Block XX | Module 1 | Lecture 1

Clinical Anatomy and Physiology of the Eye

Dr. Joanne T. Rocha, MD
April 10, 2018

LECTURE OUTLINE 5 PRINCIPAL PLANES

1. Skin
I. Accessory Structures of the Eye 2. Orbicularis Oculi
II. Normal Eye Anatomy - Lid closure
A. Orbit - Innervated by facial nerve (CN VII)
B. Eyeball 3. Areolar Tissue
C. Conjunctiva 4. Tarsal Plates
D. Sclera - Main supporting structure
E. Cornea - Dense fibrous tissue layer
F. Uveal Tract 5. Palpebral Conjunctiva
G. Lens * Levator Palpebrae
H. Aqueous Humor - lid opening (CN III)
I. Vitreous Body
J. Retina
K. Optic nerve
III. Visual Pathway
IV. Extraocular Muscles

I. ACCESSORY STRUCTURES OF THE EYE

EYEBROWS o Eyelid Margin
- Folds of thickened skin covered with hair
- Prevent sweat, water, and other debris from o ANTERIOR LAMELLA
falling down into the eye socket 1. Skin
- Important to human communication and facial 2. Orbicularis muscle
expression 3. Eyelashes
- Arranged in 2 to 3 rows
EYELIDS (palpebrae) - Life span : 3 to 4 months (cilia have no
U where the eyelashes are attached erector muscle)
- Protect the anterior surface of the globe from - Upper:100-150
local injury - Lower: 50-70
- Aid in the regulating the amount of light reaching 4. Glands of Moll (Sweat gland)
the eye 5. Glands of Zeiss (Sebaceous gland)
- Spread the tear over the cornea during blinking
o POSTERIOR LAMELLA
1. Tarsal plate
2. Conjunctiva
3. Meibomian Glands (Sebaceous gland)
U Tarsal glands, also called Meibomian glands,
are found in the roots of the eyelashes. They
secrete the oil part of tears. If it is blocked, sty is
formed.

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

o Lacrimal apparatus
1. Lacrimal glands
U Hordeolum- important to know the layer/lamella • Main
involved for surgical intervention • Accessory
o Internal- posterior lamella is affected a. Glands of Krause
(Glands of Moll and Zeiss) - Upper lid-40-42 ;
o External- anterior lamella is affected - Lower lid-6-8
(Meibomian Glands) - Deeply situated in the conjunctiva
*where Chalazion arises near the fornix on lateral side
b. Glands of Wolfring
- Few in number
- Situated near the upper border of
the tarsal plate

LACRIMAL GLANDS
- Network of structures that secrete and drain te
ars from the surface of the eyeball
- Moisten, lubricate, and protect surface of the
eye
- Continously secrete tears throughout the day
2. Lacrimal ducts
by main and accessory lacrimal gland
- Carries tears to the nose and ends in the
- Rate of tear production – 1.2 microliter/min
inferior turbinate
- Almond shape gland under the superior orbital 3. Lacrimal canals/canaliculi
rim which provides tears - epithelial-lined tubes that carry tears to the
U Tears go to the inferior punctum, then to the lacrimal sac. Lower canaliculus is more
nose via the nasolacrimal duct and then you important.
swallow it. That’s why kung mag hibi kamo, 4. Lacrimal sacs
ginasipon kamo
- Collects tears from the canaliculi.
Inflammation of the sac is called
dacrocystitis.

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

5. Nasolacrimal ducts TEAR FILM

• The tear film composition is as follows:

• Punctum – oval opening to the lacrimal sac.
May be occluded by dirt, oils, talcum powder,
etc. Lower/inferior punctum is more important.
• Plica semilunaris–crescentic fold in the medial
conjunctiva lateral to caruncle. No function.
*semilunar fold- soft, movable, thickened fold
of bulbar conjunctiva is located at the inner
canthus
• Caruncle– modified skin, vestigial organ(third
eyelid or nictitating membrane in lower
animals)
- small, fleshy, epidermoid structure attached
superficially to the inner portion of the
semilunar fold and is a transition zone
containing both cutaneous and mucous
membrane elements
1. Goblet cells - mucin
- which allows for even distribution and
stabilization of the tear film over the ocular
surface
- stabilize aqueous against the hydrophobic
epithelium
2. Main and accessory lacrimal gland - intermediate
aqueous layer of the tear film
- H20, O2, antibodies, cytokines
3. Meibomian glands – lipid outer layer of the tear
film
- which reduces the evaporation of the
underlying aqueous layer
SKELETAL MUSCLES (Extraocular Muscles/EOMs)
U 6 eye muscles = 4 recti, 2 obliques

 Dry eyes à reflex tearing

U “Lacrimal lake”
U Aids in lubrication and protection

• 4 RECTI MUSCLES
1. Superior Rectus
2. Inferior Rectus
3. Medial Rectus
4. Lateral Rectus
• 2 OBLIQUE MUSCLES
1. Superior Oblique
2. Inferior Oblique

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

U The four rectus muscles originate at a common

ring tendon (annulus of Zinn) surrounding the optic
nerve at the posterior apex of the orbit
U The oculomotor nerve (III) innervates the medial,
inferior, and superior rectus muscles and the
inferior oblique muscle. The abducens nerve (VI)
innervates the lateral rectus muscle; the trochlear
nerve (IV) innervates the superior oblique muscle.

• Orbital fat
U Surrounds the entire eyeball inside the orbital
cavity
• Eyebags – fat deposits that have escaped from the
orbital septum
II. NORMAL EYE ANATOMY
 Optical media is a series of clear lenses, one on top of
the other. The 5 clear optical media are: the cornea,
aqueous humor, lens, vitreous humor, and retina.
They must all be crystal clear.
 If the opacity is not within the optic axis, it will not
affect the visual acuity.
1. ROOF: Frontal, Sphenoid
2. LATERAL WALL: Sphenoid, Zygomatic
3. FLOOR: Zygomatic, Maxillary, Palatine
4. MEDIAL WALL: Maxillary, Ethmoid, Lacrimal,
Frontal
U Close relation to cranial cavity = orbital roof
U Thickest and Strongest wall of orbit = lateral wall
U BLOW OUT FRACTURES = Floor = Fractures of the
orbital floor ◦ Floor is easily damaged by direct
trauma to the globe, herniation of contents into
the maxillary antrum, muscle entrapment, Diplopia
Restricted movements(upgaze)
U Weakest point of bony orbit = Ethmoidal bone ,
even infection can break it
U Sinusitis (Mucocele) can cause = orbital cellulitis
U Relationship to Sinuses: Frontal sinus: above
Maxillary sinus: below Ethmoid & sphenoidsinuses:
medial

ORBIT THE EYEBALL

• Bilateral and symmetrical bony cavities enclosing • Anteroposterior diameter 24 mm
the eyeballs and associated structures • Horizontal diameter 23.5 mm
• Volume: 30 cc • Vertical diameter 23 mm
• Eyeball : occupies 1/5th • Circumference 75 mm
• Fat and muscles • Volume 6.5 ml
• Weight 7 g

Three coats of the eyeball

1. Fibrous coat
2. Vascular coat
3. Nervous coat

Segments and chambers of the eyeball

1. Anterior segment
a. Anterior chamber
b. Posterior chamber
2. Posterior segment
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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

CONJUNCTIVA 2. SCLERA PROPER

• Thin transparent mucous membrane • Dense collagen fibres
• Translucent but there are tiny blood vessels • White spherical shell
• Superior fornix and lower fornix are also covered by • Continuous with the cornea anteriorly and
the conjunctiva the dural sheath of the optic nerve
• Has glands which secrete mucus and mix with the posteriorly
tears and protect our eye • Avascular
1. PALPEBRAL CONJUNCTIVA
Lines the posterior surface of the eyelid firmly 3. LAMINA FUSCA
adherent to the tarsus • Elastic fibers
2. BULBAR CONJUNCTIVA • Blends with the supra choroidal and
Lines the anterior surface of the sclera up to supraciliary laminae of the uveal tract
the edge of the cornea
*GOBLET CELLS LIMBUS
U Boundary between the cornea and sclera
TENON’S CAPSULE (FASCIA BULBI) U Contains radially oriented fibrovascular ridges
• Fibrous membrane that envelops the globe from the known as Pallasades Of Vogt that harbor a stem
limbus to the optic nerve cell population. This is where new epithelial cells
are produced if the epithelial cells of the cornea
gets damaged.
U Ex: chemical burn: epithelium of the cornea is
affected, the stem cells located at the limbus can
produce new cells to proliferate and replaced the
damaged epithelium

CORNEA
5 Layers
SCLERA & EPISCLERA 1. Epithelium
The sclera is commonly known as the white of the eye. It 2. Bowman’s membrane
is the tough, opaque tissue that serves as the 3. Stroma
eye’s protective outer coat. 4. Descemet’s membrane
5. Endothelium
U Sclerae – structural support; collagenous outer wall
of eyeball
U Scleromalacia – weakening of sclera – collapse of
the eyes
 Outermost portion – episclera – rich
vascular network, area where bilirubin
accumulates (icterus)
 In connective tissue disease, sclera is
inflamed forming a nodule with tangled
hyperemic, episcleral and conjunctival vessels.

1. EPISCLERA
• Thin layer of elastic tissue
• Covers the sclera
• Highly vascularized

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

U Is 550 micron thick 4. DESCEMET’S MEMBRANE

U Main function is to refract light for clearer vision • Basal lamina of the corneal endotheium
U Contributed to its special characteristics like
transparency, avascularity, controlled hydration,
and high refractive power
U Optical power of cornea: 42 diopters, equal to 2/3
of the optica power of the human eye
U Avasclar: sources of nutrition: tears, oxygen from
the atmosphere, vessels of the limbus

1. EPITHELIUM
• 5-6 layers of epithelial cells
• Acts as a barrier
• Extremely sensitive to pain
• Capable of regeneration Normally adheres to the other layers but is detached in the
picture. It could be due to trauma during surgery.
2. BOWMAN’S LAYER Management: put air insdide the chamber to push it again
towards the other layers to promote adherence
• Collagen I, III, V, VI
• Purpose: tregth and relative resistance to trauma
5. ENDOTHELIUM
(mechanical and infective)
• Innermost layer
• Acellular (lack fibroblasts)
• Single layer of hexagonal cells
• Very little regenerative capacity
• Responsible for maintaining the deturgescence of
• Replaced by scar tissue
the cornal stroma (cornea is slightly dry in nature)
U If ever there is corneal abrasion that involves
• Na+/K+/ATPase (pumps Na+ and K+ out of stroma
the Bowman’s layer, when it heals, it’s no
into the aqeous humor so water will follow,
longer clear, it is replaced by a scar tissue
making the cornea slightly dehydrated)
• Little capacity for cell division
3. STROMA
• Endothelial repair is limited to enlargement and
• 90% of the corneal thickness
sliding of existing cells
• Thickest part
• Failure of endothelial function leads to corneal
• Composition:
edema
o Water
o Collagen I, III, V, VI
o Proteoglycan
o Keratocytes
• Composed of intertwining lamellae of collagen
• Stromal transparency is a consequence of the
regular arrangement of the lamellae, with uniorm
diameter and separation of collagen fibers

U Sclerae is also made up of collagen, but it is

opaque. Corrnea also made up of collagen is
transparent. The difference lies in the
orientation/arrangement of the collagen. Random
for sclerae; parallel for cornea

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

UVEAL TRACT CILIARY MUSCLES

- Middle Vascular Layer of the Eye - alter the shape of the lens during accomodation
1. Longitudinal
3 PARTS: 2. Radial
3. Circular Fibers
1. Iris
2. Ciliary Body
3. Choroid

1. IRIS
• Shallow cone pointing anteriorly
• Positioned in fron of the lens
• Pupil - central round aperture
• Divides anterior chamber from the posterior
chamber

2. CILIARY BODY
• Extends from the root of the iris to the anterior end of
the choroid

TWO IMPORTANT MUSCLES:

1. Circular muscles: located at the sphincter
2. Radial muscles: located at the sides

When light is very bright, pupil will constrict its

circular muscles so that only a small amount of light can go
inside the eye, protecting the retina from the damage of
the light. When it is dark, circular muscles relax and radial Composed of:
muscles contract making the pupil bigger, more light will 1. Capillaries and veins
enter the eye heping you to see better in the dark. 2. Ciliary processes
3. Ciliary muscles

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

ZONES OF CILIARY BODY • 3 layers of choroidal blood vessels: large, medium,

1. PARS PLICATA and small
• First 2 mm • Provides the blood supply, oxygen and nutrition to
• Corrugated anterior zone the outer retina and retinal pigment epithelium
• Ciliary processes are located • Provides oxygen and nourishment to the outer
retina and RPE
2. PARS PLANA • For dissipation of heat
• 4 mm from the limbus
• Flattened posterior zone LENS
• Double layer of epithelial cells • Biconvex, avascular, transparent
• Provides surgical access to the vitreous and retina • No pain fibers or nerve fibers (You can crack the
lens during cataract surgery without the patient
feeling any pain)
• 2-4 mm thick (can be increased up to 5-6 mm as
we age) ; 9-10 mm diameter
• 65% Water; 35% Protein and considerable
amounts of Potassium, Ascorbic acid, Glutathione
• Purpose is to focus light onto the retina with 1.336
index of refraction
• Held in place by zonules that arise from the surface
of the ciliary body and insert into the lens

CILIARY EPITHELIAL CELLS

• Produce aqueous humor, which is responsible for
providing oxygen, nutrients, and metabolic waste
removal to the lens and the cornea

• 3 layers:

3. CHOROID

• Posterior segment of the uveal tract located
between the retina and the sclera
1. Lens Capsule
2. Lens Epithelium-located at the anterior part; below
the capsule; single layer of epithelial cells that continue
to produce new fibers throughout our life; thus, lens
fiber becomes thicker and thicker as we age

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

3. Lense Fiber
A. Nucleus-oldest, hardest and thickest
B. Cortex-softest

(Larger image at the appendices)

• Aqueous humor produced by ciliary process passes
by the zonules to the posterior chamber through
the pupils then to the anterior chamber and goes
*Proteins in the lens become degraded from a clear lens to out through the anterior angle to the trabecular
an opacified cataract. meshwork.
• Trabecular meshwork is connected to the
episcleral and conjunctival veins so the humor will
go back to the general circulation.

1st picture: In order to gain access to the fibers of the lens,

a circular peel on the anterior capsule is made
2nd picture: Topical anesthesia to sculpt the nucleus and
remove the cataract.
3rd and 4th pictures: Intraocular lens (5mm) is placed inside
through a 2mm incision and unfolds when already placed
inside.
*If there are problems in the angles, the water being
AQUEOUS HUMOR produced cannot go out the anterior chamber as in the
• Produced by the ciliary body at a rate of 2–3 ul/min cases with blockage in trabecular meshwork and the
• Rich in nutrients, and is a metabolic exchange for the angles are very narrow.
avascular tissue of cornea and lens
• Occupies the anterior part of the eye; without the
aqueous, the cornea will fall flat.
• Never gets old; Changed every minute and the old
humor goes out through the anterior chamber angle

*The intraocular pressure builds up and incur changes

in the optic nerve.
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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD
*The pressure will damage the nerve and cause
glaucoma. There will be loss of visual field and
eventually blindness.
VITREOUS HUMOR
• Clear, avascular, gelatinous body that comprise 4/5
(80%) of the volume of the eye
• Volume : 4cc; Wt : 4gm
• 99% water, 1% Hyaluronic acid, Hyalocytes, Type II
Collagen
• Firmly attached to the vitreous base, optic disc,
retinal vessels, fovea
• Previously known as the “No Man’s Island.” Going
deeper inside the eye is like going in to the abyss.
*Pars Plana Vitrectomy: Accessed through the pars
plana and eat the vitreous; Indicated if there is
bleeding at the back of the eye wherein blood may
dissipate in the vitreous causing blurring of vision (may
be totally blank or dark).
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RETINA
• Multilayered sheet of neural tissue
• Receives light that the lens has focused, converts
the light into neural signals, and sends these
signals on to the brain for visual recognition.
• 3 layers:
1. Outer (Photoreceptor Layer) -only layer
that is sensitive to light
o Rods - dim light; black and white vision
o Cones - bright light; colour vision
2. Middle
o Bipolar Cells-transmit information
from rods and cones to the ganglion
cells
o Horizontal Cells
3. Inner
o Ganglion Cells-axons converge at the
optic disc to become the optic nerve
Layers of the Retina
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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

MACULA HYPEROPIA AND MYOPIA

• Center of the posterior retina

FOVEA
• Center of the macula
• Thinnest part of the retina which contains only
cones (most dense)
• Provides fine visual discrimination and high-
resolution colour vision

Macula and Fovea

NORMAL
OPTIC NERVE • Scattered light (3 blue lines) needs to converge to
• Cranial Nerve II; Paired nerve a single point or focus in order for us to have a
• Consists of about 1 million axons that arise from clear vision
the ganglion cells of the retina
• Leaves the eyeball and transmits visual information HYPEROPIA
from the retina to the brain • Far-sighted; Eyeball is too short
• Rays of light come to a focal point behind the
III. VISUAL PATHWAY retina
• Corrected with hyperopic/convex lens

MYOPIC
• Near-sighted; Eyeball is too long
• Rays of light come to a focal point even before
reaching the retina
• Corrected with a concave lens

ASTIGMATISM

• Irregularly shaped cornea

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Block XX | Module 1 | Lecture 1: Clinical Anatomy and Physiology of the Eye by Dr. Joanne T. Rocha, MD

• There are many focal points in front and behind XX. REFERENCES
the retina
• You could see the letter but it may seem that you 1. Doc Rocha’s Lecture
2. Batch MD’s notes
have monocular diplopia (persists in one eye 3. General Ophthalmology by Eva and Cunningham
despite covering the other eye and can usually be
corrected by using a pinhole)
• Corrected with astigmatic lens

PRESBYOPIA
• By age 40s or middle-age, you eventually wear
reading glasses because you could no longer
accommodate at near (difficulty reading text
messages, books)

*When we read at a distance, the ciliary bodies are relaxed

and the zonules are taut, providing tension in the lens
making it flat; At near, ciliary bodies contract and zonules
relax providing no tension pulling on the lens making the
lens rounder. Rounder lens has a higher dioptic power to
let you focus light and accommodate at near.

*When you get older, the lens becomes stiffer. Even if the
ciliary muscles contract more and zonules relax more, the
lens isn’t pliable enough to become circular. Corrected
with reading glasses.

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