Professional Documents
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DR VINEET SEHGAL
MBBS MD (AIIMS)
FELLOWSHIP IN GLAUCOMA
INCHARGE GLAUCOMA SUBSPECIALITY
SHARP SIGHT CENTRE
EX CONSULTANT- MEDANTA MEDCITY
ASSISTANT EDITOR- DJO
NTSE SCHOLAR
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Embryology
Development starts from 3 weeks
Choroidal fissure is formed due to differential growth
of optic vesicle.
If this choroidal fissure does not fuse it becomes
typical colobomas
Mesoderm forms the hyaline system of vessels
INFERONASAL COLOBOMA
NEURAL ECTODERM NEURAL CREST MESODERM
SURFACE ECTODERM
• On keratometry INTACS
- Steep cornea Intracorneal ring segments
- Bow tie pattern used to reduce corneal
- Paracentral thinning of cornea steepening, made of
Rizutti sign seen in PMMA.
keratoconus • Used in Pellucid Marginal
Acquired condition- VKC has Degeneration, post LASIK
high association. ectasia and keratoconus.
ANTERIOR SEGMENT DYSGENESIS SYNDROME
Peters anomaly
•Histopathologically, Endothelium & Descement”s is absent.
•There is central or paracentral corneal opacity.
• Peter 1 is without corneolenticular touch. Peter 2 has corneolenticular touch.
• Peter 2 having more systemic associations than Peter 1.
•Peter plus syndrome has many systemic malformations with it like, short stature, hearing defect, CVS
malformations etc. PAX 6 gene associated with it
Pterygium is a type of connective tissue degeneration. (Q)
• Probe test done to distinguish between pterygium &
pseudopterygium,
• In pseudopterygium it can pass, but not in pterygium.
(AIIMS)
• Stockers line is an evidence of iron deposition in
pterygium.
SPHEROIDAL DEGENERATION
SPECULAR MICROSCOPY
• Endothelial cell count done by specular microscopy.
• Based on the principle of specular reflection of light where
angle of reflection is equal to angle of incidence.
•Endothelium is usually made up of hexagonal, regular cells
which are uniform in shape.
ANKYLOBLEPHARON / SYMBLEPHARON
•Fusion of palpebral & bulbar conjunctiva symblepharon.
•Fusion of upper and lower palpbral conjunctiva
ankyloblepharon.
VERNAL KERATOCONJUNCTIVITIS
Other Drugs
- Sodium Cromoglycate, Ketotifen & Epinastine.
- Refractory VKC-Cyclosporine (Topical),
Tacrolimus d. acetyl cysteine 0.5%
- SIGNS- Maxwell-Lyon sign, Horner Trantas
Spots
LASIK
• Principle: Flatten or steepen the Curvature of cornea & Change refractive power
Types
-Myopic
-Hyperopic both.
• Indication age > 18 yr, no viral keratitis, stability of power of spectacles for at least six months, no lattice with
hole, adequate thickness of cornea, CCT > 490 for I LASIK & 530 micrometer for conventional LASIK. (PGI TYPE)
• Severe dryness, schirmer < 5 mm is also a contraindication. Pregancy & lactation relative contraindications
• Corneal ectatic condition like keratoconus, pellucid marginal degeneration are contraindications of doing
LASIK. There is no upper limit of age.
Note PRK is photorefractive keratectomy. That's not typical LASIK. That is superficial ablation done, followed by
laser application of laser
• SMILE- is small incision lenticular extraction, I lasik is bladeless lasik.
(Both I LASIK and SMILE use femtolaser)
• Pentacam: Now the investigative modality of choice to do any corneal topography, it may be
keratoconus, ectasia, LASIK.
• Conventional LASIK is microkeratome based that uses blade and excimer (193 micrometer) laser
•ARLTS LINE IN TRACHOMA
HERPES ZOSTER HERBERT’S PITS Can u see the
OPHTHALMICUS, opacified encirclation
Single dermatome ring near limbus.
involvement is Close differential is
there , so always arcus senilis that has
unilateral clear space between
limbus and cornea
Band shaped
keratopathy OPTICAL COHERENCE
PANNUS TOMOGRAPHY
Calcium deposition in Can you see angry vessels
on the cornea. It can be MEASURES Retinal
band shaped pattern. Nerve Fibre Layer Contour,
seen IN pterygium also but
Most common cause of the fleshy component Both macula and optic
BSK is post would be much more than nerve head can be
vitrectomized eye with the vascular component
evaluated
Silicon oil in situ
LID TARSORRAPHY HORNER TRANTAS SPOTS DENDRITIC ULCER: Seen
in Herpes Simplex Virus,
Pseudodendrites can be
seen in the other
modules like HZV and
acanthamoeba too
RING OF WESSLEY
- Acanthamoeba Keratitis
- Fungal corneal Ulcer
RETINA – ANATOMY & PHYSIOLOGY
Area of
Macula - 5.5 mm
Fovea - 1.5 mm
Foveola 0.35 mm. (Thinnest part of retina. No ganglion cells, only cones)
Signal transduction process is same in rods & cones though there number, color & intensity at
which it excites differ. (AIIMS Q)
Rods function – main fx in vision in dim light. Cones main fxn is color vision- blue, green & Red
Peak absorption at 500 nm, 120 million rods in retina, contrast to only 6.5 million cones (may be
imp in NEET & DNB)
No rods at foveola, max 20 deg of foveola, in contrast to cones that has highest concentration at
foveola
Cotton wool spots are present in nerve fibre layer.
It is seen more commonly in hypertensive retinopathy
Soft exudates or Cotton wool spots are small yellowish type,
irregular margins, due to axonal debris.
Its due to axonal transport blockage.
•
Retinal Detachment (RD)
•RPE is the 1st layer of retina that contains single layer of cells attached to
bruch’s memberane of choroid. (imp in wet ARMD)
•Curtain falling over eyes & Flashes are typical presentations of RD.
Floaters can appear in both RD, pars planitis, CRVO & Vitreous Hemorrhage.
(VH)
ROP GUIDELINES: @
WHICH BABIES TO BE SCREENED GUIDELINES:
- Less than 1500gm
- Less than 32 weeks
-Pediatrician feels the necessity looking at the baby’s condition ,like mechanical ventilation,
sepsis, prolonged oxygen therapy & hemodynamic instability
When to screen: its four week after birth or at thirty one weeks whichever is later
•If the patient is LASERED ROP, then we have to follow him long.
•If patient has ROP, but its initial stage, then we can follow up till 40 weeks or when there is no
progression or change in three successive visits.
•If there is no ROP till 36 weeks, u can be safe.
ROP REQUIRING TREATMENT
•Zone I, any stage ROP with plus disease or
•Zone I, stage 3, with or without plus disease
•Zone II, stage 2 or 3 ROP, with plus disease
NOT TO TREAT
· Zone I, stage 1 or 2 with no plus disease or
· Zone II, stage 3 with no plus disease
NON PROLIFERATIVE DIABETIC RETINOPATHY WITH CLINICALLY
SIGNIFICANT MACULAR EDEMA
DIABETIC RETINOPATHY INVOLVES WHOLE OF FUNDUS. CAN U SEE EXUDATES ALL OVER THE FUNDUS , ALSO
SMALL HEMORRHAGES AND MICROANEURYSMS, ALSO ONE IMPORTANT THING TO NOTICE IS SOME YELLOWISH
DOTS NEAR MACULA , SO OUR DIAGNOSIS IS CSME
Central Serous Retinopathy (CSR)
CLINICAL SCENARIO (AIIMS/USMLE): Young anxious male coming to OPD with chief complaints of central
scotoma/blurred vision acute onset and says this happens quite often to him but resolves itself in few months.
Ink blot appearance (more common) & Honeycomb appearance is seen in CSR on
FA.
Also note CSR have
•Central scotoma @
•Type A personalities, males, it is more common
•Ask about use of Steroids from patient
• Hyperopic shift
Mx
- Wait and observe
- LASER the leaky areas
- PDT experimentally used
MICROBIOLOGY OF RETINA
• SYPHILLIS- salt and pepper retinopathy with extensive chorioretinal scarring.
• Leprosy affects cooler parts of the body. It affects all parts of eye. Retina is very rarely involved
and that two few here and there nodules.
• In tuberculosis, there are creamy coin shaped nodules in fundus.
• Toxoplasma has excavated scar in fundus, macula is its favorite site for toxoplasma. Also
headlight in fog appearance
TOXOPLASMA SCAR-
• CMV Retinitis- Pizza Pie appearance
Healed Toxoplasma
HEADLIGHT IN
FOG
APPEARANCE
FROSTED BRANCH ANGITIS -
CMV Retinitis Fundus Photo of Sarcoidosis
The florid translucent Placoid disc lesions in TB.
perivascular exudate is • Candle wax drippings- see exudates in
fundus, & near blood vessels, note these Diffferentiate it from
called 'frosted branch
angiitis' are just yellow lesions & these are not sarcoidosis lesions where it is
hard exudates as those are more distinct more exudates around the
margines. These are characteristic
findings of sarcoidosis
vessels
BERLINS EDEMA WITH CHERRY RED
SPOT- Red spot in midst of a pale retina (
c.f Bull’s eye retinopathy, where the red
glow of fundus is maintained)
CLINICAL SCENARIOS: Iritis with joint pain – Ankylosing spondylitis.
other Associations: Reiter & Psoariasis
Most common cause of arthritis involved with anterior uveitis- Ankylosing
Spondylitis
.
•Neovascular glaucoma occurs when there is
abnormal proliferation as in DM, CRVO or OIS, in
open angle glaucoma there is no abnormal
proliferation normally.
•CRVO induced glaucoma called 90 day glaucoma.
Can u see variety of exudates, some yellow, some whitish, some confluent.
These are characterastic of ongoing leakage. Its not diabetic retinopathy as you cant see hemorrhages. Compare
it with the photo of diabetes I have given, this is COATS DISEASE fundus photo. Features are
-1st decade of life
- Telengiectasia
- Characterisitic exudates all along vessels
- Leukocoria
BEST VITELLIFORM DYSTROPHY
CILIARY STAPHYLOMA
•Vitelliform dystrophy, or Best disease, is
hereditary retinal dystrophy involving RPE and • MYOPIA
leads yellow egg yolk appearance of the macula.
• TRAUMA
It present itself in childhood or early adulthood.
• SURGERY
•EOG is characteristically decreased • UVEITIS
RETINITIS PIGMENTOSA
Centrocecal scotoma diagnostic of RP.
X linked most severe.
Bigenic inheritance pattern
Most common inheritance pattern Autosomal
Recessive.
Abetalipoproteinemia, or Bassen-Kornzweig
syndrome, AR rdisorder that interferes with the
normal absorption of fat and fat-soluble vitamins.
NARP – neuropathy, Ataxia and RP, (
Abetalipoproteinemia, refsum disease are known
associations.)
Bardet–Biedl syndrome (It is characterized
High Dose VITAMIN A & ARGUS RETINAL IMPLANTS
by obesity, polydactyly, RP, hypogonadism,
and renal failure in some cases.
•PHPV associated with
microphthalmos.
Post operative endophthalmitis
•Delayed: MC cause- Propionobacterium acnes
•MC in total- Coagulase neg Staphylococci
•MC-Post traumatic- Bacillus Cereus
•MC fungal infection in eye in HIV - Candida
FA PICTURE OF CYSTOID
MACULAR EDEMA
How to solve Fundus Based Questions
Now when u see a fundus, see the Optic nerve head and Macula first.
See any lesion or change in these two areas, and collaborate with options given
TM outflow is 90-95%,Uveoscleral 10 %
AQUEOUS OUTFLOW 2.7 MICROLITRE/MINUTE
AH produced by non pigmented ciliary epithelium
Trabecular meshwork outflow is pressure dependent ,
Uveoscleral outflow is pressure independent.
High concentration of pyruvate, lactate & ascorbate &
low concentration of protein, urea, & glucose in aqueous
humor
🔸 Protein in aqueous humor is less than blood.
Tonopen- based on REBOUND TONOMETER
Mackay marg principle,
Goldmann Applanation used for determining iop
Tonometry in scarred cornea
Gold Standard and the Ix of
choice to measure IOP.
• Mackay marg tonometer is suited for irregular corneasIt is better suited for scarred and irregular corneas
• Malkalov tonometer - Principle of fixed force and variable area. Same is case of Halberg tonometer.
• Drager & Perkins are type of Goldman that can be used without slit lamp.
GLAUCOMA PROCEDURES
Indications
- Failed Pk
- NVG
- Uveitic Glaucoma
- Aphakic Glaucoma
AHMAD GLAUCOMA VALVE
PSEUDOEXFOLIATION SYNDROME
- SURFACE ECTODERM
C LOOP IOL
CRYSTALENS
CALCIFICATION IS THE DIAGNOSTIC FEATURE.
IxOC is MRI HEAD & ORBIT WITH
FLEXER WINTERSTEINER LESIONS GALDOLINIUM CONTRAST
CHALAZION
o lipogranulomatous inflammation.
o Incision and curettage is done from
conjunctival side
o Horizontal incisions are avoided to minimize
damage to meibomian ducts.
o Recurrent chalazion and
blepharoconjunctivitis
o Adenocarcinoma and seb cell carcinoma
MC cause of u/l proptosis in children: Orbital
cellulitis
MC cause of b/l proptosis in children:
neuroblastoma
MC cause of u/l proptosis in adults: thyroid
ophthalmopathy
MC cause of b/l proptosis in children: thyroid
Its not viral keratitis, look at the scleral part, there is no inflammation at all. The PBK occurs
post intraocular surgery, due to loss of endothelial cells. The treatment is DSAEK, that is
descemnets stripping automated endothelial keratoplasty
OCULAR SURFACE
SQUAMOUS NEOPLASIA
CAN U SEE VESSELS GROWING OVER THE MASS. THIS IS NOT PTERYGIUM. PTERYGIUM FIRST OF ALL DOES NOT
HAVE THIS TYPE OF ELEVATED LESION, SECONDARILY THE VESSELS ARE NOT LIKE THIS ARBORIZING TYPE OF
PATTERN
CAPPILARY HEMANGIOMA
Port Wine Stain in Sturge weber syndrome
Propanolol is the new modality that is being used for
this lesion
ACUTE DACRYOCYSTITIS
MANAGEMENTIS ANTIBIOTICS, DON’T DO SYRINGING AND PROBING IN THIS
CHILD
MUNSON SIGN
Bulging of lower lid in Keratoconus
Don’t confuse it with the Mobius sign that is in thyroid ophthalmopathy that is loss of convergence
INCLUSION CYST
IONIZING RADIATION
IRIDODIALYSIS
This is not coloboma, this is post-traumatic
iridoialysis, iris is detached from its root
PERIPHERAL
IRIDOTOMY
Peripheral Iridotomy or Yag iridotomy
is the procedure of choice in primary
angle closure
SYNAPTOPHORE MADDOX ROD
Look that on opening the jaw the ptosis has improved, this is typically marcus
jaw winking phenomenon due to misinnervation of nerve.
Rx: Sling surgery has better results than LPS resection or Muller’s resection
BITOTS
SPOTS
POLIOSIS- Greying of
Eyelashes
Ultrasound B Scan
CT Head & Orbit Showing blow out fracture
Can you see this black and white image. It is
Ultrasound of eye B – Brightness . Showing posterior
segment of eye