aid Hap 18 Fepositioned. dvopters and astignran, ; the advantage of LASIK 5 Absence of postop . » More rapid | Clear lens ext When axial myopia ig 4 corrected by the remov The lens is inserted behind erystalline Lens and supported composed of material derived tan, MCUs: Lens is power of-3D to-20D. ASTIGMATISM DEFINITION Iis the type of refractive error, where parallel rays of light entering, the eye cannot form a point focus on reuna, bout form focal lines, In astigmatism the refractive power of comes and lens is ‘ot the same in all meridians, therefore, instead of single focal point, there are two focal points separated by focal interval, The distance between two focal points is called Shun’ conoid (Fig. 21.6) MATISM__ REGULAR ASTIG! ninetf P The regular astigmatism 1 prevent furtl meridians are at right angle to €aeh lasified ito the followin PE ae et |. With-the-rule astigmatism aah cornen: Th meridian is more cur in nore iene at 100 astigmatism require concave CYNON yylindrical lens at com rR-TH i st-the-rule astigmatism e E horizontal meridian is more curved, ¢.g a8 afbe# S30 surgery. The astigmatism require conven YW lens at 190 degree or concave cylindnial degree iii, Oblique astigmatism-The two principal meridia * not horizontal and vertical but these are angl nother ¢,g.45 degree and 135 degree (Fig. 21.7) | 90 Degree | 1, Simple Astigmatism, i Simple myopi, i His mrtan fe on ane ema: focus in front of the retina fe Scanned with CamScannerClinical Oph logy a “Simple hyp, a Meridian focus b cus behind th ——___a | Rays : sTIGMATISM vular change of refrscties a ve characterized by a” 17 —a power in diferent jerefore no geomerTical NER 2, Compound Astigmatism » co ‘ opie: The rays of the MEPS focus is formed on the retina (Fig. 2112) tive retina (Fig. 21.10) a Multiple foci | 7 | soth aysfocusedinfrontoftheretina | jg a are aol Aetiology of Astigmatism ge in the curvature meridians of cornea such as s/corneal injury of lens such as lenticonus |. Compound hypermetropic: The rays of both 4. Ch hind the retina (Fig. 2111 A) ae meridians focus bel ji, Decentering of the lens iii Change in refractive index of lens eg during development of cataract. Clinical Features They are variable i. Decreased vision: Because sharply defined umage cannot be formed by accommodation Both rays focused behind the retina coe a ‘Occurs to connnuews clear vision. effect) to achieve yg 21.11 A: Gompound hypermetropi. 3. Mixed Astigmatism ‘The rays of one meridian focus in ‘or oval appearamws ‘other mendian behind the retina Scanned with CamScanneri Comeal topography. This advanced Provides the most detailed information technol comea’s shape 1s. Astigmatic fin test Treatment Nonsurgical 1. Cylindrical tens: Correct simple astigmatism. BM. Spherooylindrical: Lens correct compound and mixed astigmatism, Mi Hard contact lens: May correct all 2-3 diopter of regular astigmatism, Surgical 4 Astigmatic keratotomy (Jimbal relaxing incision): To decrease the curvature, relaxing incision (cuts) in the axis of more plus cylinder power are given. M1. Bxtra sutures: To increase the curvature, are given at right angle to the axis of plus cylinder. PRESBYOPIA DEFINITION It is a phystologseal insufficiency of leading to impairment of vision for near work advancing age (usually 40 years) or Itisimpairmentofnear work due toadvancigage (stall 401 years) caused by decrease im che aecommedacion power of the crystalline les Aetiology Inadvancing age, there 1s decrease in the accommodation power of lens due to loss of elasticity of the erystalliny lens it is not a refrac the elasticity of lens we error but phys cal change in Onset of Presbyopia (Age of Presbyopia) * In Emmesrope: Presbyopia occurs around 40 years of aye In Hypermetrope: It occurs before 40 years of age and depends upon the diopters of hypermetropia. In Myopia: Ie occurs at a very late age Le, after 40 years ‘of age and agun depends upon the diopters of myopia. Symptoms i ‘work such, ancl Preneea e ii, Asthenopic symptoms occur due to muscle, Scanned with CamScanner(the "0 ima tinal in, lopters that i Fesults in dipig oe Mt f ize is not tolerated plopia, 1 ito single image) and Types Simple anisomer other tropia: Th Be tres he on : Fair’ ts nrral one ies, Myopic or hyper % Mound anisom ae ince pia: The both eyes are ether Tefractive error trea ear one ee shaving higher HH Mixed anisometropia: Th is hyperma ettopit: The one eye ismyapic and other Effects of Anisometropia When refractive error is less than 3 diopter the single binocular vision is maintained’ * When refractive error is high in one eye and age is below 9 years, it develops amblyopia Treatment = Spectacles = Contact lenses + Aniscikonic glasses + Intraocular lens implantation for uniocular aphakia + Refractive comeal surgery for unilateral high myopia astigmatism and hypermetropia = Removal of clear lens ANISEIKONIA y Tris a condition where images of the two eyes are ‘unequal in size and shape, s-The 5% difference in image size is adjusted by brain and object is perceived as single. «+ Diplopia-when the difference in image size is more them 3 the single Binocular vision isnot maintain and results into diplopia. Treatment Scanned with CamScannerfooren u Peripheral uk Uroparalyti Seventh nerve pal “urotrophic ulcer Ophthalmic division of ‘posure keratopathy vi ee Proptosis jutritional deficieney Vitamin A deficiency Protein deficiency ear film abnormality Keratoconjunctivitis sicea | Xerophthalmia “hemi¢al burns ) Acid burns > Alkali burns Eyelid abnormalities 9 Trichiasis © Entropion neal Disease inical Features of Cor jous types of « following, are the clinical features 12 vari meal discase- ody sensation Jebsiella and pro Pathogenesis The process of comeal ulcer Pass stages: i, Infiltrative Stage ‘When there is injury to the epith of the polymorphonuclear leukocytes and stroma. This appears clinically as 5" O' aoeneal opacity, with overlying epithelial SIN ium, ther’ nto the epithe ilowish or whitis ii, Active Stage Teresults from necrosis ane of the involved cornea. An excav ith surrounding infiltration and stroma! Chemical mediators are released from ulcerates produces clinical Clinically, it appears a5 Ex« d sloughing off, of the epithelium Sed defect (ulcer) develops: 1 oedema. The ‘d area which sh white swollen cornea with ae of dhe ulcer base, reactive hyperacmily anerer ae and blepharospasm, pain, photophobia, acrimasion vee erease in vision depending upon the severity of syanism and location of corneal ulcer. Hyporvon collection of pus cells in the anterior chamber. serra to out-poring of inflammatory cells into the siisjor chamber and it may be a frequent finding in Mmgresve ulers, The ulcer progresses laterally, and in deeper layers ofthe cornea (Fg. 82) r tyPepyEN Hazy comes Cia Fig #2 Aoww Scanned with CamScanner86 HEN Csttcinvng iii, Regressive Stage Tisinnduced by a natural host mechanism or by ee Which enhances the normal host response. A line a emarcation consisting of leukocytes develops aroun the ulcerated area, The remaining surrounding cornea becomes clear (Fg. 83), [Clearcorea Healed area Ulcer’ Demarcation line In this stage, healing occurs by progressive epitheiaization Of the ulcer with subsequent scatring as a result of new stromal lamellae formed by keratocytes. The degree of ollowing the ulceration, depends upon ti depth and the size of ulcer, Clinical Features i. Pain: There isa rapid onset of pain due to exposure and stimulation of corneal nerves, spasm of ciliary body, and raised intraocular pressure ii, Blurred Vision: Due c ulceration and oedema of cornea, jij, Lacrimation: Due to reflex over secretion of tears x: Photophobia: Due to increase sensitivity to light stion of blood vessels, Redness of eye: Due to cong : Halos: Due to comeal oedema, may be noticed by vi some patients. Hazy oedematous Ciliary congestion Hypopyon. Active ulcer come: ongestion. white or yellow ulcer is hazy due to ion by the inflammatory cells, tain is active ulcerated area of the cornea ‘Malways take stain with 2% fluorescein dye. This 's pathognomonic sign for diagnosis of corneal ulcer Wi Anterior chamber may contain exudate called hypopyon. It is also called sterile Pus, because it is free of organisms and cee contains polymn ephonuclear meshed ina r ‘work of fibrin vii Iris and ciliary body show Signs of itidocyclitis induced Ne ula! inflammatory cytokines vot This iridocyclitis. cay POPYON). in antetior ch Which contributes ¢ Pressure lopment of second, the ulcerated formation (hy, of ciliary body leased from nse exudate lamber and spasm Pain in ulcer, raised lary glaucoma, ix: Intraocular devel Clini may be due to the al Diagnostic Points ii, Corneal stain positive ill, Hazy comea Ciliary congestion Hypopyon may be present Scanned with CamScannerScanned with CamScannerFy done as a final remedy, 4, Treatment of Perforated Corneal Uleer ‘The perforated corneal ulcer is treated in the similar way as impending perforation 4, Intensive fortified topical antibiotic and 1% atropine atops. ii, Anti-collagenase tetracyeline’s ii, Pressure padand banda iv. Bandage contact lens helps in the healing process medication systemic hhelpsinsealingofperforation ¥. Tissteadhesive glue such as eyanoacrylate glue may be used. Mi. Conjunctival flap covers the perforation site and helps in healing, vii, Amniotic membrane transplant is very usefull it contains multiple growth factors and helps to promote the tissue repair. Small piece of amniotic membrane is used to fill ap and another bi aspatch. piece is then’ viii, Full thickness grafi-therapeutic keratop done asa final remedy: 5. Treatment of Non-He 5 to routine treatment for comeal b tuleer may be treated by ing Corneal Uleer € non-healing corneal ulecr, which shows poor respon: i, Conjunctival flap ii, Tarsorrhaphy ffi, Umbilical cord serum or autologous serum iv, Amniotic membrane transplantation v. Therapeutic keratoplasty Note i, Steroid therapy; It is a double-edged sword. Its use is controversial, The potential benefit of topical steroid in reducing the extent of stromal necrosis and scarring, should be weighed against their effect of decreasing fibroblast activity, inhibiting the wound healing and increasing the danger of perforation. Steroids also have 1 to prolong the infection. Routinely, they the potential are not used in infected comeal ulcers. It is not applied to pyogenic ulcer because it fides warm atmosphere and promotes the growth ia, Ie also prevents the shedding of debris, surs due to lid movement and tear film. It fective ulcer and perforating ite thickness graft-therapeutic keratoplasty may be Cor i mplications of Toxic Iridocycinis (anterior diffusion of inflammatory anterior chamber rucoma oceurs due to bl by fibrinous exudate. ard bulging or herniation luc to sloughing of corneal Jockage of anterior Secondary ¢ chamber angl Descemetocele is an oUtw of Descemet’s membrane di stroma, Perforation It is a very dreadful complication of the corneal ulcer, which produces the following vision threatening complications: of corneal ulcer i. Prolapse of immediately, following | perforation in a bid to plug the perforation (Fig. 85 Aand B) Corneal ulcer | I comeal perforation with iris prolapse Scanned with CamScannerOr dislocation o Stretching at en may gap Fuptire of the WM. Endophthalmitis: intraocular conte OTganisms into th, lammation of the due to the entry of © anterior and posterior scemerve after perforation ’ . Pinophibalmitis: te is the inflaanmation involving eh esl cavities and all the layers of syeball (Fig. 6, ry thin insignificant € i Bowman involviny sults from scarin I stroma (Fig. 88). {Corneal ulcer Fie $6: Panophthalmit Hema nor he s, when intraocular perforation. Pies nenias MiiAmerior synechiae is an eee te-formation of the anterior ore than 5 days, Pereira! Canal fda: Results, when the cena Retforation is covered with ool Organized and reforms amerin nn Perforates dire to rise in intra yamber, but re F this process forms @ permanent ‘The repetition of this pro fistula (Fig. 8.7). 5 Beaiscalcs come! fist Bs eae meting (corneal opact ermanent vistial ids to pe aes Baring 8 he course Nee ee spacey may ceri linical types of corneal opacity may Scanned with CamScannerL Vascularized opaque Fig. 8.10: Leucoma. tv. Leycoma adherent: It is a dense white corneal Opacity with iris attached on its back surface. It results when healing occurs after perforation of the corneal ulcer with incarceration of the iris (Fig. 8,11), Litatic cornea: It is a thin healed cicatrized cornea which is bulging under normal and/or ies intraocular pressure (Fig. 8.12). eudocornea: It is formed, when perforation is vered with exudate, which gets Organized, and s a thin layer of connective tissue Over which is a growth of the conjunctival ¢ Pithelium, ganized structure is called Pseudocornea staphyloma is an ectatic cornea lined / tissue, with