Ophthalmology Reference

Ophthalmology

Ophthalmology Playlist
Lecture Page Number

1) Examination of the Eye 1

2) Optics & Errors of Refraction 35

3) Orbit 45

4) Lacrimal System 49

5) Eyelids 55

6) Conjunctiva 63
7) Sclera 72
8) Cornea 75
9) Lens 87
Ophthalmology Reference

10) Uveal Tract 96

11) Glaucoma 103
12) Vitreous 112
13) Retina 115

14) Neuro-ophthalmology 126

15) Squint 137
16) Pediatric Ophthalmology 141
17) Malignancies of the Eyelids & its Adnexa 147
18) Ocular Trauma 149
19) Ocular Manifestations of Systemic Diseases 161
20) Drugs & the Eye 175

‫ن‬ ّ
‫وفلسطي وسوريا والسودان فانرصهم‬ ‫أهال غزة‬
‫ي‬ ‫اللهم إنا نستودعك‬
ُ
‫ واربط عىل قلوب هم وأمدهم بجندك‬،‫الت ال تنام‬
‫واحفظهم بعينك ي‬
‫وأنزل عليهم سكينتك وسخر لهم األرض ومن عليها‬
EYE EXAMINATION

▪ Repeat for the patient's left eye, holding the ophthalmoscope in your left hand and viewing
with your left eye.

• The patient' s eyeglasses must be removed before ophthalmoscopy

• Most examiners prefer to remove their own glasses as well (optional).
• Contact lenses worn by either patient or examiner may be left in place.

1. The Red Reflex:

- Light reflected off the fundus of the patient produces

a red reflex when viewed through the
ophthalmoscope. Normal eyes
- A normal red reflex is evenly colored, is not Red reflexes & corneal light reflexes are equal

interrupted by shadows, and is evidence that the

cornea, anterior chamber, lens, and vitreous are clear
and are not a significant source for
decreased vision.
- Red reflex evaluation is a mandatory part of the
examination of the newborn. Absent reflex
- Abnormal forms of the reflex: White reflex on abnormal eye can result from opacities
of the lens (e.g. cataract), or tumor (e.g. retinoblastoma
1. Opacities in the media (e.g., corneal scar,
cataract, vitreous haemorrhage) appear as black shadows and can be best seen when the pupil
has been dilated,
2. With a totally cataractous lens no reflex is seen (i.e., absent reflex)
3. Most retinal pathologies will not affect the red reflex. However, the presence of a retinal
detachment will elicit a grey reflex.
4. Pus in the vitreous cavity (in endophthalmitis) will give a yellow reflex,
5. A white reflex is seen in cases of retinoblastoma

2. The Optic Disc:

- The normal optic disc:

• It is slightly oval in the vertical meridian and has a pink colour that is due to extremely small
capillaries on the surface.
• The disc edge or margin is sharp (easily identified from the surrounding retina).
• A central whitish depression in the surface of the disc is called the physiologic cup.
• The ratio of the optic cup to the overall diameter of the optic disc (C/ D ratio) is important
for the diagnosis and follow up of glaucoma patients. (An average ratio range is 0.2 -0.4).
• C/ D ratios more than 0.5 or dissimilarity of C/ D ratios of more than 0.2 between both
eyes (e. g., 0.2 and 0.5) require referral to an ophthalmologist for better evaluation
• Lesions seen with the ophthalmoscope can be measured in disc diameters (1 disc diameter
equals approximately 1.5 mm).

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 EYE EXAMINATION

Keratitis
Conjunctivitis (Corneal Acute Glaucoma Acute Iritis
ulcer/abrasion
Symptoms
+ +
± burning +++ ++
Pain Stinging sharp FB
± Nausea & Vomiting Dull aching pain
sensation
Watery, mucoid,
mucopurulent
Profuse tearing
Discharge (according to the
cause)

+++ + ++
Photophobia

Normal
Vision ⬇️ ⬇️ ⬇️
Signs
Visual Acuity Not affected ⬇️ Markedly⬇️ ⬇️
Mid dilated non-reactive Miotic with sluggish
Pupil Normal Normal
vertically oval reactivity
Injection Conjunctival Ciliary Ciliary Ciliary
Ulcer, edema and/or
Cornea Normal Cloudy (edematous) Keratic precipitates
infiltration
Decreased, normal or
IOP Normal Normal Markedly increased
increased
+++
AC Normal Normal or cells & flare Shallow
Cells & flare
± Preauricular
Other Colored halos around light ± posterior synechiae
lymphadenopathy

When to Refer an Apparently Normal Patient?

1. It is recommended that patients ages 40-65 be examined by an ophthalmologist every 2-4 years
(after receiving a baseline exam at age 40 if not previously done•), and every 1 or 2 years for
patients over age 65.
2. Children should undergo an evaluation in thefirstfew months of life, then again at 6 months, 3
years, and 5 years of age by their primary care physician. Any abnormalities should be evaluated
by an ophthalmologist.
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 ERRORS OF REFRACTION

Myopia Hyperopia/ Hypermetropia

Definition
• It is a state of refraction in which parallel rays of • It is a state of refraction in which parallel rays
light entering the eye are focused in front of the of light entering the eye are focused behind the
retina, while accommodation is at rest. retina, while accommodation is at rest.
• The far point lies in front of the patient • The far point is a virtual point that lies behind
the eye.

Prevalence

Prevails in around 30-40% of the population (more Less than 10% of the population is affected
common than hyperopia)
Causes
1. Long axial length of the eye (Axial myopia): 1. Short axial length of the eye (Axial hyperopia):
Most common
Most common
2. Decreased refractive power of the cornea and/or
2. Increased refractive power of the cornea and/or the the crystalline lens (Refractive hyperopia):
crystalline lens (Refractive myopia): A. Curvature hyperopia: Decreased curvature
A. Curvature myopia: Increased curvature of the of the cornea (e.g., corneas with powers less
cornea (e.g., than 40 diopters)
keratoconus) or B. Index hyperopia: Decreased refractive
the lens (e.g., index (Rl) of the lens (e.g., Cortical cataract)
C. Aphakia (absence of the lens) or posterior
lenticonus).
dislocation of the lens

B. Index myopia:
Increased refractive index (Rl) of the cornea or
the lens (e.g., nuclear cataract) or decreased RI
Phakia Vs. Aphakia
of cortex (uncontrolled DM)
Clinical picture
• Usually presents and progresses in the 1st or 2nd • Accommodation by the ciliary muscle can
decades of life. correct hypermetropia in younger patients but
• Often stops progression in the late 2nd decade or the this ability decreases with age as the lens
early years of the 3rd decade. elasticity becomes less.

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 THE ORBIT

Investigations
1. CT/MRI of the head and/or orbits. CT/MRI of the head and/or orbits.
2. Ultrasound of the orbits.
3. Thyroid function tests.

Blow-out fracture
- Caused by a sudden increase in the orbital pressure from an impacting object that is greater in
diameter than the orbital aperture (fist, tennis ball) causing the eyeball to be displaced.
- The fracture most frequently involves the floor of the orbit along the thin bone covering the
infraorbital canal. Sometimes, the medial orbital wall may also be fractured. Those thin walls of
the orbit separate the orbital cavity from the surrounding nasal sinuses.
- Infection can spread from the nasal sinuses to the orbit with nose blowing.
- Patients suffer from early proptosis due to oedema, emphysema, and hematoma but later can
develop enophthalmos.
- Large fractures resulting in globe displacement or small fractures causing muscle entrapment
and limitation of ocular motility with double vision require surgical intervention.
- It can be associated with severe eye injury e.g., globe lacerations, corneal abrasion, lens
dislocation, retinal tear, or traumatic optic neuropathy.

Diagnosis:
1. Visual acuity and pupillary size and reaction should be recorded and monitored.
2. Periocular signs: Ecchymosis, oedema, and subcutaneous emphysema.
3. Infraorbital nerve anesthesia: Involving the lower lid, cheek, side of the hose, upper lip, upper
teeth and gums if the fracture involves the infraorbital canal.
4. Diplopia due to:
a) Hemorrhage and oedema in the orbit with restriction to movement of the globe. Ocular
motility usually improves as the hemorrhage and oedema resolve
b) Mechanical entrapment within the fracture of the inferior
oblique or inferior rectus muscles, or adjacent connective tissue
and fat. Diplopia occurs in both up gaze and downgaze.
c) Direct injury to an extraocular muscle.
5. Enophthalmos
6. Ocular damage
7. CT scan of the orbit (coronal section) Is important to diagnose floor
CT scan showing left blow-out
fractures and tissue (inferior oblique muscle) entrapment
fracture of orbital floor
Management:
1. Patients should be advised to avoid blowing the nose.
2. Prophylactic antibiotics.
3. Surgical repair will be required in case of muscle entrapment causing diplopia or large fractures
causing marked enophthalmos
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 EYELIDS

4. Blepharitis
- Definition: Inflammation of the lid margin that involves the lashes and their associated glands.
- There are two main clinical types of blepharitis:
Anterior blepharitis Posterior blepharitis
Definition
- Alteration and inspissation of meibomian
gland secretions contributing to ocular surface
It affects the area surrounding the bases of the eyelashes. irritation increased tear evaporation and an
It may be seborrheic or staphylococcal: unstable tear film.
- It is a more chronic and persistent condition
than anterior blepharitis.
Clinical findings:
Seborrheic Staphylococcal Symptoms:
- Associated with - Caused by S. aureus and S. 1. Dry eye manifestations
generalized seborrheic epidermidis. 2. Recurrent chalazia
dermatitis - May show ulceration of the lid margin. Signs:
- Characterized by: - Hard dry scales around the bases of 1. Hyperaemia and telangiectasia of the
1. Hyperemic lid lashes(collarettes) are present posterior lid margin
margin - Lashes fall with scarring and notching of 2. Foamy discharge on the lid margin
2. The presence of the lid margin leading to madarosis may be present
greasy soft scales on (permanent loss of the lashes), trichiasis 3. Either excessive abnormal (turbid)
the lashes. and poliosis (premature whitening of the meibomian gland secretions or
lashes) inspissated secretions with plugged
• Dry eye is a common finding meibomian gland orifices
Complications:
1. Madarosis, trichiasis and poliosis.
2. Recurrent styes.
3. Chronic conjunctivitis, and phlyctens.

Staphylococcal blepharitis Posterior blepharitis with foamy discharge

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 CORNEA

6,7. Arcus Senilis (Gerontoxon) vs Calcific Band Keratopathy

Arcus Senilis (Gerontoxon) Calcific Band Keratopathy

Definition
• It is bilateral annular deposition of lipids in the • It is a corneal degeneration that is composed of fine
peripheral corneal stroma. dust-like calcium deposits in the sub-epithelium,
• It is the most common peripheral corneal opacity Bowman's layer, and the anterior stroma.

Characteristics
It is characterized, clinically, by the presence of a clear • It is typically a band-like horizontal opacity in the
zone between the opacity and the limbus (Lucid interval interpalpebral portion (middle1/3) of the cornea.
of Vogt) • It grows from the periphery towards the central
cornea. Initial deposits are grey but as the deposition
Arcus senilis progresses, the band becomes chalky-white in color.

Lucid interval of Vogt

Etiology
• It frequently occurs with hyperlipidemia, especially It can appear in cases of:
in elderly individuals BUT may be associated with 1. Chronic inflammatory ocular disease
dyslipidemia in younger patients (termed arcus 2. Silicone-filled eyes (after retinal surgery)
juveniles - pseudo-gerontoxon) 3. Systemic conditions associated with hypercalcemia.
• In the presence of arcus juveniles, it is a must to
check for the lipid profile to guard against the
complications of dyslipidemia
C/O
Asymptomatic It can affect vision if the pupil is covered by the opacity.
Treatment
Requires no treatment • It can be removed (after controlling the underlying
local or systemic condition) by chemical chelation
using EDTA or by phototherapeutic keratectomy.
• Referral to an ophthalmologist in such cases is
mandatory

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UVEAL TRACT

2. Intermediate 3. Posterior uveitis

1. Anterior uveitis
uveitis (Choroiditis- Chorioretinitis)
(Iritis-Iridocyclitis)
(Pars planitis- Cyclitis)
Inflammation that involves:
The iris (iritis) and is usually Mainly focused on the
accompanied by cyclitis (inflammation vitreous and peripheral
Choroid with or without inflammation of
of the ciliary body), hence the name retina. It incorporates pars
the retina.
iridocyclitis. planitis, posterior cyclitis,
and vitritis.
Uni/Bilateral
Initially unilateral. Later, it
Usually, unilateral becomes bilateral but -
asymmetrical in both eyes
Etiology
1. Idiopathic (75%of cases) 1. Infectious causes: 1. Infectious causes:

2. Connective tissue diseases e.g. TB, syphilis, toxoplasmosis, - Bacterial: TB, syphilis, leprosy, etc.
- HLA-B27 associated: Ankylosing toxocariasis, etc. - Viral: H5V, HZV, CMV especially
spondylitis, psoriatic arthritis, IBD 2. Non-Infectious causes : with acquired immune deficiency
(ulcerative colitis and Crohn's Sarcoidosis, Multiple syndrome.
disease) sclerosis, etc. - Fungal: histoplasmosis, candidiasis,
- Non-HLA-827: juvenile idiopathic Epidemiology: - Parasitic: toxoplasmosis (most
arthritis. - Usually affects younger common), toxocariasis.
3. Infectious causes : patients, aged 15 to 40 2. Non-infectious causes:
Syphilis, TB, toxoplasmosis, HSV, years - Systemic immunosuppression may
HZV, etc. - Represents 20% of cases predispose to infections.
4. Other causes : of pediatric uveitis - Autoimmune e.g., Behcet's disease
- Sarcoidosis - It is usually idiopathic (oral ulcers, genital ulcers, and posterior
- Trauma (the most common cause in developed countries uveitis)
of non-idiopathic iridocyclitis) and due to infectious - Malignancies may present in disguise
- Following ocular surgery. causes in developing as posterior uveitis [Masquerade
countries. syndrome) e.g. Some intraocular
malignancies such as retinoblastoma,
choroidal melanoma, and systemic
hematological malignancies such as
leukemia, and lymphoma.

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 UVEAL TRACT

Clinical picture
A. Symptoms
1. As a result of reactive spasm of ciliary muscles, the
patient complains of: - Presentation is 1. Painless
typically insidious. diminution of
- Photophobia: (intolerance to the usual levels of
- Floaters vision
illumination let alone higher levels)
- Blurred vision 2. Floaters
- Ocular pain with globe tenderness and brow ache
2. Lacrimation 3. Red eye 4. Decreased vision
B. Signs
1. Vision: decreased 1. Associated with 1. Vitreous haziness,
2. Perilimbal (ciliary) injection with violaceous hue anterior uveitis in cells, and opacities.
about 50% of cases 2. ± hypopyon
3. Miosis (an early sign) with sluggish pupillary light
formation
reaction. 2. Vitreous cells
4. Precipitates and collections:
3. Vitreous
A. Anterior chamber [AC] cells: (leukocytes in the condensations with
aqueous humor) due to anterior segment inflammation hazy vitreous body
with increased vascular permeability. 4. Snowballs: aggregates
B. Hypopyon [Pus in the AC]: of inflammatory cells in
it represents a collection of the inferior vitreous
neutrophils and exudates in 5. Snow banking: grey-
the inferior part of AC. white fibrovascular
C. Aqueous flare: composed of plaques on the inferior
proteins circulating in the aqueous 2ry to inflammation pars plana.
and increased vascular permeability. This altered highly
viscous aqueous humor is called plasmoid aqueous.
D. Keratic precipitations
[KPs]: formation of clumps
of cells (WBCs) on the back
surface of the cornea
(endothelium)
5. IOP: usually decreases due
to ciliary body inflammation with decreased aqueous
production (ciliary body shutdown)
- Sometimes the IOP increases [Secondary (inflammatory)
glaucoma] due to:
a. Trabeculitis as in HSV or HZV iritis
b. Plasmoid aqueous and circulating large-sized WBCs
obstruct the trabecular meshwork resulting in impaired
aqueous drainage
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OCULAR
` TRAUMA

8 ball of the Eye Hyphemia of the Eye

Complications (VERY IMPORTANT)

▪ Re-bleeding is common in the first 5 days if injury resulting in increased incidence of other
complications
▪ Uncontrolled high IOP which can cause:
1. Blood staining of the cornea
2. Ischemic optic neuropathy
3. CRAO

Treatment
▪ Hospitalization.
▪ Medical: to prevent rebleeding in the form of:
o Complete bed rest
o Sleeping at an angle of 45 degrees
o Cycloplegic eye drops to decrease iris and ciliary body muscle contractions (decreasing the
incidence of re- bleeding).
o Topical steroids to reduce intraocular inflammation.
o IOP lowering medications (if required).
o Referral to an ophthalmologist is of utmost importance for more assessment as the condition
may require surgical intervention.
▪ Surgical:
o Evacuation of the blood in the AC. o Surgery for lowering the IOP

Hypopyon
▪ Pus in the AC (usually in neglected open wounds of the
globe with secondary infection)
▪ [post-traumatic infectious
endophthalmitis]

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 OCULAR TRAUMA

`
7) Iris And Pupil
▪ Iridodialysis
o localized separation of the iris root from its
attachment to the ciliary body.
o As a result, the pupil shape becomes D-shaped
instead of circular.
▪ Traumatic aniridia: complete separation of the iris
root from its attachment to the ciliary body.
▪ Traumatic iritis
▪ Traumatic mydriasis (more common) with sphincteric Iridodialysis
tears at the pupillary margin
▪ Traumatic miosis, Iris atrophy (late) & Iris prolapse through corneal lacerations
8) Ciliary body and IOP
▪ In the presence of hypotony (Lower than normal IOP), it is important to exclude an occult open
injury of the globe.
▪ Elevation of IOP can occur for a variety of reasons, including hyphaema and inflammation.
▪ Damage to the anterior part of the ciliary body (angle recession) is associated with a risk of
developing late secondary open-angle glaucoma
9) Lens
▪ Imprinting of iris pigment on the anterior capsule of the lens
from the pupillary margin (Vossious ring)
▪ Traumatic cataract with/ without
▪ Lens subluxation or dislocation.
10) Vitreous
▪ Posterior vitreous detachment (PVD)
▪ Vitreous hemorrhage: it might be associated with a retinal break over a retinal vessel which can
result in retinal detachment

11) Retina
▪ Rhegmatogenous RD.
▪ Commotio Retinae:
o Cloudy swelling of the retina that gives the involved area a
grey appearance (instead of being transparent).
o If the macula is involved, a 'cherry-red spot may be seen
at the fovea Commotio Retinae
o Intraretinal hemorrhages that can involve the macula may be present.
▪ Retinal dialysis (a retinal break occurring at the Ora Serrata)
▪ Traumatic macular hole formation.
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