Eyelid Anatomy and Physiology with Reference to Blepharoptosis



The eyelids provide mechanical protection to the globe, produce chemical elements to the precorneal tear film, and help distribute these layers evenly over the surface of the eye. Eyelid motility requires a sophisticated interplay of muscles and suspensory systems that are intimately related to ocular movements, coordinated by fine sensory and motor control mechanisms. This chapter reviews anatomy and physiology of the eyelids and its suspensory system as a foundation for later chapters on evaluation and surgery for blepharoptosis repair. We also discuss the forces that determine eyelid position and complex blinking movements. These include those forces exerted by the levator and supratarsal muscles and the nature of their attachments, the anterior/posterior position of the eye, and the forces of gravity. Specific fiber types and their metabolic differences are important factors in understanding the function of the levator muscle, Müller’s sympathetic muscle, and their relationship to extraocular and other skeletal muscles.


Extensor Digitorum Longus Lower Eyelid Myosin Head Levator Muscle Eyelid Margin 


  1. 1.
    Hrecko T, Farkas LG, Katic M. Clinical significance of age-related changes in the palpebral fissure between ages 2 and18 in healthy Caucasians. Acta Chir Plast. 1968;32:194–204.Google Scholar
  2. 2.
    Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: W.B. Saunders; 1994.Google Scholar
  3. 3.
    Ahl NC, Hill JC. Horner’s muscle and the lacrimal system. Arch Ophthalmol. 1982;100:488–93.PubMedGoogle Scholar
  4. 4.
    Barker DE. Dye injection studies of orbital fat compartments. Plast Reconstr Surg. 1977;59:82–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Putterman AM, Urist MJ. Surgical anatomy of the orbital septum. Ann Ophthalmol. 1974;6:290–4.PubMedGoogle Scholar
  6. 6.
    Anderson RL, Dixon RS. The role of Whitnall’s ligament in ptosis surgery. Arch Ophthalmol. 1979;97:705–10.PubMedGoogle Scholar
  7. 7.
    Reid RR, Said HK, Yu M, Haines III GK, Few JW. Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr Surg. 2006;117:65–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Harvey JT, Anderson RL. The aponeurotic approach to eyelid retraction. Ophthalmology. 1981;88:513–24.PubMedGoogle Scholar
  9. 9.
    Meyer DR, Linberg JV, Wobig JL, McCormick SA. Anatomy of the orbital septum and associated eyelid connective tissue. Ophthal Plast Reconstr Surg. 1991;7:104–13.CrossRefPubMedGoogle Scholar
  10. 10.
    Edmonds B, Manners RM, Weller RO, Steart P, Collin JR. Levator palpebrae superioris fiber size in normals and patients with congenital ptosis. Eye. 1998;12:47–50.Google Scholar
  11. 11.
    Iljin A, Zielinska A, Karasek M, Zielinski A, Omulecka A. Structural abnormalities in the levator palpebral superioris muscle in patients with congenital blepharoptosis. Ophthalmic Surg Lasers Imaging. 2007;38:283–9.PubMedGoogle Scholar
  12. 12.
    Pereira LS, Hwang TN, Kersten RC, Ray K, McCulley TJ. Levator superior muscle function in involutional blepharoptosis. Am J Ophthalmol. 2008;145:1095–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Ettle A, Priglinger S, Kramer J, Koornneef L. Functional anatomy of the levator palpebrae superioris muscle and its connective tissue system. Br J Ophthalmol. 1996;80:702–7.CrossRefGoogle Scholar
  14. 14.
    Lukas JR, Priglinger S, Denk M, Mayr R. Two fibromuscular transverse ligaments related to the levator palpebrae superioris: Whitnall’s ligament and an intermuscular transverse ligament. Anat Rec. 1996;246:415–22.CrossRefPubMedGoogle Scholar
  15. 15.
    Hwang K, Shin YH, Kim DJ. Conjoint fascial sheath of the levator and superior rectus attached to the conjunctival fornix. J Craniofac Surg. 2008;19:241–5.PubMedGoogle Scholar
  16. 16.
    Galatoire O, Touitou V, Heran F, Amar N, Jacomet PV, Gheck L, et al. High resolution magnetic resonance imaging of the upper eyelid: correlation with the position of the skin crease in the upper eyelid. Orbit. 2007;26:165–71.CrossRefPubMedGoogle Scholar
  17. 17.
    Morikawa K, Yamamoto H, Uchinuma E, Yamashina S. Scanning electron microscopic study on double and single eyelids in Orientals. Aesthetic Plast Surg. 2001;25:20–4.CrossRefPubMedGoogle Scholar
  18. 18.
    Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Iwaki M. The levator aponeurosis consists of two layers that include smooth muscle. Ophthal Plast Reconstr Surg. 2005;21:379–82.CrossRefPubMedGoogle Scholar
  19. 19.
    Anderson RL, Beard C. The levator aponeurosis. Attachments and their clinical significance. Arch Ophthalmol. 1977;95:1437–41.PubMedGoogle Scholar
  20. 20.
    Collin JRO, Beard C, Wood I. Experimental and ­clinical data on the insertion of the levator palpebrae superioris muscle. Am J Ophthalmol. 1987;85:792–801.Google Scholar
  21. 21.
    Manson PN, Lazarus RB, Magar R, Iliff N. Pathways of sympathetic innervation to the superior and inferior (Müllers) tarsal muscles. Plast Reconstr Surg. 1986;78:33–40.CrossRefPubMedGoogle Scholar
  22. 22.
    Kuwabara T, Cogan DG, Johnson CC. Structure of the muscles of the upper eyelid. Arch Ophthalmol. 1975;93:1189–97.PubMedGoogle Scholar
  23. 23.
    Morton AD, Elner VM, White VA. Lateral extensions of the Müller muscle. Arch Ophthalmol. 1996;114:1496–8.Google Scholar
  24. 24.
    Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol. 1982;100:1313–8.PubMedGoogle Scholar
  25. 25.
    Bang YH, Park SH, Kim JH, Cho JH, Lee CJ, Roh TS. The role of Müller’s muscle reconsidered. Plast Reconstr Surg. 1998;101:1200–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Anderson RL. The medial canthal tendon branches out. Arch Ophthalmol. 1977;95:2951–61.Google Scholar
  27. 27.
    Cruz AA, Távora DB, Martin LF. Effect of eyelid saccades on the position of lateral canthus in young and older subjects. Orbit. 2008;27:1–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Malone B, Maisel RH. Anatomy of the facial nerve. Am J Otolaryngol. 1988;9:494–504.Google Scholar
  29. 29.
    Maxwell LC, Carlson DS, McNamara JA, Faulkner JA. Adaptation of the masseter and temporalis muscles following alteration in length, with or without surgical detachment. Anat Rec. 1981;200:127–37.CrossRefPubMedGoogle Scholar
  30. 30.
    Frueh BR, Garber FW, Musch DC. The effects of Graves’ eye disease on levator muscle function. Ophthalmic Surg. 1986;17:142–5.PubMedGoogle Scholar
  31. 31.
    Frueh BR, Hayes A, Lynch GS, Williams DA. Contractile properties and temperature sensitivity of the extraocular muscles, levator and superior rectus of the rabbit. J Physiol. 1994;475(2):327–36.PubMedGoogle Scholar
  32. 32.
    Frueh BR, Gregorevic P, Williams DA, Lynch GS. Specific force of the rat extraocular muscles, levator and superior rectus, measured in situ. J Neurophysiol. 2001;85(3):1027–32.PubMedGoogle Scholar
  33. 33.
    Lynch GS, Frueh BR, Williams DA. Contractile properties of single skinned fibres from the extraocular muscles, levator and superior rectus, of the rabbit. J Physiol. 1994;475(2):337–46.PubMedGoogle Scholar
  34. 34.
    Berke R. Personal communication with Carl C. Johnson. 1991.Google Scholar
  35. 35.
    Frueh BR, Musch DC. Evaluation of levator muscle integrity in ptosis with levator force measurements. Ophthalmology. 1996;103:244–50.PubMedGoogle Scholar
  36. 36.
    Felt DP, Frueh BR. A pharmacologic study of the sympathetic eyelid tarsal muscles. Ophthal Plast Reconstr Surg. 1988;4:15–24.CrossRefPubMedGoogle Scholar
  37. 37.
    Ryall JG, Schertzer JD, Lynch GS. Attenuation of age-related muscle wasting and weakness in rats after formoterol treatment: therapeutic implications for sarcopenia. J Gerontol A Biol Sci Med Sci. 2007;62A:813–23.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of OphthalmologyUniversity of North Carolina – Chapel HillChapel HillUSA

Personalised recommendations