‫بسم هللا الرحمن الرحيم‬

Physiology of The Eye

‫ممدوح الكفراوى‬
The Eye brow
 Eye Brow
• Located at the junction of the
forehead and the upper eyelid.
• Is a transverse elevation of hair
that starts medially just inferior
to the orbital margin and ends
laterally above the orbital
margin.
 Superior eyelid
crease

Plica
semilunaris

Medial canthal Lateral canthal

angle angle

Caruncle
 Eye Brow
• The eyebrows are formed by
the transverse elevation of
the superciliary ridge of the
frontal bone.
The superciliary ridge is more prominent in males
and often absent or less prominent in females.
 Eye Brow
• Because it extends only over
the medial half to two thirds of
the orbit, the lateral brow lacks
this extra bony support.
Laterally, the brow is supported
by fascial attachments to the
temporalis fascia.
 Eye Brow
The eyebrow layer consists of
• The skin.
• Subcutaneous connective tissue.
• A muscular layer.
• A submuscular areolar layer.
• The pericranium.
 Eye Brow
The eyebrow skin
• Is thick and mobile and contains
sebaceous glands.
The subcutaneous tissue layer
• like that of the scalp, consists of more
fibrous tissue than fat.
• It is also correspondingly as thick as the
eyebrow skin.
 Superior eyelid
crease

Plica
semilunaris

Medial canthal Lateral canthal

angle angle

Caruncle
 Eye Brow
The muscular layer is composed of
• The vertical fibers of the frontalis.
• The horizontal fibers of the
orbicularis oculi.
• The oblique fibers of the
corrugator supercilii
 Orbital portion of
Orbicularis muscle
Frontalis muscle
Superior preseptal
Portion of
Procerus Orbicularis muscle
muscle
Superior pretarsal
Portion of
Orbicularis muscle
Anterior arm of
Medial canthal Lateral horizontal
tendon raphe
 The Corrugator Supercilii
Muscle
• originates from the frontal bone
near the superomedial orbital
margin
• inserts at the muscle and skin
behind and immediately superior
to the middle third of the
eyebrow.
 Frontalis muscle

Corrugator
muscle

Orbital portion
of orbicularis
muscle
Procerus
muscle
 The Procerus Muscle
• Arises from the nasal bone
and the upper nasal cartilage.
• It travels superiorly to insert
on the medial forehead skin.
 Frontalis muscle

Corrugator
muscle

Orbital portion
of orbicularis
muscle
Procerus
muscle
The Eye brow
 The Eye brow
Because of its position and curvature:

• The eyebrow shields the eyes from

bright light coming from directly
above.

• It is an effective barrier to liquids

running from the forehead into the
eye.
 Superior eyelid
crease

Plica
semilunaris

Medial canthal Lateral canthal

angle angle

Caruncle
 The Eye brow
The large hairs of the eyebrow
have abundant sensory
innervation and are very
sensitive to tactile stimulation.
Accordingly, stimulation of the
supercilia results in reflex
blinking of both eyelids.
 Frontalis muscle

Corrugator
muscle

Orbital portion
of orbicularis
muscle
Procerus
muscle
 The main elevator is the frontalis muscle

.Frontalis m

Corrugator
.Supercilii m

.Procerus m
.Temporalis m

Orbicularis
.Oculi m
 The Eye brow
• The eyebrows can be
elevated, depressed, or
drawn together.
• Their position is critical to
facial configuration and
expression.
 The Eye brow
• Maximal elevation of both
medial and lateral portions of
the eyebrows gives rise to the
look of surprise.
• Depression of the medial
portion of the eyebrow depicts
anger or concern.
 The Eye brow
• Elevation of only one eyebrow
portrays a quizzical or
questioning expression.
• These expressions serve as
nonverbal forms of
communication to convey
emotion.
The Eyelids
Protective Mechanism
of the eye
• The eyelids.
• The bony orbit.
• The shock-absorbing orbital fat.
• The sensibilities of the cornea.
• The lubrication of the eye by the
secretions of the lacrimal glands
and the conjunctiva.
 The protective function
of the eyelids
Is mediated by :
1) The movement of the eyelids:
• Protective from external injuries
(Physical or chemical).
• Protective from undue exposure
to light.
• Provide rest to the levator and
extra-ocular muscles ( as the eyes
turn up ).
 The protective function
of the eyelids
Is mediated by :
1) The movement of the eyelids:

• Help aqueous circulation by increasing

IOP 3-4 mmHg during closure.

• Help the drainage of tears.

• Distribution of tears on the eyeball

helping lubrication , moisture and
transparency of the cornea.
 The protective function
of the eyelids
Is mediated by :
1) The movement of the eyelids:

• Provide rest to the retina :

*allows regeneration of the

visual pigments .

*Eliminates blurring of images

during the movement of the eye
to change the fixation point.
 The protective function
of the eyelids
Is mediated by :
2) The oily secretion of Meibomian glands:

• Retards evaporation of tear fluids.

• Prevent overflow of tears at the
lid margin.
• Lubricates lid / ocular interface.
• Optical.
 Meibomian glands
Gland of Zies

The oily secretion

 The protective function
of the eyelids
Is mediated by :
3) The cilia or eyelashes:

• Easily excited by a foreign particle

to induce a reflex blink.

• The follicle is surrounded by a nerve

plexus with a very low threshold of
excitation (tactile sensation).
 Gray line

Meibomian gland
orifices

Mucocutaneous Easily excited by a foreign

junction particle
.to induce a reflex blink

Conjunctiva
Lash Follicle
Meibomian
gland The follicle is surrounded by a nerve
plexus with a very low threshold of
.excitation

Orbicularis
Oculi muscle
 Gray line

Meibomian gland
orifices

Mucocutaneous
The cilia are normally
junction
replaced every 3-5
months
Conjunctiva
Lash Follicle
Meibomian
gland
But are replaced
In two months if
forcedly removed
Orbicularis
Oculi muscle
 Sebaceous
cell

Zeiss Glands
•The sebaceous glands of Zeiss have short
wide ducts lined with stratified squamous
epithelium that empty into the follicles.
 Sebaceous
cell

Zeiss Glands
•They produce sebum from the degeneration
Of slowly proliferating basal cells and serve
To lubricate the eyelashes and prevent them
From becoming dry and brittle.
•An average of two glands

of Ziss empty into each

follicle.

•The modified apocrine

sweat glands of Moll

are less plentiful and

average less than one

per hair follicle.

The Normal Movements
Of The Eyelids
• Elevation.
• Closure.
• Blinking :
Involuntary:
Reflex.
Spontaneous.
Voluntary:
 Elevation
• Is attained mainly by Levator
muscle ( oculomotor nerve ).
• Partly by Mϋller muscle
( Sympathetic nerve ) .
• Superior rectus muscle through its
fascial attachment with the levator.
• Frontalis muscle . ( when the levator
is defective)
The center is in opposite frontal
cortex near oculogyric centre .
 Levator palpebrae
Whitnall’s superioris muscle
ligament

Levator
aponeurosis Fascial slips to
Oricularis muscle
Medial horn

Lateral horn
Levator palpebrae
superioris muscle

Müller’s superior
sympathetic
Tarsal muscle

Levator aponeurosis

Inferior sympathetic
Tarsal muscle
 Lower lid retractors
• A fibrous tissue sheet.
• Extends from the sheath of the
inferior rectus muscle to the lower
border of the tarsal plate.
• It is accompanied by the inferior
tarsal muscle of Mϋller.
Levator palpebrae
superioris muscle

Müller’s superior
sympathetic
Tarsal muscle

Levator aponeurosis

Inferior sympathetic
Tarsal muscle
 Whitnall’s
ligament

Arcuate
expansion
Lockwood’s Capsulopalpebral
ligament Fascia
Whitnall’s
ligament

Capsulopalpebral
Fascia

Arcuate Lockwood’s
expansion ligament
 Closure
Is attained :
• Mainly by orbicularis oculi
muscle ( Facial nerve ).

• Partly by the gravity.

• Center in the motor area
 Closure
• Three types of closure:

Blinking

Winking

Blepharospasm
 Blinking
Is closure of the two eyes.
• Types:
Involuntary:
Reflex:
* Tactile (corneal) reflex.
* Optical reflex.
* Auriculo-palpebral reflex.
Spontaneous.
Voluntary:
 Reflex Blinking
• It is cortical in man.
(subcortical in animals)

• Induced by certain stimuli.

• Protects the eye from the

threatening stimulus.
 Reflex Blinking
Tactile ( corneal ) reflex:
Afferent is the fifth cranial nerve (trigeminal)
Applied:
• The last reflex to be lost
in general anaesthesia.
• Early lost in a cortical lesion
of Rolandic area.
• Early impaired on the side of a cerebello-
pontine angle tumor . ( 5th and 7th ).
• Contact lens wearers develop reduced or
even absent tactile reflex (better tolerance).
Rolando fissure
 Tactile ( corneal ) reflex

the fifth cranial nerve

)trigeminal(

the seventh cranial nerve

)Facial(
 Reflex Blinking
Optical reflex blinking:
Afferent is the optic nerve .
The menace reflex:
• Due to unexpected object
approaching the eye.
(sudden presence of near object).
• Central connection cortical.
 Reflex Blinking
Optical reflex blinking:
Afferent is the optic nerve .
The dazzel reflex:
• Due to shining bright light
in the eye.
• Central connection subcortical ( colliculi ).
• Appears at the age of 2 month.
• Sometimes associated with sneezing.
• It is lost in general anaesthesia.
• May be lost in certain mesencephalic lesions
that give no other external signs.
 Reflex Blinking
Auriculo-palpebral reflex :
Afferent is the vestibulocochlear nerve.
• Reflex blinking on hearing sudden
noise.
• Subcortical.

Orbicularis reflex :
Afferent is the trigeminal nerve.
• Streching of panorbital structure.
• Cortical .
 Spontaneous Blinking
• It normally present in vertebrates living

in contact with air without any obvious

stimuli.

• In man it does not completely develop

until the age of six month . ( although

the child can screw up the lids due

to irritation)
 Spontaneous Blinking
• Normal blinking during waking hours.
• Blink rate is specific to each individual.
• Average rate : 15 times per minute.
• It is more in women than in men.
• Increases with:
attention
emotions
temperature
light air currents
conjunctival and corneal irritation.
 Spontaneous Blinking
• It diminishes by:
moisture.
dysthyroid ophthalmopathy.
• Duration : 0.3 – 0.4 seconds.
• Present in the blind (hence no retinal
stimulation is required).
• Present in-spite of surface
anaesthesia.
• Present in nystagmus and external
ophthalmoplegia.
 Spontaneous Blinking
• No discontinuity of visual sensation
during blinking. (duration of blinking
is shorter than that of after image ).
• The average inter-blink period is 2.8
seconds.
• During the blink vision is in
suspension ( blackout).

Blink period 0.3

• The blackout index =------------------------- x 100 = 10%
Interblink period 2.8
Spontaneous Blinking

If blinking is very frequent , it

might endanger occupations in

which constant perception is a

necessity , such as piloting high

speed aircraft.
 Spontaneous Blinking
• The upper lid begins to close with no
lower lid movements.
• It is followed by a zipper-like
movement from the lateral canthus
towards the medial canthus.
• This helps the displacement of the
tear film to the lacrimal puncta which
are located on the medial side of the
lids.
Spontaneous Blinking
 Spontaneous Blinking
Cause of spontaneous blinking:
• It is possible that the afferent is from
proprioceptives in the levator muscle
(trigeminal nerve).
• Efferent in (facial nerve).
• The center is probably in the basal
ganglia which discharge periodically
in the facial nerve ( since blinking is
absent in parkinsonism).
Basal ganglia
Fiber groups Cell groups
Cerebral
Corpus cortex
callosum
Septal area

Fornix Caudate nucleus

Corpus
striatum
Cortical
White Putamen
matter

Internal
capsule Globus
pallidus
Lentiform
nucleus

Basal ganglia
 Electromyographic studies
• The first change to occur in a blink is
relaxation of the levator.
• The three main functional groups of the
orbicularis oculi :
Pretarsal part: (very short contraction time)
spontaneous blinking.
corneal reflex.
Preseptal part:
spontaneous blinking.
unsustained activity.
Orbital part:
sustained activity.
(shutting the eyes).
 Applied **

• The excitability of a nerve can

be described by the weakest
stimulus that elecits an action
potential if applied for an
infinite time.

• This is known as the rheobase.

 Applied **

• Chronaxie is defined as the

time taken to elicit an action
potential if a current twice the
rheobase is applied.

• Chronaxie is a measurement
of excitability of a muscle.
 Applied **

•The palpebral portion of

the orbicularis oculi
muscle has a chronaxie
half that of the orbital
portion.
The marginal fibers of riolan:
Keep the lid margins closely opposed
To the globe at all its movement.
The palpebral part:

Pretarsal part+Preseptal part:

• Gentle closure of the lids.

( blinking and sleep)

• Expanding the sac by its deep

origin (Horner’s muscle).

• Narrows the lacrimal ampulla .

• Shortens the canaliculi.

The Orbital part:

• Forced shutting of the lids

(voluntary).

• Retraction of the globe.

• Pull the lacrimal

diaphrgam laterally

expanding the sac.

 Voluntary Winking

Is a voluntary closure of one eye.

• Most persons wink easier
with the left eye?
(predominance of right
handness).
• Contractions of both
palpebral and orbital
portions of orbicularis
oculi.
 Blepharospasm
•Squeezing the eyelids together.

•Contraction of all orbicularis

plus muscles of the brow.

•This rasises the IOP.

•Avoided by facial akinesia.

•Associated with photophobia.

•Associated with Bell’s phenomenon.

Abnormal movements
Myokymia or fibrillary twitches of eyelids:
Nerve fiber irritation may be due to:
• Fatigue.
• Thyrotoxicosis.
• Mental tension.
• Refractive error.
Weakness of orbicularis:
• Myotonic dystrophy.
• Myasthenia gravis
Associated movements of eyelids
•When the eye is turned up, the lid is elevated.
•Bell’s phenomenon : on closing the lids , the
eye turns up and out.

•Marcus Gunn (Jaw-winking phenomenon) :

Unilateral ptosis corrected by moving the
lower jaw ( abnormal neurological link
between oculomotor and trigeminal nerves ).
Marcus Gunn jaw-winking syndrome
Marcus Gunn jaw-winking syndrome
Marcus Gunn jaw-winking syndrome
Associated movements of eyelids

•Pseudo-Graefe’s phenomenon:

Ptosis in straight-ahead gaze and in abduction

corrected in adduction ( abnormal neurological

link from oculomotor nerve to levator instead of

Rectus muscle after recovery from 3rd nerve

paralysis ).
The Palpebral fissure

In the normal adults and

in the primary position:

• 30 mm long.

• 8-11 mm wide.
The Palpebral fissure
The maximum excursion
of upper lid :
•From low gaze to up gaze is
15 mm.
•The frontalis adds another
2-3 mm.
The Palpebral fissure
The width of the palpebral fissure:

•Depends on the balance between

the muscles elevating the lid

and the orbicularis

•Increases in emotions .

•Diminishes in intense light .

 The Bell’s
phenomenon
 The Bell’s phenomenon
• Is the upward rotation of the globe

during forced closure of the eyelid.

• That is , when the patient is asked to

close his eyes whilst the eyelids are held

open.

•The A - P axis rotates 15° above the

horizontal.
 The Bell’s phenomenon
•It is not seen in reflex blink closure ,

where there is rotation of 1-2° towards

the primary direction of gaze , and

approximately 1 mm retraction of the

globe.

•Bell’s phenomenon is absent in 10% of

the population.
Thank You
The Eyelids
MCQ
 With regard to reflex blinking;
: Which one is not true
A. May be caused by optical stimulation.

B. May be caused by auditory stimulation.

C. A corneal reflex is dependent on the fifth

and seventh cranial nerves.

D. Cortical function is needed for a corneal

reflex.

E. Is initiated by the pretarsal fibers of

orbicularis oculi.
 With regard to spontaneous
: blinking; Which one is not true
A. Is absent until the third month of life.

B. Blind people blink spontaneously.

C. Frequency is approximately 15 per minute.

D. Is preceded by relaxation of the levator

palpebrae superioris..

E. Duration is approximately 1-1.5 seconds.

 With regard to associated eye
movements; Which one is not
: true
A. Upward movement of the globe associated with eye
closure is known as pseudo Graefe phenomenon.
B. Bell’s phenomenon is absent in 10% of normal
people.
C. Voluntary upward gaze is associated with lid
retraction.
D. Fibrillary twitching of the eyelids may be due to
refractive errors.
E. The Marcus Gunn (Jaw winking) syndrome is
caused by pterygoid linkage with the levator
palpebrae superioris.
With regard to the effect of drugs
on the eyelids; Which one is not
: true
A. Guanethedine can be used to decrease
width of the palpebral fissure.
B. Botulinum toxin inhibits release of
acetylcholine from presynaptic terminals.
C. Botulinum toxin is used in the treatment of
blepharospasm.
D. Edrophonium acts as an indirect nicotinic
agonist in the Tensilon test .
E. The partial ptosis of Horner’s syndrome is
reversed by topical cocaine.
With regard to Bell’s phenomenon ;
: Which one is true
A. Occurs during normal blinking .

B. If absent suggests brain stem disease .

C. Is absent in Bell's palsy .

D. Is reduced or absent in patients with

thyroid orbitopathy

E. Occurs during reflex blink closure of the

eyelids.
With regard to the eyelids ; Which
: one is true
A. Myokymia or fibrillary twitching is
associated with fatigue .
B. The skin layer is glabrous ( hairless ).
C. Cilia have a very high threshold for tactile
sensation.
D. At photopic levels , blinking with duration
of up to 10 ms shows no discontinuity of
visual perception .
E. The long , thin ducts of the Zeiss glands
empty directly into ciliary follicles.
With regard to the eyelids ; Which
: one is true
A. The glands of Zeiss are less numerous than
the glands of Moll.
B. The chronaxie of the orbital portion of
orbicularis oculi is half that of the palpebral
portion
C. Cilia are replaced every one month.
D. Orbicularis oculi is an example of a yoke
muscle.
E. The cilia have a very low threshold for
tactile sensation.