Ophthalmology PDF

Ophthalmology Anatomy............................................................................................................................................5 Orbit...................................................................................................................................

Ophthalmology Anatomy............................................................................................................................................5 Orbit.......................................................................................................................................................... 5 Eyelid......................................................................................................................................................... 9 Muscles of the eye.................................................................................................................................. 12 Lacrimal apparatus.................................................................................................................................. 13 Conjunctiva............................................................................................................................................. 17 Cornea..................................................................................................................................................... 19 Pupil........................................................................................................................................................ 20 Lens......................................................................................................................................................... 21 Uveal tract............................................................................................................................................... 23 Retina...................................................................................................................................................... 25 Nerves of the eye.................................................................................................................................... 26 Ocular physiology............................................................................................................................ 27 Vision....................................................................................................................................................... 27 Blindness/loss of vision........................................................................................................................... 28 Reflexes of eye........................................................................................................................................ 30 Aqueous humor...................................................................................................................................... 36 Diseases of the orbit........................................................................................................................ 37 Orbital cellulitis....................................................................................................................................... 37 Proptosis................................................................................................................................................. 39 Diseases of the eyelid....................................................................................................................... 40 Stye/External hordeolum........................................................................................................................ 41 Chalazion................................................................................................................................................. 42 Ectropion and entropion......................................................................................................................... 44 Ptosis....................................................................................................................................................... 45 Diseases of the Lacrimal System....................................................................................................... 46 Congenital Nasolacrimal Duct obstruction............................................................................................. 46 Acute dacryocystitis................................................................................................................................ 46 Chronic Dacryocystitis............................................................................................................................. 47 DCR operation......................................................................................................................................... 49 Watery eye, Hyper lacrimation and epiphora........................................................................................ 52 1  Dry eye.................................................................................................................................................... 53 Conjunctival diseases....................................................................................................................... 55 Conjunctival Congestion vs Ciliary Congestion....................................................................................... 55 Red eye.................................................................................................................................................... 56 Conjunctivitis........................................................................................................................................... 56 Bacterial conjunctivitis........................................................................................................................ 58 Viral conjunctivitis............................................................................................................................... 61 Allergic conjunctivitis.......................................................................................................................... 62 Trachoma/Chlamydial conjunctivitis.................................................................................................. 67 Sub conjunctival hemorrhage................................................................................................................. 68 Pterygium................................................................................................................................................ 68 Cornea and sclera............................................................................................................................ 71 Keratitis, corneal ulcer............................................................................................................................ 71 Bacterial corneal ulcer........................................................................................................................ 72 Fungal corneal ulcer............................................................................................................................ 74 Viral corneal ulcer/dendritic keratitis/superficial punctate keratitis................................................. 75 Corneal Abrasion..................................................................................................................................... 76 Corneal foreign body.............................................................................................................................. 77 Fluoresecin dye test................................................................................................................................ 78 Keratoplasty............................................................................................................................................ 78 Eye bank.................................................................................................................................................. 79 Scleritis.................................................................................................................................................... 80 Refractive errors.............................................................................................................................. 82 Myopia.................................................................................................................................................... 83 Simple myopia..................................................................................................................................... 84 Pathological myopia............................................................................................................................ 85 Hypermetropia........................................................................................................................................ 87 Astigmatism............................................................................................................................................ 89 Presbyopia............................................................................................................................................... 90 Squint/Strabismus................................................................................................................................... 91 Cataract........................................................................................................................................... 93 Introduction............................................................................................................................................ 93 Congenital cataract................................................................................................................................. 95 2  Senile cataract......................................................................................................................................... 96 Complicated Cataract.............................................................................................................................. 97 Cataract surgery...................................................................................................................................... 97 Aphakia, Pseudophakia, IOL........................................................................................................... 106 Aphakia................................................................................................................................................. 106 Pseudophakia........................................................................................................................................ 106 IOL (intra ocular lens)............................................................................................................................ 107 Diseases of uveal tract................................................................................................................... 109 Uveitis................................................................................................................................................... 109 Glaucoma...................................................................................................................................... 115 Intraocular pressure.............................................................................................................................. 115 Introduction to glaucoma..................................................................................................................... 116 Primary open angle glaucoma (POAG).................................................................................................. 118 Primary Angle closure Glaucoma.......................................................................................................... 119 Secondary glaucoma............................................................................................................................. 121 Retina, Optic nerve, Vitreous.......................................................................................................... 123 Retina.................................................................................................................................................... 123 Retinoblastoma................................................................................................................................. 123 Leukocoria......................................................................................................................................... 126 Destructive operation of the eyeball................................................................................................ 127 Optic nerve............................................................................................................................................ 129 Optic neuritis..................................................................................................................................... 129 Papilledema....................................................................................................................................... 131 Optic atrophy.................................................................................................................................... 133 Systemic diseases affecting the eye................................................................................................ 135 Diabetic Retinopathy............................................................................................................................ 135 Hypertensive retinopathy..................................................................................................................... 138 Vitamin A deficiency............................................................................................................................. 139 Ocular emergency, injury............................................................................................................... 142 Hyphaema............................................................................................................................................. 144 Chemical Injury..................................................................................................................................... 145 Ocular pharmacology..................................................................................................................... 148 Mydriatics............................................................................................................................................. 148 3  Steroid................................................................................................................................................... 150 Anti-glaucoma drugs............................................................................................................................. 151 Viscoelastic substances......................................................................................................................... 152 LASIK...................................................................................................................................................... 153 4 Anatomy Orbit Q. What is orbit? Ans: The orbits are two pyramidal shaped bony cavities, situated on each side of the root of the nose. Q. How is it formed? Ans: It has 4 walls (see the picture below, better see the colored version in PDF) o Roof ▪ Frontal bone ▪ Sphenoid bone o Lateral wall ▪ Zygomatic bone ▪ Sphenoid bone o Floor ▪ Zygomatic ▪ Maxilla ▪ Palatine o Medial wall (weakest; infection can pass to and fro) ▪ Sphenoid ▪ Ethmoid ▪ Lacrimal ▪ Maxilla It has o An apex (posteriorly), which has 2 openings: ▪ Optic canal ▪ Superior orbital fissure o A base (anteriorly) 5 6 Q. What are the contents of the orbit (not DU) Ans: Contents o Eyeball o Muscle ▪ Extra-ocular muscle ▪ Levator palpebrae superioris o Lacrimal gland complex ▪ Lacrimal gland ▪ Lacrimal ducts ▪ Lacrimal punctum ▪ Lacrimal sac o Vessels: Ophthalmic artery + its branches o Nerves: ▪ Cranial nerve: III, IV, VI, V1, V2 ▪ Sympathetic nerve o Orbital fat o Orbital fascia 7 Q. Short note: Superior Orbital fissure Ans: It is a slit in the base of skull. Boundary: between lesser and greater wings of sphenoid. Below is shown the diagram of S.O.F of the right eye: (color: see the pdf) 8 Eyelid Q. Draw and label the histological structure of the upper eyelid 9 Q. Name the different layers of eyelid Ans: Layer 1: SKIN (1) Layer 2: subcutaneous tissude/superficial fascia (2) Layer 3: Muscle layer o Orbicularis oculi (3) o Levator palpebrae superioris (11) o Muller’s muscles Layer 4: submuscular zone (neurovascular zone): yellow highlighted area (14) o Contains all nerves and vessels o Area for local anesthetic application Layer 5: fibrous layer o Orbital septum (12) o Tarsal plate (15) o Tarsal/meibomian gland (7) Layer 6: palpebral conjunctiva (8) 10 Q. Mention the functions of the eyelids Ans: Keeps cornea moist Protects eyeball from injuries Secretion from tarsal gland: prevents evaporation of tear Helps in distribution/spreading of tears Helps in drainage of tears Regulates amount of light entering the eye Q. Short note: eyelid glands Ans: Location Name Type of gland Function Anterior lid margin/Lash Glands of Zeiss Sebaceous Secretion of sebum follicle gland Keep eyelashes clean Glands of Moll Modified Secretion of sweat Sweat gland Keep eyelashes clean Posterior lead Tarsal Modified Secretes oily substance, which margin/tarsal plate gland/meibomian sebaceous prevents the evaporation of tear gland gland (forms part of pre-corneal tear film) Q. Name the muscles of eyelid with nerve supple Ans: Muscle Nerve supply Function Orbicularis oculi VII (Facial) Closes eyelid Levator palpabrae superioris III (oculomotr) Keeps eyelid open/elevates upper eyelid Muller muscle Sympathetic nerve Keeps eyelid open 11 Muscles of the eye Q. Mention the extraocular + intraocular muscle with nerve supply and action Ans: Extra-ocular muscles moving the eyeball: Nerve Supply Extraocular muscle Action III (oculomotor) Superior Rectus (SR) Elevation of eyeball Inferior Rectus (IR) Depression of eyeball Medial Rectus (MR) Adduction of eyeball Inferior Oblique (IO) Elevation + extorsion IV (trochlear) Superior oblique (SO4) Depression + intorsion VI (abducent – nerve of Lateral rectus (LR6) Abduction abduction) Other extraocular muscles Muscle Nerve Action Levator palpebrae Superioris III (oculomotor) Elevation of upper eyelid Muller’s muscle Sympathetic Elevation of upper eyelid Depression of lower eyelid Intra-ocular muscles Muscle Nerve supply Action Iris muscles Dilator pupillae Sympathetic Mydriasis (dilation of pupil) Sphincter pupillae III Miosis (contraction of pupil) (oculomotor)….Parasympathetic Ciliary muscle III Accommodation (oculomotor)…Parasympathetic 12 Lacrimal apparatus Q. Draw and label the lacrimal drainage system/pathway (see PDF for color) Ans: Some extra info: 13 Q. Mention the pathway of tear Ans: Production (lacrimal gland, accessory lacrimal glands, conjunctival glands) → lacrimal duct → conjunctival sac (between palpebral and bulbar conjunctiva) → lacrimal puncta →lacrimal canaliculi → lacrimal sac → nasolacrimal duct → inferior meatus → nasal cavity Q. Mention the functions of tear/mention the functions of pre-corneal tear film Ans: Refraction function: o Keeps anterior surface of cornea smooth for refraction Lubrication function o Keeps cornea and conjunctiva moist (lubrication) o Easy movement of eyelid over eyeball: lubrication Antiseptic function o Antibacterial substance helps kill organism and prevent infections Metabolic function o Provides nutrition and oxygen to cornea o Washes away debris and noxious substances 14 Q. Short note: Pre corneal Tear film Ans: It is a layer of tear that covers the anterior surface of bulbar conjunctiva. Situated in the conjunctival sac (between bulbar conjunctiva and palpebral conjunctiva) Layer Thickness Source Component of this Function layer Outer Lipid layer 0.1 μm Meibomian Oily substance - Prevents evaporation of tear gland - Lubrication - Prevents overflow of tears Middle Aqueous 7 μm Lacrimal Water - Washes away debris layer gland NaCl (salt) - Antibacterial function Antibacterial - Nutrition to cornea (lysozyme) -Diffusion of oxygen to cornea Protien, CHO etc. from air Inner Mucous 0.2 μm Goblet cell Mucin/mucus Converts cornea from a layer in hydrophobic layer to a conjunctiva hydrophilic layer, this helps attach the tear film to the cornea Fig: Pre corneal tear film (see PDF for color) Q. Short note: Sac patency test Ans: It is a method of assessing the patency of the lacrimal drainage system Method: syringing through the lacrimal punctum Instruments required o Surface anesthesia o Nettleship punctum dilator o Lacrimal cannula o Disposable syringe o Normal saline 15  Procedure o Anesthetic applied o Punctum dilated o Cannula inserted into one canaliculi thru punctum o Syringe containing normal saline attached to cannula o Injected slowly Inference/interpretation Result Inference Unable to pass cannula Punctal occlusion Immediate clear Regurgitation thru same Block of the same (upper/lower) canaliculus puncta Immediate clear Regurgitation thru opposite Block of common canaliculus (in some puncta people, the punctum join and then drain into sac as a common canaliculus) Few minutes later turbid regurgitation thru Nasolacrimal duct block opposite puncta + bulging of the sac area Fluid passes good + patient tastes salty fluid Patent drainage system 16 Conjunctiva Q. Mention the anatomy of conjunctiva Ans: Parts of conjunctiva Palpebral conjunctiva: covers inner surface of the eyelid Fornix: the reflection between palpebral and bulbar parts Bulbar conjunctiva: covers the outer surface of the eyeball Conjunctival glands Goblet cells/Mucin secretory glands (form mucin layer of tear film) Accessory lacrimal glands Blood supply From branches of o Ciliary artery o Lacrimal artery o Nasal artery Lymph supply Lateral part: pre-auricular LN Medial part: sub-mandibular LN Nerve supply: Sensory: V1 (ophthalmic division of trigeminal) Motor (secretomotor): facial nerve (VII) Histology: 3 layers 17  Epithelium: non keratinized stratified squamous Sub epithelial layer: contains lymphocytes Fibrous layer: collagen and elastic fiber ** Plicae semilunaris and caruncle (situated in medial canthus) PS: it is a fold of conjunctive, represents 3rd eyelid of lower animals Caruncle: piece of modified skin 18 Cornea Q. Draw and label the microscopic structure of cornea Ans: Q. Name the different layers of cornea Ans: from superficial to deep, the layers are: Anterior epithelium (A) Bowman’s membrane (B) Corneal stroma (C) Descemet’s membrane (D) Endothelium /Posterior epithelium (E) 19 Q. How does cornea get nutrition? Ans: Nutrient/particles such as glucose o enter by diffusion through aqueous humor o from peri-limbal capillaries o from palpebral conjunctiva, while eyes are closed/during sleep O2 o directly from air atmosphere o diffusion through tear film Q. What are the factors responsible for maintaining corneal transparency? Ans: Anatomical factor o Uniform arrangement of stroma ▪ Less cells ▪ Uniform arrangement of collagen fibers o Absence of vessels o Absence of myelin sheath in nerves o Absence of pigment in cornea Physiological factor (factods which keep cornea relatively dehydrated) o A,E: barrier function o E: Endothelial pump: keeps cornea relatively dehydrated (most important) o Normal IOP (if IOP raised, cornea may become edematous and hazy) o Evaporation of tear from tear film o Proteins in keratocytes Pupil Q. Define pupil Ans: It is an aperture in the center of the iris (slightly infero-nasal to the center) Q. Functions of pupil (not DU) Ans: regulates amount of light entering the eye maintains the depths of focus helps in accommodation 20 Lens Q. Draw and label the structure of human crystalline lens (see PDF for color) Ans: Figure: Human crystalline lens Q. What are basic structures of human crystalline lens? Ans: ⮚ Lens capsule o Anterior capsule: Thick + less convex o Posterior capsule: Thin + more convex ⮚ Anterior Epithelium o Single layer of cuboidal cells o Columnar in equatorial region o Actively divide and form lens fibers ⮚ Lens fibers / Lens substance o Outer cortex: less compact, newer fibers 21  o Inner nucleus: More compact, older fibers ▪ Adult nucleus: puberty to rest of life ▪ Infantile nucleus: birth to puberty ▪ Fetal nucleus: 3m IU to birth ▪ Embryonic nucleus: 1st 3 months IU (Intrauterine) ⮚ Suspensory ligament/zonules: they suspend the lens from the ciliary body Q. Short note: Ectopia lentis Ans: ⮚ The displacement of lens from its normal/anatomical position is called ectopia lntis ⮚ 2 types o Subluxation: partial displacement: pupil is partly phakic partly aphakic o Dislocation: complete displacement form behind the pupil: pupil is totally aphakic ⮚ Etiology o Acquired ▪ Trauma to eye ▪ High myopia ▪ Hyper-mature cataract ▪ Tumor inside eye pushing the lens o Congenital ▪ Familial ▪ Buphthalmos ▪ Marfan’s syndrome ▪ Ehler’s danlos syndrome ⮚ Clinical feature o Pt has refractive error / poor vision o Examination: aphakia/partial aphakia seen ⮚ Investigation: to understand the etiology ⮚ Complication o May lead to acute angle closure glaucoma if presses in the angle of the anterior chamber ⮚ Treatment o Conservative ▪ Correction of refractive error ▪ Antiglaucoma drugs: if IOP raised o Surgical ▪ Removal of subluxated/dislocated lens ▪ IOL implantation maybe done 22 Uveal tract Q. Mention the parts of uveal tract with their functions Ans: Uvea/uveal tract is the middle coat of the eyeball, also called vascular coat there are 3 parts of uveal tract (from front to back) Iris Ciliary body Choroid Functions Iris o Contains constrictor and dilator pupil muscles ▪ Helps control the dilatation/constriction of pupil ▪ Controls amount of light entering eye ▪ Helps in accommodation o Forms blood aqueous barrier o Takes part in circulation of aqueous humor o Help in drainage of aqueous humor 23  Ciliary body o Ciliary muscle contraction alters size of lens: helps in accommodation o Ciliary body contains ciliary processes, which help in formation of aqueous humor Choroid o Nutrition to outer layer of retina, via the pigmented layer o Removal of metabolic waste products o Helps in absorption of light o Maintains intraocular pressure 24 Retina Q. What are the layers of retina? Ans: Fig: layers of retina **which layer of retina provides nutrition to other layers: layer 1 (retinal pigment epithelium) to the outer layers (1-5), and capillaries in “choroid” to the inner layers (layer 6-10) 25 Nerves of the eye Q. Mention the nerve supply of the extraocular muscles Ans: SO4 LR6 All 3 3rd Cranial Nerve (oculomotor) Superior Rectus (SR) Inferior Rectus (IR) Medial Rectus (MR) Inferior Oblique (IO) 4th Cranial nerve (trochlear) Superior Oblique (SO4) 6th Cranial nerve (abducent) Lateral rectus (LR) Q. Mention the ocular muscles supplied by 3rd cranial nerve Ans: Extraocular muscle Intraocular muscle (SR, IR, MR, IO) ⮚ Sphincter pupillae (pupil contraction) ⮚ Ciliary muscle (accommodation) ⮚ Levator palpabrae superioris (LPS) (elevates eyelids) Q. Mention the clinical features of 3rd cranial nerve palsy (please read the muscles supplied by 3rd nerve before reading this!!) Ans: ⮚ Extra ocular muscle o Abducted eye (unopposed action of LR-LR6) o Failure of adduction of eyeball (MR) o Failure of elevation of eyeball (SR) o Failure of depression of eyeball (IR) o Intorsion of eye (unopposed action of SO-SO4) ⮚ Intraocular muscle o Ptosis – Severe ptosis (due to paralysis of LPS) o Mydriasis (paralysis of sphincter pupil) o Cycloplegia and failure of accommodation (paralysis of ciliary muscle) 26 Ocular physiology Vision Q. Define visual acuity Ans: It refers to measure of spatial resolution of the eye Or, the ability of the eye to discriminate between 2 points Q. Short note: Visual acuity Ans: Definition Tests for VA o For distant vision ▪ Snellen’s chart ▪ Universal chart ▪ Counting finger o For near vision ▪ Snellen’s chart reduced to 1/17th size ▪ Printer’s N type o Counting finger (CF) o Hand movement (HM) o Perception of light (PL) o Projection of rays (PR) The levels of reporting visual acuity o 6/60,6/36, 6/24, 6/18, 6/9, 6/6 o 5/6, 4/6 ….. 1/6 o CF, HM, PL, PR Q. What do you mean by visual acuity 6/18? Is it normal vision? If not, what is the problem? Ans: The patient can read a line from 6 meters distance which a person with normal visual acuity can read from 18 meters distance It is not normal vision The problem is: myopia (define….) Q. What are the pre-conditions to achieve 6/6 normal vision (not DU) Ans: 27  Accurate and normal refractive apparatus o Normal cornea o Normal AH o Normal Lens o Normal vitreous body Accurate and normal neural element o Retina o Optic nerve o Optic pathway Normal interpretative function of brain + its occipital cortex Normal illumination of light Q. Short note: perimetry Ans: It is used to indicate various techniques that are used to examine the field of vision of a person Methods of perimetry o Kinetic method ▪ Confrontation method ▪ Goldman’s perimeter ▪ Lister’s perimeter o Static method ▪ Octopus perimeter ▪ Ocuplot perimeter ▪ Henson perimeter Blindness/loss of vision Q. Define blindness Ans: Uniform definition of blindness by (WHO) Visual acuity in the better eye less then 3/60 (Snellen’s) or its equivalent **legal: 4 mm of cornea invaded Q. Mention the clinical features of pterygium Ans: Mainly cosmetic; otherwise asymptomatic If symptoms present (write only bolded point o Foreign body sensation o Redness o Visual defect (astigmatism): If encroaches on cornea/pupil: o Diplopia: If pterygium affects free movement of eyeball due to becoming fibrotic Sign: Triangular fold of conjunctiva 69  o Apex towards cornea/limbus o Encroaching on the cornea o Most commonly on nasal side Problems with vision o Defective vision o Defective eyeball movement Q. What are the treatment options for pterygium/mention the treatment of pterygium Ans: Treatment options: Medical treatment: o Artificial tear o Topical steroid If not responding, advanced stage: Surgical treatment o Surgical excision of pterygium with bare sclera o Surgical excision of pterygium with application of β radiation o Surgical excision of pterygium with application of Mitomycin-C o Surgical excision of pterygium with conjunctival autograft o Surgical excision of pterygium with amniotic membrane graft [extra info: o Surgical excision of pterygium with nothing else: the sclera underneath the excised pterygium is bare now, has no conjunctival covering: called bare sclera method o Surgical excision of pterygium partially: head is lifted over from the cornea, and it is undermined beneath the body and stitched called “Transposition method” o Excision of pterygium with application of β radiation o Surgical excision of pterygium with application of Mitomycin-C o Surgical excision of pterygium with conjunctival autograft (conjunctiva taken from the patient’s other eye/same eye and stiched over the bare sclera) o Surgical excision of pterygium with amniotic membrane graft (If conjunctival autograft not enough to cover the bare sclera) *amniotic membrane graft is manufactured by Nuclear energy commission, Savar, Dhaka] Q. What are the complications of pterygium, if left untreated? Ans: Infection Visual problem (astigmatism) Blindness Diplopia Very rarely: neoplastic change 70 Q. Short note: Pterygium (definition, parts, clinical feature, treatment options) Scenario: fleshy triangular mass in eye Cornea and sclera Q. Name 4 diseases of cornea Ans: Keratitis Corneal ulcer Corneal abrasion Keratomalacia Keratoconus Keratitis, corneal ulcer Q. What is corneal ulcer? Ans: Discontinuation of epithelial continuity of cornea With inflammation and necrosis of surrounding corneal tissue Q. Causes of corneal ulcer Ans: etiological: Infective o Bacterial o Viral o Fungal o Protozoal Non infective o Allergic o Traumatic o Trophic ▪ Exposure keratitis ▪ Neurotrophic ▪ Nutritional (vit A defc.) ▪ Atheromatous o Associated with disease of skin o Assoc with dss of mucous membrane o …..disease of CT o Idiopathic 71 Based on presence/absence of hypopyon: hypopyon corneal ulcer (bacterial, fungal), without hypopyon Based on depth of ulcer: superficial, deep, impending perforation, perforated Based on location: central corneal ulcer, peripheral Q. Predisposing factors for corneal ulcer Ans: Contact lens Trauma Disease of eye o HSV keratitis o Trichiasis o Dry eye o Exposure keratopathy Vitamin A defc Measles DM Immunosuppression Q. What is hypopyon corneal ulcer: its pathogenesis. Ans: Corneal ulcer, associated with pus in the anterior chamber is called hypopyon corneal ulcer Pathogenesis: bacterial exotoxin → anterior chamber → iritis → inflammation → exudate, neutrophil, WBC (pus) →precipitation in the anterior chamber → hypopyon There is only WBC, no organism, so hypopyon is sterile Bacterial corneal ulcer Q. Name organisms than can penetrate intact cornea Ans: Neisseria gonorrheae Neisseria meningitidis Corynebacterium diphtheriae Hemophilus infleunzae Q. Management of a case of bacterial corneal ulcer. Ans: Clinical feaure: Symptom 72  o Pain o FB sensation o Watering o Photophobia o Blurred vision o Redness of eye Sign o Lid swelling o Conjunctival chemosis + congestion o Ciliary congestion o Corneal ulcer + cloudy/haziness (epithelial defect) o hypopyon (thin and horizontal) (In fungal it is thick and horizontal) o iritis: muddy, swollen iris, with small pupil o IOP maybe raised Investigation: Scraping the corneal ulcer followed by o Gram staining o KOH preparation (for fungal) o Culture and sensitivity Fluorescein dye test (to differentiate from abrasion) Treatment: Before perforation o Topical antibiotic o Systemic antibiotic o Analgesic o Atropine o Dark goggles o Hot compression o Vitamin A supplement o Surgical: ▪ Debridement ▪ Hooding ▪ Keratoplasty ▪ Conjunctival hooding ▪ Amniotic membrane graft Impending perforation/perforation: additional: o If impending perforation: patient should be advised to avoid strain o Acetazolamide (reduce IOP) o Pressure bandage 73  o Adhesive glue o Keratoplasty o Conjunctival flap o Amniotic membrane graft Q. How will you manage pain in corneal ulcer: from above Q. what are the options of surgical treatment of corneal ulcer: from above Q. what are the complications of corneal ulcer Ans: Before perforation o Corneal scarring ▪ Macula ▪ Nebula ▪ Leucoma o Descemetocele o Secondary Glaucoma o Hypopyon o Acute Anterior uveitis o Complicated cataract After perforation o Prolapse of iris o Anterior synechia o Lens: subluxation/distortion/expulsion o Anterior staphyloma o Hemorrhage o Endophthalmitis o Pan ophthalmitis o Pthisis bulbi Fungal corneal ulcer **person with pain, photophobia, redness etc with hx of injury with lead/paddy to the eye few days ago. Q. How will you manage a case of fungal corneal ulcer? Ans: 74  Symptom o History of agricultural trauma o Rest of the signs are same as bacterial Sign o Color ▪ Yellowish white: candida, ▪ Greyish white: aspergillus o Ulcer: ▪ Irregular ▪ Feathery appearance ▪ Satellite lesion present ▪ Distinct margin o Hypopyon: thick + fixed Investigation: same as bacterial; use Sabouraud’s dextrose media as culture Treatment o Same as bacterial (antibiotic, analgesic, atropine, debridement of epuithelium) o Antifungal ▪ Topical: amphotericin B ▪ Systemic Q. difference: fungal vs bacterial corneal ulcer Ans: Bacterial Fungal Symptoms More marked Less marked Signs Less marked More marked Ulcer Moist, excavated, centrally Dry, elevated Satellite lesion Absent Present Shape Circular Feathery Iris Swollen + pupil small May be normal Hypopyon Thin + mobile Thick + fixed Q. Management of hypopyon corneal ulcer. (same as bacterial corneal ulcer + add points for fungal as well) Viral corneal ulcer/dendritic keratitis/superficial punctate keratitis **young boy developed watering in the right eye, redness, foreign body sensation. On examination, there was punctate opacities on the cornea Q. Write down the clinical feature of viral keratitis 75 Ans: Symptom o Mild discomfort (not pain) o Rest are same as bacterial/fungal Sign o Cornea ▪ Punctate lesion ▪ Dendritic lesion (branching) ▪ Dendritic branches have terminal buds ▪ Reduction of corneal sensation ▪ Mild scarring o Conjunctiva: swelling/congestion o No further signs inside Q. Write down the treatment/management of viral keratitis Ans: Treatment: o Same o Antiviral o (Surgical treatment not needed) Q. complications of viral keratitis Ans: Conjunctivitis, scleritis, uveitis Esp. neurological complication o Ptosis o Facial palsy o Optic neuritis o Encephalitis o Hemiplegia Corneal Abrasion Q. define corneal abrasion Ans: breach of continuity of superficial corneal epithelium (but no inflammation/necrosis like corneal ulcer) Q. diagnosis and management of a case of corneal abrasion 76 Ans: Clinical feature Symptom o Pain, redness, lacrimation, photophobia o h/o trauma/scratching/dust sign o ciliary congestion o +ve fluorescein dye test Investigation o Fluorescein dye test o Slit lamp examination Treatment o Wash with saline o Antibiotic: topical o Analgesic/hot compression o Pad bandage for 24 hours (for eye rest, in both eyes) o Then follow up to exclude corneal ulcer Corneal foreign body Q. How will you manage a case of superficial corneal foreign body? Ans: Symptom o Pain, redness, photophobia, lacrimation, FB sensation Sign o FB can be seen with naked eye o Ciliary congestion o Fluorescein dye test: green around FB o There may be ulceration Inv o Fluorescein dye test o Slit lamp examination Mx o Sterilization of eyeball o Surface anesthesia (0.4% oxibuprocaine) o Universal eye speculum → retract lids o Remove FB by ▪ Swab stick or ▪ Hypodermic needle o Topical antibiotic o Pad bandage for 24 hours o Follow up o If ulcer develops, treatment accordingly 77 Fluoresecin dye test Q. short note: Fluorescein dye test Ans: Aim: o to detect active corneal ulcer/abrasion o to differentiate raw ulcer/abrasion from healed corneal opacity procedure o 1 drop 2% fluorescein dye given in lower conjunctival sac o Pt asked to blink several times (to disperse over eyeball) o Washed with normal saline o Slit lamp examination Interpretation o Green color lesion: active/raw ulcer/abrasion o No staining ▪ Keratitis w/o ulcer ▪ Healed corneal ulcer/corneal opacity Keratoplasty Q. define keratoplasty Ans: Operation in which Abnormal host cornea Is replaced by healthy donor cornea Q. classify keratoplasty Ans: Full thickness Partial thickness o Lamellar o Deep lamellar Endothelial keratoplasty Q. indications of keratoplasty Ans: Full thickness o Bullous keratopathy o Keratoconus o Corneal scarring 78  o Corneal degermation o Thinning of cornea o Descemetocele o cosmetic purpose Partial thickness o Opacification of superficial 1/3rd of cornea o Localized thinning o Descemetocele formation Endothelial o Fuchs endothelial corneal dystrophy Q. Short note: Q. give the criteria of ideal donor and recipient for keratoplasty Ans: Ideal donor o No corneal pathology o Normal size, shape, density, distribution of endothelial cell ▪ Density normally: 3000/mm2, density - 6D (mild- moderate myopia) 84 Q. What are the treatment options of myopia? Ans: Myopia treatment Optical treatment: Concave lens o Spectacle o Contact lens Surgical treatment o Methods to flatten the cornea ▪ LASIK (Laser In Situ Keratomileusis) ▪ LASEK (Laser epithelial keratomileusis) ▪ Radial keratotomy ▪ Photorefractive keratotomy (PRK) o Methods to reduce power of lens ▪ Clear lens exchange ▪ Posterior chamber lens implantation (between iris and human crystalline lens) **how to identify concave lens: An object seen through it appears little. When it is moved, the objects seen through it moves in the same direction of the lens movement. Pathological myopia Q. What is pathological myopia? Ans: It Rapidly progressive type of myopia Starts in childhood at 5-10 years of age Usually high myopia (2 y o Visual rehabilitation in children after cataract surgery o Treatment of associated/underlying treatable cause (if any) Q. Why will you treat congenital cataract as early as possible/what will be complications of congenital cataract if not treated promptly?/How will you counsel the parents? Ans: Complications of congenital cataract if not treated promptly: ⮚ (Stimulus deprivation) amblyopia ⮚ Squint ⮚ Nystagmus ⮚ Loss of ocular fixation reflex ⮚ Maldevelopment of binocular vision (in case of unilateral cataract) ⮚ Diplopia 95 Senile cataract Q. Management of age related/senile cataract/How will you evaluate a patient before cataract surgery Ans: ⮚ Symptoms o Gradual dimness of vision o Mono-ocular diplopia o Glare ⮚ Sign Immature cataract Mature / Hypermature/ Morgagnian cataract Visual acuity Better than CF Mature: CF Hypermature: HM Morgangian: PL/PR Color of lens Greyish white Mature: Pearly white Hypermature: Milky white Iris shadow Present Absent Fundal glow (don’t say in Present Absent viva) o Other ocular examination done: to exclude other pathology in the eye o Ophthalmoscopy: to asses status of retina ⮚ Investigation/special examination (In viva, tell only the bolded ones) o Ocular ▪ Sac patency test (to see the patency of lacrimal apparatus) ▪ Tonometry (measure IOP) ▪ Biometry (to measure power of IOL), which includes A scan USG Keratometry ▪ Retinal function test/macular function test: Light reflex PL/PR (projection of light/rays) ▪ B scan USG: to check status of vitreous and retina (if lens is so opaque than ophthalmoscopy cannot be done o Extra ocular ▪ RBS ▪ ECG ▪ Serum creatinine ▪ Other: chest xray, CBC, coagulation profile (according to need) ⮚ Treatment o Early stage: change of spectacle 96  o Surgical treatment ▪ ICCE (intra capsular cataract extraction) ▪ ECCE (extra capsular cataract extraction) Convention ECCE with Posterior chamber intra ocular lens implantation (ECCE with PCIOL) Small incision cataract surgery (SICS) with PCIOL Phaco-emulsification with PCIOL Complicated Cataract Q. Define complicated cataract. Ans: ⮚ It refers to ⮚ Opacification of the lens ⮚ Secondary to ⮚ Some other intraocular diseases Q. Mention the causes of complicated cataract Ans: ⮚ Inflammatory condition o Anterior uveitis (iridocyclitis): most common cause of complicated cataract o Other uveitis (pars planitis, choroiditis) o Endophthalmitis ⮚ Degenerative condition o Retinitis pigmentosa ⮚ Retinal detachment ⮚ Glaucoma ⮚ Intra-ocular tumor o Retinoblastoma o Melanoma Cataract surgery Q. Mention the indications for cataract surgery (not DU) Ans: ⮚ Optical indication o When poor vision affects daily activity ⮚ Medical indication o If cataract causes complications ⮚ Cosmetic indication o When obtaining black pupil is the primary goal 97 Q. Mention the different methods of cataract surgery Ans: ⮚ ICCE (intra capsular cataract extraction) (lens extracted along with capsule) ⮚ ECCE (extra capsular cataract extraction) (posterior capsule is left behind) o Convention ECCE with Posterior chamber intra ocular lens implantation (ECCE with PCIOL) o Small incision cataract surgery (SICS) with PCIOL o Phaco-emulsification with PCIOL Q. Mention the preoperative investigation/examination for cataract surgery Ans: ⮚ Ocular examination o To assess retinal function ▪ Visual acuity ▪ Pupillary light reflex ▪ Projection of rays o Macular function test ▪ Two-point discrimination test ⮚ Investigation o Ocular ▪ Sac patency test ▪ Tonometry (to measure IOP) ▪ Biometry ▪ Others (needed in special situation) Slit lamp examination: to exclude any ocular pathology B scan USG: to see state of vitrous and retine Swab from conjunctival discharge: for culture sensitivity o Systemic ▪ Random blood sugar (should be 8 mm Hg is pathognomonic of glaucoma ⮚ Maintenance of normal IOP depends on o Formation of aqueous humor o Drainage of aqueous humor o Pressure in episcleral veins ⮚ Measurement of IOP (tonometry) o Digital: by pressing two index finger on each of patient’s eyeballs o Instrumental ▪ Contact Indentation tonometry (Schiotz) Applanation tonometry (Goldman) ▪ Non contact Air puff tonometry Pneumatic tonometry 115 Q. Short note: Tonometry Ans: ⮚ The method of measuring IOP is called tonometry ⮚ Instrument to measure IOP is called tonometer ⮚ Types of tonometry o Digital tonometry: by pressing two index finger on each of patient’s eyeballs o Instrumental tonometry ▪ Contact tonometry Indentation tonometry (such as by Schiotz tonometer) Applanation tonometry (such as by Goldman applanation tonometer) ▪ Non contact tonometry (no contact between instrument and cornea) Air puff tonometer Pneumatic tonometer Introduction to glaucoma Q. Define glaucoma Ans: ⮚ Glaucoma is progressive, chronic ⮚ Optic neuropathy ⮚ Where retinal ganglion cells and their axons die ⮚ Causing a (corresponding) visual field defect ⮚ (An important risk factor of glaucoma is increased intraocular pressure) Q. Mention the diagnostic criteria of glaucoma: Presence of any 2 of the following: Ans: ⮚ Raised intra ocular pressure (measured by tonometry) ⮚ Glaucomatous optic disk change (Increased Cup/Disk ratio and thin neuroretinal rim) (detected by Ophthalmoscopy) ⮚ Change in visual field and visual acuity (loss of peripheral vision) (detected by perimetry) Q. What is low tension glaucoma/normal pressure glaucoma? Ans: It is a condition where ⮚ IOP is normal (10-20 mm Hg) ⮚ Diurnal variation in IOP is less than 8 mm Hg ⮚ But there is glaucomatous change in optic disc (Increased cup/disk ratio and thin neuroretinal rim) ⮚ And loss of (peripheral) visual field ⮚ Without any other cause of damage to the optic disc/peripheral vision 116 (glaucoma where the IOP is normal. So, glaucoma can occur without raised IOP) **the reverse is ocular hypertension. Here IOP >20 mm Hg. But no problem in cup/disk ratio or loss in peripheral vision. So raised IOP in absence of glaucoma. Q. Classify glaucoma Ans: 117 Primary open angle glaucoma (POAG) Q. Management of primary open angle glaucoma. Ans: ⮚ Symptom o Usually asymptomatic o Eyeache/headache o Frequent change of (presbyopic) glasses o Late: significant loss of peripheral visual field (patient collides with other people/objects while walking/tunnel vision) ⮚ Sign (what are the cardinal signs of POAG?) o Tonometry: raised IOP o Ophthalmoscopy: glaucomatous optic disk change ▪ Increased cup: disk ratio (>0.3) ▪ Thinning of neuro-retinal rim o Perimetry: glaucomatous field change ▪ Loss of peripheral vision o Gonioscopy: the angle of anterior chamber is open ⮚ Investigation (diagnosis usually clinical) o Optical coherence tomography o Heidelberg retinal tomography ⮚ Treatment o Medical ▪ Prostaglandin analog: Brimonidine Tartrate 0.2%, 1 drop 12 hourly (1st drug of choice) ▪ Beta blocker: Timolol Maleate 0.5%, 1 drop 12 hourly ▪ Carbonic anhydrase inhibitor: Dorzolamide, 2%, 1 drop 8 hourly o Surgical ▪ Laser surgery Laser trabeculoplasty ▪ Incisional surgery Trabeculectomy Q. D.D of glaucoma/causes of tunnel vision (not DU) Ans: 1. Glaucoma 2. Severe cataract 3. Aura phase of migraine 4. Amaurosis fugax (optic equivalent of TIA) 5. Alcoholism 6. Retinitis pigmentosa 118 Primary Angle closure Glaucoma Q. Mention the stages of primary narrow angle glaucoma/angle closure glaucoma. (not DU) Ans: ⮚ Latent stage ⮚ Sub-acute stage ⮚ Acute congestive stage ⮚ Post congestive stage ⮚ Chronic stage ⮚ Absolute stage (we only need to read about the acute congestive stage) Q. Management of acute angle closure glaucoma/acute congestive glaucoma Ans: ⮚ History o Age: usually in 5th-6th decade/over 60 years o Sex: more commonly in females o Symptom ▪ Sudden severe pain in eye (radiation to distribution of 5th CN) ▪ Severe headache ▪ Nausea, vomiting ▪ Rapidly progressive loss of vision ▪ Redness ▪ Watering/lacrimation ▪ Photophobia ⮚ sign (always check the fellow eye as well) o eyelid: edematous o conjunctiva: ciliary congestion, chemosis o cornea: edematous, insensitive o anterior chamber: shallow o pupil ▪ mid dilated ▪ vertically oval ▪ non-reactive to light and accommodation o intra ocular pressure: very high: 50-100 mm Hg o visual acuity: ▪ 6/60 to HM (hand movement) 119  ⮚ Treatment (ocular emergency….hospitalization needed) o Immediate ▪ Tab acetazolamide 250 mg two tab stat, followed by 1 tab 6 hourly ▪ K+ supplementation (to tackle hypokalemia caused by acetazolamide) ▪ Pilocarpine 2% eye drop (continued, 6 hourly, until pupils constrict) (fellow eye is treated at well) ▪ Topical steroid (Dexamethasone) 1 drop 6 hourly (to reduce corneal edema) ▪ Beta blocker: Timolol Maleate 2%, one drop 12 hourly ▪ Analgesic ▪ Anti-ulcerant ▪ Anti-emetic ▪ Pt advised to lie in supine position o If IOP is still not controlled; give osmotic agent ▪ Glycerin (orally) or ▪ Mannitol (IV) o If IOP not controlled after 48 hours, surgery ▪ Peripheral iridectomy ▪ Trabeculectomy o Treatment of the fellow eye ▪ Pilocarpine, 6 hourly until pupils constrict Q. Mention the complication of acute angle closure glaucoma Ans: ⮚ Permanent loss of vision ⮚ Supra-choroidal hemorrhage ⮚ Hyphaema **scenario of angle closure glaucoma: sudden uni-ocular pain, sudden dimness of vision, on examination: raised IOP 120 Secondary glaucoma Q. What are the causes of secondary glaucoma? Ans: Eye injury (traumatic glaucoma) Inflammation (inflammation → adhesion → block of drainage pathway Drugs such as Steroid Cataract: lens induced glaucoma o Phacomorphic o Phaco-lytic o Phaco-anaphylactic Pseudo-exfoliation glaucoma Neovascular glaucoma Pigmentary glaucoma Q. What are the types of lens induced glaucoma? Ans: there are 3 types of lens induced glaucoma Phaco-morphic glaucoma Phaco-lytic glaucoma Phaco-anaphylactic glaucoma Q. Mechanism of development of different lens induced glaucoma Ans: Phacomorphic glaucoma: Mature Cataract → hydration → swelling → swollen lens block angle of eye → impairment of drainage of AH → secondary narrow angle glaucoma Phacolytic glaucoma: Hyper-mature cataract → lens protein → escape into aqueous humor → protein engulfed by macrophage → macrophage blocks trabecular meshwork → decreased drainage → raised IOP secondary open angle glaucoma (angle is open but still drainage is impaired) Phaco-anaphylactic glaucoma: cataract → escape of lens protein → antibodies form against lens protein antigen → antigen antibody complex → complexes deposit in trabecular meshwork → inflammation→ block of trabecular meshwork → decreased drainage → raised IOP →secondary open angle glaucoma 121 Q. Mention the management o different types of lens induced glaucoma Ans: Treatment of phaco-morphic glaucoma: Anti-glaucoma drugs to reduce IOP Removal of lens as early as possible (cataract extraction with PCIOL) Treatment of phaco-lytic glaucoma Anti-glaucoma drugs to reduce IOP Cataract extraction with PCIOL Treatment of phaco-anaphylactic glaucoma Anti-glaucoma drugs to reduce IOP Cataract extraction with PCIOL Steroid (anti-inflammatory) Q. Short note: phacolytic glaucoma: write mechanism, treatment Clinical feature (like primary open angle glaucoma) History of cataract Eye ache, headache Redness of eye Watering Photophobia Signs o Anterior chamber: narrow o IOP: raised o Fundus: glaucomatous changes Q. How does synechia cause secondary glaucoma? Ans: inflammation in anterior chamber → synechia →AH cannot go to anterior chamber → accumulates in posterior chamber → iris presses against angle → sudden raised in IOP with narrow angle → secondary angle closure glaucoma 122 Retina, Optic nerve, Vitreous Retina Q. Classify the diseases of retina Ans: ⮚ Vascular disorder o Diabetic retinopathy o Hypertensive retinopathy o Central retinal artery occlusion o Central retinal vein occlusion o Retinopathy of prematurity ⮚ Macular disorder (acquired macular disorder) o Age related macular degeneration (ARMD) o Age related macular hole o Cystoid macular edema o Myopic maculopathy o Drug induced maculopathy ⮚ Retinal detachment ⮚ Inflammation of retina (retinitis) – due to o Herpes virus o CMV o Syphilis o Sarcoidosis o Toxoplasmosis ⮚ Retinal dystrophy ⮚ Retinal tumor o Retinoblastoma o Retinal hemangioma Retinoblastoma Q. Name some intraocular tumor (Not DU) Ans: ⮚ Tumor of the iris o Iris nevus o Iris melanoma o Iris cyst ⮚ Tumor of the ciliary o Ciliary body naevus o Ciliary body melanoma ⮚ Tumor of the choroid o Choroidal nevus o Choroidal melanoma 123  o Choroidal hemangioma ⮚ Tumors of the retina o Retinoblastoma o Retinal hemangioma Q. Short note: Retinoblastoma Ans: ⮚ It is a malignant, primary, intraocular tumor of children, arising form the immature cells of retina ⮚ It is the most common, primary, malignant, intraocular malignancy of childhood ⮚ Overall, it is the 2nd most common intraocular malignancy (most common is uveal melanoma) ⮚ Types o Exophytic (grows outwards towards the sclera) o Endophytic (grows inwards towards the vitreous) o Diffuse infiltrating (grows along the retina) ⮚ Clinical features o Leukocoria (white pupillary reflex) o Strabismus o Proptosis o Painful red eye (secondary glaucoma) o (Complicated) cataract o Inflammation ▪ Orbital cellulitis ▪ Pre-septal cellulitis ▪ Intraocular o Nystagmus o Raised ICP o Systemic features due to metastasis ⮚ Special examination (examination under anesthesia) o General examination o Tonometry: to measure IOP o Slit lamp examination o Ophthalmoscopy ⮚ Investigation o B scan ultrasonography o CT scan o MRI ⮚ Staging o Stage I: Quiescent stage o Stage II: Stage of glaucoma (enlargement of globe) o Stage III: Stage of extraocular extension o Stage IV: Stage of metastasis 124  ⮚ Treatment o Highly individualized o Small tumor up to 6 mm diameter ▪ Laser therapy ▪ Cryo therapy o Medium sized tumor up to 12 mm diameter ▪ Chemotherapy ▪ Radiotherapy o Large sized tumor more than 12 mm diameter ▪ Surgery: enucleation(entire eyeball)/exenteration (all contents of orbit) ▪ Chemotherapy ▪ Radiotherapy Q. How does retinoblastoma spread? Ans: ⮚ Direct spread o Intraocular tissue o Extraocular: CNS, Orbit ⮚ Lymphatic spread: pre-auricular LN 🡪 Cervical LN ⮚ Bloodstream spread o Bone o Liver o Lungs Q. Management of RB, Treatment, What is retinoblastoma: Q. What are the treatment modalities of retinoblastoma? Ans: ⮚ Surgery o Enucleations o Exenteration ⮚ Radiotherapy o External beam radiotherapy o Brachytherapy ⮚ Chemotherapy o Carboplatin o Etoposide o Vincristine ⮚ Other modalities o Transpupillary thermography o Cryotherapy o Photocoagulation 125 Q. Mention the stages of RB (see from above) Q. Treatment of RB according to stage (not DU) Ans: ⮚ Stage I o Occupying 50% of retinal surface ▪ Surgery: Conservative: Enucleation ⮚ Stage II o Surgery: Conservative: Enucleation ⮚ Stage III o Surgery: definite: Exenteration o Radiotherapy ⮚ Stage IV (distal metastasis) o Chemotherapy o Radiotherapy Leukocoria Q. Define leukocoria Ans: Abnormal white reflex from the retina, resulting in white pupillary reflex is called leukocoria Q. Enumerate the causes of leukocoria Ans: ⮚ Causes in children o Congenital cataract o Retinoblastoma o Retinopathy of prematurity (Retrolental fibroplasia) o Persistent hyperplastic primary vitreous ⮚ Causes in adult o Senile cataract o Vitreous opacity o Endophthalmitis 126 Destructive operation of the eyeball Q. What are the destructive operation of the eyeball? Ans: ⮚ Evisceration ⮚ Enucleation ⮚ Exenteration Q. Define enucleation Ans: ⮚ It is a destructive surgical procedure in which ⮚ The whole eye ball is removed ⮚ By cutting the optic nerve + its meninges + its blood vessels (optic nerve is cut, meninges is opened) Q. Define evisceration Ans: ⮚ Destructive surgical procedure in which ⮚ The intraocular contents of the eye ball are removed ⮚ Along with all three coats ⮚ Except posterior 1/5th of the sclera and the optic nerve (optic nerve isn’t removed, so meninges isn’t opened) Q. Mention 2 indications of enucleation and evisceration each **generally, infective causes are dealt with by evisceration. Since there meninges isn’t cut, so infection doesn’t spread to the brain ⮚ Indication of enucleation o In living patient ▪ Retinoblastoma ▪ Malignant melanoma ▪ Severely traumatized eye, with no perception of light (to prevent sympathetic ophthalmitis) ▪ Sympathetic ophthalmitis o In dead body: to collect donor eye (this is the commonest indication) ⮚ Indication of evisceration o Pan-ophthalmitis o Endophthalmitis o Sloughing corneal ulcer o Intra-ocular hemorrhage 127 Q. Difference between enucleation and evisceration Ans: Enucleation Evisceration Eyeball excision Complete Partial Sclera Completely excised Left behind (posterior 1/5th) Optic nerve Excised Left behind Meninges opened Yes No Communication of orbital Yes No content with inside of skull Chance of spread of infection Yes No inside brain Infective cases Never done Managed this way Common indication Intraocular tumor Pantophthalmids To prevent sympathetic Endophthalmitis ophthalmitis Excision of donor eyeball Q. Short note: Enucleation Ans: Definition, indication, why infective causes cannot be done by it; Contraindication: endophthalmitis, panophthalmitis (infection will spread into brain) Enucleation is followed by ocular implant placement within the tenon’s capsule **retinal detachment: separation of the rest of the layers of retina from the pigmented epithelial layer. 128 Optic nerve Optic neuritis Q. Define optic neuritis Ans: An inflammation of the optic nerve is referred to as optic neuritis Q. Classify optic neuritis Ans: **ON = Optic nerve ⮚ According to ophthalmoscopy finding/level of lesion o Retrobulbar neuritis: inflamm. of ON behind the globe o Papillitis: inflamm. of the ON @ the level of ON head/Optic disk o Neuro-retinitis: inflamm/ of the Optic Disk + nerve fiber layer of retina o ⮚ According to etiology o Idiopathic o Demyelinating disorder: Multiple sclerosis o Infection ▪ Local: orbital cellulits, endophthalmitis, from meningitis/sinusitis ▪ Systemic: viral, bacterial, fungal, parasitic, protozoal o Immune disorder: uveitis, Sympathetic ophthalmitis, SLE o Metabolic disorder: DM o Toxic cause: Ethambutol Q. Mention the causes of optic neuritis Ans: ⮚ Idiopathic ⮚ Demyelinating disorder: Multiple sclerosis ⮚ Infection o Local: 129  ▪ orbital cellulits, ▪ endophthalmitis, ▪ from meningitis/sinusitis o Systemic: ▪ Viral: influenza, measles, mumps, HSV, VZV, CMV ▪ Bacterial: TB, syphilis ▪ Fungal: cryptococcus, histoplasmosis ▪ Parasitic: cysticercosis ▪ Protozoal: toxoplasma ⮚ Immune disorder: o uveitis, o Sympathetic ophthalmitis, o SLE ⮚ Metabolic disorder: DM ⮚ Toxic cause: Ethambutol Q. Mention the clinical features of optic neuritis Ans: ⮚ Symptom o Sudden, severe loss of vision o Pain on eye movement o Symptoms of underlying disease ⮚ Sign o Tenderness on pressure over the globe o Visual acuity: reduced o Color vision: diminished, esp red color o Field of vision: defect in field of vision o Light reflex: relative afferent pupillary defect (2nd nerve damaged but 3rd nerve intact: if light given in this eye, neither eye will constrict. But if light shone in opposite eye, both eyes will constrict) o Ophthalmoscopy will reveal problem in optic disk and retina, if there is papillitis/neuro- retinitis, normal in case of Retro bulbar neuritis o Signs of the underlying disease Q. Treatment of optic neuritis Ans: Corticosteroid ○ At 1st, IV (mehtylprednisolone) - for 3 days ○ Then, oral (prednisolone) - for 11 days ○ Then gradually tapered Vitamin B1, B6, B12 injection Treatment of the underlying cause 130 Papilledema Q. Define papilledema Ans: Papilledema maybe defined as Bilaterl, non inflammatory Swelling of the optic disc/ON head Due to raised intracranial pressure (By definition, papilledema is due to raised ICP. Any swelling of optic disc without raised ICP is called disc swelling) Q. What are the causes of papilledema? Ans: (causes of raised ICP) Intra cranial space occupying lesion ○ Brain tumor ○ Brain abscess ○ Hematoma Impairment of CSF absorption via arachnoid villi following ○ Meningitis ○ Encephalitis ○ Cerebral trauma Vascular cause ○ Cavernous sinus thrombosis ○ Thrombosis of the other sinuses inside skull ○ Intracranial vein thrombosis ○ Cerebral aneurysms Due to hypertension ○ Malignant hypertension ○ Hypertensive retinopathy (disc swelling) Pseudotumor cerebri (idiopathic intracranial hypertension) ○ Vitamin A ○ Corticosteroid ○ OCP ○ Tetracycline ○ Nalidixic acid Blood disorder ○ Leukemia ○ Polycythemia **pathogenesis: raised ICP → block of fluid flow thru axon → edema of optic disc; or, 131 raised ICP → blockage of small veins around optic disc → edema of the optic disc **feature: loss of vision/varaibility + headache; with posutre, worst on waking up, better as day increases Q. How will you investigate a case of papilledema? Ans: CT scan of brain MRI of brain CSF analysis Angiography (to see vascular lesion) ○ CTA ○ MRA ○ CTV ○ MRV Q. DIfference: Papilledema vs Papillitis Ans: Papilledema Papillitis Definition any swelling of the optic inflammation of the optic nerve disc/optic nerve head due to (optic neuritis) at the level of raised ICP, which is non optic nerve head /optic disc inflammatory and bilateral nature of condition non inflammatory inflammatory/infective cause any cause of raised ICP inflammatory condition (MS) or infective condition distribution bilateral maybe uni/bilateral pain on pressing the eyeball no yes tenderness on movement of no yes eyeball headache, nausea, vomiting commonly present usually absent vision varies with posture yes no vision loss slow sudden, severe onset insidious sudden 132  opthlamoscopic finding degree of optic disc swelling optic disc swelling is less than in swelling is more papilledema treatment treat the underlying cause of treat the underlying raised ICP inflammation Q. Short note: Disc Swelling Ans: By definition, papilledema should always be due to raised ICP But in some cases, the optic nerve head/optic disc is swollen in absence of raised ICP Those conditions, along with papilledema, are called “Disc swelling”, which is a broader umbrella term Causes of disc swelling ○ Papilledema ○ Papillitis ○ Neuro-retinitis ○ Optic disc vasculitis ○ Central retinal vein occlusion ○ Central retinal artery occlusion ○ Anterior ischemic optic neuropathy ○ Graves disease (advanced) Optic atrophy Q. Short note: Optic atrophy Ans: ⮚ Defn: o It is a condition that occurs due to o degeneration of optic nerve o with loss of myelin sheath ⮚ 4 types o Primary optic atrophy o Secondary optic atrophy o Consecutive optic atrophy o Glaucomatous optic atrophy ⮚ Primary optic atrophy o It is a type of optic atrophy o Which occurs due to o Degeneration of optic nerve fibers outside the eyeball (behind the globe) o Cause ▪ Optic neuritis behind the globe (retrobulbar neuritis) 133  ▪ Compression of ON by tumor/mass ▪ Drug: ethambutol ▪ Hereditary ▪ Idiopathic ⮚ Secondary optic atrophy o It Is a type of optic atrophy o Which occurs due to o Degeneration of optic nerve fibers at the level of optic disc o (Associated with swelling of optic nerve head) o Cause ▪ Papilledema ▪ Papillitis ▪ Neuro-retinitis ⮚ Consecutive optic atrophy: due to destruction of ganglion cell layer of retina…associated with other retinal diseases o Retinitis pigmentosa o High myopia/pathological myopia o Retinal detachment o Occlusion of central retinal artery ⮚ Glaucomatous optic atrophy: associated with glaucoma ⮚ Q. What is primary optic atrophy? Mention 2 causes. (write from above) Q. What is secondary optic atrophy? (write from above) *features of optic atrophy: complete/partial loss of vision 134 Systemic diseases affecting the eye Q. Name some systemic diseases affecting the eye CVS: Hypertension Endocrine ○ Diabetes mellitus ○ Hyperthyroidism ○ Hypothyroidism Hematologic ○ Anemia ○ Polycythemia ○ Leukemia Nutritional deficiency ○ Vitamin A deficiency ○ B1,B6,B12 deficiency Autoimmune disease: SLE, RA Infection: AIDS, HSV Secondary metastasis to eye Diabetic Retinopathy Q. What are the ocular complications of diabetes mellitus? Ans: Diabetic retinopathy (retina) (Presenile/metabolic) cataract (lens) Iridopathy (iris) Refractive error (lens, cornea) Xanthelasma (due to associated hyperlipidemia) (orbital skin) Recurrent stye (increased risk of infection) (eyelid) Ocular motor nerve palsy (3,4,6, cranial nerve palsy) (nerves) Q. Classify diabetic nephropathy Ans: (based on ophthalmoscopic findings) Non proliferative diabetic nephropathy (NPDR) ○ Mild NPDR ○ Moderate NPDR ○ Severe NPDR Proliferative diabetic nephropathy (PDR) ○ Early PDR ○ High risk PDR Diabetic maculopathy Advanced Diabetic eye disease (ADED) 135 Another classification (based on ophthalmoscopic finding) Non proliferative, Background diabetic retinopathy (BDR) Pre-proliferative diabetic retinopathy (PPDR) Proliferative diabetic retinopathy (PDR) Advanced diabetic eye disease (ADED) Diabetic maculopathy (when there is macular involvement) Q. What are the clinical features of diabetic retinopathy? Ans: History: gradual dimness of vision/worsening of vision + history of longstanding, poorly controlled DM Examination (ophthalmoscopic findings): Background diabetic retinopathy (in this stage, earliest signs of DR) ○ Microaneurysm ○ Dot-blot hemorrhages ○ Exudates Pre-proliferative diabetic retinopathy (PDR) ○ Multiple cotton wool spots/exudate ○ Multiple dot-blot hemorrhages ○ Cluster of micro-aneurysms ○ Intraretinal microvascular abnormality ○ Venous changes: Venous loops Venous beading Proliferative diabetic retinopathy ○ Neovascularization Advanced diabetic eye disease (ADED) ○ Retinal detachment ○ Hemorrhage Preretinal Intravitreal Neovascularization of iris Diabetic maculopathy ○ It refers to presence of any of the features of retinopathy at the macula ○ Since macular is the area with most cones ○ So diabetic maculopathy will give rise to significant vision loss ○ Ophthalmoscopic findings Macular edema Macular ischemia 136 (((**pathogenesis of features Occlusion of flow in small capillaries → retinal ischemia →→ neovascularization Loss of pericyte → weakening of vessel wall → microaneurysm Weakening of capillary wall → capillary leakage → retinal edema Loss of nerve function → stoppage of axonal flow → accumulation of intra-cellular products and debris inside axon → cotton wool spots and exudates ))) Q. How will you treat a case of diabetic retinopathy Ans: Type Treatment BDR Lifestyle modification Strict control of Diabetes Treatment of risk factors PPDR Focal retinal photocoagulation (by laser) PDR Pan-retinal (whole retina)photocoagulation (by laser) Intravitreal corticosteroid Intravitreal VEGF inhibitor (to stop neovascularization) ADED Vitreo-retinal surgery + Photocoagulation (by laser) Intravitreal corticosteroid 137  Intravitreal VEGF inhibitor Diabetic Focal (macular) photocoagulation (by laser) maculopathy Intravitreal corticosteroid Intravitreal VEGF inhibitor + regular follow up Hypertensive retinopathy **pathogenesis: arteriolar narrowing, vessel leak, arteriosclerosis Long term HTN → Arteriolar narrowing/arteriola attenuation Long term HTN → Vascular leakage → hemorrhage, exudate, retinal edema Arteriosclerosis: long standing HTN → thickening of arteriolar wall → changes of veins in arterio- venous crossing (deflection of veins away from AVC - salu’s sign, banking of veins at AVC- bonnet sign, tapering of veins at AVC - gunn sign) Also, thickening of arteriolar wall → change in color of arterioles (copper wiring, then silver wiring) Q. What are the clinical features/fundal features/grades of hypertensive retinopathy (to easily read this question, please read the pathogenesis with some pain) Ans: Hx: long standing, poorly controlled/uncontrolled HTN + gradual worsening of vision Opthalmoscopic findings/findings at fundus: Grade Features Grade I Mild arteriolar narrowing/attenuation Grade II Marked arteriolar narrowing/attenuation + Deflection of veins at Arteriovenous crossing (Salu) Grade III Grade II + copper wiring + Banking of veins at Arteriovenous crossing (Bonnet) Tapering of veins at AVC (gunn) + Flame shaped hemorrhage Cotton wool spot 138  Hard exudate Grade IV Grade III + Silver wiring + Disc Swelling/Papilledema **HTN retinopathy vs DM retinopathy (not for written) HTNR DR abnormality in retinal artery retinal capillary +vein dry retina wet retina hemorrhage less more edema less more exudate less more cotton wool spot more less flame shaped hemorrhage more less Vitamin A deficiency Q. What are the nutritional sources of vitamin A? Ans: vegetable sources o green leafy vegetables o carrot o tomato o yellow ripe fruits animal sources o liver o meat o cod liver oil o egg yolk o milk o small fish fortified food items 139 Q. Mention the WHO classification of xerophthalmia Ans: the characteristic ocular manifestation of vitamin A, ranging from night blindness to corneal melting are termed as “Xerophthalmia” Classification XN – Night blindness X1A – Conjunctival xerosis X1B – Bitot spot X2 – Corneal xerosis X3A – corneal ulceration and kertamalacia involving 1/3rd ….. XS – Corneal scar XF – Xeropththalmic fundus Q. What is night blindness, what are the causes of night blindness? Ans: Definition: it is referred to as poor adaptation to darkness, leading to poor vision in the dark/dimly lit environment Causes Rod dysfunction o Vitamin A deficiency o Retinitis pigmentosa o High myopia / pathological myopia o Retinal detachment Opacity of refractive media o Lens opacity o Corneal opacity Advanced cases of primary open angle glaucoma Q. How will you manage a case of Xerophthalmia? Ans: Treatment: It is a medical emergency, should be treated in hospital. Treatment of vitamin A deficiency o 3 doses, on day 1, 2, 14 (1st day, 2nd day, 14th day) o On each day, the patient will receive the following dose, according to age ▪ Age < 6 m: 50,000 IU Retinal Palmiltate orally 140  ▪ 6-12 months: 100,000 IU ▪ >12 months: 200,000 IU Treatment of the cause Treatment of corneal ulcer and keratomalacia…if present Q. How will you prevent vitamin A deficiency? (NOT DU) Ans: Increase dietary intake of food rich in vitamin A Periodic administration of large doses of vitamin A Administration of vitamin A enriched food Q. What is keratomalacia? Ans: it is the condition where Cornea becomes soft Suppurative ulcer develops Leading to local destruction of the cornea Cause: vitamin A deficiency Treatment: same as that of xerophthalmia Q. Short note: Bitot’s spot Ans: It is stage X1B in WHO classification of xerophthalmia Here, keratin material accumulate in triangular patch close to limbus Located usually in temporal side These patches appear foamy, cheesy Cause: vitamin A deficiency Treatment o Same as treatment of xerophthalmia 141 Ocular emergency, injury Q. Name some ocular emergencies Ans: true emergency (even few hours delay will cause permanent ocular damage/extreme discomfort) o orbit: orbital cellulitis o conjunctiva: gonococcal conjunctivitis o cornea: corneal ulcer o iris: acute iritis o angle of eye: acute congestive glaucoma o retina: central retinal artery occlusion o retina: retinal detachment o trauma o chemical burn urgent cases (rx needed ASAP, but can tolerate delay of few hours-days) o unilateral exophthalmos o acute dacryocystitis o advanced stage of glaucoma o sympathetic ophthalmitis o vitreous hemorrhage o ocular tumor o optic nerve disorder Q. Name the effects on eye following blunt trauma. / A boy was hit with a cricket ball while playing. What will be the effects on his eye? Ans: orbit o fracture of orbital bones o orbital hematoma eyelid o skin abrasion o bruise/hematoma o laceration conjunctiva o subconjunctival hemorrhage cornea o corneal abrasion o corneal edema anterior chamber o hyphaema (blood in anterior chamber) angle o traumatic glaucoma 142  lens o cataract o subluxation of lens o dislocation of lens anterior uveal tract o traumatic miosis o traumatic mydriasis o irido-dialysis (part of iris detached from ciliary body) o aniridia (whole iris detached from ciliary body) o cyclodialysis (ciliary body detachment) vitreous o vitreous hemorrhage o vitreous detachment sclera o rupture choroid o rupture o hemorrhage retina o retinal hemorrhage o retinal detachment o retinal breach optic nerve o optic nerve avulsion o optic neuropathy eyeball as a whole o globe rupture Q. A man presented with penetrating corneal injury with iris prolapse. How will you proceed to manage this case? Ans: general treatment o resuscitation o IV fluid nutritional support o Broad spectrum antibiotics Specific mx of penetrating corneal trauma with prolapsed iris: o removal of the prolapsed iris o meticulous suture of the wound o prolapsed iris should never be reposited: will cause endophthalmitis o if lens injury + vitreous loss present ▪ lensectomy + anterior vitrectomy after surgery o steroid to prevent adhesion o continue antibiotic therapy 143 Hyphaema Q. Define hyphaema Ans: It refers to bleeding into the anterior chamber/presence of blood in the anterior chamber Q. What are the causes of hyphaema? Ans: trauma o ocular injury o iatrgenic: due to surgery infective o herpes zoster iritis o gonococcal iritis intraocular tumor o retinoblastoma diabetic retinopathy bleeding disorder o ITP o Hemophilia Q. Clinical features + inv of hyphaema Ans: Blood in anterior chamber Investigation Tonometry Slit lamp examination CBC Coagulation profile c/s of eye secretion Q. Treatment of hyphaema Ans: in case of small, transient hyphaema: o observation o application of bilateral pad bandage to rest eye Treatment of significant hyphaema o Tranexamic agent o Atropine o Treat associated uveitis: corticosteroid o Treat elevated IOP: timolol 144  Indication for surgery o Hyphaema persists for >2 days o IOP >50 mm hg o Early blood staining of cornea Surgey: surgical evacuation of hyphaema Post-operative bilateral pad bandage rest eye Q. Short note: Hyphaema (write from above) Chemical Injury Q. Name the common chemical agents causing ocular inury/name the causes of chemical injury to the eye Ans: Alkali o Lime (least dangerous) o Sodium hydroxide o Potassium hydroxide o Ammonia (most dangerous) Acid o Sulfuric acid o Sulfurous acid o Hydrochloric acid o Nitric acid o Acetic acid o Chromic acid Q. Which chemical injury is more injurious to the eyes and why? Ans: Alkali burns are more dangerous than acid burn. The reasons are Alkali causes liquefactive necrosis (in comparison to acid, that cause coagulation necrosis) Alkali causes saponification of fatty content of the cell membrane, causing cell disruption Alkalis bind to proteins to form gel like soluble components Alkalis make collagen more susceptible for enzymatic degradation --- all these causes increased penetration of alkalis deep into the tissue Q. Management of alkali burn/management of chemical injuries to eye/management of lime injury to the eye 145 Ans: Clinical features of chemical injury/alkali burn o History ▪ chemical accident affecting the eye ▪ painful eye ▪ red eye ▪ burning sensation ▪ blurred vision o examination finding (slit lamp examination) ▪ corneal opacity ▪ loss of corneal epithelium ▪ visible iris details ▪ iridocyclitis ▪ limbal ischemia Treatment: emergency treatment o copious irrigation with available water ▪ normal saline ▪ whatever water is found nearest at hand o double eversion of eyelid – for proper exposure o debridement of necrotic tissue medical treatment o topical steroid o atropine (to prevent synechia) o topical antibiotics (to prevent infection) o vitamin C (to promote healing) o anesthetic drops surgical management o in early case ▪ limbal