Participation of the external carotid artery in orbital vascularization

The authors present the result of 70 dissections of the arterial vascular system of the orbit. The craniofacial junction is an important location because of possible anastomosis between the two carotid systems. These anastomosis can be situated at the meningeal level, palpebral and also inside the orbit cavity. The embryology of the encephalic vascular supply allows one to explain the possible dual origin of the orbital blood supply. This work shows the frequent participation of the external carotid artery to the orbital vascularisation by mean of three collateral branches: the infraorbital artery, a branch of the maxillary artery, partakes in the arterial supply of the inferior oblique muscle in 85,7% of cases. Usually, the inferior muscular artery which is a branch of the ophthalmic artery also partakes in this supply. In very exceptional cases (2 of 70) the infraorbital artery alone supplies the muscle. the lacrimal artery which can come from the external carotid system either from the middle meningeal artery or from the anterior deep temporal artery. This meningolacrimal artery can be either a solo lacrimal artery (17,14% of cases) or be associated with another classical lacrimal artery, from the ophthalmic artery (11,43%). These lacrimal arteries coming from the external carotid system have the following characteristics: they are thinner than classical arteries, they penetrate the orbit by their own orifice, the Hyrtl canal, and they can participate in the muscular vascularisation, especially of the lateral rectus. When these arteries are unique, most often they are encountered when the ophthalmic artery has undercrossed the optic nerve.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ophthalmic arteries originating from external carotid arteries

The ophthalmic artery arises from the internal carotid at the level of the carotid siphon; in 3.5-5% of the population, it arises from the middle meningeal artery, a branch of the internal maxillary artery, terminal of the external carotid artery. We report a rare case of bilateral malformation in a 28-year-old patient. Our study covers the possible dual origin of orbital blood vascularization. This variation in the anatomic distribution is important to know, particularly if embolization is intended as inadvertent occlusion of the ophthalmic artery, because it may lead to permanent loss of vision.     

Arterial vascularization of the levator muscle of the upper eyelid

The arterial vascularization of the levator to the anterior half of the nasal edge and the posterior half of the inferior face come from the supra orbital artery or from a branch of the ophthalmic artery. The posterior third receives its arterial supply from the posterior ethmo?dal artery. The anterior portion and the lateral and medial horns get their blood supply from the lacrimal artery but the presumed supply from the palpebrae arteries has not been shown in this study. The radio-anatomic study of the muscle defines three of different arterial supplies: the lacrimal artery in the anterior part; the supra orbital or ophthalmic artery in the middle and the posterior ethmo?dal artery, posteriorly. Some arterioles traverse the entire muscle from single pedicle (supra orbital) but in a third of cases the lateral arteriole arises from the posterior ethmo?dal artery. They anastomose in the anterior portion of the muscle with the arterioles arising from the lacrimal artery through the lacrimal gland. The radio-anatomic pictures emphasize the great supply from that origin. The major practical implication of this study is the importance of better hemostasis in anterior levator surgery particularly during ptosis surgery.     

Visual loss from arterial steal in patients with maxillofacial arteriovenous malformation

OBJECTIVE: To determine whether an arterial "steal" from the ophthalmic artery accounts for the ocular manifestations associated with maxillofacial arteriovenous malformation (AVM) outside the orbit. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Seven patients with maxillofacial AVM who had been previously treated, unsuccessfully, with proximal ligation of the supplying external carotid artery branches were evaluated clinically and by superselective cerebral angiography. No cases had intraorbital arteriovenous shunting or abnormal venous drainage to the orbit. INTERVENTION: Endovascular embolization. MAIN OUTCOME MEASURES: Signs and symptoms of ocular ischemia were correlated with findings on cerebral/orbital angiography. RESULTS: Four of seven patients had signs of ocular ischemia. By selective angiography, these four patients were found to have a significant ophthalmic artery supply to the AVM. In contrast, the three patients without signs of ocular ischemia had minimal or no ophthalmic artery supply to the AVM. CONCLUSIONS: When the ophthalmic arterial blood supply is recruited, ophthalmic artery "steal" phenomenon occurs in patients with maxillofacial AVMs that do not directly involve the orbit. This mechanism appears to be the cause of ocular ischemia. It is possible that this "steal" is precipitated or worsened by previous surgical proximal ligation of external carotid arterial branches that are potential collaterals with the ophthalmic artery but fail to occlude the arteriovenous (AV) shunts.     

Gross anatomical study of veins in the orbit

The aim of this study is to clarify the major route of venous return in the orbit. Minute dissections were performed in 10 adult cadavers (5 males and 5 females) after being fixed in a 10% formalin solution. The superior ophthalmic vein (SOV) and its ascending anastomotic branch were consistently well-developed (the average maximum diameter: 6.2mm and 3.2mm, respectively) and these two veins formed the main venous channel from the orbital contents. The ascending anastomotic branch ran between the optic nerve and the medial rectus just behind the eyeball and joined the SOV. A large number of veins, including the inferior ophthalmic vein, which originated from the inferior contents of the orbit, drained into the ascending anastomotic branch. Arteries and/or nerves did not accompany their respective veins in the orbit, except for the lacrimal and ethmoidal veins. The posterior end of the SOV was severely narrowed lateral to the aponeurosis of the lateral rectus, while being conspicuously dilated just behind the eyeball. The above findings suggested that the dilated portion of SOV may act as a reservoir of the venous return of the orbit.     

Ocular and orbital blood flow in apparently healthy adults

Doppler measurements of ocular and orbital blood flow at rest were studied using duplex ultrasonography in 30 apparently healthy adult volunteers. The following linear and calculated Doppler measurements were estimated at rest: blood flow in ophthalmic artery (OA), central retinal artery (CRA), posterior ciliary arteries, central retinal vein and superior ophthalmic vein (SOV). In 10 patients Doppler measurements of blood flow in OA, CRA SOV were estimated 5 times by 2 observers with different level of skills in ultrasonographic ophthalmologic examination. Statistic analysis showed strong correlation of linear and calculated measurements in OA, CRA and venous blood flow velocity. A number of Doppler measurements with the most significant inter- and intraobserver variation were revealed. Measurements with high reproducibility were determined. Thus, a unique technique should be performed in estimation of Doppler measurements of blood flow in ocular and orbital vessels. The velocities in the main arteries (OA, CRA) and veins (SOV) were showed to have significant strong interobserver correlation. The highest reproducibility and accuracy was revealed for maximal systolic velocity in OA and CRA and maximal velocity for cardiac cycle in SOV.     

彩色多普勒超声在眼眶病诊断中的价值

目的 探讨彩色超声多普勒（color Doppler imaging,CDI）在眼眶病诊断及鉴别诊断中的应用价值。方法 应用CDI技术对288例眼眶病患者眼眶病病变内部的彩色血流显像和脉冲多普勒频谱进行检测。结果 288例眼眶病中,恶性肿瘤38例,炎性假瘤23例,泪腺混合瘤（血流信号不丰富）18例,神经鞘瘤22例,脑膜瘤7例,良性血管内皮瘤及血管外皮瘤各2例,视神经胶质瘤及神经纤维瘤各1例,瘤体内CDI均可检测出血流信号;海绵状血管瘤62便,皮样囊肿16例及脂肪瘤1例瘤体内CDI检测均无血流信号;静脉性血管瘤29例中,CDI检测出静脉血流信号16例;动静脉血管瘤3例CDI检测出动脉血流信号;静脉曲张15例在颈静脉加压和压力解除过程中示动态血流变化;婴儿性血管瘤6例应用糖皮质激素治疗后内部血流信号明显减少;颈动脉海绵窦瘘13例,其中颈内动脉海绵窦瘘（internal carotid cavernous sinus fistula,CCF)8例和硬脑膜海绵窦瘘（dural cavernous sinus fistula,DCF）5例CDI检测均显示眼上静脉扩张动脉化,同时CCF的眼上静脉的血流速度和每分血流量高于DCF,而阻力指数低于DCF。1例眼上静脉血栓性静脉炎显示眼上静脉扩张但无血流信号。结论 CDI对于多血管性肿瘤和眼眶血管性疾病有其特征性的表现。CDI检测在协助B超、CT或MRI检查眼眶病确定疾病的诊断和鉴别诊断中的重要意义。     

Thrombosis of the superior ophthalmic vein: A case report

We present the case of a 33-year-old woman, a heavy cigarette smoker, with unilateral palpebral edema, exophthalmos and dilatation of the retinal veins. CT scan was normal. An isolated thrombosis of the superior ophthalmic vein was suspected since it was impossible to visualize the ophthalmic veins by carotid arteriography. Attempts to do a frontal venography were unsuccessful. The patient was treated for five months with anticoagulant drugs (heparin and coumarin), with subsequent normalization of the clinical picture. At this time successful frontal venography showed a normal venous system in the two orbits. Occlusion (thrombosis?) of the orbital veins, even if rare, must be considered in the presence of exophthalmos with palpebral edema with the characteristics of venous stasis. Anticoagulant therapy is recommended.     

Arterial blood supply and innervation of the rectus muscles of the eyeball

The authors report on the arterial blood supply and the innervation of the rectus muscles of the eyeball from human orbital dissections. MATERIAL AND METHODS: Hundred human orbits were dissected using a superior approach after arterial injection with colored latex. The different arterial pedicles for each muscle were noted and the nervous supply was studied. RESULTS: The arterial blood supply of the rectus muscles comes from different branches of the ophthalmic artery, usually the inferior muscular artery, the lacrimal artery, the superior muscular artery when it exists, and by small branches arising from the ophthalmic artery. The superior rectus is supplied by branches of the ophthalmic artery and the lacrimal artery (1 to 5 pedicles). The medial rectus is supplied by branches of the ophthalmic artery and the inferior muscular artery (5 to 9 branches). The inferior muscle rectus is principally supplied by the inferior muscular artery (4 pedicles) and the lateral muscle is supplied by the lacrimal artery or the lateral muscular artery (3 to 6 branches). For innervation, the abducens nerve supplies the lateral rectus; the other muscles are supplied by the oculomotor nerve whose superior branch supplies the superior rectus and whose inferior branch, supplies the inferior and medial rectus. DISCUSSION: The arterial blood supply is variable. The arteries which lie near the rectus muscles usually supply one or more branches to the muscles. The arteries go into the muscles through their conal side. This arterial supply is at the posterior part of the muscle. Innervation, in contrast, is very constant and fixed. CONCLUSION: The arterial blood supply to the rectus muscles is variable but always substantial. The pedicles are numerous, often 3 to 5 for each muscle. Innervation is fixed and constant.     

Abnormal ophthalmic veins: differential diagnosis and management using color Doppler imaging

Objective: To evaluate the role of color Doppler imaging (CDI) in the diagnosis and management of patients with abnormal ophthalmic veins. Design: Records from patients with suspected abnormalities of ophthalmic veins who had been studied with color Doppler imaging were reviewed. Patients and methods: Twenty-three patients had abnormalities of their superior ophthalmic vein (SOV) due to anomalous SOV enlargement, carotid cavernous fistula (CCF), dural shunt, tumor, or Graves’ disease. Color Doppler imaging of the orbits was obtained initially and as needed during the course of each case. Abnormalities of superior ophthalmic vein included velocity greater than 8.26 cm/sec, anteriorly directed blood flow, and/or pulsatile waveform. Results: Incidental enlargement of SOV was associated with normal waveform velocity on CDI. Of three patients with CCF, two showed high velocity in one or both SOVs which resolved after embolization. One patient with a dural shunt had high SOV velocity. Four patients with clinical and CDI findings typical of dural shunt improved spontaneously and did not need angiography. Two patients with orbital tumors and one with intracranial tumor had evidence of increased venous outflow through the SOV. Two patients with Graves’ disease showed mild to moderate increase in SOV velocities. Conclusions: CDI is especially helpful in the diagnosis of incidental SOV enlargement and in management of low flow dural shunts.     

眼眶动静脉畸形致眼上静脉扩张的影像学表现

目的探讨眼眶动静脉畸形(AVM)致眼上静脉(SOV)扩张的影像学及血管造影表现。设计回顾性病例系列。研究对象6例临床表现与硬脑膜海绵窦瘘(CCF)相似的眼眶AVM患者。方法总结分析所有患者的影像学检查结果,如CT、MRI和选择性脑血管造影。主要指标影像学征象及血流动力学。结果CT和MRI均可显示所有患者的SOV扩张。另外,尚存在眼球突出、AVM畸形血管团等征象。所有6例AVM均位于眼眶内,1例尚合并颅内AVM。所有患者的主要引流静脉均为SOV,动脉包括脑膜中动脉、上颌动脉和眼动脉。结论眼眶AVM可引起与CCF相似的临床和影像学征象,但AVM通常不引起海绵窦膨大,血管造影仍是确诊的必需手段,而无创技术是辅助血管造影进行明确诊断的重要手段。(眼科,2007,16:395-398)     

Ophthalmic and facial veins are not valveless

Background: The ophthalmic and facial veins are frequently stated to be devoid of valves, facilitating the spread of infection from the mid‐face to the cavernous sinus. Methods: Twelve superior and eight inferior ophthalmic veins together with 13 angular and facial veins were harvested from adult cadavers. Each vein was opened longitudinally and examined by stereomicroscopy; the number, location and geometry of valve cusps were recorded. Results: Ten valves were identified in nine (75%) superior ophthalmic vein specimens: four valves were in the superior ophthalmic vein and the remainder were located near its origin from angular and supra‐orbital tributaries. No valves were seen in the inferior ophthalmic vein. Seventeen bicuspid valves were identified in tributaries of the angular vein or in the facial vein, but none were in the angular vein itself. Four of seven facial vein segments extending to the lower border of the mandible had valves. The orientation of valve cusps predicted the following blood flow: in the facial vein, inferiorly; in the superior ophthalmic vein, towards the cavernous sinus; and in the angular vein, to the facial or superior ophthalmic vein. Conclusions: This study demonstrates, for the first time, the existence of valves in the superior ophthalmic vein and its two main tributaries. Valves were also seen in the facial vein. It is not the absence of venous valves but the existence of communications between the facial vein and cavernous sinus and the direction of blood flow that is important in the spread of infection from the face.     

Microvasculature of the rat optic nerve head.

PURPOSE: To describe the arterial blood supply, capillary bed, and venous drainage of the rat optic nerve head. METHODS: Ocular microvascular castings from 6 Wistar rats were prepared by injection of epoxy resin through the common carotid arteries. After polymerization, tissues were digested with 6 M KOH, and the castings washed, dried, and coated for scanning electron microscopy. RESULTS: Immediately posterior to the globe, the ophthalmic artery trifurcates into the central retinal artery and two posterior ciliary arteries. The central retinal artery directly provides capillaries to the nerve fiber layer and only contributes to capillary beds in the neck of the nerve head. The remainder is supplied by branches of the posterior ciliary arteries that are analogous to the primate circle of Zinn-Haller. Arterioles arising from these branches supply the capillaries of the transitional, or laminar, region of the optic nerve head. These capillaries are continuous with those of the neck and retrobulbar optic nerve head. All optic nerve head capillaries drain into the central retinal vein and veins of the optic nerve sheath. A flat choroidal sinus communicates with the central retinal vein, the choriocapillaris, and with large veins of the optic nerve sheath. CONCLUSIONS: The microvasculature of the rat optic nerve head bears several similarities to that of the primate, with a centripetal blood supply from posterior ciliary arteries and drainage into the central retinal and optic nerve sheath veins. Association of nerve sheath veins with the choroid represents an important difference from the primate.     

Distribution of pterygopalatine ganglion efferents to the lacrimal gland in man

To trace the path taken by the putative postganglionic secretomotor fibres to the lacrimal gland the contents of the orbital and pterygopalatine fossa were removed whole, cut coronally into slabs and embedded in resin. Thin sections were cut at varying intervals to reconstruct the pathway taken. One group of rami orbitales issuing from the pterygopalatine ganglion passed dorsally adjacent to the lateral wall of the orbit, joined the retro-orbital plexus at the apex, and 5-10 rami lacrimales advanced from the plexus to enter the gland. An accessory ophthalmic artery, a branch of the middle meningeal artery, entered the orbit through the superior fissure orbital joining the ophthalmic or lacrimal artery. Perivascular nerves of the artery continued to the gland as supplementary rami lacrimales and in some orbits others served the vasculature of the eye and orbit. The nerves are presumably derived from the middle meningeal supply and may include otic parasympathetic fibres. The route taken by parasympathetic nerves serving the human lacrimal gland is demonstrated here for the first time and apart from the perivascular meningeal artery source, it is similar to that described in monkeys. The traditional assumption that secretomotor nerves pass to the gland via the zygomatic and lacrimal nerves is therefore unlikely and clinical measures to reduce lacrimation based on that assumption and involving severance of ophthalmic branches is not indicated.     

颈动脉海绵窦瘘眼眶彩色多普勒超声检查临床意义探讨

目的:探讨颈动脉海绵窦瘘(carotid cavemous fistula,CCF)眼眶彩色多普勒超声显像(color Doppler imaging,CDI)检查的声像表现及其诊断价值。方法:对39例39眼CCF患者的CDI超声表现进行回顾性分析。结果:患者39例均表现为反向动脉化血流的眼上静脉扩张,眼下静脉扩张3例,眼外肌增厚2例。压迫患侧颈总动脉,患侧颈内动脉出现不同程度的倒灌血流。结论:CDI检查可以准确显示CCF眶内扩张的血管及血流动力学状态,对CCF的诊断具有重要临床意义。     

Cavernous sinus dural arteriovenous malformations: patterns of venous drainage are related to clinical signs and symptoms

OBJECTIVE: To provide evidence that venous congestion and drainage patterns are responsible for the manifestations of cavernous sinus area dural arteriovenous malformations (CSdAVMs). DESIGN: Retrospective observational case series. PARTICIPANTS: Records of 85 patients with complete clinical and angiographic evaluations of CSdAVMs were evaluated for the clinical features of the disorder. A neuroradiologist analyzed patterns of venous drainage to and from the cavernous sinus without knowledge of the clinical features. Four venous drainage patterns (reversal of flow from the CSdAVMs into the anterior cavernous sinus, ophthalmic vein thrombosis, drainage into the inferior petrosal sinus or drainage into the superior petrosal sinus) were statistically tested for their predictive value of signs and symptoms using logistic regression. MAIN OUTCOME MEASURES: The power of prediction of orbital congestion, elevated IOP, extraocular muscle dysfunction, optic neuropathy, venous-stasis retinopathy, choroidal effusion, anterior chamber shallowing, bruits, cranial nerve paresis, and central nervous system dysfunction from four patterns of venous drainage. RESULTS: Reversal of drainage into the anterior cavernous sinus and ophthalmic veins was highly predictive (P = 0) of orbital congestion, which was seen in 77 (91%) patients. In contrast, eight (9%) patients without orbital congestion had shunts that did not drain into the anterior cavernous sinus and ophthalmic veins. Cavernous sinus dural arteriovenous malformation drainage into the anterior cavernous sinus and ophthalmic veins also predicted elevated IOP (P = 0.0023) and optic neuropathy (P = 0.047). Ophthalmic vein thrombosis significantly predicted cases with choroidal effusion (P = 0.002) and anterior chamber shallowing (P = 0.01). Third nerve paresis could be predicted from flow toward the inferior petrosal sinuses (P = 0.017). Central nervous system symptoms or dysfunction, occurring in 7 (8%) patients, was predicted by venous drainage into the superior petrosal sinus (P = 0.0008). CONCLUSIONS: The clinical features found in patients with CSdVAMs are related to the abnormal venous drainage and can be predicted by these venous drainage patterns. Venous congestion and hypertension seem to cause the clinical dysfunction in this disorder.     

外科治疗对合并缺血性眼病的颈动脉狭窄患者眼动脉血流动力学的影响及疗效评价

目的：:利用彩色多普勒超声仪（CDFI）对伴有缺血性眼病的颈动脉狭窄患者行颈动脉内膜切除术（CEA）或颈动脉支架成形术（CAS）前、后颈部血管及眼部血管的血流动力学检查,以探讨外科手术治疗对眼动脉血流动力学的影响,并比较CEA和CAS这2种不同的外科手术治疗方法对缺血性眼病的疗效。方法：:前瞻性临床研究。收集2017年...     

Effect of fezam on ocular dynamics in patients with senile macular degeneration

The complex treatment in 25 patients with non-exudative forms of senile macular degeneration (ARMD) included the use of the nootropic agent fezam. Better visual acuity after a course of therapy was noted in 76% of the eyes of patients with ARMD. Color Doppler mapping prior to treatment indicated that all the patients had a significant reduction in the maximum systolic and end-diastolic blood flow velocities (Vs and Vd, respectively), and the increased peripheral resistance index (RI) in the ophthalmic artery, central artery of the retina, and short posterior ciliary arteries as compared to the normal values. Higher ophthalmic arterial blood flow velocities after a course of therapy are indicative of better blood supply to the tunics of the eye, which is a favorable sign for the prognosis of the disease. The use of fezam is effective in the complex therapy of non-exudative forms of senile macular degeneration.     

Supraclinoid carotid artery fistula mimicking a carotid-cavernous fistula

Pulsatile exophthalmos syndrome (PES) is characterized by conjunctival injection, orbital bruit, chemosis, exophthalmos, and palpebral edema. It is usually associated with glaucoma, decreased visual acuity, and extrinsic ophthalmoplegia, and mostly secondary to carotid-cavernous fistulas (CCFs), an abnormal communication between the intracavernous segment of the carotid artery and the venous channels in cavernous sinus. We present a case of an abnormal communication between the supraclinoid segment of the carotid artery and the coronary sinus that drains into the contralateral ophthalmic vein simulating a CCF. It was succesfully treated by coil embolization using a percutaneous approach. Other reported rare causes of PES and treatment modalities by embolization are reviewed.     

Colour Doppler imaging of the orbital vasculature in Graves' disease with computed tomographic correlation

AIMS: To evaluate alterations in orbital blood flow parameters and their correlations with extraocular muscle enlargement, proptosis, and intraocular pressure in patients with Graves' disease. METHODS: In this multicentre study blood flow parameters in the ophthalmic artery, superior ophthalmic vein, central retinal artery and vein were determined by colour Doppler imaging in 111 patients with Graves' disease in two groups (A and B) and 46 normal control subjects. Group A consisted of 42 patients with Graves' disease without ophthalmopathy; group B of 69 patients with Graves' disease with ophthalmopathy as detected by orbital computed tomographic scanning. RESULTS: Peak systolic and end diastolic velocities in the ophthalmic artery, peak systolic velocity in the central retinal artery, and maximal and minimal velocities in the central retinal vein in patients in group B were statistically significantly higher than those in group A and the normal controls, whereas maximal and minimal velocities in the superior ophthalmic vein in patients in group B were statistically significantly lower than those in group A and the control subjects. Peak systolic and end diastolic velocities in the ophthalmic artery, peak systolic velocity in the central retinal artery, and maximal and minimal velocities in the central retinal vein also correlated with the sum of all extraocular muscle diameters in group B (r > or =0.31, p< or =0.021). Blood flow parameters had no consistent correlation with proptosis or intraocular pressure (p>0.05). No statistically significant difference was found in resistivity indices between the groups (p>0.05). Reversed blood flow was noted in nine (13%) superior ophthalmic veins in group B. CONCLUSION: Orbital blood flow velocities are altered in patients with Graves' ophthalmopathy and may be detected by colour Doppler imaging. Some of these changes also correlate with the enlargement of extraocular muscles. The increased blood flow velocities in arteries may be secondary to orbital inflammation.