Professional Documents
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Ophthalmology
By
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Index
Subject Page
Anatomy 3
Eye lids 6
Lacrimal apparatus 8
Conjunctiva 10
Orbit 12
Cornea 16
Uveal tract 20
Crystalline lens 24
Intraocular pressure 27
Retina 32
Optical System of the eye 36
Septic foci 38
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I- Anatomy of the Eye
Pupil Lens
Retinal artery
These are accessory structures related to the eye ball and vein
1. Eye lids. 2.Conjunctiva.
3.Lacrimal apparatus. 4. Extra-ocular ms.
5.Orbit.
Control of eye movement occur by 6 muscles: 4 Rect. (superior,
Inferior, lateral & medial) and 2 Obliques (superior & Inferior). All
muscles are supplied by the oculomoator nerve ercept the sup. Oblique.
(4th nerve trochlar) and lat. Rectus (6th nerve= abducent nerve)
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Important mcqs about the nerve supply of the eye
3rd CN
③
4th CN
6th CN
⑥ ⑤
④
②
D) Nerve Supply
Sensory: The TRIGEMINAL nerve (the ophthalmic division): through
- 6-10 short ciliary nerves.
- 2 long ciliary nerves.
Motor
1- OCULOMOTOR 2- TROCHLEAR & 3- ABUDCENT nerves
F) Lymph drainage
- Medial part drains into the submandibular lymph nodes.
- lateral part into the preauricular lymph nodes.
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Note!
If the optic nerve is affected on that level → blindness of this eye
If the defect on that level → affecting temporal fibers of the same eye, and nasal fibres of the other
1-The visual pathway starts at the photoreceptors (rods and cons) in the
retina. They synapse with the bipolar cells, which in turn synapse with the
ganglion cells run in the nerve fiber layer of the retina and converge to form
the optic nerve (second cranial nerve).
Nasal = medial
2-Axons in the optic nerve run to the optic chiasma where nasal fibers
of each nerve cross each other to reach the optic tract of the opposite side.
The temporal fibers pass uncrossed to the optic tract of the same side.
Temporal = lateral
3-Fibers of the optic tract reach the lateral geniculate body (LGB) where
they synapse. Axons from LGB spread out to form the optic radiation that
passes through a broad area of the temporal and parietal lobes of the brain.
4-Fibers of the optic radiation end in the visual cortex in the occipital
lobe. The visual cortex includes the primary visual area (area 17) and visual
association areas ( area 18 and area 19 ).
1-The orbits
2-The retrobulbar pad of fat as a shock absorber against the orbital bones.
3-The lids:
i-Closure of the lids during sleep prevents corneal dryness and ulceration.
ii-Blinking Reflex .
iii-The eye lashes and the eyebrows prevent sweat from dribbling
inside the eye.
4-The tears:
i- The precorneal tear film prevents corneal dryness and ulceration.
ii- Tears have an anti-microbial function through its lysozyme content.
The cornea:
i-Corneal sensation ( being richly supplied by sensory n.)
ii-Bells phenomenon
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The eyelids
The eyelids are 2 movable muco-cutaneous folds that meet at the canthi
and separated by the palpebral fissure that is opened by the levator
Extension:
The upper lid extends to the eye brow while the lower lid passes
without a line of demarcation into the cheek
Function :
1- protect the eye from chemical,and physical injury.
2- Drainage and distribution of tears.
3- The eye lids contain sebaceous glands which secrete oily material to
minimize evaporation of tears and facilitate eye lid movement on the
surface of the eye.
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2. Infective (ulcerative)blepharitis: Chronic infection of lid margin
skin due to staph. aureus. It is common with bad oral hygiene:
Proper oral hygiene is important to avoid eye lid scaring, and
deformity due to infected skin ulcers.
Treatment: good oral hygiene + local antibiotics.
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In Lacrimal fossa in the upper
temporal part of orbit
A) Secretory part:
1. The Main lacrimal gland: it lies at the antero-lateral part of the roof
of the bony orbit. Its ducts (6-12 in number) open in the superior
fornix .
2. The Accessory lacrimal glands and goblet cells in the conjunctiva.
B) Drainage part:
1. 2 puncti: tiny openings at the medial part of the eyelid margins.
2. 2 canaliculi: vertical part 2mm and horizontal.part 6mm.
3. Lacrimai sac: lie in larimal fossa (6 x 12mm).
4. Nasolacrimal duct: 12-24mm, which opens the inferior meatus of
the nose. So problems of the nasal cavity can lead to obstruction of
this duct leading to stagnation of tears in the lacrimal and
conjunctival sac.
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2. Sjogren's syndrome: It is an auto-immune disease that affects
middle-aged females. It is manifested by dryness of eye and mouth
due to diminished secretion of tears and saliva.
Treatment: Tear substitutes and wetting agents to avoid dryness
and ulceration of conjunctiva and cornea.
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The conjunctiva
Infective Conjunctivitis
1. Acute muco-purulent and purulent conjunctivitis:
Cause: staph, strept,gonococci.
Clinical picture: - conjunctival redness and discharge,
-oedema of lids.
Treatment: - Frequent eye wash-with sterile water +
- antibiotic eye drops and ointments.
2. Membranous conjunctivitis:
Cause: diphtheria.
Clinical Picture: Membrane is formed covering the conjunctiva
and adherent to it.
Treatment: topical and systemic Penicillin and antitoxic serum
3. Viral conjunctivitis:
May be associated with viral affection of the oral cavity and upper
respiratory tract.
C.P: Redness, itching, watering + enlarged draining Lymph nodes.
Treatment: Topical anti-viral drugs .
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4. Trachoma
Chronic conjunctivitis caused by Chlamydia trachomatis. It affects
the conjunctiva and cornea leading to scarring, deformity of eye
lids and opacity of the cornea.
Treatment: Sulfacetamide + Tetracyclines + erythromycin.
Trachoma is very common in Egypt and is the main cause of
blindness.
Allergic Conjunctivitis
2-Spring catarrh
Allergy to sun and dust: It occurs in summer and. improves in
winter. It affects young persons and improves spontaneously after
many years.
Treatment: Avoid sun and dust, cold compresses, anti-histaminics
and may be steroids in severe cases.
watery secretions
purulent discharge
burning sensation
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Diseases of the orbit
The orbit is the bony cavity that surrounds and protects the eyeball.
Each orbit is 4 sided wall pyramid with a base looking forwards and apex
directed towards the cranial cavity (middle cranial fossa). The 4 orbital
walls is are: roof (between orbit and anterior cranial fossa), medial wall
related to nose, ethmoidal sinuses and sphenoid sinus), lateral wall
(related to temporal fossa and middle cranial fossa) and floor (related to
maxillary sinus and upper jaw). Through the apex (optic canal. and
superior orbital fissure) different vessels and nerves pass from or to the
middle cranial fossa , the orbital cavity and eye ball. It contains the main
vessels, and nerves of the eye. Also, it contains a bad of fat which absorbs
any direct trauma to the eyeball. The cavity, of bony orbit is fixed in size
and has certain pressure. Any increase in that pressure due to collecting
fluid, swelling or any other cause will lead to protrusion of the eye ball
outside this cavity a condition known as exophthalmos or proptosis. The
commonest cause of this condition is inflammation of the orbital tissues
(orbital cellulitis). Remaining 15 mins
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Orbital Cellulitis
Signs:
1. Lid. odema.
2. Conjunctiva: ciliary injection
3. Proptosis (forward protrusion of the eyeball).
4. Oedema and hemorrhages of retina and optic disc (Papilledema ).
5. limitation of ocular movements.
Complications:
Intracranial extension (fatal).
Intra ocular extension (Panophthalmitis).
Optic neuritis (loss of vision).
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Treatment of orbital cellulitis:
1. Antibiotics.
2. Hot fomentation.
3. Surgical drainage of collected pus.
Cavernous sinus
[
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Cavernous sinus thrombosis
Causes :
Dental sepsis :
pterygoid pl. of veins orbit cavernous Sinus
or via blood spread cavernous sinus.
Clinical Picture :
Symptoms:
General: Fever , headache, rigors, ↑ pulse, malaise
Local : Severe ocular pain.
Drop of vision if optic neuritis occurs
Signs:
Lid. odema.
Conjunctiva: ciliary injection
Proptosis (forward protrusion of the eyeball).
Oedema and hemorrhages of retina and optic disc (Papilledema ).
limitation of ocular movements.
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directly
from air
THE CORNEA
aqueous humor
in the anterior
avascular tissue
chamber
The cornea constitutes the transparent anterior 1/6 of the outer coat
of the eye. Being a strong convex lens, it is considered the main refractive
media of the eye. IS THE ONLY TISSUE IN THE HUMAN BODY THAT HAS NO BLOOD SUPPLY
IT RECEIVES OXYGEN DIRECTLY FROM AIR (MAINLY) OR POSTERIORLY FROM THE
AQUEOUS HUMOR Blood supply also by tiny vessels at the outer edge of the cornea
2. Traumatic:
Trauma could be chemical, mechanical, thermal radiological, etc….
This may lead to ulceration or corneal wounds
. Proper management of corneal ulcers is mandatory to
avoid opacification of the cornea.
3. Inflammations: Keratitis
Inflammations are superficial(ulcer), interstitial or deep.
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N.B.
Definition
It is discontinuity of anterior corneal surface due to invasion by
bacteria.
Etiology
Predisposing factors
General: due to resistance as in:
- Old age. - D.M.
- Mal nutrition (vitamin A deficiency) - Immuno-sup. Drugs
Local: due to problem with corneal protective mechanisms
( lids, tears,corneal sensation & epithelium) as in :
(i) Trauma Abrasion (mechanical : by F.B., C. lens, or chemical,…)
(The epith. is an imp. barrier, as only 2 oganisms can invade intact epith.)
(ii) Loss of corneal sensation (neuroparalytic keratitis)
(iii) Exposure : as in lagophthalmos.
(iv) Xerosis
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Routes (sources) of infection:
(1) Blepharitis.
(2) Conjunctivitis.
(3) Dacryocysitis.
Clinical picture
*Symptoms
(1)Pain (Stitching): due to (i) irritation of exposed n. endings
by toxins & lid movement
(ii) The accompanying iritis.
(2) Photophobia
(3) Lacrimation& Blepharosopasm: reflex (due to 5th n. stimulation)
(5) Decrease of vision due to (i) necrosis & infilteration
(especially if near or at the corneal center)
Complications:
Corneal opacity interfering with vision.
Corneal perforation with intra ocular spread of infection leading to
endophthalmitis and loss of the eye.
Treatment
Eye cover, antibiotics, atropine ointment.
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A corneal ulcer is diagnosed by
positive fluorescein staining of
the cornea (appears green)
Cause:
Commonest cause is herpes simplex virus. Mcq
Predisposing factors:
The virus is dormant in the oral or nasal cavity. It is activated
and spread to the cornea following diminished body resistance
as in : - common cold or influenza or
- debilitating diseases as malignancy or severe anaemia.
Clinical Picture:
Dendritic ulcer looks like the dendrites of a tree.
Treatment:
It is treated with local and systemic antivirals.
Eye covering, atropine and antibiotics are also given.
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The Uveal Tract
The uveal tract consists of the iris, ciliary body and choroid.
The iris
It is a pigmented circular disc that contains an opening in its center
called the pupil. This pupil allows the light rays inside the eye to form the
image onto the retina. The size of the pupil can change according to the
intensity of illumination (called light reflex).
- Exposure to strong illumination narrowing the pupil
"miosis" to minimize light injury to 'the inside of the eye. This
occurs by contraction of the constrictor pupillae muscle
supplied by the parasympathetic fibers of oculomotor nerve.
- Exposure to weak illumination dilatation of the pupil
"mydriasis" to allow more light into the eye to stimulate
visualization. This occurs by contraction of the dilator papillae
muscle supplied by the sympathetic nerve. The part lining the
sclera is called choroid and ciliary body.
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Diseases of the uveal tract:
1. Congenital: Coloboma of uveal tract "absence of part of the uveal
tract".
2. Traumatic: Tearing or inflammation.
3. Inflammatory: Uveitis, Acute, subacute, chronic.
4. Tumours: Benign or malignant as malignant melanoma of the
choroid.
Uveitis
Red eye
Inflammation of the uveal tract, either
total: panuveitis
or affecting part of the uveal tract: iritis ,Cyclitis or choroiditis.
Causes of Uveitis
1. Exogenous: Perforating corneal ulcer perforating injuries or intra
ocular operations.
2. Endogenous: from distant parts of the body to the uveal tract
especially from septic foci as dental sepsis.
3. Allergic inflammations: Due to toxins of micro-organisms such as
streptococci from teeth ,sinuses, or T.B; foci.
4. Constitutional: Diabetes, Rheumatoid arthritis, gout.
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2. Allergic inflammation:
Organisms or protein, toxins in a certain focus, at one time escape
into the blood stream and sensitize the ocular tissues. Second exposure
to -their allergens will induce uveitis.
Clinical picture:
1. Iridocyclitis:
symptoms:
Pain, watering, photophobia, redness and diminution of vision are
the main presenting symptoms.
Examination
shows ciliary injection, narrow irregular pupil, aqueous is turbid,
pus in anterior chamber (hypopyon) may be seen.
2. Choroiditis:
symptoms:
pain, drop of vision, redness.
Examination shows vitreous floaters.
1. Adhesions .between the pupil and the lens lead to pupillary block
and rise of intraocular pressure (pupillary block glaucoma).
2. Adhesions between" the iris and the cornea lead to closure, of the
angle of the anterior chamber and rise of intra ocular pressure
(angle closure glaucoma).
3. Opacities of the lens (cataract) "Complicated cataract". Ttt: Replacing the lens surgically
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Management Anti inflammatory
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The Crystalline lens
It’s a transparent, avascular biconvex and elastic structure
Between the iris and vitreous
Cataract
Types:
1. Congenital cataract.
2. Acquired cataract.
a. Senile: above 50 years, usually bilateral.
b. Traumatic: blunt or perforating injury.
c. Complicated (due to local or systemic diseases).
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Congenital Cataract
Causes
1. Malnutrition of the mother e.g. vitamin D, calcium deficiency.
2. Diseases of the mother: Rubella, German measles.
3. X-ray exposure of the mother.
4. Teratogenic Drugs.
Clinical picture:
The mother always complains of:
3- whitish opacity of the pupil.
4- poor vision,
5- squint of her child.
The commonest type is zonular or lamellar cataract which is
associated with abnormal enamel of the permanent teeth and rickets. A
line is seen across the permanent teeth.
Senile cataract
Clinical picture:
Gradual painless diminution of vision which is progressive and one
eye usually precedes the other.
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Treatment
Treatment is surgical (extraction, of the opaque lens) and
correction of vision with glasses, contact lenses or Insertion of intra
ocular lenses.
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Intra ocular pressure
Mcq
Normal ocular pressure ranges from 12-24 mmHg. Increased rate
accumulation of aqueous inside the eye and rise of ocular pressure a
disease called glaucoma. Ocular pressure can be measured by an
instrument called tonometer.
Definition:
Glaucoma is rise of intra ocular pressure above its normal values
that may lead to damage to the optic nerve leading visual field defect
and finally loss of vision.
Chronic: Symptoms ave less realized by the patient
Acute: red eye and severe pain
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Types of glaucoma:
1. Congenital glaucoma due to congenital anomalies obstructing
the angle of the anterior chamber.
This leads to enlargement of the eye ball to be looking like the eye
of a buffalo condition called Buphthalmos.
2. Acquired glaucoma
Either:
I) Open angle glaucoma: The angle is open but the trabecular
meshwork at the angle is blocked, so not allowing the aqueous
to pass freely to the outside of the eye.
II) Closed Angle glaucoma: Irido-corneal contact
Symptoms:
Gradual, painless, progressive contraction of the visual field
followed by diminution of vision.
It ends by damage of optic nerve and complete blindness of the eye.
Signs:
High IOP .
optic nerve cupping
Visual field defect.
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Management:
1. Medical by eye drops
(pilocarpine, B-blockers and carbonic anhydrase inhibitors).
2. Laser treatment to open pores of trabecular meshwork.
3. Surgical operation: to
- increase rate of aqueous drainage to the outside of the eye.or
-lower rate of aqueous formation (Cyclodestruction)
Clinical picture:
Sudden severe elevation of IOP leading to:
- rapid drop of vision,
-severe ocular pain,
redness, of the eye and
the pupil is dilated and fixed.
Referred pain to the maxilla may be mistaken for toothache.
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Management
1. Miotic eye drops.
2. Tablets of carbonic anhydrase inhibitors.
3. Dehydrating measures such as mannitol (i.v.). glycerine syrup
oral.
4. Morphine I.M.
5. Surgery after control of I.O.P (peripheral iridectomy or laser
peripheral iridotomy.
Glaucoma surgery
Surgery for glaucoma is done with all types of glaucoma not
controlled with medical treatment or laser therapy. The aim -of surgery is
to open a way for aqueous humour to pass outside the eyeball to lower the
elevated I.O.P so during surgery we open the eyeball to the outside
(subconjunctival space).
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D.D of Acute Red Eye
Causes
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Retina
ANATOMY OF THE RETINA
Blood Supply
(1) Arteries:
-Inner 5 layers: from central retinal artery (from the ophthalmic artery).
-Outer 5 layers: from the choroidal vessels.
(2) Veins:
The retina is drained into the central retinal vein (CRV)
(to the superior ophthalmic vein or directly to the cavernous sinus).
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Vascular Retinopathy
It is bilateral retinal changes due to systemic vascular diseases.
Type
1. Non-proliferative (Simple) D.R.:
the retina shows hges, exudates, microaneurysms.
2. Proliferative DR.
the retina shows: -neovascular changes
-extensive hges, exudates Exudates
-vitreous proliferation
-and ends by tractional retinal detachment.
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انفصال الشبكية
Retinal detachment(RD)
Types:
1. Primary RD: tear occurs in the retina that allows fluid to pass to the
• primary/Rhegmatogenous : happen if you have a small tear or break in your retina.
• secondary: underneath of the retina separating it from the choroid.
Tractional: retina pulled from inside by traction bands diabetic retinopathy retina scars get bigger
2. retina
Exudative: Secondary RD:
is pushed The
from retina:
outside by is eitherorpulled
swelling from inside
fluid. Diseases by inflammation
that cause traction inside the eye
bands or pushed from outside by" swelling or fluid.
Treatment:
1-Primary RD is treated by closure of the hole
2-Secondary RD is managed by treating the cause.
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Ocular manifestations of diabetes mellitus
DM can lead to several ocular complications such as diabetic retinopathy,
diabetic papillopathy, glaucoma, cataract, and ocular surface diseases
Eye lids: Recurrent styes, blepharitis.
Conjunctiva: Conjunctivitis.
EOMS: Temporary paralysis: commonly 6th N, may be 3rd or 4th .
Cornea: Keratitis.
Uvea: Uveitis, neovascularisations glaucoma, (rubeotic glaucoma).
Lens: Cataract pre-senile or true diabetic cataract.
Refraction: Myopia or hyperopia.
Vitreous: Hemorrhage, fibrosis, , opacities.
Retina: Retinopathy, detachment, vein occlusion, fibrosis, death.
Optic verve: Neuritis, atrophy lose of vision.
Orbit: Cellulitis, optic neuritis.
Pupil: Miosis, poor dilatation.
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OPTICAL SYSTEM OF THE EYE
Corneal power is about 42D ,while power of the lens is about 18D.
Corneal power is fixed while that of the lens is changeable through
accommodation. Cornea and lens are important to focus the light
rays failing onto the surface of the eye at the retina.
Hypermetropia (hyperopia) +
It is the condition where the image will form at a line not at a point.
It occurs due to unequality of the power of the cornea at different
meridians. To correct astigmatism we use cylindrical lenses
(concave or convex) which has power in certain direction and nil
power in direction perpendicular to the other one.
The eye needs TORIC lens
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Aphakia:
It is the error of refraction due to removal of the lens of the eye.
It is corrected by:
1- giving the patient high convex lens.
2- Contact lens use.
3- Insertion of IOL
Presbyopia:
It is the condition affecting old age (↑ 40y) due to loss of
accommodation
It is corrected by convex lenses "reading glasses".
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Septic Foci
They are foci containing microorganisms mainly streptococci.
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8. Intra ocular surgery should be preceded by careful searching
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