The inferocentral whorl region and its directional patterns in the corneal sub-basal nerve plexus: A review.

There has been a growing application of in vivo confocal microscopy (IVCM) in the examination of corneal microstructure, including different corneal layers and corneal nerve fibers in health and in pathological conditions. Corneal nerves forming the sub-basal nerve plexus (SBNP) beneath the corneal basal epithelial cell layer in particular have been intensively researched in health and disease as a marker for corneal neurophysioanatomical and degenerative changes. One intriguing feature in the SBNP that is found inferior to the corneal apex, is a whorl-like pattern (or vortex) of nerves, which represents an anatomical landmark. Evidence has indicated that the architecture of this 'whorl region' is dynamic, changing with time in healthy individuals but also in disease conditions such as in diabetic neuropathy and keratoconus. This review summarizes the known information regarding the characteristics and significance of the whorl region of nerves in the corneal SBNP, as a potential area of high relevance for future disease monitoring and diagnostics.

Anatomic Variations of the Lateral Branch of the Supraorbital Nerve Observed in Endoscopic Forehead Surgery.

Surgeons dissect carefully in the medial third of the supraorbital rim to preserve the supraorbital nerve (SON) during surgical forehead rejuvenation. However, the anatomic variations of SON exit from the frontal bone have been researched in cadaver or imaging studies. In this study, we report a variation in the lateral branch of SON observed in an endoscopic view during forehead lifts. A retrospective review of 462 patients who underwent endoscopy-assisted forehead lifts between January 2013 and April 2020 was performed. Data, including the location, number, and form of the exit point and thickness of SON and its lateral branch variant, were recorded and reviewed intraoperatively, utilizing high-definition endoscopic assistance. Thirty-nine patients and 51 sides were included, and all patients were female, with a mean age of 44.53 (18-75) years. This nerve exited a foramen in the frontal bone ~8.82 ± 2.79 mm lateral to SON and ~1.89 ± 1.34 mm from the supraorbital margin vertically. Observed thickness variations of the lateral branch of SON included 20 small, 25 medium, and 6 large nerves. This study revealed various positional and morphologic variations of the lateral branch of SON in an endoscopic view. Thus, surgeons can be alerted of the anatomic variations of SON and establish careful dissection during procedures. In addition, the findings of this study will be useful in planning nerve blocks, filler injections, and migraine treatments in the supraorbital region.

Corneal Health during Three Months of Scleral Lens Wear.

SIGNIFICANCE: This study evaluated the effects scleral lens wear has on corneal health using fluorometry and in vivo confocal microscopy. No subclinical changes on healthy corneas of young subjects were observed during 3 months of scleral lens wear. PURPOSE: This study aimed to evaluate the effects 3 months of scleral lens wear has on the corneal epithelial barrier function, dendritic cell density, and nerve fiber morphology. METHODS: Twenty-seven neophytes (mean [standard deviation] age, 21.4 [3.9] years) wore scleral lenses of a fluorosilicone acrylate material bilaterally (97 Dk, 15.6 to 16.0-mm diameter) for 3 months without overnight wear. Subjects were randomized to use either Addipak (n = 12) or PuriLens Plus (n = 15) during lens insertion. Measurements of corneal epithelial permeability to fluorescein were performed with automated scanning fluorophotometer (Fluorotron Master; Ocumetrics, Mountain View, CA) on the central cornea of the right eye and the temporal corneal periphery of the left eye. Images of the distributions of corneal nerve fibers and dendritic cells and nerve fibers were captured in vivo with a confocal laser scanning microscope (Heidelberg Retina Tomograph, Rostock Cornea Module; Heidelberg Engineering, Heidelberg, Germany) on the central and inferior peripheral cornea of the left eye. Corneal measurements and imaging were performed at baseline and after 1 and 3 months of lens wear. RESULTS: The corneal permeability values in natural log, dendritic cell densities, and nerve fiber morphology did not significantly change from baseline to 1 and 3 months of lens wear, for both central and peripheral corneal regions (P > .05). Dendritic cell density at the inferior cornea was higher than the central cornea throughout the study (P < .001). No relationships were observed between each outcome measurements and the saline solution groups (P > .05). CONCLUSIONS: Scleral lens wear for 3 months on healthy cornea of young subjects did not affect corneal epithelial barrier function, nerve fiber, and dendritic cell densities. Buffered and nonbuffered saline solutions impacted the corneal health in similar ways.

Anatomical study of the supraorbital and supratrochlear nerves: A new classification and application to understanding some migraine headaches.

The frontal nerve is the largest branch of the ophthalmic nerve. This nerve gives rise to two terminal branches, the supraorbital (SON) and supratrochlear nerves (STN). To the best of our knowledge, there are no reports describing the detailed proximal course of these nerves while inside the orbit. Therefore, the goal of this study was to clarify the anatomy of the SON and STN inside and at their exit from the orbit. Twenty sides from ten fresh-frozen cadavers were used in this study. Intra and extra orbital dissections were performed to observe the course of the SON and STN. Additionally, measurements of the nerves were made at these locations. The course of the SON and STN inside the orbit was classified into three groups depending on the STN branching pattern from the SON. The group without any branch from the SON and STN inside the orbit was the most common. The exit points of these nerves were via the supraorbital notch, foramen, or neither a notch nor foramen. A distinct fibrous band was consistently found tethering the nerve except in specimens with nerves traversing a bony foramen. The mean diameters of the SON and STN were 1.3 ± 0.2 and 0.7 ± 0.1 mm, respectively. The results of this study further our knowledge of the course and morphology of the SON and STN and might be useful for better understanding and potentially treating some forms of migraine headache due to SON or STN compression/entrapment. Clin. Anat. 33:332-337, 2020. © 2019 Wiley Periodicals, Inc.

Mapping the entire nerve architecture of the cat cornea.

OBJECTIVE: To provide a complete nerve architecture and neuropeptide distribution in the cat cornea. ANIMALS STUDIED: Two adult domestic cats. PROCEDURE: The cat corneas were stained with protein gene product (PGP) 9.5 antibody-a pan marker for nerve fibers-and then divided into four quarters and double labeled with calcitonin gene-related peptide (CGRP) or substance P (SP) antibodies. Relative corneal nerve fiber densities and nerve terminals were evaluated in whole mount images by computer-assisted analysis. RESULTS: An average of 21.5 ± 2.1 thick stromal nerves enters the cornea around the limbus where they split into many branches going up to the anterior stroma. Some branches link to each other, but most of them penetrate the basement membrane in the periphery to give origin to subbasal bundles, which run centripetally and merge to form a whirl-like structure (vortex) at the center. These nerve bundles send out many fine terminals that innervate the epithelial cells. Subbasal nerve density and nerve terminals were greater in the center than in the periphery of the cornea. Additionally, CGRP-positive central epithelial nerve fibers and terminals were more abundant than SP-positive nerves and terminals. CONCLUSION: The architecture of cat corneal nerves shows similarities to human and mouse cornea innervation. This study provides useful data for researchers who use the cat model to assess corneal nerve pathological alterations, as well as in the veterinary field where corneal opacities, ulcerations, and infections damage the nerves and decrease sensitivity.

A Relationship Between the Supratrochlear Nerve and Trochlea: Anatomical Study and Application to Migraine Headaches.

Supratrochlear nerve (STN) is a terminal branch of the frontal nerve arising from the ophthalmic nerve (V1). Compression of the STN by adjacent structures might result in migraine headaches. The aim of this study was to explore the relationship of the STN and trochlea for a better understanding of potential entrapment of the STN. Nineteen orbits from ten fresh-frozen cadaveric heads were dissected. The relationship of the STN and the trochlea was classified into three types: In type I, the STN passed lateral to the trochlea; In type II, the STN passed through the trochlea; In type III, the STN passed medial to the trochlea. Type I was found in 52.6% (10/19 sides), type II was found in 42.1% (8/19 sides), and type III was seen in 3.4% (1/19 sides). In type III, both the STN and infratrochlear nerve were identified as separate branches. The authors propose a new classification of the pathway of the STN based on its relationship with the trochlea. This study might shed light on headaches emanating from this region.

Long-Term Impacts of Orthokeratology Treatment on Sub-Basal Nerve Plexus and Corneal Sensitivity Responses and Their Reversibility.

PURPOSE: To examine the effects of one year of overnight orthokeratology (OK) treatment on the sub-basal nerve plexus (SBNP) and corneal sensitivity and to assess the reversibility of these effects one month after treatment interruption. METHODS: Thirty-two subjects with low-moderate myopia underwent OK treatment for one year. Fifteen non-contact lens wearers served as controls. At the time points baseline, one year of treatment, and one month after removing the OK lenses, two tests were conducted: corneal sensitivity (Cochet-Bonnet esthesiometer) and SBNP imaging by in vivo confocal microscopy. RESULTS: In participants wearing OK lenses, significant reductions over the year were produced in SBNP nerve density (P=0.001 and P=0.006) and number of nerves (P<0.001 and P=0.001) in the central and mid-peripheral cornea, respectively. Differences over the year were also detected in central objective tortuosity (P=0.002). After lens removal, baseline values of nerve density (P=0.024 and P=0.001) and number of nerves (P=0.021 and P<0.001) for the central and mid-peripheral cornea, respectively, were not recovered. At one month post-treatment, a difference was observed from one-year values in central corneal sensitivity (P=0.045) and mid-peripheral Langerhans cell density (P=0.033), and from baseline in mid-peripheral objective tortuosity (P=0.049). Direct correlation was detected at one year between nerve density and tortuosity both in the central (P<0.01; r=0.69) and mid-peripheral cornea (P<0.01; r=0.76). CONCLUSIONS: Long-term OK treatment led to reduced SBNP nerve density and this was directly correlated with corneal tortuosity. After one month of treatment interruption, nerve density was still reduced.

Short-Term Effects of Overnight Orthokeratology on Corneal Sub-basal Nerve Plexus Morphology and Corneal Sensitivity.

OBJECTIVE: To assess the effects of a short period of orthokeratology (OK) on corneal sub-basal nerve plexus (SBNP) morphology and corneal sensitivity. METHODS: Measurements were made in 56 right eyes of 56 subjects with low-to-moderate myopia who wore 2 OK lens designs (Group CRT: HDS 100 Paragon CRT, n=35; Group SF: Seefree; n=21) for a period of 1 month and in 15 right eyes of noncontact lens wearers as controls. The variables determined in each participant were corneal sensitivity using a Cochet-Bonnet esthesiometer and 12 SBNP variables determined on laser scanning confocal microscopy images using 3 different software packages. Correlation between SBNP architecture and corneal sensitivity was also examined. RESULTS: Few changes were observed over the 1-month period in the variables examined in the OK treatment and control groups. However, significant reductions were detected over time in the number of nerves in the central cornea in the groups CRT (P=0.029) and SF (P=0.043) and in central corneal sensitivity in CRT (P=0.047) along with significant increases in central and midperipheral corneal Langerhans cell counts in SF (P=0.001 and 0.048, respectively). CONCLUSIONS: This study provides useful data to better understand the anatomical changes induced by OK in corneal SBNP. The different response observed to the 2 OK lens designs requires further investigation.

Sensory Innervation of the Upper Eyelid.

The aim of this study was to elucidate the sensory territory of the trigeminal nerve on the upper eyelid.Eight hemifaces from Korean cadavers were dissected. The frontal nerve (FN), supraorbital nerve (SON), supratrochlear nerve (STN), infratrochlear nerve (ITN), and lacrimal nerve (LN) were traced.The terminal branches to the eyelid margin of FN were distributed between 1/6 and 2/5 of the palpebral fissure width lateral to the medial canthus and 1/6 of the eyebrow height from eyelid margin. The SON was distributed between 2/5 and 9/10 of the eye width lateral to the medial canthus, at 1/3 of the eyebrow height. The STN was distributed between -1/4 and -1/5 of the eye width medial to the medial canthus, at 1/5 of the eyebrow height. The ITN was distributed at -1/4 and 1/10 of the eye width medial to the medial canthus, and at 1/5 of the eyebrow height. The LN was distributed between approximately 3/5 and 13/10 of the eye width lateral to the medial canthus, and at 1/4 of the eyebrow height. The main branches of FN and SON ran deep to the orbicularis from the supraorbital notch to the upper border of the tarsal plate. In the pretarsal area, they were between the orbicularis and tarsal plate. The STN and ITN were between the orbicularis and the skin. The LN was observed between the orbicularis and the tarsal plate.Upper eyelid was mainly supplied by SON and FN. The medial extremity was supplied by STN and ITN, and the lateral extremity by LN.

Anatomy of the Corrugator Muscle.

The aim of this article is to systematically review the anatomy and action of the corrugator muscle. PubMed and Scopus were searched using the terms "corrugator" AND "anatomy." Among the 60 full texts from the 145 relevant abstracts, 34 articles without sufficient content were excluded and 4 articles drawn from the reference lists were added. Among the 30 articles analyzed (721 hemifaces), 28% classified by oblique head and transverse head, and 72% did not. Corrugator originated mostly from the medial supraorbital rim (45%), followed by the medial frontal bone (31%), the medial infraorbital rim (17%), and the upper nasal process (7%). Corrugator extended through the frontalis and orbicularis oculi (41%), only the frontalis (41%), or only the orbicularis oculi (18%). Corrugator ran superolaterally (59%), or laterally (41%). Corrugators inserted mostly to the middle of the eyebrow (57%), or the medial half of the eyebrow (36%), but also to the glabella region (7%). The length of the corrugator ranged 38 to 53 mm. The transverse head (23.38 mm) was longer than the oblique head (19.75 mm). Corrugator was thicker at the medial canthus than at the midpupillary line. Corrugator was innervated by the temporal branch of the facial nerve (66%), the zygomatic branch (17%), or the angular nerve (zygomatic branch and buccal branch, 17%). Supraorbital nerve (60%) or supratrochlear nerve (40%) penetrated the corrugator. The action was depressing, pulling the eyebrow medially (91%), or with medial eyebrow elevation and lateral eyebrow depression (9%). Surgeons must keep this anatomy in mind during surgical procedures.

Morphological Characteristics of the Sphenoid Sinus and Endoscopic Localization of the Cavernous Sinus.

The aim of this study was to investigate the relationship between the morphological characteristics of the sphenoid sinus and endoscopic localization of the cavernous sinus (CS) using an extended endoscopic endonasal transsphenoidal approach. Thirty sides of CS in 15 adult cadaver heads were dissected to simulate the extended endoscopic endonasal transsphenoidal approach, and the morphology of the sphenoid sinus and anatomic structures of CS were observed. The opticocarotid recess (OCR), ophthalmomaxillary recess (V1V2R), and maxillomandibular recess (V2V3R) in the lateral wall of the sphenoid sinus were presented in 16 sides (53.3%), 6 sides (20%), and 4 sides (13.3%) of the 30 sides, respectively. OCR is a constant anatomic landmark in endoscopy and coincides with the anterior portion of the clinoidal triangle. The C-shaped internal carotid artery (ICA) in the lateral wall of the sphenoid sinus was presented in 11 sides (36.7%), the upper one-third of which corresponds to the middle portion of the clinoidal triangle, and the lower two-thirds of which correlates to the supratrochlear triangle, infratrochlear triangle, and ophthalmic nerve in CS, around which the medial, lateral, and anteroinferior interspaces are distributed. From a front-to-behind perspective, the C-shaped ICA consists of inferior horizontal segment, anterior vertical segment, clinoidal segment as well as partial subarachnoid segment of the ICA. OCR and C-shaped ICA in the lateral wall of the sphenoid sinus are the 2 reliable anatomic landmarks in the intraoperative location of the parasellar region of CS.

Communications Between the Trigeminal Nerve and the Facial Nerve in the Face: A Systematic Review.

The aim of the article is to elucidate the communications between the trigeminal nerve and facial nerve in the face. In a PubMed search, 328 studies were found using the terms 'trigeminal nerve, facial nerve, and communication.' The abstracts were read and 39 full-text articles were reviewed. Among them, 11 articles were analyzed. In the studies using dissection, the maxillary branch (V2) had the highest frequency (95.0% ±â€Š8.0%) of communication with the facial nerve, followed by the mandibular branch (V3) (76.7% ±â€Š38.5%). The ophthalmic branch (V1) had the lowest frequency of communication (33.8% ±â€Š19.5%). In a Sihler stain, all of the maxillary branches and mandibular branches had communications with the facial nerve and 85.7% (12/14 hemifaces) of the ophthalmic branches had communications. The frequency of communications between the trigeminal nerve and facial nerve were significantly higher (P = 0.00, t-test) in the studies using a Sihler stain (94.7% ±â€Š1.1%) than the studies using dissection (76.9 ±â€Š35.8). The reason for the significantly higher frequency of trigeminal-facial communication in the studies using a Sihler stain is because of the limitation of the Sihler stain itself. This technique cannot differentiate the motor nerves from sensory nerves at the periphery, and a crossover can be misinterpreted as communication near to nerve terminal.

Pain. Part 2a: Trigeminal Anatomy Related to Pain.

In order to understand the underlying principles of orofacial pain it is important to understand the corresponding anatomy and mechanisms. Paper 1 of this series explains the central nervous and peripheral nervous systems relating to pain. The trigeminal nerve is the 'great protector' of the most important region of our body. It is the largest sensory nerve of the body and over half of the sensory cortex is responsive to any stimulation within this system. This nerve is the main sensory system of the branchial arches and underpins the protection of the brain, sight, smell, airway, hearing and taste, underpinning our very existence. The brain reaction to pain within the trigeminal system has a significant and larger reaction to the threat of, and actual, pain compared with other sensory nerves. We are physiologically wired to run when threatened with pain in the trigeminal region and it is a 'miracle' that patients volunteer to sit in a dental chair and undergo dental treatment. Clinical Relevance: This paper aims to provide the dental and medical teams with a review of the trigeminal anatomy of pain and the principles of pain assessment.

Somatotopic organization of trigeminal ganglion: three-dimensional reconstruction of three divisions.

Clearing the somatotopic organization of trigeminal ganglion can help us to improve the precision of treatment for trigeminal neuralgia. The distribution of primary afferent perikarya of 3 branches of trigeminal nerve in the trigeminal ganglion was investigated in the rabbit, and 3D model was reconstructed then. After application of wheat germ agglutinin-horseradish peroxidase and DiI to the cut endings of the 3 branches of trigeminal nerve, ophthalmic cells were found in the anteromedial part of the trigeminal ganglion, mandibular cells in the posterolateral part, and maxillary cells in the middle part. The results suggest that the somatotopic organization of the ganglion in rabbits is a mediolateral direction reflecting the mediolateral order of the ophthalmic, maxillary, and mandibular nerves.

Microsurgical anatomy of the trigeminal nerve.

The objective of this study is to review surgical anatomy of the trigeminal nerve. We also demonstrate some pictures involving the trigeminal nerve and its surrounding connective and neurovascular structures. Ten adult cadaveric heads were studied, using a magnification ranging from 3× to 40×, after perfusion of the arteries and veins with colored latex. The trigeminal nerve is the largest and most complex of the cranial nerves. It serves as a major conduit of sensory input from the face and provides motor innervation to the muscles of mastication. Because of its size and complexity, it is essential to have thorough knowledge of the nerve before diagnoses and treatment of the pathologic processes in the orofacial, temporomandibular, infratemporal, and pterygopalatine areas. The trigeminal nerve is encountered with imaging or surgery of the skull base surgery. Thus, a comprehensive knowledge of the anatomy of the trigeminal nerve is crucial for performing the surgical procedures without significant complication.

Corneal nerve architecture in a donor with unilateral epithelial basement membrane dystrophy.

BACKGROUND: Epithelial basement membrane dystrophy (EBMD) is by far the most common corneal dystrophy. In this study, we used a newly developed method of immunofluorescence staining and imaging to study the entire corneal nerve architecture of a donor with unilateral EBMD. METHOD: Two fresh eyes from a 56-year-old male donor were obtained; the right eye of the donor was diagnosed with EBMD and the left was normal. After slit lamp examination, the corneas were immunostained with anti-ß-tubulin III antibody. Images were recorded by a fluorescent microscope equipped with a Photometrics digital camera using MetaVue imaging software. RESULTS: The left cornea appeared normal as observed by slit lamp and stereomicroscope, but the right eye had numerous irregular geographic patches in the basement membrane. Immunofluorescence showed no difference in the stromal nerve distribution between the 2 eyes, but there were areas without innervations in the EBMD cornea. Subbasal nerve fibers also showed tortuous courses and fewer divisions. There was a significant decrease in the density of subbasal nerve fibers and the number of terminals in the right eye. CONCLUSION: We show for the first time detailed nerve architecture in an EBMD cornea. Our results suggest that EBMD-induced abnormalities of basement membrane altered epithelial nerve architecture and decreased nerve density, contributing to the pathology of the disease.

Supratrochlear and supraorbital nerves: an anatomical study and applications in the head and neck area.

BACKGROUND: This article elucidates the anatomical details of the course and territory of the supraorbital (SO) and supratrochlear (ST) nerves. Possible applications of the SO and ST nerves for sensory nerve transfer are also examined. METHODS: The dissection of 3 fresh cadaver heads (6 hemifaces) was performed. In each hemiface, the ST and SO nerves were identified. The following data were recorded: 1) number of branches, 2) skin boundaries, 3) communicative branches, and 4) branch length. The feasibility of specific nerve-transfer procedures was also examined. RESULTS: In 4 hemifaces the SO nerve exited from the SO notch and in 2 hemifaces from the SO foramen. The position was lateral to the midline, with a mean distance of 1.93 cm. In all dissections, a maximum of 4 SO branches (range 2-4) were identified. The ST nerve exited the orbital rim medial to the SO nerve, and lateral to the midline with a mean distance of 0.866 cm. The mean distance between the SO and ST nerves at the level of the SO rim was 1.06 cm. In 5 of 6 hemifaces, several sub-branches emerged from the main trunk of the ST nerve. In 1 hemiface the ST nerve was divided in 2 main branches. CONCLUSIONS: The data presented in the current study are in agreement with previous anatomical studies. Both ST and SO nerves can be used as sensory nerve donors in the head and neck area for numerous expanding applications.

How normal is the transparent cornea? Effects of aging on corneal morphology.

PURPOSE: To ascertain the effects of aging on corneal morphology and to illustrate the morphologic diversity of the different layers in the normal cornea as seen by in vivo confocal microscopy (IVCM). DESIGN: Observational cross-sectional study. PARTICIPANTS: A total of 150 healthy subjects, evenly distributed over 5 age categories, comprising 75 men and 75 women. METHODS: Both transparent corneas (n = 300) of all subjects were examined in duplicate by white light IVCM (Confoscan 4, NIDEK Technologies, Albignasego, Padova, Italy). After reviewing the IVCM examinations for morphologic variations of the corneal layers, we selected the 8 most common features to illustrate the morphologic diversity. Subsequently, all 600 IVCM examinations were assessed for the presence of these features. We used binary logistic regression analyses to assess the age-relatedness of each feature. MAIN OUTCOME MEASURES: Age distribution of bright superficial epithelial cells, dendriform cells, alterations characteristic of epithelial basement membrane dystrophy (EBMD), tortuous stromal nerves, stromal microdots in the anterior stroma, folds in the posterior stroma, opacification of Descemet's membrane, and corneal guttae. RESULTS: Four features were found characteristic of the aging cornea: stromal microdots in the anterior stroma (P<0.0001), folds in the posterior stroma (P<0.0001), opacification of Descemet's membrane (P<0.0001), and corneal guttae (P<0.0001). Alterations characteristic of EBMD were found in 3% of all eyes and only detected in subjects aged ≥40 years, suggesting age-relatedness (P = 0.09). Other features, such as bright superficial epithelial cells (n = 38, 13%), dendriform cells (n = 42, 14%), and tortuous stromal nerves (n = 115, 38%), were age-independent. We also found a novel phenotype of corneal endothelium in 4 normal eyes of 2 subjects, which we coined "salt and pepper endothelium." We could not establish whether this novel phenotype represented a morphologic variant of normal endothelium, an early stage of a known corneal endothelial disorder, or a completely new disease entity. CONCLUSIONS: Knowledge of the common morphologic variations of the corneal layers and the effects of aging on corneal morphology as seen by IVCM increases our understanding of corneal degenerative disorders and is essential to detect corneal pathology. Our finding of a novel phenotype of corneal endothelium emphasizes the morphologic diversity of this optically transparent tissue.

Ciliary ganglion afferents and efferents variations: a possible explanation of postganglionic mydriasis.

PURPOSE: Ciliary ganglion is a pre-visceral vegetative ganglion, relay of ocular bulb vegetative pathways, concerning three types of fibers: parasympathetic, sympathetic and somatosensory. The objective of this study was to describe the different patterns of distribution of those fibers around the ciliary ganglion to explain rare post-traumatic or postoperative ocular symptoms. METHODS: Dissection of 20 orbits, from cavernous sinus to ocular bulb, after intravascular injection of colored latex. RESULTS: Concerning afferents, or roots, three dispositions have to be described: all of them were identified (55 %); parasympathetic root was absent and ciliary ganglion was attached directly to the inferior branch of the oculomotor nerve (25 %); sympathetic root was absent (20 %). Somatosensory root, coming from nasociliary nerve, was constant. Efferents (short ciliary nerves), including these three types of fibers, were variable in number but always constituted two bundles. CONCLUSION: The absence of identifiable parasympathetic root, resulting in a close relationship between ciliary ganglion and the inferior branch of the oculomotor nerve, could be a possible explanation of postganglionic mydriasis following blow-out orbital floor fracture or surgical repair of this type of fracture. The absence of sympathetic root is due to a forward retro-orbital connection between internal carotid plexus and ophthalmic nerve within cavernous sinus, corresponding to gray rami communicans.

Corrugator supercilii transection for headache emanating from the frontal region: a clinical evaluation of ten patients.

Chronic daily headache (CDH) located in the frontal region is a common problem. We have previously described the positive results that were achieved with botulinum toxin (BTX) injections in the musculus corrugator supercilii (MCS) for this disorder. Nowadays, we offer transection of this muscle to patients following a minimum of two BTX injections, provided these injections result in a significant reduction of pain. This procedure is based on the assumption that the pathophysiological mechanism in some of these patients suffering from CDH is a neural entrapment of the supratrochlear nerve in the corrugator muscle. To assess the effect of transection, we have evaluated all the consecutive patients (n = 10) so far. Treatment was successful in nine of these patients. Prior to the treatment, the mean pain score in the 9 successfully treated patients was 8.1 (range 6-9), after transection this had been reduced to 0.8 (range 0-3). All of these successfully treated patients ceased their daily use of pain relief medication for their frontally localised headaches. Moreover, they stated that they would definitely undergo surgery, if they were to find themselves in the same situation again. Therefore, we conclude that transection of the MCS is an efficient and successful procedure for a carefully selected group of patients suffering from CDH in the frontal region. Most of all we intend to popularise this pathophysiological concept based on the distinct possibility that some headaches might be due to neural entrapment.