Dissector Answers - Eye

Learning Objectives:
Upon completion of this session, the student will be able to:
1.
2.
3.
4.
5.

Identify the prominent bony features of the orbit with included foramina and fissures.
Describe the components of the eyelids with associated muscles, tarsal glands, connective tissue fascia and conjunctiva.
Identify the extraocular muscles, their function and innervation.
Identify all sensory, motor and autonomic nerves of the orbit and trace their routes to and within the orbit.
Identify branches of ophthalmic arteries and veins.

Learning Objectives and Explanations:

1. Identify the prominent bony featrues of the orbit with included foramina and fissures. (N2, N11, TG7-03, TG7-57)
There are 7 bones that make up the orbit:

Frontal - entire roof of orbit. There are 3 prominent foramina to know in this region - the supraorbital notch (superior
margin) and the anterior and posterior ethmoidal foramina (at junction of frontal/ethmoid bones). Nerves and vessels pass
FROM the orbit TO the nasal cavity through these foramina

Ethmoid bone - a very delicate bone in medial wall of orbit.

Maxilla - medial wall and much of floor. Infraorbital groove is a deep groove on the orbital floor, where infraorbital n. lies.
The anterior lacrimal crest is on the medial margin. (note relation with sphenoid bone, info below)

Lacrimal - very small bone; gives a crest - posterior lacrimal crest; between the post. and ant. crests is the fossa for the
lacrimal sac (not to be confused with the lacrimal fossa of the roof of the orbit, where the gland is located under the frontal
bone).

Zygomatic - lateral margin and the rest of the floor

Sphenoid - forms the apex; there are a number of openings:

1. medially: optic canal for optic n./ophthalmic a.
2. laterally: superior orbital fissure for a number of nerves (III, IV, V1, VI) & superior ophthalmic v.; it separates the
greater and lesser wings of this bone

3. inferior orbital fissure between sphenoid and maxilla: through here brs. of maxillary nerve and artery pass; also
veins from deep face region pass through here connecting with veins within orbit

Palatine - not very important; however, note below under bony orbit, its small role in the floor of the orbit

Orbit (bony): pyramidal-shaped space, formed by seven bones of the skull - four walls and an apex; medial walls are parallel and 2 cm
apart, the space in between consists of the ethmoidal air cells and sphenoid sinus; the lateral walls diverge at 45 degrees from the
medial walls, and left and right are 90 degrees apart; the margins of the orbital aperture are strong; the bone of the margins is much
heavier than that of the walls within the cavity
Roof - orbital plate of frontal bone, and near the apex, lesser wing of the sphenoid bone; concave, especially laterally where the lacrimal
fossa accommodates the lacrimal gland; the frontal sinus frequently extends over the roof of the orbit nearly to its apex
Lateral wall - formed in front by the zygomatic bone and behind by the greater wing of the sphenoid bone; the lateral wall, stronger,
separates the orbit from the temporal fossa
Floor - slopes upward toward medial wall; formed by orbital surface of maxilla, supplemented laterally and anteriorly by the zygomatic
bone and medially and posteriorly by the palatine bone; near the middle of the floor is the infraorbital groove extending forward from the
inferior orbital fissure, ending in the infraorbital canal; the floor of the orbit is a bony separation between the orbit and the maxillary
sinus
Medial wall - nearly vertical; consists of frontal process of the maxilla, the lacrimal bone and the orbital lamina of the ethmoid bone, and
a small part of the body of the sphenoid bone; anteriorly the medial wall forms only a thin partition between the orbit and the ethmoidal
air cells and sphenoid sinus
Openings - the principle openings of the orbit lie at the junction of its walls

Optic canal - junction of roof and medial wall; transmits ophthalmic artery and optic nerve (covered by meninges)
Superior orbital fissure - upper lateral angle at apex of orbit; transmits CN III, IV, V1, VI, sympathetic fibers from cavernous
plexus, and superior ophthalmic vein
Inferior orbital fissure - junction of lateral wall and floor; from apex of the orbit 2/3rds distance to base; accommodates
structures which have only an indirect relation to orbit, i.e., infraorbital nerve and artery, communication between inferior
ophthalmic vein and pterygoid plexus, and infraorbital & zygomatic brs. of V 2
Other fissures/openings
o Supraorbital notch/foramen
o Zygomatico-orbital foramen for zygomatico-orbital n. in lat wall
o Ant. & post. ethmoidal foramina
o Canal for nasolacrimal duct, leads inferiorly from lacrimal groove

Other features of the bony orbit

anterior lacrimal crest: see maxilla bone

posterior lacrimal crest: see lacrimal bone
lacrimal fossa: depression on roof laterally to accommodate the lacrimal gland
anterior ethmoidal foramen: see frontal bone
posterior ethmoidal foramen: see frontal bone
optic canal: see sphenoid bone, and see below
superior orbital fissure: see below
inferior orbital fissure: see sphenoid bone, and see below
periorbita (orbital periosteum): fascia surrounding the orbit and its contents

2. Describe components of eyelids with: muscles, tarsal glands, connective tissue fascia & conjunctiva. (N26, N81, N82, TG7-30, TG757, TG7-58A, TG7-58B, TG7-58C)
Orbicularis oculi m: sphincter m. of eyelids; the lacrimal portion of the orbicularis oculi m. is associated with the posterior offshoot of the
medial palpebral ligament; a small fascicle of muscle fibers covers the deep surface of this band, arising from the posterior crest of the
lacrimal bone; passing behind the lacrimal sac, the muscle divides into two slips for insertion into the medial parts of the tarsal plates of
both lids ; fibers also attach to the lateral wall of the sac, creating a suction action when the lids are closed

palpebral part: arises from the medial palpebral ligament, makes up the muscular layer of the eyelid; fibers run elliptically
toward lateral palpebral raphe (where muscle bundles of the two lids intermingle)
orbital part: surrounds the bony orbit

Palpebral fissure: opening of eye itself; slit between two eyelids, a.k.a. palpebrae
Lateral angle, canthus, commissure: lateral corner of eye
Medial angle, canthus, commissure: medial corner of eye; at this corner are the lacrimal caruncle, semilunar fold
Lateral palpebral ligament: attach the lateral portion of the tarsal plates to the zygomatic bone, deep to the raphe
Medial palpebral ligament: about 5mm long, arises from the frontal process of the maxilla, anterior to the lacrimal groove; extends
lateralward into the eyelid in front of the lacrimal sac and divides; its parts continuous with the tarsal plates of the upper and lower
eyelids; an offshoot of the ligament leaves its posterior surface lateral to the lacrimal sac and attaches to the posterior lacrimal crest of
the lacrimal bone
Conjunctival sac

palpebral conjunctiva: the part of the conjuctiva that lines the inside of the lid

bulbar conjunctiva: the part of the conjuctiva that covers the eyeball
fornix: reflection of the conjunctiva from the eyeball to the eyelid; a potential space filled with nothing but tears; the
lacrimal gland secretes tears and they fill this sac; superior fornix directly receives tears from the lacrimal gland through
small ducts that empty from the deep lobe of the gland

Cornea: sclera, pupil, iris; the transparent cornea is dense, its surface is bulbar conjunctiva, is nonvascular and it is richly supplied with
sensory nn from the ciliary nerves
Pupil: the central aperture of the iris; size is controlled by smooth muscle of the iris
Iris: thin, contractile membrane, having a central aperture, the pupil; within the loose stroma of the iris are two involuntary mm: sphincter
pupillae m. (same parasympathetic innervation as the ciliary m.) and dilator pupillae muscle (sympathetic supply from superior cervical
ganglion, reach the eye from the cavernous plexus through the short ciliary nn.); iris separates chambers of the eye, filled with aqueous
humor
Lacrimal caruncle: mound of skin found at medial canthus (corner of eye)
Lacrimal lake: located in the medial canthus, collects tears as they distribute over eye through blinking
Semilunar fold: the edge of the lacrimal caruncle narrows out to form a thin fold of skin
Lacrimal apparatus

lacrimal papillae: slight elevations on the edge of the eyelids at the medial corner; in each of these is a little opening or
punctum
lacrimal puncta (pores): little openings in the lacrimal papillae; these openings drain fluid from the lacrimal lake by sucking
the tears into the lacrimal canaliculi. The lacrimal fluid then passes through them into the lacrimal sac.
lacrimal gland: produces tears, fills conjunctival sac; uppermost lateral part of the orbit, in the lacrimal fossa of the frontal
bone; the gland is divided into superficial and deep parts by the levator palpebrae superioris m; on the deep lobe there are
a number of small ducts that empty DIRECTLY into the superior conjunctival fornix
lacrimal sac: tears sucked by lacrimal puncta from lake into canaliculi to the sac, where they drain on through the duct into
the inferior meatus of the nasal cavity
nasolacrimal duct: continuation of the lacrimal sac, extends downward and slightly lateralward and backward to the
inferior meatus of the nose; occupies the nasolacrimal canal formed by the maxilla, the lacrimal bone and the inferior
nasal concha, but traverses the mucous membrane of the nose obliquely, so that its opening is partially guarded by the
lacrimal fold

Orbital septum: (the superior palpebral fascia in the upper lid and the inferior palpebral fascia in the lower lid), continuous with the
periosteum of the bones of the superior and inferior margins of the orbit and ends in the anterior surfaces of the tarsal plates

Tarsal plates: dense fibrous plates of tarsofascial layer; inferior is narrower than superior; they give support and form to the eyelids;
semilunar in shape; straight edge is at the lid margin; medially, tarsal plates are continuous with the bifurcated ends of the medial
palpebral ligament; laterally they attach to the zygomatic bone by the lateral palpebral ligament, deep to the corresponding muscular
raphe; embedded within, at the posterior surface, are the tarsal glands
Tarsal glands: embedded in the posterior surface of the tarsal plate in each lid; vertically arranged and parallel, they number ~30 in
upper, a little less in lower; these glands secrete an oily substance that waterproofs the palpebral margins, so tears don't seep over the
lid margins
Orbital sheath: when the optic nerve enters the orbit through the optic canal (sphenoid bone), it brings with it a meningeal coat of dura,
arachnoid, and pia mater; these cover the nerve all the way to the back of the eyeball
Bulbar fascia: the fascia that covers the eye; forms a loose capsule within which the eyeball can move in all 3 axes of rotation; the
sheath is continuous with the muscle sheaths that surround the various muscles of the eye; anchored to orbital margins via check
ligaments
Muscle sheaths: the fascia covering the eye muscles, continuous with the bulbar fascia, and connects to the medial and lateral sides of
orbit by check ligaments; this anchors the bulbar fascia to orbital margins by check ligaments
Check ligaments: connect muscle sheaths to sides of orbit; anchors bulbar fascia to orbital margins
Annulus: at apex of orbit, dense fascial ring, a.k.a. common ring tendon; surrounds both the optic canal and 1/2 superior orbital fissure;
the four rectus mm. arise from it
Summary of eyelid:

movable folds capable of closing in front of the eye, providing protection - upper lid is larger, more movable (due to having
an elevator muscle - levator palpebrae superioris)
the eyelid is composed of five layers
o skin: thin
o subcutaneous tissue: lax, scanty, rarely contains fat; anterior edge of lid are cilia (eyelashes); cutaneous nn. of
eyelid = brs of V1 and brs. of infraorbital br. of V2; rich vascular supply
o muscular layer: mostly palpebral portion of orbicularis oculi m, arises from med palb lig
o tarsofascial layer: an important plane of division in the eyelid between a superficial zone continuous with
subcutaneous tissues of face/scalp and a deeper area continuous with space of the orbit; this layer consists of:
tarsus: dense fibrous plate; embedded within are the tarsal glands
orbital septum: membrane

conjunctiva: lines inner surface of each eyelid (palpebral) and is reflected over the anterior portion of the sclera and
cornea of the eyeball as the bulbar conjunctiva

3. Identify extraocular muscles, their function and associated innervation. (N84, N86, N121, TG7-59, TG7-61B, TG7-62A, TG762B, TG7-63A, TG7-63B)
There are 7 extraocular muscles - 6 that move the eyeball and 1 elevator of the upper eyelid. All except inferior oblique muscle are at
the apex of the orbit and pass forward at the sides of the eyeball. Of the 6 muscles that attach to the eyeball, 4 are straight (rectus) and
2 are oblique.
Levator palpebrae superioris m.
As the uppermost extraocular muscle, it expands beneath the roof of the orbit and ends anteriorly in a wide aponeurosis
Origin: above and in front of optic canal
Insertion: superficial fibers - upper border of the superior tarsus (smooth muscle/ superior tarsal m.); deep layer of m. - ends in sup.
fornix of conjunctiva
Innervation: III (sup. div.) Continuously active during waking hours except during closing of the lids
Simple lowering of the upper lid is accomplished by decrease of levator activity, but blinking is result of contraction of orbicularis oculi
m.
Muscular annulus
Origin point for all 4 rectus muscles
Superior rectus m.
Elevates & Adducts (Up & In); rotates superior pole of eyeball medially
Origin: annulus
Insertion: sclera just posterior to cornea
Innervation: III (sup. div.)
Narrowest of rectus mm
Inferior rectus m.
Depresses & Adducts (Down & In) rotates superior pole of eyeball laterally
Very inferior part of orbit
Origin: annulus
Insertion: sclera
Innervation: III (inf. div.)
Medial rectus m.
ADducts eye ONLY
Origin: annulus
Insertion: sclera just posterior to cornea
Innervation: III (inf. div.)
Broadest of rectus mm.
Lateral rectus m.

ABducts eye ONLY

Origin: two heads - one on either side of sup orbital fissure; separated by the nerves and the ophthalmic vein that enter the orbit
through the fissure
Insertion: tendinous expansion into sclera behind the margin of the cornea
Innervation: VI
Longest of rectus mm.
Superior oblique m.
Depresses & Abducts (Down & Out); rotates superior pole of eyeball medially
Extreme medial upper part of orbit;
Origin: immediately above the optic canal, runs forward to trochlea, attached in the trochlear fovea of the frontal bone
Insertion: sclera behind the equator of eye
Innervation: IV
Runs forward, enters J-shaped ring of dense connective tissue: trochlea
Inferior oblique m.
Elevates & Abducts (Up & Out); rotates superior pole of eyeball laterally
Origin: near orbital margin
Insertion: eyeball
Innervation: III (inf. div.)
The only muscle that takes origin close to the orbital margin (the other 5 extraocular mm. take origin at apex); here it moves obliquely
backward and inferior to attach to eyeball
Summary of Clinical Testing
Medial and lateral rectus can be tested by simply adducting and abducting the eye, respectively, looking for discrepancies in the degree
of motion to one side or the other.
For the obliques and superior and inferior rectus, think of situps. People do bent-leg situps to prevent iliopsoas muscle from acting in
trunk flexion, so that the six-pack muscles get a better workout. By flexing the hip, iliopsoas is prevented from doing its other action,
trunk flexion.
Superior and inferior rectus can both adduct the eye in addition to elevating or depressing the gaze. So, prevent them from doing their
second actions by doing the first - adduct the eye or turn the gaze inward toward the nose. Now the superior and inferior rectus are not
able to do elevation or depression (just like bent-leg situps), so only superior oblique can depress the gaze, and only inferior oblique
can elevate the gaze.
Turn the gaze outward, and now the oblique muscles are too short to do their other actions of elevation and depression. Ask the patient
to look up or down to test superior or inferior rectus muscles.
4. Identify nerves and trace them to and from cavernous sinus. (N86, N104, TG7-60A, TG7-60B)
The nerves of the orbit are the:

3 motor nn. to its muscles (CN III, IV, VI) [LR6, SO4, AO3]
sensory ophthalmic division of CN V
optic nerve arises in the retina of the eye, the other nn. enter the orbit through the sup. orbital fissure

optic n. (CN II)

ophthalmic n. (V1)
o frontal n. divides into the supraorbital n and supratrochlear n, which supply upper eyelid, forehead and scalp
supraorbital n.
supratrochlear n.
o nasocilliary n.: sensory nerve to the eye, supplies several brs. to the orbit
anterior ethmoidal n. - terminal br. of nasocilliary, supply mucous membrane of the sphenoidal and
ethmoidal sinuses and the nasal cavities, and the dura of the ant. cranial fossa
long cilliary nn. - brs. of nasociliary n., transmit afferent fibers from the iris and cornea and some postsynaptic sympathetic fibers to dilator pupillae
o lacrimal n.: arises in lat wall of cavernous sinus, passes to the lacrimal gland, giving brs. to conjunctiva and skin of
superior eyelid and providing secretomotor fibers from zygomatic n. (V2)

oculomotor n. (CN III): aside from supplying most ocular mm., it supplies parasympathetic innervation to the sphincter
pupillae m. of the iris and the ciliary m. of accommodation; it has 3 nerve components: somatic efferent (motor), general
somatic afferent (to same mm), general visceral efferent (mm of iris and ciliary body with a synapse in the ciliary ganglion)
o superior division: sup. rectus/ levator palpebrae superioris m.
o inferior division: proceeds forward in orbit below optic n.; medial rectus, inferior rectus, inferior oblique & motor br.
to ciliary ganglion
trochlear n. (CN IV): smallest of CN's, supplies only one muscle - the sup. oblique; only CN that emerges from the dorsal
aspect of the brainstem; most superior nerve entering in superior orbital fissure; in orbit it is medial to frontal nerve
abducens n. (VI): like CN IV, it supplies only ONE muscle: the lat. rectus m.; enters the cavernous sinus by piercing the
dura mater on the dorsum sellae of the sphenoid bone, turning over a notch in the bone below the posterior clinoid
process; passing forward within sinus on lateral side of internal carotid a., enters orbit through the lower potion of the
superior orbital fissure; at apex of orbit, passes between the two heads of origin of lateral rectus m., inferior to other nn. in
this location

Sensory

Motor

Autonomic

sympathetic
parasympathetic

o
o

o
o

preganglionics from oculomotor (III)

cilliary ganglion: located between optic nerve and lat. rectus m, ~1cm from post limit of orbit; motor root from inf. br.
of CN III, fibers contained in this root synapse in ciliary ganglion; the sensory root of ganglion is a br. of nasociliary
n. of CN V1; the sympathetic root from the cavernous plexus passes to the ganglion adjacent to the sensory root;
the nerve fibers of both the sensory and sympathetic roots pass through the ganglion WITHOUT synapsing; 6-10
short ciliary nn. leave ant. part of ganglion and course forward above and below optic nerve, to pierce the back of
the eyeball
short ciliary - postganglionic parasympathetics to sphincter pupillae and ciliary muscles of eyeball, postganglionic
sympathetics to dilator pupillae
postganglionic parasympathetics from pterygopalatine ganglion to lacrimal glands; preganglionics from facial, CN
VII, via greater petrosal

5. Identify branches of ophthalmic arteries and veins. (N85, N87, N70, TG7-62, TG7-73)
Ophthalmic a.: branch of the intracranial portion of the internal carotid, as it emerges from the cavernous sinus; passes directly forward
and enters orbit through optic canal, below and lateral to optic nerve; curves across optic nerve toward medial side of orbit, anteriorly;
brs include: Central artery of the retina, Lacrimal, Short posterior ciliary, Supraorbital, Long posterior ciliary, Posterior ethmoidal,
Anterior ciliary, Anterior ethmoidal, Medial palpebral, Supratrochlear (terminal branch), Doral nasal (terminal branch), Muscular brs.

central artery of retina (runs within optic nerve): is the first and one of the smallest branches; arises close to the optic
canal and pierces optic near at the middle of its intraorbital course; accompanied central vein of retina; its brs on retina
are: superior nasal, superior temporal, and inferior nasal and inferior temporal
superior ophthalmic v.: begins in nasofrontal vein, enters orbit through supraorbital foramen (notch), after communicating
with supraorbital vein; has tributaries which correspond to upper branches of ophthalmic a, usually joined by inf.
ophthalmic vein at medial end of sup. orbital fissure; may leave head between two head of lat. rectus or above the
muscular cone; ends in cavernous sinus; DOES NOT CONTAIN VALVES.

Review:

cavernous sinuses: lie on either side of body of sphenoid, extend from sup. orbital fissure (in front) to the apex of petrous
portion of temporal bone (in back); formed between the meningeal and periosteal layers of dura and trabeculae from each
layer cross space, giving it a reticular (cavernous) structure; for more on this review item see page 325 in Woodburne and
Burkel
anterior cranial fossa: limited behind by post borders of lesser wings of sphenoid and groove for optic chiasma; floor is
formed by orbital plates of frontal bone, cribriform plate of ethmoid and lesser wings and fore part of body of sphenoid;
anterior midline is the crest of frontal bone leading to the foramen cecum, through which emissary vein passes from nasal
cavity to beginning of sup. sagittal sinus; for more see page 319-320 WB.

Questions and Answers:

1. Define conjunctival sac. (N81, TG7-58)
See objective 2 above.
2. Define tarsal glands. (N81, TG7-58)
See objective 2 above.
3. What is the flow of lacrimal fluid across the eye? (N82, TG7-58)
Tears secreted from the lacrimal gland moves across eye via blinking, toward the medial canthus and lacrimal lake; drained off by
lacrimal canaliculi; empty into lacrimal sac, then pass through nasolacrimal duct to inferior meatus of nasal cavity
*NOTE: when formed in normal amounts, the amount reaching nose evaporates; it is when the amount is increased (by emotion or
other causes) that it flows from the nose
**NOTE: the parts of the lacrimal apparatus are: lacrimal gland; lacrimal canaliculi; lacrimal sac; nasolacrimal duct
4. Define orbicularis oculi m.: palpebral part vs. orbital part. What are differences? (N26, TG7-30, TG7-57, TG7-58)
The orbital part of orbicularis oculi surrounds the bony orbit, while the palpebral part extends into the lids.
5. What is the attachment of the medial palpebral ligament? (N81, TG7-57)
It attaches to the frontal process of the maxilla and extends into the eyelids to attach to both tarsal plates.
6. Define layers of superior lid. (N81, TG7-58)
Skin, subcutaneous tissue, palpebral part of orbicularis oculi, tarsofascial layer (tarsal plate attached to orbital septum, with tarsal
glands embedded within plates), palpebral conjunctiva.
7. What is the relationship of lacrimal gland to eyelid? (N82, TG7-58B)
The lacrimal gland lies superolaterally in the bony orbit, deep to the conjunctival fornix.
8. Define tarsal plate and attachments. (N81, TG7-57, TG7-58)
The tarsal plates are attached to the medial and lateral palpebral ligaments and the orbital septum.
9. Define orbital septum. (N81, TG7-57)
The orbital septum is a fascial sheet extending from the orbital margins to the tarsal plates within the eyelids.
10. Where does the lacrimal part of orbicularis oculi attach? (N26, TG7-57)
The lacrimal part of orbicularis oculi arises from the lateral wall of the lacrimal sac and the bone posterior to it. It passes into the lids to
insert on the tarsal plates.
10a. What is the action of the lacrimal portion of the orbicularis oculi muscle? (N26, TG7-57)
The lacrimal portion of the orbicularis oculi muscle pulls backward and holds the eyelids close against the eyeball. It also aids in dilating
the lacrimal sac, creating a syphon-like action during blinking.
11. What is the drainage to the lacrimal sac? (N81, N82, TG7-43, TG7-58)
Lacrimal puncta drain the lacrimal fluid through lacrimal canaliculi into the lacrimal sac.
12. What muscles does the trochlear n. (CN IV) supply? (N86, N121, TG7-80)
Trochlear nerve innervates superior oblique muscle, which acts around a trochlea or pulley.
12a. How can you test the action of the superior oblique muscle? (N84, TG7-59)
To test the superior oblique muscle, the patient is asked, first, to direct the gaze medially and then down. By turning the gaze medially,
the inferior rectus is shortened and prevented from performing its other action, turning the gaze down.

13. What is the distribution of anterior ethmoidal branch of the nasociliary nerve (V 1)? (N86, N42, TG7-45, TG7-63)
Supplies twigs to ant. ethmoidal air cells; supplies internal nasal branches to mucosa of septum and nasal wall; ends as the external
nasal br., supplies skin on lower half of the bridge of the nose (more pg 297 WB).
14. Define parts of lacrimal gland. (N82, TG7-58)
The orbital part of lacrimal gland lies in the lacrimal fossa of the orbital plate of the frontal bone. The palpebral part extends down into
the lateral part of the upper lid by wrapping around the lateral margin of the levator palpebrae superioris.
15. What is the relation of lacrimal gland to levator palpebrae sup. aponeurosis? (N82, TG7-58)
The orbital part of the lacrimal gland lies superior to the aponeurosis, while the smaller palpebral part passes around the lateral edge of
the aponeurosis and beneath it.
16.What is the innervation to the two heads of the lateral rectus m.? (N86, N121, TG7-63, TG7-86)
Abducens nerve (CN VI).
17. What are the relations of oculomotor and nasociliary nn. to optic n. and ciliary ganglion? (N86, N121, TG7-63)
The inferior division of the oculomotor nerve sends a short motor root up to the ciliary ganglion, which lies lateral to the optic nerve. The
inferior division then passes anteriorly along the lateral edge of the inferior rectus. Nasociliary sends a branch to reach ciliary ganglion
and then passes anteromedially superior to the optic nerve.
18. Define short ciliary nn. from ciliary ganglion to bulb. (N86, N121, TG7-62, TG7-79)
Short ciliary nerves carry postganglionic parasympathetics and sympathetics and sensory fibers from the ciliary ganglion to the back of
the eyeball.
18b. What does the superior ophthalmic v. drain into? (N85, N104, TG7-61, TG7-73)
Cavernous sinus through the superior orbital fissure.
19. What are the actions of extraocular mm (ant. view?) (N84, TG7-59)
Superior oblique - turns pupil down and out (abducts & depresses)
Inferior oblique - up and out
Superior rectus - up and in
Inferior rectus - down and in
Medial rectus - in
Lateral rectus - out
20. With clinical testing of the mm., what are their actions and innervation? (N84, TG7-59)
See chart and explanation above.
21. How is the sheath (meninges) of optic n. formed? (N87, TG7-64)
The meninges pass through optic canal with the optic nerve.
22. How far does the subarachnoid space extend? (N87, TG7-64)
To the back of the eyeball.

Clinical Case - Eye

A 32 year-old patient presents with septic temperatures, frequent chills, vomiting and intermittent delirium. When lucid, the patient
complains of nausea and severe headache, especially on his right side. The patient's case history indicates that he had developed a
boil on his right lip six days prior. Earlier in the day, the patient's family physician administered penicillin to the patient. As the patient did
not improve, the family physician admitted the patient to the hospital. On physical exam, the patient shows rigidity of his neck muscles,
a sign of meningeal irritation. His right cheek , nose and upper lip are swollen and hard to the touch. There is some oozing pus from
several points along his upper lip. Extraocular muscle testing shows inability to abduct the right eye. The patient is diagnosed with
infectious cavernous sinus thrombosis predicated by staphylococcal infection of the subcutaneous tissue of the upper lip, and partial
extraocular paralysis in his right eye.
Questions to consider:
1. Why would trauma to the cavernous sinus

affect ocular muscle function?

The nerves of each eye that control the extraocular muscles travel directly through (abducens nerve), or are in the walls of
the respective cavernous sinus (oculomotor and trochlear nerves). Thrombotic congestion and edema could lead to
compression damage of the nerves.
2. What anatomical structures facilitate the spread of the infection to the cavernous sinus?
Since veins are valveless, they allow bi-directional flow. If the blood flowed from the labial vein toward the beginning of the
facial vein at the inner angle of the eye, it could then enter the angular vein which communicates with the superior
ophthalmic vein, directly draining into the cavernous sinus. Similarly, the infection could have spread from the labial vein
to the deep facial vein to the pterygoid plexus directly into the cavernous sinus.
3. Discuss a possible course by which the infection spread.
See answer to question two above. Also note that the infection could also spread from the right cavernous sinus to the left
cavernous sinus via the anterior and posterior intercavernous sinuses.
4. Review the innervation to the extraocular muscles. Which nerve and muscle were affected in this patient?
The superior oblique muscle
is innervated by the trochlear nerve (CN IV). The lateral rectus is innervated by
the abducens nerve (CN VI). The oculomotor nerve (CN III) innervates the rest of the extraocular muscles. Since the
patient was unable to abduct his right eye, it was his lateral rectus that was paralyzed. The lateral rectus is innervated by
the abducens nerve (CN VI).

5. If the patient also presented with ptosis,

what muscle and nerve are likely affected?

The eyelid is held up by the levator palpebrae superioris muscle, which is innervated by the oculomotor nerve. Thus
damage to CN III can result in muscle paralysis as well as ptosis. Note that CN III also provides parasympathetic
innervation for the sphincter pupillae muscle of the iris and for the ciliary muscle of accommodation.
Clinical Note: Extraocular muscle testing
Since the actions of the extraocular muscles are complex, it is necessary to turn the eye to a position where a
single action of each muscle predominates when evaluating the individual muscles. For the superior and inferior
recti, turning the eye outward (abduction) by approximately 25 degrees places the superior rectusin position to
raise the eye and the inferior rectus to lower the eye. Similarly, turning the eye inward (adduction) approximately 51
degrees places the inferior oblique in position to raise the eye and the superior oblique to lower the eye.
The medial and lateral recti may be checked while the eye is staring straight ahead since they have simple planar
actions.

A 46-year-old man who had undergone right-sided pneumonectomy for carcinoma of the bronchus was seen by his thoracic surgeon as
a follow-up after the operation. The patient said that he felt fit and was gaining some weight. He noticed that a week ago his right upper
eyelid tended to droop slightly when he was tired at the end of the day. After a careful physical examination, the surgeon noticed that in
addition to the ptosis of the right eye, the patient's right pupil was constricted and that his face was slightly flushed on the right side.
Further examination revealed that the skin on the right side of the face appeared to be warmer and drier than normal. Palpation of the
deep cervical lymph nodes revealed a large hard fixed node just above the right clavicle. The surgeon made the diagnosis of a rightsided Horner's syndrome which happened as a result of tumor metastasis to the right sympathetic cervical trunk.
Questions:
1. How would you explain the right ptosis and pupillary constriction in this case?
The ptosis is due to the interruption of the sympathetic innervation of the levator palpebrae superioris muscle, which
elevates the upper eyelid. Though its major innervation comes from the oculomotor nerve, an injury to its sympathetic
innervation will also result in ptosis that is milder and related, as in this case, to the rhythmic activity of the autonomic
system. Postganglionic sympathetic fibers to the orbit lie on the surface of the internal carotid artery.
The pupillary constriction results from interruption of sympathetic supply to the dilator pupillae muscle of the iris. The
unopposed action of the intact sphinctor pupillae muscle (supplied by parasympathetic innervation from the oculomotor
(CN III) nerve will cause pupillary constriction.

The other skin findings in this case could also be explained by interruption of the sympathetic innervation to sweat glands
and blood vessels.

Practice Quiz - Eye

Below are written questions from previous quizzes and exams. Click here for a Practical Quiz - old format or Practical Quiz - new
format.
1. You are testing the extraocular muscles and their innervation in a patient who periodically experiences double vision. When you
ask him to turn his right eye inward toward his nose and look downward he is able to look inward, but not down. Which nerve is
most likely involved?
Abducens
Nasociliary
Oculomotor, inferior division
Oculomotor, superior division
Trochlear
The correct answer is:

trochlear

To understand this question, you need to understand how the motions of the eye are tested. Since the actions of the extraocular
muscles are complex, it is necessary to turn the eye to a position where a single action of each muscle predominates when
evaluating the individual muscles. A key principle for muscle testing is: if a muscle has two actions and you perform one of those
two, then it can't perform its other action. Superior and inferior recti turn the eye in and up or in and down. Superior and inferior
oblique turn the eye out and down or out and up. So, if you turn your eye in (with the superior and inferior rectus as well as
medial rectus), then only superior and inferior oblique can move the eye down or up (because the superior and inferior recti are
already shortened by turning the eye in - they can't shorten any more). Similarly, if you turn the gaze out (with the obliques and
lateral rectus) then only superior and inferior rectus can turn the eye up or down.
In this case, the patient has the eye turned inward, so the doctor must be testing the oblique muscles. The superior oblique
muscle is the muscle that lowers the eye when it is turned inward. Since the patient can't do this, the superior oblique must not
be functioning, and this muscle is innervated by the trochlear nerve.
Abducens (CN VI) innervates the lateral rectus muscle, which is not involved in the eye test. The nasociliary nerve comes from
the ophthalmic division of the trigeminal nerve (V1). It is a sensory nerve to the eyeball that also carries some sympathetic fibers.
The inferior division of the oculomotor nerve innervates inferior rectus, inferior oblique, and medial rectus. All of these muscles

appear to be functioning. Finally, the superior division of the oculomotor nerve innervates levator palpebrae superioris and
superior rectus. These are not the muscles that appear to be malfunctioning.

2. The outermost layer of the optic nerve sheath is a continuation of the:

Arachnoid membrane
Meningeal dura
Periosteal dura
Pia mater
Retina

The correct answer is:

meningeal dura

The optic nerve comes off the base of the brain and passes through the optic canal. As it leaves the brain, it still retains all of the
meningeal layer coverings. So, it is covered by meningeal dura, arachnoid membrane, and pia mater. This is significant, because an
increase in intracranial pressure will increase the pressure in the subarachnoid space. This may squeeze the optic nerve and make the
optic nerve bulge into the eye, a condition known as papilledema.
The periosteal dura is the layer of periosteum covering the internal surface of the calvaria. The retina is the inner layer of the
eyeball which receives and absorbs visual light rays.
3. The inner lining of the eyelid is called the:
Orbital septum
Palpebral conjunctiva
Periorbita
Sclera
Tarsal plate

The correct answer is:

palpebral conjunctiva

The palpebral conjunctiva is the thin membrane that lines the eyelid. It is continuous with the bulbar conjunctiva which lines the
eyeball. The orbital septum is a weak membrane that spans from the tarsal plates to the margins of the orbit where it becomes
continuous with the periosteum. It contains orbital fat and can limit the spread of infection in the orbit. The periorbita is the periosteum
lining covering the bones forming the orbit. The sclera is the outer fibrous layer of the eyeball. Finally, the tarsal plate is a thin,
cardboard-like layer of connective tissue in the eyelids which forms the "skeleton" of the eyelids.
4. What would the examining physician notice in the eye of a person who has taken a sympathetic blocking agent?
Exophthalmos and dilated iris
Enophthalmos and dry eye
Dry eye and inability to accommodate for reading
Wide open eyelids and loss of depth perception
Ptosis and miosis (pin-point pupil)

The correct answer is:

Ptosis and miosis (pin-point iris)

Start this question out by thinking about what a sympathetic blocker would do to the pupil of the eye. Since sympathetic nerves
allow the pupil to dilate, a sympathetic blocker would stop the eye from dilating and make the pupil constrict. Now think about the other
issues. First, remember that sympathetic nerves innervate the superior tarsal muscle, which elevates the eyelids. If there is a problem
with the regional sympathetics (as is the case with Horner's syndrome), the superior tarsal muscle will be paralyzed, and the eyelid will
droop (ptosis). If the sympathetic nervous system is inhibited, sweating will cease, and you will observe the eye sinking back into the
orbit.
Accomodation is not mediated by the sympathetic system; accomodation is a function of parasympathetic nerve so this should not
be affected. Finally, the lacrimal gland is innervated by parasympathetics, so there should not be a major change in eye secretions after
a sympathetic blocker. Putting all of these factors together, answer choice E is the only one that fits!

5. You are examining a patient who has a pituitary tumor involving the cavernous sinus. While doing a preliminary eye exam, you
suspect the right abducens nerve of the patient has been damaged by the tumor. In which direction would you have the patient
turn his right eye to confirm the defect?
Inward
Outward
Downward
Down and out
Down and in
Upward
Up and out
Up and in

The correct answer is:

outward

To understand this question, you need to understand how the motions of the eye are tested. Since the actions of the extraocular
muscles are complex, it is necessary to turn the eye to a position where a single action of each muscle predominates when evaluating
the individual muscles. For the superior and inferior recti, turning the eye outward (abduction) by approximately 25 degrees places the
superior rectus in position to raise the eye and the inferior rectus to lower the eye. Similarly, turning the eye inward (adduction)
approximately 50 degrees places the inferior oblique in position to raise the eye and the superior oblique to lower the eye. The medial
and lateral recti may be checked while the eye is staring straight ahead since they have simple planar actions.
In this case, you're interested in testing an "easy" muscle. Since the lesion appears to be in the abducens, which innervates the
lateral rectus muscle, you could just ask the patient to turn the eye outward. If the patient could not do this, it would confirm that there
was a lesion in the abducens nerve, since the muscle responsible for lateral movement of the eye would be paralyzed.
Also remember--a tumor in the cavernous sinus could affect many nerves. The oculomotor nerve (CN III), trochlear (CN IV),
ophthalmic division of trigeminal (CN V1), and abducens (CN VI) all pass through the cavernous sinus.

6. You have a patient with a drooping right eyelid. You suspect Horner's syndrome. Which of the following signs on the right side
would confirm this diagnosis?
Constricted pupil
Dry eye (lack of tears)
Exophthalmos
Pale, blanched face
Sweaty face

The correct answer is:

constricted pupil

Horner's syndrome is a disorder involving damage to the sympathetic trunk in the neck. This means that the sympathetics of the
head will be disrupted. This causes a variety of very characteristic symptoms, including a constricted pupil. Remember--sympathetic
nerves innervate the dilator pupillae muscle. This muscle allows the eye to dilate. If these sympathetic nerves are lost, the pupil will
contract.
Several of the other listed symptoms are the opposite of what you would expect with Horner's syndrome. Exophthalmos is the
protrusion of the eye, but in Horner's syndome the eye sinks in, possibly due to the paralysis of a smooth muscle in the floor of the orbit.
The face does not become blanched and sweaty with Horner's syndrome--instead, it becomes red and dry. Without the sympathetic
nerve supply, the vasculature of the face cannot constrict. So, the arterioles in the patient's face are vasodilated, making the face red.
Sympathetic nerves also innervate sweat glands; if these nerves are interrupted, the patient will not sweat and the face will appear very
dry. Finally, the lacrimal gland is innervated by parasympathetics, not sympathetics. So, Horner's syndrome should produce no
appreciable changes in tearing.
Make sure to know the different symptoms and signs of Horner's syndrome!

7. Following endarterectomy on the right common carotid, a patient is found to be blind in the right eye. It appears that a small
thrombus embolized during surgery and lodged in the artery supplying the optic nerve. What artery would be blocked?
Central artery of the retina
Infraorbital
Lacrimal
Nasociliary
Supraorbital

The correct answer is:

Central artery of the retina

The central artery of the retina is a branch of the ophthalmic artery. It is the sole blood supply to the retina; it has no significant
collateral circulation and blockage of this vessel leads to blindness. The branches of this artery are what you view during a fundoscopic
exam. The infraorbital artery is a branch of the maxillary artery. It comes through the infraorbital foramen, inferior to the eye. It supplies
the maxillary sinus, the maxillary incisors, canine and premolar teeth, and the skin of the cheek below the orbit. The supraorbital artery
is another branch of the ophthalmic artery. It comes through the supraorbital foramen or notch and supplies blood to the muscles, skin
and fascia of the forehead. The lacrimal artery is a branch of the ophthalmic artery that supplies the lacrimal gland. The nasociliary
artery doesn't exist, but there is a nasociliary nerve (the third and lowest branch of the ophthalmic division) that travels with the
continuation of the ophthalmic artery.
8. You are asked to check the integrity of the trochlear nerve in the right eye of a patient. Starting with the eyes directed straight
ahead, you would have the patient look:
Inward, toward the nose and downward
Inward, toward the nose and upward
Toward the nose in a horizontal plane
Laterally in a horizontal plane
Outward, away from the nose and downward
Outward, away from the nose and upward

The correct answer is:

Inward, toward the nose and downward

To understand this question, you need to understand how the motions of the eye are tested. Since the actions of the extraocular
muscles are complex, it is necessary to turn the eye to a position where a single action of each muscle predominates when evaluating
the individual muscles. To test the superior and inferior recti, a patient needs to turn the eye outward approximately 25 degrees. At this
postion, the superior rectus will simply act to raise the eye, and the inferior rectus will lower the eye. To test the superior and inferior
obliques, a patient needs to turn the eye inward approximately 50 degrees. When the eye is in this position, the superior oblique muscle
will act to lower the eye, and the inferior oblique will act to raise the eye.
So, now that you understand how to the test the eye, you have to decide which muscle is innervated by the trochlear nerve. And
that's the superior oblique. So, to test this muscle, the eye needs to turn inward (toward the nose) and downward.
What nerves innervate the other muscles? The abducens nerve (CN VI) innervates the lateral rectus muscle. The oculomotor
nerve (CN III) innervates the superior rectus, inferior rectus, medial rectus, and inferior oblique muscles.
9. The ducts of the lacrimal gland open into the:
Superior fornix of the conjunctiva
Inferior fornix of the conjunctiva
Lacrimal puncta
Lacrimal canaliculi
Lacrimal lake

The correct answer is:

Superior fornix of the conjunctiva

Lacrimal fluid is produced by the lacrimal gland, which lies in a fossa in the superolateral part of each orbit. The fluid from this
gland enters the conjunctival sac through up to 12 lacrimal ducts that open into the superior conjunctival fornix. The tears then flow to
the medial angle of the eye and collect in the lacrimal lake. The lacrimal papilla are small elevations on the eyelids, found near the
lacrimal lake. These papillae have small openings called the lacrimal puncta; tears flow from the lacrimal lake into these puncta. From
there, the lacrimal fluid goes into small canniliculi which drain the fluid into the lacrimal sac. The lacrimal sac continues on as the
nasolacrimal duct and drains tears into the inferior nasal meatus. Take a look at Netter Plate 77 and try to follow the path of tears from
the lacrimal gland to the inferior meatus!

10. Starting from a position gazing straight ahead, to direct the gaze downward, the inferior rectus muscle must be active along with
the:
Superior oblique
Inferior oblique
Medial rectus
Lateral rectus
Superior rectus

The correct answer is:

Superior Oblique

The inferior rectus muscle depresses the eye and medially rotates it. So, to direct the gaze downward, you want to find a muscle
that will depress the eye while counterbalancing the medial rotation with lateral rotation. And, the superior oblique, innervated by the
trochlear nerve (CN IV), does just that--it depresses the eye while laterally rotating it. The inferior oblique muscle laterally rotates the
eye and elevates the eye. The medial rectus adducts the eye--it does not raise or lower the eye. The lateral rectus abducts the eye--it
also does not raise or lower the eye. Finally, the superior rectus elevates the eye and draws it medially.
11. During a physical examination it is noted that a patient has ptosis. What muscle must be paralyzed?
Orbicularis oculi, lacrimal part
Orbicularis oculi, palpebral part
Stapedius
Superior oblique
Superior tarsal (smooth muscle portion of levator palpebrae)

The correct answer is:

Superior tarsal

The superior tarsal muscle is a smooth muscle which is sympathetically innervated. It is an involuntary muscle that elevates the
eyelid. It is innervated by the cervical sympathetic trunk, and this muscle's functioning provides a good indication of the integrity of the

cervical sympathetic trunk. If the cervical sympathetic trunk has been damaged, a patient will have ptosis, a droopy eyelid. Orbicularis
oculi is innervated by the facial nerve. If this muscle is paralyzed, the problem won't be a droopy eyelid--instead, the patient won't be
able to close the eyelid. This is why patients with Bell's palsy are prescribed lubricating eye drops--if they can't close the eyelid, they
may be at risk for corneal irritation. Stapedius is another muscle innervated by the facial nerve -- it serves to dampen the vibrations of
the stapes and the tympanic membrane. Finally, the superior oblique muscle depresses the eyeball and turns it laterally. It does not
affect the eyelid.
12. The extraocular muscle that does not originate at or near the apex of the orbit is the :
Inferior oblique
Inferior rectus
Levator palpebrae superioris
Superior oblique
Superior rectus

The correct answer is:

Inferior oblique

The inferior oblique muscle does not originate at the apex of the orbit. It takes origin from the floor of the orbit, lateral to the
lacrimal groove. The inferior rectus and superior rectus muscles take origin from the common tendinous ring at the apex of the orbit.
The levator palpebrae superioris takes origin from the apex of the orbit above the optic canal. The superior oblique muscle takes origin
from the apex of the orbit, above the optic canal. For a picture of this, see Netter Plate 79.

13. An adolescent boy suffers from severe acne. As is often the case he frequently squeezed the pimples on his face. He
subsequently develops a fever and deteriorates into a confused mental state and drowsiness. He is taken to his physician and
after several tests a diagnosis of cavernous sinus infection and thrombosis is made. The route of entry to the cavernous sinus
from the face was most likely the:
Carotid artery
Mastoid emissary vein
Middle meningeal artery
Ophthalmic vein
Parietal emissary vein

The correct answer is:

Ophthalmic vein

The ophthalmic veins are continuous with the facial vein and the pterygoid plexus of veins. These veins drain the face toward the
cavernous sinus. They are valveless, so infections from the face can drain into the cavernous sinus. Besides causing fever and
confusion, thrombotic congestion and edema in the cavernous sinus can compress the nerves that traverse that space to exit through
the superior orbital fissure(CN III, CN IV, CN V1, and CN VI). This can affect the function of the ocular muscles, so one symptom of a
cavernous sinus infection might be an inability to perform different eye movements.
The carotid artery and middle meningeal artery would not be the source of the infections. Infections do not tend to enter through
arterial circulation. Remember--the common carotid is the major source of blood to the head and neck, and the middle meningeal artery
is the branch of the maxillary artery that supplies blood to the dura. The emissary veins are valveless veins of the scalp. These veins
can carry blood from the scalp to the dural venous sinuses or in the reverse direction depending on blood pressure. These veins may
carry infectious materials from the scalp into the dural venous sinuses, but they are not important for carrying infections to the
cavernous sinus.

14. If a person looking inward towards their nose is unable to look down, which nerve may be injured?
Abducens (CN VI)
Inferior division of oculomotor (III)
Optic (II)
Superior division of oculomotor (III)
Trochlear (IV)

The correct answer is:

Trochlear (IV)

To understand this question, you need to understand how to evaluate the muscles of the eye. Since the actions of the extraocular
muscles are complex, it is necessary to turn the eye to a position where a single action of each muscle predominates. To isolate the
superior and inferior recti, the patient needs to turn the eye outward by approximately 25 degrees. This places the superior rectus in
position to raise the eye and the inferior rectus in position to lower the eye. Turning the eye inward approximately 50 degrees places the
inferior oblique in position to raise the eye and the superior oblique in position to lower the eye. The medial and lateral recti are the easy
muscles -- they may be checked while the eye is staring straight ahead since they have simple planar actions
So, this patient is looking inward, which means that the obliques are being tested. The patient can't look downward, which shows
that the superior oblique is not functional. This is the only muscle innervated by the trochlear nerve (CN IV).
Abducens (CN VI) innervates the lateral rectus muscle, which is tested by asking the patient to move the eye outward. The inferior
division of the oculomotor nerve innervates inferior rectus, inferior oblique, and medial rectus. The superior branch of the oculomotor
nerve innervates levator palpebrae superioris and superior rectus muscles. Finally, the optic nerve (CN II) provides the special sense of
vision, and it is not tested in the eye-movement tests.
Are you getting the idea that you really need to know about testing the eye muscles? Take the time and really understand this
concept--you'll be glad that you did!

15. If a person is taking a sympathetic blocking agent, what would you notice in her or his eyes?
Dry eyes and inability to accommodate for reading
Enophthalmos and teary eyes (III)
Exophthalmos and dilated pupil
Ptosis and constricted pupil
Wide open eyes and loss of depth perception (IV)

The correct answer is:

Ptosis and constricted pupil

To understand this question, it's important to look at all the different choices and determine which ones fit with a sympathetic
block. First, the lacrimal gland is innervated parasympathetically, so a sympathetic blocker should have no effect on eye secretions.
Accomodation is also a function of the parasympathetic nervous system; it should not be altered by a sympathetic blocker.
Enophthalmos is the name for the eye sinking into its orbit. A sympathetic block does cause enophthalmos, due to the paralysis of a
smooth muscle in the floor of the orbit. Exophthalmos is the opposite of enophthalmos--it is the protrusion of the eye from the orbit. You
would not see exophthalmos with a sympathetic blockade. Sympathetic nerves allow the eye to dilate--if you blocked these nerves, the
eye would constrict. A sympathetic blocker would also cause ptosis--it would paralyze the superior tarsal muscle, which holds the lids
up involuntarily and receives sympathetic innervation. Finally, the sympathetic blocker should not affect depth perception. If you put all
of these things together, answer choice D is the correct one.
If it helps to remember, taking a sympathetic blocking agent will lead to similar symptoms in the head and neck as Horner's
syndrome, a disease characterized by a loss of sympathetic innervation to the head and neck.