UNIVERSITY OF MEDICINE AND PHARMACY “JULIU HATIEGANU” CLUJ-NAPOCA OPHTHAMOLOGY Assoc. Prof. Dr. Cristina Nicula ‘apLioreca ce CLUJ-NAPOCA 2011@_EDITURA MEDICALA UNIVERSITARA “IULIU HATIEGANU” CLUJ-NAPOCA. CRISTINA ARIADNA NICULA OPHTHALMOLOGY Descrierea CIP a Bibliotecii Nationale a Rominiei NICULA, CRISTINA ARIADNA Ophthalmology / Cristina Nicula, - Cluj Napoca : Editura Medicala Universitara “luliu Hagieganu", 2011 Bibliogr. ISBN 978-973-693-435-3 617.7 Toate drepturile acestei editii sunt rezervate Eqiturii Medicale Universitare “Tuli Hatieganu". Tipérit in Romania, Nici o parte din aceastd lucrare nu poate fi reprodusi sub nici o form, prin nici un mijloc mecanic sau electronic, sau stacaté intr-o bazd de date far acordul prealabil, in scris, al eaiturii, Copyright © 2011 EDITURA MEDICALA UNIVERSITARA “IULIU HATIEGANU” CLUJ- NAPOCA Editura Medical Universitara “Iuliu Hatieganu” CLUJ-NAPOCA Universitatea de Medicina si Farmacie “Iuliu Hatieganu” Cluj - Napoca. 400023 Cluj-Napoca, 13, Emil Isac str’ tel. + 40-264-597256, Fax: +40-264-596585 Director Editur8: Ioana Robu Coperta: Idea Design & Media Print S.R. Tiparul executat la Tipografia Universitatii de Medicina si Farmacie “Iuliu Hatieganu” Cluj - Napoca, str. Mofilor 33, telefon: + 40-0264- 598701. PRINTED IN ROMANIAPreface Our goal was to produce a concise book, providing essential clinical diagnosis tips and specific therapeutic information resembling the eye disease. The book was elaborated concording the analitical programme and also in order to give the most modern informations regarding the clinical tools and surgical tehnicques. The book has also attached a CD with pictures from the whole pathologi of the eye. We feel, this book will be a welcome companion to the medical students from english section involved in learning about eye problems. The authorCONTENTS b —— Page | Chapter 1 | THE ANATOMY OF THE EYE .... Chapter 2 CLINICAL FILE ‘Chapter 3 VISUAL FUNCTION |...) Chapter 4 ] OCULAR REFRACTION .... a 43 Chapter 5 DISORDERS OF THE BINOCULAR VISION Chapter 6 PATHOLOGY OF THE ORBIT .... Chapter 7 LACRIMAL SYSTEM PATHOLOGY Chapter 8 EYELIDS PATHOLOGY ............... Chapter 9 7 DISEASES OF THE CONJUNCTIVA. Chapter 10 PATHOLOGY OF THE CORNEA ..... Chapter 11 PATHOLOGY OF THE SCLERA Chapter 12 PATHOLOGY OF THE UVEAL TRACT...... Chapter 13 PATHOLOGY OF THE PUPIL ..... Chapter 14 PATHOLOGY OF THE LENS .... Chapter 15 GLAUCOMA ........ 0. eee Chapter 16 PATHOLOGY OF THE RETINA Chapter 17 OPTIC NERVE PATHOLOGY..., Chapter 18 OCULAR TRAUMATOLOGY . Tee _ 3 63 69} 83 91 | 95 101 105 113 e REDO eee LTT L t 129 &e{ | Assoc. Prof. Dr. Cristina Nicula - "The anatomy of the eye" Chapter 1 THE ANATOMY OF THE EYE 1, The external structures of the eyeball 1.1. The orbit Itis a pear shaped cavity whose stolk is the optic canal. It lies behind the orbital septum and has a: - roof, - floor ~ medial wall ~ lateral wall. © The roof It consists of two bones: - the lesser wing of the sphenoid, - the frontal bone. Itis located adjacent to the frontal sinus and anterior of the cranial fossa. The lacrimal gland fossa is located in the supertemporal aspect of the roof. In the internal angle there is the trochlea (that can be palpated) (fig.1.1) ¢ The lateral wall It consists off =the greater wing of the sphenoid bone - the zygomatic bone. (fig.1.2) * The floor Ttis made oft ~ zygomatic bone - maxillary bone - palatine bone. It forms the roof of the maxillary sinus, (fig. 1.3) * The medial wall It consists of 4 bones: - maxillary bone - lacrimal bone - othmoid bone - sphenoid bone. ‘The orbit has communications with the cranial cavity: 7Assoc. Prof. Dr. Cristina Nicula - "The anatomy of the eye" ~ optical canal, in which lies the optic nerve and ophtalmic artery. - sphenoidal zone, between the two wings of the sphenoid, in which lies: - the third, fourth and sixth pairs of cranial nerve. - the fifth pair of cranial nerve - ophtalmic branch. - the sensitive branch of the ciliar ganglion. lacrimal artery. - opbtalmic veine. (fig. 1.4) 1.2. The eyelids There are two eyelids : - the upper eyelid - the lower eyelid. ‘There are modified folds of the skin, consisting in orbital and palpebral portions. In the upper eyelid - the orbital portion extends down from the eyebrow to cover the upper part of the orbit, and the palpebral portion covers the upper part of the eyeball. In the lower eyelid - the orbital portion extends up from the cheek to cover the lower part of the orbit, and the palpebral portion covers the lower part of the eyeball. Structure: contains seven layers: © The skin. ©. The subcutaneous layer. © The striat muscle layer - which contains: - the orbicular muscle - forms an. oval sheet of eee muscle fibers surrounding the eyelids; - the levator superior muscle - it extends into the upper lid from its origin in the apex of the orbit; - it is associated with smooth Mi located along the margin of the lid. © The lax conjunctive tissue layer ¢ The fibrous layer - formed by: ~ in the central part by the tarsal plate ~ in the peripheral part by the orbital septum « The smooth muscle Miiller « The conjunctiva - the palpebral opening is the entrance into the conjunctival sac, which is bounded by the upper and lower lid margins; these margines terminate: ler muscle - that retract the lid and it isAssoc, Prof. Dr. Cristina Nicula - "The anatomy of the eye" a) laterally in an acute angle - the lateral canthus (that is attached to the bony orbit by the lateral palpebral ligament b) medially in an elliptical junction - the medial canthus (that is attached to the bony orbit by the medial palpebral ligament), (fig.1.5) The lid margin - is a narrow zone that separates the outer surface of the eyelid from its inner (conjunctival) surface. It contains: - the papilla - that is localised at the junction of the medial one third and the lateral two thirds of the lid margin; it contains the lacrimal punctum. - the eyelashes — are more numerous on the upper eyelid. - the intermarginal sulcus - lies behind the eyelashes and is visible clinic as a “grey line”; it is important surgically because it represents the line of division of the lid into its anterior portion (skin and orbicular muscle) and its posterior one (tarsal plate and conjunctiva) ~ the openings of the ducts of the Meibomian glands. Eyelid glands - the role is to form the lipid layer of the precorneal tear film; their secretion lubricates the lid margin and prevents.the overflow of tears. There are: © Meibomian glands - which are tarsal glands. * Zeiss glands - which are sebaceous glands and are associated with the lash follicles. * Moll glands - which are’ modified sweat glands and they open into a lash follicle. Vascularisation of the eyelid ~ eyelids arteries (branches from ophtalmic artery) irrigates: - palpebral conjunctiva - fornix conjunctiva - bulbar conjunctiva beyond 3-4mm from the limbus - temporal artery ~ facial artery. Inervation of the eyelid - orbicular muscle - inervated by the seventh pair of cranial nerve ~ levator - inervated by the third pair of cranial nerve. 1.3, Conjuctiva It is a mucuous membrane that lines the undersurface of each eyelid (palpebral conjuctiva) and covers the surface of the eyeball (bulbar conjunctiva) The palpebral and bulbar conjunctiva are separated by a potential space (the conjunctival sac or fornix) that is closed:Assoc. Prof. Dr. Cristina Nicula - "The anatomy of the eye" - above by the superior fornix (where the palpebral conjunctiva is reflected to form the bulbar conjunctiva) - below by the inferior fornix - medially at the medial canthus - laterally at the lateral camthus ‘The bulbar conjunctiva ends at the corneal margin (limbus), although its epithelium is continuos with the comeal epithelium. Other structures: - plica ‘semilunaris - crescent — is a shaped fold of conjunctiva arising from the region of the medial canthus lateral to the caruncule - the earuncule - is a small red fleshy body laying on the medial side of the plica at the medial canthus. Histological structures of the conjuctiva: - the epithelium - the stroma Conjunctival glandes are : - goblet cells - mucus glands - Henle’s glandes - located in the fornix - Manz's glandes - near the limbus - accessory lacrimal glandes (Wolfting Krause)- located in the stroma. Vascularisation of the conjuctiva - eyelids artery - which irrigates the palpebral conjuctiva, the conjuctival fornix and the bulbar conjuctiva beyond three-four mm from the limbus. - cilliary artery - which isrigates the bulbar conjuctiva - three-four mm surrounding the limbus. 1.4. The lacrimal system Consists in the structures concerned with the production and drainage of the tears. It is formed by the lacrimal gland and the lacrimal drainage system. Lacrimal gland * Main lacrimal gland About 95% of the acqueous component of the tears is produced by the main Jacrimal gland. It consists in two portions: - the orbital portion (posterior) - it lies in a fossa of the frontal bone. - the palpebral portion (anterior) - separated by the tendon of the levator of the eyelids. The secretion of the lobular acini of the lacrimal gland pass first into fine interlobular ductules and finally into about 12 definive secretory ducts that open into the upper fornix. (fig.1.6) * Accessory lacrimal glandAssoc. Prof. Dr. Cristina Nieula - "The anatomy of the eye” About 5% of the acqueous component of the tears is produced by them: Krause and Wolfting gland. Lacrimal drainage system It is formed by: + the punta - located in the papilla (near the medial end of each eyelid), - the canaliculi - it is formed by a vertical and horizontal part. - the common canaliculi - the lacrimal sac - lies in the lacrimal fossa between the anterior and posterior lacrimal crests. (fig. 1.7) 1.5. The extrinsec ocular muscles There are six extrinsec ocular muscles concerned with the Totatory movements of each eye, that form a cone. There are four rectus muscles and two obliques muscles, The rectus muscles Arise near the apex of the orbit and passes forwards on the lateral, medial, inferior and superior surface of the sclera in front of the equator of the eyeballl and forme a cone, The oblique muscles: * the superior oblique - arises near the apex of the orbit and passes forwards on the upper and medial surface of the eye to the anterior part of the the roof of the orbit where it hooks round the trochlea before passing backwards and outwards above the eye, to be inserted on the upper and outer surface of the sclera behind the equator. * the inferior oblique - arises from the anteromedial part of the floor of the orbit and passes backwards and outwards below the eye and is inserted on the lower and outer surface of the sclera behind the equator. (fig.1.8) Inervation of the extrinsec ocular muscle: ~ the superior, medial, inferior, rectus and the inferior oblique is inervated by the third pair of the cranial nerve. ~ the lateral rectus is inervated by the sixth pair of the cranial nerve, ~ the superior oblque is inervated by the fourth pair of the cranial nerve. 2. The eyeball It is composed by three covers: * the external one is formed by cornea and sclera. * the medium one (vascular layer) is formed by the iris, ciliary body and choroid ‘the intemal one (nervous layer) is formed by the retina.Assoc. Prof. Dr. Cristina Nicula - "The anatomy of the eye" 2.1. The external cover of the eyeball Cornea It is a perfect transparent membrane. It forms the anterior one sixth of the outer coat of the eye. The horizontal diameter is approximately twelve mm (depends on the age). The curvature is approximately 7,6 mm, It offers 43D. Cornea's role - transparency and refractive role, Cornea's structure It consists of five layers: - the epithelium. ~ Bowman’s layer. - . the stroma. - Descemet’s membrane. - the endothelium. (fig.1.9) Inervation of the cornea - is made by the fifth pair of cranial nerve (the ophthalmic branch) - the cornea has no vascularisation! - the precorneal tear film provides a smooth refractive surface on the front of the eye. It acts as a lubricant for the lids, as a vehicle for antibacterial and some nutritional components. The sclera It forms the five-sixths of the protective outer coat of the eye. Tt is a dense fibrous tissue. It is continuous anteriorly with the stromal.part of the cornea, Its outer surface is the episcleral tissue containing the deep episcleral vascular plexus, Vascularisation of the sclera: - from episcleral and choroidal system. 2.2. The medium cover of the eyeball ‘The uveal tract It forms the middle coat of the eyeball. Ithas three different parts: the iris, the ciliary body and the choroid. (fig.1.10) © The iris = this forms a forward projection from the ciliary body in front of the lens ~ it is more or less circular and has a central opening called the pupil. Structure: - outer endothelial layer - stromal layerAssoc, Prof. Dr. Cristina Nicula - "The anatomy of the eve” - two inner layers of pigment epithelium - The stromal layer contains blood vessels and two muscles: © the sphincter muscle - runs circumferemtially in the pupillary part ~ causes a constriction of the pupil © dilator muscle ~ runs radially in its cilliary part ~ dilates the pupil. * The ciliary body - it is formed o a ry processes - containing highly vascularised tissue. ~ itis concemed with the formation of acqueos humour by dialysis and secretion ary muscles - longitudinal and oblique fibres causes a forward movement and thickening of the cilliary body which goes to + accomodative change in the lens by a relaxation of the suspensory ligament. * The choroid - isa vascular coat composed of arteries and veins with a layer of capillaries (the choriocapillaris) on its inner surface; that is separated from the underlaying retina by Bruch’s membrane. Structure: - lamina fusca - the vascular layer - the choriocapillar layer ~ the Bruch's membrane. Vascularisation of the uveal tract is from: - the cilliary arteries: ~ short posterior cilliary arteries irrigates the sclera and the choroid. - long posterior cilliary arteries irrigates the choroid and the cilliary body. - anterior cilliary arteries irrigates the iris. (fig.1.11) 2.3. The internal cover of the eyeball The retina It forms the inner coat of the eye. Is concerned with the reception of the images of the fixation object and of other objects. 13Assoc. Prof. Dr. Cristina Nicula - "The anatomy of the eye” Structure: - Pigment epithelium. - Rods and cones layer - that Jays immediately beneath the pigment epithelium. - Outer piexiform layer. - Inner plexiform layer. - Inner nuclear layer in which we have bipolar cells. - Inner layer of ganglionar cells. - Nerve fiber layer. - Inner limiting membrane. (fig.1.12) Vascularisation of the retina: = central retinal artery is a branch of ophtalmic artery. It enters the eye through the optic nerve head and divides into four main branches that supply each retinal quadrant. Each of these arteries acts as an end artery, so that its occlusion causes a loss function in a retinal sector. They supply only the inner half of the retina, ~ choriocapillaris from the choroid which supplies the outer half of the retina. 3. The transparent structures The lens It is a biconvex structure that lays behind the iris and in front of the vitreous. It is held in the position by the Zinn zonule. Is developped from ectoderm, Structure: - capsule surrounds the lens and is concerned with the alterations that occur in the shape of the lens during accomodation. It is attached to the cilliary body through the Zinn zonule (suspensorry ligament). = epithelium is present only over the anterior part of the lens. Is concerned with the formation of lens fibers. - fibers in the middle of th lens, (fig.1.13) Role: ~ transmission and reftaction of light rays. - it offers 15D. Vitreous body : It is a transparent gel-like substance that fill the space between the posterior surface of the lens and its zonule, the retina, cilliary body and optic nerve. It has no refraction role.Assoc, Prof. Dr. Ci fina Nicula - "The anatomy of the eye" 4, The eye chambers The anterior chamber Itis formed by the comea, iris and the lens. The posterior chamber Itis formed by the iris, Zinn zonule and the lens. 5. The optic nerve Arises in the retinal ganglionary cells layer. It has 4 parts: - the intraocular part the orbital part - within the muscle cone. It has contacts with central retinal ~ artery. the intracanalicular part - lays within the optic canal. ~ the intracranial part - lays between the intracranial opening of the optic canal and the optic chiasm. (Fig. 1.14).Assoc. Prof. Dr. Cristina Nicula - "Clinical file" Chapter 2 CLINICAL FILE 1, Personal data ~ name ~age - sex - profession 2. Symptoms and signs - are those that determine the patient to come to the ophtalmologist. © Symptoms a. vision troubles: - decreased visual acuity. ~ hesperanopy (difficulty in seeing the object at low intensity of light) Example : pigmentary retinopathy. - diplopia. - scotomas in the visual field. - trouble of chromatic sense. b. ocular pains: ° - character, = rhythm, - location. - iradiation. Examples: - conjunctivitis - sensation of gritiness or itchness, or foreign body (“sand in the eye”) + acute glaucoma; - intense ocular pain. - decreased visual acuity. - red eye, irradiation around the eye and half of the head, - vomiting. ¢. photophobia - tipical symptom in corneal disease * Signs a. conjunctival congestion - superficial:Assoc. Prof. Dr. Cristina Nicula - "Clinical file” ~ focalised at the level of palpebral conjunctiva, fornix conjunctiva and bulbar conjunctiva till three or four mm around the limbus. - is in the teritory of the palpebral arteries. ~ it is associated with the inflamation of the external structure of the orbit (conjuctiva, orbit, eyelids, lacrimal system). - profound: - localised at the level of bulbar conjunctiva, three or four mm around the limbus. - is in the teritory of anterior cilliary areteries. ~ it is associated with ocular illness: keratitis, scleritis, uveitis and acute glaucoma. b. excessive watering of the eyes - may be the result of the overabundant production of tears (lacrimation) or the failure of adequate drainage of the tears (epiphora). ¢. pathological discharge: - watery ~ mucous - mucopurulent - purulent - membranous . - in different types of conjunctivitis, d. tumors of the: - eyeball - eyelids - lacrimal system = orbit = conjunctiva. e, traumatology signs: - foreign bodies ~ lacerations/perforating ocular wounds - chemical burns - comeal] abrasion. f. strabismus (squints): - deviation of the eyeball, which can be orizontal (convergent/divergent) or vertical (up/down). g. motility troubles (nystagmus) h. proptosis (exophthalmos) - means the eyeball protrusion and it can be unilateral or bilateral. 3. History, establishes: - the onset of the ocular illness: 18Assoc. Prof. Dr. Cristina Nicula - "Clinical file" - acute. Example: acute glaucoma, obstruction of the central retinal artery. - chronic. Example: cataract, macular degeneration. - the evolution since the onset. - if there is any treatment applied. 4, Personal records - physiological - pathological - diabetus mellitus - arterial hypertension - theumatism - chronic rheumatism. - arthropaties - multisystem disease (sarcoidosis) - nervous demielinisation disease (multiple sclerosis) 5. Heredocolateral records ~ diseases with genetic/hereditary transmission: - pigmentary retinopathy ~ strabismus - refraction troubles, = glaucoma ~ cataract - corneal dystrophies. 6. General exam = general physique - the state of well being, 7.Ocular exam - the facial expression and complexion - the position of the head: a. at the natural daylight: - putting the patient in front of a window (or artificial light from an electric light source) - it offers informations about: -the external stractures of the eyeball: orbit, eyelids, lacrimal system, conjunctiva = the anterior segment of the eye: cornea, sclera, anterior chamber, iris, pupil, lens. b. in the dark room: - slit-lamp examination - ophtalmoscopic examination 19Assoc. Prof. Dr. Cristina Nicula - "Clinical file" - it offers information on the anterior and posterior segment of the eye. 7.1. Daylight exam a. The eyelids - we are interested in the: position, motility, sensitivity, lids margin and total exam. «Position - Normal: - the superior eyelid covers the limbus at 12 o'clock with 2 mm - the inferior eyelid is tangent at the limbus at 6 o’clock. - Abnormal: - ptosis ~ the superior eyelid covers the limbus at 12 a clock with more than 2mm - ectropion means the lid margin is everted.so that it fails to be in contact with the surface of the eye with the exposure of the palpebral conjunctiva and persistant epiphora. - entropion means the lid margin is inverted so that the lashes rub against the eyeball, causing iritation and discharge * Motility - Normal ~ active motility - blinking - passive motility. - Abnormal - lagophtalmos means inability to close the eyelids properly - blepharospasm means spasm of the eyelids. © Sensitivity - we examine the sensitivity of the eyelids passing the finger on the lids and asking the patient the way he feels. - Normal - the sensation is identical for both eyelids. ~ Abnormal - afier zona zoster infection, in the teritory of the fifth cranial nerve the patient doesn't feel anything in that teritory comparing with the other side, * Lid margin - we examine the papille, the eyelashes and the colour ~ abnormal we can have: * Jack of lacrimal punctum * increased number of eye lashes 20Assoc. Prof. Dr, Cristina Nicula - "Clinical file” = decreased number of eye lashes or even lack of it (necrotic blepharitis) * redness of the lid margin (blepharitis) © Total exam of the eyelid - colour: modified in hematomas (after injuries). - shape: “horizontal $” in dacrioadenitis (inflamation of the lacrimal |. gland), b, Lacrimal system - Lacrimal gland * Inspection - Normal: we cannot see the lacrimal gland in the supero- temporal part of the orbit - Pathological: in dactioadenitis or luxation of lacrimal gland; we can see it. © Palpation - Normal: it cannot be felt. - Pathological: it can be palpated in the two conditions antherior mentioned. * Functional tests - Schirmer test - Purpose - to measure the tear production. - Technique: one end of a strip of filter paper (4mm in width) is inserted into the lateral part of the inferior formix of each eye with the main part of the paper projecting over the lid margin and down the cheek. ~ Results: the extent of the passage of tears down the paper is measured over a short period (up to 5 min.) ~ Normal: - 15to 18mm. - less than 10 mm means low secretion of tears. ~ less than 5 mm means sicca syndrome {dry eye). - Lacrimal drainage system It is composed by; lacrimal punctum, lacrimal canaliculus, common canaliculus, lacrimal sac, nasolacrimal duct, ostium of nasolacrimal duct. ¢ Inspection - only the lacrimal punctum can be seen. ¢ Palpation - Normal: we cannot palpate anything. -Pathological: inflamatory signs in dacryocis (inflamation of the lacrimal sac) and tumor of the lacrimal sac. 21Assoc. Prof. Dr. Cristina Nicula - "Clinical file" Functional tests - to establish the patency of the lacrimal passage. Methods: - Instilation_of the coloured substances in the conjunctival fornix (such as fluorescein). - after some minutes we detect the fluorescein in the nasal secretions, if there is no obstruction in the lacrimal draining system. - results: negative means an obstruction at this level. Syringing: ~ consisting in: - local anesthetic. - dilating the lacrimal punctum with a dilator and introducing a cannula through the inferior lacrimal punctum and then we irrigate the tear sac with saline. ~ Results: - Indications: - Technique: - Normal: free entry of the fluid into the nose and into the throat implies patency of all passages. - Pathological: = no entry of fluid into the nose and regurgitation of fluid from both canaliculi implies some obstruction beyond the point of formation of the common canaliculus. - no entry of fluid into the nose and regurgitation of fluid only from the canaliculus that is being syringed means some obstruction in the canaliculus before the formation of the common canaliculus. in congenital lacrimal obstruction ~ local anesthetic - dilation of lacrimal punctum with a dilator - a fine lacrimal probe should be passed through the inferior punctum till we feel a bony resistance (lacrimal bone), then we 22Assoc. Prof. Dr. Cris tina Nicula - "Clinical file" change the direction of the probe vertically and we make a little pressure - then we irrigate with saline ic examination - irrigation of the lacrimal passages with a radiopaque substance (Example: Lipiodol) provides a radiography that gives an accurate picture of the site of obstruction. ¢. The orbit Examination of the orbit demands attention to detail. ‘There are certain signs that demonstrate an orbital illness such as protrusion of the eyeball (exophtalmos/proptosis) « Inspection reveals: = position of exophtalmos: ~ axial - the pathological process is retrobulbar ~ lateral - the pathological process on the opposite part © Palpation - with the eyelids closed which establish the reductability and pulsatility. * Radiology - routine skull x-rays, including the optic foramina provide details of the bony orbit. * CT-scan - gives details of the optic canal and paranasal sinuses. * Ultrasonography - can give us informations about the extrinsee muscles, orbit fat and the presense of foreign body, blood ot tumors of the orbit. ¢ Exophtalmometric measurements - with Hertle exophtalmometer. - Normal: ~ the protrusion of the eye is 12-20mmv/the difference between the two orbits is not more than 2mm. - Abnormal: ~more than 20mm or the difference between the two orbits is more than 2mm, d. Conjunctiva Tt has 3 segments: palpebral, formix and bulbar conjuctiva. ‘We are interested in: * Colour: - Normal: pink - Pathological: -red in conjunctivitis, subconjunctival hemorrhages - pale in anaemias, i * Discharge: - mucous, purulent, hemorrhage, pseudomembraie in different types of conjunctivitis 23Assoc. Prof. Dr. Cristina Nicula - "Clinical file" « Surface denivelation ~ can be: - localised - symblefaron means adherence between the bulbar and palpebral conjunctiva - foreign bodies - laceration - follicules - papilles - pseudomembranes - generalised - chemosis means conjunctival oedema. e. The cornea It is a perfect transparent membrane. We are interested in its shape, dimension, glitter, transparency, sensitivity * Shape - Normal: spherical segment - Abnormal: - keratoconus is a corneal distrophy (conical ectasia). - keratoglob * Dimensions - Normal: i ~ having a vertical diameter of 11mm - having a horizontal diameter of 12 mm. - Abnormal: = microcornea (small cornea) - in microphtalmios. The diameter is under 11mm - megalocomea - in congenital glaucoma (high myopia). The diameter is above 12mm. © Glitter ~ is concerned with the integrity of the comeal epithelium and precorneal tear film. - Abnormal - loss of glitter: - loss of integrity of corneal epithelium in: comeal abrasions, chemical burns, epithelium oedema, corneal inflammation ~ lack of precorneal tear film: sicoa syndrome (dry eye). * Transparency - is concerned with the histological structure of the cornea constant hidration and absence of vessels. ~ Abnormal - loss of transparency i 24Assoc. Prof. Dr. Cristina Nicula - "Clinical file" - comeal inflammation, corneal oedemas, neovascularisation on the cornea, corneal scars * Sensitivity - Normal: - the comeal epithelium is very sensitive to touch - it serves as a protective function - Abnormal: - low sensitivity in herpes simplex ! Fluorescein test ~ this dye stains immature epithelial cells, exposed by the removal of the surface cells following injury or disease ~ the area with defective epithelium is coloured in green f. The sclera We are interested in its colour and surface, * Colour - Normal: white - Abnormal: red (scleritis) * Surface - Normal: without denivelation - Abnormal: scleral ectasia (scleromalacia), nodular area in scleritis and foreign body in the sclera ! Adrenaline test ~ purpose: it makes the difference between the superficial congestion and deep conjunctival congestion. > if after instilation of one drop of adrenaline, the conjunctival congestion dissapears, then the congestion is superficial. ; ~ ifthe congestion remains, then it is a deep one. g. Anterior chamber We are interested in its depth and contents. Normal, is filled with acqueos humour, which is a clear liquid * Depth - Normal: 2 to 3.7mm in front of the pupil | - Abnormal: i - reduced anterior chamber in perforating corneal wound and acute glaucoma - increased anterior chamber in high myopia, congenital glaucoma, keratoconus, aphakia, anterior luxation (dislocation) of the lens ~ unequal: subluxation of the lens \ 25Assoc. Prof. Dr. Cristina Nicula - "Clinical file” « Contents - Normal: aqueous humour - Abnormal — we can find: ~ pus in anterior chamber is called hypopion - blood in anterior chmaber is called hiphema = Iens cells - Jens - foreign body jh. Iris ‘We are interested in its shape, colour and relief (surface denivelation). * Shape - Normal, the iris is perfect circular. - Abnormal: ~ iris colobama means lack of iris and it can be congenital or after surgery. - iridodialisis means desinsertion of iris root. * Colour ~ Normal: it varies from blue to brown and it’s identically at both eyes. - Abnormal: - heterocromia (different colours at both eyes) - pale in stromal atrophy ~ green in iritis (inflamation of the iris) newvessels in rubeosis iridis (diabetes) denivelation surf ~ Abnorma - iris tumor. - newvessels, - foreign body. - trembling of iris in jtidodonezis (in lens subluxation) i, Pupil We are interested in its shape, dimension, position and colour. * Shape ~ Normal: perfectly round. - Abnormal: - irregular in posterior synechies. - pear shape in acute glaucoma, « Dimension ~ Normal: 2 to 4 mm. ~ Abnormal: - smaller than 2 mim means miosis. 26 | |Assoc. Prof, Dr. Cris fina Nicula - "Clinical file" larger than 2 mm means midriasis. © Position - Normal: central location, - Abnormal: superior in vitreous loss (comeal perforating wound, cataract surgery) * Colour - Normal: black. - Abnormal: ~ white in cataract ~ yellow in retinoblastoma - red in vitreous hemorrhages. Pupillary reflexes 1. Direct reaction to light: a light stimulus to one eye produces a constriction of pupil of the stimulated eye and of the other eye. 2. Consensual reaction to light: convergence 3. Accommodation - pupil reflex - during accommodation the pupil constricts and during convergence the eyes converge towards the nasal area. 7.2. The exam in the dark room a, The slit lamp microscope It is an essential instrument in the examination of the fine structural details of both the anterior and posterior segments of the eye. The beam of light from the slit-lamp is maintained accurately in focus on different parts of the eye by means of a movable mechanical arm that"houses the projection Jamp. The light may be varied in intensity and shape. Such a beam is usually narrow so that it passes, without much diffusion, through the optical media of the eye (cornea, anterior chamber and lens). The microscope is capable of being adjusted to provide varying magnifications and is maintained accurately in different positions by its attachment to a second movable mechanical arm. During the examination, the patient’s head is fixed in a steady position by a chin rest that is attached to the table supporting the microscope and projection Jamp; the patient and the doctor sit on stools at opposite ends of the table. tra attachments of slit-lamp * Purpose: provide facilities for a: - detailed examination of the region of filtration angle gonioscopy). - measurement of IOP {applanation tonometry). + measurement of corneal thickness (pachimetry). 27Assoc. Prof. Dr. Cristina Nicula - "Clinical file" - Volk jens/ the lens with three mirrors to examine the ocular fundus. - the optical system of slit-lamp can also be used as the vehicle for accurate delivery of photocoagulation burns from a laser source to the trabecular meshwork, iris and retina, © Methods of illumination - Diffuse illumination = provides a general view of the patient’s eye and adjacent structures - Focal illumination * is a concentrated and bright type of illumination that is directed to particular patts of the eye so that they are revealed with great clarity. b. Ophtalmoscopic examination 1, Direct ophtalmoscopy ¢ Structure - light from projection lamp of the ophtalmoscope is reflected into the eye of the patient by an angled mirror and the light that emerges from the eye is viewed by the observer through a small hole in the center of mirror. - the image is focused by a system of lenses mounted on a movable circular disc in the head of the ophtalmoscope, that compensate for any errors in the refraction of different parts of the fundus. - the ophtalmoscope provides a magnified view of the fundus (= 15 times) * Technique - itis held close to the eye of the patient and to the eye of the observer during this examination. - the observer's right eye should be used in examination of the patient’s right eye with the ophtalmoscope held in the right hand; the process is reversed for the patient’s left eye. 2. Indirect ophtalmoscopy If the retina is brightly illuminated, the emergent rays may be converged by a strong (+20 D) convex lens to produce a real inverted image of about five times magnification that lies between the lens and the observer. Advantag - it offers a wider field of view, that is binocular, also the ability to penetrate to some extent, opacities in the media. 28eC Assoc. Prof. Dr. Cristina Nicula - "Clinical file” ~~ the source of light is attached to a head-band, one hand is free to hold the lens while the other may be used to manipulate a scleral indenter, that permits a detailed examination of the peripheral retina, 29eS 3Assoc. Prof. Dr. Cristina Nicula - "Visual function" Chapter 3 VISUAL FUNCTION The specific stimulant of the visual analisor is the light (with visible spectra 400-760nm). The visual analisor is composed by the eye, the optical pathways (optic nerve, chiasm, optical banddeletes and the optic radiations) and the visual cortex (18,19 Brodman’s areas), The eye is the peripheral segment of the visual analisor and contents the retina, which consists of photoreceptor cells, which are the cones and the rodes: a, the cones ~ are aproximately 6 million - the visual purple is iodopsine ~ they are present throught the retina, but particularly in the fovea ~ they are concerned with form and colour appreciation - they are sensitive at high light intensity, so that it assures the photopié vision b, the rodes - are proximately 130 million - the visual purple is rhodopsina - they are present thought the retina, but are absent in the fovea - they are concemed with the scotopic vision because of their sensivity at low light intensity - they assure the orientation in the space On light exposure, the rhodopsine and iodopsine suffers some chemical changes (fig a, fig b) 31 | |Assoc. Prof. Dr. Cristina Nicula - "Visual function" light li thodopsine |» retinal + opsine iodopsinge =< ————> ins retinol A vitamin (from Retinal we “ n Pigmeniaty Epithelium) A\vitarrin (from general circulation) Figa, Fig b. From didactical point of view they are: - the light sensation - the form sensation - the culour sensation (vision). 1. Light sensation 1,1 Definition Light sensation means perception and reflection of the visual cortex of the stimulating process of the visual cells by the light 1.2. Adaptation ~ at light: ‘ - is rapid in 1 to 6 minutes. - it is possible because of the delay of the photochemical substances. ~ at dark: - is long in 60 minutes. - it is possible by recompose of the photochemical substances. 1.3. Examination of light sensation Test of light projection Itis done with the light of the ophthalmoscope. The purpose is to establish the functional state of the retina when the examiner is unable to see the retina, as in the presence of mature cataract or severe corneal ' scarring. 32Assoc. Prof. Dr. Cristina Nicula - "Visual function” Technique - this test is done by covering the other eye completely and holding a light source in four different quadrants in front of the eye in question. The patient is asked to identify the direction from which the light is approaching the eye. Results - if all answers are correct, the examiner may be reasonable certain that retinal function is normal. The adaptograme (dark adaptation) Itis done with the Goldmann machine, The purpose is to establish the dark adaptation curve. Technique - the eye to be tested is exposed to a bright light for 10 minutes and then all light are extinguished. At intervals of 30 seconds a measurement of light threshold is made in one area of the visual field by presenting a gradually increasing light stimulus until it is barely visible to the patient (fig c.). Photoreceptor cells activity 5s 10° 30° Examination time . ¢. Adaptation curve Zz ® The graph of decreasing retinal threshold shows an initial steep slope denoting cone adaptation and a subsequent gradual slope due to dark adaptation of rhods, In retinitis pigmentosa there is a depression of the dark adaptation curve. Electroretinogram (ERG) The purpose is to detect the difference potential between the outer-and inner layers of the retina, Technique - the recording is done with a comeal contact lens electrode and a reference electrode on the forehead. The graph detected is a biphasic wave: an carly negative "a" curve generated by the rhods and cones, followed by a larger positive "b” wave generated from the bipolar cells. 33Assoc. Prof. Dr, Cristina Nicula - "Visual function” Ag rer 0 100 200 msec Fig. d. ERG. Indications: useful in evaluating the hereditary and constitutional disorders of the retina, useful in evaluating early retinal function loss before ophtalmoscopic changes are evident. useful for diagnose in retinitis pigmentosa, chorioretinal degeneration, vascular disorders of the retina, ocular siderosys, malignant myopia, retinal detachment. Disadvantages: the ganglion cells do not contribute to the ERG, so we cannot establish the activity of this cells. Visual Evoked Potential (VEP) The electrical currents resulting from light stimulation are transmitted to the visual cortex and recorded as VEP. Indications: is useful to assess the functional state of the visual system beyond the retinal ganglion cells when ERG + VEP are abnormal it means the presence of retinal lesions. when ERG is normal and VEP is abnormal means lesions on the optical pathways or at the level of visual cortex. 34icula - “Visual function” 1.4, Light sensation defects Hesperanopy Is connected with rode cells deficit. The orientation of the patient in low light intensity is very difficult. Types: - congenital: retinitis pigmentosa which has hereditary transmittance with the cause and treatment unknown - gained from: © general cause - A hypovitaminosis. © ocular cause - chorioretinal degenerations, ocular siderosis, malignant myopia and retinal detachment. Nictalopy Is connected with cone cells deficit. Types: - congenital + cone dystrophy. - the patient complains of poor visual acuity, color vision and photophobia. - gained - in the macular diseases. 2. The form sensation (sense) of the eye 2.1. Definition The form sensation represents the perception and reflection by the occipital cortex of the objects images formed on the retina, It is composed by central vision or visual acuity and peripheral vision or visual field. 2.2. Visual acuity (VA) Tis the macular capacity of perception of the objects. it is defined by two parameters: = minimum visible represents the ability of the visual cortex to appreciate the nature of a stimulus by a perceptual process. - minimum separable represents the power of the eye to discriminate between two separate but adjacent stimuli. The minimum separable under conditions of normal illumination is about one minute and this represents the angle which the object subtends at the model point of the eye. 35Assoc. Prof. Dr. Cristina Nicula - "Visual function" Examination of visual acuity The VA of each eye separately is recorded in 2 ways: - the distance VA. - the near VA, a, Distant VA. This measures the form sense of the eye, which is made up of two components enumerated above: minimum separable and minimum visible. This is used as a basis for the construction of square - shaped sherif letters or the figure’s of the Snellen’s test types technique. Technique - VA is examined one eye at a time, the other eye being occluded. - pressure on the occluded eye may be avoided so that there will be no distortion of the image when that eye is tested subsequently. - if the patient normally wears glasses, the test should both be made with and without corrected lenses and recorded as “uncorrected” and “corrected”, - the chart most commonly used for distance vision with literate patients is the Snellen chart: ©. is situated at 5 meter away from the patient; © is diffusely illuminated without glare. - at this distance, the rays of light from the object in view are almost parallel, and no effort of accommodation (focusing) is necessary for the normal eye to see the subject clearly; ~ the Snellen chart is made up of letters of graduated sizes, arranged in 10 lines, with a gradual reduction in size from above down, so that the largest letter or figure is placed at the top of the chart, and the smallest letter / figure are placed as a line at the bottom of the chart; - . the VA corresponding to each line is written near each line, - the distant VA of each eye is recorded as an expression of the line of letters that can be discerned at a particular distance (approximately 5 meter) from the eye. d VA= D - where D is the distance from where we can see the line and d is the normal distance from where that particular line is seen Normal VA is 5/5: the patient sees all the lines from 5 meters. © If the patient sees only the top line from 5 meters > VA=5/10 =1/10=0,1. If the patient is unable to read the top letter at Smeter, he is asked to approach to the chart, until he is able to read the top line; » Examples: ° 36Assoc. Prof, Dr. Cristina Nicula - "Visual function” * if this distance is 3meter > VA = 3/50 © if this distance is Imeter > VA = 1/50. ©. if the patient is unable to read the top letter of the chart from 1 meter, we show him our fingers and ask him to count them — VA = counting fingers at x cm. (CF) ©. ifthe patients cannot count the fingers, we move our hand in front of the eye > V.A. = hand movement (HM). © ifthe patient cannot see the hand, then we put a light on the eye and we ask if he sees it > V.A. = light perception (LP). ©. ifhe is not able to see the light — he is blind = no light perception (NLP). For preschool children or patients who are unable to read should be shown the “E” chart. Patients are instructed to point their finger in the direction of the bars of theE. * He Children younger than 3 years of age may be able to cooperate in this testing or we can use Allan charts (with certain pictures). Test of light projection - may demonstrate normal retinal function when vision is extremely poor and the examiner is unable to see the retina (ex.: mature cataract, vitreous hemorrhage and corneal scaring). It is done by covering completely the other eye and holding a light source in four different quadrants in front of the eye in question. The patient is asked to identify the direction from which the light comes, If all answers are correct, the examiner may be reasonably certain that retinal function is normal. b. Near VA It is measured using special reading charts. The patient holds the chart at 30-35 cm from the eye and reading separately with each eye with and without glasses. For normal near VA he has to read the smallest print, VA is maximum in fovea and minimum in the periphery of the retina, Causes of decreased VA are: ~refraction disturbances. ~ opaque medias. ~ retinal or optic nerve diseases. ~ amblyopia (decreased VA without any organic causes), 2.3. Visual field (VF) Represents the whole space seen by one or both eye The VF limits are: -for white light: superior — 50°, temporal - 90°, nasal - 60°, inferior - 70°. - for colours, it is lower with 10° for blue, 20° for red, 30° for green. 37Assoc. Prof. Dr. Cristina Nicula - "Visual function” Examination of VF The purpose of VF examination is to determine the outer limits of visual perception by the peripheral retina and varying qualities of vision within that area. VF interpretation is important for: - diagnostic purpose - locating the disease in the visual pathway, between retina and the occipital cortex - determing the evolution of the disease (progress, stabilize/remission) ~ each eye is tested separately Techniques methods: - confroniation test - perimetry - tangent screen a. Confrontation test No special instruments are required Principle - to estimate the patient’s VF by comparing it with the examiner's VF (it is assumed that the examiner’s VF is normal). Technique: - the patient-and the examiner face each other at a distance of Imeter - with the left eye covered, the patient is instructed to look with the right eye at the left eye of the examiner, whose own right eye is covered = asa target we may use a pencil - the examiner places her hand midway between the patient and herself - as the test object is moved slowly towards the line of vision between, patient and examiner, the patient is asked to respond as soon as he is able to see the target Results- may pick up gross alteration in VF defects due to ocular disease (chorioretinitis and advanced glaucoma). b. Perimetry It is more accurate to examine the VF. ‘The perimetry’s methods are varying the size and the target lightness as well. May be: - kinetic perimetry made by Goldman perimeter - involves moving a constantly suprathreshold test object from nonseeing to seeing areas of vision. ~ static perimetry (automated perimetry) - is a nonmoving test targets flashed at different locations - Advantage: picks up the earliest, most subtle field defects - Disadvantage: 38Assoc. Prof. Dr. Cristina Nieula - "Visual, function" - patient fatigue. - the expense of the machine. - the need for trained personnel to run them, Technique: - the patient is seated at the perimeter with one eye covered and the chin on the chin rest. - the patient must fix his or her vision on the central target and a test target static or kinetic is presented at some location in the field, - _ the pacient is asked to signal immediately when he or she sees the target, indicte when it disappears and again when it reappears. ~_ by the end of the test, the entire 360 degrees of field have been mapped out. Results - may detect all defects of the peripheral vision and central defects of visual fields. c, Tangent screen It is an accurate central field test. Technique: ~ _ the patient is seated Im from a 2 m? block screen with a direct line of fixation on the central object in the tangent screen, i - one eye is tested at a time. - a3-50 mm white test is brought to central fixation, ~ the patient indicates perception of the object, when it disappears and when it reappears, so that the examiner may map areas of decreased or absent vision. * Visual field defects In the periphery: ~ generalized constriction of the VF (retinitis pigmentosa, optic atrophy), ~ partially constriction of the VF (retinal detachment, glaucoma). i ~ hemianopsia which can be: ! - binocular (in chiasm lesions) ~ monocular (in optic radiation lesions). - in the interior of VF (scotomas): - physiological scotoma (blind spot) ~ is the projection of the optic head and is between 12-18°, - pathological scotomas - can be: * positive scotomas - seen by the patient and they are due to opacities in the clear mediums. 1 * Negative scotomas - are not seen by the patient, it appears on I the VF graph and they are due to retinal and optic nerve i disease. + round, triangular or arcuate (according the shape) | t 39Assoc. Prof. Dr. Cristina Nicula - "Visual function" * central, centrocecal, paracentral, inferior and superior (according the location) 3. Color vision 3.1. Definition The color sense of the eye is the ability to distinguish different colors. Is mediated essentially by the cones. White light consists of impulses of different wave lengths, so that it forms a spectrum with the following colors: red, orange, yellow, green, blue-green, blue, violet. 3.2. Pathogenetical theories ‘The trichromatic theory (Young-Helmholtz) The tricromatic theory assumes the existence in the retina of three separate colours perceiving elements and color transmitting mechanism are concerned with this three fundamental colors: red, green and blue. So, all colors are produced by varying degrees of stimulation of these elements and mechanisms. A white color is produced by an equal stimulation of all three, The tetrachromatic theory (Hernig) ‘The tetrachromatic theory assumes the existence of 4 fundamental colors: red, green, yellow and blue. 3.3 Colors features The tone It is the quality which defines the color, For each tone there are 15 nuances (shades), The saturation Represents the quantity of radiations with the same wavelength which is contained by a color. The brightness Represents the quantity of white color contained by a chromatic color. There are achromatic colors which has a single feature: the brightness. 3.4 Tests for color sense ‘The lantern tests It is used: - for the screening of patients with color sense troubles. - an annual exam for patients who needs normal color vision (electricians, air plane drivers or car drivers) Technique: - ona white table it is projected different color lights. - _ the patient has to recognize the color of the light projected. The equalize test 40Assoc. Prof. Dr. Cristina Nicula - "Visual function" The principle of this test is the Rayleigh equation: RED + GREEN = YELLOW (by combining red with green we obtain yellow).. Technique: - it is done with the Nagel’s anomaloscope. - this apparatus has a screen divided in two areas: - the inferior part is yellow. - the superior part is red and green, - the patient has to combine red with green in order to obtain yellow. The discrimination test It is done with the Ishihara Stilling charts. The test is more subtle than the lantern test and is of value in identifying the anomalous thrichromats who are ofien able to pass the lantern tests successfully. The match tests The Farnsworth - 100 tones. 100 tablets of different colors and tones are presented to the patient and he is asked to put the tablets in a certain ordain of the tones. 3.5. Defects of color vision Congenital - hereditary transmission sex linked. - most frequent on male. - bilateral and symmetrical. ~ no treatment a, The monochromat: - absence of color appreciation, so everything is seen in white and black. - there are two types: - cone monochromatism (cone dysfunction syndrome). - there is a disturbance of cone function. - photopic ERG-abnormal scotopic ERG-normal. - rod monochromatism - the visual function of the eye is grossly abnormal with poor visual acuity and nistagmmus. 5, The dichromat: - the absence of perception of one fiindamental color, - Examples: - protanope ~ for red. -deuteranope ~ for green. - tritanope — for blue. ¢. The thrichromat: ~ shows an anomaly (not absence) of one fundamental color. ~ Examples: - protanomalous thrichromat -deuteranomalous thrichromat. at iAssoc. Prof. Dr. Cristina Nicula - "Visual function" - tritanomalous thrichromat. Obtained (Gained) - chromatopsy: global perception of one color. - Examples: - eritropsy — vitreous hemorrhage. - xantopsy — Digital intoxication. - cynopsia — after extraction of the lens. - cortical troubles: in vascular strokes localized in the occipital part of the brain. | | a : [| {4a Nicula - " Ocular Refraction " Chapter 4 OCULAR REFRACTION 1. Definition Ocular refraction represents the changes in the direction of the light when it passes from a medium to another with different refractive index, The ocular diopter (system) is formed by the cornea and lens The power is 60 D (45D-from the cornea, 15D-from the lens) * The cornea The influence of the cornea on refraction is exerted almost entirely by its anterior surface, which is a curved convex surface producing convergence of parallel light Tays entering the eye. * The lens The anterior and posterior surfaces of the lens are curved convex surfaces so that they cause increased convergence of light rays passing through the lens, 2. Examination methods of refraction The techniques for the examination of refraction are the subjective and objective one, a. The subjective method (Donders technique) The pationt stays at 5 m from the Snellen chart. One eye is occluded and we test the visual acuity of the unoccluded eye. There are two situations: - when the visual acuity is 1, it means that the patient is emmetopic or has a small hyperopia, We put a convergent lens of 0,5 D in front of the eye.If the vision becomes blurred it means that the eye is emmetropic and became myopic putting the lens in front of the eye. If the vision is better it means that the eye has a small hyperopia. - when the visual acuity is less than 1 it means that we have a refraction disorders or an organic cause of visual acuity decreasing, In order to make the distinction between them we use the pinhole test (a black lens with a small aperture in the central part of it) which acts as an artificial small pupil. If there is a refractive error present, a blur circle is formed on the retina, which is dependent on the size of their pupil (smaller pupil means smaller blur circle).In this case, when we put the pinhole in front of the eye, the visual acuity becomes better. If the patient complains of decreased visual acuity, it means that there is an organic cause of decreased visual 43Conf. Dr. Cristina Nicula - " Ocular Refraction" acuity. In this case, we have to examine the patient with the slitlamp or with the ophthalmoscope. b, The objective methods This includes examination with the ophthalmoscope, retinoscope, auto refractometers or astigmometer, Retinoscopy: Is particurarly useful in testing children under 7 years of age.Jt has to be done cicloplegia in order to obtain a temporarly paralyses of ciliary body and inhibit accomodation. A retinoscope is an instrument used to asses the objective refraction of the eye.A bright streak of light is shown through the pupil and is seen as a red reflex reflected from the retina. Autorefractometry offers all details about the whole refration of the eye, ax of the astigmatism. Astigmometer gives detailes about corneal astigmatism and radial curvature of the cornea. Types of corrective lenses 1. Spherical lenses ~ have equal curvature in all meridians ~ they can be: * convex or plus lenses ~ they refract light rays so as to make them more convergent ~ thick in the middle ~ thin at the edges * concave or minus lenses - they refract light rays so as to make them more divergent ~ thin in the middle - thick at the edges } ~ Indications: statical refractive disturbances correction 2. Toric lenses ( Spherocylinders) ~ are shaped like a section through a football - one meridian is more curved than all the others, and the meridian at right angles to the steepest meridian is flatter than all of the other meridians.Conf. Dr. Cristina Nicula - " Ocular Refraction" - in a toric ens, the meridian of least curvature and the greatest curvature are always at right angles to one another and are referred to as principal meridians. ~ Indications: ~ correction of astigmatism - can be: - plus lenses i - minus lenses - one principal meridian plus, and the other minus ~ meniscus lenses - planocylinder form in which the principal meridian has zero optical power. 3. Prism ~ an object viewed through a prism appears to be displaced in the direction of the prism apex; instead, the focus is not altered and no magnification or minification occurs. ~ indications: - divergent squints correction - paralitical squints (diplopia) i 4. Types of refraction i a) statical refraction It is the eye refraction without accommodation (in a relaxed state). * Emmetropia ~ has a normal type of refraction so that parallel rays of light t 4 entering the eye come to focus on the retina. (Fig.4.1) Disorders of statical refraction ar - hyperopia - myopia - astigmatism b) dynamic refraction (accommodation) - the comea is a static or fixed structure ~ the lens is capable of increasing its power. This is referred to as focusing ot accommodation, * Mechanism of accommodation When the ciliary muscle is relaxed the power mention a slight tension on the capsule. The constriction of the ciliary muscle (which is a circular sphincter like muscle) gives a slight decrease in the diameter of the circle. This reduces the tension of the zonules and the lens capsule, which is elastic and squeezes the lens fibers in such a way that the anterior pole and, to a lesser extent, the posterior pole 45Conf. Dr. Cristina Nicula - ” Ocular Refraction " becomes more convex, thereby increasing the power of the lens. This change is accommodation. * Parameters of accommodation 1. Punctum proximum - PP (near point) - is the nearest point at which a person can see clearly using the accommodation. 2. Punctum remotum - PR (far point) - is the farthest point at which a patient can see clearly without accommodation. 3. Amplitude of accommodation - is the range of plus power the lens can produce. This varies with age. * Disorders of aecomimodation - physiological ~ is called presbyopia - pathological can be: - astenopy of accommodation - paralyzed of accommodation - spasm of accommodation Disorders of statical refraction A. Hyperopia It’s a spherical statical refraction disorder, in which the image is formed behind the plane of the retina (Fig.4,2) The eye is “too short” The sign of hyperopia is “+” (plus) 1. Frequency Most children are born hyperopic, but this usually resolves by age 12. 2. Classification — hyperopia can be: a). Ethiology - axial hyperopia — the eye is shorter than normal in its antero-posterior diameter, although the refraction mediums (cornea, lens) are normal; - curvature hyperopia ~ results where either the lens or the comea has a weaker than normal curvature , inducing lower refractive power. - index of refraction hyperopia — is the result of decreased index of refraction due to decreased density in some or several parts of the optic system. b). Degree of hyperopia -low-0-++3D -medium —+3 > +6 D - high ~ above +6 D. 3. Accommodation in hyperopia - is a key dynamic factor in correcting the hyperopia - PR is beyond the infinity 46Ee Conf. Dr. Cristina Nicula - " Ocular Refraction" - PP is far from the eye - presbyopia is earlier in life 4, Components of hyperopia: - latent hyperopia: is the part of the hyperopia completely corrected by accommodation “it is measurable only with paralysis of accommodation ~ manifest hyperopia: -is the part of the hyperopia that may be corrected by the patients own powers of accommodation, by corrective lenses or both, 5. Clinical features: - frontal headaches ~ worsening as the day progresses - uncomfortable vision ~ when the patient must focus at a fixed distance for prolonged periods; - blurred distance vision ~ with refractive errors great than 3-4 D; ~ intermittent sudden blurring of vision is due to spasm of accommodation and induces a pseudomyopia. 6. Complications of hyperopia: - in children: convergent strabismus ~ in younger age: asthenopia ~ in adults: angle~closure glaucoma (because of the shorter anterior segment with closing of the filtration angle) 7. Treatment of hyperopia’ ~ optical: ~ with convex spherical lenses ~ contact lens - surgery: ~ phakic JOL ~ for young high hyperopic patients(>18 years) ~ clear lens extraction with foldable intraocular lens implantation — in hyperopic and presbyopic patients (>40 years) ~ laser Excimer — for hyperopia under +6D. It is only indicated after 18 years old B, Myopia It’s a spherical statical refractive disorder in which the image is formed in frout of the retina. (Fig.4.3) The eye is “too long”. The sign of myopia is 2" (minus) 1. Classification a). Ethiology - axial myopia: -the anteroposterior diameter of the eye is longer than normal, although the comeal and lens curvatures are normal. 4a?Conf. Dr. Cristina Nicula - " Ocular Refraction" - curvature myopia: - results when the curvature of the cornea is steeper than average or the lens curvature is increased (e.g. hyperglycemia) - increased index of refraction — is the result of increased density of the lens (e.g.: cataract), b). Degrees of myopia: - low: 0 -3 D - medium: -3 - -6 D - high: above -7 D. 2. Accommodation in myopia - PR is anterior to the retina - PP is near the eye than in emetropia - presbyopia is later or never. 4, Types of myopia - simple myopia:- discovered after the age of 6 - progressive myopia: - more than 10 D - the reftactive changes stabilize around the age of twenty. 5. Clinical features © Symptoms blurred distance vision squeezing to sharpen distance vision by attempting ~ pinhole effect through narrowing of the palpebral fissures -headaches - rare, but may be seen in patients with uncorrected low myopia errors. © Signs in progressive myopia: ©. vitreous floaters © chorioretinal changes * choroidal atrophy © peripapilhary-atrophy * choroidal hemorrhage which is called Fuchs spot , localized in the macular area © posterior staphyloma which means the thinning of the posterior part of the sclera 6. Complications of myopia ~ retinal detachment = cataract (opacification of the lens) - lens sublucxation (weakness of the Zinn zonule) 7, Treatment of myopia - optic - spherical negative lenses ~ contact lenses ~ surgery 48Conf. Dr. Cristina Nicula - " Ocular Refraction " ~ laser Excimer ~ in low, medium myopia ~ clear Jens extraction ~ in high myopia - phakic intraocular lens ~ in medium, high myopia ~ surgery can be performed after the age of 18 | C. Astigmatism 1. Definition It’s an aspherical static refractive disorder. Many optical systems are thoric surfaces in which the curvature varies in different meridians, thus refracting light unequally in those meridians ~ so light rays passing i through a steep meridian are thus deflected more than those passing through a { flatter meridian, (Fig.4.4) | In the astigmatic eye, the refractive effect is different according to the meridian in which those rays traverse the eye. 2. | . . . Types of astigmatism. Astigmatism: against the rule: if the horizontal meridian in steeper; with the rule: if the vertical meridian is steeper. Astigmatism: irregular: is due to an unevenness of the corneal surface (ex: comeal scarring, keratoconus ) ~ regular ~ has principal meridians in each eye with similar but opposite axes. Astigmatism simple myopic - ] image is on the retina and 1 is in front of the retina simple hyperopic ~ 1 image is on the retina and 1 is behind the retina composed myopic — both images are in front of the retina -composed hyperopoc ~ both images are behind the retina mixed ~ an image is in front of the retina and one is behind the retiia . Clinical features blurred vision tilting of the head in oblique astigmatism squeezing to achieve “pin hole” vision clarity asthenopia (when astigmatism is lower than 1D) transient blurred vision front headaches when staring a task, 4.Treatment a, Irregular astigmatism ~ hard contact lenses and comeal grafting b, Regular astigmatism: optical 49Conf. Dr. Cristina Nicula - " Ocular Refraction" * cylinder lenses * combination of spherical and cylinder lenses © toric contact lenses - surgery — laser Excimer - toric phakic intraocular lens, after 18 years of age. Disorders of accommodation A. Presbyopia 1. Definition It is a physiologic decrease in the amplitude of accommodation associated with aging. When the eye attempts to accommodate there is Jens of change in the curvature of the lens for each unit of contraction. By the early forties, accommodative amplitude has usually decreased to less than 4D and objects less than 20 cm away cannot be brought into focus. Presbyopia appears earlier in hyperopic eyes and later in myopic eyes. 2. Symptoms: ~ symptoms develop when the amount of accommodation needed to focus at near exceeds more than half of the total amplitude of the eye. - longer reading distance required ~ inability to focus on close work ~ excessive illumination required. 3. Treatment - with spherical convex lenses. B, Asthenopia Tt is the fatigability of ciliar muscle. It is very frequent, Itappears frequently in hyperopia with or without astigmatisin « Symptoms: - headaches, frontal and periorbital pains ~ nausea - red eyes - blurred vision. * Treatment - correction of hyperopia +: astigmatism C. Paralysis of accommodation Causes: + in cranial nerve pair IJ paralisation 50Conf. Dr. Cristina Nicula - " Ocular Refraction " = congenital traumatic (concusion of the eye) infections (botulism, diphteria) cerebral tumors. local: instillation of cycloplegic drugs (atropine) Symptoms: - blurred near vision - normal vision at distance. Treatment: - corrective spherical lenses for near (+4D) D. Spasm of accommodation Etiology: - uncorrected refractive disorders (hyperopia + astigmatism) + troubles of binocular vision (phorias) - drugs: morphine Symptoms: - normal near vision + blurred vision at distance Treatment: - correction of refractive disorders - ethiological 51| | Assoe. Prof. Dr. Cristina Nicula - "Disorders of the binocular vision" Chapter 5 DISORDERS OF THE BINOCULAR V: 1. Basic anatomy of the extrinsec eye muscle Extrinsec muscle of the ocular globe are: four rectus muscles and two oblic muscles. The four rectus muscles arise from a tendinous cuff called tendinous ring (Zinn tendon), which sorrounds the optic canal. From the origin, they run anteriorly and insert to the eyeball posteriorly to the sclerocomeal junction. The two oblique muscles: ~ the superior one arise from Zinn tendon anteriorly, superior and medial to the superior and medial rectus muscles; it goes through a loop called trochiea (localised in the medial angle of the orbital wall), turus posteriorly and superolateral quadrant of the sclera behind the ecuator, ~ the inferior one arise also from Zinn tendon, goes inferior and lateral and inserts onto the inferolateral quadrand of the sclera behind the ecuator (fig. 5.1). 2. Ocular movements There are three types of ocular movements: ~ ductions, which represents separate movements of the eye. - versions, which represents concomitent movements of both eyes, in the same gaze direction. ~ vergences, which represents concomitent movements of both eyes, in the opposite direction. (fig.5.2). 3. The muscles action The muscles actions are: - the superior rectus makes the elevation, adduction and internal rotation. - the inferior rectus makes the depresion, abduction and external rotation. ~ the Jateral rectus makes the abduction, ~ the medial rectus makes the adduction. - the superior oblique makes the depression, abduction and internal rotation. ~ the inferior oblique makes the elevation, abduction and external rotation, 63Assoc. Prof. Dr. Cristina Nicula- "Disorders of the binocular vision" 4, Inervation of the extrinsec muscles of the eyeball - the superior rectus, the inferior rectus, medial rectus and inferior oblique are inervated by the third pair of cranial nerve. - the lateral rectus is ineryated by the sixth pair of cranial nerve. - the superior oblique is inervated by the fourth pair of cranial nerve, 5, Definition of binocular vision Bionocular vision represents the visual cortex capacity to fusion in on sensation the two images formed on the two retinas. 6. Binocular vision degrees | Binocular vision degrees are: a. Simultanous projection : - represents the ability of each eye to super impose two different objects. i b. Fusion ~ represents the ability of the eye to produce a composite picture from two similar objects, each of which is incomplete in one detail. c. Stereopsis : - - represents the perception of the third dimension (tridimensional image). 7. Conditions for normal binocular vision For a normal binocular vision, we need the following conditions. a, The anatomical and optical integrity of the eye. b. The muscle integrity. c. Binocular visual field. d. Normal retinal correspondence. Each point of the nasal retina correspond with a point of the temporal retina. The two points forms a pair of normal corresponding retinal pait and they have the same direction of projection of images in the space. The two maculas which are the ideal retinal corresponding points have a straight direction of projection of images in the space. 8. Physiopathology of the binocular vision Ortophoria indicates that the eye are perfectly aligned with no deviation, even when fusion is artificially disrupted by the examiner. 54Assoc. Prof. Dr. Cristina Nieula - "Disorders of the binocular vision" The squint only represents the beginning of a new series of events which take place because of the accurance of double vision (DV). Double vision or diplopia is the direct result of the squint, which causes the visual axes of the two eyes to be directed to two different objects, thereby causing a super imposion of the two different images. This double vision is called confusion and is the result of stimulation of corresponding retinal points by two different objects and which also causes the stimulation by one object of retinal areas in the two eyes which do not correspond with one another, thereby causing a separation of the two images (the true and the false image) of the object (diplopia). For confusion and diplopia the following adaptation may occur (fig. 5.3): - Supression: - the vision of the squint eye may be ignored by a process of active neglect of the eye by the visual cortex, but this is a temporary phenomenon, which occurs only when both eyes are given the opportunity of acting visually. - it is a feature of the early stages of a uniocular squint and persists in an alternating or intermittent squint, but on transferring fixation from one eye to the oher spontaneouly or by covering the fixing eye there is an immediate cesation of the suppression. - Ambioplia ~ the vision of the squinting eye may be ignored by a process of active neglect of the eye by the visual cortex, but unlike suppression this cortical inhibition is a progressive and permanent phenomenon (in the absence of treatment). - Excentric retinal fixation - the. fixation of the squinting eye may become abnormal by the development of an excentric type of retinal fixation, The retinal elements may retain their normal projection despite marked ambliopia. - when the squints occurs at an carly age and when is a prolonged interval between the onset of the squint and the start of effective treatment, this ability is lost and some other retinal area assumes the principal visual direction so that it becomes a point of excentric retinal fixation. + Anomalous Retinal Correspondence - the eyes may develop an anomalous association with one another in order to obtain a form of binocular vision despite the presence of the squint. 9, General order of examination for strabismus A. History (from the parents) a, deviation: - age of onset: - under eight months or at birth. ~ after eight months of age.Assoc. Prof. Dr. Cristina Nicula - "Disorders of the binocular vision" - frequency and-duration: if the deviation is sometimes or constantly. - previous treatment: spectacles or occlusion, b. Personal data: = pre and postnatal factors. - course of pregnancy. - delivery. - growth and development. - medication. - surgery c. Family data: ~ strabismus in blood relatives. B. General observation: - abnormal head posture. ~ spontaneous closure of one eye (squint) C. Visual acuity - without glasses and with glasses - techniques for the examination of the visual acuity: © under 1 year of age: the preferential looking technique permits reliable measurements of visual acuity to be made in infants ‘from birth to age 1. * in the illiterate and in preschool children - we use “E” game. the parents instruct the child at home to indicate with the hand the direction in which the three bars of a test letter E held by the examiner are pointing to, - Allen tests - with figures: small animals or common images the child can recognize. ~ types of visual acuity: - with isolated letters or figures - whole lines of letters or figures. ‘+ in the amblyopic eye: the visual acuity for isolated letters is greater than for whole lines of letters. It is the so called crowding phenomena. D. Motor tests a. Extraocular muscle function ~ versions - simultancous movement of both eyes in the same direction (horizontal version, vertical version). = vergences - are equal simultaneous movement of the eyes in opposite directions (convergences, divergences, vertical vergences). + ductions - movements of just one eye (abduction, adduction, infraduction, supraduction). b. Phoria or tropia detection: Cover test(CT) ~ the patient must fixate a small target. 56 aAssoc. Prof. Dr. Cristina Nieula - "Disorders of the binocular vision" - CT for heterophoria detection: - Phoria: deviations are kept latent by the fusion mechanism | as long as both eyes are in simultaneous use. \ - each eye is covered separately in turn of 2 - 3 seconds and the occluder then quickly removed, (covered eye’s deviation occurs if heterophoria is present) i ~ if there is no movement of either eye when covered and then uncovered, then is no strabismus. ~ if when uncovered; one eye moves outward or inward to fixate than itis phoria (eso or exo). small angle phorias cannot be detected. - CT for heterotropias detection - heterotropias - no fusion is present. = covering the fixing eye will require the deviated eye to move to take up fixation, and this movement of the uncovered eye is looked for by the observer. | = each eye must be covered in tum and the fellow eye | wached for a fixation shift to determine whether tropia is | present or not. | c, Measurement of the strabic deviation - Hirshberg’s test Sete - a fixation light is held 33 cm from the patient and the deviation of | corneal light reflex from the center of pupil is estimated. - each mm. of deviation corresponds to 7 degrees of ocular deviation. ~ Krimsky's method - playing succesively increasing prism power before the deviating eye until the reflection is similarly positioned in both eyes. - Perimeter's method - the patient fixates the “o”mark on the perimeter with the preferred eye as the examiner moves a light along the back side of the perimeter until the corneal reflex of the light appears in the pupitlary center of the deviated eye. - 1° means 2 prism diopters of deviation. = CT and prism - when the prism power becomes equal to the strabic angle (so no movement occurs) as the eye behind the prism takes up fixation. - Synopiophore - measures the angle of the squint. E. Senzory tests - stereops - the Titmus stereotest, - the Lang stereotest 87Assoc. Prof. Dr. Cristina Nicula - "Disorders of the binocular vision" = synoptophore: = fusion - amplitudinal fasion - stereo fiision - Optokinetical nigsagmus - in congenital strabismus F. Fixation -visuscope: - foveal - excentric fixation - the visuscope = a modified ophtalmoscope that projects an asterix onto the patient's retina. - the patient is asked to look directly at the asterix while the examiner observes the fundus. in central fixation, the asterix is on the macula ~ in excentric fixation, the asterix is on the extrafoveal area. G. Slit-lamp examination and Fundus examination - for differential diagnosis. H. Cycloplegic refraction 1. Phoria’s test: Maddox'rod testing Maddox rod - is a red ribbed lens a point source of light shinning through this lens is seen like a stick the patient views the fixing light of a cross put on the wall, with both eyes. if the stick is on this light > ortophoria if the stick is displaced away: —+ phorias or tropias — dyplopia - on the same site = esodeviation - on the opposite site = exodeviation J. Diplopia’s test Lancaster red green projection red glasses test - with the patient fixating on a bright white light, a red glass is placed before the deviated eye, making the second image visible to the patient. diplopia - uncrossed diplopia ~+ esodeviation ( abductor paralysis) - crosseed diplopia + exodeviation ( adductor paralysis) 58Assoc. Prof. Dr. Cristina Nicula - "Disorders of the binocular vision" i 10. Types of squint (strabismus) There is a paralitical strabismus and a nonparalitical strabismus. i a. The paralitical strabismus | - is a condition in which there is a paresis (partial loss of function) or paralysis i (complete loss of function) of one or more of the extrinsec ocular muscle. - Etiology: = Congenital abnormalities. - Gained (Acquired). - inflammatory conditions (encephalitis neuritis); - toxic disorders: bacterial toxins (tetanum, botulism); - intoxication with alchool, snake venin; - demyelinating diseases: multiple sclerosis; - metabolic disorders (B vitamin deficiency, diabetes mellitus); \ - vascular lesions (intracerebral hemorrage, subarahnoidian ' hemorrage, trombosis, embolism); - neoplastic diseases (localised in the orbit or in the brain) - degenerative lesions: ~ traumatic lesions. - Clinical features - Symptoms - Diplopia: - it appears early; - is uncomfortable; - it appears because of the formation of the images on the noncoresponding retinal points; - it can be homonimous (when the image is formed on the same part with the paralised muscle and it indicates an i abductor paralysis) and heteronimous (when image is fornied i on the opposite part with the paralised muscle and it | indicates an adductor paralysis). - False projection: - there is an incorrect appreciation of an object in space so that is wrong located by the paretic muscle, ~ Nausea. | - Signs: - Squint or strabismus, - The limitation of the ocular movement in the direction of the paralised muscle. ~ The variability of the squint angle. } + Abnormal head posture for diplopia (lig.5.4). 59Assoc. Prof, Dr. Cristina Nicula - "Disorders of the binocular vision” - pseudostrabismus; - Concomitant squints (Heterotropias) — there no limitation of the ocular movement and the squint angle is constant. Treatment: — - it’s important to treat the cause - optical correction with prism in order to eliminate the diplopia - surgery after 6 months in case of the maintaince of the squint Differential diagnosis 4. The non paralitical strabismus -maybe: _ - latent (heterophorias) or = constant (concomitant squints) - heterotropias. 1. Heterophorias © Ostophoria - indicates that the eyes are perfectly aligned with no deviation even when fusion is artificially disrupted by the examiner. © Heterophoria—is a misalignment in which fusion keeps the deviation latent. Causes: - uncorrected refraction defects (ex.Hyperopia). Clinical features: - headache - ooular pain; - ocular itchness - the squint angle is demonstrated by cover-uncover tests: when the cover is removed and if only one eye is moving then phoria is present; ~ the angle is: - small and intermittent. Treatment: — - optical correction of the refraction defect; ~ orthoptic treatment at the synoptophore to stimulate the fusion. 2. Heterotropias - is a manifest misalignment of the ocular axis. Causes: - optical defect: - hyperopia: - anizometropia; - myopia; - sensorial defects: - congenital cataracts; - toxoplasmic macular scars; - retinoblastoma; - optic nerve atrophy; ~ anatomical and motors defects at the muscle or ligament levels. Classification: Concerning the: - direction of deviation — it can be esotropia (deviation of the eye in to the nasal direction) and exotropia (deviation of the eye in to the temporal direction) ~ the onset - it can becongenital strabismus (under 8 months) or late onsét strabismus (after 2 years); - the location of squint — it can be monolateral or bilateral (alternative) Clinical features: 60Assoc. Prof. Dr. Ci ina Nicula - "Disorders of the binocular vision" - nothing or visual acuity impairment in monolateral squints; ~ the squint is present: - cover test: when the cover is removed if neither eye moves or if. both eyes moves and stay moved, tropia is present; - the angle is constant in all direction gaze and the eye movements are normal, Clinical types: L.Esotropia _-are more frequent; -it can be: - congenital - is usually noted shortly after birth but may not become clinically apparent for 1-2 months; - the angle of deviation is great; - generally is associated with small optical defects (small hyperopia) (fig. 5.5). - late onset - on 2-3 years old; ~ it may be pure or partial accomodative - they are associated with medium or high optical defects 2. Exotropias ~ it can be caused by: - divergence excess - the most frequent type; - the distance deviation is significantly greater than the near é deviation; - convergence insufficiency — the near deviation is significantly greater than the distance deviation (fig. 5.6). Treatment of concomitant squint - optical correction — with glasses; - treatment for amblyopia: occlusion therapy with patching of the preferred eye (direct occlusion); - orthoptic ~ to correct the binocular vision defects. It is indicated in: heterophorias; exoforias; and a ccomodative esotropia; - prismatic correction which is indicated in exophoria and convergence insufficiencies - surgery - orthoptic postsurgery. GtAssoc. Prof. Dr. Cristina Nicula - “Pathology of the orbit” Chapter 6 PATHOLOGY OF THE ORBIT Inflammations of the orbit 1. Osteoperiostitis 1.1, Anterior form (preseptal cellulitis) Is a relatively common infection of subcutaneous tissues anterior to the orbital septum. Causes: - skin trauma; - spread of local infection: acute hordeolum or dacryocistitis; - from remote infection, either of the upper respiratory tract or middle car, caused by Haemophilus influenzae and streptococcus pyogenes. Clinical features: Signs: - unilateral, tender, red, periorbital and lid swelling: - minimal proptosis; - visual acuity and ocular motility are unimpaired. (fig.6.1) ‘Treatment: - general antibiotics. 1.2. Posterior form Ttis caused by the spreading of anterior form, posteriorly to the peak. Clinical features: Sign: - the same as in the anterior form plus: © sphenoidal aperture syndrome: - proptosis - imobility of the ocular globe in the area of II, IV, VI cranial nerve action; - anestesy of the V cranial nerve. * orbital peak syndrome: sings of sphenoidal aperture syndrome and the visual acuity is low because of optic nerve compression Evolution- without any treatment evoluates to orbital cellulites Treatment: - etiological; - systemic antibiotics, 2. Orbital cellulites Is the most common cause of proptosis (exophtalmus); Is an infection of the soft tissues behind the orbital septum} 63Assoc. Prof. Dr. Cristina Nicala - “Pathology of the orbit" The most common organism that cause orbital cellulites are: staphylococcus aureus; streptococcus; Haemophilus influenzae (at children under 5 years old). Causes: - sinus related (etmoidal sinusitis); - spread from adjacent dacryocistitis and mid facial or dental infection; ~ posttraumatic: after-an injury that penetrates the orbital septum; - post surgical: after retinal or orbital surgery. Clinical features: Symptoms: - the onset is with malaise, fever and ocular pain. Signs: - the eyelids are very swollen, red, warm and tender; - chemosis (conjuctival edema) - proptosis; - ocular movements are restricted and painfull. (fig.6.2). Complications: 1, Ocular complications include: - exposure keratopathy: - occlusion of the central retinal artery or vein; - contiguous inflammation of optic nerve; Il. Intracranial complication: - rare; - meningitis - brain abcesses - cavernous sinus thrombosis — it is suspected when: ~‘there is evidence of bilateral involvement; rapidly progressive proptosis; - pupillary abnormalities; - congestion of the facial, conjunctival and retinal vessels; - abrupt progression of clinical signs associated with prostration, severe headache and vomiting. ‘Treatment: antibiotics in high’ doses and anticoagulants, Prognosis is very severe, TH. Subperiostal abscess ~ most located along the medial wall of the orbit; TV. Orbital absc: is rare. Treatment: —- surgical drainage of the affected sinus; - antibiotic therapy should be started without delay; - in children: Ampicillin 200 mg per day + Penicillin 100 mg per day); ~ in adults: Cephalosporins + Metronidazole (to cover anaerobes); - surgical: incision and drainage indicated in orbital abscesses. - local: instillation of antibiotics (ofloxacine ~ 5x/day) 64 | |Assoc. Prof. Dr. Ci ina Nicula - "Pathology of the orbit” 3. Orbital miositis This is an immunologically induced inflammations which usually affects one extraocular muscle. Types: * Acute — appears in orbital cellulitis Clinical features: - lid oedema, ptosis and chemosis; - sudden onset of redress and pain over the involved muscle; - when the patient attempts to move the eye in the field of action of the involved muscle the pain is worsened; - diplopia as a result of under action; - mild proptos Treatment: - corticosteroids. Evolution: - recurrences may occur * Chronic ~ appears in tuberculosis, syphilis Clinical features: = less pain; - the eye cannot move in the direction of the involved muscle. Treatment: —_ - corticosteroids; - radiotherapy to the involved muscle. 4, Tenonitis Hee Represents the inflammation of Tenon’s capsule (fibrous capsule which covers the muscle). * Ethiology: - orbital cellulitis = panophtalmy - rheumatism Types: * Serous Clinical features: - mild proptosis - painfull ocular movement - redness of the eye. © Purulent Clinical features: - great proptosis = very painfull ocular movement. Treatment: — - ethiological; - general antibiotics and nonsteroidal anti-inflammatory drugs. 65 }Assoc. Prof. Dr. Cristina Nicula - “Pathology of the orbit" Graves orbitopathy (tyroid eye disease) © Ethiology: - appears in the first 6 — 12 months of hyperthiroidism - male patients and smokers have a more aggressive disease Clinical features: - in active phase: mark = redness of the eye = lagophtalmos = chemosis = reduced colour vision secondary to compressive optic neuropathy "CT scan: - enlarged medial and inferior rectus muscles > in inactive stable phase: bilateral proptosis periorbital swelling eyelid retraction esotropia skin changes Treatment - inactive phase: = immunosupresive (pulsed steroids therapy, azathioprine) * orbital radiotherapy ~ in inactive phase: » surgery of the orbit, muscle, eyelids can be considered. Orbital tumors Clinical features: It is characterized by proptosis: hard; axial or lateral; painless; ireductible. The tumors located behind the muscle cone is associated with: low visual acuity and retinal hemorrhages and dilated retinal veins at the fundus. (fig.6.3).. The tumors located except the muscle cone is associated with: diplopia and extraocular muscle paralises. Diagnosis: - xray of orbit; - CT-scan; - MRI. Classification: - primary tumors: - congenital; ~ acquired: neurofibrom, rabdomiosarcoma, hemangioma; 66Assoc. Prof. Dr. Cristina Nicula - "Pathology of the orbit” | = secondary tumors: - from the nervous system, sinus and ocular globe - metastatic: chest cancer, hung cancer, renal cancer, prostatic cancer, bone cancer. Treatment: - surgical (extirpation of tumor or exenteration of the orbit); - radiotherapy; - chimiotherapy. | | | 6768Assoe. Prof. Dr. Cristina Nieula - "Lacrimal system pathology" Chapter 7 LACRIMAL SYSTEM PATHOLOGY 1. Dacryoadenitis It is the lacrimal gland inflammation. Causes: - dental, nose or sinus infection (in acute form); - tuberculosis or syphilis (in chronic form), Mikulitz Syndrome Clinical features: Symptoms: - acute onset of discomfort in the region of lacrimal gland. Signs: -swelling in the region of the lacrimal gland fossa with mild downward and inward displacement of the globe; - the palbebral portion of the lacrimal gland may be injected and tender; - oedema of the lateral aspect of the eyelid may give rise to a characteristic S shaped ptosis; ~ reduction in tear secretion as compared with the other side, (fig.7.1). Differential diagnosis made with lacrimal gland tumors. Treatment: - non steroidal - anti-inflammatory drugs. = cthiological - 2. Dacryocystitis It is the infection of the lacrimal sac and it is usually secondary to obstruction of the nasolcarimal duct. Causes of nasolacrimal duct obstruction: - congenital; ~ acquired: - idiopathic stenosis (most commom); - naso-orbital trauma; - following irradiation; - nasopharingeal tumours; - thinitis; - dental inflammation; ~ sinusitis. 2.1. Congenital dacryocystis The nasolacrimal duct is the last portion of the lacrimal drainage system to canalize; At birth the lower end of the nasolacrimal duct is frequently non-canalised, but this is of no clinical significance in most neonates because it canalizes spontaneously soon after birth. 69Assoc: Prof. Dr. Cristina Nicula - "Lacrimal system pathology" Signs of delayed canalization: - epiphora and matting of the lashes, witch may be constant or intermittent when the child has a cold or upper respiratory tract infection; ~ gentle pressure over the lacrimal sac causes reflux of purulent material from the pusicta: (ffig.7.2). Treatment: - massage of the nasolacrimal duct increases the hydrostatic pressure. and thereby ruptures the membranous obstruction; - probing overcomes the obstructive membrane. 2.2, Acquired dacryocystis It may be acute or chronic. Acute Clinical features: - presentation is with sudden onset of pain at the medial canthus and epiphora. Signs:.a,yory tender, red, tense swelling at the medial canthus which may be associated with preseptal celulitis in severe cases. (fig.7.3). Treatment: - systemic antibiotics and warm compresses; - stab incision through the skin may be necessary if the sac is distended and filled with pus; - surgical - dacriocistorinostomy ~ after the acute infection has been controlled. Chronic Clinical features: - presentation is with epiphora associated with a chronic or recurrent unilateral conjunctivitis. Signs: - apainless swelling at the inner canthus - in some cases swelling is absent although pressure over the sac results in reflux of mucopurulent material through the canali. Complication: - Blepharo-conjunctival inflammation because of persistence of purulent discharge; - Corneal ulceration after infection of the cornea with bacteria coming fiom lacrimal sac, after minimal erosion; - Acute dacryocystisis; - Lacrimal abscess or phlegmon when the bacteria from the lacrimal sac pass through the walls of it within the tisues surrounding the sac; - Lacrimal sae mucocel appears by closing openings of the lacrimal sac into conjurictival sac Treatment: is surgical, consisting in dacriocistorinostomy or extirpation of lacrimal sac in mucocel. 70 a