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Functional Anatomy of the Levator Palpebrae

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Functional Anatomy of the Levator Palpebrae 702Br7B ishJournal of Ophthalmology 1996;80:702-707 Functional anatomy of the levator palpebrae superioris muscle and its connective tissue system Br J Ophthalmol: first published as 10.1136/bjo.80.8.702 on 1 August 1996. Downloaded from A Ettl, S Priglinger, J Kramer, L Koornneef Abstract to the level of the culmination point of the Aimslbackground-The connective tissue LPS, the ligament itself is unlikely to sus- system ofthe levator palpebrae superioris pend the levator muscle. However, a muscle (LPS) consists of the septa sur- suspension ofthe LPS may be achieved by rounding its muscle sheath, the superior the radial connective tissue septa of the transverse ligament (STL) commonly re- superior orbit. The TSFE in connection ferred to as 'Whitnall's ligament' and the with the globe may have an additional common sheath which is the fascia be- supporting function. The elasticity of tween the LPS and the superior rectus Whitnall's ligament and its connections muscle (SRM). The anterior band-like with highly elastic structures including component ofthe common sheath is called Tenon's capsule, may provide the mor- transverse superior fascial expansion phological substrate for the previously (TSFE) of the SRM and LPS. It mainly proposed passive (that is, without orbicu- extends from the connective tissue of the laris action) lowering of the lid during trochlea to the fascia of the lacrimal downward saccades. gland. A detailed description of the rela- (BrJ Ophthalmol 1996;80:702-707) tion between the LPS and its connective tissue is presented. Furthermore, the course ofthe LPS in the orbit is described. The study was conducted to provide a morphological basis for biomechanical The preservation of the suspensory connective and clinical considerations regarding tissue system of the levator palpebrae superi- ptosis surgery. oris muscle (LPS) is regarded to be an impor- Methods-Postmortem dissections were tant principle in ptosis surgery.' According to performed in 16 orbits from eight cadav- the literature, the superior transverse ligament ers. The microscopical anatomy was dem- (STL) represents the main part of the suspen- onstrated in six formalin preserved orbits sory system of the LPS.' 2 from six cadavers which had been The superior transverse ligament (Whit- http://bjo.bmj.com/ sectioned in the frontal and sagittal plane nall's), is a condensation ofthe fascial sheath of and stained with haematoxylin and the LPS on its superior surface which extends azophloxin. Surface coil magnetic reso- from the connective tissue complex of the tro- nance imaging in the sagittal and coronal chlea medially, to the capsule of the orbital plane was performed in five orbits from lobe of the lacrimal gland and the orbital wall Orbital Center, five normal volunteers using a Ti laterally. The STL has also bilateral connec- Department of weighted spin echo sequence. tions to the horns ofthe aponeurosis. The STL on September 30, 2021 by guest. Protected copyright. Opthalmology, Results-The STL and the TSFE sur- is largely located in the transitional zone Academic Medical round the LPS to form a fascial sleeve between muscular levator and the aponeuro- Center, Amsterdam, .3 the Netherlands around the muscle which has attachments sis., A Ettl to the medial and lateral orbital wall. The In some patients with congenital2 and L Koornneef TSFE, which is thicker than the STL, involutional4 ptosis, the STL has been ob- blends with Tenon's capsule. The STL and served to be atrophic or dehiscent. It has been Department of the fascial sheath of the LPS muscle are suggested that these cases may benefit from Ophthalmology, General Hospital, St suspended from the orbital roof by a repair of Whitnall's ligament in addition to Polten, Austria framework of radial connective tissue conventional ptosis surgery.2 4 A Ettl septa. MR images show that the TSFE is The function ofthe STL has been controver- located between the anterior third of the sially discussed: Whitnall' stated that the STL Institute for superior rectus muscle and the segment of would act as a check ligament of the LPS. Orthoptics, Hospital the LPS muscle where it changes its Lemke et al 5 noted that the ligament Barmherzige Brfuder, However, inz, Austria course from upwards to downwards. In is not under tension during lid closure and S Priglinger this area, the LPS reaches its highest point Dutton6 believes that the check function of the in the orbit (cunlmination point). The STL is not significant under physiological con- CT and MRI Institute, culmination point is located a few milli- ditions. Anderson and Dixon2 mentioned that Linz, Austria metres posterior to the equator and supe- larger amounts of levator resections are re- J Kramer rior to the globe. quired if Whitnall's ligament is severed and Correspondence to: Conclusion-Whitnall's ligament can be therefore recommended its preservation dur- Dr med Armin Ettl, considered to consist of two distinct ing ptosis surgery. They suggested that the Kaiserwaldweg 55 a, A-8010 parts-the TSFE inferior to the LPS and superior transverse ligament would act as a ful- Graz, Austria. the STL superior to the LPS. Since the crum which translates the anteroposterior Accepted for publication medial and lateral main attachments of force of the LPS into a vertical upward motion 17 May 1996 Whitnall's ligament are situated inferior of the eyelid. Boergen and Scherz' who cut Functional anatomy of the levatorpalpebrae superioris muscle and its connective tissue system 703 Whitnall's ligament during large levator resec- the medial palpebral ligament, and check liga- tions, stated that 'negative consequences' were ment of the medial rectus muscle. Laterally, not observed following this procedure. there are weak attachments to the superolateral Br J Ophthalmol: first published as 10.1136/bjo.80.8.702 on 1 August 1996. Downloaded from The so called 'common sheath' is the periorbit via the fascia of the lacrimal gland intermuscular fascia between the LPS and the (Fig 2). More firm extensions insert into the SRM.8 Fink9 has called its anterior part the lateral retinacular complex which includes the 'transverse superior fascial expansion (TSFE) lateral palpebral ligament, the lateral check of the levator and superior rectus muscles'. ligament, and the adjacent periorbit. The Whitnall,' Jones,8 and Dutton6 briefly men- medial attachment of the fascial sleeve of the tioned the relation between the STL and the LPS is much thicker than the lateral attach- common intermuscular fascia. ment. Thin connective tissue septa pass in a The architecture of the connective tissue more or less radial orientation from the STL system of the orbit contributes to the course of through the preaponeurotic fat pad to the peri- the extraocular muscles and therefore ma have orbit of the orbital roof and margin (Fig 3). important functional implications.'0 The The STL is connected to the LPS with present study was undertaken to investigate the stronger attachments at the medial and lateral course ofthe LPS muscle and its relation to the borders of the muscle. Loose connective tissue connective tissue system of the superior orbit. connects the TSFE with the overlying LPS and For this purpose, high resolution magnetic the underlying SRM. Firm connections exist resonance imaging (MRI) was performed in between the LPS and the SRM at their margins vivo in addition to anatomical and histological (Fig 4). The TSFE extends from the fascia of studies. A series of photographs of macro- the lacrimal gland (Fig 2) towards the connec- scopic dissections is shown in order to illustrate tive tissue of the superior oblique tendon and the morphological relations for the eyelid the trochlea (Fig 5). It starts at a level below surgeon. the STL and extends posteriorly for about 10 mm. The TSFE sends delicate connective Material and methods tissue fibres into the superior fornix, previously Macroscopic anatomical dissections were per- described as the 'suspensory ligament of the formed in 16 orbits from eight unfixed superior fornix' (Fig 4). cadavers (age range 40-85 years) via a If the LPS is reflected and the TSFE is care- transconjunctival or a combined transcutane- fully incised, the bare surface of the SRM and ous and transcranial approach. the sclera is exposed indicating that the TSFE En bloc excised and formalin fixed orbits represents a condensation of Tenon's capsule from six cadavers (age range 26-73 years) which blends with the fascial sheath of the which had been decalcified with ethylenedi- muscles in this area (Fig 6). amine tetra-acetic acid, embedded in celloidin, Histological sections in the frontal plane serially sectioned (60 gm) in the frontal plane (Fig 7) confirm that the STL and the TSFE (n=3 orbits) and in the sagittal plane (n=3 unite at the medial and lateral borders of the http://bjo.bmj.com/ orbits), and stained with haematoxylin and LPS and extend further laterally to the capsule azophloxin'0 were analysed microscopically. of the lacrimal gland and medially to the MRI of the orbit was performed in five connective tissue of the trochlea. The TSFE volunteers (age range 29-54 years), after blends with Tenon's capsule. Fibres from the consent had been obtained, on a 1 Tesla scan- TSFE course inferiorly to insert into the ner (Impact, Siemens, Germany) using a connective tissue of the medial and lateral rec- surface coil with a diameter of 10 cm. Oblique tus muscle. Posterior to the equator of the on September 30, 2021 by guest. Protected copyright. sagittal (sections parallel to the optic nerve) globe, the common sheath blends with the and coronal (sections in the frontal plane) Ti superolateral intermuscular septum and with weighted images of the orbit were obtained by Tenon's capsule medially. Throughout the spin echo sequences with an echo time (TE) of length of the entire orbit, a network of radial 15 ms and a repetition time (TR) of 440-520 septa connects the fascial sheath of the LPS ms.
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