Revision Ophthalmology

Dr Anuradha Dhawan
MBBS MS (PGI Chandigarh) FRCS Glasgow
Ophthalmology Faculty

Email: [email protected]

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https://t.me/joinchat/xSW1-Mqq6l83MzM1

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Refractive Errors
• Total refractive power of the eye +60 D

• Refractive power of the cornea +45 D

• Refractive power of the lens +15 D

Correction of Myopia
Correction of Hypermetropia
Biconvex Lens
Pathological Myopia

Temporal Crescent

Posterior Staphyloma

Foster F ch spot

Lacquer cracks

CNVM

Peripheral retinal degenerations (Lattice degeneration, holes)

Rhegmatogenous Retinal detachment

Astigmatism
Pinhole

The diameter of the central hole is 1mm

Allows only central rays to pass through

Improvement in visual acuity indicates refractive error

Worsening of visual acuity indicates central pathology

Aphakic glasses

• Image magnification

• Narrow field of vision

• Anisokenia

• Spherical aberrations:
Pin Cushion effect
Jack in the box scotoma
Correction of Refractive Error

• Glass Prescription from Retinoscopy

Glass Prescription from Retinoscopy
Correction of Refractive Error

• Glass Prescription from Retinoscopy

Correction of Refractive Error

• Identify refractive error from prescription

Spherical Equivalent

• Used when patient does not wish to wear Astigmatic/Cylindrical

glasses

• Formula:

Spherical Power + Half of Cylindrical Power

Contact Lenses
Refractive Surgeries
• LASIK

• RELEX/SMILE

• Phakic IOL - ICL

Conjunctiva
TRACHOMA

• By Chlamydia trachomatis A, B, Ba, C

• Serotypes D to K cause adult inclusion

conjunctivitis (swimming pool conjunctivitis)

• Another cause of swimming pool conjunctivitis:

Adenovirus)
 TRACHOMA

• Sago grain follicles in upper tarsal conjunctiva

• He be f ic e i b

• A line subtarsal fibrosis

• He be i
OPHTHALMIA NEONATORUM
Conjunctivitis in a neonate (within 28 days)
CHEMICAL: within hour

GONOCOCCAL: 1-4 days

CHLAMYDIAL: 5-14 days

STAPH AUREUS: after 1 week

HERPES SIMPLEX: after 1-2 weeks

COVID 19 infection

• Most common ocular symptom: Conjunctivitis

• Follicular Conjunctivitis

• F)
VERNAL KERATOCONJUNCTIVITIS
 VERNAL KERATOCONJUNCTIVITIS

• Type 1 hypersensitivity

• Itching with ropy discharge

• Cobblestone papillae

• Horner T a a spots

• Shield ulcer

• Pseudogerontoxon
Giant Papillary Conjunctivitis
PHYLCTENULAR CONJUNCTIVITIS
• TYPE IV hypersensitivity reaction

• Secondary to TB, staph

• Corneal involvement: Fascicular ulcer

 PTERYGIUM

• Elastotic degeneration, UV rays

• Head eck B d S cke i e

• Excision with MMC, Conjunctival autograft,

Amniotic membrane graft
Cornea
CORNEAL LAYERS 6 layers

1. Latest Corneal layer Discovered D a layer

2. Most Metabolically Active Layer of Cornea ENDOTHELIUM

3. Layer Maximally responsible for Corneal

Hydration/Transparency ENDOTHELIUM

4. BOWMAN Membrane layer can not regenerate.

5. Descemet Membrane Most elastic Layer

6. D a Layer Toughest Layer

ENDOTHELIAL CELLS SHAPE Hexagonal single layer

Na-K ATPase pump present in ENDOTHELIUM

Normal Endothelial cell count 3000-3500 cells/ mm square

Below 500 cells/mm2 in endothelium: Permanent corneal

decompensation
1. PACHYMETRY Measurement of Corneal Thickness

2. KERATOMETRY Measurement of Corneal Curvature

3. CORNEAL TOMOGRAPHY Mapping of Corneal surface

(curvature+thickness)

4. SPECULAR MICROSCOPY Study of Endothelial Cell

Count + Morphology
Corneal Ulcers: Bacterial
• Developed countries Contact lens use (Most common Risk Factor)
• Developing countries Trauma
Photophobia, Redness, Pain, Decreased vision, Discharge

Causative organisms : Pneumococcus, Staph aureus, Pseudomonas

Bacterial Corneal Ulcer

Wet Infiltrate, Ulcer margins defined,

Hypopyon is sterile, Mobile,
Early Vascularization (+), Perforation (+)
Complications of bacterial corneal ulcer
• Perforation

• Pseudocornea formation

• Corneal Opacity

• Anterior Staphyloma
Corneal Ulcers: Fungal

Most common Cause Filamentous Fungi

• (Fusarium & Aspergillus)

• Candida: In Immunocompromised
Trauma with organic & vegetative matter
• Dry, Raised infiltrate, Feathery, ill defined margins
Satellite lesions
Hypopyon is Large, Dome shaped
Non Sterile, Fixed
Vascularization & Perforation Uncommon
Fungal Corneal Ulcer
Viral Keratitis

• Reduced Corneal Sensations

Herpes simplex keratitis

• Punctate Epithelial Keratopathy

• Dendritic ulcer Geographic Ulcer

• Stromal keratitis, Disciform Keratitis

• Endothelitis

• Metaherpetic keratitis
Viral Keratitis
Herpes zoster Keratitis

Immunocompromised patients

Pseudodendritic keratitis
Viral keratitis: Treatment
Acanthamoeba Keratitis

• Contact Lens Use with poor Hygiene, Sharing of CL

• Highly Painful ulcer

• Ring shaped ulcer

M e Ulcer

• Idiopathic Peripheral Ulcerative Keratitis

• Rodent Ulcer
• Auto-immune
Drug contraindicated in infective corneal ulcer steroids

Drug given in all infective corneal ulcer Cycloplegics: Atropine

• Neuroparalytic Keratitis
Neurotrophic Keratitis
Keratoconus
Irregular Astigmatism Scissoring Reflex on Retinoscopy RIZZUTI SIGN

Oil Droplet reflex DDO

Irregular Cornea on Placido Disc

M ig

Stromal Thinning on Slit lamp

Vogt's Stria Vertical in Descemet's membrane

Fleisher Ring Iron Ring in Epithelium

Keratoconus
• CORNEAL HYDROPS - S dde R e f De ce e e ba e C ea Sca i g

• IOC: Corneal Tomography

• RGP contact lenses in Mild cases

• Collagen Cross linking C3R- Riboflavin Dye, UV-A Ra Red ce P g e i

• INTACS (Intra Stromal Corneal Ring Segments)

• KERATOPLASTY
CORNEAL DEPOSITS
• ARCUS SENILIS - Lipid deposition, Starts in superior and Inferior part
ARCUS JUVENILIS

BSK- Calcium deposition

Chronic uveitis
Phthisis Bulbi
Silicone oil induced Keratopathy
Hypercalcemia
CORNEAL DEPOSITS

Keyser Fleisher (KF) ring

C e de ii Wi Di ea e
Chalcosis = copper deposition

Gonioscopy Best method for early KF ring

Not present in all patients of Wilson disease
N ah g ic f Wi di ea e
Thinnest part of sclera: Posterior to insertion of
extraocular muscles

Most common association of Scleritis is Rheumatoid

arthritis
 Scleromalacia perforans

seen in long standing RA

Posterior Scleritis:

T-sign on USG Bscan

Exudative retinal detachment
Lens
Most common type of congenital cataract Blue dot
cataract

Most common type of visually significant congenital

cataract Lamellar/Zonular Cataract

Ride a e ee i La e a Z a Ca a ac
Most common type of acquired cataract Senile cataract

Index Myopia/Second Sight of old age seen in Nuclear Sclerosis

Cataract causing Glare/early vision disturbance Posterior subcapsular

Cataract

Cataract causing vision difficulty in dim light Cunieform Cortical Cataract

Colored Halos Early Cortical Cataract

Phacomorphic glaucoma is due to Intumescent Mature
Cataract

Most common complication of Morgagnian hypermature

cataract Phacolytic glaucoma

Complication of Sclerotic Hypermature Cataract-

Dislocation of lens
Snowflake Cataract Diabetes
Rosette Cataract Blunt Trauma
Oil droplet Cataract Galactosemia
Reversible Cataract - Galactosemia
Sunflower Cataract Wi Di ea e
Christmas tree Cataract- Myotonic Dystrophy
Polychromatic lustre/Breadcrumb appearance
Complicated Cataract
Ga B e ca a ac True exfoliation cataract

Steroid induced cataract Posterior subcapsular cataract

Ectopia lentis superotemporal dislocation Ma fa

syndrome

Ectopia lentis inferonasal dislocation Homocystinuria

Laser used in Cataract Surgery Femtosecond Laser

Ideal site of IOL implantation In the capsular bag

Flexible IOL material Acrylic, Rigid IOL PMMA

Formula IOL power calculation SRK II Formula

IOL power calculation in post-refractive surgery cases-

Haigis formula, Holladay II formula
Cataract surgery and IOL implantation in children

Under-correction of IOL power in children due to Myopic shift

• < 2 years of age: 80% IOL power

• 2-8 years of age: 90% IOL power
• >8 years: 100% IOL power
Most common late complication of Cataract Surgery
After Cataract/Posterior Capsular opacification

Treatment of After cataract Nd Yag Laser

Capsulotomy
Most dangerous complication of Cataract Surgery Endophthalmitis

Most common cause of acute endophthalmitis Staph epidermidis

Most common cause of late endophthalmitis Propionibacterium acne,

Fungi

Treatment of Endophthalmitis Intravitreal Antibiotics/Pars plana

vitrectomy
Glaucoma
Aqueous Humor produced by Ciliary processes of Ciliary body

Aqueous Humor Nutrition to Cornea and Lens

Aqueous Humor outflow major pathway Trabecular meshwork

Aqueous Humor outflow minor pathway Uveoscleral pathway

Normal IOP: 10-21 mm Hg

 NORMAL
OPTIC DISC INCREASED C:D

SPLINTER
HEMORRHAGE NASALISATION OF
VESSELS

LAMINAR DOT
BAYONETTING OF
SIGN
VESSELS
VISUAL FIELD DEFECTS IN GLAUCOMA
Buphthalmos congenital glaucoma

Haab ia ee i Buphthalmos
Surgery of choice for congenital glaucoma with
clear cornea Goniotomy

Surgery of choice for congenital glaucoma with

hazy cornea Trabeculotomy
Primary open angle glaucoma
Primary angle closure glaucoma
Acute angle closure glaucoma/Acute congestive glaucoma
 First line anti-glaucoma drug or Drug of choice

Prostaglandin analogues:
Latanoprost/Travoprost/Bimatoprost/Tafluprost

Mechanism of action of Prostaglandin analogues: Increased

uveoscleral outflow

Most common side effect of Prostaglandin analogues:

Trichomegaly/Dark Iris
Antiglaucoma drug contraindicated in Asthma, COPD, Heart block:
Beta blockers

Antiglaucoma drug contraindicated in Children: Brimonidine

Antiglaucoma drug causing sleep apnea: Brimonidine
Drug of choice for Acute angle closure glaucoma: Pilocarpine

Drug contraindicated in Acute angle closure glaucoma: Atropine

Antiglaucoma drug causing retinal detachment: Pilocarpine

Drug contraindicated in Uveitis with glaucoma: Pilocarpine, PG analogues

Netrasudil
• New antiglaucoma medication
• Rho-kinase inhibitor

• MOA: Increases Aqueous Outflow through Trabecular meshwork by

relaxation of trabecular meshwork

• Side effects: Conjunctival hyperemia, Vortex Keratopathy

• No Systemic Contraindications
Laser done for angle closure Nd Yag Laser Iridotomy

Laser done for open angle glaucoma Laser Trabeculoplasty

Surgery for Glaucoma trabeculectomy

Seton surgery is Glaucoma valve surgery/Drainage implant

Retina
Retinal Detachment separation of neurosensory retina from RPE

Most common Retinal degeneration - lattice degeneration

Rhegmatogenous RD Due to retinal break

Most dangerous retinal break Horse shoe tear

Most dangerous location of retinal break Superotemporal

Signs of Flashes/Photopsia/Curtain like shadow - Rhegmatogenous RD
Shafe ig T bacc d i g - Rhegmatogenous RD

Most common cause of Tractional RD Proliferative DR

Shifting fluid is seen in Exudative RD

Diabetic retinopathy
 Non-proliferative DR

• Microaneurysms: earliest and hallmark sign

• Hard exudates: lipid
• Soft exudates: cotton wool spots
• Dot and blot haemorrhages
• Absence of new vessels
 Proliferative DR

• New vessels seen on disc and elsewhere on retina

• Neovascularisation
 Diabetic macular edema

• Hard exudates and retinal thickening

• Most common cause of visual loss
• Can occur with any stage of DR
Diabetic Retinopathy: Treatment

Pan retinal photocoagulation PRP laser - PDR

Focal Laser or Grid laser Diabetic Maculopathy

Intravitreal Anti- VEGF injections

Pars Plana Vitrectomy Vitreous haemorrahge or TRD

Examination Schedule for Diabetic Retinopathy

Type 1 DM 5 years after onset or after puberty

Type 2 DM At the time of diagnosis

 Central Retinal vein
occlusion CRVO

• Tomato splash appearance/Blood in thunder appearance

• 90-day/100-day glaucoma
 Central Retinal
Artery Occlusion CRAO

• Pale retina
• Cherry red spot
• Cattle truck appearance of blood vessels
 Age related macular degeneration
ARMD
• Dry ARMD: Drusens

• Wet ARMD or exudative ARMD: neovascular

 Retinitis Pigmentosa

• Night blindness
• Difficulty in driving due to ring scotoma
• Pale disc, attenuated arterioles, bony spicule pigmentation
• ERG
Retinoblastoma
• Retinoblastoma gene 13q 14

• 40% Heritable, 60% Non-Heritable

• Most common Presentation

• Flexner-Wintersteiner Rosettes
 HERITABLE NON-HERITABLE
RETINOBLASTOMA RETINOBLASTOMA

GERMLINE MUTATION SOMATIC MUTATION

1st mutation in Gamete 1st mutation in Retinal Cell
2ndmutation in Retinal Cell 2nd mutation in Retinal Cell

Multifocal , Bilateral tumor Unifocal , Unilateral tumor

Passed to Offsprings (AD) Can not be passed to

40% Offsprings

Risk of Secondary tumors No Risk of Secondary tumors

(Osteosarcoma)
-
Trilateral Retinoblastoma
( Pinealoblastoma)
Retinoblastoma
Retinoblastoma
 Treatment

• Focal therapy

• Chemotherapy

• Enucleation

• Radiotherapy
International Classification
of Retinoblastoma (ICRB)

Group A: Very low risk

Group B: Low risk

Group C: Moderate risk

Group D: High risk

Group E: Very high risk

Uveitis
Iris Nodules: Busacca Nodules and Koeppe Nodules
UVEITIS WITH ARTHRITIS

1. ANKYLOSING SPONDYLITIS

2. REITER S SYNDROME

3. PSORIATIC ARTHRITIS

4. JUVENILE RHEUMATOID ARTHRITIS

Toxoplasma
VOGT-KOYANAGI-HARADA DISEASE

• Oculo-neuro-cutaneous signs

• Bilateral chronic Granulomatous Panuveitis

• S g i a sign Perilimbal vitiligo

• Sun-set glow fundus

SYMPATHETIC OPHTHALMITIS

• Severe Inflammation in both eyes after injury (including intraocular

surgery) in one eye

• Penetrating wound is the prerequisite

• Wounds involving Ciliary Body Dangerous

• INJURED EYE EXCITING EYE

• NORMAL EYE SYMPATHEZING EYE

SYMPATHETIC OPHTHALMITIS

• Granulomatous Panuveitis in both eyes

• Onset after 2 weeks of injury

• Earliest symptom Weakness of Accommodation, Photophobia

• Earliest sign Retrolental flare

Dalen F ch nodules
Neuro-ophthalmology
Optic Neuritis

• Papillitis

• Retrobulbar Neuritis

• Neuroretinitis

• Most common cause Multiple sclerosis

Signs and symptoms of optic neuritis
Decreased vision, Pain on ocular movements

Defective color Vision

Marcus Gunn Pupil

Central or centrocaecal scotoma

Fundus examination is normal in case of Retrobulbar neuritis

Argyll Robertson Pupil
HORNER SYNDROME
Squint
Extraocular Muscles Actions
Strabismus : Ocular misalignment

Latent Squint - Phoria Manifest Squint – Tropia

Extraocular Muscles – Nerve Supply

• MR, IR, SR, IO 3rd cranial nerve

• SO - 4th cranial nerve

• LR - 6th cranial nerve

LR6 SO4 O3
Features of Paralytic Squint:

• Diplopia

• Confusion

• Eye movement restricted

• Compensatory head postures

3rd Nerve Palsy

• Most common cause Ischemic (DM, HTN)

• Surgical Causes Trauma, Tumors, Aneurysms

Eye down & out

Diplopia in all directions except down & out

Ptosis

Pupillary Reactions

Loss of accommodation
FOURTH NERVE PALSY

• Hyperdeviation
• Head tilt to opposite direction
• Limited depression in adduction
• Diplopia: worse on looking down
Amblyopia:

TREATMENT

Occlusion therapy

Penalisation

Active Vision Therapy

Lids and Adnexa
Entropion

Surgeries J e procedure

Weis procedure

Quickert procedure

Whee e ced e
Ectropion

Treatment

• Medial conjunctivoplasty
• Modified Kuhnt procedure
• V-Y procedure
• Lazy T procedure
• Z-plasty
Surgery for Ptosis

• Fasanella servat procedure

• Levator resection

• Frontalis sling surgery/Frontalis suspension

Complicated Ptosis

Marcus Gunn Synkinetic ptosis

(Marcus Gunn Jaw Winking Phenomenon)

Aberrant connection b/w third & fifth nerve

Myasthenia Gravis
Congenital NLDO
Failure of canalization of NLD by end of gestation.
Site of obstruction Valve of Hasner

Rx
• Criggler a age till 9 months
• Syringing & probing 9 months -4 year
• DCR after 4 years

DCR anastomosis between lacrimal sac & middle meatus

Orbit
• Proptosis Protrusion of eyeballs

• Measurement of proptosis Exophthalmometry

• Hertel’s Exophthalmometer

• Most common cause of Proptosis in Adults Thyroid Eye Disease

• Most common cause of Proptosis in Children Orbital Cellulitis

First Sign in Thyroid Ophthalmopathy Lid
Retraction/Dalrymple Sign

Most common/First muscle involved in thyroid eye disease

Inferior Rectus
Orbital Cellulitis
Most common benign intraorbital tumor in children is- Dermoid

Most common primary malignant orbital tumor in children is

Rhabdomyosarcoma

Most common benign orbital tumor in adults- Cavernous hemangioma

Most common primary malignant orbital tumor in adults- Lymphoma

Ocular Trauma
• Blunt Trauma
Orbital Blow out fracture
Intraocular foreign body
Exam Techniques
Instruments
Direct Ophthalmoscope
For Central Retina
Magnification 15 X
Virtual Erect Image
Distant Direct Ophthalmoscopy
Indirect Ophthalmoscope
Peripheral Retina
Magnification 3-5 X
Real Inverted Image
Binocular stereoscopic view
Titmus Fly Test
Chalazion Clamp & Scoop
Lacrimal Probe
Enucleation Spoon
Evisceration
Pars Plana Vitrectomy
 LASERS in OPHTHALMOLOGY

• Nd YAG LASER : Capsulotomy, Iridotomy

• EXCIMER LASER: PRK, LASIK

• FEMTOSECOND LASER: SMILE, LASIK, Laser assisted Cataract surgery

• Fd Nd YAG LASER: Retinal Photocoagulation

• DIODE LASER: Retinal Photocoagulation, Thermotherapy

• ARGON LASER: Retinal Photocoagulation

all the best