ophthalmology

Ophthalmology  is the branch of 

medicine that deals with the anatomy,
physiology and diseases of the eyeball
 and orbit.
• An ophthalmologist is a medical doctor who specializes in eye and
vision care. Ophthalmologists differ from optometrists and opticians in
their levels of training and in what they can diagnose and treat. As a
medical doctor who has completed college and at least eight years of
additional medical training, an ophthalmologist is licensed to practice
medicine and surgery. An ophthalmologist diagnoses and treats all 
eye diseases, performs eye surgery and prescribes and fits eyeglasses
 and contact lenses to correct vision problems. Many ophthalmologists
are also involved in scientific research on the causes and cures for eye
diseases and vision disorders.
 Optometrists

• Optometrists are healthcare professionals who provide primary

vision care ranging from sight testing and correction to the
diagnosis, treatment, and management of vision changes. An
optometrist is not a medical doctor. An optometrist receives a
doctor of optometry (OD) degree after completing four years of
optometry school, preceded by three years or more years of
college. They are licensed to practice optometry, which
primarily involves performing eye exams and vision tests,
prescribing and dispensing corrective lenses, detecting certain
eye abnormalities, and prescribing medications for certain eye
diseases.
 Opticians

• Opticians are technicians trained to design, verify

and fit eyeglass lenses and frames, contact lenses,
and other devices to correct eyesight. They use
prescriptions supplied by ophthalmologists, who are
medical doctors and surgeons or optometrists, but
do not test vision or write prescriptions for visual
correction. Opticians are not permitted to diagnose
or treat eye diseases.
 INTRODUCTION
 The Eye is the organ
of vision
Composed of :
1.Eyeball.
2. The adnexa:

The ocular adnexa include the:

• Orbits
• Extraocular muscles
• Eyelids
• Lacrimal system
• Optic nerves

5
Anatomy of the eyeball
 The three tunics of the eye

I- An external fibrous

tunic

II- A middle vascular

tunic

III- An internal tunic

I. An external fibrous tunic: that gives form to and
protects the eyeball; it’s the only complete tunic.

II. A middle vascular tunic: that consist largely

of blood vessels and smooth muscle
 concerned with the nutrition of the
eyeball and the regulation of the shape
of the lens and size of pupil
III. An internal tunic: that consists largely of
nervous tissue
 concerned with vision and translation of visual
stimuli into nerve impulses for interpretation by
the brain.
 Fibrous tunic
• The outer layer of the eye is the fibrous tunic,
which is composed of 2 parts: the anterior
one-sixth is the transparent cornea, and the
posterior five-sixths is the opaque sclera.
 The cornea
• The cornea is a complex structure which, as
well as having a protective role, is responsible
for about three-quarters of the optical power
of the eye.
• The normal cornea is free of blood vessels;
nutrients are supplied and metabolic
products removed mainly via the aqueous
humour posteriorly and the tears anteriorly.
• The cornea is the most densely innervated
tissue in the body . A subepithelial and a
deeper stromal nerve plexus are both
supplied by the first division of the trigeminal
nerve.
 cornea
• The average corneal
diameter is 11.5 mm
vertically and 12 mm
horizontally.
• It is 540 μm thick
centrally on average,
and thicker towards
the periphery.
1) The epithelium is stratified squamous and non-keratinized and is
composed of:
○ A single layer of columnar basal cells attached by hemidesmosomes
to an underlying basement membrane.
○ Two to three strata of ‘wing’ cells.
○ Two layers of squamous surface cells.
○ The surface area of the outermost cells is increased by microplicae
and microvilli that facilitate the attachment of the tear film and
mucin. After a lifespan of a few days superficial cells are shed into the
tear film.
○ Corneal stem cells are located at the corneoscleral limbus, possibly in
the palisades of Vogt. Deficiency may result in chronic epithelial
defects and ‘conjunctivalization’ (epithelial instability, vascularization
and the appearance of goblet cells). They are thought to be critical in
the maintenance of a physiological barrier, preventing conjunctival
tissue from growing onto the cornea (e.g. pterygium). Deficiency may
be addressed by stem cell auto- or allotransplantation.
2) The Bowman layer is the acellular
superficial layer of the stroma, and is
formed from collagen fibres.
3) The stroma makes up 90% of corneal
thickness. It is arranged in regularly
orientated layers of collagen fibrils whose
spacing is maintained by proteoglycan
ground substance (chondroitin sulphate
and keratan sulphate) with interspersed
modified fibroblasts (keratocytes).
Maintenance of the regular arrangement
and spacing of the collagen is critical to
optical clarity. The stroma can scar, but
cannot regenerate following damage.
• 4) Descemet membrane is a discrete sheet
composed of a fine latticework of collagen fibrils
that are distinct from the collagen of the stroma.
The membrane consists of an anterior banded
zone that is deposited in utero and a posterior
non-banded zone laid down throughout life by
the endothelium, for which it serves as a modified
basement membrane. It has regenerative
potential.
• 5) The endothelium consists of a monolayer of
polygonal cells. Endothelial cells maintain corneal
deturgescence throughout life by pumping excess
fluid out of the stroma. The young adult cell
density is about 3000 cells/mm2. The number of
cells decreases at about 0.6% per year and
neighbouring cells enlarge to fill the space; the
cells cannot regenerate. At a density of about 500
cells/mm2 corneal oedema develops and
transparency is impaired.
 Limbus`

• The border or margin of a structure, especially

the junction of the cornea and sclera in the
eye.
 Sclera
• The scleral stroma is composed of collagen bundles of varying size and shape
that are not uniformly orientated as in the cornea, and so are not transparent.
The inner layer of the sclera (lamina fusca) blends with the uveal tract. Anteriorly
the episclera consists of a connective tissue layer between the superficial scleral
stroma and tenon capsule. There are three pre-equatorial vascular layers:
• • Conjunctival vessels are the most superficial; arteries are tortuous and veins
straight.
• • Superficial episcleral plexus vessels are straight with a radial configuration. In
episcleritis, maximal congestion occurs at this level. Topical phenylephrine 2.5%
will also constrict the conjunctival and 10% also the superficial episcleral vessels.
• • Deep vascular plexus lies in the superficial part of the sclera and shows
maximal congestion in scleritis; a purplish hue, best seen in daylight, is
characteristic.
• The vascular tunic of the eye is formed from behind forward by the
choroid, the ciliary body, and the iris.  The choroid invests the
posterior five-sixths of the bulb, and extends as far forward as the
ora serrata of the retina. The ciliary body connects the choroid to the
circumference of the iris. The iris is a circular diaphragm behind the
cornea, and presents near its center a rounded aperture, the pupil.
 Choroid

Choroid is a thin but highly vascular membrane lining

the inner surface of sclera. It extends from anteriorly
ora serrata to the optic nerve posteriorly. It has a
rough outer surface which is attached to sclera at the
optic nerve and at the exit of the vortex veins. The
smooth inner surface of choroid is attached to the
retinal pigmented epithelium (RPE).Choroid becomes
continuous with pia and arachnoid at the optic nerve.
Choroid is normally 100-220 µm thick ; thickness is
highest at macula 500- 1000 µm.
• Ora serrata: the transition zone:
• The ora serrata can be termed as the
anterior border of the neurosensory retina.
Ora serrata shows forward extensions into
the retina, which are well defined in the
nasal side and less so temporarily. Dentate
processes are “teeth-like” extensions of
neurosensory retina in to pars plana. There
are approximately 20 to 30 dentate
processes per eye. Ora bays are rounded
extensions of the pars plana.
• Topographically, ora serrata corresponds to
the insertion of the medial and lateral
rectus muscles.
 Iris

• Iris is the anterior most part of the uveal tract. It is a thin and
circular structure which forms a diaphragm like structure in front of
the crystalline lens. The word “iris” has originated from a Greek
word. In Greek mythology the iris is the name of Greek goddess of
rainbow.
• The diaphragm formed by iris contains a central aperture known as
pupil. The location of the pupil is not exactly central, its little nasal
to the center. The pupil determines the amount of light entering
the eye. The normal size of pupillary aperture is 3-4 mm. Details on
pupil will be discussed in chapter "Pupil".
• Iris is attached to the middle of anterior surface of ciliary body. The
iris divides the space in front of the lens into anterior chamber and
posterior chamber.
 Topography of IRIS
• Average diameter of the iris is
10 to 11 mm. It is thickest at
collarette, which is located
approximately 1.5 mm from
the pupillary margin and
thinnest at iris root, the part of
iris which joins with the ciliary
body. The thickness of iris root
is approximately 0.5 mm.
 Iris
• Pupillary Zone: Pupillary zone extends from pupillary
margin to collarette. Pupillary zone is relatively flat. Pupillary
margin is marked by a dark border, known as pupillary ruff.
Pupillary ruff is the anterior termination of the pigmented
layer, which lines the posterior surface of iris.
• Ciliary Zone: Ciliary zone of iris extends from collarette to
iris root. There are some depressions or pit arranged in rows
present in this area known as crypts. Crypts are found in
two locations. Those present near collarette are relatively
larger and known as Fuchs’s crypt and few are seen in
periphery of the iris.
 Iris
• Posterior surface of Iris: Posterior surface of
the iris is much more uniform.Posterior
surface of the iris is darker than the anterior
surface and shows numerous radial
contraction folds. However circular folds are
also seen.
 Microscopic structure of Iris :
• 1. Anterior limiting layer :Anterior limiting layer lines the iris
and is the anterior most condensations of iris stroma. The layer
consist of mainly fibroblasts and melanocytes. These cells are
arranged in a meshwork-fibroblasts are located on the surface
and melanocyte beneath them.
• The colour of iris depends on the thickness of the layer and
melanocyte dispersed in anterior limiting layer. The color of the
iris is largely determined by three main variables: (1) the density
and structure of the iris stroma, (2) the pigment epithelium, and
(3) the pigment content (granules) within the melanocytes of
the iris stroma. Anterior limiting layer is absent at the areas of
crypts and very thin at the contraction furrows.
 Microscopic structure of Iris :
• 2. Iris stroma: Iris stroma forms the main bulk of iris tissue and
contains sphincter pupillae, dilator pupillae muscles, vessels and
nerves
• 3. Anterior pigment epithelium: The cells in anterior pigment
epithelial layer of the iris have two distinct portions. 
Muscular basal portion anteriorly (lies next to stroma):
composed of elongated, contractile, smooth muscle fibres. 
• 4. Posterior pigment epithelium of iris: Posterior pigment
epithelium is the second layer of pigmented epithelium situated
posterior to the iris stroma. The cells are rectangular or
pyramidal in shape with round cell nucleus and their cytoplasms
contain large pigment granules.
Muscles in iris stroma
 Muscles in iris stroma:

• The sphincter pupillae muscle is a circular muscle, 0.75 to

1 mm wide, composed of smooth-muscle cells. The
muscle is 0.1 to 1.7 mm in thickness and is considerably
thicker than the dilator papillae.It encircles the pupil and
is located in the pupillary zone of the stroma. The
sphincter muscle is firmly adherent to the surrounding
stroma of iris. Sphincter muscle is composed of spindle-
shaped cells that are oriented parallel to the pupillary
margin, so, contraction of the sphincter causes the pupil
to constrict (a process known as miosis). The muscle is
innervated by the parasympathetic system.
 Muscles in iris stroma:

• The dilator pupillae muscle extends from  the  iris root  to

a point in the stroma below the midpoint of the 
sphincter. A dense band of connective  tissue separates
the sphincter and dilator muscles from each other .
However near the termination  of  the  dilator  muscle, 
small  projections  insert  into  the sphincter. Because  of
the radial arrangement of the fibres of the muscle,
contraction of the dilator pupillae muscle pulls the
pupillary portion  toward  the  root,  thereby  enlarging
the the size of pupil ( a process ka mydriasis). The dilator
pupillae muscle is sympathetically innervated.
• Blood vessels in iris stroma:
• Iris vessels include arterioles, venules, and capillaries.
The iris arteries are branches of major circle of the
iris, located in the ciliary body near the iris root. The
iris vessels usually follow a radial course from the iris
root to the pupil margin. These vessels are
surrounded by a dense network of collagenous fibrils
which is embedded in to the collagen network of the
stroma. Such arrangement of collagen network
prevents the iris vessels from kinking  and 
compression  during  the extensive  iris movement 
during constriction and dilatation of pupil. Iris veins
have very thin walls consisting of endothelium
surrounded by a thin layer of collagen. Capillaries are
formed by a single layer of unfenestrated epithelium,
which forms a part of the blood-aqueous barrier.
• Nerves in iris stroma:
• Iris nerves are usually unmyelinated, however some
nerves are found be enclosed by Schwann cells.
 Ciliary body
Ciliary body is the middle part of the uveal tract .
It is a ring (slightly eccentric ) shaped structure which
projects posteriorly from the scleral spur, with a
meridional width varying from 5.5 to 6.5 mm.  It is brown
in colour due to melanin pigment.  Anteriorly it is
confluent with the periphery of the iris (iris root) and
anterior part of the ciliary body bounds a part of the
anterior chamber angle. Posteriorly ciliary body has a
crenated or scalloped periphery, known as ora serrata,
where it is continuous with the choroid and retina. The
ora serrata exhibits forward extensions, known as
dentate process, which are well defined on the nasal side
and less so temporally. Ciliary body has a width of 
approximately 5.9 mm on the nasal side and 6.7 mm on
the temporal side.
Ciliary body
•Parts of ciliary body: Ciliary body, in cross section, is a triangular structure ( in
diagram it can be compared as ∆ AOI). Outer side of the triangle (O) is attached
with the sclera with suprachoroidal space in between. Anterior side of the
triangle (A) forms part of the anterior & posterior chamber. In its middle, the iris
is attached. The inner side of the triangle (I) is divided into two parts. The
anterior part (2 mm) with finger like processes is known as pars plicata (corona
ciliaris) and posterior smooth (4 mm) is known as pars plana (orbicularis ciliaris).
•Pars plicata: The pars plicata is the portion of ciliary body which contains the
ciliary processes. Ciliary processes are the finger like projections , which  extend 
into the posterior  chamber. The  regions between ciliary processes are called
valleys of Kuhnt. They are approximately  70  to  80  in numbers. A ciliary
process measures approximately 2 mm  in  length, 0.5 mm  in width, and 1 mm
in height.
•Pars plana: pars  plana  is  the  flat or smooth  part  of  the  ciliary body. It
terminates at the ora serrata, which is the transitional zone between ciliary
body and choroid. Histologically, the pars plana consists of a double layer of
epithelial cells: the inner, nonpigmented epithelium, which is continuous with
neurosensory retina; and the outer, pigmented epithelium, which is continuous 
with the retinal pigment epithelium (RPE) .
•The pars plana is a relatively avascular zone, which is important surgically in the
pars plana approach to the vitreous space.The pars plana provides surgical
• Muscle in ciliary stroma: ciliary muscle
• Ciliary muscle is a nonstriated or smooth muscle primarily situated in the
anterior two thirds of the ciliary body stroma. The muscle has three parts
• Outer longitudinal or meridional portion (Brücke's muscle): This is the most
external part (nearest to the sclera) of the ciliary muscle. This part of the muscle
is v shaped, the base of the v is attached to the scleral spur and limbs are
inserted into the stroma of choroid.
• Middle oblique portion (also called reticular or radial):  This part of the muscle
also originates from the scleral spur and the muscle fibres are attached to the
collagenous substances near ciliary processes.
• Inner circular portion (Müller's muscle): Here the muscle bundles are circular in
shape ( that's why it is also called annular part of ciliary muscle) and act as a
sphincter. It lies close to the periphery of lens and embedded in ciliary stroma
near the major arterial circle of iris.
• Contraction of the ciliary muscle, especially of the longitudinal and circular
fibers, pulls the ciliary body forward during accommodation. This forward
movement of ciliary body relieves the tension in the suspensory lens ligament
(zonules), making the elastic lens more convex and there by helps the eye in
accommodation by increasing the refractive power of the lens.
 ciliary process
• Ciliary processes are finger like projections seen in pars plicata of
ciliary body. Ciliary processes are approximately 70 to 80 in numbers
in each eye and extend into the posterior chamber, and the regions
between these ciliary processes are called valleys of Kuhnt.
• Zonules of lens (suspensory ligaments of lens) are inserted in these
valleys. Each of these ciliary processes are 2 mm in length and 0.5
mm in diameter. The ciliary process lies 0.5 mm from the
periphery(equator) of the crystalline lens. The ciliary processes are
white whereas the valleys of Kuhnt are dark in colour.
• Ciliary processes increase the surface area of pars plicata, which is
approximately 6 square centimetre, approximately five times the
surface area of corneal endothelium.
Ciliary body
• Ciliary muscle is innervated by the autonomic nervous system,
parasympathetic postganglionic fibres derived from the
oculomotor nerve. The nerve fibres reaches the muscle via short
ciliary nerve. The  parasympathetic stimulation activates the
muscle for contraction, whereas sympthetic innervation likely has
an inhibitory effect.
• Parasympathetic fibers, coming from the Edinger Westphal
nucleus with the oculomotor nerve, are mixed with nerve fibres
from the ciliary ganglion and form a plexus in the ciliary muscle.
• Sympathetic fibers from the cervical sympathetic trunk, synapse
in the superior cervical ganglion, and run to the ciliary muscle via
the long ciliary nerve. The sensory fibers, coming from the
nasociliary branch of the trigeminal nerve, also run in the long
ciliary nerve to the ciliary body and terminate in the ciliary
muscle.
 Layers of ciliary body:
From inside to outside (from sclera to vitreus )
ciliary body consists of following layers.
 Crystalline Lens

The lens is suspended in

position by the zonules
of Zinn, which consist of
delicate yet strong fibers
that support and attach
it to the ciliary body.
 Crystalline lens
The crystalline lens lies posterior to the
iris and anterior to the vitreous body
It is a transparent, biconvex structure
whose functions are
• to maintain its own clarity
• to refract light
• to provide accommodation

The lens has no blood supply or

innervation after fetal development, and
it depends entirely on the aqueous
humor to meet its metabolic
requirements and to carry off its wastes.
 Cristalline Lens

The lens is able to refract light .

In its nonaccommodative
state, the lens contributes
about 15–20 diopters (D) of the
approximately 60 D of
convergent refractive power of
the average human eye.
 Crystalline Lens
• The lens is composed of the
capsule, lens epithelium, cortex,
and nucleus
• The anterior and posterior poles
of the lens are joined by an
imaginary line called the optic
axis, which passes through them.
• Lines on the surface passing from
one pole to the other are
referred to as meridians. 
• The equator of the lens is its
greatest circumference.
 Crystalline Lens
• The lens continues to grow throughout life. At birth, it
measures about 6.4 mm equatorially and 3.5 mm
anteroposteriorly and weighs approximately 90 mg. The adult
lens typically measures 9 mm equatorially and 5 mm
anteroposteriorly and weighs approximately 255 mg. The
relative thickness of the cortex increases with age. At the same
time, the lens adopts an increasingly curved shape so that
older lenses have more refractive power. However, the index
of refraction decreases with age, probably as a result of the
increasing presence of insoluble protein particles. Thus, the
eye may become either more hyperopic or more myopic with
age, depending on the balance of these opposing changes.
 Vitreous

• Vitreous is a transparent, colour less gel like structure which

occupies the posterior compartment of the eye. It comprises
about 80% of the total volume of the globe (two third of total
volume of eye), about 4mL. The surfaces of the intraocular
structures that interface with vitreous are mainly basement
membrane in nature e.g. pars plana of cilliary body, internal
limiting membrane of retina and vitreous is attached to them with
varying strength of adhesion.
• Vitreous at a glance:
• Contains more than 98% of water
• It has viscosity more than 2-3 times than that of water.
• Refractive index 1.33
 Retina
• Retina is the innermost tunic of the
eyeball
• Thin,delicate,transparent
membrane
• Highly developed tissue of the eye
• Appears purplish red

retina extends from optic disc to ora

serrata
Surface area:266sq/mm
 Grosss anatomy
Three distinct regions of retina:
•  A.Optic disc • Pale pink in colour; well defined
circular area • Diameter: 1.5mm • All the retina
layers terminate here,except the nerve fibre which
pass through the lamina cribrosa
• B, Macula lutea • The macula lutea is comparatively
dark area 5.5 mm in diameter , situated at the
posterior pole of the eyeball , temporal to optic disc
• also called as yellow spot or area centralis •
Primary function :- photoptic vision • Fovea centralis
is central depression in macula;measurin 1.85 mmin
diameter & 0.25 thickness • It is most sensitive part
of retina
• Foveola • Diameter:- 0.35 • Central floor of fovea •
Umbo is the tiny depression in centre of foveola
macula Fovea centralis foveola umbo
• C. peripheral retina
Peripheral retina
Microscopic structure of the retina
 Aqueous production
• Aqueous humour is produced from plasma by the ciliary
epithelium of the ciliary body pars plicata, using a combination
of active and passive secretion. A high-protein filtrate passes out
of fenestrated capillaries (ultrafiltration) into the stroma of the
ciliary processes, from which active transport of solutes occurs
across the dual-layered ciliary epithelium. The osmotic gradient
thereby established facilitates the passive flow of water into the
posterior chamber. Secretion is subject to the influence of the
sympathetic nervous system, with opposing actions mediated by
beta-2 receptors (increased secretion) and alpha-2 receptors
(decreased secretion). Enzymatic action is also critical – carbonic
anhydrase isamong those playing a key role.
 The trabecular meshwork
• The trabecular meshwork (trabeculum) is a sieve-like structure
at the angle of the anterior chamber (AC) through which 90% of
aqueous humour leaves the eye.
• It has three components :
○ The uveal meshwork is the innermost portion, consisting of
cord-like endothelial cell-covered strands arising from the iris
and ciliary body stroma. The intertrabecular spaces are
relatively large and offer little resistance to the passage of
aqueous.
○ The corneoscleral meshwork lies external to the uveal
meshwork to form the thickest portion of the trabeculum. It is
composed of layers of connective tissue strands with overlying
endothelial-like cells. The intertrabecular spaces are smaller
than those of the uveal meshwork, conferring greater resistance
to flow.
○ The juxtacanalicular (cribriform) meshwork is the outer part of
the trabeculum, and links the corneoscleral meshwork with the
endothelium of the inner wall of the canal of Schlemm. It
consists of cells embedded in a dense extracellular matrix with
narrow intercellular spaces, and offers the major proportion of
normal resistance to aqueous outflow.
 The Schlemm canal
• is a circumferential channel within
the perilimbal sclera. The inner wall
is lined by irregular spindle-shaped
endothelial cells containing
infoldings (giant vacuoles) that are
thought to convey aqueous via the
formation of transcellular pores.
The outer wall is lined by smooth
flat cells and contains the openings
of collector channels, which leave
the canal at oblique angles and
connect directly or indirectly with
episcleral veins. Septa commonly
divide the lumen into 2–4 channels.
• Aqueous flows from the posterior
chamber via the pupil into thevAC, from
where it exits the eye via three routes
• Trabecular outflow (90%): aqueous
flows through the trabeculum into the
Schlemm canal and then the episcleral
veins. This is a bulk flow pressure-
sensitive route so that increasing IOP will
increase outflow.
• Uveoscleral drainage (10%): aqueous
passes across the face of the ciliary body
into the suprachoroidal space, and is
drained by the venous circulation in the
ciliary body, choroid and sclera.
• Iris: some aqueous also drains via the
iris.