بسم الله الرحمن الرحيم

Orbital region (I) Eyelids, lacrimal apparatus and orbital muscles O OO Orbital region (I) E EE Eyelids, lacrimal apparatus and orbital muscles College of medicine in Al-AhsaCollege of medicine in Al-Ahsa King Faisal University King Faisal University Dr. Mohammad Bahgat (1431 – 1432 H) Dr. Mohammad Bahgat (1431 – 1432 H)

Objectives By the end of this lecture, you are expected to: 1- Know the anatomical features of the eyelids. 2- Know the anatomical features of the lacrimal apparatus. 3- Know the anatomical features of the orbital muscles. 4- Use anatomical knowledge to understand and explain clinical features resulting from clinical features resulting from paralysis of the orbital muscles. paralysis of the orbital muscles.

Dr. Bahgat lacus lacrimalis Lateral angle Medial angle Palpebral fissure

Eyelids The eyelids are placed in front of the eyes to The eyelids are placed in front of the eyes to protect them from injury and excessive light. protect them from injury and excessive light. When the eye is opened, the space between the eyelids is called When the eye is opened, the space between the eyelids is called the palpebral fissure. the palpebral fissure. The eyelids meet each other at the medial and lateral angles. The eyelids meet each other at the medial and lateral angles. The lateral angle of the palpebral fissure is acute and The lateral angle of the palpebral fissure is acute and lies in contact with the eyeball. lies in contact with the eyeball. The medial angle is more rounded and is separated from the eyeball by The medial angle is more rounded and is separated from the eyeball by a small space called lacus lacrimalis. a small space called lacus lacrimalis. The upper eyelid is larger and more mobile than the lower eyelid. The upper eyelid is larger and more mobile than the lower eyelid. The upper eyelid covers the cornea completely when the eye is closed, and covers its upper margin when the eye is opened. The upper eyelid covers the cornea completely when the eye is closed, and covers its upper margin when the eye is opened. The lower eyelid lies below the cornea when the eye is opened and The lower eyelid lies below the cornea when the eye is opened and rises only slightly when the eye is closed. rises only slightly when the eye is closed.

Dr. Bahgat Conjunctiva 3- Tarsus 2- Orbicularis oculi muscle Skin 1- Skin Layers of the eyelid

Dr. Bahgat Sagittal section of the upper eyelid I- Skin II- Orbicularis oculi M III- Tarsus VI- Conjunctiva Anterior Posterior The subtarsal sulcus Layers of the eyelid

Dr. Bahgat Sagittal section of the upper eyelid The glands related to the eyelids 1- Sebaceous glands (of Zeis): open into the eyelash follicles.

Dr. Bahgat 2- Ciliary glands (of Moll): modified sweat glands open between the eyelashes. The glands related to the eyelids

Dr. Bahgat modified sebaceous glands open onto They open onto the eyelashes Tarsal glands The glands related to the eyelids Their secretion prevents the overflow of tears and makes the closed eyelids airtight. that pour their oily secretion onto the margin of the lid. The lid margin behind

Eyelids - The eyelids consist of the following layers - The eyelids consist of the following layers from superficial to deep aspect: from superficial to deep aspect: 1- Skin. 2- Orbicularis oculi muscle. 1- Skin. 2- Orbicularis oculi muscle. 3- Tarsus. 4- Conjunctiva. 3- Tarsus. 4- Conjunctiva. - The eyelashes are present on the free edge and arranged in - The eyelashes are present on the free edge and arranged in double or triple rows at the mucocutaneous junction. double or triple rows at the mucocutaneous junction. - The glands related to the eyelids are: - The glands related to the eyelids are: 1- Sebaceous glands (of Zeis): 1- Sebaceous glands (of Zeis): open into the eyelash follicles. open into the eyelash follicles. 2- Ciliary glands (of Moll): 2- Ciliary glands (of Moll): modified sweat glands open between the eyelashes. modified sweat glands open between the eyelashes. 3- Tarsal glands: 3- Tarsal glands: modified sebaceous glands that pour their oily secretion onto modified sebaceous glands that pour their oily secretion onto the margin of the lid. They open behind the eyelashes. the margin of the lid. They open behind the eyelashes. Their secretion prevents the overflow of tears and Their secretion prevents the overflow of tears and makes the closed eyelids airtight. makes the closed eyelids airtight.

Dr. Bahgat The superior tarsal plate The tarsi are dense fibrous plates The lateral ends of the tarsal plates are attached by the lateral palpebral ligament to a bonny tubercle just within the orbital margin within the orbital margin The medial ends of the tarsal plates the medial palpebral ligament to the anterior lacrimal crest (frontal process of the maxilla). The inferior tarsal plate are attached by connected to The aponeurosis of pierces the orbital septum to reach the anterior surface of the superior tarsal plate The tarsal plates the orbital margin by the levator palpebrae superioris fibrous orbital septa the lacrimal sac

Tarsi and palpebral ligaments - The tarsi are dense fibrous plates connected to - The tarsi are dense fibrous plates connected to the orbital margin by fibrous orbital septum. the orbital margin by fibrous orbital septum. - The lateral ends of the tarsal plates are attached by - The lateral ends of the tarsal plates are attached by the lateral palpebral ligament to a bonny tubercle the lateral palpebral ligament to a bonny tubercle just within the orbital margin. just within the orbital margin. - The medial ends of the tarsal plates are attached - The medial ends of the tarsal plates are attached by the medial palpebral ligament to by the medial palpebral ligament to the anterior lacrimal crest (frontal process of the maxilla). the anterior lacrimal crest (frontal process of the maxilla). - The tarsal glands are embedded in the - The tarsal glands are embedded in the posterior surface of the tarsal plates. posterior surface of the tarsal plates. - The outer surface of the orbital septum and tarsal plates are covered by - The outer surface of the orbital septum and tarsal plates are covered by the palpebral fibers of the orbicularis occuli muscle. the palpebral fibers of the orbicularis occuli muscle. - The aponeurosis of the levator palpebrae superioris pierces the - The aponeurosis of the levator palpebrae superioris pierces the orbital septum to reach the anterior surface of the superior tarsal plate. orbital septum to reach the anterior surface of the superior tarsal plate.

Dr. Bahgat Sagittal section of the upper eyelid VI- Conjunctiva Anterior Posterior It is reflected from the eyelid To form The fornix The conjunctival sac to the eyeball to the eyeball is a thin mucous membrane that lines the inner surface of the eyelids. Its epithelium is continuous with the corneal epithelium. The subtarsal sulcus

Dr. Bahgat Sagittal section of the eye & eyelids Anterior Posterior The conjunctival sac Palpebral Conjunctiva is reflected from the eyelid is reflected from the eyelid to the eyeball to the eyeball to form to form Bulbar Conjunctiva The angles between The angles between Palpebral Conjunctiva And Bulbar Conjunctiva form form Superior fornix and inferior fornix Its epithelium is continuous with the corneal epithelium.

Dr. Bahgat Sagittal section of the upper eyelid The conjunctival sac The conjunctiva thus forms a potential space called the conjunctival sac This sac is closed when the eye is closed and it opens through the palpebral fissure when the eye is opened

Dr. Bahgat Sagittal section of the upper eyelid The subtarsal sulcus This sulcus traps small foreign particles that may enter the conjunctival sac So it is clinically important is a groove on the inner surface of the eyelid parallel and close to the lid margin

Conjunctiva - The conjunctiva is a thin mucous membrane - The conjunctiva is a thin mucous membrane that lines the inner surface of the eyelids. that lines the inner surface of the eyelids. It is reflected onto the eyeball at the superior and inferior fornices. superior and inferior fornices. Its epithelium is continuous with the corneal epithelium. - The conjunctiva thus forms a potential space called the conjunctival sac. the conjunctival sac. This sac is closed when the eye is closed, and This sac is closed when the eye is closed, and it opens through the palpebral fissure when the eye is opened. it opens through the palpebral fissure when the eye is opened. - The subtarsal sulcus is - The subtarsal sulcus is a groove on the inner surface of the eyelid a groove on the inner surface of the eyelid parallel and close to the lid margin. parallel and close to the lid margin. This sulcus traps small foreign particles This sulcus traps small foreign particles that may enter the conjunctival sac that may enter the conjunctival sac and is thus clinically important. and is thus clinically important.

Dr. Bahgat lacus lacrimalis lacrimal caruncle plica semilunaris lacrimal papilla lacrimal punctum leading to lacrimal canaliculus Lateral angle Medial angle The conjunctival sac

- At the medial angle of the palpebral fissure, - At the medial angle of the palpebral fissure, there is a depression called lacus lacrimalis. there is a depression called lacus lacrimalis. The lacus lacrimalis contains a small reddish yellow elevation called lacrimal caruncle a small reddish yellow elevation called lacrimal caruncle and a reddish semilunar fold called plica semilunaris lying and a reddish semilunar fold called plica semilunaris lying on the lateral side of the caruncle. on the lateral side of the caruncle. - Near the medial end of the margin of the eyelid, - Near the medial end of the margin of the eyelid, there is a small elevation called lacrimal papilla. there is a small elevation called lacrimal papilla. - On the summit of the papilla, - On the summit of the papilla, there is a small hole called lacrimal punctum leading to there is a small hole called lacrimal punctum leading to a small canal called lacrimal canaliculus. a small canal called lacrimal canaliculus. This canaliculus carries the tears into the lacrimal sac This canaliculus carries the tears into the lacrimal sac

Dr. Bahgat Lacrimal apparatus Lacrimal gland Lacrimal punctum lacrimal canaliculus lacrimal canaliculus the lacrimal sac Nasolacrimal duct

Dr. Bahgat Lacrimal gland secretes tears into the superior fornix Tears collect in the lacus lacrimalis and enter the lacrimal canaliculi through the puncta Canaliculi drain into the lacrimal sac Nasolacrimal duct drains tears into The inferior meatus of the nasal cavity Lacrimal apparatus (flow of tears)

Dr. Bahgat Flow of Tears Lacrimal gland 2- Excretory ducts 3- Surface of eye 4- lacus lacrimalis 5- Lacrimal punctum 6- Lacrimal canaliculus 7- Lacrimal sac 8- Nasolacrimal duct 9- Nasal cavity 6

Lacrimal apparatus This system consists of: This system consists of: I- Lacrimal gland. I- Lacrimal gland. I- The lacrimal gland: It lies in the anterolateral part of the roof of the orbit above the eyeball. It lies in the anterolateral part of the roof of the orbit above the eyeball. It consists of large orbital part (superior) It consists of large orbital part (superior) and small palpebral part (inferior) continuous together around the lateral margin of continuous together around the lateral margin of the aponeurosis of the levator palpebrae superioris muscle. the aponeurosis of the levator palpebrae superioris muscle. The gland has about ducts. These ducts open into the upper lateral part of the conjunctival sac. These ducts open into the upper lateral part of the conjunctival sac. II- Lacrimal ducts: 1- Puncta lacrimalia. 1- Puncta lacrimalia. 2- Lacrimal canaliculi. 2- Lacrimal canaliculi. 3- Lacrimal sac. 3- Lacrimal sac. 4- Nasolacrimal duct. 4- Nasolacrimal duct.

Lacrimal fluid - The lacrimal gland secretes tears into the conjunctival sac. - The lacrimal gland secretes tears into the conjunctival sac. - The tears circulate across the cornea and accumulate in the lacus lacrimalis. - The tears circulate across the cornea and accumulate in the lacus lacrimalis. From here the tears enter the lacrimal canaliculi through the puncta lacrimalia. -The lacrimal canaliculi pass medially and open into the lacrimal sac. -The lacrimal canaliculi pass medially and open into the lacrimal sac. - The lacrimal sac lies in the lacrimal groove - The lacrimal sac lies in the lacrimal groove (in the anterior part of the medial wall of the orbit) behind (in the anterior part of the medial wall of the orbit) behind the medial palpebral ligament. the medial palpebral ligament. - The lacrimal sac is continuous below with - The lacrimal sac is continuous below with the nasolacrimal duct. the nasolacrimal duct. This duct is 0.5 inch long and descends This duct is 0.5 inch long and descends downward, backward and laterally in an osseous canal and opens into downward, backward and laterally in an osseous canal and opens into the anterior part of the inferior meatus of the nose. the anterior part of the inferior meatus of the nose. This opening is guarded by a fold of mucous membrane This opening is guarded by a fold of mucous membrane known as lacrimal fold. It prevents air from being known as lacrimal fold. It prevents air from being forced up into the lacrimal sac on blowing the nose. forced up into the lacrimal sac on blowing the nose.

Parasympathetic supply of the lacrimal gland Preganglionic fibers the lacrimatory nucleus in the pons The facial nerve The greater petrosal nerve Unites with The deep petrosal nerve To form The nerve of pterygoid canal the pterygopalatine ganglion Then pass to postganglionic fibers the maxillary nerve zygomatic nerve zygomaticotemporal nerve Then communication to lacimal nerve to reach the lacrimal gland. pass to pass to

Dr. Bahgat Nerve supply of the lacrimal gland postganglionic fibers the maxillary nerve zygomatic nerve zygomaticotemporal nerve Then communication to to reach the lacrimal gland. The lacimal nerve

Dr. Bahgat Lacrimal nerve Zygomatic nerve Zygomaticotemporal Nerve supply of the lacrimal gland Then communication to postganglionic fibers Lacrimal gland to reach

Lacrimal apparatus Its parasympathetic supply is derived from the lacrimal nucleus of the facial nerve (in the pons). the lacrimal nucleus of the facial nerve (in the pons). The preganglionic fibers pass along the facial nerve greater petrosal nerve pass along the facial nerve greater petrosal nerve nerve of pterygoid canal to reach the pterygopalatine ganglion. pterygopalatine ganglion. The postganglionic fibers pass along the maxillary nerve zygomatic nerve pass along the maxillary nerve zygomatic nerve zygomaticotemporal nerve then lacimal nerve to reach zygomaticotemporal nerve then lacimal nerve to reach the lacrimal gland. the lacrimal gland.

Orbital muscles

Dr. Bahgat Walls of the Orbit Roof lateral lateral medial medial orbital plate of frontal bone Lateral wall lesser wing of sphenoid Zygomatic bone Medial wall greater wing of sphenoid frontal process of the maxilla frontal process of the maxilla lacrimal bone lacrimal bone orbital plate ofethmoid bone orbital plate of ethmoid bone Floor body of the sphenoid body of the sphenoid orbital plate of maxilla Zygomatic bone Orbital process of palatine bone Orbital process of palatine bone

Dr. Bahgat Features of the Orbit lateral lateral medial medial Roof Lacrimal fossa Optic canal Optic canal Medial wall Lacrimal groove Anterior ethmoid foramen Posterior ethmoid foramen Floor Infraorbital groove Infraorbital canal Infraorbital foramen Superior orbital fissure Roof Lateral wall Inferior orbital fissure Floor

Dr. Bahgat The Orbital muscles 2 oblique muscles orbital muscles The orbital muscles are Levator palpebrae superioris The 4 recti muscles superior rectus inferior rectus medial rectus lateral rectus superior oblique inferior oblique medial lateral

Muscles of the orbit The orbital muscles are: 1- Levator palpebrae superioris. 1- Levator palpebrae superioris recti muscles: 2- 4 recti muscles: - superior rectus - superior rectus - inferior rectus - inferior rectus - medial rectus - medial rectus - lateral rectus - lateral rectus 3- 2 oblique muscles: 3- 2 oblique muscles: - superior oblique - superior oblique - inferior oblique - inferior oblique

Dr. Bahgat Orbital muscles (origin) The 4 recti muscles Originate from the common tendinous ring Superior Rectus Medial Rectus Inferior Rectus Lateral Rectus (2 heads) Levator palpebrae superioris Originates from From the lower surface of the lesser wing of sphenoid bone (posterior part of the roof of the orbit). Inferior Oblique Originates from From the anteromedial part of the floor of the orbit lateral lateral medial medial

Dr. Bahgat Orbital muscles (origin) The 4 recti muscles Originates from The common tendinous ring Originates from the anteromedial part of the floor of the orbit Originates from The body of the sphenoid bone The superior oblique oblique The inferior oblique

Dr. Bahgat Orbital muscles (insertion) The recti muscles Are inserted into In front of the equator of the eyeball The oblique muscles Are inserted into behind the equator of the eyeball Levator palpebrae superioris the sclera

Nerve supply Muscle Lateral Rectus* Superior Rectus Medial Rectus Inferior Rectus Inferior Oblique Superior Oblique* Nerve supply CN VI – Abducent CN III CN IV - Trochlear Oculomotor CN III Levator palpebrae superioris Inferior division Oculomotor Superior division

Levator palpebrae superioris

Dr. Bahgat Cut end (origin) Cut end (insertion) (dilator) Levator palpebrae superioris Levator palpebrae superioris m. Orbital Roof is removed (seen from above) Superior rectus Superior oblique

Dr. Bahgat Levator palpebrae superioris m.

Dr. Bahgat Levator palpebrae superiorismuscle (origin) Levator palpebrae superioris muscle (origin) Levator palpebrae superioris Originates from the lower surface of the lesser wing of sphenoid bone (posterior part of the roof of the orbit). lateral lateral medial medial

Dr. Bahgat Levator palpebrae superioris Is inserted into The superior tarsal plate

Dr. Bahgat Its tendon forms a wide aponeurosis which splits into two lamellae The superior lamella contains striated muscle fibers To be inserted into the anterior surface of the superior tarsal plate and the skin of the upper eyelid The inferior lamella contains smooth muscle fibers It is inserted into the upper border of the superior tarsal plate It pierces the orbital septum Levator palpebrae superiorismuscle (insertion) Levator palpebrae superioris muscle (insertion)

Dr. Bahgat Levator palpebrae superiorismuscle (nerve supply) Levator palpebrae superioris muscle (nerve supply) Nerve supply: Superior lamella by superior division of oculomotor nerve oculomotor nerve Inferior lamella by sympathetic fibers derived from the superior cervical sympathetic ganglion.

Dr. Bahgat Sagittal section of the eye Aponeurosis of Levator palpebrae superioris Action: Elevation of the upper eyelid sympathetic stimulation results in further elevation of the upper eyelid To open the palpebral fissure the palpebral fissure

Levator palpebrae superioris Origin: Origin: From the lower surface of the From the lower surface of the lesser wing of sphenoid bone lesser wing of sphenoid bone ( posterior part of the roof of the orbit). ( posterior part of the roof of the orbit). Insertion: Insertion: - Its tendon forms - Its tendon forms a wide aponeurosis which splits a wide aponeurosis which splits into two lamellae. into two lamellae. - The superior lamella: - The superior lamella: (contains striated muscle fibers) (contains striated muscle fibers) is inserted into the anterior surface is inserted into the anterior surface of the superior tarsal plate and of the superior tarsal plate and the skin of the upper eyelid. the skin of the upper eyelid. - The inferior lamella: - The inferior lamella: contains smooth muscle fibers. It is inserted into the upper border It is inserted into the upper border of the superior tarsal plate. of the superior tarsal plate. Nerve supply: Nerve supply: Superior lamella by superior division of oculomotor nerve. Superior lamella by superior division of oculomotor nerve. Inferior lamella by Inferior lamella by sympathetic fibers derived sympathetic fibers derived from the superior cervical sympathetic ganglion. from the superior cervical sympathetic ganglion. Action: Action: - Elevation of the upper eyelid. - Elevation of the upper eyelid. - sympathetic stimulation - sympathetic stimulation results in further elevation results in further elevation of the upper eyelid. of the upper eyelid. - Injury of oculomotor nerve or - Injury of oculomotor nerve or sympathetic supply leads to sympathetic supply leads to dropping of the upper eyelid dropping of the upper eyelid (ptosis). (ptosis).

Recti muscles

Dr. Bahgat Recti muscles (origin) The 4 recti muscles Originate Originate from the common tendinous ring Superior Rectus Medial Rectus Inferior Rectus Lateral Rectus (2 heads) lateral lateral medial medial

Dr. Bahgat Recti muscles (insertion) The recti muscles Are inserted into In front of the equator of the eyeball the sclera the sclera

Dr. Bahgat Nerve supply of recti muscles superior rectus Superior division of oculomotor Medial rectus inferior division of oculomotor Inferior rectus inferior division of oculomotor

Dr. Bahgat Nerve supply of recti muscles superior rectus Superior division of Medial rectus inferior division of Inferior rectus inferior division of oculomotor nerve

Dr. Bahgat lateral rectus Abducent nerve Nerve supply of recti muscles

The 4 recti muscles Origin: Origin: - They arise from a fibrous ring called - They arise from a fibrous ring called the common tendinous ring. the common tendinous ring. - This rig is - This rig is a thickening in the periosteum. a thickening in the periosteum. It surrounds the optic canal It surrounds the optic canal and bridges the superior orbital fissure. and bridges the superior orbital fissure. - Each rectus muscle arises - Each rectus muscle arises from a part of the ring from a part of the ring corresponding to its name : corresponding to its name : Superior rectus ---- upper part. Superior rectus ---- upper part. Inferior rectus lower part. Inferior rectus lower part. Medial rectus medial part. Medial rectus medial part. Lateral rectus by Lateral rectus by two heads from the two heads from the lateral part of the ring. lateral part of the ring. Insertion: Insertion: - Each muscle pierces the - Each muscle pierces the fascial sheath of the eyeball to be fascial sheath of the eyeball to be inserted into the sclera about inserted into the sclera about 6 mm behind the corneoscleral junction 6 mm behind the corneoscleral junction In front of the equator of the eyeball. In front of the equator of the eyeball. Nerve supply: Nerve supply: - The lateral rectus - The lateral rectus by the abducent nerve. by the abducent nerve. - The other 3 recti by oculomotor nerve. superior rectus (superior division) superior rectus (superior division) medial and inferior recti (inferior division) medial and inferior recti (inferior division)Action: - lateral rectus moves the eye laterally. - lateral rectus moves the eye laterally. - Medial rectus moves the eye medially. - Medial rectus moves the eye medially. - Superior rectus: - Superior rectus: moves the eye upward and medially. moves the eye upward and medially. - Inferior rectus: - Inferior rectus: moves the eye downward and medially. moves the eye downward and medially.

Oblique muscles

Dr. Bahgat superior oblique Inferior oblique Trochlea Oblique muscles lateral view lateral view

Dr. Bahgat superior oblique Oblique muscles Superior view Superior view

Dr. Bahgat Inferior oblique Oblique muscles Anterior view Anterior view

Dr. Bahgat Oblique muscles (origin) Superior oblique Originates from body of the sphenoid bone Inferior Oblique Originates from the anteromedial part of the floor of the orbit the anteromedial part of the floor of the orbit lateral lateral medial medial Posterior part of the medial wall of the orbit at its junction with the roof at its junction with the roof

Dr. Bahgat Oblique muscles The oblique muscles Are inserted into behind the equator of the eyeball the sclera the sclera Oblique muscles (insertion) lateral view lateral view

Dr. Bahgat Inferior oblique Are inserted into the sclera behind the equator of the eyeball. & Superior oblique Superior view Lateral view Lateral view

Dr. Bahgat superior oblique Nerve supply of oblique muscles Is supplied by Trochlear nerve lateral view lateral view

Dr. Bahgat Nerve supply of oblique muscles Inferior oblique Is supplied by inferior division of oculomotor nerve lateral view lateral view

The 2 oblique muscles I- Superior oblique: I- Superior oblique: Origin: Origin: From the From the body of the sphenoid bone. body of the sphenoid bone. Insertion: Insertion: - Its rounded belly - Its rounded belly passes forward and forms passes forward and forms a slender tendon which a slender tendon which rotates around the trochlea rotates around the trochlea (fibrocartilaginous bulley). (fibrocartilaginous bulley). - Then the tendon passes - Then the tendon passes downward, backward and laterally below the downward, backward and laterally below the superior rectus muscle. superior rectus muscle. and pierces the and pierces the fascial sheath of the eyeball fascial sheath of the eyeball to be inserted into the sclera to be inserted into the sclera behind the equator of the eyeball. behind the equator of the eyeball. Nerve supply: - by the trochlear nerve. - by the trochlear nerve. Action: Action: - It moves the eyeball - It moves the eyeball downward and laterally. downward and laterally.

The 2 oblique muscles II- Inferior oblique: II- Inferior oblique: Origin: Origin: - From the anterior part of the floor of the orbit. - From the anterior part of the floor of the orbit. Insertion: Insertion: - It passes upward, backward and laterally - It passes upward, backward and laterally below the inferior rectus and below the inferior rectus and pierces the fascial sheah of the eyeball to be inserted into pierces the fascial sheah of the eyeball to be inserted into the sclera behind the equator of the eyeball. the sclera behind the equator of the eyeball. Nerve supply: Nerve supply: - by the oculomotor nerve (inferior division). - by the oculomotor nerve (inferior division). Action: Action: - It moves the eyeball upward and laterally. - It moves the eyeball upward and laterally.

Movement of the eyeball around different axes around different axes

Dr. Bahgat elevation depression Movement around the axes Transverse axis

Dr. Bahgat Adduction Abduction Movement around the axes Vertical axis

Dr. Bahgat Intorsion Extorsion Movement around the axes Visual axis (Anteroposterior)

Action of Individual orbital muscles orbital muscles

Dr. Bahgat medial rectus lateral rectus Adduction Abduction

Dr. Bahgat superior rectus inferior rectus Elevation & adduction Depression & adduction

Dr. Bahgat superior oblique inferior oblique Depression & abduction Elevation & abduction

lateral rectus medial rectus inferior rectus superioroblique superior oblique superior rectus inferior oblique Looking lateral Looking medial Looking down medial Looking down lateral Looking up medial Looking up medial Looking up lateral Looking up lateral Action of individual muscles

Leftlateral rectus Left lateral rectus Rightmedial rectus Right medial rectus Leftmedial rectus Left medial rectus Rightlateral rectus Right lateral rectus Leftinferior rectus & Left inferior rectus & Leftsuperior oblique Left superior oblique Rightinferior rectus & Right inferior rectus & Rightsuperior oblique Right superior oblique Leftsuperior rectus & Left superior rectus & Leftinferioroblique Left inferior oblique Rightsuperior rectus & Right superior rectus & Rightinferioroblique Right inferior oblique Leftinferior rectus Left inferior rectus Rightsuperior oblique Right superior oblique Leftsuperioroblique Left superior oblique Rightinferior rectus Right inferior rectus Leftsuperior rectus Left superior rectus Right inferior oblique Rightsuperior rectus Right superior rectus Left inferior oblique Looking to left side Looking to right side Looking downward Looking downward Looking upward Looking upward Looking down & right Looking down & left Looking up & right Looking up & right Looking up & left Looking up & left Conjugate movement of the two eyes

Dr. Bahgat M.R. L.R. 1 To right side L.R. M.R. 2 To left side Both S.R. + I.O. 3 upward Both I.R.+ S.O. 4 downward S.R I.O. 5 Up & left side S.R. I.O. 6 Up & right side I.R. S.O. 7 Down & left side S.O. I.R. 8 down & right side

Looking to right side Leftmedial rectus Left medial rectus Rightlateral rectus Right lateral rectus Looking to left side Leftlateral rectus Left lateral rectus Right medial rectus Looking upward Looking upward Leftsuperior rectus & Left superior rectus & Leftinferioroblique Left inferior oblique Rightsuperior rectus & Right superior rectus & Rightinferioroblique Right inferior oblique Looking downward Looking downward Leftinferiorrectus & Left inferior rectus & Leftsuperioroblique Left superior oblique Rightinferio rectus & Right inferio rectus & Rightrsuperioroblique Right r superioroblique Rightsuperior rectus Right superior rectus Left inferior oblique Looking up & left Looking up & left Leftsuperior rectus Left superior rectus Right inferior oblique Looking up & right Looking up & right Leftinferior rectus Left inferior rectus Rightsuperior oblique Right superior oblique Looking down & right Leftsuperioroblique Left superior oblique Rightinferior rectus Right inferior rectus Looking down & left Conjugate movement of the two eyes

Dr. Bahgat What is this?

Dr. Bahgat Case 1 Patient: survived a posterior cerebral aneurysm ptosis dilated pupil left eye is Conclusion lesion of the oculomotor nerve (CN III) Why? directed downward and abducted. wrinkled forehead wrinkled forehead Signs: Symptoms: double vision cannot accommodate

Dr. Bahgat Case 2 What is the patient’s problem? Medial Strabismus Caused by paralysis of lateral rectus Results in diplopia right eye is directed Medially (i.e. adducted).

What is the diagnosis Case 1 Case 2

Dr. Bahgat What is this?

Testing Extraocular Movements

In the setting of an eye movement problem, it can help to check movement in the direction in which that muscle is the primary mover. This can be assessed as follows: Superior oblique: Depresses the eye when looking medially Inferior oblique: Elevates the eye when looking medially Superior rectus: Elevates the eye when looking laterally Inferior rectus: Depresses the eye when looking laterally Depresses the eye when looking laterally Medial rectus: Adduction when moving the eye along horizontal plane Adduction when moving the eye along horizontal plane Lateral rectus: Abduction when moving the eye along horizontal plane Testing individual muscles

References Last’s anatomy Regional and applied Last’s anatomy Regional and applied (R.M.H. McMinn) – 9 th edition Clinical anatomy (Richard S. Snell) – 7 th edition Clinical anatomy (Richard S. Snell) – 7 th edition Grey’s anatomy – 39 th edition Grey’s anatomy – 39 th edition

Good luck

Testing Extraocular Movements Practically speaking, cranial nerve testing is done such that the examiner can observe eye movements in all directions. The movements should be smooth and coordinated. To assess, proceed as follows: Stand in front of the patient. Ask them to follow your finger with their eyes while keeping their head in one position Using your finger, trace an imaginary "H" or rectangular shape in front of them, making sure that your finger moves far enough out and up so that you're able to see all appropriate eye movements (ie lateral and up, lateral down, medial down, medial up). At the end, bring your finger directly in towards the patient's nose. This will cause the patient to look cross-eyed and the pupils should constrict, a response referred to as accommodation.