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356 Cards in this Set

  • Front
  • Back

Normal IOP

11-21mmHg

What are the factors which regulate IOP

Aqueous formation


Aqueous outflow


Episcleral venous pressure

Glaucoma

**

Enucleation

removal of the eye that leaves the eye muscles and remaining orbital contents intact.


An intraocular tumor excision requires an enucleation, not an evisceration.



-Endophthalmitis
- cosmetic for blind eye
- RB & other tumors
- sympathetic ophthalmitis
- prosthesis w/ degeneration


- anophthalmia/microthalmia - uveal melanoma


Evisceration

removal of the iris, cornea, and internal eye contents, but with the sclera and attached extraocular muscles left behind



-endophthalmitis
- cosmetic for blind eye
- painful blind eye

Exenteration

removal of the contents of the eye socket, including the eyeball, fat, muscles, and other adjacent structures of the eye. The eyelids may also be removed in cases of cutaneous cancers and unrelenting infection.


-large orbital tumors


-IO tumors spreading to orbit


-mucormycosis

Bones which form the orbit

Maxillary. Frontal. Zygomatic. Ethmoid. Lacrimal. Sphenoid. Palatine.


(Many friendly zebras enjoy lazy summer picnics)

Optical canal

Optic nerve


opthalmic artery

Enophthlamos

Nerves


Lacrimal. Frontal. Trochlear. Superior Oculomotor. Abducens. Nasal. Inferior Oculomotor.


(Live frankly to see absolutely no insult)


Vessels Superior opthalmic vein. Inferior opthalmic vein. Meningal artery. Lacrimal artery

Inferior orbital fissure

Maxillary nerve (V2)


Infraorbital vessels


Zygomatic nerve


Emissary vein

Annulus of Zinn

fibrous tissue surrounding the optic nerve at its entrance at the apex of the orbit. It is the origin for the four rectus muscles

Structures inside Annulus of Zinn

Normal optic disc size

1.5mm to 2mm

Normal optic cup size

0.2 to 0.4 mm


Central non-neural tissue in optic disc. Increased in myopes, decreased in hypermetropes.

Normal cup/disc ratio? (CDR)

0.3 (0-0.8mm range)


>0.9 suggests glaucoma

Abnormal CDR

>0.8mm


Or


Difference of 0.2mm between eyes

Circumcorneal injection

Ciliary flush. Dilation of ciliary and conjunctival vessels near limbus


- Uveitis


- Keratitis


- Angle closure glaucoma

Causes of Epiphora

Children: failure of recanalization of duct Mucocele & Dacrocystitis


Elderly Infection & trauma

Angle closure glaucoma

Sp. Hypermetropes (small eye, far-sightedness)

open angle glaucoma

Sp. Myopes (large eye, short sighted)

Floaters and flashers (photpsia)

Post virteous detachment

what is strabismus

**

Correction of myopia

diverging lens

correction of hypermetropia

converging lens

Correction of astigmatism

cylindrical lens


Toric lens (IOL) (difference power and different focal lengths perpendicular to each other)

muscae volitans

Old age floaters seen due to degeneration of the vitreous humor.


Floaters>Entoptic Phenomenon>visual effects whose source is within the eye

xanthelasma

lipid deposits around the eye, seen in hyperlipidemia. Can be removed with green laser but recur. Usually found on the anterior surface of the eye, bilateral, near inner angle of the eye. Surgical removal for cosmetic reasons.

Corneal arcus

Grey-ish ring around corneal periphery.


Esterified cholesterol


Old age and dylipidemia

Trachoma

**

Hirschberg test

screening test for stabisumus/ocular misalignment.


shining a light in the person's eyes and observing where the light reflects off the corneas. In a person with normal ocular alignment the light reflex lies slightly nasal from the center of the cornea

Esotropia

Abnormal eye turned in

Exotropia

Abnormal eye turned outwards

Hypotropia

Abnormal eye lower than normal one

Hypertropia

abnormal eye higher than normal one

Krimsky Test

Prism reflex method


Quantifies ocular misalignment. Patient fixates on a light, a prism is placed before the fixating eye, apex towards deviation, until the light reflexes are symmetrical, strength of prism required to center the corneal reflection in strabismic eye measures angle of deviation.

Direct Ophthalmoscopy

1. monocular


2. Limited field of view


3. Magnified 15


4. No stereopsis


5. Virtual erect image


6. affected by refractive errors


7. examination close to patient eye


8. easy to learn, cheap


9. low illumination


10. fundus send just beyond equator


11. 2 disc diameter focus

Indirect ophthalmoscopy

1. binocular


2. wide field of view


3. low magnification (3)


4 Stereopsis


5. Real, inverted image


6. not affected by refractive errors


7. examination from arms length distance


8. costly


9. bright illumination, possible to see thru hazy media


10 retina seen unto ora seratta


11. 8 disc diameter focus

Foster Kennedy syndrome


aka Kennedy syndrome


aka Gowers-Paton-Kennedy syndrome

Findings associated with frontal lobe tumors:


* optic atrophy in the ipsilateral eye
* Papilledema in the contralateral eye
* Central scotoma in the ipsilateral eye
* anosmia ipsilaterally


Optic nerve & olfactory nerve compression. High ICP due to a mass (meningioma)

Pseudo FKS

pre-existing one-sided optic atrophy with papilledema in the other eye but with the absence of a mass.



Seen in ischemic optic neuropathy (optic disc swelling – new episode, optic atrophy – old episode) e.g. Giant cell arteritis.

Cataract

Opacification of crystalline lens of eye.
Curtain/waterfall, difficult to see across (nuclear, cortical, posterior)


-age -dermatitis -congenital (rubella) -trauma -steroids -diabetes
-radiation -galactosemia
-genetics -Wilson’s disease

Band calcific keratopathy

**

Myopia

Parallel rays of light entering the eye are focused in front of the retina in the un- accommodated eye. In this case the optical power is too high mostly due to increased axial length of the eyeball. Concave lens used for correction.

hypermetropia

Parallel rays of light entering the eye are focused behind the retina with accommodation at rest. Optical power is too low mostly due to decreased axial length. The reduced refractive error can be increased by increased accommodation hence increased convergence leading to esotropia (crossed eyes) and monocular amblyopia. Convex lens used for correction.

Astigmatism?

Optical power of cornea and lens in different planes is not equal hence parallel rays of light focus on different points on the retina. Cylindrical lens used for correction (toric lens)

presbyopia

Loss of accommodation with age because of decrease in elasticity of the lens. Occurs earlier in hypermetropes, is worse in dim light and morning (fatigue). Corrected by converging lens (+ve lens

emmetropia

There is no refractive error and with accommodation at rest, image forms on retina.

Ametropia

Condition where light not focusing on retina. Refractive error


myopia (short-sightedness)


hypermetropia (long-sightedness)
astigmatism (parallel rays of light focus at different points on retina)

Aniseikonia

Disparity in image size between the two eyes


unequal size and shape of image

Anisocoria

Unequal size of pupils

Anisometropia

Disparity in refractive error of the two eyes


can lead to amblyopia (lazy eye)


hyperopic eye is chronically blurred.

Aphakia & pseudophakia?

After cataract extraction, the eye is rendered highly hypermetropic. This is because the lens provides 1/3 of the refractive power of the eye. Corrected by IOL, contact lenses or aphakic spectacles.


After cataract, eye in aphakic


IOL makes it psedophakic

How to calculate far point?

Far point is the point at which an object must be placed on the optical axis for the image to be formed on the retina without accommodation. AKA farthest point from the eye at which clear image is formed.



Lens Power = 1/f(meters)


inverse relationship with power

what is the most common cause of registerable blindness?

20-60 years - diabetes


>60 years - ARMD

Most common cause of preventable blindness

Trachoma

Most common cause of treatable blindeness

Cataract

Retinitis Pigmentosa (Rhodopsin mutation)

Group of hereditary disorders characterized by slowly progressive pigmentary retinal dystrophy affecting rods more than cones.

Inheritance pattern of RPA

Isolated


Autosomal dominant (best prognosis)


Autosomal recessive (intermediate prognosis)


X-linked (worst prognosis)

Progress of RPA

Photoreceptor dystrophy starts at equatorial region--ring scotoma-central & peripheral extension -- tunnel vision-- blindness.



Presents as night blindness (early) & tunnel vision. Decreased visual acuity, normal color vision.

Fundoscopic findings of RPA

-Attentuated vessels


-waxy pale optic disc


- pigmentary bony corpuscles


-maculopathy

Tx of RPA

None.


Use Vit A and E to delay blindness


reduce exposure to sunlight

Syndromes associated with RPA

Also seen in Usher’s syndrome, mitochondrial diseases, Abetalipoproteinemia

Amblyopia

Amblyopia AKA lazy eye is decreased visual acuity of un-identifiable organic disease. It is rarely bilateral. It occurs below 8 years of age, due to any cause, congenital or acquired during critical period of development (first 6 months of life – nerve pathway to brain does not develop)

Types of Amblyopia

1. strabismic


2. anisometropia difference 1D


3. visual deprivation (ptosis, congenital cataract, corneal opacity)


4. Hypermetropia >5D; bilateral 9 (aka isometropic amblyopia)


5. Meridional (astigmatism) >1D difference


6. Bilateral amblyopia (alcohol tobacco poisoning)


7. Toxic (Methanol)

Tx Amblyopia

1. remove organic cause, if any


2. cataract


3. anisometropia/refractive error


4. Occlusion therapy


5. Correct stabismus

Benign Lid Lumps

**

Chalazion

common, painless, obstruction in meibomion gland--granuloma within tarsal plate. Resolves in 6 months if not then surgical (incision + curettage)

Internal horedeolum (abscess of meibomian gland)

painful abscess of meibomion gland. Topical antibiotics and excision.

External hordeolum (stye)

Painful abscess of eyelash follicle. Removal of eyelash + hot compression + systemic antibiotics.

Molluscum contagiosum

umbilicated lesion on margin of eyelid caused by pox virus, irritation of eye (red eye) with follicular conjunctivitis (increased lymphoid tissue on tarsal conjunctiva). Surgical excision.

Cysts

Sebaceous (obstruction of pilosebaceous structure; opaque, painless, excision) -


Cyst of Moll (translucent, obstruction of sweat gland)
- Cyst of Zeis (opaque, blockage of accessory sebaceous gland)
- Keratinous (epithelium filled with cheesy keratin + debris)


- Dermoid (hair follicle)

Squamous cell papilloma

common frond-like lid lesion with fibrovascular core & thickened squamous epithelium, asymptomatic, excision.

Xanthelasmas

lipid containing, bilateral, hypercholesterolemia.

Keratoacanthoma

brownish pink, fast growing, central crater filled with keratin, treat by excision careful histology (DDX-SCC)

Naevus (mole)

arrested epidermal melanocytes, no treatment necessary.

Malignant Tumors of eyelid

**

Basal Cell Carcinoma

Most common (90% of eyelid malignancies)


Slow growing


Locally invasive


No Mets



Rodent ulcer, (nodular, ulcerative, sclerosing with pale margins)



Tx Excision biopsy with clear margins

Squamous Cell Carcinoma

Malignant, Mets to lymph node.



Hard nodule or scaly patch. Rapid growth. Check cervical lymph node



Tx Excision biopsy with clear tissue margin.

Causes of Ptosis


(blepharatosis)

Mechanical Lid lesions, lid edema, scarring


Neurological CN III palsy, Horners, Marcus Gunn


Myogenic Myasthenia gravis, muscular dystrophy, external ophthalmoplegia


Congenital – maldevelopment


Aponeurotic – senile, trauma (pregnancy)


Involutional - disinsertion of levator palpebrae muscle (elderly)

Priniciple of applantation tonometery

Method of Applantation tonometery

determined by the force required to flatten the cornea, for the Imbert-Fick law, the force required to flatten the cornea is directly proportional to the IOP.



local anesthetic (topical – proxymetacaine)


fluorescein drop (stain tear film)
clear plastic cylinder with prism against cornea (may use air instead)


force applied until two hemicircles interlock calibrated into mmHg

Cause for Leukocoria (cat eye reflex)

congenital cataract
- retinoblastoma


- retinopathy of prematurity (retrolental fibroplasia) - uveitis
- coats’ disease (retinal telangiectasis)
- vitreous hemorrhage


- persistent hyperplastic primary vitreous (PHPV) [primary vitreous & hyaloid vasculature do not regress]
- incontinentia pigmenti (macular hyperpigmentation)
- toxocara granuloma (toxocariasis)


- endophthalmitis
- norrie disease (x-linked, accumulation of immature retinal cellsàleukocoria, cataract, blindness)
- retinal dysplasia (small eye)
- retinal astrocytoma (NF 1 association)
- inflammatory cyclitic membrane (fibrous membrane that bridges anterior part of vitreous cavity behind the lens from ciliary body to ciliary body – sequelae of ocular inflammation)
- coloboma

Latanoprost

Prostaglandin analogue (F2 α) enhances uveoscleral outflow. Prodrug, hydrolyzed by esterases in cornea.
A.E: decreases BP, increases pigmentation of iris, mild conjunctival hyperemia, thickened eyelashes, cystoid macular edema, uveitis (rare)

Keratoplasty


aka corneal graft

Patient’s diseased cornea is replaced by donor’s healthy cornea.

Types of keratoplasty

1) Penetrating keratoplasty (full thickness corneal replacement)
Indicationsàcorneal opacity, pseudophakic bullous keratopathy, corneal dystrophies, keratoconus, trauma.
2) Lamellar keratoplasty (partial thickness procedure to replace anterior cornea)
a. Superficial anterior lamellar (SALK); involving anterior 1/3 of cornea; indications - superficial scars (previous surgeries), superficial infection.
b. Deep anterior lamellar (DALK); involving 90% of anterior cornea; no endothelial rejection risk; indications - keratoconus, post-herpetic scars, post-infectious opacities, acid/alkali burns.
c. Decement’s stripling automated endothelial (DSAEK); better visual acuity; indications - Fusch’s, endothelial dystrophies, post-cataract surgery edema (aphakic or pseudophakic bullous keratopathy)

early Complications of keratoplasty

- wound leak (seidel positive)
- flat anterior chamber
- iris prolapse
- secondary infection
- secondary glaucoma (retained viscoelastic)
- persistent epithelial defect (ocular surface diseases) - primary graft failure (poor quality of graft)
- endophthalmitis

late complications of keratoplasty

graft rejection (immune)


- microbial keratitis


- recurrence of disease


- astigmatism (contact lenses may be required)

Corneal graft rejection

Early:
- poor qualityàfailure
- 1st POD, cloudiness because of endothelial dysfunction


Late (immune; 6 months - 1 year):
- Epithelial; linear opacity – graft epithelium replaced by host epithelium in a line; treatment – topical steroids
- Endothelial (serious); permanent corneal edema and iritis - khodadoust line (inflammatory cell/graft endothelium demarcation line); treatment – topical and systemic steroids.

psuedoexfoliation syndrome (PEX)?

Age related systemic disease (>65 years) manifesting itself primarily in the eyes; characterized by the accumulation of microscopic granular amyloid-like protein fibers. Buildup of protein clumps can block normal drainage of aqueous humor and can cause a buildup of pressure leading to glaucoma and loss of vision.

TRUE EXFOLIATION of lens capsule

infrared radiation, electric shock or electro-convulsion therapy AKA glass blowers cataract

Baby <2 years presenting with squint?

Rule out RB


Check refractive error

Steven Johnson Syndrome (SJS)?

Autoantibodies against basement membrane and hemidesmosomes causing separation of epidermis from dermis (epithelium from basement membrane). This is a type II hypersensitivity reaction (IgA/IgG).

Caused of SJS

Drugs


Infection


Genetics

Causes of catract

Diabetes posterior subcapsular (snowflakes, white), bilateral


(b) Steroids posterior subcapsular (troubled by bright light)
(c) RP posterior subcapsular
(d) Trauma unilateral (rosette shaped cataract)


(e) Myopes posterior capsular opacity
(f) Nuclear cataract aging, associated with myopia (increased refractive index & spherical aberration of lens). Patients may be able to read again because of induced myopia due to increased refractivity of lens nucleus (SECOND SIGHT OF OLD AGE)

Painless uveitis?

still’s disease (triad: spiking fever, joint pain (systemic inflammatory disease), salmon- pink rash)
- Juvenile Chronic Arthritis (<16 years, pauciarticular associated with iritis, less involvement of joints – white eye)

flare

Light scattering seen in anterior uveitis due to proteins that leak from blood vessels.

Koeppe’s nodules? (Iris nodules)

Nodules seen at inner margin of iris in patients with granulomatous anterior uveitis (sarcoidosis, TB). Histologically composed of epithelioid and giant cells surrounded by lymphocytes.

Busacca nodules? (Iris nodules)

Nodules seen on surface of iris away from pupil in granulomatous anterior uveitis, they are nodules of the iris stroma.
Berlin’s nodulesàanterior chamber angle nodules

Rubeosis Iridis?

Tiny dilated capillary tufts of red spots at pupillary margin; abnormal iris blood vessels obstruct the angle and cause iris to adhere to peripheral corneaàsecondary angle closure glaucoma.
Caused by VEGF, proliferative diabetic retinopathy, central retinal vein (or artery) occlusion (CRVO, CRAO)

Phthisis Bulbi?

Shrunken, non-functional eye. Softened eyeball with no position or control. - uveitis - hypotony
- vit A deficiency -endophthalmitis


Treatmentàprosthetic eye

index myopia?

Nuclear sclerosis cataract causes myopia as it increases the refractive index of the lens

appearance of retina in malignant HTN.

Hall mark of malignant HTN is swelling of optic nerve (papilledema)


Grade 1: diffuse arteriolar narrowing, concealment of vein by arterioles
Grade 2: focal arteriolar narrowing, Salus sign (deflection of veins at crossing) Grade 3: retinal edema, flame shaped hemorrhages, cotton wool spots, exudates


copper wiring, Bonnet sign (banking of veins distal to crossings), Gunn sign


(tapering of veins at either side of crossings) Grade 4: silver wiring, papilledema

Types of lenses

Convexàmagnifies, away (converging) Concaveàminimizes, towards (diverging) Cylinder à tilts/distorts
Prismàshifts towards base

Persistent hyaloid artery?

Part of persistent fetal vasculature syndrome (leukocoria + vitreous hemorrhage) 95% of premature infants
Complicationàvitreous hemorrhage
Remnantsàanterior (Mittendorf’s dot – pinpoint scar on posterior surface of


lens)
àposterior (Bergmeister’s papilla)

Persistent fetal vasculature syndrome (PFVS)?

Failure of regression of primary vitreous, stalk of fetal vessels (hyaloid remnants) Anterioràleukocoria, cataract
Posterioràleukocoria, strabismus, nystagmus
Treatmentàsurgical removal of lens and persistent vascular stalk tissue

Valsalva Retinopathy?

Increase in intrathoracic pressure causes increase pressure in orbital veins,


causes rupture of prefoveal capillaries


pre retinal hemorrhage


floaters and loss of vision

DDx Corneal opacification

congenital glaucoma
- birth trauma
- rubella keratitis, congenital syphilis (TORCHS cross placenta – toxoplasma, rubella, CMV, Herpes, HIV, syphilis)


- sclerocornea


- mucopolysaccharidosis


- endophthalmitis


- cataracts


- bacterial keratitis


- lipid storage diseases like Fabre’s disease

Complication of myopia

(1) Posterior subcapsular cataract (nuclear)
(2) Retinal detachment (RD) & macular holes (increased risk of RD, more increased during laser capsulotomy)
(3) Choroidal hemorrhage leading to Forster-Fuchs' spots (dark pigmented lesion in macula)
(4) Posterior vitreous detachment (PVD)
(5) Posterior staphyloma (protrusion of uveal tissue into sclera)
(6) Myopic crescent (optic disc change – temporal crescent – Bruch’s falls short, sclera visible)
(7) Breaks in Bruch’s membrane (lacquer cracks)
(8) Subretinal neovascularization (due to break in Bruch’s)
(9) Lattice degeneration in peripheral retina (snail track appearance)
(10) Chorioretinal atrophy
(11) Ocular HTN (glaucoma)

ROP STAGES

(1) Demarcation line (parallel to ora serrata between vascularized posterior and immature peripheral retina (i.e. avascular retina))


(2) Elevated ridge (blood vessels enter the ridge – mesenchymal shunt joining arterioles with venules)
(3) Extraretinal fibrous vascularization (from ridge to vitreous cavity)


Signs after stage 3 (plus disease)
- failure of pupils to dilate because of vascular


engorgement of iris
- vitreous haze
- dilation of veins and increased tortuosity of arteries (at least 2 quadrants)
- increased preretinal & vitreous hemorrhage


80% spontaneously regress after stage 3.
(4) Partial retinal detachment (subtotal – because of exudation from neovessels & contracting fibrous component)
(5) Complete retinal detachment (failure of vascularizationàaggressive neovascularizationàextension into vitreousàretinal traction (fibrous component)à detachment)

Tx ROP

Treatment:
- Laser photocoagulation (peripheral retinal ablation; main stay treatment because visual/anatomical outcomes superior to others and induces less myopia)


- Intravitreal bevacizumab injection (anti-VEGF – angiogenesis inhibitor)


- Lens sparing pars plana vitrectomy (stage 4 & 5 – tractional RD)


- Cryotherapy

Berlin’s edema AKA commotioretinae?

After blunt injury to eye.


Retina appears white in periphery, but vasculature is normal. no edema


Decreased visual acuity that is self resovling

Cherry red spots in macula

Clinical sign seen in context of thickening & loss of transparency of retina at the posterior pole.


Sphingolipidosis


Sphingolipids deposit on retina, except fovea because of absence of ganglion cells



Hence contrast made

Bull’s eye maculopathy?

vortex keratopathy (drug deposits; swirling grey lines from infraretinal cornea – altered foveal reflex)


Chloroquine retinopathy


drug binds to melanin in retinal pigment epithelium (RPE)à paracentral depigmentation of RPEàparacentral scotomaàspreads over entire fundusàwidespread retinal atrophy & visual loss

explain Glaucoma Scotoma (i.e. Seidel's sign or Bjerrum Scotoma)

arcuate scotoma ISNT



(1) Arcuate fibers (most vulnerable to glaucomatous changes)
(2) Pappilomacular/transverse (most resistant)


(3) Nasal fibers (relatively straight course)



sparing of only central island (tunnel vision), sparing of temporal island (nasal fibers)

Glaukomflecken

It is the anterior subcapsular or capsular opacity of lens associated with focal epithelial infarct from past acute angle closure glaucoma

Rush disease?

Aggressive Posterior ROP (AP-ROP).


ROP type II


ill-defined nature of the retinopathy + plus disease + posterior involvement

Optic cup?

Well-demarcated central non-neural tissue of optic disease

Fundus examination?

Look at far object to prevent accommodation

Leber’s hereditary optic neuropathy?

Mitochondrially inherited degeneration of retinal ganglion cells and their axons

Different IOP conditions

Normal tension glaucoma IOP <21
Ocular HTN (OHT) IOP >21
Ocular hypotony (deformed globe) IOP ≤ 5

Iridodialysis

separation/tearing of iris from its attachment to ciliary body

Iridodonesis

vibration of iris with eye movement e.g. due to lens subluxation or aphakia

Prevalence of RG blindness

Male 7%


Female is 0.1 to 0.3%

Dual supply of retina

Central RA - peripheral supply


Cilioretinal in 30% of pop – macular supply (saved central vision in CRAO)

How much is vision reduced in glaucoma and iritis?

Glaucoma vision is down to counting to fingers Iritis reduced to 6/9 or 6/12

siderosis oculi?

(progressive pigmentary degeneration of retina pigmentary glaucoma)


caused by iron FB

Kayser-Fleischer ring?

bilateral pigmented ring surrounding iris


- Ruby red, green, blue, yellow, or brown


granular deposits of copper, 1-3mm, located just inside limbus at level of Descemet membrane (sunflower cataract)



Wilsons disease

keratoglobus

Rare, non-inflammatory bilateral corneal ectasia characterized by diffuse protrusion and thinning of cornea.


entire cornea is abnormally thin and therefore the eye bulges.


(Keratoconus, only centre part is thin)

causes of keratoglobus

congenital (Ehler-Danlos type IV, Leber Amaurosis, blue sclera syndrome)


acquired (end stage keratoconus, vernal keratoconjunctivitis, dysthyroid


ophthalmopathy, chronic marginal blepharitis)

Tx of keratoglobus

scleral contact lenses - LAK

types of iron accumulation in the eye

(1) Fleischer’s ring (base of cone in keratoconus)
(2) Rust ring (foreign body)
(3) Hudson stahli line (a long line of lid closure/junction of middle & lower third of cornea, normal in elderly)
(4) Stocker’s line (vertical line associated with pterygium (interpalpabral bulbar conjunctiva cyst), caused because of direct UV sunlight exposure, is located nasally with apex found cornealy, may encroach visual axis)
(5) Ferry’s line (adjacent to limbal filtering blebs & corneal scar)

keratoconus

Sporadic disorder (rarely inherited) in which there is a progressive thinning of the center of the corneaàirregular conical shape of cornea

causes of keratoconus

primary (idiopathic, autosomal dominant (10%))


secondary (ocular, systemic) (a) Ocular:


- congenital (aniridia, retinitis pigmentosa)
- allergic conjunctivitis


constant eye rubbing - vernal disease/ROP
- hard contact lenses
- blue sclera syndrome
- Leber syndrome


(b) Systemic:
- Apert’s - Down’s


- Turners
- Marfan
- Ehler-Danlos
- Osteogenesis imperfecta - atopic dermatitis
- mitral valve prolapse
- eczema
- hay fever

What is corneal topography (aka belin/ambrosia)?

Corneal mapping in severe allergy when no abnormality is found on slit lamp examination. Very sensitive test to see keratoconus and to monitor its progression (shows irregular astigmatism).

keratoconus pathology

Defective synthesis of mucopolysaccharide and collagen tissueàfragmentation of BM, Bowman’s membrane, degeneration of stromal collagen fibersàthinning & forward bulging of corneaàAXIAL MYOPIA & ASTIGMATISM

Signs of keratoconus

decreased visual acuity (myopia & irregular astigmatism)
oil droplet reflex (distorted red reflex – distant direct ophthalmoscopy) àMunson’s sign (bulging of lower eyelid on looking down)
retinoscopy (scissors reflex) – image distortion


keratoscopy (irregular rings)
slit lamp exam (thinning & forward bulging cornea)
Vogt’s lines – vertical, fine, deep, stromal striae which disappear with external


pressure

Tx keratoconus

first = counseling for nature of disease, progression, impact on life
> spectacles (correct myopia in early cases)
> rigid contact lenses (used for higher degrees of astigmatism)
> intacs (intracorneal ring segment)
> collagen cross linking AKA CXL (riboflavin drops + removal of epithelium + UV radiationàstops progression of keratoconus)
> keratoplasty (DALK) – if severe astigmatism/normal DM, prior hydrops is a contraindication due to descemet membrane discontinuity
> penetrating keratopathy (significant corneal scarring)
> acute hydrops treated with hypertonic saline & patching contact lens

What is Cupid’s bow in vernal catarrh?

Cupid’s bow refers to the marginal corneal opacity, resembles arcus senilis (pseudogerontoxon).


seen in vernal keratoconjunctivitis

Effect of penetrating trauma on the pupil

-peaked pupil corectopia (movement of iris to patch surrounding sclera)


-teardrop pupil (injury to the cornea)

Which walls of the orbit are the weakest?

Inferior wall (maxillary)


Medial (lamina papriciya) ethmoid

Progression of vision loss in myopes?

Initially rapidly changing glasses & progression in 2nd decade, slows down at 20-30 years, does not progress after 30 years.

Unilateral loss of red reflex?

corneal opacity (infection, scar) - lenticular lesion
- retinal lesion


- cataract (leukocoria) - RB (leukocoria)
- RD


- ROP

orthophoria

A normal condition of balance of the ocular muscles of the two eyes in which their lines of vision meet at the object toward which they are directed.

Phoria

Phoria is any tendency of deviation of the eyes from the normal when fusional stimuli are absent or fusion is otherwise prevented.

What is the use of rose bengal in the eye?

It is a stain with increased affinity to dead cells used to stain the devitalized cells of conjunctiva and cornea before they actually degenerate & drop off. Useful in xerophthalmia/keratoconjunctivitis sicca (dry eye syndrome).

uses of fluorescein?

Corneal ulcers/abrasion


applanation tonometery


FFA


fitting of hard lens


seidel test (check leakage from eye)

Schirmer’s test

measure amount of tears produced.



filter paper at junction of middle and outer third of lower lid, eyes closed for 5 minutes. Amount of moisture in the paper measured.


Normal ≥ 10mm Borderline 5-10mm Xenophthalmia < 5mm

keratoconjunctivitis sicca (KCS)?


aka dry eye syndrome

decreased tear production or increased tear film evaporation; the aqueous tear production is insufficient to maintain normal tear film.

causes of KCS

- Pure keratoconjunctivitis siccaàlacrimal glands involved only


- Congenital alacrima
- Denervation hyposecretion (CN V surgery – trigeminal ganglion)
- Idiopathic hyposecretion
- Primary sjogren syndrome (xerophthalmia + xerostomia (dry mouth))
- Secondary sjogren syndrome (systemic disease (which involves lacrimal glands), trauma, infection (trachoma), sarcoidosis, thyroid, Steven-Johnson, RA, SLE, benign & malignant tumors of lacrimal gland, leukemia, lymphoma)

Xerophthalmia

drys eye due to failure of tear production due to vitamin A deficiency

Xerosis

extreme ocular dryness with keratinisation

Dx KCS?

- Tear film break up time; <10s


-Rose bengal stain


-schrimer's test

Tear film layers

Oil-Aqeous-Mucin


Oil:retards evaporation + breaks surface tension


Aqueous: anti-bacterial + wash debris + Oxygen to cornea


Mucin: makes cornea epithelium hydrophilic

Lacrimal glands

Lacrimal 95%


Accessory


(a) Krause’s glands: small, mucous glands
(b) Wolfring’s glands (Ciaccio’s glands): small, tubular glands

Tx of KCS

Artificial tears


Isoptoplain (cellulose) – medium viscosity


Liquifilm (polyvinyl alcohol) – low viscosity


lacrilube eye gel (petroleum mineral oil i.e. paraffin) – high viscosity



Mucolytic agents


pilocarpine hydrochloride


(plug)


retinoids


treat blephritis


tarsorrhapy

Convergence exercises

Prescribed for convergence insufficiency/disorder. Bring pencil slowly to within 2-3cm of eye just above the nose about 15minutes/day, 5 times a week.

Extracapsular cataract surgery?

- Indicated for hard cataracts
- Removal of entire lens except elastic posterior capsule - Large incision + sutures (unlike phaco)
- Iris prolapse
- Increased risk of infection

bullous keratopathy?

Bullae form on cornea as the endothelium stops working, fluid accumulates under the epithelium and causes irritation (<1000 cell/mm2)

Herberts pits?

Limbal follicles scar to form Herbert pits. Seen in trachoma. Specific for cicatricial phase of follicles (fibrosis).

List the causes of increased IOP post cataract surgery?

viscoelastic not removed, it solidifies and blocks aqueous outflow (2) uveitis (if iris is irritated)
(3) bleeding
(4) blockade of iridiocorneal angle

Recurrent episodes of chalazion?

Meibomian cell carcinoma

frontalis sling surgery?

Done for congenital ptosis – eyelid coupled to frontalis relieves dysfunctional levator from contributing to eyelid elevation. (Use fascia lata for the surgery)

Uses of prisms

(1) Treatment for paralytic strabismus
(2) Diagnostic for other types of strabismus
(3) Treatment for binocular diplopia
(4) Applanation tonometryàfor IOP measurement (5) Indirect ophthalmoscopy
(6) Gonioscopic lens (is a prism containing lens)

ophthalmoplegic migraine?

Recurrent attacks of migraine associated with paresis of one of more ocular nerves (commonly CN III) in the absence of demonstrable intra-cranial lesion other than within the affected nerve. It is a rare disorder that usually occurs in children <10 yrs

Fuchs endothelial dystropy

Due to mutated gene for collagen VIII α2


Central wart deposits on Descemet membrane, defect in endothelial cells function and anatomy resulting in corneal edema


Tx first relieve corneal edema (hypertonic agents, treatment of ocular HTN, contact lenses), then PKP or DSAEK surgery (for visual rehab)

Hertel's Exophthalmometer?


Abnormal protrusion of the eye in:
- hemorrhage - dysthyroid eye disease


- edema - inflammation


>3mm difference exophthalmos/proptosis

What are secondary causes of glaucoma?

Pre-Trabecular


neovascular glaucoma


iridiocorneal syndrome (endothelial) – abnormal endothelial growth over angle – closed angle


ingrowth – epithelial down growth through wound over angle – closed angle

What are secondary causes of glaucoma?


Trabecular

(a) pigmentary glaucoma – pigment in AC, cornea, trabecular, iris - open angle
(b) red cell glaucoma – acute open angle – hyphema (hemolytic glaucoma)


(c) ghost cell glaucoma – bleached erythrocytes in AC – open angle – also hyphema
(d) phacolytic glaucoma –lens protein and macrophages that engulf them in AC with hypermature cataract – open angle)


(e) acute anterior uveitis glaucoma – angle zipped shut by peripheral anterior synechiae (closed angle) OR inflammation (acute open angle)


(f) pseudoexfoliation glaucoma – deposited pseudoexfoliative material and pigment in trabecular meshwork – open angle

What are secondary caused of glaucoma?


Post Trabecular

increased Pe (episcleral venous pressure)


Cartotidocavernous fistula


ii. sturge-weber syndromeàembryonic developmental anomaly resulting from errors in mesodermal and ectodermal development


SVC Obstruction

What are two characteristic signs of pigmentary glaucoma?

1) Pigmentary loss and increased red reflex


2)Krukenberg syndrome


Generally affectedàmyopes, males>females, 25-40 years

What is the pathogenesis of rubeotic glaucoma (90 days glaucoma)?

Ischemia>VEGF>neovasculaization at angle of anterior chamber>Impairs aqueous outflow > Open angle



Neovascularization>Fibrosis>blocks trabeculum>contracture of iris to block trabeculum>close angle glaucoma


risk factors - ischemic CRVO, diabetic retinopathy)

What is iridiocorneal endothelial syndrome?

- abnormal corneal endothelium migrates across angle, trabecular meshwork, and anterior iris.


- corneal edema + iris atrophy + secondary open/closed angle glaucoma


HSV

What is the pathophysiology of sympathetic ophthalmia?

- Rare, devastating, bilateral, granulomatous uveitis that comes 10 days to many years (90% within a year) following a perforating eye injury (involves injured + healthy eye)


Immune response to retina antigens


- Treatment:
> enucleation of traumatized eye within 10 days
> steroids + cyclosporine(immune suppression)àto preserve vision in fellow eye

What is Amaurosis Fugax (CRAO)?

- Transient retinal ischemia


Emboli


Cholesterol - Carotid artery


Calcific - Heart valves


Fibrin -diseased carotid artery



Tx Cardiac workup


Dec. IOP
ocular massage


CO2 breath


anterior chamber parencenteis s

Ischemic retinal disease

- Pale edematous retina,


cherry red spot,


atrophic disc,


cattle trucking,


emboli

Loss of peripheral field vision?

Absolute>branch retinal artery occlusion (cilioretinal supplies center)


Relative>retinal detachment (large, bright still seen)


Disease>retinitis pigmentosa (tunnel vision)

Macular holes seen in?

Idiopathic or blunt trauma (associated with vitreous detachment – vitreous traction, edema causes lamellar macula hole)



- Peripheral retinal holes>retinal detachment


- CMO - Laser injury - DR


- RD (rheg) - HTN - ERM/vitreomacular traction syndrome

List the complications of blepharitis

Trichasis. madarosis. stye. poliosis. ptosis


Conjunctivitis


Keratitis, tear film disruption,

Treatment for corneal ulcer

Control infection


pain relief


prevent perforation - anti-glaucoma drugs, pressure bandage, conjunctival flap, contact lens, corneal graft, paracentesis, avoid straining factors, NO eye pad as it gives too good a condition for bacteria to grow



Corneal ulcer complications

perforation, uveitis, endophthalmitis, anterior synechiae, open angle glaucoma, scar, corneal fistula

What is RAPD (Marcus-Gunn pupil)?

You know this :P


The most common cause of Marcus Gunn pupil is a lesion of the optic nerve (between the retina and the optic chiasm) or severe retinal disease.

RAPD +ve conditions?

Optic neuritis


RD


Optic nerve atropy


neuropathy


cellulitis


sever glaucoma

RAPD -ve?

- Dense cataract
- Corneal opacities
- Macular disease
- Macular edema

What is absolute APD (absolute afferent pupillary defect)?

No response to light stimulation of a completely blind/amaurotic eye. Consensual reflex is intact in affected eye.

Pupillary light-near disassociation?

Normal near response > eyes focus on near object, they converge and pupils constrict. Due to APD, there is decreased response to light (i.e. miosis test) but normal near reflex



- tonic/Adie’s pupil (due to ciliary ganglionitis)àthere is anisocoria


- midbrain tumor (parinaud’s syndrome)
- infarction - CNS degenerative disorder



- diabetes - not seen with opacities of corneal lens - chronic alcoholism
- encephalitis

papilledema

Optic disc swelling caused by increased ICP (intracranial pressure)



blurring of margins of optic disc (earliest sign)


venous engorgement & hyperemia of optic disc (early)
loss of venous pulsation due to increased ICP compressing vein


hemorrhages (hemorrhagic disc swelling) with cotton wool spots


elevation of optic disc – filling of the cup
Paton’s lines (radial lines emerging from optic disc)



ICP (Headache, tinnitus)
Transient dec of VA

Fundoscopic findings in ION (ischemic optic neuropathy)

Peripapillar hemorrhages on disc and disc margins - Cotton wool spots around disc
- Giant cell arteritis

What are the types of age related macular degeneration (ARMD)?

Atropic - nonexudative, more common, less severe, slow progress, dry. Lipofuschin deposits b/w bruch's membrane and RPE (DRUSEN)


Exudative less common, rapid loss of vision, severe, wet (neovascularization),


RPE detached. VEGF. neovascularisation. subretinal leaks



Tx Argon laser


Photodynamic therapy

Hermansky-Pudlak?

abnormalities in synthesis of melanin resulting in pigment deficiencies. Associated systemic disease with albinism


Features – decreased visual acuity, photophobia, nystagmus, strabismus, ametropia, iris hypopigmentation


Fat, young guy presenting with blurred vision in one eye?

MS


Optic neuritis


Signsàdecreased visual acuity


àdecreased color vision
à RAPD
àpapilledema (fat nerve head) àcentral scotoma


- Diagnosed by CT, MRI, perimetry (field testing)
- Treatmentàsteroids (IV methylprednisolone)
- Complicationàrepeated episodes can lead to optic atrophy

stargardt’s dystrophy?

- Variant of fundus flavimaculatus is an inherited form of juvenile macular degeneration (affects both the RPE and, secondarily, the photoreceptors)àprogressive vision lossà blindness [rapid decrease of visual acuity (6/18 – 6/60)]



Fundus flavimaculatusàvision more preserved, widespread pisciform yellow flecks Shiny – ‘16 37


throughout the fundus (more in adulthood)

Describe basal cell carcinoma (BCC)?

most common


slow growing


local invasion


non metastasis


painless lesion (ulcerative, sclerosing, nodular)


ectropion or entropion + loss of eye lashes (madarosis)



Tx Excision. clear margins. cryo. radio.




Describe squamous cell carcinoma (SCC)?

Less common


malignant


neck nodes


scaly patch, hard nodule


Tx excision



*- SC papillomaàfrond like lid lesion (fibrovascular core + thickened squamous epithelium) - asymptomatic

Iris bombe

Iris bombe is a condition in which there is apposition of the iris to the lens or anterior vitreous, preventing aqueous from flowing from the posterior to anterior chamber. This causes increased pressure in posterior chamberàanterior bowing of peripheral irisà obstruction of trabecular meshworkàacute attack of ACG (angle closure glaucoma) IOP at presentation is usually ≥ 60

Risk factors iris bombe



#39

àage > 60 years


àfemales > males (4:1)
àrace (white, south east Asians, Chinese, eskimos)
à+ve family history
àrelative anterior location of iris lens diaphragm (because lens grows throughout life)


Shiny – ‘16 38


àshallow anterior chamber/small corneal diameter ànarrow entrance to chamber angle àhypermetropes (short axial length)
àlarge lens (older, cataractous)

Tx of acute close angle glaucoma

àprophylactic peripheral laser iridotomy (YAG laser) or iridectomy àintermittent angle closure (increased by physiologic mydriasis, prone and semi-prone)
àacute attack – IV acetazolamide, oral + IV mannitol, oral glycerine, topical pilocarpine (2%), β-blockers
àALWAYS TREAT OTHER EYE PROPHYLACTICALLY

chronic open angle glaucoma risk factors

àage > 65


àrace (blacks)
àfamily history
àmyopes* (disc more vulnerable to scleral canal morphology) àsteroid use (increase IOP)
à diabetes*
àretinitis pigmentosa*
àfusch’s dystrophy*

pathophysio of chronic open angle glaucoma

(1) thickening of trabecular lamellae (decreased pore size)
(2) decreased number of trabecular cells
(3) increased extracellular material in meshworkàdecreased outflow through meshwork

Chronic open angle glaucoma SX

- Symptoms:
à asymptomatic/painless àdecreased vision loss
àincreased IOP (diurnal variability) àcupping (high C/D)

TX chronic open angle glucoma

β-blockers


Prostaglandin analogues àα2 agonists
carbonic anhydrase inhibitor à miotics


adrenergic drugs
argon laser trabeculoplasty àdiode laser trabeculoplasty àsurgery: fistulization trabeculotomy
ciliary body ablation

DX chronic open angle glaucoma

- For diagnosis:
à tonometry


à pachymetry
à gonioscopy
àexclude secondary causes àCDR – fundoscopy àperimetry – tunnel vision

Drugs for Glaucoma

B-Blockers (Timilol) - reduce aqueous production


increases asthma and CVD, decreases BP and HR



Prostaglandin analogue (Latanoprost)-increases uveoscleral outflow


iris pigmentation, darkening of eyelashes, conjunctival hyperemia, macular edema, uveitis



Carbonic anhydrase inhibitors (Dorzolamide)
- decreases aqueous secretion


tinging, headache, unpleasant taste (local), SJS



α2 agonists (Brimolidine)
- increases uveoscleral outflow, decreases secretion


red eye, fatigue, drowsiness



Parasympatheticomimetic (Pilocarpine)


increases outflow by pulling at longitudinal fibers of ciliary body
- adverse effects – headache (due to ciliary spasm), pupillary constriction, visual blurring, retinal detachment (intense ciliary spasm causes pulling effect on ora serrata causing RD)



Sympatheticomimetic (Adrenaline)
- increases outflow, decreases secretion
- adverse effects – red eye, headache, palpitation, avoid in angle closure glaucoma as it causes mydriasis



laser for glaucoma

Laser trabeculoplasty (diode or argon)


Laser ciliary ablation (diode)



laser only reduces IOP by 30%, so for IOP > 28 laser is not effective

Surgery for glaucoma

TRABECULECTOMY- fistula b/w AC and subconjuctival space



Dec IOP


Infection


Shallow AC


cataract



no sympthamimetics (cause scarring)


5-FU to prevent scarring

function and mechanism of action of photodynamic therapy?

- Treatment for age related macular degeneration (ARMD)
- Photosensitive dye (verte porfin) that preferentially accumulates in active new vessels is infused IV then activated by non-thermal laser beam. Resultant reaction (generation of free radicles) causes thrombosis of new vessels.


- Subfoveal vascular membranes cannot be treated by argon laser since energy is sufficient to damage photoreceptors (indocyanine greenàporphyrin like dye)

Anti-VEGF?

Lucentis (Ranibizumab) – 94% vision stabilization (2) Avastin (Bevacizumab)
(3) Eylea (Aflibercept)

LASER

Light Amplification by Stimulated Emitted Radiation, single wave length



Photocoagulation green Argon, red Kyrpton, diode
Photodistruptive


Photoevaporative


Photodecomposition


Photocoagulative Laser

àthermal laser, tissue pigments absorb light and convert it into heat, thus raising target tissue temperature high enough to coagulate and denature cellular component


green argon laser


krypton red laser
diode laser
used for diabetic retinopathy, retinal vein occlusion, ROP, retinal holes (laser: glial cellsàfibroblastsàfibrosis), glaucoma, tumors (laser trabeculoplasty; trabecular meshwork, iris, and ciliary body)

Photo disruptive laser

Yag Laser


Capsulotomy, iridotomy, anterior capsular contraction, posterior capsule opacification,



release of giant pulse of energy, when pulse is focused on a spot, light exceeds a critical level of energy density, optical breakdown occurs in which temperature rises so high that electrons are stripped from atoms resulting in a physical state called plasma. Plasma expands with increasing pressures cutting ocular tissues

photoevaporative laser

absorbed by water, does not enter Vitrous cavity


CO2+erbium+horilium


surface lesions, lid lesions, blood less incisions,

photodecomposition

Argon+fluorine


breaks bonds and converts polymers to smaller tissue


PRK, LASIK, LASEK, superfical corneal opacity

Argon laser for Diabetic retinpathy

- The laser is used around the retina
- Macular region is saved by promoting nutrient uptake, preventing peripheral neovascularization, and putting an end to release of vasogenic factor (proliferative)


- Diabetic maculopathy>focal or grid pattern laser photocoagulation
- Most effective treatment>pararetinal photocoagulation (PRP)


àtreating entire retina except temporal arcade (macula + optic nerve)

Jones Test I and II

Test 1 to see if lacrimal system working as a whole


Test 2 to see where the obstruction is



Partial obstruction


Total Obstruction


Pump failure

Posterior polar cataract?

Very dangerous because capsule is degenerated. Never do hydrodissectionàopens up


weak areaàdamage to posterior capsule

Cherry red spots in ischemia?

- Fovea has decreased layers, it is the thinnest part of the retina, so dual supply of chorioretinal artery shows as cherry red spot (choroid reflection)
- No RGC therefore no sphingolipids deposition

Hippus AKA pupillary athetosis (unstable pupil)?

Irregular dilation and constriction of pupil


Continuous sympathetic flow.


Aconite poison. Cirrhosis.

iridodonesis

Tremorous or agitated iris with eye movement caused by lens subluxation or aphakia or ectopia lentis.

Disadvantage of LASIK?

Thin cornea


Diffus lamillar keratitis


flap complications (don't lose the flap)

Use of pachymetry

Measure corneal thicknessàif IOP readings very high on tonometry, you can measure corneal thickness to rule out any possible over estimation.

What is solar keratopathy?

UVA keratitis


Pinguecula.(fibrofatty) Ptergium. (fibrovascular)

FFA stages

1) choroidal phase>mosaic pattern, lack of dark areas
2) arterial phase>arteries filled
3) arterio-venous phase>arteries filled + veins starting to


4) venous phase>veins filled
5) late stage>recirculation of dye

steroid keratopathy?

band calcific keratopathy

Red tears

Rifampicin; endometriosis of conjunctiva

Cosopt

Timolol (β-blocker) + Dorzolamide (carbonic anhydrase inhibitor)

What is plica semilunaris?

remnant of nictitating membrane (third eyelid)

What are Purkinje-Sanson images?

They are reflections of objects in slit lamp examination from the structure of the eye.


P1àouter cornea P3àanterior lens
P2àinner cornea P4àposterior lens (inverted)


Piggy bank lens?

Smaller lens on bigger lens (soft lens floats on cornea for comfort, hard lens on soft lens


for vision correctionàused in keratoconus, astigmatism

Trauma


-

Trauma to cornea > astigmatism
- Leakage of aqueous > decrease in anterior chamber depth

Corneal Incision healing time

3 months; avascular

Orbital bones in order of increasing weakness?

Lacrimal
Zygomatic
Frontal
Ethmoid (weak because of ethmoid air cells – sinus) Maxillary (weakest)

Cataract with yellowish hinge?

Post subcapsular

Indications for FFA?

DM/HTN
Central Macular Odema (CMO)
CRAO
CRVO


ARMD


Planing retinal laser

Indocyanine green use?

Used for choroidal vessels; binds to protein and does not leak.


choroidal neovascular membrane.

Natural location of CA I (acetazolamide)?

- Kidney - RBCs - Eye - GI - CNS

Drugs for allergic eye disease?

Mast cell stabilizers, anti-allergies, weak steroids, Xepat (Olopatadine)

What are shield ulcers?

Central, corneal ulcers covered by exudate i.e. vernal ulcers with adherent mucus plaque (seen in vernal KC)

Complications of Chronic blepharitis?

- Inflammation of the eyelid
- Tear film instability/dry eye
- Bacterial keratitis
- Marginal keratitis
- Recurrent conjunctivitis
- Hordeolum


- Chalazion
- Corneal infiltration
- Trichiasis
- Madarosis


- Poliosisà

Inherited cataract occurs at which age

30-40

Complication of Avastin (Bevacizumab)?

Corneal ulcer/abscess

Traumatic cataract?

Rossete shape

Placido’s disc?

Instrument for examining the front surface of the cornea


seen through a convex lens mounted in an aperture at the center of the pattern. Such an instrument gives a qualitative evaluation of large corneal astigmatism, and is useful in cases of irregular astigmatism as in keratoconus.

Scotomas?

Centrocecal > macula + blind spot (retinal ganglion cells)



Altitudinal > either upper or lower half of visual field affected (retinal vascular disease,


glaucoma, etc.)

Pulsation of CRA?

This is abnormal and indicates occlusion

Factors predisposing to HSV keratitis?

- Sunlight
- Immunosuppression
- Extremes of age
- Stress
Primary infectionàself-limiting conjunctivitis Immunosuppressionàreactivation (latent in trigeminal ganglion)àkeratitis (epithelial, stromal, endothelial)àrequires treatment

Marginal naevus?

In a nevus there is a marginal growth of vessels.

Subconjunctival hemorrhage

Trauma


Bleeding disorder


HTN


Anticoagulant


Inc. pressure


atheroscelrosis


What is HUG syndrome?

Hyphema, uveitis, glaucoma



Late post-op period after cataract surgeryàendothelial cell damageàstromal edema - àbullous keratopathy

Apraclonidine

Short acting β-blocker given after YAG laser treatment (e.g. capsulotomy) to prevent rise in IOP

How does adrenaline cause pigmentation?

Disrupts melanin metabolismàpigmentation on underside of eyelid

Indications for vitrectomy?

- RD (rheg or tractional)
- Retinal tear
- Vitreous hemorrhage


- Posterior lens displacement
- Trauma
- Severe inflammatory debris (floaters)
- Subhyaloid hemorrhage
- Macular edema/holes

Differentials for Rubeotic Iridis?

- Diabetic retinopathy
- CRVO (most common)
- BRVO
- Glaucoma (end stage)
- ROP
- Trauma
- Chronic RD
- Acute retinal necrosis (complication of HZV) - Behcet’s disease


- malignant melanoma - RB
- TB
- Sarcoidosis


- Sickle cell retinopathy - Leukemia/lymphoma - CMV retinitis
- Chronic uveitis


- Coat’s disease

Clinically significant cataract?

central location

Hydrodissection

Is performed to separate nucleus and cortex from lens capsule so that nucleus can be more easily and safely rotated

Lens development?

From surface ectoderm.


Hence people with skin problems are likely to develop cataract

How to remove lens?

Phaco - Hard part


Aspiration and irrigation - soft part

Modes of anesthesia?

Retrobulbar > ciliary ganglion block – 25G long needle


Peribulbar> short needle


Subtenon> under conjunctiva


Topical > drops, gel


General Anesthesia (GA)

Treatment for congenital cataract?

Under GA
Lensectomy + vitrectomy + IOL placement ASAP (at age of 2 years)

Types of cataract?


- Nucleosclerotic (age related)


Shiny – ‘16 51


- Posterior subscapular - Polar
- Cortical
- Mature

Giant papillae seen in?

allergies


contact lens users

Transient blurring of vision in DM?

- TIA


- Sorbitol> swelling of lens

Gonioscopy

Used to see angle of anterior chamber - edge of cornea (schwalbe's line)
- trabecular meshwork
- sclera (scleral spur)>open


- ciliary body (anterior part) – deep angle>increased in myopes & aphakia

What are corneal verticillata?

Sub-epithelial corneal deposits; fine, gold-brown, bilateral AKA vortex keratopathy (branch out from central whorl)
- Amiodarone - HCQ, CQ - Indomethacin - Phenothiazine
- Fabry’s disease

What is Asteroid hyalosis?

Degenerative condition of the eye involving small white opacities in the vitreous humor – calcium degeneration in vitreous, commonly seen in DM, HTN, hypercholesterolemia (cause unknown)

Drugs after trabeculectomy?

Abx


steroids +5FU

Most common cause of distorted pupil?

post-catract

Radial keratotomy?

Refractive surgical procedure to correct myopia
Cuts in cornea (diamond knife)
Adverse effects: epithelial plugsàincreased infections

Choroidal sclerosis?

Atrophy of choroidal blood vessels > RPE/photoreceptor atrophy

Sight threatening features of Paget’s disease?

Paget’s diseaseàchronic enlarged and misshapen bones because disorganized bone remodeling
(1) compression of optic nerve (skull deformity)
(2) angioid streaks (bilateral narrow irregular lines deep to retina because of breaks in Bruch’s membrane, radiating from optic discàresemble vessels)

Angioid streaks in?

- Pseudoxanthoma elasticum - Ehler-Danlos syndrome
- Paget’s disease of bone
- Sickle cell disease


- Acromegaly - Idiopathic


Can decrease vision if:
- choroidal neovascularization (CNV)
- choroidal rupture
- streaks damage RPE at fovea (subfoveal hemorrhages)

Cataract post-op complications?


- Folds in descemet membrane (if IOP decreases)
- Cystoid macular edema (hypotony) – late complication
- Anterior chamber with unusual cells, lens matter – early complication - Irregular pupil (iris prolapse) – early complication
- Lens position
- Increased IOP – early complication
- Vitreous loss – late complication
- RD (increased risk in myopes) – late complication
- Wound leak – early complication
- Endophthalmitis – early complication
- Posterior capsular opacity (PCO) – late complication
- Corneal decompensation – late complication

Capsular tension ring

Used in pseudoexfoliation syndrome (AKA exfoliation glaucoma)>weak zonules

Iris hooks

Used if synechiae are present or if pupil does not dilate during surgery

Watery eyes due to stenosed punctum?

3 snip surgery to obliterate any punctum blockage

Posterior capsular opacification?

Residual cells migrate across its surface leading to opaque scar
Elschnig pearls (focal retention of lens fibers that have undergone proliferative and degenerative changes surrounded by lens capsular fragments seen after extracapsular cataract extraction)
Capsular fibrosis (fibrous metaplasia of epithelial cells)

Injectable lens

Optic


Haptic

Phaco machine (pumps)

- Peristaltic (vacuum only when port is blocked) - Venturi (always vacuum, more aggressive)

Viscoelastic

- maintains chamber
- protects corneal endothelium sodium hyaluronate (cock’s comb) chondroitin (shark’s cartilage)
synthetic

Peri-operative complications

- prolonged phaco> stitches needed, corneal edema,


uveitis - posterior capsular rupture
- loss of lens fragments
- dislocation of lens


- suprachoroidal hemorrhage

Phaco probe – double tube

- vacuumàsucks out lens
- continuous fluid flowàkeeps chamber deep, pushes back posterior capsule; neutralizes the heat produced

Adenoviral conjunctivitis

Immuune complex deposits on cornea

Treatment of Retrobulbar optic neuritis (isolated)

IV steroids (3 days), then oral – giving oral first will lead to increased severity of later events

Signs in allergies

Acute (<6wk) Chronic/Vernal (>6wk)



Sign


Papillae


Shield ulcer


Trantas spots (gelatinous white clumps, upper limbus)


lid edema


conjunctival injection


cupid bow

Axial Length of eyeball

Normal 22-24mm


Myopes >24mm


Hypermetropia <22mm

Back vertex distance BVD?

Distance b/w surface of contact lens and cornea.


Ideal 14mm

Steroids for glaucoma/cataract

Systemic Cataract>Glaucoma


Topical Glaucoma/Cataract

Post op Endophthalmitis

Syx


Red eye


pain


Dec VA


Hypophon



TX


Steroids


ABx (Intravitreal)

Corneal transparency is maintained by?

Avascularity


Lattice framework


tight epithelial junctions


endothelial pump function


tear film


equal refractive power of all layers

Complex lid injury?

Medical 1/3 canthus of eye


orbital fat visible


eyelid margin tear


Greater than 25% skin lost

Tx Retrobulbar hemorrhage

Epicanthotomy



Do not do in globe rupture

Open globe

Pentrating injury through cornea sclera or both. Eye margin is sclera and ant. cornea

Tenon capsule

Connective tissue layer between conjunctiva and sclera.


Makes sheath around rectus muscle

Choroidal folds seen in

Dusthyroid eye


orbital tumors

Delien Effect

Post-trabeculectomy bleb at limbus causes cornea to become thin and dry



Bleb prevents tear film distribition



Tx Lubricant or bandage lens

Minimum vision for driving

20/40 or 6/12



Visual field



120 left and right


20 up and down

Chronic lens wear lead to?

Giant papillae


Muller muscle damage


ptosis

Normal endothelial cell count

3000 cornea is longer horizontally


<1000 bullous keratopathy

Define orbital blow-out fracture

# of one of the walls of the orbit, but orbital rim remains intact



Sx


Enopthalmosis


emphysema


diplopia


infraorbital anesthesia

gonitomy done is what conditions

Buphthalmos


Haab striae


Gonidodysgeneis

naevus of ota

Congenital melanosis bulbi. Entrapped melancoytes in upper 1/3 of dermis



Heterochromia


inc risk of melanoma

Cause of heterochromia

Congenital horners


Physiological (inherited)


hemmorhage


FB


glaucoma


medicines (latanoprost)


melanoma


pigment deposition syndrome


Fuchs uvieits


ICE syndrome

Blunt trauma to the eye consequences

Lid: Edema > ptosis


Lacrimal puncta > epiphora


Cornea >abrasion, edema


Conjunctiva > hemorrhage, chemosis


Scelra> rupture


Iris > iridodialysis, iridonesis


Lens > subluxation, cataract


Angle > recession



Mydriasis, uveitis, Retinal dialysis, Vit hemorrhage, blowout fracture, phthisis bulbi, commotio retina, choroidal tear, optic neuropathy

How to measure IOP?

Goldman applanation


Non contact/air puff


Tono pen


Rebound


Palpation


Pneumo


Electronic indentation


Schiotz

Aniridia

Absence of iris, usually B/L


WAGr syndrome

Role of NaCl in corneal edema

Hypertonic saline > hypertonic tearfilm > draws water out of cornea

Morgagnian cataract

Hypermature cataract > liquefication

Altitude retinopathy

Ophthalmoscope will show flame shaped hemorrhages, dis edema, tortuous veins. Blurring of vision.

Chemical injury

Acid > causes coagulation of proteins to make barrier. prevents further damage. Eye is red


Alkali > keeps penetrating. eye is white

Berlin/ambriosa

Corneal topography

Difinition and classification of amlyopia

Dec in visual acuity of one eye w/o organic disease



-Strabismus


-Deprivation of light


-Anisometropia


-Meridoneal (astigmatism)


-Isometropia (Hypermetropia)

Manual small incision cataract surgery

Entire lens exposed thru self-healing tunnel. Wound > phaco

Intracapsular cataract extraction

Removal of lens and lens capsule in one piece

IOP in normal tension glacoma

<21mmHG

In squint exam corneal image can calculate degree of squint b/w?

15 to 40

Fundoscopy, it is necessary to give patient a target to prevent?

Accommodation

Intrapalpebral staining or cornea + conjunctiva leads to

Aqueous tear deficiency

Different stains

Sup Conjunctival stain > superior limbus, KC


Inferior cornea + conjunctiva > blephritis + exposure

Normal corneal thickness

540 micrometer

Chronic allergy

CUpid bow/ shield ulcer

Corneal graft success

Visual improvement (2 snellen chart lines)


Clarity of cornea


no infection


cosmetic

Dense cataract complications

Phacolytic glaucoma


Phacomorphic glaucoma


Phacoananaphylactic uveitis

How to check color vision aside from ishiara chart

100 hue test

Tx chronic blephritis

botox

use of epicentral fold

no function


skin fold of upper eyelid, covering medial canthus

OD and OS stand for

Oculus dexter (right)


Oculus sinister (left eye)

Mylination of optic nerve fibre is called

pseudo-papiledema

Peter's anomaly

Developmental disorder of anterior segment



incomplete separation of cornea from iris or lens

Distichiasis

Abnormal growth of lashed from meibomian gland orfices

Maxiden is

dexamethsone

trilateral RB

pinealoma and B/L RB

For glaucoma is Oct or perimetery better?

OCT

Lisch iris nodule

Seen in NF1


Pigmented nodular aggregate of dendritic melanocyte affecting iris

Differenciate b/w Fuchs uveitis and simple uveitis

Heterochromia


KP in stellar arrangment (diffuse)


Absence of synechia

Blepharophimosis

B/L ptosis, reduced lid size, vertical and horizontal

Pellucid marginal degeneration

**

Ankyloblepharon

Adhesion of the ciliary edges of the eyelids to each other

Corneal scarring stages

Nebula


Macula


Leucoma


Adherent Leucoma

Symblepharon

Adhesion of the globe to the eyelid (conjunctiva)



Due to disease or trauma

Pavingstone degeneration

peripheral small areas of retinopathy in the outer retinad

difference between PRK and LASIK

PRK - laser applied to corneal surface after removing epithelium



LASIK partial thickness flap created, laser applied, flap restored

Which disease had long arms

Marfan syndrome


Ectopic lentis, RD, myopia, Keratoconus

Which corneal dystropies are autosomal recessive? (AD)

Macular. Gelatinous. Congenital Hereditary Endothelial Dystrophy II

Staphlyoma

Abnormal profusion of uveal tissue thru weak point in eyeball.

jack in the box phenomenon

Aphakic eye with glasses. Central field magnified, and peripheral field is blurred.


So when something moves into centre its pops out.

Phlyctenule

Subepithelial inflammatory nodule resulting from cell mediated Ag-Ab reatcion.

Uthoff's syndrome

Worsening of neurological symptoms in MS when body is heated.


Heat slows doen nerve impulses

Epiblepharon

Congential horizontal fold of skin near upper margin of eyelid caused by abnormal insertion of muscles

River blindness

Onchocerciasis, parasitic worm

Visual blue in white cataract

Visualize capsuleT

tobaco dust particles

Pigmented cells in the citrous and occasionally AC in rheg RD

With the rule atsigmatism

Vertical meridian steepest, -ve cylinder is used for correction



normal in nature

Against the rule astigmatism

Horizontal meridian is steepest. +ve cylinder is used for correction

Colobma

Incomplete fusion of choroidal tissue leading to hole in the iris, retina or choroid. Most affect the iris

Small perforation of cornea Tx

Cyanoacrylate glue + bandage contact lens

Hutchinson sign

vesicle at tip of nose, HZV ophthalmicus.

Hutchinson triad

Interstitial keratitis


Deafness


notched central incisors



(syphillis ^ + saddle nose)

Hutchinson pupil

dilated pupil, poorly reactive to light, supratentorial mass Inc ICP, coma patiEents

Embryotoxon

Congenital opacity at margin of cornea