FINALS: EYES 2.

Posterior segment – between the

posterior lens and the retina including
CHAPTER 63
the vitreous chamber.
 The eyeball has three fluid containing
chamber:
1. Aqueous filled anterior chamber – lies
between the posterior cornea, anterior
iris and pupil.
2. Posterior chamber – small aqueous
containing space between the posterior
iris and pupil, and anterior lens.
3. Vitreous chamber – containing clear
gelatinous vitreous fluid. The largest
chamber in the ocular fundus between
the lens and retina. It also very
OVERVIEW sensitive.
 The eyeball is moved through all fields of
gaze by the extraocular muscles.
 The four rectus muscles and two oblique
muscles are innervated by cranial nerves
(CNs) III, IV, and VI.
 Normally, the movements of the two eyes
are coordinated and the brain perceives a
single image.
 The eyeball is compost of three layers:
1. Outer dense fibrous layer – sclera, and
transparent cornea.
2. Middle vascular layer – iris, ciliary
body, and choroid
 Tears are vital to eye health.
3. Inner neural layer – retina, optic nerve,
 Formed by the lacrimal gland and the
and visual pathways.
accessory lacrimal glands, tears are
 Eyeball is divided into two segments:
secreted in response to reflex or emotional
1. Anterior segment – between the
stimuli.
anterior cornea and posterior iris,
 A healthy tear is composed of three layers:
including the anterior and posterior
lipoid, aqueous, and mucoid.
chamber.
 The conjunctiva, a thin transparent mucous 1. Epithelium
membrane, provides a barrier to the 2. Bowman membrane
external environment extending under the 3. Stroma
eyelids (palpebral conjunctiva) and over 4. Descemet membrane
the sclera (bulbar conjunctiva). 5. Endothelium
 The junction of the two portions is known  The uveal tract is the vascular middle layer
as the fornix. of the eye consisting of the iris, ciliary
 The conjunctiva meets the cornea at the body, and the choroid.
limbus on the outermost edge of the iris.  The iris surrounding the pupil is a highly
 The aqueous humor (transparent nutrient- vascularized pigmented collection of fibers
containing fluid that fills the anterior and that give the eye color.
posterior chambers of the eye) is produced  The ciliary body work together to form
in the posterior chamber by the ciliary aqueous fluid.
body.  The choroid lies between the retina and the
 Production of aqueous humor is related to sclera, supplying blood and oxygen to the
intraocular pressure. outer retina.
 Normal IOP is less than 21 mmHg.
FLOW OF AQUEOUS HUMOR
 Vitreous humor, which is composed
mostly of water and encapsulated by a 1. Produced by the ciliary bodies

hyaloid membrane, helps maintain the 2. Flows through the pupil

shape of the eye. 3. Fills the anterior chamber

 Attached to the retina by collagenous 4. Drains away through the angle (between

filaments. the iris and cornea)

 The vitreous shrinks and shifts with age. 5. Trabecular meshwork

 The sclera is the white avascular dense 6. Canal of Schlemm

fibrous structure that helps maintain the 7. Vein or Bloodstream

shape of the eyeball and protects the  The lens enables focusing for near and

intraocular contents. distance vision through accommodation.

 Scleral thinning and changes of the scleral  The retina—the innermost surface of the

collagen fibers can cause the underlying fundus composed of neural tissue—is an

uveal pigment to be seen, resulting in a extension of the optic nerve.

blue or grey sclera. DISORDERS

 The cornea, a vulnerable transparent
1. CATARACT
avascular domelike structure, forms the
 The clouding or opacity of the natural lens.
most anterior portion of the eyeball and is
 Occurs gradually over time.
the main refracting surface of the eye.
 Cornea has 5 layers:
  Changes color: clear is normal, hazy, - progress at a highly variable rate
yellow, sea green. - vision is worse in very bright light
 Affects nearly 25 million Americans who - sunlight exposure is a risk factor
are • 40 years or older.  POSTERIOR SUBCAPSULAR
 by 80 years more than half of the CATARACTS
Americans • have cataract - occur in front of the posterior capsule
- develops in younger people
Risk Factors
- associated with corticoid use, DM and
1. aging ocular trauma

2. associated ocular conditions such as myopia, - near vision diminished, sensitive to

retinal detachment and surgery, Infection bright light

3. nutritional factors: poor nutrition, obesity

4. toxic factors: ionizing radiation, aspirin,

corticosteroids, cigarette smoking

5. physical factors: blunt trauma, perforation of

the lens with sharps, UV radiation, x-ray

6. systemic diseases: DM, Down syndrome

PATHOPHYSIOLOGY
CLINICAL MAN
 Can develop in one or both eyes at any age
 painless, blurry vision is characteristic of
from a variety of risk factors
cataracts.
 Three common types defined by their
 Perceived surrounding as dimmer.
location: nuclear, cortical, posterior
 Light scattering, sensitivity to glare,
subcapsular
reduced visual acuity
 NUCLEAR CATARACT
 others: myopia, astigmatism, diplopia,
- has substantial genetic components
color changes
- causes central opacity in the lens
- it is associated with myopia that
worsens when cataract progresses

 CORTICAL CATARACTS
- involves the anterior, posterior or
equatorial cortex of the lens

INTRAOPERATIVE
EARLY POSTOPERATIVE
MEDICAL MAN
 no medications, eye drops, glasses that can
LATE POSTOPERATIVE
prevent cataracts
SURGICAL MAN
 the patient's functional and visual status is
the primary consideration
 PHACOEMULSIFICATION - anterior
capsule is removed, allowing extraction of
the nucleus and the cortex while the
posterior capsule zonular support left
intact.
 LENS REPLACEMENT – for the patient
to see clearly.
 3 lens replacements: aphakic eyeglasses,
contact lenses, and IOL implants.
 Aphakic glasses – are rarely used. Objects
are magnified by 20%, making them
TYPES OF GLAUCOMA
appear closer. Peripheral vision is also
limited. Binocular vision is impossible.
 Contact Lenses – provides patient with
almost normal vision but because contact
lenses need to be removed occasionally,
the patient will also need aphakic glasses.
 Insertion of IOL is the most common
approach to lens replacements.
PREOPERATIVE COMPLICTION
1. Retrobulbar hemorrhage – when there is an
infiltration of anesthetic agents if the short
ciliary artery is located by the injectia.
1. Rupture of the posterior capsule
2. Suprachoroidal (expulsive) hemorrhage
1. Acute bacterial endophthalmitis
- S. aureus, S. epidermidis,
Pseudomonas, Proteus
1. sutured-related problems
2. malposition of IOL
3. chronic endophthalmitis
2. GLAUCOMA
 a group of ocular disorders characterized
by an increased in intraocular pressure,
optic nerve damaged and visual field loss
in some patients
 damage of the optic nerve results from
increase pressure in the eye
 estimated to affect 2.2 million Americans
 prevalent in people older than 40 years
1. WIDE ANGLE/OPEN ANGLE
- Usually bilateral, but one eye may be
more severely affected than the other.
In wide angle glaucoma, the anterior
chamber is open and appears normal.
- Normal tension glaucoma
(IOP more than 22 mmHg with optic
nerve damage and visual field defects).
 - Ocular Hypertension
(elevated IOP, possible ocular pain or
headache)
2. NARROW ANGLE/CLOSE ANGLE
- Obstruction in aqueous humor outflow
due to the complete or partial closure
of the angle from the forward shift of
the peripheral iris to the trabecula. The
obstruction results in an increased IOP.
- Acute angle-closure glaucoma;
rapidly progressive visual impairment,
periocular pain. Ocular emergency,
administration of hyperosmotics.
- Subacute angle-closure; transient
burning of vision, halos around light,
temporal headache. Prophylactic
peripheral laser iridotomy.
- Chronic angle-closure; progression of
glaucomatous cupping and significant
visual field loss. Medication.
PHYSIOLOGY
 normal IOP is between 10 and 21 mm Hg
 IOP is determined by the:
- rate of aqueous humor production
- the resistance encountered by the
aqueous humor as it flows out the
passages
- venous pressure of the episcleral veins
that drain into the ciliary vein
 when aqueous humor is inhibited from
flowing out, pressure builds up within the
eye
 normally, aqueous humor is secreted in the
posterior chamber, gains access to the
anterior chamber by flowing through the
pupil. In an angle of the anterior chamber,
it passes through the canal Schlemm into
the venous system.
 In wide angle glaucoma, the outflow of
aqueous humor is obstructed at the
trabecular meshwork.
 In narrow angle glaucoma, the aqueous
humor encounters resistance to flow
through the pupil.
 Increase pressure in the posterior chamber
produces a forward bowing of the
peripheral iris so that the iris blocks the
trabecular meshwork.
PATHOPHYSIOLOGY
 there are two theories how increased IOP
damages the optic nerve in glaucoma:
- 1. Direct mechanical theory –
suggests that high IOP damages the
retinal layer as it passes the through the
optic nerve head
- 2. Indirect ischemic theory – suggests
that high.
- IOP compresses the microcirculation in
the • optic nerve head resulting in cell
injury and • death
 some glaucomas appear exclusively
mechanical, and some are exclusively
ischemic. Typically, most cases are
combination of both.
CLASSIFICATION
  Primary (unknown) or Secondary (from
other diagnosis)
 Open-angle glaucoma (wide angle) or
angle-closure glaucoma (pupillary block or
narrow angle)
 congenital and glaucoma associated with
other conditions
 the two common clinical forms in adults
are:
- primary open-angle glaucoma (POAG)
- angle-closure glaucoma
CLINICAL MAN
 often called the “silent thief of the sight”
because most patients are unaware that
they have the disease until they have
experienced visual changes and vision loss
 blurred vision
 halos around lights
 difficulty focusing or adjusting to low
lighting
 loss of peripheral vision
 pain or discomforts around the eyes
 headache
ASSESSMENT & DIAGNOSIS
 optic nerve changes are pallor and cupping
of the optic nerve disc
- pallor is due to lack of blood supply
- cupping is exaggerated bending of the
blood vessels as they cross the optic
disc resulting in enlarged cup with
thinned rim
 as optic nerve damage increases, visual
perception decreases
 scotomas, a localized area of visual loss,
represents loss of retinal sensitivity and
nerve fiber damage
 measurement of pressure – Tonometer
 evaluate the health of optic nerve
 evaluate cause of increase pressure
MEDICAL MAN
 The goal of treatment is prevention of
optic nerve damage.
 Treatment includes: pharmacologic, laser
procedures, surgery or combination of
these approaches
 The IOP is set at 30% lower than the
current pressure
 Optic nerve appearance is monitored, if
there is evidence of optic nerve damage,
the IOP is again lowered until stable
 Glaucoma damage cannot be reversed but
progression can be prevented
MEDICATIONS:
  decrease pressure by reducing fluid going - bleeding, infection as it is an invasive
into the eye, or making easier for the fluid surgery
to leave the eye - blurred vision (post op)
 Decrease inflow - late infection
 1. beta blockers – Timolol, - Post-operatively, instruct patient to
Betagan; decrease aqueous humor report to the doctor the presence of:
production pain, redness, decrease vision
 2. carbonic anhydrase inhibitor –
acetazolamide (Azopt, Truzopt);
decrease aqueous humor
production.
 Increase outflow
 1. cholinergics (miotics) –
pilocarpine; increase AH outflow
by constricting ciliary muscle and
constricting the pupil
 2. prostaglandins analogues –
3. Glaucoma success of treatment is
Lumigan, Xalatan Travatan.
dependent on:
increase uveoscleral outflow
- Pressure control, should be consistent
 Decrease production and
with drops
increase outflow
- Monitoring, consistent follow up.
 Alpha adrenergic agonists
apraclonidine (Alphagan).

SURGERY 3. RETINAL DETACHMENT

- the separation of the retina from the
1. Laser trabeculoplasty
choroid, a membrane dense with blood
- focusing the laser in the inner
vessels, that supply oxygen and
surface of the trabecular
nutrients to the eye
meshwork, to open the
- when the retina detaches, it is deprived
intratrabecular spaces and widen
of blood supply and nourishment and
the canal of Schlemm
loses its ability to function
- improve fluid outflow
- this can impair vision to the point of
- may cause 75% pressure reduction
blindness
2. Trabeculectomy filtering technique
part of the trabecular meshwork is remove
risk CAUSES AND RISK FACTOR

- age – as we age retina may weaken

 - highly myopic 2. TRACTION
- trauma like from sports: boxing, - cause by tension or pulling force
basketball - fibrous scar tissue provides traction
- DM - fibrous scar form diabetic
- degeneration of the retina retinopathy, vitreous hemorrhage
- previous retinal detachment on the - A patient can have both
other eye rhegmatogenous and traction
- family history of retinal detachment retinal detachment.

FOUR TYPES OF RETINAL DETACHMENT

 rhegmatogenous
 traction
 combination of rhegmatogenous and
traction
 exudative

1. RHEGMATOGENOUS DETACHMENT
- the most common for a hole or tear
3. EXUDATIVE RETINAL
developed in the sensory retina allowing
DETACHMENT
liquid vitreous to seep through the sensory
- results from production of serous
retina and detach it from retinal pigment
fluid under the retina from the
epithelium (RPE)
choroid
- people at risk: highly myopic and
- conditions such as uveitis and
aphakia (absence of natural lens following
surgery)

macular degeneration

CLINICAL MAN
 - a sensation of shade or curtain
falling across the vision of one eye
- cobwebs
- bright flashing lights
- sudden onset of great number of
floaters
- it is an ocular emergency, requiring
immediate surgical interventions.

DIAGNOSTICS FINDINGS

- evaluate visual acuity - PNEUMATIC RETINOPEXY

- dilated fundus examination - injection of gas bubble, silicone oil

- use of ophthalmoscope or liquids into the vitreous cavity to

- stereo fundus photography and help push the sensory retina to the

fluorescein angiography are up against the RPE.

commonly used. NURSING MAN

SURGICAL MAN

- SCLERA BUCKLING
- the surgeon compresses the sclera
with a scleral buckle or silicone
band.
- PARS PLANA VITRECTOMY
- an intraocular procedure that - consist of educating the patient and
allows introduction of light source
through an incision
- the second incision is for the
vitrectomy instrument
- can be used in various procedures
like removal of foreign body,
dislocated lenses, vitreous opacity providing supportive care

such as blood - For pneumatic retinopexy, postoperative

positioning is critical as injected bubble
must float into a position overlying the
detachment.
 4. REFRACTIVE DISORDERS - laser-assisted in situ keratomileusis
3 basic abnormalities: - reshapes the cornea to enable light
 MYOPIA/NEARSIGHTEDNESS entering the eye to be properly focused in
- light rays are focused in front of the retina the retina to produce a clearer vision
- in most cases myopia is caused by eyeball
that is longer than normal
- treatment: concave or minus lens
 HYPEROPIA/FARSIGHTEDNESS
- light rays are focus behind the eyes
- the image that falls on the retina is blurred
- treatment: convex or plus lens
 ASTIGMATISM
- light rays are not bent equally by the
cornea, focus not attained
- commonly caused by abnormal curvature
of the cornea
- treatment: astigmatic or cylindrical lens

5. OCULAR TRAUMA
- the leading cause of blindness among
children and young adults, especially male
trauma victims
- Causes:
- occupational injuries e.g. construction
industry
- contact sports, weapons e.g. air guns
- assaults
- motor vehicle crashes e.g. broken
windshields
- explosions e.g. blast fragments

TYPES OF OCULAR TRAUMA

1. chemical burn
 with chemical burn, the eye should be
immediately irrigated with tap water or
normal saline

LASIK SURGERY 2. foreign object in the eye

 first response is critical
  with a foreign body, no attempt should
be made to remove the foreign object

ALL:

 the object should be protected from

jarring or movement to prevent further
ocular damage
 no pressure or patch applied to affected
eye
 all other traumatic eye injuries should
be protected with patch or shield (or
stiff paper cup).