Professional Documents
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Explorer
1st Edition
Dhaval Patel
MD (AIIMS)
Ophthalmology Explorer
Ophthalmology Post-PG Examination Guide
Dhaval Patel MD (AIIMS)
drdpatel87@gmail.com
by ophthalmologyexplorer.blogspot.com
1st edition, April 2014
This is a compilation effort from my preparation notes and other sources, thus
any contributions or comments are welcomed in the effort to improve this book.
Therefore, feel free to e-mail me at
drdpatel87@gmail.com
Ophthalmology Explorer
Dhaval Patel MD
PREFACE
The CLASS is knowing what to say, when to say and when to stop.
Dear Friends,
If you are reading this, then either you are approaching your final ophthalmology exams
or you are preparing for further study courses in ophthalmology.
So first thing I want you to know is the course for this exam include all aspects of
ophthalmology in different amounts and nobody knows it perfectly. This preparation manual I
have prepared during my residency and added up while preparing for senior residency/
fellowship examinations preparation which may serve as a small guide to your preparation. It
will also serve as a good collection of facts which we might forget/neglect during overall MD/MS
exam preparation.
So whatever it may serve you, I am proud of what I have prepared and I feel it worth
sharring with all emerging ophthalmologist friends.
All the Best..!!
-Dhaval Patel MD
Ophthalmology Explorer
Dhaval Patel MD
INDEX
Ophthalmology Explorer
Dhaval Patel MD
Genes ....................................... 29
Aquaporins ................................... 7
HLA .......................................... 37
Blocks ......................................... 9
Inheritence .................................. 41
Connexins .................................. 19
Craniosynostosis .......................... 20
Diameters .................................. 20
Ophthalmology Explorer
Dhaval Patel MD
DME ...................................... 74
ROP....................................... 76
ARMD .................................... 77
Glaucoma ................................ 82
ON ........................................ 83
NAION .................................... 83
MISC ...................................... 83
Surface Tension ........................... 84
Specific Gravity ............................ 84
Surface Area ............................... 85
Survival Rates.............................. 85
Test Distances ............................. 86
Thickness ................................... 87
VEGF Facts ................................ 88
Vitreous cavity volume displacement ... 89
Water Content.............................. 89
Basic Sciences ............................... 90
Optics & Refraction ........................ 122
Cornea ....................................... 160
Lens .......................................... 192
Glaucoma ................................... 205
Retina ........................................ 226
Uvea.......................................... 264
Strabismus .................................. 275
4
Ophthalmology Explorer
Dhaval Patel MD
Ophthalmology Explorer
Dhaval Patel MD
Exploring EYE
Ophthalmology Explorer
Dhaval Patel MD
60 year: 4.8 mm
80 year: 5.2 mm
Aquaporins
Water channels are known as aquaporins and lens epithelial cells contain an abundance of
these.
MIP26 is believed to be a very old (and not very efficient) member of the aquaporin family
and is termed aquaporin O.
Types
o
AQP1 in cornea endothelium, ciliary and lens epithelia and trabecular meshwork
AQP2 is not present in eye and is restricted to the kidney collecting duct
AQP3 in conjunctiva
NMO-IgG is a disease-specific autoantibody for neuromyelitis optica (NMO) and its target
antigen is aquaporin-4 (AQP4) water channel.
Acquisition time
Pentacam: 2 sec
OCT: 1 to 5 sec
Ophthalmology Explorer
o
Dhaval Patel MD
Fixation Axis: This is a straight line that joins center of rotation of eyeball with fixation point
Optical Axis: A line passing through center of cornea, center of lens and posterior pole of
retina is the optical axis of eyeball
Visual Axis: A line joining point of fixation with fovea and passing through nodal point of
eyeball is called visual axis. Nodal point of eyeball is just anterior to posterior capsule of lens.
Fixation point is the point which is being seen with fovea at any particular moment.
Pupillary Line: This is a straight line that passes through center of pupil
Angle Alpha is the angle formed between optical axis and visual axis. AOV
Angle Kappa is the angle formed between visual axis and pupillary axis. KaVPa
Angle Gamma is the angle formed between optical axis and fixation axis. GOF
Thyroid orbitopathy (for women occur from ages 40 to 44 years and 60 to 64 years; for
men from ages 45 to 49 years and 65 to 69 years)
Hodgkin's lymphoma (early peak at 15 to 35 years of age and a second peak after 50)
8
Ophthalmology Explorer
Ocular Trauma
Dhaval Patel MD
Blocks
Atkinsons block: In it superior branches of the facial nerve are blocked by injecting
anaesthetic solution at the inferior margin of the zygomatic bone.
Nadbath block: facial nerve is blocked as it leaves the skull through the stylomastoid
foramen.
Other Blocks
Ophthalmology Explorer
Dhaval Patel MD
p53 mediates arrest of the cell cycle in the G1 phase after sublethal DNA damage
Rb gene arrests cells in the G1 or G1/S-phase of the cell cycle, and stops further
proliferation.
Collagen Collection
Type 2: vitreous
Type 4: Descemet membrane, lens capsule, PNBZ, basal lamina of corneal epithelium
Type 7: ABZ
Type I 50-55%
Type III ~ 1%
Type VI 25-30%
Type IV 8-10%
Ophthalmology Explorer
Dhaval Patel MD
BM of ciliary process and ciliary muscles ECM: laminin and collagen types I, III, and IV
steroid-induced glaucoma shows increase in fine fibrillar material stains for collagen type
IV in the subendothelial region of the Schlemm canal
anterior uveitis: reducing the density of collagen type I in the extracellular matrix of the
ciliary body leading to increase in uveoscleral flow
lamina cribrosa of the human optic nerve head: collagen types I through VI, laminin, and
fibronectin
Topical prostaglandin F2alpha treatment reduces collagen types I, III, and IV in the
monkey uveoscleral outflow pathway
M.K. Media (4days): Tc199, Dextran, PH 7.0-7.5, Osmolality 295-355, gentamycin sulphate
75-150 micro gm/ml, HEPES as buffer, Phenol red as indicator
K-Sol: Tc 199, MEM & Earles media, HEPES, Gentamicin, Chondroin sulphate 2.5%
Dexol: MEM, 1.35% Chondrotin Sulphate, 1mM Sodium pyruvate, 1mM non- essential
amino acids, Antioxidants, 1% dextran40.
Optisol GS: MEM, 1.35% Chondrotin Sulphate, 1mM Sodium pyruvate, 1 mM non-essential
aminoacids, Antioxidants, 1% dextran40, ATP, Iron, cholestrol, L-hydroxyproline, Vitamins, 2
antibiotics- Gentamycin, Streptomycin
Eusol-C: Store at 4 deg.C, Dextran, Sodium Piruvate, Glucose, Essential & non-essential
aminoacids, mineral salts, Vitamins, Gentamin, hepes buffer, Bicarbonate, Phenol Red
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Ophthalmology Explorer
Dhaval Patel MD
Organ culture medium: Fetal Bovine Serum, L-Glutamine, Earle's salts and 0.44%
Mercaptoethanol in addition to the other constituents present in most intermediate storage
media
Aqueous contents
Relative to plasma, aqueous humor has
Only calcium and phosphorus are in concentrations of about one-half that in plasma.
Chloride and bicarbonate vary from 20% to 30% above or below plasma levels.
Protein and antibodies in aqueous equilibrate with those in serum when a plasmoid
aqueous occurs with an anterior uveitis
Tear contents
o
Lipid layer
Aqueous layer
Water
cytokines
Ophthalmology Explorer
Mucinous layer
Dhaval Patel MD
EDS, EDS6, AR
JOAG, Myocillin, AD
Stargardts, ABCA4, AR
ARMD, CFH1
Usher syndrome, AR
Chromosome 2:
Ophthalmology Explorer
PXE, laminin/fibrillin, AR
Dhaval Patel MD
Chromosome 3:
BPES 1 (with premature ovarian failure) and BPES 2 (without premature ovarian failure) are
caused by type 1 mutations in FOXL2 gene
Chromosome 4:
CSNB, PDE6, AR
Chromosome 5:
Ophthalmology Explorer
Dhaval Patel MD
Mutations in TGFB1 on chromosome 5 cause CDB1, CDB2, lattice type 1, lattice type 3A,
Avellino, and granular dystrophy. These are therefore allelic variants.
Chromosome 6:
Adult-onset macular vitelliform dystrophy is caused by mutation in the RDS gene on chrn
Dysromosome 6p, as well as the BEST1 gene in common with juvenile-onset Best
dystrophy.
VEGF
Chromosome 7:
Chromosome 8:
Chromosome 9:
Lattice 2, gelsolin, AR
Chromosome 10:
Crouzon syndrome Inheritance is usually AD, but 25% of cases represent a fresh mutation.
The gene (FGFR2) has been isolated to chromosome 10.
Ophthalmology Explorer
NTG-COAG, optineurin, AD
Dhaval Patel MD
Chromosome 11:
Nanophthalmos, NNO1, AD
OCA, TYR/OCA2, AR
CFEOM2: 11q13
Chromosome 12:
CFEOM-1:
CHSD, DCN, AD
Chromosome 13:
Retinoblastoma, 13q14, AD
Sclerocornea, HCCS, AD
Microphthalmos, Trisomy 13
Congenital microcornea, AD
Ophthalmology Explorer
CFEOM-3
Dhaval Patel MD
Chromosome 14:
Chromosome 15:
Chromosome 16:
Chromosome 17:
Meesman dystrophy, AD
NF1, NF1, AD
Cystinosis, CTNS, AR
Chromosome 18:
Transthyretin
17
Ophthalmology Explorer
Dhaval Patel MD
Chromosome 19:
Chromosome 20:
PPMD2, VSX1, AD
Chromosome 21:
Chromosome 22:
NF2, NF2, AD
Chromosome X:
XR
Megalocornea, LTBP2
FEVR, NDP
Choroderemia, REP1
Ophthalmology Explorer
Dhaval Patel MD
XD
Aicardi syndrome
Ichthyosis, STS
Chromosome Y:
Connexins
Connexin 43:
oculodentodigital syndrome
Connexin 50, connexin 37, and connexin 40 are all encoded by genes consisting of a single
exon on chromosome 1q21
A zonular pulverulent cataract has been localized to chromosome 13 near the connexin
46 gene.
19
Ophthalmology Explorer
Dhaval Patel MD
Craniosynostosis
SPOT:
Scaphocephaly: sagittal suture closure (aka 'dolichocephaly')
Plagiocephaly: unilateral Coronal suture (anterior) or Lamboid (posterior)
Oxycephaly: coronal suture plus any other suture, like the lambdoid
Trigonocephaly: metopic suture closure
Syndromes
Apert syndrome
Crouzon syndrome
Pfeiffer syndrome
Saethre-Chotzen syndrome
Diameters
20
Ophthalmology Explorer
Dhaval Patel MD
Drug Resistance
CMV UL97 mutations (a CMV DNA polymerase mutation that confers ganciclovir
resistance) were detected in 3% of patients treated with ganciclovir over 3 months and in
none treated less than 3 months.
0.15% trypan blue (less costly when compared to the cost of ICG)
Posterior Segment
o
IFCG: 0.05%
TA
PB
BrB
NaF
Electromagnetic Spectrum
(part of spectrum which is important in ophthalmology)
21
Ophthalmology Explorer
Dhaval Patel MD
Ultraviolet B rays: This band is responsible for snow blindness and photo keratitis caused
by welding arc. Prolonged exposure to these rays can cause formation of pingicula and
pterigium.
Ultraviolet A rays: This band of UV rays is absorbed by crystalline lens and thus retina is
protected against their bad effects. Prolonged exposure to these rays causes cataract
formation. IOLs implanted during cataract surgery have chromophores [inhibitors of UV rays]
to protect retina against UV rays.
Infrared A rays are responsible for macular burn in solar eclipse [photo retinitis].
Infrared rays B and C can cause corneal opacity and cataract formation on prolonged
exposure.
Ophthalmology Explorer
Dhaval Patel MD
Lucentis (ranibizumab injection); Genentech; For the treatment of diabetic macular edema,
Approved August 2012
Zioptan (tafluprost ophthalmic solution); Merck; For the treatment of elevated intraocular
pressure, Approved February 2012
Acuvail (ketorolac tromethamine); Allergan; For the treatment of pain and inflammation
following cataract surgery., Approved July 2009
Bepreve (bepotastine besilate ophthalmic solution); Ista Pharmaceuticals; For the treatment
of itching associated with allergic conjunctivitis, Approved September 2009
Besivance (besifloxacin 0.6% ophthalmic suspension); Bausch & Lomb; For the treatment
of bacterial conjunctivitis, Approved June 2009
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Ophthalmology Explorer
Dhaval Patel MD
Ozurdex (dexamethasone); Allergan; For the treatment of macular edema following branch
retinal vein occlusion or central retinal vein occlusion, Approved June 2009
Zirgan (ganciclovir ophthalmic gel); Sirion Therapeutics; For the treatment of acute herpetic
keratitis, Approved September 2009
Astepro (azelastine hydrochloride nasal spray); Meda Pharmaceuticals Inc.; For the
treatment of seasonal and perennial allergic rhinitis, Approved October 2008
Durezol (difluprednate); Sirion Therapeutics; For the treatment of inflammation and pain
associated with ocular surgery, Approved June 2008
AzaSite (azithromycin); InSite Vision; For the treatment of bacterial conjunctivitis, Approved
April 2007
Lucentis (ranibizumab); Genentech; For the treatment of neovascular (wet) age related
macular degeneration, Approved June 2006
Macugen (pegaptanib); Pfizer / Eyetech Pharmaceuticals; For the treatment of wet agerelated macular degeneration., Approved December 2004
Restasis (cyclosporine ophthalmic emulsion); Allergan; For the treatment of low tear
production., December 2002
Travatan (travoprost ophthalmic solution); Alcon; For the reduction of elevated intraocular
pressure in patients with open-angle glaucoma or ocular hypertension, Approved March
2001
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Ophthalmology Explorer
Dhaval Patel MD
Valcyte (valganciclovir HCl); Roche; For the treatment of cytomegalovirus retinitis in patients
with AIDS, Approved March 2001
Betaxon; Alcon; For lowering IOP in patients with chronic open-angle glaucoma or ocular
hypertension, Approved February 2000
Rescula (unoprostone isopropyl ophthalmic solution) 0.15%; Ciba Vision; For the
treatment of open-angle glaucoma or ocular hypertension, Approved August 2000
Visudyne (verteporfin for injection); QLT; For the treatment of wet age-related macular
degeneration (wet AMD), Approved April 2000
ZADITOR; Ciba Vision; Treatment for the prevention of itching of the eye, Approved July
1999
Alrex; Bausch & Lomb, Pharmos; Treatment for seasonal allergic conjunctivitis, Approved
March 1998
Cosopt; Merck; Treatment for glaucoma or ocular hypertension, Approved April 1998
Lotemax; Bausch & Lomb, Pharmos; Treatment for post-operative eye inflammation,
Approved March 1998
Salagen Tablets; MGI Pharma; Treatment for Sjogren's Syndrome, Approved February 1998
Viroptic; King Pharmaceuticals; Treatment for inflammation of the cornea in children due to
herpes simplex virus, Approved February 1998
Vitravene Injection; Isis Pharmaceuticals; Treatment for CMV in AIDS patients, Approved
August 1998
Ophthalmology Explorer
Dhaval Patel MD
Acular (ketorolac tromethamine ophthalmic solution) 0.5%; Allergan; Treatment for postsurgical inflammation following cataract extraction, Approved November 1997
BSS Sterile Irrigating Solution; Alcon; Treatment during ocular surgical procedures,
Approved December 1997
Ocuflox (ofloxacin opthalmic solution) 0.3%; Allergan; Treatment for corneal ulcers,
Approved May 1996
Vistide (cidofovir); Gilead; Treatment for cytomegalovirus (CMV) retinitis, Approved June
1996
Vitrasert Implant; Chiron; Drug delivery system for the treatment of cytomegalovirus,
Approved March 1996
Ophthalmology Explorer
Dhaval Patel MD
3. Class III devices (eg, excimer lasers, intraocular lenses, extended -wear contact lenses,
intraocular fl uids) are considered significant-risk devices that present a potential
unreasonable risk of illness or injury. Class III devices are those for which insufficient
information exists to ensure safety and effectiveness solely through general or special
controls. Class III devices cannot be marketed in the United States until the FDA
determines that there is a reasonable assurance of safety and effectiveness when used
accordi ng to the approved indications for use. Most class III devices come to market
through the premarket approval (PMA) process and require an extensive review by the FDA
before approval is granted for marketing.
Field of View
First in Genetics
Wow!! Its amazing that all of following diseases first described in each category has an eye
manifestation!!! (Ref: Alex Levin MD, WEI, PA, USA)
Ophthalmology Explorer
Dhaval Patel MD
Keratoconus: 50% of normal fellow eyes will progress to keratoconus within 16 years
PXG: A patient with unilateral PXG and only PXF in the fellow eye is at high risk (50% in 5
years) of developing glaucoma in the fellow eye. A patient with unilateral PXG who does not
have PXF in the fellow eye has only a low risk of developing glaucoma in the normal eye.
Patients with advanced AMD (late ARM) in one eye, or even moderate vision loss due to
non-advanced AMD in one eye, have about a 50% chance of developing advanced AMD in
the fellow eye within 5 years.
In Age related Macular Hole, risk of involvement of the fellow eye at 5 years is around 10%.
In NAION, Involvement of the fellow eye occurs in about 10% of patients after 2 years and
15% after 5 years.
AAION affects 3050% of untreated patients of which one-third develop involvement of the
fellow eye, usually within 1 week of the first.
7% of patients with CRVO develop a nonsimultaneous venous occlusion of the fellow eye
within 2 years
The risk of any vascular occlusion in the fellow eye is estimated to be 0.9% per year.
The Macular Photocoagulation Study (MPS) reported that the 5-year risk of
neovascularization in fellow eyes of individuals with unilateral neovascular AMD was 10%
in those without large drusen and 3046% in those with large drusen
POHS with CNVM, 20% risk over a 2-3-year period of developing choroidal
neovascularization in the macula of the fellow eye
50-75% of patients with angle closure in one eye will have an attack in the fellow eye
often within 1 year (up to 10years) despite miotic treatment. Prophylactic laser iridotomy in
fellow eyes of patients presenting with unilateral acute PAC also appears to be safe and
effective in preventing acute PAC in 100%, and in preventing long-term rise in IOP in 89%
28
Ophthalmology Explorer
Dhaval Patel MD
Acute retinal necrosis may occur in the fellow eye in approximately 30% of patients at an
average interval of 4 weeks.
Frequency of Probes
USG: 10 MHz
UBM: 50 MHz
HI-SCAN: 35 MHz
Genes
PXF: LOX L1
BPES: FOX L2
Pterygium: KL-6
5q31.2
Phenotypic heterogeneity
GREAT
Granular
Reis Buckler
29
Ophthalmology Explorer
EBMD
lAttice
Thiel Behnke
Dhaval Patel MD
Aniridia
Gillespe
WAGR
Axenfield Reiger Spectrum (AD) genotypic heterogeneity, multiple genes causing same
disease
o
RIEG2 13q14
COL4A1 13q34
(MCQ: all except type question, so remember its Chromosomes 4, 6 and 13)
Following all genes do cause Fuchs and other diseases mentioned below.
COL8A2: PPMD
SLC4A11: CHED
ZEB1: PPMD
30
Ophthalmology Explorer
Dhaval Patel MD
GLC1F: POAG 7q
GLC3B: 1p36
GLC3C: 14q24
Ophthalmology Explorer
o
Dhaval Patel MD
BCC:
SeCA:
32
Ophthalmology Explorer
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LTA: Large T Antigen binds to host proteins, forces cell into Sphase
ARMD
o
Apolipoprotein E: 19q13.2
Retinal/Macular Dystrophies
o
BEST1,
Chr11 AD/AR
AR
ELOVL4 Chr 6 AD
Chr 6 AD
33
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Dhaval Patel MD
EFEMP1
Chr 2 AD
Unknown
Chr 5 and 6
Unknown
AD
Unknown
Chr 7 AD
Unknown
Unknown
AD
AD
Chr 1 AR
Mutations of LHON
o
3460: 8-15% of patients, high incidence of visual recovery, family history positive
Gene therapy: for LCA, RPE 65 gene, NEJM 2008 study, Lancet 2009
Sonic hedgehog
Paired box
Subfamily A:ABCA
Adrenoleukodystrophy
34
Ophthalmology Explorer
Zellweger syndrome
Cone-rod dystrophy
Dhaval Patel MD
Subfamily G: ABCG
Giant Cells
Langhans giant cells: peripheral ring of nuclei, associated with tuberculosis, sarcoidosis
Touton giant cells: midperipheral ring of nuclei surrounded by a peripheral ring of lipid,
associated with xanthogranulomatous disease
Foreign body giant cells: randomly dispersed nuclei, associated with foreign material and
fungi
Growth Factors
only Ang1 and Ang2 currently are known to have roles in ocular neovascular disease
Ophthalmology Explorer
Dhaval Patel MD
Half Life
IVTA
o
PST
o
Aqueous: 11 days
Vitreous: 17 days
Plasma: 25 days
5 days in humans
3 days in monkeys
Strontium-90: 28 years
36
Ophthalmology Explorer
Dhaval Patel MD
HLA
HLA wise Diseases
A2: JIA
B13: sarcoidosis
PXF: A1/33, B8
Ophthalmology Explorer
Dhaval Patel MD
VKH: HLA-DR4 and HLA-Dw53 are more common in Chinese patients, HLA-DR1 and HLA
DR4 more common in Hispanic patients, and HLA DRB1 in Indian patients
TEN: HLA-B12
Rhinovirus: ICAM-1
Ophthalmology Explorer
Dhaval Patel MD
Definitive:
o
Intermediate host
o
Hypersensitivity in Eye
Gell, Coombs, and Lackmanns classification of Hypersensitivity Reactions
o
Type 4: TB, WG, Contact dermatitis, herpes disciform keratitis, sarcoidosis, transplant
rejection
39
Ophthalmology Explorer
Dhaval Patel MD
IHC Markers
Epithelial markers: Cytokeratins (CAM 5.2, AE1, AE3, CK7, CK20, involucrin, etc.)
Muscle markers: Muscle specific actin (MSA), smooth muscle action (SMA), desmin,
myogenin
lymphoid tumors
o
CD3: T cells
CD20: B cells
Retinoblastoma is positive for neuron-specific enolase (also found in aqueous of RB), class
III tubulin isotype (h4), microtubuleassociated protein 2 (MAP2), and synaptophysin; they
are negative for glial fibrillary acidic protein and S-100 protein
40
Ophthalmology Explorer
Dhaval Patel MD
Inheritence
Norrie XL
XLRS XL
Glodman favre AR
FEVR AD AR XR
All MPSs are transmitted by the AR mode, except MPS II (Hunter syndrome) which is
XR.
albinism inheritance
OA are XR.
Macular AR
Gelatinous droplike AR
LCD type 3 AR
41
Ophthalmology Explorer
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Dhaval Patel MD
CHED type 2 AR
Microcornea: AD
Megalocornea: XR
The nuclei of the Mller cells lie in the inner nuclear layer, whereas the nuclei of the
photoreceptors lie in the outer nuclear layer.
The nerve fiber layer contains the axons of the ganglion cells.
The inner plexiform layer has axons of the bipolar and amacrine cells and the synapses
of the ganglion cells.
The outer plexiform layer has connections between the photoreceptors, horizontal cells,
and bipolar cells.
The footplates of the Mller cells form the internal limiting membrane.
cell bodies whose processes project into the lateral geniculate and pretectal nuclei
ganglion cell layer
cell bodies whose processes form spherules and pedicles outer nuclear layer
42
Ophthalmology Explorer
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Beta 1a:
Beta 1b:
o
Gamma
o
chronic granulomatous disease, kidney tumors and leishmania and other parasites.
43
Ophthalmology Explorer
Dhaval Patel MD
Intraocular Gases
Physical characteristics
Gases
Mol wt.
Purity
(mole%)
Expansion
Longevity
(days)
Nonexpansile
conc. (%)
Air
29
99.99
5-7
----
SF6
146
99.9
1.9-2.0 times
10-14
18
C3F8
188
99.7
4 times
55-65
14
Intracameral Dosages
Vancomycin: 1 mg/ml
Cefazolin: 1 mg/0.1 ml
Irrigating fluid
o
Pilocarpine: 0.1 ml of the drug (25 mg/ml) is diluted in 0.1 ml ringer lactate
44
Ophthalmology Explorer
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Intrastromal Dosages
Intravitreal Dosages
Antibiotics
o
Vancomycin: 1mg/0.1ml
Ceftazidime: 2.25mg/0.1ml
Antifungals
o
Voriconazole: 50-100micrgram/0.1ml
Amphotericin B: 5 migrogram/0.1 ml
Antivirals
o
Steroids
o
Anti VEGFs
o
Ophthalmology Explorer
o
Dhaval Patel MD
1 ampoule: 0.2 ml
1 vial: 4 ml or 16 ml of 25 mg/ml
Intravitreal Implants
delivers the medication for approximately 32 weeks (8 months) and has been
shown to halt the progression of CMV
nondegradable
5/4.5 mg implant
Ophthalmology Explorer
Dhaval Patel MD
releases drug at steady state between 0.3 and 0.4g/day for approximately 30
months
25-gauge
helical screw coated with triamcinolone acetonide that delivers the drug intravitreally
for 36 months
25-gauge
drug is entirely within the coating on the helical structure and not within the bulk of
the device
1.5 ng/day
2 years or more
NT-503
47
Ophthalmology Explorer
o
Dhaval Patel MD
For ARMD
JXG nodules are composed of histiocytes and Touton giant cells: JXG
Koeppe nodules are collections of inflammatory cells, near pupillary margin: granulomatous
and non-granulomatous uvetis
Bassaca Nodules are seen at base: only in granulomatous uveitis (sarcoid, Tb, syphilis,
VKH); often look gelatinous
Laser Facts
Brief History
Ophthalmology Explorer
Dhaval Patel MD
Instrument Wavelengths
(Chronological order in nm)
Therapeutic Wavelengths
(nm)
Ophthalmology Explorer
Nd YAG: 1064
Dhaval Patel MD
DLCP: 810 nm, 2 mm from limbus, 8 spots per quadrent, 2000 ms, 1200-2000 mW
50
Ophthalmology Explorer
Dhaval Patel MD
PRP: df NdYAG
o
200-500 ms
200-500 mW
50-100 ms
50-100 mW
Repetition rate: 5 Hz
Ablation depths:
o
Modes of Laser
There are three modes of laser: continuous, Q-switched and mode-locked.
o
Laser from continuous mode has a constant power and is measured in watts.
51
Ophthalmology Explorer
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Dhaval Patel MD
Mode-locked laser compresses the laser more than Q-switched laser and therefore
produces more energy.
Laser Mediums
Solid state lasers have lasing material distributed in a solid matrix, e.g., the ruby or
neodymium-YAG (yttrium aluminum garnet) lasers. The neodymium-YAG laser emits
infrared light at 1.064 micrometers.
Gas lasers (helium and helium-neon, HeNe, are the most common gas lasers) have a
primary output of a visible red light. CO2 lasers emit energy in the far-infrared, 10.6
micrometers, and are used for cutting hard materials.
Excimer lasers (the name is derived from the terms excited and dimers) use reactive gases
such as chlorine and fluorine mixed with inert gases such as argon, krypton, or xenon.
When electrically stimulated, a pseudomolecule or dimer is produced and when lased,
produces light in the ultraviolet range.
Dye lasers use complex organic dyes like rhodamine 6G in liquid solution or suspension as
lasing media. They are tunable over a broad range of wavelengths.
Semiconductor lasers, sometimes called diode lasers, are not solid-state lasers. These
electronic devices are generally very small and use low power. They may be built into larger
arrays, e.g., the writing source in some laser printers or compact disk players.
Ophthalmology Explorer
Dhaval Patel MD
Class IV: Also pose a significant fire and skin hazard; most therapeutic laser beams used in
ocular surgery are in this class
Latest Drugs
Lampalizumab: new monoclonal antibody that inhibits complement factor D, which is a ratelimiting enzyme of the alternative complement pathway, first positive treatment result for
patients with dry age-related macular degeneration and geographic atrophy.
Pazopanib is a small molecule lipophilic potent and selective multitargeted receptor tyrosine
kinase inhibitor of VEGFR-1, VEGFR-2, VEGFR-3, PDGFR-a/, and c-kit that inhibits
angiogenesis.
AGN-150998:
o
Concept Study
Selectively binds to vascular endothelial growth factor-A with high binding affinity.
ROCK inhibitors:
comparable to latanoprost
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Aganocides: novel class of compounds that mimic the bodys natural defense against
infection
o
Mapracorat:
Phase II study is evaluating its effectiveness in preventing the signs and symptoms
of allergic conjunctivitis. In addition, a Phase III study is underway for the
treatment of ocular inflammation after cataract surgery.
Adenosine has been shown to inhibit leukotriene B4 (LTB4), which is part of the
arachidonic acid cascade for the synthesis of prostaglandins and leukotrienes
Lifitegrast: lifitegrast is a potent and selective small molecule drug being investigated for
the treatment of dry eye and ocular allergy. It inhibits T-cell inflammation by blocking the
binding of two key cellular surface proteins that mediate the chronic inflammatory cascade.
Ophthalmology Explorer
Vismodegib (GDC-0449):
Orally active
Statins
Vitamin D3
Rapamycin (sirolimus)
Macrolide antibiotic
PLX4032 (V600E-BRAF)
C-KIT inhibiors
o
Dhaval Patel MD
Imatinib
Sutent: Sunitimab
o
Ophthalmology Explorer
o
FOVISTA: Binds PDGF-B, phase 3 trials going on for wet AMD and CNVM.
NT- 501
Dhaval Patel MD
o CNTF is a cytokine, which is a survival factor for various neuronal cells and seems to
prevent neurodegeneration.
o
Bevasiranib (CAND5) is a siRNA which switches off VEGF production, but clinical effect is
not seen till the preexisting VEGF is cleared. It has a potentially longer duration of effect
than currently available anti-VEGF agents. It is well tolerated at multiple doses.
Fenofibrate is drug of the fibrate class used to treat dyslipidemia. Raises HDL and lowers
LDL and triglycerides and typically is used in combination with a statin. It lowers lipid levels
by activating peroxisome proliferator-activated receptor alpha (PPAR). PPAR activates
lipoprotein lipase and reduces apoprotein CIII, which increases lipolysis and elimination of
triglyceride-rich particles from plasma.
Fenretinide in Dry AMD: This drug is an oral vitamin A binding protein antagonist and is
being studied in patients with geographic atrophy (GA).It halts the accumulation of retinol
(vitamin A) toxins through affinity for retinol-binding protein. One of the hallmarks of dry
macular degeneration is the accumulation of lipofuscin that is responsible for drusen
formation and geographic atrophy. One year interim data showed that fenretinide slowed the
growth of geographic atrophy lesions by 45% in the 300 mg dose.
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Mechanism of Action
Fluoroquinolones: bactericidal agents that act by inhibiting DNA replication. They have dual
targets, topoisomerase II (DNA gyrase) and topoisomerase IV
Bacitracin and gramidicin: Bacitracin disrupts bacterial cell-wall synthesis by inhibiting the
dephosphorylation of a lipid pyrophosphate, while gramicidin interferes more with cell
membrane permeability
Polymyxins: interact with the phospholipids of the bacterial cell membrane, which increases
the cell permeability and disrupts osmotic integrity. This process results in leakage of
intracellular constituents, leading to cell death
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Trifluridine: potent inhibitor of thymidylate synthetase and therefore inhibits DNA synthesis
Vidarabine: interfere with the early steps of viral DNA synthesis and arrests the growth of the
viral deoxynucleotide chain
Polyenes: binds esterols in the fungal cell wall, forming blisters and causing lysis of the cell
Imidazoles: affect the formation of ergosterol needed by the cell membranes by inhibiting
the enzyme lanosterol 14 -demethylase
MIP
The most abundant membrane protein of the lens is intrinsic membrane protein 26 (MP26,
MIP). It is a lens-specific single polypeptide with a molecular mass of 28,200 kDa (263
residues) that makes up about 50% of the lens membrane protein.
MIP26 is a member of the aquaporin (AQP) family, members of which transport small
molecules such as water and glycerol.
A locus for autosomal dominant cataracts has been mapped to chromosome 12q12-14.1
near the MIP gene
MMPs
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Molecular Weights
VEGF: 45kDa
Ranibizumab: 48 kDa
Air: 29
MUCins
Mucins are classified by the nomenclature MUC121 and are divided into secreted and
membrane-spanning categories
o
Membrane-spanning mucins consist of a short intracellular tail, membranespanning domain, and large, extended extracellular domain that forms the
glycocalyx.
Ophthalmology Explorer
Dhaval Patel MD
MUC 1, MUC 4, and MUC 16: apical surface of the corneal epithelium
MUC 5AC and MUC 2: aqueous layer of the tear film (membrane-spanning, gel-forming
mucins)
NV %
BRVO
NVI: 1
NVD: 10
NVE: 30
Ischemic BRVO
40% of patients with an ischemic BRVO develop NVE or NVD.
60% of the patients with NVE-NVD develop VH/PRH.
Ich CRVO
NVI: 50
NVD: 30-35
NVE: 20-25
NVG: 45
CRAO
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NVI: 20
NVD: 2
OIS
NVI: 67
NVD: 35
NVE: 8
EALES DISEASE
NVI: 0.5-0.8 %
NVD: 10-18 %
NVE: 50 %
Sec RRD: 8-11 %
OCT Review
Slow acquisition speeds, high signal-to-noise ratio, poor view of the choroid
Light echoes from each time delay, all measured simultaneously (high-speed
spectrometer)
Fast acquisition speeds, low signal-to-noise ratio, view to the choroid possible
52,000 A-scans per minute, 20-40 B-scans per macula (up to 100), 5-m resolution
Ophthalmology Explorer
Dhaval Patel MD
The further from the zero-delay line (ZDL), the lower the signal resolution.
EDI moves the ZDL closer to the choroid; negative images when the ZDL is crossed.
Image depth of 2.6 mm vs. 1.9 mm for EDIeven more ideal for choroidal tumors
Ophthalmology Explorer
Dhaval Patel MD
Orders of Abberations
0. Piston
1. Vertical and horizontal prisms
2. Myopia (positive defocus), hyperopia (negative defocus), Regular (cylindrical)
astigmatism
3. Coma, trefoil
4. Spherical astigmatism
5. rosette
6. pentacle, axial coma
Percentages % Primer
3050% of individuals with glaucomatous optic nerve damage and visual field loss have an
initial intraocular pressure measurement less than 22 mmHg.
sporadic inheritance of aniridia need to be evaluated for Wilms tumor, which is associated
with 25% of cases.
83% of macular holes are idiopathic, and 15% are due to some sort of trauma
Ophthalmology Explorer
Dhaval Patel MD
ACUTE ACG: 4080% chance of an acute attack in the fellow eye over the next 510 years.
13.5% of those eyes in which blood filled half of the anterior chamber,
in 27% of those eyes in which blood filled greater than half of the anterior chamber,
and
Up to 10% of patients with greater than 180 degrees of angle recession will eventually
develop a chronic traumatic glaucoma
PCO: 8-50%
HLA B27 is present in 90% of patients with AS and 80% of those with Reiters disease.
80% of cases develop within 3 months of injury, and 90% develop within 1 year.
Among patients whose CD4+ count is less than 50 cells/mL, 20% per year develop CMV
retinitis.
Ophthalmology Explorer
Dhaval Patel MD
complement factor H gene is a single nuclear polymorphism responsible for nearly 50% of
ARMD risk.
Approximately 10% of patients with a BRVO will develop a retinal vein occlusion in the
fellow eye.
In uveal melanoma, if no epithelioid cells are present, the expected survival at 15 years is
72%. If epithelioid cells are present (mixed, epithelioid, or necrotic cell type), the survival at
15 years drops to 37%.
Liver metastases occur in 93% of patients who develop metastatic uveal melanoma. Other
sites include the lungs (24%) and bone (16%).
Phacomatosis
The 9 Phacomatosis: (there are total 9 phacomatosis which are numbered as follow)
Ophthalmology Explorer
Dhaval Patel MD
Phakomatosis is an outdated term and concept and term. Neither the AAOs monograph on
Inherited Diseases and the Eye (Traboulsi) nor the WHOs text on CNS Tumors includes the
term in the index. The WHO lists the disorders as familial cancer syndromes
Principles
CSLO: light projected toward the plane of interest through a conjugated set of pinholes
allows the light to reach the detector only from the desired plane, while light coming from all
other locations is blocked.
4 prism test: Hering law and convergence, this test differentiates bifoveal fixation (normal
BSV) from a central suppression scotoma (CSS) in microtropia.
Faden procedure: suture the muscle belly to the sclera posteriorly so as to decrease the
pull of the muscle in its field of action without affecting the eye in the primary position.
VEP: recording of electrical activity of the visual cortex created by stimulation of the retina.
Nd-YAG: photodisruption.
Jackson Cross-Cylinder (JCC) test: placing the circle of least confusion on the retina
Keratometer: The cornea (with its overlying tear film) acts as a convex mirror to produce a
virtual, erect image of the ring. The size and position of the virtual image are measured
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Scheiners disc: Light enters the two pinholes and produces two images on the retina until
the light is brought to a focus.
OPD-Scan optical path difference scanning system: dynamic SkiaScopy and involves
acquisition of 1440 data points to produce a map of the optics of the whole eye
The most sensitive ocular structure is the lens. (The minimum cataractogenic dose was
5.5 Gy and the maximum noncataractogenic dose was 11 Gy)
The sclera is the most resistant: easily tolerating >1000 Gy. Even up to 5000 Gy has
been given to the sclera without causing perforation
lacrimal gland, cornea, and conjunctiva: can tolerate up to 50 Gy (5000 rad) of radiation
The retinal pigment epithelial (RPE) cells were more radioresistant than
photoreceptors and RPE cell loss was only observed at doses of more than 1500
cGy
Rates
Ophthalmology Explorer
Dhaval Patel MD
Pseudofacility:
o
0.06 l/min/mmHg
Tear Evaporation:
o
Recurrence %
Pterygium Surgeries
o
Free flaps: 5%
Thiotepa: 11%
meningioma: 22%
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Refractive Indices
Water: 1.33
Cornea: 1.375 (for power calculation it is fudged to 1.337 to take into account negative
posterior curvature)
Aqueous 1.336
Vitreous 1.336
PFCL: 1.27-1.33
IOLs
o
Ophthalmology Explorer
CeeOn: 1.46
Crystalens: 1.43
SmartIOL: 1.47
Dhaval Patel MD
Glasses
o
CR-39: 1.49
Polycarbonate: 1.58
Resolutions
Ophthalmology Explorer
Dhaval Patel MD
RB Stats
RB1gene: 13q14
2 forms of mutations
o
More multifocality
Unilateral only
Laterality
o
Trilateral: ~1%
About 40% of all retinoblastomas are caused by germinal mutation and are therefore
heritable. (this occurs due to very high mutation rate of RB gene)
Ophthalmology Explorer
o
Dhaval Patel MD
if both parents are normal and one sibling has unilateral retinoblastoma:
1% of sibling
8% of offspring
If both parents are normal and one sibling has bilateral retinoblastoma
40% of offspring
DR
Ophthalmology Explorer
Dhaval Patel MD
Highly intensive glycemic control and combination of fenofibrate 160 mg q.d. and
simvastatin reduced the proportion whose retinopathy progressed by about one-third
at 4 years
A FIELD study analysis found that fenofibrate reduces the first laser treatment by
31%; reduced macular edema by 31% and proliferative retinopathy by 30%.
Fenofibrate reduced the development or progression of retinopathy by reducing 22%
in all patients and 79% in patients with pre-existing retinopathy.
Anti-VEGF Therapy
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RCT studying whether lisinopril, an ACE inhibitor, would reduce the rate of diabetic
retinopathy progression in type-1 diabetes
showed that patients randomly assigned to lisinopril treatment had a lower risk of
diabetic retinopathy progression than controls.
However, the investigators found that at baseline patients in the lisinopril group had
lower baseline hemoglobin A1C levels than control patients.
DRCR.net
o
DME
DRCR.net
o
Ophthalmology Explorer
BOLT
o
DA VINCI
o
Sixteen weeks after focal/grid laser for DME in eyes with a definite reduction,
but not complete resolution, of central edema, it is likely that somewhere
between 23% and 63% of these eyes will continue to improve without
additional treatment.
RESTORE
o
In patients with DME who have good visual acuity, peribulbar triamcinolone,
with or without focal photocoagulation, is unlikely to be of substantial benefit
to pursue with additional trials.
Dhaval Patel MD
VISTA
o
Ophthalmology Explorer
Dhaval Patel MD
Extended Follow-up of Patients With Macular Edema due to Retinal Vein Occlusion
(Diabetic Macular Edema) (RETAIN)
o
Group 2: RBZ TE
ROP
CRYO- ROP
o
Treatment of avascular zone in threshold ROP reduces poor visual and structural
outcomes
44.4% cryo vs. 62.6% observed <20/200 and 27.2% vs. 47.9% had unfavorable
structural outcomes (p<0.001)
Use of supplemental oxygen did not did not significantly reduce the number of infants
requiring peripheral ablative surgery.
A reduction in the ambient-light exposure does not alter the incidence of ROP
Unfavorable visual outcome reduced from 19.8% to 14.3% (p<0.05) and unfavorable
structural outcome from 15.6% - 9.0% (p<0.0001) at 9 months in type I ROP.
Ophthalmology Explorer
Dhaval Patel MD
significantly higher rate of recurrence with Zone I disease when treated with
conventional laser therapy compared to intravitreal bevacizumab (42 percent vs. 6
percent, p=0.003)
ARMD
AREDS 1
o
Vitamin C: 500 mg
Vitamin E: 400 mg
Beta carotene: 15 mg
Zinc: 80 mg
Cu: 2 mg
AREDS 2
o
Vitamin C: 500 mg
Vitamin E: 400 mg
Lutein 10 mg
Zeaxanthin 2 mg
Zinc: 25 mg
DHA: 350 mg
EPA: 650 mg
OMEGA study: Othera Eye Drops (antioxidant, anti-inflammation and anti angiogenic)
ENVISION Clarity trial in geographic atrophy: Pills for Dry AMD-Acucela (ACU-4429)
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Role of CCR3 (chemokine receptor): Anti-CCR3 antibodies may prevent tube formation
prior to vascularization and reduce the proliferation of CECs following laser-induced injury.
PrONTO
o
The 0.5-mg dose of ranibizumab appears to be the most effective, but HARBOR also
showed us that in those rare cases in which we might need a higher dose 2.0 mg or
every-2-weeks dosing, it may be safe.
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bevacizumab was found to suppress systemic VEGF much more than ranibizumab
At 1 year, patients received an average of only 4.9 injections and had 9 office visits,
and mean VA declined continuously after patients completed the 3-dose initiation
phase
SAILOR identified prior stroke, cardiac arrhythmias, and a history of congestive heart
failure as risk factors for stroke while receiving anti-VEGF therapy
SUSTAIN
o
inject-and-extend protocol
Ophthalmology Explorer
Dhaval Patel MD
Study to Observe the Effectiveness and Safety of Ranibizumab in the Real-life Setting
(LUMINOUS)
o
Pazopanib Eye Drops vs. Ranibizumab Intravitreal Injections for the Treatment of
Neovascular AMD
o
VIEW 1 and 2
o
VIEW 1=[North America] VEGF Trap-Eye Investigation of Efficacy and Safety in Wet
AMD VIEW 2=[International]
ASSESS Study
o
intravitreal aflibercept injection (IAI) in subjects who were previously treated with
ranibizumab and/or bevacizumab for exudative AMD
2 mg of IAI every month for the first 3 months, followed by 2 mg once every 2 months
MIVI-5 trial
o
INTREPID Trial
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The 2-year follow-up data showed that radiotherapy treatment was associated with a
significant 25% reduction in the number of anti-VEGF injections over 2 years. "With
appropriate case selection, injections were reduced by 45% and there was a trend
for better visual acuity,"
IVAN
MANTA
Ocriplasmin Trials
o
MIVI
Nonsurgical closure of macular holes was achieved in 40.6% of ocriplasmininjected eyes vs. 10.6% placebo
Ophthalmology Explorer
Dhaval Patel MD
MIVI-5
OASIS Trial
Glaucoma
(ONE CAGe)
OHTS: 20% lowering of IOP reduced risk of glaucomatous VF loss from 9.9% to 4%
NTGS: Reduction of normal pressures by 30% slowed the rate of glaucomatous progression
in a significant number of patients
EMGT: 25% decrease in IOP from baseline and maximum absolute 25mmHg reduced risk
of progression by 50%.
CIGTS: No difference in VF change between treatment modalities. IOP lower with surgery.
Higher rate of cataracts with filtering surgery
AGIS: Greater IOP reduction with trabeculectomy first. For black patients; better visual
preservation with laser first. For white patients better visual preservation with trabeculectomy
first. Low IOP associated with reduced visual field defect progression
GLT: Initial laser trabeculoplasty found as effective as initial topical Timolol to lower IOP and
preserve vision
CNTGS: found that by reducing the intraocular pressure by 30% the rate of visual-field
progression was reduced from 35% to 12%.
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ON
ONTT: Optic Neuritis Treatment Trial: Oral steroids alone did not have a significant
difference in visual recovery compared with the control group; however, the recurrence rate
of optic neuritis was increased. The IV steroid group had faster recovery of visual acuity and
a slight improvement in acuity over the control group.
NAION
IONDT: Ischemic Optic Neuropathy Decompression Trial: Patients in the surgery group did
no better when compared with the observation group regarding improved visual acuity of
three or more lines at 6 months. Approximately one third of the surgery patients had
improvement in acuity, whereas over 40% of the observation patients improved. Moreover,
surgery was associated with a higher risk of loss of three or more lines of acuity (surgery:
24%, observation: 12%). The IONDT conclusively states that optic nerve sheath
decompression is not effective.
MISC
IVT AFL treatment for myopic CNV started with 1 dose of IVT-AFL and induced
significant and clinically meaningful improvements in visual and anatomic parameters
compared with sham injections.
For TMVL
A subgroup analysis of those individuals with TMVL treated medically had 50% lower
risk of ipsilateral stroke than those patients with hemispheric TIA.
Ophthalmology Explorer
Dhaval Patel MD
Greater effect with paired incisions, increasing age, longer incisions, smaller OZ
Surface Tension
Gases: 70
SiO (1000 cs): 21.2
SiO (5000 cs): 21.3
PFCL: 14
Specific Gravity
Silicon Oil
o
PFCL: 1.76-2.03
o
Ophthalmology Explorer
Dhaval Patel MD
Surface Area
Fovea: 1.75-mm2
RPE: 240 mm2 at the fourth month 800 mm2 by 2 years of age
Conjunctival sac: 16 cm2 (roughly 17 times more surface area than the cornea)
Shunts (mm2)
o
Nonvalved
Valved
Survival Rates
craniopharyngioma: 10-year actuarial survival rates were 52% for subtotal resection alone
and 87% for subtotal plus radiation
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rhinocerebral mucormycosis: 14% when untreated, 57% with amphotericin B and surgery
Graft survival in FECD: 5 year and 10 year 97% and 90% respectively
Test Distances
0-6 months 38 cm
7-12 months- 55 cm
>12 months-84 cm
OKNOVIS: 60 cm
Ishihara: 75 cm
Ophthalmology Explorer
Pelli-robsons chart: 1 m
ETDRS: 4 m
FACT chart: 1 m
Amsler chart: 30 cm
Dhaval Patel MD
Thickness
Tear film: 7 um
ABZ: 3 m
PNBZ: 9 m
Corneal endothelium: 6 um
suprachorodial space: 30 m
tarsal plate: 1 mm
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VEGF Facts
Pegaptanib
o
an aptamer, which is a single strand of RNA or DNA (RNA in the case of pegaptanib)
that folds up in such a way that its shape meshes with the VEGF molecule like a lock
and key.
There are several isoforms of VEGF, all of which are active in the angiogenesis
process. Pegaptanib selectively inhibits only the VEGF-165 isoform of VEGF, which
may explain the relatively lower efficacy of this drug compared with others in the
class.
Bevacizumab
o
It was developed as a systemic antineoplastic therapy but has been used off-label for
neovascular AMD since 2005, first systemically and then intravitreally.
Ranibizumab
o
Like its parent molecule, ranibizumab binds all isoforms of the VEGF-A family.
Aflibercept
o
recombinant protein in which the binding domains of VEGF receptors 1 and 2 have
been combined with the Fc portion of IgG.
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o
Dhaval Patel MD
The molecule has a very high binding affinity for all VEGF-A isoforms as well as for
the related molecules placental growth factor-1 and factor-2 and VEGF-B
3 5 mm sponge: 0.110.20
Water Content
Cornea: 80%
Sclera: 70%
Lens: 65%
Vitreous: 99%
Aqueous: 99.9%
Contact Lenses
Medium: 46% to 58% water, used for both daily and extended wear
IOLs
o
Ophthalmology Explorer
o
Dhaval Patel MD
Basic Sciences
Copper accumulates in Descemet's membrane, the lens capsule, and other basement
membranes, whereas iron accumulates in basal epithelial cells.
The dimensional characteristics of the optic nerve can be remembered with the mnemonic
phone number 125-1017, which stands for the lengths of the intraocular (1), intraorbital (25),
intracanalicular (10), and intracranial (17) portions of the optic nerve.
The inferior nasal retinal fibers cross in the anterior chiasm and were thought to loop
anteriorly in the contralateral optic nerve before traveling posteriorly, leading to the term
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Wilbrand's knee (NI=Nasal + Inferior). It is now thought that Wilbrand's knee may be an
artifact.
the inferior fibers of the optic radiations pass extremely close to the internal capsule.
Compared with plasma, aqueous is slightly hypertonic and acidic. Aqueous has a marked
excess of ascorbate (15 times greater than that of arterial plasma) and a marked deficit of
protein (0.2% in aqueous as compared to 7% in plasma).
The four divisions of the optic nerve head correlate roughly with a four-part blood supply.
The surface fiber layer is supplied mainly by branches of the central retinal artery.
The lamina cribrosa region is also supplied by vessels that come directly from the
short posterior ciliary arteries to form a dense plexus in the lamina.
The retrolaminar region is supplied by both the ciliary and retinal circulations,
with the former coming from recurrent pial vessels. The central retinal artery provides
centripetal branches from the pial region.
The superior orbital fissure transmits the branches of cranial nerve V1, III, IV, and VI.
Cranial nerve V2 enters the orbit through the inferior orbital fissure.
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The optic pits first appear on day 23 of gestation. Evagination of the optic vesicle occurs
on day 25 with induction of the lens on day 28. Closure of the optic fissure occurs on day
33.
Lid colobomas do not occur from failure of the fetal fissure to close.
Lens: 10 and 6 mm
Myelination of the optic nerve starts in the seventh month of gestation and is completed
about 1 month after birth. Myelination starts at the LGB optic tract chiasm and
progresses toward the lamina cribrosa.
The inferior or superior muscular branches of the ophthalmic artery provide all or part
of the blood supply to all the extraocular muscles except the lateral rectus. The lateral rectus
blood is supplied by a single vessel derived from the lacrimal artery. Each rectus muscle,
except the lateral rectus, receives two anterior ciliary arteries that communicate with the
major arteriole circle of the ciliary body.
The trigeminal nerve divides into three segments: ophthalmic (V1), maxillary (V2), and
mandibular (V3).
o
The ophthalmic nerve is divided into three branches: nasociliary, frontal, and
lacrimal. O-NFL
The frontal nerve, a branch of the ophthalmic (V1) segment, divides into the
supraorbital and supratrochlear nerves. F-SS
The maxillary (V2) segment divides into the infraorbital, zygomatic, and superior
alveolar nerves. The zygomaticofacial and zygomaticotemporal nerves are branches
of the zygomatic nerve (V2). M-IZS
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Bowman's membrane represents a compact collagen layer at the anterior aspect of the
corneal stroma. It is not a true basement membrane.
All of the recti muscles originate from the annulus of Zinn. The superior oblique and levator
palpebrae originate superior to the annulus.
The accessory lacrimal glands are the basic secretors. These include the glands of
Krause and Wolfring. The reflex secretor is the main lacrimal gland.
Although type I collagen exists in the stroma, it is associated with normal stroma. Type III
collagen is associated with stromal wound healing.
The reasons for relatively miotic pupils in infancy include immaturity of dilator pupillae
muscle.
The optic nerve is generally myelinated to the lamina cribrosa 4 to 6 months before
foveal maturation.
The lower lids are more frequently involved by congenital ectropion and congenital
entropion.
most common clinical finding in infants with congenital rubella syndrome SNHL
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Although children with congenital rubella syndrome may develop either cataract or
glaucoma, their coincidence in an infant is rare.
In rubella cataract after surgery, Excessive rebound uveitis is caused by live virus
retained within the residual lens cortex.
Hutchinson's triad of congenital syphilis: peg-shaped teeth, eighth nerve deafness, and
interstitial keratitis.
M Pathway subserves: motion & pursuit, direction, speed judgement, coarse stereopsis
Occipitoparietal: magnocellular, WHERE pathway localization and movement
P Pathway subserves: fine acuity, shape, colour, fine stereopsis
OccipitoTemporal: parvocellular, WHAT pathway color, shape and pattern
The central retinal artery arises from the ophthalmic artery after ophthalmic artery passes
through the optic canal. The central retinal artery then dives into the center of the optic
nerve where it travels until it exits from the optic nerve head.
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Volume of conjunctival cul de sac is 7 uL. Ideal drop size should be 20 uL. Ideal drop
viscocity should be 12-15 cps.
The sclera, like the cornea, is virtually avascular except for two areas: (i) the superficial
vessels of the episclera, and (ii) the intrascleral vascular plexus located immediately
posterior to the limbus.
The trabecular meshwork consists of thin, perforated connective tissue sheets arranged in
a layered pattern. The connective tissue beams are lined by a monolayered
endothelium. The trabecular meshwork is derived from the neural crest tissue.
Animal outflow studies have shown that the juxtacanalicular trabecular meshwork (TM),
which is immediately proximal to Schlemm's canal, is the primary limiting factor for
outflow facility.
Retinal pigment epithelium (RPE) cells in the foveal area are taller, more closely packed,
and have more and larger melanosomes, contributing to the relative hypofluorescence of
this area during fluorescein angiography.
Rods and cones are characterized by three components: the synaptic body, the inner
segment, and the outer segment. The synaptic body of a rod is called a spherule, whereas
that of the cone is called a pedicle. Photopigment is stored in discs in the outer segments.
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In rods, the discs are not attached to the cell membrane, but cone discs are continuous with
it.
Approximately 120 million rods and 6 million cones interact with 1.2 million ganglion
cells in an eye. Therefore, the ratio of rods to cones is approximately 20:1. (Some studies
cite a ratio as low as 12:1.)
A cilioretinal artery contributes to the vascular supply of the retina in approximately 50% of
individuals and 30% of eyes. In 15% of individuals, it contributes to macular circulation.
Levator is served by a single subnucleus. It sits dorsal, central, and at the inferior end of the
group of subnuclei that compose the two third-cranial nerve nuclei. The superior recti have
two subnuclei, each controlling the contralateral nerve. In contrast, the inferior obliques
and the medial recti each have individual subnuclei that control the ipsilateral nerves. The
superior oblique is served by the fourth nerve. The lateral rectus is supplied by the sixth
cranial nerve.
The pupillomotor fibers of the third cranial nerve run in the inferior division, which carries
them to the ciliary ganglion. They are among the axons in the periphery of the nerve,
making them easily susceptible to compression.
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Neural crest cells give rise to ciliary musculature, corneal stroma, and endothelium (but not
corneal epithelium), most of the sclera (except for a temporal portion which is of
mesodermal origin), choroidal stroma, some of the orbital bones, orbital cartilage, orbital
connective tissue, nerve sheaths, and uveal melanocytes. Extraocular muscles form from
paraxial mesoderm.
Blood vessel endothelia, extraocular muscles, and temporal sclera are all mesodermal in
origin. The mesoderm also contributes to the formation of the vitreous. The pupillomotor
muscles are neuroectodermal in origin. The trochlea originates from the neural crest.
Conjunctival epithelium is derived from surface ectoderm, but the substantia propria is
derived from the neural crest.
Sporadic aniridia is associated with Wilms' tumor (usually because of deletion of the
PAX6 gene and the adjacent Wt1 Wilms' tumor gene). Aniridia is not typically found in
patients with autosomal-dominant Wilms' tumor.
Aqueous humor provides most of the glucose needed by the endothelium, stroma, and
epithelium. Hydrophobic molecules penetrate the epithelium most easily, whereas
hydrophilic molecules penetrate stroma more easily.
Enzymes in Aqueous:
Carbonic anhydrase, although present in only trace amounts in the aqueous humor, has a
high enough turnover that it is felt to be functionally significant.
Hyaluronidase is present in aqueous humor and may participate in the regulation of
resistance to aqueous outflow.
Lysozyme is present and provides antibacterial protection.
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Lactate dehydrogenase, not normally detectable in aqueous humor, may be a marker for
retinoblastoma.
Lens epithelium cells are located anteriorly underneath the lens capsule. Epithelium cells in
a ring around the anterior lens, or the germinative zone, exhibit the highest level of
deoxyribonucleic acid (DNA) synthesis (the S phase in the cell cycle). Newly formed cells
migrate toward the lens equator, where they differentiate into lens fiber cells.
The water-soluble proteins of the lens are divided into three types of crystallins that are
fractionated into four electrophoretic groups.
Alpha crystallins are the largest, with molecular weights of >500,000 daltons.
Beta crystallins are the most abundant, making up approximately 55% of the water-soluble
protein.
Gamma crystallins are the smallest.
Unlike the retina, the lens can function without oxygen but not without glucose,
primarily because the lens mostly relies on anaerobic glycolysis to generate adenosine
triphosphate (ATP). In a glucose-depleted environment, the lens will become hazy after
several hours.
Photoreceptors are more active electrically (depolarized) in the dark! With light
absorption, transducin (via phosphodiesterase [PDE]) lowers cyclic guanosine
monophosphate (cGMP) concentration, which hyperpolarizes the cell and decreases
synaptic exchange with bipolar cells.
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Cromolyn sodium is a mast cell stabilizer and has no direct antihistaminic effect (receptor
blockade). It is only effective if used prophylactically.
Because of increasing resistance to vancomycin, the Center for Disease Control and
Prevention (CDC) has recommended avoidance of the use of empiric vancomycin in
patients with neutropenia unless clear evidence for a beta-lactam-resistant Gram-positive
infection can be demonstrated.
Serum purine levels in patients with Down's syndrome are typically elevated. The
enzymes required for the biosynthesis of purities are coded by genes present on the long
arm of chromosome 21. The presence of a third set of these genes presumably results in
the elevation of serum purine levels.
The expression of multiple discrete anomalies in various organs caused by a single gene
mutation is termed genetic pleiotropism.
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The iris sphincter receives parasympathetic innervation by the inferior division of the
oculomotor nerve (which also supplies the inferior oblique muscle) (These are the only
fibers that synapse in the ciliary ganglion).
The iris dilator is supplied by sympathetic fibers running with the nasociliary and long
ciliary nerves, branches of the first division of the trigeminal nerve (V1).
Motor units, defined as one terminal motor nerve branch and all the muscle fibers it serves,
are smaller in the extraocular muscles than anywhere else in the body. This permits the
finest control of force generation and muscle action possible.
There are approximately 20 short posterior ciliary arteries, which enter the sclera in a
circle around the optic nerve. There are two long posterior ciliary arteries, which usually
enter the sclera on either side of the optic nerve at the 3- and 9-o'clock positions. The
posterior ciliary arteries supply the uveal tract, the sclera, conjunctiva, and cilioretinal
arteries. There are seven anterior ciliary arteries, which provide muscular feeding
branches (supplying the extraocular muscles) and terminate in the major arterial circle of the
iris.
Ganglion cells are the first retinal cells to differentiate into a recognizable level.
Rod outer segment shedding in animal models will persist even after several days in the
dark. On the contrary, dark deprivation (i.e., constant light adaptation) will rapidly ablate
normal rod disc shedding.
The cell most commonly used for karyotypic analysis is the T lymphocyte.
Nuclear third-nerve palsy may feature contralateral upgaze palsy because SR is served
by a contralateral brainstem subnucleus.
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The level of retinopathy before pregnancy is the strongest risk factor for significant
progression during pregnancy. NPDR to PDR 5%
The corneal and retinal pigment epithelium (RPE) damage is limited to historical reports of
patients treated with much higher dosages of tamoxifen, where the chance of toxicity is
much higher. Ocular toxicity has not been reported with cumulative doses of <10 g.
As per DCCT, once progression occurs, patients who rigorously control their blood sugars
are twice as likely to recover, compared with less-controlled diabetics. Therefore, early
worsening is a temporary effect among patients undergoing intensive treatment.
Studies have shown that preoperative (72 hours) antibiotic reduces bacterial counts to a
greater degree than 3 days of preoperative povidone-iodine. Adding povidone-iodine at
the time of surgery exerts a synergistic effect. Some studies have suggested that saline
flushes actually increase bacterial colony counts.
Cigarette smoking has been most strongly associated with choroidal neovascularization.
(also with RPE hyperplasia as per beaver dam study.)
55 minutes is the shortest duration of cataract surgery that has resulted in photic
maculopathy.
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A human metabolite of a bioflavonoid found in grapefruit juice, but not in orange juice,
inhibits several cytochrome components of the P450 isozyme group.
Carbonic anhydrase inhibitors are most likely to be of benefit in disorders of the retinal
pigment epithelium (RPE) and significantly less likely to help in cases of primary retinal
vascular disease.
CME: Fishman and colleagues have established that 500 mg/day of acetazolamide is
more effective than 250 mg/day. They have subsequently demonstrated that methazolamide
50 mg twice daily is less effective than acetazolamide.
No urine test results have been found to be affected by recent fundus angiography.
Cortisol, thyroxine, and quinidine are affected for up to 3 hours, with digoxin being affected
for up to 12 hours. Serum creatinine levels may be affected, but this appears to be shortlived (<3 hours).
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In pathology specimen, a fold at the ora serrata-is a fixation artifact found in newborn eyes
called Lange's fold.
Transient Myopia
Sulfonamides
Tetracycline
Perchlorperazine (Compazine)
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Steroids
Carbonic anhydrase inhibitors
Iris Heterochromia
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Congenital:
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Dhaval Patel MD
Acquired:
The trem protan, deutran and tritan are derived from Greek word meaning first, second
and third.
The term CALOTTE is used in ocular histopathology for the two hemispheres which are
cut from the globe.
FischerKhunt spot: (Senile scleral plaque) bluegray area of hyalinized sclera anterior to
horizontal rectus muscle insertions in elderly individuals
Purkinje shift: Shift in peak spectral sensitivity from photopic (555 nm, cones) to scotopic
(507 nm, rods) conditions.
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Recurrent nerve loop of Axenfeld: Described in 1895 by T. Axenfeld was a nerve that
makes a loop in the sclera anteriorly. The nerves travel through the sclera usually originating
from the long ciliary nerves and some may approach the surface of the sclera about 1-6
mm from the limbus. The nerves bend 180 degrees creating a mushroomed loop at the
surface. They may produce symptoms of irritation and tenderness.
Steps to reduce OCR- OculoCardiac Reflex: use of atropine and light sedation
The inner layer of the optic cup contains the pluripotent retinal progenitor cells, which
differentiate in a specific chronologic sequence and defined histogenic order into the final
seven retinal cell types. In general, the RGCs differentiate first, followed by the cone
photoreceptors, amacrine cells, horizontal cells, and finally, the rod photoreceptors, bipolar
cells, and Mller cells. GCAHRBM God Can Always Help Revealing Best Messages.
High doses of digoxin can cause objects to appear yellow (xanthopsia). Withering
reported visual side effects of digoxin in his classic paper in 1785
Emsley Fincham test: The stenopic slit is kept in front of the eye and the patient is asked to
look at a light source. The slit is then moved in front of the eye
In conjunctivitis and in glaucoma, there is no fan effect. In cataract, there is fan effect.
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Colored halos caused by cataract (lenticular) seem to break into a moving fan but not
that caused by glaucoma (corneal) which only become slightly dim. Moreover, the VIBGYOR
of the rainbow is within outwards in lenticular halos and without inwards in corneal halos.
This is because; in glaucoma colored halo is due to corneal edema which is
homogeneous. In cataract, it is due to accumulation of water droplets in lens; which
is a heterogeneous phenomenon.
Nerves which escapes after retrobulbar block: trochlear, conjunctival sensory nerves and
few sympathetics
Optic nerve has 1.5 million axons whereas trochlear nerve has 1500 axons. Its smallest
cranial nerve.
Orbital lobe of lacrimal gland is anterior and Palpebral lobe is posterior. REMEMBER
This. Else you can remember orbital lobe is superior and palpebral lobe is inferior.
Lacrimal gland structures are post-septal structure whereas lacrimal sac structures are
pre-septal.
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Dhaval Patel MD
Inflammation:
Acute (exudative): Polymorphonuclear leukocytes, Mast cells and eosinophils
Chronic (proliferative):
Nongranulomatous: Lymphocytes and plasma cells NLP
Granulomatous: Epithelioid histiocytes, giant cells GEG
Doxycycline changes the lipid viscosity of the meibomian gland secretions, improving
oil secretion from the gland into the tear film. This superficial lipid layer is needed to keep
the tears from evaporating too quickly.
Color of the Fundus: The color of the fundus depends on the melanin content of the retinal
pigment epithelium, the melanin content of the melanocytes in the choroidal stroma, and
the hemoglobin in the choroidal and retinal vasculature. The melanin contribution to the
color parallels the complexion of the patient's skin and hair, the fundus being darker in black
races and lighter in whites.
Cilioretinal vessels originate from the circle of Zinn, which is formed around the optic nerve
in the sclera from the short posterior ciliary arteries.
The small white light reflex at the center of the fovea centralis is produced by the
reflection of the ophthalmoscope light from the concavity of the fovea.
With the pupil widely dilated, the peripheral fundus can be seen with the direct
ophthalmoscope up to the equator only. You cannot see beyond the equator by direct
ophthalmoscope. The patient must be instructed to move the eyeball in the appropriate
direction so that each quadrant of the retina can be brought into view.
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Chlamydia
o
No cell wall
No energy production
Dhaval Patel MD
The optic nerve fibers are separated from the retinal layers by a ring of glial tissue, the
intermediary tissue of Kuhnt.
The continuation of this glial tissue, the border tissue of Jacoby (glial), separates the
choroid from the optic nerve fibers
Ring of collagenous tissue of scleral derivation, the marginal tissue of Elschnig (fibrous,
temporal), lies outer to the glial sheaths.
Striated muscle of the leg can contain several hundred muscle fibers per motor unit; in the
extraocular muscles, each axon innervates 3 to 10 fibers. This dense innervation
provides for precise fine motor control of the extraocular muscles resulting in high velocity
ocular movements, necessary in saccades, (up to 1000 degrees per second) and very
accurate pursuits (velocities of 100 degrees per second) and fixations.
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STYCAR: Sheridan/Screening Tests for Young Children and Retardates, Sheridan 1973
Posterior border - elevation formed by the oblique insertion of uveal trabeculae into
limbal stroma
50-150 microns
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Dhaval Patel MD
the major perforating branches of the anterior ciliary arteries at the ciliary body level.
The main attachment of the uvea however is at the scleral spur where the
longitudinal muscle of Brucke (tensor choroidalis) inserts.
shallow anterior=supraciliary
Cilioanterior
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Cilioequatorial
Cilioposterior
orbiculoanterior and orbiculo posterior: these fibers originate from the dentate
processes of the retina, form the orbiculohyaloidal interspace of Hannover, rest
on the anterior hyaloid and suspend the anterior vitreous.
Subretinal space borders: border tissue of Kuhnt (posterior cul-de-sac) ora serrata
(anterior cul-de-sac)
Suprachoroidal space borders: border tissue of Elschnig (posterior cul-de-sac)
scleral spur (anterior cul-de-sac)
Middle limiting membrane: junctional complexes between rod spherules and cone
pedicles.
Mueller cells elaborate the internal limiting membrane which is their cell base (base in,
apex out).
The Mueller cell apex points to the photoreceptors and elaborates the external limiting
membrane, a desmosomal junctional system.
The inner 1/3 and outer 2/3rd of OPL is separated by the middle limiting membrane
which is composed of synapses and their junctional systems connecting the axons of rods
and cones (inner fibers of Henle) to the outer neurons. The middle limiting membrane
denotes the limit of retinal capillaries as well as a barrier to exudates.
The cystoid spaces develop first at the outer plexiform layer. If these spaces
coalesce, typical degenerative retinoschisis results.
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Very rarely, a retinal detachment can develop in the presence of holes in the inner
and outer layers of the schisis cavity.
The anterior margin of the optic cup is called the Marginal sinus of von Szily. It advances
on the posterior surface of the iris stroma.
Pupillary ruff: Marginal sinus of von Szily reaches pupil in the 4th month and forms the iris
sphincter and dilator. If it fails to do so, the condition is called Aniridia.
Internal ulcer of von Hippel: If endothelial (Descemets) defect occurs related to incomplete
separation of lens
The differentiation of the macula is not complete until 46 months after birth.
Ganglion cell nuclei are initially found directly over the foveola and gradually are displaced
peripherally, leaving this area devoid of accessory neural elements and blood vessels as
neural organization develops to adult levels by age 6 months.
This delay in macular development is one factor in the inability of newborns to fixate, and
improvement in visual activity parallels macular development.
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The superior orbital fissure at the orbital apex lies between the greater and lesser wings
of the sphenoid bone.
Paranasal Sinuses:
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All paranasal sinuses are normally present at birth (apart from the frontal sinus which
is rudimentary until 2 years of age).
All sinuses are lined by a pseudostratifieci columnar ciliated epithelium, which aids
the passage of mucus into the nasal cavity.
The maxillary sinus drains via the hiatus semilunaris into the middle meatus of the
nose.
The anterior and middle ethmoidal air cells, along with the frontal air cells, also drain
into the middle meatus of the nose.
The posterior ethmoidal air cells drain into the superior meatus whereas the
sphenoidal air cells drain into the sphenoethmoidal recess.
All lymph drainage from the paranasal sinuses is to the submandibular nodes,
except the sphenoidal sinuses and posterior ethmoidal sinuses which drain into
the retropharyngeal group of nodes.
The osseous canal for the nasolacrimal duct is formed by the maxilla, the lacrimal bone, and
the inferior nasal concha; it opens into the inferior meatus of the nose.
The conjunctiva becomes continuous with the keratinised skin epithelium along the
posterior margins of the tarsal gland openings and not at the grey line, which lies
anterior to these openings.
The grey line marks the tissue plane along which the eyelid may be split into an anterior
lamella consisting of skin, subcutaneous tissue and orbicularis, and a posterior lamella
consisting of the tarsal plate and conjunctiva.
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The final diameter of the cornea is determined by the diameter of the optic cup.
Corneal Development:
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By the third month the stroma is a structure of 2530 layers a thin Descemets
membrane is present and the endothelium is now a single layer.
Cold and pain are the only stimuli of the corneal epithelium.
The palisades of Vogt are formed by epithelial cells, which are thrown into folds by the
subepithelial connective tissue at the limbus.
The ciliary epithelium is a bilayered cuboidal epithelium that forms an integral part of the
blood aqueous barrier.
The two cell layers lay apex to apex, the inner layer being rich in golgi apparatus and rough
endoplasmic reticulum while the outer layer contains numerous melanocytes.
There are numerous tight junctions between the cells of the inner layer but not between cells
of the two layers.
The basement membrane of the inner layer is continuous with the internal limiting
membrane of the retina, whereas the basement membrane of the outer layer is continuous
with that of the retinal pigment epithelium.
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The sphincter and dilator muscles arise from the anterior epithelial layer.
Sclera is thickest (1 mm) at its posterior pole, thins to 0.6 mm at the equator and is thinnest
(0.3 mm) immediately posterior to the tendinous insertions of the recti.
The outer plexiform layer is the watershed region of the retina: structures that lie peripheral
to this layer (rods and cones in the outer nuclear layer) receive their nutrients by diffusion
from the choroidal circulation, whereas the inner two-thirds of the retina receive nutrients
directly from the central retina artery and its tributaries.
The anterior portion attaches to the frontal process of the maxillary bone and serves
as the origin of the superficial head of the pretarsal orbicularis.
The posterior portion inserts on the posterior lacrimal crest and fossa. The
posterior limb of the medial canthal tendon, the deep head of the pretarsal
orbicularis, and the deep head of the preseptal orbicularis muscles are important in
maintaining apposition of the eyelids to the globe.
The lacrimal sac is positioned anterior to the orbital septum and, therefore, does not
lie within the orbit.
Ophthalmology Explorer
Dhaval Patel MD
It is the lower eyelid retractor system with contributions from intermuscular septae
and Tenon's capsule.
Posteriorly, it arises from fibrous attachments to the inferior side of the inferior rectus
muscle and continues anteriorly as the capsulopalpebral fascia (lower eyelid
retractors).
arises from the compaction of the sheath of the anterior portion of the levator muscle.
Laterally, it attaches to the capsule of the orbital lobe of the lacrimal gland and to the
lateral orbital wall above the lateral orbital tubercle.
There are extensions to the medial and lateral retinacula. This structure acts to
change the direction of pull of the levator muscle from horizontal to vertical and
serves to limit the elevation of the eyelid.
Although Whitnall's ligament attaches to the fascia on the superior and medial
surfaces of the lacrimal gland; it does not pass anteriorly to the lacrimal gland.
The lacrimal gland is divided into orbital and palpebral lobes by the lateral horn of the
levator aponeurosis.
Soemmering's ligaments
Whitnall's ligament
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Dhaval Patel MD
The orbital portion is involved in forced eyelid closure. It originate from the anterior
medial canthal tendon and periosteum.
The palpebral portion of the muscle is also responsible for reflex blinking (as
opposed to the orbital portion, which screws the eyelids tightly together)
The pretarsal portion arises from the posterior lacrimal crest and anterior limb of
the medial canthal tendon. The lateral portion of the pretarsal muscle becomes the
lateral canthal tendon. The deep head of the pretarsal muscle (tensor tarsi muscle
of Horner) encircles the canaliculi to facilitate tear drainage.
The preseptal orbicularis originates from the fascia around the lacrimal sac and
posterior lacrimal crest. Superficial origins arise from anterior fibers of the medial
canthal tendon. Laterally, it forms the lateral palpebral raphe overlying the lateral
orbital rim.
It is a muscle of facial expression that is derived from the second branchial arch
and is therefore supplied by a branch of the facial nerve.
Ophthalmology Explorer
O2 tension
o
Aqueous: 72 mmHg
RQ of cornea is 1.
Dhaval Patel MD
Clonal deletion: Fas ligand expressed in uveal tissue causes deletion of the Fas+ T
cells that enter that tissue and recognize antigen
Gene Therapy
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Ophthalmology Explorer
Current trials are going on for AMD, Leber congenital amaurosis type2, Stargardt
disease, choroideremia, Usher syndrome 1B, choroideremia, and retinitis
pigmentosa due to MERTK mutations.
Apoptosis
Autophagy
Necrosis
Caspase-Dependent Apoptosis
o
External death signals such as tumor necrosis factor (TNF) or Fas ligand (FasL)
Dhaval Patel MD
intrinsic signals such as mitochondria damage and reactive oxygen species (ROS).
Neuroprotection Strategies
o
Caspase inhibition
Ophthalmology Explorer
o
Brimonidine
Dhaval Patel MD
Rabl's lamellae: radiating pattern of lens fibres in periphery, fibers being more uniform
beneath the epithelium and becoming thicker and irregular as they age and approach the
nucleus
Resistance to diffusion of solutes and bulk fluid flow are of considerable importance to
maintaining normal corneal function (resistance to diffusion of solutes and fluid flow:
epithelium [2000] endothelium [10] > stroma [1])
The nasolacrimal duct derives from ectodermal tissue in the nasolacrimal groove between
the lateral nasal and maxillary processes. This tissue is known as the nasolacrimal
ectodermal cord. Mesenchymal tissues from the maxillary process cover the ectodermal
tissue medially, before it canalizes.
The central cells of the cord degenerate until there is a superior membrane composed of
canalicular and conjunctival epithelium, as well as an inferior membrane of nasolacrimal and
nasal epithelium. These superior and inferior ends are usually patent at the time of birth.
The lacrimal gland arises from an outpouching of the conjunctiva as a modified salivary
gland.
Ophthalmology Explorer
Dhaval Patel MD
F2: Reduces intraocular pressure, Has minimal effect on inflammation, Has minimal
effect on miosis
In streak retinoscope, when para-stop is at Down position, rays coming out are Divergent
from convex/ plane mirror. If position of para-stop is up, rays coming out are convergent
from concave mirror.
Ophthalmology Explorer
Dhaval Patel MD
5. Substract +0.5 tear lens (created by fitting +0.5 overflattened contact lens)
Most commonly used material for glasses is CR-39 (C stands for Columbia and R stands
for resin). This material can withstand heat up to 100 C. Its refractive index is 1.498.
Chemically it is Allyl Diglycol Carbonate. (ADGC)
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V-value Constringence or Abbes number: The degree to which the material has the
same refractive index for different wavelengths of light. Lenses made with lower V values
more quickly show rainbows, color fringes and degradation of best acuity when the eye
turns towards the periphery of a spectacle lens, the effect being proportional to the power of
lens. In simple language it is a positive value that indicates the degree of transverse
chromatic aberration. High V-value means low dispersive power and vice versa. Thus
Crown glass has V-value of 59 and CR-39 has V-value of 57.8 and thus patient does not
complain of colored fringes due to their low dispersive power. In contrast-high index lenses
and polycarbonate lenses have a low V-value thus high dispersive power and cause colored
fringing of objects.
A lens with base curve of 6D is known as deep meniscus lens and with a base curve of
1.25D is known as Periscopic lens.
Photochromatic lenses darken on exposure to light and become colorless in dark again.
This is because silver chloride crystals which change into free silver on exposure to
sunlight. This free silver forms silver colloids which absorb UV radiations to cause darkening
of lenses. In indoor conditions silver particles, combined with trapped halides and silver
halide crystals are reformed and lens appears clear.
These lenses darken only in sunlight but not in artificial light because UV radiations are
required for the darkening effect. Hence car windows which block UV rays also render these
lenses less effective inside the car.
AR coating decreases reflection of incident light on lens and increases its transmittance. As
the AR coating absorbs ultraviolet rays hence less light is available for activation of
photochromic property of lens. Thus a photochromic lens with AR coating becomes less
dark on exposure to light as compared to a normal photochromic lens.
Balance Lens: This type of lens is used to balance the weight of the other lens in the
spectacle frame where one eye is practically blind. For better cosmetic appearance, the
balance lens power and style should match the other lens.
Lenses with refractive index between 1.64 and 1.73 are called high index lenses
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Vergence is defined as the reciprocal of the distance from a reference point (in meters) to
the point of focus. By convention, divergence is given in minus (-) vergence power and
convergence is given in plus (+) vergence power.
Converging lenses have real/inverted images that are on the opposite side of the lens from
the object.
Diverging lenses create virtual/erect images that are on the same side as the object.
The primary focal point (F1) of a lens is also called the Object-Space Focus.
For a plus lens, this is the point from which light must originate to emerge parallel from the
lens. Thus, the image is at infinity.
For a minus lens, this is the point towards which the incident light must be directed in order
for the image rays to emerge parallel.
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Secondary focal point (F2) of a lens is also called the Image-Space Focus.
For a plus lens, this is the point where parallel rays from a distant point object are rejoined
to form an image at that point. When parallel rays enter the optical surface, they will focus at
the secondary focal point.
For a minus lens, this is the point from which diverging rays seem to come from, after a
parallel bundle of rays are refracted by a negative lens.
The anterior focal point is approximately 17mm (1/-60 = -16.67mm in front of the cornea)
and the eye is 22.6mm in length with the nodal point 5.6mm behind the cornea.
The nodal point is the point in the eye where light entering or leaving the eye and passing
through the nodal point, is undeviated. This allows similar triangles to be used to determine
the retinal image size of an object in space. For example, to determine the retinal image size
of a Snellen letter (viewed at 6 meters), the following formula would be used: Retinal image
height/Snellen letter height = 17mm/6000mm
The far point of the eye is the object point imaged by the eye onto the retina in an
unaccommodated eye.
The near point of the eye is found when the uncorrected refractive error of the eye is added
to the accommodative ability of the eye. If the amplitude of accommodation is 10D, the near
point is 10cm in front of the eye (specifically, 10cm in front of the vertex of the cornea which
is used as a convenient reference point).
According to Knapps Law, the retinal image size will not be different between the two
eyes, no matter what amount of axial ametropia exist, when the spectacle lens is placed at
the eyes anterior focal point.
Ophthalmology Explorer
Dhaval Patel MD
When wearing contact lenses, the convergence requirement is the same as that of an
emmetrope, because the lenses rotate with the eye and the line of sight remains relatively
well directed through the center of the lenses.
As a myope converges to bi-fixate a near object, his line of sight departs from the center of
his spectacle lenses and encounters increasing amounts of base in prismatic effect. The
spectacle wearing hyperope encounters base out prismatic effect, as he converges to bifixate a near object. Thus, to bi-fixate a given object at a distance less than infinity, the
bespectacled myope converges less than the emmetrope or the contact lens wearer, while
the hyperope wearing spectacles converges more than the emmetrope or the contact lens
wearer. Therefore, the myope who discards his spectacle lenses in favor of contact lenses,
must converge more to bi-fixate a given near object, while the hyperope will converge less
under the same conditions.
Relative Distance Magnification = r/d where r = reference or original working distance and
d = new working distance
Relative Size Magnification = S2/S1 where S1 = original size and S2 = the new size
The ratio of the image size to the object size or image vergence to object vergence is called
transverse or linear magnification. MT = I/O=U/V = v/u
The power of a lens is an indication of how strongly it refracts (bends) incoming light rays.
The power, P, is equal to one over the focal length in meters and has units of Diopters (D).
P (diopters) = 1/f (m)
The Airy's disc is a diffraction pattern when light passes through the edge of an
obstacle. It contains a bright central disc ie. Airy's disc that receives about 90% of the
luminous flux. This disc is surrounded by concentric light and dark rings. The radius of the
disc is proportional to the wavelength of the light but inversely proportional to the pupil size.
Sir George Airy, (18011892) Astronomer, was the first to calculate the energy distributions
in the pattern.
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Approximately 84% of the total energy of the diffraction pattern is in the Airy disc. The
remaining energy is distributed in the surrounding rings that become progressively fainte
Two object sources of light (S1 and S2) cannot be resolved if their diffraction patterns (Airy
discs) overlap substantially.
Rayleighs criterion: central maxima of one diffraction pattern falls on the first minima of
the diffraction pattern from the second source, and the two images can just be resolved.
Polarimetry uses the birefringence of the NFL (nerve fibrelayer) to quantitate its thickness
indirectly. The change in the polarization of light as it passes through the NFL, or
retardation, is measured and linearly correlated to the NFL thickness.
Illuminance and irradiance are terms used to refer to the amount of light arriving at a given
point. Radiance refers to the amount of light leaving a certain point.
Catoptric images are images reflected from the surfaces of the eye. It is other name of
commonly known purkinje images.
The eye can accommodate in the absence of convergence. However, in normal daily life
a patient with normal binocular vision will convergence when he/she accommodates. The
normal ratio is 3:1 to 5:1.
The refractive index of a material is different for different wavelength and in general it
is usually measured with yellow sodium flame.
The frequency of a light does not change as it travels from one medium into another but the
wavelength become shorter.
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The later explain why cornea has a stronger refractive power than lens in human eye
although its refractive index is less. The wavelength of the light also affects the vergence
power of the lens.
The first focal length has the same length as the second focal length only if the media
on either side of the lens are the same.
The first focal length of a convex lens is to the left of the lens whereas that of the concave
lens is to the right of the lens.
By convention, the second focal length has a positive sign for convex lens and a negative
sign for concave lens. As lenses are designated by their second focal lengths, a convex
lens is also called a plus lens and a concave lens a negative lens.
Maddox rod is used to measure distant phoria and Maddox wing for near phoria. Double
Maddox rod can be used to measure cyclotorsion.
Placed before an ametropic eye, the cross-cylinder does not alter the spherical
equivalent, but it will enlarge or contract the interval of Sturm, blurring or clarifying the
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image, as it increases or decreases the net astigmatic ametropia. The power of the
cylinder is twice that of the sphere and of opposite sign.
The image is moved forward when a correcting lens is moved forward irrespective if the
lens is concave or convex.
The accommodation is the sum of the patient's refractive state + 4D. For comfortable
near vision, one-third of accommodation should be kept in reserve.
The Franklin design is a split bifocal in which a distance lens is mounted on a near lens.
The cemented design involves attaching a supplementary lens to the surface of a distance
lens of the same refractive power.
Fused bifocal is made by heat-fusing a near portion made of flint glass into a depression on
a crown glass with a lower refractive index.
Varifocal glasses have three sections: distance, intermediate (for VDU or working at arm
length) and near (for reading).
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Piggyback contact lens involves the use of two lense; the soft contact lens provides the
fitting surface for the rigid gas permeable lens.
Corneal warpage refers to change in the corneal curvature associated with contact lens
wear.
Corneal oedema is absent.
It is commoner with rigid gas permeable contact lens than soft contact lens.
The result is reversible. Biometry or refractive surgery should be avoided until the cornea
returns to its normal shape otherwise the results of the measurement or surgery will be
inaccurate.
Wollaston prism is used in the Javal-Schitz instrument to double the image formed by
reflection on the cornea.
As neutrality is approached, the reflex becomes Faster, brighter and thinner. When the
refractive error is neutralized, the pupil is suddenly filled with light.
When the retinoscopy reveals +2.00-1.75 X 180 at working distance of 67cm, the final
refraction will be +0.50 -1.75 X 180. This cylinder portion of the correction is
unchanged.
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In monocular refraction one aims to obtain the maximum positive correction with
the accommodation fully relaxed. However, if the eye not being examined
accommodates behind the cover, then the maximum correction will not be achieved.
Binocular balancing is a check for this small amount of accommodation.
Remember to give maximum positive sphere equal to best visual acuity and minimum
negative sphere.
Cross compound lens: a combination of lens in which power of cylinder is more than
power of spherical lens with opposite signs.
Patient having mixed astigmatism may not complain of defective vision as the circle of
least diffusion falls on his retina and hence his visual acuity is very good even without
glasses.
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Clinical Applications
1. To diagnose presence or absence of lens.
2. Keratometry makes use of first Purkinje image.
3. Type of cataract: In MSC and HMSC, Fourth Purkinje image is absent.
4. Hirschberg test: First Purkinje image is used for estimation of angle of squint.
Remember that while checking a lens if its convex or concave, if image seen by it moves in
same direction, then its concave lens which is used in myopia. Dont confuse this with
refraction in which reflex moves in opposite if its myopia >1.5D.
Concave mirror converges parallel rays of light and convex mirror diverges parallel rays of
light. This is in contrast to concave lens which diverges parallel rays of light and convex
lens which converges parallel rays of light.
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3. Fusional: It is initiated by a bi-temporal retinal image disparity and is not associated with
change in refractive status of eyeball. It ensures that image of an object falls on
corresponding retinal points in the two eyes.
Speed of light is the fastest anything has been observed to move. In vacuum, the
speed is three lakh kilometers per second or one lakh eighty six thousand miles per
second. At this speed, it takes light one ten thousandth of a second to travel around the
earth.
The angle of incidence, for which angle of refraction is 90 is known as critical angle.
For example, fibre-optic cables, gonioprisms, diamond shining at night.
A sound wave, by contrast, vibrates back and forth along its propagation direction and thus
is not polarizable.
It states that the intensity of light, i.e. luminance radiating from a point source is
inversely proportional to the square of the distance from the source.
E = 1/d
Positive angle kappa represents a slight temporal position of the fovea relative to the
optical axis. This causes a slight temporal rotation of the globe to keep the image on the
fovea. This, in turn, causes the corneal light reflex to be displaced nasally. The deviated light
reflex remains stable with cover testing as the fovea never spontaneously moves relative to
the optical axis
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Manual Method: See a straight line through a prism. It appears broken. Line
appears to be deviated towards its apex. Now place a prism of known strength in
such a way that base is towards apex of test prism. When prism of correct power is
chosen, straight line appears unbroken again.
Another Method: Check prism by using the Prism Reference Point (PRP), also
called the Prism Compensation device in the lensometer by noting the displacement
of the mires from the central ring of the PRP. Each ring is marked with a number, the
center is zero. Each ring represents one diopter of prism. If the mires are located two
rings from the center, the prescription contains 2 diopters of prism.
In PST (photostress recovery test), Patients who have a maculopathy will take longer (90 to
180 seconds) to recover pretest vision after looking into a bright light for 10 seconds.
Patients with optic nerve disease will have a normal recovery time (<60 seconds). The test
is probably only valid for patients with vision better than 20/80.
A pattern VER (as opposed to a flash VER) is required for visual acuity assessment in
preverbal children.
In patients with macular disease VA is frequently worse when the patient looks through a
pin-hole.
A lens is a transparent medium bound by two surfaces which are part of spheres.
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Aspheric or aplanatic glasses are grinded in such a way that their curvature (and
hence power) is maximum in the center and gradually decreases towards periphery.
Thus an aspheric lens of +10 DS has a power of +10 DS at the center and +6 DS at
the extreme periphery
The reciprocal of the best Snellen acuity is equal to the plus power of the lens required.
For example, if a patient can read 20/60, a +3.00 D will suffice. The reciprocal of the diopter
power gives the reading distance (i.e., 33 cm).
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Geneva lens clock: A device to determine the base curve of the back surface of a
spectacle. It is often used clinically to detect plus cylinder spectacle lenses in a patient
used to minus cylinder lenses. It is specifically calibrated for the refractive index of crown
glass. A special lens clock is available for plastic lenses.
Snell's law (law of refraction) = the incident and refracted rays and the normal to the
surface at the point of incidence lie in the same plane and the ratio of the sine of the angle
of incidence i to the sine of the angle of refraction r is a constant for any two media. This
constant is called the relative index of refraction ie.
sin i / sin r = refractive index
The nodal point of a lens is at the intersection between the principal axis and the principal
plane.
In trifocals the intermediate lens usually has an addition of 1 dioptre over the distance
correction or half of near add.
The LTF stands for luminance transmission factor when considering tints.
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Relative spectacle magnification = Actual size corrected with spectacle/size seen by the
emmetropic eye
PorroAbbe prism: type of reflection prism used in some optical instruments to alter the
orientation of an image. It is made from a piece of glass shaped like four right-angled
reflecting prisms joined face-to-face in a twisted fashion. Light enters one flat face, is
internally reflected four times from the sloping faces of the prism, and exits the second flat
face offset from, but in the same direction as the entrance beam.
In DO, the optic disc may not be focused as you see it, as hypermetropic patients require
more plus (green numbers) lenses for clear focus of the fundus while myopia patients
require more minus (red numbers).
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It has generally accepted that 0.25 diopter difference of refraction causes 0.5% differences
in image size.
Six meters is accepted from practical point of view because most rays from a distance of 6
meter and more are as good as parallel rays.
The angle of minimum deviation is produced by a prism when light undergoes equal
bending at the two faces. When light strikes the prism perpendicular to one of its surfaces
(Prentice position), the angle of deviation is greater.
Glass prisms are usually calibrated in the Prentice position, in which one face is
perpendicular to the incident light.
Plastic prisms and prism bars are usually calibrated with the angle of minimum deviation
Frontal position. When measuring strabismus with glass prisms, they must be held in this
position to be accurate; that is, glass prisms must be held with one surface perpendicular to
the visual axis. Real images are deviated toward the prism base. Virtual images are
deviated toward the apex.
The absolute value of the back vertex power of a meniscus spectacle lens is always
greater than that of the front vertex power. Because the focal length measured from the
rear vertex of a meniscus lens is always shorter than the corresponding front focal length,
the absolute value of the back vertex power (P = n/f, where n = 1 in air) is always greater
than that of the front vertex power. The true power is somewhere between the two.
The flatter (not steeper) peripheral cornea tends to counteract spherical aberration.
The total interval of chromatic aberration in the human eye is approximately 1.25D. Tilting a
lens along its horizontal axis induces cylinder of the same (not opposite) sign and along the
same axis, as well as sphere of the same sign. Shorter wavelengths of light are refracted
more than longer wavelengths. When polychromatic light is focused on the retina (as is the
case in emmetropia or proper spectacle correction), blue light is 0.87D anterior to the retina,
green light is 0.37D anterior to the retina, and red light is 0.37D posterior to the retina.
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A Maddox line produces two line images of a point light source: a real image that is too
close to the eye to be seen, as well as a virtual image running through the light source. The
real image is parallel to the cylinders' axes, whereas the virtual image is perpendicular. This
is true for all spherocylindrical lenses (even those with no power in one meridian).
The angular size of the field of view for an observer looking at a plane mirror is independent
of the observer's position.
Conjugate planes are related by being the object and image of one another.
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Most distortions of aphakic spectacle lenses stem from their position anterior to the pupil
and include image magnification, ring scotoma, pincushion distortion, and the so-called jackin-the-box phenomenon. Aphakic spectacle lenses can also create cosmetic problems not
only because of their size but also because they can make the patient's eyes look
magnified.
The magnification associated with any corrective lens diminishes as the lens
approaches the eye's nodal point.
The spherical equivalent is discovered by fogging the eye (adding a lot of plus sphere) to
relax accommodation, then adding minus sphere until vision is sharpest. At this point, the
circle of least confusion is on the retina. Then, the cross-cylinder is introduced to find axis
and power. The circle of least confusion must remain on the retina throughout cross-cylinder
testing. When fogged, the circle of least confusion is anterior to the retina.
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The sphere end point can be verified by the duochrome test, but this test does not relax
accommodation. Therefore, the test should be introduced with the patient slightly fogged,
such that the letters on the red side are clearer (the red letters will focus behind the green
letters, closer to the retina). Then, minus sphere is added until letters on the green and red
sides are equally clear.
An emmetropic person sees red and green colors equally sharp. After giving correction
patient is asked to read FRIEND. FIN letters are written in green and RED letters are written
in red color. If myopia is over corrected or hypermetropia is under corrected patient will
appreciate green letters much better than red letters. On the other hand if myopia is under
corrected or hypermetropia is over corrected patient will appreciate red color much better.
Or simply you can remember,
If RED clear, add MINUS
If GREEN clear, add PLUS.
Image jump can occur in any correction whose add does not have its optical center at the
top of the segment. Round-top segments typically produce more image jump than flattop segments, as they have much lower optical centers.
Image displacement occurs in all corrections as gaze moves away from the optical center
of the correcting lens; this is unlikely to be significantly distressing unless an imbalanced
displacement occurs, as in anisometropia. The other situation where image displacement is
troublesome is when an increased demand is made on already taxed vertical fusional
system ability, as in compensated vertical phoria.
Holding the radius of curvature constant, larger diameter lenses are effectively steeper.
At a given diameter, radius of curvature and lens steepness is inversely proportional.
If the center of curvature of the refracting surface is on the same side as the medium of
higher index of refraction, the surface is positive, regardless of direction of light
propagation.
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Candela is the unit of measure of luminous intensity, which is defined as the light emitted
per unit of solid angle.
Luminous flux is the quantity of light leaving a source or passing through a region of space,
and it is measured in lumens.
Illuminance is the quantity of light per unit area incident on a surface or at an image, and it
is measured in lux.
Luminance is the light reflected or emitted by a surface per unit area and per unit solid
angle, and it is measured in apostilbs.
MRI Prism Glasses: Non-Magnetic Prism Glasses allow the patient to see the room outside
the bore of magnet during their scan, allowing a companion or scenic picture to be viewed.
A simple and cost effective comfort measure to be used alone, or in conjunction with a
sound system for ultimate relaxation in an MR environment. Also known as recumbent
spectacles.
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Visual acuity is usually better in blue cone monochromatism than rod monochromatism.
Becker's test: A test for astigmatism that uses diagrams of sets of three lines radiating in
different meridians.
Multiply the amount of magnification by 4 to get the Dioptric Power of the lens.
Divide the Dioptric power into the number 40 to get the number of inches from the
eye.
For example, a 4X lens is 16 Diopters. Divide into 40, we get a 2.5" working
distance; a 5X lens is 20 Diopters and has a reading distance of 2 inches
Aspheric lenses are lenses which have a relatively flat surface, yet still offer the same
vision quality as non aspheric lenses. This is because although the lens is thinner and
flatter, it still refracts light to exactly the same degree as a conventional lens.
Double aspheric lenses are essentially an even better version of the already useful
aspheric lenses. Not only is the front of the lens aspheric, but the back of the lens has
the same aspheric design, hence the name, double aspheric. Typically, when you look
out from the edge of your lenses, the image you see can be distorted. Double aspheric
lenses limit this distortion of image right up to the edges of the lens. This is done by
ensuring that a large area of the lens is the focal point.
Photoreceptors:
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"red" cones (64%), "green" cones (32%), and "blue" cones (2%)
The green and red cones are concentrated in the fovea centralis.
The "blue" cones have the highest sensitivity and are mostly found outside the
fovea, leading to some distinctions in the eye's blue perception.
visual acuity or visual resolution is much better with the cones, the rods are better
motion sensors
Rods Do Not See Red! The light response of the rods peaks sharply in the blue;
they respond very little to red light.
The ship captain has red instrument lights. Since the rods do not respond to
red, the captain can gain full dark-adapted vision with the rods with which to
watch for icebergs and other obstacles outside.
Dispersion is the variation of refractive index with wavelength. In general, the shorter the
wavelength, the higher the refractive index. For instance, in spectacle crown glass, light of
wavelength 656 nm (corresponding to red) has an index of 1.520, whereas light of
wavelength 480 nm (corresponding to blue) has an index of 1.531. In the crown glass
example, the dispersion is 0.011 (= 1.531 - 1.520).
Light scattering:
If light strikes a structure larger than 1000 nm, the light is absorbed.
However, if the object has a size between 1 and 1000 nm, light will be absorbed
and re-emitted as a ray of similar wavelength, but in a different direction.
Magnesium fluoride (MgF2), a durable substance with an index of 1.38 at 550 nm, is the
most commonly used coating material for single-layer antireflection coatings. Instead of
one reflection at the air-glass interface, there is now a reflection at the air-MgF2 interface
and a second reflection at the MgF2-glass interface. These reflections interfere
destructively, resulting in a minimum reflectance within the visible spectrum (at normal
incidence) of 1.5% or less, as compared with the original 4% for the uncoated glass surface
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The rods have peak sensitivity at 500 nm that corresponds to blue-green, and the foveal
cones have peak sensitivity at 562 nm or in yellow-green. The significance of this shift in
sensitivity is that the foveal cones respond more strongly to longer wavelengths where
chromatic aberration gradually increases, whereas rods respond more strongly to the region
of rapidly increasing chromatic aberration.
When a glassblower or other glass worker heats glass directly in a flame, the flame
surrounding the glass emits a yellow light termed sodium flare.
Didymium or neodymium glass absorbs this light, which is emitted at approximately 589
nm, making it easier for the glass worker to view his or her work.
Most common mirror coating materials are chromium, aluminum, and copper.
Melanin strongly absorbs all ultraviolet and invisible wavelengths. However, this
absorption by melanin decreases with increasing wavelengths.
Hemoglobin has strong absorption in the violet (420 nm) and green (514 nm)
wavelength. Deoxygenated hemoglobin absorbs red more strongly than does
oxyhemoglobin.
Xanthophyll which is the pigment most densely distributed in the macular area,
absorbs the blue wavelength (460 nm).
Saturation (abney effect): As white is added to a hue, the hue appears to change
slightly in color. The effect is similar to adding yellow. Blue greens become
greener and yellow greens become yellower. Reds and oranges also become
yellower. The exception is a yellow of 570 nm.
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State of dark adaptation (purkinje effect): The relative luminosity curve illustrates
the eye's sensitivity to different wavelengths of light. When the eye is light adapted
(daytime), yellow, yellow green, and orange appear brighter than do blues, greens,
and reds. The cones' peak sensitivity is to light of 555 nm. A relative luminosity
curve can also be constructed for the rods in a dark-adapted eye. The lights are so
dim that the observer cannot name the various wavelengths used. Rods are most
sensitive to light of 505 nm (blue). It has been postulated that rods share the
pathways used by blue cones. As the eye dark adapts and rods begin to send
messages, more blue messages are sent to the hue center. Therefore, at dusk,
although the brightness of all colors decreases, blues and greens appear to gain in
relative brightness when compared with yellows and reds. This phenomenon is
called the Purkinje effect after the Czechoslovakian scientist Purkinje, who first
described it while watching blue and green flowers become relatively brighter (as
compared with red and yellow) at dusk.
Eigengrau: (dark light, retinal self-light): Complete dark adaptation of the eye does
not produce a sensation of absolute black. Instead, a uniform gray with superimposed
phosphene-like dots is generally noted. The dots observed in this entoptic phenomenan
are more mobile than phosphenes and may form colored patterns that drift about the field.
Troxler fading
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Haag-streit slit lamp decreases binocular viewing angle from 13.5 degrees to 4.5 degrees.
Cornea absorbs rays shorter than 295 nm. Therefore rays between 600 and 295 nm only
can reach the crystalline lens.
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The normal human eye is insensitive to wavelengths between 400 and 350 nm (ultraviolet
rays) because they are absorbed by the crystalline lens of the eye.
In aphakic eyes the light rays between 350 and 400 nm can also pass on the retina.
Therefore, the Aphakic eyes are sensitivc to those wavelengths which give rise to the
sensation of blue or violet colour so the newly aphakic patients often complain that every
thing looks bluer than visualized before the operation.
Persistence of the eye is 0.1 second: i.e. if the time interval between two successive light
pulses is lesser than 0.1 second, eye cannot distinguish them separately
Raman Effect: The light (or photons) impinging on a molecule interacts in various ways but
the final outcome always results in the scattering of light. For example, we do not see light
directly. We always see light and objects as a result of scattered light. Scattering is
absorbance of incident light used in exciting the atom and reradiation of this light. The
Raman scattering is the result of inelastic collisions in which the scattered photons
exchange energy with the vibrational energy modes of an atom.
In a toric surface, one principal meridian is more curved than the second principal
meridian. The principal meridian with minimum curvature, and therefore with minimum
power, is called base curve of a toric lens.
A reduction of 1 mm in the depth of the anterior chamber (through a forward shift of the
crystalline lens) would increase the eye's total power by about 1.4 D.
Night myopia or twilight myopia: The shift from photopic to scotopic vision at twilight is
associated with increased sensitivity to the shorter wavelengths of light. The
emmetropic eye, if accommodated for the middle range of the visual spectrum, will be
slightly myopic for the shorter wavelengths.
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Symmetric astigmatism: refers to the regular astigmatism in which the principal meridia in
each eye have similar but opposite axes, e.g. 15 in left eye and 165 in right eye which
together add up to 180 +- 15.
Depth of field: the range of distance from the eye in which an object appears clear without
change of accommodation.
Depth of Focus: The range at the retina in which an optical image may move without
impairment of clarity is termed as depth of focus.
Reaction time:
Accommodation: Far to near: 0.64 s
Accommodation: Near to Far: 0.56 s
Direct light reflex: 0.26 s
Convergence response: 0.2 s
Uncorrected hypermetropia
Angle of convergence becomes smaller with increasing fixation distance and becomes
larger with increasing IPD.
In air, the speed of light remains relatively constant. When the light passes through a
higher index of refraction, its properties change and aberrations are formed. This can be
explained by the following equation:
F = Vn/
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The waves of light are joined at a single point in time by what is called a wavefront and
always travel perpendicular to it. The distorted shape that a wavefront takes after emerging
from an irregular optical media is called a wavefront aberration.
Point spread function (PSF) is the intensity with which an optical system distributes
an image from a point source onto the retina. The point source is influenced by the pupil
size. The larger the pupil, the more irregular the shape of the point source imaged on the
retina
Modulation transfer function (MTF): MTF is the ability of the eye's optics to focus a
sharp image on the retina with high contrast. As light passes through optical structures of
the eye, it undergoes a process of degradation which can be measured by MTF.
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Styles-Crawford effect: This is the effect of light entering the cones transversely
from the pupil margin, which is perceived half as bright as the light entering the center of
the pupil. In simpler terms, light that passes through the edge of the pupil contributes
less to image quality than light entering the center of the pupil.
Chromatic aberrations
arises because the index of refraction of the media is not the same for all
wavelengths.
Monochromatic aberrations
Types:
1. Piston
2. Tilt
3. Defocus
4. Spherical aberration
5. Coma
6. Astigmatism
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The main focus of laser refractive surgery nowadays is to not only correct refractive errors
such as defocus and astigmatism, but to create customized ablations which compensate for
induced higher-order aberrations (HOA) such as spherical aberration (optimized ablation)
and also correct pre-existing aberrations (customized ablation).
Glare
Starbursts
Haloes
Ghost images
The term aberrometry is used to describe the science of the detection and analysis of
wavefront aberrations.
optical path length (OPL) is defined by the number of oscillations of these light waves from
a point source of light, traveling through a media of x index of refraction at any given length.
The tear film contributes to up to 70% to the corneal refractive power. Dry eyes, for
example, have greater coma and spherical aberrations compared to non-dry eyes.
With an increasing market and demand for super sharp vision (i.e. super-vision), scientists
have worked hard at making this technology clinically available in many different forms.
There are two types of wavefront customized ablations: wavefront guided ablations
(WGA) and wavefront optimized ablations (WOA).
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Both types of treatment aim to correct for HOAs in the eye. In WGA, the treatment is
aimed to correct the pre-operative HOAs, while in WOA, the treatment attempts to
reduce HOAs generated during surgery. The WOA profile corrects expected HOAs
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for an average eye, and those that are anticipated as a result of the surgery. This
means that an eye with higher than normal HOAs, will end up with near equally high
HOAs after treatment in WOA.
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Excimer lasers used to treat wavefront-customized ablations typically use a smalldiameter and circular flying spot laser.
Ophthonix, Inc. (Vista, CA), has designed a lens available for commercial use,
which consists of a three-layer structure with a refractive index of 1.6. The middle
layer consists of a patented photo-polymer in between two coated lenses. The lens
corrects HOAs from the 2nd to 6th order using wavefront guided technology.
The company's aberrometer measures both lower- and higher-order aberrations
using the Talbot effect.
To compensate for positive spherical aberration, aspheric IOLs were designed and
are commercially available, such as the Tecnis-Z9000 (Pfizer, New York, NY) and
SN60WF (Alcon, Fort Worth, TX). These lenses are designed with a prolate anterior
surface, hence the term aspheric, and have the same radius of curvature at every
point on the surface.
Larsen noted that the axial length of the neonate's eye was 17 mm and that it increases 25
percent by the time the child reaches adolescence.
Neonate's visual appreciation for fine detail at birth is one-thirtieth (2/60) or approximately 3
percent & by the age of 12 months, the infant's level of visual acuity is 25 percent (20/80).
Most cases of myopia have an elongated eye. The stretching and weakening of the
sclera seems to depend on two major factors.
First, that the intraocular pressure maintains a constant force on the sclera.
The coordination of the power of the cornea, crystalline lens, and axial length to process a
sharp retinal image of a distant object is known as emmetropization.
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The cornea, which averages 48 diopters of power at birth and has an increased
elasticity, loses about 4 diopters by the time the child is 2 years of age. One may assume
that the spurt in growth of the sagittal diameter of the globe during this period pulls the
cornea into a flatter curvature. The fact that the average corneal diameter is 8.5 mm at 34
weeks of gestation, 9 mm at 36 weeks, 9.5 mm at term, and about 11 mm in the adult eye
supports this pulling, flattening hypothesis.
The crystalline lens, which averages 45 diopters during infancy, loses about 20 diopters
of power by age 6 years. To compensate for this loss of lens power, the axial length
increases by 56 mm in that same time frame. (In general, 1 mm of change in axial length
correlates with a 3-diopter change in refractive power of the eye.)
Specifically, the size of the retinal image depends on an entity known as the nodal
distance, which averages 11.7 mm in the newborn and 16.7 mm in the adult emmetropic
schematic eye, giving a ratio of adult to infant retinal images of 1.43.
A partial list of giants of physiologic optics who have created schematic or reduced eyes
includes Listing, Helmholtz, Wllner, Tserning, Matthiessen, Gullstrand, Legrand,
Ivanoff, and Emsley.
In many infants the amount of astigmatism can rise to a level of greater than 2
diopters in the first year of life. The orientation of the distortion is usually horizontal
(180 degrees) initially. In the course of the next 2 years, the meridian of distortion
rotates to the vertical and the amount of the astigmatism diminishes. This slow
rotation of the axis of exaggeration can help activate different groups of brain
cells, which become sensitive to features in the retinal image with different tilts.
Drs. Hubel and Wiesel were awarded the Nobel Prize for Medicine in 1981.
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Miller & Benedek proved that if the spaces consisting of glycosaminoglycan and the
size of the collagen fibers were smaller than one-half a wavelength of visible light,
the cornea is clear, even if the fibers were arranged randomly. An orderly
arrangement of the fibers also helps maintain corneal transparency.
Because the index of refraction of water is greater than air, objects underwater appear about
one-third closer and thus one-third larger than they would in air (i.e. magnification = 1.33)
Parenthetically, the cornea of many birds, from pigeons to hawks, can change shape to
accommodate. The avian cornea does not change flexibility with age; therefore these
birds do not become presbyopic. However, there is no free lunch in nature. The human
lens, sitting within the eye surrounded by protective fluid is far less vulnerable to injury than
the cornea.
The bird retina does not have blood vessels. The human retina has retinal blood
vessels that cover some of the retinal receptors and produce fine angioscotomas. A
bird's retina obtains much of its oxygen and nutritive supply from a tangle of blood
vessels (the pectin), which is covered with black pigment and sits in the vitreous in
front of the retina and above the macula (so as to function as a visor).
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distance between the centers of these tightly packed cones is about 2 m. The cone
diameters themselves measure about 1.5 m (a dimension comparable to three
wavelengths of green light) and are separated by about 0.5 m.
One minute of arc is the spacing between the bars of a 20/20 symbol. Interestingly,
the sizing of the symbol was originally determined empirically.
chart luminance between 80 and 320 cd/m2 meet such criteria (160 cd/m2 is a favorite
level of illumination).
Clean printed charts using black characters on a white background usually have a
character-to-background luminance contrast ratio between 1/20 and 1/33.
For projected charts, the contrast ratio drops to a range of 1/5 to 1/10.
A patient happy with his or her vision but with visual acuity worse than 20/20 has been
described as a 20/happy patient. With physical evaluation alone it may not be possible to
diagnose such happiness, but subjective tests such as a quality of life questionnaire may
help identify it.
Contrast may be considered as the difference in the luminance of a target against the
background:
photometer to measure the luminance of a target against the background. For example, a
background of 100 units of light and a target of 50 units of light yields the following.
A young, healthy subject may have a contrast threshold of 1 percent, or 1/100 (i.e. a
contrast sensitivity of 100)
In the visual psychology literature, the contrast threshold is described in logarithmic terms.
Therefore a contrast sensitivity of 10 is 1, a contrast sensitivity of 100 is 2, and a contrast
sensitivity of 1000 is 3.
When a transparent structure loses its clarity, the physicist describes it as a light scatterer
rather than a light transmitter.
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The word opaqueness conjures up the image of a cement wall that stops light.
most cataracts scatter light rather than stop light, the most graphic involves the
science of holography.
LeClaire et al observed that many patients with cataracts showed good visual acuity
but had poor contrast sensitivity in the face of a glare source.
Patients with significant corneal astigmatism who wear thin soft contact lenses
experience blur that affects their contrast sensitivity.
Contrast sensitivity or glare testing may also be useful in detecting the earliest signs
of graft rejection.
The lens of a typical 20-year-old absorbs about 30 percent of incident blue light. At age
60, the typical lens absorbs about 60 percent of incident blue light.
Vernier acuity: there is a visual task (Vernier acuity), which has a threshold of about 5
seconds of arc (1/12th of a minute of arc)
Some human studies have shown that use of atropine drops in children partially inhibits
the development of myopia.
Human use of topical pirenzepine was reported in two studies which showed a small but
statistically significant reduction in myopia and axial length.
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Rayleigh scattering, in that the intensity of the scattered light depends on the fourth power
of the frequency, so blue light is scattered much more strongly than red light
A lens free from distortion exhibits orthoscopy (or no distortion). The excess minification in
the periphery of minus lenses generally produces barrel distortion, while the excess
magnification of plus lenses generally produces pin-cushion distortion
In PelliRobson contrast sensitivity letter chart, there is decreasing contrast of 0.15 log
units for groups of three letters.
There are 400 smaller 5 mm squares in AMSLER GRID and when viewed at about one-third
of a metre, each small square subtends an angle of 1.
For FAF, a pre-injection study is performed with both the excitation and barrier filters in
place.
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Optics of corrected Aphakes is like Galilean telescope and so image is magnified, while
optics of overcorrected myopes if like Reverse Galilean telescope and hence the image
is minified.
To define the astigmatic axis: the handle of the lens parallel to the axis
Maddox rods are cylinders of high plus power. Light is focused very close to the rods
forming real image (too close to actually see); and a virtual image perpendicular to these
lights is visible at some distance.
A person who did not receive optical correction for severe astigmatic refractive error in
childhood sometimes shows persistent impairment of corrected vision that is confined to the
more ametropic meridians. This phenomenon is known as meridional amblyopia.
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Polaroid is made of an extremely thin layer of many fine crystals of iodine and quinine
sulfate. This compound, known as herapathite, after its discoverer W.B. Herapath, is unique
in that it strongly absorbs one of its double-refracted beams so that light vibrating in only one
direction gets through.
Weber's law: for a difference to be detectable, that is, to exhibit a just noticeable difference,
it must be a nearly constant fraction of the background luminance, or /\L/L = constant. This
ratio is about 1% for brightness discrimination and was extended it to other senses
Drop-ball test:
o
To be considered impact resistant, a lens must pass the dress ophthalmic lens dropball test.
lens must be able to withstand the impact of a 5/8-inch (15.875-mm) steel ball
dropped from a height of 50 inches (1.27 m) onto the lens front surface.
The FDA-mandated drop-ball test results in an impact energy of 0.2 joules (J) or 0.15
foot-pounds (ft-lb) on the lens front surface. Many simple accidents and sports
missiles result in energies that exceed this value by anywhere from 2 to 100 times.
Cornea
The cornea of the bodys highest densities of nerve endings; and the sensitivity of the
cornea is 100 times that of conjunctiva. Thus cornea is MOST sensitive structure in the
body and BRAIN is the LEAST sensitive structure in the body..!!
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Fungal hypopyon has convex upper border, hyphae seen, low mobility with head posture
and yellow in color.
Bacterial hypopyon has a concave border, mobile with head posture, no hyphae seen and
whitish in color.
Cornea is Meniscus Lens. (Convex Concave). Its minus meniscus lens. But in the body is
acts as converging lens i.e. plus lens. If in vitro, it will act as real minus meniscus lens i.e.
diverging lens.
Plus Meniscus: Steep anterior, Flat posterior converging
Minus Meniscus: Flat anterior, Steep anterior divergent
Prolate: (eg. Egg on its Tip) Steeper front, flat side causes positive spherical abberations.
(CORNEA is prolate)
Oblate: (eg. Egg on its Side) Flat front, steep side. causes negative spherical
abberations.
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Keratitis with lid lesions: zoster, chickenpox, molluscum contagiosum, and ulcerative
blepharitis with keratitis caused by staphylococcal infection.
Keratitis without lid lesions: vaccinia, adenoviral infections (types 3, 7, and 8 and 19),
chlamydial infections, herpes zoster and Epstein-Barr keratitis.
Common causes of DLK are: Meibomitis, bacterial endotoxin, marker ink, microkeratome
blade debris, preservatives in drops, interface hemoglobin.
Important complication of trachoma is dry eye due to fibrosis of the upper fornix affecting
accessory lacrimal glands.
Hirschbergs sign: Pale round spots (Koplik spots) on conjunctiva and caruncle in
measles
In GPC, In contrast to VKC, keratopathy is rare due to less secretion of toxic cytokines.
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In PUK, Unlike Mooren ulcer the process may also extend to involve the sclera.
Rizuttis sign: Triangle of light on iris from oblique penlight beam focused by cone in
keratoconus
Khodadoust line: Corneal graft endothelial rejection line composed of inflammatory cells
Deficiency of the mucin layer may be a feature of both aqueous deficiency and
evaporative states.
Goblet cell loss is associated with cicatrizing conjunctivitis, vitamin A deficiency, chemical
burns and toxicity to medications.
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Keratoconus is rare in diabetes. Diabetes, Aging and Smoking increases corneal collagen
cross linking just like C3R.
Membrane on conjunctiva:
o
True membrane:
Greyish white dense membrane covering both the bulbar and palpebral
conjunctiva
Corynebacterium Diphtheria
Pseudo membrane:
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Streptococcus pyogenes
Infectious Crystalline Keratopathy ICK is most commonly seen after post keratoplasty.
The corneal endothelium and stroma are derived from the neural crest, but the
epithelium is derived from surface ectoderm.
The limbal lesions in vernal keratoconjunctivitis are more papilliform because they have a
central vascular core.
When a central pit full of degenerated eosinophils forms, the term Horner-Trantas dot is
applied.
Horner-Trantas dots are clumps of degenerated eosinophils, whereas Herbert's pits are
depressed, necrotic follicles at the limbus.
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The cornea transmits radiation from approximately 310 nm in the ultraviolet to 2500 nm in
the infrared region.
The cornea is extremely sensitive to UV radiation at 270 nm and corneal absorption of this
radiation results in photo keratitis after exposure to welding arcs.
Conjunctival papillae form whenever there is conjunctival swelling of any cause in certain
areas. The tarsal and limbal conjunctiva is unique because their subepithelial substantia
propria contains fibrous tissue septa that interconnect to form polygonal lobules with a
central vascular bundle. Any inflammation in these regions will result in papillae. Papillae <1
mm in diameter are entirely nonspecific. When papillae are >1 mm in diameter (giant
papillae), they are more specific.
Most young people with healthy eyes will have small conjunctival papillae along the superior
margin of the upper tarsus
In GPC, the inferior fornix is generally the least involved, whereas in viral conjunctivitis,
it tends to be the most severely involved.
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Follicular conjunctivitides are typically more severe inferiorly than superiorly except for
trachoma.
This is in stark contrast to inclusion conjunctivitis, another chlamydial disease, which is
more severe inferiorly.
Typical microcystic corneal epithelial edema is in the intercellular space and results from
an imbalance between corneal turgescence (swelling due to intraocular pressure [IOP]) and
deturgescence (drying due to endothelial pumping).
Intracellular epithelial edema does occur, as a result of epithelial hypoxia, but this appears
different clinically as a fine, frosted-glass appearance (Sattler's veil), generally
associated with contact lens use.
Sattlers veil: Superficial corneal edema (bedewing) caused by hypoxia (contact lens)
Endophthalmitis rates are higher with laser-assisted in situ keratomileusis (LASIK) than
with photorefractive keratectomy (PRK). LASIK does offer a reduced incidence of stromal
haze and more rapid epithelial healing. Photorefractive keratectomy (PRK) can have
significant postoperative pain. PRK offers a reduced incidence of endophthalmitis and
corneal perforation.
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Intranuclear inclusion bodies of herpes simplex virus (HSV) epithelial infection: Lipschtz
bodies (Papanicolaou (Pap) smear)
multinucleated giant cells seen in epithelial herpes simplex virus (HSV) infection: Tzanck
prep (Giemsa stain)
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Viral capsid antigen (VCA)-IgG and Epstein-Barr nuclear antigen (EBNA) provide lifelong
evidence of Epstein-Barr virus (EBV) infection.
Like bacteria (and unlike viruses), chlamydiae have both DNA and RNA, replicate by binary
fission, have lipopolysaccharide cell walls, and respond to certain antibiotics. Unlike
bacteria, chlamydiae do not possess all organelles and require a host cell for replication.
Amphotericin has less predictable activity against filamentous species than natamycin.
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Local steroids do not reactivate latent virus, but caution should be exercised because
intermittent shedding of the virus from the trigeminal ganglion (unrelated to steroid use) may
coincide with steroid use and exacerbate subsequent disease.
Pedunculated conjunctival papillomas are generally associated with human papilloma virus
(HPV) types 6 and 8.
sessile conjunctival papillomas are associated with HPV-16 and HPV-18.
Blephroconjunctivits:
Collarettes indicate Staphylococcus.
Scurf indicates seborrhea.
Sleeving of the lashes is a sign of Demodex infestation.
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Dhaval Patel MD
Type 1 herpes: The gasserian (or trigeminal) ganglion, located in Meckel's cave, contains
the cell bodies of the trigeminal nerve.
Reactivation and not Reinfection has been reported to lead to typical herpes zoster
ophthalmicus (HZO).
Postherpetic neuralgia: oral TCA & Steroids (7 to 10 days after eruption of active
dermatitis)
Herpes zoster dendrites (pseudodendrites) are typically smaller and less branching
than their simplex counterparts.
About one half of patients with superior limbic keratoconjunctivitis (SLK) have some
form of thyroid disease.
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Treatment of the thyroid disorder, however, has little effect on the SLK.
A recent study suggests that orbital decompression for thyroid optic neuropathy is required
more frequently in patients with thyroidassociated SLK.
steroids are not effective therapy for superior limbic keratoconjunctivitis (SLK).
Surgical resection of the superior bulbar conjunctiva is definitive.
In scleritis, the scleral (deep episcleral) plexus is immobile and bluish-red in color;
episcleritis appears salmon pink.
Lastly, scleritis is frequently seen with systemic connective tissue disorders; this is
not true of episcleritis.
Posterior uveitis occurs in virtually all patients with posterior scleritis and is not
uncommon in patients with anterior scleritis. Anterior uveitis occurs in about one third of all
patients with scleritis.
Eyes without any astigmatism will not have any wavefront aberration. Wavefront analysis is
used to analyze irregular astigmatism.
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Munnerlyn's formula: The ablation depth (in microns) is equal to the diopters of myopia
divided by 3 and multiplied by the square of the optical zone (in millimeters). It is most useful
with low amounts of correction (<7 diopters).
Sometimes, 15 microns ablation per diopter of myopia is taken.
Natamycin is a polyene antifungal that is the drug of choice for filamentous fungi.
Topical miconazole is the drug of choice for Paecilomyces lilacinus.
Topical amphotericin is used to combat infections caused by Aspergillus and Candida
spp.
Flucytosine is used as an adjunctive agent for treatment of Candida spp.
In PMD, protrusion of the cornea above the area of maximal thinning inferiorly in the
cornea, whereas in keratoconus, corneal protrusion is at the point of maximal thinning.
CHED: Nystagmus is associated with the recessive, but not the dominant form of the
disease.
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The most common stromal dystrophy is lattice, followed by granular and macular.
Patients with Fuchs' endothelial dystrophy have malfunctioning Na-K ATPase pumps in
the lateral cell wall of the endothelial cells. This diminished pump function results in swelling
of the corneal stroma. Cytochrome oxidase is also reduced, which may indicate a decrease
in the metabolic activity of the endothelial mitochondria.
Coroneo Effect: Nasal segment of cornea gets highest UV exposure effect which is
responsible for pterygium.
Most serious ACID INJURY is hydrofluoric acid & MC is sulfuric acid. (Survey ophth)
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Most serious ALKALI INJURY is ammonia/ lye & MC is Lime. (Survey ophth)
precipitation of ciprofloxacin onto the corneal surface do occur. Not with other FQ.
Thygeson's superficial punctate keratitis: HLA-DR3 have a 5.65 greater relative risk.
A number of features are shared between dendritic infection from HSV and HZV.
Both may have an accompanying skin rash (along a dermatome in HZV) and corneal
anesthesia.
The active viral replication causes sloughing of epithelial cells in HSV, whereas in HZV,
the epithelial cells are swollen and heaped up.
Both conditions may recur. Iritis and elevation in IOP can be found with both viral infections;
however, iris atrophy is more common with HZV.
interstitial keratitis
o
Cogan's syndrome affects middle-aged adults with hearing loss, vertigo, and
interstitial keratitis.
thinnest paracentral quadrants of cornea (in descending order) are the temporal (28%),
inferior (19%), nasal (11%), and superior (4%). TINS
Pingueculae: ultraviolet light, changes in the subepithelial collagen. Although these fibers
stain with some elastin stains, the fibers are not true elastin and will not be degraded by
elastase. This finding is known as elastosis.
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Agents that have been used for Acanthamoeba include- neomycin, natamycin, miconazole,
propamidine, dibromopropamidine, polyhexamethylene biguanide, and chlorhexidine.
Oval graft with the long axis at 90 produces against-the-rule astigmatism (and therefore
neutralizes with-the-rule astigmatism common to circular grafts).
Coats ring: White granular corneal stromal opacity containing iron from previous metallic
foreign body
Although keratitis is not universal in patients with herpes simplex virus (HSV) uveitis, it is
usually present in affected children.
More than 50% of uveitis in the pediatric population has a posterior component.
The brain and retina (a part of the brain) are the sites where Toxoplasma organisms
survive best.
TBUT should be done first as a Schirmers would create an artificial dry spot to appear at
the point of its contact with the eye, thus falsely reducing the TBUT.
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Schirmer's test:
Schirmer's II (with anesthesia) has been purported to measure basal tear secretion, i.e.
nonstimulated tears. Values below 5.5 mm of wetting are diagnostic of aqueous tear
deficiency.
A Schirmer's I (without anesthesia) has become the generally accepted method for
assessing aqueous tear production. It measures both basal and reflex tear secretion.
REMEMBER this by test 1 measures 2 things and vice versa. Test 3 is with nasal irritation.
In case of GPC, in vernal catarrh the reaction is IgE mediated and in Giant papillary
conjunctivitis the reaction is type 1 or type 4 hypersensitivity reaction.
Recurrence of corneal dystrophy: Reis-Bckler > macular > granular > lattice
The Athens Protocol: The management of keratoconus and post-LASIK ectasia by means
of combined, same-day, topography-guided partial PRK and collagen cross-linking.
The excimer laser was originally applied to the cornea to produce more accurate RK
incisions, not for surface ablation or laser in situ keratomileusis (LASIK), for which the
excimer laser is now used.
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Arcuate keratotomy differs from LRIs by its midperipheral location and its greater relative
depth.
Studies have demonstrated that up to 15 of cyclotorsion can occur when patients move
from an upright to a supine position.
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Tsukamurella keratitis
o
gram-positive bacilli
infiltrates in the peripheral parts of the cornea near the limbus, resembling that of
marginal keratitis.
Corneal Nerves
o
Keratoconus.
Ichthyosis
Corneal edema
Congenital glaucoma
Acanthamoeba Keratitis
Trauma.
Idiopathic.
MEN IIb
Neurofibromatosis.
Acanthamoeba perineuritis.
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primary amyloidosis
sequential sector conjunctival epitheliectomy (SSCE): for partial LSCD involving the visual
axis
Boston scleral lens= PROSE: Prosthetic Replacement of the Ocular Surface Ecosystem,
sed for irregular corneas
Concentration of riboflavin for C3R: 0.1%, in 20% dextran, 30 min, 370 nm, 3 mW/cm2
Ophthalmology Explorer
Dhaval Patel MD
Positive: center of the cornea is flatter than the periphery, oblate cornea
Actinomyces
Streptomyces
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Dhaval Patel MD
Acid injuries causes less damage than alkalies in general except Hydrofluoric acid
used in glass etching and cleaning also tends to rapidly penetrate the eye, whilst sulphuric
acid may be complicated by thermal effects and high velocity impact after car battery
explosions.
Phenol red thread test uses a thread impregnated with a pH sensitive dye. The end of the
thread is placed over the lower lid and the length wetted (the dye changes from yellow to red
in tears) is measured after 15 seconds. A value of 6 mm is abnormal. It is comparable to
Schirmer test but takes less time.
The adenoid superficial layer of the conjunctiva does not develop until about 3 months
after birth, hence the inability of the newborn to produce a follicular conjunctival reaction.
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Ceftriaxone 1 gm IM + azithromycin 1 gm PO
Even if concurrent chlamydia is not suspected, treat with both drugs as azithromycin
covers ceftriaxone resistance.
Hertoghe sign is characterized by absence of the lateral portion of the eyebrows. It is seen
in Atopic Keratoconjunctivitis.
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The currently accepted WHO guidelines include community-wide antibiotic treatment if there
is >10% active trachoma in children aged 19 years. This treatment should be
reinstituted annually for 3 years, with reassessment at that time.
In contrast to VKC, the papillary hypertrophy of AKC is more prominent in the inferior
conjunctival fornix.
Cause of the foamy appearance of the Bitot's spot: due to gas production by
Corynebacterium xerosis in the horny epithelium
Types of xerosis:
o
Anterior stromal cautery: Application of light burns to Bowman's layer using a thermal
cautery (Salleras procedure)
Unlike meibomian gland secretion, sebum contains more triglycerides and free fatty acids
and considerably less sterol esters. Squalene is present in sebum and absent in meibomian
gland secretion. The wax ester proportion is similar in both secretions. Overall, sebum is
much more polar and will contaminate the tear film when mixed with it.
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Follicular reactions are not seen in the neonate because of the immaturity of the immune
system and adenoid layer of conjunctiva is not matured till 3 months.
2. Biochemical stabilization:
3. Cytotoxic effect:
Trometamol (Tris-[hydroxymethyl]aminometane)
Keratoconus indices
o
Ophthalmology Explorer
o
Dhaval Patel MD
INTACS
o
150 degrees
PMMA segments
7.5 to 8.1 mm
68% depth
Conjunctival SCRAPPING is done for chlamydia and viruses as they are intracellular,
conjunctival SWAB is taken for bacteria.
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FK 506
Rapamycin
15-deoxypergualin
antiVEGFs
leflomide
Conjunctival Sickle Sign: Abnormalities of the bulbar conjunctival blood vessels provide
direct evidence of the vaso-occlusive process and were one of the earliest reported ocular
changes.
Acanthameba Stains:
The trichrome-eosin and iron-hematoxylin stains showed good color contrast for
detecting all three stages, the trophozoite, cyst and flagellate
Modified Fields and modified AFB stains stained only the trophozoite stage.
Depending on the purpose, all these stains (except the AFB stain) can be used.
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accumulation of fluid in the LASIK flap interface due to steroid induced IOP spike,
uveitis, and vitreoretinal and cataract surgery, as well as endothelial decompensation
Corneal Inlays
o
Dhaval Patel MD
ACI 7000
Presbia
Hydrophilic acrylic
Nonrefractive Inlays
Hydrogel
Multifocal ablations
Monofocal ablations
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A rare clinical syndrome consisting of a fixed dilated pupil, iris atrophy, and glaucoma,
known as Uretts-Zavalia syndrome, has been observed following penetrating keratoplasty
and deep lamellar keratoplasty for keratoconus.
Photochemical keratodesmos
o
It uses rosebengal dye, which activated by low energy argon ion laser at a
wavelengtyh of 514 nm.
A randomized, masked clinical trial of 18 participants allergic to grass pollen found that
signs of allergic conjunctivitis were reversed most effectively by CCs plus ATs or EH
drops; however, hyperemia was reduced more by ATs combined with CC than other
treatments.
designed to test new approaches for the measurement of cataract surgical quality in
settings with poor rates of follow-up.
Brown-McLean Syndrome:
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peripheral corneal stromal and epithelial edema that spares the central and superior
cornea with pigment deposits are present on the underlying endothelium
The peripheral iris may show transillumination, but the trabecular meshwork is not
necessarily hyperpigmented.
If the patient is bilaterally aphakic, the syndrome is usually present in both eyes.
The adenovirus test, which detects the most common cause of viral conjunctivitis, requires
only 10 minutes to develop after sample collection. It uses direct sampling microfiltration,
similar to a home pregnancy test, to produce visual results, with a blue control line and, if
positive, a red test line. Compared with cell culture, the traditional definitive test for
adenovirus infection, this rapid test has a 90% sensitivity and a 96% specificity.
The pump-leak hypothesis: When the rate of fluid leakage into the stroma is balanced by
the rate of fluid pumped out of the stroma, normal corneal architecture and thickness are
maintained.
Location of corneal epithelial stem cells (SC): basal layer of the limbus
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X+Y = Z
PPMD: Pleomorphism, irregular large cells with scalloped edges as dark rings
around lighter center, vescicles/pits in DM, Disrupted by crater-like focal lesions
ICE: enlarged ICE cells, white reflections in center of dark cells dark-light reversal,
no disruption from craters or guttae
TYROSINEMIA
o
Dhaval Patel MD
type 1
most common
hepatorenal tyrosinemia
no corneal involvement
type 2
Left eyes seem to be affected more commonly than right eyes because neonates usually
present in the left-occiput-anterior position
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Unlike meibomian gland secretion, sebum contains more triglycerides and free fatty acids
and considerably less sterol esters. Squalene is present in sebum and absent in meibomian
gland secretion. The wax ester proportion is similar in both secretions. Overall, sebum is
much more polar and will contaminate the tear film when mixed with it.
Lens
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Polyopia, pupillary block, and corneal-lenticular touch are indications for medical or
surgical intervention in lens subluxation (which can be accomplished with the implantation of
a Morcher endocapsular tension ring).
Decreased vision often can be corrected solely with an aphakic refraction.
Pyramidal cataracts are a distinct and more severe form of anterior polar opacity, named
because the shape of the anterior opacity resembles a pyramid. A more accurate and
modern description is a likeness to the shape of the chocolate candy called the Hershey's
Kiss. The tips of these opacities extend into the anterior chamber and rarely have even
been known to be fused with the cornea. They are fibrous and may be associated with an
anterior subcapsular cataract that, when present, often progresses to become visually
significant. At surgery, the fibrous Hershey's Kiss is not easily removed with the
vitreous cutter. After it is detached from the anterior capsule, it usually spins around the
anterior chamber and has to be delivered through the incision using forceps. These
pyramidal cataracts are almost always bilaterally symmetric and may be dominantly
inherited.
Homocystinuria
o
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Affected patients are generally tall with osteoporosis, scoliosis, and chest
deformities.
These patients are at increased risk of thrombotic vascular occlusions, and this
should be taken into consideration if general anesthesia is planned.
Lens dislocation occurs in 90% of patients and is generally inferior and bilateral.
Homocystinuria may lead to angle closure glaucoma if the lens dislocates into the
anterior chamber.
A diet low in methionine and high in cysteine can reduce lens dislocation.
The Malyugin ring is a device to enlarge a small pupil and/or stabilize an atonic iris. This
may be necessary in patients with pilocarpine treatment, pseudoexfoliation, and IFIS.
Pupillary dilation is usually not an issue in ectopia lentis.
Z-syndrome refers to a complication of the Crystalens in which the plate haptics are bent
asymmetrically so the lens has a Z configuration.
Z phenomenon: earliest models of foldable IOLs were too long, so that when they were well
fixated within the capsular bag they caused wrinkling of capsule centrally because of
capsule contraction.
Coloboma of the lens is not a true coloboma. Instead the notch in the equator resulted from
an absence of zonular fibers from an underlying colobomatous ciliary body. This absence
results in a lack of tension on the lens capsule in that region. The lens tissue is not missing.
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Hyperlysinemia
Weill-Marchesani syndrome
Homocystinuria
Amiodarone and phenothiazine cause stellate cataracts in the anterior lens capsule.
All forms of steroids have been associated with cataract formation.
Monocular visual deprivation, most likely with nuclear cataract, is the most amblyogenic.
Vitamin B6 homocystinuria
Coenzyme Q Leber's hereditary optic neuropathy
Vitamin A retinitis pigmentosa
The peristaltic pump has rollers that move along tubing and create a relatively rapid
rise in vacuum.
The diaphragm pump has valves over both the inlet and outlet of a fluid chamber
covered by a diaphragm. This system allows a slower build of vacuum.
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The Venturi pump produces the most rapid increase in vacuum. This, however, can
be the most dangerous because it allows almost instantaneous engagement of
unwanted tissues such as capsule or iris.
PMMA lenses, when packaged, may pick up static charges that attract dust and debris
when opened. Therefore, the lens may be rinsed with balanced salt solution before
insertion. Silicone lenses do not require this and, in fact, may be more difficult to handle
once they have gotten wet. Application of a viscoelastic, such as sodium hyaluronate, may
facilitate insertion of a lens, especially a foldable one, through a small incision.
Lane and colleagues evaluated IOP elevation associated with three commonly used
viscoelastic agents (sodium hyaluronate, chondroitin sulfate, and hydroxymethylcellulose)
and all produced significant pressure elevations at 4 1 hours postoperatively. Removing
the viscoelastic did not eliminate significant postoperative IOP elevation, although when
chondroitin sulfate was removed, the pressure elevation was slightly less.
The ciliary sulcus is only 0.83-mm posterior to the limbus vertically and 0.46-mm posterior
horizontally
The incidence of clinical cystoid macular edema is less than 1% following uncomplicated
cataract extraction. The incidence of angiographic evidence of cystoid macular edema is
approximately 10 times this.
Congential epicapsular pigment stars: its can be seen normally on anterior lens capsule.
They are remnants of the anterior tunica vasculosa.
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White to chalky-white spots are produced, which are seen in front of and around the
posterior capsular defect.
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The capsule behind the opaque lens may show a partial or a complete white ringshaped opacity. This opacity is contained within the posterior cortex, while the
posterior capsule shows a hole with chalky-white spots on and around the defect.
Rarely, an opening in the posterior capsule shows pigment along the margins. Fine
dustlike pigment along with fine dense white opacities may be seen in the
Berger space. The presence of pigment suggests widespread movement of the fluid
beyond the posterior capsular defect.
Advantages of capsulorrhexis:
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ELP better
Resists tearing
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Disadvantage of capsulorrhexis:
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Phimosis
The predominant yellow chromophores in the young human lens are metabolites of
tryptophan, especially N-formyl kynurenine glucoside.
Calib chop: preoperatively calculated the calibrated tip not only marks the entry point on
lens surface, it also measures as it reaches the desired depth when a vertical chop can be
effectively and safely executed called a calibchop.
The IDEM lens or the IDeal EMmetropia lens, was that IOL power which when implanted
within the eye restored emmetropic status after cataract surgery. The power of this lens was
mathematically deduced to be +17.0 D for an AC lens, +19.0D for an iris fixated lens and
+21.0D for a posterior chamber lens.
The Third and fourth generation IOL power calculation formulae incorporate a bit of both
theoretical and regression types which was called the Fudge factor by duke elder.
4th generation formula which was an adaptation of the formula first suggested by
Gernet, Ostholt and Werner as early as 1970
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The versatility of the formula lies in the three individualized A constants namely a0,
a1 and a2.
The a1 is linked to the pre operative ultrasonically measured ACD (this has a default
value of 0.4).
a2 which is linked to the axial length measurements and which has a default value
of 0.1
Desmosomes of lens epithelial cells contain VIMENTIN whereas most epithelial cells in
the body contain cytokeratin.
Prechopping techniques:
Preslice technique
Ultrachopper technique: Luis Escaf, ultrasonic knife that cuts the nuclear
substance
The patients who are left with < 1.0 D of astigmatism remain comfortable after surgery,
particularly if the astigmatism happens to be against the rule (ATR), as the patient will
experience increased depth of focus due to pseudoaccomodation.
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Vitamin A does not have protective mechanism against oxidation in the lens.
LOCS III:
The LOCS III contains an expanded set of standards that were selected from the
Longitudinal Study of Cataract slide library at the Center for Clinical Cataract
Research, Boston, Mass.
It consists of six slit-lamp images for grading nuclear color (NC) and nuclear
opalescence (NO),
Cataract severity is graded on a decimal scale, and the standards have regularly
spaced intervals on a decimal scale.
During fetal development they are continuous with the blood supply of the
developing lens.
The pupillary membrane begins to atrophy during fetal life, but atrophy may not be
complete until 4 to 8 weeks of age.
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Anterior and posterior Y sutures are formed by FETAL nucleus and not EMBRYONIC
nucleus.
Anterior polar cataracts are usually small and nonprogressive, do not usually impair vision,
and may be seen in association with microphthalmos, a persistent pupillary membrane, and
anterior lenticonus.
Posterior polar cataracts cause more visual impairment and tend to be larger than anterior
polar cataracts. Both can be autosomal dominant or sporadic. Posterior polar cataracts may
be associated with posterior lenticonus or a remnant of the tunica vasculosa lentis.
Raman spectroscopy is used for normal aging and pathologic processes in the lens.
Ron Krueger who first investigated the effect of intralenticular femtosecond laser
surgery on accommodation
low-energy (2.0 J to 5.0 J per pulse) and high-frequency (100 kHz) infrared laser
(1040 nm).
The width of each single laser pulse is less than 400 femtoseconds.
The laser process is controlled by an integrated OCT imaging system. The laser is
able to cut 3-dimensional patterns with a working field diameter of up to 9.0 mm
within the crystalline lens. The presbyopia reversal cutting process is characterized
by an extremely low gas bubble production due to a low energy threshold.
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Crystalens HD and AO
Hara et al
Synchrony IOL
Alcon ReSTOR
Hanita SeeLens MF
Physiol IOL
FineVision IOL
Lentis Mplus
Lenstec SBL-3
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Trifocal IOLs
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25% hydrophilic acrylic IOL has, in addition to a near foci (+3.50 D), a foci for
intermediate vision (+1.75 D) to provide treated patients with a full range of
correction.
Dhaval Patel MD
(+3.33 D near add and +1.66 D intermediate add at the IOL plane
The pulsed electron avalanche knife (PEAK-fc, Carl Zeiss Meditec) is an electrosurgical
cutting device that allows precise "cold" and traction-free tissue dissection
The PEAK-fc appears to be a helpful cutting device for complicated cases of cataract
surgery, especially for mature and congenital cataracts.
Hydroxybenzophenones
Hydroxyphenylbenzotriazoles
Both absorb UV light energy and transform it into harmless heat energy (only a
fraction of a degree) by a process known as photoautomerism.
Compared with no surgery, timely cataract surgery that improved the patient's vision was
associated with a 40% reduction in mortality risk.
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Glaucoma
Loss of 5 db in sensitivity occurs when 20% of ganglion cells are gone from that
area.
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Ciliary body ablation should not be considered in NLP eyes because of the risk of
sympathetic ophthalmia.
Failure to relieve postoperative angle closure with iridotomy suggests malignant glaucoma,
which often responds to potent cycloplegics. If medical management fails, laser treatment
to open the anterior hyaloid face, or even pars plana vitrectomy, is necessary.
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P: IOP
A: area of applanation
B: force needed to bend the cornea
Allow alcohol to evaporate or dry prism head to prevent corneal epithelial toxicity
Outflow facility = Rate of loss of aqueous per mm Hg of raised IOP per minute
Total outflow facility = C value = True outflow facility + Pseudo facility
C averages 0.28 microliters / min / mmHg (abnormal C < 0.20)
Miotics cause a paradoxical rise in IOP in angle recession glaucoma due to reduction in
the uveoscleral outflow.
Vogts sign: White anterior lens opacities (glaukomflecken) caused by ischemia of lens
epithelial cells from previous attacks of angle-closure
Range of HVF is 0.08 asb to 10000 asb. Decibel range is 0-51 db.
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Decreased aqueous humor formation with increased IOP (pseudofacility) has been
disputed by studies indicating that rate of aqueous formation is relatively pressureinsensitive (Shields, 1992).
Koeppe gonioscopy is considered best for evaluating a patient with potential angle
recession because this system allows easier comparison of one eye with the fellow eye, or
one portion of the angle with another.
Scheies line: Pigment on lens equator and posterior capsule in pigment dispersion
syndrome
Split fixation is the presence of visual field loss that comes close to fixation. A typical
pattern of progression is (i) loss near fixation (paracentral scotoma) to (ii) split fixation to (iii)
loss of fixation. Thus, the eye at greatest risk is not one with a 5-degree central field, but
one with the split-fixation in the horizontal meridian.
It is important to correlate changes in visual field with changes in the optic disc. The
following should raise suspicion about the diagnosis of glaucoma: (i) an optic disc that is
less cupped than would be expected for observed field loss, (ii) pallor of the disc that is
more impressive than the cupping, (iii) markedly asymmetric dyschromatopsia, or (iv)
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visual field defects uncharacteristic for glaucoma (e.g., respecting the vertical meridian).
A relative afferent pupillary defect (APD) can occur with glaucoma.
The sine qua non of PDS is radial defects in the iris pigment epithelium.
The patient with very narrow angles and elevated pressure may have mixed mechanism
glaucoma with partial angle closure caused by pupillary block superimposed on open-angle
glaucoma. To determine if an angle-closure component is present, the effect of minimizing
pupillary block on intraocular pressure (IOP) must be determined. Cholinergic miotics
(pilocarpine) will cause miosis and lessen pupillary block and will also exert traction on the
trabecular meshwork (TM) and lower IOP by this unrelated mechanism. Thymoxamine, a
selective alpha-adrenergic antagonist, causes miosis and lessens pupillary block, without
affecting outflow facility. A decrease in pressure after thymoxamine (lessened pupillary
block) implies partial angle closure, and iridotomy is indicated. No change in IOP after
thymoxamine-induced miosis implies that an iridotomy may not be helpful.
In central retinal vein occlusion (CRVO), there may be transudation of serum into the
vitreous, driven by the elevated intravascular pressure. This hydration causes vitreous
swelling with subsequent secondary angle closure. There may also be ciliary body swelling
associated with CRVO.
Direct-acting miotics interact directly with the acetylcholine receptor, whereas indirect-acting
agents increase the activity of native acetylcholine at the synaptic junction (by blocking its
enzymatic degradation). Pilocarpine is a purely direct agent, whereas carbachol is felt to
exhibit both direct and indirect effects.
Miotics: indirect-acting agents-echothiophate, carbachol, demecarium.
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The most common complication of both Nd:YAG and argon laser iridotomies is acute
glaucoma. Malignant glaucoma has been reported after a variety of seemingly benign
ocular laser procedures.
Short-term fluctuation (SF) and Corrected pattern standard deviation (CPSD) are not
available on SITA.
Central corneal thickness is increased in eyes with aniridia which may result in incorrect
measurement of IOP.
When performing laser trabeculoplasty a pigmented Schwalbe line should not be confused
with the posterior pigmented trabeculum. In laser trabeculoplasty it is important to identify
the scleral spur because the application of burns posterior to it will result in greater
inflammation, with consequent increased risk of early post-laser rise in IOP and the
formation of peripheral anterior synechiae.
A pupillary diameter of less than 3 mm can cause general depression of the field.
The Humphrey automated perimeter has a number of ways to test the reliability of the test
taker. A fixation loss occurs when the patient responds as if seeing a light when a target is
displayed in his blind spot. A false-negative response occurs when the patient fails to
respond to a suprathreshold stimulus at a location that would be expected to be seen. This
response may indicate a patient who is falling asleep or losing interest. Intermittently, the
perimeter will pause and the motorized light will change position, but no stimulus will be
presented. If the patient presses the button, a false-positive response is recorded. A
nervous or trigger-happy patient may have a high false-positive rate. Short-term
fluctuation describes the change in sensitivity when the same point is retested.
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For the early detection of glaucomatous optic nerve damage, the most important
variable appears to be focal narrowing or notching of the neuro-retinal rim. Other
important variables are optic cup size in relation to optic disc size, disc asymmetry, and
presence of disc hemorrhages. However, disc hemorrhages can occur in other conditions
(e.g., anterior ischemic optic neuropathy [AION]) and disc asymmetry may be a normal
finding if the difference is slight (<0.2 difference).
Up to 50% of optic nerve axons can be lost before any change is detected on the
Goldmann visual field.
Corticosteroids are thought to raise IOP by lowering outflow facility perhaps due to an
accumulation of glycosaminoglycans in the trabecular meshwork.
Patients at particular risk for aqueous misdirection are those with crowded anterior
segments (i.e., angle closure, nanophthalmos). Postoperative inflammation may cause
swelling of the ciliary body and ciliary processes leading to aqueous misdirection.
Latanoprost and travoprost lower IOP by increasing uveoscleral outflow. (these 2 are
ProDrugs.)
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Acute myopia is the only ocular reaction commonly associated with carbonic anhydrase
inhibitors.
The most frequent cause of failure after filtration surgery is bleb scarring due to episcleral
fibrosis.
In addition to inhibiting fibroblast proliferation, 5-FU also inhibits the growth of epithelial
cells of the conjunctiva and cornea. It is associated with several undesirable
complications including conjunctival wound leaks, corneal epithelial defects, thin-walled
ischemic blebs, hypotony, and suprachoroidal hemorrhage.
Laser trabeculoplasty effectively lowers IOP in patients with POAG, pigmentary glaucoma,
or pseudoexfoliation. It is ineffective and may actually worsen the IOP in eyes with
inflammatory glaucoma, recessed angles, or membranes in the angle, and in young patients
with developmental defects.
When treated with SLT, a primarily biologic response is induced in the trabecular
meshwork. This response involves the release of cytokines, which trigger macrophage
recruitment and other changes leading to IOP reduction. The laser beam bypasses
surrounding tissue, leaving it undamaged by light. This is why, unlike ALT, SLT is
repeatable several times. ALT patients can receive two treatments in a lifetime, whereas
SLT patients can receive two treatments a year. Even though SLT is a promising new
technology, further studies need to be done to prove that SLT is in fact better than ALT at
decreasing IOP pressure; at best, SLT is currently equivalent to ALT at reducing IOP.
In some cases, it may be advantageous to use both lasers: the argon for its coagulative
effects and the Nd:YAG for its disruptive properties.
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Antifibrotic agents should be used with caution in young myopic patients due to the risk
of hypotony.
Cyclodialysis clefts occur after traumatic injuries. Chronic hypotony usually results. These
clefts close spontaneously weeks to months later, usually resulting in a sudden increase in
the IOP. Usually, the trabecular outflow system will begin functioning more normally a short
period of time after the pressure spike has occurred.
The Glaucoma Laser Trial study has demonstrated that ALT is a reasonable alternative to
medication (timolol) in the initial treatment of POAG. However, 2 years into the study, 56%
of laser-treated eyes needed supplemental medical therapy to control IOP. Laser-treated
eyes had a lower mean IOP.
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In acute angle closure glaucoma, hydropic degeneration and impaired axoplasmic flow
cause swelling and hyperemia of the optic nerve.
Patients with POAG and relatives of POAG patients have a higher incidence of elevated
IOP in response to topical or systemic corticosteroids, but this is not a risk factor for
POAG; rather, it is a risk factor for steroid-induced secondary open angle glaucoma.
In Aqueous Humor, Only calcium and phosphorus are in concentrations of about one-half
that in plasma. Sodium, potassium, magnesium, iron, zinc, and copper all approximate
levels found in plasma. Chloride and bicarbonate vary from 20% to 30% above or below
plasma levels.
In lactating women, concentration of timolol in breast milk is higher than serum level.
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In infantile glaucoma, an affected parent has about a 5% chance of having a child with
infantile glaucoma, and the next subsequent sibling has approximately a 5% chance of
being affected.
Corneal clouding or tearing is more likely to be the presenting symptom in patients with
glaucoma in whom the onset is before the age of 3 months, whereas corneal enlargement
will probably be the presenting finding in older infants.
The 3 syndromes that comprise ICE have the common features of iris distortion, corneal
edema, and secondary angle-closure glaucoma due to angle endothelialization and
peripheral anterior synechiae formation. The specific findings of each syndrome are:
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Iris nevus (Cogan-Reese) syndrome: flattening and effacement of the iris stroma,
pigmented iris nodules (pseudonevi) composed of normal iris cells that are bunched
up from the overlying membrane, corectopia, and ectropion uveae.
Chandlers syndrome: corneal edema often with normal IOP, and mild or no iris
changes (minimal corectopia, iris atrophy, peripheral anterior synechiae).
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Riegers anomaly: Axenfelds plus iris hypoplasia with holes. Glaucoma develops in
50%.
Riluzole and Lifarazine are neuroprotective as they inhibit the release of glutamate.
Memantine and Felbamate are neuroprotective as they block the NMDA receptors.
Each 1 mmHg reduction in IOP leads to a 10% reduction in the rate of nerve fibre loss.
Total internal reflection: Total internal reflection at the tear-air interface prevents a direct
view of the anterior chamber. To overcome this limitation, the critical angle must be
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increased for the tear-air interface by applying a plastic or glass goniolens to the surface.
Total internal reflection also occurs in fiberoptic tubes and indirect ophthalmoscopes.
Haemorrhage from iridectomy which tracked itself into the vitreal cavity
During the iridectomy, the ciliary body was inadvertently cut resulting in vitreous
haemorrhage.
Systemic evaluation of the neonate with glaucoma: urinalysis for proteinuria and
aminoaciduria.(LOWES SYNDROME)
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Aqueous flow, outflow facility, and episcleral venous pressure are thus the primary
determinants of IOP. In the eye, the driving pressure for aqueous outflow equals the
difference between intraocular pressure (IOP) and episcleral venous pressure (Ve). The
outflow facility is the reciprocal of resistance.
Blood may enter Schlemm's canal when episcleral venous pressure exceeds intraocular
pressure (IOP). It occurs in carotid-cavernous fistula, severe thyroid eye disease, excessive
digital pressure on a Goldmann gonioscopic lens, ocular hypotony.
If a patient has glaucomatous visual field-type defects, corresponding optic nerve head
abnormalities should exist.
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the situation that may be the one most frequently misdiagnosed as normal-tension
glaucoma is primary open-angle glaucoma (POAG) in which intraocular pressure (IOP)
fluctuations have obscured the actual nature of the disease. In addition, there are other
disorders that can feature pseudoglaucomatous optic nerve cupping, namely: (i)
chiasmal compression, (ii) arteritic anterior ischemic optic neuropathy (AAION), (iii) toxic
optic neuropathies (such as methanol toxicity), and (iv) hypotension (shock optic
neuropathy).
pigmentary glaucoma: The sine qua non of this condition is radial defects in the iris
pigment epithelium. Pigmentary glaucoma usually occurs in young myopic men, typically in
their third or fourth decade of life. For obscure reasons, women with the disease tend to be
older than men. Exercise or pupillary movements may induce a shower of iris pigment
release, with resultant increased intraocular pressure (IOP).
Both mydriatics and miotics can precipitate angle-closure in eyes with shallow anterior
chambers. This is true for both topical medications and systemic drugs that affect the pupil.
Examples include antihistamines, which can have anticholinergic activity.
narrow anterior chamber angles and normal IOP DRPPT (most predictive but no
prospective study yet), darkness will induce pupillary dilation, and prone positioning will
move the lens forward.
narrow anterior chamber angles and elevated IOP thymoxamine test. Patients may
have mixed mechanism glaucoma with partial angle closure caused by pupillary block
superimposed on open-angle glaucoma. To determine if an angle-closure component is
present, the effect of minimizing pupillary block on intraocular pressure (IOP) must be
determined. Cholinergic miotics (pilocarpine) will cause miosis and lessen pupillary block
and will also exert traction on the trabecular meshwork (TM) and lower IOP by this unrelated
mechanism. Thymoxamine, a selective alpha-adrenergic antagonist, causes miosis
and lessens pupillary block, without affecting outflow facility. A decrease in pressure
after thymoxamine (lessened pupillary block) implies partial angle closure, and iridotomy is
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The blood-aqueous barrier allows formation of the gradient necessary to draw fluid from
the vitreous. Interruption of this gradient as in inflammation decreases the effectiveness
and duration of osmotic effects.
Mannitol is distributed only in the blood compartment, whereas urea moves freely in total
body water, so mannitol is more effective.
The effect on pressure reduction depends on the pre-treatment pressure, age of the
patient and type of glaucoma.
Ophthalmology Explorer
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The Tonopen appears to have more accurate pressure readings in patients after laserassisted in situ keratomileusis (LASIK) surgery. Goldmann readings can be artificially low
after LASIK.
Iridencleisis: Historical procedure, from observation that that inadvertently incarcerated iris
in the wound after intracapsular cataract extraction or surgical iridectomy sometimes
resulted in IOP lowering
targets the magnocellular ganglion cells, which are damaged early on in the course
of glaucoma. It does this by utilizing the illusion of frequency doubling produced by a
low spatial frequency grating undergoing high temporal frequency reversal.
The anterior border of the trabecular meshwork is defined by Schwalbe's line and the
scleral spur defines the posterior border.
Pilocarpine increases the aqueous outflow through the trabecular meshwork and therefore
is ineffective in the presence of raised episcleral pressure like SWS.
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Boussinesq model of natural convection in the human eye and the formation of
Krukenberg's spindle: When paths of pigment particles are calculated based on the
predicted flow field, the particles circulate throughout the anterior chamber but tend to be
near the vertical centerline of the eye for a greatest period of time. Further, the particles are
usually in close proximity to the cornea only when they are near the vertical centerline. We
conclude that the convective flow pattern of aqueous humor is consistent with a vertical
pigment spindle.
STAR Calculator:
small pupil
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Ghost cells represent hemolyzed red blood cells and not Hemosiderin-laden macrophages.
ParvoCellular
Small field
Magnocellular
Large field
KonioCellular
Large field
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Some of the new-technology IOLs have a yellow filter which may conceivably
interfere with blue on yellow perimetry, also known as short wavelength
automated perimetry (SWAP). A recent study confirmed there was no
interference by the yellow filter in the IOL as determined by SWAP.
The continuous-wave argon laser was the unit most commonly used for creating
iridotomies in the early days of laser surgery; however, the pulsed Nd:YAG laser is
probably the more commonly used today.
Iridotomies created with an argon laser have more extensive early edema and tissue
destruction at the margins of treatment histologically as compared with those created with
the Nd:YAG laser. Argon laser has the disadvantage of more iritis, pupillary distortion,
and late closure of the iridotomy.
Clinically, the Nd:YAG laser has the disadvantage of frequent bleeding. In general, Nd:YAG
laser iridotomies require fewer total applications with a marked reduction in total energy as
compared with argon laser iridotomies. In some cases, it may be advantageous to use both
lasers: the argon for its coagulative effects and the Nd:YAG for its disruptive properties.
Patients with Fuchs' heterochromic iridocyclitis typically have abnormal vessels present
in the angle without peripheral anterior syndrome (PAS), but they do not have a
hyperpigmented meshwork.
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Isolated depressed quadrantic defects result if the patient misses the early portion of the
test in which the machine attempts to determine the threshold for each quadrant.
A tube shunt can be placed in the presence of a scleral buckle. In post vitrectomy cases, the
tube can be placed through the pars plana.
GDx VCC is not useful in patients with associated macular pathology like ARMD.
Trabectome
o
Ab-Interno Trabeculotomy
The ablation of trabecular meshwork and inner wall of the Schlemm canal create a
cleft that is theoretically less prone to fibrosis than goniotomy or trabeculotomy
chromatic visualevoked potential (VEP), which utilizes red-green flicker, was found to be
altered in nonglaucomatous optic neuropathies, but not in glaucomatous optic neuropathies.
Diabetes has not yet been shown to increase the incidence of glaucoma. Although the
weight of available evidence suggests that diabetes is probably a risk factor for glaucoma,
this has not been a consistent finding. Self- reported diabetes was associated with COAG
progression in the AGIS and the CIGTS (Collaborative Initial Glaucoma Treatment Study)
but not in the CNTGS or the EMGT.
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brimonidine
Patients with sleep apnea were 1.67 times more likely to develop glaucoma than patients
without apnea
Women who have used oral contraceptives for 3 years or more and who have additional
risk factors for glaucoma should be checked annually for the disease during their eye exams
as OCPs doubled their risk for glaucoma.
Retina
In CME, The fluid is accumulated between the outer plexiform layer and the inner
nuclear layer.
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Retina has no sensitivity to pain and sensitivity of retina is limited to light generally, thats
why any flashes or sudden shower of floaters becomes significant.
Siegrist streaks: Linear chain of hyperpigmented spots over sclerosed choroidal vessel in
chronic hypertension or choroiditis
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(which is produced with a green filter that does not provide sufficient blue light to
stimulate autofluorescence).
On the other hand, pseudo-autofluorescence results from reflection of light from lightcoloured or white fundal structures such as myelinated nerve fibres, sclera, hard
exudates or cotton wool spots.
Nodular (hard) drusen consist of a focal thickening of the basement membrane of the
retinal pigment epithelium. Clinically, they appear as small yellow or yellow-white spots
measuring 50 m in diameter.
Soft (exudative, fluffy) drusen are bigger and appear less dense and fluffier
Basal laminar deposits consist of banded basement membrane material (wide-spaced
collagen) located between the basal plasmalemma of the retinal pigment epithelium and its
basement membrane.
Basal linear deposits refer to material located external to the basement membrane of the
retinal pigment epithelium.
The etiology of Coats' disease is unknown, and there does not appear to be any genetic,
familial, racial, or ethnic predisposition. However, Coats'-type retinal vascular changes have
been noted in patients with facioscapulohumeral muscular dystrophy, Turner's syndrome,
Senior-Loken syndrome, and one variant of the epidermal nevus syndrome. In addition,
Coats'-like retinopathy has been noted in up to 3.6% of patients with retinitis pigmentosa.
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The retinopathy of Alport's syndrome is generally mild and nonprogressive and resembles
fundus albipunctatus clinically.
DME
o
Hyperglycemia
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Hypertension
Hyperlipidemia
Pregnancy
Dhaval Patel MD
Patons lines: Circumferential peripapillary retinal folds due to optic nerve edema
The radiating fibers of Henle in the outer plexiform layer lead to the cystic spaces in
CME.
POHS is thought to be more prevalent in the Ohio-Mississippi river valley than in the rest
of the United States. The San Joaquin valley has been linked to coccidiomycosis, and
the Rocky Mountains have been linked with Lyme disease or Rocky Mountain spotted
fever.
Approximately 10% of patients with dry ARMD will progress onto the wet form.
Conditions that may have CME without leakage of fluorescein include Goldmann-Favre,
retinitis pigmentosa, and nicotinic acid maculopathy. Epiretinal membranes may cause
a CME that leaks from traction and distortion of paramacular capillaries.
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Depression sign of Goldberg: Focal loss of nerve fiber layer after resolution of cotton-wool
spot
In patients with higher degrees of myopia, more substantial fundus changes may occur. The
enlarged temporal crescent's width may exceed one third of a disc diameter. A crescent light
finding known as the Weiss-Otto reflex may become apparent on the nasal aspect of the
disc. This reflex results from concentric piling up of the nasal retina and choroid, and it is
best appreciated in young persons.
True silent choroid is defined as the blockage of underlying choroidal fluorescence during
fluorescein angiography by material in the RPE cells. This occurs classically in patients who
have Stargardt's disease. Lipofuscin accumulation within RPE cells results in the blockage
of underlying choroidal fluorescence and gives the appearance of a very dark or silent
choroid. Systemic argyrosis, which occurs in patients who are receiving systemic silver
(e.g., from tanning agents), can also cause an angiographically dark choroid.
In a patient without a vitreous hemorrhage, the argon laser allows the placement of excellent
laser burns. The wavelength of krypton red (647 nm) is best able to penetrate vitreous
hemorrhages and deliver the energy necessary to create photocoagulation scars. This laser
also penetrates nuclear sclerotic cataracts better than the argon. The xenon arc emits a
large spectrum of wavelengths and has been replaced with the monochromatic lasers. The
CO2 laser is well-absorbed by water and is used for surface tissue ablation.
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The most common traumatic retinal tear is an inferotemporal retinal dialysis. The vast
majority of retinal dialyses occur in this quadrant. After trauma, the most common retinal tear
is inferotemporal dialysis, followed by giant tears, flap tears, and tears around lattice. These
statistics are true only for blunt ocular injury.
Fluorescein leakage is not a feature of either solar maculopathy or photic injury. Both
may be associated with intense staining of the damaged RPE, particularly in the acute
phases of the injury. As the injured RPE heals, the fluorescein angiogram would be
characterized by persistent window defects.
Juvenile X-linked retinoschisis typically is associated with schisis at the level of the nerve
fiber layer. (spoke wheel pattern)
Reticular retinoschisis is characterized by an involutional splitting of the retina in the
nerve fiber layer.
Involutional retinoschisis has splitting at the outer plexiform layer.
Because the photoreceptors are unaffected, the a-wave on the ERG is intact, but both the
scotopic and photopic b-waves are reduced in proportion to the amount of retinal schisis.
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The EOG and dark adaptation test are normal or abnormal depending on the stage of
disease.
The macula is involved early, showing microcysts and radiating retinal folds, but fluorescein
angiography exhibits no leakage.
Perimetry may also be helpful in the differential diagnosis of retinoschisis. Relatively flat
retinoschisis can be readily differentiated from shallow retinal detachment in that the former
invariably causes an absolute field defect, while the latter causes only a relative defect.
Perimetry is less specific for bullous detachment, because an absolute field defect could be
found in either detachment or retinoschisis.
Gyrate atrophy is a metabolic disorder that is associated with a deficiency in the ornithine
aminotransferase enzyme, critical in the urea cycle.
Surface tension of silicone oil is significantly less than the surface tension of all gases,
including air.
Ganglion cells do not contribute to the ERG response. The ERG may be normal in the
presence of total disc cupping.
The negative a-wave (late receptor potential) originates in the photoreceptors.
The positive b-wave originates in the bipolar cell layer, probably in response to increased
potassium concentration in the extracellular space of the bipolar cells.
The positive c-wave appears to originate from the RPE.
Ocular structures that autofluoresce include the corneal epithelium and endothelium, lens,
macular and RPE pigments, optic nerve drusen, and RPE deposits in Best disease.
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Partial PVD, detected with OCT has been shown to start perifoveally and progressively
detach in stages, leaving the foveal and the optic nerve attachment to separate last.
Flashes of light that appear as jagged lines or heat waves often lasting 10 to 20 min
and present in both eyes, are more likely to be a migraine. These fortification lines may or
may not be followed by a headache. Visual function returns to its premigraine baseline.
ETDRS found that twice as many untreated patients lost vision. It is not accurate to
conclude that laser treatment is likely to improve vision in diabetic macular edema.
Intraretinal processing occurs from photoreceptors to bipolar cells to ganglion cells, with
modulation by horizontal (outer plexiform layer) and amacrine (inner plexiform layer) cells.
A cilioretinal artery contributes to the vascular supply of the retina in approximately 50% of
individuals and 30% of eyes. In 15% of individuals, it contributes to macular circulation.
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Normally, axons of ganglion cells do not become myelinated until after they pass through
lamina cribrosa, as part of the intraorbital optic nerve. When myelinated fibers are visible
ophthalmoscopically, oligodendrocytes have migrated anteriorly.
RPE degenerations have been identified in patients with Hunter's, Hurler's, Sanfilippo's,
and Scheie's mucopolysaccharidoses. Maroteaux-Lamy syndrome is not usually
associated with RPE degeneration.
RPE cells comprise the outer blood-retinal barrier; the inner blood-retinal barrier consists of
the endothelium lining the retinal blood vessels.
The retina is attached at the ora serrata and the optic nerve. The uvea has attachments at
the optic nerve, scleral spur, vortex veins, and long and short posterior ciliary vessels. This
anatomic difference helps to separate choroidal detachments from retinal detachments on
ultrasonography.
Ophthalmology Explorer
Dhaval Patel MD
The ATP-dependent Na+-K+ pump can be found on the Apical surface of the RPE cell.
The rods are 100 to 1000 times more sensitive to light than the cones, allowing better
vision in dim light. The highest concentration of rods is actually 20 from the fovea.
lack of vitritis
CNV
Doses >3 mg/kg/day or 300 g total of chloroquine, and >6.5 mg/kg/day (<400 mg/day
appears safe) or 700 g total of hydroxychloroquine may produce the bulls eye
maculopathy. The total daily dose seems more critical than the total cumulative dose.
The maculopathy often progresses after medications are discontinued because the drug
concentrates in the eye. Hydroxychloroquine appears safer since it does not readily cross
the bloodretinal barrier (toxicity rarely occurs with use <7 years).
Check visual acuity, red Amsler grid and visual fields (central 10 with red test object)
at baseline and every 6 months (chloroquine) or 12 months hydroxychloroquine) while
patient is taking medications; color fundus photographs (especially if abnormalities seen)
and color vision (preferably including the blue-yellow axis) are optionally checked.
The two most sensitive tests for detecting these defects are the Adams Desaturation15 test and the Hardy-Rand-Rittler test.
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High risk patients with drug use >5 years with high fat level body habitus, renal or liver
disease, and age >60 years old especially if frail or extremely thin are at higher risk of
developing toxicity and should be checked more frequently.
Low-risk patients (defined as nonobese individuals under age 60 years old, using less than
3 mg/kg/day of chloroquine or 6.5 mg/kg/day of hydroxychloroquine for fewer than 5 years,
and without concomitant renal, hepatic, or retinal disease) require no additional screening
evaluations.
Most common cause of vision loss in ARMD is fibrous scarring. (not CNVM ??)
Origin of the myopic crescent. As the eye enlarges, the choroid and retina gradually pull
away from the temporal optic nerve head. Thus, in extreme cases, sclera is seen. In less
extreme enlargement, choroid or a rim of pigment epithelium can be seen.
Patients with soft drusen are more likely to develop choroidal neovascular membrane.
A longitudinal study including 447,407 people with diabetes but without macular edema
found that diabetic neuropathy (hazard ratio [HR], 1.59) was second only to type 1
diabetes in predicting which patients would progress to macular edema. Diabetic
nephropathy had an HR of 1.41, Latino race had an HR of 1.28, and black race had an HR
of 1.14.
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An analysis of AREDS found that, compared with those without AMD, the odds of death
associated with circulatory disease in men with advanced AMD was about 2 times
greater.
AREDS found that high-dose antioxidants protect against AMD. A new analysis of data
from the AREDS population found that high-dose antioxidants do not affect intraocular
pressure.
study of AMD in Wisconsin found 512 incident cases of early AMD and 117 incident cases
of late AMD. The routine use of aspirin 10 years before the study was significantly
associated with the incidence of late AMD. The estimated incidence was 1.76% in those
who regularly used aspirin and 1.03% in nonusers. Early AMD was not significantly
associated with aspirin use.
myopic patients with diabetes may be up to 60% less likely to develop diabetic
retinopathy than patients without myopia.
Aldose reductase gene mutation causes more susceptibility of type 2 DR patients for
developing retinopathy.
In all, 13.4% of the patients receiving ocriplasmin and 3.7% of the placebo group achieved
nonsurgical resolution of vitreomacular adhesion at day 28. intravitreal injection of
ocriplasmin (125 g).
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IOFB with >90% copper generally cause an acute inflammatory response (including
intraocular necrosis), concentrations of 70% to 90% cause chalcosis leading to a copper
ring (identical to the Kayser-Fleischer ring in Wilson's disease) and sunflower cataract.
Concentrations <70% can be tolerated; however, other factors such as location and fibrous
encapsulation modulate the tissue reaction.
Gunns dots: Light reflections from internal limiting membrane around disc and macula
22% of eyes had vitreous detachment by age 65. This number increased to 60% by age 75.
Retinal attachment:
1. negative pressure in the subretinal space created by the metabolic pump of the retinal
pigment epithelium and
2. the relatively higher oncotic pressure in the choroid,
3. interdigitation of the pigment epithelial cell processes and the outer segment of
photoreceptors, and
4. mucopolysaccharide glue between the pigment epithelium and the sensory retina
A retinal dialysis is a circumferential linear tear, the anterior margin of which is at or near the
ora serrata. The retina is thinnest and least developed at the ora, especially in the inferior
temporal quadrant. Dialyses occur at any age, but they are particularly common in youth
hence the well-known clinical entity of inferior temporal dialysis of the young.
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About 75% of retinal breaks that occur after blunt ocular trauma are retinal dialyses.
The distribution of retinal breaks throughout the quadrants of the fundus is different for
each type of break.
Horseshoe tears are most common in the superior temporal quadrant; the second most
susceptible site is the superior nasal quadrant.
Operculated tears are also located most frequently in the superior quadrants, although
they tend to occur more posteriorly than horseshoe tears.
Atrophic retinal breaks are also usually located in the superior temporal quadrant, but
the second most common quadrant is the inferior temporal.
Dialyses are found most frequently in the inferior temporal quadrant
The pupil should be dilated to the maximum possible diameter. Mydriatics, such as 2.5% or
10% phenylephrine, used alone are totally inadequate; the moment the bright light is
projected into the eye, the strong stimulation to sphincter con- traction will overcome the
action of the dilator muscle, and the pupil will become miotic. On the other hand,
cycloplegics used alone, while much more satisfactory than mydriatics alone, do not give
maximum dilation but they do result in a dilation that is not affected by the strong light.
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Laser test:
Laser intensity is adjusted to create a medium-intensity laser spot in normal retina. This
same intensity is then applied to the area of the retina in question. Where retinoschisis is
present, a white spot will result, but where retinal detachment is present, there will be no
visible reaction to the laser.
If the choroidal detachment is not in the area of the retinal break, the surgeon should
simply proceed with retinal surgery. If, however, the choroidal detachment is in the area of
the retinal break or in the area where subretinal fluid must be drained, the surgeon should
begin the operation with drainage of the suprachoroidal fluid. Normal intraocular pressure
can be maintained during drainage with use of a pars plana cannula for the continuous
infusion of a balanced salt solution into the vitreous cavity. The surgeon may then proceed
immediately with conventional retinal reattachment surgery.
The ora serrata is the anterior limit of the sensory retina. It is characterized nasally by
prominent ora teeth, which point anteriorly. Between each pair of teeth is an ora bay. There
are approximately 48 ora teeth per eye. The pattern of serration is not present temporally,
where the ora teeth are small or absent
Detachment of the pars plana is more common on the nasal side, apparently because of the
narrower retinochoroidal adhesion. Detachment of the pars plana epithelium is an important
feature, and the pars plana must be carefully examined with scleral indentation to detect the
presence of breaks in the area, particularly along the anterior limit of the vitreous base.
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It is helpful to recall that the distance from the ora to the equator is approximately 4 disc
diameters and that the equator is just slightly anterior to the vortex ampullae.
Drusen are more common in the equator than in the macula. Equatorial drusen may be
associated with reticular pigmentary degeneration and are most often found in the elderly.
A diagnostic feature of retinoschisis is the white Swiss cheese appearance of the outer
layer of the schistic retina as it is frozen. In contrast, the retinal pigment epithelium deep to
an overlying detached retina appears dull orange when viewed during cryopexy.
Type 1 schisis detachment refers to detachment that does not extend beyond the area of
retinoschisis, whereas type 2 schisis detachment extends beyond the schisis. Type 2
schisis detachments generally require retinal detachment repair, whereas type 1 generally
do not.
Asymptomatic eyes include those with and without additional risk features. Cases in which
lesions are diagnosed in a second (fellow) eye following a detachment in the first eye are
discussed in a separate section below.
The term non-fellow eye indicates absence of a history of retinal detachment in the other
eye.
three basic steps in closing retinal breaks and reattaching the retina:
1. Conducting thorough preoperative and intraoperative examinations with the goal of
locating all retinal breaks and assessing any vitreous traction on the retina.
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2. Creating a controlled injury to the retinal pigment epithelium and retina to produce a
chorioretinal adhesion surrounding all retinal breaks so that intravitreal fluid can no longer
reach the subretinal space.
3. Employing an appropriate technique, such as scleral buckling and/or intrav- itreal gas, to
approximate the retinal breaks to the underlying treated retinal pigment epithelium.
Factors considered in the selection of a drainage site include (1) the distribution of
subretinal fluid when the eye is in a position at which drainage will be performed, (2) the
location and size of the retinal break(s), (3) the location and configuration of the buckle, (4)
the vascularity of the choroid, (5) features of vitreoretinal and epiretinal membrane traction,
and (6) the ease of exposure of the proposed drainage site.
The optimal locations for drainage are usually just above or below the lateral rectus muscle,
because major choroidal vessels are avoided and exposure of sclera is excellent.
A positive Watzke Allen sign is seen in 95% of eyes with full thickness macular hole.
All patients of Macular Hole will report a positive laser beam (50microns) sign.
Congenital cyst of retina: bilateral, same location, may look like RD, DD is melanoma.
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The risk of retinopathy of prematurity (ROP) does not correlate with the postdelivery age but
with gestational age (postconception age).
ROP is not DIRECTLY related with arteriolar oxygen level and not related to NEC.
Zone 1 is a circle of radius (not diameter ..!!) 30 degrees (twice the distance from optic
disc to macula) centered on the optic disc. Zone 2 extends to the nasal ora and the temporal
equator (radius 60 degrees). Zone 3 is the remaining crescent-shaped region anterior to
zone 2 in the temporal retina.
65% of premature infants with birth weight <1,250 g will develop some stage of ROP.
In acute leukemic oculopathy, Flame-shaped nerve fiber hemorrhages are the one
most common funduscopic finding. White-centered hemorrhages (Roth's spots), cotton-wool
spots, optic disc swelling, and perivascular infiltration also may be seen but are less
common.
Diffuse arteriolar attenuation is not a characteristic finding in renal failure, although it may
occur if there is severe associated hypertension.
In albinism, fewer ganglion cell fibers decussate at the chiasm than in normal visual
pathways.
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Retinitis punctata albescens is not a form of congenital stationary night blindness (CSNB)
but is progressive (although more slowly than typical retinitis pigmentosa).
Visual function in the pattern dystrophies of the retinal pigment epithelium (RPE) is
usually good.
Aicardi's syndrome is limited to the female sex because it is X-linked dominant. It is lethal
in male infants or fetuses.
In CSR, The early FFA finding is the presence of smoke stack or ink blot and the late
FFA finding is the presence of mushroom or umbrella shape accumulation of dye
Ophthalmology Explorer
Dhaval Patel MD
Risk factors for expulsive suprachoroidal hemorrhage include increased axial length,
glaucoma, atherosclerosis and previous expulsive suprachoroidal haemorrhage. It may be
reduced by
o
Control of IOP
Control of HTN
It is polycythemia and not thrombocytopenia which may be associated with VHL. It is due
to erythropoietin secretion from cerebellar hemangioblastoma.
Early CMV retinitis and CWS can be differentiated by presence of hemorrhage and
enlargement of the lesion in case of former.
ROP like condition but without history of prematurity: FEVR (it is AD condition)
ERG:
o
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Salmon in Sickle cell patients: actually they have Smoked salmon. Salmon patch
haemorrhages (and therefore red as in smoked salmon cf. with poached salmon which is
pink) occur from pre-retinal and internal lining membrane haemorrhages occurring near an
occluded arteriole.
The asteroid hyalosis opacities are dense and uniformly high reflective
Regular follow up
Ophthalmology Explorer
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Dhaval Patel MD
1st generation
less than optimum activation wavelength (630 nm) for maximizing tissue
penetration
2nd generation
Purlytin
Hydrophobic
Dilated NON TORTUOUS retinal veins: always think for Ocular Ischemic Syndrome.
Dermal electrodes
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CSNB
XL retinoschisis
CRAO
MAR
Autoimmune retinopathy
CAR
Wet ARMD
Behcets disease
Copper was added to the AREDS formulations containing zinc to prevent copper deficiency
anemia, a condition associated with high levels of zinc intake.
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Despite its close association with the choroid, the RPE is considered a part of the retina
because it is from the same embryologic germ cell layerneural ectoderm.
In choroideremia, in contrast to primary retinal dystrophies, the fovea is spared until late.
The internal elastic lamina separates the intima from the media. Retinal arterioles contain
smooth muscle within their walls, but unlike arteries the internal elastic lamina is
discontinuous.
Pan Retinal 2.2 is a hybrid lens which uniquely combines magnification nearly that of the
20D lens with a field of view approaching that of the 30D lens. Excellent for virtually every
examination procedure, including small pupil examinations.
Ophthalmology Explorer
Dhaval Patel MD
the indirect ophthalmoscope can be used to see the forest and the slit lamp to see
the individual trees.
The retina itself is a thin transparent tissue, which is thickest near the optic nerve, where it
measures 0.56 mm. It thins to 0.18 mm at the equator and to 0.1 mm at the ora serrata. At
the foveal area, it has thinned to about 0.2 mm. The nerve fiber layer increases at the edge
of the disc and is the only retinal structure that continues into the disc to become the optic
nerve.
Ophthalmology Explorer
Dhaval Patel MD
Blue cones express the SWS1 opsin group VP 420, have a subtle but unique blue cone
morphology, contact cone BCs and HCs, with a strong preference for a blue ON BC.
Red and green cones express VP 530 or VP 560 from the LWS opsin group, are
structurally indistinguishable from each other, contact cone BCs and HCs, but avoid the blue
ON BC.
The resolution limit set by the packing density of the cones is similar to, but slightly higher
than, the limit set by the optics of the eye. As a result, under ideal conditions, an observer
with excellent vision can just resolve fine detail whose angular subtense approaches
that of a single cone.
The exact shape of the fall in acuity with eccentricity depends on the type of target used, but
acuity falls roughly to half at 1 and to one-fourth at 5.
Cone dystrophy implies a panretinal disorder and not a localized dysfunction, such as in
macular degeneration, where the photopic ERG is normal. Cone dystrophies are
characterized by a decreased or nonrecordable photopic ERG and a normal scotopic ERG.
The suffix -opia denotes dichromacy. The suffix -anomaly denotes anomalous
trichromacy in which two of the cone classes are more similar in spectral sensitivity than
the corresponding normal cones:
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In 25% of humans a cilioretinal artery hooks around the temporal margin of the optic disk
and provides a portion of the macula with the arteriolar supply.
Retinal circulation: Low level of flow (15 34 mg/min), High O2 extraction (40%)
Choroidal circulation: High level of flow (677 735 mg/min), Low O2 extraction (4%)
Crystalline lens
Astrocytic hamartoma
Sclera
Coats disease may be part of a spectrum of related genetic disorders known as retinal
hypovasculopathies which includes Norrie disease, familial exudative vitreoretinopathy
(FEVR), fascioscapulohumeral muscular dystrophy (FSHD), and the osteoporosis
pseudoglioma syndrome
melanocytoma appears to have an equal incidence in all races, whereas uveal melanoma is
uncommon in black people
Ablatio fugax: photocoagulation and cryotherapy of peripheral tumors in VHL can often
lead to massive retinal hard exudate accumulation and retinal edema in the macula,
contributing to further decrease in vision following treatment.
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300mW of power
83 seconds
Diffuse pigmentary retinal changes in congenital rubella syndrome may be confused with
retinitis pigmentosa. However, the ERG is normal in congenital rubella.
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X-linked retinoschisis
cone dysfunction
The choriocapillaris does not communicate freely with the optic disc capillaries. The
choroidal circulation is from the posterior ciliary arteries; the optic disc and retinal arterioles
are branches of the ophthalmic artery.
choroidal hemangioma
This is an uncommon hamartoma that has been reported to exhibit two clinical
growth patterns:
The lesion is histologically benign; however, the lesion can lead to an exudative
retinal detachment if untreated.
von Hippel-Lindau disease has vascular lesions of the retina and cerebellum;
however, these are capillary hemangioblastomas.
Ophthalmology Explorer
Dhaval Patel MD
Shifting Fluid:
o
Exudative RD
Old RD
Aphakic RD
Lattice Degeneration:
o
Crisscrossing, fine, white lines that account for the name lattice degeneration are
present in roughly only 10% of lesions and most likely represent hyalinized blood
vessels
Various pigmentary disturbances occur in more than 80% of lattice lesions. Whiteyellow flecks, similar to that seen with degenerative retinoschisis, are an additional
common associated feature.
Atrophic retinal holes and tractional retinal tears may complicate lattice degeneration
and increase the risk of retinal detachment.
When retinal thinning and pigmentary disturbances are found along retinal vessels,
these lattice lesions are referred to as radial perivascular chorioretinal degeneration
and are classic findings in Wagner and Stickler disease, a familial vitreoretinal
degenerative syndrome
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Tractional tears located at the margin of lattice account for 55-70% of retinal
detachments in lattice degeneration and are the result of a posterior vitreous
detachment.
Different RDs:
o
Iridofundal Coloboma
o
Aymptomatic
Leucocoria
Failure of the embryonic fissure to close along the inferonasal aspect of the optic cup
and stalk
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Endophthalmitis
o
Diabetes mellitus (DM) is a risk factor for both types of endophthalmitis. Both
types of endophthalmitis are associated with pain and decreased long-term visual
acuity. Vitrectomy and/or vitreous tap with intravitreal antibiotics can be used to treat
both forms of endophthalmitis. In endogenous endophthalmitis, Streptococcus and
Staphylococcus aureus predominate. Intravenous antibiotics may be indicated for
endogenous endophthalmitis to treat the source, whereas they usually play no role in
the management of postoperative endophthalmitis (especially postoperatively in
patients who have undergone cataract surgery, as per the Endophthalmitis
Vitrectomy Study [EVS] study).
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With 1 ml of gas bubble, IOP by schiotz tonometry shows error of 8 mmHg in range of 10-20
mmHg and 15 mmHg in range of 30-40 mmHg.
dot and blot hemorrhages in the midperipheral retina that may extend into the
posterior pole
Anterior segment manifestations include a limbal flush, anterior chamber cell and
flare, neovascularization of the iris and angle, and cataract.
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Floaterectomies:
treat-and-extend protocol: the patients are treated during each visit regardless of
activity. If there is no sign of activity, the control and treatment intervals are extended
gradually, whereas if there are signs of recurrence, the intervals are shortened.
As needed treatment (PRN- Pro Re Nata): where patients are seen monthly and
treated if signs of exudation appear.
For AMD
Ophthalmology Explorer
o
Dhaval Patel MD
In 2012
designed to reflect new insights derived from SD-OCT and, as such, is strictly
anatomy-based (derived from OCT images alone).
Full Thickness Macular Hole: foveal lesion with interruption of all retinal
layers from the ILM to the RPE
OCT is VEGF-meter of retina. It identifies 3 basic types of fluid collection in the retina.
Intra-retinal fluid
Sub-retinal fluid
Sub-RPE fluid
type I reaction: it can react directly with substrates to form radicals or radical ions
type II reaction: it can react with endogenous ground state oxygen (3O2) by means
of an energy transfer mechanism in producing excited oxygen species, such as
singlet oxygen (1O2). This latter reaction is known as the photodynamic reaction.
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The risk for retinal detachment is 4-fold greater after pseudophakic cataract surgery than
in the patient's untreated eye, according to a large, population-based Danish study.
A reanalysis of data from AREDS has identified genetic polymorphisms that predict
which patients with moderate to severe age-related macular degeneration (AMD) are most
likely to respond to antioxidant or zinc supplementation.
In a related calculation, the researchers estimate that "genotype-directed therapy of the
study population would have more than doubled (>200%) the reduction in AMD
progression rate compared with treatment with the AREDS formulation."
The Atherosclerosis Risk in Communities (ARIC) study found that patients with moderate to
severe retinopathy had 2.37 times the risk for stroke compared with those with no
retinopathy. Patients with mild retinopathy had 1.35 times the risk.
Mark Humayun, MD
epi-retinal
patients with severe to profound outer retinal degeneration, whose remaining visual
acuity is worse than 2.3 logMAR in both eyes
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Uvea
Local Therapies
o
Status of difluprednate
Biologics
o
Golimumab, certolizumab
Anti-CD20
Rituximab
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Use in uveitis/scleritis
Sarcoidosis
Syphilis
kerato uveitis
toxoplasmosis
Dhaval Patel MD
MEWDS
AZOOR
MFC
AIBSE
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Ankylosing Spondylitis
Psoriatic arthritis
IBD
Ophthalmology Explorer
Dhaval Patel MD
KunkmannWolffian bodies: Small white peripheral iris spots that resemble Brushfield
spots but occur in normal individuals. They are more peripheral than brushfields apots
which are around midperiphery.
Patient with uveitis undergoing cataract surgery, Prophylactic systemic steroid treatment is
only recommended in patients with previous macular oedema caused by the uveitis.
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JIA is not the same as juvenile rheumatoid arthritis (JRA); the former is negative for
rheumatoid factor whereas the latter is positive. JRA is the same disease as rheumatoid
arthritis except that it occurs before the age of 16 years.
In Fuchs heterochromic iridocyclitis, the fine stellate KP are found scattered diffusely
on the entire posterior surface of the cornea, unlike most KP, which are located in the
inferior cornea.
In Uveitis, Low intraocular pressure (IOP) may occur as a result of reduced secretion of
aqueous by the ciliary epithelium. Occasionally the intraocular pressure may be elevated
(hypertensive uveitis) as in herpetic uveitis and PosnerSchlossman syndrome.
In CAU, Aqueous flare may be more marked than cells in eyes with prolonged activity and
its severity may act as an indicator of disease activity (contrary to previous teaching).
The classical teaching that only cellular reaction in the anterior chamber represents active
inflammation has been challenged. Flare is caused by chronic break-down of the blood
aqueous barrier, but the intensity of the flare can also indicate an active process, which
may respond to therapy.
Iris atrophy that is sectoral occurs characteristically in herpes simplex and herpes
zoster. Diffuse iris atrophy occurs in Fuchs uveitis syndrome.
Large KPs in granulomatous disease have a greasy (mutton-fat) appearance. They are
often more numerous inferiorly and may form in a triangular pattern with the apex pointing
up = Arlt triangle
Onchocerciasis: Also known as river blindness, this is caused by infection with the filaria
parasite Onchocerca volvulus, which is transmitted by the bite of species of Simulium flies
(so-called buffalo gnats). Clinically there are skin changes, nodules and eye changes that
can lead to blindness. The nodules develop in subcutaneous tissue especially near bony
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structures and contain living or dead adult worms. Fundus of oncocerciasis is known as
Ridleys fundus.
MAGIC Syndrome: Mouth and genital ulcers with inflamed cartilage syndrome is a
cutaneous condition with features of both Behet's disease and relapsing polychondritis
Dadizumab (Zenapax): A completely humanised IL- 2 receptor antibody used in kidneytransplant recipients, has shown encouraging clinical results in uveitis patients. In a phase 2
trial, subcutaneous daclizumab was injected at the dose of 2 mg/kg separated by 2 weeks
and then 1 mg/kg subcutaneous(SC) every 2 weeks for 26 weeks. The objective of the trial
was to reduce the load of the other immunosuppressive agents by half. Immunosuppressive
therapy was tapered off in a staggered fashion to SO% or less in 8 to 12 weeks. At 12
weeks, 10 of the lS patients (67%) receiving SC daclizumab successfully achieved the
primary end point of reducing concomitant immunosuppression load by SO%.
AC flare: Tyndal effect focused beam of light illuminating the anterior chamber becomes
visible, just as a projector beam is visible in a smoky room. This phenomenon, which is
termed aqueous flare or ray, is caused by the Tyndall effect.
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AC cells: The cells normally move with the convection currents in the aqueous. (They sink
anteriorly where the aqueous is cooled by the cornea and rise posteriorly where the
aqueous is heated by the iris.) Absence of cellular convection currents may indicate clotting
of fibrin-rich aqueous in a case with severe vascular permeability.
Nozik technique: a 25-gauge, 1/2-inch needle is used. If the injection is given in the
superote m poral quadrant (the preferred location), the upper eyelid is retracted and t he
patient is instr u cted to look down and nasally. After anesthesia is applied with a cotton
swab soaked in propa racaine or tetracaine, the needle is placed bevel-down against the
sclera and advanced through the conjunctiva and Tenon capsule using a side-to- side
movement, which allows the physician to deter mine whether the needle has entered the
sclera or not. As long as the globe does not torq ue with the side-to-side movement of the
needle, the physician can be reasonably sure t hat the needle has not penet rated t he
sclera. Once the needle has been advanced to the hub, t he corticosteroid is injected into
the sub-Tenon space. Complications of the superotem poral approach include upper lid
ptosis, periorbital hemorrhage, and globe perforation.
The Goldmann-Witmer (GW) coefficient is a test that compares the levels of intraocular
antibody production to that of serum, as measured by enzyme-linked immunosorbent assay
(ELISA) or radioimmunoassay. The coefficient is defined as GW = X/Y; where GW =
Goldmann-Witmer coefficient; X = specific antibody in aqueous or vitreous divided by total
IgG in aqueous or vitreous; and Y = specific antibody in serum divided by total IgG in serum.
A GW ratio > 4 is diagnostic of local antibody production to a specific microbial pathogen.
Its especially useful for ARN.
KPs
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Types of KPs
The absence of CME distinguishes Fuchs heterochromatic iridocyclitis from other uveitis
syndrome with chronic vitritis.
Aspirin is the treatment of choice for patients with Kawasaki syndrome. Systemic
corticosteroid therapy use is associated with an increased rate of coronary artery aneurysm
formation and is therefore contraindicated.
affects the anterior and posterior segments and is generally a bilateral process.
Recurrent explosive inflammatory episodes are typical with active episodes that
range from 2 to 4 weeks.
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The retinitis of Behet's disease is very suggestive of a viral retinitis and must be
considered in the differential.
Toxoplasmosis drugs
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an insidious, chronic intraocular inflammation that may not respond well to topical
corticosteroids.
Blue irides become more blue, and brown irides become less brown in cases of
Fuchs' heterochromic iridocyclitis.
Gonioscopy will reveal evidence of abnormal bridging vessels in the angle, although
neovascular glaucoma with angle closure does not develop.
Cataract surgery is not associated with any higher rate of vitreous loss or posterior
capsular rupture compared to normal eyes.
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Nevus of ota
NF-1
Peters
Axenfield Reigers
Gordons dictum for systemic steroids in uveitis Use enough, soon enough, taper and
discontinue
Although syphilitic uveitis may mimic any other form of uveitis, intermediate uveitis is a
distinctly uncommon presentation.
Primary intraocular lymphoma: leopard skin pattern of yellowish retinal pigment epithelium
and subretinal infiltration of lymphomatous cells are typically seen in patients over the age of
70 years
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recoverin, a calcium-binding protein that selectively localizes to the retina and pineal
gland, associated with cancer-associated retinopathy
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Strabismus
The Bruckner test is a bilateral red reflex test, and if strabismus is present the brighter reflex
is in the deviated eye. This is because the light reflects from peripheral retina in the
deviated eye. Because there is less pigment in the peripheral retina than the macula,
there is more reflection of light from the peripheral retina of the deviated eye.
Alexanders law: Jerk nystagmus, usually increases in amplitude with gaze in direction
of the fast phase
The inferior and superior obliques are abductors of the eye in synergy with the lateral
rectus. The superior, inferior, and medial recti are all adductors.
A very important thing to understand about Moebius is that many other characteristics have
been found in patients who have the signal features of lack of abduction (or in some cases,
gaze palsy) and weakness of the facial muscles. These include: deafness, webbed fingers
or toes, supernumerary digits, defects in the muscles of the chest (Poland syndrome),
neck and tongue, missing fingers or toes and more. Because of the wide list of associated
features some would prefer to call this the Moebius sequence.
The parieto-occipital lobe controls the slow pursuit component, whereas the frontal lobes
control the saccadic component.
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Several ocular and systemic anomalies have been associated with DRS: cataracts, iris
anomalies, Marcus Gunn jaw winking, microphthalmos, crocodile tears, Goldenhar's
syndrome, maternal thalidomide use, and Klippel-Feil syndrome.
There are three and possibly 4 classes of CFEOM that are genetically defined and have
different characteristics.
Class 1 has aligned eyes in down gaze which become esotropic on attempted up gaze.
Class 2 characterized by limited up gaze, ptosis and exotropia.
Class 3 is a milder form that can be a mixture of class 1 and 2 and may be unilateral. A new
classification of CFEOM called Turkel has an added finding of missing fingers. CFEOM is a
rare genetic disorder that results in varying degrees of inability to look up along with ptosis
and a chin up head posture. Treatment of any of the classes of CFEOM presents a
significant challenge and is usually done in stages.
Large vertical fusional amplitudes (>5 prism diopters) and facial asymmetry from
childhood headtilting suggest a decompensated congenital lesion.
In case of Restrictive Myopathy, A rectus muscle should never be resected but only
recessed.
Positive forced ductions indicate a restrictive process that may be caused by thyroid eye
disease, blow-out fractures, fat adherence syndrome, and Brown's syndrome, among
others.
A strabismic deviation can be neutralized by orienting an appropriate power prism with the
apex in the same direction as the deviation.
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A prism diopter is defined as the amount of deviation of a light by the prism measured at
100 cm.
Prism power can be represented by vectors and added as this mathematical entity.
All rays parallel to the lens axis will converge on the secondary focal point whose location
can be calculated as 100 cm/Power = distance cm.
The normal range of fusion as measured from 0 on the major amblyoscope is that of 30-35
convergence, 5 of divergence and 3-4 of vertical vergence.
Incidence of amblyopia in myopia is much less almost unknown for the reason that
myopia at least sees the near objects more clearly than in hypermetropia where all
accommodation reserve is up for distance and he neither sees dist/ance nor see near
objects clearly. Therefore, near vision stimulus is not deprived in myopia.
4-PD base-in prism test differentiates convergence insufficiency [near vision improves]
from accommodative insufficiency [near vision worsens]
Faden: The lever arm of the muscle is weakened thus decreasing its action. Best for
MR and not for LR. (as MR has 6.0 mm arc of contact, LR has 15 mm arc of contact.)
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Paralytic strabismus
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In the presence of microtropia "with identity," the cover test result is negative but the 4
prism diopter base-out test reveals a foveal suppression scotoma in one eye that
generally is also amblyopic.
The limbal incision for squint surgery may be done at the limbus for MR-LR-IR - but allow
a 1.5 to 2.0 mm "cuff" for SR to avoid increasing pannus at superior limbus.
A compensatory head posture with the chin elevated and pointing toward the opposite
shoulder permits fusion in Brown syndrome.
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DVD
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During times of visual inattention, the nonfixating eye slowly drifts up, extorts, and
abducts without a corresponding hypotropia of the fellow eye on alternate cover
testing. This is the hallmark of this disorderit does not obey Hering's law.
DVD can simulate Inferior Oblique Overaction (IOOA) in side gaze when the nose
acts as an occluder. The hyperdeviation in DVD is of the same amount in adduction,
abduction, and primary position. This is in contrast to IOOA, in which the
hyperdeviation is greatest in its field of action.
Two syndromes associated with this are: Goldenhar and Wildervanck syndrome.
The child can have a hearing or a speech disorder as well
The phenomenon commonly seen is the leash phenomenon and a severe leash is
treated with Y splitting of the lateral rectus muscle with posterior fixation sutures of
the lateral rectus muscle.
A right superior oblique palsy can result in vertical or torsional diplopia. Vertical diplopia
may be treated with either ipsilateral inferior oblique myectomy or anterior transposition,
contralateral inferior rectus recession or ipsilateral superior oblique tuck (sometimes in
combination}. Torsional diplopia can be treated with anterior transposition of the superior
oblique muscle.
Differentiation of unilateral from bilateral fourth nerve palsy is essential for successful
surgical management.
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Features of unilateral fourth nerve palsy include: head tilt to the affected side,
unilateral hypertropia on lateral gaze, less than 5 of exocyclotorsion.
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Features of bilateral fourth nerve palsy Include: chin down posture with eyes
looking up, alternating hypertropia on right and left gaze respectively, large
exocyclotorsion of more than 10
Infantile esotropia has large angle esotropia. Binocular single vision is usually poor
despite early treatment. The temporal-to-nasal movement is usually better than nasal-totemporal movement on optokinetic testing. Dissociated vertical deviation and inferior oblique
overaction are common and have been reported in about 90% of patients. Post-surgical
esotropia may be caused by an accommodative component.
Optokinetic response tests the pursuit and saccadic movements. When the drum is
rotated to the right, the pursuit movement is mediated by the right parietal lobe and the
saccadic movement by the right frontal lobe, i.e. the optokinetic response tests the
pursuit and saccadic movement on the side towards which the drum is moving.
Parinaud's syndrome causes up-gaze palsy and vertical rotation of the drum will elicit
convergence retraction nystagmus. In a patient with a frontal lobe lesion, there may be
deviation of his or her eyes to the side of the lesion. However, provided the contralateral
frontal lobe is intact, rotating an optokinetic drum away from the side of the frontal lobe will
elicit a response.
Septum so that one half of the field is seen by one eye exclusively and the other by
the other eye.
Red-green glasses, which are complementary in the sense that with red filter sees
only red light other with green filter sees only green.
Polaroid dissociation, each eye views through polaroid filters each one at 90
degrees to each other.
Bagolini's striations, a spot light scattered striations, the two glasses set at 90 to
other.
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The torsional eye movements occur around the anteroposterior or Fick's Y axis. This does
not pass through the centre of cornea but at a point on the lateral limbus as shown by
Linwong.
Magician Forceps Phenomenon: On passive adduction of the dominant eye, the other
eye's exodeviation gets corrected. This reflex is present even in the dark. This reflex is
abolished by deep retrobulbar anesthaesia.
Isolated agonist model was described by Duane for eye movements. However, it is
important to remember that during eye movements, all six extraocular muscles are in some
state of contraction or relaxation, and it is strictly hypothetical to discuss the movement of
the eye as if only one muscle contracts.
Both horizontal rectus muscles are displaced inferiorly with age (MR >> LR)
The superior rectus and inferior rectus muscles do not change locations
greater variety in fiber sizes, increased connective tissue in the muscle, increased
adipose tissue in the bundles, deposits of lipofuscin, and degenerative changes.
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Antepodean Strabismus: It is present when the patient has esotropia while fixing with
one eye and exotropia when fixing with the other eye. This occurs with anisometropia
and an improperly corrected refractive error. Some cases are believed to be due to unequal
accomodation.
Principle of Faden: Point of posterior fixation is new insertion for action. As antagonist
entire muscle acts. Therefore limits muscle action only in field of its action.
Adherence syndrome: The orbital fat is separated from the globe by Tenons capsule. If an
accidental opening is made in the portion of Tenons capsule that separates the orbital fat
from sclera, orbital fat may be pressed through the opening and adhere to the globe. This
adherence often results in limited eye moments. It is best treated by prevention. The orbital
fat comes forward around the equator of the globe to within 10 mm of the limbus. Care
should be taken not to cut Tenons capsule more than 10 mm from the limbus.
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In class 7 SO palsy, traumatic paresis plus restriction of relaxation of the superior oblique,
also known as the canine tooth syndrome because it is most frequently caused by a dogbite injury to the trochlear area, requires surgery to correct the Brown syndrome first, with a
subsequent attempt at correcting paresis of the superior oblique if possible.
Cooper's Dictum: Stretched scar may have been the mechanism behind Cooper's report of
failure of advancing previously recessed medial recti for consecutive exotropia. He
advocated instead recessing the antagonist lateral recti. This principle is known as
Cooper's Dictum.
Liquid crystal glasses have recently been developed as a new treatment for amblyopia.
They provide an electronic, controlled, intermittent occlusion of the sound eye allowing for
visual stimuli input to the amblyopic fellow eye. A liquid crystal glass in the sound eye is
used as an intermittent flickering shutter switched between on, or occlusion and off or
light transmission. The flickering sequence can be adapted to the depth of amblyopia, the
length of treatment, and the patients age.
CAM Vision Stimulator - Amblyopic eye is stimulated by slowly rotating, high contrast,
square wave gratings of different spatial frequencies for 7 minutes but the results are not
much promising.
Hertle Dell Osso proceduce: tenotomy and re attachment (rectus muscle) surgery done
for nystagmus.
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Neurophthalmology
Location of Lesion:
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Internuclear ophthalmoplegia: Ipsilateral MLF, i.e. the same side as the eye that
has adduction restriction.
The lesion for skew deviation is in the brain stem but the exact location is
unknown.
Aberrant regeneration of the oculomotor nerve occurs in surgical third nerve palsy and
not in 'medical' third nerve palsy such as diabetes mellitus or hypertension. Retraction of the
upper lid on down-gaze is called pseudo von Graefe's sign and miosis of the pupil on
adduction is termed pseudo Argyll-Robertson pupil.
Kollners Rule:
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The Pulfrich phenomenon probably reflects delayed conduction in the demyelinated nerve.
Oscillating objects perceived by the affected eye appear to be behind the image seen with
the healthy eye, simulating three-dimensional movement where there is only movement
within one plane.
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lce test- reduced ptosis after ice pack applied for 2 minutes.
Alternating Anisocoria:
One pupil larger in light and other is larger in dark 3rd nerve palsy and horners
syndrome
discreet entity not found in normal subjects but which may be present in more than
one member of a family
Horner syndrome with 6th nerve palsy together: cavernous sinus lesion
30 times more fibres serve miosis through accommodation than through light.
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Causes:
Unilateral
Afferent conduction defect
Adie pupil
Herpes zoster ophthalmicus
Aberrant regeneration of the 3rd nerve
Bilateral
Neurosyphilis- Argyll Robertson pupils
Type 1 diabetes
Myotonic dystrophy
Parinaud (dorsal midbrain) syndrome
Familial amyloidosis
Encephalitis
Chronic alcoholism
There is no clinical condition in which the light reflex is present but the near response absent
but vice versa is not true.
The midbrain centre for the near reflex is probably located more ventrally than the
pretectal nucleus and this is why compressive lesions such as pinealomas, preferentially
involving the dorsal internuncial neurones involved in the light reflex, spare the near reflex
fibres until later.
Pupillary sphincter has atlease 20 segments each of this innervated by different branches of
short ciliary nerve.
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In afferent (sensory) lesions, the pupils are equal in size. Anisocoria (inequality of pupillary
size) implies disease of the efferent (motor) nerve, iris or muscles of the pupil.
Reverse RAPD: When the pupil of the involved eye is nonreactive or nonfunctional, observe
the fellow, normal eye for a reverse RAPD (dilation when light is on nonreactive eye,
constriction when light is shined on reactive eye).
Morning glory disc is a congenital coloboma of the disc or glial tissue of the disc head.
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Ophthalmic artery obstruction usually does not produce a cherry-red spot due to underlying
choroidal ischemia.
Approximately half of the fibers of the optic nerve decussate in the optic chiasm, and the
input to each of the parasympathetic nuclei in the brain stem remains equal. Therefore,
relative afferent pupillary defects do not cause anisocoria because any changes in light
input are distributed equally to both pupils.
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Retinal migraine: Ocular migraine, rare; monocular scotoma or visual loss for minutes to
an hour due to retinal or optic nerve ischemia.
Willebrandts knee: Inferonasal optic nerve fibers that decussate in chiasm and loop into
contralateral optic nerve before traveling back to optic tract
Inadvertent ocular exposure to anticholinergic agents also has been reported. Patients using
scopolamine patches have been noted to have self-limited mydriasis, which has been
dubbed cruise ship anisocoria.
Anticholinesterases- flea collar anisocoria
Clonazepam and suboccipital craniotomy have been used in the treatment of downbeat
nystagmus in patients with Arnold-Chiari malformation.
The differential diagnosis for posterior ischemic optic neuropathy (PION) should include
radiation optic neuropathy, status post-coronary artery bypass graft, anemia, acute systemic
hypotension, giant cell arteritis (GCA), and syphilis.
Well-controlled essential hypertension is associated with anterior ischemic optic neuropathy
(AION) but not PION.
In Giant cell arteritis: CRP > 2.45 mg%, ESR >47 mm/hour
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In general, optic nerve compression >1 cm posterior to the globe does not cause disc
edema.
A skew deviation is a motility disturbance with a vertical component that does not have a
pattern consistent with a discrete muscle underaction or nerve palsy. They are generally
due to supranuclear or vestibuloocular dysfunction and generally reflect brainstem
disease. They are typically comitant but not always.
Although transient changes in vertical eye movements and slowing of vertical saccades can
result from lesions of the paramedian pontine reticular formation, nuclei crucial for the
initiation of vertical eye movements are the rostral interstitial nucleus of the medial
longitudinal fasciculus (riMLF) and the interstitial nucleus of Cajal (INC).
Czarneckis sign: Segmental pupillary constriction with eye movements due to aberrant
regeneration of cranial nerve III
Exotropia in primary position can occasionally occur in association with a bilateral INO (A
lesion that involves both medial longitudinal fasciculi near their junctions with the third nerve
nuclei) resulting in a syndrome called wall-eyed bilateral INO - WEBINO.
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Sixth nerve palsy caused by an intracavernous lesion may present as abduction palsy
plus miosis because within the cavernous sinus, sympathetic branches of the paracarotid
plexus join the sixth nerve briefly.
In the cavernous sinus, cranial nerves III, IV, and V are relatively protected within the
walls of the sinus, but cranial nerve VI runs in the middle of the sinus and is more prone
to injury.
Horizontal saccades originate in the contralateral frontal lobe, but either hemisphere can
produce ipsilateral saccades if the other hemisphere is damaged.
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The period between detection of movement and the beginning of smooth pursuit (for
tracking) is between 125 and 135 milliseconds. Initiation of saccadic movement requires
from 150 to 200 milliseconds from the first perception of a target. The latency in
generating a pursuit movement is shorter than that for a saccade movement.
Skew deviation is, by definition, a vertical misalignment of gaze that cannot be assigned to
a single nerve or muscle weakness. In the presence of an internuclear opthalmoplegia
(INO), the hypertropic eye is often on the same side as the adduction deficit (medial rectus
dysfunction).
Monocular nystagmus has been associated with chiasmal and hypothalamic gliomas. It is
also seen in blind eyes, multiple sclerosis (MS), and spasmus nutansa transient, fastbeating, but low-amplitude nystagmus found during the first 5 years of life.
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Upbeat nystagmus can be caused by lesions of the anterior vermis and lower brainstem,
as well as drugs and Wernicke's encephalopathy.
Downbeat nystagmus may be localized to anatomic structures at the craniocervical
junction (e.g., Arnold-Chiari malformation) and may be seen in certain intoxications (alcohol,
lithium).
Vestibular nystagmus has its etiology within the vestibular system.
Periodic alternating nystagmus also can localize to the craniocervical junction but may be
seen in other forms of posterior fossa disease.
Seesaw nystagmus results from third ventricle tumors or diencephalic lesions involving the
connections to the interstitial nucleus of Cajal (INC) and is therefore the most localizing.
Vergence eye movements are felt to have a pathway of their own for stimulating the
brainstem motor nuclei. Saccades originate in the contralateral frontal lobe, whereas
pursuits arise in the ipsilateral parietal lobe.
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The afferent pupillomotor fibers exit the optic tracts just before the lateral geniculate body
(LGB); they do not pass through the LGB. Although postganglionic pupillomotor fibers in the
sympathetic pathway do arise from the superior cervical ganglion, the sympathetic pathway
leading to these fibers is thought to originate in the posterior hypothalamus. In addition,
postganglionic sympathetic fibers enter the orbit with the ophthalmic division of the
trigeminal nerve through the superior orbital fissure. The consensual pupillary response is
seen because of decussation at the pretectal nuclei. Were the chiasm split in half,
consensual responses would be preserved.
In uncal herniation and basilar meningitis, pupil dilation may be the only sign of third
nerve palsy. In the case of a cerebral aneurysm, the pupil is usually involved, along with
other functions of the third nerve. If the pupil is not involved, it is less likely that an aneurysm
is the cause of the palsy. Total oculomotor palsy with a spared pupil in elderly patients
usually suggests a microvascular etiology.
Horner's syndrome is defined as ipsilateral ptosis and miosis. Ptosis is secondary to lack
of Mller's muscle function. Anhidrosis may or may not be present.
Localization of the lesion in Horner's syndrome is part of the clinical workup and sometimes
guided by the extent of anhidrosis.
First-order lesions (central nervous system) cause ipsilateral anhidrosis of the entire body.
Second-order lesions (Pancoast's tumor, neck trauma) cause ipsilateral facial anhidrosis.
Third-order lesions (carotid dissection) cause anhidrosis only around the affected eye or
none at all.
1. In response to 4% cocaine, a normal pupil will dilate, but a Horner's pupil will dilate
poorly.
2. Hydroxyamphetamine (Paredrine) will cause a similar response in preganglionic
Horner's syndrome only.
Painful Horner's syndrome may be caused by many disorders (neck trauma, migraine,
cluster headaches), but spontaneous dissection of the common carotid artery must be ruled
out with angiography or magnetic resonance imaging (MRI)/magnetic resonance
angiography (MRA)
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It is important to examine the optic disc carefully in all patients with suspected central
serous retinopathy. (a/w Optic Disc Pit)
The temporal 30 degrees of a binocular visual field is perceived by the nasalmost retina of
the ipsilateral eye only. These temporal crescents are represented in the anterior-most
occipital lobe. Therefore, a lesion in this area will produce a monocular visual field defect in
the far temporal periphery of the contralateral eye, the so-called temporal crescent
syndrome. For example, a right anterior occipital lobe lesion would produce a far temporal
field defect in the left eye. Similarly, a right posterior occipital lobe lesion may spare the far
temporal field in the left eye.
Inferior nerve fibers from the superior retina course anteriorly in Meyer's loop; therefore,
lesions affecting Meyer's loop will result in pie-in-the-sky defects contralateral to the lesion.
The various ways to differentiate the NAION from optic neuritis include (i) the absence of
pain with eye movement, (ii) the age group affected, and (iii) delayed optic disc filling
present in 75% of NAION cases (whereas filling should be normal in optic neuritis).
Collateral vessels (optociliary shunt vessels) at the disc connecting the retinal and
choroidal vascular systems may be seen in association with optic nerve meningioma, central
retinal vein occlusion (CRVO), sphenoid wing meningioma, long-standing primary openangle glaucoma (POAG), optic gliomas, or chronic papilledema.
Patients with papillophlebitis have normal or near normal visual acuity. It may be a form
of incomplete central retinal vein occlusion (CRVO) and usually resolves spontaneously
within 12 months.
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Optic nerve hypoplasia is seen with greater incidence in children of diabetic mothers and
following fetal exposure to antiepileptic medications, quinine, or lysergic acid diethylamide
(LSD). Optic nerve hypoplasia, particularly bilateral involvement, has been associated with
other midline developmental anomaliesthat is, absence of the septum pellucidum and
hypothalamic-pituitary abnormalities. Endocrine dysfunction is manifested as hypoglycemic
seizures and growth retardation. This combination of clinical findings is known as
DeMorsier's syndrome in 10% (septo-optic dysplasia).
Babies of IDDM mothers more likely to have superior segment hypoplasia giving rise to
inferior field defects.
Nonsecreting pitutary tumors often present with visual field loss, whereas secreting
tumors present with endocrine dysfunction. An exception is prolactin-secreting tumor in
male patients because the decreased libido and impotence are often not reported early in
their course.
Bitemporal macular hemianopia can only arise from compression of the posterior
chiasm. Although most lesions responsible for this compression are parasellar, a lesion
distant from this site (e.g., a tumor at the base of the brainstem) also may lead to chiasmal
compression. This occurs if the lesion causes obstructive hydrocephalus, which enlarges
the third ventricle, compressing the chiasm.
The most common location for a cerebral aneurysm with third nerve palsy is the junction
of posterior communicating artery and internal carotid artery. PCA-ICA
Third nerve aberrant regeneration never occurs with diabetic oculomotor neuropathy.
Aberrant regeneration of the third nerve implies another etiology, such as aneurysm, tumor,
inflammation, or trauma. Other classic findings of aberrant regeneration include persistent
vertical gaze limitation secondary to simultaneous contraction of superior and inferior recti,
and pupillary miosis with elevation, adduction, or depression.
The earliest loss of visual field in chronic papilledema is typically in the inferior nasal
quadrant.
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Retinal and optic nerve lesions produce field defects that do not generally respect the
vertical midline. The presence of a field defect that respects the vertical midline should
always arouse suspicion of a neurologic lesion (e.g., cerebrovascular accident, tumor),
especially when the disc and field changes do not correspond.
The only location at which oculomotor superior division nerve palsy could occur without
affecting additional cranial nerves or the inferior division of cranial nerve III is in the orbital
apex.
The location of a lesion affecting the oculomotor nerve can be determined by the associated
neurologic deficits. An oculomotor nuclear lesion also involving the ipsilateral cerebral
peduncle causes contralateral hemiparesis (Weber's syndrome). Cranial nerve III palsy
with contralateral decreased sensation and contralateral tremor (red nucleus affected) is
Benedikt's syndrome.
The parasympathetic pupillomotor fibers controlling the pupil are found on the outside of the
oculomotor nerve and are the first to be injured with external pressure. Diabetic
microvascular insults affect the central fibers of the nerve to a greater degree than the outer
fibers, and as a result, pupil involvement is less common (<20%).
A contralateral relative APD would be present if the optic tract was damaged because
relatively more nasal fibers from the contralateral eye cross in the chiasm.
A relative afferent pupillary defect never causes anisocoria because the pupillary fiber
decussations in the chiasm and posterior commissure ensure equal efferent input to both iris
sphincter muscles.
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Uhthoff's symptom occurs with optic neuritis and is a decrease in vision with an increase in
body temperature. Exercise or hot showers may trigger this symptom.
Lhermitte's sign is the electric shock sensation with neck flexion and is found in patients
with multiple sclerosis.
The Riddoch phenomenon occurs in patients with cortical blindness who are able to
perceive objects in motion, but cannot see stationary objects.
The nuclei controlling the superior rectus and superior oblique muscles have crossed
projections.
Horner's syndrome can be confirmed with the cocaine test and damage to the second order
neuron is supported with the hydroxyamphetamine test.
In the cocaine test, 4% (not 10% as some advocated) cocaine is instilled into both eyes.
Horner's pupil dilates little or none at all. Reuptake of the norepinephrine occurs normally in
the synaptic cleft. Cocaine blocks the reuptake, causing rapid accumulation within the
synaptic cleft resulting in dilation of a normal pupil. The presynaptic nerve endings in
Horner's syndrome have impaired sympathetic tone and therefore respond poorly or none at
all to the effect of cocaine.
Hydroxyamphetamine stimulates the release of norepinephrine from the presynaptic nerve
endings resulting in dilatation of the pupil. If the nerve is damage, the nerve will not release
norepinephrine as is the case with third order neurone lesion. In the case of first and second
order neurone lesion, the pupil will dilate as the third order neurones are intact.
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The optic nerve is generally myelinated to the lamina cribrosa 4 to 6 months before foveal
maturation.
It should be emphasized that in afferent (sensory) lesions, the pupils are equal in size.
Anisocoria (inequality of pupillary size) implies disease of the efferent (motor) nerve, iris or
muscles of the pupil.
Visual evoked potentials (VEPs) document 20/20 acuity by the age of 6 to 8 months.
Preferential looking testing (PLT) cannot document 20/20 until 24 to 30 months.
superior rectus and medial rectus are closely attached to the dural sheath of optic
nerve, at their origin. This accounts for the characteristic pain felt on moving the eyeball up
and in, in a case of retrobulbar neuritis.
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In the setting of an upgaze paresis, upturning of the eyes on forceful opening of closed
eyelids implies a supranuclear lesion.
Although there is some redundancy of the optic nerve within the orbit, the intracranial optic
nerve has little slack.
53% of the retinal ganglion cells cross in the chiasm (this difference is occasionally
important clinically).
The macular fibers constitute a large portion of the optic chiasm and most decussate in the
posterior chiasm.
The inferior nasal retinal fibers cross in the anterior chiasm and were thought to loop
anteriorly in the contralateral optic nerve before traveling posteriorly, leading to the term
Wilbrand's knee. It is now thought that Wilbrand's knee may be an artifact.
The chiasm lies approximately 1 cm (not 1 mm) above the anterior pituitary gland.
ipsilateral ganglion cells synapse in layers 2, 3, and 5, whereas the contralateral ganglion
cells synapse in layers 1, 4, and 6.
Inferior fibers of the optic radiations pass extremely close to the internal capsule.
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Agnosia
Right-left confusion
Asymmetric OKN
seizures
unformed hallucinations
macular sparing
Occipital lobe infarcts can be associated with visual hallucinations, denial of vision
loss (Anton-Babinski syndrome), and the ability to perceive moving but not
static objects (Riddoch phenomenon).
OKN Sign?
80% of patients with cavernous sinus-dural fistulae will develop ocular hypertension.
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Nonarteritic anterior ischemic optic neuropathy (NAION) is far more common than arteritic
anterior ischemic optic neuropathy (AAION) (approximately 95% vs. 5%) and patients have
a lower mean age at diagnosis than patients with AAION (60 years vs. 70 years). It usually
occurs in a younger age group and may resemble optic neuritis.
The various ways to differentiate the NAION from optic neuritis include
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delayed optic disc filling present in 75% of NAION cases (whereas filling should be
normal in optic neuritis).
Although aspirin may prevent further strokes in patients with NAION, its effect on the
contralateral eye is unclear.
16% of patients with an initial attack of optic neuritis with a negative magnetic resonance
imaging (MRI) will develop multiple sclerosis (MS) at 15-year follow-up.
More than 50% of patients with three or more lesions that are visible on MRI will develop
MS at 15-year follow-up.
Best method for detecting decompensated congenital fourth nerve palsy is: vertical
fusional amplitude measurements.
Within the cavernous sinus, sympathetic branches of the paracarotid plexus join the sixth
nerve briefly. Sixth nerve palsy caused by an intracavernous lesion may present as
abduction palsy plus miosis.
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Congenital motor nystagmus has several features, including normal visual acuity,
paradoxic optokinetic nystagmus (OKN) (caused by the abnormal movements of nystagmus
appearing slow and against the expected direction of target tracking), dampening by
convergence, and aggravation by fixation. Fortunately, oscillopsia (the sensation of the
world moving) is not normally a problem.
Although 75% of all myasthenics will have eye findings at presentation, only 33% to 50% will
have ocular myasthenia only. A higher percentage (90%) of patients with myasthenia gravis
(MG) will develop ocular symptoms during the course of the disease. Ptosis is the most
common. 5% of patients bwith Graves' disease will develop myasthenia gravis (MG) as
well. 10% of myasthenic patirnts have thymomas.
For a patient to be reassured that systemic disease is unlikely, ocular myasthenia should
remain localized for 2 years.
Patients with embolic central retinal artery occlusion (CRAO) are at great risk of myocardial
infarction (MI).
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Painful Horner's is an acute dissection of the internal carotid artery until proven otherwise.
The diagnosis of exclusion then becomes migraine if the angiogram is normal.
The -triptan antimigraine drugs are used for symptomatic relief of migraines but are
contraindicated in patients with basilar artery migraine.
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Binding (not blocking) antibodies to acetylcholine receptors are found in 90% of patients
with generalized myasthenia gravis (MG).
Pupillary fibers from the optic tract exit before reaching the lateral geniculate body (LGB)
and exit into the pretectal olivary nuclei.
About 1 % prevalence
Bilateral in 20%
An enlarged blind spot may be present with a peripapillary lesion, and peripheral
lesions may give corresponding field defects. Myopia and amblyopia may be
associated, and symptomatic macular involvement has been reported. Rarely,
associated retinal vascular abnormalities can be present.
Systemic associations include NF1 and Gorlin (basal cell naevus) syndrome.
Optic nerve pits are usually in the inferotemporal quadrant or central part of the disc.
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Botulinum Toxin
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Botox A
causes irreversible blockage of the pre-synaptic neurone and thus inhibits the
release of acetylcholine.
3rd CN comes out in between posterior cerebellar and superior cerebellar arteries.
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Premature baby has no pupillary light reaction until 3 weeks of gestational age
Ethambutol toxicity: up to 6% at a daily dose of 25 mg/kg and rare with a daily dose not
exceeding 15 mg/kg. Toxicity typically occurs within 36 months of starting treatment.
Schilder disease, which is a very rare, relentlessly progressive, generalized disease with
an onset prior to the age of 10 years and death within 12 years. Bilateral optic neuritis
without subsequent improvement may occur.
Two important risk factors for fellow eye involvement in NAION are poor visual acuity in
the first eye and diabetes mellitus.
In GCA, the severity and extent of involvement are associated with the quantity of elastic
tissue in the media and adventitia. Intracranial arteries, which possess little elastic tissue,
are usually spared.
As the optic radiations pass posteriorly, fibres from corresponding retinal elements lie
progressively closer together. For this reason, incomplete hemianopia caused by lesions of
the posterior radiations are more congruous than those involving the anterior radiations.
Cogan dictum: If the lesion is in the occipital lobe, the smooth pursuit pathways are intact
and OKN will be symmetrical. If a homonymous hemianopia is due to a lesion in the parietal
lobe, the smooth pursuit pathways towards the side of the lesion are likely to be affected,
making this component of OKN defective.
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An important sign of cavernous sinus lesions is sensory loss over the distribution of the first
division of the trigeminal nerve.
Even with a Complete Homonymous Hemianopia, visual acuity should still be 20/20..!! as
half a macula is still intact.
Thus the cuneus gyrus receives projections from the superior retina and the lingual gyrus
from the inferior retina.
Ophthalmology Explorer
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Dhaval Patel MD
The first documented observation of the phenomenon was in the 1660s by Edme
Mariotte in France. At the time it was generally thought that the point at which the
optic nerve entered the eye should actually be the most sensitive portion of the
retina; however, Mariotte's discovery disproved this theory.
Kestenbaum's number: Kestenbaum proposed a test that is loosely based on the Gunn
phenomenon, in which the patient fixes in the distance with one eye, while the other eye is
occluded by the palm of the hand. The examiner holds a handlight with fresh batteries 1 inch
from the uncovered eye for 5 seconds to allow the pupils to stabilize. The size of the
uncovered pupil is then measured with a pupil gauge to the nearest 0.25 mm. The size of
the opposite pupil is then measured in the same fashion, and the difference between the two
eyes is determined after correcting for any initial anisocoria. This result is called
Kestenbaum's number.
Supranuclear Imbalance:
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Saccadic eye movements in neurological lesions are reduced in velocity, while restrictive
defects manifest normal saccadic velocity with sudden halting of ocular movement.
Patients with tonic pupil may also sweat excessively, sometimes only on one side of the
body. The combination of these 3 symptoms abnormal pupil size, loss of deep tendon
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reflexes, and excessive sweating is usually called Rosss syndrome. Mx: Thoracic
sympathectomy
Any lesion anterior to the lateral geniculate body would cause the ganglion axon cells to
degenerate leading to optic atrophy.
Monocular defects are prechiasmal except that the far temporal visual field is seen only by
one eye. Watch this in an anterior occipital infarct, which can produce a monocular temporal
defect.
Patients with postchiasmal defects typically have normal visual acuity, normal pupils, and
a normal exam of the ocular fundus. Papilledema, however, may be seen in patients with
space-occupying lesions.
Optic nerve sheath decompression does not relieve the orbital congestion and would not be
effective in thyroid eye disease.
D15 testing can help distinguish the usual red-green color blindness from tritan axis defects,
which are commonly found in dominant optic atrophy.
The inability to initiate voluntary saccades is known as ocular motor apraxia. The patient
with the congenital onset of this disorder is unable to initiate voluntary horizontal saccades,
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but can make normal vertical saccades. Acquired ocular motor apraxia usually occurs with
bilateral cerebral hemisphere disease. Patients with Parkinson's disease show difficulty in
initiating multiple repetitive saccades.
Oculoplasty
The valve of Krause (and sinus of Arlt) is located at the junction of the
nasolacrimal sac and duct.
The spiral valve of Hyrtle and the valve of Taillefer are located within the
nasolacrimal duct.
Enophthalmos
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Blow-out fracture
A rare variant of dermoid cyst, which has been termed a conjunctivoid occasionally, is
found in the nasal orbit. These unusual dermoids are lined by conjunctival epithelium and
has goblet cells which are PAS positive.
~50% of the lesions originate from epithelial elements of the lacrimal gland and 50%
are of nonepithelial origin.
Of nonepithelial lesions, 50% are lymphoid tumors and 50% are comprised of
various infections and inflammatory pseudotumors. (though now inflammatory are
more common 60-80%)
Among the epithelial tumors of the lacrimal gland, ~50% are pleomorphic
adenomas (benign mixed tumors) and 25% adenoid cystic carcinoma, while the
remaining tumors are composed of other types of carcinoma.
Rundle Curve: According to the Rundle's curve, Graves' ophthalmopathy (GO) worsens
during an initial phase up to a peak of maximum severity, to then improve and reach a
static plateau, with the activity curve preceding the severity curve by a few months.
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Detection of mild pulsatile proptosis: Mild pulsation is best detected on the slit-lamp,
particularly during applanation tonometry.
The rate subsequently returned to its baseline level of 1% per year over the next
3 to 5 years.
data from the COMS published in 1998 demonstrated that no survival advantage
was gained by pre-enucleation radiation in more than 1,000 patients with large
choroidal melanomas. This result suggests that metastasis occurs prior to
enucleation.
Choroidal melanoma
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Pseudoretraction is ruled out by elevating the other side eyelid (appearing ptotic) and
making that eye to fixate. In case of pseudoretraction the retracted appearing eyelid
assumes normal position once the contralateral eye is made to take up fixation.
Causes of pseudoretraction are: ptosis of the other eye, namely acquired apponeurotic
type, facial palsy of the same side causing unopposed action of the levator and hemifacial
spasm on the opposite side.
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Floppy eyelid syndrome would have a papillary conjunctival reaction. Filaments are not
associated with this condition.
Although Marfan's disease is a disorder of collagen synthesis, blue sclera is not seen in this
condition?
(This is controversial! some reference says it is a cause of blue sclera and some says it is
not. I also found one MCQ which answers marfans as an exception of cause of blue sclera.
Oh Dear GOD!)
Dermoids are choristomas containing ectodermal elements (skin, hair, fat, and sebaceous
glands). Muscle tissue is not expected to be found in such a lesion.
von Graefe's sign: slow or restricted descent of the lid on attempted down gaze seen in
thyroid ophthalmopathy.
Limbal dermoids are usually an isolated abnormality but may on occasion be part of
Goldenhar's syndrome, Treacher Collins' syndrome or the naevus sebaceous
syndrome of Jadassohn.
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Phthirus pubis (crab louse) infests pubic hair and eyelashes and is transmitted by sexual
contact. Treatment is by mechanical removal or with bland ointments applied to the lids to
suffocate adult lice. Physostigmine is effective as a respiratory poison against the lice but
has many ocular side effects, limiting its effectiveness.
Demodex is a normal commensal in adults living in meibomian glands. Classically,
sleeves are found at the base of lashes, indicating Demodex infestation. Treatment is
through lid scrubs. Collarettes are found more commonly with staphylococcal blepharitis.
Basal cell carcinoma is the most common malignant tumor of the eyelid skin, but
squamous cell carcinoma is the most frequently occurring malignancy of the conjunctiva.
Squamous papillomas are benign lesions that can, on rare occasions, undergo malignant
transformation.
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Congenital NLDO:
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Synophrys is extension of the eyebrows to the midline. It can occur in naturally hairy
individuals who are otherwise normal. It also occurs in Cornelia de Lange syndrome which is
characterized by mental retardation, limb reduction, flared nostrils, and hirsutism.
After permanent punctal occlusion with cautery, 20-30% rate of recanalization is expected.
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potential ocular complications associated with nevus of Ito & nevus of Ota:
a. Open-angle glaucoma.
b. Malignant melanoma.
Squamous cell carcinoma is the most common malignant tumour of the conjunctiva and
typically affects the limbus. It typically occurs in people over the age of 50. Because of its
limbal location, it may sometimes be misdiagnosed as pterygium or pingueculae.
SCC is rare amongst healthy young people, its occurrence in patients under the age of 50
should raise the possibilities of AIDS. In African countries where AIDS is endemic, SCC
conjunctiva is now recognized as an AIDS defining disease.
Basal cell carcinoma that involves the medial canthus is the most likely to invade the deep
orbital structure.
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Congenital acquired fistula: probe test positive, both opening probe touchwhy to
differentiate? as it does not close its own.. whereas acquired one closes once u treat the
cause.
Quikert suture: entropion and ectropion: place knot where u want lid to be.If entropion, at
margin and vice versa.
An iris nevus can be distinguished from a melanoma by: size (<3 mm in diameter),
thickness (<1 mm thick), and the absence of vascularity, ectropion uveae,
secondary cataract, secondary glaucoma, and growth.
Iris fluorescein angiogram (a nevus has a filigree filling pattern that becomes
hyperfluorescent early and leaks late or is angiographically silent, whereas a
malignant melanoma has irregular vessels that fill late), and B-scan ultrasound or
UBM to rule out ciliary body involvement. Transillumination may also be helpful.
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The orbit is pear-shaped. Its widest dimension approximately 1 cm posterior to the anterior
rim.
Blunt cranial trauma is often transmitted to the sphenoid, with secondary indirect
traumatic optic neuropathy as a consequence.
In hypertelorism, the medial orbital walls are separated excessively. In exorbitism, the
lateral walls diverge excessively (>90 degrees).
The most frequent cause of bilateral proptosis in adults is thyroid ophthalmopathy. The
most common cause of bilateral proptosis in children is not definitively established, but
metastatic neuroblastoma and/or leukemia should be considered.
The most common cause of unilateral proptosis in adults is thyroid ophthalmopathy.
The most common cause of unilateral proptosis in children is orbital cellulitis.
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Although computed tomography (CT) scan does use greater radiation than plain films, it
involves less than plain film tomography, which requires multiple exposures. An orbital CT
scan administers a dose of 1 to 2 centigrays per scan.
A bluish bulge above the medial canthal tendon (MCT) is typically a meningocele, whereas
one below is typically a dacryocele.
most common risk factor for the development of preseptal cellulitis- recent skin trauma
most common risk factor for the development of orbital cellulitis- ethmoid sinusitis
Orbital studies are incomplete without coronal sections (preferably nonreconstructed, which
requires the patient to lie prone).
Capillary hemangiomata will blanch with pressure, whereas the nevus flammeus does not.
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The fragile pial vessels supplying the optic nerve are easily disrupted by any attempt to
remove optic nerve meningoma. Surgery is usually undertaken if there is intracranial
extension or severe proptosis and severe visual loss.
Fibrous dysplasia may be monostotic (affect only one bone) or polyostotic. The
polyostotic variety may present with precocious puberty and dermal hyperpigmented
macules. This disorder, Albright's syndrome, rarely involves the orbit. Orbital disease is
nearly always monostotic and rarely associated with precocious puberty, regardless of age.
Surgical curettage or excision is usually undertaken. Only woven bone, not cancellous, is
found microscopically.
Eosinophilic granuloma frequently involves the orbital bones. The classic triad of HandSchller-Christian disease consists of proptosis, lytic skull lesions, and diabetes
insipidus. Orbital involvement is rare in Letterer-Siwe disease.
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The central nervous system (CNS) is not routinely surveyed in patients with orbital
lymphoma. This is in contrast to patients with intraocular lymphoma.
The three orbital deposits that are hyperintense on T1-weighted images are blood,
melanin, and mucous. (Fat..?)
The tripod complex is produced by three distinct fractures along suture lines
zygomaticofrontal, zygomaticomaxillary, and the zygomatic arch. Ocular motility may or
may not be normal in pure tripod fractures, but upgaze should be spared. Repair is indicated
when there is marked cosmetic deformity or potential mandibular instability.
Telecanthus and rounding of the medial canthus are characteristic findings in direct
naso-orbital-ethmoid fractures.
The deep head of the pretarsal muscle (Horner's tensor tarsi) is a localized bundle of
pretarsal orbicularis that is critical to adequate tear drainage. It surrounds the lacrimal sac
and, with each blink, pumps tears downward into the nasolacrimal duct.
The lacrimal sac fossa is formed by the frontal process of the maxilla and the lacrimal
bone. It cradles the lacrimal sac and is continuous with the nasolacrimal canal.
The lacrimal gland fossa lies in the anterolateral orbital roof within the zygomatic process
of the frontal bone.
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Cogans sign: Upper eyelid twitch when patient with ptosis refixates from downgaze to
primary position; nonspecific finding in myasthenia gravis; also refers to venous
engorgement over lateral rectus muscle in thyroid disease
Epibulbar dermoids are solid choristomas. Adnexal dermoids are generally cystic.
Ophthalmology Explorer
The eye that does not have the skin crease appears smaller because the upper
eyelid skin forms a hood over the lid margin
The height of the skin crease is due to the interplay of several structures: the level of
the orbital septum, the amount of subcutaneous fat and the level of insertion of the
levator aponeurosis to the skin. In the East Asians (mainly Chinese, Koreans and
Japanese), the skin crease is lower or absent in comparison with other races for the
following anatomical reasons:
Dhaval Patel MD
the fusion of the orbital septum to the levator aponeurosis is lower (usually
below the superior tarsal border);
the primary insertion of the levator aponeurosis into the orbicularis muscle
and the eyelid skin occurs closer to the eyelid in the East Asians.
To achieve eyelid symmetry, the best way is to create a symmetrical skin crease in
the eye without one. This may be achieved by two means:
Surgical method: The skin crease may be created by excising a strip of skin
+/- orbicularis oculi or by the buried suture method.
Non-surgical method: The skin crease may be formed using sticker or glue.
This may be or by other cosmetic means (sticker or glue).
Cavernous haemangioma typically present in patient over the age of 30 and the
lesion tends to be intraconal. Blood fluid level is uncommon.
Capillary haemangioma usually becomes appear ant at birth or within the first 8
weeks of birth. The lesion typically gives a red cutaneous appearance.
Orbital varix shows positional proptosis and typically involves the superior
ophthalmic vein.
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attempt of the body to form barrier to limit its growth. Bleeding into cystic spaces
gives a blood-fluid level.
Clinically, lymphangioma causes a slowly progressive proptosis with globe
displacement, ptosis, and restrictive eye movement. The eyelid may have a bluish
discoloration from subcutaneous involvement. Sudden worsening of the proptosis
may be caused by bleeding into the cystic spaces. Enlargement of the lesion
following upper respiratory tract infection is a characteristic feature; this is caused by
lymphoid reaction in response to infection. Macroscopically, the lesion usually
appears dark red with cystic spaces which may contain dark blood. Histologically,
the lesion is made up of bloodless ectatic lymph channels and contain spaces lined
by a single layer of flat mesothelial cells.
Prognosis for histiocytosis is poor in Children with disease onset younger than 2 years
with multifocal disease (especially those with compromised liver or lung function, or impaired
hematopoiesis).
The distinction between fibrous dysplasia and ossifying fibroma is generally made
histologically. If osteoblasts are present, then the lesion is called an ossifying fibroma;
if absent, the term fibrous dysplasia is applied.
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pathology of the nevus flammeus (port-wine stain): dilated capillaries without the
endothelial cell proliferation which accounts for their flat clinical appearance.
Rhabdomyosarcoma
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The cell of origin is presumably an undifferentiated, pluripotent cell of the soft tissue.
These cells have the capacity to differentiate toward muscle with production of
myosin and actin and to show cross-striations.
Immunohistochemistry shows positivity for vimentin, myosin, myoglobin, musclespecific actin, and desmin.
Positive staining for S-100 is characteristic of any cell derived from the neural crest.
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Most important two tests in pre-surgical work-up of PTOSIS are corneal sensations and
bells phenomenon, as if abnormal, they are contraindications to surgery.
Two common surgical procedures for senile entropion will be: Bick procedure modified by
Reeh and Jones, Reeh and Wobig procedure.
The distance between the lateral orbital rim and the anterior corneal surface is measured
while doing exophthalmometry. The corneal reflex that is seen in the mirror of the
exophthalmometly is then taken as the reading.
Naugle exophthalmometer uses the upper and lower orbital rims for fixation of the
instrument
Orbital emphysema usually results from medial wall fractures (not floor fracture..!!) such
that sneezing or nose-blowing forces air from the paranasal sinuses into the orbital tissue.
Prophylactic antibiotic prevents orbital cell ulitis. The fracture is often small and difficult to
locate even with a CT scan. The majority of cases resolve spontaneously and surgery is
rarely required.
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The Ellebogens' criteria for the ideal eyebrow position and contour are:
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the brow ends laterally at an oblique line extending from the ipsilateral alar base and
ipsilateral medial canthus
the brow ends laterally at an oblique line extending through the ipsilateral alar base
and lateral canthus
the medial and lateral ends of the eyebrow lie at about the same horizontal level
the apex of the brow lies directly above the lateral limbus of the eye
the brow arches above the supraorbital rim in women and lies about at the level of
the rim in men
The epithelial cells of the phakomatous choristoma stained positively for S-100
protein and vimentin, the intermediate filament normally found in lens epithelial cells.
Keratin markers were negative.
Steroid Injection for Chalazion: A steroid injection can lead to permanent depigmentation
or atrophy of the skin at the injection site. The manufacturer of triamcinolone has recently
recommended against its use intraocularly and in the periocular region. Vigorous injection
can rarely result in retrograde intraarterial injection with resultant central retinal artery
occlusion. Use of triamcinolone injection for chalazion treatment must include a detailed
discussion between physician and patient, as well as adequate documentation in the
patient's record.
Papilloma is benign eyelid tumor but remember that it is not caused by human papilloma
virus.
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Conjunctival melanoma arises 75% from PAM, 26% mortality and they metastatise to
regional noded unlike uveal melanoma which metastatise to liver.
rare, mostly benign neoplasms and are mostly found on the caruncle.
This tumor arises from accessory lacrimal glands in the caruncle, especially in
elderly women. It also can arise from accessory lacrimal glands.
Histologic examination reveals solid nests and cords of polyhedral cells exhibiting
abundant, finely granular acidophilic cytoplasm and round to oval paracentral nuclei,
usually containing a single prominent nucleolus. Cystic cavities are identified within
the tumor.
Mesotherapy: In this technique drugs or nutrients are injected in the skin and subcutaneous
tissue to obtain a therapeutic effect. This modality of therapy has not yet received FDA
approval.
Chemical Peeling agents: Alfahydroxy acid peel, Trichloracetic acid peel, Phenol peel.
Fillers:
Temporary fillers are- Zyderm and Zyplast, Cosmodum and Cosmoplast, Hyaluronic
acid gel, Restylane, Radiance FN, Revidum intra, Cymetra sculptra
Permanent fillers are- Artecoll- PMMA microspheres in 3.5% collagen. Sheba
Injectable microionised humandermis.
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Botulinum toxin A
Milles Syndrome: facial nevus flammeus and angioma of the choroid in absence og
glaucoma.
Centurion syndrome is characterized by anterior malposition of the medial part of the lid,
with displacement of puncta out of the lacus lacrimalis due to a prominent nasal bridge.
Sump syndrome complication of DCR, in which the surgical opening in the lacrimal bone is
too small and too high. There is thus a dilated lacrimal sac lateral to and below the level of
the inferior margin of the ostium, in which secretions collect, unable to gain access to the
ostium and thence the nasal cavity.
Giant fornix syndrome: This is due to retained debris in the upper fornix that is colonized
by S. aureus, usually in elderly patients with levator disinsertion. Secondary corneal
vascularization and lacrimal obstruction are common. Treatment involves thorough cleaning
of the fornix, and topical and systemic antibiotics.
The brow fat-pad continues into the upper lid as filmy areolar tissue found posterior to the
orbital and preseptal orbicularis muscle, termed the retro-orbicularis oculi fat (ROOF),
located within the superficial musculoaponeurotic system (SMAS).
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In lower lid, deeper suborbicularis oculi fat (SOOF), less substantial than the malar fat,
extends over the body of the zygoma and is continuous inferiorly with the fat deep to the
zygomatic major and minor muscles. The suborbicularis oculi fat is located deep to the
SMAS and may also droop with aging. In cases of paralytic ectropion from Bell's palsy,
ptosis of the suborbicularis oculi fat may need to be addressed in the surgical management.
PIEZOMETRY: orbitometry
Iliff's sign: This involves everting the eyelid and asking the patient to look up. Failure of the
eyelid return to its normal position when the patient looks up indicates poor LPS muscle
function.
The ETA as described by Baylis is an accurate technique for ptosis correction in patients
with poor EPMs.
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not only elevates the upper eyelid but also provides a spacer or graft for the lower
eyelid
dictyoma
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aka medulloepithelioma
Removal of the palpebral part of lacrimal gland leads to the gland becoming non-secreting.
The Neosynephrine test is an evaluation of the effect of Mullers muscle contraction on the
degree of ptosis. One drop of 2.5% phenylephrine is placed in the eye. After 5 minutes, the
degree of ptosis is reevaluated. The phenylephrine causes contraction of the sympathetic
Horners muscle, sometimes causing dramatic improvement in the degree of ptosis. If
phenylephrine corrects the ptosis completely, many surgeons elect to perform a Mullers
muscle resection as opposed to a levator resection.
Contraction of the orbicularis muscle provides a positive pressure in the tear sac,
forcing tears into the nose through the valve of Hasner.
Once the eyelids open and move laterally, a negative pressure is produced in the
tear sac, which is maintained by the valve of Hasner.
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The lacrimal sac fossa is bordered by the anterior lacrimal crest of the maxillary bone and
the posterior lacrimal crest of the lacrimal bone. In a dacryocystorhinostomy (DCR), the
ostomy is created at the maxillolacrimal suture line located in the lacrimal sac fossa.
Pseudostratified columnar epithelium lines the nasolacrimal sac, duct, and canaliculi.
The slight indentation or groove in the central aspect of the eyelid margin is the sulcus
intermarginalis of Graefe or the gray line which corresponds to the lid's orbicularis muscle
layer, the muscle of Riolan. It is not the mucocutaneous junction of the eyelid margin. The
mucocutaneous junction occurs posterior to the eyelashes near the opening of the
meibomian glands.
The Reese-Ellsworth classification was developed in the 1950s as a guide for predicting
visual prognosis in eyes treated by methods other than enucleation. It has been used
erroneously to predict patient prognosis for life.
The capillary hemangiomas are characteristically high flow lesions, in contrast to cavernous
hemangiomas, which are hemodynamically low flow.
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The two most common causes of DCR failure are obstruction at the common canaliculus
and obstruction at the bony ostomy site.
Pneumococci are the most common organism causing acute dacryocystitis. Other
organisms include streptococci, diphtheroids, Klebsiella pneumonia, Haemophilus
influenzae, Pseudomonas aeruginosa, and mixed organisms. Actinomyces and fungi, such
as Candida, are also frequently seen.
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propionica (previously Streptothrix), Nocardia, and fungi, such as Candida albicans and
Aspergillus niger, have been documented to cause canaliculitis.
Of patients with mucormycosis, 70% have diabetes mellitus, 5% have renal disease, 18%
have other immunosuppressed states, 3% have leukemia, and only 4% have no systemic
illness.
The clinical signs of thyroid-related orbitopathy can be generally grouped into two
independent manifestations: type 1 and type 2 orbitopathy.
Type 1 orbitopathy comprises symmetric proptosis with symmetric eyelid retraction,
minimal orbital inflammation, and minimal extraocular muscle inflammation or restrictive
myopathy.
Type 2 orbitopathy comprises extraocular muscle myositis, restrictive myopathy, orbital
inflammation, and chemosis. Compressive optic neuropathy is more commonly a feature of
type 2 orbitopathy.
Fuchs' adenoma:
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Homer-Wright rosettes are characterized by cells that line up around an area containing
cobweb-like material, but no acid mucopolysaccharides are present. These rosettes are
not specific for retinoblastoma and are found also in neuroblastoma and
medulloepithelioma. Rhabdomyosarcoma displays no rosette formation.
In contrast, Flexner-Wintersteiner rosettes are the characteristic rosettes of
retinoblastoma but are not always present. The presence of Flexner Wintersteiner rosettes
makes the diagnosis of a well-differentiated retinoblastoma. In Flexner-Wintersteiner
rosettes, the cells line up around an apparently empty central lumen. However, special
stains show hyaluronidase-resistant acid mucopolysaccharides in the lumen.
lentigo maligna and nodular melanoma each occur in 10% of cases. Lentigo maligna,
also known as melanotic freckle of Hutchinson, is sun induced.
Both have a long horizontal growth phase before invading the deeper tissues.
Nodular melanoma is more aggressive with earlier vertical invasion and has worst
prognosis.
Fibrous histiocytoma
o
Most are benign (>90%), and have a storiform, or matlike, pattern on histopathology.
Ten percent have metastatic potential. Another 16% are termed locally aggressive
but not frankly malignant.
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Papilloma is treated with interferon alpha 2b. in recurrent cases oral cimetidine can be used.
number of diseases have now been recognized as part of the spectrum of IgG4-RD,
and these include sclerosing cholangitis, Mickulicz disease, Kttner tumor
(sclerosing sialadenitis), Riedel thyroiditis, multifocal fibrosis, Ormond disease
(idiopathic retroperitoneal fibrosis), and others
Dacryoadenitis,
Orbital myositis
Treatment
rituximab.
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Community Ophthalmology
WHO declared the year 1976 as "The Year of Prevention of Blindness" and stated that
the 6 main causes of blindness were:
o
Cataract
Trachoma
Xerophthahnia
Onchocerciasis
Glaucoma and
Trauma
In 1948, the first randomized clinical trial (RCT) was published on the use of
streptomycin in pulmonary tuberculosis.
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reporting of randomized clinical trials (RCTs) in order to allow the reader to adequately
judge the quality of the study.
Average visual acuity is significantly better than 20/20 in individuals younger than 60
years.
Pediatric blindness most commonly occurs from corneal scarring and retinal diseases.
Studies have shown that ethnicity does not affect the incidence of ophthalmia neonatorum,
but socioeconomic status certainly does.
Topical: saline lavage hourly, bacitracin eye ointment qid, or penicillin drops
5000-10,000 IU/ml
Worldwide, 135 million people have vision <20/60, and approximately 45 million have vision
<20/400. (?)
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National Fortnight on Eye Donation is celebrated from 25th August to 8th September. Late
Prime Minister Shri Rajiv Gandhi pledged his eyes for donation on the 25th August to
motivate people. Since then a fortnight is celebrated every year.
Childhood Blindness
o
prevalence of uncorrected refractive error (myopia) among age groups 7 -15 years is around
7.3% in urban and 4% in rural.
The prevalence of ocular trauma in a study urban slums Delhi s= 2.4% (2008)
In South India (Andhra Pradesh Eye Disease Study) = 3.97% (2000)
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DR in community:
o
Blindness Prevalence:
o
Cataract blindness as per NPCB criteria in 50+population- 5.32% (8 % as per 198689 Survey)
Assistance of Rs. 1500/- per case for management of diseases like diabetic
retinopathy, glaucoma, childhood blindness including squint and ROP etc
Assistance of Rs. 5000/- per case for corneal transplantation, vitreo-retinal surgery
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India Study of Age-related Eye Disease (INDEYE study) (RPC and LAICO)
o
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Miscellaneous
AR
AR
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presence of some pigment in the hair, skin, and eyes of all patients beyond
infancy
maps to 15q11
Ocular Albinism:
o
XR
NettleshipFalls type
eyes show hypomelanosis with nystagmus, and the hair and skin have no or little
clinical manifestation
mother is carrier
Five tests can be performed to diagnose XLOA or to detect the carrier state: iris
illumination, fundus examination, skin biopsy, VEP, and DNA tests
Ophthalmology Explorer
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OCA 4: MATP
OA 1: XL
There are nine distinct subtypes of EDS but type 6 and, rarely, type 4, are associated with
ocular features.
Eye-Protective Mechanisms
Tear production
Corneal sensation
Ocular motility
Bell's phenomenon
Gadolinium and fat suppression are T1 techniques and both should be used together as
no use of giving only gadolinium.
FLAIR is T2 technique that suppreses water (CSF). It may be confused with T1.
Melanin: melanoma
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NAION
Papilledema
Heavy eye syndrome: This condition occurs when the globe enlarges on the basis of axial
myopia. This globe enlargement results in dehiscence of the intermuscular membrane in the
superior temporal area which in turn results in the superior rectus shifting nasally and the
lateral rectus inferiorly. In some cases the eye is also hypodeviated in this condition. A
relatively new procedure described by Yokoyama unites the belly of the nasally displaced
superior rectus muscle with the inferiorly displaced lateral rectus with reported good results.
If the medial rectus is tight, it could be recessed or some would consider the use of Botox.
Hutchinsons pupil: Fixed, dilated pupil in comatose patient due to uncal herniation and
compression of cranial nerve III
Hutchinsons sign: Involvement of tip of nose in herpes zoster ophthalmicus (nasociliary
nerve involvement)
Hutchinsons triad: Three signs of congenital syphilis interstitial keratitis, notched teeth,
and deafness
In USG, Gain adjusts the amplification of the echo signal, similar to volume control of a
radio. Higher gain increases the sensitivity of the instrument in displaying weak echoes such
as vitreous opacities. Lower gain only allows display of strong echoes such as the retina and
sclera, though improves resolution because it narrows the beam.
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Ophthalmomyiasis:
Myiasis is coined from the Greek word myia denoting fly. It refers to the infestation of
tissues by the larvae (maggots) of diptera (two-winged) flies. The condition is well
recognised in animals but rare in humans. Cases of human myiasis have been reported in
various parts of the world and could be attributed to one of the three dipteran families:
Oestriade, Calliphroidae and Sarcophagidae.
In South-East Asia, animal myiasis is endemic and the main causative agent is Chrysomya
bezziana, also known as screwworm fly of the Old World. This fly belongs to the
Calliphoridae family and causes obligatory myiasis (it requires a living host for the
development of the larval stages). It infests mainly domestic animals and may cause great
losses in livestock industry if not treated rapidly.
Screwworm infestation is transmitted by the female fly that lays her eggs on a superficial
wound, but occasionally on unbroken soft skin, especially if it has blood or mucous
discharge on its surface. Eggs are deposited in batches of 150 to 500 and hatch in about 15
hours. The larval bodies, measuring 10 to 15mm are armed with broad, encircling bands of
spines. The larvae feed on blood and serum and burrow deep into the tissue with their
mouth-hooks causing considerable destruction. Infested wounds often attract other female
screwworms resulting in multiple infestations. After feeding for 5 to 7 days, the larvae leave
the wound and fall to the ground where they burrow and pupate for one week or more to
emerge as adult flies. The life cycle from egg to egg takes about 24 days.
The sclera of a child is easier to penetrate than that of an adult.
Draize eye test: Justified by an exigency for public protection, the Draize eye test became a
governmentally endorsed method to evaluate the safety of materials meant for use in or
around the eyes. The test involves a standardized protocol for instilling agents onto the
cornea and conjunctiva of laboratory animals. A sum of ordinal-scale items of the outer
eye gives an index of ocular morbidity
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serous retinal detachment (from the breakdown of the retinal pigment epithelium
barrier)
It was thought at the time that animal eyes actually generated light and that the more excited
the animal, the brighter the light. This idea was ultimately put to rest by Prevost (1818) who
showed that one never saw a luminous eye when the animal and observer were in a totally
dark room. At about the same time Gruithuisen discovered that the eyes of some animals
(e.g., dogs and cats) contain a unique layer behind the retina, the tapetum lucidum that
reflects light and is responsible for the luminous appearance of animal eyes.
Key idea in the invention of the ophthalmoscope: the illumination axis and the observers
viewing axis have to be as close as possible.
Ophthalmology Explorer
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The Singaporean Chinese community, in particular, has a very high incidence of primary
angle-closure glaucoma.
Mydriatic recovery in normal eyes is as follows: atropine (7-10 days), scopolamine (3-7
days), homatropine (1-3 days), cyclopentolate (1 day), and tropicamide (6 hours).
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During the procedure C3R, 0.1% Riboflavin eye drops in Dextran solution are applied to the
cornea for 30 minutes followed by exposure to UV-A light (365 nm) at 3mW/cm2 to achieve
cross-linkage of the corneal collagen fibres.
The term lagophthalmos comes from the Greek word for hare (lagos) because rabbits
were thought to sleep with their eyes open.
Color blindness was not recognized as a congenital defect until 1794 when the famous
chemist John Dalton described his own red-green deficiency.
AD/ MCI/ Normal Cognition: Patients with probable AD had significantly narrower retinal
veins and decreased retinal blood flow compared with those with MCI and normal controls.
But the MCI group had significantly lower blood flow and blood speed than those with
normal cognition.
Bionic Eye: US Food and Drug Administration (FDA) approved a retinal prosthesis that
may help blind people with advanced-stage retinitis pigmentosa avoid obstacles and read
large letters. It does not restore normal vision, but it does produce patterns of light that the
brain learns to interpret as specific objects in the environment
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Sweet syndrome: key clinical features in this case are the abrupt onset of fever, bilateral
ocular inflammation nonresponsive to topical steroids, and tender skin nodules in a
patient with a known diagnosis of ulcerative colitis. Two features are absolutely required for
diagnosis: the abrupt onset of a typical skin eruption that consists of tender erythematous
plaques, nodules, or pustules, and the histologic finding of neutrophilic infiltration in the
dermis without leukocytoclastic vasculitis on skin biopsy.
Antibiotic impregnated
Pterygium Graft
Chorioretinal adhesion
Cyanoacrylate
Octyl-2-cyanoacrylate
Adal-1 cyanoacrylate
Iso-amyl-cyanoacrylate
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experimental use of oral rifampin and mifepristone (RU486) has recently been suggested
especially in chronic or bilateral cases of CSCR.
An ancient eye test-using the stars: Vision testing in ancient times was as important as it
is today. The predominant vision testing in some cultures was the recognition and
identification of constellations and celestial bodies of the night sky. A common ancient
naked eye test used the double star of the Big Dipper in the constellation Ursa Major or the
Big Bear. The second star from the end of the handle of the Big Dipper is an optical double
star. The ability to perceive this separation of these two stars, Mizar and Alcor, was
considered a test of good vision and was called the "test" or presently the Arab Eye Test.
This article is the first report of the correlation of this ancient eye test to the 20/20 line in the
current Snellen visual acuity test. This article describes the astronomy, origin, history, and
the practicality of this test and how it correlates with the present day Snellen visual acuity
test.
Fishhook contains the barb at its end, so once inside, its difficult to remove it in cases of
eye injury.
Ophthalmology Explorer
Dhaval Patel MD
Previous work by scientists had pointed to an anatomical location, the optic nerve head,
where vision loss most likely occurs in glaucoma. This study is the first to pinpoint where
within the optic nerve head the blinding insult is likely to be, which would explain the very
characteristic pattern of blindness in glaucoma
Paget's disease:
the patient who need a bigger hat develop an afferent pupillary defect
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This causes enlargement of the skull due to disorganization of the bony structure. This can
cause compressive optic atrophy in the optic canal.
Visual claudication
woman complains of discomfort in both arms and a transient loss of vision which occurs on
exercises
Takayasu's syndrome with involvement of the carotid and axillary arteries. Exercise
causes a "steal" syndrome leading to retinal ischaemia.
VITAL Study: VIsion TriAL for depression management, related to low vision aids.
condition that causes patients with visual loss to have complex visual
hallucinations, first described by Charles Bonnet in 1760 and first introduced into
English-speaking psychiatry in 1982.
Sufferers, who are mentally healthy people with often significant visual loss, have
vivid, complex recurrent visual hallucinations (fictive visual percepts). One
characteristic of these hallucinations is that they usually are "lilliputian"
(hallucinations in which the characters or objects are smaller than normal). The most
common hallucination is of faces or cartoons. Sufferers understand that the
hallucinations are not real, and the hallucinations are only visual, that is, they do not
occur in any other senses, e.g. hearing, smell or taste
Serif fonts and Sans Serif fonts are two broad categories of letters.
National Institute for the Visually Handicapped NIVH is situated at 116 Rajpur Road,
Dehradun - 248 001, Uttaranchal, India. Phone: + 91 135 274 4491
Coenurosis is a parasitic infection that results when humans ingest the eggs of dog
tapeworm species Taenia multiceps, T. serialis, T. brauni, or T. glomerata. There are many
different tapeworm species belonging to the genus Taenia, but these four in particular are
responsible for the rare human disease, coenurosis.
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In 1974, US National Institutes of Health held a conference on the naming of diseases and
in 1975, JAMA published an article and decided to drop the possessive s in all its
publications (Down syndrome not Downs Syndrome) but has not been able to convince
journal editors.
Tyndall effect: A very sensitive way to detect particulates is to bathe the air with intense
light. The scattering of light by particulate impurities in air and other gases, and in liquids, is
known today as the Tyndall Effect or Tyndall Scattering.
Uyemuras syndrome: xerophthalmic fundus, White spots of the fundus combined with
night blindness and xerosis
Bermanns locator
Carnays locator
Ophthalmometalloscope of Hale
Limbal ring method for detection of FB was described by Stallard and Somerset. It was
used basically to detect FB is intraocular or extraocular.
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types of magnets
o
FUGO Blade:
o The working end of the tool is the blunt tip of a steel wire, varying in size from 100
micron to 600 microns
o plasma energy from the activated working tip is transferred to the molecules of the
tissues, by the process of resonance
Lodoxamide (Alomide)
H1 receptor antagonists
o
Levocabastine (Livostin)
Emedastine (Emadine)
Ketotifen (Zaditor)
Olopatadine (Patanol)
Pemirolast (Alamast)
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Echothiophate iodide is an irreversible cholinesterase inhibitor whose effects may persist for
days after discontinuation of the drug.
Ciprofloxacin has broad gram-positive and gram-negative bacterial activity by interfering with
DNA gyrase; however, recent reports have described the growing resistance of
streptococci to ciprofloxacin.
Lateral Thinking
Stigler's Law of Eponymy, which states, "No scientific discovery is named for the
original discoverer" As proof, Stigler freely admits that others postulated the idea before he
named it for himself.
In describing Stigler's Law, Malcolm Gladwell stated, "We think we're pinning medals on
heroes. In fact, we're pinning tails on donkeys.
"Domino" effect: chain reaction that occurs when a small change causes a similar
change nearby, which then causes another similar change, and so on in linear sequence.
The term is best known as a mechanical effect, and is used as an analogy to a falling row
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of dominoes. It typically refers to a linked sequence of events where the time between
successive events is relatively small. It can be used literally (an observed series of actual
collisions) or metaphorically (causal linkages within systems such as global finance or
politics).
Butterfly effect is the sensitive dependency on initial conditions in which a small change at
one place in a deterministic nonlinear system can result in large differences in a later state
Lewis Carroll conceives of Alice seeing things smaller than they were was because of
Migraine in which he had episodes of micropsia during his migraine attacks.
The concept of removing clouded cornea was described by Erasmus Darwin, grandfather
of Charles Darwin.
Samuel Thomas van Sommerring was a german anatomist, who first described
importance of macula and in older literature, macula is also referred as Sommerrings
spot.
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William Conner and Richard Alexander started a small pharmacy Alcon (AL from
Alexander and CON from Conner, in texas in 1949 making sterile medical appliances and
drugs. It grew over time and was bought by a swiss company and sold off again recently to
NOVARTIS as one of the biggest business deal 28 billion USD.
ALLERGAN:
The innovative spirit that infuses Allergan today can be traced back to Allergan's founder,
pharmacist Gavin S. Herbert. In 1948, Mr. Herbert was already the successful owner of a
chain of drug stores in Los Angeles. But his interest and entrepreneurial instincts were
ignited when a close friend and chemist, Stanley Bly, approached him with an idea for an
anti-allergy nose drop containing the antihistamine neoantergan (aka MEPYRAMINE).
They set up a small laboratory on the balcony of Mr. Herbert's drugstore in Los Angeles to
make the solution, which they named ALLERGAN Nasal Drops. Responding to the
suggestion of an ophthalmologist friend, Mr. Herbert and Mr. Bly later reformulated the
product as an eye drop to treat allergic conjunctivitis (inflammation of the eye). The result
was ALLERGAN, the first antihistamine eye drop in the United States.
Norma Jeane Mortenson became Marilyn Monroe after cosmetic aesthetic surgery.
Literal meaning of cul-de-sac is a road with one end blocked or dead end.
In 1850s, Eye Mirror or Eye Speculum was a popular name for an emerging
ophthalmic instrument among the Europe augenspiegel (german name of eye mirror)
which later become ophthalmoscope.
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The word ophthalmoscope was first introduced by Maressal de Marsilly from Calais,
France, in 1852.
The term daltonism was described for color blindness of John Dalton, the great chemist
who first described his own anomaly.
It was Sir Isaac Newton who first proposed that binocular vision results from partial
decussation of optic nerve fibres at optic chiasm.
Another term suggested for ICE syndrome is NUDE syndrome..!! (not approved still) Now
the syndrome described by Al Reese and me is characterized by nodules, unilateral
glaucoma, Descemet's membrane and endothelial extension; why not call it by the acronym
NUDE syndrome.
Elschnig:
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Elschnig's syndrome (Elschnigs complex): Also known as Blepharo-cheilodentin (BCD) syndrome. Features include ectropion of lower eyelids, distichiasis of
upper eyelids, euryblepharon(symmetrical enlarge-ment of the palpebral aperture
associated with large eyelids), bilaterally cleft lip/palate, oligodontia, and conical
crown form. Initially known under the eponym Elschnig syndrome.
Elschnig's intracapsular forceps: fine untoothed forceps for holding tissue, swabs,
sutures, etc; removing things like clots, capsule fragments, lens, etc; used in cataract
surgery
Elschnig's scleral ring: Scleral ring is a white circular band that separates the
intrapapillary region of optic disc from the peripapillary area.The scleral ring itself
does not belong to optic disc.This is important for all optic disc measurements
because the inclusion of scleral ring as part of optic disc falsely enlarges the
neuroretinal rim & decreases cup/disc ratio.Loss of nerve fiber layer in Glaucoma
can make the scleral ring more visible due to loss of overlying tissue.
Vogt:
o
Vogt's striae: Seen in keratoconus, With thinning of the cornea vertical lines in the
Descemet's membrane become visible. They disappear with pressure on the globe
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Arctic explorer develops disc swelling due to Vitamin A toxicity from eating polar bear
liver. The liver of polar bear is dangerously high with vitamin A.
Acute angle closure glaucoma can present with abdominal pain with nausea and
vomiting.
Crocodile Tears: Following damage to the facial nerve as in Bell's palsy, misdirection of the
regenerating fibres may innervate the lacrimal gland rather than the mouth muscles and the
parotid glands. Consequently, chewing food causes weeping. Legend has it that the
crocodile has compassion and remorse for its prey and wept with sorrow when it eats its
prey.
Bungee jumper with blurred vision: Valsalva's retinopathy. The build-up of pressure in
the venous cava causes the retinal vein to burst and produce haemorrhage.
Tool maker's eye: Argyrosis. It is a term applied to the deposition of silver salts in the
tissue. In the conjunctiva, the deposition of silver turns black on oxygenation.
Famous Victorian writer who is also an ophthalmologist: Sir Arthur Conan Doyle, the
creator of Sherlock Holmes. Apparently not a good one, as he had plenty of time for writing
due to lack of patients.
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Albert Einstein's eyes were removed by his ophthalmologist Dr. Henry Abrams during the
autopsy in 1955 and stored in a safety deposit box. The eyes were put up for auction in
1994.
Uvea means a grape. The term was first used by Galen, a Roman physician to include both
the choroid and the iris because they resemble a grape from which the stalk had been torn
out leaving a hole in front, the hole being the pupil of the eye.
Carotid is derived from a Greek word meaning "to put to sleep" because pressure on the
carotid arteries can cause loss of consciousness. Rufus of Ephsus said (about 100 AD):"
The ancients called the arteries of the neck carotid because they believed that when they
were pressed hard the animal became sleepy"
Atropine poisoning: "hot as a hare, blind as a bat, dry as bone, red as a beet, mad as a
hen".
coast of Maine:
Fibrous dysplasia (Albright's syndrome)
It is characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine
dysfunction, with precocious puberty in females. The borders of the pigmentation has an
irregular or jagged edge (coast of Maine). The involvement of the orbit can lead to
shallowing and proptosis.
coast of California:
Neurofibromatosis.
The pigmentation has a smooth edge (coast of California). In some patients, the congenital
absence of sphenoid bone leads to encephalocele and proptosis
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Iago blandly warns Othello that jealousy is "a green-eyed monster which doth mock the
meat it feeds on." In China, covetousness is "red-eye disease".
H.G.Wells one of the story, a sighted man fell into the Valley of the Blind and fell in love
with a blind girl. When faced with the threat of losing his sight, he fled. The famous quote is
in the country of the blind, the one-eyed man is King.
Ella Wheeler Wilcox (1850-1919): Laugh, and the world laughs with you; Weep, and
you weep alone
Ovid advised man to shed tears. "They move the most adamant natures. Let her, if
possible, see tears on your cheeks, in your eyes." And if you can't produce tears at will, he
says, bring a vial of water and fake it.
Darwin observed that the English wept less than the Mediterranean.
One recent survey found that Israelis cry less than Britons, possibly, the authors
suggest, because of mandatory military service in Israel, which "encourages an active
and resourceful approach to the solution of problems and produces someone better able
to cope with difficulties.
Women cry more often and longer than men. In one study they wept 5.3 times a
month, compared to 1.4 for men. They also use tears more commonly as a coping
device, to win sympathy and shame malefactors.
Grief is not the sore cause of tears. Glory, success after extreme effort, can bring
tears. Perhaps the oddest of all, music can cause tears. One duct-squeezing trick entails
repeating a musical theme a step higher or lower than when the listener first heard it, as
in Albinoni's Adagio for Strings. Another, even more effective, is the appoggiatura, or
delay in resolving a musical theme. The Beatles' "Yesterday" begins with one, and
appoggiaturas abound in tear jerking tunes. They build a kind of anxiety, which the
melody finally resolves
In La Vita Nuova, Beatrice flashes love from her eyes and inflames Dante.
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Love at first sight usually involves eye contact, and the Greek poet Meleager (1st
century B.C) placed Cupid inside the eyes, whence he aimed his barbs. In much
subsequent lover poetry, and later among Arab poets and Provencal Versifiers of the 12th
century, the eyes shoot arrows, darts, or fiery beams that wound the soul and infect with
longings
BACCIO BANDINELLI Vasari describes repeatedly the poor color quality of Baccios
paintings, but without specifying why. The paintings tend to use a monochrome yellow or
ochre for flesh tone.
EAGLES HAVE TWO FOVEAS: One fovea optimizes monocular vision to the side and the
other optimizes binocular vision to the front. An extremely soft lens of the eye allows for
rapid accommodation
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This is the fact which you will use in Toric IOLs and all your other kind of LASIK
procedures. The reasons I found are..
fusion loss (Park et al., 2009; Hori-Komaii et al., 2007; Fea et al., 2006; Chernyak,
2004; Swami et al., 2002);
dynamic cyclotorsion: blurring of the fixation target happens during ablation (after
epithelium removal in surface ablation and following flap lifting in LASIK)
(average cyclotorsion resulting from the shift from the upright to the supine position is
about 4)
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Ophthalmology Explorer
Dhaval Patel MD
Multiple theories
Duane 2006: The longer wavelengths of light penetrate water more deeply than do
the short wavelengths and are eventually absorbed. The shorter wavelengths are
reflected about in the superficial layers of water and reflected back to the observer,
making the water appear blue. In addition, the water is illuminated by the blue sky.
Some of this blue light is reflected toward the observer, contributing to the blueness.
(This is not believed now.I checked in physics book and article)
Now it is proved that it is due to: The longer wavelengths of light like red and
orange are absorbed in superficial layers of water and short wavelengths like blue
penetrate better which then get reflected and this is how water appears blue.
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Ophthalmology Explorer
o
Dhaval Patel MD
Latest theory just like above: intrinsic blueness of water is the only example from
nature in which color originates from vibrational transitions
Healing is accelerated by 50 %
Epithelial hypertrophy
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Ophthalmology Explorer
Dhaval Patel MD
improved aqueous humor outflow through the trabecular meshwork, ie, increased
aqueous outflow facility.
Trabecular meshwork endothelial cells from glaucomatous eyes that were exposed
to ultrasound had increased interleukin-1 (IL-1 ), a stress hormone and pathologic
marker for primary open-angle glaucoma, through NFB translocation from the
cytoplasm into the nucleus.
Ophthalmology Explorer
Dhaval Patel MD
Important History
The term astigmatism is the joining of a and stigmata, a term suggested by Dr. William
Whewell (1794-1866)
In 1837, the astronomer Sir George Biddle Airy made a cylindric lens and used it to
correct astigmatism.
History of JCC:
o
Stokes lens: consisted of two cylinders, one planoconvex and one planoconcave,
with flat surfaces approximated and arranged so that they could be rotated in
opposite directions.
Edward Jackson realized the instrument's potential for determining cylinder power
modified Stokes lens with axes fixed perpendicular to one another came to be
known as the Jackson crossed cylinder
In 1984, Mazzocco et al introduced the first foldable plate haptic silicone lens produced
by STAAR Surgical. It became known as the Mazzocco Taco because of the way it
appeared when folded.
One of the most important and challenging tasks in IOL power calculation is to predict the
ELPo for a given eye - Dr. Haigis
Vitrectomy History
o
In 1974, OMalley designed a smaller vitreous cutter with a diameter of 0.9mm (20gauge). This less invasive 3-port 20-gauge cannula-entry system is still used today.
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Ophthalmology Explorer
Dhaval Patel MD
Salssmann (1914) was first to perform direct gonioscopy & is known as Father of
Gonioscopy.
Ophthalmology Explorer
Dhaval Patel MD
Mucormycosis Rx Amphotericin B
Pigmentatory changes between posterior pole and equator [salt and paper retinopathy] are
seen in all of following except? Resolving retinal detachment, Rubella, Phenothiazine
toxicity, Fundus flavimaculatus Fundus flavimaculatus
Which of the following procedure most commonly performed by eye surgeon at district level
Phacoemulsification
A patient diagnosed with chalazion c/o pain. True statement is chalazion is lipogranuloma
True about pterygium resection via bare sclera technique cause recurrence of 30-70%
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