Major Review

Anatomy of Secretory Glands in the Eyelid and

Conjunctiva: A Photographic Review
Yasuhiro Takahashi, m.d., ph.d.*, Akihide Watanabe, m.d.†, Hiromichi Matsuda, m.d.*,
Yasuhisa Nakamura, m.d., ph.d.*, Takashi Nakano, m.d., ph.d.‡, Ken Asamoto, m.d., ph.d.‡,
Hiroshi Ikeda, m.d., ph.d.§, and Hirohiko Kakizaki, m.d., ph.d.*
*Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi, Japan; †Department of Ophthalmology,
Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan; and Departments of ‡Anatomy and
§Pathology, Aichi Medical University, Nagakute, Aichi, Japan

Although both the orbital and the palpebral lobes are located
Abstract: The eyelid and conjunctiva are main targets in posterior to the orbital septum,12 the posteriorly situating gland
ophthalmic plastic surgery. Although dry eyes are known is in front of the bulbar conjunctiva and is called the “palpebral
to occasionally occur after ophthalmic plastic surgery, little lobe” (Fig. 1).12,13 The anteriorly situating gland is, therefore,
attention has been paid to the secretory glands in the eyelid and the “orbital lobe,” the location of which is in the lacrimal fossa
conjunctiva. The secretary glands in the eyelid and conjunctiva (Fig. 2).12,13 Both lobes sandwich the lateral horn of the levator
contain the main lacrimal gland, accessory lacrimal glands of aponeurosis12,13 and part of the palpebral lobe is situated below
Wolfring and Krause, goblet cells, ciliary glands of Moll and the lateral canthal band.14,15 The main lacrimal gland ducts
Zeis, and the meibomian gland of the tarsal plate. Understanding mostly open in the superior conjunctival fornix12; however, 2
the details of these glands is helpful in preventing and managing ducts or 5 ducts from the palpebral lobe below the lateral can-
secretion reduction after oculoplastic procedures. thal band15 empty into the lower fornix.14
(Ophthal Plast Reconstr Surg 2013;29:215–219)
Accessory Lacrimal Glands
of Wolfring and Krause

T he eyelid and conjunctiva are main targets in ophthalmic There are 2 types of accessory lacrimal glands.13 The
plastic surgery. Although dry eyes are known to occasion- Wolfring gland is situated around the border of the tarsal plate
ally occur after ophthalmic plastic surgery,1–11 little attention and the Krause gland is situated around the conjunctival fornix
has been paid to the secretory glands in the eyelid and conjunc- (Figs. 3 and 4).3,12,13 Although these are similar serous glands, the
tiva except for the main lacrimal gland and meibomian gland. difference is only in their locations.13 The ducts of the accessory
The secretory glands in the eyelid and conjunctiva contain the lacrimal gland open into the palpebral conjunctival surface.13
main lacrimal gland, accessory lacrimal glands of Wolfring and
Krause, goblet cells, ciliary glands of Moll and Zeis, and the Secretion by the Main and Accessory
meibomian gland of the tarsal plate.3 It is necessary to under- Lacrimal Glands
stand the details of these glands to prevent and manage secre-
tion reduction after oculoplastic procedures. The main and accessory lacrimal glands secrete the water
Six orbits from 6 Japanese cadavers (3 men and 3 women) component of the lacrimal fluid.3 Although it has been specu-
aged 63 to 94 years at death (mean: 78.2 years) were fixed in 10% lated that the main gland contributes to reflex secretion and the
buffered formalin before examination. All cadavers were registered accessory glands provide basic secretion, both are now thought
with Aichi Medical University, and proper consents and approvals to work complementarily in tear secretion.3 The contribution
were obtained prior to use. Methods for securing human tissues were to the water component from the main lacrimal gland is 95%
humane and complied with the tenets of the Declaration of Helsinki. and that from the accessory glands is 5%.16 Although the main
All the microscopic specimens had a 7 μm thickness. and accessory lacrimal glands produce aqueous tears, they also
Microscopic photographs were taken with a digital camera sys- secrete electrolytes, mucin, growth factors, hormones, immuno-
tem attached to a microscope (Moticam 2000, Shimadzu Rika globulins, cytokines, and antibacterial substances, such as lyso-
Kikai, Tokyo, Japan) that was merged with Adobe Photoshop zyme, β-lysin, and lactoferrin.17–19
CS5 (Adobe Systems Inc., San Jose, CA, U.S.A.).
Surgical Tips for Prevention of Secretory Reduction. The
Main Lacrimal Glands main lacrimal gland and its ducts may be injured during
recession of the lateral horn of the levator aponeurosis via the
The main lacrimal gland is situated in the superolat-
transconjunctival approach for correction of the temporal flare.1
eral orbit and comprises the orbital and palpebral lobes.12,13
The transcutaneous approach is a safer procedure with securing
of the main lacrimal gland and its ducts to prevent them from
Accepted for publication December 10, 2012. being injured inadvertently.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Hirohiko Kakizaki, m.d., Injury or loss of the accessory lacrimal glands was pro-
Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi posed as occurring during transconjunctival eyelid surgery,3
480-1195, Japan. E-mail: cosme@d1.dion.ne.jp although no significant adverse effect on tear production was
DOI: 10.1097/IOP.0b013e3182833dee reported.20,21 This was due to a conjunctival incision that was

Ophthal Plast Reconstr Surg, Vol. 29, No. 3, 2013 215

Y. Takahashi et al. Ophthal Plast Reconstr Surg, Vol. 29, No. 3, 2013

FIG. 1. Overview of the main lacrimal gland and magnified

views of the orbital and palpebral lobes (Masson trichrome
stain).
FIG. 3. An accessory lacrimal gland, Krause, is shown.

required to be performed above the tarsal plate margin not con-

taining the accessory lacrimal glands. Management for Secretory Reduction After Prior Therapy.
The sensory nerve disruption and ocular surface inflam- Orbital and periorbital irradiations induce atrophic changes in
mation cause a decrease in ocular surface sensation, which is the main and accessory lacrimal glands.8,9 A previous study
essential for main lacrimal gland stimulation.2 As the sensory demonstrated that all patients that received irradiation doses of
branches run into the pre-, intra- and suborbicularis plane,22 >57 Gy and 19% of the patients with irradiation doses of <45
it may be necessary to preserve the orbicularis oculi muscle Gy developed severe dry eyes.8 To manage this complication,
in eyelid surgery.10 The use of a corneal protector and lubri- artificial tear solutions and sodium hyaluronate are used as
cation is a simple measure for minimizing ocular surface first-line treatments.23 Diquafosol—which is an agonist of
inflammation.10 the P2Y2 purinergic receptor existing in the palpebral and
The botulinum toxin type A injection for crow feet bulbar conjunctival epithelium, goblet cells, and meibomian
wrinkles has a potential risk to cause transient aqueous- glands—eyedrops are another measure of treatment, promoting
deficient dry eyes.4,11 The underlying mechanism is denervation tear secretion from the lacrimal gland.24 For severe cases,
of the parasympathetic nervous system to the main lacrimal punctal plugs or surgical occlusion of the lacrimal system is
gland.4 The botulinum toxin needs to be injected superficially necessary.23,25,26
and at least 1 cm lateral to the bony orbit or 1.5 cm outside the
lateral canthus to avoid toxin diffusion in the main lacrimal Goblet Cells
gland.11 The mucin component comprises mucin, a general term
for high molecular glycoproteins,27 which is secreted mainly by
the epithelia of the conjunctiva and the cornea (Fig. 5)28 and
partly by the lacrimal gland.19 Although mucin has been thought
to make the bottom layer of the tear,29 it is difficult to strictly
differentiate the layers as the mucin dissolves in the water

FIG. 4. The glands of Wolfring and Krause. The Wolfring gland

is situated around the border of the tarsal plate and the Krause
FIG. 2. The orbital lobe lacrimal gland is situated in the lacri- gland is situated around the conjunctival fornix. These are simi-
mal fossa. lar serous glands (Masson trichrome stain).

216 © 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 29, No. 3, 2013 Anatomy of Secretory Glands in the Eyelid and Conjunctiva

open into the follicles of the eyelashes.12 Although these glands

are described in many textbooks simultaneously with descrip-
tions of the main and accessory lacrimal glands,35,37,38 it is doubt-
ful whether they contribute to the formation of a lacrimal fluid
component, according to their anatomical location.
Although little is known about the exact functions of
the Zeis gland, several theories have been proposed.39 First,
the sebum exhibits self-sterilizing properties, which affects the
viability of some kinds of bacteria.39 Second, as the secreted
lipid contains vitamin E, it prevents the aging process and helps
maintain a healthy skin barrier.39 Third, glycerol produced in the
FIG. 5. The mucin secreting mucous cells (Masson trichrome pilosebaceous follicle plays a role in skin hydration.39 Fourth,
stain).
sebaceous gland dysfunction causes insufficient hair cell func-
tion, suggesting that the sebaceous gland is essential for a
component.29 According to the structure, mucin is divided into proper functioning of the hair follicles.39
the secreted and membrane-bound types.27,28 The Moll gland has positive immunohistochemical reac-
The secreted type is produced by the goblet cells of the tions by producing secretory components, such as immuno-
conjunctiva. The goblet cells are mostly distributed through- globulin A, mucin 1, and lysozymes in the glandular cells. This
out the normally covered areas of the open eye, including the suggests that the Moll gland is a vital component for immune
superior and inferior bulbar and palpebral conjunctivae.30,31 defense against pathogenic microorganisms in the eyelid and
The secreted mucin can freely move in the lacrimal fluid.32 The ocular surface.40 Although the Moll gland fully develops during
membrane-bound type is secreted from the corneal and con- infancy, the effect for immune defense is activated from birth.40
junctival epithelia and covers the ocular surface by attaching
to their cytoplasmic membranes.32 The secreted type helps with
lacrimal fluid diffusion and the membrane-bound type maintains Management for Secretory Reduction After Prior Therapy.
lacrimal fluid stability.33 Other roles of mucin are, for example, Irradiation causes an atrophy of the Zeis glands, although
prevention of infection and avoidance of adhesion between the the Moll glands have a relatively radioresistant nature.9 The
mucosal epithelia.32 decreased functions of the ciliary glands may be relevant to the
occurrence of blepharitis,40 for which eyelid hygiene and topical
and oral antibiotics are effective.41
Management for Secretory Reduction After Prior Therapy.
The number of goblet cells is anticipated to decrease after plaque Meibomian Gland
radiotherapy for intraocular tumors.5 In addition, the number of
goblet cells and the expression of mucin-5 subtypes A and C The meibomian gland (Fig. 7) is called the “tarsal gland”
were lower in patients that underwent brachytherapy (the mean and contributes to form the lipid component of the lacrimal
dose was 455 Gy at the sclera and 100 Gy at the tumor apex) fluid.29,35 This gland is a sebaceous gland with holocrine
for uveal melanomas than in those of normal controls.5 The secretion.36,42,43 There are about 25 glands in the upper eyelid and
diquafosol eyedrops stimulate mucin secretion from the goblet 20 in the lower eyelid.43 The meibomian orifices are located at the
cells.24 The rebamipide eyedrops also increase production of eyelid margins, just anterior to the mucocutaneous junction.44,45
mucin-like substances in the cornea and conjunctiva.34 The meibomian gland contains acini along a single long central
duct, which are disposed at regular intervals in the tarsal plate.44
Ciliary Glands of Zeis and Moll These structural features can be easily and clearly detected
using a noninvasive, noncontact meibography system.46,47 This
There are 2 types of secretory glands in the ciliary area: the noncontact meibographic examination is useful for evaluating
Moll and the Zeis glands.35 The Zeis gland is a sebaceous gland loss of the meibomian glands or meibomian gland dysfunction.47
with holocrine secretion and the Moll gland is an apocrine gland
(Fig. 6).36 The ciliary glands are located at the eyelid margin and

FIG. 6. The ciliary glands (Moll and Zeis glands). The Moll FIG. 7. The meibomian glands. The meibomian gland is a
gland is an apocrine gland and the Zeis gland is a sebaceous sebaceous gland, embedded in the tarsal plate, with holocrine
gland with holocrine secretion (Masson trichrome stain). secretion (Elastica van Gieson stain).

© 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 217
Y. Takahashi et al. Ophthal Plast Reconstr Surg, Vol. 29, No. 3, 2013

The lipid secreted by the meibomian gland is stored at 13. Obata H. Anatomy and histopathology of the human lacrimal gland.
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during blinking, contributing to a lacrimal fluid stability by pre- 14. Wasano T. [Supplementary knowledge about the accessory or-
venting evaporation.43,45,48 The lipid also works as a lubricant in gans of Japanese eyeballs; the smooth muscles and the lachrymal
glands]. Fukuoka Igaku Zasshi 1948;39:53–62.
blinking.29 15. Kang H, Takahashi Y, Ichinose A, et al. Lateral canthal anatomy: a
The lacrimal lipid layer is a mixture of polar and nonpo- review. Orbit 2012;31:279–85.
lar lipids.29 The polar lipids build bridges between the nonpolar 16. Schrader S, Wedel T, Kremling C, et al. Amniotic membrane as
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17. Nelson JD. A clinician looks at the tearfilm. Adv Exp Med Biol
1998;438:1–9.
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A transplanted tarsal graft removes the meibomian resection: effect on tear production. Ophthal Plast Reconstr Surg
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glands,6 as they are vulnerable to even transient ischemia.6 In
22. Scott KR, Tse DT, Kronish JW. Vertically oriented upper eyelid
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