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本文为Rhoton解剖视频中《Navigating the Orbit》这一章节，主要讲解了眼眶的骨性结构、眶内结构、各种眼眶入路等内容。视频时间较长，笔者将部分内容按顺序重新编排，共截取270张图片。 笔者水平所限，错误之处请批评指正！ 
眼眶解剖
Navigating the orbit ▼我们今天的主题是眼眶，但也会涉及邻近的颅底。对于局限于眶内的病变，尤其前眶部，主要由眼科来处理。 We're talking about orbit today, but we include adjacent skull base because if a lesion is strictly within the orbit especially the anterior part, those lesions are dealt with predominantly by ophthalmology,
▼而如下情况则需要神经外科干预，例如病变侵犯了邻近颅底，或累及视神经管或眶上裂，或累及眶周骨质。因此，我们需要应对的不仅仅是眶部，还包括眶周的颅底。 but neurosurgery becomes involved if a lesion extends to the adjacent skull base,or extends through the optic canal or superior orbital fissure,or involves the bones surrounding the orbit. So,we're often asked not only to deal with the orbital part,but also we get called in because of the involvement of the adjacent skull base.
▼神经外科需处理的眶周病变常累及视神经管、眶上裂、毗邻的鼻窦壁包括额窦、筛窦以及蝶窦(下图)。病灶也可通过眶底侵及上颌窦 So that when we look at an orbit,neurosurgery tends to become involved if the lesion extends through the optic canal,or through the superior orbital fissure,or through the adjacent walls from either the sinuses, the frontal,ethmoid and sphenoid sinus.Lesions can also extend from below and involve the maxillary sinus as well as the orbit,
▼又如，在蝶骨嵴脑膜瘤中，眶外的病灶可累及眶外侧壁并侵入眶内。因此，眼眶及眶周病变均需要我们神经外科的干预。 or as in sphenoid ridge meningiomas, they can involve the lateral orbital wall and extend into the orbit. So, we often get involved when the adjacent areas as well as the orbit is involved.
▼眶内病变亦可累及颞窝、颞下窝（下图） Lesions in the orbit can involve temporal fossa,infratemporal fossa,
▼这是上颌神经（下图），从眶尖下方走行，进入翼腭窝，或经由眶下裂进入眶内。 or here we see V2, pass below the apex of the orbit, and extend into pterygopalatine fossa，or through the inferior orbital fissure into the orbit.▼这是眶部的外侧观。眶外侧壁为病变侵犯眼眶的途径之一。病变也可经由眶上裂入眶，或通过视神经管，或经由内侧的鼻窦，也可经由眶下裂内侧部或者翼腭窝，向上通过眶下裂进入眶尖。 神经外科常需处理的情况包括眼眶及眶周病变。另外，越邻近眶尖的病变，需要神经外科处理的几率越高。 But we'll talk in greater detail about the anatomy within the orbit.But here we're looking at orbit from laterally and lesions can extend through the lateral orbital wall. They can access the orbit through the superior orbital fissure or the optic canal, or from the sinus medially,or they can pass upward here in the medial part of the inferior orbital fissure and pterygopalatine fossa up through the fissure into the orbital apex. But, commonly neurosurgery is involved when not only the orbit is involved but the adjacent structure. Also the closer the lesion is to the orbital apex,the more often the neurosurgery becomes involved in dealing with the pathology 
▼学习眼眶解剖，首先需了解眶壁骨性结构 In looking at orbit, we want to first of all understand the osseous wall of the orbit
▼因为打开骨质，是我们从上方、从内侧的鼻腔及鼻窦、从眶外侧壁、或从下方的上颌窦顶壁，来进入眼眶的前提，其中上颌窦顶壁正是构成了眼眶底壁。 because we're doing osteotomy that will deliver us to the orbit from above,or from medially through the nasal cavity and the sinuses, or laterally through the lateral wall through a lateral orbitotomy, or from inferiorly through the roof of the maxillary sinus which forms the floor of the orbit. 
▼我们从骨性眶壁说起。蝶骨小翼构成了眶顶的后部。蝶骨大翼构成眶外侧壁的大部。 So we'll start out and talk initially about the walls of the orbit. And, the lesser sphenoid wing forms the posterior part of the roof of the orbit.The greater wing forms a large part of the lateral wall of the orbit.
▼蝶窦于此处（下图黄色区域）与筛窦相连，构成了眶上裂的部分内侧壁。 And here, sphenoid sinus here that adjoins the ethmoid forms some of the medial wall of the superior orbital fissure. So that we wanna have a good understanding of the osseous anatomy because it's through the bony walls that we access the orbit.
▼这是圆孔，上颌神经从中穿过而行于眶底。 Here we see foramen rotundum, through which V2 passes to course in the floor of the orbit.
▼这是翼管，内有翼管神经走行，该神经包含副交感传出纤维，支配位于眶上外侧部的泪腺分泌。 Here is the vidian canal that transmits the vidian nerve that eventually provides the parasympathetic outflow for the lacrimal gland in the superior lateral orbit.
▼来看眶尖部，这是眶上裂、视神经管（箭头处）。 So when we look at the orbital apex, superior orbital fissure,optic canal area.
▼我们需要与周围的颅骨结合起来看，例如，蝶骨大翼的上部、与蝶骨小翼的前部分别参与组成眶外侧壁和眶顶，下图所示黄色区域与额骨结合一起构成完整的眶顶。 We wanna see the surrounding bony anatomy, such as the upper part of the greater and anterior part of the lesser wings that contribute to the lateral wall and roof of the orbit, and join the frontal bone here along this yellow area to complete the orbital roof.
▼侧方的颧骨与此处的蝶骨（下图黄色区域）相结合，即构成了眶外侧壁的大部。 Laterally we want to see the zygomatic articulation with the sphenoid that completes the much of the lateral wall of the orbit.
▼另外，此处（下图黄色区域）连于筛骨即构成眶内侧壁的大部，内含有气房，是到达眶内侧壁的一个手术通道。 And then, we have an articulation with the ethmoid bone that forms much of the medial wall of the orbit, as providing a group...as well as providing a group of air cells through which we can access medial wall of orbit.
▼在下方与此处（下图黄色区域）相连的是腭骨，一起构成的是眶底。 And then, below we have an articulation with the palatine bone that contributes to the formation of the floor of the orbit.
▼外侧的眶上外部为蝶骨嵴的外侧界，这一区域，为额、顶、颞、蝶四骨相交处，即为翼点，恰位于眶上外侧部。 以上就是我们需最先掌握的蝶骨解剖。 Laterally here at the superior lateral part of the orbit we have the lateral edge of the sphenoid ridge, and here in this area, the pterion where the frontal, parietal, temporal and sphenoid bone meet here right at the superolateral part of the orbit. So that we start with sphenoid bone.
▼接下来我们加入了筛骨。 So that we add in the ethmoid now.
▼筛骨的外侧壁即为 眶板。 And the lateral wall of the ethmoid forms the orbit plate.
▼这是中鼻甲，其外侧为筛窦气房。 And here we see middle turbinate, and then laterally, these ethmoid air cells.
▼如果我们从中鼻甲下方，打开气房，打开筛骨纸板，即筛骨外侧壁、眶内侧壁，即可进入眼眶内侧部。 And if we get in under the middle turbinate here, and open the air cells, we have a route through the nasal cavity and through the lamina papyracea, the lateral ethmoid wall, the medial orbital wall,a route into the medial orbit.
▼这是筛骨的上面观。筛骨与额骨连于此处，额骨构成了筛窦气房的顶壁。筛骨的外侧，即气房的外侧，即为筛骨的眶部，其构成了眶内侧壁，经此可进入眶内。 And here we see the ethmoid from above. But here it articulates, and the ethmoid air cells are roofed above by the frontal bone.And then laterally in the ethmoid, lateral to the air cells,we see the orbital plate of the ethmoid that forms the medial wall of the orbit through which we can approach it.
▼这是筛骨眶板的外侧观。上方与额骨相连。后方与蝶骨体外侧部相连，下方与一小部腭骨相连，这里与下方的上颌骨相连，前方与之相连的是泪骨 以及上颌骨的额突。 Just a lateral view of the orbital plate of the ethmoid. Above it articulates with the frontal bone.Posteriorly it articulates with the lateral part of the sphenoid body.Below it'll articulate with a little bit of the palatine bone.And then below with a maxillary,and anteriorly it'll articulate then with a lacrimal bone and the frontal process of the maxilla. But you wanna see all of these adjacent relationships.
▼筛窦气房可分为前组和后组。分界线位于中鼻甲附着于筛骨的后部。 And the ethmoid air cells can be divided into a anterior group and a posterior group.And that division is right at the posterior part of the attachment of the middle turbinate to the ethmoid.
▼下图示中鼻甲
▼通过后组筛房，可至眶尖附近，或可进入蝶窦外侧部。 And if you go through posterior ethmoid, you end up near orbital apex and in the lateral part of sphenoid sinus.
▼通过前组筛房向上，则可顺着筛板进入前颅窝。 If you work through the anterior ethmoid air cells above, you end up along the cribriform plate in the anterior fossa.
▼再换个角度来看筛骨。它实质上是两块骨在中线由筛板连接而成。 So here we see the ethmoid bone again. It's really two blocks of bone here connected across the midline by the cribriform plate.
▼筛骨的这部分即为中鼻甲。 And as the part of it, we have the middle turbinate.
▼从中鼻甲的外侧即可进入筛房。进一步向外侧打开，即可经由眶内侧壁，实现眶内侧入路的其中一种。 And if you get in lateral to the middle turbinate, you're into the air cells. And then you can open laterally, through the medial wall of the orbit to complete one of the types of medial orbitotomy.
▼筛窦气房的顶壁由额骨这一裂隙处的骨质封闭 And roofing the ethmoid air cells above is the hiatus in the frontal bone
▼额骨构成了眶顶。 frontal bone that forms the orbital roof.
▼现在我们将筛骨嵌入额骨的筛切迹。 And here we fit the ethmoid into the ethmoid notch of the frontal bone.
▼可见眶板的上界（箭头处）连于额骨，在其外侧即为眶顶。 And here the upper edge of the orbital plate articulates with the frontal bone, and then lateral to that is the orbital roof.
▼现在加入完整的上颌骨（下图）以重构完整的眶内侧壁、眶底及眶缘的下部。 And then we add in the full maxilla that complete the medial wall and floor or lower part of the orbital rim of the orbit.
▼我们再加入蝶骨，蝶骨大翼构成眶外侧壁的后部 And then we can complete the lateral wall of the orbit,
▼再加入构成眶外侧壁前部的颧骨 by adding a zygomatic bone which forms the anterior part of the lateral wall of the orbit.
▼下图示 上颌窦顶，其构成眶底。 And then below we have the roof of the maxillary sinus that forms the floor of the orbit.
▼在上颌骨、蝶骨大翼和颧骨（下图）之间，即为眶下裂，其外侧部常在进行眶外侧入路或眶颧入路前打开。 Also, here between maxilla, greater wing of sphenoid and zygomatic bone we have inferior orbital fissure,which we often open into the lateral part of it before doing a lateral orbitotomy or an orbitozygomatic approach.
▼下图示腭骨的眶突，参与构成眶底的一小部分。毗邻于筛板及上颌骨构成的眶底后部。 we have the orbital process of the palatine bone that forms a small part of the floor of the orbit. And then forming part of the floor of the orbit here adjacent the ethmoidal plate and the posterior part of the floor formed by the maxilla,
▼这部分腭骨，称为眶突 But, here's the part of the the palatine bone, the...
▼眶突，构成眶底的后内侧一小部分。 orbital process that forms the posteromedial part of the orbital floor
▼其后方为蝶腭孔，内有上颌动脉的分支穿行入鼻腔，供血于鼻中隔瓣，其常用于颅底的修补。 and behind that is the sphenopalatine foramen,through which the branches of the maxillary artery enter the nasal cavity that provide the vascularity for the nasoseptal flap that we use to close skull base.
▼下图示上颌骨（正面观）。筛骨眶板下方的眶内侧壁由上颌骨构成。 But that medial wall below the orbital plate is formed by maxilla.
▼这是上颌骨（内侧观）
▼这是上颌窦内侧的自然开口 Here's the natural hiatus in the medial wall of the maxillary sinus
▼这是腭骨
▼上颌窦内侧的自然开口被腭骨、下鼻甲遮蔽。 the hiatus that is closed in by palatine bone, by inferior turbinate.
▼上颌窦内侧的自然开口被下鼻甲的这一部分（下图1）以及这部分腭骨的垂直板（下图2）所遮蔽。 by this part of the inferior turbinate and also by some of the perpendicular plate of the palatine bone to close the maxillary hiatus.
▼沿此处附着的是筛骨的眶板。 And then attached along all of this area, is the orbital plate of the ethmoid.
▼因此，眶由7块颅骨构成。包括 眶顶的额骨（下图），眶外侧壁的蝶骨大翼 和颧骨，眶底则由上颌窦顶构成，眶内侧壁由上颌骨额突、泪骨、筛骨眶板、腭骨眶突构成 So the orbit is made up of seven bones. We have frontal bone in the roof,the lateral wall formed by greater wing of sphenoid and the zygomatic bone,the floor of the orbit formed by the roof of the maxillary sinus,
▼下图示眶外侧壁的蝶骨大翼和颧骨 the lateral wall formed by greater wing of sphenoid and the zygomatic bone,
▼眶底则由上颌窦顶构成，沿此部位有眶下沟或眶下管，开口于眶下孔，内有上颌神经走行。 the floor of the orbit formed by the roof of the maxillary sinus, along which we have the infraorbital groove, canal here ending at the infraorbital foramen along which V2 passes.
▼内侧，眶缘内侧部由上颌骨额突、以及泪骨构成。下图示上颌骨额突。 Medially, we have here medial part of orbital rim formed by frontal process of maxilla, and then the lacrimal bone
▼泪骨（下图）连于筛骨眶板的前界，并向上连于额骨，形成额筛缝。 lacrimal bone that articulates with the anterior edge of the orbital plate of the ethmoid, which articulates above with the frontal bone along the frontoethmoidal suture.
▼下图示筛骨眶板
▼下图示额骨，额筛缝、筛前、筛后管。 筛前管、筛后管内走行有眼动脉的筛前和筛后支，以及筛前和筛后神经。 We see the anterior and posterior ethmoidal canals that transmit the anterior and posterior ethmoidal branches of the ophthalmic artery, and the anterior and posterior branches of the ethmoidal nerves.
▼后方为视神经管（下图），其走行于蝶骨小翼内侧部。视神经管的外侧部由视柱构成，内侧部为蝶骨体。 Posteriorly, we have the optic canal that passes through the medial part of the lesser wing and the lateral part of the optic canal is formed by the optic strut which extends from the body of the sphenoid to the base of the anterior clinoid.
▼筛骨下方连于上颌骨。 Below the ethmoid we have the articulation here with the maxilla.
▼筛骨的后下界连于腭骨的眶突（下图），后者参与构成眶底。 And then at the posterior inferior edge,we have the part of the orbital floor formed by the orbital process of the palatine bone.
▼筛骨的后方连于蝶骨体（下图），此处为蝶窦的前界。 And then, along the posterior ethmoid, we have the articulation with the sphenoid body at the anterior edge of the sphenoid sinus in this area.
▼在充分掌握了这部分骨性解剖后，我们需进一步了解神经解剖。在眶尖，可见视神经管、视柱、前床突、眶上裂。 So that you wanna see and understand all of these articulations and begin to fit them together with the neuroanatomy. So that, at the orbital apex, we have optic canal, optic strut, anterior clinoid,and superior orbital fissure.
▼环绕于这一区域的是总腱环。总腱环是一环形腱环，为四块眼直肌的共同起点。其环绕于视神经管及眶上裂的中央部。 And surrounding this area we have the annular tendon. The annular tendon is the circular tendon from which the four rectus muscles arise. And the annular tendon surrounds the optic canal and the central part of the superior orbital fissure.
▼总腱环分为两部分，一部分内有视神经管，内有眼动脉穿行。另一个外侧部由这部分眶上裂围成，即为动眼神经孔，内有进出总腱环的神经穿行。 下图示视神经管及眶上裂的中央部。 And the tendon has two parts, a part through which the optic canal and the ophthalmic artery pass,and then the lateral part bordering the fissure is the oculomotor foramen, through which the nerves entering inside and outside the annular tendon pass.
▼通常可见一小的突起位于眶上裂外侧壁，即为总腱环的附着点。 Usually there's a small prominence on the lateral wall of the fissure to which the annular tendon attaches.
▼来看看四块眼直肌，均由总腱环发出。这是上直肌（下图） Here we have the four rectus muscles,which arise from the annular tendon.superior rectus,
▼这是 内直肌
▼这是 下直肌
▼这是 外直肌
▼眼动脉和视神经均穿行于 视神经管。 And, the ophthalmic artery and optic nerve pass through the optic canal.
▼在眼直肌内，为肌锥区域。 But inside the rectus muscles, you have the intraconal area
▼下图示动眼神经的分支，即上支和下支 The oculomotor...branches or divisions of the oculomotor nerve, superior and inferior division pass
▼动眼神经与外展神经（下图）相伴行。上述结构穿行于总腱环内，另外穿行其中的还有一些三叉神经的分支。 along with the abducens nerve，They pass through the annular tendon as does some of the branches of the first trigeminal division.
▼在眶尖部，走行于总腱环以外的是滑车神经（下图）、额神经的分支（包括眶上和滑车上神经），在外侧尚有发自眼神经的泪腺神经。 outside the annular tendon at the orbital apex, passes the 4th nerve, the branches of the frontal nerve, the supraorbital and supratrochlear, and then laterally from 1st division you have lacrimal nerve.
▼下图示额神经的分支，包括眶上神经、滑车上神经
▼下图示发自眼神经的泪腺神经。
▼另外，眼上静脉和眼下静脉 从总腱环以外穿出眼眶，但在远侧的眼眶内，上述静脉位于肌锥内，即在四块眼直肌内走行。 And then the superior and inferior ophthalmic veins run outside the annular tendon as they exit the orbit, but further forward in the orbit these veins come into the intraconal area here between the four rectus muscles.
▼这是动眼神经上支，其支配上睑提肌和上直肌。 We have here superior division of 3rd nerve that supplies levator and superior rectus.
▼动眼神经下支 支配内直肌、下直肌、下斜肌，并内含副交感运动性纤维行至睫状神经节。 inferior division of 3rd nerve. The inferior division supplies the medial rectus, inferior rectus, and inferior oblique muscles, as well as giving rise to the motor, parasympathetic root of the ciliary ganglion.
▼另外一支穿行于总腱环内的神经是三叉神经第一支（眼神经）发出的鼻睫神经。 And then passing through the annular tendon,we have the nasociliary branch of V1 that passes through the annular tendon.
▼而眼神经发出的额神经和泪腺神经 则在总腱环外走行。 While, the branches of the frontal and the lacrimal nerve pass outside the annular tendon.
因此我们需掌握穿行于视神经管内、总腱环以外、以及动眼神经孔内的各个结构。 So you wanna think about the structures that pass through the optic canal, and then the group of structures that pass outside the annular tendon, plus have an understanding of the structures that pass through the oculomotor foramen, part of the annular tendon.
▼再来看周围的结构，下图可见额窦 So that as you look at the surrounding structures, you wanna see the frontal sinus medially
▼下图示筛窦、蝶窦。 the ethmoid, and then the sphenoid.
▼去除眶顶即暴露眶骨膜。其内部填满了脂肪。对于穿行于脂肪内的结构我们需要掌握，但同样需要了解一点，即在眶内进行手术时，需要尽可能保留这些脂肪，因为去除脂肪，将使得眶内的肌肉和神经形成疤痕化，从而影响眶内结构的功能。 眼眶手术，神经外科对其作出的一项革新是自动牵开器的应用，这可在术中保留解剖层面的同时保护眶内脂肪而维持重要结构的功能。 And then if you remove the orbital roof you see the periorbita, and inside of this it's filled with fat.And we wanna understand the structures passing through that fat,and also understand that when we're doing orbital surgery，you wanna preserve that fat as much as possible,because if you lose that fat,then the muscles and nerve become scar together and the orbit doesn't function very well. So for working in the orbit,one of the innovations of brain surgery which are self-retaining retractors become very important in maintaining those surgical planes for surgery while preserving the fat that makes the orbit function as well as it does.
▼这是眶上裂 Here we see the superior orbital fissure,
▼这是视神经管
▼眶内侧壁的鼻窦可为进入眶内的通路 the sinuses along the medial wall that are routes to the orbit,
▼而眶外侧壁，可为眶外侧入路提供路径。 or the lateral orbital wall that provides the route for the lateral orbitotomy.
▼在处理视神经附近时，我们需要了解眶内有一些结构，沿着外侧壁入眶，但随后即越过视神经上方走向内侧，从而阻碍我们暴露视神经（下图） And we want to understand as we work toward the optic nerve,that there are a group of structures in the orbit that enter the orbit on the lateral wall of the orbit but then cross medially above the optic nerve and tend to block access to the nerve
▼其中之一即为滑车神经。 one of these is the trochlear nerve.
▼切开总腱环的位置可位于上斜肌和上睑提肌之间。但这一切口需注意保护滑车神经。 You can divide the annular tendon here between superior oblique and levator. But if you make an incision, you wanna preserve trochlear nerve.
▼同样地，额神经以及其分支眶上神经和滑车上神经 在眶内的走行也是从外向内。 Also, frontal nerve with its supraorbital and supratrochlear branches passes from lateral to medial here in the orbit.
▼另外还有数个从外向内横跨于眶内的结构。其中一个是眼上静脉，从上方越过视神经。 And we'll talk about a number of other structures that cross from lateral to medial. Another one is the superior ophthalmic vein that crosses above the optic nerve
▼眼动脉同样从上方越过视神经。 as does the ophthalmic artery.
▼再来看眶尖。我们从上直肌和外直肌之间分离，即从外侧打开眶尖。 And here we're back at the orbital apex.We've divided between the superior and lateral rectus here.You can open the orbital apex from laterally.
▼这是发自眼神经的额神经，于总腱环外进入眼眶。 Here we see the frontal branch of V1 pass to the orbit outside the annular tendon.
▼但同样为眼神经分支的鼻睫神经（下图），则行于总腱环内，它也是横跨于视神经上方的众多结构之一。 But the nasociliary nerve, the branch of V1,passes through the annular tendon,and it's a number of...one of the structures that passes above the optic nerve.
▼这是外展神经，其穿行于总腱环内，支配外直肌。 We see the 6th nerve pass through the annular tendon to the lateral rectus.
▼这是泪腺神经，其向上行至泪腺区域。 And here's the lacrimal nerve, that passes up to the area of lacrimal gland.
▼这是眼动脉，在90%的病例中，其从外向内走行于视神经上方，但10-15%的情况下，其走行于视神经下方。 Here's the ophthalmic artery, which in 90% of cases will pass above the optic nerve from lateral to medial,but in about 10-15% of cases you'll find the ophthalmic artery below the nerve.
▼我们切开总腱环，将外直肌翻向外侧。可见外展神经进入外直肌 Just another picture we've divided the annular tendon between the lateral rectus that we've folded laterally here.We see the abducens nerve entering it,
▼鼻睫神经（下图）在上方跨越视神经 the nasociliary crossing above here the optic nerve,
▼同样的还有额神经（下图）和滑车神经。 as does the frontal branch and the trochlear nerve here.
▼下图示滑车神经
▼这是睫状长神经的一支，内含行至眼球的交感纤维。 Here we see one of the long ciliary branches that carries sympathetics to the globe.
▼这是动眼神经下支，内含进入睫状神经节的副交感节前运动纤维。 But here we see the inferior division of the oculomotor nerve that gives rise to the motor, parasympathetic root of the ciliary ganglion in this area.
▼相关内容稍后再会讨论，但最先需要掌握的就是上述骨性结构及眶内复杂的解剖。 And we'll talk a little bit more about that, but you wanna understand the osseous wall as well as the complex anatomy inside the orbit.
▼接下来我们分层打开眶顶，打开眶骨膜 Just when we take off the orbital roof,and open the periorbita,
▼首先暴露的神经为支配上斜肌的滑车神经 the first nerves that we see are trochlear nerve to superior oblique,
▼还有发出滑车上神经及眶上神经的额神经 the frontal branch gives rise to supratrochlear and supraorbital,
▼外侧的泪腺神经 and then laterally the lacrimal nerve.
▼进一步深入，则可见眼上静脉，其越过视神经上方。 And then as we go deeper we see the superior ophthalmic vein that passes above the optic nerve.
▼在其附近，其他横跨视神经上方的结构包括鼻睫神经（下图），以及眼动脉。 And then adjacent it, other structures that pass above the nerve, the nasociliary nerve,and the ophthalmic artery.
▼下图示眼动脉
▼这支走行于视神经下方的是 动眼神经下支的分支 Here we see another nerve that passes below the optic nerve. What is that nerve? That's the branch of the inferior division inferior division of 3rd nerve
▼这里暴露的是支配内直肌的动眼神经下支。其走行于视神经下方。 Here we see this branch to the medial rectus again that passes below the optic nerve to reach the medial rectus, the branch of the inferior division.
▼眶尖外侧部最重要的一个解剖，即为发源于眼动脉的视网膜中央动脉。 One of the important bits of anatomy, very critical to dealing here at the lateral part of the orbital apex is the origin of the central retinal artery.
▼它通常是第一个发自眼动脉的分支，并在动脉跨越视神经之前即发出。 And it's commonly the first branch of the ophthalmic artery before it crosses above the nerve.
▼视网膜中央动脉 穿入视神经鞘并向前行至眼球，进入视神经中央。 And here just a picture of the central retinal artery. The artery enters through the sheath and then passes forward to the globe. and the center of the optic nerve.
▼微小的出血、轻微的电凝，即可损坏该细小动脉，若损伤了这支小动脉，患者将失去该侧视力。 And just losing that tiny little branch, just get a little bleeding, a little bipolar, and a tiny artery and it's lost and the patient can end up with a blind eye.
▼因此需要特别注意保护视网膜中央动脉，特别在眶尖外侧部、视神经外下侧进行操作时。 So it's very important to think about saving the central retinal artery in here below and lateral to the optic nerve along the lateral part of the orbital apex.
▼在处理眼眶及视神经管区域时 As you approach the orbit, and working from the optic canal
▼可在总腱环内侧，于上睑提肌和上斜肌之间分离。 you can divide the annular tendon mediallybetween the levator and superior oblique.
▼但需注意保护滑车神经，这里可见总腱环已打开，而滑车神经也得以保留。 But you wanna preserve the trochlear nerve, and here it's been divided with the trochlear nerve preserved.
▼也可在总腱环外侧进行分离，以处理累及眶上裂的病变。但在上睑提肌和外直肌之间分离总腱环外侧时，需将眼上静脉留在外侧。 You can also divide the annular tendon laterally if you're working with a lesion coming through the superior orbital fissure. But to divide the annular tendon laterally between levator and lateral rectus you wanna let the superior ophthalmic vein go laterally.
▼眼上静脉较为粗大，下图示眼上静脉。
▼若将眼上静脉与上睑提肌一起推向内侧，则会阻挡对于眶尖部视神经外侧的暴露。 and if you pull it medially with the levator, it blocks access to the orbital apex on the lateral side of the optic nerve.
▼因此，恰当的方式是将眼上静脉牵向外侧，将上睑提肌牵向内侧。 So it's better to let that vein go laterally, and let the levator without the vein be retracted medially.
▼一旦从上睑提肌和由外展神经支配的外直肌之间打开，即可见动眼神经分成上支和下支。下图示上睑提肌（左侧） Here once you open between the levator and here 6th nerve going to lateral rectus, you see the division of the oculomotor into superior and inferior division.
▼下图示外展神经
▼下图示动眼神经 分为上支、下支
▼动眼神经分叉处位于前床突下方。下图示前床突（已磨除） Those occur below the area of the anterior clinoid.
▼下图示向内走行的滑车神经。 the 4th nerve is passing medially.
▼这是鼻睫神经，穿过总腱环行于视神经之上。 And here we see nasociliary nerve pass through the annular tendon above the optic nerve.
▼这是睫状神经节。 here we see ciliary ganglion.
▼这是一支感觉神经，支配角膜的感觉。它并不在睫状神经节内形成突触。 Can anyone tell me what nerve that is? That's the sensory root, that's the nerve that carries corneal sensation.It doesn't synapse in the ciliary ganglion.
▼这是动眼神经下支。其内发出副交感根，在睫状神经节内换元控制瞳孔的舒缩。 But here's inferior division of III. This is the parasympathetic root, the motor root of the ciliary ganglion that controls the pupil.
▼再来看看通过眶内侧壁的入路。这是上斜肌，及其骨性附着处 Here's just the approach along the medial orbital wall. Here, the trochlea of the superior oblique muscle
▼上斜肌走行于上直肌下方，附着于眼球的外侧部（箭头处）。 diving in under the superior rectus and attaching to the lateral part of the globe.
▼这是鼻睫神经 But here's nasociliary nerve,
▼这是眼动脉
▼这是泪腺神经，支配泪腺，发自眼神经。 Here's lacrimal branch going to lacrimal gland that comes from V1.
▼支配泪腺的副交感纤维是如何走行的？该通路起源于后颅窝的面神经、岩前大神经、翼管神经 But, lacrimation starts back in the facial nerve in the posterior fossa, greater petrosal,to vidian nerve,
▼翼管神经行于翼管内，到达翼腭神经节，随后在眶底进入上颌神经。 How does parasympathetic innervation get to lacrimation? It gets there from vidian nerve that we saw coming through vidian canal to pterygopalatine ganglion. It gets into V2 along the floor of the orbit.
▼上颌神经发出颧神经，其支配眶外侧的部分皮肤感觉。 From V2...the V2 gives off the zygomatic nerve that innervates some of the skin around the lateral orbit.
▼这些副交感分支即随着上颌神经的颧支进入眼神经的泪腺神经 those parasympathetic branches that get into the zygomatic branch of V2 jump to the lacrimal nerve
▼而泪腺神经即为到达泪腺的副交感最后通路。 the final pathway for lacrimation then comes through lacrimal nerve.
▼这是上述相关结构的概览，在颅中窝，眼神经的分支进入眶尖，上颌神经沿着眶底外侧走行，下颌神经进入颞下窝。 you wanna see this all in the context of the adjacent structures,middle fossa,branches of V1 entering the orbital apex, V2 running along the lateral orbital floor, and then V3 here entering infratemporal fossa.
▼放大上述解剖结构，可见颅内病变侵入眶内的多条路径，包括从鼻窦、颅神经孔道、视神经管 进入眶内。我们需掌握所有这些复杂的解剖关系。 But as you blow up all of this anatomy where there...there're multiple routes that intracranial pathology can extend to the orbit out of the sinuses, or along the foramen of the cranial nerves, or along the optic canal,to the orbit. And you wanna understand all of these complex relationships.
▼再来快速复习一下后方的海绵窦，动眼神经行于前床突下方. then we do just a quick review of cavernous sinus behind with 3rd nerve passing below the anterior clinoid,
▼滑车神经、眼神经、外展神经于此处穿行于眶上裂 here, 4th nerve, V1,abducens nerve,here passing through the superior orbital fissure
▼上颌神经于此处离开中颅窝，沿着眶底走形。 V2 exiting here middle fossa to run along the floor of the orbit.
▼我们移除了前床突。在前床突下方，可见滑车神经穿行至眶尖外侧部，向内走行支配上斜肌。 Here we've removed the clinoid. And just under the clinoid here,we see the 4th nerve passing from lateral part of orbital apex,to the medial part to innervate the superior oblique.
▼此处可见动眼神经分成上支和下支 And here we see the division of the 3rd nerve into superior and inferior division,
▼动眼神经分叉处恰位于前床突前部的下方。 this taking place below the anterior part of the anterior clinoid.
详细海绵窦解剖请参见本公众号文章《海绵窦解剖---Rhoton解剖视频学习笔记系列》
▼这是左侧眶尖，前床突已移除 Here we see another orbital apex, clinoid removed,
▼这是视神经管
▼在视神经管外侧，可见这些结构穿行于动眼神经孔（属于总腱环的一部分），以及其他行于总腱环以外的结构。 And then, lateral to the optic canal, we see some of the structures passing through the oculomotor foramen of the annular tendon,and other structures passing outside.
▼这里，我们移除前床突，以及眶上裂的外侧壁。 Here now, we see we've removed the clinoid,the lateral wall of the superior orbital fissure.
▼这是动眼神经孔 Here you see the oculomotor foramen
▼滑车神经于眶尖上方走行 the trochlear nerve passing above the orbital apex,
▼额神经行于总腱环以外。 frontal nerve passing outside the annular tendon.
▼外展神经（下图）和鼻睫神经在眶尖处穿行于动眼神经孔的外侧缘。 But 6th nerve and nasociliary nerve passing through the lateral edge of the the oculomotor foramen here at the orbital apex.
▼下图示鼻睫神经
▼这里我们牵开额神经 Here we retract the frontal nerve.
▼可见鼻睫神经 You see the nasociliary nerve
▼鼻睫神经下方为外展神经，其行至外直肌 and below it the 6th nerve going to the lateral rectus,
▼动眼神经在此处分成上支和下支 and here the division into superior and inferior divisions of 3rd nerve,
▼滑车神经向内侧走行于已被移除的前床突的前部下方。 and the trochlear nerve passing medially below the anterior part of the anterior clinoid that has been removed.
▼现在我们在总腱环的外侧进行分离 Here we've divided the annular tendon laterally here,
▼可见动眼神经上支进入上睑提肌、上直肌 and we see superior division of 3rd nerve going to levator, superior rectus,
▼动眼神经下支进入下直肌、下斜肌 inferior division going to inferior rectus,inferior oblique,
▼动眼神经下支发出副交感运动根进入睫状神经节。 giving rise also to the motor parasympathetic root of the ciliary ganglion.
▼这是行经睫状神经节的感觉根，支配角膜的感觉，其发自眼神经。 And here we see the sensory root of the ciliary ganglion that conveys corneal sensation through V1.
▼下图所示这些神经分支发自鼻睫神经（下图），负责眼球的交感功能。 And, some of the branches of nasociliary nerve that carry sympathetic function to the globe.
▼现在我们从前方来看眼眶。这是眼轮匝肌。 We wanna just look at the orbit a little bit from anteriorly. Here we see the orbicularis oculi.
▼在眼眶前部，上方，与上睑提肌相结合的是上睑板 And, looking into the anterior orbit,above here, incorporated into the levator is the superior tarsal plate of the eye,
▼这是内侧和外侧眦韧带。 medial and lateral canthal ligament.
▼可见走行于上直肌下方的上斜肌肌腱。 We see diving in under the superior rectus, the tendon of the superior oblique.
▼下方可见附着于上颌骨的下斜肌 And below we see the attached to the maxilla, the inferior oblique
▼下斜肌 走行于下直肌下方，至上斜肌附近附着于眼球的外侧部。 the inferior oblique that passes below the inferior rectus to attach near the superior oblique along the lateral part of the globe.
▼深入观察眶顶，可见上斜肌肌腱 附着于此处（箭头处）的额骨。该处的额骨上有一小凹陷。 As you look into the orbital roof,we see the tendon of the superior oblique anchored here to frontal bone.There's a little dimple in the bone at that point.
▼这是滑车上神经
▼这是眶上神经
▼下图示上睑提肌、上斜肌、内直肌和外直肌。 the levator, superior oblique,and medial and lateral rectus muscles.
▼抬起上睑提肌，可见上直肌 Here we've elevated the levator, we see the superior rectus,
▼下图示 上斜肌肌腱 the tendon of the superior oblique, 
▼下斜肌行于下直肌下方 the inferior oblique passing below the inferior rectus
▼这是外直肌 和 内直肌。 the lateral and medial rectus muscles.
▼从前方进入眼眶时，附着于眶缘的是眶隔，其分隔后方的眼球和眶脂肪与前方的巩膜和角膜。 And, when you enter the orbit from anteriorly, attached along the orbital rim is the orbital septum, that separates the globe and the orbital fat from the sclera and cornea anteriorly.
▼下图示巩膜和角膜。 sclera and cornea anteriorly.
▼到达眶顶、眶外侧壁或两者的入路，可通过这一小骨辦完成 And for the approaches to roof and lateral wall and both involved, you can use this small bone flap
▼这在之前已介绍过，详见本公众号文章《眶颧入路---Rhoton解剖视频学习笔记系列》。这一入路可到达眼眶，或可进入外侧裂。 we've shown before. That gives access to the orbit, or along the Sylvian fissure.
▼对于巨大病变，可行单骨片眶颧开颅，或双骨片，或三骨片眶颧入路暴露该区域。 For larger lesions you can do one-piece orbitozygomatic craniotomy, or two-piece,or three-piece approaches to this area.
▼或者也可作一小骨瓣打开眶顶和外侧壁，显露硬膜和眶骨膜。 Or you can use very small craniotomies of the superior and lateral wall that give access to dura and the periorbita. 
因此可以选择上述不同的入路作不同的骨瓣。
So you can tailor these approaches from above using a variety of flaps.
▼但对于眶外侧入路，需注意面神经的颞支，其支配额肌以及眼轮匝肌。 but lateral orbitotomy, you always in doing it wanna be very careful of these branches of the facial nerve that go to frontalis and the orbicularis oculi.
▼但也可经所谓的外眦切开术。我认为现今这个入路更受欢迎，从这里（箭头处）稍向后暴露出眶外侧壁，从而来进行眶外侧切开术。 But you can do it through a lateral sort of canthotomy. I think a more favoured one today is to come through this area, and then turn back a little bit on the lateral orbital wall for a lateral orbitotomy.
▼暴露额骨、颧骨。 And here we see frontal,zygomatic bone.
▼然后行眶外侧切开术，沿着此处的颧骨，去除眶外侧缘和部分眶外侧壁。可进一步向后扩展至眶尖。 you can do the lateral orbitotomy here along the zygomatic bone, and lift up the lateral orbital rim and some of the lateral orbital wall. You can extend this back to lateral to the orbital apex. 
▼现在从外侧向内暴露，可见外直肌、下直肌 Here looking in from laterally we see the lateral rectus,inferior rectus
▼这支纤长的神经向前，发自动眼神经下支，支配下斜肌。 and then this really long nerve that's going forward from the inferior division to the Inferior oblique, that's...forward.
▼上方的是泪腺神经 
▼如今，对于海绵窦前部（箭头处）的暴露，也可通过该入路进行。 And, one of the things that's happening today is that for getting into anterior part of cavernous sinus,the bone in this area has been removed. 
▼现在抬起外直肌，可见视网膜中央动脉，位于视神经下方。 here we just lift up the lateral rectus and we see the central retinal artery here below the nerve.
▼我们可进一步向后方切除眶上裂的外侧缘，即可进入海绵窦的前部，即通过上述入路向后扩展。 And, you can elevate backwards and remove the lateral edge of the superior orbital fissure, and then get into the anterior part of cavernous sinus through this approach, and work back through this area.
▼我们可从侧方打开总腱环，即可暴露从海绵窦前部一直向前至眶内。 You can divide the annular tendon laterally, and have access to anterior cavernous sinus all the way forward into the orbit.
▼再简单看看眶外侧入路，去除眶外侧壁，可见泪腺。 Just another quick lateral orbitotomy here, and lateral orbital wall remove,lacrimal gland,
▼这是外直肌 
▼随后将外直肌抬起。这里再次暴露出视神经的下外方为视网膜中央动脉，这在术中需时刻注意保护。损伤该血管即会导致失明。 and then the lateral rectus elevated. And again in this area, inferolateral below the optic nerve,you have the central retinal artery that is always to be preserved if possible.If lost, it leads to a blind eye.
▼我们还可以通过上颌窦打开眶底 Then you can access the orbit through the maxillary sinus through the floor here,
▼或打开上颌窦后壁进入翼腭窝，可见翼管 or you can get in through the possible wall to the pterygopalatine fossa,▼或向内进入蝶窦和筛窦。这是眼眶的筛板壁，恰位于上颌骨上方。 or work medially into the sphenoid sinus and ethmoids. The ethmoidal wall of the orbit is here just above the maxilla.
▼因此，我们可利用该区域，经眶底入眶。 So that, you can get in through this area, come through the floor and have great access to the floor of the orbit. 
▼我们可进入上颌窦，从前方将其打开 And you can come into the maxillary sinus here from anteriorly,
▼随后从下方经眶底进入眶内。这常用于Graves病的眶部减压。 and then work below, through the floor of the orbit.This is often used for orbital decompression in Graves.
▼这里可见筛窦气房 在眶下方延伸的范围。这里显露出了所有筛窦气房。因此我们也可利用筛窦，进行经筛窦的眼眶入路，通过眶内侧壁，以及此处的眶底进入眶内。 And here you see how far the ethmoid air cells extend below the orbit.These are all ethmoid air cells that have been drilled out.So the route through the ethmoid,you can come in through the nose through the ethmoid and access medial wall of orbit,as well as floor in this area.
▼也可经筛窦进入上颌窦，并向前暴露所有这片区域，直至下斜肌。 And then you can get into maxillary sinus and have access to all of this area forward to the inferior oblique muscle.
▼我们来看下方入路，这里看到的又是视网膜中央动脉， 从下方进入视神经。 And just a view from below but we see again the central retinal artery entering the optic nerve from below.
▼在视神经下方，动眼神经下支的一部分在视神经下方行至内直肌。 And this is a view from below the nerve, part of inferior division going under the optic nerve to the medial rectus.
▼这是一例少见的眼动脉，其向内走行于视神经下方。 And this is one of these uncommon ophthalmic arteries that passes medially below the optic nerve. 
▼将眼动脉牵向后方，这是视网膜中央动脉 Here we pull that ophthalmic artery posteriorly, and you see the central retinal artery
▼视网膜中央动脉进入视神经的下表面。 entering the lower surface of the optic nerve. 
▼通过内侧上颌骨切开术进入眶内的入路有多种术式。 可以仅仅在此处切开皮肤，向后沿着上颌骨额突、泪骨、筛骨眶板（下图）到达眶内侧壁。 And then there're a variety of medial maxillotomy approaches that you can access the orbit. You can just do an incision here, and work back along the frontal process of the maxilla, along the lacrimal bone back to the orbital plate to access medial orbit.
▼也可作局限的内侧上颌骨切开术，在中鼻甲下方进入鼻腔，然后经由筛窦气房进入眶内侧壁。 You can do a small medial maxillotomy and get into the nasal cavity under the middle turbinate,and work through the ethmoid air cells into the medial orbit,
▼这就是向内侧，从中鼻甲下方，经筛窦入眶。 you have medially then,you can get under the middle turbinate,work through the ethmoids.
▼也可从前方打开上颌窦，经筛窦和上颌窦顶，进入眶内侧。 Or you can get into the anterior wall of the maxillary sinus, work through the ethmoids, and the roof of the maxillary sinus to the medial orbit. 
▼这是经上颌窦入眶。 You can come through the maxillary sinus.
▼或仅仅作一小切口（下图箭头），通过内眦切开，向后至眶尖。 Or just a small incision, a sort of medial canthotomy approach back to the orbital apex. 
▼但是 经由上颌骨的入路，通过筛窦、外侧蝶窦、以及鼻腔，可暴露所有这片区域。 But...using these routes through maxilla,through the ethmoids,through the lateral sphenoid,through the nasal cavity,you can access all of this area.
▼这是眶尖，附近为总腱环。另外，利用鼻窦从内向外的入路也可到达所有上述区域。 Here we see the orbital apex, adjacent the annular tendon. But, coming through the sinuses medially you have access to all of this area.
▼来看看鼻腔，这是下鼻甲、中鼻甲、上鼻甲。 And just the view as you work through the nasal cavity, inferior, middle, superior turbinate.
▼切除中鼻甲和上鼻甲，打开鼻腔外侧壁的筛窦气房。即可显露筛骨纸板，即为眶的内侧壁 We remove middle and superior turbinate and open the ethmoid air cells in the later wall of the nasal cavity.And you're up to the lamina papyracea here, the ethmoidal medial wall of the orbit,
▼打开即可见内侧的眶骨膜。 and here the periorbita medially.
▼因此利用这些经鼻腔入路，通过筛窦、上颌窦顶，可以对眶底和眶外侧壁实现广泛的暴露。 And using the approaches through nasal cavity, through ethmoid, roof of maxillary sinus,you have fairly wide access to the floor and lateral wall of the orbit
▼这是从中鼻甲下方进入 So that you get in under the middle turbinate,▼我们可向外侧，通过中鼻甲，打开筛窦（下图）。 So you can work lateral to the middle turbinate,through the ethmoids.
▼在开放筛窦后，即可暴露所有眶板区域，直至由额骨构成的筛房顶壁（下图）的下方。通过此处还可进入前颅窝。 And when you work through the ethmoids,well, you expose all of this orbital plate below the roof of the ethmoids here that's formed by frontal bone.That leads to the anterior fossa.
▼因此我们仅仅从中鼻甲下方，即可暴露整个眶内侧壁。下图示眶内侧壁 But just getting in under the middle turbinate, you have access to all of this medial wall of the orbit.
▼去除筛窦气房，即可暴露眶尖附近的眶内侧壁。 and remove ethmoid air cells, and it delivers you up here to medial wall of orbit near the orbital apex. 
▼还可打开部分海绵窦，其位于眶尖后方。 You can access some of cavernous sinus here behind the orbital apex. 
▼蝶骨小翼的内侧部，有视神经管通过，包绕于视神经及眶上裂的结构，即为总腱环，眼球各直肌起源于此。 And it's good as you think of the osseous anatomy to think of the related neural and vascular structures. So that, here at the medial part of the lesser wing, we have the optic canal, and then, here surrounding the optic nerve and superior orbital fissure,we have the annular tendon from which the rectus muscles arise. 
▼视神经管在大多数情况下，位于蝶窦的上外侧，但在少数情况下，筛窦可向后延伸，此时的视神经管可位于筛窦的后部。 And the optic canal can either be...well, most commonly, in the superior lateral part of the sphenoid sinus, but at times, the ethmoid can extend posteriorly,and you'll find the optic canal in the posterior part of the ethmoid sinus.
▼此处，走行于眶底的是上颌神经，在眶下裂的内侧部。 Below here, along the floor of the orbit, we have V2.And below the medial part of the inferior orbital fissure,
▼有开口与翼腭窝相沟通，此处包含翼管的前端、圆孔，内走行有上颌神经，其沿着眶底走行。 opening into the fissure is the pterygopalatine fossa, where we see the anterior end of the vidian canal, and foramen rotundum transmitting V2, that runs along the floor of the orbit. So as we look at osseous anatomy, we always want to have that view of the related neurovascular anatomy.
▼通过此入路，还可暴露蝶鞍（下图） And working through that area, you can access sella,
▼继续暴露右侧的海绵窦前内侧壁、动眼神经、眼神经、外展神经、上颌神经， anteromedial wall of cavernous sinus, 3rd nerve,V1,6th nerve, V2,...right side,
▼这是左侧所见。向前经眶板（箭头处） same anatomy on the left side.And then, once you work forward through the orbital plate,
▼即可经眶内侧壁，循着上述神经血管至眼眶内侧部。 well, you're into the medial orbital wall and can follow all of these structures into the medial orbit.
▼有时，当病变极其复杂时，我们可进行低位上颌骨切开术 And then sometimes the pathology gets very complicated, and you can use a lower maxillotomy
▼从牙槽突向上至眶底。 from the alveolar process, up to the floor of the orbit.
▼同时联合额颞开颅，则可显露眶底、眶外侧壁、海绵窦、眼神经、上颌神经、下颌神经。这基本上可暴露所有前外侧颅底的复杂病变。 And combine that then with a frontotemporal craniotomy that gives you access to floor, lateral wall of orbit, cavernous sinus, and V1, V2, V3. That can basically expose all of the anterolateral skull base for very complicated lesions.
▼最后，从上方，我们可作一双额骨瓣开颅，来暴露复杂病变 And from above, you can use bifrontal craniotomy to access complicated lesions that may
▼其范围包括双侧眼眶的内侧壁 involve both medial wall of both orbits,
▼或向后扩展至蝶窦。 or extend back into the sphenoid sinus.
▼用该入路我可以切除累及所有这些鼻窦、眶内侧壁的脊索瘤。 And I've removed chordomas involving all of this area of sinus, medial wall of orbit. 
▼另外还可进行硬膜下操作。 以上就是眼眶的解剖及相关入路的概述。 And you have intracranial access.That's an overview of the different walls of the orbit and the intraorbital anatomy.
我们学习解剖的目的是通过我们最完美的手术技术使每一例患者得到最佳的救治。 We've studied all of this anatomy to make what is a delicate, fateful, awesome experience for our patients more accurate, gentle and safe.
▼Rhoton解剖视频学习笔记系列，请点击浏览： 1.幕上解剖(1)---Rhoton解剖视频学习笔记系列 3.前颅底(2)与鼻腔解剖---Rhoton解剖视频学习笔记系列 5.颞骨解剖(中颅窝部分)---Rhoton解剖视频学习笔记系列
6.颞骨解剖(乳突部分)---Rhoton解剖视频学习笔记系列 7.颞骨解剖(后颅窝部分)与桥小脑角区---Rhoton解剖视频学习笔记系列 8.筋膜间-骨膜下入路---Rhoton解剖视频学习笔记系列 11.头颈部解剖---Rhoton解剖视频学习笔记系列 12.耳后经颞入路至颈静脉孔区---Rhoton解剖视频学习笔记系列
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