Current Anaesthesia & Critical Care (2000) 11, 286d292

^ 2000 Harcourt Publishers Ltd

doi:10.1054/cacc.2000.0296, available online at http://www.idealibrary.com on

FOCUS ON: THE EYE

Anatomy of the eye and orbit

D. Smerdon
North Riding Infirmary, Newport Road, Middlesbrough, TS1 5JE, UK

KEYWORDS
anatomy, eye, orbit

Summary The anatomy of the eye and orbit is summarized. The important surface
anatomy, anatomical dimensions and relationships are described with some clinical
correlations. ^ 2000 Harcourt Publishers Ltd

INTRODUCTION

SURFACE ANATOMY

Each orbit is roughly pyramidal (Fig. 1). The lateral,

superior and inferior walls of the orbit bulge anteriorly
to accommodate the equator of the globe. The orbit
narrows progressively to the orbital apex, through and
around which enter the important nerve vessels and, of
course, the optic nerve. Behind the apex of the orbit is
the cavernous sinus and the important structures of the
midbrain. The thin medial walls of the orbit are parallel to
each other. Between the medial walls are sinuses, the
nasal cavity and the nasolacrimal system. Outside the
lateral wall is the temporal fossa, which houses the
temporalis muscle. Outside the roof of the orbit is the
frontal lobe of the brain posteriorly and the frontal sinus
anteriorly. Outside the floor of the orbit is the maxillary
sinus and the infra-orbital nerve. The thick lateral wall of
the orbit is at 453 to the medial. The two lateral walls are
at right angles to each other.
The optic nerve and globe are centred on the orbital
axis which is 22.53 lateral to the saggital axis. Looking
straight ahead (the primary position) the optic axis is at
22.53 to the orbital axis.
The position of the globe in the orbit is very variable,
but in the primary position it projects forward from the
lateral wall by about 17 mm (as measured by Hertel
exophthalmometry)1 and the medial wall by about 7 mm.
The projecting brow, nasal bones and zygomatic arch
provide protection to the globe. The eye measures
23 mm on average2 (range 17d33 mm)3 from front to
back and slightly less equatorially. The intra-orbital optic
nerve measures about 25 mm. The distance between the
back of the eye and the apex of the orbit is slightly less
(the optic nerve takes a sinuous course to allow for eye
movement). The distance between the centre of the
orbits varies considerably but is around about 65 mm on
average.

In health, only a small part of the eye is exposed

anteriorly. Seven-eighths of the cornea and a small
area of the nasal and larger area of the temporal sclera
is visible when looking straight ahead. Viewed
from the side, a considerable portion of the globe
(17 mm on average) is anterior to the lateral orbital
margin, but this is very variable and may be much
less with age. The cornea only protrudes about 7 mm
beyond the anterior lacrimal crest, and does not
protrude at all beyond the roof of the orbit. The optic
canal at the apex of the orbit is directly behind the
caruncle. The lowest point of the anterior orbital margin
is directly inferior to the lateral limbus in the primary
position.

Correspondence to: DS. Tel. 01642 854 069.

THE EYE (Fig. 2)

There is considerable variation in both the size of the eye
and the corneal curvature. The ultrasonic axial length of
the eye is 23 mm (range 17d33 mm), equating to a radius
of curvature of the sclera of just over 10 mm. The cornea
curvature is 43 dioptres (range 37d52 mm),3 equating to
a radius of curvature of just over 7 mm. The cornea
measures approximately 12 mm horizontally and 11 mm
vertically (there is a small encroachment of the sclera
superiorly). It is about 0.5 mm thick centrally and
about 0.75 mm thick peripherally. The cornea is composed of a multilayered epithelium with a basement membrane, a condensation of the anterior stroma
(Bowmans layer), the stroma (95% of the cornea)
which consists of crossed layers of collagen in a highly
organized pattern, Decemets membrane and the
endothelium.
The clear cornea joins the white and opaque sclera
(similar to cornea but without the structured collagen
arrangement), with which it is contiguous, at the limbus.
The sclera comprises the rest of the wall of the eye. It is
pierced posteriorly and medially by the optic nerve. The
short ciliary nerves enter the posterior sclera around the

ANATOMY OF THE EYE AND ORBIT

Figure 1 The general arrangement of the orbit.

Figure 2 The globe.

optic nerve. The long ciliary nerves enter on either side

of the optic nerve.
Internal to the posterior sclera is the choroid, or
blood vessel layer. It is part of the uveal tract (choroid,
ciliary body and iris). It has an outer layer, a layer of large
blood vessels, a layer of small blood vessels and then the
choriocapillaris.
The next internal layer is Bruchs membrane. This
is a double-basement membrane. Externally is the
basement membrane of the choriocapillaris, internally
is the basement membrane of the retinal pigment
epithelium (Bruchs membrane splits and allows sub-

287
retinal neovascularization in wet age-related macular
degeneration).
The retinal pigment epithelium (RPE) and the retina
comprise the next two layers. Embyologically they are
derived from the invagination of the neuroectoderm, the
internal layer of which is the retina, the external layer of
which is the RPE. There is a potential space between
the two layers (this potential space opens in retinal
detachment). The RPE is a single layer of epithelial cells
which is intimately related to the retinal photoreceptors.
It is regarded as the most external of the 10 layers of the
retina. The other layers are the photoreceptor layer, the
external limiting membrane, the outer nuclear layer (rod
and cone nucleii), the outer plexiform layer, the inner
nuclear layer, the inner plexiform layer, the ganglion cell
layer, the nerve fibre layer and the internal limiting
membrane.
The posterior part of the globe is full of vitreous.
Internal to the anterior part of the sclera is the ciliary
body. Internally, from behind coming forward, there is
the smooth part (pars plana) just anterior to the anterior
edge of the retina (ora serrata). Next there is a ridged
part (pars plicata). The ridges are the ciliary processes.
This area gives rise to the zonular fibres which support
and maintain tension on the crystalline lens capsule. The
ciliary body contains the ciliary muscle. This muscle
produces an internal sphincter beneath the limbus.
Contraction of this muscle (innervated by the postganglionic parasympathetic fibres from the ciliary
ganglion) narrows the sphincter, and so reduces tension
on the zonule which allows the lens to assume its natural,
more spherical shape.
The crystalline lens is a clear and elastic biconcave
disc measuring about 10 mm equatorially. The posterior
surface of the lens is the more curved. It is enclosed
within a strong and elastic capsule. Its natural state
is to become more spherical. The tension in the zonular
fibres makes the lens less spherical. Aqueous is the
clear fluid which fills the space in front of the crystalline
lens.
The iris arises from the front of the ciliary body.
The pupil is the central aperture in the iris through which
light enters. The iris contains a sphincter muscle and
a dilator muscle. The sphincter is innervated by the
parasympathetic fibres which have synapsed in the ciliary
ganglion. The dilator is innervated by sympathetic fibres.
The angle formed by the inner aspect of the cornea
and the iris is called the drainage angle. It contains
the trabecular meshwork which drains aqueous into
Schlemms canal and back into the venous system.

THE BONES OF THE ORBIT (Fig. 3)

The orbital margin provides great protection to the
globe from blunt trauma. The anterior orbital margin is
very strong and is only fractured by very severe trauma
(RTAs). The lateral orbital margin is set far more
posteriorly than the medial. The superior margin is more
anterior than the inferior.

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CURRENT ANAESTHESIA & CRITICAL CARE

Figure 3 The bones of the orbit.

The roof of the orbit is mainly frontal bone. The

medial wall is mainly lacrimal and ethmoid. The floor of
the orbit is mainly maxilla with a small amount of palatine
bone posteriorly. The lateral wall is mainly frontal and
zygomatic bone anteriorly and greater wing of sphenoid
posteriorly. The orbital fissures are (superior) between
the greater and lesser wings of the sphenoid and
(inferior) between the greater wing of sphenoid and the
maxilla. The optic foramen is in the lesser wing of the
sphenoid.
The bones which make up the orbit are covered with
periosteum known as periorbita. Periosteum becomes
periorbita at the orbital margin.

THE EXTRAOCULAR MUSCLES

The orbit contains the six extraocular muscles and the
levator palpebrae superioris. All the extraocular muscles,
with the exception of the inferior oblique, arise

from the Annulus of Zinn a common tendon at the apex

of the orbit. The Annulus surrounds the optic canal and
the medial part of the orbital fissure. The levator extends
forward under the roof of the orbit, becomes tendinous
and is inserted into the skin (between the orbicularis
fibres) and into the anterior part of the tarsal plate. A
posterior, non-striated expansion, Mullers muscle, splits
off and is inserted into the upper part of the tarsal
plate.
The four rectus muscles insert in the cardinal positions
around the equator of the globe. The muscles have
a central belly but become tendinous as they approach
their insertions. The distance of the insertions from the
limbus, in mm, is given by the mnemonic SLIM (superior
7.5, lateral 7.0, inferior 6.5, medial 5.5). The inferior
oblique arises from the inside of the medial part of the
lower orbital margin and is inserted obliquely near the
fovea at the posterior pole of the globe (Fig. 4). The
superior oblique arises from the Annulus of Zinn, passes
forward to the upper inner aspect of the orbit, becomes

ANATOMY OF THE EYE AND ORBIT

289

FASCIAL COMPARTMENTS OF
THE POSTERIOR ORBIT
Expansions of fibrous tissue extend from muscle to
adjacent muscle and divide the orbital fat into linear
compartments extending from the front to the back of
the orbit. These compartments are very variable. This
may, in part, explain the occasional variability which can
occur with needle local anaesthesia and could be an
argument for hyalase. The orbit is filled with fat which is
soft and pliable and almost liquid at body temperature.
The fat is held in place anteriorly by the orbital septum.

THE EYELIDS
Figure 4 The globe from behind.

tendinous and passes through a fibrous pulley called the

trochlea. It then reflects back to the globe, more or
less parallel to the inferior oblique to be inserted on
the posterior of the globe near the fovea. The balance
between the backward pull of the rectus muscles and
the forward pull of the oblique muscles helps to
suspend the globe in its position in the orbit.
All the extraocular muscles are innervated by
the oculomotor nerve except for the lateral rectus
(VI) and the superior oblique (IV). The nerves enter
the muscles at junction of middle and posterior thirds
on the ocular side (except for superior oblique).
Mullers muscle is innervated by the sympathetic
system.

THE CONJUNCTIVA
The conjunctiva is a mucus membrane which covers
the internal aspect of the eyelids (tarsal conjunctiva),
reflects back in the conjuctival fornices (deepest
superiorly, then inferiorly, then laterally and least
medially) and covers the globe (bulbar conjunctiva) as far
as the limbus.

TENONS CAPSULE
Beneath the bulbar conjunctiva on the globe is Tenons
capsule. This arises 2 mm back from the limbus and
separates the globe from the orbital fat. It forms part of
the orbital septum and restricts the orbital fat to the
posterior part of the orbit even when the globe is
removed. It is very smooth and mobile. Expansions of the
Tenons capsule extend back along the optic nerve, the
extraocular muscles and other structures passing
through to reach the globe (Fig. 4). This permits
movement of the eye without damage to these delicate
structures. A sub-Tenons anaesthetic is placed under
this layer.

The eyelids are covered with thin sensitive skin. The

palpebral (eyelid) part of orbicularis oculi provides gentle
closure of the eye by its sphincter effect. Orbicularis is
supplied by the facial nerve. Under the orbicularis is the
levator muscle, anterior expansions of which pass
between the annular orbicularis into the skin, especially
superiorly where the lid sulcus is formed. The levator
inserts in the lower anterior part of the tarsal plate.
Internal to the orbicularis is the tarsal plate. The tarsal
plate is a semi-rigid D-shaped plate which provides
rigidity to the eyelid. It contains the Meibomian glands.
On the lid margin, near the junction between the
conjunctive and the skin (the grey line) are the openings
of the Meibomian glands. These secrete a light oil,
released by orbicularis movement, which reduces tear
evaporation. There are about 35 Meibomian glands in the
upper lid and 25 in the lower lid. They extend the full
height of the tarsal plate (damage to the Meibomian gland
allows release of the oil into the substance of the lid
which produces a granuloma known as a chalazion). Just
anterior to the tarsal plate are the peripheral and
marginal arcade vessels. Part of the levator muscle
inserts into the anterior part of the tarsal plate, while
Mullers muscle inserts into the superior aspect of the
tarsal plate. There are fibrous expansions of the tarsal
plates extending both medially and laterally, joining
similar expansions from the opposing lid to form the
medial and lateral palpebral ligaments which are attached
at the anterior part of the lateral and medial wall of the
orbit. The internal aspect of the eyelid is covered by
tarsal conjunctiva.
The eyelashes leave the distal part of the eyelid skin
and curve away from the globe.

THE LACRIMAL APPARATUS

The almond-shaped lacrimal gland is situated in the upper
outer orbit in a shallow depression, the lacrimal fossa.
There is a small part of the gland which is outside the
fossa, the palpebral part. The gland is supplied by the
lacrimal greater petrosal nerve and by the sympathetic
system.
On the medial aspect of both upper and lower eyelids
is a lacrimal punctum, the opening to the nasolacrimal

290
system. The punctum is directed back towards the globe
to contact the globe very close to the plica. The punctum
opens into the canaliculus which turns medially sharply
and joins its opposing fellow as the common canaliculus.
This enters the lacrimal sac in the lacrimal fossa which is
formed by the spiral of the anterior bony orbital margin.
Expansions of the orbicularis are attached around the
lacrimal sac and are said to form a pump.

THE SENSORY NERVES OF THE EYE

AND ORBIT (Fig. 5 and 6)
The sensory nerve supply to the globe is via the
trigeminal nerve. Branches of the ophthalmic division
pass through the superior and inferior orbital fissures
(lacrimal, frontal, nasociliary).

Figure 5 The orbit and its contents.

CURRENT ANAESTHESIA & CRITICAL CARE

The lacrimal nerve passes forwards to the lacrimal
gland and supplies sensation to the conjunctiva and skin
of the lateral part of the upper lid.
The frontal nerve passes superiorly to the levator and
divides into the supratrochlear and supra-orbital
branches. They supply the upper lid and conjunctiva as
well as the skin of the forehead.
The nasociliary nerve lies along the optic nerve below
the superior rectus. It branches into the anterior
ethmoidal and the infratrochlear nerve (sensory supply
of inner canthus, lacrimal sac). It gives a branch to the
ciliary ganglion (the sensory root). Other important
branches are the long ciliary nerves (sensory supply to
iris, cornea and ciliary muscle).
The ciliary ganglion (Fig. 5) is situated 10 mm anterior
to the optic canal between the optic nerve and the lateral
rectus. It is an ovoid measuring 2 mm antero-posteriorly

ANATOMY OF THE EYE AND ORBIT

Figure 6 The sensory nerves and arteries of the anterior part

of the orbit.

and 1 mm vertically. It has three roots; the parasympathetic root whose fibres synapse and the sensory
and parasympathetic which pass through without
synapsing. The ciliary ganglion gives off the multiple short
ciliary nerves with multiple interconnections which then
pierce the sclera around the optic nerve, and extend
forward with the long ciliary nerves to form a plexus
which supplies the cornea, ciliary body and iris. Postganglionic parasypathetic fibres provide innervation to
the sphincter pupillae and the ciliary muscle.
Other contributions to the sensory supply of the
eyelids include the maxillary division of the trigeminal
nerve gives the infra-orbital nerve (from the infra-orbital
foramen) whose palpebral branch supplies the skin and
conjunctiva of the lower lid (Fig. 6).

ARTERIAL SUPPLY TO GLOBE AND

ORBIT
The ophthalmic artery arises from the internal carotid
just above the cavernous sinus. It passes forward medial
and inferior to the optic nerve. It passes through the
optic foramen within the dural sheath of the optic nerve,
first inferior and then lateral to the nerve. The posterior
part of the orbit is within the muscle cone between the
optic nerve and the lateral rectus. It then crosses
superiorly to the optic nerve, to reach the medial wall of
the orbit. It passes forwards between the superior
oblique and the medial rectus towards the anterior part
of the orbit where it divides into dorsal nasal and supratrochlear branches.

MAIN BRANCHES SUPPLYING THE

EYE AND ORBIT (VARIABLE)
The central retinal artery leaves the ophthalmic near the
optic foramen. It passes in a sinuous course below and

291
adjacent to the optic nerve. About 15 mm back from the
globe it pierces the underside of the nerve and enters the
eye through the optic nerve. It divides into superior and
inferior branches on the optic disc and then further
divides into the nasal and temporal branches to supply
the inner part of the retina.
The posterior ciliary arteries, two in number, divide
into 20 or so small branches, the short ciliary arteries,
and two long ciliary arteries which pierce the sclera
round the optic nerve (Fig. 4).
The lacrimal artery follows the upper border of the
lateral rectus to the lacrimal gland which it supplies. It
passes through the gland to supply the conjunctiva and
the eyelids from the lateral side.
Muscular branches supply the extraocular muscles.
Part of these branches pass through the muscles as the
anterior ciliary branches. They supply the conjunctival
arcade. Branches pierce the sclera to anastomose with
the posterior ciliary vessels.
The supra-orbital artery leaves the ophthalmic
artery as it crosses over the optic nerve. It climbs
above the superior rectus and passes through the
supra-orbital notch or foramen to supply the eyelid and
scalp.
The medial palpebral arteries supply the medial part of
the eyelids.
The anterior and posterior ethmoidal branches leave
the orbit on the medial side to supply the sinuses and
nasal cavity.
The dorsalis nasal artery leaves the orbit above
the medial palpebral ligament. A pulse can often
be felt here. It supplies the lacrimal sac and root of the
nose.
The supratrochlear artery passes out of the orbit
superomedially, medial to the supra-orbital artery.

THE VENOUS DRAINAGE OF THE

ORBIT (VARIABLE)
Superior ophthalmic vein, formed at the root of the
nose, passes back over the medial palpebral ligament to
take the same path as the ophthalmic artery, passing
through the superior orbital fissure into the cavernous
sinus.
Its two main tributaries are the inferior ophthalmic
vein and the angular vein. The inferior ophthalmic vein
starts as a plexus on the floor of the anterior orbit and
passes on the upper surface of the inferior rectus to join
the superior orbital vein posteriorly. The angular vein is
formed by the supra-orbital and supratrochlear veins. It
runs down the medial side of the nasal bridge where it is
often visible. It is a hazard when performing an external
dacryocystorhinostomy. Other veins generally are
venous partners of the arteries.
There are no obvious lymphatic vessels in the orbit.
The regional lymph nodes are the deep parotids for the
lids and conjunctiva and the sub-mandibular for the
medial lower lid.

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CURRENT ANAESTHESIA & CRITICAL CARE

References

Suggestions for Further Reading

1. Knudtzon K. On exophthalmometry. Acta Psychiatr Neurol 1949;

24: 523
2. Itoffer K J. Biometry of 7500 cataractous eyes. Am J Ophthalmol
1980; 90: 360}368.
3. Smerdon D. Unpubl. data on biometry of 3150 serial cataract
operations.

1. Warwick R. Eugene Wolff s Anatomy of the Eye and Orbit. London:

H K Lewis, 1976.
2. McMinn R M, Hutchings R T. A Colour Atlas of Human Anatomy:
Wolfe Medical Publications, 1997.