Formation and Fixation of the Annulus of Zinn and Relation With Extraocular Muscles: A Plastinated Histologic Study and Its Clinical Significance.

Purpose: This study aimed to clarify the formation and fixation of the annulus of Zinn (AZ) and its relationship with the extraocular muscles by using ultrathin plastination and three-dimensional models. Methods: Eighteen cadaveric heads (36 sides of the orbital apex) were plastinated to coronal (16 sides), sagittal (13 sides), and horizontal (5 sides) ultrathin plastination sections to be investigated at both macroscopic and microscopic levels. One cadaveric head was used for endoscopic dissection to identify anatomic landmarks. Results: There were two fibrous triangles adhered to both ends of the anterior surface of the optic strut. The superior rectus muscle originated from the superior fibrous triangle, and the lateral, inferior, and medial rectus muscles emerged from the inferior fibrous triangle. It was not until 5.46 ± 0.41 mm anterior to the optic strut that the complete tendinous ring composed of rectus muscles, optic nerve sheath, and periosteum was formed. The superior oblique and levator palpebrae superioris muscles originated from the medial fibrous band of the AZ. At the posterior of the AZ, there was a potential passage between the medial rectus muscle and the optic nerve. Conclusions: The fixation of the AZ was composed of the connection of the annular tendon to the optic strut posteriorly and the attachment of the complete tendinous ring to the lesser and greater wings of the sphenoid bone anteriorly. The triangular route area between the optic nerve and medial rectus muscle was located on the anterior side of the base of the optic strut.