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SUBJECT: Ophthalmology

TOPIC: Ocular media, binocular vision
SHIFTING/DATE: September 11, 2008

I. Ocular Media - complete or partial
 Cornea- constant refractive power of 43 diopters -crystalline lens subluxate upward due to
(38-47D) congenital weakness of the zonular fibers,
 Lens- refractive power 17 diopter (12-22D) hence, stronger zonule will pull lens up.
 Total refractive power- 60 diopters - Subluxate downward as seen in trauma
*vitreous- minimal contribution of diopters Other conditions:
II. Diopter  Homocysteinuria- disclocation is superior and
- unit of lens power nasal
- lens with 1 DO of power will bring parallel rays of  Marfan’s syndrome- disclocation is superior and
light to a focus at distance of 1 meter temporal
*Formula: D=1/f Signs and Symptoms:
eg. 2 DO= 50cm or 0.5m  Same with aphakia, monocular diplopia may
be experienced
III. Refractive States of the Eye
 Emmetropia- parallel rays of light brought to
focus on retina
 Ametropia- condition where parallel rays of light
are brought to focus behind, in front or at 2
planes of retina

IV. Types of Ametropia
 Hyperopia (far-sighted)
 Myopia (near-sighted) Treatment
 Astigmatism  Use of corrective lenses: plus (+) lenses
 Surgical removal of crystalline lens
V. Hyperopia  Mioticconstrict pupil to focus patient’s sight
- rays of light not refracted enough
- point of focus is behind the retina 3. Presbyopia
- short eye - decrease power of accommodation
- AP diameter or axial length is in range of 21mm- - usually occurs when a patient reaches 42 yo
22.75mm Signs and Symptoms:
-normal length 23mm to 23.75mm  Blurring or inability to read fine prints
Other Features: Treatment
 Glaucoma may develop  Use of convex lenses
 Anterior chamber is shallow, pupils smaller, optic
nerve small VII. Myopia
 Pseudopapilledema or pseudo-optic neuritis may - Parallel rays of light focus in front of retina
be present - Excessive refractive power
Signs and Symptoms: - Eye is long
 BOV especially at near vision - AP diameter or axial length about 24 to 26mm
 Headache, frontal in origin - Increase in curvature of the lens- see incipient
 Sensitive to light cataract may develop “secondary sight”
Correction: - Elevated blood glucose level myopic 
 Use of plus (+) lenses or biconvex lenses changes in the index of refraction
- AC is deep, pupils are wide, fundus appears
VI. Special Types of Hyperopia bigger and myopic crescent
1. Aphakia Signs and Symptoms:
-absence of crystalline lens (congenital)  Poor vision for far with good vision for near
-blurring at far and near vision  Holds reading material close to the face
-iridodonesis: nothing holding or pushing the iris Treatment
-surgical removal of lens as in cataract  Use of concave lenses (minus lens)
extraction  Choroid appears black
-Tx: high plus (+) lenses or convex lenses
VIII. Accommodation
2. Lens Dislocation/Subluxation

SUBJECT: optha
TOPIC: ocular media and binocular vision
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- Flexible mechanism by which the eye changes -routinely done in children <6yo
refractive power due to changes in shaoe of the -utilizes the objective method which uses a
crystalline lens retroscope to accurately measure refractive error
- Results from an innervational stimulus producing
an increase tonicity of ciliary muscle and XII. Types of Optical Lenses Used
relaxation of zonules allowing elasticity of lens to  Glasses and plastic lenses
assure a more biconvex state and produce a  Contact lenses
greater refractive power o Extended wear contact lens
- Consist of vertical and horizontal meridian o Daily wear contact lens
***circle of least confusion: focusing of iris (like a o Rigid gas permeable contact lens
camera) o Toric contact lens: expensive
o Astigmatism correction ≥100
IX. Astigmatism
- Light rays entering eye focus on 2 separate lines  Intraocular lenses
instead of a point o Specialized
- Light is not refracted equally on all meridians o Polymethacrylate
- Sometimes clear vision, sometimes blurred o Silicon polymethacrylate
vision o Hydrogels
- Blurred vision: only complaint in higher o Become more inert
astigmatism error o Causes lot of reactions: uveitis
- Tilting of head: 2nd most frequent complaint in XII. Other modalities of correcting Refractive errors
high degrees of oblique astigmatism  Photorefractive Keratectomy (PRK)
- Narrowing of the eyelids to achieve a pinhole or  Laser-in-situ keratomileusis (LASIK)
stenopeic effect
 Intracorneal lens
- Squints both for distance and near task
- Frontal headaches are common  Implantable contact lens
- Test by using astigmatic clock (five finger) or dial  Radial Keratotomy (R.K.)

X. Types of Astigmatism
1. Simple hyperopic astigmatism (SHA)
-focus of light rays one behind and one above
the retina
2. Simple myopic astigmatism (SMA)
-focus of light rays one in front and one above
the retina
3. Compound hyperopic astigmatism (CHA)
-focus of light rays both behind the retina but in
**Radial Keratotomy is an
different levels
established surgical
4. Compound myopic astigmatism (CMA)
procedure whose purpose is
-focus of light rays both in front of the retina but
to remove or reduce
in different levels
ametropia resulting from
5. Mixed astigmatism (MA)
myopia and/or myopic
-focus of light rays on top of retina in two
astigmatism. The whole
different degrees
point of RK is to reduce the
central corneal curvature sufficiently so as to move the
cornea's focus back onto the retina
XI. Method of Refraction
1. Subjective Method
-utilize individual’s ability to choose the lens I. Anatomy of Extraocular muscle and inner fascia
-utilizes a set of Trial lenses  3 pairs of EOM
-patient must be intelligent o Horizontal – medial and lateral recti
-trial and error o Vertical – superior and inferior recti
2. Objective Method
o Oblique – superior and inferior obliques
-uses retinoscope
-useful in children, decreased IQ, unconscious or
-see vertical or horizontal light
3. Cycloplegic Method
-drugs used to paralyze accommodation power
of ciliary body such as:
 Atropine 1%
 Tropicamide 0.5%
 Cyclopentolate and homatropine (2%)
SUBJECT: optha
TOPIC: ocular media and binocular vision
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b. Inferior rectus
i. Primary- depression
ii. Secondary- adduction and
V. Oblique muscles
 Superior oblique muscle
o originate from the annulus of zinn and
passes anteriorly and upward along the
superomedial wall of the orbit becoming
tendinous before passing through the
trochlea located on the nasal side of the
superior orbital rim. The tendon is reflected
inferiorly, posteriorly and laterally, forming
an angle of 51° with the visual axis of the
II. Nerve Supply
eye and inserts in the posterosuperior
a. Lateral rectus – CN 6 (Abducens)
temporal quadrant of the yeball passing to
b. Superior oblique – CN4 (Trochlear)
the SR muscle
c. The rest of the EOM are supplied by CN3
o Primary action – incycloduction
i. Upper division (levator palpabrae
o Secondary action – depression and
muscle & Superior rectus)
ii. Lower division (Medial rectus, inferior
 Inferior oblique muscle
rectus, inferior oblique)
o The parasympathetic innervations to the o originates from the periosteum of the
spinchter papillae and ciliary muscle travels maxillary bone, just posterior to the orbital
with the branch of the lower division of the rim and lateral to the orifice of lacrimal
occulomotor nerve which supplies the fossa. It passes laterally, superiorly and
inferior oblique muscle posteriorly, going to the inferior rectus and
o Formula: LR6SO4 under the lateral rectus to insert in the
posterolateral position of the globe. It
III. Horizontal rectus muscles
forms an angle of 51° with the visual axis n
 Medial and lateral rectus muscles – arise
primary position
from annulus of zinn, course along the
o primary action: excycloduction
medial and lateral orbital wall and
o secondary: elevation and abduction
inserts 5.5mm and 7mm from the
**ANNULUS OF ZINN – holds EOM together except
limbus, respectively

IV. Vertical Rectus muscles
 Superior rectus and inferior rectus
 Superior rectus muscle originates from
the Annulus of Zinn, courses anteriorly,
upward over the eyeball and laterally,
forming an angle of 23° with the visual
axis of the eye in primary position. VI. Rectus muscle insertion relationship
 It inserts 7.7mm from the limbus  The rectus muscle tendons insert
a. Superior rectus progressively further from the limbus in the
i. Primary action- elevation orders of the medial rectus, inferior rectus,
ii. Secondary action- adduction and lateral rectus, superior rectus, by drawing a
incycloductin continuous curve which asses through these
SUBJECT: optha
TOPIC: ocular media and binocular vision
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insertions, one obtains a spiral, known as the
spiral of Tillaux

VIII. Tenon’s capsule (Fascia Bulbi)
 This is an envelope of elastic connective
tissue which is attached to the optic nerve
posteriorly and becomes fused with the
intermuscular membrane 3mm from the
o Posterior Tenon’s capsule – is a
fibrous condensation that separates
the orbital fat inside the muscle cone
VII. Blood supply of the EOM from the sclera, keeping the sclera
 Most important blood supply – medial and
o Anterior Tenon’s capsule – extends
lateral muscular branches of the ophthalmic
artery forward over the muscle and
separates them from the orbital fat
 Lateral muscular branch supplies LR, SR, SO
and structure lying outside the
and LPS
muscle cone
 Medial muscular branch supplies IR, MR and
 Lacrimal artery partially supplies the lateral
rectus and the infraorbital artery partially
supplies the IO and IR muscles
 7anterior cilliary arteries accompanying the
4rectus muscles and each muscle has 2
anterior ciliary arteries except the lateral
rectus with only 1 artery
 Venous system empties into the superior and
inferior orbital veins there are 4vortex veins
and located posterior to the equator near the
nasal and temporal margins of the SR and IR
 There is a high ratio of nerve fibers to eye
muscle fibers (1:3 to 1:5) than in skeletal
muscle which has a low ratio of (1:50 to

IX. Sherrington’s law of reciprocal innervations
 States that increased innervations and
contraction of a given EOM is accompanied
by a reciprocal decrease in innervations of
its antagonist

X. Version and Vergence
 Heering’s Law of Motor correspondence –
states that the equal and simultaneous
innervations flow to synergistic muscle
concerned with the desired direction of gaze.
This is particularly useful on binocular eye
movement and evaluating yolk muscles.
1. ophthalmic artery, 2. central retinal artery, 3.
 When the eye movement is conjugate and
ciliary arteries, 4. two long posterior ciliary
the eyes more in the same direction, it is
arteries, 5. short posterior ciliary arteries. 6. long
posterior ciliary arteries travel in the
suprachoroidal space anteriorly then supply the
choroid anteriorly via recurrent branches, 7.
SUBJECT: optha
TOPIC: ocular media and binocular vision
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known as VERSION. When the eye 1. Alteranting- spontaneous alterantion of fixation
movement are disconjugate and the eyes 2. Monocular- definite preference of fixation
move in opposite direction, the movement is D. Age of onset
called VERGENCE 1. Congenital-ocular deviation occurs prior to age 6
 YOLK MUSCLES – describes 2 muscles one months
from each eye which are the prime movers 2. Acquired- ocular deviation occurs after to age 6
of their respective eyes in a given position of months
gaze. XIV. Evaluation of Strabismus
 History
XI. Binocular Vision  Visual acuity
1. Corresponding Retinal Points  Ocular Alignment
 The foveas are the most important - Monocular cover-uncover test
corresponding retinal areas due to their high - Alternate cover test
resolving power - Simultaneous prism cover test
 Associated with foveal fixation
2. Fusion:
 The cortical unification of visual objects into
a single percept
 For retinal images to be fused, they must be
similar in size and shape
3. Depth perception and stereognosis
 Depth perception is the monocular sensation
of depth  Corneal Light reflex test
 Stereognosis is the binocular sensation of - Hirschberg’s method
relative depth covered by horizontal retinal - Modified krimsky’s tets
image - Ambiyoscope
XII. Abnormalities of Binocular Vision  Disimilar Image test
1. Diplopia - Maddox rod test
 Is a result from a misalignment of the visual - Double Maddox rod test
axes, wherein an image falling on the fovea - Red filter test
of one eye and simustaneously on a non-  Special Motor test
foveal point in the other eye - Forced duction test
2. Suppression - Active force generated test
 Is the alteration of the visual sensation that - Saccadic velocity
results from the images of one eye being  Refraction
inhibited or prevented from reaching - Cycloplegic refraction
consciousness - Manifest refraction
3. Ambiyopia  Pseudostrabismus- due to broad nasal bridge
 Is a unilateral or bilateral reduction of and often associated with epicanthal folds
corrected central visual acuity without a XV. Esodeviation
visible organic lesions commensurals with A. Congenital
this loss 1. Congenital or infantile esotropia
XIII. Classification of Strabismus -onset of the esotropia at birth
A. Fusional Status - Documented presence at six month of age
1. Orthophoria-ideal ocular balance - Family history of genetic patterns are unusual
2. Heterophoria-deviation kept latent by - Seen in children with cerebral palsy and
fusional mechanism hydrocephalus
3. Heterotropia-deviation which is manifest at - Treatment: full cycloplegic refraction and surgery
all times by 18th month of age
B. Variation of the deviation with gaze
1) Comitant- deviation does not vary with direction
of gaze
2) Incomitant- deviation does vary with direction of
C. According to fixation:
SUBJECT: optha
TOPIC: ocular media and binocular vision
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Moments with 3b =)
2. Early onset esodeviation with accommodative
- Common type of esodeviation
- Majority of patients have both an
accommodative and a non-accomodative
- Also called mixed mechanism
- Treatment: when after full hyperopic
- Surgery is considered. The non-
accomodative is managed surgically.
3. Duanes syndrome
- Assocaiated with other congenital
abnormalties such as:
- Goldenhar’s syndrome
- Mobius syndrome
- Klippel-feil syndrome
- Treatment: full refractive correction and
 Type I: Limitation of abduction- most
commonly seen and frequently affecting the
left eye
 Type II: Limitation of adduction
 Type III: Limitation of abduction and

B. Acquired
1. Comitant accomodative esotropia
- Onset is from 6 months to 7 years with an
yes parang model lang…
average of 2 ½ years
- Aften hereditary
- Ambitopia is frequent, with no diplopia
- Refractive accommodative, Non-refractive
accommodative and combined form or
mixed mechanism esotropia are some of the
2. Non- accommodative esotropia
- Stress induced and can be precipitated by
debilitating illness, emotional trauma,
physical injury and ageing
- Can be cyclic or have a variable cycle of 24- Moments daw oh…
48 hours
- Treatment: full hyperopic correction. Some
require surgery when they progress to cyclic
3. Incomitant esotropia
- Medial rectus muscle restriction such as in
thyroid myopathy, medial orbital wall
fracture, excessively resected medial rectus

- Lateral rectus muscle weakness as seen in
abducens palsy
SUBJECT: optha
TOPIC: ocular media and binocular vision
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Happy =) sad =(