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Ophthalmology Concept Book
Ophthalmology Concept Book
Next Generation
“OPHTHALMOLOGY”
Active Recall Based
Integrated Edition
Published by Delhi Academy of Medical Sciences (P) Ltd.
HEAD OFFICE
Delhi Academy of Medical Sciences (P.) Ltd.
4-B, Grovers Chamber, Pusa Road,
Near Karol Bagh Metro Station,
New Delhi-110 005
Phone : 011-4009 4009
http://www.damsdelhi.com
Email: info@damsdelhi.com
ISBN : 978-93-89309-25-6
CONCEPTS
 Concept 1.1 Basic anatomy
Time Required
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1 reading 20 mins
2nd look 5 mins
Basic Anatomy
The eye is placed in a bony socket called the orbit
Three parts – outer fibrous, middle vascular, inner neural
Fig.1.1:
Outer Fibrous:
Anterior 1/6th — transparent cornea, posterior 5/6th opaque sclera. Junction is called
limbus
Time Required
1st reading 20 mins
nd
2 look 10 mins
The eyeball receives arterial blood primarily via the ophthalmic artery. (branch of the
internal carotid artery)
The ophthalmic artery gives rise to many branches, which supply different components
of the eye.
• The central artery of the retina is the most important branch – supplying the internal
surface of the retina.
Fig.1.2:
• The ciliary arteries are divisible into three groups, the long posterior, short posterior,
and the anterior.
A. Short posterior ciliary arteries -
2 trunks from ophthalmic artery
↓
Each trunk divides into 10-20 branches
↓
Pierce sclera around optic nerve
Supplies the choroid
B. Long Posterior ciliary Arteries –
2 in number
Nasal and Temporal
↓
Anatomy and Embryology | 5
Run in suprachoroidal space to reach the ciliary muscle
↓
Anastamose with each other and anterior ciliary arteries
↓
Major Arterial Circle – [Circulus Arteriosus Major] (At root of iris)
C. Anterior ciliary Arteries – (7)
Derived from muscular branches of ophthalmic artery
↓
Pass anteriorly in episclera
↓
Give branches to sclera – limbus and conjunctiva
↓
Pierce sclera near limbus to enter ciliary muscle
↓
form Major Arterial Circle
↓
Some branches B
ranches run supply ciliary radially through
iris processes towards pupillary margin to
form ‘Circulus arteriosus minor’.
Venous drainage of the eyeball is carried out by vortex veins, central retinal vein into
the superior and inferior ophthalmic veins. These drain into the cavernous sinus, a dural
venous sinus behind the eye.
LYMPHATIC DRAINAGE
Fig.1.3:
Time Required
1st reading 30 mins
2nd look 10 mins
A
Thickening
Optic sulcus
C
Optic veside
D
Prosencephalon
E F
H
Optic vesicle
Optic stalk
Optic vesicle
G H
Fig.1.4:
Anatomy and Embryology | 7
During the folding of the neural tube, a ridge of cells comprising the neural crest develops
from the tips of the converging edges and migrates to the dorsolateral aspect of the
tube. Neural crest cells from this region subsequently migrate and give rise to various
structures within the eye and the orbit.
Fig.1.5:
Fig.1.6:
Hyaloid vasculature
Hyaloid vessel extends from the optic disc through the vitreous humor to the lens.
It starts regressing at 4 months and disappear by 8th month.
• Persistence after birth is called Persistent Hyperplastic primary vitreous.
• Anterior remnant of hyaloid artery is known as Mittendorf spots and posterior remnant
of hyaloid artery is known as Bergmeister’s papilla.
8 | Ophthalmology
Fig.1.8: Mittendorf dot Fig.1.9: Bergmister papilla
Anatomy and Embryology | 9
Coloboma
Colobomas due to defective closure of the embryonic cleft. Typical coloboma occur in
the lower part of the eye.
Fig.1.10:
Fig.1.11: Iris coloboma Fig.1.12: Eyelid coloboma
Fig.1.13: Lens coloboma Fig.1.14: Choroid coloboma
10 | Ophthalmology
Worksheet
• DO THIS CHAPTER FROM DQB
Anatomy and Embryology | 11
• Name the structures of eye in the pic
e
a
b
c
d
• Identify _________________
• Identify _________________
2 Lens
CONCEPTS
 Concept 2.1 Anatomy, Physiology and
Investigations
Time Required
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1 reading 20 mins
2nd look 10 mins
• 80% glucose is metabolized anaerobically.
• Lens derives its nutrition from aqueous humour.
• Antioxidant system of the lens constitutes: Vitamin C, vitamin E, and glutathione.
• Weigerts Ligament - It is adhesion between lens and anterior vitreous (hyaloid)
• Zonules of lens are suspensory ligaments which support the lens.
Anatomy:
Biconvex.
Diameter: 9-10 mm.
Refractive index: 1.39
Total power : 16-17 D.
Two surfaces:
Anterior and Posterior.
Anterior surface has a radius of curvature of 10 mm while posterior surface has 6mm
(more convex and stepper than anterior surface).
Lens capsule Thickest - pre - equator Thinnest - At
poles- thinnest at posterior pole.
Anterior epithelium Single layer of epithelial cells.
Cuboidal cells at centre.
Anterior capsule
Become columnar at periphery.
Lens fibres Nucleus (old lens fibers) Anterior epithelium
Infantile
Foetal
Parts of nucleus: Embryonic
1. Embryonic nucleus
2. Fetal nucleus
3. Infantile nucleus
4. Adult nucleus
Fig.2.1:
14 | Ophthalmology
Concept 2.2: Etiology of cataracts
Learning objectives
To know and identify different types of congenital and acquired cataracts
To learn morphologies of various cataracts
Time Required
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1 reading 40 mins
nd
2 look 15 mins
Birth Trauma.
Malnutrition.
Fig.2.2:
Lens | 15
b. Sutural cataract/Anterior axial embryonic cataract: When these blue dots are
crowded in the Y sutures.
c. Cataracta centralis pulverulenta: Central sphenoidal or biconvex opacity consisting
of powdery fine white dots within the embryonic or fetal nucleus.
2. Zonular Cataract (Lamellar Cataract):
Most common type of congenital cataract causing diminution of vision
• In foetal nucleus.
• Small linear opacities towards equator – Rider and spokes
Fig.2.3:
Acquired Cataracts:
Diabetic Cataract
• Snow-flake or snow-storm cataract
• Sorbitol accumulation in lens due to aldose reductase pathway leads to overhydration
of lens
Fig.2.4:
16 | Ophthalmology
Traumatic Cataract (Blunt Trauma): Rosette shaped cataract
Fig.2.5:
Fig.2.6:
Wilson’s disease:
• Hepatolenticular degeneration
• Sunflower cataract
Fig.2.7:
Lens | 17
• Kayser – Fleischer Ring: In Descement’s membrane of cornea
Fig.2.8:
Fig.2.9:
Fig.2.10:
18 | Ophthalmology
Galactosaemic cataract:
• Deficiency of GPUT [Galactose Uridyl Transferase]: Oil-droplet cataract
Fig.2.11:
Fig.2.12:
Steroids
Miotics
Chlorpromazine (Phenothiazines)
Gold
Busulphan
Amiodarone
Morphologies of cataracts
Fig.2.13:
Time Required
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1 reading 20 mins
2nd look 10 mins
Senile Cataract:
Stages of maturation of cortical cataract
NUCLEAR CORTICAL
Cuneiform-
Radial Spokes and
Cupulliform-Posterior
subcapsular
Fig.2.14:
Nuclear sclerosis
• Second sight phenomeon (due to myopic shift)
• Vision improves with pin hole
Fig.2.15: Nuclear Sclerosis Fig.2.16: Cuneiform cataract
Fig.2.18:
Time Required
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1 reading 45 mins
nd
2 look 15 mins
Surgeries:
Congenital Acquired
• Mydriatics/ Optical iridectomy for stationary • Intracapsular cataract extraction (ICCE)
central cataracts • Extracapsular cataract extraction (ECCE)
• Lens aspiration with primary posterior • Small incision cataract surgery (SICS)
capsulotomy with anterior vitrectomy • Phacoemulsification.
Steps of Phacoemulsification
1. Preparation
Retrobulbar, peribulbar or topical anesthesia
2. Clear corneal tunnel/Limbal incisiom
Stab incision with 2.75-3.2 mm keratome for main wound
3. Fill anterior chamber with viscoelastic
4. Continuous circular capsulorrhexis- trypan blue dye can be used
5. Hydrodissection (cleavage between cortex and capsule) and hydrodelineation
(cleavage between nucleus and epinucleus)
Lens | 23
Fig.2.19:
6. Phacoemulsification of nucleus
Fig.2.20:
Fig.2.21:
24 | Ophthalmology
7. Soft lens aspiration
Aspirate soft lens with automated infusion- aspiration cannula
8. IOL implantation
Insert foldable IOL into capsular bag
9. Wound closure if necessary
Fig.2.23: SICS
Lens | 25
Fig.2.24: ICCE
Fig.2.25:
PCIOL
AC-IOL. – examples are Kelman multiflex., Iris-supported-worst’s or Singh’s iris claw
lens
26 | Ophthalmology
Fig.2.26: ACIOL
Fig.2.27: Scleral fixated IOL (placed behind iris, done when there is no posterior capsule support)
Biometry:
• It is the process of calculating the power of IOL
SRK Formula:
• P= A-2.5L-0.9 K
A= constant
L=Axial length
K= Curvature of cornea
Lens | 27
Fig.2.29: Keratometry
28 | Ophthalmology
Concept 2.5: Complications of Cataract Surgery
Learning objectives
To learn about various complications during and after cataract surgery
Time Required
1st reading 30 mins
nd
2 look 10 mins
Fig.2.30: Elschnig pearls Fig.2.31: Posterior capsular opacification
Lens | 29
Cornea
Ciliary Body
Aqueous
Lens
Vitreous
Aqueous
Fig.2.33: A
QUEOUS MISDIRECTION SYNDROME/ MALIGNANT GLAUCO
30 | Ophthalmology
Concept 2.6: Congenital Anomalies and Ectopia lentis
Learning objectives
To know some terms of congenital anamoly of lens
To learn about causes of subluxation
Time Required
st
1 reading 20 mins
2nd look 10 mins
Hyperlysinaemia
Aniridia
Lens | 33
• Oldest lens fibres are _____________
• Antioxidant system of the lens constitutes _________________________________
• Rider and spokes are seen in ____________________________
• Identify - ____________________________
1
2
3
4
5
6
7
8
• SRK Formula = __________________________
• Ideal site of IOL implantation is _______________________
• Treatment of this complication of cataract surgery is _______________________
• Identify - _______________
Lens | 35
• Identify the IOL - _______________
5
36 | Ophthalmology
EXTRA POINTS:
3 Cornea and Sclera
CONCEPTS
 Concept 3.1 A
natomy, Physiology and
Investigations
 Concept 3.3 C
orneal Degenerations and
depositions
Time Required
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1 reading 30 mins
nd
2 look 10 mins
It is a transparent, avascular structure, forming 1/6th of the outer fibrous coat of eyeball
Horizontal diameters -11.7 mm.
Vertical diameter of anterior surface is 10.6 mm while that of posterior is 11.7 mm.
Refractive power: 43-45D
Refractive index: 1.376.
Structure:
It consists of six distinct layers (from anterior to posterior):
Fig.3.1:
Cornea and Sclera | 39
• Epithelium.
• Bowman’s membrane, Not a true membrane but a condensed superficial part of
stroma.
• Stroma: 90 % thickness
• Dua’s layer
• Descemet’s membrane: Ends at the anterior limit of trabecular meshwork as
Schwalbe’s ring.
• Endothelium.
Physiology:
Cornea is avascular, dehydrated, transparent structure with aerobic metabolism.
Factors Responsible for Maintaining the Transparency of Cornea:
1. Epithelium :. Made up of stratified squamous non-keratinized epithelial cells. Have
microvilli.
2. Stroma: regular arrangement of collagen fibrils in a lattice form separated from
each other by less than the wavelength of light [4000-7000A]. Stroma pressure has
also role in maintain transparency.
3. Endothelium: barrier function and pump function. It has Na+/K+ ATPase pump.
Made up of a single layer flat polygonal cells. Cell density in young adults is 3000
cells/mm2. The most metabolically active layer of cornea is endothelium.
4. Avascular cornea
Nervous supply
Fig.3.2:
40 | Ophthalmology
Special investigations related to cornea:
Pachymetry Measures cornea thickness
Specular microscopy Evaluates corneal endothelium
Keratometry Measures corneal curvature
Keratoscopy/Placido disc/ Topography Detects abnormalities of corneal shape
Vital stainings Flourescein stain stains corneal defects
Rose-Bengal stain: It stains dead cells and mucous
Placido disc
Fig.3.3:
Fig.3.5: AESTHESIOMETER
Cornea and Sclera | 41
Concept 3.2: Infective keratitis/Corneal ulcer:
Learning objectives
To know and identify various forms of infective keratitis
To learn about different corneal opacities
Time Required
st
1 reading 60 mins
2nd look 20 mins
General symptoms
Watering, photophobia (1st), redness, pain, mild discharge, diminuition of vision
Fig.3.6: FUNGAL CORNEAL ULCER Fig.3.7: FUNGAL CORNEAL ULCER with hypopyon
Fig.3.8: ACANTHAMOEBA KERATITIS Fig.3.9: BACTERIAL CORNEAL ULCER
Fig.3.10: H
ERPES SIMPLEX Fig.3.11:
Dendritic ulcer
42 | Ophthalmology
Endothelium
Involvement –
Disciform ulcer,
Steroids are
contraindicated in
epithelial keratitis
Topical cycloplegics are adjuvant treatment for keratitis
Fig.3.12:
Interstitial Keratitis:
It is an inflammation of the corneal stroma with no primary involvement of the epithelium
or endothelium.
Fig.3.13:
Moorens Ulcer:
It’s a peripheral ulcerative keratitis caused by ischemic necrosis caused by vasculitis of
limbal vessels. Vasculitis occurs due to the enzyme collagenase and proteoglyconase
produced from adjacent conjunctiva. It is of two types:
• Limited form: Usually unilateral and affects the elderly.
• Progressive form: Usually bilateral and affects the young individuals.
Cornea and Sclera | 45
Corneal Opacities:
1. Nebula: superficial scars involving bowman’s layer and superficial stroma (less than
1/3rd). Treatment is keratectomy by excimer laser or by lamellar keratoplasty.
2. Macular opacity: Semi dense opacity resulting from scarring of about 1/3rd to 2/3rd
cornea stroma. Treatment is optical iridectomy or by keratoplasty.
3. Leucoma: Dense opacity resulting from scarring of more than 2/3rd of stroma.
Treatment is same as Macular one.
4. Adherent leucoma: Healing occurs after perforation of cornea with incarcination of
iris.
Fig.3.14:
Photophthalmia:
Keratoconjunctivitis due to exposure of UV rays especially from 311 to 290 nm
46 | Ophthalmology
Concept 3.3: Corneal Degenerations and depositions:
Learning objectives
To know and identify various degenerations of cornea
To learn the layers in which depositions are seen in various conditions
Time Required
st
1 reading 30 mins
nd
2 look 10 mins
Arcus Senilis:
Bilateral lipid deposition starting in superior and inferior perilimbal cornea and progress
circumferentially to form 1 mm wide band.
Age related or it may be associated with hyper lipoproteinaenmia
Fig.3.15:
Etiology:
1. Pthisis bulbi.
2. Chronic uveitis in children.
3. Hypercalcemia.
4. Idiopathic.
Treatment: Chelation which is done with EDTA
Time Required
st
1 reading 30 mins
nd
2 look 15 mins
Ectatic Degenerations:
a. Keratoconus.
b. Keratoglobus.
c. Pellucid marginal degeneration
d. Terriens marginal degeneration
Keratoconus:
Non-inflammatory, usually bilateral ectasia of the cornea giving it a conical shape with
resultant myopia with irregular astigmatism.
Keratoconus – Clinical features
Symptom Impaired vision due to progressing myopia and irregular
astigmatism
Uniocular diplopia
Slit–lamp examination Vogt’s Striae
Prominent corneal nerves
Hurricane keratopathy - Whorl pattern of sub-
epithelialkeratopathy due to effect of contact lens.
Retinoscopy Scissors reflex/Yawning refle
Keratometry Irregular astigmatism
Keratoscopy Irregularity
Munsons Sign V-shaped deformity of lower lid in down gaze
Fleischers ring Iron deposition in epithelium
Acute hydrops Sudden hydration of corneal stroma due to rupture of
Descements membrane.
Investigations: Corneal topographic is diagnostic (Pentacam/Orbscan)
Treatment:
Astigmatic spectacles → Rigid gas permeable contact lens [RGPs] → collagens crosslinking
(C3 R) → Penetrating Keratoplasty.
Cornea and Sclera | 49
Fig.3.21: Keratoconus Fig.3.22: FLEISHER RING under
Cobalt blue light
Fig.3.25: VOGT’s striae Fig.3.26: PROMINENT CORNEAL NERVES
50 | Ophthalmology
Concept 3.5: Corneal Dystrophy:
Learning objectives
To know various corneal dystrophies and their salient features
Time Required
st
1 reading 40 mins
2nd look 10 mins
Corneal Dystrophy:
Group of spontaneous appearing, usually inherited, bilateral, stationary or slowly
progressive corneal alterations that develop in absence of inflammation.
Corneal Dystrophies
Layer Dystrophy Causative Inheritance Deposit
gene characteristics
Fig.3.27: Cogan microcystic Fig.3.28: Meesman
Fig.3.31: GRANULAR TYPE
Fig.3.32: MACULAR TYPE
Time Required
st
1 reading 25 mins
2nd look 10 mins
Keratoplasty:
Replacement of diseased cornea by a graft of homologous tissue. It is of two types
i.e. penetrating and lamellar. Donor cornea should be obtained from cadaveric eyes
preferably within 6 hours, but can be permitted till 12 hrs.
Keratoplasty
Type Purpose Indications
Optical To improve vision keratoconus, scarring, corneal dystrophies
Tectonic to preserve corneal integrity descemetocele
Therapeutic facilitates removal of infected corneal Corneal ulcer
tissue
Cosmetic to improve the appearance of the eye Rarely done
Penetrating Keratoplasty:
Replacement of whole (full-thickness) cornea.
Lamellar Keratoplasty:
Replacement of partial thickness of cornea.
Types:
a. Inlay lamellar keratoplasty – can be anterior (Anterior lamellear keratoplasty) or
posterior (Descement Stripping Endothelial keratoplasty)
b. Onlay lamellar keratoplasty – Epikeratoplasty/Epikeratophakia.
Keratoprostheses
They are artificial corneal implants used in patients unsuitable for keratoplasty.
Indicated in bilateral blindness from severe but inactive anterior segment disease with
no realistic chance of success from conventional keratoplasty, e.g. Stevens–Johnson
syndrome, ocular cicatricial pemphigoid, chemical burns and trachoma.
Fig.3.38: Boston keratoprosthesis Fig.3.39: Osteo-odonto keratoprosthesis
56 | Ophthalmology
Concept 3.7: Sclera:
Learning objectives
To learn salient features of scleritis and episcleritis
To know about types of staphylomas
Time Required
st
1 reading 25 mins
nd
2 look 10 mins
Episeleritis Scleritis
Pathophysiology Idiopathic inflammation Autoimmune dysregulation
Symptoms Acute onset Mild pain Redness, Subacute onset Severe pain Pain with eye
irritation movement Blurred vision/vision loss Photophobia
Physical Exam Mobile vessels Adherent vessels
Blanch with phenylephrine drops Does NOT blanch with phenylephrine drops
Reddish hue Bluish hue
Slit lamp may reveal nodules, scleral thinning, and
corneal changes
Systemic inflammation (joint pain, rashes, etc)
Treatment Self-limited Ophthalmology consult
Consider topical steroids in Systemic steroids/NSAIDs +/- Topical antibiotics
refractory cases
Fig.3.40: Episcleritis Fig.3.41: Scleritis
Scleromalacia Perforans:
It is anterior necrotizing scleritis without inflammation.
Common in women with long-standing seropositive rheumatoid arthritis. Spontaneous
perforation is rare, unless intraocular pressure is elevated.
Cornea and Sclera | 57
Staphyloma:
It is an ectatic condition of the eyeball with herniation of uveal tissue
Type Uveal tissue lining Cause
Anterior staphyloma Iris plastered behind Pseudocornea (the scar formed from organized
sloughed cornea exudates and fibrous tissue covered by epithelium)
Intercalary staphyloma Occurs at limbus, lined Causes are secondary angle closure glaucoma,
internally by root of iris and cataract surgery, scleromalacia perforans, anterior
anterior portion of ciliary scleritis, marginal corneal ulcer and injuries to
body. limbus.
Ciliary staphyloma Ciliary body is incarcerated in Causes are scleritis, trauma, developmental
the region of sclera ectasia. glaucoma, end stage primary/secondary glaucoma.
Equatorial staphyloma Occurs at equatorial region Causes are uncontrolled glaucoma, scleritis,
of the eye with incarceration degenerative myopia.
of the choroid.
Posterior staphyloma Occurs at posterior pole and is Degenerative high axial myopia is a major cause
lined by choroid from inside.
Fig.3.42:
Fig.3.43: Anterior Fig.3.44: Intercalary
58 | Ophthalmology
Fig.3.45: Ciliary Fig.3.46: Posterior
Cornea and Sclera | 59
Worksheet
• DO THIS CHAPTER FROM DQB
60 | Ophthalmology
• Most vital layer of cornea is _____________
• Investigation to measure corneal thickness is ______________________________
• Satellite lesions are characteristic of which corneal ulcer _______________________
Ferry’s line
Siderosis
Identify _______________
Corneal Dystrophies
Stromal Macular
Endothelial Fuch’s endothelial
Posterior polymorphous Vesicular
or band-like opacities
Cornea and Sclera | 63
EXTRA POINTS:
4 Conjunctiva
CONCEPTS
 Concept 4.1 Basic Anatomy and histology
Time Required
st
1 reading 10 mins
nd
2 look 3 mins
Palpebral conjunctiva Begins from the anterior margin of the edge of the lids. 3 parts: Marginal,
Tarsal and Orbital parts
Conjunctival fornix Continuous cul- de-sac uniting the palpebral and bulbar conjunctiva
Bulbar conjunctiva Covers the anterior part of the eye ball over sclera and limbus
Fig.4.1:
66 | Ophthalmology
Epithelium
Adenoid
Layer
Substantia
Propria
Fibrous
Layer
Fig.4.2:
Conjunctiva | 67
Concept 4.2: Allergic Conjunctivitis
Learning objectives
• To know important features of Vernal and Phlyctenular conjunctivitis
Time Required
1st reading 20 mins
nd
2 look 5 mins
Vernal Keratoconjunctivitis:
• Also called spring catarrh
• Bilateral condition, Type I hypersensitivity to exogenous antigen, like pollen or dust.
• It is a conjunctivitis with no follicular reaction, only papillary reaction.
• Common in ages of 4-20 years.
• More common in male children
• VKC patients have increased incidence of keratoconus.
Clinical Features: Intense ocular itching, lacrimation, photophobia, foreign body
sensation, burning, thick mucus ropy like discharge
Palpebral VKC Limbal VKC
Papillary hypertrophy most marked on superior tarsus. Limbal papillae with smooth, round surface
Papillae – become large – Cobble-stone appearance. “Horner-Trantas spots” composed predominantly
of eosinophils.
Phlyctenular Keratoconjunctivitis:
• Unilateral mostly.
• Type 4 hypersenstivity- non-specific delayed hypersensitivity reaction to
Staphylococcus (most common) or tubercular antigens
• Predominantly affects children
• Small pinkish – white nodule near the limbus, surrounded by hyperaemia called
corneal Phlycten
• Corneal involvement: Fascicular ulcer or Sacrofulous ulcer
Fig.4.6:
Treatment:
• Topical steroids.
• Any associated staphylococcal blepharitis must be treated.
Conjunctiva | 69
Concept 4.3: Trachoma
Learning objectives
• To learn and identify clinical signs of trachoma and to know its management
Time Required
1st reading 20 mins
nd
2 look 5 mins
• Chronic Keratoconjunctivitis.
• By Chlamydia trachomatis – Serotypes A, B, Ba, C.
• Conjunctival reaction in trachoma is both follicular and papillary
• Chlamydia trachomatis is epitheliotropic and produces intra – cytoplasmic inclusion
bodies called H.P bodies (Halber Staedter – Prowazeke bodies)
• Major vector of infection is flies
• Incubation period is 5-12 days
• Clinical features: 1-9 year child presents with lot of itching and watering. There are
follicles (boiled Sago grain appearance) in the upper palpebral conjunctiva and upper
limbus.
• SAFE strategy : It is a WHO strategy to control trachoma in a community.It stands for
Surgery, Antibiotics, Facial Cleanliness, Environment.
• Treatment: The choice of treatment is Azithromycin.
• Other drugs: Tetracycline ointment 1%, Topical erythromycin eye ointment and
topical sulphonamides eye drops and ointmen
Follicles
Trachomatous inflammation (TI)- Inflammatory thickening of the
tarsal conjunctiva that obscures more than half of the normal deep
tarsal vessels
Trachomatous scarring (TS)- The presence of scarring in the tarsal
conjunctiva. Arlt’s line: Linear scar in sulcus subtarsalis
Arlt’s line
Trachomatous trichiasis (TT)- At least one eyelash rubs on the eyeball
Corneal Opacity (CO)-
Fig.4.7: H
erbert’s pits: Cicatrized follicles at the Fig.4.8: P
annus: Infiltration of cornea associated with
superior limbus. vascularization
Conjunctiva | 71
Concept 4.4: Viral Conjunctivitis:
Learning objectives
• To learn features of adenoviral conjunctivitis
Time Required
1st reading 10 mins
nd
2 look 5 mins
Adenoviral Keratoconjunctivitis:
Usually affects children with Upper respiratory tract infection
Time Required
1st reading 25 mins
nd
2 look 10 mins
Treatment
Topical antibiotics
Systemic antibiotics for Haemophilus influenza, gonococcal or meningococcal
conjunctivitis
Conjunctiva | 73
Fig.4.11: M
embranous conjunctivitis Fig.4.12: G
ONOCOCCAL CONUNCTIVITIS
Time Required
st
1 reading 40 mins
2nd look 15 mins
Fig.4.14:
Aqueous-deficient Evaporative
Sjögren
syndrome dry Non-Sjögren
Intrinsic Extrinsic
eye (primary or syndrome
secondary
Intrinsic
• Meibomian gland deficiency, e.g. posterior blepharitis, rosacea.
• Disorders of lid aperture, e.g.lid retraction, proptosis
• Low blink rate, e.g. Parkinson disease, prolonged computer monitor use, reading,
watching television.
Extrinsic
• Vitamin A deficiency.
• Contact lens wear.
• Allergic conjunctivitis.
Investigations:
Tear film break- up time Normal – 34 seconds.
< 10 seconds → abnormal.
Rose Bengal Staining
Fluoroscein staining
Lissamine staining
Schirmers test Normal > 15 mm.
Borderline → Between 5 mm and 10 mm.
Abnormal - <5 mm.
Phenol red thread test
Treatment:
1. Tear substitutes:
a. Cellulose derivatives.
b. Polyvinyl alcohol.
2. Mucolytic Agents – 5% acetylcysteine drops.
3. Reduction of tear drainage – Punctal Occlusion.
Xerophthalmia describes a dry eye associated with vitamin A deficiency
Treatment:
A. Local Ocular Therapy:
a. Topical artificial tears.
b. If Keratomalacia – full-fledged treatment of corneal ulcer.
B. Vitamin A Therapy:
Age Oral dose at 0,1 and 14 days
< 6 months 50000 IU
6 m – 1 year 1 lakh IU
>1 year 2 lakh IU
Prophylaxis of Xerophthalmia:
• 6-12 months – 1 lakh IU orally every 3-6 months.
• 1-6 years – 2 lakhs IU orally every 6 months.
• < 6 months – 50,000 IU orally.
• Lactating mothers – 20,000 IU orally once at delivery or during next 2 months.
78 | Ophthalmology
Concept 4.7: Conjunctival degenerations:
Learning objectives
• To learn about pterygium and pingencula
Time Required
1st reading 20 mins
nd
2 look 5 mins
Pterygium
• Degenerative and hyperplastic condition of conjunctiva.
• The subconjunctival tissue undergoes elastotic degeneration and proliferates as
vascularized tissue.
• Corneal epithelium, bowman’s layer and stroma is destroyed.
• Etiology: UV rays, dry heat, dusty environment.
• It appears to be a triangular fold encroaching over the cornea in the area of palpebral
aperture, usually on nasal side.
• It is an asymptomatic condition in early stages except for cosmetic intolerance.
Visual disturbance due to encroachment of pterygium on papillary area or corneal
astigmatism.
• Diplopia can very occasionally occur due to ocular movement limitation.
Treatment:
Asymptomatic is best left alone.
Otherwise surgery is the only effective treatment.
Simple excision or Bare sclera technique is associated with high recurrence (80%), so
conjunctival autografting is the most popular approach
Fig.4.21: Stocker line (iron deposition in epithelium of cornea)
Pingencula
Asymptomatic elastotic degeneration of the conjunctival
stroma. A yellow–white fatty like mound is seen on the
bulbar conjunctiva. Calcification is occasionally present.
Treatment is usually unnecessary
Fig.4.22
Conjunctiva | 79
Worksheet
• DO THIS CHAPTER FROM DQB
80 | Ophthalmology
• Phlyctenular Keratoconjunctivitis is which hypersensitivity reaction _____________
• Chlamydia trachomatis is caused by which serotypes ________________________
__________
Most common cause of vision deterioration in this is - ____________________________
Lipid layer
Aqueous layer
Mucin layer
Treatment for 2 year old child with this is _______________________
Conjunctiva | 81
CONCEPTS
 Concept 5.1 Basic Structure
 Concept 5.3 V
ascular supply of retina and related
investigations
Time Required
1st reading 15 mins
nd
2 look 5 mins
Fig.5.1:
Time Required
1st reading 20 mins
nd
2 look 5 mins
RETINA HISTOLOGY
Fig.5.2:
Muller cell
6 Inner nuclear layer (supporting glial cell)
Bipolar cell
Amarcine cell
5 Outer plexiform layer
Horizontal cell
Rod
Cone
4 Outer nuclear layer
3 Outer limiting
membrane Pigment cells
2 Photoreceptor layer
1. Pigment epithelium
Choroid
Fig.5.3:
86 | Ophthalmology
Layer
Internal limiting membrane
Nerve fibre layer Axons of ganglion
cells running centrally into the optic nerve
Ganglion cell layer
Inner plexiform layer consisting of synapses
Inner nuclear layer the nuclei of the bipolar, Muller, amacrine, horizontal cells
Outer plexiform layer consisting of synapses
Outer nuclear layer the nuclei
of the rods and cones
External limiting membrane
Photoreceptors This layer transform light energy to the visual impulse. There are
120 million rod cells and 6 million cone cells
Retinal Pigment Epithelium Hexagonal cells, firmaly adherent to bruch’s membrane and
loosely to rods and cones of the sensory retina. This layer provide
metabolic support to neuro- sensory layer. Other important
fuctions are photoreceptor renewal, integrity of subretinal space,
phagocytic of photoreceptor, regenerative and reparative
Most radiosensitive layer of the retina: Rods and cones.
Most radioresistant layer of the retina: Ganglion cell layer.
Time Required
st
1 reading 20 mins
2nd look 10 mins
Retinal vascular system Inner six layers derive its nutrition from central retinal artery. The retinal
vessels are end arteries and do not anastomose with each other.
Choroidal vascular system Outer four layers of retina get its nutrition from choriocapillaries i.e.
choroidal vascular system (short posterior ciliary artery)
There is anastomosis of central retinal artery and short posterior artery with the arterial
circle of Zinn or Haller.
Blood-Retinal Barrier:
• Inner: Tight junctions of retinal capillary endothelial cells.
• Outer: Retinal pigment epithelial cells.
Arteriole Venule
Inner limiting membrance
Superficial
capillary Retinal nerve fibre layer
network
Deep
capillary Ineer nuclear layer
network
Pigment epithelium
Fig.5.5:
88 | Ophthalmology
Fluorescein Angiography (FA):
FA is used in studying the normal physiology of the retinal and choroidal circulation and
to detect any abnormalities.
Procedure:
5 ml of 10% Fc is injected in antecubital vein and photograph taken at 1sec interval
between 5 and 25 s after injection.
Findings:
It may be normal, hypoflourescence or hyperflourescence.
Hypoflourescence: It may be due to blocked fluorescence as a result of haemorrhage
or exudates OR due Capillary Non-Perfusion.
Hyperflourescence: It occurs either due to leakage or RPE defects. A leakage will
increase in size but size of RPE defects will remain normal.
Indocyanine Angiography:
ICG angiography is helpful for diagnosing choroidal lesions as it is 98% bound to the
plasma proteins.
Time Required
st
1 reading 35 mins
2nd look 15 mins
Separation of sensory retina from retinal pigment epithelium (RPE) by subretinal fluid.
Type of Pathology and Features Configuration Treatment
detachment cause
Rhegmatogenous Due to break • Floaters: opacities Convex Vitreo-retinal
formation in the vitreous surgery
either due to cavity (Pars plana
traction, trauma • Photopsia: flash of vitectomy)
or predisposing light seen by the or
degenerations. patient. It occurs Scleral buckling
due to irritation of
rods and cones.
• Decreased visual
acuity if macula is
involved.
• Visual field defect
Mobility: Detached
retina undulates
freely.
Tractional Vascular • Decreased visual Concave Vitreo-retinal
pathology of acuity if macula surgery
retina like DM, is involved. (Pars plana
CRVO, Eales • Visual field defect vitectomy)
disease • Mobility:
Reduced
Exudative Due to choroidal • Floaters: They Convex Treatment of the
lesions like are seen due to primary choroidal
tumour associated vitritis. lesions
[Melanoma, • Vision
Hemangioma or diminuition
metastasis] or is sudden and
Central Serous progresses rapidly
Retinopathy • Smooth retina
• Shifting fluid:
Present
90 | Ophthalmology
Grey reflex: in old detached retina on distant direct ophthalmoscopy
Vitreous substitutes that can be used are Air, SF6, perflourocarbons like C3F8 and
silicone oil.
Scleral buckling - Aim of treatment in rhegmatogenous RD is closure of break.
a. Drainage of SRF [subretinal fluid].
b. Injection into vitreous: To repose the detached retina:
c. Cryotherapy: To seal retinal break
d. Explant: Buckling is done to internally indent the sealed break. It is done with buckle
explant or encirclage band
RETINAL DETACHMENT
Pathogenesis:
Dysfunction of RPE
↓
Accumulation of fluid in subretinal space
↓
Local detachment of sensory retina at macula
Clinical features
Sudden onset of blurred vision (painless)
Micropsia
Metamorphopsia
VA is 6/9 → 6/12 – mild vision loss
Elevation of sensory retina at posterior pole, borders of which are outlined by glistening reflex [Ring Reflex
Fig.5.10: C
ENTRAL SEROUS RETINOPATHY Fig.5.11: INK BLOT/SMOKE STACK IN CSR
Treatment:
• Spontaneous resolution is common (by 6-12 months).
• Laser photocoagulation – hasten symptomatic relief by speeder resolution of serous
detachment.
92 | Ophthalmology
Concept 5.5: Diabetic Retinopathy
Learning objectives
• To learn about different types of detachment
• To learn about Central Serous Retinopathy
• To learn about Cystoid macular edema
Time Required
st
1 reading 60 mins
nd
2 look 20 mins
Prevalence of DR is higher in IDDs (> 5 years) than in NIDDs (can present with DR at
time of diagnosis).
Features of DR
Non-Proliferative DR Proliferative DR
Microaneurysm: First clinically detectable lesion of Neovascularisation – NVD, NVE, Rubeosis iridis:
DR (Inner nuclear layer) NVG
Intra-retinal Haemorrhage: Dot and blot (deep); RD: Tractional RD can later lead to Rhegmatogenous
flame-shaped (superficial). RD
Hard exudates: Lipid deposits within the retina Haemorrhage: intravitreal, pre-retinal
Soft exudates/ cotton wool spots: Due to disturbance
of axoplasmic flow which causes accumulation of
waste product in nerve fibre layer
Venous looping, beading and sausage-like
segmentation.
IRMA (intra-retinal microvascular abnormalities).
A-V shunts due to capillary closure.
Retina | 93
Classification of DR
Grade Features
No DR No abnormality
Mild NPDR Microaneurysm a only
Moderate NPDR More than just microaneurysms and less than severe NPDR
Severe No signs of PDR
NPDR Presence of any one of the following
4 quadrants of intra retinal hemorrhages
(> 20/quadi ant)
Venous beading in >2 quadrants
IRMA in >1 quadrant
PDR Presence of neovascularization
Presence of preretinal or vitreous hemorrhage
Fig.5.12: M
ICRO-ANEURYSMS Fig.5.13: NON-PROLIFERATIVE RETINOPATHY
94 | Ophthalmology
Fig.5.14: Fig.5.15:
Time Required
1st reading 15 mins
nd
2 look 5 mins
Time Required
1st reading 20 mins
nd
2 look 5 mins
Predisposing factors:
• Increasing age – 6th/7th decade.
• Unilateral.
• Systemic hypertension, Diabetic mellitus, Arteriosclerosis.
• Blood dyscrasias – Hyperviscosity
• Raised IOP.
• Hypermetropia
• Periphlebitis – Sarcoidosis, Behcet’s disease.
• Use of OCPs
Clinical features:
• Decreased visual acuity.
• Loss of part of the visual field.
• Dilated and tortuous veins, flame- shaped and deep haemorrhages. Retinal edema,
cotton-wool spots.
Complications:
• CME
• Neovascularisation leads to vitreous haemorrhage and TRD
Time Required
1st reading 20 mins
nd
2 look 5 mins
Central Retinal Artery Occlusion: Due to emboli from atherosclerosis from heart or
carotid artery
Fig.5.23:
Clinical features:
• Acute and profound, PAINLESS loss of vision.
• White cloudy/milky white retina due to intracellular edema- Cherry-red spot
• Marcus - Gunn pupil
• Segmentation of blood column in venules and arterioles: Cattle –Track Appearance
of blood flow.
Time Required
st
1 reading 25 mins
2nd look 10 mins
Snail-track Denegerations
Acquired retinoschisis
White with pressure
White without pressure
Choroidal Neovascularisation:
Proliferation of fibrovascular tissue from choriocapillaris through defects in Bruch’s
membrane into sub- RPE space and later into the sub –retinal space.
Cuses of Choroidal Neovascularisation
Wet ARMD
POHS – Presumed Ocular Hstoplasmosis syndrome.
Severe myopia.
Angioid streaks
Choroidal rupture
Inappropriate laser photocoagulation.
Optic disc drusen.
Retina | 103
Concept 5.10: Retinal Dystrophy
Learning objectives
• To learn names and corresponding layers of various retinal dystrophies
• To learn about features of Retinitis pigmentosa
• To learn about Electroretinogram and Elecrooculogram
Time Required
1st reading 40 mins
nd
2 look 15 mins
Retinitis Pigmentosa:
It’s a photoreceptor dystrophy with damage to rod system is predominant
Clinical features:
• Nyctalopia/night blindness-due to impaired rod function.
• Impaired dark adaptation.
• Tunnel vision in later stages
Fig.5.27:
Investigations:
Subnormal amplitude of ERG mainly scotopic. EOG is also subnormal in later stages
Perimetry: In initial stage of the disease there is ring scotoma due to involvement of the
midperipheral retina whereas in the late stage patient has tubular vision.
104 | Ophthalmology
Treatment: No effective treatment
Vitamin A and Docosahexonoic acid can be given
Systemic associations of RP
Ushers syndrome –RP with deafness. It is the most common
Refsum’s syndrome
Bassen-kornzweig syndrome
Kearns- sayre syndrome – associated with ocular myopathy and heart defects
Bardet-Biedl syndrome − mental handicap, polydactyly.
Laurence − Moon syndrome − features of Bardet- Biedl syndrome with spastic paraplegia
Cockaynes syndrome.
Friedreich’s ataxia
Fig.5.28: BEST DISEASE –egg yolk stage Fig.5.29: BEST DISEASE –scrambled egg stage
Angioid Streaks
These are crack-like dehiscences in the collagenous and elastic portions of the bruch’s
membrane with secondary changes in RPE and choriocapillaris.
Fig.5.31:
106 | Ophthalmology
It can be idiopathic or is associated with:
Pseudoxanthoma elasticum.
Paget’s disease.
Ehler-Danlos syndrome
Sickle cell anemia
Incontinenta pigmenti
Causes:
• Chloroquine toxicity
• Cone dystrophy
• Battens disease/Batten-Mayo syndrome: It is a cerbromacular degeneration
Electrophysiological Tests:
Electroretinogram[ERG] It is the record of the action potential produced by the retina when it
is stimulated by the light of adequate intensity. It is elicited both in
photopic and scotopic state
A wave- due to rods/cones
B wave- due to bipolar/muller cells
c- due to RPE
Electrooculogram[EOG It measures the standing action potential between the cornea
and the back of the eye. It reflects the activity of the RPE and the
photoreceptors [eg BEST”S Ds].
Visual Evoked Potential When light falls on the retina, the series of nerve impulses generated
and passed into the visual cortex is measured by VEP. It indicates
activity from ganglion cell layer to the visual cortex.
Retina | 107
Concept 5.11: Retinopathy of Prematurity
Learning objectives
• To learn risk factors, staging and treatment of ROP
Time Required
1st reading 30 mins
nd
2 look 15 mins
Risk factors:
• Prematurity: Gestational age <32 weeks (most important)
• Birth weight <1.5kg.
• Oxygen therapy: Excessive oxygen use
Pathogenesis:
Excessive free radicals
↓
Inhibit spindle cell migration
↓
Produces angiogenic factors
↓
ROP
Stage I Demarcation line
Stage III Ridge formation
Stage III Ridge with extra retinal fibrovascular proliferation
Stage IV Sub-total Tractional Retinal Detachment
Stage V Total retinal detachment.
108 | Ophthalmology
Severe
extraretinal Detached retina
fibrovascular
proliferation
Fig.5.32:
Treatment of ROP:
• Ablation of avascular immature retina by either cryotherapy or laser photocoagulation.
• Vitamin – E therapy – Its antioxidant role helps in prevention of the ROP.
• If Retinal detachment present → Vitreoretinal surgery
110 | Ophthalmology
Worksheet
• DO THIS CHAPTER FROM DQB
Retina | 111
• Identify the cell marked _____________
CONCEPTS
 Concept 6.1 Visual pathway and its lesions
 Concept 6.6 S
upranuclear Disorder of Eye
Movement
Time Required
st
1 reading 40 mins
nd
2 look 15 mins
Fields of vision
Nasal
hemiretinas
Total blindness
Temporal of pslateral eye
hemiretinas
Bitemporal
Optic heteronymous
tract hemianopsia
Anterior junction syndrome (Junctional will lead to ipsilateral central scotoma and contralateral
scotoma of Traquair: Lesion at the junction of superotemporal quandrantopia.
the chiasma and the optic nerve)
Optic Tract Incongruous homonymous hemianopia
Wernicke’s hemianopic pupil
Optic atrophy
Lateral geniculate body (Pupillary reflex Homonymous key hole defects
normal)
Optic Radiations (Pupillary reflex normal) Congruous homonymous defects
• Lesions of Temporal Radiations C/L homonymous Superior quadrantopia (Pie in sky)
• Lesions of Parietal Radiations C/L homonymous Inferior quadrantopia (Pie on the floor)
Occipital Cortex (Pupillary reflex normal)
• Occlusion of posterior cerebral artery Macula sparing congruous homonymous hemianopia
• Occlusion of middle cerebral artery Congruous homonymous macular defects
Chiasma lesions
Fig.6.2:
120 | Ophthalmology
Concept 6.2: Pupillary reflex
Learning objectives
• To learn about pupillary pathway and abnormal pupils
• To learn about sympathetic pathway and Horner syndrome
Time Required
1st reading 40 mins
nd
2 look 15 mins
Fig.6.3: LIGHT REFLEX/Pupillary/Parasympathetic pathway – afferent 2nd nerve, efferent 3rd nerve
Argyl Robertson Pupil Light reflex absent but near reflex present.
Holmes-Adie Pupil Tonic pupil with slow response to light and near. Due to denervation of post –
ganglionic supply.
Horner’s Syndrome Due to disruption of sympathetic pathway. Characterised by ptosis, miosis (same
in dark conditions), enophthalmos. Pupillary reaction to both light and near are
normal. Heterochromia iridis in congenital cases.
Neurophthalmology | 121
Fig.6.7: S
ympathetic pathway – Central (from hypothalamus to C8-T2), Pre ganglionic – till superior cervical
ganglion, Post-ganglionic – to iris dilator muscle
Time Required
st
1 reading 50 mins
2nd look 20 mins
Optic nerve
It is 3.5 cm to 5.5 cm long from optic disc to chiasma. It is divided into
intraocular (1 mm)
intraorbital (25-30mm)
intracanalicular (6-9 mm)
intracranial (10 mm)
OPTIC NEURITIS
Optic neuritis is an acute inflammatory optic nerve disease.
Fig.6.9:
Neurophthalmology | 125
It can be divided into:
Retrobulbar neuritis The fundus examination is normal as the affected part of the optic nerve is behind
the eye ball
Papillitis inflammation of optic nerve head
Neuroretinitis inflammation of optic nerve and nerve fibre layer of retina.
Signs:
Dise hyperemia and dilated capillaries (telangiectatic microangiopathy).
Vascular tortuosity.
Swelling of peripapillary nerve fibre layer
126 | Ophthalmology
Fig.6.10:
Treatment:
Prognosis is relatively poor with generally severe, bilateral and permanent visual loss.
• High–dose systemic steroids are used in some cases.
• Stop smoking and excessive drinking.
Fig.6.11: Arteritic ischemic optic neuritis Fig.6.12: Non - Arteritic ischemic optic neuritis
Time Required
st
1 reading 20 mins
2nd look mins
Papilloedema
Papilledema is bilateral optic nerve head swelling secondary to raised intracranial
pressure
Increased CSF pressure
↓
Due to disturbance of pressure gradient across the lamina cribosa.
↓
Stasis of axoplasm in prelaminar area
↓
Axonal swelling
↓
Venous congestion
↓
Extra-cellular edema
Fig.6.13:
Neurophthalmology | 129
Pseudotumour Cerebri:
Also known as Benign Intracranial Hypertension
Risk factors Clinical features Investigations Treatment
Time Required
st
1 reading 20 mins
2nd look 5 mins
Optic Atrophy:
It is the end result of any pathological process that damages the axons coursing between
retinal ganglion cells and LGB
Primary optic atrophy Secondary optic Glaucomatous optic Consecutive optic
atrophy atrophy atrophy
Chalky white in color, Disc is dirty white in Pathologically - Pale waxy disc.
disc margins are clear colour, with blurred Cavernous optic atrophy
margins
Causes:
• Tobacco- Cyanide acts as a toxic agent which causes degeneration of the ganglionic
cells of the macular area
• Ethambutol.
• Deficiency of Vitamins- Thiamine, B12
• Ethyl alcohol.
• Methyl alcohol- Methyl alcohol poisoning is more dangerous than ethyl alcohol because
it leads to direct damage of ganglion cells.
• Quinine.
• Chloroquine.
• Isoniazid.
• Digoxin.
• NSAIDs.
132 | Ophthalmology
Concept 6.6: Supranuclear Disorder of Eye Movement
Learning objectives
• To learn about features of Supranuclear eye Disorder
• To learn about Internuclear ophthalmoplegia and one and half syndrome
Time Required
st
1 reading 20 mins
2nd look 5 mins
Features are:
• Gaze palsies.
• Normal vestibulo-ocular reflexes.
• Absence of diplopia.
Horizontal Gaze Centre: It is located in pons, known as PPRF i.e. Pontine Parareticular
Formation. PPRF controls the lateral rectus of the same side whereas the medial rectus
of the opposite side is controlled by MLF [Medial Longitudinal Fasciculus].Lesion of MLF
leads to Internuclear Ophthalmoplegia
Right Internuclear
Ophthalmoplegia (INO)
Left abduction
nystagmus magnus
R L
Fig.6.18:
Neurophthalmology | 133
One And A Half Syndrome:
It occurs due to lesion of PPRF and MLF of the same side.
An alternative anatomical cause is a lesion of the abducens nucleus (VI) on one side
(resulting in a failure of abduction of the ipsilateral eye and adduction of the contralateral
eye = conjugate gaze palsy towards affected side), with interruption of the ipsilateral
medial longitudinal fasciculus after it has crossed the midline from its site of origin in the
contralateral abducens (VI) nucleus (resulting in a failure of adduction of the ipsilateral
eye).
Fig.6.19:
134 | Ophthalmology
Concept 6.7: Nystagmus
Learning objectives
• To learn about basic types of nystagmus
Time Required
1st reading 20 mins
nd
2 look 5 mins
Clinical Types:
a. Pendular:
Velocity is equal in each direction.
b. Jerk:
Has slow drift and a fast phase.
c. Mixed:
Pendular in primary position and jerk in lateral gaze.
Causes:
a. Physiological:
Optokinetic nystagmus [OKN]. It consists of saccadic and pursuit movements.
Defect in OKN indicates parietal lobe lesion
End gaze
Vestibular – COWS (cold water induces nystagmus to opposite side)
b. Motor Imbalance:
Congenital nystagmus.
Spasmus nutans: It is associated with head nodding.
Latent nystagmus: In Infantile Esotropias
Ataxic nystagmus In Internuclear ophthalmoplegia
See-saw nystagmus: seen in patients with bitemporal hemianopia.
c. Ocular Nystagmus: Due to sensory deprivation.
Neurophthalmology | 135
Worksheet
• DO THIS CHAPTER FROM DQB
136 | Ophthalmology
• Fill in the visual field defects _____________
Optic Radiations
• Lesions of Temporal Radiations--------
• Lesions of Parietal Radiations-----------
Occipital Cortex
• Occlusion of posterior cerebral artery-
• Occlusion of middle cerebral artery-
Left abduction
nystagmus magnus
R L
140 | Ophthalmology
EXTRA POINTS:
7 Glaucoma
CONCEPTS
 Concept 7.1 Definitions and Basic physiology
Time Required
1st reading 35 mins
nd
2 look 10 mins
Definition:
Glaucoma is a multifactorial optic neuropathy in which there is characteristic optic nerve
damage
Classification:
Primary Glaucoma
Glaucomas
Secondary Glaucoma
Developmental
Glaucoma
Primary Glaucoma
• Open angle Primary open angle Glaucoma IOP high, VF and OD changes+
Normal tension Glaucoma IOP Normal, VF and OD changes+
Ocular Hypertension IOP high, VF and OD Normal
closed angle
ar tra
b e cut k b
me ecuta
tra hwor shw r
s ork
me
Fig.7.1:
144 | Ophthalmology
Concept 7.2: Investigations in glaucoma
Learning objectives
• To know about investigations done in glaucoma patient
Time Required
1st reading 60 mins
nd
2 look 25 mins
Gonioscopy:
Bimicroscopic examination of anterior chamber angle
Indirect Angle is examined by reflected light
Ex- Goldman, Zeiss, Posner, Susman
Direct Keoppe, Barkan, Thorpe and Swan Jacob goniolenses
Gonioscope
Gonioscope Mirror
Ocular
Lubricant Cornea
Iridocorneal
Angle
Lens Iris
Fig.7.2: Fig.7.3:
Glaucoma | 145
Normal Anterior chamber depth is 2-3 mm.
Deep anterior chamber: Myopics, Males.
Shallow anterior chamber: Hypermetropes, Old people, Females
Measurement of IOP:
• Goldmann
• Perkin
• Schiotz
• Malkalov
• Non contact
• Drager
Applanation Indentation
Applanation
• Tonopen and Dynamic
• Mak-Kay-Marg Indentation Contour
• PASCAL
Fig.7.4: GOLDMANN’S TONOMETER
Fig.7.9: TONOPEN
Kinetic
• Lister
• Tangent Screen / Bjerrum Screen
Static
• Automated Perimetry
Octopus
Humphey field analyser
Combined kinetic and static: Goldmann Perimeter
Campimetry: Central visual field evaluation (Central 30°)
Fig.7.12: C
onfrontation visual Fig.7.13: Goldmann kinetic Perimeter Fig.7.14: H
umphrey automated
fiel exam perimetry static
148 | Ophthalmology
Provocative Tests:
For PACG For POAG
• Mydriatic test: Rise in IOP of >8mmHg after instillation of Water drinking test
tropicamide
• Dark Room/ prone provocative test: Patient in dark room for 60-90
min. If >8 mmHg in IOP; test is +ve
Time Required
st
1 reading 50 mins
2nd look 20 mins
Clinical Features:
• Mild headache/Eye ache
• Difficulty in reading and close work
• Frequent change of presbyopic glasses
• Delayed dark adaptation
Signs:
IOP Changes:
Increase in IOP (The normal range of IOP is between 10- 21mmHg
Exaggeration of normal diurnal variation of IOP of >8 mmHg (Normal variation is around
5mmHg)
• Isopter contraction: Earliest but non specific visual field defect. Mild constriction of
central and peripheral field.
• Paracentral scotoma: Small ring shaped sotoma which happens to be either above
or below the blind spot in bjerrum’s area. Earliest clinically significant field defect.
152 | Ophthalmology
• Siedel’s scotoma: It is a sickle shaped scotoma formed by paracentral joining of
the blind spot.
• Bjerrum’s or Arcuate scotoma: Extension of scotoma in the area either above or
below the fixation point.
• Double arcuate or ring scotoma: When two arcuate scotomas join together, it is
called double arcuate scotoma.
• Roenne’s central nasal step: Two arcuate scotomas run in different arcs and meet
to form a sharp right angled defect
Time Required
st
1 reading 30 mins
2nd look 10 mins
PACG
Characterized by all the features of open angle glaucoma i.e. IOP changes, fundus
changes and field defects, but the angle is closed.
Treatment of angle closure – Laser peripheral iridotomy→ Medical management →
Surgery
Acute congestive/acute angle closure glaucoma:
Dim light or pupil mid dilating precipitate the pupil block and lead to high rise in IOP.
Features
• Whole 360 degree angle is closed.
• Patient suffers from severe pain associated with nausea and vomiting.
• The IOP is in the range of 60 mmHg (40-70 mm Hg).
• Coloured halos due to corneal edema
• Severely congested eye associated with lid oedema.
• Shallow AC.
• Closed angle
• Vertically oval semidilated pupil - non reactive to light
154 | Ophthalmology
• Field defects are not prominent in this stage
• Vogt’s Triad:
• Pigment dispersion on the corneal endothelium
• Sector iris atrophy
• Glaucomaflecken
angle open to
trabecular meshwork
tra
b
me ecuta
shw r
ork
Fig.7.22:
Before going on for surgical procedures, it is important to control the raised IOP. IV
mannitol or IV acetazolamide is used for this purpose. Once the IOP is down, laser/
surgical procedure is performed
Absolute glaucoma: It’s a painful blind eye. The eye is stony hard. Cyclophotocoagulation
is done to decrease IOP.
Glaucoma | 155
Concept 7.5: Treatment modalities in glaucoma
Learning objectives
• To learn about different treatment options in glaucoma
• To know major side effects of glaucoma medications
Time Required
st
1 reading 60 mins
2nd look 25 mins
Medical therapy
Drugs Mechanism of action Side effects
beta blockers Decrease aqueous production Precipitation of bronchial asthma
Selective: Betaxolol. Arrhythmias
Non- selective: Timolol Dry eyes
Nasolacrimal duct blockage
Miotics: Pilocarpine Increase trabecular outflow Uveitis
Ciliary spasm
Myopia
Cataract
Iris cyst
Retinal detachment
Sympathomimetics: Decrease aqueous Allergic conjunctivitis
Non selective- Adrenaline, production Angle closure glaucoma
dipivefrine Increase uveoscleral outflow Adrenachrome deposition
Selective –Brimonidine, Aphakic cystoid macular edema
Apraclonidine Drowsiness
Lid retraction
Carbonic anhydrase inhibitors Decrease aqueous C/I in sulfa drug allergics.
Dorzolamide and Brinzolamide production Acetazolamide: Hypokalemia,
(Topical). Acetazolamide metabolic acidosis, kidney stones,
(Systemic). chronic renal failure.
Dorzolamide and Brinzolamide:
corneal decompensation.
PG analogues: Increase uveoscleral Uveitis
Latanoprost, Travoprost, outflow Iris hyperchromia
Bimatoprost Blephroconjunctivitis
Trichomegaly
Hyperosmotics: Dehydrates vitreous Decompensation in congestive heart
Mannitol, glycerol failure, pulmonary edema
156 | Ophthalmology
Surgical Treatment:
Trabeculectomy- Creation of new channel for aqueous outflow between the anterior
chamber and subtenon’s space
Flow of aqueous
Fig.7.28: TRABECULECTOMY
DRAINAGE IMPLANTS
Fig.7.31: ISTENT
Time Required
1st reading 20 mins
nd
2 look 10 mins
Fig.7.33:
160 | Ophthalmology
Treatment:
• Goniotomy - It is the choice of surgery done for congenital glaucoma. In this procedure
cuts are given through the angle.
• Trabeculotomy - It is the procedure to cut open the schlemn canal. It is done if
corneal haze is there and angle not visualised
• Combined trabeculotomy and trabeculectomy
Time Required
1st reading 30 mins
nd
2 look 15 mins
Inflammatory Glaucoma:
Due to Uveitis:
Secondary ACG with pupil Secondary ACG without pupil Secondary OAG
block block
Due to posterior synechiae. Due to anterior synechiae. Inflammatory cells blocking
meshwork
Pigmentary Glaucoma:
• In pigment dispersion syndrome.
• Pigments block the trabecular meshwork, iris transillumination, Krukenburg spindles
• Treatment- On lines of POAG.
Causes:
• DR.
• CRVO.
• Eales disease.
• Sickle - Cell retinopathy.
162 | Ophthalmology
Treatment - Panretinal photocoagulation with Artifical shunt operation.
Traumatic Glaucoma:
Blunt injury-
• Angle Recession Glaucoma
• Inflammatory Glaucoma
• Due to intra-ocular haemorrhage:
Red cell Glaucoma Due to RBCs.
Haemolytic Glaucoma Due to macrophages laden with RBCs
Ghost cell Glaucoma In vitreous haemorrhage.
Hemosiderotic Glaucoma Due to iron from phagocytosed haemoglobin
Cornea
Ciliary Body
Aqueous
Lens
Vitreous
Aqueous
Glaucoma | 165
Primary Glaucoma
• Open angle ____________________ IOP high, VF and OD changes+
Normal tension Glaucoma _____________________
Ocular Hypertension IOP high, VF and OD Normal
Applanation Indentation
Applanation
and
Indentation
• PASCAL
Fill in
Red cell Glaucoma
Haemolytic Glaucoma
Ghost cell Glaucoma
Hemosiderotic Glaucoma
168 | Ophthalmology
EXTRA POINTS:
8 Orbit
CONCEPTS
 Concept 8.1 Orbit Anatomy
Time Required
1st reading 20 mins
nd
2 look 5 mins
Fig.8.1:
(a) Simplifed geometry of the orbits (b) The orbits from above
Medial
wall
Lateral
Lateral wall wall
Medial
wall
Floor
Fig.8.2:
Time Required
1st reading 30 mins
nd
2 look 10 mins
Fig.8.3: Structures passing through superior orbital fissure and inferior orbital fissure
172 | Ophthalmology
Superior orbital fissure Syndrome
It is also known as Rochen-Duvigneaud syndrome: is a collection of symptoms caused
by compression of structures just anterior to the orbital apex. Cranial nerves passing
through superior fissure: IIIrd, IVth, V-1, VIth.
Clinical features:
• Onset is slow
• Proptosis (ptosis masked by proptosis)
• Dereased corneal sensation (due to V-1/ ophthalmic branch of trigeminal nerve).
• Ophthalmoplegia due to III,IV and VI nerves
Orbital Apex Syndrome: Orbital apex = superior orbital fissure syndrome+ involvement
of optic nerve
Orbit | 173
Concept 8.3: Blow out fracture of orbit
Learning objectives
• To know different Xray views and blow out fracture
Time Required
1st reading 20 mins
nd
2 look 5 mins
Blow-Out Fracture:
It is the fracture of orbital floor which typically occurs by a sudden increase in the orbital
pressure by a striking object > 5 cm in diameter such as a fist or tennis ball.
Two types:
• Pure blow-out fracture -Does not involve the orbital rim.
• Impure blow-out fracture - Involves the rim
Clinical Features:
• Ecchymosis
• Subcutaneous emphysema: It occurs only if medial wall is also fractured.
• Enophthalmos.
• Infraorbital nerve anesthesia: It leads to decreased sensation on the affected cheek.
• Diplopia.
• Tear drop sign
Treatment:
• Conservatively by antibiotics and anti-inflammatory.
• Surgery: If no improvement in enophthalmos or diplopia then surgical intervention
is needed.
174 | Ophthalmology
X-Ray Views of Orbit:
NAME VIEWS STRUCTURES SEEN
Caldwell-luc view PA View Superior orbital fissure.
Occipitofrontal Greater and lesser wing of sphenoid. Ethmoid
and frontal sinus.
Floor of sella.
Town’s view AP view. Frontooccipital Dorsum sellae of sphenoid bone.
Inferior orbital fissure.
Water’s View Occipito-meatal. Maxillary sinus and floor of orbit. (in blow-out
fractures)
Rhese view For optic foramen.
Orbit | 175
Concept 8.4: Proptosis
Learning objectives
• To know about different tests and examples of proptosis
Time Required
1st reading 40 mins
nd
2 look 15 mins
Proptosis
Forward protrusion of normal- sized eyeball > 21 mm beyond the lateral orbital margin
or > 2mm protrusion compared to the other eye.
Measurement of proptosis:
Nafzigger test Inspection of the eyeballs from behind the patient looking over his
forehead.
Hertel’s Exophthalmometre To measure the distance between the apex of cornea and lateral orbital
margin.
Leude’s Exophthalmometre It is useful in children.
Topometre Useful for non-axial proptosis.
Simple plastic rule
Bilateral proptosis
Painful Cavernous sinus- thrombosis
Painless Grave’s disease
Pseudotumor
Lymphoma
Carotico-cavernous fistula
Leukemia
Metastasis
Developmental anomalies
176 | Ophthalmology
Unilateral proptosis
Painful Painless
Axial • Orbital haemorrhage. • Hemangioma
(central • Orbital cellulitis. • Meningioma
protusion) • Orbital mucocoele • Glioma
• Cavernous sinus thrombosis • Schwanoma
• Pseudotumor
Non-axial • Adenoid cystic carcinoma of lacrimal • Down and medial- Dermoid, lacrimal
(non-central gland gland tumors
protusion) • Nasopharyngeal carcinoma • Down and temporal - Frontoethmoid
• Metastasis mucocoele, lacrimal sac tumours
• Superior - Maxillary sinus tumor and
mucocele.
Pseudoproptosis:
The eye ball appears to be proptosed by actually there is no forward displacement.
• High axial myopia
• Shallow orbit due to craniofacial synostosis
• Retraction of the upper eyelids
• Enophthalmos of the other eye
Orbit | 177
Concept 8.5: Dysthyroid Ophthalmopathy
Learning objectives
• To know about signs of Thyroid eye disease
Time Required
1st reading 40 mins
nd
2 look 15 mins
May or may not be associated with hyperthyroidism. The patient may be euthyroid,
hyperthyroid or hypothyroid
Retroorbital
fat
Retroorbital
muscles
Fig.8.10
178 | Ophthalmology
Time Required
1st reading 40 mins
nd
2 look 15 mins
Malignant:
• Adenoid cystic carcinoma : It is the most common malignant tumour, painful as there
is perineural invasion.
• Pleomorphic adenocarcinoma
• Mucoepidermoid carcinom
Time Required
1st reading 30 mins
nd
2 look 10 mins
Orbital Cellulitis
It is the inflammation in the orbit behind the orbital septum.
Fig.8.18:
Ant. cerebral a.
Int. carotid a.
Optic
chiasma
Oculomotor (III) n.
Trochlear (IV) n.
Hypophysis
Oculomotor (V1) n.
Maxillary (V2) n.
Sphenold
sinus Pia
Arachnold
Dura
Abducens (VI) n.
Time Required
st
1 reading 45 mins
2nd look 15 mins
Genetics:
• Inheritance – AD, but only 6% cases are familial.
• Unilateral in 70-75% while bilateral is 25%-30%
• Familial cases have early onset, bilateral involvement and are predisposed to develop
non- ocular malignancy including pinealoblastoma and osteogenic sarcoma.
• B/L retinoblastoma with pinealoblastoma is termed as trilateral retinoblastoma.
• The specific area corresponding to retinoblastoma gene was identified on
• 14 band, on long arm of chromosome 13 – i.e. 13 q 14.
• 13q syndrome - Retinoblastoma when associated with other dysmorphic features
(microcephaly, broad nasal bridge, hyperteleorism and mental handicap).
• Knudson’s two hit hypothesis: In hereditary retinoblastoma, first genetic change/hit
in RB gene is in- herited from an affected parent while second mutation (second hit)
occurs in post natal life and both alleles are lost.
• In non-hereditary retinoblastoma, both mutations (first and second hits) occur in post
natal life.
Clinical features:
Mode of presentations are:
• Leukocoria (60%): It is the most common mode of presentation.
• Strabismus (20%): It is the second most common mode of presentation.
• Secondary glaucoma.
• Pseudouveitis.
• Orbital inflammation - mimicking orbital cellulitis.
• Proptosis.
• Heterochromia iridis, rubeosis iridis.
Growth patterns
• Exophytic: towards choroid
• Endophytic: towards vitreos
• Diffuse infitrating
Orbit | 185
Pathology:
Gross:
• Chalky white friable mass with dense foci of calcification and necrosis.
• Seeding into vitreous cavity.
• Extension to uvea, epibulbar structures, optic nerve and orbit.
Microscopic:
Basophillic mass with light eosinophillic areas due to necrosis.
A. Well - differentiated:
Flexner-Wintersteiner rosette (specific for retinoblastoma).
Homer- Wright roset.
Fleurette formation.
Poorly differentiated: Poor prognosis.
Investigations:
X-ray- Rheese view will show enlargement of optic foramen
USG: B scan. It helps to visualize calcification in tumour.
CT-Scan - (for intracranial extension).
MRI- Investigation to choice to assess spread of tumour (via optic nerve).
E- enucleation
2 Optic nerve Most common mode of spread is via optic nerve Enucleation with
invasion radiotherapy/Chemotherapy
3 Orbital Exenteration
extension
4 Distant- Palliative
Metastasis
186 | Ophthalmology
Enucleation: Removal of the eyeball with long piece of optic nerve
Laser Photocoagulation: for posterior tumours
Cryotherapy: Tripple freezing - thaw technique, for anterior tumours
Differential Diagnosis of Leukocoria: It is collectively known as Pseudogliomas (These
are the conditions which simulate retinoblastoma due to the presence of leukocoria)
Differentiating features of pseudoglioma from retinoblastoma:
• IOP is raise in Retinoblastoma while decreased/normal in pseudoglioma
• There is intraocular calcification in retinoblastoma which is not seen in pseudoglioma.
• Congenital cataract.
• PHPV [Persistent hyperplastic prima- ry vitreous].
• ROP [Retinopathy of prematurity].
• Toxocariasis.
• Coats disease.
• Coloboma of optic nerve.
• Retinal astrocytoma: It is the benign counterpart of retinoblastoma.
• Fungal endophthalmitis.
• Retinal dysplasias.
Enucleation: Evisceration: Exenteration:
Removal of eyeball with stump Removal of entire intraocular Complete removal of eyeball, the
of optic nerve leaving behind the contents of the eye, leaving the retrobulbar orbital soft tissues,
extra ocular muscles scleral shell and extraocular and most or all of the eyelids, uptil
muscle attachements intact. periosteum
Blind painful eye. Expulsive choroidal hemorrage Orbital extension of Malignancies.
Intraocular tumor. Pan-ophthalmitis Mucormycosis.
Pthisis bulbi. Bleeding anterior staphyloma Chronic orbital pain.
Microphthalmia. Severe trauma with risk of Orbital deformities.
sympathetic ophthalmitis.
188 | Ophthalmology
Inferior orbital fissure: Between ______________
Superior orbital fissure: Between ______________
Optic canal/Optic foramen: Formed by ____________
• Name some nerves passing from upper part of superior orbital fissure and
inferior orbital fissure
• Identify the sign? _______________________
Occipitofrontal
Rhese view
Fill in
Most common benign intraorbital tumor in children is –
Most common primary malignant orbital tumor in children is –
Most common cause of benign intraorbital tumour in adults-
Most common primary malignant orbital tumor in adult is –
Orbit | 191
EXTRA POINTS:
9 Lacrimal
Eyelids
drainage system
and
CONCEPTS
 Concept 9.1 Eyelid anatomy and muscles
 Concept 9.4 M
iscellaneous eyelid and eylash
disorders
Time Required
st
1 reading 20 mins
2nd look 5 mins
Fig.9.1:
Eyelid Anatomy
The eyelid is divided into the upper lid and lower lid. It has 7 layers
Skin- Thinnest skin in body
Subcutaneous tissue
Striated muscles
▫ Orbicularis oculi: Three portions: Orbit, Palpebral (Preseptal and Pretarsal) and
Lacrimal – supplied by 7th nerve
▫ Levator palpebral superioris – supplied by 3rd nerve
Submuscular areolar tissue- contains veseels and nerves
Orbital septum and Tarsal plate (Fibrous skeleton of lids containing Meibomian
glands)
Smooth muscle – Muller
Palpebral conjunctiva
Fig.9.2: Levator palpebral superioris – elevation of Fig.9.3: Origin: Lesser wing of sphenoid
upper eyelid
194 | Ophthalmology
Insertion:
• Skin crease
• Medial and lateral palpebral ligaments (including Whitnall’s ligament)
• Anterior surface of tarsal plate
Time Required
st
1 reading 50 mins
2nd look 20 mins
Fig.9.14:
Fig.9.15:
198 | Ophthalmology
• Bell’s Phenomenon: If Bell’s phenomenon is absent, then it is a contraindication for
surgery
• Tensilon Test: It is done for myasthenia gravis
• Phenylepherine Test: On instilling 10% phenylephrine, if within 10-15 minutes the
ptosis improves, it is due to muller muscle underaction as in Horner’s syndrome
• Upper lid crease: M- 10 mm; F - 8 mm.
• Vertical fissure height: M: 7-10 mm, F: 8-12 mm
Treatment of acquired ptosis – treatment of underlying cause
For mild ptosis-Fasanella: Servat procedure
Fig.9.16:
Fig.9.17:
Fig.9.18:
200 | Ophthalmology
Concept 9.3: Entropion and Ectropion
Learning objectives
• To know about different causes and treatment of entropion and ectropion
Time Required
1st reading 40 mins
nd
2 look 15 mins
ENTROPION
Fig.9.25: PARALYTIC Fig.9.26: MECHANICAL
Fig.9.27: CONGENITAL
Eyelids and Lacrimal drainage system | 203
Concept 9.4: Miscellaneous eyelid and eyelash disorders
Learning objectives
• To learn and identify various terminology in eyelids and eyelash disorders
Time Required
1st reading 30 mins
nd
2 look 15 mins
Fig.9.28: CHALAZION
Fig.9.29: STYE
204 | Ophthalmology
Internum Hordeolum: It is small abscess caused by an acute staphylococcal infection
of meibomian gland. It presents as a painful swelling in the lid. It is treated with hot
formentation, oral antibiotics and anti-inflammatory. Incision and drainage if required,
can be done.
Trichiasis: Misdirection of the eyelashes. It presents as irritation, pain, lacrimation,
blepharospasm. It can lead to punctuate epithelial erosions, corneal ulcer and pannus.
Distichiasis:It is a congenital anomaly characterized by extra row of lashes
Symblepharon: It is the adhesion of lid with the globe. It can occur due to burn,
chemical injuries, ulcers or after surgeries.
Ankyloblepharon: Adhesion of the margins of both the lids and both palpebral
conjunctiva. Causes are same as symblepharon.
Lagophthalmos: Inability to close the eyes.
It can lead to exposure keratopathy. Causes are: Cicatrization of the lids, Paralysis of
orbicularis oculi and proptosis
Madarosis: Loss of eyelashes or loss of eyebrows, both are termed as madarosis.
Causes:
Local:
Blepharitis Trachoma, S. J. syndrome.
Infilterating tumors.
Burns.
Radiotherapy or cryoth of lid tumors.
Skin:
▫ Psoriasis.
▫ Generalized alopecia.
Systemic:
▫ Myxoedema.
▫ Leprosy.
▫ Syphilis.
▫ SLE.
Following Removal:
▫ Iatrogenic trichiasis.
▫ Trichotillomania.
Poliosis: Whitening of eye lashes is known as poliosis.
Causes:
Local:
▫ Chronic blepharitis.
▫ Sympathetic uveitis.
Systemic:
▫ VKH syndrome.
▫ Waardenberg syndrome.
Eyelids and Lacrimal drainage system | 205
Time Required
st
1 reading 40 mins
nd
2 look 20 mins
Fig.9.36:
Fig.9.37:
Eyelids and Lacrimal drainage system | 207
Watering of Eyes
Lacrimation: It is the over-production of the tear.
Epiphora- It is overflowing of the tear due to blockage of the drainage system
Causes of Blockage:
Anatomical:
Strictures.
Obstruction.
Foreign body
Tumor
Physiological:
Lacrimal pump failure.
Dacrocystitis:
It is the inflammation of the lacrimal sac at the medial canthus region. It may be:
Congenital (chronic) or acquired (either acute or chronic).
Congenital dacrocystitis:
It is due to congenital blockade of the lacrimal duct.
Usually presents as mild grade chronic inflammation.
Characterised by:
Epiphora
Regurgitation of mucopurulent discharge on applying pressure over lacrimal sac
region, (positive regurgitation test).
Swelling over the sac area.
Fig.9.42: DACRYOCYSTITIS
Eyelids and Lacrimal drainage system | 209
Treatment:
• Upto 9 months -Massage over the lacrimal sac region with topical antibiotics
• 9 months to 4 years -Probing of Nasolacrimal duct:Bowman’s probe is used for this
purpose.
• After 4 years -Dacrocystorhinostomy
Acquired Dacrocystitis:
It may be acute or chronic.
a. Acute dacrocystitis: It is acute suppurative inflammation having marked swelling,
tenderness, redness over lacrimal region with the presence of epiphora.
Treatment:
Cellulitis stage: Systemic and topical antibiotics are given. Systemic anti inflammatory
and analgesics are added along with hot fomentation to relieve pain and swelling.
Lacrimal abscess stage: In addition to above treatment, when the pus starts
pointing out on the skin,it should be drained with a small incision. Later on, either DCR
(Dacrocystorhinostomy)
External lacrimal fistula: After controlling the acute infection with systemic antibiotics,
fistulectomy along with DCR.
Chronic dacrocystitis: It is more common than acute form. It occurs as a result of
obstruction of NLD due to various causes like chronic inflammation of nasal mucosa or
by polyp pressure etc. Treated by DCR.
Eyelids and Lacrimal drainage system | 211
Levator palpebral superioris –
Action ______________
Origin: __________
Insertion: ___________
Name some nerves passing from upper part of superior orbital fissure and inferior orbital
fissure
• Which is being tested? _______________________
CONCEPTS
 Concept 10.1 Uveal anatomy
 Concept 10.3 S
ystemic Associations of Uveitis:
Arthritis
 Concept 10.4 S
ystemic Associations of Uveitis:
Infections
 Concept 10.5 O
ther Systemic Associations of
Uveitis
216 | Ophthalmology
Concept 10.1: Uveal anatomy
Learning objectives
• To know about basic anatomy of uveal layer
Time Required
1st reading 25 mins
nd
2 look 10 mins
Iris
Circular disc, 12 mm in diameter with an aperture of 3-4 mm called pupil. Its is thinnest
at its root. The anterior surface is divided into ciliary zone and pupillary zone by a zig-
zag line called Collarette (represents attachment of pupillary membrane).
Microscopic:
Anterior limiting layer (anterior most condensed part of stroma). Has melanocytes and fibroblast
Stroma (contains vessels, nerves, sphincter pupillae, dilator muscle)
Anterior epithelial layer
Posterior pigmented epithelial layer.
• Disinsertion of iris from its root is called iridodialysis. The pupil in iridodialysis becomes
D-shaped.
• Aniridia - The iris may be apparently absent, however, a narrow rim exists at the
ciliary border. Wilms tumour is associated with sporadic cases.
• Polycoria –multiple pupil, corectopia – displaced pupil
Fig.10.3: IRIDO-DIALYSIS
Uvea| 217
Ciliary Body
It’s a forward continuation of choroid at ora-serrata.
It is divided into two parts:
• Pars plicata.
• Pars plana.
Microscopic:
Supraciliary lamina (outermost condensed stroma), consists of pigmented collagen fibres Stroma (consists
of longitudinal, circular and radial fibres and vascular stroma)
Layer of pigmented epithelium
Layer of non-pigmented epithelium
Internal limiting membrane.
Accomodation is mainly done by circular and radial muscles. The resting tone of ciliary
muscles is +1D.
Choroid
Extremely vascular membrane. From retina to sclera, it has
• Thin elastic membrane, membrane of Bruch.
• Capillary plexus of fenestrated vessels, the choriocapillaris.
• the layer of medium-sized vessels, while most externally are the large vessels, the
whole being held together by a stroma consisting of branched pigmented connective
tissue cells.
• It is not firmly adherent to sclera - potential space between the two structures - the
suprachoroidal space.
218 | Ophthalmology
Concept 10.2: Uveitis
Learning objectives
• To know about classification of uveitis
• To learn features of different types of uveitis
Time Required
st
1 reading 50 mins
2nd look 20 mins
Classification:
Anatomical Clinical Pathological
Anterior uveitis Acute uveitis: Granulomatous
Intermediate uveitis Sudden onset and persists less than 6 weeks Nongranulomatous
Posterior uveitis Chronic uveitis:
Panuveitis Insidous onset and persists months or years
Fig.10.4:
Anterior Uveitis:
Inflammation of iris (iritis) and anterior part of ciliary body i.e. pars plicata, (iridocyclitis).
Most common form of uveitis accounting for 70% cases (approx).
Uvea| 219
Causes of Anterior Uveitis:
Autoimmune Psoriasis, ankylosing Spondylitis, Inflammatory bowel disease, Sarcoidosis, Behcet’s disease.
Infections Herpes zoster, Herpes simplex, TB, Syphilis, Leprosy, leptospirosis.
Malignancy Leukemia, retinoblastoma, malignant melanoma, lymphoma
Others Idiopathic, trauma, Fuch’s heterochromatic iridocyclitis.
Most common cause of anterior uveitis is IDIOPATHIC.
Clinical features:
• Photophobia, pain, redness, decreased vision, lacrimation.
• Circumcorneal (ciliary) congestion
• Keratic precipitates (KP): Proteinaceous cellular deposits at the back of the cornea.
It is a pathognomic sign.
Mutton fat KPs Large and are composed of epitheloid cells and macrophages. Seen in
granulomatous inflammation.
Small Granular KPs Also known as They are composed of lymphocytes, and are characteristic of
non-granulomatous uveitis.
Red KPs Composed of RBCs and inflammatory cells. Seen in haemorrhagic uveitis.
Old KPs In healed uveitis with crenated margins.
• Aqueous flare: Due to leakage of proteins from the inflamed capillaries of the iris
and pars plicata. It is based on Tyndal phenomenon/Brownian movements.
• Posterior Synechiae
Treatment:
Steroids: Topical
Mydriatics with strong cycloplegic action (Atropine).
Uvea| 221
Intermediate Uveitis or Pars Planitis
Primary
Idiopathic, insidious, chronic, intra-ocular inflammation typically affecting children or
young adults.
Secondary:
• Sarcoidosis
• Retinitis pigmentosa
• Multiple sclerosis
• TB, syphilis, Lyme’s disease, toxocara
Clinical features:
• Floaters
• Diminished vision- if associated with Cystoid macular edema
• Vitritis: Cells, Snow balls or cotton balls. Mild peripheral periphlebitis. Sheathing of
terminal venules (Snow – Banking): Hallmark of pars planitis.
Fig.10.11:
Complications:
• CME.
• Secondary cataract.
• Tractional RD.
• Cyclitic membranes.
Treatment:
It is four step approach.
• Periocular steroid injections.
• Systemic steroid and cytotoxic drugs.
• Cryotherapy of vitreous base.
• Vitrectomy
222 | Ophthalmology
Posterior Uveitis:
It is the inflammation of the choroid along with associated structures i.e. vitreous, optic
disc, macula, peripheral retina and retinal veins. It is usually insidious in nature.
Clinical features:
• Choroiditis: It is seen as round yellowish patches.
• Cystoid macular edema: CME.
• Vitritis
• Papillitis
• Retinal edema
• Periphlebitis
There is no pain, photophobia, lacrimation or circumcorneal congestion.
Most common cause of posterior uveitis is Toxoplasmosis
Treatment:
• Local steroids: Sub-tenon injections of triamicilone acetate.
• Systemic steroids.
Complications of Uveitis:
In the Cornea Iris Lens In the Globe Posterior Segment
• Sclerosing • Atrophy • Complicated • Secondary • CME
keratouveitis • Rubeosis cataract Glaucoma • RD
• Corneal edema • Pthisis bulbi. • Cyclitic membrane
• Bullous keratopathy formation →
• Disciform keratitis Cilio- Choroidal
• Band-shaped detachment →
keratopathy Hypotony.
• Choroidal
neovascular
membrane
Uvea| 223
Concept 10.3: Systemic Associations of Uveitis: Arthritis
Learning objectives
• To know about some arthritis related uveitis
• To learn features of different types of uveitis
Time Required
st
1 reading 15 mins
2nd look 5 mins
Time Required
st
1 reading 20 mins
2nd look 5 mins
Chronic iridocyclitis:
Most frequent feature
Choroditis: Focal or multifocal.
Retinal vasculitis.
Moderate vitritis.
Severe ischemic periphlebitis.
Peripheral capillary closure →
neovascularisation.
Uvea| 225
Time Required
st
1 reading 50 mins
2nd look 20 mins
Sarcoidosis:
It is an idiopathic, multisystem disorder characterised by presence of non-caseating
granulomata in lungs and other organs.
Ocular features:
Adnexa Granuloma conjunctiva, episclera, sclera.
KCS- due to involvement of lacrimal gland
Anterior uveitis Chronic granulomatous iridocyclitis
Iris nodules
Fundus Changes Periphlebitis- Advanced stage of vascular sheathing leads to Candle- wax
drippings.
Pre-retinal nodules- Lander’s sign
Snow ball opacities in vitreous
Disc granuloma
Optic atrophy
Behcet’s Disease:
Idiopathic multisystem disorder, affecting young men leading to obliterative vasculitis
due to circulating immune complexes.
Uvea| 227
Clinical Features:
• Oral ulceration.
• Recurrent genital ulceration.
• Skin lesions: Erythema nodosum
• Positive pathergy test.
• HLA- B5 associated.
• Eye involvement- Severe bilateral nongranulomatous panuveitis (Acute recurrent
iridiocyclitis with transient hypopyon, retinitis, vitritis, vasculitis)
HLA-DR4 associated.
Skin and Hair Neurological Features: Auditory Ocular Features
Changes: symptoms
Alopecia Meningeal Irritation Tinnitus Bilateral granulomatous panuveitis
Poliosis Encephalopathy Vertigo Dalen-Fuchs nodules (inflammatory cells
Vitiligo CSF- Lymphocytosis Deafness. in RPE and Bruch’s membrane)
(Suguiras sign) Pigment epithelial atrophy (sunset glow
fundus)
Multifocal choroiditis and exudative RD
Treatment:
• Vigorous steroid therapy by all possible routes of administration.
• Immunosuppressive therapy: with chlorambucil, cyclophosphamide or cyclosporin, in
severe steroid – resistant cases.
• Enucleation- within 2 weeks of injury will prevent sympathetic uveitis
Ophthalmia Nodosum
Severe, granulomatous iridocyclitis with nodule formation, due to caterpillar hair inside
the eye
Etiology:
• Idiopathic.
• Hypersensitivity to tuberculo protein leads to peripheral retinal vasculitis.
Uvea| 229
Presentation:
• Sudden blurring of vision with floaters as a result of vitreous haemorrhage.
• Sheathing of small peripheral retinal veins.
• Massive proliferative retinopathy → Vitreous or retinal haemorrhage → TRD.
Treatment:
1. PRP
2. Pars plana vitrectomy
Complications:
Cataract.
Glaucoma – usually of open- angle type
Organisms:
Exogenous endophthalmitis:
• Post-operative: Acute post-operative ie within 7 days after surgery: Staphylococcus
epidermidis, Staphylococcus aureus, Streptococcus. Delayed onset i.e. from a week
to months after surgery: Fungi, P. acne (most common).
• Post traumatic: Bacillus, Staphylococcus epidermidis, Fungi, Streptococcus.
Endogenous endophthalmitis: Bacillus cereus (drug abusers), Staphylococcus aureus,
Streptococcus, Haemophilus in- fluenzae, meningococci etc.
Clinical features:
• Severe ocular pain.
• Redness.
• Lacrimation.
• Photophobia and marked loss of vision.
• Swollen lids.
• Chemosis of conjunctiva.
• Conjunctival and circumcorneal congestion.
• Hypopyon.
• Corneal edema.
• Amourotic cat’s eye reflex.
Treatment:
Intravitreal antibiotics
Topical and systemic steroids
Pars plana vitrectomy
Panophthalmitis:
Inflammation of all the structures of the eye
Complications include:
• Orbital cellulitis.
• Cavernous sinus thrombosis.
• Meningitis.
• Encephalitis.
Treatment:
Eviseration
Systemic antibiotics
Uvea| 231
Worksheet
• DO THIS CHAPTER FROM DQB
232 | Ophthalmology
• Identify
• Write features of
Reiters Syndrome ______________
• Sympathetic Ophthalmitis:
CONCEPTS
 Concept 11.1 Extraocular muscles and actions
 Concept 11.3 C
oncomitant vs Inconcomitant
squint
Time Required
st
1 reading 40 mins
2nd look 20 mins
EXTRAOCULAR MUSCLES
GAZE POSITIONS
Fig.11.2:
Hering’s law: It states that during any conjugate eye movement, equal and simultaneous
innervation flows to the yolk muscles.
Sherrington’s Law of reciprocal innervations: It states that increased innervation
and contraction of a muscle is automatically associated with a reciprocal decrease in
innervations and relaxation of its antagonists.
Primary position of gaze: Position of eyes in binocular vision when, with the head
erect, the object of regard is at infinity and lies at intersection of saggital plane of the
head and horizontal plane passing through the centre of rotation of the two eye balls.
Secondary position: Supreversion, Infraversion, Levoversion, Dextroversion.
Tertiary position: Vertical + Horizontal position i.e. dextroelevation, Levoelevation,
dextrodepression, Levodepression.
238 | Ophthalmology
Concept 11.2: Squint: Definition and tests
Learning objectives
• To know about types of squint
• To learn various tests to determine squint
Time Required
st
1 reading 50 mins
2nd look 25 mins
The misalignment of the visual axis of the two eyes is known as squint or strabismus.
Strabismus is classified as:
Latent squint [Phorias]: It is further classified as exophoria, esophoria, hypophoria or
hyperphoria.
Manifest squint [Tropias]: It can be classified as: Esotropia, Exotropia, Hypeotropia or
Hypertropia
Fig.11.3:
Fig.11.4:
Cover-uncover test:
• Cover component:
Detects heterotropias
Cover straight eye
Look at uncovered deviated eye (movement indicates tropia)
• Uncover component:
Detects heterophorias
Uncover straight eye
Look at uncovered eye for deviation and refixation (movement indicates phoria in this
eye)
Alternate –Cover Test: In this test we alternate cover both the eyes with the cover
and see the movement of the uncovered eye.
240 | Ophthalmology
COVER TEST FOR TROPIAS
Fig.11.5:
Squint| 241
COVER-UNCOVER TEST FOR PHORI
AS/LATENT SQUINT
Fig.11.6:
Krimky’s test/Prism bar test: Prisms of increasing power are placed in front of
deviated eye till the eye appears straight or light reflex is aligned straight. It measures
heterotropias. [Light rays are deviated towards the base of the prism, and the objects
appear displaced towards the apex].
Alternate prism cover test: Measures total deviation (heterotropias and phorias).
Prism over deviated eye and alternate cover each eye until no movement is seen.
Maddox rod and Maddox wing are used to assess the latent squint.
In Maddox wing -Dissociates two eyes for near fixation
In Maddox rod - Dissociates two eyes for distance fixation. It consists of series of fused
high power cylinder red rods.
Fig.11.9:
Squint| 243
Concept 11.3: Concomitant vs Inconcomitant squint
Learning objectives
• To know about types of squint
• To learn various tests to determine squint
Time Required
st
1 reading 60 mins
2nd look 25 mins
Concomitant squint
Concomitant esotropia:
• Infantile esotropia- Presents at 6 months of birth Large angle (> 30 prism
D).Alternating fixation in primary position but cross
• Accomodative esotropia- Refractive- corrected by spectacles. Non refractive- high
AC/A ratio (accommodative convergence/accommodation_- corrected by bifocals.
Mixed- components of both
• Sensory esotropia (disruption of binocular single vision in children e.g. congenital
cataract)
• Consecutive esotropia (after correction for exotropia)
Concomitant exotropia:
• Infantile exotropia- Present at birth, large and constant angle
• Intermittent exotropia- Convergence insufficiency (worse for near, needs MR resection
or recess-resect). Divergence excess (worse for distance, needs LR recession):
• Sensory exotropia (disruption of binocular single vision in children e.g. congenital
cataract)
• Consecutive exotropia (after correction for esotropia)
Treatment :
Incomitant/Paralytic Squint:
Wait for 5-6 months, if no improvement do surgery.[For an underacting muscle we do
resection and for a overacting muscle we do recession].
Time Required
1st reading 40 mins
nd
2 look 15 mins
The synoptophore
Test of Binocular single vision
It dissociates two eyes for both near and distance fixation
Fig.11.14: SYNAPTOPHORE
Binocular Vision:
Defined as that state of simultaneous vision with two seeing eyes that occurs when
an individual fixes his visual attention on an object of regard. It is assessed by a
synaptophore.
Grades:
I – Grade- Simultaneous perception
II- Grade – Fusion.
III- Grade – Stereopsis
Horopter:
It is the sum total of points in physical space; that stimulate corresponding retinal
elements of the two eyes.
Panum’s Area:
The field in front of and behind the horopter in which the expected diplopia does not
occur is known as “Panums fusional space”.
Squint| 247
Visual reflex (fixation) in infants starts developing at 6 weeks of age and develops fully
till 4 month of age.
Binocular function fully develops by 6 years and orthoptic exercises are most useful till
8-9 years of age.
Visual acuity is a measure of form sense.
Fig.11.16: FUSION
248 | Ophthalmology
Fig.11.17: STEREOPSIS
Fig.11.18:
Squint| 249
Fig.11.19: Randot E Fig.11.20: TNO
Fig.11.21: Lang Fig.11.22: Frishy
252 | Ophthalmology
• The obliques are inserted behind the equator and form an angle of ____ with the
visual axis
• If the patient is normal, he will _________ from right eye and _______ from left eye
CONCEPTS
 Concept 12.1 Basics
Time Required
1st reading 20 mins
nd
2 look 5 mins
Visual angles:
a. Angle Alpha (α):
Angle between optical axis and visual axis at the nodal point.
b. Angle Gamma (γ):
Angle between optical axis and fixation axis at the centre of rotation of the eyeball.
c. Angle Kappa (κ):
Angle between visual axis and pupillary line at cornea
Fig.12.1:
Optics| 259
Positive angle kappa – Pseudo exotropia. It is a feature of hypermetropia.
Negative angle kappa- Pseudo esotropia. It is a feature of myopia.
Purkinje image:
Formed when strong beam of light is projected on eye.
• Ist and IInd image- by anterior and posterior surface of cornea.
• IIIrd and IVth image- by anterior and posterior surface of lens.
• IVth image- is inverted.
In aphakia, 2 images are absent (3rd and 4th).
In pseudophakia, 4 images
Fig.12.2:
260 | Ophthalmology
Time Required
st
1 reading 30 mins
nd
2 look 10 mins
Snellen chart
Near visual acuity is assessed commonly at 40 cm, using charts with different size print
samples. Jaeger, Snellen are examples.
Optics| 261
Landolt C chart chart is a way to check vision for illiterate or mute patients.
262 | Ophthalmology
ETDRS chart (Early Treatment of Diabetic Retinopathy Study Chart)
Fig.12.6:
Same number of letters per row (five letters per row). When using a LogMAR chart, visual
acuity is scored with reference to the logarithm of the minimum angle of resolution. It
is done at 4 m.
Vision testing in infant: The pattern visual evoked potential (VEP) and preferential
looking behaviour by Teller chart. An objective measure of the visual acuity may also be
made by utilizing the phenomenon of opticokineticnystagmus.
Lea figure testing in a young child. The child matches the presented figure. The child
points to one of four choices to match the figure or letter he or she sees on the computer
monitor or chart in the distance.
HOTV acuity testing. The child is asked to match the indicated letter on the chart with
a hand-held card displaying the HOTV letters.
Time Required
st
1 reading 20 mins
nd
2 look 5 mins
SLIT LAMP
The slit-lamp is essential for a thorough examination of the eye. The magnification can
be varied by changing the power of the eye pieces and the objective lens. It can view
upto anterior 1/3rd of vitreous. Coupled with additional lens, fundus and optic disc can
also be seen (slit lamp biomicroscopy)
For an emmetropic, magnification of Direct ophthalmoscope is 15 times, image formed
is virtual and erect and is used to see central retina.
Magnification of Indirect ophthalmoscope with 20D lens is 3 times, image formed is real
and inverted and is used to see the periphery of the retina.
Optics| 265
Fig.12.9: DIRECT OPHTHALMOSCOPE Fig.12.10: INDIRECT OPHTHALMOSCOPE
Time Required
st
1 reading 40 mins
nd
2 look 15 mins
Errors of Refraction:
Myopia:
It is a refractive error where the light rays are focused in front of the retina. It is
corrected by using concave lens. Any myopia of more than 6D is called high myopia.
Myopia with fundus changes is called pathological myopia.
Far Point and Near Point Come Nearer in Myopia.
Hypermetropia:
It is a refractive error where the light rays are focused behind the retina. It is corrected
by convex lenses.
The fundus changes are:
• Pseudopapillitis.
• Silk shot appearance.
• Degenerative retinoschisis.
Near Point Becomes Distant in Hypermeropia.
Refractive Error
Fig.12.12:
Optics| 267
Astigmatism:
When the refractive power in the two principal axis of the eye is different, it is called
astigmatism. It is corrected by cylindrical lenses.
It can be due to corneal curvature abnormality, lenticular curvature abnormality/oblique
position of lens and oblique displacement of macula.
Fig.12.13:
Fig.12.14:
Anisometropia:
When the total refraction of the two eyes is unequal by > 2.5 D.
Aniseikonia:
When the images projected to the visual cortex from the two retina are abnormally
unequal in size and/or shape.
Pseudomyopia:
• Due to excessive ciliary muscle tone which causes increase in accommodation leading
to increase in the power of the lens.
• Distant vision is decreased while near vision is good.
• Present in children who try to compensate their refractive error
• Can also be drug induced eg. Cholinergic drugs since it causes ciliary spasm and will
increase the tone of the ciliary muscle.
Aphakia:
Absence of the Lens:
• Eye becomes highly hypermetropic.
• Total power of eye is reduced to + 44 D from + 60 D [less by 16D-17D].
• Total loss of accommodation.
• Best available treatment for aphakia is posterior chamber intraocular lens.
Treatment
Near glasses (plus)
Bifocals (if patient has refractive error for far as well)
Fig.12.17: BIFOCALS
Time Required
st
1 reading 20 mins
nd
2 look 5 mins
PIN-HOLE
Pinhole aperture compensates for the effect of refractive errors, and consists of an
opaque occlude perforated by one or more holes of about 1 mm diameter. If the vision
is subnormal, the visual acuity is again determined by asking the patient to read the
letters through a pinhole. If it improves, it indicates an underlying refractive error.
However, visual acuity in patients with macular disease and posterior lens opacities may
be worse with pin hole.
Fig.12.19:
Fig.12.20: Normal Amsler grid Fig.12.21: Amsler grid with metamorphosia and
positive scotoma
Optics| 273
Time Required
st
1 reading 20 mins
nd
2 look 5 mins
Amblyopia:
It is defined as deficiency of form sense resulting in reduction in visual acuity of greater
than two lines between the eyes or an absolute reduction in acuity below 6/9.
Squint is the most common cause of amblyopia.
Pathophysiology: Cell shrinkage in parvocellular layers of lateral geniculate body.
Types:
• Strabismic Amblyopia – due to squint
• Form deprivation Amblyopia: congenital cataract, rubella keratitis.
• Refractive Amblyopia:
Anisometropic Amblyopia.
Ametropic Amblyopia.
Meridional Amblyopia.
Treatment:
• Refractive correction.
• Occlusion.
• Penalisation (with atropine).
• CAM stimulator (high contrast square wave gratings of different frequency).
• Pleoptics – Stimulation of fovea by means of after–images in case of eccentric fixation.
• Drug therapy: Levodopa/Carbidopa:
• Occlusion therapy is the mainstay of the treatment in which NORMAL eye is occluded
274 | Ophthalmology
Concept 12.7: Retinoscopy
Learning objectives
• To know steps of retinoscopy
• To know about refractive error prescription
• To learn basics of contact lenses
Time Required
st
1 reading 40 mins
nd
2 look 15 mins
Retinoscopy
Also called Skiascopy or shadow test, is an objective method of finding out the error of
refraction by the method of neutralisation.
Observation:
Depending upon the movement of red reflex, when a plane mirror retinoscope is used,
reflex direction is seen like these 3:
"Against"
Fig.12.24:
Optics| 275
Plus lens are added if reflex moves in same direction with movement of retinoscope
Minus lens are added if reflex moves in opposite direction with movement of retinoscope
Deduction of cycloplegic:
Atropine- 1D: <7 yrs of age: Atropine should be used for cycloplegic.
Atropine ointment is the choice of cycloplegic in children. 1% ointment is given 3 times
a day for 3 days.
Homatropine- 0.5D
This is done in two axis. The final prescription is given as- example
Contact Lens:
Contact lens is a small polymer material designed to rest on the cornea or sclera
Purpose:
• Optical- used to correct refractive errors.
• Therapeutic – Bandage contact lens
• Cosmetic – coloured contact lenses
Types:
Material:
• Hard- Gas-impermeable –PMMA (Poly methyl methacrylate)
• RGP-Rigid gas-permeable –
CAB- Cellulose Acetate Butyrate.
Styrene.
Siloxane- methacrylate.
Fluoro based or fluorinated silicon.
276 | Ophthalmology
• Soft:
Hydrogel- HEMA.
Elastomer- Silicon rubber.
• Patients using soft contact lens (if use tap water for cleaning the lens) are at increased
risk of Acanthamoeba Keratitis.
• DK- Symbolises oxygen permeability of contact lens; where D is diffusion co- efficient
and K is solubility co-efficient.
• DK/t: Denotes oxygen transmissibility, where t is the thickness of the contact lens.
• Fluorescein: Is not used in soft- lens fitting evaluation as it stains the lens. Except for
large molecules fluorescein like Flourexon.
• Benzalkonium chloride should never be used for disinfecting soft contact lens.
• Toric lenses- For correcting astigmatism, contact lenses with cylindrical power are
called toric lenses.
• X- chrom lenses- These lenses transmit light in red part of the spectrum and are
useful to patients with red-green defective vision.
Optics| 277
Time Required
st
1 reading 40 mins
nd
2 look 15 mins
REFRACTORY PROCEDURES
Procedure Detail Range
Radial keratotomy Linear radial incisions (80% depth) are made in Upto - 6 D
peripheral cornea sparing a central optic zone
thereby flattening it
Intracorneal rings or inserted in a paracentral corneal stromal pocket Upto - 6 D
segments lead to central flattening
Photorefractive keratotomy Excimer laser ablation of the superficial layer of Upto -4D
(PRK) the cornea, after removing the epithelium. Astigmatism up to
around 3 D and low–
moderate hypermetropia
Laser assisted epithelial Resembles excimer laser PRK with an epithelial
keratomileusis (LASEK) flap.
Laser-assisted in situ Excimer laser beam reshapes the cornea by +4 to -12D
keratomileusis (LASIK) ablating the superficial stroma to a predetermined astigmatism up to 5 D
extent after lifting a flap of the cornea with a
sharp
Microkeratome or femtosecond laser
Refractive lenticule Refractive lenticule extraction (ReLEx) uses a +4 to -12D
extraction (SMILE) femtosecond laser to cut a lens-shaped piece of astigmatism up to 5 D
corneal tissue (a lenticule) within the intact
cornea. This is then removed a minimally
invasive 4 mm incision (small incision lenticule
extraction – SMILE).
Fig.12.25: Refractive lenticule extraction (SMILE)
Fig.12.26:
Optics| 279
PHOTOREFRACTIVE KERATECTOMY
Laser epithelial keratomileusis
Optics| 281
• Write the diagnosis of each
Refractive Error
• Aniseikonia is __________________________
• Identify the spectacles
• _____ lens are added if reflex moves in same direction with movement of retinoscope
• This chart is used for ___________________
Optics| 283