Applied Anatomy

Applied Anatomy

A detailed knowledge of the applied anatomy of the eye is

essential for successful local anesthesia. Without this, the patient is
subjected to serious complications (Hamilton, 1996).

A. The eyeball (Fig. 1-1,2,3)

The eyeball, which is just under 25 mm in all diameters, is
formed by segment of two spheres of different sizes: a prominent
anterior segment and a larger posterior segment .
The optic nerve enters the eye about 3 mm to the nasal (medial)
side of the posterior pole.
The eyeball is formed by three coats: a fibrous outer coat, a
vascular middle coat and an inner neural coat "the retina" (Snell
and Lemp, 1998).

i. The fibrous coat:

The fibrous coat comprises a transparent anterior part (the
cornea) and an opaque posterior portion (the sclera).
Peripherally, the cornea is continuous with the sclera at the
sclerocorneal junction. The sclera is a tough, fibrous membrane
which is responsible for the maintenance of the shape of the
eyeball. Posteriorly, it is pierced by the optic nerve, with whose
dural sheath it is continuous (Snell and Lemp, 1998).

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ii. The vascular coat:

This is made up of the choroid, the ciliary body and the iris.
The choroid is a thin but highly vascular membrane lining the
inner surface of the sclera. Posteriorly it is pierced by the optic
nerve, and anteriorly it is connected to the iris by the ciliary body.
The ciliary body includes the ciliary ring, the ciliary processes
and the ciliary muscles.
The iris is the contractile disc surrounding the pupil. It consists
of four layers:
1- An anterior mesothelial lining
2- A connective tissue stroma containing pigment cells.
3- A group of radially arranged smooth muscle fibres.
4- A posterior layer of pigmented cells that is continuous with
the ciliary part of the retina (Snell and Lemp, 1998).

iii. The neural coat:

The retina is formed by an outer pigmented and an inner
nervous layer.
Anteriorly, it presents an irregular edge "the ora serrata" while
posteriorly the nerve fibres on its surface collect to form the optic
nerve. Near its posterior pole there is a pale yellowish area "the
macula lutea", and medial to this is the pale optic disc formed by

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the passage of nerve fibres through the retina, corresponding to the

‘blind spot’. The central artery of the retina emerges from the disc.
The vitreous body is a thin transparent gel contained within a
delicate membrane "the hyaloid membrane" and pierced by the
lymph-filled hyaloid canal (Snell and Lemp, 1998).

N.B.1: The fascial sheath of the eye: "Tenon’s fascia"

A thin fascial membrane ensheaths the eyeball from the corneo-
scleral junction to the optic nerve; here it fuses with the dural
sheath of the nerve as it enters the eyeball. This fascia separates the
eyeball from the surrounding orbital fat, which lies between it and
the ocular muscles (Parks, 1987).

N.B.2: The eyelids and conjunctiva:

Of the two eyelids, the upper is the larger and more mobile, but
apart from the presence of the levator palpebrae superioris in this
lid, the structure of the eyelids is essentially the same. Each
consists of the following layers, from without inwards: skin, loose
connective tissue, fibres of the orbicularis oculi muscle, the tarsal
plates of very dense fibrous tissue, tarsal glands and conjunctiva.
The conjunctiva is the delicate mucous membrane lining the
inner surface of the lids, from which it is reflected over the anterior

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part of the sclera to the cornea. Over the lids it is thick and highly
vascular, but over the sclera it is much thinner (Ellis et al., 2004).

N.B.3: The lacrimal apparatus:

The lacrimal gland is situated in the upper, lateral part of the
orbit in what is known as the lacrimal fossa. The gland is drained
by a series of 8–12 small ducts that pass through the palpebral lobe
into the the superior conjunctival fornix (Ellis et al., 2004).

B. The Orbit (Fig.1-1,2,3)

The medial orbital wall is roughly in a sagittal plane forming a
45-degree angle with the lateral wall. The inferior wall rises to the
apex at an angle of approximately 10 degrees. The volume of the
orbit is approximately 30cm3. The anatomic axis of the orbit
diverges by 23 degrees from the visual axis in primary gaze
position, which lies in the sagittal plane (Stevens et al., 1993).

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Fig.1-1: Orbit In Transverse Section (Kumar, 2007)

Fig.1-2: Sagital Section Of The Eye (Kumar, 2007)

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The orbit is compartmentalized by a framework of partly

discontinuous connective tissue septa that are more developed in
the anterior part of the orbit than in the retrobulbar region and
toward the apex where the intermuscular septa are partly missing
in the inferotemporal and superotemporal quadrants (Koorneef,
1977).
There are structural differences between the intraconal and
extraconal fat compartments (Fig.1-3), although the less mobile
extraconal fat lobules communicate with the more fusiform and
mobile intraconal fat lobules through gaps in the septa between the
rectus muscles (Gills et al., 1993).
The ocular muscles are embedded in this framework of orbital
septa and are in close proximity to the orbital walls. Only the
medial rectus muscle is separated from the orbital wall by a fat
compartment which communicates with superior and inferior
compartments and ultimately with the orbital apex.
The optic nerve leaves the globe 3 mm to the nasal side of its
posterior pole. The intraorbital portion of the optic nerve measures
3 cm and takes a winding course to pass the space of 2.5cm
between the posterior pole and the optic foramen (Liu et al.,
1992).

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This excessive length of the optic nerve allows free eye

movements without tearing the optical nerve fibers in extreme gaze
positions.
The cerebrospinal fluid communicates freely with the subdural
space around the optic nerve. The dura fuses anteriorly with the
sclera and posteriorly with the periorbita around the optic foramen.
The ciliary ganglion is located temporal to the optic nerve inside
the muscle cone 7 to 10mm anterior to the orbital apex (Dutton,
1994).

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Fig.1-3: Compartments Of The Orbit (Ellis et al., 2004)

C. Sensory Innervation (Fig.1-4)

The sensory nerve supply to the ocular adnexa is provided by
the first two branches of the trigeminal nerve which are known as
the ophthalmic and maxillary branches. The ophthalmic division,
enters the orbit via the superior orbital fissure and has three
branches: the lacrimal, the frontal, and the nasociliary (Sullivan
and Beard 1993).
The lacrimal nerve supplies sensation to the lacrimal gland and
to the skin of the lid and periorbital region superolaterally. The
frontal nerve runs forward in the roof of the orbit just under the
periorbita. It divides into the supraorbital and supratrochlear
nerves, which supply sensation to the skin and deeper tissues of the
lid and periorbital regions in the superonasal and frontal areas. The
nasociliary nerve gives off sensory fibers to the ciliary ganglion
and then passes above the optic nerve, where long ciliary nerves
branch to the globe. It continues forward superiorly and nasally in
close proximity to the ophthalmic artery, dividing into the anterior
ethmoidal nerve, the posterior ethmoidal nerve (often not present),
and the infratrochlear nerve. The ethmoidal nerves supply
sensation to the nasal mucosa. The infratrochlear nerve supplies

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sensation to the side and tip of the nose and the lacrimal sac and
canaliculi (Sullivan and Beard 1993).
The maxillary nerve is the second division of the trigeminal
nerve and courses forward through the foramen rotundum. The
zygomatic nerve is a branch that subdivides into the
zygomaticofacial and zygomaticotemporal nerves. These sensory
branches exit through foramina in the lateral wall of the orbit and
supply sensation to the skin of the lateral orbit. The infraorbital
nerve is the terminal branch; it runs along the orbital floor,
supplying sensation to skin of the lower lid, the upper lip, and
some teeth (Sullivan and Beard 1993).
Fully understanding the anatomical relationships of these nerves
as they exit the orbit allows for successful anesthetic infiltration.
Four of the nerves are palpable as they leave the orbit: the
supraorbital, the infraorbital, the supratrochlear, and the
infratrochlear (Bruce, 1982).
The supraorbital foramen is usually located 2.7 cm lateral to the
midline of the glabella, and the supratrochlear and infratrochlear
nerves are 1.7 cm lateral to the midline. The infraorbital nerve exits
approximately 1 cm below the inferior orbital rim in a vertical line
drawn from the supraorbital notch. To effectively block these
nerves’ sensory distribution, a few milliliters of local anesthetic
can be infiltrated around their points of exit from the orbit. When

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injecting the local anesthetic, anesthesia providers should always

aspirate before injecting to minimize the risk of an intravascular
injection, because these nerves also run with blood vessels (Bruce,
1982).
D. Motor Innervation (Fig.1-4)
The ocular muscles are innervated by the trochlear nerve (IV),
the abducens nerve (VI), and the oculomotor nerve (III), which
also carries proprioceptive and parasympathetic fibers that pass
through the ciliary ganglion (Katsev et al., 1989).
All nerves are innervated multifocally by small nerve branches
entering their respective muscles along their posterior and anterior
parts. The oculomotor and the abducent nerves enter the orbit
inside the annulus of Zinn and can be affected by intraconally
injected agents. The oculomotor nerve splits into a superior part
innervating the superior rectus and the levator palpebrae muscle
while the inferior portion divides into even more branches
innervating the medial rectus, the inferior rectus, and the inferior
oblique muscle. The presynaptic parasympathetic fibers arise from
the Edinger-Westphal nucleus and separate from the inferior
portion of the oculomotor nerve to enter the ciliary ganglion. The
trochlear nerve enters the orbit through the superior oblique orbital
fissure outside the muscle cone together with the two sensory
nerves, the frontal nerve and the lacrimal nerve, and passes over

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the levator palpebrae muscle to innervate the superior oblique

muscle (Katsev et al., 1989).
This explains isolated activity of the superior oblique muscle
after an isolated retrobulbar anesthesia. The orbicular muscle of the
eyelids is innervated by the facial nerve, which splits into multiple
branches at the level of the parotid gland and innervates the
orbicular muscle via multiple fine branches crossing over the
lateral orbital rim into the muscle (Sacks, 1983).

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Fig.1-4: Nerve Supply Of The Eye (Agur et al., 1992).

E. Orbital Blood Supply

Because the orbit forms a cone, the space is narrower toward the
apex and delicate orbital structures are more tightly packed in the
posterior portion of the orbit. In the anterior and middle regions of
the orbit, however, the inferotemporal, the superotemporal, and the
extremely medial compartments are relatively avascular (Hayreh
and Dass, 1962).
The ophthalmic artery enters the orbit inferonasal to the optic
nerve (Fig.1-5). It then runs around the optic nerve, crosses it
superiorly, or inferiorly in a minority of cases, and runs under the

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superior oblique muscle toward the medial part of the orbit (De
Santis et al., 1984).
The large principal orbital “superior ophthalmic” vein is located
in the superior medial quadrant running along the medial border of
the superior rectus muscle. It enters the muscle cone and passes
through it within a septum of connective tissue to exit the
intraconal space laterally and the orbit through the superior orbital
fissure (Koorneef, 1977).
The superior medial quadrant and the lateral part of the orbital
apex have the highest concentration of large vessels. The vortex
veins run from the equator of the globe posteriorly and one of them
is in close proximity with the lateral border of the inferior rectus
muscle (Hogan et al., 1971).
Because of the large variability of the venous and even arterial
blood supply to the orbit, it is safest to avoid the superior medial
quadrant and the orbital septa close to the rectus muscles entirely.
The inferotemporal, the superotemporal, and the extremely nasal
orbital adipose compartments, however, are relatively free of
delicate vascular structures, especially in the anterior and middle
regions of the orbit (Stevens, 1992).

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Fig.1-5:Arterial Blood Supply Of The Eye (Agur et al., 1992).

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