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Fig. 1.4 Practical instruction—an experienced OR assistant explains the instruments to the aspiring surgeons
51 Introduction
Fig. 1.5 By taking on the position of the assistant staff, the aspiring surgeon can gain a good overview of the instruments and medical products used
6 F. Wilhelm and S. Priglinger
At this point, the partnership between surgeons
and industry should be remembered, which has
made the development and technical foundations
of many new surgical procedures possible in the
first place. Only through this has the care of our
patients continuously improved over the past
decades. By consistently adhering to the code
guidelines, this partnership still exists today.
Every beginner who maintains this will recognize its special value!
In the contributions, the individual authors
of the respective chapters have tried to establish
guidelines whose adherence has proven itself
many times over. It cannot be ruled out that
there are deviations in the procedure, i.e., that
the mentor proceeds differently, as his personal
experiences have shown, and that it is specified
differently in the training institution.
For the operations to be treated in detail, both
the traditional “beginner operations” such as
small eyelid surgical procedures, pterygium, and
enucleation, as well as the intravitreal injection
required by the new specialist training regulations and cataract surgery as the domain of ophthalmic surgery were selected.
References and Further Reading
1. Bartisch G (1908) Das ist Augendienst. Dresden
1583. In: Graefe-Saemisch, Handbuch der gesamten Augenheilkunde. vol. 13: Julius Hirschberg,
Geschichte der Augenheilkunde im Mittelalter und in
der Neuzeit, Lpz., W. Engelmann, 2. ed. 546 S., p 338
2. Blaskovics-Kettesy A (1970) Eingriffe am Auge. Enke,
Stuttgart, pp 2–3
3. Deutsche Ophthalmologische Gesellschaft (2012)
Empfehlungen zur Qualitätssicherung operativer
Eingriffe in der Augenheilkunde
4. Eisner G (1978) Augenchirurgie. Einführung in die
operative Technik. Springer, Berlin
5. Höting H (1993) Aktiv und gesund durch die magischen
Quigong-Kugeln aus China. Dt. Spurbuchverl., p 46 S
6. Kuhn F (2016) Vitreoretinal surgery: strategies and
tactics. Springer, Berlin
7. Velhagen K (1964) Propädeutische augenärztliche
Operationslehre. VEB Georg Thieme, Leipzig, pp 3–7
Topographical and Clinical Anatomy for Ophthalmic Surgeons
Jochen Fanghänel and Thomas Koppe
Contents
2.1 Introduction................................................... 7
2.2 Orbital Bone (Orbit) ............................................ 8
2.3 Eyelids (Palpebrae)............................................. 12
2.4 Lacrimal Gland (Glandula lacrimalis) and Tear Drainage System......... 17
2.5 Conjunctiva (Conjunctiva, Tunica conjunctiva) ....................... 18
2.6 Cornea (Cornea) ............................................... 19
2.7 Eyeball (Bulbus oculi) and Eye Membranes ......................... 19
2.8 Orbital Levels and Compartments ................................. 24
References and Further Reading ....................................... 30
2
2.1 Introduction
The anatomist Tiedemann summarized in 1754,
“Doctors without anatomy are like moles. They
work in the dark, and their hands’ day’s work
are mounds of earth.” This saying shows the
importance of anatomy! It is a science for the
study of the structure and organization of the
Prof. Fanghänel unfortunately passed away during the
production of the English translation of this title. We are
grateful for his valuable contribution.
J. Fanghänel
Universitätsmedizin Greifswald, Poliklinik für
Kieferorthopädie, Greifswald, Germany
T. Koppe ()
Institut für Anatomie und Zellbiologie,
Universitätsmedizin Greifswald, Greifswald,
Germany
e-mail: thokoppe@uni-greifswald.de
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_2
organism and is above all the foundation of all
medical actions. Secured knowledge and understanding of the structure of the human body
create the prerequisite for recognizing, understanding, and ultimately treating changes caused
by various circumstances and causes. In this
regard, the operating ophthalmologist is particularly challenged to grasp the complicated and
specific structures of the eye to ensure optimal
treatment. Ultimately, it is about preserving or
restoring function; in addition, the preservation
of aesthetics of the face presents great challenges to the ophthalmic surgeon. Let us just
look at the head of the ancient Egyptian queen
Nefertiti, to see what significant contributions
the eyes make to facial morphology!
This chapter is intended to serve as a guide for
the surgeon in planning and performing procedures to prevent unexpected courses and complications. Structures that are less in the focus of the
operating ophthalmologist were not considered.
7
8 J. Fanghänel and T. Koppe
palpebrales of A. lacrimalis
amus lateralis nasi of A. facialis
Ramus
A. supraorbitalis
Ramus temporalis of
N. facialis
Ramus frontalis of
A. temporalis supercialis
A. zygomaticoorbitalis
Lateral palpebral aa.
Inferior arcus palpebralis
Rami zygomatici of
N. facialis
Fig. 2.1 Right orbital region with muscles and conduits. (From [23])
lateralis
N. supraorbitalis
Ramus
medialis
Arcus palpebralis superioris
A. and N. supratrochlearis
Medial palpebral aa.
Rami palpebrales of
N. infratrochlearis
A. and V. angularis
A. dorsalis nasi
Ramus nasalis externus of
N. ethmoidalis anterior
R
Rami palpebrales inferiores of
N. infraorbitalis
region and is characterized by the aditus orbitae
and the eyelids with their muscular foundation,
the M. orbicularis oculi. It has a rich sensory supply through branches of the N. ophthalmicus and
N. maxillaris (Fig. 2.1). At the medial third of the
upper orbital margin, the skin branches of the N.
supraorbitalis are found, at the inner canthus the
Nn. supra- and infratrochlearis, and at the lateral
orbital margin the skin branches of the N. lacrimalis, all parts of the N. ophthalmicus. The lower
orbital margin is finally innervated by branches of
the N. infraorbitalis (N. maxillaris).
region are provided by the A./V. temporalis superficialis (lateral orbital margin and lateral sections
of the upper orbital margin), branches of the A./V.
frontalis (central and medial third of the upper
orbital margin), the A./V. supratrochlearis (nasal
orbital margin), the A./V. infraorbitalis, and the
A./V. transversa faciei (lower orbital margin).
the orbital region is divided into two parts. The
nasal parts of the orbital margin drain to the Nll.
submandibulares and the lateral parts to the Nll.
parotidei superficiales et profundi.
At the nasal orbital margin, there is an
Orbital region: It belongs to the anterior facial
The arterial and venous supply of the orbital
The superficial lymphatic drainage from
anastomosis between branches of the A./V.
facialis and branches of the A./V. angularis.
The venous connection represents a potential infection gateway for ascending infections via the V. ophthalmica superior up to
the sinus cavernosus.
2.2 Orbital Bone (Orbit)
The orbit has a basic shape that resembles a
four-sided pyramid. While the apex of this pyramid lies in the canalis opticus, its base forms the
aditus orbitae (Fig. 2.2a). Its total volume is 24
to 27 cm3.
Aditus orbitae: The bony edges of the aditus
orbitae are formed by the os frontale, os lacrimale, the maxilla, and the os zygomaticum. The
aditus orbitae is about 32–35 mm high and about
40 mm wide, with a total area of 1178 mm
adults, there are is sometimes pronounced gender differences sexual dimorphism in the shape
and size of the aditus orbitae. While the basic
shape in men is more rectangular, it appears circular to transversely oval in women. The shape
of the aditus orbitae is largely genetically determined and is suitable for kinship studies. In most
cases, the (left) lower orbital margin is lower
than the right. With the exception of the nasal
edge of the aditus orbitae, the edges of the aditus
orbitae are sharp-edged. Above the sharp-edged
2
. In
a
Frontozygomatic suture
Sphenozygomatic Suture
b
92 Topographical and Clinical Anatomy …
Frontomaxillaris suture
Frontolacrimalis suture
Suture ethmoidolacrimalis
Infraorbital foramen
Fig. 2.2 Walls of the orbit. a View from the front. b View from the side. (From [23])
margo supraorbitalis, there is a more or less pronounced arcus supraciliaris, especially in men.
The formation of the medial, rather shallow orbital rim involves the frontal process of
the maxilla, the frontal bone, and, with variable involvement, the lacrimal bone. The frontal process of the maxilla features a bony ridge,
the anterior lacrimal crest, at the entrance to
the nasolacrimal canal. In the medial third of
the supraorbital margin is the supraorbital foramen, which can sometimes be divided. In many
cases, a palpable supraorbital notch can be
observed instead of the supraorbital foramen
(passage point for the supraorbital nerve and
artery, and vein). In some cases (2–4%), an isolated frontal foramen appears as a passage point
for the supratrochlear nerve. The distance from
the supraorbital foramen to the midpoint of the
10 J. Fanghänel and T. Koppe
superior orbital fissure is generally 45.7 mm
[16].
Below the infraorbital margin lies the infraorbital foramen (Fig. 2.2a) as the facial opening of
the infraorbital canal. It can be oval, crescentshaped, or round. Sometimes it is overlapped
by a bony lingula. The infraorbital foramen is
located about 6 mm caudal to the lower orbital
rim. The distance between the infraorbital foramen and the median plane is 25 to 27 mm. The
supraorbital, infraorbital, and mental foramina
represent the trigeminal pressure points. They lie
on an imaginary vertical line.
2.2.1 Walls of the Orbit
Orbital roof, superior wall (Tables 2.1 and
2.2): The orbital roof is mostly formed by the
frontal bone and to a small extent by parts of
the lesser wing of the sphenoid bone. It is relatively thin, being about 3 mm thick in the area
of the lesser wing. Depending on the extent of
the frontal sinus, it is more or less completely
pneumatized. The orbital roof directly borders
the anterior cranial fossa. It slopes slightly laterally and has a shallow fossa in the lateral third
(Sect. 5.1) for the accommodation of the lacrimal gland. In the medial anterior orbital rim,
about 5 mm behind the supraorbital margin, is
the trochlear fossa, which contains the trochlea.
Lateral wall of the orbit, Paries lateralis: It
is comparatively thick and is composed of the
frontal bone and the zygomatic bone in the front
and parts of the greater wing of the sphenoid
Table 2.1 Walls and neighboring relationships of the
orbit
Walls Neighboring relationships
Orbital roof Anterior cranial fossa
Frontal lobe
Orbital floor Maxillary sinus
Lateral orbital wall Pterygopalatine fossa
Medial orbital wall Nasal cavity
Ethmoidal cells
Apex of the orbit Middle cranial fossa
Temporal lobe
bone in the rear. The lateral wall borders the
temporal fossa and the middle cranial fossa. At
the border between the upper and lateral orbital
wall is the superior orbital fissure (length 20
mm) (Fig. 2.2a). It communicates with the middle cranial fossa. In the orbital part of the zygomatic bone lies the zygomaticoorbital foramen,
which carries branches of the zygomatic nerve
to the face. At the border between the lateral
and lower wall of the orbit is the inferior orbital
fissure (length 29 mm) with connections to the
infratemporal fossa and pterygopalatine fossa.
Floor of the orbit, Paries inferior: The floor
(Fig. 2.2a) is formed by the orbital plate of the
maxilla, an extremely thin bony lamella (thickness about 0.5 mm), which can give way in
blunt trauma as a “locus minoris resistenciae”
and thus result in a “blow-out fracture”.
Any patient with orbital fractures should
refrain from blowing their nose.
The floor slopes slightly downward laterally
and borders directly on the maxillary sinus. The
term blow-out fracture generally refers to the
orbital floor. It is so common because the roof
of the maxillary sinus has unfavorable resistance. Although the medial wall (lamina papyracea) is much thinner, the pressures arising here
are much better dissipated and cushioned by the
honeycomb-like ethmoid bone, so fractures are
somewhat less common here!
The inferior wall of the orbit contains a bony
groove, the infraorbital sulcus , which transitions
into the infraorbital canal and opens into the
infraorbital foramen. In rare cases, the infraorbital canal begins directly at the inferior orbital
fissure. The total length of the infraorbital sulcus
and canal is approximately 27 to 29 mm.
Medial wall of the orbit, Paries medialis: The
medial orbital wall (Fig. 2.2b) is formed from
anterior to posterior by parts of the maxilla, the
lacrimal bone, the ethmoid bone, and the lesser
wing of the sphenoid bone, and it also borders
the sphenoid body at the back. It has a length
of approximately 45 to 50 mm and is extremely
112 Topographical and Clinical Anatomy …
thin in places. The lesser wing contains the optic
canal. At the boundary between the orbital plate
of the ethmoid bone and the frontal bone are
the ethmoidal foramina. The paper-thin orbital
plate of the ethmoid bone is also known as the
lamina papyracea (length 14.7 mm, thickness
0.3 mm), which makes it particularly suitable
for opening during procedures on the nasolacrimal ducts. The distance between the two ethmoidal foramina is given as 13 mm. Occasionally,
an accessory ethmoidal foramen appears. The
larger anterior ethmoidal foramen (diameter
1.5–2 mm) is located about 14–18 mm behind
the anterior orbital margin and 23 mm behind
the so-called nasomaxillofrontal. Approximately
4–7 mm behind the posterior ethmoidal foramen
is the optic canal (Fig. 2.2b), while the center of
the superior orbital fissure is located about 15
mm behind the posterior ethmoidal foramen. In
the anterior lower part of the medial wall of the
orbit lies the lacrimal fossa between the anterior
lacrimal crest (maxilla) and the posterior lacrimal
crest (lacrimal bone). It opens downward into the
nasal opening of the nasolacrimal canal (Fig. 2.3).
2.2.2 Orbital Relationships
The orbit directly borders the following structures and regions, which are particularly important for understanding fractures and the spread
of infections (see Table 2.2). The orbital region
is considered a prime example of an area requiring interdisciplinary care.
The periorbita and orbital septum are
important physiological (anatomical) barriers to infections. Postseptal spread of infection can lead to the highly feared orbital
phlegmon!
Clinically significant foramina and fissures (see
Table 2.2, Fig. 2.2a, b)
the
Fig. 2.3 Overview of the tear drainage pathways. Right eye. (From [23])
Lacrimal canaliculi
Nasi lower shell
12 J. Fanghänel and T. Koppe
Table 2.2 Foramina, Fissures, and Connections of the Orbit
Connections of the orbit
Fossa cranii media
Canalis opticus N. opticus (I)
Fissura orbitalis superior N. oculomotorius (III)
Fossa pterygopalatina, Fossa infratemporalis
Fissura orbitalis inferior N. zygomaticus (V2)
Gesicht
Canalis infraorbitalis—Foramen infraorbitale N. infraorbitalis (V2)
Foramen supraorbitale/Inciusura supraorbitalis N. supraorbitalis, R. lateralis (V1)
Incisura frontalis N. supraorbitalis, R. medialis (V1)
Cellule ethmoidales—Cavitas nasi—Fossa cranii anterior
Foramen ethmoidale anterius N. ethmoidalis anterior (V1)
Foramen ethmoidale anterius N. ethmoidalis posterior (V1)
Meatus nasi inferior
Canalis nasolacrimalis Ductus nasolacrimalis
A. ophthalmica
N. trochlearis (IV)
N. abducens (VI)
N. ophthalmicus (V1)
V. ophthalmica superior
N. infraorbitalis (V2)
A. infraorbitalis
V. ophthalmica inferior
A. infraorbitalis
A. supraorbitalis
V. supraorbitalis
A. supratrochelaris
A., V. ethmoidalis anterior
A./V. ethmoidalis posterior
Periorbita and Orbital Septum The orbit is lined
by a periosteum, the periorbita (Fig. 2.4). It also
lines the various foramina and fissures of the
orbit, thereby communicating in part with the
dura mater. The periorbita transitions anteriorly
at the orbital margins into a frontally oriented
connective tissue plate, the orbital septum. The
orbital septum is fused at the orbital margins and
serves as an attachment for the eyelids (Chap. 4).
The orbit is traversed by the nerves and vessels
that extend to the face (Table 2.2). The periorbita
and orbital septum are important physiological
barriers to infections (e.g., orbital cellulitis).
In the case of a blow out fracture, the
orbital roof, the orbital floor, and the medial
wall of the orbit are particularly at risk.
However, the most common occurrence is
a breach in the lower wall. In complex Le
Fort fractures and skull base fractures, the
orbit is often involved. Any patients with
orbital fractures should refrain from blowing their nose, as this can lead to a dangerous intraorbital emphysema [11].
2.3 Eyelids (Palpebrae)
Eyelids are movable skin folds that serve for
light protection, protection against drying out,
and mechanical protection. The larger upper
eyelid, palpebra superior, and the smaller lower
eyelid, palpebra inferior, connect medially and
laterally with each other. Thus, they enclose the
light slit (Rima palpebrarum), resulting in an
inner (nasal) and an outer (temporal) canthus
(Figs. 2.4 and 2.6).
The front surface of the eyelids consists of
multi-layered keratinized squamous epithelium
of the outer skin (epidermis). It is low in fat and
Fig. 2.4 Sagittal section through the orbit, eyeball, and optic nerve. (From [23])
a
132 Topographical and Clinical Anatomy …
Upper Tarsus
Lower Tarsus
b
Upper Tarsus
Lower Tarsus
sides
Fig. 2.5 Orbital entrance with eyelid support apparatus. (a) Orbital septum, tarsal plates, and eyelid liga-
ments, (b) lacrimal gland. (From [23])
14 J. Fanghänel and T. Koppe
Fig. 2.6 Sagittal section through the anterior segment of the eye and the eyelids. (From [23])
movable. In middle and older age, an excess of
eyelid skin can occur (dermatochalasis, bags
under the eyes, droopy eyelids). The back surface of the eyelids represents the non-kerati-
inner and outer bony edge by strong ligaments,
the Ligg. palpebralia mediale and laterale (Fig.
2.5). The medial ligament also encircles the lac-
rimal sac, Saccus lacrimalis, with two limbs.
nized multi-layered squamous epithelium of the
conjunctiva (Figs. 2.3, 2.4 and 2.6).
The structural basis of both eyelids is the
orbital septum (see above), which extends from
the periosteum of the orbit and radiates into the
From a surgical perspective, the eyelids are
divided into an anterior lamella and a posterior
lamella. Anterior lamella: epidermis, muscula-
ture; posterior lamella: tarsus, conjunctiva.
tarsal plates, tarsus superior and tarsus inferior.
The larger tarsus superior (upper eyelid) with
a size of 10 mm and the smaller tarsus inferior
Both eyelids contain striated and smooth
musculature.
(lower eyelid) with a size of 5 mm form the
“skeletal” basis of the eyelids. This plate, also
referred to as the so-called “tarsal cartilage,”
2.3.1 Striated Musculature
consists of felted collagenous connective tissue. The tarsus of both eyelids lies just beneath
the back surface and ends at the posterior eyelid margin. Both tarsal plates are attached to the
The M. orbicularis oculi belongs to the facial
musculature and is located in front of the tarsal plate and the orbital septum. The pars