Ocular

Anatomy &
Physiology

John C. Lloyd, MD
Sunnybrook HSC
December 2017
 Financial Disclosure

• Consultant to:
– Abbott Medical Optics (AMO)
– Alcon
Eye = The “Globe”

• Dimensions – average eye is about 23 mm in diameter

– about the size of a quarter
• Antero-posterior diameter – or “axial length”
– Varies between 20 – 30 mm or more
– Each mm results in a refractive change of ~ 3 D
– Hyperopic eyes shorter, myopic longer
– A highly myopic eye would be about the size of a “toonie”
– Laser and ultrasonic measurements allow this to be
measured accurately within 0.05 – 0.1 mm, allowing good
refractive accuracy post cataract surgery
Conjunctiva

• Clear mucous membrane covering the sclera and

reflected back onto the inner eyelids
• Epithelial layer including mucous secreting goblet
cells, and a vascular substantia propria containing
lymphatics, plasma cells, macrophages, and mast cells
• “Tenon’s capsule” is a thin fibrous layer between the
conjunctiva and the sclera
Conjunctiva

• Innervated by trigeminal nerve (V1)

• Bulbar conjunctiva on the globe, and palpebral
conjunctiva on inside of lids, fornix the cul-de-sac
where it reflects from the globe to the lids
• Impossible for a contact lens to “get behind the eye”,
though the superior fornix is deep and it can get lost up
in there!
• Upper lid requires “double-eversion” to see this area
Conjunctiva
1. Limbus
2. Bulbar Conjunctiva
3. Fornix
4. Palpebral Conjunctiva
5. Punctum
6. Lid margin
Lid Eversion
Conjunctiva

• Accessory lacrimal glands of Krause and Wolfring are

in the stroma, and the mucous secreting goblet cells
are in the epithelium
• This is why conjunctival alkali burns, or Stevens-
Johnson syndrome cause severe dry eye when the
conjunctiva is damaged
• The accessory lacrimal glands and goblet cells may
function less well with aging, contributing to dry eye
symptoms – including the paradox of the associated
watery eye from “reflexive” tearing from the main
lacrimal gland
Cornea

• Clear window allowing light to pass through, though

composed of the same elements as sclera
• Regular spacing and orientation of collagen fibrils
permit clarity; disruption by injury or edema causes the
cornea to become opaque & white
• Convex, contributes about 2/3 of eye’s refractive
power
• 0.5 mm centrally, 1 mm peripherally
 Cornea
• Laser eye surgery creates a flap about 0.12
mm thick in the cornea, and then about 0.012
mm is removed per diopter of refractive
correction
Cornea

• Avascular and in a state of relative dehydration

(endothelial pump)
• Receives nutrients from tears, atmospheric oxygen,
aqueous humour & limbal capillaries
• 5 layers:
– Epithelium – 35-50 microns
– Bowman’s membrane – 10-12 microns
– Stroma – 450 microns centrally, 900 peripheral
– Descemet’s membrane – 3-12 microns
– Endothelium – 4-6 microns
 Corneal Layers
Graphic Microscopy

1. Epithelium
2. Bowman’s membrane
3. Stroma
4. Descemet’s membrane
5. Endothelium
Corneal injuries

 Epithelium heals rapidly without scarring

 Innervated by CN V1 – epithelial injuries expose
superficial nerve plexus which is very painful
 Bowman’s layer and stroma heal with scarring if
damaged and do not regenerate
 Endothelium when damaged does not regenerate;
adjacent cells enlarge and slide to cover the
damaged area; if enough cells are damaged the
cornea will swell from failure of the “pump” and an
edematous cloudy cornea will result – “bullous
keratopathy”
 The epithelium may not adhere well to the swollen
cornea, and slough off – causing pain
Failure of Endothelial “Pump”

Endothelial Cells Bullous Keratopathy

 Posterior Radial Keratotomy

WW2 Japanese pilots, initial success, also led to the

discovery of the importance of the corneal
endothelium !
Cornea

• Diameter ~ 12 mm
• Most contact lenses are 14 mm in diameter, to allow
an overlap of 1 mm around the cornea
• Cornea blends into the sclera at a junction called the
“limbus”
• The limbus has stem cells than can regenerate the
corneal epithelium – damage to the limbus will prevent
re-epithelization after injury
Aqueous Humour
 Fills the anterior & posterior chambers lying
between the cornea and the ciliary body
 Provides nutrients to the cornea and lens, and
removal of waste
 Produced by the ciliary body epithelium at a
rate of about 2 ul/min
Anterior Chamber

• Anterior chamber is about 3 mm deep centrally, and

has a volume of 200 ul
• The aqueous humour turns over about every 1.5 – 2
hours
• Drains via the trabecular meshwork into the canal of
Schlemm, then into the episcleral veins
• The intraocular pressure results from the balance
between inflow and outflow of the aqueous humour
 Uveal Tract:
Iris, Ciliary Body & Choroid
u·ve·a
͞
ˈyoovēə/
noun
(Latin uva – “grape”)

The pigmented layer of the eye, lying beneath the sclera and cornea, and
comprising the iris, choroid, and ciliary body.

The name is possibly a reference to its reddish-blue or almost black

colour, wrinkled appearance and grape-like size and shape when
stripped intact from a cadaveric eye.
 Uveal Tract: Iris

 Iris arises from the ciliary body and separates

the anterior and posterior chambers
 Visible coloured portion of the eye
 Pupil is central aperture; constricts via the
sphincter muscle (parasympathetic) and dilates
via the radial muscle (sympathetic)
 “Flight or fright” response = sympathetic = pupil
dilation !
 Pupil regulates the amount of light to provide
the correct contrast for the retinal image
Uveal Tract: Ciliary Body

 Triangular body, extending from the scleral spur to

the ora serrata (edge of the retina)
 Pars plicata is the more anterior portion, consisting
of ridged ciliary processes which produce aqueous
humour
 The zonules of Zinn arise from valleys between the
ciliary processes and support the lens
 Pars plana is more posterior, quite avascular,
extends 4 mm from the pars plicata to the ora, and
lies about 3-4 mm posterior to the limbus
 Pars plana provides the safest surgical option to the
retina and vitreous (PPV = pars plana vitrectomy)
 ORA
SERRATA
INJECTIONS VIA THE
“PARS PLANA”
Ciliary Body: Muscles

• Longitudinal muscles in
the ciliary body can
contract, pulling against
the scleral spur and
opening the trabecular
meshwork and
increasing aqueous
outflow
• Cholinergics (ie
pilocarpine) work by this
mechanism
Ciliary Body: Muscles

• Circular muscle fibres

in the ciliary body can
constrict, narrowing
the diameter of the
body allowing the
zonules to relax – this
allows the lens to
become more convex
and “accommodate”
moving the eye’s focal
point to near
 Accommodation
(Animation Courtesy of Daniel B. Goldberg, MD)
Uveal Tract: Choroid

 Continuous with the iris

and ciliary body, and
extending posteriorly
under the retina (beneath
the retinal pigment
epithelium)
 Vascular plexus
supplying the outer
retina, and dissipating
heat from retinal
metabolic processes
 About 0.22 mm thick
centrally, 0.1 mm
peripherally
Lens

• Transparent, biconvex refractive body enclosed in a

capsule
• Lens cells are primarily water and clear lens proteins
called crystallins
• Accounts for about 1/3 of the refractive power of the eye
• 9-10 mm in diameter, and thickens during life from 3
mm at birth to about 6 mm at age 80 (continual addition
of new lens fibres)
• Contraction of the ciliary body muscle relaxes the
zonules supporting the lens, causing the elastic lens to
assume a more spherical globular shape and increasing
its refractive power (accommodation)
IOL

• With modern
cataract surgery,
the lens is removed
by ultrasound
through a small
opening in the
anterior portion of
its capsule – the
intraocular lens
(IOL) is implanted
within the capsular
“bag”
MODERN CATARACT SURGERY
Vitreous Humour

• Clear, gel-like fluid composed of 99% water and 1%

collagen and hyaluronic acid
• Volume is about 4 mL, and it fills about 4/5 of the eye;
gives shape to the globe
• Attached at the vitreous base (2 mm anterior and 4
mm posterior to the ora serrata), as well as some
attachments to the optic disc, retinal vessels, and
perimacular region
Vitreous Humour

• Liquifies with age, and may separate from the inner

retina – “posterior vitreous detachment” = PVD
• This can lead to retinal tears in a small % of patients,
and the fluid can then leak through the tears under the
retina – causing “rhegmatogenous” retinal detachment
• Many patients with PVD will see a prominent “floater”
called a “Weiss ring” caused by thickened vitreous that
used to be attached to the optic disc
PVD & RD
Retina

• Thin, transparent neural layer 0.15 – 0.3 mm thick

• The orange-ish colour of the fundus comes from the
underlying retinal pigment epithelium (RPE) and
choroid – not from the retina
• The “inner” retina refers to the retina abutting the
vitreous; the central retinal artery and its branches
(visible on fundoscopy) supply the inner retina
• The “outer” retina is next to the choroid, from which it
receives its nutrient supply
Macula

Fovea
Retina – ten layers
Retina

• The retina is a neural layer that is an extension of the

optic nerve
• Light has to travel through the inner layers of the retina
to reach the photoreceptors
• The “inner” nerve fibre layer becomes whitish/opaque
when swollen (ie with small infarcts – “cotton wool
spots”, blunt eye trauma “commotio retinae”, or
papilledema)
Cotton Wool Spots

Commotio Retinae

Papilledema
Retina

• Two types of photoreceptors:

– rods and cones
• Cones: about 6 million, greatest density in macular
area, responsible for colour vision
• Centre of the macula is the fovea, and its centre –
the foveola – consists entirely of close packed cones
– resulting in high visual acuity in this area
• Macular degeneration damages this area, resulting
in severe visual acuity loss
 OCT

Choroid
Sclera
Retina

• Rods: 120 million rods, greater peripherally, none at

foveal centre, function best in dim light
• Require about 30 minutes to become dark-adapted for
peak function in the dark
• Contain rhodopsin, which is broken down by light and
must be continually synthesized – which requires
vitamin A
Retinal Pigment
Epithelium

 Pigmented hexagonal monolayer

of cells
 Multiple functions including:
 Vitamin A metabolism
 Phagocytosis of rod and cone outer
segments
 Absorption of light (reduction of scatter)
 Heat exchange
 Maintenance of outer blood-retina
barrier
 Formation of basal lamina (part of
Bruch’s membrane)
Retinal Pigment Epithelium

 Incomplete “digestion”
of rod and cone outer
segments results in
yellow deposits under
the RPE called drusen
 Drusen may indicate a
decline in cellular
function of the RPE
 “Dry” age-related
macular degeneration
(ARMD) tends to occur
in areas with drusen
Bruch’s membrane

• Series of connective tissue sheets between the RPE

and the inner choroid (choriocapillaris) which includes
the basal lamina of both structures
• Defects in this membrane can allow choroidal
vasculature to get under the retina (“wet” macular
degeneration) where the vessels eventually fibrose
leading to “disciform scarring” and severe visual loss if
it occurs in the macular area
“Dry” vs “Wet” ARMD
Sclera

• Outermost layer of the globe

• Tough, fibrous opaque layer, covers 5/6 of eye,
structurally similar to cornea but collagen fibres
arranged haphazardly
• 1 mm thick, except at EOM insertions only 0.3 mm
thick
• Ruptures from trauma – occur at EOM insertions,
limbus or optic nerve insertion
Extraocular Muscles

• Six muscles – four recti (straight) and two oblique

(angled)
• Rectus muscles originate at the Annulus of Zinn at the
apex of the orbit, and all are about 40 mm long and 10
mm wide
– Superior Rectus: Elevate, Intort, Adduct
– Inferior Rectus: Depress, Extort, Adduct
– Medial Rectus: Adduct
– Lateral Rectus: Abduct
Extraocular Muscles

• Oblique muscles:
– Superior oblique: Depress, Intort, Abduct
– Inferior oblique: Elevate, Extort, Abduct
• All CN III, except lateral rectus (VI) & superior oblique
(IV) – LR6, SO4
• Superiors INTORT – “SIN” not “SEX”
• Superior oblique (IV) palsy – vertical diplopia –
hypertropia (elevation) of affected eye
Extraocular Muscles

1. Levator Palpebrae
Superioris
2. Superior Rectus
3. Superior Oblique
4. Medial Rectus
5. Lateral Rectus
6. Inferior Oblique
7. Inferior Rectus
8. Superior Orbital
Fissure
9. “
10. Optic canal
Optic Nerve

 About 1.2 million axons

 Axons originate in the
ganglion cell layer of the
retina and synapse in the
lateral geniculate body
 Visible optic disc on
fundoscopy is only 1.5 mm
in size; no photoreceptors
on the disc – therefore it
creates the physiologic blind
spot
 25-30 mm from the eye to
the optic foramen
 “Cupping” of Optic Disc

Normal Large Disc –

“Physiologic”
large cup

Normal size disc –

pathologic large
cup
GCA – Global Optic Nerve Edema
Ischemia & NAION – watershed
Thrombosis infarct

Papilledema –
external
compression of ON
Optic Pathways
Eyelids
 Upper eyelid raised by
levator palpebrae (CN III)
 Closure by

7
orbicularis oculi (CN VII)
 Both upper and lower lids
usually cover a small part of the
cornea
 Blink rate – 10-30 times per
III
minute, average about 15;
decreases to as low as 4-7 times
per minute with computer tasks
– contributing to dry eye
symptoms
Eyelid Structure

Gray Line
EYE
EXAMINATION
IN THE
PRIMARY
CARE OFFICE
Order of Examination

• Visual Acuity
• Visual Fields
• Pupils
• Motility
• External Exam
• Tonometry
• Ophthalmoscopy
Visual Acuity

• Always ask patient to wear glasses appropriate to

the testing distance (VAcc OD OS)
• Must test each eye separately
• Children < 2-3 yrs – document ability to fix &
follow with each eye
• If VA < 20/400, document best of CF=“counting
fingers”, HM=“hand motions”, LP=“light
perception” or NLP=“no light perception”
Pinhole

• A pinhole occluder will correct refractive errors up

to 3-4 diopters
• It is especially useful on top of glasses, if the
glasses are “out of date”
• Vision only improves if the cause is “refractive” in
nature – not with organic pathology
Near Visual Acuity

• Useful with inpatients or if no distance chart

available in office/clinic
• Older patients will require reading glasses unless
myopic (“nearsighted”)
• Can improvise with magazine, newspaper
Large Headlines
20/200 – 20/800
Myopia & Hyperopia
 MYOPIA HYPEROPIA
• Retinal • Angle closure
detachment glaucoma
• Open angle
glaucoma
• Macular
degeneration
Visual Fields

 Many acceptable techniques

 Most common is monocular finger counting in
four quadrants
 Will only pick up very gross abnormalities
 Some patients will attribute right or left visual
field loss to the eye on the affected side
Pupils

• Size (mm) in dim light, reactivity to light (1-4+)

• Anisocoria = different sized pupils
• “Swinging-flashlight test”
Anisocoria
LARGER SMALLER
 CN 3 palsy  Horner’s
syndrome
 Adie’s pupil
 Iritis
 Trauma/surgery  Miotic drops (pilocarpine)
 Long-standing Adie’s
 Dilating drops  Argyll-Robertson pupil(s)

* 10-15% of patients have a small (< 1 mm) difference at times

(physiologic anisocoria) but both pupils react normally
Relative Afferent Pupillary Defect
• Indicates optic nerve disease or global retinal
disease
• Optic neuritis, ischemic optic neuropathy,
advanced asymmetrical glaucoma, optic atrophy
• Central retinal artery or vein occlusion, retinal
detachment
• NO RAPD seen in “media” problems, such as
cataracts, corneal scarring, or vitreous
hemorrhage
Motility

• Can test bilaterally up/down, right/left

• Little to no sclera seen when eye fully abducts/adducts
• ⅓ iris covered by upper lid with upgaze,
• ½ by lower lid in downgaze
• If abnormal, must then test each eye separately
 ⅓

No white

½
 Corneal Light Reflexes
(Hirschberg)
Abnormal Eye Normal Eye
(note pupil reflex)

CN 3 palsy Down and out

CN 4 palsy Displaced up

CN 6 palsy Turned in
External Exam

• Just get up close with a light (transilluminator or

ophthalmoscope) and look
• Lids/lashes, conjunctiva/sclera, cornea, anterior
chamber, iris/pupil, lens
 Cortical Cataract Blepharitis

Marginal Infiltrates Nuclear and Posterior

Cataract
Tonometry
Red Reflex Test
(Bruckner)

• A good red reflex requires clear ocular media, no

large refractive error, and normal eye alignment
• This is best performed a couple of feet away,
shining the direct ophthalmoscope light (set to zero
diopters and largest aperture) at both eyes
• Patient is asked to look AT the light
Normal Red Reflexes
Strabismus
S/P IOL Left Eye
Cataracts
Red Reflexes

• Are an excellent way to screen infants & children for

asymmetrical refractive errors & strabismus
• They should be a part of your general assessments
and well baby checks
Fundoscopy

• Optic disc & macula can usually be seen

through undilated pupil
• (If you would like to dilate, try to check for
shallow angles first)
• Approach just slightly temporal to straight
on (15º)
• Diopter dial is just to correct refractive error
(yours & patient’s) – start at zero
• Ask patient to look at light when you want
to see the macula
Shallow Anterior Chamber
Macula

Fovea
 Summary
• Visual Acuity – with glasses !
• (Visual Fields) – if visual
complaints, and normal VA !
• Pupils – “swinging flashlight”
• Motility – together, then
separately
• External Exam – get in close
• Ophthalmoscopy – simultaneous
bilateral red reflexes !