Manual of Oculoplasty Ruchi Goel
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flow chart, and t refer to table.
A
Abducens nerve 11
course of 12f
Ablepharon 163
Accessory lacrimal glands 198, 199f
Krause 197
Wolfring 197
Acne rosacea 167
Acquired nasolacrimal duct obstruction
primary 211, 212, 222
secondary 223
Acquired ptosis
classification 136
management 136
mechanical 136
unilateral 136f
Acrochordon 299
Actinomyces israelii 213
Acyclovir 172
Adalimumab 69
Adenoid cystic carcinoma 35, 248, 249f, 302, 303f
Adenoma sebaceum 292
Adult orbital xanthogranulomatous
disease 55
disorder 55
Airbag deployment 161
Airway obstruction 215
Alkylating agents 54
Amantadine 161
Amblyopia 165, 215
American Academy of Neurology 172
American Academy of Otolaryngology 172
American Joint Committee on Cancer 265b
Amniotocele 215
Anesthesia 223
Angioma, tufted 238
Angiosarcoma 238
Angiotensin converting enzyme 21
Angular blepharitis 168
management 168
Anisocoria 74
Ankyloblepharon 164
internal 164
Annulus of Zinn 6, 7, 11, 12
Anophthalmia 40, 104, 105f, 109, 164
acquired 104, 105
bilateral congenital 113f
congenital 104, 104f, 105f, 106, 113f
consecutive 40
primary 40
secondary 40
Anophthalmic socket
deeper tissues of 106f
evaluation 104
management 104
Antiacetylcholine receptor antibody assay 138
Antibiotic 44
Antibody
antinuclear 53
based therapy, targeted 67
Antiglaucoma therapy 206
Antineutrophil cytoplasmic antibody 53
Antinuclear cytoplasmic antibody 22
Antioxidants 67
Antitubercular drugs 45
Antiviral agents 172
Apert syndrome 39
Aponeurotic ptosis 139
Apraclonidine 138, 158
Argon laser ablation 156
Artery
angular 14
anterior ciliary 14
ciliary 14
cilioretinal 14
ethmoidal 15
forceps 314, 314f
infraorbital 14, 15, 79
lacrimal 14
supraorbital 14
zygomaticofacial 14
zygomaticotemporal 14
Aspergillosis 46
Asthma, adult onset 55
Astigmatism 215
Astrocytoma, intracranial 292
Atonic sac 213
Auricular cartilage graft-surface marking 177f
Auricular nerve, posterior 171
Autoimmune inflammatory disorder 61
Axillary freckles 244
Azathioprine 54
Azzopardi phenomena 302
B
B cell lymphoma 57f
Bacitracin, topical 168
Baclofen 161
Bacteroides 212
Ballet's sign 63
Balloon
dacryoplasty 218, 218f
technique 286
Bard-Parker handle 313
Barraquer wire speculum 312
Basal cell 35
carcinoma 102, 192, 249, 253-255, 301, 301f, 318
management of 260
pigmented 255f
nervous syndrome 255
Basal tear production 197
Basic secretion test 207
Basolacrimal duct obstruction 232
Baylis incision 83
Bazex syndrome 255
B-cell lymphoma 246, 293
Beard's classification 123
Bell's palsy 172, 173, 192, 205
Bell's phenomenon 124, 173
grading of 124
Benzodiazepines 161
Berke's canthal splitting lateral linear incision 91
Berke's guidelines, modified 128
Berke's incision 84, 85f
Reese modification of 85, 85f
Berke's method 123
Berke-Reese incision 84
Bicanalicular stent 316, 317f
Bick's procedure 144, 144f
modified 144, 144f
Bicurve needle 322
Binocular single vision 75
Biomicroscopy, ultrasound 281
Biopsy
conjunctival map 260
specimen, size of 311
Bioresorbable implants 77
Bleeding 74, 225
diathesis 223
Bleomycin 240
intralesional 240
Blepharitis 167, 216
anterior 167
chronic 167
classification of 167fc
posterior 168
Blepharochalasis 188
Blepharon 187
Blepharophimosis 166f
syndrome 131, 131f, 133f, 142, 166
Blepharoplasty 69, 181, 187, 188
Blepharospasm 160, 183, 192
benign essential 160
clinical presentation 160
differential diagnosis 160
epidemiology 160
essential 183
etiology 160
investigations 160
treatment of 161f
Blind eye, painful 92
Blindness 87
Blood
count, complete 53, 223, 254
pressure 223
sugar 223
Blow-in fractures 73, 74
Blow-out fractures 72, 73f, 74, 79
Blunt injury 72
Bogorad's syndrome 172
Bone
cortical 71
destruction of 35f
flap 86f
graft 77
lacrimal 4
saw 317
thickest 5
Bony decompression 89
Bony destruction 45
Bony facial canal 171
Bony orbit, smaller 104f
Bony orbitotomy 86
Bony ostium 224
Boston sign 63
Botulinum toxin 161, 181-183, 184f
complications 184
indications 183
injection of 161f, 173, 184
mechanism of action 182
precautions 184
type injection, reconstitution of 161
Bowen's disease 255
Bowman's lacrimal probe 309, 310f
Bradycardia 238
Brailey's sign 20
Brain 245
sac-like herniation of 250
Breast cancer 206
Brow fat
show 191
span 188
Brow lift 174
Brow ptosis 181
correction 181, 191
Brow suspension repair 128
Brown's syndrome 245
Browpexy, internal 193
Bulbar conjunctiva
medial 263f
superior 176
Bulbar conjunctival lesion, pink 275f
Buphthalmos 19
Burkitt's lymphoma 253
Burrow's operation, modified 154
Butyl alcohol, tertiary 211
Byron-Smith lazy-T procedure 145t
C
Café-au-lait spots 244
Calamari's sign 221, 222f
Calcium binding protein 302
Canalicular abnormalities 214
Canalicular blocks, open distal 309
Canalicular channels, accessory 215
Canalicular laceration 212
repair 221
Canalicular mucosa 222f
Canalicular obstruction, common 209
Canalicular stenosis 206
Canaliculitis 212
Canaliculodacryocystorhinostomy 214, 228
Canaliculus 227f
inferior 147f
obstruction 211
vertical 231f
Canthal defects, lateral 175
Canthal distance, outer inter 39f
Canthal dystopia, lateral 74
Canthal reconstruction 175
Canthal sling, lateral 147, 147f
Canthal tendon
lateral 5, 141, 143f, 145f, 175, 178, 179f
laxity, lateral 141
posterior reflection of medial 180f
sling, lateral 142
Canthoplasty
lateral 132
medial 147, 147f
Canthotomy, lateral 94f, 142, 143f, 173
Canthus
lateral 144f
medial 215f
Carbamazepine 161
Carbidopa 161
Carboplatin 289
Carcinoma
conjunctival 265b
in situ 255
Carotid artery 238
internal 286, 288f
Carotid cavernous fistula 241
Carotid supply
external 5
internal 5
Caruncle 66, 206
Caruncular edema 65
Castroviejo's calipers 311, 311f
Castroviejo's suture-tying forceps 307
Cat's paw 308
Cataract, congenital 285
Catarrhal dacryocystitis, stage of chronic 212
Cavernous fistula 241
Cavernous sinus 15f, 238
thrombosis 42, 43
Cavernous venous malformation 239, 239f
Cellulitis, stage of 213
Central nervous system 277, 290
component of 10
Cephalocele 250
Cerebellar hemangioblastoma 291
Cerebrospinal fluid 293
Cervical ganglion, sympathetic root of 6
Chalazion clamp 309, 309f
Chalazion cyst 169
Chandler's clinical staging 43t
Cheatle's forceps 315, 315f
Chemical
burns 106, 148
injury 111f
Chemiluminescence 211
Chemosis 65
excessive 75
Chemotherapy 286, 287f, 289, 289b
intra-arterial 286, 288, 288f
topical 265
Chlamydia psittaci 274
Chlorambucil 54
Chorda tympani 171
Choristoma 250, 276
complex 277
conjunctival 276
epibulbar 277f
Choroid cell layer pigments 303f
Choroidal lesions, yellowish 294f
Choroidal melanoma, diagnosis of 282
Choroidal nevus 281f
Cicatricial conjunctival diseases 108
Ciliary artery
long posterior 14
posterior 14
short posterior 14
Ciliary body 284
melanoma 281
Ciliary ganglion 13, 13f
Ciliochoroidal melanoma 282
Cionni's ring 320
Circular sclerotomy, posterior 99f
Cirrhosis, hepatic 158
Citelli's bone punch 313, 313f
Clefting syndromes 40
Clostridium botulinum 182
Coats’ disease 285
Cockayne syndrome 40
Cogan's eyelid twitch sign 137
Collier's sign 158
Coloboma 285
Comminuted displaced 75f
left zygomatico-maxillary complex fracture 75f
Compartment syndrome 79
Computerized tomography 28, 216
scan 71, 72
Congestion 88
Conjunctiva 20, 118, 120, 176, 181, 182, 190, 206, 273
biopsy of 309
bulbar 262, 274f
closure of 99f
edema of 66
fibrous tumor of 273
forniceal 262
histiocytic tumor of 275
myogenic tumors of 275
myxoid tumors of 275
neural tumors of 272
surrounding 266
Tenon layers, excessive sacrifice of 108
vascular tumors of 270, 272f
Conjunctival fornices, superior 254
Conjunctival lymphoma, management of 274
Conjunctival melanoma
management of 269
staging of 269
Conjunctival nodule, pink 269f
Conjunctival tumors, orbital extension of 102
Conjunctivitis, hemorrhagic 271
Conjunctivodacryocystorhinostomy 214, 227, 228f
Conjunctivoplasty 144
Cornea 20, 140, 206
Corneal button, removal of 98f
Corneal epithelium 165
Corneal exposure 88, 184
Corneal foreign bodies 205
Corneal irritation 205
Corneal nerves, thickened 244
Corneal sensation 124
Corneal ulceration 147, 184
Corrugator supercilii 192
Corticosteroids 53, 58, 158
Cowen's sign 63
Cranial fossa
anterior 3
middle 3
Craniofacial abnormalities 166
Cranio-orbital fracture 74, 75f
Craniosynostosis syndromes 39
C-reactive protein 53
Crigler massage 216
Crouzon syndrome 19, 39
Crow's feet 184f
disappearance of 184f
Cryotherapy 156
Cryptophthalmos 163
incomplete 163f
Crypts of Henle 197, 198
Curvilinear incision, large 91
Cushing's syndrome 18
Cutaneous flaps, local 176f, 176t
Cutler beard procedure 178, 179f, 180
Cyclic adenosine monophosphate 61
Cyclophosphamide 54
Cyclosporine 54
Cylindroma 248
Cyproheptadine 161
Cyst 28, 29f
developmental 250
Echinococcus 251
epithelial 281
hematic 251
implantation 251
intact 50f
primary 280
secondary 280
simple 251
site of 48
unresolving 251
Cystic eye, congenital 28
Cystic lesions 27, 50f
Cysticercosis 251
cellulosae, internal invaginations of 50f
cyst 28f
Czerny's retractor 309
D
Dacryoadenitis 18, 45, 51, 218
Dacryocystectomy 228
surgeries 309
Dacryocystitis 206, 212, 215, 228
acute 213, 216, 222
adult 212
chronic 212, 216
complications of 213
persistent suppurative 216
recurrent 228
stage of chronic suppurative 212, 213
Dacryocystocele, congenital 215
Dacryocystogram, normal 209
Dacryocystography, contrast 209, 211
Dacryocystorhinostomy 209, 221, 223f
external 224f
pediatric 218
surgery 5
Dacryoendoscopy 216
Dacryolithiasis 213
Dacryology
recent advances in 230
science of 230
Dacryops 219
Dalrymple's sign 63, 64f, 158
Decompensation, corneal 88
Demodex folliculorum 168
Demyelinated lesions 161
Dense lymphoplasmacytic infiltrate 55
Dental anomalies 164f
Depressor supercilii 192
Dermal fillers 181, 185
Dermatochalasis 187
bilateral age related 188f
Dermis fat graft 101, 109, 111f
Dermoid 28
conjunctival 276
cyst 28, 215, 250, 299
external angular 28f
indenting globe, transocular scan of 28f
internal angular 250f
epibulbar 164
tumors 28
Dermolipoma 276
conjunctival 276f
Desmarre's retractor 308
Diabetes mellitus 18
Dibutylphthalate 211
Dimethylphthalate 211
Diode laser 156
Diplopia 79, 181, 184
charting 48
Distichiasis 157
congenital 120
Dorsal nasal artery 14, 15
Down's syndrome 142, 165, 166
Drainage
impairment of 205
system 197, 205
anatomy 197
Dry eye 167
disease 188
Dry socket 108
Dry spots 205
Duke-Elderhad theory 215
Dye disappearance test 207
Dysplasia, fibrous 245, 246f
Dysplastic nevus 258
Dysthyroid 158
eyelid retraction 159
optic neuropathy 61
Dystopia
canthorum 39, 166
horizontal 18
transverse 18
E
Echinococcosis 47
Echinococcus
definite host of 47
granulosus 47
Echography, quantitative 24
Echothiophate iodide 206
Ectoderm, surface 117f
Ectodermal epithelium 197
Ectropion 140, 141, 143, 144f, 157, 170, 206
acquired 142
cicatricial 145
classification of 140t
congenital 142, 165
grading of 141
involutional 142
management of 142
mechanical 145, 148
medial moderate 142f
uveae 244
Electrolysis 156
Electron microphotograph, scanning 230f
Electron microscopy, scanning 230
Electrophysiologic tests 138
Elephantiasis neuromatosa 244
Embryology drainage system 197
Encephalocele 40, 215
Endocrine disorders 52
Endophthalmitis 92
endogenous 285
Endoscopic lacrimal surgeries, three-dimensional 232
Endothelium 300f
Enophthalmos 18, 74, 79
Enroth's sign 63
Entropion 140, 143, 147, 157, 170, 206
cicatricial 148, 152, 157
clamp 314, 314f
classification of 140t, 148
congenital 148, 149, 149f, 164, 165
grade of 157, 148
intermittent 140
involutional 148, 148f
Enucleation 92
scissors 307
Epiblepharon 148, 149, 164
inferior 148
nonresolving 149f
superior 148
Epicanthal folds 165, 165f
Epicanthus
inversus 165, 166f
palpebralis 165
palpebralis, left 165f
superciliaris 165
tarsalis 165
Epidermis 181
deepithelized of 143f
Epidermoid 28
cyst 250
Epinephrine 206
Epiphora 205, 215, 216, 227
Epistaxis 74, 225
Epithelial cells, flattened 299
Epithelial neoplasms, secondary 237
Epithelial tumor, malignant conjunctival 263
Epithelioid cells 169
Epithelium
flattened 300f
nonpigmented 280
Erdheim-Chester disease 55, 247
Erythema 65
Erythrocyte sedimentation rate 53
Erythromycin 168
Etanercept 54
Ethmoid
foramina
anterior 4
posterior 4
orbital plate of 4
sinus 3, 42f
Ethmoidal artery
anterior 14, 15, 79
posterior 14, 15, 75, 79
Ethmoidal foramina, posterior 5f
Ethmoidal nerve
anterior 12
posterior 12
Etoposide 289
European Group on Graves’ Orbitopathy Classification 67, 69t
Euryblepharon 166
Everbusch technique 127f
Evisceration 92, 97
scoop 313, 313f
Ewing's sarcoma 35
Excretory system 200
Excretory tests 207
Exophthalmometry 20, 21, 48
comparative 21
Exophthalmos 18, 65
Exorbitism 18
Exotropia 134f, 135
Extraocular motility 43
Extraocular muscle 7, 49f, 95f, 97f, 242f
belly of 50f
enlargement 30t
motility of 48
origin of 8f
thickened belly of 30f
thickness 30t
weakness 184
Extraorbital branches 14
Extraorbital extension 52
Eyeball 105, 312
Eyebrow 192, 120, 256
mobility of 193
position of 188, 193
Eyelid 119f, 120, 163, 166, 142, 163, 175, 181, 193, 249, 253
anatomy of 117
approach, swinging 91
biopsy of 259
capillary hemangioma of 272f
closure 203
coloboma of 163, 164, 277
congenital abnormalities of 163
crease incision, lateral 91
defect 177f
development of 117
edema 66
fluctuating 65
embryology of 117
fat pads of 182
folds develop 118f
fullness of 64f, 66
incision 129
swinging of 83f
inferior 164
inflammation of 167
inflammatory disorders of 167
laxity, generalized 140, 141f
lymphatic drainage of 121f
malformations of 163
malignant melanoma of 258
margin 120, 148f
notching 177
opening 203
position of 164
reconstruction of lower 179f
retraction 19, 137, 158
congenital 158
treatment 159
skin 82f, 187
split technique 82
superior 164
surgery 69
swelling 184
surrounding 52f
tissue, full thickness triangular excision of 144f
tumors
malignant 253
orbital extension of 102
treatment of malignant 260
Eyes 38
abnormalities of 39
congenital ptosis, right 124f
examination of 94f
management 168
mechanical entropion, left 148f
prominent 39
F
Facial
asymmetry 122
dystonia 192
fractures
lower 74
mid 74
upper 74
hemiatrophy, progressive 19
nerve 171, 172
anatomy of 171
branches of 171
decompression 173
functions of 171
grafting 173, 174
lid disorders of 183
palsy 192
surgical management of 173
palsy 171
etiology of 172t
rejuvenation 181
soft tissues 192
tissues 244
Faria-E-sousa method 140
Farkas canthal index 38
Fasanella-Servat surgery, modified 126
Fascia
capsulopalpebral 119, 120
lata sling 128, 129
bilateral 133f
surgery 130f
Fascial lata, harvesting of 129
Fat
compartment 88
decompression 88
complications of 89
pad
central 182f
excision of 190f
medial 182f
Femur, lateral condyle of 130f
Fibroma molluscum 244
Fibrotic sac, stage of chronic 213
Fine needle aspiration biopsy 282
Fisher's syndrome 158
Fish-tail configuration 292
Fissure length, horizontal palpebral 39f
Fistula 238
arteriovenous 241
formation 213f
stage of 213
Flach modification of primary Jones dye test 207
Flaps
anastomosis 224
formation 224
Fleshy tumor, pinkish 293f
Flexner-Wintersteiner rosettes 302
Fluorescein dye disappearance 221
Forehead flap, median 179, 179f
Fornicial fat head 141f
Fossa
glandulae lacrimalis 198
stare, posterior 158
Fox pentagon technique 128, 128f
Fracture 73f
floor 26f
linear 72, 74
medial wall
blow-in 74
blow-out 74
repair, incomplete 79
Frey's syndrome 172
Frontal bone, orbital plate of 4
Frontoethmoidal suture line 4
Full thickness buccal mucosa, graft of 153f
Fundus 43
lesions, pigmented 244
Fungal orbital cellulitis 45, 46t, 53
Fungus, types of 46
Fusobacterium 212
G
Ganglionic cells 170
Gardner syndrome 292
Gastrointestinal discomfort 238
Gastrointestinal tract 254
carcinoma of 284
Genetic mutation 274
Germline mutation 284
Giant cells 169
Gifford's sign 63
Glabellar
forehead flap 180f
furrows 184f
Gland
orifices 168f
branched tubulo-alveolar 199
Glands of
Krause 198
Manz 198
Moll 197, 198
Wolfring 198
Zeiss 120, 169, 197, 198
Glaucoma 244, 281
Globe
displacement, amount of 48
dystopia 46f
injury, closed 75
subluxation, acute 88
Glucocorticoids 67
Glycosaminoglycan 62
Goblet cells, conjunctival 197198
Goldenhar syndrome 40, 163, 164, 276f
Goldzeiher's sign 63
Gorlin syndrome 255
Granulation, fibrovascular 270
Granuloma 211
adult onset 55
eosinophilic 56
formation 186
Graves’ disease 61, 158, 237
Graves’ hyperthyroidism 61, 65
Graves’ ophthalmopathy 29
Graves’ orbitopathy 63, 66, 66t
Griffith's sign 63
Grove sign 63
Growing fracture 74
Growth factor, insulin-like 62
Gull wing incision 82
Gustatory lacrimation 172
Gustatory sweating 172
Guyton's hairline incision 85, 86f
H
Haik's classification 238
Halstead's mosquito artery forceps 314
Hamartoma 292
astrocytic 285, 292
calcified astrocytic 292f
combined 285
Hand-Schuller-Christian
disease 56
syndrome 247
Hartmann nasal speculum 309, 310f
Harvested dermis fat graft 111f
Hashimoto thyroiditis 61, 65
Hasner's valve 203
Headache, chronic 183
Helicobacter pylori 274
Hemangioblastoma 238
Hemangioendothelioma, benign 238
Hemangioma 215, 237, 300f, 301
capillary 30, 238, 271, 272f, 291, 301
cavernous 31, 31f, 32f, 238, 239, 271, 272f, 291
choroidal 283, 283f
diffuse choroidal 283, 283f
hypertrophic 238
infantile 238
juvenile 238
noninvoluting congenital 238
Hemangiopericytoma 238, 239
Hematoma 30
Hemifacial spasm 160, 161, 183
clinical presentation 161
differential diagnosis 161
epidemiology 160
etiology 161
investigations 161
Hemoglobin 223
Hemorrhage 79
risk of 241
Hepatic dysfunction 172
Herpes
simplex 170
virus 172
zoster 170
management 170
Hertel's exophthalmometer 21, 21f
Hewes flap 178, 179f
Hidrocystoma 299
Hippel-Lindau syndrome 291
Histiocytic disorders 237
Histiocytoma, fibrous 245
Histiocytosis 18, 247
Hodgkin's disease 219
Hollow prosthesis 111f
Holmes, Glasgow benefit inventory 233
Holoprosencephaly 39
Homer-Wright rosettes 302
Hordeolum externum 169, 169f
management 169
Hornblass variation of primary Jones dye test 207
Horner's muscle 201
Horner's syndrome 138
causes of 138
Hot fomentation 44
Hounsfield unit 24
Hughes procedure 175, 178, 179
Human pericardium 100
Hutchinson's sign 170
Hyaluronan, synthesis of 62
Hyaluronic acid
advantages of 185
compounds 185
derivatives 185
properties of 185
Hyperglobus 18
Hypernephroma 291
Hyperopia 31f
Hypersecretion 205
Hypertelorism 18, 39, 166
Hyperthyroidism 61
Hypertrichosis 157
Hypertrophy, congenital 292, 292f
Hyphema 75
Hypoesthesia 81
infraorbital 74
Hypoglobus 18, 74
Hypoglycemia 238
Hypoplasia 39
Hypotelorism 38, 166
Hypotension 238
Hypothyroidism, primary 61
Hypotropia 134f, 135, 135f
I
Ice test 125
Ichthyosis 142, 142f
Ideal orbital implant, characteristics of 100b
Idiopathic orbital inflammation syndrome 50, 53
signs of 58fc
symptoms of 58fc
Iliac spine, anterior superior 130f
Iliff modification 149, 149f
Immunologic disorders 206
Immunosuppressive drugs 54
Immunotherapy, topical 266
Impetigo 169
Incision 223
conjunctival 82
cutaneous 79
over
conjunctiva 192f
orbital septum 192f
T-shaped 84, 85f
vertical full thickness 151f
Incontinentia pigmenti 285
Infection 79
chronic 108
direct inoculation of 41
extension of 41
Infectious disorders 53
Inferior ligament of Schwalbe 199
Inferior rectus 8, 49f, 50f
muscle 65
recession 134f
Inferior tendon of Zinn 7
Inflammation 67, 108, 168
Inflammatory disorders 17, 206
Infliximab 54, 69
Infraorbital nerve 12
Infratrochlear nerve 12
Interorbital region, normal growth of 38
Intralesional steroid 169
injection 238
Intraocular paraneoplastic syndrome 294
Intraocular tumors
classification of 280b
extraocular of 102
orbital extension of 102
Intraosseous mass 82f
Iridodialysis repair 320
Iris 284
cyst 280
classification of 280b
pigment epithelium cyst 280
stroma cyst 280
Isobutyl cyanoacrylate 241
J
Jaeger lid plate 312, 312f
Jaesche-Arlt's operation 154
Jameson muscle hook 314, 314f
Jaw movements 125
Jaw winking 134f, 135
phenomena, elimination of 133f
Jellinek's sign 63
Jendrassik's sign 63
Joffroy's sign 63
Jones dye test 208f
primary 207
secondary 208
Jones muscle 119
Jones tube 316, 317f
fixation 228f
K
Kaposi sarcoma 271
Kaposiform hemangioendothelioma 238
Kasabach-Merrit syndrome 238
Kelman McPherson forceps 307
Keratitis sicca 205
Keratoacanthoma 192, 256, 263, 263f
Keratoepithilectomy 269
Keratosis, actinic 255
Kerrison's bone punch 313, 313f
Ketssey's operation, modified 154
Kidney function test 254
Kimura's disease 253
Kinetic echography 25
Knapp's lacrimal sac retractor 308
Knies sign 63
Kocher's incision 84, 85
Kocher's sign 63, 64f
Krönlein incision 91
modified 84, 85f
standard 84, 84f
Kuhnt-Szymanowski procedure 144
L
Lacrimal abscess
right-sided 213f
stage of 213
Lacrimal apparatus 9, 197, 204
Lacrimal canaliculi 201, 204f
Lacrimal cannula 309, 310f
Lacrimal crest
anterior 200
posterior 200
Lacrimal disorders 233
acquired 211
Lacrimal diverticulum 215
Lacrimal drainage obstruction
complex secondary acquired 232
secondary acquired 211
Lacrimal excretory system 9, 10f, 200f, 201f
development of 198f
Lacrimal fascia 201
Lacrimal fistula, congenital 215
Lacrimal fossa 5
exposure of 224, 224f
lesions 34
masses, classification of 247, 247f
Lacrimal gland 8, 9, 197, 199f, 247, 300f, 302
adenocarcinoma of 35f
autonomic innervation of 200f
bilateral palpebral 51f
ducts 199
enlargement 66
epithelial tumors of 219
fascia 5
main 197, 198
mass 256
pleomorphic adenoma of 300f, 301
swellings of 218
tumors 237, 247
Lacrimal irrigation 208
Lacrimal mucocele, stage of 212
Lacrimal nerve 6, 12
Lacrimal papilla of Arruga 201
Lacrimal passage 206
nerve supply of 202
vascular supply of 201
Lacrimal pathway, normal 205
Lacrimal piezosurgery 232
Lacrimal probing 220
Lacrimal pump 204f
failure 205
theory 203
Lacrimal puncta 201
Lacrimal sac 8, 201, 221, 230
dissector 309, 311f
flaps 225
mucocele 215
suspected
malignancy of 223
tuberculosis of 223
tumors 206, 214
malignant 228
Lacrimal scintillography 210
Lacrimal secretory 205
physiology of 197
Lacrimal stent 231
surface of 232f
Lacrimal surgeries 220
image-guided 232
Lacrimal symptom scores 233
Lacrimal system 7, 219
obstructions, congenital etiology of 214
optical coherence tomography 231
ultrastructure of 230
Lacrimal thermography 211
Lacrimal trephine 309, 311f
Lacrimation 156, 205, 205
Lacunae 292
Lagophthalmos 64, 64f
Laissez faire 180
Lambert-Eaton syndrome 184
Lamella, posterior 118, 143f, 146f
Lamellar advancement, posterior 155f
Lamellar graft, posterior 152, 153f, 155, 156f
Lamellar keratectomy 269
Lamellar repositioning, anterior 153, 154f
Langenbeck retractor 309
Langerhans cell histiocytosis 53, 56, 247
Laser skin resurfacing 181, 187
advantages 187
complications 187
contraindications 187
Lens
pit 117f
vesicle 117f
Lentigo maligna 258
melanoma 258
Lesser wing of sphenoid 3, 4
Letterer-Siwe disease 56, 247
Leukemia 18
orbital involvement in 250f
Leukocoria 284
Leukocyte count 21
Levator action, Beard's classification 123
Levator aponeurosis 133f
lateral horn of 5
Levator function 123
Levator muscle 182
dystrophy of 122
Levator palpebrae superioris 8, 199f
Levator resection 126
Levodopa 161
Lid
anatomy of 118
arterial supply of 121f
cleaning 168
closure 204f
colobomas 164
crease, placing of 190f
examination 206
excursion 123
malignant tumors of 253
margin 143f, 157, 177f
position of 148
posterior 167f, 177f
massage 168
position 206
retraction 63, 157, 159f, 206
acquired 158
inferior 145f, 152
sagittal section of 118f
scrubs 168
section of 199f
separation of 118f
shortening procedures, horizontal 143
speculum 312, 312f
split 154
tone 206
traction, lateral 141f
Lieberman eye speculum 312
Lignocaine hypersensitivity 56f
Limbus 262
Lip augmentation 186f
Lipodermoid 164
Liposculpture 191
Lisch's iris nodules 244
Liver 245
function test 254
Lockwood's ligament 5, 119, 120
Lower eyelid 90f, 120, 254, 256
blepharoplasty 181
indications of 189
entropion management, involutional 149
margin 177, 179f
tissue, full thickness segment of 179f
Lower lid 119, 255f
blepharoplasty 189
steps of 192f
cicatricial entropion 153f
management of 152
coloboma 164, 164f
congenital entropion, right 165f
crease 82f
defects 180f
large 175
laxity 173
margin 190
nodular malignant melanoma 258f
reconstructed 179
retractors 119, 120f
plication of 152, 153f
suspensory ligament of 5
Lower motor neuron facial palsy, left 171f
Lowi's sign 63
Lung 245
carcinoma 249
Lyme disease 172
Lymph nodes, preauricular 256
Lymphangiectasia 271
conjunctival 272f
Lymphangioma 31, 31f, 239, 271
conjunctival 273f
paraocular scan of 32f
T2-weighted image of 31f
transocular B scan of 32f
Lymphatic drainage 9, 10, 200
Lymphatic malformation 239
Lymphatic tissues, intraorbital 241
Lymphaticovenous 238
Lymphoid hyperplasia 246
atypical 273
benign 219
reactive 273
Lymphoid tissue, mucosa-associated 246
Lymphoid tumor, intraocular 280
Lymphoma 18, 246
acute lymphoblastic 277f
choroidal 293, 294f
chronic lymphocytic 246
conjunctival 273, 274, 274f
intraocular 293
systemic 246
Lymphomatous cells 293f
Lymphoproliferative
disorders 237, 246
response 241
tumors 273
Lymphosarcoma 253
Lynch approach 90
Lynch incision 82, 83f
Lytic defects 247
M
Madarosis 157
Magnetic resonance 28
imaging 23, 24, 26, 72, 210
Malar depression 74
Malformations, arteriovenous 32, 241
Malik's Safdarjung suture 144, 145f
Mandibulofacial dysostosis 40164
Mantle cell lymphoma subtypes 274
Marcus Gunn
jaw winking grading 125
phenomenon 133f
ptosis 132
Margin crease distance 124
measurement 124f
Margin limbal distance 123
Margin reflex distance 123
measurement of 123f
Margin sutures, location of 177f
Masson trichrome 231f
Maxilla
frontal process of 4
orbital plate of 5
Maxillary lacrimal suture 200
Maxillary sinus 3, 26f, 42f
Medial canthal
defects 175, 180f
laxity 141f
plication 144, 145f
reconstruction 180
tendon laxity 141
Medpore orbital implants 112f
Medulloepithelioma 285, 293, 293f
diagnosis of 293
Meibomian cyst 169
Meibomian gland 167, 168, 169, 197, 256
orifices, loss of 167f
Meibomitis 168
Meige syndrome 183
Melanocytic conjunctival epithelial tumors 267
Melanocytoma 283
Melanocytosis, choroidal 281f
Melanoma 192, 318
amelanotic 258
choroidal 249, 281f, 282, 282f
conjunctival 269, 269f, 271b
malignant 269
cutaneous 258, 259t, 261t
in situ 258, 260
iris 303
malignant 253, 258, 302
management of malignant 261
superficial spreading 258
Melphalan 289
Membrane, epiretinal 282
Meningeal artery 14
recurrent 14
Meningeal tissues 242
Meningioma 242
Meningitis 87
Meningocele 40
Meningoencephalocele 40
Meningoendothelial cells 242
Merkel cell 259
carcinoma 259
Mesenchymal origin 214
Mesenchymal tumors 237, 244, 253
miscellaneous 245
Metastasis, diagnosis of 284
Metastatic carcinoma 18
Metastatic conjunctival infiltration 277
Metastatic disease, risk for 282
Metastatic melanoma 277
Metastatic neuroblastoma 18, 290
Metastatic tumor 35, 237, 249, 284
adults 249
children 249
of iris 284f
Methicillin-resistant Staphylococcus aureus 42
Methotrexate 54, 69
Meyerhoefer curette 309
Micro-balloon catheter 286
Microblepharon 163
Microcystic lesions 240
Microphthalmia 28, 29f, 40, 164
right 251f
Microphthalmos with cyst 250
Microsomia, hemifacial 40, 164
Midfacial retrusion 39
Migraine, chronic 183
Mikulicz syndrome 218
Minimally invasive orbital surgery 79
Minimonoka stent 222f, 317f
Mirror tuck technique 227, 228f
Mitomycin C 231, 232f
effect of 232f
Moebius's sign 63
Mohs' micrographic surgery 260
Moll glands 202
Molluscum contagiosum 170
management 170
Monamine oxidase inhibitors 161
Monocanalicular stent 316
Monocular elevation deficit 135
Montoux test 53
Moraxella lacunata 168
Motility deficits 239
Motor nerves 10
Mucocele 206, 215, 250
late frontal 74
Mucoid layer 197
Mucoperiosteal flap 226f
Mucormycosis 46, 102
Mucus 209
discharge 216
membrane graft 111f, 154
membrane pemphigoid 148
Müller's muscle 8, 119-121, 139, 158, 159, 182
Müllerectomy 159
Multiple conjunctival papilloma 263f
Muscles 7, 8, 30
extraocular 24
inferior oblique 8, 182f
oblique 7, 8
Muscular branches 14, 171
Muscular cone 8
Mustarde cheek rotational flap 179, 180f
Myasthenia gravis 137, 192
Mycophenolate mofetil 54
Myoconjunctival technique 290
Myogenic ptosis 137
Myopathy, entrapment 75
Myositis 29, 30, 51
Myotonic dystrophy 137, 192
Myxoma, conjunctival 275f
N
Naffziger's method 19
Naffziger's view 19f
Nasal cavity 198f, 220
Nasal decongestants 44, 220
Nasal discharge, clear 74
Nasal endoscopy 211
Nasal examination 206
Nasal fat pads, exposure of 190f
Nasal irritation and inflammation 205
Nasal mucoperichondrium graft 156f
Nasal mucosal flaps 224, 225
Nasal mucous membrane 176
Nasal obstruction 205
Nasal packing 226
forceps 309, 310f
Nasociliary nerve 6, 12
branches of 4
Nasolacrimal canal 5, 200
Nasolacrimal duct 5, 200, 201, 212, 230
obstruction 209, 212
congenital 309
functional 223
probing 209, 216
Nasolacrimal endoscopy 211
Naso-orbito-ethmoid fracture 74
bilateral 75f
Nasopharyngeal angiofibroma 36f
Natural eye 316
Nausea 74
Necrobiotic xanthogranuloma 55, 247
Needle 321
aspiration biopsy 281
holder 308, 308f
parts of 321
point, types of 322f
Neovascular glaucoma 92
Nerves 8
frontal 6
of Wrisberg 171
palsy, congenital third 135, 135f
paralysis, seventh 158
structure of 33t
supraorbital 12
zygomaticofacial 12
zygomaticotemporal 12
Nervous tissue 253
Nettleship's punctum dilator 309, 310f
Neural tumors 32, 237, 242
Neurilemoma 33, 243
Neuroblastoma 35
Neuroendocrine carcinoma 259
Neurofibroma 243, 272
diffuse 244
localized 244
Neurogenic ptosis 138
Neuroma, acoustic 192
Neuromuscular structures, functional disorders of 17
Neuron lesions
first-order 138
second-order 138
third-order 138
Neurosensory retina 280
Neurotrauma 79
Nevus
congenital 258
conjunctival 267, 267f, 269
cutaneous sebaceous 277
sebaceous syndrome 277f
Nitrous oxide 317
Nodular basal cell carcinoma 255f
Nodular melanoma 258
Nodular sebaceous cell carcinoma 256f, 257f
Nonabsorbable sutures 320
Non-Hodgkin's lymphoma 246, 253, 293
Non-Hodgkin's tumors 246
Nonsteroidal anti-inflammatory drugs 44, 53, 58
Nonsurgical facial rejuvenation 181
Norrie's disease 285
Numerous tumor cells 303f
O
Oblique muscle, superior 8
Ocular adnexa 253
Ocular adnexal examination 44
Ocular blood supply 14f
Ocular branches 13
Ocular coherence tomography image 231f
Ocular cysticercosis 251
Ocular examination 122
Ocular motility 125
abnormalities 132
limitation of 74
Ocular prosthesis 105, 112f
custom made 109f
customized 110f
making of customized 109
role of 108
Ocular surface
inflammation 205
squamous neoplasia 263
tumors 262
classification of 262, 262b
Oculoauriculovertebral dysplasia 40, 164
Oculodermal melanocytosis 281
Oculomotor nerve 10
course of 11f
Oculopharyngeal dystrophy 137, 192
Oculoplastic emergencies 75b
Oculoplastic instruments 307
Open globe injuries 75
Ophthalmic artery 13, 287
branches of 4
infusion 286
Ophthalmic emergencies 75b
Ophthalmic vein
inferior 6, 15
superior 6, 15, 33f
Ophthalmological examination 20
Ophthalmopathy 69t
Ophthalmoplegia, chronic progressive external 137
Ophthalmoscope 48
Optic disk 239, 280, 283
melanocytoma 283f
pallor 294
Optic foramen 6
Optic nerve 10, 44f, 96f, 99
avulsion 75
function 239
glioma 33, 33f, 242
right 242f
guide 312
head coloboma 277
injury 87
lesions 32
meningiomas, primary 33
sheath meningioma 242
primary 243
secondary 243
Optic neuropathy
acute dysthyroid 88
compressive 65
traumatic 75
Optic vesicle lies 117f
Optical coherence tomography 231, 282
Oral analgesics 228
Oral antibiotic 44
Oral doxycycline 168
Oral mucous membrane 176
Oral propranolol 238
Orbicularis 152f
muscle weakness 205
oculi muscle 187, 189f, 192
Orbit 38, 40, 89f, 119f, 166
anterior 51
arterial supply of 14f
asymmetric 40
cystic lesions of 27
depth of 4
dimensions of 4f
morphological landmarks of 38
posterior 51
relations of 3
shape of 3
size of 3
small 40
superior 57f
surgical
anatomy of 3
spaces of 9f
zones of 81, 81f
syndromes of 38
ultrasound of 50f
vascular supply of 13
venous drainage of 15f
Orbital abscess 42, 43
Orbital anomalies, congenital 38
Orbital biopsy 53
Orbital branches 14
Orbital cavity 52
Orbital cellulitis 26, 42, 43, 44f, 58fc
right 27f, 28f
staging of 27t
Orbital compartment syndrome 75
Orbital contents, herniation of 26f
Orbital cysticercosis 47
Orbital cysts 28t, 237, 250
Orbital decompression 69, 88
areas of 88
Orbital disease 55, 290
Orbital disorders 17
evaluation of 17
Orbital dissection, extensive 108
Orbital dystopia 18
Orbital exenteration 92, 101
indications of 102b
Orbital fat 7, 187
Orbital fibroblasts, types of 62
Orbital fissures 6f
inferior 6
superior 6, 6f
Orbital floor 5, 76
blow-in fracture 74
blow-out fractures 74
fracture 73f
right 79f
Orbital foreign body 57
granuloma 53
Orbital fracture 71, 74, 74t, 76, 76t, 79t, 80
mechanism of 72, 72t
repair, complications of 78, 79t
Orbital fullness, superior 46f
Orbital hematoma, staging of 27t
Orbital hemorrhage 57
Orbital hydatid cyst 47
Orbital imaging 23
Orbital implant 92, 110, 111f, 316, 317f
migrated 108
Orbital infection 41, 42
Orbital inflammation 41, 49, 57f
drug-related 56
nonspecific 29
secondary 56
specific 54
Orbital inflammatory
disease, recalcitrant 102
disorder 49, 53t
pediatric 53
Orbital lesions, diagnosis of 25fc
Orbital lymphangioma, inferior 273f
Orbital lymphoma 239, 247f
Orbital lymphoproliferative disorder 56
Orbital margin
height of 3
width of 3
Orbital mass 137f
lesions, non-graves 237f
Orbital nerves 10
Orbital pathology 18t
common 25
Orbital prosthesis 109
Orbital pseudotumor 29
Orbital reconstruction 76t
Orbital retinoblastoma 290
management in 291f
microscopic 290
primary 291f
Orbital rhabdomyosarcoma 275
Orbital rim 45f
destruction, superior 46f
Orbital roof
blow-in fracture 74
fracture 76
Orbital septum 5, 7, 182
extension of 7f
Orbital soft tissue 7
tuberculoma 45
Orbital surgery 87
Orbital tuberculosis 44, 53
Orbital tumor 237, 251
primary 102
secondary 237, 249
variety, malignant 251
Orbital varices 31
Orbital varix 32f, 33f
Orbital venous drainage system 42f
Orbital wall 3, 42f
blow-out fractures of 72
intraorbital dissection of 4f
medial 4
Orbito-facial fracture 74
classification of 74t
Orbitonometry 21
Orbitotomy 81
anterior 81, 82
approaches, medial 83f
lateral 83, 86f
medial 82
scissors 307
Orphenadrine 161
Osteology 4, 200
Osteoma 249
choroidal 283
Osteotomy 86f, 225, 227f
Ostium
boundaries of 224
cicatricial closure of 225
P
Pain 74, 156
chronic 88
Palatine 5
Palpebral aperture 122
Palpebral artery
lateral 14, 15
medial 14, 15
Palpebral conjunctiva 263f
surface 90f
Palpebral fissure
abnormal orientation of 166
abnormalities of 166
measurement, vertical 123f
Palpebral ligament 118
medial 132, 201
Palpebralis 165f
Panfacial fracture 74, 76
Panophthalmitis 92
Papillary projections 299
Papilloma, conjunctival 262, 263f
Papillon-Lefèvre syndrome 263
Paralytic ectropion 147
Paranasal sinuses 42f, 45, 253
Paraneoplastic retinopathy 294
Paraneoplastic syndromes 294
Parasitic blepharitis 168
management 168
Parasitic cyst 28, 45, 250
Parasympathetic root 13
Paresis of levator 87
Parotid lymph nodes 256
Parry-Romberg syndrome 19
Peek sign 137
Penetrating injury 72
Penetrating trauma 92
Pericanalicular tissue 222f
Periocular
lesions, large 238
skin soreness 216
xanthogranuloma 55, 247
Periorbital
ecchymosis 74
skin lesions 259
Periosteal elevator 310f
Periostitis, classical 45, 45f
Peripapillary choroidal osteoma 284f
Peripheral branches 171
Peripheral nerve sheath tumors 242, 243
Peripheral orbital
fat 8
nerves 242
space 8
Permanent canthal deformity 215
Phenylephrine test 125
Phenytoin 161
Pheochromocytoma 291
Phospholine iodide 206
Phthisical eye, small 92
Phthisis bulbi 92, 284
Pierce Hoskin forceps 307
Pigment epithelium, tumors of 280
Pilocarpine 206
Pinch test 140, 141f
Pituitary adenomata 18
Pleomorphic adenoma 34, 219, 247, 300f
right 35f
Plexiform neurofibroma 33, 272
left 244f
paraocular scan of 34f
Plexiform neurofibromatosis 35f
Poliosis 157
Poly methyl methacrylate 317
Polybutylate coated braided polyester 321
Polycaprolactone bioresorbable implant 78f
Polydioxanone 77
Polylactide bioresorbable implant 78f
Polymerase chain reaction 46
Polymethylmethacrylate, nonintegrated 98
Polyp 211
Polyposis, familial adenomatous 292
Polypropylene 320
Polytetrafluoroethylene 100
Polyvinyl siloxane cast 216
Porous polypropylene 77
implant 77f
titanium implant 78f
Port wine stain 238
Postenucleation socket syndrome 105, 105f, 106f
Postganglionic neuron 138
Prebent anatomical titanium implant 78f
Precorneal tear film, formation of 203
Preexisting lesions 253
Preseptal cellulitis 42, 43
Preseptal orbicularis
fibers 151f
muscle 118, 204f
Pretectal syndrome 158
Prophylactic enucleation 93
Propionibacterium propionicum 212
Proptosis 18, 22f, 30f, 63, 74, 88, 284
abaxial 17
axial 19
bilateral 18
causes of 18t
common causes of 18
reduction 90t
amount of 90
right 247f
Prosthesis retention 108f
Prostigmin 158
test 138
Protractors 118
Proximal tarsal segment 156f
Pseudoenopthhalmos 74
Pseudoepitheliomatous hyperplasia 263
Pseudohypopyon 285
Pseudomonas pyocyanea 212
Pseudoproptosis 74
causes of 18
Pseudoptosis 125
Pseudoretinoblastomas 285
Pseudotumor 29, 66, 66t
of orbit 30f
Pterygoid plexus 6, 121
Pthirus pubis 168
Ptosis 81, 122, 166f, 184
acquired 136
amount of 123
clamp 316, 316f
complicated congenital 131
congenital 122, 124, 125, 132, 134f, 135, 136f, 165
severe 165f
examination 122
involutional 125
management of 122
measurements, complete 48
mechanical 137f
severe 133f
surgical treatment of 139
worsening of 137
Pulsatile proptosis 244
Punctal abnormalities 214
Punctal agenesis, congenital 214
Punctal atresia, congenital 214
Punctal cheese-wiring 225
Punctal eversion, medial 144
Punctal obstruction 211
Punctal plug, perforated 223f
Punctal stenosis 170, 230, 231f
etiopathogenesis of 230
management of 221
primary 211
secondary 211
Punctoplasty 221
three-snip 223f
Punctum 146f, 206, 231f
external surface of 230f
Pupillary reaction 43
Putterman's method 123
Pyogenic granuloma 270, 272f
Pyridostigmine bromide 138
Q
Quasi-integrated implants 101
Quickert procedure 150, 151f
Quickert-Rathbun suture 149
R
Racemose hemangioma 291
Radiation therapy 289
external beam 286
Radioactive iodine 67
Radiological investigation 53
Radionuclide dacryoscintigraphy 210
Radiotherapy 53, 67
Rampley's sponge holding forceps 315, 315f
Ramsay hunt syndrome 172
Rash 238
Rectus check ligament, lateral 5
Rectus dysfunction, superior 134f
Rectus forceps, superior 307
Rectus muscles 7, 99f
insertions, injection over horizontal 66
lateral 65
medial 65
right medial 35f
superior 65, 120
Red painful eye 284
Reddish tumor 292f
Reflex blepharospasm 156
Reflex tear production 197
Refractive errors 205
Regional lymph node 265, 274
metastasis 259
Renal dysfunction 172
Retention cysts 251
Retina 294
tumors of 280
Retinal arterioles, constricted 294
Retinal artery, central 13, 14
Retinal detachment 75, 285
Retinal hemangioblastoma 291, 292f
Retinal pigment
epithelial hyperplasia 294
epithelium 280, 292, 292f
Retinal striae 239
Retinal vessel attenuation 294
Retinoblastoma 106, 112f, 237, 249, 284, 285, 285f, 285t, 287f, 289, 290f, 292, 302, 287f, 303
advanced 288
classification of 286t
enucleation 290
focal therapy 290
intra-arterial chemotherapy 286
intravenous chemotherapy 286
intravitreal chemotherapy 288
radiation therapy 289
rosette 303f
therapy in 289
treatment 290
options for 286
undifferentiated 303
Retinocytoma 303
Retinopathy
cancer associated 294
of prematurity 285
Retinoschisis, X-linked 285
Retractors 308, 308f
Retrobulbar hemorrhage 75
Retrobulbar optic nerve, examination of 24
Rhabdomyoma, cardiac 292
Rhabdomyosarcoma 33, 35f, 244, 245, 303
classification of 245t
conjunctival 275
Rheumatic arthritis 206
Rheumatologic disorder 53
Rhino-orbital-cerebral-mucormycosis 46
Rhinotomy incision, lateral 36f
Rhombo syndrome 255
Riesman's sign 63
Rituximab 69
Rootman's classification 238
Rosenbach's sign 63
Rosenmuller valve 10
Round cells, malignant 303f
Rudimentary adnexa 104f
Rudimentary socket 113f
S
Sabouraud dextrose agar 46
Salmon patch appearance 246
Sarcoidosis 18, 53, 55, 219
Scar formation 186
Schinzel-Giedion syndrome 40
Schirmer's test 206, 207
Schwann cells 242
Schwannoma 33, 243, 272
of orbit 34f
Scissors 307, 308f
Sclera 309
Scleral melanocytosis 281f
Scleral petals 99f
Scleral quadrisection 99
Sclerosing idiopathic orbital inflammation 52
Sebaceous cell carcinoma 35, 169, 249, 257f, 257t, 302
Sebaceous gland 299f
carcinoma 102, 253, 256
management of 260
modified 197
Seborrheic blepharitis 167
Secretory system 197
Secretory tests 206
Semicircular musculocutaneous flap 178f
Sensory
nerve 10, 11
supply of orbit 12f
root 13, 171
Serum
angiotensin-converting enzyme 53
calcium 53
lysozyme 53
Shallow orbit 19
Shunts 238
Silicon
intubation 212
orbital prosthesis 107f
silastic sling 128
sling 316, 316f
tubes, retropassage of 214
Sino-orbital fungal diseases, invasive 102
Sinus
discharging 45f
frontal 3, 87
Skin 118
crease incision 82f
excision of 189f
flaps 175
graft, full thickness 176f
incision 169, 176, 189f
visible 79
infection 169
muscle excision 149f
neurofibromas 244
orbicularis muscle 149
surrounding 45f
technique of 128
Skull base fracture 74
Slit-lamp examination 206
Snap back test 141
Socket contraction, different grades of 107f
Soft globe 75
Soft tissue
assessment of 24
edema 242f
swelling 44f
Solitary fibrous tumor, cellular variant of 245
Somatostatin analogs 67
Sommering's ligament 199
Sphenoid
body of 4
greater wing of 3, 5
sinus 42f
anterior part of 3
wing dysplasia 35f
Sphenopalatine ganglion 6
Spindle procedure, medial 144, 145f
Spoon-like instrument 312
Sporadic genetic mutations 253
Sporadic mutation 284
Squamous cell 35
benign 300f
carcinoma 102, 192, 249, 253, 255, 260, 263, 301f, 302, 318
conjunctival 265
dysplasia 255
papilla of 300f
Squamous neoplasia 263, 264f, 266f, 277
invasive 256
surface 266b
Squamous papilloma 299
Squint measurements 48
Stainless steel disposable blades 313
Stallard incision 85, 91
Stallard-Wright incision 84
S-shaped 86
Stapedius muscle 171
Staphylococcal blepharitis 167
Staphylococcus aureus 42, 167, 168, 169
Staphyloma 19
Steel ruler 311
Stellwag's sign 63
Stents 316
Sterile fluid 215
Sterile orbital cellulitis 284
Steroids, dose of 53
Steroid-sparing immunosuppressive drugs 67
Steven's tenotomy scissors 308
Steven-Johnson syndrome 148, 156, 157
Stickler syndrome 39
Stock eye, fitting of 109f
Stoploss jones tube 316
Storiform fibrosis 55
Strabismus 67, 239, 284
prevalence of 165
surgery 69
Streptococcus
aeruginosa 42
haemolyticus 213
pyogenes 169
Stromal cyst 280, 281
Sturge-Weber syndrome 283
Subocularis oculi fat 173
Suboptimal surgical technique 108
Suboptimal tissue coverage 108
Suborbicularis oculi fat 191
Subperiosteal abscess 42, 43, 44t, 45f
Subperiosteal space 8
Sub-Tenon's space 9
Suction tip 315f
Sudoriferous cyst 299
Suker's sign 63
Sunken eyes 40
Superciliaris 165f
Superonasal orbital meningioma 34f
Superotemporal orbital inflammation 57f
Supraorbital hypoesthesia 74
Supraorbital nerve injury 87
Supraorbital paresthesia 74
Supratrochlear artery 14, 15
Supratrochlear nerve 12
Surgical needle, parts of 321f
Suture 318, 319
absorbable 321, 321t
and needles 318
glide 320
growth of 38
material 320
passing 307
properties 320
zygomaticosphenoid 5
Sweat gland 253
Sympathetic fibers 6
Sympathetic ophthalmia, prevention of 92
Sympathetic root 13
Synechiae, intranasal 225
Synopsis 251
Systemic chemotherapy 206
Systemic disease 206, 257
Systemic tetracycline 169
T
Tacrolimus 54
Taper cut 322
Taper point 322
Tarsal borders, nonmarginal 120
Tarsal conjunctiva 143f
Tarsal ectropion 141
right lower lid 142f
Tarsal excision 155
Tarsal fracture 152, 153f
Tarsal muscle, superior 119, 182
Tarsal plate 153f, 156f, 182
span 191
Tarsal remnants 180f
Tarsal strip 142
lateral 142
Tarsal sutures, placement of 177f
Tarsal wedge resection 154
Tarsalis 165f
Tarsoconjunctiva
diamond shaped 145f
edge of 146
Tarsoconjunctival flap 178, 179f
Tarsorrhaphy 147, 173
lateral permanent 148f
Tarsus 181
cut portion of 156f
lower
border of 151f, 152, 152f
portion of 156f
wedge of 152f
T-cell inhibitors 54
Tear
break up time 206
causes of 205, 205t
elimination 203
film 202, 206
break up 203, 204f
dynamics 203
evaporation 203
properties 203t
retention 203
structure of 202f
hypersecretion of 205
meniscus level 206
secretion 203
volume 206
Telangiectasia 167f
Telecanthus 18, 39, 74, 166
primary 39, 166
secondary 39, 166
syndrome 166f
Temporal forehead flap 179
Temporal fossa 3, 52
Temporalis muscle 173
transposition of 174
Temporary tarsorrhaphy 99f
Tenon's capsule 7, 9
Tenon's fascia, posterior 97f
Tensilon test 125
Tenzel's semicircular flap 177, 178f
Teprotumumab 69
Teratoma 250
Third nerve palsy, left congenital 134f
Thirty degree test 32
Thymectomy 138
Thyroid
associated orbitopathy 61, 69
classification of 65
carcinoma 249
disease 206
disorders 17
dysfunction 205
eye disease 30f, 61, 88, 159f, 205
diagnosis of 65
signs of 63t
follicular cell 61
function tests 21
gland dysfunction, treatment of 67
hormone release, regulation of 62fc
ophthalmopathy 20, 20f, 30, 53
orbitopathy 18, 29f
peroxidase 61
profile 53
releasing hormone 61
stimulating hormone 61
Thyrotropin receptor 61
Tissue
biocompatibility 320
fibrous 50f, 211
forceps 307, 307f
of origin, classification on 253
Titanium implant, anatomical prefabricated 77f
Tocilizumab 69
Tolosa hunt syndrome 51
Toothed forceps 307
Topographic echography 24
Towel clamps 309, 310f
Toxocariasis 285
Trabecular carcinoma 259
Transblepharoplasty browpexy 193
Transcaruncular 83
approach 90
incision 83f
Transconjunctival
approach 84f, 90, 90f, 190
incision 83f
Transcranial orbitotomy 87
Transcutaneous anterior orbitomy 82f
Transcutaneous approach 90
Transmitted pulsation 19
Transorbital decompression, orbital incisions for 88f
Transverse ligament, superior 199
Treacher Collins syndrome 164, 164f
Treacher Collins-Franceschetti syndrome 40
Triamcinolone acetonide 169
Trichiasis 156, 170
Trigeminal nerve, maxillary division of 6
Trigonocephaly 38
Trihexyphenidyl 161
Trochlear nerve 6, 11
course of 11f
Tube prolapse 225
Tuberculosis 18, 219
adnexal 44
Tumors 30, 205, 209, 235
benign mixed 247
conjunctival 277
stromal 270
epithelial 247
fibrous conjunctival 273
hypocellular 275
intraocular 280
secondary 35
vascular 30, 238, 253
U
Ultrabiomicroscopy 282
Ultrasonography 24, 30t
Ultrasound 48
Upper eyelid 122, 187
blepharoplasty 181, 187, 188
indications of 187
epiblepharon 188
margin 177
retraction 158
Upper lid 119, 120, 157, 179, 182
blepharoplasty 191f
chronic blepharitis, left 167f
cicatricial entropion 155f
management of 153, 154t
coloboma 164f
right 178f
ectropion 142f, 155f
lag 64f
mass, transillumination of 20f
retraction, right 63f, 64f
retractors, posterior surface of 156f
right 241f
Urinary retention 184
Urinary tract infection 184
Urine culture 53
Urticaria 186
Uveal lesions, unilateral 293
Uveal melanoma 281
risk for 281
Uveal tract, tumors of 280
V
Vacuolated cells 299f
Valacyclovir 172
Valsalva's maneuver 32f, 33f, 241
van Dyke's relief classification 66b
Vanna's scissors 308
Varicella zoster virus 172
Varices 271
Venous congestion 30
Venous drainage 9, 15, 200
Venous malformation 241
Vessels 8, 9
Vigouroux sign 63, 64f
Vincristine 289
Viral infection 172
Vision 43, 48, 67
blurred 74, 184
double 74
losing 81
poor 75
Visual
acuity 122, 242
deterioration 239
loss 79
Vitreoretinal lymphoma 293f
primary 293
Vitreoretinopathy, familial exudative 285
Vitreous cells 293f
Vitreous disease 289
Vitreous hemorrhage 75, 284, 285
Vogt-Koyanagi-Harada syndrome 157
Vomiting 74
von Graefe's knife 227
von Graefe's sign 63, 64f
W
Waardenburg syndrome 39, 157
Webbed skin scar 225
Wedge resection 155f
Wegener's granulomatosis 22, 53, 54
Weiss procedure 149, 150, 150f
Wells enucleation spoon 313f
Werner's Nospecs classification 66t
Westcott scissors 308
Wet socket 108
Wheeler's orbicularis strip procedure 150
Wheeler's procedure
Hill's modification of 150, 151f
modified 152f
technique of 150
White eyed blow-out fracture 73, 75
pediatric 79
Whitnall's ligament 199
Whitnall's tubercle 5, 118
Worm's eye view 19, 19f
Wound
breaking strength 320
closure 224
complications 79
dehiscence 225
management 79
Wright's fascia
lata needle 132f
needle 315, 315f
Wright's incision 91
X
Xanthogranuloma 247, 275
adult onset 247
juvenile 285
types of 247t
Xanthogranulomatosis 53
Xeroderma pigmentosum 255
Y
Y-V plasty, marking of 131f
Z
Zeiss glands 202, 256
Z-plasty 146f, 176
double 131
Zygoma 5
Zygomatic nerve 6
Zygomatico-maxillary complex fracture 74
×
Chapter Notes

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1Orbit
  • Surgical Anatomy of Orbit
  • Evaluation of Orbital Disorders
  • Orbital Imaging
  • Congenital Orbital Anomalies
  • Orbital Infection and Inflammation
  • Thyroid-associated Orbitopathy
  • Orbital Fractures: A Conceptual Approach
  • Orbitotomy
  • Orbital Decompression
  • Enucleation, Evisceration, Orbital Exenteration and Orbital Implants
  • Anophthalmic Socket: Evaluation and Management2

Surgical Anatomy of OrbitCHAPTER 1

Shaloo Bageja,
Ishita Anand,
Swapnil Jadhav
 
INTRODUCTION
A comprehensive knowledge of the orbit and periorbital area aids in diagnosis and management of disorders in this region.
The two orbital cavities are situated on either side of the sagittal plane of the skull between the cranium and the skeleton of the face.
 
RELATIONS OF ORBIT
  • Superiorlyanterior cranial fossa and frontal sinus
  • Laterallytemporal fossa (anteriorly); middle cranial fossa (posteriorly)
  • Inferiorlymaxillary sinus
  • Mediallyethmoid sinus and anterior part of sphenoid sinus.
Due to the close proximity of these structures, any infection can spread across these regions. For instance, an infection of the ethmoid sinuses can easily invade the orbit through the thin lamina papyracea.
 
EMBRYOLOGY
 
Orbital Walls
  • The orbital walls are derived from the cranial neural crest cells which expand to form the frontonasal process and maxillary process
  • Inferior, medial, and lateral walls develop from the lateral nasal process and maxillary process
  • Orbital roof is formed from capsule of forebrain
  • Ossification of the orbital bones can be either enchondral or membranous
  • First bone to develop is maxillary bone, around 6 weeks of intrauterine life. It develops from elements in the region of the canine tooth. Secondary ossification centers are in the orbitonasal and premaxillary regions
  • Other orbital bones develop at around 7 weeks of intrauterine development
  • Frontal, zygomatic, maxillary, and palatine bones have intermembranous origin
  • Sphenoid bone has both enchondral and membranous origin
    • Lesser wing of sphenoid—develops at 7 weeks of intrauterine development. It has enchondral origin
    • Greater wing of sphenoid—develops at 10 weeks, has intermembranous origin
    • Both wings join at 16 weeks of age.
  • Ossification completes at birth, except the orbital apex
  • In the early stages of development, human eyes are directed in opposite direction. With facial development, angle between optic stalk decreases and is about 68° in adults.
 
Size, Shape, and Volume of Orbit
Orbit is shaped like a quadrilateral pyramid, with the base anteriorly and apex directed posteriorly. The orbits are aligned such that medial walls are parallel to each other and lateral walls are perpendicular to each other. The angle between medial and lateral wall is 45°. The axis between visual axis and orbital axis is 23°.
The average dimensions of the orbit are as follows (Figs. 1A and B):
  • Height of orbital margin—40 mm
  • Width of orbital margin—35 mm
  • Interorbital distance—25 mm4
zoom view
Figs. 1A and B: (A) Dimensions of the orbit; (B) Depth of Safe limit for intraorbital dissection of orbital walls during surgery.
  • Volume of orbit—30 cm3
  • Depth of orbit—40–50 mm
  • It is approximately 1 cm shorter from the lateral orbital rim to apex
  • The widest circumference of the orbit is 1.5 cm inside the orbital rim at the level of lacrimal recess.
 
OSTEOLOGY
The orbit is composed of seven bones: frontal, lacrimal bone, zygoma, maxilla, ethmoid, sphenoid, and palatine bone (Fig. 2).
 
Superior Wall or Roof
  • Formed by:
    • Orbital plate of frontal bone
    • Lesser wing of sphenoid
  • Concave in shape
  • Separates orbit from anterior cranial fossa
  • Optic foramina in lesser wing of sphenoid:
    • Transmits optic nerve and ophthalmic artery from middle cranial fossa.
  • The medial aspect has fovea for trochlea, 4 mm behind the orbital margin
  • The lateral most aspect accommodates fossa for lacrimal gland, behind the zygomatic process of frontal bone
  • The superior orbital rim has a notch at the junction of medial one-third and lateral two-thirds:
    • Transmits supraorbital nerve and vessels-supplies forehead.
 
Medial Orbital Wall
Composed of four bones, from anterior to posterior:
  1. Frontal process of maxilla
  2. Lacrimal bone
  3. Orbital plate of ethmoid
  4. Body of sphenoid.
zoom view
Fig. 2: Seven bones of the orbit.
Orbital plate of ethmoid is the largest part of medial orbital wall. It is very thin (papyraceous). It separates orbit from ethmoid sinuses.
The frontoethmoidal suture line marks the approximate level of ethmoidal sinus roof, hence any dissection above this line should be avoided as it will expose the cranial cavity.
Anterior and posterior ethmoid foramina are present behind the medial orbital rim at the junction of medial wall and roof. They transmit anterior and posterior ethmoidal arteries (branches of ophthalmic artery) and ethmoidal nerves (branches of nasociliary nerve). The anterior ethmoidal foramen is located at a distance of 24 mm from the anterior lacrimal crest, while the posterior ethmoidal foramen is located at a distance of 36 mm from the anterior lacrimal crest (Fig. 3).5
zoom view
Fig. 3: Relations of anterior and posterior ethmoidal foramina.
Lacrimal fossa is a depression in the inferomedial orbital rim. It is formed by maxillary (anterior part) and the lacrimal bone (posterior part). It is bounded by two projections, i.e. anterior lacrimal crest of maxillary bone and posterior lacrimal crest of lacrimal bone. Lacrimal bone is thin whereas the maxillary bone is quite thick. If maxillary bone is predominant in the lacrimal fossa, then osteotomy becomes quite difficult during dacryocystorhinostomy (DCR) surgery.
Nasolacrimal canal lies in the inferomedial part of orbit through which nasolacrimal duct traverses.
The nasolacrimal duct is 3–4 mm in diameter, it passes backward, downward, and laterally to open into the inferior meatus under the inferior turbinate.
Sutura longitudinalis imperfecta of Weber lies in the frontal process of maxilla just anterior to the lacrimal fossa. This suture runs parallel to the anterior lacrimal crest. Small branches of infraorbital artery pass through this groove to supply the nasal mucosa. The presence of these vessels should be anticipated in any lacrimal sac surgery to avoid intraoperative bleeding.
Disruption of medial wall leading to nasoorbitoethmoidal fracture (NOE fracture) or any lateral displacement of the walls leads to hypertelorism.
Any trauma to frontal process of maxilla where medial canthal ligament is attached, leads to telecanthus.
 
Lateral Wall
  • Formed by:
    • Greater wing of sphenoid (posteriorly)
    • Zygoma (anteriorly)
  • Thickest bone
  • Greater wing of sphenoid separates orbit from middle cranial fossa. Congenital absence of this bone in cases like neurofibromatosis results in pulsatile proptosis due to orbital encephalocele
  • Whitnall's tubercle:
    • 4–5 mm behind the lateral orbital rim
    • 1 cm inferior to frontozygomatic suture
    • Attachments:
      • Lateral canthal tendon
      • Lateral horn of levator aponeurosis
      • Lateral rectus check ligament
      • Suspensory ligament of lower lid (Lockwood's ligament)
      • Lacrimal gland fascia
      • Orbital septum.
  • The frontal process of zygomatic bone and zygomatic process of frontal bone are thick bones and thus protect globe during injury
  • Posterior part of this lateral wall is thin (about 1 mm), composed of orbital plate of greater wing of sphenoid and posterior zygomatic bone
  • The superior orbital fissure (between lateral and superior walls of orbit) and the inferior orbital fissure (between lateral and inferior walls of orbit) transmit important structures
  • Zygomaticosphenoid suture is an important landmark for lateral orbitotomy. Superiorly the bony incision is usually made just above the frontozygomatic suture. The lateral wall removal is completed by fracturing the bone at the zygomaticosphenoid suture
  • The recurrent meningeal branches of the ophthalmic artery (internal carotid supply) exit the orbit via the frontosphenoid suture to anastomose with the middle meningeal artery (external carotid supply)
  • The zygomaticofacial and zygomaticotemporal neurovascular structures leave the orbit via their respective foramina.
 
Orbital Floor
  • Triangular in shape and shortest of all the walls
  • Formed by:
    • Orbital plate of maxilla
    • Zygoma
    • Palatine.
  • Separated from lateral wall by inferior orbital fissure
  • Inferior orbital fissure weakens the floor. Blow out fractures usually occur medial to it
  • Medially, it is bounded by maxilla ethmoidal strut. It is important to preserve this during orbital decompression surgery to avoid hypoglobus and postoperative diplopia
  • Infraorbital groove becomes a canal anteriorly, through this groove passes the infraorbital nerve and artery (maxillary division of trigeminal nerve and the terminal 6branch of internal maxillary artery). They exit through the infraorbital foramen to supply the lower eye lid, cheek, upper lip, and upper anterior gingiva
  • The infraorbital foramen is located about 6–10 mm below the infraorbital rim
  • The inferior oblique muscle arises anteromedially, immediately lateral to the nasolacrimal canal.
 
FISSURES AND CANAL
Various important nerves and vessels are transmitted through fissures and canals in the orbit (Fig. 4).
 
Superior Orbital Fissure
  • Location—between greater and lesser wing of sphenoid. It lies between roof and lateral walls of orbit (Fig. 5).
  • Also known as sphenoidal fissure
  • It is 22 mm long, largest communication between orbit and middle cranial fossa
zoom view
Fig. 4: Orbital fissures and foramina.
zoom view
Fig. 5: Superior orbital fissure.
  • It usually narrows laterally and widens medially, below the optic foramen
  • Its tip is about 30–40 mm from frontozygomatic suture
  • Its medial part is separated from optic foramen by posterior part of lesser wing of sphenoid
  • The annulus of Zinn, a tight fibrous ring, divides the superior orbital fissure into intraconal and extraconal spaces.
Structures passing through upper part:
  • Lacrimal nerve
  • Frontal nerve
  • Trochlear nerve
  • Superior ophthalmic vein.
Structures passing through annulus of Zinn:
  • Superior division of 3rd nerve
  • Nasociliary nerve
  • Sympathetic root of cervical ganglion
  • Inferior division of 3rd nerve
  • 6th nerve
  • Sympathetic fibers.
Structures passing through lower part, outside the annulus of Zinn:
Inferior ophthalmic vein.
 
Inferior Orbital Fissure
  • Location—lies between lateral wall and floor of the orbit. It is about 1 cm posterior to the inferolateral orbital rim
  • It is also known as sphenomaxillary fissure
  • It is about 20 mm long
  • The orbit communicates with the pterygopalatine and infratemporal fossa
  • Structure passing:
    • Maxillary division of the trigeminal nerve
    • Zygomatic nerve
    • Branches from the sphenopalatine ganglion
    • Branches of the inferior ophthalmic vein leading to the pterygoid plexus
  • The maxillary division of trigeminal nerve and the terminal branch of internal maxillary artery enter the infraorbital groove and canal to become the infraorbital nerve and artery.
 
Optic Foramen
  • The foramen is present in the lesser wing of sphenoid lies medial to the superior orbital fissure and is separated from it by a bony optic strut
  • Conveys the optic nerve and ophthalmic artery
  • The optic foramen is about 6.5 mm in diameter
  • Optic canal attains its adult size by 3 years of age. It is supposed to be bilaterally symmetrical. Any variation 7in size between two sides should be considered pathological
  • In adults the optic canal is 8–10 mm long and 5–7 mm wide
  • Any trauma to optic canal, can result in injury to optic nerve.
 
ORBITAL SOFT TISSUES
  • Orbital septum
  • Periorbita
  • Orbital fat
  • Extraocular muscles
  • Lacrimal system.
 
Orbital Septum
  • It is anterior soft tissue boundary. It is extension of periorbita (Fig. 6)
  • It originates from arcus marginalis. It extends from tarsus to orbital rim
  • It acts as a physical barrier, separates the orbital contents from eyelids
  • It is covered anteriorly by preseptal orbicularis muscle and skin.
 
Periorbita
  • It is periosteal lining of the orbital walls
  • It is firmly attached at the suture lines, the foramina, the fissures, the arcus marginalis, and the posterior lacrimal crest
  • Posteriorly, the periorbita is continuous with the optic nerve sheath where the dura is fused to the optic canal
  • Periorbita thickens on the orbital surface of the optic canal and the medial aspect of the superior orbital fissure and gives rise to the tendinous attachments of the four rectus muscles, the levator superioris, and the superior oblique muscle. This tendinous ring is called the annulus of Zinn.
zoom view
Fig. 6: Extension of orbital septum.
 
Tenon's Capsule
  • Also known as fascia bulbi or bulbar sheath
  • It is dense, elastic, and vascular connective tissue that surrounds the globe
  • It begins from perilimbal area and extends posteriorly along the globe till optic nerve and fuses with dural sheath and sclera
  • It is separated from sclera by periscleral lymph space which is in continuation with subdural and subarachnoid space.
 
Orbital Fat
  • Acts as a cushion to orbital structures
  • In upper eyelid it lies anterior to levator complex and posterior to orbital septum
  • It is divided into compartments by connective tissue septa
  • Infratrochlear nerve and medial palpebral artery branch of the ophthalmic artery course through the medial fat pad
  • In lower eyelid, medial fat pad is separated from central pad of fat by inferior oblique muscle.
 
Extraocular Muscles
Each orbit contains six extraocular muscles that function together to move the eye:
  • Rectus muscles (4)—superior, inferior, lateral, and medial recti muscle
  • Oblique muscles (2)—superior and inferior
  • Other muscles—the levator palpebrae and Müller's muscle (Fig. 7).
 
Recti Muscles
The rectus muscles originate at the annulus of Zinn, a fibrous tendon that encircles the optic foramen. The annulus of Zinn is divided into the superior Lockwood tendon and the inferior tendon of Zinn. The inferior tendon gives origin to parts of medial and lateral recti and entire inferior rectus muscle. The superior tendon gives origin to part of medial and lateral recti and all of the superior rectus muscle. The attachments of superior and medial recti muscles are close to the dural sheath of optic nerve. Thus causing pain during 8extreme eye movements in retrobulbar neuritis. The recti are inserted 6–8 mm posterior to the limbus into the sclera.
zoom view
Fig. 7: Origin of extraocular muscles.
(SR: superior rectus; IR: inferior rectus; SO: superior oblique; IO: inferior oblique; LR: lateral rectus; MR medial rectus; LPS: levator palpebrae superioris)
Actions:
  • Medial rectus—Adduction
  • Lateral rectus—Abduction
  • Superior rectus—Elevation, adduction, intorsion
  • Inferior rectus—Depression, adduction, extorsion.
 
Oblique Muscles
The superior and inferior oblique muscles originate separately from the posterior orbital wall.
The superior oblique muscle arises from the sphenoid bone superomedial to the optic canal. It courses in the forward direction lying above the medial rectus, and through a cartilaginous pulley (the trochlea) attached to the frontal bone. Thereafter, the tendon passes posterolaterally, running inferior to the tendon of the superior rectus to insert into the posterior sclera.
The inferior oblique muscle arises from the maxilla at the anteromedial floor of the orbit, passes in a posterolateral direction, immediately inferior to the inferior rectus to insert into the posterior sclera.
Actions:
  • Inferior oblique—extorsion, elevation, abduction
  • Superior oblique—intorsion, depression, abduction.
Nerve supply: The superior oblique muscle is supplied by the trochlear nerve, the lateral rectus by the abducent nerve, and all the other extraocular muscles are supplied by the oculomotor nerve.
 
Levator Palpebrae Superioris
It is a striated muscle. It helps in elevation of the eyelid.
 
Origin
Levator palpebrae superioris (LPS) arises from the under surface of lesser wing of sphenoid just above and in front of optic foramen, and usually it is blended with the origin of superior rectus muscle. From this attachment this ribbon-like muscle passes forward below the roof on top of the superior rectus muscle.
 
Insertion
Levator palpebrae superioris inserts into the skin of the upper eyelid and upper tarsal plate.
 
Nerve Supply
It is innervated by the superior division of 3rd cranial nerve.
 
Müller's Muscle
It is a smooth muscle which acts as an eyelid elevator.
 
Origin
It arises from the inferior aspect of LPS.
 
Insertion
Inserted into the upper edge of tarsal plate.
 
Nerve Supply
It is innervated by sympathetic fibers.
 
SURGICAL SPACES (FIG. 8)
  • Subperiosteal space
  • Peripheral orbital space
  • Muscular cone.
 
Subperisoteal Space
  • It lies between orbital bones and periorbita
  • It is limited anteriorly by strong adhesions between periorbita and orbital margins.
 
Extraconal Space
  • It is bounded peripherally by periorbita and centrally by four recti muscles and their intermuscular septa, anteriorly by orbital septum and posteriorly by:
    • Peripheral orbital fat
    • Muscles—superior and inferior oblique, LPS
    • Nerves—lacrimal, frontal, trochlear, anterior and posterior ethmoidal
    • Vessels—superior and inferior ophthalmic veins
    • Lacrimal gland
    • Lacrimal sac.9
zoom view
Fig. 8: Surgical spaces of orbit (in sagittal and coronal sections).
 
Intraconal Space
  • Bounded anteriorly by Tenon's capsule, peripherally by four recti and intermuscular septa and posteriorly continuous with peripheral space
  • Contents:
    • Central orbital fat
    • Nerves—optic nerve, oculomotor, abducens, nasociliary, ciliary ganglion
    • Vessels—ophthalmic artery, superior ophthalmic vein.
 
Sub-Tenon's Space
It lies between sclera and Tenon's capsule.
 
LACRIMAL APPARATUS
Lacrimal apparatus comprises of lacrimal gland and its excretory passage.
 
Lacrimal Gland
The lacrimal gland lies in the superotemporal orbit, in lacrimal fossa of the frontal bone. It measures about 20 mm by 12 mm. It is divided into larger orbital and smaller palpebral part by levator aponeurosis. The gland is composed of numerous secretory units known as acini which progressively drain in to small and larger ducts. About 2–6 ducts from the orbital lobe pass through the palpebral lobe joining with the ducts from the palpebral lobe to form 6–12 tubules to empty into the superolateral conjunctiva. Hence, damage to the palpebral lobe may block drainage from the entire gland. About 20–40 accessory lacrimal glands of Krause are located in the superior conjunctival fornix, about half this number is located over the lower fornix.
 
Nerve Supply
Nerve supply is innervated by branches from 5th and 7th cranial nerves, sympathetic supply to lacrimal gland is via the nerves from the superior cervical ganglion. The parasympathetic fibers are supplied via the 6th nerve. Sensory supply is via the branches of trigeminal nerve.
 
Vessels
  • Arterial supply—lacrimal artery branch of ophthalmic artery
  • Venous drainage—ophthalmic veins
  • Lymphatic drainage—preauricular lymph nodes.
 
Lacrimal Excretory System
The lacrimal excretory system begins with punctum, about 0.3 mm in size. It lies at the medial end of each eyelids, at the junction of ciliated and nonciliated part. The punctal opening widens into ampulla, makes a sharp turn to drain into the canaliculi. The canaliculi measures 0.5–1 mm in diameter and courses parallel to the lid margins. It has two parts—vertical 2 mm in size and horizontal about 8 mm in length. The superior canaliculus is slightly shorter than the inferior canaliculus. In 90% of individuals the superior and inferior canaliculi merge into a common canaliculi before draining into lacrimal sac.10
zoom view
Fig. 9: Lacrimal excretory system.
There is a valve at the junction of common canaliculus and lacrimal sac known as the Rosenmuller valve. The lacrimal sac resides in the lacrimal fossa. It measures about 12–15 mm vertically and 4–8 mm anteroposteriorly. It opens into nasolacrimal duct, which is about 15 mm in length. It has interosseous and meatal part. It is directed downward, backward, and laterally and opens in inferior meatus. Valve of Hasner is found at the lower end of the nasolacrimal duct at the level of inferior meatus of nose. Imperforate Hasner's valve in new born infants results in congenital nasolacrimal obstruction (Fig. 9).
 
Vessels
  • Arterial supply—palpebral branch of ophthalmic artery, angular and infraorbital arteries, and nasal branch of sphenopalatine
  • Venous—angular and infraorbital vessels above and nasal veins below
  • Lymphatic drainage—submandibular and deep cervical nodes.
 
Nerve Supply
Infratrochlear and anterior superior alveolar nerves.
 
ORBITAL NERVES
Orbit contains seven nerves. It comprises of:
  • Component of central nervous system—Optic nerve
  • Motor nerves—Oculomotor, trochlear, and abducens nerves
  • Sensory nerve—Ophthalmic division of trigeminal nerve (V1) and some contribution from maxillary division (V2)
  • Autonomic center—Ciliary ganglion.
 
Optic Nerve
Optic nerve is the second cranial nerve
  • It is about 4 cm in length
  • Parts:
    • Intraocular—1 mm
    • Intraorbital—30 mm
    • Intracanalicular—5 mm
    • Intracranial—10 mm
  • Intraocular: The nerve fibers start from axons of ganglion cell layer of retina, converge on the optic disc, and pierce the layers of the eye. It is 1.5 mm in diameter and expands to 3 mm behind sclera as it receives myelin sheaths
  • Intraorbital: Extends from back of eye to optic foramina
    • Its course is tortuous
    • The entire intraorbital optic nerve is surrounded by meningeal and arachnoidal sheaths in continuation with the respective intracranial layers
    • The optic nerve lies within the muscular cone
    • Relations:
      • Long and short ciliary nerves and arteries surround the optic nerve before they enter the eyeball
      • Ophthalmic artery, superior ophthalmic vein and nasociliary nerve crosses the nerve superiorly from lateral to medial side
      • Between optic nerve and lateral rectus muscle lies ciliary ganglion, nasociliary nerve, divisions of oculomotor nerve, and abducent and sympathetic nerve.
    • Nerve passes through the optic canal to enter the middle cranial fossa.
  • Intracanalicular:
    • Ophthalmic artery crosses inferiorly from medial to lateral side
    • Sphenoid and posterior ethmoidal sinuses lie medially to it, thus results in retrobulbar neuritis following infection.
  • Intracranial—Lies above cavernous sinus and combines with opposite nerve to form optic chiasma.
 
Motor Nerves
  • Oculomotor nerve (III)
  • Abducens nerve (VI)
  • Trochlear nerve (IV).
 
Oculomotor Nerve (Fig. 10)
  • The oculomotor nerve divides in the cavernous sinus into superior and inferior divisions that enter the orbit through the annulus of Zinn. Within this ring, 11nasociliary nerve lies between two branches, while abducens nerve on the outside
  • The two branches enter the muscular cone and diverges
  • The superior division moves up on the lateral side of optic nerve. It supplies the LPS and superior rectus muscles
  • The inferior division is located inferiorly and outside the optic nerve and then splits to supply the medial rectus, inferior rectus, and the inferior oblique
  • The branch to inferior oblique travels along the lateral border of inferior rectus and enters the inferior oblique
  • From the branch to inferior oblique a small branch arises which goes to ciliary ganglion to form its parasympathetic root. After synapses the fibers of third nerve combine with sympathetic fibers to constitute short ciliary nerve which supplies ciliary muscle and iris sphincter.
 
Trochlear Nerve (Fig. 11)
  • The trochlear nerve enters the orbit just outside the annulus of Zinn, having crossed superior to the oculomotor nerve in the lateral wall of the cavernous sinus
  • It travels forward in the orbit crossing from lateral to medial above the origin of LPS to enter the lateral border of superior oblique at the junction of the posterior third and anterior two-thirds.
 
Abducens Nerve (Fig. 12)
  • The abductor nerve starts in the medial part of the superior orbital fissure inside the annulus of Zinn and outside the branches of the oculomotor nerve
  • It travels along the medial surface of lateral rectus piercing the muscle at the junction of the posterior third and anterior two-thirds.
 
Sensory Nerves (Fig. 13)
  • The trigeminal nerve supplies sensory innervation to the orbit and surrounding structures. It originates at the lateral and ventral portion of the pons
  • Most of the supply is from ophthalmic division (V1) of trigeminal nerve with some contribution from maxillary division (V2)
  • The ophthalmic division extends from the trigeminal ganglion and passes through the cavernous sinus to the orbit via the superior orbital fissure.
zoom view
Fig. 10: Course of oculomotor (III) nerve.
zoom view
Fig. 11: Course of trochlear (IV) nerve.
12
zoom view
Fig. 12: Course of abducens (VI) nerve.
  • Before entering the orbit through superior orbital fissure it divides into lacrimal, frontal, and nasociliary branches
  • The lacrimal and frontal nerves enter the fissure outside the annulus of Zinn and travel forward in the superior orbit
  • The lacrimal nerve, the smallest branch of ophthalmic nerve, travels along the superior border of the lateral rectus and supplies the postganglionic secretomotor fibers to the lacrimal gland, and sensory fibers to surrounding conjunctiva and upper eyelid. The parasympathetic fibers travel from the lacrimal nucleus in the pons to the greater superficial petrosal nerve via the nervus intermedius, to the vidian nerve, to the sphenopalatine ganglion, to the zygomatic branch of the maxillary nerve, to the zygomaticotemporal nerve, and to the lacrimal nerve, to innervate the lacrimal gland
  • The frontal nerve, largest division of ophthalmic nerve, divides into the supraorbital and supratrochlear nerves. The supraorbital nerve moves anteriorly above LPS, leaves the orbit through the supraorbital notch, and supplies the forehead, scalp, upper eyelid, and frontal sinus. The supratrochlear nerve, medial one, runs anteriorly above the trochlea and supplies medial part of the forehead and upper eyelid
  • The nasociliary branch enters the orbit through the annulus of Zinn. It crosses the optic nerve and passes forward between the superior oblique and medial rectus muscles. Its branches into the anterior and posterior ethmoidal nerves, two or three long posterior ciliary nerves to the globe, short ciliary nerves which pass through the ciliary ganglion, and do not synapse. It terminates as the infratrochlear nerve which supplies the medial canthus and the tip of the nose. The ethmoidal nerves contribute branches to the nasal cavity and external nose. The long ciliary nerves carry sympathetics from the superior cervical ganglion responsible for dilatation of the pupil
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Fig. 13: Sensory nerve supply of orbit.
(ST: supratrochlear nerve; SO: supraorbital nerve; Lac: lacrimal nerve; ZT: zygomaticotemporal nerve; ZF: zygomaticofacial nerve; IO: infraorbital nerve; NC: nasociliary nerve; AE: anterior ethmoidal nerve; PE: posterior ethmoidal nerve; IT: infratrochlear nerve)
  • The maxillary division of the trigeminal nerve leaves the middle cranial fossa through the foramen rotundum and enters the pterygopalatine fossa
  • Within fossa after giving off sphenopalatine, posterior superior alveolar, and zygomatic branches, the main part of nerve passes through the inferior orbital fissure to enter the infraorbital sulcus as the infraorbital nerve. It exits at the infraorbital foramen and supplies the lower lid skin, conjunctiva, cheek, and the upper lip
  • Within the infraorbital canal, the infraorbital nerve gives off the anterior superior alveolar branch supplying the upper front teeth
  • The zygomatic branch of V2 passes through the inferior orbital fissure and divides into zygomaticotemporal and zygomaticofacial branches that supply the skin overlying the lateral orbit and zygoma. The zygomaticotemporal branch also gives secretomotor fibers to the lacrimal nerve that supplies lacrimal gland.13
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Fig. 14: Ciliary ganglion.
 
Ciliary Ganglion (Fig. 14)
  • It is peripheral parasympathetic ganglion
  • It is located near the orbital apex
  • Lies between the optic nerve and lateral rectus
  • It has three roots:
    1. Motor or parasympathetic root—comes from the inferior branch of the third cranial nerve (by the inferior oblique branch). Its fibers mainly innervate the ciliary muscle and, to a lesser extent, the sphincter of the iris.
    2. Sympathetic root—a branch of the carotid plexus which enters the orbit via the common tendinous ring
    3. Sensory root—a long and fine fiber which rejoins the nasociliary nerve where it enters the orbit. This supplies the eye and the cornea.
  • Filamentous branches of the ganglion, 8–10 in number, are called the short ciliary nerves and they move forward around the optic nerve, together with ciliary arteries and the long ciliary nerves.
 
VASCULAR SUPPLY OF ORBIT
 
Arterial Supply (Fig. 15)
  • Ophthalmic artery, first main branch of internal carotid artery, provides the main arterial supply to the orbit, with some contributions from maxillary and middle meningeal artery, branches of external carotid artery
  • The ophthalmic artery originates from the internal carotid medial to the anterior clinoid process, as it exits the cavernous sinus. The ophthalmic artery courses on the inferior aspect of the optic nerve and enters the orbit through the optic canal
  • At the entrance, it lies lateral to optic nerve and medial to ciliary ganglion. Then accompanied by the nasociliary nerve, it turns medially, crossing the optic nerve superiorly and below the superior rectus muscle. It then moves forward between superior oblique muscle and the medial rectus muscle. It terminates by splitting into two different arteries, the supratrochlear artery and the angular artery
  • Branches are divided into three groups—ocular, orbital, and extraorbital
    • Ocular branches:
      • Central retinal artery
      • Ciliary arteries
      • Collateral branches to optic nerve
    • Orbital branches:
      • Lacrimal artery
      • Muscular arteries
      • Periosteal branches
    • Extraorbital branches:
      • Posterior and anterior ethmoid arteries
      • Supraorbital artery
      • Medial palpebral artery
      • Dorsal nasal artery
      • Supratrochlear artery.
 
Ocular Branches (Fig. 16)
 
Central Retinal Artery
  • First and smallest branch of ophthalmic artery
  • End artery
  • Course: It runs beneath the optic nerve, then at about 10–15 mm behind the posterior part of eyeball it pierces the dural and arachnoid sheath of the optic nerve and enters the eyeball through lamina cribrosa14
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    Fig. 15: Arterial supply of orbit.
    (OA: ophthalmic artery; CRA: central retinal artery; PC: posterior ciliary artery; Lac: lacrimal artery; LP: lateral palpebral artery; IO: infraorbital artery; ZT: zygomaticotemporal artery; ZF: zygomaticofacial artery; Mid men: middle meningeal artery; Rec meningeal: recurrent meningeal artery; Ang: angular artery; MP: medial palpebral artery; DN: dorsal nasal artery; ST: supratrochlear artery; SO: supraorbital artery; AE: anterior ethmoidal artery; PE: posterior ethmoidal artery)
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    Fig. 16: Ocular blood supply.
  • It continues till papilla and then gives the terminal branches.
 
Ciliary Arteries
  • Three types—long posterior ciliary artery, short posterior ciliary artery, and anterior posterior ciliary artery
  • Long posterior ciliary arteries:
    • Commonly two in number
    • Arise in the ophthalmic artery at the point at which it crosses over the optic nerve. These enter the sclera not far from where the optic nerve entry point
    • It runs in the epichoroidal space till the ciliary body, where it divides into upper and lower branches and encircle iris
    • Anastomose with artery ciliary arteries to form major arterial circle of iris
  • Short posterior ciliary arteries:
    • Seven in number
    • Moves in forward direction around the optic nerve and pierce sclera and supply choroid
    • At equator it anastomoses with long posterior ciliary artery, anterior ciliary artery, and major arterial circle of iris.
  • Anterior ciliary arteries:
    • Seven in number
    • Arise from muscular branches and pass in front, over the tendons of the rectus muscles.
 
Cilioretinal Artery
  • Present in 15–20%
  • Enters from lateral aspect of optic nerve
  • Supplies retina between disk and macula.
 
Orbital Branches
 
Lacrimal Artery
  • Arises near the optic canal above and lateral to optic nerve. It travels superolaterally above the lateral rectus muscle to supply lacrimal gland
  • Branches:
    • Lateral palpebral artery supplies upper and lower eyelid and anastomoses with medial palpebral artery
    • Zygomatic artery which passes through zygomatic facial and zygomatic temporal foramina
    • Muscular branch to lateral rectus
    • Recurrent meningeal anastomoses with the middle meningeal artery.
 
Muscular Branches
  • Supply the extraocular muscles
  • Accompany oculomotor nerve along their course.
 
Extraorbital Branches
 
Supraorbital Artery
  • Runs between levator muscle and periorbita
  • Leaves orbit through superior orbital foramen along with the nerve
  • It anastomoses with supratrochlear and superficial temporal arteries.15
 
Supratrochlear Artery
  • It is the terminal branch
  • Pierces the orbital septum above superior oblique pulley.
 
Ethmoidal Arteries
 
Anterior Ethmoidal Artery
  • Enters anterior ethmoidal canal
  • Supplies anterior and middle ethmoidal cells, frontal sinus, meninges, anterior nasal mucosa, and skin of nose.
 
Posterior Ethmoidal Artery
  • Runs between medial rectus and superior oblique muscle to enter posterior ethmoidal canal
  • It supplies posterior ethmoidal sinuses, dura of anterior cranial fossa, and upper nasal mucosa.
 
Medial Palpebral Artery
  • It arises below the superior oblique pulley
  • Descends behind the lacrimal sac
  • It pierces the orbital septum and forms peripheral and marginal arterial arches; runs between the orbicularis oculi and tarsal plate.
 
Lateral Palpebral Artery
  • Branches from lacrimal artery
  • Supplies eyelid
  • Anastomoses with medial palpebral artery.
 
Dorsal Nasal Artery
  • Terminal branch
  • Pierces the orbital septum and passes above the medial palpebral ligament and descends to nose
  • Supplies lacrimal sac and anastomose with facial artery.
 
Infraorbital Artery
  • A terminal branch of the maxillary artery
  • It courses through the inferior orbital fissure into the infraorbital sulcus where it gives off branches to the orbital fat and muscular branches to the inferior rectus and inferior oblique muscles prior to entering the infraorbital canal to exit at the infraorbital foramen
  • It anastomoses with the angular artery and the inferior palpebral vessels.
 
Venous Drainage (Fig. 17)
The venous drainage of the orbit is through the valve less superior and inferior ophthalmic veins.
 
Superior Ophthalmic Vein
  • Larger of the two
  • It is formed superomedially near the trochlea by the union of the angular, supraorbital, and supratrochlear veins
  • It communicates with central retinal vein, receive inferior ophthalmic vein and two vorticose veins from upper part of eyeball
  • Leaves the orbit through superior orbital fissure and drains into the cavernous sinus (Fig. 18).
 
Inferior Ophthalmic Vein
  • It is usually formed anteriorly as a plexus within the inferomedial orbital fat
  • It also communicates with the pterygoid plexus via the inferior orbital fissure and facial vein
  • Receives muscular branches and inferior vorticose veins
    zoom view
    Fig. 17: Venous drainage of orbit.
    zoom view
    Fig. 18: Cavernous sinus.
  • 16It courses posteriorly along the inferior rectus and usually drains into the superior ophthalmic vein.
SUGGESTED READING
  1. Cornelius CP, Mayer P, Ehrenfeld M, et al. The orbits—Anatomical features in view of innovative surgical methods. Facial Plast Surg. 2014;30(5):487–508.
  1. Martins C, Costa e Silva IE, Campero A, et al. (2011). Microsurgical anatomy of the orbit: The rule of seven. Hindawi Publishing Corporation, Anatomy Research International.  [online] Available from https://www.hindawi.com/journals/ari/2011/468727/abs/. [Accessed January, 2019].
  1. Patanaik VVG, Bala S, Sangla RK. Anatomy of the bony orbit-some applied aspects. J Anat Soc India. 2001;50(1):59–67.
  1. René C. Update on orbital anatomy. Eye (Lond). 2006;20(10):1119–29.
  1. Rootman J, Stewart B, Goldberg RA. Orbital anatomy. In: Orbital Surgery: A Conceptual Approach, 1st edition. Philadelphia, New York: Lippincott-Raven;  1995. pp. 75–150.
  1. Turvey TA, Golden BA. Orbital anatomy for the surgeon. Oral Maxillofac Surg Clin North Am. 2012;24(4):525–36.