharon
• It is a partial or complete adhesion of
the palpebral conjunctiva of the eyelid
to the bulbar conjunctiva of the eyeball.

70. Ankyloblepharon
• It is an adhesion of the ciliary edges
of the eyelid to each other.

71. Clinical correlations of eyelashes
• Triachiasis
Inward misdirection of cilia.
• Distichiasis
Extra row of cilia occupies the position of Meibomian
glands which opens into their follicles.

72. • Madarosis
Partial or complete loss of eyelashes.
• Poliosis
Whitening of eyelashes.

73. Reference
• Anatomy and Physiology of eye = A.K
Khurana
• Comprehensive Opthalmology = A.K
Khurana
• Section 7 - Orbit_ Eyelids_ and Lacrimal
System ( American Academy of
Ophthalmology )
• Previous presentation
• Internet