May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.

Ces.Christian.Elaine.Riza.Kristel.Ezra.G oldie.Buff.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika .Macky.Viki.Joan.Precious.Kate.Katrina.Ams.Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

Subject: Ophthalmology Date: June 19, 2008

Topic: Anatomy of the eye Lecturer:

Trans Group: juday and forever friends

ORBIT • The socket that is intended to house the eyeball for which protection and space for its movement are provided • The space through which the muscles, the blood vessels and nerves going to the eyeball pass through • The cavity of the orbit is roughly quadrangular pyramid lying on its side • Has a roof, medial, & lateral sides, a floor, an apex pointing to the midcranium, & a base forming the bony margin of the face


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The entire cavity is lined with periosteum called periorbita, which extends anteriorly to the tarsus and canthal ligaments forming the orbital septum The entire orbital contents are completely enclosed except at the palpebral fissures Traversed by fibrous extensions from the periosteum (orbital fascia) that divides it into 4 compartments Pathway for CN II, III, IV, V, VI

4 compartments or the orbit: 1. SUBPERIOSTEAL SPACE • Potential space between periorbita and bone • At the apex, the periorbita is firmly attached to the dural sheath of the optic nerve; in front it becomes continues with the periosteum over the forehead and face • Between these attachments, the periorbita is readily peeled off from the bone, thus facilitating the surgical removal of orbital contents – exenteration 2. MUSCLE CONE • Space formed by the recti muscles and their intermuscular membranes with Tenon’s capsule • Aka: central surgical space • The base of this cone is the posterior part of the eyeball, while its apex is towards the optic foramen • Tumors or growth in this space will proptose the eyeball directly forward 3. PERIPHERAL SURGICAL SPACE • Space located between the periorbita and the muscle cone • Limited anteriorly by the orbital septum, the canthal ligaments, & the condensation of the Tenon’s capsule • This space contains the orbital fat that serves as a cushion for the eyeball and its delicate structures • Any effusion of fluid or blood into this space produces an early lid swelling of both upper and lower eyelids • However, chronic fatty swelling may produce proptosis as in thyrotrophic exophthalmos 4. EPISCLERAL SPACE • The potential space between the sclera and Tenon’s capsule EYELIDS • Nature’s curtain which consist of skin, subcutaneous tissue, muscles, tarsus, & conjunctiva • Not only to protect the globe from external injury & excessive light but also to distribute tears uniformly over the anterior surface of the eye • The skin is thin and elastic, joined to the underlying muscle by loose areolar tissue, which makes this area prone to ecchymosis and excessive swelling

The lid margins contain a muco-cutaneous border, the grayline, 3 rows of lashes or cilia, the opening of the meibomian glands, & the superior & inferior punctum • An incision made along the grayline will split the lids into a posterior part containing the tarsal plate & conjunctiva and an anterior part containing the orbicularis oculi muscle, skin, & hair follicles • Opening into the follicle of each cilium are the ducts of the sebaceous gland of Zeiss and the modified sweat gland of Moll • There are many pain fibers near the lid margin making that portion the most sensitive part of the eyelid • Behind the subcutaneous connective tissue are the muscles of the eyelids: orbicularis oculi, levator palpebrae superioris, & the palpebral smooth muscle of Muller Orbicularis oculi – innervated by CN VII; has two parts: peripheral orbital part which serves to squeeze the eyelid shut and the central palpebral part that is necessary for the involuntary blinking Levator palpebrae superioris – closely related to the superior rectus muscle in its origin and course; innervated by CN III Superior & Inferior palpebral muscles of Muller – supplied by sympathetic nerves

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Tarsus – plate of fibroelastic tissue that gives form to the eyelids; contains parallel rows of sebaceous glands (meibomian glands) Blood supply: lacrimal and ophthalmic arteries; wide anastomosis provided by branches of the external carotid artery through the facial, superficial temporal, and infraorbital arteries Venous return: into the cavernous sinus or into the internal jugular vein via te superior & inferior ophthalmic veins Lymphatics: medial 2/3 of lower lid & medial 1/3 of upper lid drain into the submaxillary lymph glands; lateral 1/3 of lower eyelid & lateral 2/3 of upper lid drain into the peri-auricular lymph glands CN V (first or ophthalmic division) provides sensory innervationto the upper lid and lateral portion of lower lid. Remaining portion innervated by the maxillary division through the infraorbital nerve.

LACRIMAL APPARATUS Secretory - produces tears and pre-corneal film which is formed by a deep mucoid-mucin, a middle watery-tears (thickest layer), & superficial oily secretion Excretory - provides the normal passageway for the conduction of tears from the conjunctival cul-de-sac to the inferior meatus of the nose SECRETORY SYSTEM Two types: 1. BASIC SECRETORS • Mucin secretors – conjunctival goblet cells, crypts of Henle, & glands of Manz • Lacrimal secretors – exocrine glands in the subconjunctival tissue: glands of Krausse & glands of Wolfring • Oily secretors – made up of meibomian glands, glands of Zeiss, & glands of Moll; oily layer lessens the evaporation of the watery layer of the tears

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May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.G oldie.Buff.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika .Macky.Viki.Joan.Precious.Kate.Katrina.Ams.Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

Subject: Ophthalmology Date: June 19, 2008

Topic: Anatomy of the eye Lecturer:

Trans Group: juday and forever friends

2. REFLEX SECRETORS • Are the amin lacrimal gland in the upper temporal portion of the orbit and the adjacent palpebral gland • Exocrine glands that have efferent parasympathetic nerve supply • Serous acinous glands similar to the salivary glands • Always involved primarily in true hypersecretion Schirmer’s test – standard in secretion test Schirmer’s I – test the basic secretion; with anesthetic Schirmer’s II – test for reflex secretion; without anesthetic EXCRETORY SYSTEM a. lacrimal pump – consists of the movements of the orbicularis oris muscles to direct the flow of tears to the punctal area in the nasal side of the eye b. superior & inferior punctum – opening of the drainage system c. ampulla d. superior & inferior cannaliculus – 8mm e. common cannaliculus – present in 80% of individuals f. lacrimal sac – 10mm g. nasolacrimal duct (NLD) – 12mm; runs between the anterior & posterior lacrimal crests of the lacrimal bone in the medial wall of the orbit; exits in the inferior meatus of the nose h. valve of Rosenmuller – one way valve found between the common cannaliculus & lacrimal sac i. valve of Hassner – one way valve between the NLD & inferior meatus CONJUNCTIVA • mucosal lining of the inner part of the lids & anterior portion of the eyeball • has 2 divisions: palpebral & bulbar portion separated by the fornix • palpebral portion has 3 sections: marginal – groove near the lid margin to which it is adherent tarsal – vascular portion attached to the tarsus orbital - which is loosely connected to the palpebral muscle • bulbar portion – thin layer that overlies the Tenon’s capsule but becomes fixed to it near the limbus • has an epithelium of non-keratinized cells varying from 35 layers thick GLOBE • the anterior one third of the globe externally is occupied by the cornea and the posterior 2/3 is the sclera

CORNEA • Transparent anterior structure of the eye • This is the major refracting structure of the eye (estimated total power 40 diopters) • The cornea forms part of the boundary in the anterior chamber angle

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2. 3.

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Infections and inflammations in the anterior chamber area can produce fibrosis attaching the cornea to the iris and commonly called anterior synechiae (similarly, the iris can produce attachments to the anterior lens capsule and is called posterior synechiae) Layers of the cornea: epithelium • Anteriormost layer of the cornea near the tear film • It regenerates in 24-72 hours & responsible for maintaining corneal hydration anteriorly • If destroyed by trauma, infections & inflammations, corneal edema amy be evident that may extend up to the stromal layer bowman’s membrane corneal stroma or substancia propria • 90% collagen; 5% cells (keratocytes & 5% mucopolysaccharides • thickest part of the cornea descemet’s membrane endothelium • a monolayer of mesodermal cells • innermost layer of the cornea • responsible for maintaining deturgescence by acting as a mechanical barrier & as a pump wherein it is responsible for exchange of water and electrolytes between the cornea and the aqueous humor Has a rich sensory nerve supply, which is part of the protective mechanism of the eye. Thus pain is the most common symptom of corneal dse. Avascular and it is entirely dependent on air and tears anteriorly & aqueous humor posteriorly for its nutrition

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the junction of the two structures is called limbus, which is the anatomical location of the trabecular meshwork internally limbusthe average axial length is 23.5mm. longer axial lengths can produce myopia and shorter lengths can produce myopia and shorter lengths can produce hyperopia. Normal lengths are called emmetropias. The central/paracentral area (spherical) is where the light bends Light does not bend in the peripheral area (flat)

ANTERIOR CHAMBER Angle structures: 1. Schwalbe’s line – most anterior part of the angle; it is the posterior part of the cornea at the area of the limbus 2. Anterior TM – nearest the cornea; angles are closed if it’s only the TM (trabecular meshwork) structure seen in angle examination (gonioscopy) 3. Posterior Tm – angles are open if this area is viewed clearly in gonioscopy 4. Scleral spur – part of the posterior sclera seen in the posterior angle 5. Iris processes – peripheral part of the iris that attaches to the scleral spur 6. Ciliary body – longitudinal muscles and part of the ciliary body are seen as the most posterior part of the angle *pars plicata – w/ ciliary epithelium & muscle *pars plana – no structures like muscles; just connects ciliary body & uveal tract *ciliary muscles – constricted with use of pilocarpine TRABECULAR MESHWORK • The main site of the drainage of aqueous humor • Three layers that make up the meshwork:

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May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.G oldie.Buff.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika .Macky.Viki.Joan.Precious.Kate.Katrina.Ams.Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

Subject: Ophthalmology Date: June 19, 2008
1. 2. 3.

Topic: Anatomy of the eye Lecturer:
• •

Trans Group: juday and forever friends

uveal meshwork corneoscleral meshwork cannalicular meshwork – studies on open angle glaucoma determined this structure as the main site of obstruction

PATHWAY OF AQUEOUS HUMOR FLOW a. Non-pigmented epithelium of the ciliary body b. Posterior chamber c. Pupil d. Anterior chamber e. Trabecular meshwork f. Schlemm’s canal g. Episcleral vessels *milky color of the aqueous humor may be 2O to inflammation *increase intraocular pressure may cause blurred vision LENS • Crystalline biconvex soft structure behind the iris-pupil diaphragm and in front of the vitreous body. • Composed of central hard nucleus (older lens fibers) and a peripheral soft cortex (newer lens fibers) enclosed by a capsule • Held in position by zonular fibers coming from the ciliary body that fused with the capsule at the region of the equator • It contributes 20 diopters of refractive power • Parts include the following: a. Anterior capsule b. Lens epithelial cells – beneath the anterior capsule & is responsible for the growth of lenticular fibers c. Lens stroma – anterior & posterior cortex and nucleus d. Posterior capsule CHOROID • Layer anterior to the posterior sclera and the posterior part of the uveal tract (iris, ciliary body, choroids) • Contains the blood supply to the retina VITREOUS HUMOR • Clear, gel-like structure that occupies the posterior spacein front of the retina • Strong attachments are seen in the following structures: a. Vitreous base b. Optic disc c. Macula d. Blood vessels • Retina tears and detachments are often seen in these areas in case of trauma, aging, dystrophies, degenerations, & high myopia • Opacities are sometimes observed in this structure due to deposition of inflammatory cells in endophthalmitis and posterior uveitis, calcium (asteroid hyalosis) in hypercalcimic conditions and cholesterol deposit (synchisis scintillans) in hypercholesterolemic conditions which can cause blurring of vision • TORCH - TOxoplasma, R, Chlamydia, H ;causes congenital glaucoma • Syneresis (??) – liquefaction of vitreous humor bleedingcauses blurring of vision RETINA

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Innermost layer of the eye A delicate structure where the image of the objects from the outside world is focused and converted into a nerve impulse which is transmitted to the visual center of the brain The photoreceptors or visual cells which receive the light energy are located at the posterior portion of the retina Light consequently has to traverse the whole thickness of the retina in order to reach the visual cells which converts the light energy to the electrical energy of the nerve impulse Layers of the retina: a. Inner limitng membrane – closest the vitreous body b. Nerve fiber layer – contains the axons of the optic nerve c. Ganglion cell layer – cell body of the optic nerve axons and displaced amacrine cells d. Inner plexiform layer – axons of bipolar cells; transmits signals vertically e. Inner nuclear layer – nuclei of bipolar, horizontal and amacrine cells f. Outer plexiform layer – rods and cones axons g. Outer nuclear layer – cell bodies of rods and cones h. Potoreceptor layer • RODS – responsible for night vision and spatial orientations; numerous throughout the retina; occupies most of the peripheral retina • CONES – responsible for acute and color vision i. Retinal pigment epithelium – involved in the phagocytosis of the outer segments of the rods and cones (rods before sunrise and cones at sunset) and is also involved in the vitamin A cycle where it isomerizes all trans retinal to 11 cis retinal that are used by photoreceptors; also serves as the external mechanical barrier for blood flow from the choriocapillaries to the retina and maintains homeostasis in the retina by supplying small molecules such as ascorbic acids and glucose j. Outer limiting membrane

Muller cells - glial cells that run almost through the entire length of the retina (ganglion cells to layers of rods and cones); provides nutritive and physical support to retinal structures and recently been described as ‘nature’s fiber optics’ due to its ability to transmit light through the thickness of the retina to the rods and cones pesteriorly • Parts of the retina: a. Ora serrata – anteriormost part of the retina near the pars plana of the ciliary body; can be seen with the use of a gonioscope b. Equator of the eye – middle part of the retina; can be seen wit the use of indirect ophthalmoscope c. Posterior pole – most posterior part of the retina; can be seen with the use of direct & indirect ophthalmoscope • Macula – central part of the posterior pole responsible for acute vision; central part is called the fovea (its center is known as foveola) • Optic nerve head – 1.5mm in diameter and located 2.5 disc diameter from the macula; where all nerve fibers exit • Central retinal arteries and veins  Superior temporal vessels

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May.Yvette.Allain.Cristina.Ralph.Sheryl.Bart.Heinrich.Pipoy.KC.Jam.Cecille.Denesse.Mike.Hoops.Ces.Christian.Elaine.Riza.Kristel.Ezra.G oldie.Buff.Mona.AM.Maan.Adi.KC.Peng.Karla.Alphe.Aaron.Kyth.Anne.Eisa.Kring.Candy.Isay.Marco.Joshua.Fars.Rain.Jassie.Mika.Shar.Erika .Macky.Viki.Joan.Precious.Kate.Katrina.Ams.Memay.Pau.Rachelle.Esther.Joel.Glenn.Toni

Subject: Ophthalmology Date: June 19, 2008

Topic: Anatomy of the eye Lecturer:

Trans Group: juday and forever friends

• •

 Inferior temporal vessels  Nasal vessels  Papillomacular Cottonwood spots – non-profused areas of the retina; pale retina with cherry red spot (CRAO-central retinal artery occlusion) Macula divides into temporal and nasal visual fields; retinal nerve divides the structures into temporal & nasal sides

OPTIC NERVE Parts: a. Intraocular ON – 1.75mm in length and is divided into 3 layers: • Prelaminar layer – central part of the head is called the optic cup, which is devoid of nerve fibers & vessels. Enlargement of this area may be 2O apoptosis of nerve fibers in glaucoma and ischemic optic neuropathies • Laminar layer – oriented beside the lamina cribrosa of the posterior sclera • Postlaminar layer – thickening of the diameter to 3-4mm 2O to myelination of the optic nerve b. Intraorbital ON – 25-30mm in length c. Intracannalicular ON – 5-6mm in length; adherent of the dura of the optic canal; site of injury in direct and indirect trauma of the orbit d. Intracranial ON – 10-12mm; unites as optic chiasm just above the pituitary gland VISUAL PATHWAY • Nerve fiber layer of the retina 1. superior arcade – retinal lesions in this area can produce unilateral inferior defect 2. inferior arcade – unilateral superior field arcuate defect 3. nasal fibers – temporal wedge defect 4. papillomacular bundle – central (<5 degrees in field) & paracentral (10-15 degrees) visual field defect; involvement of the papillomacular & inferior or superior bundles can produce altitudinal field defect (superior or inferior half of field) • Optic nerve – unilateral visual field loss • Optic chiasm – bitemporal hemianopsia; junctional scotoma wherein there is a visual loss of one eye & superotemporal quadrant of the other eye secondary to compression of one side of the chiasm where inferonasal fibers of the less involved eye as it crosses the chiasm travels a short distance posteriorly as Willbrand’s knee • Optic tract – posterior to the chiasm & produce an incongruous hemianopsia (temporal loss: laterality of the hemianopsia and nasal VF loss: laterality of the lesion in the optic tract); visual pathway field loss respects the vertical meridian, crossing the macular area or central field while optic nerve fiber type defects respects the horizontal meridian and oriented/connected with the physiologic blindspot. One way to identify lesion in this area is presence of relative afferent pupillary defect (RAPD or Marcus Gunn pupil) • LGB of the thalamus • Optic radiations to the parietal lobe – pie on the floor effect • Optic radiations to the temporal lobe – pie in the sky defect

Optic radiations to the occipital lobe – when the radiations from the parietal & temporal lobes meet as it approaches the visual cortex, the defect can be a quadrantanopsia or a congruous hemianopsia Visual cortex – a quadrantanopsia if the lesion is above or below the calcarine fissure; a congruous hemianopsia if the lesion is the left or right visual cortex; macular sparing which are often seen in lesions of the cisual cortex are due to predominance of macular fibers of the tip of the visual cortex & its dual supply (middle & posterior cerebral artery) sparing them from damage in the mild to moderate ischemia of the occipital cortex; complete hemianopsia if it affects the whole half of the visual fields of both eyes

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