Levator superioris muscle latin. Extraocular muscles and their innervation

The eyelids, in the form of movable flaps, cover the front surface of the eyeball and perform a number of functions:

A) protective (from harmful external influences)

B) tear distribution (tears are distributed evenly during movements)

B) maintain the necessary moisture of the cornea and conjunctiva

D) wash away small foreign bodies from the surface of the eye and promote their removal

The free edges of the eyelids are about 2 mm thick and, when the palpebral fissure is closed, fit tightly to each other.

The eyelid has an anterior, slightly smoothed edge from which the eyelashes grow, and a posterior, sharper edge facing and fitting tightly to the eyeball. Along the entire length of the eyelid between the anterior and posterior ribs there is a strip of flat surface called Intermarginal space. The skin of the eyelids is very thin, easily folded, has delicate vellus hairs, greasy and sweat glands. The subcutaneous tissue is loose and completely devoid of fat. When the palpebral fissure is open, the skin of the upper eyelid, slightly below the brow ridge, is retracted deeper by the fibers of the levator muscle attached to it. upper eyelid, as a result, a deep superior orbitopalpebral fold is formed here. A less pronounced horizontal fold is present on the lower eyelid along the lower orbital margin.

Located under the skin of the eyelids Orbicularis oculi muscle, in which the orbital and palpebral parts are distinguished. The fibers of the orbital part begin from the frontal process upper jaw on the inner wall of the orbit and, having made a full circle along the edge of the orbit, are attached at the place of their origin. The fibers of the palpebral part do not have a circular direction and spread in an arcuate manner between the internal and external ligaments of the eyelids. Their contraction is caused by the closure of the palpebral fissure during sleep and during blinking. When you close your eyes, both parts of the muscle contract.

The internal ligament of the eyelid, starting as a dense bundle from the frontal process of the upper jaw, goes to the inner corner of the palpebral fissure, where it bifurcates and is woven into the inner ends of the cartilages of both eyelids. The posterior fibrous fibers of this ligament turn back from the internal angle and attach to the posterior lacrimal crest. As a result, a fibrous space is formed between the anterior and posterior knees of the internal ligament of the eyelids and the lacrimal bone, in which the lacrimal sac is located.

The fibers of the palpebral part, which start from the posterior knee of the ligament and, spreading through the lacrimal sac, are attached to the bone, are called the lacrimal muscle (Horner). During blinking, this muscle stretches the wall of the lacrimal sac, in which a vacuum is created, sucking tears from the lacrimal lake through the lacrimal canaliculi.

The muscle fibers that run along the edge of the eyelids, between the fibers of the eyelashes and the excretory ducts of the meibomian glands, make up the ciliary muscle (Riolan). When it is pulled, the posterior edge of the eyelid is tightly adjacent to the eye.

The orbicularis oculi muscle is innervated by the facial nerve.

Posterior to the palpebral portion of the orbicularis muscle is a dense connective plate called eyelid cartilage, although it does not contain cartilaginous cells. The cartilage serves as the skeleton of the eyelids and, due to its slight convexity, gives them the appropriate appearance. Along the orbital margin, the cartilages of both eyelids are connected to the orbital margin by the dense tarso-orbital fascia. In the thickness of the cartilage, perpendicular to the edge of the eyelid, there are meibomian glands that produce fatty secretions. Excretory ducts they emerge through pinholes into the intermarginal space, where they are located in a regular row along the posterior edge of the eyelid. The secretion of meibomian gland secretion is facilitated by the contraction of the ciliary muscle.

Functions of grease:

A) prevents tears from flowing over the edge of the eyelid

B) directs the tear inwards into the lake of tears

C) protects the skin from maceration

D) retains small foreign bodies

D) when the palpebral fissure is closed, creates its complete sealing

E) participates in the formation of the capillary layer of tears on the surface of the cornea, delaying its evaporation

Along the front edge of the eyelid, eyelashes grow in two or three rows; on the upper eyelid they are much longer and there are more of them in number. Near the root of each eyelash there are sebaceous glands and modified sweat glands, the excretory ducts of which open into the hair follicles of the eyelashes.

In the intermarginal space at the inner corner of the palpebral fissure, due to the bending of the medial edge of the eyelids, small elevations are formed - lacrimal papillae, at the top of which lacrimal puncta gape with small holes - the initial part of the lacrimal canaliculi.

Attached along the superior orbital margin of the cartilage Levator superioris muscle, which starts from the periosteum in the area of ​​the optic foramen. It runs forward along the upper wall of the orbit and, not far from the upper edge of the orbit, passes into the broad tendon. The anterior fibers of this tendon are directed to the palpebral bundle of the orbicularis muscle and to the skin of the eyelid. The fibers of the middle part of the tendon are attached to the cartilage, and the fibers of the posterior part approach the conjunctiva of the upper transitional fold. The middle part is actually the end of a special muscle consisting of smooth fibers. This muscle is located at the anterior end of the levator and is closely connected with it. Such a harmonious distribution of the tendons of the muscle that lifts the upper eyelid ensures the simultaneous lifting of all parts of the eyelid: skin, cartilage, conjunctiva of the upper transitional fold of the eyelid. Innervation: the middle part, consisting of smooth fibers, is the sympathetic nerve, the other two legs are the oculomotor nerve.

The posterior surface of the eyelid is covered with conjunctiva, tightly fused with cartilage.

The eyelids are richly supplied with vessels due to branches of the ophthalmic artery from the internal carotid artery system, as well as anastomoses from the facial and maxillary arteries from the external carotid artery system. Branching out, all these vessels form arterial arches - two on the upper eyelid and one on the lower.

Sensitive innervation of the eyelids is the first and second branches of the trigeminal nerve, motor innervation is the facial nerve.

This also includes the muscle that lifts the upper eyelid (m. levator palpebrae superioris).

Start : thin narrow tendon fixed to the lesser wing sphenoid bone above the common tendon ring of Zinn and above and outside the optic foramen.

Attachment : orbital septum 2-3 mm above the edge of the cartilage (8-10 mm from the edge of the eyelid).

Blood supply : superior (lateral) muscular artery (branch of the ophthalmic artery), supraorbital artery, posterior ethmoidal artery, peripheral arterial arch of the upper eyelid.

Innervation : bilateral through the superior branch of the oculomotor nerve (n. III). Upper branch n. III enters the levator from below at the border of its posterior and middle thirds - 12–13 mm from the apex of the orbit.

Anatomy details : abdominal length - 40 mm, aponeurosis - 20–40 mm.

Three servings of muscle:

• The middle muscle portion, consisting here of a thin layer of smooth fibers (rostio media; m. tarsalis superior s. m. H. Mulleri), is woven into the upper edge of the cartilage; this portion is innervated by the cervical sympathetic nerve, while the remaining mass of striated levator fibers receives innervation from the oculomotor nerve.
• The anterior portion of the levator ending, turning into a wide aponeurosis, is directed to the tarso-orbital fascia; slightly below the superior orbital-palpebral groove it penetrates in separate bundles through this fascia, reaches the anterior surface of the cartilage and spreads all the way to the skin of the eyelid.
• Finally, the third, posterior, portion of the levator (also tendon) is directed to the upper fornix of the conjunctiva.

Such a triple ending of the muscle that lifts the upper eyelid, during its contraction, provides the possibility of joint movement of the upper eyelid as a whole through the cartilage (middle portion), the skin of the upper eyelid (anterior portion) and the upper conjunctival fornix (posterior portion of the muscle).

With normal levator tone, the upper eyelid occupies such a position that its edge covers the cornea by about 2 mm. Dysfunction of the elevator is expressed by the main symptom - drooping of the upper eyelid (ptosis) and, in addition, smoothness of the superior orbital-palpebral groove.

In the lower eyelid, there is no formalized muscle similar to the levator, i.e., the “descender” of the eyelid. Nevertheless, the lower eyelid is pulled back when the eye turns downward by fascial processes that penetrate into the thickness of the eyelid and into the lower transitional fold of the conjunctiva from the sheath of the inferior rectus muscle of the eyeball. These cords, to which smooth muscle fibers may be mixed, are then given by some authors the name m. tarsalis inferior.

The course of the muscle is located lateral to the superior oblique and over the superior rectus muscle. In the anterior part of the upper part of the orbit, the levator is surrounded by a thin layer of fatty tissue, and here it is accompanied by the superior orbital artery, frontal and trochlear nerves, separating it from the roof of the orbit.

The superior rectus and levator of the upper eyelid are easily separated, despite their close proximity, except for their medial part, where they are connected by a fascial membrane. Both muscles originate from the same area of ​​mesoderm. Both muscles are innervated by the superior branch of the oculomotor nerve. The nerve penetrates the muscles from the lower side at a distance of 12-13 mm from the apex of the orbit. Usually the nerve trunk approaches the levator from the outside of the superior rectus muscle, but it can also pierce it.

Directly behind the superior edge of the orbit, a section of dense fibrous tissue (the superior transverse ligament of Withnell, which supports the eyeball) is attached superiorly to the levator. The connection between them is quite strong, especially in the outer and inner parts. In this regard, their separation is possible only in the central areas. On the medial side, the Withnell ligament ends near the trochlea, while it passes in the form of fibrous cords under the superior oblique muscle of the eye behind, mixing with the fascia covering the supraorbital recess. On the outside, the ligament of Withnell connects to the fibrous capsule of the lacrimal gland and the periosteum of the frontal bone.

Withnell suggests that the main function of this ligament is to limit posterior displacement (tension) of the muscle. The author put forward this assumption due to the fact that its localization and distribution are similar to the limiting ligaments of the external muscles of the eye. The tension of the ligament provides support for the upper eyelid. If the ligament is destroyed, the levator of the upper eyelid sharply thickens and with inside ptosis occurs.

The distance from the transverse ligament of Withnell to the lower edge of the cartilaginous plate is 14-20 mm, and from the levator aponeurosis to the circular and skin insert is 7 mm.

In addition to the palpebral insertion, the levator aponeurosis forms a wide fibrous cord that attaches to the edge of the orbit immediately behind the internal and external eyelid ligaments. They are called the inner "horn" and the outer "horn". Since they are quite rigid, during levator resection it is possible to maintain the upper eyelid in the desired position by fixing the “horn” with an instrument.

The outer “horn” is a rather powerful bundle of fibrous tissue that partially divides the inner part of the lacrimal gland into two parts. It is located below, attaching in the area of ​​the outer tubercle of the orbit to the outer ligament of the eyelid. Failure to take this anatomical feature into account when removing a lacrimal gland tumor can lead to ptosis of the lateral part of the upper eyelid. The internal "horn", on the contrary, becomes thinner, turns into a thin film that passes over the tendon of the superior oblique muscle towards the internal ligament of the eyelid and the posterior lacrimal crest.

The fibers of the levator tendon are woven into the connective tissue of the cartilaginous plate of the upper eyelid approximately at the level of its upper third. When the muscle contracts, the eyelid rises and at the same time the preaponeurotic space is shortened and the postaponeurotic space is lengthened.

Ptosis (drooping) of the upper eyelid is an uncontrolled disruption of the muscles that raise and lower the upper eyelid. Muscle weakness is expressed as a cosmetic defect in the form of asymmetry in the size of the palpebral fissures, which develops into a host of complications, including loss of vision.

The disease affects patients of any age, from newborns to pensioners. All treatment methods, including the main surgical therapy for ptosis, are aimed at increasing the tone of the eye muscles.

Blepharoptosis (drooping of the upper eyelid) is a pathology of the muscular system in which the eyelid partially or completely covers the iris or pupil, and in advanced stages, completely covers the palpebral fissure. Normally, the right and left eyelids should cover no more than 1.5-2 mm of the upper edge of the iris. If the muscles are weak, poorly innervated, or damaged, the eyelid loses control and droops below normal.

Ptosis is a disease of only the upper eyelid, since the lower eyelid lacks the levator muscle, which is responsible for lifting. There is a small Müller muscle located there, which is innervated in the cervical region and is capable of expanding the palpebral fissure by only a couple of millimeters. Therefore, with paralysis of the sympathetic nerve, which is responsible for this small muscle in the lower eyelid, ptosis will be insignificant, completely unnoticeable.

Physical obstruction of the visual field leads to a number of complications that are especially dangerous in childhood, when visual function is just developing. Ptosis in a child leads to impaired development of binocular vision.

All these complications are typical for adults, but when they appear in infant contribute to the brain's incorrect learning to make comparisons visual images. Subsequently, this will lead to the impossibility of correcting or restoring correct vision.

Classification and reasons

Muscle weakness can be acquired or congenital. Congenital ptosis of the upper eyelid is a disease of young children, its causes are underdevelopment or absence of the muscles that lift the eyelid, as well as damage to nerve centers. Congenital ptosis is characterized by bilateral damage to the upper eyelid of the right and left eyes simultaneously.

Watch an interesting video about the congenital form of the disease and treatment methods:

Unilateral lesions are characteristic of acquired ptosis. This type of ptosis develops as a complication of another, more serious pathological process.

Classification of ptosis of the upper eyelid depending on the cause of its appearance:

1. Aponeurotic blepharoptosis – excessive stretching or relaxation of muscles, loss of tone.
2. Neurogenic ptosis is a violation of the passage of nerve impulses to control muscles. Neurogenic ptosis is a symptom of a central nervous system disease; the appearance of neurology is the first signal for additional examination of brain structures.
3. Mechanical blepharoptosis is post-traumatic muscle damage, tumor growth, and scarring.
4. Age-related – the natural physiological processes of aging of the body provoke weakening and stretching of muscles and ligaments.
5. False blepharoptosis – observed with a large volume of skin folds.

Other causes of blepharoptosis in adults include:

• damage, bruises, ruptures, eye injuries;
• diseases of the nervous system or brain: stroke, neuritis, multiple sclerosis, tumors, neoplasms, hemorrhages, aneurysms, encephalopathy, meningitis, cerebral palsy;
• paresis, paralysis, ruptures, muscle weakness;
• diabetes mellitus or other endocrine diseases;
• exophthalmos;
• consequence of unsuccessful plastic surgery, Botox injections.

By stages:

• partial;
• incomplete;
• full.

Ptosis has 3 degrees, which are measured in the number of millimeters of distance between the edge of the eyelid and the center of the pupil. In this case, the patient’s eyes and eyebrows should be relaxed and in a natural position. If the location of the edge of the upper eyelid coincides with the center of the pupil, this is the equator, 0 millimeters.

Degrees of ptosis:

1. First degree – from +2 to +5 mm.
2. Second degree – from +2 to -2 mm.
3. Third degree – from –2 to –5 mm.

Symptoms of the disease

Eyelid ptosis is characterized by the main, most obvious visual symptom - drooping with a partially or completely closed palpebral fissure. At the early stage of the disease, pay attention to the symmetry of the location of the eyelids of the right and left eyes relative to the edge of the cornea.

Other manifestations of blepharoptosis:

• decreased visual acuity in one eye;
• fast fatiguability;
• astrologer pose, when the patient has to throw his head back to get a clear image;
• double vision;
• the pathological eye stops blinking, this leads to;
• the resulting pocket under the drooping eyelid contributes to the accumulation of bacteria, subsequently the development of frequent inflammation;
• double vision;
• unconsciously the patient tries to lift the upper eyelid using the brow ridges or forehead muscles;
• gradual development of strabismus.

Diagnostics

Diagnostics is aimed at identifying the root cause of the disease, purpose adequate treatment. drooping eyelid early stages hardly noticeable, but it's extremely important sign the onset of serious diseases such as a brain tumor. Therefore, it is important for the ophthalmologist to find out whether ptosis is congenital or appears suddenly. To do this, the patient is interviewed and an anamnesis is collected.

It happens that the patient has not noticed the prolapse before or cannot say exactly when it appeared. In this case, it is necessary to carry out additional examinations to exclude everything possible reasons diseases.

Stages of diagnosing blepharoptosis:

1. Visual inspection, measurement of the degree of ptosis.
2. Measurement of acuity, visual field, intraocular pressure, fundus examination.
3. Biomicroscopy of the eye.
4. Measurement of muscle tone, fold symmetry and blinking.
5. Ultrasound of the eye, electromyography.
6. Radiography.
7. MRI of the head.
8. Checking for binocular vision.
9. Examination by a neurosurgeon, neurologist, endocrinologist.

How to cure upper eyelid ptosis

It is necessary to fight ptosis only after finding out the cause. In the early stages congenital pathology in the absence of visual impairment or a small cosmetic defect, it is recommended not to treat, but to carry out comprehensive prevention.

Treatment of ptosis is divided into conservative and surgical. Conservative methods go well with homemade folk recipes.

For ptosis due to injury or nerve dysfunction, it is recommended to wait about a year after the incident. During this time effective treatment can restore all nerve connections without surgery or significantly reduce its volume.

What to do if your eyelid droops after Botox

Botox (botulinum toxin) is medicine, derived from botulinum bacteria, which disrupts the neuromuscular connection. The drug contains a neurotoxin, which in small dosages, when applied locally, attacks and kills nerve cells in the muscles, due to which they completely relax.

When using the drug in the cosmetic industry, a complication of incorrect or inaccurate administration can be ptosis of the upper eyelid after Botox injection, the treatment of which is very long. Moreover, the first few procedures can be successful, but each subsequent one requires an increase in the amount of the drug, which can lead to an overdose, as the body learns to develop immunity and antibodies to botulinum toxin.

Removing prolapse (blepharoptosis) is difficult, but possible. The first option for the simplest non-surgical treatment is to do nothing or just wait. After about 2-3 months, the body will build additional lateral branches of the nerves, which will allow it to regain control of the muscle on its own.

The second method helps to speed up this process; for this, physiotherapeutic procedures (UHF, electrophoresis, massage, darsonval, microcurrents, galvanotherapy), injections of proserine, taking large doses of B vitamins, and neuroprotectors are actively used. All this accelerates the restoration of innervation and promotes rapid resorption of Botox residues.

Operation

Surgery to correct ptosis (drooping) of the upper eyelid is called blepharoplasty. The operation is indicated in cases of advanced ptosis with impaired quality of vision. The intervention is carried out under local anesthesia outpatient. The rehabilitation period lasts about a month, during which the patient is observed by the operating surgeon.

There are many methods of operation, but the essence is the same - to shorten the relaxed muscle either by cutting and removing a part, or by folding it in half and stitching it. The cosmetic suture is hidden in a natural fold of skin, and over time it completely dissolves.

The cost of the operation depends on:

• complexity of the operation;
• stages of ptosis;
• additional research;
• the medical institution you have chosen;
• number of specialist consultations;
• number of laboratory diagnostics;
• type of anesthesia;
• accompanying pathologies.

On average, the amount per operation varies from 20 to 60 thousand rubles. You can find out the exact figure directly at your appointment, after examination by a specialist.

Watch the video to see how the operation (blepharoplasty) goes:

Home treatment

Ptosis of the upper eyelid can be treated conservatively at home. Treatment without surgery uses medications, massage, alternative medicine, physiotherapeutic procedures.

Methods for treating drooping eyelids using folk remedies:

• a mask of raw chicken eggs with sesame oil is applied to the skin once a day, washed off with warm water;
• lotions or warm compresses from infusions of chamomile, calendula, rose hips, black tea, birch leaves;
• applying “dry heat” using a cloth bag with super-fried sea salt;
• a potato mask made from grated raw potatoes is applied for 20 minutes once a day;
• a mask of honey with aloe pulp is applied 2 times a day.

Traditional medications used internally, mainly B vitamins, neuroprotectors, drugs that stimulate growth, as well as regeneration of nerve tissue, enhancing the nutrition of nerve cells. Everything is prescribed individually and depends on the stage, form, and cause of ptosis.

Physiotherapy:

• vacuum massage for ptosis of the upper eyelid;
• electrophoresis;
• warming up;
• myostimulation with currents.

All procedures and medications must be clarified and agreed upon with your attending ophthalmologist. The information on the site is for informational purposes only; do not use it as a guide to action.

Additionally, we invite you to watch a video about ptosis. Elena Malysheva will tell you in detail about the disease and ways to combat it.

17-09-2011, 13:32

Description

Sensitive innervation of the eye and orbital tissues is carried out by the first branch of the trigeminal nerve - the orbital nerve, which enters the orbit through the superior orbital fissure and is divided into 3 branches: lacrimal, nasociliary and frontal.

The lacrimal nerve innervates the lacrimal gland, the outer parts of the conjunctiva of the eyelids and eyeball, and the skin of the lower and upper eyelids.

The nasociliary nerve gives off a branch to the ciliary ganglion, 3-4 long ciliary branches go to the eyeball, in the suprachoroidal space ciliary body they form a dense plexus, the branches of which penetrate the cornea. At the edge of the cornea, they enter the middle sections of its own substance, losing their myelin coating. Here the nerves form the main plexus of the cornea. Its branches under the anterior border plate (Bowman's) form one plexus of the “closing chain” type. The stems coming from here, piercing the border plate, fold on its anterior surface into the so-called subepithelial plexus, from which branches extend, ending with terminal sensory devices directly in the epithelium.

The frontal nerve is divided into two branches: supraorbital and supratrochlear. All branches, anastomosing among themselves, innervate the middle and inner part of the skin of the upper eyelid.

Ciliary, or ciliary, the node is located in the orbit on the outside optic nerve at a distance of 10-12 mm from the posterior pole of the eye. Sometimes there are 3-4 nodes around the optic nerve. The ciliary ganglion includes sensory fibers of the nasopharynx nerve, parasympathetic fibers of the oculomotor nerve and sympathetic fibers of the plexus of the internal carotid artery.

4-6 short ciliary nerves depart from the ciliary ganglion, penetrating the eyeball through the posterior part of the sclera and supplying the eye tissue with sensitive parasympathetic and sympathetic fibers. Parasympathetic fibers innervate the sphincter of the pupil and the ciliary muscle. Sympathetic fibers go to the dilator muscle.

The oculomotor nerve innervates all the rectus muscles except the external one, as well as the inferior oblique, levator superior pallidum, sphincter pupillary muscle, and ciliary muscle.

The trochlear nerve innervates the superior oblique muscle, and the abducens nerve innervates the external rectus muscle.

The orbicularis oculi muscle is innervated by a branch facial nerve.

Adnexa of the eye

The appendage apparatus of the eye includes the eyelids, conjunctiva, tear-producing and tear-draining organs, and retrobulbar tissue.

Eyelids (palpebrae)

The main function of the eyelids is protective. The eyelids are a complex anatomical formation that includes two layers - musculocutaneous and conjunctival-cartilaginous.

The skin of the eyelids is thin and very mobile, freely gathers into folds when opening the eyelids and also freely straightens when they close. Due to mobility, the skin can easily be pulled to the sides (for example, by scars, causing eversion or inversion of the eyelids). The displaceability, mobility of the skin, the ability to stretch and move are used in plastic surgery.

Subcutaneous tissue is represented by a thin and loose layer, poor in fatty inclusions. As a result, severe swelling easily occurs here due to local inflammatory processes, and hemorrhages due to injuries. When examining a wound, it is necessary to remember about the mobility of the skin and the possibility of large displacement of the wounding object in the subcutaneous tissue.

The muscular part of the eyelid consists of the orbicularis palpebral muscle, the levator palpebrae superioris, the Riolan muscle (a narrow strip of muscle along the edge of the eyelid at the root of the eyelashes) and the Horner muscle (muscle fibers from the orbicularis muscle that surround the lacrimal sac).

The orbicularis oculi muscle consists of the palpebral and orbital bundles. The fibers of both bundles begin from the internal ligament of the eyelids - a powerful fibrous horizontal cord, which is the formation of the periosteum of the frontal process of the upper jaw. The fibers of the palpebral and orbital parts run in arcuate rows. The fibers of the orbital part in the area of ​​the outer corner pass to the other eyelid and form a complete circle. The orbicularis muscle is innervated by the facial nerve.

The muscle that lifts the upper eyelid consists of 3 parts: the anterior part is attached to the skin, the middle part is attached to the upper edge of the cartilage, and the posterior part is attached to the upper fornix of the conjunctiva. This structure ensures the simultaneous lifting of all layers of the eyelids. The anterior and posterior parts of the muscle are innervated by the oculomotor nerve, the middle by the cervical sympathetic nerve.

Behind the orbicularis oculi muscle is a dense connective tissue plate called eyelid cartilage, although it does not contain cartilage cells. The cartilage gives the eyelids a slight bulge that follows the shape of the eyeball. The cartilage is connected to the edge of the orbit by a dense tarso-orbital fascia, which serves as the topographic boundary of the orbit. The contents of the orbit include everything that lies behind the fascia.

In the thickness of the cartilage, perpendicular to the edge of the eyelids, there are modified sebaceous glands - meibomian glands. Their excretory ducts exit into the intermarginal space and are located along the posterior edge of the eyelids. The secretion of the meibomian glands prevents the overflow of tears over the edges of the eyelids, forms a lacrimal stream and directs it into the lacrimal lake, protects the skin from maceration, and is part of the precorneal film that protects the cornea from drying out.

The blood supply to the eyelids is carried out from the temporal side by branches from the lacrimal artery, and from the nasal side - from the ethmoid artery. Both are terminal branches of the ophthalmic artery. The greatest accumulation of eyelid vessels is located 2 mm from its edge. This must be taken into account during surgical interventions and injuries, as well as the location of the muscle bundles of the eyelids. Considering the high displacement capacity of eyelid tissues, minimal removal of damaged areas during primary surgical treatment is desirable.

The outflow of venous blood from the eyelids goes to the superior ophthalmic vein, which has no valves and anastomoses through the angular vein with the cutaneous veins of the face, as well as with the veins of the sinuses and pterygopalatine fossa. The superior orbital vein leaves the orbit through the superior orbital fissure and flows into the cavernous sinus. Thus, an infection from the skin of the face and sinuses can quickly spread to the orbit and into the cavernous sinus.

The regional lymph node of the upper eyelid is lymph node, and the lower one - submandibular. This must be taken into account during the spread of infection and metastasis of tumors.

Conjunctiva

The conjunctiva is the thin mucous membrane that lines the back surface of the eyelids and the front surface of the eyeball up to the cornea. The conjunctiva is a mucous membrane richly supplied with vessels and nerves. She easily responds to any irritation.

The conjunctiva forms a slit-like cavity (bag) between the eyelid and the eye, which contains the capillary layer of tear fluid.

In the medial direction, the conjunctival sac reaches the inner corner of the eye, where the lacrimal caruncle and the semilunar fold of the conjunctiva (vestigial third eyelid) are located. Laterally, the border of the conjunctival sac extends beyond the outer corner of the eyelids. The conjunctiva performs protective, moisturizing, trophic and barrier functions.

There are 3 sections of the conjunctiva: the conjunctiva of the eyelids, the conjunctiva of the fornix (upper and lower) and the conjunctiva of the eyeball.

The conjunctiva is a thin and delicate mucous membrane, consisting of a superficial epithelial and deep submucosal layer. The deep layer of the conjunctiva contains lymphoid elements and various glands, including lacrimal glands, which provide mucin and lipids for the superficial tear film covering the cornea. Additional lacrimal glands Krause are located in the conjunctiva of the superior fornix. They are responsible for the constant production of tear fluid in ordinary, non- extreme conditions. Glandular formations can become inflamed, which is accompanied by hyperplasia of lymphoid elements, an increase in glandular discharge and other phenomena (folliculosis, follicular conjunctivitis).

The conjunctiva of the eyelids (tun. conjunctiva palpebrarum) is moist, pale pinkish in color, but quite transparent, through it you can see the translucent glands of the cartilage of the eyelids (meibomian glands). The surface layer of the conjunctiva of the eyelid is lined with multirow columnar epithelium, which contains a large number of goblet cells that produce mucus. Under normal physiological conditions there is little of this mucus. Goblet cells respond to inflammation by increasing their numbers and increasing secretion. When the conjunctiva of the eyelid becomes infected, the goblet cell discharge becomes mucopurulent or even purulent.

In the first years of life in children, the conjunctiva of the eyelids is smooth due to the absence of adenoid formations here. With age, you observe the formation of focal accumulations of cellular elements in the form of follicles, which determine special forms follicular lesions of the conjunctiva.

An increase in glandular tissue predisposes to the appearance of folds, depressions and elevations that complicate the surface relief of the conjunctiva, closer to its arches; in the direction of the free edge of the eyelids, the folding is smoothed out.

Conjunctiva of the fornix. In the fornix (fornix conjunctivae), where the conjunctiva of the eyelids passes into the conjunctiva of the eyeball, the epithelium changes from multilayered cylindrical to multilayered flat.

Compared to other sections in the vault area, the deep layer of the conjunctiva is more pronounced. Numerous glandular formations are well developed here, including small additional lacrimal jelly (Krause's glands).

Under the transitional folds of the conjunctiva there is a pronounced layer of loose fiber. This circumstance determines the ability of the conjunctiva of the fornix to easily fold and straighten, which allows the eyeball to maintain full mobility.

Cicatricial changes in the conjunctival fornix limit eye movements. Loose fiber under the conjunctiva contributes to the formation of edema here during inflammatory processes or congestive vascular phenomena. The upper conjunctival fornix is ​​wider than the lower one. The depth of the first is 10-11 mm, and the second - 7-8 mm. Typically, the superior fornix of the conjunctiva extends beyond the superior orbitopalpebral groove, and the inferior fornix is ​​at the level of the inferior orbitopalpebral fold. In the upper outer part of the upper fornix, pinholes are visible, these are the mouths of the excretory ducts of the lacrimal gland

Conjunctiva of the eyeball (conjunctiva bulbi). It distinguishes between a movable part, covering the eyeball itself, and a part of the limbus region, fused to the underlying tissue. From the limbus, the conjunctiva passes to the anterior surface of the cornea, forming its epithelial, optically completely transparent layer.

The genetic and morphological similarity of the epithelium of the conjunctiva of the sclera and cornea determines the possibility of transition pathological processes from one part to another. This occurs with trachoma even in its initial stages, which is essential for diagnosis.

In the conjunctiva of the eyeball, the adenoid apparatus of the deep layer is poorly represented; it is completely absent in the cornea area. The stratified squamous epithelium of the conjunctiva of the eyeball is non-keratinizing and under normal physiological conditions retains this property. The conjunctiva of the eyeball is much more abundant than the conjunctiva of the eyelids and fornix, equipped with sensitive nerve endings (the first and second branches of the trigeminal nerve). In this regard, even small foreign bodies or chemical substances causes a very unpleasant feeling. It is more significant with inflammation of the conjunctiva.

The conjunctiva of the eyeball is not connected to the underlying tissues in the same way everywhere. Along the periphery, especially in the upper outer part of the eye, the conjunctiva lies on a layer of loose tissue and here it can be freely moved with an instrument. This circumstance is used when performing plastic surgeries when moving sections of the conjunctiva is required.

Along the perimeter of the limbus, the conjunctiva is fixed quite firmly, as a result of which, with significant swelling, a vitreous shaft is formed in this place, sometimes hanging over the edges of the cornea.

The vascular system of the conjunctiva is part of the general circulatory system of the eyelids and eyes. The main vascular distributions are located in its deep layer and are represented mainly by links of the microcircular network. Many intramural blood vessels The conjunctiva ensures the vital activity of all its structural components.

By changing the pattern of blood vessels in certain areas of the conjunctiva (conjunctival, pericorneal and other types of vascular injections), differential diagnosis of diseases associated with the pathology of the eyeball itself and diseases of purely conjunctival origin is possible.

The conjunctiva of the eyelids and eyeball is supplied with blood from the arterial arches of the upper and lower eyelids and from the anterior ciliary arteries. The arterial arches of the eyelids are formed from the lacrimal and anterior ethmoidal arteries. The anterior ciliary vessels are branches of the muscular arteries that supply blood to the external muscles of the eyeball. Each muscular artery gives off two anterior ciliary arteries. An exception is the artery of the external rectus muscle, which gives off only one anterior ciliary artery.

These vessels of the conjunctiva, the source of which is the ophthalmic artery, belong to the system of the internal carotid artery. However, the lateral arteries of the eyelids, from which branches supplying part of the conjunctiva of the eyeball arise, anastomose with the superficial temporal artery, which is a branch of the external carotid artery.

The blood supply to most of the conjunctiva of the eyeball is carried out by branches originating from the arterial arches of the upper and lower eyelids. These arterial branches and the accompanying veins form conjunctival vessels, which in the form of numerous stems go to the conjunctiva of the sclera from both anterior folds. The anterior ciliary arteries of the scleral tissue run above the area of ​​attachment of the rectus tendons towards the limbus. 3-4 mm from it, the anterior ciliary arteries are divided into superficial and perforating branches, which penetrate through the sclera into the eye, where they participate in the formation of the large arterial circle of the iris.

The superficial (recurrent) branches of the anterior ciliary arteries and the accompanying venous trunks are the anterior conjunctival vessels. The superficial branches of the conjunctival vessels and the posterior conjunctival vessels anastomosing with them form the superficial (subepithelial) body of the vessels of the conjunctiva of the eyeball. This layer contains the greatest number of elements of the microcircular bed of the bulbar conjunctiva.

The branches of the anterior ciliary arteries, anastomosing with each other, as well as the tributaries of the anterior ciliary veins form the marginal circumference of the limbus, or the perilimbal vascular network of the cornea.

Lacrimal organs

The lacrimal organs consist of two separate topographically distinct departments, namely the tear-producing and lacrimal-discharge parts. The tear performs protective (washes out foreign elements from the conjunctival sac), trophic (nourishes the cornea, which does not have its own vessels), bactericidal (contains nonspecific factors immune defense- lysozyme, albumin, lactoferin, b-lysine, interferon), moisturizing functions (especially the cornea, maintaining its transparency and being part of the precorneal film).

Tear-producing organs.

Lacrimal gland (glandula lacrimalis) in its anatomical structure it is very similar to the salivary glands and consists of many tubular glands, collected in 25-40 relatively separate lobules. The lacrimal gland, by the lateral portion of the aponeurosis of the muscle that lifts the upper eyelid, is divided into two unequal parts, the orbital and palpebral, which communicate with each other by a narrow isthmus.

The orbital part of the lacrimal gland (pars orbitalis) is located in the upper outer part of the orbit along its edge. Its length is 20-25 mm, diameter is 12-14 mm and thickness is about 5 mm. In shape and size it resembles a bean, which is attached convex surface to the periosteum of the lacrimal fossa. The gland is covered in front by the tarso-orbital fascia, and in the back it is in contact with the orbital tissue. The gland is held in place by connective tissue cords stretched between the gland capsule and the periorbita.

The orbital part of the gland is usually not palpable through the skin, since it is located behind the bony edge of the orbit that hangs here. When the gland enlarges (for example, tumor, swelling or prolapse), palpation becomes possible. The lower surface of the orbital part of the gland faces the aponeurosis of the muscle that lifts the upper eyelid. The consistency of the gland is soft, the color is grayish-red. The lobules of the anterior part of the gland are closed more tightly than in its posterior part, where they are loosened by fatty inclusions.

3-5 excretory ducts of the orbital part of the lacrimal gland pass through the substance of the inferior lacrimal gland, receiving part of its excretory ducts.

Palpebral or secular part The lacrimal gland is located somewhat anteriorly and below the superior lacrimal gland, directly above the superior fornix of the conjunctiva. When the upper eyelid is inverted and the eye is turned inward and downward, the lower lacrimal gland is normally visible in the form of a slight protrusion of a yellowish tuberous mass. In the case of inflammation of the gland (dacryoadenitis), a more pronounced bulge is found in this place due to swelling and compaction of the glandular tissue. The increase in the mass of the lacrimal gland can be so significant that it sweeps away the eyeball.

The lower lacrimal gland is 2-2.5 times smaller than the upper lacrimal gland. Its longitudinal size is 9-10 mm, transverse - 7-8 mm and thickness - 2-3 mm. The anterior edge of the inferior lacrimal gland is covered with conjunctiva and can be palpated here.

The lobules of the lower lacrimal gland are loosely connected to each other, its ducts partly merge with the ducts of the upper lacrimal gland, some open into the conjunctival sac independently. Thus, there are a total of 10-15 excretory ducts of the upper and lower lacrimal glands.

The excretory ducts of both lacrimal glands are concentrated in one small area. Scar changes in the conjunctiva in this place (for example, with trachoma) may be accompanied by obliteration of the ducts and lead to a decrease in the lacrimal fluid secreted into the conjunctival sac. The lacrimal gland comes into action only in special cases when a lot of tears are needed (emotions, foreign agents entering the eye).

In normal condition, to perform all functions, 0.4-1.0 ml of tears produce small accessory lacrimal glands Krause (20 to 40) and Wolfring (3-4), embedded in the thickness of the conjunctiva, especially along its upper transitional fold. During sleep, tear secretion slows down sharply. Small conjunctival lacrimal glands, located in the boulevard conjunctiva, provide the production of mucin and lipids necessary for the formation of the precorneal tear film.

Tear is a sterile, clear, slightly alkaline (pH 7.0-7.4) and somewhat opalescent liquid, consisting of 99% water and approximately 1% organic and inorganic parts (mainly sodium chloride, but also sodium carbonates and magnesium, calcium sulfate and phosphate).

At different emotional manifestations The lacrimal glands, receiving additional nerve impulses, produce excess fluid that drains from the eyelids in the form of tears. There are persistent disturbances in tear secretion towards hyper- or, conversely, hyposecretion, which is often a consequence of pathology of nerve conduction or excitability. Thus, tear production decreases with paralysis of the facial nerve (VII pair), especially with damage to its geniculate ganglion; trigeminal nerve palsies (V pair), as well as in some poisonings and severe infectious diseases With high temperature. Chemical, painful temperature irritations of the first and second branches of the trigeminal nerve or zones of its innervation - conjunctiva, anterior parts of the eye, nasal mucosa, hard meninges accompanied by profuse tearing.

The lacrimal glands have sensitive and secretory (vegetative) innervation. General sensitivity of the lacrimal glands (provided by the lacrimal nerve from the first branch of the trigeminal nerve). Secretory parasympathetic impulses are delivered to the lacrimal glands by fibers of the intermediate nerve (n. intermedrus), which is part of the facial nerve. Sympathetic fibers to the lacrimal gland originate from the cells of the superior cervical sympathetic ganglion.

Lacrimal ducts.

They are designed to drain tear fluid from the conjunctival sac. Tear as an organic liquid ensures normal vital activity and function anatomical formations composing the conjunctival cavity. The excretory ducts of the main lacrimal glands open, as mentioned above, into the lateral section of the upper fornix of the conjunctiva, which creates a semblance of a lacrimal “shower”. From here, the tear spreads throughout the conjunctival sac. The posterior surface of the eyelids and the anterior surface of the cornea limit the capillary gap - the lacrimal stream (rivus lacrimalis). By moving the eyelids, the tear moves along the tear stream towards the inner corner of the eye. Here is the so-called lacrimal lake (lacus lacrimalis), limited by the medial areas of the eyelids and the semilunar fold.

The lacrimal ducts themselves include lacrimal openings (punctum lacrimale), lacrimal canaliculi (canaliculi lacrimales), lacrimal sac (saccus lacrimalis), and nasolacrimal duct (ductus nasolacrimalis).

Lacrimal puncta(punctum lacrimale) are the initial openings of the entire lacrimal apparatus. Their normal diameter is about 0.3 mm. The lacrimal puncta are located at the top of small conical projections called lacrimal papillae (papilla lacrimalis). The latter are located on the posterior ribs of the free edge of both eyelids, the upper one is approximately 6 mm, and the lower one is 7 mm from their internal commissure.

The lacrimal papillae face the eyeball and are almost adjacent to it, while the lacrimal puncta are immersed in the lacrimal lake, at the bottom of which lies the lacrimal caruncle (caruncula lacrimalis). Close contact of the eyelids, and therefore the lacrimal openings with the eyeball, is facilitated by constant tension of the tarsal muscle, especially its medial sections.

The holes located at the top of the lacrimal papillae lead into the corresponding thin tubes - superior and inferior lacrimal canaliculi. They are located entirely in the thickness of the eyelids. In direction, each tubule is divided into a short oblique vertical and a longer horizontal part. The length of the vertical sections of the lacrimal canaliculi does not exceed 1.5-2 mm. They run perpendicular to the edges of the eyelids, and then the tear ducts turn towards the nose, taking a horizontal direction. The horizontal sections of the tubules are 6-7 mm long. The lumen of the lacrimal canaliculi is not the same throughout. They are somewhat narrowed in the bending area and ampullarly widened at the beginning of the horizontal section. Like many other tubular formations, the lacrimal canaliculi have a three-layer structure. The outer, adventitial membrane is composed of delicate, thin collagen and elastic fibers. The middle muscular layer is represented by a loose layer of bundles of smooth muscle cells, which apparently play a certain role in regulating the lumen of the tubules. The mucous membrane, like the conjunctiva, is lined with columnar epithelium. This arrangement of the lacrimal canaliculi allows them to stretch (for example, under mechanical influence - the introduction of conical probes).

The terminal sections of the lacrimal canaliculi, each individually or merging with each other, open into the upper section of a wider reservoir - the lacrimal sac. The mouths of the lacrimal canaliculi usually lie at the level of the medial commissure of the eyelids.

Lacrimal sac(saccus lacrimale) makes up the upper, expanded part of the nasolacrimal duct. Topographically, it relates to the orbit and is located in its medial wall in the bone recess - the fossa of the lacrimal sac. The lacrimal sac is a membranous tube 10-12 mm long and 2-3 mm wide. Its upper end ends blindly; this place is called the vault of the lacrimal sac. In the downward direction, the lacrimal sac narrows and passes into the nasolacrimal duct. The wall of the lacrimal sac is thin and consists of a mucous membrane and a loose submucosal layer connective tissue. The inner surface of the mucous membrane is lined with multirow columnar epithelium with a small number of mucous glands.

The lacrimal sac is located in a kind of triangular space formed by various connective tissue structures. The sac is limited medially by the periosteum of the lacrimal fossa, covered in front by the internal ligament of the eyelids and the tarsal muscle attached to it. The tarso-orbital fascia runs behind the lacrimal sac, as a result of which it is believed that the lacrimal sac is located preseptally, in front of the septum orbitale, i.e., outside the orbital cavity. In this regard, purulent processes of the lacrimal sac extremely rarely give complications to the tissues of the orbit, since the sac is separated from its contents by a dense fascial septum - a natural obstacle to infection.

In the area of ​​the lacrimal sac, under the skin of the internal angle, there is a large and functional important vessel- angular artery (a.angularis). It is a link between the external and internal systems carotid arteries. The angular vein is formed at the inner corner of the eye, which then continues into the facial vein.

Nasolacrimal duct(ductus nasolacrimalis) is a natural continuation of the lacrimal sac. Its length is on average 12-15 mm, width 4 mm, the duct is located in the bone canal of the same name. General direction channel - from top to bottom, from front to back, from outside to inside. The course of the nasolacrimal duct varies somewhat depending on the width of the nasal bridge and pear-shaped opening skulls

Between the wall of the nasolacrimal duct and the periosteum of the bone canal there is a densely branched network venous vessels, this is a continuation of the cavernous tissue of the inferior turbinate. Venous formations are especially developed around the mouth of the duct. Increased blood filling of these vessels as a result of inflammation of the nasal mucosa causes temporary compression of the duct and its outlet, which prevents tears from moving into the nose. This phenomenon is well known to everyone as lacrimation during an acute runny nose.

The mucous membrane of the duct is lined with two-layer columnar epithelium; small branched tubular glands are found here. Inflammatory processes and ulceration of the mucous membrane of the nasolacrimal duct can lead to scarring and its persistent narrowing.

The lumen of the outlet end of the nasolacrimal duct has slit-shaped: its opening is located in front of the lower nasal passage, 3-3.5 cm away from the entrance to the nose. Above this opening there is a special fold called the lacrimal fold, which represents a duplication of the mucous membrane and prevents the reverse flow of tear fluid.

In the prenatal period, the mouth of the nasolacrimal duct is closed by a connective tissue membrane, which resolves by the time of birth. However, in some cases, this membrane may persist, which requires urgent measures to remove it. Delay threatens the development of dacryocystitis.

The tear fluid, irrigating the front surface of the eye, partially evaporates from it, and the excess collects in the tear lake. The mechanism of tear production is closely related to the blinking movements of the eyelids. The main role in this process is attributed to the pump-like action of the lacrimal canaliculi, the capillary lumen of which, under the influence of the tone of their intramural muscular layer associated with the opening of the eyelids, expands and sucks in fluid from the lacrimal lake. When the eyelids close, the canaliculi are compressed and the tear is squeezed into the lacrimal sac. Of no small importance is the suction effect of the lacrimal sac itself, which during blinking movements alternately expands and contracts due to the traction of the medial ligament of the eyelids and the contraction of part of their circular muscle, known as Horner’s muscle. Further outflow of tears along the nasolacrimal duct occurs as a result of the expelling action of the lacrimal sac, and also partly under the influence of gravity.

The passage of tear fluid through the lacrimal ducts in normal conditions lasts about 10 minutes. Approximately this amount of time is required for (3% collargol, or 1% fluorecein) from the lacrimal lake to reach the lacrimal sac (5 minutes - canalicular test) and then the nasal cavity (5 minutes - positive nasal test).

- (m. levator palpebrae superioris, PNA, BNA, JNA) see List of anat. terms... Large medical dictionary

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