Lecture Notes in

Ophthalmology

By

Prof. Dr Yasser Soliman

Professor of ophthalmology
Cairo University

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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

A) Coats of the Eye

1- Outer protective coat : Cornea & sclera.
2- Middle Nutritive coat : Iris, ciliary body & Choroid.
3- Inner Nervous coat : Retina.

B) Chambers & Contents

Anterior chamber : Between the cornea & iris & contains aqueous humor.
Posterior chamber : between the iris & lens & contains aqueous humor.
Vitreous chamber : Between the lens & retina & contains vitreous humor.
Crystalline lens : Between the iris & vitreous & suspended by the zonule.

C) Adenexa of the Eye

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

E) Blood Supply of the Eye Ball

1. Arterial : from the ophthalmic artery (from the internal carotid)
2. Venous : into the ophthalmic veins (into the cavernous sinus)

F) Lymph drainage
- Medial part drains into the submandibular lymph nodes.
- lateral part into the preauricular lymph nodes.

The diopteric power of the normal eye:

T h e diop t eric po w er of th e e y e is a pproxim a t ely 60 diop t ers ( D ) . I t
is determined by:
• The power of the cornea : which is about 42D
• The power of the lens : which is 18 D without accommodation.

The refractive media of the eyeball are:

• The cornea: refractive index = 1.37
• The aqueous: refractive index = 1.34
• The lens: refractive index = 1.42
• The vitreous: refractive index = 1.33

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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

The Visual Pathway

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 ).

PROTECTIVE MECHANISMS OF THE EYE

Pupils quickly and symmetrically (both eyes will respond) constrict to a bright light directed into either of the eyes
Bright light can damage the retina so the pupil reflex (constriction) helps change the diameter of the pupil to control how much light enters eye
Since the eye is an important organ, it is protected by several mechanisms.

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

palpebrae superioris muscle (supplied by the oculomotor nerve) and are

closed by the orbicularis oculi muscle (supplied by the facial nerve).

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.

Eyelid problems in relation to dentistry:

1. Recurrent styes : Acute suppuraive inflammation of Zeiss glands

at the roots of eye lashes. Painful reddish lid Swelling appears at
the roots of lashes.
Treatment: local antibiotic drops + ointment, hot fomentations.
Incision and drainage of collected pus.
Recurrent styes are common with dental sepsis.

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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.

3. Bell's palsy: It is lower motor neurone facial nerve palsy due to

exposure to cold air currents or ear infection. it is manifested by
inhability to close the eye dryness and ulceration of cornea and
conjunctiva. It also shows deviation of the mouth to the healthy
side.
Treatment:
- Surgical closure of eyelids
- wetting eye drops and ointments.
Physiotherapy + systemic steroids may help rapid recovery

4. Marcros gunn's phenomenon: drooping of the upper eyelid that

improves on jaw movement. Cause is either congenital acquired
paradoxical innervation of the jaw and upper eye lid. Surgical
correction is difficult.

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 In Lacrimal fossa in the upper
temporal part of orbit

The lacrimal system

The lacrimal apparatus consists of lacrimal secretory system which

secretes the tears and lacrimal drainage system which drains the tears into
the nasal cavity. Tears = over production by the lacrimal gland Or decreased drainage

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.

Problems of the lacrimal apparatus:

1. Dental sepsis may lead to inflammation of the lacrimal gland that
may lead to increased tear secretion in the acute stage or deficient
tear formation in the chronic stage.

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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.

3. Nasal swellings or deviated septum: may occlude the opening of

the nasolacrimal duct. This will lead to stagnation of tears in the
lacrimal and conjunctival sac. This will invite secondary bacterial
infection.
Treatment: Removal of nasal swellings and correction of the
deviated septum. .

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 The conjunctiva

The conjunctiva is a thin mucous membrane which lines the back

of the eyelids (palpebral) and covers the sclera(bulbar). It secretes mucus
which moistens the surface of the eye and allows free and smooth
movement of the lids over the surface of the eyes. palpebral bulbar

Problems of 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

1-Simple allergic conjunctivitis:

Allergy to external irritants, cosmetics, the eye is red, watery +
burning sensation .
Treatment: avoid irritants + local and systemic anti-histamincs.

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.

Causes of red eye

watery secretions

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

Relation between teeth and orbit:

1. Dental sepsis mayspread to the orbit leading to orbital cellulitis and
optic neuritis.
2. Some orbital tumours are of dental origin e.g.; dentigerous cyst and
adamantinoma.
3. Some orbital cysts contain teeth e.g. dermoid cysts.

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Orbital Cellulitis

Causes of orbital cellulitis

1. Spread of infection from surrounding structures such as nasal
infections, dental infections, ear infections.
2. Perforating injuries to the orbit.
3. Extension of infection from the eye ball to the orbit as in
endophthalmitis.
4. Distant spread of infection through the blood stream.

Clinical picture of orbital cellulitis:

Symptoms:
General: Fever , headache
Local : Severe ocular pain.
Drop of vision if optic neuritis occurs

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.

Dental infection can spread to the orbit by:

1. Direct in subperiosteal abscess along anterior surface of the
maxilla.
2. Blood borne spread especially after teeth extraction.
3. Spread Horn teeth maxillary sinus orbit.
4. Teeth sepsis along pterygoid plexus of veins (thrombophlebitis)
orbit or to cavernous sinus.

Cavernous sinus
[

Connections of the cavernous sinus (communications ).

1. Orbit, via superior and inferior ophthalmic veins.
2. Face, angular V. ophthalmic veins.
3. Mouth, nasal sinuses, pharynx: pterygoid pleuxus. inferior
ophthalmic vein.
4. Tissue behind the ear, (Mastoid emissary veins lateral. sinus
superior petrosal sin.).
5. Middle ear: inferior petrosal sinus.
6. Other cavernous sinus, (inter cav. connections).

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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.

Treatment: antibiotics, anticoagulants.

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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

Diseases of the cornea:

1. Congenital & developmental:

Keratoconus: cone-shaped, cornea due to weakness of the stroma and
bulging forwards of the cornea. This leads to high myopia and
astigmatism.

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.

(A) Bacterial Corneal Ulcer

These are either primary or secondary to spread from
conjunctivitis, blephraitis or dacryo-cystitis. Secondary corneal
ulcers to purulent conjunctivitis is considered one of the
commonest causes of blindness in Egypt.

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)

(ii) The accompanying iritis

*Signs:
Examination shows
(1) Lid: Odema.
(2) Conjunctiva: Ciliary injection.
(3) Cornea: shows - The ulcer ( + ve fluorescein test)
(4)A Ch.: shows signs of accompanying iritis e.g, aqueous flare or hypopyon.

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)

B) Viral corneal ulcers: More linear in shape

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.

Corticosteroids are contraindicated in such conditions.

N.B. Hatchinson's teeth:

Notching of upper two central incisors + deafness interstitial keratitis.
This triad is pathognomonic of congenital syphilis.

*Corneal opacities, are treated with either surgical excision of opaque

cornea and replacing it with clear cornea from a cadaver (keratoplasty
op.) of laser -removal of superficial corneal opacities. Peripheral
corneal opacities are better left alone so long they are not affecting
vision because keratoplasty may fail(rejection) and need reoperation.

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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.

The ciliary body

It has two main functions:
1. Secretion of aqueous humour: watery-fluid, that fills the anterior
part of the eye cavity.
2. Modification of the power of the lens of the eye "Accommodation"
according to the distance of vision, and by the ciliary muscle.

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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.

Relation between teeth and Uveitis:

1. Endogenous infections. Streptococci escape from dental sepsis into
the blood stream to the uveal tract inducing suppurative uveitis. Dental
sepsis can produce transient bacteremia especially following
extraction. This occurs in 10% of patients and rise to 75% following,
teeth extraction. Few hours later, the bacteremia disappears and blood
cultures prove sterile.

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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.

Complication of uveitis: Iris adheres to the lens → posterior synechiae

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

4. Choroiditis may lead to retinal detachment.

5. Spread of infection to the surrounding ocular tissues will lead to
endophthalmitis and loss of the eye.

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 Management Anti inflammatory

1. Local: Corticosteroicis, atropine antibiotics.

2. Systemic: Antibiotics, steroids, analgesics.
3. Treatment of the cause: Septic foci (dental sepsis…) Systemic
diseases as T.B, syphilis.

Cause of the red eye

① ulcers
② uveitis

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 The Crystalline lens
It’s a transparent, avascular biconvex and elastic structure
Between the iris and vitreous

Diseases of the lens

May affect its:
1- Transparency : cataract.
2- Position : Subluxation and dislocation

Cataract

Cataract is opacification of the lens which occurs due to

disturbance of its metabolism .

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

It is commonest type of cataract usually bilateral. It occurs above

50 years of age. The cause is not definitely known; but it may be
disturbed metabolism of the lens.

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.

Relation between teeth and cataract

1. Congenital cataract (zonular type). It occurs due to vitamin D and
calcium deficiency of the mother. It is associated with skeletal
deformities and white line across the teeth of the child.
2. Before cataract operation the dentist should examine the patient
and treat any dental septic foci at least 2-3 days before cataract
operation to avoid post-operative intra ocular infection and loss of
the eye.
3. Removal of loose teeth before insertion of the "anaesthetic tube; in
the oral cavity to avoid swallowing of these teeth during operation.
4. Dental septic foci could be the cause of some type of complicated
cataract.

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 Intra ocular pressure

The eye ball is a closed space filled by aqueous humour and

vitreous body. Size of vitreous is fixed since .birth while amount .of
aqueous is changeable, so ocular pressure-depends upon the balance
between rate of aqueous secretion and rate of its drainage outside the eye.

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.

Circulation of aqueous humor:

Aqueous humor is secreted by the ciliary processes of the ciliary
body. It is poured into the posterior chamber. Then passes through the
pupil to the anterior chamber. Then to the angle of the anterior chamber.
It then passes through the trabecular meshwork to the canal of schlemm
to the episcleral veins to the systemic venous circulation .

Glaucoma ‫ِمياه َزْرقاء‬

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

Open angle glaucoma

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)

Closed angle glaucoma

it usually occurs in females, anxious patients with small eyeball

(hypermetropic),
The anterior chamber is shallow angle of A.C is narrow,
The attack of angle closure follows dilatation of die pupil due to
mydriatic eye drops or excitation of the patient.

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).

Relation between teeth and glaucoma:

1. D.D pain of glaucoma and; pain due to dental diseases, glaucoma
pain is referred to the temple, forehead or upper jaw. Teeth pain
may be referred to the eye. Local ocular as well as dental
examination will help differentiating these two conditions.
2. Pre-operative dental examination to treat dental sepsis at least 3
days before glaucoma operation. Dental sepsis is one of the causes
of serious postoperative infection.
3. Removal of loose teeth before insertion of the tube of anesthesia.
4. Dentists should be aware of the predications that may lead to
glaucoma such as steroids or belladonna extracts (e.g., atropine).

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 D.D of Acute Red Eye

Acute conjunctivitis Acute IC Acute glaucoma

Vision Normal Affected Markedly affected
Pain Mild Moderate Severe
Redness Moderate Severe Severe
Discharge Present Absent Absent
Pupil Normal Small, irregular Dilated, fixed
Tension Normal Normal or high v. high

Causes

• Corneal herpetic infection or herpes.

• Corneal ulcer.
• Uveitis (panuveitis ,iritis ,Cyclitis or choroiditis)
• acute glaucoma
• conjunctivitis
• Conjunctivial hemorrhage
• Allergies.
• Blepharitis (eyelid inflammation)
• Chalazion or stye, (from inflammation in the glands of your eyelid)
• Complication from a recent eye surgery.
• Contact lens complication.
• Corneal abrasion (scratch).

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 Retina
ANATOMY OF THE RETINA

It is the innermost layer of the eyeball.

• It starts at ora serrata & ends at optic disc.
• It is very thin & transparent showing the red color of choroid.
• It contains the visual receptors: rods for vision in dim illumination
and cones for vision in strong illumination.
• It is sensitive only to light (translates photons to electrical impulses
that reach the visual cortex and transformed into a visual sensation).

* Anatomically, the retina is divided into :

1- Central Retina : Macula lutea. The center of the macula is an
avascular depression called "fovea centralis .
Function: (Mainly cones). Responsible for Visual acuity,
Color vision,& Form sense.
2- Peripheral Retina: ends at the ora serrata
Function: (Mainly rods) responsible for night vision and
peripheral field .

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.

Types such as:

1. Diabetic retinopathy.
2. Hypertensive, atherosclerotic.
3. Renal (due renal failure).
4. Toxemia of pregnancy).

Diabetic retinopathy (DR)

It is one of the common causes of blindness. It occurs in old

standing diabetes (more than 15 years).

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.

Treatment: 1-Control of diabetes

2-laser treatment.
3- Surgery:Surgical removal of fibrovascular proliferations
and reattachment of detached retina.

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 ‫انفصال الشبكية‬

Retinal detachment(RD)

Retinal detachment means its separation from the underlying

tissues (so the retina is separated from its nourishing bed). Gradually, the
retina will degenerate and lose its function.

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

-The eyeball is about 24 mm in diameter in adult, emmetropic person.

It may be smaller in hypermetropic person or longer in myopic person.
It is also smaller in size in young persons.

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.

Emmetropia (neutral eye)

In emmetropic eye: focused image is formed onto the retina.

Hypermetropia (hyperopia) +

In hypermetropic eye: image is formed behind the retina.

and the eye needs convex lens to focus the image on the retina.

Myopia (short sight) _

In myopic eyes "long eyes" image is focused in front of the retina.

The eye needs concave lens to displace the image backwards to
form on the surface of the retina.
A : no
Astigmatism: Stigma : point

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".

N.B: Laser corneal therapy may be used to change the power of

cornea in cases of myopia and hypermetropia and astigmatism. So,
laser may be helpful to get red of glasses.

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 Septic Foci
They are foci containing microorganisms mainly streptococci.

Sites: Teeth, tonsils, nasal sinuses, gall bladder, appendix, prostate.

Danger: Transient bacteremia occurs every now and then especially on
disturbing the sites of these foci. This may occur even under umbrella of
antibiotics. Incidence ranges from. 10% in silent conditions and rising up
to 70% following teeth extractions. Bacteremia usually remains for few
hours then blood cultures prove sterile.

Spread: from septic foci

1. Endogenous: micro-organisms are carried by blood stream to
distant organs inducing suppurative inflammation.
2. Allergic inflammation, the tissues are at first sensitized to bacterial
antigens or their toxins. Re-exposure to the same antigen will lead
to inflammatory reaction of the tissues.

Ocular problems due septic foci

1. Eyelids: Recurrent styes, chronic blepharitis.
2. Conjunctiva: Chronic conjunctivitis, phlyctenular conj.
3. Cornea: Deep keratitis.
4. Sclera: Scleritis, episcleritis.
5. Uvea: Uveitis (suppurative or allergic).
6. Orbital diseases:
a. Cellulitis.
b. Optic neuritis.
c. Cavernous sinus thrombosis.
7. Metastatic endophthalmitis and panophthalmitis.

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 8. Intra ocular surgery should be preceded by careful searching

Any source of sepsis should be treated thoroughly at least 3 days

before surgery. Under cover of antibiotics , operations can be performed
safely after resolution of bacteremia.

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