Orbital apex

Orbital apex
- Provides for COMMUNCATION between the intracranial cavity and orbit via superior
orbital fissure and optic foramen
- Includes posterior part of inferior orbital fissure
- Connects with pterygopalatine ganglion
Optical foramen (canal):
- Optic nerve (C2)
- Ophthalmic artery
 - Sympathetic fibres
Superior orbital fissure:
- Oculomotor nerve (CN3)
- Trochlear nerve (CN4),
- Abducens nerve (CN6)
- Trigeminal nerve Ophthalmic division (CN V1) – frontalis, lacrimal and nasociliary nerve
- Superior ophthalmic vein
- Sympathetic fibres
Annulus of Zinn (common tendinous ring)
- Optic nerve (CN2)
- Ophthalmic artery (CN3)
- Oculomotor nerve (CN3)
- Abducens nerve (CN6)
- Nasociliary nerve (CV1)
- Sympathetic fibres
Inferior orbital fissure
- Trigeminal nerve maxillary division (CV2)
- Inferior ophthalmic vein
- Parasympathetic branches from sphenopalatine (pterygopalatine) ganglion
EOM attachments and orbital insertions
- 4 rectus muscles = commone tendinous ring (annulus of Zinn) located at the orbital apex
- Superior oblique = lesser wing of the sphenoid, medial to optic canal; passes forward &
through the trochlea ‘pulley’ to the globe
- Inferior oblique = maxillary bone, anterior orbit floor, just inside orbital rim

-
 Summary: EOM nerves and blood supply

Vascular supply and drainage:

- Ophthalmic artery muscular arties
- Lateral (superior) + medial (inferior)
- Mascular veins vortex veins superior & inferior ophthalmic viens cavernous sinus

Main soft tissues within orbit

 Extraconal space = area outside the muscle cone
and adjacent to orbital wall

Intraconal space = within the muscle cone;

contains optic nerve, vessels and CN3, CN4 & CN6.

Orbital soft tissues (connective tissues)

Eyeball is covered by a capsule

Periorbita = orbital periosteum = orbital fascia
= Lining!
- Periorbita is a DENSE CONNECTIVE
TISSUE THAT COVERS orbital BONES
from anterior orbit to the muscle
cone;
- It serves as an attachments site for
muscles, tendons and ligaments
- envelops the optic canal and superior
orbital fissure
- It is the support structure for blood
supply to orbital bones
- Firmly attaches at the suture lines,
foramina, fissures; elsewhere loosely
adherent to bone and easily
separated from the bone
- Continuous with optic nerve dura that
is fused to the optic canal then go
back to the brain
- Superior orbital fissure is bound by
thickened periorbital
- Anteriorly is continuous with orbital
 septum
- Periorbita also lines with lacrimal
fossa
- At the ortbial margins the periorbita is
continuous with a connective tissue
sheet called orbital septum
Orbital septum = circular dense connective
tissue sheath
- Circumferential attachment from
tarsal plate to bony orbital margin;
separates facial and orbital
structures (pre-septal & post-
septum=orbital)
- Forms a barrier = prevents anterior-
posterior spread of infection and
inflammation
- Maintains orbital fat in place
Importance of orbital septum:
Tenon’s capsule (or bulbar fascia) = sheet of
dense connective tissue that encases the globe
(eye and muscles) = Fibroelastic membrane
- It lies between the conjunctiva and
episclera & encircles the globe & fuses
with them anteriorly @limbus
- Its pierced by optic nerve, vortex veins,
the ciliary vessels and nerves and EOM.
- At muscle insertions, Tenon’s capsule
forms sheaths that cover the tendons
- Posteriorly, tenon’s capsule fuses with
the dural sheath of optic nerve
- This dense connective tissue capsule
acts as a BARREIER to prevent the
spread of orbital infection into the
globe.

- Posteriorly SEPARATES ORBITAL FAT

from the globe and muscles
- Anteriorly – muscular fascia thickens
and connects with orbital wall check
ligaments of the EOMs; these prevent
overaction of muscle from which they
extend
- Lateral check ligament inserts on lateral
orbital tubercle
- Medial rectus check ligament inserts
behind the posterior lacrimal crest

The 4 rectus muscles have their origin on annulus of Zinn. This oval band of connective tissue is
continuous with the periorbita, and is located at the apex of the orbit anterior to the optic
foramen, and the medial part of superior orbital fissure.
- Upper
Orbital fat
- Orbital structures are surrounded by orbital
fat
- Orbital fat = provides a CUSHIONS of support
for globe & fills most of the retrobulbar
space
Upper eyelid:
- Orbital septum covers a central pre-
aponeurotic fat-pad;
- A smaller medial fat-pad is separated by the
trochlea
Inferior orbit FP =(orbital) Fat-pads
- Lateral fat pad is divided from central 3rd by T= trochlea
fascial attachments of the inferior oblique IOM = inferior oblique muscle
muscle
- Medial and central fat-pads of the lower lid T divides fat pads in the upper eyelid.
are separated by the inferior oblique muscle IOM divides medial from central fat
Arcuate expansion fascia of the inferior
oblique divides the central from the
lateral fat pads in lower eyelid.
The orbital fat is contained BEHIND the
orbital septum.

Increase age = weakened orbital septum

in lids = orbital fat prolaspses into the
front of orbial septum = forms a bulge in
the upper lid

Ligaments support globe and eyelid positioning

Superior transverse ligament (Whitnall’s ligament) Suspensory ligament (of Lockwood)
- Fibrous condensation of levator palpebrae - Stretches across the inferior
muscle orbit; analogous to Whitnall’s
- Forms a superior transverse band ligament in the upper lid
- Extends from fascial layers (covers the - Support structure for globe
trochlea and tendon of the superior oblique - Extends from the lateral orbital
muscle) to the superolateral orbital corner tubercle to the medial canthal
adjacent to capsule of the lacrimal gland. tendon
Orbital septal system = connective tissue network
- This is a web of connective tissue septa organise, that organise the orbital space
surrounding the globe into radial compartments
- Surrounds the globe and all other orbital structures, including EOMs, orbital blood vessels
and nerves
- Connects to periorbital lining
- Globe motility restrictions after trauma related to herniation of periobita, ortbial fat and
connecive tissue septa into paranasal sinuses
- Eye muscles in the right direciton = guide muscle connections identifyed in the MRI
 - Collagenous strands connect the periorita to Teno’s capsule and intermuscular
membranes.
- This connective tissue system of ‘slings’ anchors and supports the EOM and blood vessels;
attach them to adjacent orbital walls
- The slings associated with each of the muscles matian correct positioning of muscles
during eye movements
- Varying degreres of connectivity
- Intimiately liked web of connective tissue septa a
- This is a
- Connects to the periorbital lining
-

The superior palpebral LEVATOR muscle = retractor of upper eyelid = located within the orbit
above the globe and extends into the upper lid.
- O= lesser wing of sphenoid bone & in front of optic foramen
- Levator muscle sheath blends with the sheath of superior rectus muscle (SR)
- As levator muscle approaches the eyelid from its posterior origin (O) at the orbital apex, a
ligament, the superior transverse ligament = whitnall’s ligament acts as a fulcrum =
changing the anteroposterior direction of the levator to superoinferior
- Whitnall’s ligament = firbous band that spans the anterior superior orbit from trochlea to
the lacrimal gland fascia;
- Provides support for upper lid & orbital structures
Whitnall’s ligament =point where levator muscle fibres end and aponeurosis begins
Levator aponeurosis
- As levator muscle enters the eyelid, levator becomes a fan-shaped tendinous expansion =
called LEVATOR APONEUROSIS (a tendon)
- Unlike a typical tendon, the aponeurosis spreads out into an extensive sheet POSTERIOR
to the orbital septum
- The fibres of aponeurosis PENETRATE orbital septum & EXTENDS into the upper lid =
fanning out across its entire width.
- Aponeurosis goes through the sub-muscular connective tissue, the posterior fibres insert
 into the LOWER ANTERIOR surface of the TARSAL PLATE
- The anterior fibres run between the muscle bundles of orbicularis to insert primarily into
the skin of eyelid.
- Fibres of Levator aponeurosis anchors the skin to the underlying tissues in the pretarsal
area of eyelid and creates the palpbral sulcus
 (superior & inferior palpebral sulcus = fold at the top & bottom of eyelid)
 The eastern Asian descent, the orbital septum attaches to the tarsal plate more
inferiorly and the aponeurotic fibres do NOT ATTACH as extensively to the
cutaneous tissue
Levator action
- Contraction of levator muscle = elevation of eyelid
- Connection between sheath of levator and sheath of superior rectus muscle (SR)
coordinates eyelid position so that when the eye is elevated, lid is raised.
- Levator innervation superior division of oculomotor motor nerve, CN3.
- Eyelids are closed by relaxation of levator and contration of orbitulcar oculi msucles
Retractor of lower eyelid = capsulopalpebral fascia (lower eyelid aponeurosis)
- = an anterior extension from the sheath of the IR muscle and suspensory ligament, inserts
into the INFERIOR edge of the tarsal plate
- The capsulopalpebral fascia fuses with the orbital septum and sends some fibres to insert
into the inferior fornix
Tarsal muscle (of Muller)
Superior tarsal muscle (of muller) is composed of smooth muscles
- O = posterioinferior aspect of levator muscle
- Begin to appear within the striated muscle at where the muscle becomes aponeurotic
- I = on the superior edge of tarsal plate
- Contraction of Muller’s muscles can provide 2mm of additional lid elevation
The inferior tarsal muscle is found at lower eyelid
- O = inferior rectus muscle sheath
- I = lower conjunctiva and lower border of tarsal plate
Both nerves are innervated by the sympathetic fibres that widen the palpebral fissure when
activated

Tarsal plate
- Anterior surface = adjacent to submuscular connective tissue
- Posterior surface = adherent to palpebral conjunctiva
- The orbital border of tarsus is attached to the orbital septum, marginal border lies at the
lid margin.
- The sides of tarsal plates are attached to bony orbital margin by palpebral or tarsal
ligaments (medial & lateral canthus tendon)
Cranial nerves and EOMs
Cranial nerves Origin Destination
II optic Retinal ganglion cells Lateral geniculate nucleus
(LGN)
III. Oculomotor, inferior Midbrain MR, IR, IO muscles
division Ciliary ganglion
III. Oculomotor, superior Midbrain SR muscle
division Superior palpebral levator
muscle (eyelid)
IV Trochlear Midbrain Superior Oblique muscle
VI Abducens Pons LR muscle
VII Facial Pons Frontalis, procerus, corrugator
and orbicularis muscles

Pterygopalatine or
sphenopalatine ganglion

EOM origins (attachments)

4 Rectus muscles Superior Oblique Inferior Oblique
Common tendinous ring Lesser wing of the sphenoid, Maxillary bone, anterior orbit
(annulus of zinn) located at Medial to optic canal; passes floor, just inside orbital rim
orbital apex forward & through the
trochlear globe
Skeletal muscles
1. Tendon: attaches muscle to bone ( or sclera for eye)
2. Muscles composed of bundles of fibres
3. Muscle bundles surrounded by ‘wrapping’ – epimysium, perimysium, endomysium
4. Fascicles = muscle bundles
5. Myofibrils = thin actin filaments & thick myosin filaments

EOMs are BILAMINAR

Global layer (GL)
Fibres of the EOM
- The fibres of EOM have a layered organisation

Global layer (GL)

- Consists of fibres of various diameters
- Adjacent to the globe in RECTUS MUSCLES and in the central core of OBLIQUE MUSCLES
- Become continuous anteriorly with the terminal tendon that inserts on the sclera for
rectus muscles and Superior Oblique (SO) muscle.
- This group of fibres extends the full lengths of the muscles and is attached at the origin
and insertion through TENDONS.
- I: sclera = causes movement of globe
- 10,000 to 15,000 fibres in EOM in humans
Outer Orbital layer (OL)
- Consist of smaller-diameter fibres
- Adjacent to orbital bone
- Terminates posterior to sclera, and at least some of its fibres insert on connective tissue
pulleys in orbit
- Located on orbital surface of rectus muscles and forms a concentric peripheral layer for
oblique muscles
- More vascularised than global layer
- Inserts into the connective tissue muscle pulleys that can influence the rotational axis of
the muscles.
- Make up of 40-60% of fibres within EOM
 Global layer
- Medial and lateral
rectus
- Muscle fibres and
fascicles.
- Blacker ones are the
nerve
Orbital layer
- Spaced out fascicles

Pulley

EOM
- Divided into types having some of the usual characterises of STRIATED muscles
All types involve in muscle contraction

Difference between ocular muscles (EOM) and skeletal muscles

Ocular muscles (μm) Skeletal muscles (μm)
Fibre diameter 5-15 (surface/orbital layer) 90-100
10-40 (global layer)
Nerve muscles fibres 1:1 to 10 Up to 1:300+
Contraction time Fast Slow
ACh sensitivity High Low or absent
- Muscle fibres included in a motor unit; each axon innervates 3-10 fibres
- Allows for FAST PRECISE fine MOTOR CONTROL of EOMs required for SACCADES, PURSUITS
& FIXATIONS
Fast or slow twitch fibres
- Mixture of fibres are seens in EOMs but ~ 85% are fast myosin & 15% are ‘slow’ myosin’
- EOMs = very fast but don’t fatigue (cf skeletal muscle)
- Can be SINGLE or MULTIPLE innervation per fibre
SLOW Twitch Fibres FAST Twitch Fibres
- Thin motor nerve fibres (= signal travel - Thick motor nerve fibres (= signal travel
slower) faster)
- Multiple innervated (en grappe) - Single innervated (en plague)
- Large poorly defined muscle fibres - Small, well defined muscle fibres
- No conduction of AP - Conduction of AP
- Slow sustained contraction (tonic) - Fast contraction (phasic)
- Mostly orbital - Mostly bulbar
 Summary of EOMs compared to skeletal muscles
- EOM muscles shealth (epimysium) is generally very thin
- Fibres not tighly packed but separated by unusally large amounts of connective tissue
(perimysium)
- Muscle fibres rounded or oval in shape with small fibres (5-15 μm) around the periphery of
the muscle and larger fibres (10-40 μm) in the centre
- EOM – most vascular in the body, next to myocardium; orbital aspect most vascular
- Afferent fibres in EOMs are transmitted initially for the part of their course in the respective
cranial nerve innervating the muscle (either 3,4, or 6); however these leave nerves and join the
ophthalmic division of the trigeminal, either in the cavernous sinus or in the brainstem
- Different function of EOM & skeletal muscles = different structures
 EOMs must maintain the constancy of activity (even during sleep), rapid and fine
control of EOM contraction required for fixsation on the fovea (critical for vision)

The orbital pulley system

Connective tissue pulleys in the orbit
- ORIGIN OF EOM = AT ITS PULLEY!
- Pulley = ‘sleeves’ or pulley located near the EQUATOR
- CONNECT EOMs to orbital walls, adjacent EOMs, equatorial Tenon’s by band of collagen,
elastin and smooth muscle
MRI studies have shown that EOMs do NOT follow
straight-line paths from their origins to scleral
insertions
- EOM paths are infected by pulleys
- Discrete rings of dense collage encircling EOM
~ 2mm length
- Location and site of pulley mechanical insertion
influences EOM action
- Pulley = BE ELASTIC & smooth muscle = some
flexibility!
Understanding EOM pulleys Passive vs Active pulley hypothesis
- Passive pulley = EOMs slide freely through their pulley sleeves
- Active pulley = as the EOM moves, the pulley moves with it
NOT SOLVED.
Axes of eye movement: Fick’s axes and Listing’s plane
- ALL EYE MOVEMENTS can be described as rotation in the Fick coordinate system (axes)
- Eye POSITION = result of ROTATING EYEBALL FROM ITS PRIMARY POSITION via rotations
around diff axes.
Rotation around a head-fixed vertical axis (z)
Rotation around an eye-fixed horizontal position (x)
Rotation around the line of sight (y)

Extraocular muscles and Axes of eye movements

- The x, y, z axes meet at the centre of rotation of
the eye.
- Vertical rotation occur about the x-axis,
horizontal about the z axis and torsional about
the y-axis
- Y -axis = a sagittal axis passing through the pupil;
it is perpendicular to Listing’s plane (x-z axes)

Terms for monocular eye movements

- Adduction = towards midline – nose
- Abduction = away from midline –
temporal
- Elevation = supraduction – up
- Depression = infraduction – down
- Intorsion = incyclorotation – rotate
medially (inwards)
- Extorsion = excyclorotation – rotate
laterally (outwards)
Functions of EOMs in the eye
1. For x-axis, only LR & MR muscles are
involved
2. Axis of eyeball & the orbit are NOT the
same, the insertions of the msucles are
NOT always linear
affects (vertical) y-axis & z-axis
(anterioposterior) movements

Sherrington’s law of recuiprocal innervation = any innervation to a muscle to contract (agonist)

will be accompanied by an equal inhibitory input to the direct anatagonist to relax
Agonist = muscle doing the movement
Anatgonist = muscle acting in the opposite direction

Contraction of a muscle  simutaneous and proportional relaxation of an antagonist

Yoke muscles = msucles of the two eyes act together to cause binocular movements
- Hering’s law of equal innervation = innervation to the msucles of the two eyes is EQUAL
and SIMULTAENOUS  movements of the 2 eyes are normally symmretic
 Hence
Look to the right = equal and simutaenous
innervation supplied to the yoke muscles
(right LR and Left MR)

Convergence (look towards to your nose)

= equal and simultanous innervation
supplied to the yoke muscles (right MR and
Legt MR)

External globe = sclera, and the relations of the sclera to other tissues of the eye
1. Describe main features of the external globe – the sclera[
2. Describe relations of the sclera to other tissues of the eye
3. Discuss the functionsal significance of the sclera
Sclera = outer fibrous coat of the eye; continuous anterior to the cornea, inside the eye, adjancet
to choroid with transition across lamina fusca
- Tough outer coat of the eye
- Covers ~90% of human eye c.f. cornea
Episclera = most superifical layer
- LOTS OF BLOOD VSESELS PASSING THROUGH but it doesn’t have its own blood supply
 On the outside, it is supplied by the sclera muscles
- Collagen bundles are loosely arranged and contains melanocytes and immune cells
- A rich sensory nerve supply (which nerve?)
- Episcleral vessels drain aqueous humour via c