Redefining all check ligaments of extraocular muscles using true color sectioned images

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Although all extraocular muscles are expected to have corresponding check ligaments, this is not consistently documented in anatomical literature. This study aims to clarify the check ligaments using acquired high-resolution true color sectioned images and surface modeling. Methods From the sectioned images of one male cadaver, the check ligaments and related structures were outlined and surfaces models were reconstructed using 3D Slicer and Maya to analysis their morphology. Results The seven check ligaments corresponding to the seven extraocular muscles, along with the supporting ligaments, were clearly delineated. Previously unrecognized attachment points of the check ligaments, especially to fasciae, were highlighted. In addition to exploring in more detail the tendinous role of Whitnall’s ligament and Lockwood’s ligament, we focused on the morphology of the ligaments on the lower eyelid. Conclusion Through the reconstruction of surface models based on true color sectioned images, we were able to differentiate all extraocular check ligaments and supporting structures, aligning to their respective roles. Oculomotor Muscles Orbit Cross sectional anatomy Three-dimensional image Visible Human Projects Figures Figure 1 Figure 2 Figure 3 Introduction The check ligaments of the extraocular muscles and the tarsal muscles are composed of dense connective tissue, although less dense than typical ligaments. They function to restrict the movements of the eyeball, thereby enabling the ocular muscles to work in a coordinated and controlled manner [ 17 ]. Notably, the check ligaments of the levator palpebrae superioris muscle and the superior tarsal muscle in the eyelid are the most influential structures in blepharoptosis, a medical condition characterized by abnormal drooping of the eyelid that is prevalent among Asians, particularly the elderly [ 5 ]. Further, impairment in check ligaments of the lower eyelid are related to malposition’s of it such as entropion and ectropion, which if severe, may require reconstruction surgeries [ 6 ]. However, in official anatomical terminology of the Terminologies Anatomica, only the check ligament of the lateral rectus muscle and Lockwood’s ligament (suspensory ligament of eyeball) are listed, while other check ligaments are not even mentioned [ 3 ]. Furthermore, structures such as Whitnall’s ligament (the superior transverse ligament of eye) and intermuscular ligament are used in clinical contexts [ 17 ] and are not commonly used in anatomical literature. This is likely because attempts to clarify the exact morphology of these ligaments through gross anatomical dissection remain challenging, as the fibrous strands are intermixed and difficult to differentiate, and their insertions are inevitably displaced during the dissection process. Several researchers have attempted to identify these structures using high-resolution imaging modalities such as MRI [ 2 ]. While MRI allows for differentiation between muscles and connective tissues within the orbit, it is not capable of distinguishing connective tissues based on their density. Ultimately, the only method capable of distinguishing very delicate sheath of soft tissue in a small space while preserving their natural colors was the sectioned images from the Visible Korean. The Visible Korean dataset offers whole-body images with 48-bit color depth and a minimum pixel size of 0.04 mm × 0.04 mm, enabling the visualization of any region of the human body, including those with subtle color differences or extremely small anatomical structures [ 8 ]. The aim of this study is to clearly define and distinguish the check ligaments of each extraocular muscle within the orbit in an Asian decent cadaver, which is clinically important to better understand blepharoptosis in this population. To achieve this, we highlighted the actual morphology and location of these ligaments using sectioned images and surface models, as if dissected, thereby providing direct anatomical evidence. Material and Methods We produced sectioned images of the whole body of a Korean male cadaver in 2021 (resolution, 8,688 × 5,792; interval, 0.25 mm in the head; pixel size, 0.05 mm × 0.05 mm; color depth, 48-bit color) [ 16 ] as part of the Visible Korean project. The donor died due to lung cancer in 2021. His height, weight, and age of death were 1,634 mm, 46 kg, and 71 years old, respectively, and had no significant health issues regarding the eye. From the whole-body sectioned images, we selected images of the head at 0.5 mm intervals. In the selected images, the regions outside the head skin were filled with black, and the head region was cropped to a resolution of 4,089 x 4,589. In the head sectioned images, we segmented the structures around the left orbit (Table 1 ) using Photoshop 2025 (Version 26.1.0, Adobe Systems, Inc., San Jose, CA, USA). To accurately distinguish the check ligaments within the subcutaneous tissue of the orbit, we enhanced the color contrast of the images by adjusting their saturation and brightness levels. We then manually outlined the check ligaments using the Pen tool. These outlined ligaments were filled with white, while the surrounding areas were filled with black to enhance contrast, thereby creating segmented images. Except for the outlining step, this process was automatically repeated for each structure (Table 1 ). Because Photoshop's built-in Automate-Batch tool was not sufficient for the task, we created a script to automate the complex, multi-step workflow of trimming, filling, and generating segmented images in the MATLAB R2025a (MathWorks®, Boston, MA, USA) with the assistance of ChatGPT-5.1. Table 1 Twenty-eight segmented structures in the sectioned images for Surface models Tissue (the number) Structure Check ligament (7) Superior check ligament, Inferior check ligament, Medial check ligament, Lateral check ligament (Check ligament of lateral rectus muscle*), Superior oblique check ligament, Inferior oblique check ligament, Levator palpebrae superioris check ligament Supporting ligament (6) Trochlea*, Medial palpebral ligament*, lateral palpebral ligament*, Whitnall’s ligament, intermuscular ligament, Lockwood’s ligament (suspensory ligament of eyeball*) Skeletal (2)* Cranium (without mandible), mandible Muscular (9)* Superior rectus muscle, Inferior rectus muscle, Medial rectus muscle, Lateral rectus muscle, Superior oblique muscle, Inferior oblique muscle, Levator palpebrae superioris muscle, Superior tarsal muscle, Inferior tarsal muscle Glandular (1)* Lacrimal gland Etc (3)* Eyeball, Superior tarsus, Inferior tarsus *Official anatomical terms of Terminologia Anatomica(FIPAT, 2011) The white areas of segmented structure representing all segmented images were automatically detected and reconstructed into surface models using the Segment Editor tool in Surface models on Slicer 5.8.1 ( https://www.slicer.org/ ). The shape and position of these models were verified and exported in Object (OBJ) format. A total of twenty-seven empty polygons were generated in Maya 2026 (Autodesk Inc., San Rafael, CA, USA) at 1 mm intervals. Without any loss of resolution, the corresponding twenty-seven sectioned images were imported and embedded into their respective planes using Polygon Plane tool. This process was automated using a Python script written in Maya, developed with the assistance of ChatGPT-5.1. The surface models (OBJ files) were imported into the surface models in which the sectioned images had been embedded. After adjusting their location and direction, these surface models were superimposed onto the sectioned images displayed on the polygon planes. All objects were saved as Maya ASCII (MA) format. Subsequently, the objects were converted to Portable Document Format (PDF) files using Maya Surface models PDF Exporter version 14.0.11. Results We classified the ligaments into two categories: The check ligaments and the supporting ligaments. The check ligaments were defined as structures that connect to an extraocular muscle and support its function (Table 2 ) (Zhuang et al., 2019). The supporting ligaments were defined as structures that connect to bone, muscle, or other ligaments and function to assist or reinforce the role of adjacent ligaments (Table 3 ). We were able to differentiate supporting ligaments from other connective tissues since they link the check ligaments to bones, supporting the stabilization of muscles. Table 2 Definitions of check ligaments of extraocular muscles Check lig. From To (muscle with excessive contraction restriction) Direction of excessive movement restriction Superior check lig. (Figs. 1 A, B) Levator palpebrae superioris check lig. Medial portion of superior rectus m. Superior rotation of eyeball, retraction Inferior check lig. (Figs. 1 C, D) Frontal process of maxilla, Lockwood’s lig. Anterior portion of inferior rectus m. Inferior rotation of eyeball, retraction Medial check lig. (Figs. 1 E, F) Lacrimal bone, Lacrimal part of orbicularis oculi muscle Anterior portion of medial rectus m. Medial rotation of eyeball, retraction Lateral check lig. (Figs. 1 G, H) Whitnall’s tubercle* of zygomatic bone, Fascia of lacrimal gland Anterior portion of lateral rectus m. Lateral rotation of eyeball, retraction Superior oblique check lig (Fig. 2 A, B) Fascia of lacrimal gland Lateral portion of superior oblique m. Inferior and medial rotations of eyeball, protraction Inferior oblique check lig (Fig. 2 C, D) Lockwood’s lig. Lateral portion of inferior oblique m. Superior and lateral rotations of eyeball, protraction Levator palpebrae superioris check lig (Figs. 2 E, F) Medial check lig. Medial portion of levator palpebrae superioris m. Retraction and slight lateral movement of eyelid *The official anatomical term of Whitnall’s tubercle is the orbital tubercle (FIPAT, 2011). lig., ligament; m., muscle . Table 3 Definitions of supporting ligaments of extraocular muscles Supporting lig. From to Primary role Results of primary role Trochlea (Figs. 2 A, 3 A, B) Trochlear fovea of frontal bone Same as left Pulley for the superior oblique m. Redirection of the movement of the superior oblique m. Lateral palpebral lig (Fig. 3 D) Whitnall’s tubercle on zygomatic bone Lateral end of tarsi Anchoring of tarsi to lateral orbital wall Supporting eyelids to maintain proper position Medial palpebral lig (Fig. 3 D) Frontal process of maxilla Medial end of tarsi through orbicularis oculi muscle Anchoring of tarsi to medial orbital wall Supporting the eyelids to maintain proper position Whitnall’s lig (upper layer) (Fig. 3 A-D) Whitnall’s tubercle on zygomatic bone* Nasal part of frontal bone Pulley for the levator palpebrae superioris m. Redirection of the movement of the levator palpebrae superioris m. Whitnall’s lig (lower layer, intermuscular lig.) (Fig. 3 A-D) Whitnall’s tubercle on zygomatic bone* Nasal part of frontal bone Superior tarsal m. Tendon role of superior tarsal m. Stabilization of the position of the superior tarsal m. Lockwood’s lig. (Figs. 3 E, F) Frontal process of zygomatic bone, Frontal process of maxilla Inferior tarsal m. Tendon role of inferior tarsal m. Attachment sites of inferior check and inferior oblique check lig. Stabilization of the position of the inferior tarsal m., Inferior check lig., and inferior oblique lig. *The official anatomical term of Whitnall’s tubercle is the orbital tubercle. lig., ligament; m., muscle 1. Check ligaments The superior check ligament extended from the levator palpebrae superioris check ligament to the medial portion of the superior rectus muscle (Fig. 1 a, b; Table 2 ). The inferior check ligament extended from the medial portion of Lockwood’s ligament and the maxilla to the anterior portion of the inferior rectus muscle (Fig. 1 c, d; Table 2 ). The medial check ligament originated from the lacrimal bone and the lacrimal part of the orbicularis oculi muscle, to reach the anterior portion of the medial rectus muscle. The ligament was connected to the lacrimal part of the orbicularis oculi muscle, which was anchored to the medial palpebral ligament (Fig. 1 e, f; Table 2 ). The lateral check ligament originated from both Whitnall’s (orbital) tubercle of the zygomatic bone and the fascia of the lacrimal gland, and extended to the anterior portion of the lateral rectus muscle (Fig. 1 g, h; Table 2 ). The superior oblique check ligament connected from the fascia of the lacrimal gland to the lateral portion of the superior oblique muscle (Fig. 2 a, b; Table 2 ). The inferior oblique check ligament extended from the lateral portion of the Lockwood’s ligament to the lateral portion of the inferior oblique muscle (Fig. 2 c, d; Table 2 ). The levator palpebrae superioris check ligament originated from the medial check ligament, which is affixed to the medial orbital wall (frontal process of the maxilla), and ended at the medial portion of the levator palpebrae superioris muscle (Fig. 2 e, f; Table 2 ). In summary, the check ligaments of the rectus muscles started from a more anteriorly located point than their corresponding muscles (Fig. 1 a-h; Table 2 ), whereas the two oblique check ligaments of the oblique muscles were attached to these muscles from the posterolateral orbital wall (Fig. 2 a-d; Table 2 ). Thus, the check ligaments of all extraocular muscles were positioned opposite to the direction of muscle contraction. 2. Supporting ligaments The lateral and medial palpebral ligaments anchored the superior and inferior tarsi to the zygomatic bone and maxilla, respectively. For the medial palpebral ligament, it did not directly attach to the tarsi but connected indirectly via the orbicularis oculi muscle (Fig. 3 b; Table 3 ). The Whitnall’s ligament connected with the frontal bone and zygomatic bone, which were located on opposite sides of the orbit. The central portion of the ligament consisted of upper and lower (intermuscular ligament) layers, with the levator palpebrae superioris muscle passing between the layers. The fusion of the upper and lower layers at both lateral ends of the muscle resulted in a sleeve-like structure of the muscle. (Fig. 3 a-d; Table 3 ). The lower layer of the Whitnall’s ligament, also referred to as the intermuscular ligament, traversed the space between the levator palpebrae superioris muscle and the superior tarsal muscle, and also attached to the superior part of the the superior tarsal muscle (Fig. 3 c, d; Table 2 ). The Lockwood’s ligament bridged the inferior portion of the medial and lateral orbital walls. Moreover, its upper part was attached to the inferior tarsal muscle (Fig. 3 e, f; Table 2 ). Discussion The check ligaments of extraocular muscles are known to stabilize the eyeball by restricting its excessive movements of extraocular muscles [ 4 , 17 ]. However, in the official international anatomical terminology [ 3 ] and the anatomy textbooks [ 1 , 14 ], only medial, lateral, and inferior check ligaments and suspensory ligament of eyeball (Lockwood’s ligament) are mentioned. The reason these ligaments are not fully described in textbooks is that they are extremely difficult to identify through real cadaver dissections. Formalin fixation causes most connective tissues in a cadaver to appear similar in color, and because the removal of adjacent structures or the ligament itself is often unavoidable, the true morphology of the check ligaments is frequently obscured or lost [ 11 ]. These limitations by cadaver dissection can be overcome by using sectioned images, provided by the Visible Korean project [ 8 , 16 ]. Structures identified on sectioned images are as valid as those found through traditional dissection, since they rely of direct observation. In fact, due to their greater preservation of detail, visibility beyond the limits of naked eye, and avoidance of dissection-related tissue distortion, sectioned images are more useful when studying small spaced, similar colored tissues. Based on these anatomically valid and reliable sectioned images, several noteworthy findings were made regarding the check ligaments, as described below. To stabilize the eyeball during extraocular muscle movement, Inferior, medial, and lateral check ligaments typically connected the muscles directly to bone. The ligaments were known originally to attach to the orbital wall [ 9 ]. These ligamentous connections could be identified relatively easily by not only cadaver dissection but also the sectioned images, so the three ligaments were described in the anatomy textbooks [ 1 , 14 ]. We also confirmed that the ligaments connect the muscles to the bone. Furthermore, we demonstrated that a part of the medial check ligament was also connected anteriorly to the fascia of the orbicularis oculi muscle (Fig. 1 f; Table 2 ), and a part of the lateral check ligament to the fascia of the lacrimal gland (Fig. 1 h; Table 2 ). Superior check, superior oblique check, and inferior oblique check ligaments atypically connected the muscles indirectly through other ligaments or fascia before attaching to bone. The superior check ligament linked to the levator palpebrae superioris check ligament, which then connected to the medial check ligament, ultimately attaching to the lacrimal bone at the medial orbital wall (Fig. 1 a, b). The medial check ligament therefore functions both as a check ligament and as a fixation point for other ligaments, because it is firmly anchored to the bone. Superior oblique check ligament and a part of the lateral ligament attached to the dense fascia of the lacrimal gland, which the gland was anchored to bone (Fig. 1 h). Also, the inferior oblique check ligament was seen to attach to the Lockwood’s ligament (Fig. 3 e), which bridges the lower part of the medial and lateral orbital walls (Fig. 1 c, d; Tables 2 , 3 ). Accordingly, these check ligaments are very difficult to identify through dissection because they do not attach directly to bone. This likely explains why they have not been clearly described in textbooks or previous studies. The overlapping check ligaments in the upper part of the eyeball were clearly differentiated. Previous studies on blepharoptosis focused exclusively on the ligaments associated with the levator palpebrae superioris muscle [ 15 ], and lacked clear classification due to the limitations of gross anatomical methods. In this study, we distinguished the check ligaments of the levator palpebrae superior muscles and superior rectus muscle by identifying their respective terminal muscle attachments (Fig. 1 a, b; 2 c, d; Table 2 ). The overlapping check ligaments in the lower part of the eyeball were also clearly differentiated. Earlier studies described the check ligaments of the inferior rectus and inferior oblique muscles as being jointly enclosed within the capsulopalpebral fascia [ 12 ]. However, our findings revealed that the inferior check ligament corresponds to the fascia's inferior layer and medial horn, attaching to the medial portion of Lockwood’s ligament. In contrast, the inferior oblique check ligament corresponds to the superior layer and lateral horn, attaching laterally to the Lockwood’s ligament and positioned superior to the inferior check ligament (Fig. 3 e; Table 2 ). Although previous studies have noted the attachments between the tarsal muscles and surrounding ligaments [ 10 , 13 ], their functional role was unclear due to innate limitations of cadaveric dissection. Our findings revealed that the ligaments served as tendinous origins for the tarsal muscles. Specifically, the Whitnall’s ligament stabilized the superior tarsal muscle by supporting its superior portion, while the Lockwood’s ligament anchored the inferior tarsal muscle to the orbital walls (Fig. 3 d, e). Further, although earlier studies described three ligaments (Lockwood’s, superior, and inferior ligaments) anterior to the capsulopalpebral fascia in the lower eyelid [ 7 ], our study found only two ligaments, which we defined as the upper and lower parts of the Lockwood’s ligament, both spanning from the medial to lateral orbital walls (Fig. 3 e, f; Table 3 ). As both the inferior check ligaments and inferior oblique check ligament attach to the lower part, the Lockwood’s ligament likely functions as a supportive pillar for these structures. Conclusion In the sectioned images, the check and supporting ligaments and their surrounding structures were clearly distinguishable from the naked eye, providing direct visual evidence of their anatomical presence. The surface models allowed three-dimensional visualization of the orbit and precise identification of the positional relationships between the check ligaments and surrounding anatomical structures. This study exposed all check ligaments that were previously difficult to observe through conventional cadaveric dissection. Furthermore, the functional actions of each ligament in relation to the corresponding extraocular muscles were conforted by their clearly exposed orientations. However, due to the lack of sample size, it was hard to verify our findings with other cadavers. Future work on other sectioned images as well as fresh cadavers would provide support in strengthening our claims. Nevertheless, the anatomy of these orbital structures can now be understood with clarity, providing guidance for surgeons during procedures. Declarations Competing interest The authors declare that they have no competing or financial interests, either directly or indirectly, in the products listed in the study. Funding This work was supported by the new faculty research fund of Ajou University School of Medicine [M-2024-C0460-00088] Author Contribution Sunwoo Ahn: Manuscript writing, Data collection and analysisGeoffroy Noel: Manuscript editing**Jin Seo Park: Project development, Data collection, Manuscript editing** Acknowledgments This work was supported by the new faculty research fund of Ajou University School of Medicine [M-2024-C0460-00088] References Dalley AF, Agur II (2023) Anne M. R: Moore’s Clinically Oriented Anatomy. In: Dalley (ed.), Lippincott Williams & Wilkins, 9th edition. Pennsylvania: Philadelphia, 839 999 Ettl A, Zonneveld F, Daxer A, Koornneef L (1998) Is Whitnall's ligament responsible for the curved course of the levator palpebrae superioris muscle? Ophthalmic Res 30(5):321–326. https://doi.org/10.1159/000055491 FIPAT (2019) Terminologia Anatomica. In: FIPAT (ed.), Thieme, 2nd edition Holmstrom H, Santanelli F (2002) Suspension of the eyelid to the check ligament of the superior fornix for congenital blepharoptosis. Scand J Plast Reconstr Surg Hand Surg 36(3):149–156. https://doi.org/10.1080/028443102753718023 Hu S, Chen X, Zheng G, Zhao Y, He X, Liu X, Lu F, Lin Y (2024) The Prevalence and Risk Factors of Blepharoptosis in an Elderly Asian Population. Aesthetic Plast Surg 48(7):1298–1305. https://doi.org/10.1007/s00266-023-03804-2 Kakizaki H, Malhotra R, Madge SN, Selva D (2009) Lower eyelid anatomy: an update. Ann Plast Surg 63(3):344–351. https://doi.org/10.1097/SAP.0b013e31818c4b22 Kakizaki H, Zako M, Nakano T, Asamoto K, Miyagawa T, Iwaki M (2004) Three ligaments reinforce the lower eyelid. Okajimas Folia Anat Jpn 81(5):97–100. https://doi.org/10.2535/ofaj.81.97 Kim CY, Chung MS, Park JS (2024) Visible Korean based on true color sectioned images for making realistic digital human, twenty years' record: a review. Surg Radiol Anat 46(7):935–947. https://doi.org/10.1007/s00276-024-03381-2 Lockwood CB (1885) The Anatomy of the Muscles, Ligaments, and Fasclae of the Orbit, including an Account of the Capsule of Tenon, the Check Ligaments of the Recti, and the Suspensory Ligaments of the Eye. J Anat Physiol 20(Pt 1):i2–25 Lukas JR, Priglinger S, Denk M, Mayr R (1996) Two fibromuscular transverse ligaments related to the levator palpebrae superioris: Whitnall's ligament and an intermuscular transverse ligament. Anat Rec 246(3):415–422. https://doi.org/10.1002/(SICI)1097-0185(199611)246:3%3C415::AID-AR13%3E3.0.CO;2-R Minelli L, Brown CP, van der Lei B, Mendelson B (2024) Anatomy of the Facial Glideplanes, Deep Plane Spaces, and Ligaments: Implications for Surgical and Nonsurgical Lifting Procedures. Plast Reconstr Surg 154(1):95–110. https://doi.org/10.1097/PRS.0000000000011078 Nam YS, Han SH, Shin SY (2012) Detailed anatomy of the capsulopalpebral fascia. Clin Anat 25(6):709–713. https://doi.org/10.1002/ca.22013 Park JM, Roh MS, Kim MH, Jeung WJ, Ryu WY, Kwon YH, Ahn HB (2013) Microscopic characteristics of the inferior tarsal muscle and its surroundings in Korean. Int J Ophthalmol 6(2):126–130. https://doi.org/10.3980/j.issn.2222-3959.2013.02.03 Standring S, Borley NR (2009) Gray's Anatomy: The Anatomical Basis of Clinical Practice. In: Susan Standring (ed.), Churchill Livingstone/Elsevier, 40th edition. Edinburgh: Churchill Livingstone Santanelli F, Paolini G, Renzi LF, Longo B, Pagnoni M, Holmstrom H (2011) Correction of myopathic blepharoptosis by check ligament suspension: clinical evaluation of 89 eyelids. J Plast Surg Hand Surg 45(4–5):194–199. https://doi.org/10.3109/2000656X.2011.600035 You Y, Kim CY, Kim SK, Chung BS, Har D, Choi J, Park JS (2022) Advanced-sectioned images obtained by microsectioning of the entire male body. Clin Anat 35(1):79–86. https://doi.org/10.1002/ca.23795 Zhuang W, Fang S, Fan H, Zhu W, Chen Y, Tang W, Liu C, Liu X, Zhang Z, Xing X, Yang C (2019) Anatomical study of the extraocular check ligament system. J Plast Reconstr Aesthet Surg 72(12):2017–2026. https://doi.org/10.1016/j.bjps.2019.09.002 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Feb, 2026 Read the published version in Surgical and Radiologic Anatomy → Version 1 posted Editorial decision: Revision requested 27 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor assigned by journal 19 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 17 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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05:34:24","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74193,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8383902/v1/87b53bc32db55bf2e44c3214.html"},{"id":100005538,"identity":"5abbf1f0-fe4e-44a1-9090-9ba2e888eb44","added_by":"auto","created_at":"2026-01-12 05:34:24","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3928048,"visible":true,"origin":"","legend":"\u003cp\u003eSurface models (left column) and sectioned images (right column) of the check ligaments of the rectus muscles. (A) The superior rectus muscle is held by the superior check ligament via the levator palpebrae superioris check ligament. (B) The overlap of two check ligaments is revealed. (C) The inferior rectus muscle is supported by the inferior check ligament, which is anchored to Lockwood’s ligament. (D) The inferior check ligament is anchored to maxilla and Lockwood’s ligaments. (E, F) The medial rectus muscle is affixed to the lacrimal bone and the orbicularis oculi muscle by the medial check ligament. (G, H) The lateral rectus muscle is connected to the lacrimal gland through the lateral check ligament\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8383902/v1/0adede9f725069008ef738db.png"},{"id":100005536,"identity":"7c68c451-48c4-4d3d-b7a0-79d512bd7423","added_by":"auto","created_at":"2026-01-12 05:34:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2705002,"visible":true,"origin":"","legend":"\u003cp\u003eSurface models (left column) and sectioned images (right column) of the check ligaments of oblique muscles. (A) The superior oblique muscle is held by the superior oblique check ligament which goes to the lacrimal gland. (B) The superior oblique check ligament is anchored to fascia of lacrimal gland. (C) The inferior oblique muscle is stabilized by the inferior oblique check ligament with the support of Lockwood’s ligament. (D) The inferior oblique check ligament is anchored to Lockwood’s ligament. (E) The levator palpebrae superioris muscle is stabilized by its check ligament with the support of the medial check ligament. (F) The levator palpebrae superioris check ligament is connected to the medial check ligament.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8383902/v1/888b49f0e95db62765f91cc4.png"},{"id":100361666,"identity":"84ee5f9c-60a6-43c4-9727-03e96298d218","added_by":"auto","created_at":"2026-01-16 07:45:29","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":759074,"visible":true,"origin":"","legend":"\u003cp\u003eSurface models and sectioned images of the Whitnall’s ligament and Lockwood’s ligament. (A) In the medial portion of the levator palpebrae superioris muscle, the upper and lower layers of Whitnall’s ligament are fused. (B) Real shape of the fused layers of Whitnall’s ligament is observed. (C) Four layers including Whitnall’s ligament is identified in upper eyelid. (D) The superior and inferior tarsal muscles support the superior and inferior tarsi, respectively, and the lower layer of Whitnall’s ligament is observed to serve as a tendon for the superior tarsal muscle. (E) The upper and lower parts of Lockwood’s ligament serve as the tendon for the inferior tarsal muscle and as anchoring points for the two check ligaments, respectively. (F) The inferior check ligament and the inferior oblique check ligament are attached to Lockwood’s ligament.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8383902/v1/6f73d7e4bc66eace013c47b0.jpeg"},{"id":103765762,"identity":"1c51fd64-4ac4-4735-9db6-1151f404a2f7","added_by":"auto","created_at":"2026-03-02 16:08:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7870256,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8383902/v1/fce063c5-966c-4ebd-9807-136188a67b0d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Redefining all check ligaments of extraocular muscles using true color sectioned images","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe check ligaments of the extraocular muscles and the tarsal muscles are composed of dense connective tissue, although less dense than typical ligaments. They function to restrict the movements of the eyeball, thereby enabling the ocular muscles to work in a coordinated and controlled manner [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Notably, the check ligaments of the levator palpebrae superioris muscle and the superior tarsal muscle in the eyelid are the most influential structures in blepharoptosis, a medical condition characterized by abnormal drooping of the eyelid that is prevalent among Asians, particularly the elderly [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Further, impairment in check ligaments of the lower eyelid are related to malposition\u0026rsquo;s of it such as entropion and ectropion, which if severe, may require reconstruction surgeries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, in official anatomical terminology of the Terminologies Anatomica, only the check ligament of the lateral rectus muscle and Lockwood\u0026rsquo;s ligament (suspensory ligament of eyeball) are listed, while other check ligaments are not even mentioned [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, structures such as Whitnall\u0026rsquo;s ligament (the superior transverse ligament of eye) and intermuscular ligament are used in clinical contexts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and are not commonly used in anatomical literature. This is likely because attempts to clarify the exact morphology of these ligaments through gross anatomical dissection remain challenging, as the fibrous strands are intermixed and difficult to differentiate, and their insertions are inevitably displaced during the dissection process.\u003c/p\u003e \u003cp\u003eSeveral researchers have attempted to identify these structures using high-resolution imaging modalities such as MRI [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While MRI allows for differentiation between muscles and connective tissues within the orbit, it is not capable of distinguishing connective tissues based on their density.\u003c/p\u003e \u003cp\u003eUltimately, the only method capable of distinguishing very delicate sheath of soft tissue in a small space while preserving their natural colors was the sectioned images from the Visible Korean. The Visible Korean dataset offers whole-body images with 48-bit color depth and a minimum pixel size of 0.04 mm \u0026times; 0.04 mm, enabling the visualization of any region of the human body, including those with subtle color differences or extremely small anatomical structures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of this study is to clearly define and distinguish the check ligaments of each extraocular muscle within the orbit in an Asian decent cadaver, which is clinically important to better understand blepharoptosis in this population. To achieve this, we highlighted the actual morphology and location of these ligaments using sectioned images and surface models, as if dissected, thereby providing direct anatomical evidence.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eWe produced sectioned images of the whole body of a Korean male cadaver in 2021 (resolution, 8,688 \u0026times; 5,792; interval, 0.25 mm in the head; pixel size, 0.05 mm \u0026times; 0.05 mm; color depth, 48-bit color) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] as part of the Visible Korean project. The donor died due to lung cancer in 2021. His height, weight, and age of death were 1,634 mm, 46 kg, and 71 years old, respectively, and had no significant health issues regarding the eye. From the whole-body sectioned images, we selected images of the head at 0.5 mm intervals. In the selected images, the regions outside the head skin were filled with black, and the head region was cropped to a resolution of 4,089 x 4,589.\u003c/p\u003e \u003cp\u003eIn the head sectioned images, we segmented the structures around the left orbit (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) using Photoshop 2025 (Version 26.1.0, Adobe Systems, Inc., San Jose, CA, USA). To accurately distinguish the check ligaments within the subcutaneous tissue of the orbit, we enhanced the color contrast of the images by adjusting their saturation and brightness levels. We then manually outlined the check ligaments using the Pen tool. These outlined ligaments were filled with white, while the surrounding areas were filled with black to enhance contrast, thereby creating segmented images. Except for the outlining step, this process was automatically repeated for each structure (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Because Photoshop's built-in Automate-Batch tool was not sufficient for the task, we created a script to automate the complex, multi-step workflow of trimming, filling, and generating segmented images in the MATLAB R2025a (MathWorks\u0026reg;, Boston, MA, USA) with the assistance of ChatGPT-5.1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTwenty-eight segmented structures in the sectioned images for Surface models\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTissue (the number)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCheck ligament (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuperior check ligament, Inferior check ligament, Medial check ligament, Lateral check ligament (Check ligament of lateral rectus muscle*), Superior oblique check ligament, Inferior oblique check ligament, Levator palpebrae superioris check ligament\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupporting ligament (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrochlea*, Medial palpebral ligament*, lateral palpebral ligament*, Whitnall\u0026rsquo;s ligament, intermuscular ligament, Lockwood\u0026rsquo;s ligament (suspensory ligament of eyeball*)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkeletal (2)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCranium (without mandible), mandible\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscular (9)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuperior rectus muscle, Inferior rectus muscle, Medial rectus muscle, Lateral rectus muscle, Superior oblique muscle, Inferior oblique muscle, Levator palpebrae superioris muscle, Superior tarsal muscle, Inferior tarsal muscle\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlandular (1)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLacrimal gland\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtc (3)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEyeball, Superior tarsus, Inferior tarsus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Official anatomical terms of Terminologia Anatomica(FIPAT, 2011)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe white areas of segmented structure representing all segmented images were automatically detected and reconstructed into surface models using the Segment Editor tool in Surface models on Slicer 5.8.1 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.slicer.org/\u003c/span\u003e\u003cspan address=\"https://www.slicer.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The shape and position of these models were verified and exported in Object (OBJ) format.\u003c/p\u003e \u003cp\u003eA total of twenty-seven empty polygons were generated in Maya 2026 (Autodesk Inc., San Rafael, CA, USA) at 1 mm intervals. Without any loss of resolution, the corresponding twenty-seven sectioned images were imported and embedded into their respective planes using Polygon Plane tool. This process was automated using a Python script written in Maya, developed with the assistance of ChatGPT-5.1.\u003c/p\u003e \u003cp\u003eThe surface models (OBJ files) were imported into the surface models in which the sectioned images had been embedded. After adjusting their location and direction, these surface models were superimposed onto the sectioned images displayed on the polygon planes. All objects were saved as Maya ASCII (MA) format. Subsequently, the objects were converted to Portable Document Format (PDF) files using Maya Surface models PDF Exporter version 14.0.11.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe classified the ligaments into two categories: The check ligaments and the supporting ligaments. The check ligaments were defined as structures that connect to an extraocular muscle and support its function (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (Zhuang et al., 2019). The supporting ligaments were defined as structures that connect to bone, muscle, or other ligaments and function to assist or reinforce the role of adjacent ligaments (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We were able to differentiate supporting ligaments from other connective tissues since they link the check ligaments to bones, supporting the stabilization of muscles.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDefinitions of check ligaments of extraocular muscles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCheck lig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTo (muscle with excessive contraction restriction)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDirection of excessive movement restriction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperior check lig.\u003c/p\u003e \u003cp\u003e(Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevator palpebrae superioris check lig.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedial portion of superior rectus m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuperior rotation of eyeball, retraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInferior check lig.\u003c/p\u003e \u003cp\u003e(Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontal process of maxilla,\u003c/p\u003e \u003cp\u003eLockwood\u0026rsquo;s lig.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnterior portion of inferior rectus m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInferior rotation of eyeball, retraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial check lig.\u003c/p\u003e \u003cp\u003e(Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE, F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLacrimal bone,\u003c/p\u003e \u003cp\u003eLacrimal part of orbicularis oculi muscle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnterior portion of medial rectus m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedial rotation of eyeball, retraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral check lig.\u003c/p\u003e \u003cp\u003e(Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eG, H)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhitnall\u0026rsquo;s tubercle* of zygomatic bone,\u003c/p\u003e \u003cp\u003eFascia of lacrimal gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnterior portion of lateral rectus m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLateral rotation of eyeball, retraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperior oblique\u003c/p\u003e \u003cp\u003echeck lig (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFascia of lacrimal gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLateral portion of superior oblique m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInferior and medial rotations of eyeball, protraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInferior oblique\u003c/p\u003e \u003cp\u003echeck lig (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC, D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLockwood\u0026rsquo;s lig.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLateral portion of inferior oblique m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuperior and lateral rotations of eyeball, protraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevator palpebrae superioris check lig (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE, F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedial check lig.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedial portion of levator palpebrae superioris m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetraction and slight lateral movement of eyelid\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*The official anatomical term of Whitnall\u0026rsquo;s tubercle is the orbital tubercle (FIPAT, 2011). lig., ligament; m., muscle\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDefinitions of supporting ligaments of extraocular muscles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupporting lig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eto\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary role\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResults of primary role\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrochlea\u003c/p\u003e \u003cp\u003e(Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrochlear fovea of frontal bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSame as left\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePulley for the superior oblique m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRedirection of the movement of the superior oblique m.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral palpebral lig (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhitnall\u0026rsquo;s tubercle on zygomatic bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLateral end of tarsi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnchoring of tarsi to lateral orbital wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupporting eyelids to maintain proper position\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial palpebral lig (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontal process of maxilla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedial end of tarsi through orbicularis oculi muscle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnchoring of tarsi to medial orbital wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSupporting the eyelids to maintain proper position\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhitnall\u0026rsquo;s lig (upper layer)\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhitnall\u0026rsquo;s tubercle on zygomatic bone*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNasal part of frontal bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePulley for the levator palpebrae superioris m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRedirection of the movement of the levator palpebrae superioris m.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhitnall\u0026rsquo;s lig (lower layer, intermuscular lig.) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhitnall\u0026rsquo;s tubercle on zygomatic bone*\u003c/p\u003e \u003cp\u003eNasal part of frontal bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuperior tarsal m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTendon role of superior tarsal m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStabilization of the position of the superior tarsal m.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLockwood\u0026rsquo;s lig.\u003c/p\u003e \u003cp\u003e(Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE, F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontal process of zygomatic bone,\u003c/p\u003e \u003cp\u003eFrontal process of maxilla\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInferior tarsal m.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTendon role of inferior tarsal m.\u003c/p\u003e \u003cp\u003eAttachment sites of inferior check and inferior oblique check lig.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStabilization of the position of the inferior tarsal m.,\u003c/p\u003e \u003cp\u003eInferior check lig., and inferior oblique lig.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*The official anatomical term of Whitnall\u0026rsquo;s tubercle is the orbital tubercle. lig., ligament; m., muscle\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e1. Check ligaments\u003c/p\u003e \u003cp\u003eThe superior check ligament extended from the levator palpebrae superioris check ligament to the medial portion of the superior rectus muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, b; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe inferior check ligament extended from the medial portion of Lockwood\u0026rsquo;s ligament and the maxilla to the anterior portion of the inferior rectus muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec, d; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe medial check ligament originated from the lacrimal bone and the lacrimal part of the orbicularis oculi muscle, to reach the anterior portion of the medial rectus muscle. The ligament was connected to the lacrimal part of the orbicularis oculi muscle, which was anchored to the medial palpebral ligament (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee, f; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe lateral check ligament originated from both Whitnall\u0026rsquo;s (orbital) tubercle of the zygomatic bone and the fascia of the lacrimal gland, and extended to the anterior portion of the lateral rectus muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eg, h; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe superior oblique check ligament connected from the fascia of the lacrimal gland to the lateral portion of the superior oblique muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea, b; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe inferior oblique check ligament extended from the lateral portion of the Lockwood\u0026rsquo;s ligament to the lateral portion of the inferior oblique muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec, d; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe levator palpebrae superioris check ligament originated from the medial check ligament, which is affixed to the medial orbital wall (frontal process of the maxilla), and ended at the medial portion of the levator palpebrae superioris muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee, f; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, the check ligaments of the rectus muscles started from a more anteriorly located point than their corresponding muscles (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea-h; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), whereas the two oblique check ligaments of the oblique muscles were attached to these muscles from the posterolateral orbital wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea-d; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Thus, the check ligaments of all extraocular muscles were positioned opposite to the direction of muscle contraction.\u003c/p\u003e \u003cp\u003e2. Supporting ligaments\u003c/p\u003e \u003cp\u003eThe lateral and medial palpebral ligaments anchored the superior and inferior tarsi to the zygomatic bone and maxilla, respectively. For the medial palpebral ligament, it did not directly attach to the tarsi but connected indirectly via the orbicularis oculi muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe Whitnall\u0026rsquo;s ligament connected with the frontal bone and zygomatic bone, which were located on opposite sides of the orbit. The central portion of the ligament consisted of upper and lower (intermuscular ligament) layers, with the levator palpebrae superioris muscle passing between the layers. The fusion of the upper and lower layers at both lateral ends of the muscle resulted in a sleeve-like structure of the muscle. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea-d; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe lower layer of the Whitnall\u0026rsquo;s ligament, also referred to as the intermuscular ligament, traversed the space between the levator palpebrae superioris muscle and the superior tarsal muscle, and also attached to the superior part of the the superior tarsal muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec, d; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The Lockwood\u0026rsquo;s ligament bridged the inferior portion of the medial and lateral orbital walls. Moreover, its upper part was attached to the inferior tarsal muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee, f; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe check ligaments of extraocular muscles are known to stabilize the eyeball by restricting its excessive movements of extraocular muscles [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, in the official international anatomical terminology [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and the anatomy textbooks [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], only medial, lateral, and inferior check ligaments and suspensory ligament of eyeball (Lockwood\u0026rsquo;s ligament) are mentioned. The reason these ligaments are not fully described in textbooks is that they are extremely difficult to identify through real cadaver dissections. Formalin fixation causes most connective tissues in a cadaver to appear similar in color, and because the removal of adjacent structures or the ligament itself is often unavoidable, the true morphology of the check ligaments is frequently obscured or lost [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese limitations by cadaver dissection can be overcome by using sectioned images, provided by the Visible Korean project [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Structures identified on sectioned images are as valid as those found through traditional dissection, since they rely of direct observation. In fact, due to their greater preservation of detail, visibility beyond the limits of naked eye, and avoidance of dissection-related tissue distortion, sectioned images are more useful when studying small spaced, similar colored tissues.\u003c/p\u003e \u003cp\u003eBased on these anatomically valid and reliable sectioned images, several noteworthy findings were made regarding the check ligaments, as described below.\u003c/p\u003e \u003cp\u003eTo stabilize the eyeball during extraocular muscle movement, Inferior, medial, and lateral check ligaments typically connected the muscles directly to bone. The ligaments were known originally to attach to the orbital wall [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These ligamentous connections could be identified relatively easily by not only cadaver dissection but also the sectioned images, so the three ligaments were described in the anatomy textbooks [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We also confirmed that the ligaments connect the muscles to the bone. Furthermore, we demonstrated that a part of the medial check ligament was also connected anteriorly to the fascia of the orbicularis oculi muscle (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and a part of the lateral check ligament to the fascia of the lacrimal gland (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eh; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSuperior check, superior oblique check, and inferior oblique check ligaments atypically connected the muscles indirectly through other ligaments or fascia before attaching to bone. The superior check ligament linked to the levator palpebrae superioris check ligament, which then connected to the medial check ligament, ultimately attaching to the lacrimal bone at the medial orbital wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, b). The medial check ligament therefore functions both as a check ligament and as a fixation point for other ligaments, because it is firmly anchored to the bone. Superior oblique check ligament and a part of the lateral ligament attached to the dense fascia of the lacrimal gland, which the gland was anchored to bone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eh). Also, the inferior oblique check ligament was seen to attach to the Lockwood\u0026rsquo;s ligament (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee), which bridges the lower part of the medial and lateral orbital walls (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec, d; Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Accordingly, these check ligaments are very difficult to identify through dissection because they do not attach directly to bone. This likely explains why they have not been clearly described in textbooks or previous studies.\u003c/p\u003e \u003cp\u003eThe overlapping check ligaments in the upper part of the eyeball were clearly differentiated. Previous studies on blepharoptosis focused exclusively on the ligaments associated with the levator palpebrae superioris muscle [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and lacked clear classification due to the limitations of gross anatomical methods. In this study, we distinguished the check ligaments of the levator palpebrae superior muscles and superior rectus muscle by identifying their respective terminal muscle attachments (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, b; \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec, d; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe overlapping check ligaments in the lower part of the eyeball were also clearly differentiated. Earlier studies described the check ligaments of the inferior rectus and inferior oblique muscles as being jointly enclosed within the capsulopalpebral fascia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, our findings revealed that the inferior check ligament corresponds to the fascia's inferior layer and medial horn, attaching to the medial portion of Lockwood\u0026rsquo;s ligament. In contrast, the inferior oblique check ligament corresponds to the superior layer and lateral horn, attaching laterally to the Lockwood\u0026rsquo;s ligament and positioned superior to the inferior check ligament (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough previous studies have noted the attachments between the tarsal muscles and surrounding ligaments [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], their functional role was unclear due to innate limitations of cadaveric dissection. Our findings revealed that the ligaments served as tendinous origins for the tarsal muscles. Specifically, the Whitnall\u0026rsquo;s ligament stabilized the superior tarsal muscle by supporting its superior portion, while the Lockwood\u0026rsquo;s ligament anchored the inferior tarsal muscle to the orbital walls (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed, e).\u003c/p\u003e \u003cp\u003eFurther, although earlier studies described three ligaments (Lockwood\u0026rsquo;s, superior, and inferior ligaments) anterior to the capsulopalpebral fascia in the lower eyelid [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], our study found only two ligaments, which we defined as the upper and lower parts of the Lockwood\u0026rsquo;s ligament, both spanning from the medial to lateral orbital walls (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee, f; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). As both the inferior check ligaments and inferior oblique check ligament attach to the lower part, the Lockwood\u0026rsquo;s ligament likely functions as a supportive pillar for these structures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the sectioned images, the check and supporting ligaments and their surrounding structures were clearly distinguishable from the naked eye, providing direct visual evidence of their anatomical presence. The surface models allowed three-dimensional visualization of the orbit and precise identification of the positional relationships between the check ligaments and surrounding anatomical structures. This study exposed all check ligaments that were previously difficult to observe through conventional cadaveric dissection. Furthermore, the functional actions of each ligament in relation to the corresponding extraocular muscles were conforted by their clearly exposed orientations. However, due to the lack of sample size, it was hard to verify our findings with other cadavers. Future work on other sectioned images as well as fresh cadavers would provide support in strengthening our claims. Nevertheless, the anatomy of these orbital structures can now be understood with clarity, providing guidance for surgeons during procedures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interest\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing or financial interests, either directly or indirectly, in the products listed in the study.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the new faculty research fund of Ajou University School of Medicine [M-2024-C0460-00088]\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSunwoo Ahn: Manuscript writing, Data collection and analysisGeoffroy Noel: Manuscript editing**Jin Seo Park: Project development, Data collection, Manuscript editing**\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThis work was supported by the new faculty research fund of Ajou University School of Medicine [M-2024-C0460-00088]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDalley AF, Agur II (2023) Anne M. R: Moore\u0026rsquo;s Clinically Oriented Anatomy. In: Dalley (ed.), Lippincott Williams \u0026amp; Wilkins, 9th edition. Pennsylvania: Philadelphia, 839 999\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEttl A, Zonneveld F, Daxer A, Koornneef L (1998) Is Whitnall's ligament responsible for the curved course of the levator palpebrae superioris muscle? Ophthalmic Res 30(5):321\u0026ndash;326. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000055491\u003c/span\u003e\u003cspan address=\"10.1159/000055491\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFIPAT (2019) Terminologia Anatomica. In: FIPAT (ed.), Thieme, 2nd edition\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmstrom H, Santanelli F (2002) Suspension of the eyelid to the check ligament of the superior fornix for congenital blepharoptosis. Scand J Plast Reconstr Surg Hand Surg 36(3):149\u0026ndash;156. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/028443102753718023\u003c/span\u003e\u003cspan address=\"10.1080/028443102753718023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu S, Chen X, Zheng G, Zhao Y, He X, Liu X, Lu F, Lin Y (2024) The Prevalence and Risk Factors of Blepharoptosis in an Elderly Asian Population. Aesthetic Plast Surg 48(7):1298\u0026ndash;1305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00266-023-03804-2\u003c/span\u003e\u003cspan address=\"10.1007/s00266-023-03804-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKakizaki H, Malhotra R, Madge SN, Selva D (2009) Lower eyelid anatomy: an update. Ann Plast Surg 63(3):344\u0026ndash;351. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/SAP.0b013e31818c4b22\u003c/span\u003e\u003cspan address=\"10.1097/SAP.0b013e31818c4b22\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKakizaki H, Zako M, Nakano T, Asamoto K, Miyagawa T, Iwaki M (2004) Three ligaments reinforce the lower eyelid. Okajimas Folia Anat Jpn 81(5):97\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2535/ofaj.81.97\u003c/span\u003e\u003cspan address=\"10.2535/ofaj.81.97\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim CY, Chung MS, Park JS (2024) Visible Korean based on true color sectioned images for making realistic digital human, twenty years' record: a review. Surg Radiol Anat 46(7):935\u0026ndash;947. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00276-024-03381-2\u003c/span\u003e\u003cspan address=\"10.1007/s00276-024-03381-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLockwood CB (1885) The Anatomy of the Muscles, Ligaments, and Fasclae of the Orbit, including an Account of the Capsule of Tenon, the Check Ligaments of the Recti, and the Suspensory Ligaments of the Eye. J Anat Physiol 20(Pt 1):i2\u0026ndash;25\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukas JR, Priglinger S, Denk M, Mayr R (1996) Two fibromuscular transverse ligaments related to the levator palpebrae superioris: Whitnall's ligament and an intermuscular transverse ligament. Anat Rec 246(3):415\u0026ndash;422. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/(SICI)1097-0185(199611)246:3%3C415::AID-AR13%3E3.0.CO;2-R\u003c/span\u003e\u003cspan address=\"10.1002/(SICI)1097-0185(199611)246:3%3C415::AID-AR13%3E3.0.CO;2-R\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinelli L, Brown CP, van der Lei B, Mendelson B (2024) Anatomy of the Facial Glideplanes, Deep Plane Spaces, and Ligaments: Implications for Surgical and Nonsurgical Lifting Procedures. Plast Reconstr Surg 154(1):95\u0026ndash;110. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/PRS.0000000000011078\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000011078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNam YS, Han SH, Shin SY (2012) Detailed anatomy of the capsulopalpebral fascia. Clin Anat 25(6):709\u0026ndash;713. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ca.22013\u003c/span\u003e\u003cspan address=\"10.1002/ca.22013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark JM, Roh MS, Kim MH, Jeung WJ, Ryu WY, Kwon YH, Ahn HB (2013) Microscopic characteristics of the inferior tarsal muscle and its surroundings in Korean. Int J Ophthalmol 6(2):126\u0026ndash;130. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3980/j.issn.2222-3959.2013.02.03\u003c/span\u003e\u003cspan address=\"10.3980/j.issn.2222-3959.2013.02.03\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStandring S, Borley NR (2009) Gray's Anatomy: The Anatomical Basis of Clinical Practice. In: Susan Standring (ed.), Churchill Livingstone/Elsevier, 40th edition. Edinburgh: Churchill Livingstone\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantanelli F, Paolini G, Renzi LF, Longo B, Pagnoni M, Holmstrom H (2011) Correction of myopathic blepharoptosis by check ligament suspension: clinical evaluation of 89 eyelids. J Plast Surg Hand Surg 45(4\u0026ndash;5):194\u0026ndash;199. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/2000656X.2011.600035\u003c/span\u003e\u003cspan address=\"10.3109/2000656X.2011.600035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYou Y, Kim CY, Kim SK, Chung BS, Har D, Choi J, Park JS (2022) Advanced-sectioned images obtained by microsectioning of the entire male body. Clin Anat 35(1):79\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ca.23795\u003c/span\u003e\u003cspan address=\"10.1002/ca.23795\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhuang W, Fang S, Fan H, Zhu W, Chen Y, Tang W, Liu C, Liu X, Zhang Z, Xing X, Yang C (2019) Anatomical study of the extraocular check ligament system. J Plast Reconstr Aesthet Surg 72(12):2017\u0026ndash;2026. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bjps.2019.09.002\u003c/span\u003e\u003cspan address=\"10.1016/j.bjps.2019.09.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Oculomotor Muscles, Orbit, Cross sectional anatomy, Three-dimensional image, Visible Human Projects","lastPublishedDoi":"10.21203/rs.3.rs-8383902/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8383902/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eVisualizing the check ligaments of extraocular muscles is essential to understand their role as stabilizers of the extra-ocular muscles, acting as their antagonists. Although all extraocular muscles are expected to have corresponding check ligaments, this is not consistently documented in anatomical literature. This study aims to clarify the check ligaments using acquired high-resolution true color sectioned images and surface modeling.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom the sectioned images of one male cadaver, the check ligaments and related structures were outlined and surfaces models were reconstructed using 3D Slicer and Maya to analysis their morphology.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe seven check ligaments corresponding to the seven extraocular muscles, along with the supporting ligaments, were clearly delineated. Previously unrecognized attachment points of the check ligaments, especially to fasciae, were highlighted. In addition to exploring in more detail the tendinous role of Whitnall\u0026rsquo;s ligament and Lockwood\u0026rsquo;s ligament, we focused on the morphology of the ligaments on the lower eyelid.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThrough the reconstruction of surface models based on true color sectioned images, we were able to differentiate all extraocular check ligaments and supporting structures, aligning to their respective roles.\u003c/p\u003e","manuscriptTitle":"Redefining all check ligaments of extraocular muscles using true color sectioned images","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 05:34:19","doi":"10.21203/rs.3.rs-8383902/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-27T08:10:25+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T17:56:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-19T12:03:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T03:40:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Surgical and Radiologic Anatomy","date":"2025-12-17T09:16:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8814a1df-a34d-4bbe-89ad-593865e811d5","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:06:08+00:00","versionOfRecord":{"articleIdentity":"rs-8383902","link":"https://doi.org/10.1007/s00276-026-03838-6","journal":{"identity":"surgical-and-radiologic-anatomy","isVorOnly":false,"title":"Surgical and Radiologic Anatomy"},"publishedOn":"2026-02-27 15:57:15","publishedOnDateReadable":"February 27th, 2026"},"versionCreatedAt":"2026-01-12 05:34:19","video":"","vorDoi":"10.1007/s00276-026-03838-6","vorDoiUrl":"https://doi.org/10.1007/s00276-026-03838-6","workflowStages":[]},"version":"v1","identity":"rs-8383902","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8383902","identity":"rs-8383902","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}