GNK485 The eye and related structures. Prof MC Bosman 2012

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1 GNK485 The eye and related structures Prof MC Bosman 2012

2 Surface anatomy Bony orbit Eyeball and Lacrimal apparatus Extra-ocular muscles Movements of the eye Innervation Arterial supply and venous drainage Visual- and reflex pathways Clinical applications

3 Surface anatomy Sclera Cornea Palpebral fissure Sclerocorneal juncture Pupil Iris Superior eyelid Inferior eyelid Eyelashes Conjunctiva bulbar and scleral Conjunctival sac Medial angle of the eye: lacrimal lake, lacrimal caruncle, semilunar conjunctival fold lacrimal punctum, lacrimal papilla

4 Bony orbit Orbit - Cone-shaped - Roof - Floor - Medial wall lamina papyracea - Lateral wall - Apertures optic canal orbital fissures superior inferior nasolacrimal canal

5 Bony orbit Orbit - Cone-shaped - Roof - Floor - Medial wall lamina papyracea - Lateral wall - Apertures optic canal orbital fissures superior inferior nasolacrimal canal

6 Eyeball

7 Eyeball

8 Eyeball

9 Eyeball - layers Outer: Fibrous [white of eye] Sclera opaque [posterior 5/6] Cornea transparent [anterior 1/6] Middle: Vascular [uvea] Choroid dark, reddish brown, blood vessels located near sclera, capillaries innermost Ciliary body folds are ciliary processes secrete aqueous humor suspensory ligaments to lens Iris pupil sphincter and dilator pupillae [autonomic control] Inner layer Retina - optic part: neural layer, pigmented layer non-visual part: covers ciliary body and iris Fundus posterior part with optic disc, macula lutea with fovea centralis Ora serrata optic part terminates

10 Eyelids Eyelids Conjunctiva Peri-orbital fat Fibrous attachments

11 Eyelids Orbital septum Palpebral ligaments

12 Lacrimal apparatus

13 Extra-ocular muscles Rectus muscles - Superior - Inferior - Medial - Lateral Superior oblique Inferior oblique (Levator palpebrae superioris)

14 Movements of the eye

15 Movements of the eye Superior oblique Inferior oblique Superior rectus Inferior rectus Medial rectus Lateral rectus Depression Intorsion, Abduction Elevation Extorsion, Abduction Elevation Adduction, Intorsion Depression Adduction, Extorsion Adduction Abduction Levator palpebrae superioris Elevation of upper eyelid

16 Innervation III IV VI V1 Lacrimal glands Eyelids VII (Greater petrosal n) Lacrimal glands Autonomic Sympathetic Deep petrosal n via plexus on ICA Parasympathetic Short ciliary nn from ciliary ganglion (III) (LR 6 SO 4 ) 3

17 Arterial supply Arterial supply from the ophthalmic branch of the internal carotid artery Facial artery joins the dorsal nasal branch of the ophthalmic artery Maxillary artery infra-orbital artery

18 Venous Drainage Venous drainage via superior and inferior ophthalmic veins Pterygoid venous plexus Facial vein and danger area Cavernous sinus

19 Visual pathway Optic radiations (Meyer s loop) Visual association cortex, areas 18 & 19 involve posterior temporal lobe (Wernicke)

20 Reflex pathway Constrictor pupillae Ciliary muscle Short ciliary nerves (postganglionic fibres) Optic nerve Ciliary ganglion CN III (preganglionic fibres) Substantia nigra Optic tract Red nucleus Lateral geniculate body Medial geniculate body Edinger-Westphal nucleus Pretectal area Brachium of superior colliculus Pulvinar of thalamus Superior colliculus Posterior commissure

21 Reflex pathway

22 Corneal reflex Any stimulus to the conjunctiva or cornea excites blinking. Afferent fibres travel via the ophthalmic division of the trigeminal nerve and synapse in the spinal tract and nucleus of CN V. Efferent impulses in branches of the facial nerve to orbicularis oculi. Patient not blinking: Either V1 or VII Test V1 on forehead to exclude

23 Accommodation reflex Pathways from visual cortex Pretectal area Fibres from III, IV and VI cause: (i) Vergence of the extra-ocular muscles via frontal eye fields (squint) (ii) Parasympathetic activation of the constrictor and ciliary muscles within each eye

24 Clinical applications

25 Trochlear nerve (IV) The patient is attempting to look down and to the left, but his movement is impaired in the right eye. The patient present with diplopia, especially when reading, and difficulty in walking downstairs.

26 Oculomotor nerve (III) Dense ptosis due to CN III lesion - eye rests in down and out position Parasympathetic component ciliary ganglion dilated pupil with lack of constriction sphincter pupillae = loss of normal pupillary reflex Loss of accommodation ciliary muscle

27 Abducent nerve (VI) Strabismus en diplopia Weakness or paralysis of ipsilateral lateral rectus cannot abduct past midline (LMN lesion) Several mechanisms: vascular (aneurysms, infarct in pons) 4 th ventricle (will also affect CN VII), infection (esp. in otitis media), skull-base fractures, cavernous sinus pathology

28 Sympathetic supply Horner s syndrome: (oculosympathetic paresis) Ipsilateral injury to cervical sympathetic trunk / T1 C8 Ptosis (partial) Miosis (parasymp) Facial anhidrosis

29 Facial nerve palsy Paralysis of orbicularis oculi closure of eyelids Ectropion turning outward of eyelid margin Movement of eye unaffected Lacrimation affected dry eye

30 Entropion Old age Spasm of orbicularis oculi

31 Hyphema Blood in the anterior chamber of the eye

32 Tumours Position: In ethmoid or sphenoid sinuses erodes orbital walls Compression of CN II Proptosis Tumour metasteses Middle cranial fossa Temporal / Infratemporal fossa superior orbital fissure inferior orbital fissure

33 Trauma Foreign object Retinal detachment

34 Trauma Blowout fracture Restricted left upgaze caused by orbital floor fracture. Displacement of orbital wall Unstable muscle attachments Medial wall: -Ethmoid -Sphenoid Floor: Maxillary sinus Proptosis: intra-ocular bleeding

35 Trauma Raccoon eyes Peri-orbital bruising, # frontal skull area, cavernous sinus thrombosis

36

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