& |4vi|kiete«|t| 4

3 Layers of EyebaLL

-
U
|

1. Sclera [5/6] and Cornea [1/ 6]- Outermost

^
- .
2. Uvea Iris Ciliary body and Choroid

3. Retina - Innermost

•Junction of Cornea with Conjunctiva * Limbus # High - Yield

•Tenon s Capsule- Attached around the limbus

'

•Sub Tenon s space* Episcleral space.

'

•EQUATOR OF EYEBALL- 14mm behind Limbus-> 4 Vortex veins pierce eyeball - Choroidal venous blood drainage
•Ciliary zonules * Suspensory ligaments of Zinn
•Peripheral termination of retina at PARS PLANA - Ora Serrata-> Thinnest part of Retina
•Ciliary Ganglion- Located between Optic nerve and Lateral Rectus muscle

I ORBIT !
Eyeball is located in ORBIT- Pyramidal shape - Made of T bones

.
1 Medial wall* Thinnest wall

-
Bones forming medial wall anterior to posterior Maxilla- Lacrimal

bone- Ethmoid- Sphenoid

2. Lateral wall* Thickest / Strongest

-
3. Floor Weakest wall/ MC wall to be fractured

n Floor of orbit * BLOWOUT FRACTURE

Tear drop Sign on CT- scan

Nerve Injured* Infra orbital nerve

1
 0 Previous Year Questions # NEET PG 3021

There is history of trauma with chisel and hammer and patient states that foreign body enters the
eye . Which of the investigation will be detrimental?
A. MRI Orbit ©
B. Xray orbit
C. CT scan
D. Bscan

0 Previous Year Questions # NEET PG 2018

Most common wall of orbit involved in a blowout fracture is:

A . Medial
B. Floor ©
C. Lateral
D. Roof

AQUEOUS HUMOR

• Production- Ciliary process [Pars plicata]

• Mechanism- Active secretion. Diffusion, Ultrafiltration.

. Rate of production- 2.3 uL/min

• Outflow- S0%- Aqueous outflow-> Trabecular meshwork-> Schlemm' s canal

10%- Uveoscleral outflow-> Suprachoroidal space

EMBROIOGY ]
1. Surface ectoderm derivatives

Lacrimal apparatus

i. Lids and their glands

ii. Lens

v. Conjunctival and Corneal Epithelium

2
 2. Neuroectoderm derivatives

Optic nerve
i. Retina

n. Ciliary and Iris epithelium

v . Dilator and Sphincter Pupillae muscles
v. Zonules of Zinn

VI . Vitreous Gel

3. Hesoderm derivatives

Choroid

i. Primary Vitreous
ii . Belly of Extraocular muscles
v. Temporal portion of Sclera

«i. Neural Crest cells

Ciliary muscle
ii. All corneal layers except Corneal Epithelium [ Bowmann' s layer, Corneal stroma, Descemet' s membrane,

Endothelium ]

in . Sclera[ maximum] with Tenon' s capsule

IV. Tendons of extraocular muscles

v. Orbital bones

VI . Trabecular meshwork, Schlemm' s canal, Angle

VII . Melanocytes

VOLUME )
1. Orbit * 30 ml

2. Eyeball- 6.5 ml

3. Vitreous- k.5 ml

k. Aqueous humor - Anterior Chamber * 0.25 ml; Posterior Chamber 0.06 ml

-
3
REFRACTIVE INDICES |
Aqueous/ Vitreous 1.33

Cornea 1.3T 6

Lens cortex 1.3*1

Lens nucleus * MAXIMUM i.m

RATE OF PRODUCTION

1. Tear film * 1.2 uL / min

2. Aqueous humor * 2.3 uL /min

4
 CMMCTROPIA ]
- Normal vision.

- When the rays of light focus on retina

A Hyperopia
(hyperopic defocus)
B Emmetropia
(sharp vision)
C Myopia
(myopic defocus)
Focal
Focal Focal point
point point

l /
Retina
\
Retina \Retina

MYOPIA / SHORT SIGHTEDNESS |

Distant vision is blurred
Rays of light converge in front of retina

Types:

1. Axial Hyopia

HC Cause of Myopia

Due to long eyeball

1 mm increase length-> 3 D myopia

2. Curvatural myopia

More corneal curvature. E.g- Keratoconus

More curvature of cornea- More Keratometry (K ) reading

^
3. Index Myopia

Refractive index of lens increases e.g- Nuclear cataract

Rx * Concave lenses / MINUS lenses

Myopia should never be overcorrected

5
DUOCHROHE TEST- To determine whether eye is over or under -corrected and adjust
the fine power. PO TE
If Letters in Red are clearer - Add -0.25 D
^ N F A K
If letters in Green are dearer -> Remove -0.25 D

When both are equally dear -> Correct correction point

PATHOLOGICAL MYOPIA

Fundus findings:

1. Foster -Fuch' s spots

2. Temporal crest

3. Macular degeneration

Lattice degeneration
"
L

TEST FOR DISTANT VISUAL ACUITY f

1. Snellen' s chart

VS

F P "2
T O Z ~3
L F E E ‘4-
p E c F D » 5
E D F C Z P
** 6
T E L O P Z D
D C r P O T E C -
Ni
7
0

-n 9
«
10
«

6
2. ETDRS chart (Early Treatment of Diabetic Retinopathy Study)
» «*
*

H V Z D S
N C V K D - *-
»

C Z S H N
-• »
O N V S R -•*
Hi
K D N R O
Z K C S V --
41

D V O H C - --
41

O H V C K
H z C K O
-41

--
•I*
•
•I*
I
N
* •
.•
-
e
C
K H

••••-
»
o --
41
M

-4*»
•u
•*•••

*9
\

HYPERMETROPIA / LONG SIGHTEDNESS }

Rays of light focus behind Retina
Types:
1. Axial hypermetropia- Short eyeball

2. Curvatural hypermetropia- Flatter cornea

3. Index hypermetropia- Decreased refractive index

Newborns are HYPERMETROPIC

Rx » Concave / PLUS lenses

TEST FOR NEAR VISUAL ACUITY = Jager' s Chart

PRESBYOPIA
^
Loss of accommodation with age

Corrected by - Convex / PLUS lenses

•K) yrs- +1D correction required

-
MS yrs +1.5 D correction required

50 yrs- +2 D correction required

55 yrs- +2.5 D correction required

60 yrs- + 3 D correction required

7
 0 Previous Year Questions # NEET PG 2018

A 50- year-old emmetropic patient, presbyopic correction needed is?

A. + 2 D ©
B. + 4 D
C. +3D
D. +tD

ASTIGMATISM ]
1. Regular astigmatism- 2 different foci due to 2 different principle meridian- one steepest and the other with the
flattest curvature. Types:

With the rule- Vertical curvature more than horizontal

-
Correction + Cylinder x SO’ or -Cylinder x180‘

n. Against the rule- Horizontal curvature is more than vertical

-
Correction + Cylinder x 180' or -Cylinder x SO'

in . Oblique - The two axis are perpendicular but between 30-60’ and 120-150' respectively

-
BIOBLIQUE ASTIGMATISM The 2 principle meridian are not perpendicular to each other.

2. Irregular astigmatism- More than 2 foci

TYPES BASED ON THE POSITION OF THE 2 FOCI:

-
1. Simple Astigmatism 1 focus on Retina and other one not on retina.

Simple Myopic Astigmatism- 1 focus on Retina and other one in front of retina
n. Simple Hypermetropic astigmatism- 1 focus on Retina and other behind the retina.

-
2. Compound Astigmatism When both the focal points are either in front/ behind retina at different locations

i. Compound Myopic Astigmatism - Both foci in front of retina at different locations

ii. Compound Hypermetropic Astigmatism - Both foci behind the retina at different locations

-
3. Mixed Astigmatism One focus in front and the other behind the retina

8
0 Previous Year Questions # MEET PG 2021

A 15 year old girl, who is a case of myopic astigmatism is non- compliant for myopic glasses, what
can be prescribed?
A. Lasik
B. Femtolasik
C. ICL
D. Spherical alternative correction ©

0 Previous Year Questions # NIET PG 2019

Which of the following is an example of compound myopic, against the rule astigmatism:
A. -2 D Sph - 2 Dcyl at 180
B. -2D Sph - 1 Dcyl at 90 ©
C. + 2 D Sph - 2Dcyl at 90
D. - 2 Dcyl at 90

STURM ' S C0N01D = Describes the Optics of Regular Astigmatism

The 2 focal points are termed as f1 and f 2

Sturm' s Focal interval Distance between f1 and f 2

2

Midpoint of f1 and f 2 = Circle of least diffusion

0 Previous Year Questions # NUT PG 2018

Which is an example of the simple myopic astigmatism among the prescriptions given below ?
A. Treatment with ( + ) spherical lens
B. Treatment will be cylindrical/piano ( - ) lens ©
C. Treatment will be (-) spherical lens
D. (-) ( + ) ( + ) (- ) on both 90 and 180-degree axis

9
 PARR ROOM PROCCDURCsTp

1. RETINOSCOPY

Done with Retinoscope

Detects the refractive errors

Done at distance of 1 metre from patient

Movement of the Light streak:

1. With the Light movement- Myopia < 1 D, Emmetropia,

Hypermetropia
2. Against the Light movement- Myopia > 1 D

3. No movement- Myopia of 1 D

2 . DIRECT OPHTHALMOSCOPY-

Done very dose to the patient' s eye with direct

ophthaLmoscope
MonocuLar

VirtuaL, Erect, Magnified image obtained

Magnification * 15X
Retina upto equator can be visualized.

Easy for beginners- E.g Intern called to casuaLty for examination will do Direct OphthaLmoscopy.

Magnification * Power of eye /k

For emmetropic eye- Power * +60 D

-
Thus M 60/k 15 -

3. DISTANT DIRECT OPHTHALMOSCOPY -

Done with direct ophthaLmoscope at a distance of 25 cm

Red GLow * Normal

-
Grey Glow Retinal Detachment

10
 Block spots on red background" Cataract / Corneal opacity

-
Black Vitreous hemorrhage

-
Yellow glow Endophthalmitis

4. INDIRECT OPHTHALMOSCOPY-

-
Done with 2 piece instrument Indirect Ophthalmoscope- Head piece + Hand held lens

Binocular vision

Real, Inverted, Magnified Image obtained

Magnification = 5X
Power of hand lens lens ® + 20 D

Retina upto Ora Serrata (Pars Plana) can be seen

Requires practice and experience

Magnification * Power of eye/ Power of lens

-
Commonly used lens is of +20D. Thus Magnification 60 / 20 * k

11
 tuM
PTERYGlUMf
Fibrovascular proliferation of conjunctiva and sub -conjunctival tissues on

cornea

More common on NASAL side

.
Risk factors: Sunlight- UV-B, Limbal stem cell deficiency [Limbal stem

cells usually present in Pallisades of Vogt

Rx of choice * Excision + Conjunctival limbal autograft

0 Prevwus Year Questions # NiFT PG 2019

Visual disturbance in the following condition is due to:

A. Lesion occluding pupil

B. Astigmatism ©
C. Cataract
D. Myopia

VERNAL KERATOCONJUNCTIVITIS / SPRING CATARRH [

Young boys with recurrent, seasonal episodes of severe itching and eye
rubbing, which resolves with puberty
ROPY discharge seen

Signs:
1. Cobblestone/ Pavement stone appearance of papilla

2 . -
MAXWELL-LYON SIGN Discharge between papilla

12
 3. Horner-Trantas dots- Eosinophils with cpi+helial debris

•i. Shield Corneal ulcer

5. Pseudogerontoxon / Cupid' s bow

Rx - DOC * hast cell stabilizers

Low dose steroids can be used

Refractory cases- Cyclosporine / Tacrolimus eye drops

0A female comes with history of contact lens use comes with following. Diagnosis is:
Previous Year Questions
Jr NOT PG 3021

A. Trachoma
B. GPC ©
C. Spring Cataract
D. Acute follicular conjunctivitis

TRACHOMA / EGYPTIAN OPHTHALMIA )

HC Infectious couse of Preventable blindness in the

world

Chlamydia Trachomatis- Serotype A, B, Ba, C

Blindness due to PANNUS- Cellular and vascular

infiltration between corneal epithelium and

Bowmann' s membrane.

WHO- FISTO STAGING

1. F- Follicles / Herbert' s follicles * Pathognomic

[ >5 follicles of >0.5mm size ]

2. I- Inflammation of palpebral conjunctiva

13
 3. S- Scar- ARLT'S LINE

•i. T- Trichiasis- Misdirected eyelashes

5. 0- Opacity of cornea

WHO- SAFE Strategy

1. S- Surgery- Tertiary prevention

2. A- Antibiotics- DOC * Azithromycin- Secondary prevention

3. F- Face washing- Primary prevention

*i. E- Environmental hygiene- Primordial prevention

0 Previous Year Questions

ft iNicrr 2021

SAFE strategy for trachoma includes all except:

A. Surgery for trichiasis
B. Antibiotics
C. Facial cleanliness
D. Evaluation of program ©

0 Previous Year Questions

# NIET PC 2018

What is the most serious cause of conjunctivitis that cause blindness in children?
A. N. gonococcus
B. Streptococus
C. Staphylococcus
D. Chlamydia ©

XER 0PHTHALM1A = VITAMIN A DEFICIENCY *

HC cause of preventable blindness

Staging:
1. XN - Night blindness [Earliest]

14
 2. X1A * Conjunctival Xerosis

X1B * Bitot’s spots

3. X 2 * Corneal xerosis

k. X3A * Corneal ulceration <1/3rd cornea

X 3B * Corneal ulceration >1/ 3rd cornea

5. XF* Fundus changes, 6. XS * Corneal scars

Bitot’s spots

0 Previous Year Questions # Nirr PO 2031

A child came in due to complaints of diminished vision in dim light along with dry eyes and rough
corneal surface. Which deficiency is associated?
A. Iron
B. Protein
C. Niacin
D. Retinoic acid ©

ACUTE HEMORRHAGIC CONJUNCTIVITIS |

Cause * Enterovirus TO

KERATOCONJUNCTIVITIS S )CCA = DRY EYES |

Sjogren syndrome is one of the causes

Stain used to diagnose * Rose Bengal dye
Test * Schirmer’s test

Normal- >10mm in Smins

Dry eye- <10mm

Tear film break up time- If <10sec * Dry eye

Rx * Tear supplement- Hethylcellulose eye drops

15
PHLYCTENULAR CONJUNCTIVITIS |
Commonly seen in children
Type IV hypersensitivity reaction to Staphylococcal / TB Protein
formation with jscicular ulcer

-
DOC Topical Steroids

OPHTHALMIA NEONATORUM]

-
MC Cause Chlamydia [ Earlier- Gonnococus ]

-
Crede ' s method was used in past- 2% Silver nitrate- S/E Chemical conjunctivitis

Rx - Erythromycin

16
Cornea is AVASCULAR

AEROBIC HETABOLISH

Nerve supply * Trigeminal Nerve-> Nasociliary nerve-> Long ciliary nerve [Unmyelinated free corneal nerve endings]

Corneal sensation tested by * COCHET BONNET ESTHESIOMETER

CORNEA = 5 LAYERS

1. Epithelium- Stratified Squamous Non- keratinized epithelium

Layers of the cornea
2. Boumann' s Layer- NEVER REGENERATES IF DAHAGED. Injury
^ - Epithelium
Corneal Opacity
Bowman t
layer

3. Corneal Stroma- Parasol cells / Wing cells / Umbrella cells.

Regular arrangement of Collagen seen- Thickest layer . — Stroma

-
k. Descemet' s membrane STRONGEST Layer

5. Endothelium * Host metabolically active layer

-
Pre- Descemet' s layer DUAS LAYER. It is the 6* Corneal layer.
1 —
Descemet t
membrane

- tndotheth

Iron can get deposited in the corneal EPITHELIUM from Lactoferrin in stagnant tears. It is called as-

1. -
Pterygium STOCKER ' S LINE
-
2. Keratoconus FLEISHERS RING

-
3. Old age HUDSON-STAHLI LINE

k. -
Around filtering bleb of Glaucoma surgery FERRY ' S LINE

0 Previous Year Questions

« iNKfT 2020

True statement regarding KF ring:

1. Seen in all patients with neurological involvement
2. Is pathognomonic for Wilson's disease ©
3. Resolves with treatment
4. Seen in all patients with hepatic involvement
5. Starts first in superior and inferior quadrant

17
GRADES OF CORNEAL OPACITY
^

Iris Damage
A. Nebula Faint scar Iris with details seen Only Bowman' s membrane (BH)
B. Macula Denser scar Iris seen but without BH + Less than 1/ 3rd stroma
details
C. Leucoma Completely white Not seen BM+ More than % stroma
D. Adherent Leucoma + Iris Not seen Penetrating injury
leucoma stuck to cornea

irxTtitL IHQGUDJ
dWEI33&-

Cause Seen in Layer

1. Arcus Senilis Lipid degeneration Old age Bowmann' s layer
2. Arcus Juvenilis Lipid deposition in DM Bowmann' s layer
< kO yr old Familial hypercholesterolemia
3. Kayser Fleisher Copper deposition Wilson' s disease Descemet' s layer
ring Chalcosis

Clear Interval of Vogt is seen in Arcus Senilis.

18
DESCEMENT ' S MEMBRANE TEARS ]1

-
1. Horizontal tears- In Congenital Glaucoma HAAB'S STRIA

-
2. Vertical tears- In keratoconus VOGT’S STRIA

SCHWALBE' S LINE * Peripheral termination of Descemets membrane on cornea

Visualized by * GONIOSCOPE

| ENDOTHELIUM-
Has endothelial pumps like Na+ K+ ATPase

Single layer of Hexagonal cells

Endothelial cell density - Seen by SPECULAR MICROSCOPE

-
Critical density 500 cells/ mm3

Endothelial dysfunction * POLYME6ATHISM

0 Previous Year Questions # NUT PG 2020

Which layer of cornea helps in maintaining hydration of stroma of cornea:

A. Descemet's membrane
B. Endothelium ©
C. Epithelium
D. Stroma

BAND- SHAPED KERATOPATHY

^
Calcific degeneration of Bowman' s membrane

-
Cause Iridocyclitis [ HC ]. Systemic hypercalcemia, Pthisis bulbi

-
Rx * Excimer laser Photoablation

EDTA chelation

19
MEASUREMENT )

1. Corneal Thickness * PACHYMETRY

Normal CCT (Central Corneal Thickness) = 500-600 u

2. Corneal curvature * KERATOMETRY

Normal K reading * +k 3 D to +k6 D

Steeper cornea * Hore value of keratometry * More power of cornea

[ measured in diopters-Dl— Seen in Keratoconus . Keratoglobus
Flat cornea * Cornea Plana

Total normal eye power * Power of Cornea + Power of lens

+60 D +k5 D +15 D

Cornea contributes to 2 /3rd of total eye power

Hicrocornea = Horizontal dimension <10 mm

Megalocornea = Horizontal dimension >13 mm

|KERATOCONUSf

Inferior Paracentral Corneal thinning

Due to weak stromal collagen with less covalent bonds

CLINICAL SIGNS:

1. Earliest * Scissoring reflex on Retinoscopy due to IRREGULAR ASTIGMATISH

2. Retinoscopy- Scissoring reflex. Yawning reflex

3. MUNSON S SIGN * Lower lid indentation on looking downward

k. Vogt stria in Descemet' s membrane

20
 5. Distant Direct Ophthalmoscopy- Oil droplet reflex

6. Fleisher ring in epithelium

t. Acute hydrops - > Apical scarring

IOC= Corneal Topography

Placido Disk ->Distortion of Mires

Rx «

1. Rigid Gas Permeable Contact lenses [RGP-CL ], Rose K

.
Contact lens Scleral contact lens, Reverse Geometry

Contact lenses [ ORTHOKERATOLOGY ] used

SOFT CONTACT LENSES ARE CONTRAINDICATED

2. Implantable Collamer lens Another lens implanted [Phakic

-
IOL ]

3 . Corneal Collagen- Crosslinking / PHOTOPOLYMERISATION by using Riboflavin eye drops with UV-A.

k. ICRS/ Intracorneal Ring Segment - Alters corneal curvature. PMMA rings placed in mid-peripheral cornea.

REVERSIBLE.

5. LASIK/ Laser Assisted In-Situ Keratomileusis- Excimer laser. C /I Thin cornea-

6 . Keratoplasty- Penetrating keratoplasty / DALK

KERAT 0PIASTY = CORNEAL TRANSPLANT !

Types-

-
1. Penetrating Keratoplasty Full thickness keratoplasty. All 5 layers taken

-
2. Lamellar keratoplasty Partial thickness keratoplasty

.
i Anterior Lamellar keratoplasty [ ALK ]

A. Superficial [ SALK ]- Epithelium+ BM+ Anterior vi stroma

B. Deep [ DALK ]- Epithelium BM+ Full stroma
*

21
 n. Posterior Lamellar keratoplasty

A. Endothelial keratoplasty

B. DSEK [Descemet' s membrane stripping endothelial keratoplasty ]

COMPLICATION-

1. HC * Irregular astigmatism

2. Corneal Rejection- KHODADOUST LINE on endothelium V,

DONOR CORNEA- 4
*
Taken within 6 hrs of death

- Minimum endothelial density * 2200 / mm3

Khodadoust Line
PRESERVATIVES

1. Hoist chamber- 2k hr

2. HK medium- 4 days

3. Optisol medium- 4 weeks

CORNEA VERT 1C1LLATA / VORTEX KERATOPATHY

CAUSES

1. Chloroquine/ Hydroxychloroquine
2. Fabry ' s Disease

3. Indomethacin

4. Phenothiazine

CORNEAL DYSTROPHIES -)

A. EPITHELIAL DYSTROPHY-

1. Cogan' s dystrophy
Defective Hemidesmosomes
Painful corneal excisions in fingerprint / map / dot pattern

22
 -
Rx Bandage contact- lenses

Making anterior stromal puncture with Nd-Yag laser

2. Heesman microcystic dystrophy

B. BM DYSTROPHY

1. Reis- Buckler dystrophy

2. Thiel- Behnke dystrophy

C. STROMAL DYSTROPHY

Hacular Granular Lattice

AR AD AD

Abnormal Deposit Mucopolysaccharide Hyaline Amyloid

Stain used Alcian blue Masson' s Trichrome Congo red

D. ENDOTHELIAL DYSTROPHY

-
MC Fuch s Endothelial dystrophy

Beaten metal appearance/ Guttata in endothelium

Causes Bullous keratopathy

KERATITIS / CORNEAL ULCER

Symptoms- Circumcorneal Redness. Pain. Watering, Photophobia

1. Bacterial Keratitis

MC -

1. In the world/ In contact lens users- Pseudomonas

2. In India- Streptococcus Pneumoniae a /k / a Serpiginous ulcer / Ulcus serpens / Creeping ulcer

3. -
Peripheral corneal ulcer Staphylococcus Aureus
k. MC Cause of Hypopyon corneal ulcer
- Streptococcus Pneumoniae

-
5. HC Cause of rapidly spreading/ perforating corneal ulcer Pseudomonas

23
Rx » Topical Vancomycin + Cephalosporin/ Aminoglycoside

Bacteria which can penetrate intact epithelium of cornea —

1. Shigella
2. Neisseria

3. Haemophilus
k. Corynebacterium

5. Listeria

STAINS |

1. Topical Fluorescein 2%- Orange dye Stains floor of ulcer

-
Observe under Cobalt blue filter - Green fluorescence

2. - Stains dead epithelial cells and mucin

.
Use- Viral keratitis Keratoconjunctivitis Sicca [ dry eyes ]

0 Previous Year Questions * NIFT PO 3019

Most common cause of neonatal eye infection is?
A. Staphylococcus
B. Streptococus ©
C. N. Gonorrhoeae
D. Chlamydia

AGANTHAMOEBA KERATITIS |

H/o Contact lens wear

Cleaning contact lens with water / Swimming with contact lenses

Pain out of proportion to signs due to Radial Perineuritis [ HALLMARK ]

24
 Ring stromal abscess
Stain * LAC Stain [Lactophenol Cotton Blue, Acridine orange , Calcoflour white]

Culture * Non- nutrient agar with E.coli overlay

DOC * PHHB (Poly Hexa Methyl Biguanide )

Propamidine

FUNGAL KERATITIS [

Cause- Injury with organic matter / leaf / twig or chronic use of local steroids
MC * Aspergilus Fumigatus
HC in Immunocompromised * Candida Albicans

Signs out of proportion to symptoms

Feathery margins, dry, SATELLITE LESIONS
IHHUNE RING OF WESSELEY

Endothelial plaque / Fungal ball->Fixed, Thick, Infected hypopyon

-
DOC NATAHYCIN

-
DOC for Candida Amphotericin B

0 Previous Year Questions # Nf IT PG 3020

Characteristic finding of fungal ulcer:

A. Satellite lesions ©
B. Dendritic ulcer
C. Ring abscess
D. White hypopyon

VIRAL KERATITIS I

PAINLESS ULCERS due to loss of corneal sensation

Can cause-

1. Dendritic ulcers caused by HSV [ have terminal knobs ]

Pseudodendritis caused by HZV

25
 2. Geographical/ Amoeboid corneal ulcer

-
Rx Topical Acyclovir

3. Nummular / Disciform Kerati+is- Antigen- Antibody reactions, Deposited in stroma

-
Rx Steroids [ Only keratitis where steroids can be used]

k. Viral endothelitis-> Inflammatory Glaucoma

-
Rx Antivirals + Steroids + Drugs to lower IOP

Herpes Zoster Ophthalmicus [ HZO ]

MC Nerve involved * Frontal Nerve

MC Cranial nerve involved * III Nerve

HUTCHINSON'S RULE * If patient develops vesicles on tip of nose, then definitely there is corneal involvement as both

are supplied by NASOCILIARY NERVE.

Rx * Systemic Antivirals [No use of topical]- Acyclovir , Valacyclovir, Famciclovir

EXPOSURE KERATITIS \
Due to inability to dose eyes [ Facial / VII Nerve Palsy ]

Epithelial defect seen in INFERIOR 1/ 3® OF CORNEA

CLOUDY CORNEA

1. All Mucopolysaccharidoses cause Cloudy Cornea EXCEPT HUNTER SYNDROME

-
2. Peter ' s Anomaly Failure of separation of lens placode from cornea

3. Intrauterine infections

k. Trauma

5. Sclerocornea

26
GOLDENHAR SYNDROME-

Pre- Auricular skin tags

Hemiver+ebrae

Limbat dermoid [ CHORISTOHA ]

1
n

27
STAPHYLOMA ]
Ectasia of the ou+er coafs of eyeball wi+h Incarcerafion of uveal tissues

Types:
1. Anterior Staphyloma- Corneal ectasia with Iris lining

Cause * Central corneal ulcers / injuries

2. Intercalary Staphyloma- At Limbus with lining if Iris root

Cause * Perforating peripheral corneal ulcer / Injury

3. Ciliary Staphyloma- Scleral ectasia with ciliary body lining

Cause * Scleritis, Absolute Glaucoma

Equatorial Staphyloma- Sclera with choroid lining

Cause * Absolute Glaucoma, Pathological myopia

5. Posterior Staphyloma- Sclera with choroid lining

Cause * Pathological Myopia

Diagnosis * Ultrasound B- Scan

SGLCR 1T 1s|f

MC Cause * Rheumatoid Arthritis

ANTERIOR SCLERITIS- Painful, Redness + Vision is normal

POSTERIOR SCLERITIS- Painless

T- Sign on Ultrasound B- scan due to fluid accumulation in Sub- Tenon space.

Can cause Serous Retinal Detachment- Decreased vision

^

28
SCLCROMALACIA PCRFORANS |

HC Cause * Rheumatoid Arthritis

Painless ischemic necrosis

Misnomer- No inflammation, rarely perforation

Nevus OF OTA 1
Due to hyperplasia of melanocytes in Lamina fusca- Innermost layer of sclera

Blue SCLERA CAUSCS- f

1.
F*
Osteogenesis Imperfecta
2. Ehlers Danlos Syndrome

3. Harfan' s Syndrome

*i. Congenital Glaucoma

29
 Located in Patellar fossa

-
Covered by Lens Capsule Thinnest a+ the

posterior pole
Diameter * ‘
MOmm

Attached to ciliary process by Suspensory

Ligaments of Einn
Posterior curvature is more than Anterior

curvature.

CATARACT

Opacification of the lens and /or capsule

HC Cause of Blindness worldwide

TYPES:

I. NUCLEAR CATARACT- Due to denaturation of lens proteins.

- .
Causes HEHARLOPIA Day blindness Second Sight in Old people.

II . -
CORTICAL CATARACT Due to hydration of lens fibres. Based

on location of opacity:

I. CUNEIFORM CATARACT- Peripheral wedge- shaped

opacities ->NYCTALOPIA [ More vision loss at night]

II . -
CUPULIFORM CATARACT Central posterior

subcapsular opacity
III. ANTERIOR SUBCAPSULAR CATARACT

i. GlaucomflecUen

ll. Amiodarone

30
 IV. ANTERIOR POLAR CATARACT

Pilocarpine
.
II Perforating corneal injuries
V. POSTERIOR SUBCAPSULAR CATARACT- Causes Maximum Glare / Maximum Visual handicap

Steroids

i. Complicated cataract
n. Infrared radiation / Glass Blower ' s cataract

v. Cupuliform cataract
VI. POSTERIOR POLAR CATARACT

Congenital cataract with Mittendorf ' s dot

Coloured Halos- FINCHAM' S TEST- Differentiate between Early cataract and Acute Congestive Glaucoma
^
Continuous Halos-> Acute Congestive Glaucoma

Broken H a l o s E a r l y cataract

INCIPIENT CATARACT- Early cataract. Causes polyopia and coloured halos

INTUMESCENT CATARACT- Lens gets swollen due to hydration of fibres and pushes the iris forward causing

Secondary Angle Closure Glaucoma-> PHACOMORPHIC GLAUCOMA

Immature cataract with iris shadow Mature cataract - no iris shadow

IMMATURE CATARACT MATURE CATARACT

Greyish - white Pearly white

Iris shadow present No iris shodow

31
HYPERMATURE CATARACT

I. HYPERMATURE SCLEROTIC CATARACT

II. HYPERMATURE MORGAGNIAN CATARACT - Liquifactive degeneration of cortex and nucleus sinks.

Capsule degenerates- Leakage of lens

^
matter - Secondary Open Angle Glaucoma-
^
PHACOLYTIC GLAUCOMA

CONGENITAL CATARACT ]
1. Blue dot cataract / Cataracta Punctata coerulea

MC congenital cataract

Does not affect vision

2. LAMELLAR / ZONULAR CATARACT-

MC Visually Significant Congenital cataract

Fetal Nuclear Cataract

Spokes of a wheel appearance a/k /a Rider' s Cataract

.
Causes- Hypocalcemia. Tetany / Rickets TORCH infections

-
Seen in Congenital Rubella Syndrome Nuclear cataract, Salt and

Pepper retinopathy. Glaucoma

32
NAMED CATARACTS

S High- Yield Cause

1. Rosette cataract Blunt trauma
2. Snowflake cataract Uncontrolled type 1 DM
3. Christmas tree cataract Myotonic dystrophy
k. Sunflower cataract Wilson' s diseases, Chalcosis
5. Oil droplet cataract Galactosemia
6. Propellar cataract Fabry' s disease
1. Stellate cataract Down' s syndrome
8. Shield cataract Atopic dermatitis
*1. Lamellar / Zonular cataract Hypocalcemia / Hypovitaminosis D

Rosette cataract- Blunt trauma Snowflake cataract- Uncontrolled type 1 DM

Christmas tree cataract- Myotonic dystrophy Sunflower cataract- Wilson' s diseases. Chalcosis

33
 Oil droplet cataract- Galactosemia Shield cataract- Atopic dermatitis

Propellar cataract- Fabry's disease Stellate cataract- Down' s syndrome

COMPLICATED CATARACT

Caused by diseases of the eye

-
HC cause Iridocyclitis

Posterior Subcapsular cataract

Bread Crumb appearance / Polychromatic Lustre seen

34
MANAGEMENT OF CATARACT

1. BIOMETRY / IOL POWER CALCULATION-

SRK FORMULA [ Sanders Retzlatt Kaff ] - A- OT K- 2.5 L

Where A * Lens constant

K “ Keratometry reading

L * Axial Length

Other formulas used :

Myopia Holladay I
Hypermetropia Holladay 11 / Hotter Q
PostLASIK Haigis L

2. SURGICAL TECHNIQUES

A. EXTRACAPSULAR TECHNIQUE- Preterred

ECCE/ Extracapsular Cataract Extraction

i. SICS/ Small Incision Cataract Surgery

ii. Phacoemulsitication
B. INTRACAPSULAR TECHNIQUE- Only used in cases ot Dislocated Lens

ECCE SICS Phacoemulsion

Incision site Limbus Sclero-corneal tunnel Peripheral clear cornea

Incision length 12mm 6mm 3mm
Technique Entire lens removed as one Nucleus removed as on Phacoprobe [Titanium probe of
piece piece. Cortex is aspirated 50000 Hz] tragments nucleus
also
Lens used Rigid IOL- PMMA Rigid IOL Foldable IOL- Acrylic,
Hydrogel. Silicone
Astigmatism Maximum Least Correction ot pre existing
astigmatism also
Sutures Must Not required Not required
Visual rehabilitation Slowest Fastest

Glasses [it required] are prescribed atter 6 weeks

PHACONIT * <1mm incision

35
 .
TORIC IOL * For astigmatism Identified by Dialing holes

PC- IOL [ Posterior Chamber IOL ] is commonly used

AC- IOl- UGH Syndrome is a unique complication- UGH * Uveitis, Glaucoma, Hyphema.

3. STEPS OF SURGERY:

Incision on cornea

i. Anterior capsulotomy- Continuous Curvilinear Capsulorrhexis(CCC )

ii. Hydrodissection- Injecting water to separate cortex from capsule

v. Hydrodilineation- Injecting water to separate nucleus
v. Phacoemulsification

VI. Irrigation and aspiration

VII. Foldable IOL insertion

4 . POSTERIOR CAPSULE OPACIFICATION / AFTER CATARACT

HC Complication of cataract surgery

i. ELSHNIG' S PEARLS- Affect vision

II. SOHMERINGs RINGS

Rx * Nd- Yag Laser posterior capsulotomy

Elsctmg't peart Soemmerings
after cataract after cataract
[ PHOTODISRUPTION]

[ECTOPIA IENTIS
Uniocular diplopia [ Diplopia persists even when one eye is closed]

36
 # -
High Yield Features Dislocation
1. Marfan' s Syndrome Tall, thin, Hyperextensible joints, Superotemporal dislocation
Arachnodactyly
2. Homocystinuria Fair skinned, Mental retardation, Inferonasal dislocation
Thromboembolism

3. Weil- Marchesani Short stature, Short and stubby Anterior / Inferior dislocation-
^
Syndrome fingers and toes, Microspherophakia PHACOTOPIC GLAUCOMA [ Secondary

Angle Closure Glaucoma]

0 Previous Year Questions

# NKT PC 2021

A boy came with thin built, lens subluxation and long fingers, shows deficiency of cystathione
synthase. Which AA should be supplemented?
A. Serine
B. Tyrosine
C. Methionine
D. Cysteine ©

ICNTlCONUs ]
1. Anterior Lenticonus= Alport Syndrome

2. Posterior Lenticonus= Lowe Syndrome

37
 OortXS

Consists of Iris, Ciliary body [Pars Plicata and Pars Plana] and

Choroid

Bruch' s Membrane separates choroid from Retina Lens UVEA

Muscles of iris - Sphincter pupillae and Dilator pupillae

Sphincter pupillae Dilator pupillae

Circular muscle Radial muscle

Contraction
^ Miosis Contraction

Mydriasis
Parasympathetic Sympathetic
innervation innervation

Supply: Short ciliary nerve Supply: Long ciliary

nerve

UVEITIS ]
Anatomical Classification:

Structure involved Clinical features

1. Anterior Uveltl s = Irldocydltls Inflammation of Iris and Pars Painful decrease in vision [ due to

plicata ciliary muscle spasm] + Redness

2. Intermediate Uveitis Pars planitls Painful decrease in vision + Redness +

Floaters

3. Posterior Uveitis Chorioretinitis Painless decrease in vision + Floaters

PAN UVEITIS * Anterior Intermediate + Posterior Uveitis

38
Differential Diagnosis of Redness of eye with Painful decrease in vision:

1. Corneal Ulcer

2. Acu+e Congestive Glaucoma

3. Anterior uveitis

0 Previous Year Questions i INKET 3020

Iritis is seen in all except?

1. Rheumatoid arthritis ©
2. Behcet's disease
3. Ulcerative colitis
4. SLE ©
5. Psoriatic arthritis

ANTERIOR UVEITIS / 1RID0CYCUTIS: |

MC cause = Idiopathic

Clinical features:

AQUEOUS FLARE " Earliest Sign of Iridocyclitis [ Seen due to Tyndall Effect]

AQUEOUS CELLS " Earliest sign of Active Iridocyclitis [ Seen due to

Brownian movement]. SUN Grading is used to measure the intensity of

inflammation.

Muddy iris/ featureless iris- Due to edema

Keratic precipitates (KPs) seen in Arlt' s triangle Keratic precipitates in Arlt' s triangle

(triangle in inferior part of cornea)

39
 Synecbiae/ Adhesions-
1. Anterior synechiae- Central or peripheral anterior synechiae

2. Posterior synechiae-

i. Total posterior synechiae (Entire iris stuck to lens ) Occlusio

Pupillae
n. Only pupillary border is stuck to lens * Festooned pupil
m. Annular pupillary synechiae * Seclusio P u p i l l a e C a n cause Iris Bombe
Iris Bombe

Keratic Precipitates:

1. Fine / Granular KPs- Due to lymphocytes. Seen in non- granulomatous uveitis.

2. Hutton-Fat KPs- Due to macrophages. Seen in Granulomatous uveitis. E.g- TB, leprosy , Syphilis, Sarcoidosis,

Sympathetic Ophthalmia.

TYPES OF IRIS NODULES:

1. Koeppe s Nodules * On pupillary border

2. Busacca' s Nodules * On the body of Iris

HLA ASSOCIATED ANTERIOR UVEITIS

1. Ankylosing Spondylitis- HLA B2T

2. Birdshot Chorioretinitis- HLA A2*t

-
Rx Topical steroids Cydoplegics

-
HC complication Secondary Glaucoma

FUCH S HETEROCHROMIC IRIDOCYCLITIS:

i
i

40
 Stellate KPs with diffuse distribution k / a Endothelial dusting

Triad: Heterochromia of iris, Fine stellate KPs, Cataract .

>
AMSLER'S SIGN* Paracentesis - Hyphema [ Bleeding in the anterior chamber ]

P0 SNER - SCH10SSMAN SYNDROME / HYPERTENSIVE UVEITIS / GIAUCOMATO- CYCUTIC

CRISIS:

Stony hard eye due to raised IOP [Secondary open angle glaucoma]
Dilated pupil
White eye [ no redness ]

INTERMEDIATE UVEITIS }

Idiopathic pars planitis

SNOW BANKING seen at inferior pars plana * PATHOGNOMIC

C / f * Floaters

>
Rx * KAPLAN' S Step up Approach is used: Steroid injections into Sub Tenon' s space - Intravitreal steroids -
^
Cyclodestruction-> Vitrectomy

POSTERIOR UVEITIS

MC Cause * Toxoplasmosis - Headlight in Fog Appearance

- -
MC Immune cause Sarcoidosis Has retinal nodules [LANDER ' S SIGN] with inflammatory exudates at retinal vessels

[ CANDLE WAX DRIPPINGS]

MC Cause in Immunocompromised/ HIV + patients with CDk <50 /uL

- CMV Chorioretinitis- Bushfire appearance / Pi2za

. -
pie appearance / Sauce and Cheese appearance Rx Ganciclovir

41
RUBEOSIS IRIDIS = NEOVASCULARISATION OF IRIS

HC Cause * Proliferative Diabetic Retinopathy

Due to VEGF produced by hypoxic retina

Neovascularisation is first seen on the Iris [ T* site * Pupillary border ]

Can cause Neovascularisation Glaucoma- Due to neovascularisation at the angle

Rx * Pan- RETINAL photocoagulation

SYMPATHETIC OPHTHALMIA [
Penetrating injury to an eye [Exciting eye ] causes Granulomatous Pan uveitis of the other eye [ Sympathizing
eye ] after a period of 2 weeks to 3 months due to formation of autoantibodies against the Retinal S antigen
Maximum risk of sympathetic ophthalmia in injury to Ciliary region [Danger zone ]
V * symptom * Blurred near vision

-
T* sign Retrolental flare in sympathizing eye

-
DALEN FUCH S NODULES Seen in choroid

Rx * Enucleation of the EXCITING eye within 2 weeks of injury, Systemic steroids

0 Previous Year Questions # NIET PC 2030

Pre requisite for sympathetic ophthalmitis is due to:

A. Penetrating trauma to eye ©
B. Blunt ocular trauma
C. Uveitis due to sarcoidosis in one eye
D. Urinary tract infection

42
ENDOPHTHALMITIS)

Inflammation of the inner structures of the eyeball with the layers

except sclera.
HC Cause

-
1. Early Post- operative endophthalmitis Staphylococcus

Epidermidis
-
2. Delayed post-operative endophthalmitis Propionibacterium acnes

3. Fungal post-operative endophthalmitis- Candida Albicans

M. Traumatic endophthalmitis- Bacillus Cereus

C / f: Redness with painful decrease in vision, Hypopyon, Vitreous exudates

Diagnosis: Intravitreal tapping and culture

Treatment: Intravitreal Antibiotics/ Antifungal + Dexamethasone

If does not improve in *i8- T 2 hrs ~> Vitrectomy

0 Previous Year Questions # NUT PC 2018

A 70 years old lady 2 days following cataract surgery presents with eye complaints as shown in the
image. Next step in its management is?

A. Intravitreal antibiotic Q
B. Intravitreal steroids
C. Eye patch and dressing
D. Intravitreal mannitol

PANOPHTHALMITIS |
Inflammation of the contents of eyeball with the coverings including Sclera
and TENON S CAPSULE.

C / f: Features of endophthalmitis + Lid edema, Proptosis, Chemosis.

43
 Rx « Evisceration- Emptying out the contents of eyeball [ Enucleation is C / I as it can cause meningitis due to
spread of infection through exposed meninges]

MALIGNANT MELANOMA OF CHOROID |

HC primary malignancy of eye in Adults

Collar stud/ Mushroom shaped tumor

Ruptures the Bruch' s membrane

Can cause serous retinal detachment

Metastasize: Via vortex veins to Liver

Modified CALLENDER Classification - Histopathological classification

Spindle A » Best prognosis

Epitheloid * Worst prognosis
RXB Enucleation

For small tumors- Brachytherapy can be used.

MISCELLANEOUS |

1. D - shaped pupil- Iridodialysis 2. Festooned pupil- Iridocyclitis

3. Tear shaped pupil- Iris coloboma [ MC locations Inferonasal ]

44
 Normal IOP * 10-21 mm Hg

2nd HC Cause of Blindness in the world

Glaucoma is a chronic progressive condition due +o death of retinal ganglion cells resulting in characteristic

Optic disc changes and visual field defects with IOP being a modifiable risk factor.

T 0N0METRY = MEASUREMENT OF IOP 1 ’

*
J
A. INDENTATION TONOMETER - Cornea is indented by the tonometer .
\ /
\
1. Schiotz Tonometer - Readings affected by scleral rigidity. Falsely low -pressure readings
in decreased sderal rigidity. Eg- Myopes.

7
B. APPLANATION TONOMETER - Imbert -Fick Principle is used

1. Goldmarm Tonometer - GOLD STANDARD. Readings affected by

Central Corneal Thickness [10U-> 1mm Hg difference in IOP ].

Thicker cornea gives falsely high IOP readings.

2. Perkin's Tonometer - Hand held

3. Mackay - Marg Tonometer - Can measure IOP in scarred/ edematous cornea, and through soft contact

lenses.

4. Tonopen

5. Non- contact Airpuff Tonometer

c. iCare Tonometer - For self -use

D. Dynamic Contour Tonometer / Pascal -

Principle * Contour matching

Use * PostLASIK IOP Measurement

45
PRIMARY OPEN ANGLE GLAUCOMA: |

More commonly seen.

Slow progressive painless decrease in vision

Risk factors: Aging, Blacks, DM, Decreased central corneal thickness, Myopia, Cigarette smoking. Family history.

Optic Disc Changes :

1. Increased Cup-Disc Ratio (CDR ) [Normal is upto 0.6 ]

2. Difference in CDR of the two eyes > 0.2

3. ISN' T RULE IS BROKEN as the inferior fibres are

first affected- Inferior Notching of the rim

^
ISNT RULE * Normally cup is thickest Interiorly and thinnest
Temporally

[ Inferior I > Superior S > Nasal N > Temporal T]

k. Bean- Pot cupping of the disc

5 . Laminar Dot sign [Lamina cribrosa seen through the thinned out disc]

6. Nasalisation of vessels

T. Bayonetting sign
8. Baring of the circumlinear vessels

Visual field defects:

1. Contraction of Isopter (Earliest )

2. Paracentral Scotoma / Bjerrum' s scotoma (Earliest Visually significant)

3. Arcuate scotoma / Seidel' s scotoma Bjerrums area

Bjerrum scotoma
k. Biarcuate / Ring scotoma- Has Nasal step of Roenne
Paracentral scotoma
[ Papillo- Macular Bundle is spared]
Blind spot
5. End stage- Temporal island of vision is spared Seidel scotoma

Centrocecal scotoma

Central scotoma

Nasal step

46
0 Previous Year Questions
ft iNicrr 3030

True regarding POAG.

1. Abnormality of trabecular meshwork is seen on gonioscopy
2. First degree relatives have more chances of developing steroid induced glaucoma
3. Dilatation of pupil is associated with exacerbation of IOP
4. First degree relatives are at 1% increased risk of POAG ©
5 . Visual field defect can exist with normal C:D ratio ©

0 Previous Year Questions

ft NEET PG 3018

Last vision to go in glaucoma is:

A. Temporal ©
B. Superior
C. Inferior
D. Nasal

PRIMARY ANGLE CLOSURE GLAUCOMA

Risk factors: Hypermetropia, Asians Wbl / / Red eye< '

r V' *

Acute painful decrease in vision with redness of eye

Vertically oval, mid-dilated pupil, Non-reactive to light

Shallow AC (Anterior chamber )

Corneal edema

differentiates between coloured halos of cataract Cprneal

and glaucoma Mid-dilated v i .f • haze

pupil

VOGT'S TRIAD

1. Iris atrophy

2. Mid-dilating non-reactive pupil

3. Glaucomflecken [ Anterior Sub capsular cataract]

Rx * First line- To decrease IOP * Mannitol

Drug of choice * Pilocarpine

Treatment of choice * Laser Peripheral Iridotomy with Nd-Yag laser

47
 Provocative tests: Tests to suggest the tendency to have angle-closure Glaucoma [Not diagnostic] —

1. Dark room test

2. Prone test

3. Water drinking test

k. Mydriatic Test

5. Mydriatic- Miotic test " BEST AND MOST RELIABLE TEST

ANTIGLAUCOMA DRUGS:]

A. Drugs increasing Trabecular Outflow

1. Pilocarpine

2. Epinephrine, Dipivefrine

3. Netarsudil (Rho kinase Inhibitor )

k. Bimataprost

0 Previous Year Questions i Mien 7070

How to differentiate the causes of a dilated pupil?

1.1% Phenylephrine
2.1% Pilocarpine ©
3.0.25% Pilocarpine
4.4% Cocaine
5. Epinephrine

B. Drugs increasing the Uveosderal Outflow

1. Prostaglandin Analogues [ Bimataprost increases both- Uveosderal and Trabecular Outflow ]

2. Epinephrine. Dipivefrine

3. Brimonidine

k. Apraclonidine

48
 C. Drugs that decrease aqueous production

1. Alpha agonists- Apradonidine, Brimonidine [ Also has Neuroprotective Action ], Clonidine, Dipivefrine,

Epinephrine.
2. Beta Blockers-

3. Carbonic Anhydrase inhibitors- Acetazolamide (Systemic)

Brinzolamide , Dorzolamide (Topical)

D. Hyperosmotic Agents- Mannitol, Glycerol.

CONTRAINDICATIONS

1. Prostaglandin- Ocular Inflammation

2. Beta blockers- Asthma except Betaxold can be given

3. Alpha agonists- C/I In children as they cause Respiratory depression and Apnea.

0 Previous Year Questions

# NtfT PC 3019

Which anti- glaucoma drug causes ocular hypotension with apnea in an infant?
A. Latanoprost
B. Timolol
C. Brimonidine ©
D. Dorzolamide

0 Previous Year Questions # NUT PO 3019

Drug used in acute congestive glaucoma are:

A. Atropine
B. Pilocarpine
C. Acetazolamide
D. Both BandC ©

49
SURGICAL MANAGEMENT OF GLAUCOMA

Trabeculectomy * GOLD STANDARD

Glaucoma Drainage device / Setons - Used for Neovascular / Resistant Glaucoma. Drain aqueous from AC to the

subconjunctival space.
Ahmed Glaucoma Valve * MC used

ExPRESS shunt * Stainless steel

iStent * Titanium

solX * Gold- Drains aqueous into suprachoroidal space.

0 Previous Year Questions

# MEET PG 2019

Which one of the procedure involves using glaucoma drainage device?

A . Seton operation ©
B. Deep sclerectomy
C. Viscocanalostomy
D. Trabeculectomy

CONGENITAL GLAUCOMA ]

Triad

1. Photophobia

2. Watering

3. Blepharospasm

Buphthalmos (Bull eye )

Haab ' s striae - Horizontal DM tears

Rx * Clear cornea-> GONIOTOMY

Hazy cornea-> TRABECULOTOMY

Best surgery * Trabeculotomy Trabeculectomy

50
 0 Previous Year Questions # NEET pc 2021

A one month baby comes with watering and megalocornea , diagnosis is:

* f

A. Buphthalmos ®
B. Cataract
C. MPS
D. Hurler syndrome

PIGMENT DISPERSION GLAUCOMA -

Krukenberg spindle

1. KRUKENBERG SPINDLE * Spindle on endothelium

2. Radial transillumination Iris Defects TRIAD

3. Pigmented Trabecular Meshwork

k. SAMPAOLESl ’S LINE * Prominent Schwalbe' s line seen in Descemet' s membrane

NORMAL TENSION GLAUCOMA

Visual field defects and Optic disc changes in the absence of raised IOP. It increases the risk of POAG.

51
OCULAR HYPERTENSION

Raised IOP in the absence of optic disc or visual field defects.

GON1QSCOPY )

Non -pigrr pnted trabecular meshworfc

.
Schw Ibe ' s line .
Pigmented trabecular meshworfc
Scleral spur

Ciliary body band

Used to visuali2e the angle structures

To differentiate between angle closure and open angle Glaucoma

Angle structures visualized Angle Inference

I Iris root 50' Wide open angle

Can Ciliary Body band Wide open angle

See Scleral spur 30' Open angle

Till Trabecular mesbwork 20* Almost closed angle

Schwalbe Schwalbe' s line 10" Closed angle

ASSESSMENT OF VISUAL FIELD |

1. Confrontation Test

2. PERIMETRY

52
I. STATIC PERIMETRY- The brightness of the light target changes, the target does not move.

.
E.g- Automated perimeters [ Humphrey ' s perimeter, Octopus perimeter Field master ]

II. kINETIC PERIMETRY- The light target is moved from non- seeing to seeing area. Light targets of —
different sizes can be used. Types:

-
Gddmann perimeter GOLD STANDARD. Assess central + Peripheral field

-
Bjerrum's tangent screen, Campimetry Assessing the central field
n.
-
Lister's perimeter Assessing the peripheral field

ISOPTER = Line joining the areas of equal Retinal sensitivity.

53
 Primary Vitreous Hyaloid artery Mesoderm

Secondary Vitreous Vitreous gel Neuroectoderm

Tertiary Vitreous Ciliary 2onules of Zinn Neuroectoderm

REMNANTS OF PRIMARY VITREOUS

[ Hyaloid Artery ]- Wetgers ligament

Primary vitreous
1. CLOQUETS CANAL
Antenor hyaloid
membrane * Posterior hyaloid
* membrane
2. BERGMEISTER ' S PAPILLA Patellar fossa
( Space of Berger ) * * Optic disc

3. MITTENDORFS DOT
Vitreous base
HUSCAE VOLITANTES (4 mm) *
Cloquefs canal
*
Ora serrata Secondary vitreous

Structures of Vitreous

Persistent Hyperplastic Primary Vitreous-

1. Hicrophthalmia

2. Leucocoria

3. Elongated Ciliary process

Vitreous hemorrhage during cataract surgery

VITREOUS HEMORRHAGE

MC Cause- Proliferative Diabetic Retinopathy

Clinical features-

1. Small hemorrhages- Floaters

2. Hassive hemorrhage- Sudden painless loss of vision

EAIE’S DISEASE-

Recurrent vitreous hemorrhage in an apparently healthy male

Mid- peripheral retina

54
 Periphlebitis of retinal veins
Delayed hypersensitivity to TB proteins

VITREOUS DEGENERATION- }
1. Synchisis Scintillans- Cholesterol/ lipid particles

2. Asteroid hyalosis- Calcium particles

55
Retina has 10 layers Retinal layers Components

9 Nerve fiber layer — 10 Inner limiting membrane

Outermost to innermost are:
Axons at surlace of
retina passing via
8 Ganglion cell layer — optic nerve, chiasm
1. Retinal Pigment Epithelium and tract to lateral
geniculate body
2. Layer of photoreceptors 7 Inner plexiform layer — Ganglion cell

3. External Limiting Membrane

Muller cell
6 Inner nuclear layer — ( supporting glial cell)
*i. Outer nuclear layer
Bipolar celt

5. Outer Plexiform layer Amacnne cell

5 Outer plexiform layer —
Horizontal cell
6. Inner Nuclear layer
Rod
Cone
t. Inner Plexiform layer
4 Outer nuclear layer —
8. Ganglion cell layer 3 Outer limiting membrane —
Pigment cells
2 Photoreceptor layer —
*1. Retinal Nerve Fibre layer
10. Internal limiting membrane 1 Pigment epithelium —
Choroid

CRAP / CENTRAL RETINAL ARTERIAL OBSTRUCTION |

-
HC Cause Embolism

Cholesterol embolus is k /a Hollenhorst Plaque

-
MC Site Lamina Cribrosa

C / f- Sudden painless loss of vision

Fundus -
1. Milky white retina with Cherry-Red spot

2. Cattle trucking / Box carring of retinal vessels

Irreversible in k-6 hrs

-
Rx- First and best treatment Ocular massage

Differential Diagnosis of Cherry Red Spot

1. CRAO
2. Trauma
3. Gaucher ' s disease
k. Tay- Sach' s disease

56
CRVO / CENTRAL RETINAL VEIN OCCLUSION |

MC Cause * Atherosclerosis

HC Site * Lamina Cribrosa

C / f- Slow , painless loss of vision

Fundus * Splashed Toma+o appearance / Blood and Thunder Appearance

Neovascular Glaucoma * SO day Glaucoma / 100 day Glaucoma

0 Previous Year Questions # NiiT PG 2018

100- day glaucoma is seen in

A. Central retinal vein occlusion ( CRVO ) ©
B. Central retinal artery occlusion ( CRAO )
C. Diabetic retinopathy
D. After injury

0 Previous Year Questions * win PC 2018

Cause of given retina image is:

A. Acute leukemia ©
B. Sickle cell anemia
C. Beta thalassemia
D. Uveal melanoma

57
DIABETIC RETINOPATHY

HC Vascular disease of retina

Severity depends on: Duration of diabetes, Control of blood sugar , a / w
Smoking. Pregnancy, HTN
Stages: NPDR and PDR

1. NPDR / NON PROLIFERATIVE DIABETIC RETINOPATHY —

> No new blood vessels seen

> Earliest/ 1st sign * Microaneurysms
> Dot- Blot hemorrhages
> IRMA / Intra Retinal Microvascular Anomalies

2. PDR / PROLIFERATIVE DIABETIC RETINOPATHY

> Hallmark * Neovascularisation

> -
Rx Pan-Retinal Photocoagulation by Argon Green Laser;
Start with the inferior quadrant
Anti VEGFs- Bevaci 2umab, Ranibi 2umab Pan- Retinal Photocoagulation
( PRP )

Pathology Layer of Retina

1. Superficial/ Splinter hemorrhage RNFL

2. Soft exudates / Cotton- wool spots

3. Microaneurysm Inner nuclear layer

k. Deep/ Dot- Blot hemorrhage Outer plexiform layer

5. Hard exudates/ Macular star

SCREENING j

1. Type 1 DM = Begin screening 5 yrs after diagnosis , then Annually

2. Type 2 DH = Screening at the time of diagnosis, then Annually

0 Previous Year Questions * NUT PO 1011

An elderly female with gradual painless DOV fundus image

A. Hard exudates in DR ©
B. Flame Hemorrhages in HTN —>
C. Soft exudates in HTN
D. CRVO

58
HYPERTENSIVE RCTlNOPATHYf
Earliest sign * Arteriolar spasm

Hallmark * Flame shaped hemorrhage / Splinter hemorrhage in RNFl

KEITH- WAGNER- BARKER CLASSIFICATION:

1. Grade 1- Arteriolar attenuation

2. Grade 2- Splinter Hemorrhage

SALUS SIGN [ Deflection of vein at arterial crossing]

3. Grade 3- GUN SIGN [Tapering of vein on either side of arterial crossing]

BONNET SIGN [Distal banking of the vein ]

Soft exudates / Cotton- wool spots

Copper- wiring of arterioles

k. Grade k- Silver- wiring of arterioles

Papilledema

RETINAL DETACHMENT ]

I
1. RHEGMATOGENOUS RETINAL DETACHMENT

> Causes: Pathological myopia, Trauma, Lattice

degeneration of retina
> C / f: Sudden painless loss of vision like a Curtain coming

down'. Flashes and Floaters

> Signs: RAPD, Greyish reflex at pupil, SHAFFER ' S SIGN

[ Tobacco dusting of Vitreous ]

> IOC * Indirect Ophthalmoscopy

> LINCOFF RULE * Used to identify the site of retinal break

> -
VITREOUS SUBSTITUTES Used to reattach the detached retina.

Liquid * Silicone oil/ Perfluorocarbon liquid

Non- expansile gas * Air, N20 [ Avoid general anaesthesia- Second gas effect]

ii. -
Expansile gas SF6, C3F8 [ Avoid air travel as gas expands-> Functional CRAO ]

59
 2. TRACTIONAL RETINAL DETACHMENT

> Due +o retinal neovascularisation

> Causes: MC * Proliferative Diabetic Retinopathy, Ischemic CRVO, Retinopathy of prematurity, Sickle

cell Retinopathy [ Sea fan neovascularisation]

> Rx * Vitrectomy + Pan retinal photocoagulation

3. SEROUS/ EXUDATIVE RETINAL DETACHMENT

> Due to fluid in sub retinal space

> Hallmark * Shifting fluid

> Causes: PIH, Posterior scleritis. Malignant melanoma of

choroid

> Rx * Treat the underlying disease

0 Previous Year Questions # NIET PG 2020

Shifting fluid sign in:

A. Exudative Retinal Detachment ©
B. fractional RD
C. Rhegmatogenous RD
D. Retinal dialysis

RETINOBLASTOMA |

HC Primary Malignant Intraocular Tumor in Children

Rb gene located on chromosome 13q14 [Knudson' s two hit hypothesis ]

60
 HC Presentation * Leukocoria followed by Squint

Pseudohypopyon can be seen due to tumor cells in AC

HC site of metastasis * Brain

Trilateral Retinoblastoma * Bilateral retinoblastoma + Pinealoblastoma

HC Second malignancy in Rb mutation * Osteosarcoma

Hallmark * Flexner - Wintersteiner Rosette

Commonest cause of intraocular calcification

0 Previous Year Questions

ft NIET PG 3021

A child with whitish pupillary reflex has undergone enucleation & shows Flexner winter Steiner
rosette. Diagnosis is?
A. Retinoblastoma ©
B. Rhabdomyosarcoma
C. Medulloblastoma
D. Astrocytoma

0 Previous Year Questions * INICET 2021

Retinoblastoma most commonly spread via:
A. Lymphatic spread
B. Hematogenous spread
C. Direct spread
D. Optic nerve invasion ©

0 Previous Year Questions

# INICET 2021

There is a Proptosis in a child with desmin positive tumor. What is the probable diagnosis?
A. Embryonal rhabdomyosarcoma ©
B. Leukemia
C. Lymphoma
D. Ewing's sarcoma

61
 0 Previous Year Questions # MEET PG 2019

Chemotherapy agents for retinoblastoma:

A. Vincristin, carboplatin and etoposide ©
B. Vinblastine, etoposide and bleomycin
C. Vinblastine, vincristine and etoposide
D. Vinblastine, vincristine and cisplati

RETINITIS PIGMENTOSA ]

MC Hereditory retinal detachment involving rode > cones retinitis pigmentosa

HC Inheritance ® AR

Earliest symptom Night blindness

®

Earliest sign * Delayed a wave on ERG

Perimetry * Ring scotoma-> Tunnel vision

Fundus-

1. Black bony corpuscles in mid-peripheral retina

2. Waxy yellow pallor of optic disc

3. Arteriolar attenuation

Syndromes associated with RP:

1. USHER SYNDROHE * MC- SNHl with retinitis pigmentosa

2. COCKAYNE Syndrome

3. REFSUH DISEASE- Abnormal phytanoic acid oxidase

k. BASSEN- KORNHWEIG DISEASE- Abetalipoproteinemia

5. LAURENCE- HOON-BIEDL Syndrome- Obesity , Polydactyly , Mental retardation

62
 Central Serous Retinopathy (CSR) Cystoid Macular Edema (CHE)
Spontaneous serous detachment of the Fluid accumulation in Henle' s layer (Outer

neurosensory retina in macular region plexiform and inner nuclear layer)

Due to Choroidal hyperpermeability Breakdown of inner blood-retinal barrier

Causes Steroid, emotional stress, Cushing' s Many ocular disorders

syndrome, 3rd trimester of pregnancy Niacin

Prostaglandin analogues
FFA [Fundus Floreseein Ink blot/ Smoke stack pattern Flower Petal appearance

Angiography]

Fundoscopy Circular ring reflex Honey- comb appearance

• r' X '1

Rx Self -resolving Anti- prostaglandins/ steroids

OCT

63
0 Previous Year Questions
# NEET PG 2020

Which vitamin in supra physiologic dose cause macular oedema and macular cyst:
A. Vitamin A
C. Vitamin E
B. Vitamin D
D. NIACIN ©

0 Previous Year Questions # NEET PG 2019

Which of the Parameter is Decreased in Retinitis Pigmentosa?

A. Arachidonic Acid
B. Trielonic Acid
C. Thromboxane
D. Docosahexanoic acid ©

RETINOPATHY OF PREMATURITY (ROP )

Seen in preterm babies due to incomplete vascularisation of retina- Hypoxia

>
Screening- Ideally 2 screening tests.

T* Screening

28- 34 weeks OR <2000 gms At weeks

<28 weeks OR <1200 gms At 2-3 weeks

Staging-

Stage 1- Demarcation line

Stage 2- Demarcation ridge

Stage 3- Neovascularisation

Stage 4- Subtotal retinal detachment

Stage 5- Total retinal detachment

64
Plus disease * Dilatation and Tortuosity of blood vessels in 2 quadrants

Rush diS i' * Rapidly progresses to stage 5

Rx * Type 1 ROP- Laser photocoagulation of peripheral avascular retina within 48 hrs

Type 2 ROP- Observation

Rush disease- Anti- VEGF

0GUCH1 DISEASE

Congenital stationary night blindness

Has MIZUO PHENOMENON [Fundus has a Golden Yellow glow which becomes
normal with prolonged dark adaptation]

65
 Fut Li^S & L'lo'liH'll
PTOSIS }

Ham lid elevator * Levator Palpebrae Superiors (LPS) - III Nerve

supply
Muller' s muscle has Sympathetic supply

Causes of Ptosis:

1. Neurogenic: III nerve injury, Horner' s syndrome (Muller ' s muscle)

2. Myogenic: Hyastenia gravis, Hyotonic dystrophy

3. Mechanical: Due to any lid mass

Involutional: Senile ptosis

5. Congenital Ptosis- LPS has aberrant nerve supply from Mandibular branch of V nerve, which also supplies

Lateral Pterygoid Huscle-> Marcus Gunn Jaw Winking Phenomenon

Rx:

1. Ptosis due to Horner ' s syndrome * Fasanella- Servat Procedure [ Tarso Hullerectomy ]

-
2. Congenital ptosis Tarso- Frontalis sling operation

-
3. Senile ptosis LPS Resection. 2 approaches:

i.
-
Conjunctival approach BLASKOVIC 'S Operation
ii. -
Skin approach EVERBUSCH Operation

0 Previous Year Questions

# NIFT PG 3021

The given defect is most likely associated with which complication?

••

A. Cataract
B. Exposure keratitis ©
C. Difficulty in eye movement
D. Glaucoma

66
 0 Previous Year Questions # MEET PG 2019

Which is the most common ocular finding in myasthenia gravis?

A. Ptosis ©
B. Lagophthalmos
C. Proptosis
D. Enophthalmos

ENTROPION

= Inward turning of lid margins

Surgeries:

1. Quickert suture

2. Jones Procedure

3. Wies Procedure

ECTROPION |

= Outward turning of lid margins

TRICHIASIS |

= Misdirection of eyelashes

67
| D1STICH1ASIS )

Extra row of eyelashes due +o Hebomian gland me+aplasia

0 # NIET PC 2020

Presence of extra layer of cilia posterior to grey line is:

A. Tylosis
B. Madarosis
C. Distichiasis ©
D. Trichiasis

TR 1CH0MEGALY

= Hypertrophy of eyelashes. Side effect of Prostaglandin analogues.

68
MADAROSIS

* Loss of eyebrows. Seen in Leprosy, Hypothyroidism

LID GLANDSf
Base of eyelash has

1. Zeis gland- Modified sebaceous gland

2. Holl gland- Modified sweat gland

Tarsal gland" Meibomian gland

A . Acute suppurative inflammation

1. Hordeolum Externum/ Stye

r Infection of Gland of Zeis- Painful swelling of lid margin

with pus pointing at the base of eyelid.

-
Rx Hot Fomentation. Epilation (removal of eyelash)

2. Hordeolum lnternum= Infection of Meibomian gland

Painful nodule which develops away from the lid margin

Rx * Hot fomentation, Incision and Drainage ( Vertical incision given to

prevent damage to neighbouring gland ducts )

Recurrent Hordeolum in child/ young adults can be due to Uncorrected Refractive errors while in elderly should lead to

the suspicion of Sebaceous gland carcinoma.

B . CHALAZION= Chronic lipogranulomatous inflammation of

-
Meibomiar gland. Rx Intralesional Triamcinolone, Curettage.

69
LACRIMAL GLAND AND LACRIMAL APPARATUS

Hain Lacrimal gland has an Orbital Lobe and a Palpebral Lobe-

Reflex Tear secretion

Accessory Lacrimal gland- Basal tear secretion

KERATOCONJUNCTIVITIS SICCA (RCS)= DRY £YC |

HC Cause * Sjogren syndrome

MC Cause of secondary KCS * Rheumatoid arthritis

-
SCHIRMER ' S TEST Measures the quantity of tear production. Whatmann filter paper No. 41 is used.

Normal* >10 mm

Tear - Film Break Up Time * Normal >10 sec

CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION)

Due to imperforate valve of the nasolacrimal duct [ Hasner ' s valve ]

C / f Swelling near medial canthus and watering of eye / Epiphora

Rx * First 6 months- Lacrimal sac massage / Crigler s massage

6 months to 4 years- Probing and Syringing by Bowman probe

After 4 years * DCR (Dacrocystorhinostomy)

DCT/ Docrocystectomy- Done only when DCR is contraindicated:

.
1 <4 yr age

2. Atrophic rhinitis

3. Lacrimal sac malignancies

70
DACR 0CYST 1TIS

Infection of the lacrimal sac

C / f: Acute painful swelling near the medial canthus

Regurgitation test- POSITIVE [Pressure over lacrimal sac -> Mucopurulent

discharge from punctum]

-
Rx Systemic Antibiotics and NSAIDS [ I and D is C / I as it can form Lacrimal

fistula]

Rx of chronic dacrocystitis DCR

-
-
DACROCYSTOCOELE Enclosed cyst of lacrimal sac seen in children, bluish appearance

Regurgitation Test- NEGATIVE

IACRIMAI GIAND TUMORS ]

-
1. HC tumor Pleomorphic Adenoma

-
2. MC Malignancy Adenocystic carcinoma

-
Malignancy with worst prognosis Mucoepidermoid carcinoma

0 Previous Year Questions

ft INKfT 2021

Most common Lacrimal gland tumor:

A. Pleomorphic adenoma ©
B. Mucoepidermoid CA
C. Adeno cystic CA
D. Non- Hodgkin lymphoma

71
EXTRAOCUIAR MUSCLES ]

4 recti- HR, LR , SR, IR

2 obliqui- SO, 10

Longed musde/ Longed tendon SO -

Shortest musde / No tendon / Husde inserted

closest to macula 10 -
Thicked muscle * MR

-
Grave' s diseased Fibrotic contracture IR> MR

Cheater's muscle SO -
All extraocular muscles are supplied by III [ Oculomotor nerve ] EXCEPT Lateral rectus- VI NERVE [ Abducens ] and

Superior Oblique- IV nerve [Trochlear ], {50k LR6}

-
Angle of insertion of SR/ IR 23'

-
Angle of insertion of SO/IO 51’

0 Previous Year Questions

« iNicrr 202i

Identify the structure located at the level of nucleus supplying the muscle marked in this image.

A. Red nucleus ©
B. Pyramid
C. Olive
D. Facial colliculus

72
ACTION OF MUSCLES [

Primary action Secondary action Tertiary action

HR Adduction

LR Abduction

SR Etevation Intorsion Adduction

IR Depression Extorsion Adduction

SO Intorsion Depression Abduction

10 Extorsion Elevation Abduction

[Remember: Superiors INtort, Recti ADDuct- SIN RADD]

Yoke MUSCLES
YOKE HUSCLE5 = Synchronous Huscles of the 2 eyes for a particular ga2e.
IRight and up gaze Up gaze Left and up gaze i
JT

Right SR Left IO SR ( IO ) iTwryim

Right gaze Primary position Left gaze

„
Right eye Left eye

Right and down gaze Downgaze Left and down gaze

HI
Right IR I Left SO IR ( SO ) Right SO f Left IR
Fig. 13.11 Full cxtraocular movements In a normal subject. IO. Inferior oblique: IR. inferior rectus;
LR. lateral rectus; MR. medial rectus; SO. superior oblique; SR. superior rectus.

1. Herring' s law of Equal innervation of Yoke muscles

2. Sherrington' s law of Reciprocal innervation- Antagonistic muscle of same eye relaxes when a muscle contracts.

0 Previous Year Questions

# NIIT PG 3011

Yoke muscle for right lateral rectus in dextroversion movement of eye is:
A. Left medial rectus ©
B. Left superior rectus
C. Left superior oblique
D. Left inferior oblique

73
TESTING THE INDIVIDUAL MUSCLESTj

HR- Adduction

LR-Abduc+ion

SR- Elevation of Abducted Eye

IR- Depression of Abducted eye

SO- Depression of Adducted eye

10- Elevation of Adducted eye

SQUINT |

-
Orthophoria Both the eyes are parallel. No squint.
-
Heterophoria Latent squint is present.
-
Heterotropia Manifest squint is present.

Types of squint:

1. -
Esophoria / Esotropia convergent squint
-
2. Exophoria/ Exotropia divergent squint

3. Hyperphoria / Hypertropia The - squinting eye is above the other eye

-
Hypophoria / Hypotropia The squinting eye is below the other eye

0 Previous Year Questions # NIH PG 2070

Esotropia is most commonly associate with:

A. Hyperopia ©
B. Myopia
C. Emmetropic
D. Astigmatism

0 Previous Year Questions

# NEfT PO 3019

Esotropia is commonly seen in which type of refractive error?

A. Myopia
B. Hypermetropia ©
C. Astigmatism
D. Presbyopia

74
COVER - UNCO VCR TEST |«
Cover- uncover Test
To detect the presence of Latent squint.

One eye is covered. This eye takes up it' s normal

position if squint is present. E.g. In exophoria, this

eye will move outwards behind the cover.
On uncovering the eye. the eye moves back inwards.

This return of movement is diagnostic of exophoria.

0 Previous Year Questions

# NffT RG 2019

Identify the instrument:

A. Maddox rod ®
B. Maddox wing
C. Maddox glass
D. Red glass

0 Previous Year Questions # MIH PG 2019

Identify the test shown in the Image:

A. Cover-uncover test ©
B. Maddox rod test
C. Occlusion test
D. None of the above

75
HIRSCHBERG TEST -}
o Normal corneal reflex
Used to roughly calculate the angle of
1 mm deviation » 15 diopters
squint.
Torch is flashed between the eyes and the <1" 'O 2 mm deviation & 30 diopters

<$'' -O
reflection of torch light is seen on the
3 mm deviation 45 diopters
cornea. *
1 degree ” 2 prism dioptre

GRADES OF BINOCULAR VISI0N-

< O
?N 4 mm deviation » 60 diopters

Grade 1- Simultaneous perception

Grade 2- Fusion

Grade 3- Stereopsis

Prim Angle between the two eyes when the normal eye is fixating at the object.
Se cond D Angle between the two eyes when the squinting eye is fixating at the object.

TYPES OF SQUINTf
1. Concomitant Squint- Angle between the two eyes remains same in all directions. No diplopia. Primary

-
deviation Secondary deviation

2. Incomitant squint- Angle between two eyes changes in every ga2e. Binocular diplopia is seen (diplopia only
when both eyes are open).

i. Restrictive Squint Due to restriction/ fibrosis of a muscle

Forced duction test- POSITIVE

HC cause ” Thyroid ophthalmopathy

First involved: Inferior rectus > Medial rectus

ii. Paralytic Squint - Due to nerve palsy ( III, IV or VI nerve palsy )

Secondary deviation > Primary deviation

76
 Forced duction test- NEGATIVE

A and V paHerns can be seen

0 Previous Year Questions # NEET PG 2020

A 65 - year old male with history of diabetes and hypertension presents to the OPD with complaints
of diplopia and squint. On examination secondary deviation is seen to be more than primary
deviation. Which of the following is the most probable diagnosis?
A. Paralytic squint ©
B. Concomitant squint
C. Restrictive squint
D. Pseudo squint

0 Previous Year Questions

# NEET PG 2020

Middle aged women with b/ l proptosis, with restricted ocular movements, and chemosis, is
euthyroid. What is the probable diagnosis?
A. Orbital cellulites
B. Thyroid ophthalmopathy ©
C. Pseudotumor of Orbit
D. Orbital lymphoma

0 Previous Year Questions # NEET PG 2019

The most common cause of proptosis in adults is:

A. Orbital cellulitis
B. Preseptal cellulitis
C. Thyroid eye disease ©
D. Capillary hemangioma

77
Ill NERVE PALSY

Eyes moves down and out

+
P osis

0 Previous Year Questions

# IMCFT 2021

Identify the condition in the given image:

A. Oculomotor nerve palsy ©

B. Trochlear nerve palsy
C. Abducens nerve palsy
D. Medial rectum palsy

0 Previous Year Questions # NUT PC 2020

The movement is lost in:

A. Third nerve palsy ©

B. Trochlear palsy
C. Sixth nerve palsy
D. Facial palsy

0 Previous Year Questions # NlfT PO 20!«

3rd nerve palsy in diabetes mellitus characteristically shows?

A. Absent light reflex, accommodation is present
B. Intact light reflex, accommodation is absent
C. Both light and accommodation reflex is absent
D. Both are normal ©

78
IV NERVE PALSY

Eye moves upwards and inwards

Head tilt to opposite shoulder

VI NERVE PALSY

Eye moves inwards

0 Previous Year Questions # NEET PG WO

Unilateral proptosis with Bilateral Sixth Nerve Palsy is seen in :

A. Cavernous sinus thrombosis ©
B. Thyroid ophthalmopathy
C. Retinoblastoma
D. Orbital pseudotumor

ABNORMAL HEAD POSITION is seen in incomitant squint.

Head tilt

Chin lift

Face turn

79
Bielchowsky / Pork ' s 3 - step test is used to determine the muscle paralysed.

Eg- If diplopia is increased on looking to the left and with a right head tilt, which is the muscle paralysed if

eye position is as follows?

"•"“ V

Ans-

Stepl = From the eye position, it can be Right hypertropia or Left hypotropia . Thus muscles paralysed could

be:

Right Eye

T
SR

LR •
*

Step 2 = Diplopia increases on looking to left -> Thus, out of these, the muscles used in looking to left are

affected.

Right Eye Left Eye

* LR

IR

80
| Step

Remember: Superior palsy ( SO and SR ) cause opposite head tilt and inferior palsy ( 10 and IR ) has same
sided head tilt.

As here, diplopia increases with right head tilt

^ the patient tilts his head to left. Thus opposite side (Right
sided superior ) or same side (left sided inferior ) is affected. But here, left sided inferior muscle is excluded
in above steps. Thus here it is Right SO palsy.

Thus, Right SO palsy will be compensated by: 7f I .

ikAAT H

1. Left head tilt

2 ocular unice
2. Left face turn

3. Chin down. » hoi

'*
Rp r 2 Tn«i of tW COT
*

81
VISUAL FIELD DEFECTS |

VISUAL FIELD IIIN2 1 I

Eye Nasal Temporal

Optic nerve
B
A
o#
Ipsilaferal blindness
Optic chiasma
< i
Ditemporal hemianopia

Optic tract
C
i c
Homonymous hemianopia

Lateral
geniculate nucleus

c c
Homonymous ttemianopia
Gemcutocaicannc tract

Visual code *

Location Visual field defect

1. Optic nerve Monocular blindness

2. Optic Chiasma Bitemporal hemianopla

3. Optic tract Contralateral homonymous hemianopia

k. Optic radiation
.
i Meyer' s loop= Inferior fibres in Pie In the sky

temporal lobe
it. Baum' s loop * Superior fibres in parietal Pie on the floor
lobe

5. Occipital lobe Contralateral homonymous hemianopia with macular

sparing

82
 0 Previous Year Questions
# MEET PG 2021

A 33 yr. female with complaints of diminishing vision on right halves of both eyes. Probable
diagnosis?
A. Left optic tract ©
B. Right occipital lobe
C. Optic chiasma
D. Right optic nerve

0 Previous Year Questions

« IN KIT 2021

Identify the site of the lesion:

in

' *
*
nmiimn

-.
tuiitttttiii •*. .'.
•PIIMI
Itlintt
.•.• . * 4M
tr *
»* * « » |

.
‘

mu!mi
mi.iu
1}
itn

3C

PATTERN PATTERN
DEVTATON DEVIATON

Jilin
l a
a
a a a

A. Optic chiasma
B. Left occipital lobe ©
C. Left LGB
D. Right occipital lobe

PUPILLARY REFLEX PATHWAY )

Light foils on Retina -> Optic Nerve -> Optic Chiasma Optic tract -> Pretectal nucleus -> Bilateral Edinger-
Westphal nucleus -> III Nerve -> Pupillary constriction

Direct light Reflex- Light thrown on one eye causes pupillary constriction of the same eye.

Consensual Light Reflex- Light thrown on one eye causes pupillary constriction of the opposite eye.

| ABNORMAL PUPILS |

1. Amaurotic Pupils- Lesion in the optic nerve

Absent direct and Indirect light reflex.

83
2. Argyll -Robertson pupil
Accomodation reflex present, Pupillary (light) reflex absent [ ARP-PRA ]
[Light-near dissociation]

Bilateral constricted pupils

Seen in neurosyphilis

3. Adie' s pupil

Seen in young women with absent knee jerks

Unilateral Dilated pupil

Lesion in Ciliary ganglion

Light- near dissociation is seen

Vermiform( slow ) pupillary movement

0.1% pilocarpine causes pupillary constriction due to Denervation Hypersensitivity [Normally 2% pilocarpine

is required]

4. Wernicke s Hemianopic pupil

Light throun from one side causes pupillary constriction, but thrown from other side does not. Due to Optic
tract lesion.

5. Marcus- Gunn pupil

First sign of optic neuritis

Due to RAPD (Relative Afferent Pupillary Defect)

-
Tested by SWINGING FLASHLIGHT TEST On swinging light to the eye with optic neuritis, the pupil appears to

dilate.

6. Horner ' s Syndrome

C / f - Ptosis, Anhidrosis, Miosis, Enophthalmos, Loss of Ciliospinal reflex PAMELa!

'

Due to a lesion in the ocular sympathetic pathway

Confirmation of diagnosis * COCAINE (1st to be done )

-
Localisation of lesion HYDROXYAMPHETAMINE

COCAINE HYDROXY AMPHETAMINE

Normal Pupil Dilates
Horner ' s syndrome pupil No dilatation Dilates- Pre- ganglionic Horner ' s syndrome
^
>
No dilatation- Post- ganglionic Horner's syndrome

Suboptimal dilatation- Central Horner ' s syndrome

^
84
 ANISOCORIA]

Difference in the si2e of the two pupils

I. Anisocoria increases in dark- Horner ' s

Syndrome
n. Anisocoria increases in light-

Apply Pilocarpine 0.1%-

a. If pupils constrict * Adie s pupil

b. Not constrict- Argyll Robertson pupil

| GAZE PALSY ]

Location of lesion Deficit

Cerebral cortex 1. Frontal Eye field area C /L Horizontal gaze palsy
Parameter frontal eye fields
pontine reticular (Area 8) 2. PPRF l/L Horizontal gaze palsy
formation (PPflf)
3. HLF lesion ( Internuclear l/L Adduction deficit + C /L
I Ophthalmoplegia) Abduction nystagmus

Abducens , 2 k. B /L MLF Lesion - WEBINO B /L Adduction deficit /

nucleus / Medal longitudinal
lasociSus IMLF) syndrome [ Wall Eyed Divergent squint

0 Oculomotor
nucleus
Bilateral Inter Nuclear

Ophthalmoplegia]
1

5. One and a half syndrome * l/L eye * No movement at all

AgM lateral Left medial
rectus muscle
- rectus muscle Lesion of both PPRF MLF C /L eye * Only abduction can

be done
•• U
f
Right eye [H'TJL.
c- v.
.. ] Left eye
**

(Lesion sues are indicated by 1 4)

85
 PAPILLEDEMA PAPILLITIS PSEUDOPAPILLITIS
Cause Due to raised intracranial Due to optic neuritis Hypermetropia
pressure
Pain +++

FA Vertically oval pool of dye Minimal dye leakage No leakage

86
1. FFA [ Fundus Fluorescence Angiography] vs Autofluorescence
FFA- Vessels appears white due to the contrast dye.

Autofluorescence- No dye used. Vessels appear dark .

Fundus Fluorescein Angiography ( FFA ) Autofluorescence

2. FFA in Macular Ischemia

Emulsified Silicone oil in Anterior Chamber

87
4. Chemical Injuries of Eye
Alkaline injuries are more dangerous than acids

Acid Alkali
Host common H2SO, Ca hydroxide

Most dangerous Hydrofluoric acid Ammonia

ROPER HALL / DUA CLASSIFICATION is used

.
Rx * Irrigation with water Topical antibiotics, cycloplegics, lubricants, steroids, Vitamin C, Doxycydine.

5. Both eye drops and ointment need to be applied

Eye drops should be applied first. After 15 minutes eye ointment should be applied.

6. RBSK [ Rashtriya Bal Swasthya Karyakram ]

Includes the following eye diseases:

Vitamin A deficiency

Vision impairment

M. Retinopathy of Prematurity
v. Congenitd cataract

7. Anterior ethmoidal nerve block

88
8. Nasociliary nerve block

v ^ .
V f

Meca :amhjs

*1. Photostress test-

Used to differentiate retinal/macular vs optic nerve pathology .

Bright light is thrown on the eyes and time taken for recovery of visual acuity is noted.

Delayed in retinal/ macular pathology

0 Previous Year Questions # NfFT PG 3020

Lesion producing incongruous homonymous hemianopia with Wernicke's hemianopia pupil. Site
of lesion is:
A. Optic tract ©
B. Visual cortex
C. Optic radiations
D. Optic Nerve

89