Comprehensive Ophthalmology 4th Edition by A K Khurana PDF

Comprehensive OPHTHALMOLOGY  This page intentionally left blank Comprehensive OPHTHALMOLOGY Fourth Edition A K Khurana Professor, Regional Institute of Ophthalmology, Postgraduate Institute of Medical Sciences, Rohtak- 124001, India NEW AGE I...

Comprehensive OPHTHALMOLOGY  This page intentionally left blank Comprehensive OPHTHALMOLOGY Fourth Edition A K Khurana Professor, Regional Institute of Ophthalmology, Postgraduate Institute of Medical Sciences, Rohtak- 124001, India NEW AGE INTERNATIONAL (P) LIMITED, PUBLISHERS New Delhi Bangalore Chennai Cochin Guwahati Hyderabad Jalandhar Kolkata Lucknow Mumbai Ranchi Visit us at www.newagepublishers.com Copyright © 2007, 2003, 1996, A K Khurana Published by New Age International (P) Ltd., Publishers All rights reserved. No part of this ebook may be reproduced in any form, by photostat, microfilm, xerography, or any other means, or incorporated into any information retrieval system, electronic or mechanical, without the written permission of the publisher. All inquiries should be emailed to [email protected] ISBN (13) : 978-81-224-2480-5 PUBLISHING FOR ONE WORLD NEW AGE INTERNATIONAL (P) LIMITED, PUBLISHERS 4835/24, Ansari Road, Daryaganj, New Delhi - 110002 Visit us at www.newagepublishers.com  Dedicated To my parents and teachers for their blessings To my students for their encouragement To my children, Aruj and Arushi, for their patience To my wife, Dr. Indu, for her understanding  This page intentionally left blank  (vii) P R EPREFACE FACE Fourth edition of the book has been thoroughly revised, updated, and published in an attractive colour format. This endeavour has enhanced the lucidity of the figures and overall aesthetics of the book. The fast-developing advances in the field of medical sciences and technology has beset the present- day medical students with voluminous university curriculae. Keeping in view the need of the students for a ready-made material for their practical examinations and various postgraduate entrance tests, the book has been expanded into two sections and is accompanied with ‘Review of Ophthalmology’ as a pocket companion, and converted into a comprehensive book. Section 1: Anatomy, Physiology and Diseases of the Eye. This part of the book includes 20 chapters, 1 each on Anatomy and Physiology of Eye and rest 18 on diseases of the different structures of the eye. Section II: Practical Ophthalmology. This section includes chapter on ‘Clinical Methods in Ophthalmology’ and different other aspects essential to the practical examinations viz. Clinical Ophthalmic Cases, Darkroom Procedures, and Ophthalmic Instruments. Review of Ophthalmology: Quick Text Review and Multiple-Choice Questions. This pocket companion provides an indepth revision of the subject at a glance and an opportunity of self-assessment, and thus makes it the book of choice for preparing for the various postgraduate entrance examinations. Salient Features of the Book
Each chapter begins with a brief overview highlighting the topics covered followed by relevant applied anatomy and physiology. The text is then organized in such a way that the students can easily understand, retain and reproduce it. Various levels of headings, subheadings, bold face and italics given in the text will be helpful in a quick revision of the subject.
Text is complete and up-to-date with recent advances such as refractive surgery, manual small incision cataract surgery (SICS), phacoemulsification, newer diagnostic techniques as well as newer therapeutics.
To be true, some part of the text is in more detail than the requirement of undergraduate students. But this very feature of the book makes it a useful handbook for the postgraduate students.
The text is illustrated with plenty of diagrams. The illustrations mostly include clinical photographs and clear-line diagrams providing vivid and lucid details.
Operative steps of the important surgical techniques have been given in the relevant chapters.
Wherever possible important information has been given in the form of tables and flowcharts.
An attraction of this edition of the book is a very useful addition of the ‘Practical Ophthalmology’ section to help the students to prepare for the practical examinations.  (viii) It would have not been possible for this book to be in its present form without the generous help of many well wishers and stalwarts in their fields. Surely, I owe sincere thanks to them all. Those who need special mention are Prof. Inderbir Singh, Ex-HOD, Anatomy, PGIMS, Rohtak, Prof. R.C. Nagpal, HIMS, Dehradun, Prof. S. Soodan from Jammu, Prof. B. Ghosh, Chief GNEC, New Delhi, Prof. P.S. Sandhu, GGS Medical College, Faridkot, Prof. S.S. Shergil, GMC, Amritsar, Prof. R.K. Grewal and Prof. G.S. Bajwa, DMC Ludhiana, Prof. R.N. Bhatnagar, GMC, Patiala, Prof. V.P. Gupta, UCMS, New Delhi, Prof. K.P. Chaudhary, GMC, Shimla, Prof. S. Sood, GMC, Chandigarh, Prof. S. Ghosh, Prof. R.V. Azad and Prof. R.B. Vajpayee from Dr. R.P. Centre for Opthalmic Sciences, New Delhi, and Prof. Anil Chauhan, GMC, Tanda. I am deeply indebted to Prof. S.P. Garg. Prof. Atul Kumar, Prof. J.S. Tityal, Dr. Mahipal S. Sachdev, Dr. Ashish Bansal, Dr. T.P. Dass, Dr. A.K. Mandal, Dr. B. Rajeev and Dr. Neeraj Sanduja for providing the colour photographs. I am grateful to Prof. C.S. Dhull, Chief and all other faculty members of Regional Institute of Opthalmology (RIO), PGIMS, Rohtak namely Prof. S.V. Singh, Dr. J.P. Chugh, Dr. R.S. Chauhan, Dr. Manisha Rathi, Dr. Neebha Anand, Dr. Manisha Nada, Dr. Ashok Rathi, Dr. Urmil Chawla and Dr. Sumit Sachdeva for their kind co-operation and suggestions rendered by them from time to time. The help received from all the resident doctors including Dr. Shikha, Dr. Vivek Sharma and Dr. Nidhi Gupta is duly acknowledged. Dr. Saurabh and Dr. Ashima deserve special thanks for their artistic touch which I feel has considerably enhanced the presentation of the book. My sincere thanks are also due to Prof. S.S. Sangwan, Director, PGIMS, Rohtak for providing a working atmosphere. Of incalculable assistance to me has been my wife Dr. Indu Khurana, Assoc. Prof. in Physiology, PGIMS, Rohtak. The enthusiastic co-operation received from Mr. Saumya Gupta, and Mr. R.K. Gupta, Managing Directors, New Age International Publishers (P) Ltd., New Delhi needs special acknowledgement. Sincere efforts have been made to verify the correctness of the text. However, in spite of best efforts, ventures of this kind are not likely to be free from human errors, some inaccuracies, ambiguities and typographic mistakes. Therefore, all the users are requested to send their feedback and suggestions. The importance of such views in improving the future editions of the book cannot be overemphasized. Feedbacks received shall be highly appreciated and duly acknowledged. Rohtak A K Khurana  (ix) CONTENTS CONTENTS Preface............................................................................................................................................ vii SECTION I: ANATOMY, PHYSIOLOGY AND DISEASES OF THE EYE 1. Anatomy and Development of the Eye............................................................................... 3 2. Physiology of Eye and Vision............................................................................................ 13 3. Optics and Refraction......................................................................................................... 19 4. Diseases of the Conjunctiva............................................................................................... 51 5. Diseases of the Cornea...................................................................................................... 89 6. Diseases of the Sclera...................................................................................................... 127 7. Diseases of the Uveal Tract............................................................................................ 133 8. Diseases of the Lens........................................................................................................ 167 9. Glaucoma........................................................................................................................... 205 10. Diseases of the Vitreous................................................................................................... 243 11. Diseases of the Retina...................................................................................................... 249 12. Neuro-ophthalmology........................................................................................................ 287 13. Strabismus and Nystagmus.............................................................................................. 313 14. Diseases of the Eyelids.................................................................................................... 339 15. Diseases of the Lacrimal Apparatus................................................................................ 363 16. Diseases of the Orbit....................................................................................................... 377 17. Ocular Injuries.................................................................................................................. 401 18. Ocular Therapeutics, Lasers and Cryotherapy in Ophthalmology................................ 417 19. Systemic Ophthalmology.................................................................................................. 433 20. Community Ophthalmology.............................................................................................. 443 SECTION II: PRACTICAL OPHTHALMOLOGY 21. Clinical Methods in Ophthalmology................................................................................. 461 22. Clinical Ophthalmic Cases................................................................................................ 499 23. Darkroom Procedures....................................................................................................... 543 24. Ophthalmic Instruments and Operative Ophthalmology................................................. 571 Index........................................................................................................................................... 593  This page intentionally left blank Section-I ANATOMY, PHYSIOLOGY AND DISEASES OF THE EYE  This page intentionally left blank  1 Anatomy and CHAPTER 1 Development of the Eye ANATOMY OF THE EYE z Formation of lens vesicle z The eyeball z Formation of optic cup z Visual pathway z Changes in the associated mesoderm z Orbit, extraocular muscles and z Development of various ocular appendages of the eye structures z Structures derived from the embryonic DEVELOPMENT OF THE EYE layers z Formation of optic vesicle and z Important milestones in the development optic stalk of the eye Coats of the eyeball ANATOMY OF THE EYE The eyeball comprises three coats: outer (fibrous This chapter gives only a brief account of the anatomy coat), middle (vascular coat) and inner (nervous coat). of eyeball and its related structures. The detailed 1. Fibrous coat. It is a dense strong wall which anatomy of different structures is described in the protects the intraocular contents. Anterior 1/6th of relevant chapters. this fibrous coat is transparent and is called cornea. Posterior 5/6th opaque part is called sclera. Cornea is THE EYEBALL set into sclera like a watch glass. Junction of the Each eyeball (Fig. 1.1) is a cystic structure kept cornea and sclera is called limbus. Conjunctiva is distended by the pressure inside it. Although, firmly attached at the limbus. generally referred to as a globe, the eyeball is not a 2. Vascular coat (uveal tissue). It supplies nutrition sphere but an ablate spheroid. The central point on to the various structures of the eyeball. It consists of the maximal convexities of the anterior and posterior three parts which from anterior to posterior are : iris, curvatures of the eyeball is called the anterior and ciliary body and choroid. posterior pole, respectively. The equator of the eyeball lies at the mid plane between the two poles 3. Nervous coat (retina). It is concerned with visual (Fig.1.2). functions. Dimensions of an adult eyeball Segments and chambers of the eyeball The eyeball can be divided into two segments: Anteroposterior diameter 24 mm anterior and posterior. Horizontal diameter 23.5 mm Vertical diameter 23 mm 1. Anterior segment. It includes crystalline lens (which is suspended from the ciliary body by zonules), Circumference 75 mm and structures anterior to it, viz., iris, cornea and two Volume 6.5 ml aqueous humour-filled spaces : anterior and posterior Weight 7 gm chambers. 4 Comprehensive OPHTHALMOLOGY Fig. 1.1. Gross anatomy of the eyeball. z Anterior chamber. It is bounded anteriorly by z Posterior chamber. It is a triangular space the back of cornea, and posteriorly by the iris containing 0.06 ml of aqueous humour. It is and part of ciliary body. The anterior chamber is bounded anteriorly by the posterior surface of about 2.5 mm deep in the centre in normal adults. iris and part of ciliary body, posteriorly by the It is shallower in hypermetropes and deeper in crystalline lens and its zonules, and laterally by myopes, but is almost equal in the two eyes of the ciliary body. the same individual. It contains about 0.25 ml of 2. Posterior segment. It includes the structures the aqueous humour. posterior to lens, viz., vitreous humour (a gel like material which fills the space behind the lens), retina, choroid and optic disc. VISUAL PATHWAY Each eyeball acts as a camera; it perceives the images and relays the sensations to the brain (occipital cortex) via visual pathway which comprises optic nerves, optic chiasma, optic tracts, geniculate bodies and optic radiations (Fig. 1.3). ORBIT, EXTRAOCULAR MUSCLES AND APPENDAGES OF THE EYE (FIG. 1.4) Each eyeball is suspended by extraocular muscles Fig. 1.2. Poles and equators of the eyeball. and fascial sheaths in a quadrilateral pyramid-shaped  ANATOMY AND DEVELOPMENT OF THE EYE 5 bony cavity called orbit (Fig. 1.4). Each eyeball is z Visceral mesoderm of maxillary process. located in the anterior orbit, nearer to the roof and Before going into the development of individual lateral wall than to the floor and medial wall. Each eye structures, it will be helpful to understand the is protected anteriorly by two shutters called the formation of optic vesicle, lens placode, optic cup eyelids. The anterior part of the sclera and posterior and changes in the surrounding mesenchyme, which surface of lids are lined by a thin membrane called play a major role in the development of the eye and conjunctiva. For smooth functioning, the cornea and its related structures. conjunctiva are to be kept moist by tears which are produced by lacrimal gland and drained by the lacrimal passages. These structures (eyelids, eyebrows, conjunctiva and lacrimal apparatus) are collectively called ‘the appendages of the eye’. DEVELOPMENT OF THE EYE The development of eyeball can be considered to commence around day 22 when the embryo has eight pairs of somites and is around 2 mm in length. The eyeball and its related structures are derived from the following primordia: z Optic vesicle,an outgrowth from prosencephalon (a neuroectodermal structure), z Lens placode, a specialised area of surface ectoderm, and the surrounding surface ectoderm, z Mesenchyme surrounding the optic vesicle, and Fig. 1.3. Gross anatomy of the visual pathway. Fig. 1.4. Section of the orbital cavity to demonstrate eyeball and its accessory structures. 6 Comprehensive OPHTHALMOLOGY FORMATION OF OPTIC VESICLE AND OPTIC STALK The area of neural plate (Fig. 1.5A) which forms the prosencepholon develops a linear thickened area on either side (Fig. 1.5B), which soon becomes depressed to form the optic sulcus (Fig. 1.5C). Meanwhile the neural plate gets converted into prosencephalic vesicle. As the optic sulcus deepens, the walls of the prosencepholon overlying the sulcus bulge out to form the optic vesicle (Figs. 1.5D, E&F). The proximal part of the optic vesicle becomes constricted and elongated to form the optic stalk (Figs. 1.5G&H). FORMATION OF LENS VESICLE The optic vesicle grows laterally and comes in contact with the surface ectoderm. The surface ectoderm, overlying the optic vesicle becomes thickened to form the lens placode (Fig. 1.6A) which sinks below the surface and is converted into the lens vesicle (Figs. 1.6 B&C). It is soon separated from the surface ectoderm at 33rd day of gestation (Fig. 1.6D). FORMATION OF OPTIC CUP The optic vesicle is converted into a double-layered optic cup. It appears from Fig. 1.6 that this has happened because the developing lens has invaginated itself into the optic vesicle. In fact conversion of the optic vesicle to the optic cup is due to differential growth of the walls of the vesicle. The margins of optic cup grow over the upper and lateral sides of the lens to enclose it. However, such a growth does not take place over the inferior part of the lens, and therefore, the walls of the cup show deficiency in this part. This deficiency extends to Fig. 1.5. Formation of the optic vesicle and optic stalk. Fig. 1.6. Formation of lens vesicle and optic cup.  ANATOMY AND DEVELOPMENT OF THE EYE 7 some distance along the inferior surface of the optic In the posterior part of optic cup the surrounding stalk and is called the choroidal or fetal fissure fibrous mesenchyme forms sclera and extraocular (Fig. 1.7). muscles, while the vascular layer forms the choroid and ciliary body. DEVELOPMENT OF VARIOUS OCULAR STRUCTURES Retina Retina is developed from the two walls of the optic cup, namely: (a) nervous retina from the inner wall, and (b) pigment epithelium from the outer wall (Fig. 1.10). (a) Nervous retina. The inner wall of the optic cup is a single-layered epithelium. It divides into several layers of cells which differentiate into the following three layers (as also occurs in neural tube): Fig. 1.7. Optic cup and stalk seen from below to show CHANGES IN THE ASSOCIATED MESENCHYME The developing neural tube (from which central nervous system develops) is surrounded by mesenchyme, which subsequently condenses to form meninges. An extension of this mesenchyme also covers the optic vesicle. Later, this mesenchyme differentiates to form a superficial fibrous layer (corresponding to dura) and a deeper vascular layer Fig. 1.8. Developing optic cup surrounded by mesenchyme. (corresponding to pia-arachnoid) (Fig. 1.8). With the formation of optic cup, part of the inner vascular layer of mesenchyme is carried into the cup through the choroidal fissure. With the closure of this fissure, the portion of mesenchyme which has made its way into the eye is cut off from the surrounding mesenchyme and gives rise to the hyaloid system of the vessels (Fig. 1.9). The fibrous layer of mesenchyme surrounding the anterior part of optic cup forms the cornea. The corresponding vascular layer of mesenchyme becomes the iridopupillary membrane, which in the peripheral region attaches to the anterior part of the optic cup to form the iris. The central part of this lamina is pupillary membrane which also forms the tunica vasculosa lentis (Fig. 1.9). Fig. 1.9. Derivation of various structures of the eyeball. 8 Comprehensive OPHTHALMOLOGY Crystalline lens The crystalline lens is developed from the surface ectoderm as below : Lens placode and lens vesicle formation (see page 5, 6 and Fig. 1.6. Primary lens fibres. The cells of posterior wall of lens vesicle elongate rapidly to form the primary lens fibres which obliterate the cavity of lens vesicle. The primary lens fibres are formed upto 3rd month of gestation and are preserved as the compact core of lens, known as embryonic nucleus (Fig. 1.11). Fig. 1.10. Development of the retina. Secondary lens fibres are formed from equatorial cells of anterior epithelium which remain active through z Matrix cell layer. Cells of this layer form the rods out life. Since the secondary lens fibres are laid down and cones. concentrically, the lens on section has a laminated z Mantle layer. Cells of this layer form the appearance. Depending upon the period of bipolar cells, ganglion cells, other neurons of development, the secondary lens fibres are named as retina and the supporting tissue. below : z Marginal layer. This layer forms the ganglion z Fetal nucleus (3rd to 8th month), cells, axons of which form the nerve fibre z Infantile nucleus (last weeks of fetal life to layer. puberty), (b) Outer pigment epithelial layer. Cells of the outer z Adult nucleus (after puberty), and wall of the optic cup become pigmented. Its posterior z Cortex (superficial lens fibres of adult lens) part forms the pigmented epithelium of retina and the Lens capsule is a true basement membrane produced anterior part continues forward in ciliary body and by the lens epithelium on its external aspect. iris as their anterior pigmented epithelium. Cornea (Fig. 1.9) Optic nerve 1. Epithelium is formed from the surface ectoderm. It develops in the framework of optic stalk as 2. Other layers viz. endothelium, Descemet's below: membrane, stroma and Bowman's layer are derived from the fibrous layer of mesenchyme lying anterior z Fibres from the nerve fibre layer of retina grow to the optic cup (Fig. 1.9). into optic stalk by passing through the choroidal fissure and form the optic nerve fibres. Sclera z The neuroectodermal cells forming the walls of Sclera is developed from the fibrous layer of optic stalk develop into glial system of the nerve. mesenchyme surrounding the optic cup (corres- z The fibrous septa of the optic nerve are ponding to dura of CNS) (Fig. 1.9). developed from the vascular layer of mesenchyme Choroid which invades the nerve at 3rd fetal month. It is derived from the inner vascular layer of z Sheaths of optic nerve are formed from the layers mesenchyme that surrounds the optic cup (Fig. 1.9). of mesenchyme like meninges of other parts of central nervous system. Ciliary body z Myelination of nerve fibres takes place from z The two layers of epithelium of ciliary body brain distally and reaches the lamina cribrosa just develop from the anterior part of the two layers before birth and stops there. In some cases, this of optic cup (neuroectodermal). extends up to around the optic disc and presents z Stroma of ciliary body, ciliary muscle and blood as congenital opaque nerve fibres. These develop vessels are developed from the vascular layer of after birth. mesenchyme surrounding the optic cup (Fig. 1.9).  ANATOMY AND DEVELOPMENT OF THE EYE 9 Vitreous 1. Primary or primitive vitreous is mesenchymal in origin and is a vascular structure having the hyaloid system of vessels. 2. Secondary or definitive or vitreous proper is secreted by neuroectoderm of optic cup. This is an avascular structure. When this vitreous fills the cavity, primitive vitreous with hyaloid vessels is pushed anteriorly and ultimately disappears. 3. Tertiary vitreous is developed from neuro- ectoderm in the ciliary region and is represented by the ciliary zonules. Eyelids Eyelids are formed by reduplication of surface ectoderm above and below the cornea (Fig. 1.12). The folds enlarge and their margins meet and fuse with each other. The lids cut off a space called the conjunctival sac. The folds thus formed contain some mesoderm which would form the muscles of the lid and the tarsal plate. The lids separate after the seventh month of intra-uterine life. Fig. 1.11. Development of the crystalline lens. Iris z Both layers of epithelium are derived from the marginal region of optic cup (neuro- ectodermal) (Fig. 1.9). z Sphincter and dilator pupillae muscles are derived from the anterior epithelium (neuro- ectodermal). z Stroma and blood vessels of the iris develop from the vascular mesenchyme present anterior Fig. 1.12. Development of the eyelids, conjunctiva and to the optic cup. lacrimal gland. 10 Comprehensive OPHTHALMOLOGY Tarsal glands are formed by ingrowth of a regular 2. Neural ectoderm row of solid columns of ectodermal cells from the lid z Retina with its pigment epithelium margins. z Epithelial layers of ciliary body Cilia develop as epithelial buds from lid margins. z Epithelial layers of iris z Sphincter and dilator pupillae muscles Conjunctiva z Optic nerve (neuroglia and nervous elements Conjunctiva develops from the ectoderm lining the only) lids and covering the globe (Fig.1.12). z Melanocytes Conjunctival glands develop as growth of the basal z Secondary vitreous cells of upper conjunctival fornix. Fewer glands z Ciliary zonules (tertiary vitreous) develop from the lower fornix. 3. Associated paraxial mesenchyme The lacrimal apparatus z Blood vessels of choroid, iris, ciliary vessels, Lacrimal gland is formed from about 8 cuneiform central retinal artery, other vessels. epithelial buds which grow by the end of 2nd month z Primary vitreous of fetal life from the superolateral side of the z Substantia propria, Descemet's membrane and conjunctival sac (Fig. 1.12). endothelium of cornea Lacrimal sac, nasolacrimal duct and canaliculi. z The sclera These structures develop from the ectoderm of z Stroma of iris nasolacrimal furrow. It extends from the medial angle z Ciliary muscle of eye to the region of developing mouth. The z Sheaths of optic nerve ectoderm gets buried to form a solid cord. The cord is z Extraocular muscles later canalised. The upper part forms the lacrimal sac. z Fat, ligaments and other connective tissue The nasolacrimal duct is derived from the lower part structures of the orbit as it forms a secondary connection with the nasal z Upper and medial walls of the orbit cavity. Some ectodermal buds arise from the medial z Connective tissue of the upper eyelid margins of eyelids. These buds later canalise to form the canaliculi. 4. Visceral mesoderm of maxillary process below the eye Extraocular muscles z Lower and lateral walls of orbit All the extraocular muscles develop in a closely z Connective tissue of the lower eyelid associated manner by mesodermally derived mesenchymal condensation. This probably IMPORTANT MILESTONES IN THE corresponds to preotic myotomes, hence the triple DEVELOPMENT OF THE EYE nerve supply (III, IV and VI cranial nerves). Embryonic and fetal period STRUCTURES DERIVED FROM Stage of growth Development THE EMBRYONIC LAYERS Based on the above description, the various 2.6 mm (3 weeks) Optic pits appear on either structures derived from the embryonic layers are given side of cephalic end of below : forebrain. 3.5 mm (4 weeks) Primary optic vesiclein- 1. Surface ectoderm vaginates. z The crystalline lens 5.5 to 6 mm Development of embr- z Epithelium of the cornea yonic fissure z Epithelium of the conjunctiva 10 mm (6 weeks) Retinal layers differ- z Lacrimal gland entiate, lens vesicle formed. z Epithelium of eyelids and its derivatives viz., cilia, 20 mm (9 weeks) Sclera, cornea and extra- tarsal glands and conjunctival glands. ocular muscles differen-tiate. z Epithelium lining the lacrimal apparatus.  ANATOMY AND DEVELOPMENT OF THE EYE 11 25 mm (10 weeks) Lumen of optic nerve obliter- z Corneal diameter is about 10 mm. Adult size ated. (11.7 mm) is attained by 2 years of age. z Anterior chamber is shallow and angle is narrow. 50 mm (3 months) Optic tracts completed, pars z Lens is spherical at birth. Infantile nucleus is ciliaris retina grows present. forwards, pars iridica retina z Retina. Apart from macular area the retina is fully grows forward. differentiated. Macula differentiates 4-6 months 60 mm (4 months) Hyaloid vessels atrophy, iris after birth. sphincter is formed. z Myelination of optic nerve fibres has reached 230-265 mm Fetal nucleus of lens is the lamina cribrosa. complete, z Newborn is usually hypermetropic by +2 to +3 D. (8th month) all layers of retina nearly z Orbit is more divergent (50°) as compared to developed, macula starts adult (45°). differentiation. z Lacrimal gland is still underdeveloped and tears 265-300mm Except macula, retina is fully are not secreted. (9th month) developed, infantile nucleus Postnatal period of lens begins to appear, z Fixation starts developing in first month and is pupillary membr-ane and completed in 6 months. hyaloid vessels disappear. z Macula is fully developed by 4-6 months. z Fusional reflexes, stereopsis and accommodation Eye at birth is well developed by 4-6 months. z Anteroposterior diameter of the eyeball is about z Cornea attains normal adult diameter by 2 years 16.5 mm (70% of adult size which is attained by of age. 7-8 years). z Lens grows throughout life.  This page intentionally left blank  CHAPTER 2 2 MAINTENANCE OF CLEAR INTRODUCTION OCULAR MEDIA
Physiology of tears

Physiology of cornea Physiology of Eye and Vision Physiology of crystalline lens PHYSIOLOGY OF VISION
Phototransduction
Processing and transmission of visual impulse
Visual perceptions PHYSIOLOGY OF OCULAR MOTILITY AND BINOCULAR VISION
Physiology of aqueous humour and
Ocular motility maintenance of intraocular pressure
Binocular single vision
Crystalline lens, and INTRODUCTION
Vitreous humour Sense of vision, the choicest gift from the Almighty PHYSIOLOGY OF TEARS to the humans and other animals, is a complex function of the two eyes and their central connections. The Tear film plays a vital role in maintaining the physiological activities involved in the normal transparency of cornea. The physiological apsects functioning of the eyes are : of the tears and tear film are described in the chapter
Maintenance of clear ocular media, on diseases of the lacrimal apparatus (see page 364).
Maintenance of normal intraocular pressure, PHYSIOLOGY OF CORNEA
The image forming mechanism,
Physiology of vision, The cornea forms the main refractive medium of the
Physiology of binocular vision, eye. Physiological aspects in relation to cornea
Physiology of pupil, and include:
Physiology of ocular motility.
Transparency of cornea,
Nutrition and metabolism of cornea,
Permeability of cornea, and MAINTENANCE OF CLEAR
Corneal wound healing. OCULAR MEDIA For details see page 90 The main prerequiste for visual function is the PHYSIOLOGY OF CRYSTALLINE LENS maintenance of clear refractive media of the eye. The The crystalline lens is a transparent structure playing major factor responsible for transparency of the ocular media is their avascularity. The structures forming main role in the focussing mechanism for vision. Its refractive media of the eye from anterior to posterior physiological aspects include :
Lens transparency are :
Metabolic activities of the lens
Tear film,
Cornea,
Accommodation.
Aqueous humour, For details see page 39 and 168 14 14 Comprehensive OPHTHALMOLOGY COMPREHENSIVE OPHTHALMOLOGY PHYSIOLOGY OF AQUEOUS HUMOUR AND stages (Fig. 2.1). The all trans-retinal so formed is MAINTENANCE OF INTRAOCULAR PRESSURE soon separated from the opsin. This process of The aqueous humour is a clear watery fluid filling the separation is called photodecomposition and the anterior chamber (0.25ml) and the posterior chamber rhodopsin is said to be bleached by the action of (0.06ml) of the eyeball. In addition to its role in light. maintaining a proper intraocular pressure it also plays Rhodopsin regeneration. The 11-cis-retinal is an important metabolic role by providing substrates regenerated from the all-trans-retinal separated from and removing metabolities from the avascular cornea the opsin (as described above) and vitamin-A (retinal) and the crystalline lens. For details see page 207. supplied from the blood. The 11-cis-retinal then reunits with opsin in the rod outer segment to form the rhodopsin. This whole process is called PHYSIOLOGY OF VISION rhodopsin regeneration (Fig. 2.1). Thus, the bleaching Physiology of vision is a complex phenomenon which of the rhodopsin occurs under the influence of light, is still poorly understood. The main mechanisms whereas the regeneration process is independent of involved in physiology of vision are : light, proceeding equally well in light and darkness.
Initiation of vision (Phototransduction), a function of photoreceptors (rods and cones),
Processing and transmission of visual sensation, a function of image processing cells of retina and visual pathway, and
Visual perception, a function of visual cortex and related areas of cerebral cortex. PHOTOTRANSDUCTION The rods and cones serve as sensory nerve endings for visual sensation. Light falling upon the retina causes photochemical changes which in turn trigger a cascade of biochemical reactions that result in generation of electrical changes. Photochemical changes occuring in the rods and cones are essentially similar but the changes in rod pigment (rhodopsin or visual purple) have been studied in more detail. This whole phenomenon of conversion of light energy into nerve impulse is known as phototransduction. Photochemical changes The photochemical changes include : Fig. 2.1. Light induced changes in rhodopsin. Rhodopsin bleaching. Rhodopsin refers to the visual pigment present in the rods – the receptors for night Visual cycle. In the retina of living animals, under (scotopic) vision. Its maximum absorption spectrum constant light stimulation, a steady state must exist is around 500 nm. Rhodopsin consists of a colourless under which the rate at which the photochemicals are protein called opsin coupled with a carotenoid called bleached is equal to the rate at which they are retinine (Vitamin A aldehyde or II-cis-retinal). Light regenerated. This equilibrium between the photo- falling on the rods converts 11-cis-retinal component decomposition and regeneration of visual pigments of rhodopsin into all-trans-retinal through various is referred to as visual cycle (Fig. 2.2).  PHYSIOLOGY OF EYE AND VISION 15 Table 2.1. Differences in the sensitivity of M and P cells to stimulus features Stimulus feature Sensitivity M cell P cell Colour contrast No Yes Luminance contrast Higher Lower Spatial frequency Lower Higher Temporal frequency Higher Lower The visual pathway is now being considered to be made of two lanes: one made of the large cells is called magnocellular pathway and the other of small cells Fig. 2.2. Visual cycle. is called parvocellular pathway. These can be Electrical changes compared to two-lanes of a road. The M pathway The activated rhodopsin, following exposure to light, and P pathway are involved in the parallel processing triggers a cascade of complex biochemical reactions of the image i.e., analysis of different features of the which ultimately result in the generation of receptor image. potential in the photoreceptors. In this way, the light VISUAL PERCEPTION energy is converted into electrical energy which is further processed and transmitted via visual pathway. It is a complex integration of light sense, form sense, sense of contrast and colour sense. The receptive PROCESSING AND TRANSMISSION OF VISUAL field organization of the retina and cortex are used to IMPULSE encode this information about a visual image. The receptor potential generated in the 1. The light sense photoreceptors is transmitted by electrotonic It is awareness of the light. The minimum brightness conduction (i.e., direct flow of electric current, and required to evoke a sensation of light is called the not as action potential) to other cells of the retina viz. light minimum. It should be measured when the eye horizontal cells, amacrine cells, and ganglion cells. is dark adapted for at least 20-30 minutes. However, the ganglion cells transmit the visual The human eye in its ordinary use throughout the signals by means of action potential to the neurons day is capable of functioning normally over an of lateral geniculate body and the later to the primary exceedingly wide range of illumination by a highly visual cortex. complex phenomenon termed as the visual The phenomenon of processing of visual impulse adaptation. The process of visual adaptation is very complicated. It is now clear that visual image primarily involves : is deciphered and analyzed in both serial and parallel
Dark adaptation (adjustment in dim illumination), fashion. and Serial processing. The successive cells in the visual
Light adaptation (adjustment to bright pathway starting from the photoreceptors to the cells illumination). of lateral geniculate body are involved in increasingly complex analysis of image. This is called sequential Dark adaptation or serial processing of visual information. It is the ability of the eye to adapt itself to decreasing Parallel processing. Two kinds of cells can be illumination. When one goes from bright sunshine distinguished in the visual pathway starting from the into a dimly-lit room, one cannot perceive the objects ganglion cells of retina including neurons of the lateral in the room until some time has elapsed. During this geniculate body, striate cortex, and extrastriate cortex. period, eye is adapting to low illumination. The time These are large cells (magno or M cells) and small taken to see in dim illumination is called ‘dark cells (parvo or P cells). There are strikinging adaptation time’. differences between the sensitivity of M and P cells The rods are much more sensitive to low to stimulus features (Table 2.1). illumination than the cones. Therefore, rods are used 16 16 Comprehensive OPHTHALMOLOGY COMPREHENSIVE OPHTHALMOLOGY more in dim light (scotopic vision) and cones in bright where there are maximum number of cones and light (photopic vision). decreases very rapidly towards the periphery (Fig. Dark adaptation curve (Fig. 2.3) plotted with 2.4). Visual acuity recorded by Snellen's test chart is illumination of test object in vertical axis and duration a measure of the form sense. of dark adaptation along the horizontal axis shows that visual threshold falls progressively in the darkened room for about half an hour until a relative constant value is reached. Further, the dark adaptation curve consists of two parts: the initial small curve represents the adaptation of cones and the remainder of the curve represents the adaptation of rods. Fig. 2.4. Visual acuity (form sense) in relation to the regions of the retina: N, nasal retina; B, blind spot; F, foveal region; and T, temporal retina. Components of visual acuity. In clinical practice, measurement of the threshold of discrimination of two spatially-separated targets (a function of the fovea centralis) is termed visual acuity. However, in Fig. 2.3. Dark adaptation curve plotted with illumination of theory, visual acuity is a highly complex function that test object in vertical axis and duration of dark adaptation along the horizontal axis. consists of the following components : Minimum visible. It is the ability to determine whether When fully dark adapted, the retina is about one an object is present or not. lakh times more sensitive to light than when bleached. Resolution (ordinary visual acuity). Discrimination Delayed dark adaptation occurs in diseases of rods of two spatially separated targets is termed resolution. e.g., retinitis pigmentosa and vitamin A deficiency. The minimum separation between the two points, Light adaptation which can be discriminated as two, is known as When one passes suddenly from a dim to a brightly minimum resolvable. Measurement of the threshold lighted environment, the light seems intensely and of discrimination is essentially an assessment of the even uncomfortably bright until the eyes adapt to function of the fovea centralis and is termed ordinary the increased illumination and the visual threshold visual acuity. Histologically, the diameter of a cone rises. The process by means of which retina adapts in the foveal region is 0.004 mm and this, therefore, itself to bright light is called light adaptation. Unlike represents the smallest distance between two cones. It is reported that in order to produce an image of dark adaptation, the process of light adaptation is minimum size of 0.004mm (resolving power of the eye) very quick and occurs over a period of 5 minutes. the object must subtend a visual angle of 1 minute at Strictly speaking, light adaptation is merely the the nodal point of the eye. It is called the minimum disappearance of dark adaptation. angle of resolution (MAR). 2. The form sense The clinical tests determining visual acuity measure It is the ability to discriminate between the shapes of the form sense or reading ability of the eye. Thus, the objects. Cones play a major role in this faculty. broadly, resolution refers to the ability to identify the Therefore, form sense is most acute at the fovea, spatial characteristics of a test figure. The test targets  PHYSIOLOGY OF EYE AND VISION 17 in these tests may either consist of letters (Snellen’s 1. Trichromatic theory. The trichromacy of colour chart) or broken circle (Landolt’s ring). More complex vision was originally suggested by Young and targets include gratings and checker board patterns. subsequently modified by Helmholtz. Hence it is called Recognition. It is that faculty by virtue of which an Young-Helmholtz theory. It postulates the existence individual not only discriminates the spatial of three kinds of cones, each containing a different characteristics of the test pattern but also identifies photopigment which is maximally sensitive to one of the patterns with which he has had some experience. the three primary colours viz. red, green and blue. Recognition is thus a task involving cognitive The sensation of any given colour is determined by components in addition to spatial resolution. For the relative frequency of the impulse from each of the recognition, the individual should be familiar with the three cone systems. In other words, a given colour set of test figures employed in addition to being able consists of admixture of the three primary colours in to resolve them. The most common example of different proportion. The correctness of the Young- recognition phenomenon is identification of faces. Helmholtz’s trichromacy theory of colour vision has The average adult can recognize thousands of faces. now been demonstrated by the identification and Thus, the form sense is not purely a retinal chemical characterization of each of the three pigments by recombinant DNA technique, each function, as, the perception of its composite form (e.g., having different absorption spectrum as below (Fig. letters) is largely psychological. 2.5): Minimum discriminable refers to spatial distinction
Red sensitive cone pigment, also known as by an observer when the threshold is much lower erythrolabe or long wave length sensitive (LWS) than the ordinary acuity. The best example of minimum cone pigment, absorbs maximally in a yellow discriminable is vernier acuity, which refers to the portion with a peak at 565 mm. But its spectrum ability to determine whether or not two parallel and extends far enough into the long wavelength to straight lines are aligned in the frontal plane. sense red.
Green sensitive cone pigment, also known as 3. Sense of contrast chlorolabe or medium wavelength sensitive It is the ability of the eye to perceive slight changes (MWS) cone pigment, absorbs maximally in the in the luminance between regions which are not green portion with a peak at 535 nm. separated by definite borders. Loss of contrast
Blue sensitive cone pigment, also known as sensitivity results in mild fogginess of the vision. cyanolabe or short wavelength sensitive (SWS) Contrast sensitivity is affected by various factors cone pigment, absorbs maximally in the blue-violet like age, refractive errors, glaucoma, amblyopia, portion of the spectrum with a peak at 440 nm. diabetes, optic nerve diseases and lenticular changes. Further, contrast sensitivity may be impaired even in the presence of normal visual acuity. 4. Colour sense It is the ability of the eye to discriminate between different colours excited by light of different wavelengths. Colour vision is a function of the cones and thus better appreciated in photopic vision. In dim light (scotopic vision), all colours are seen grey and this phenomenon is called Purkinje shift. Theories of colour vision The process of colour analysis begins in the retina and is not entirely a function of brain. Many theories have been put forward to explain the colour perception, but two have been particularly influential: Fig. 2.5. Absorption spectrum of three cone pigments. 18 18 Comprehensive OPHTHALMOLOGY COMPREHENSIVE OPHTHALMOLOGY Thus, the Young-Helmholtz theory concludes that
Colour apponency occurs at ganglion cell onward. blue, green and red are primary colours, but the cones According to apponent colour theory, there are with their maximal sensitivity in the yellow portion of two main types of colour opponent ganglion cells: the spectrum are light at a lower threshold than green.
Red-green opponent colour cells use signals It has been studied that the gene for human from red and green cones to detect red/green rhodopsin is located on chromosome 3, and the gene contrast within their receptive field. for the blue-sensitive cone is located on chromosome
Blue-yellow opponent colour cells obtain a 7. The genes for the red and green sensitive cones yellow signal from the summed output of red and are arranged in tandem array on the q arm of the X green cones, which is contrasted with the output chromosomes. from blue cones within the receptive field. 2. Opponent colour theory of Hering. The opponent colour theory of Hering points out that some colours PHYSIOLOGY OF OCULAR appear to be ‘mutually exclusive’. There is no such colour as ‘reddish-green’, and such phenomenon can MOTILITY AND BINOCULAR VISION be difficult to explain on the basis of trichromatic PHYSIOLOGY OF OCULAL MOTILITY theory alone. In fact, it seems that both theories are See page 313. useful in that:
The colour vision is trichromatic at the level of PHYSIOLOGY OF BINOCULAR SINGLE VISION photoreceptors, and See page 318.  CHAPTER OPTICS
Light 3 3
Geometrical optics Optics and Refraction
Optics of the eye (visual optics) ERRORS OF REFRACTION Anomalies of accommodation
Presbyopia
Insufficiency of accommodation
Paralysis of accommodation
Spasm of accommodation
Hypermetropia
Myopia DETERMINATION OF ERRORS OF
Astigmatism REFRACTION
Anisometropia
Objective refraction
Aniseikonia
Subjective refraction ACCOMMODATION AND ITS ANOMALIES SPECTACLES AND CONTACT LENSES Accommodation
Spectacles
Mechanism
Contact lenses
Far point and near point
Range and amplitude REFRACTIVE SURGERY in phakic eye; and those between 600 nm and 295 OPTICS nm in aphakic eyes. LIGHT GEOMETRICAL OPTICS Light is the visible portion of the electromagnetic The behaviour of light rays is determined by ray- radiation spectrum. It lies between ultraviolet and optics. A ray of light is the straight line path followed infrared portions, from 400 nm at the violet end of the by light in going from one point to another. The ray- spectrum to 700 nm at the red end. The white light optics, therefore, uses the geometry of straight lines consists of seven colours denoted by VIBGYOR to account for the macroscopic phenomena like (violet, indigo, blue, green, yellow, orange and red). rectilinear propagation, reflection and refraction. That Light ray is the term used to describe the radius of is why the ray-optics is also called geometrical optics. the concentric wave forms. A group of parallel rays of The knowledge of geometrical optics is essential light is called a beam of light. to understand the optics of eye, errors of refraction Important facts to remember about light rays are : and their correction. Therefore, some of its important
The media of the eye are uniformally permeable aspects are described in the following text. to the visible rays between 600 nm and 390 nm.
Cornea absorbs rays shorter than 295 nm. Reflection of light Therefore, rays between 600 nm and 295 nm only Reflection of light is a phenomenon of change in the can reach the lens. path of light rays without any change in the medium
Lens absorbs rays shorter than 350 nm. Therefore, (Fig. 3.1). The light rays falling on a reflecting surface rays between 600 and 350 nm can reach the retina are called incident rays and those reflected by it are 20 Comprehensive OPHTHALMOLOGY reflected rays. A line drawn at right angle to the 2. Spherical mirror. A spherical mirror (Fig. 3.3) is a surface is called the normal. part of a hollow sphere whose one side is silvered Laws of reflection are (Fig. 3.1): and the other side is polished. The two types of 1. The incident ray, the reflected ray and the normal spherical mirrors are : concave mirror (whose at the point of incident, all lie in the same plane. reflecting surface is towards the centre of the sphere) 2. The angle of incidence is equal to the angle of and convex mirror (whose reflecting surface is away reflection. from the centre of the sphere. Cardinal data of a mirror (Fig. 3.3)
The centre of curvature (C) and radius of curvature (R) of a spherical mirror are the centre and radius, respectively, of the sphere of which the mirror forms a part.
Normal to the spherical mirror at any point is the line joining that point to the centre of curvature (C) of the mirror.
Pole of the mirror (P) is the centre of the reflecting surface.
Principal axis of the mirror is the straight line joining the pole and centre of curvature of spherical mirror and extended on both sides. Fig. 3.1. Laws of reflection. Mirrors A smooth and well-polished surface which reflects regularly most of the light falling on it is called a mirror. Types of mirrors Mirrors can be plane or spherical. 1. Plane mirror. The features of an image formed by a plane mirror (Fig. 3.2) are: (i) it is of the same size as the object; (ii) it lies at the same distance behind the Fig. 3.3. Cardinal points of a concave mirror. mirror as the object is in front; (iii) it is laterally inverted; and (iv) virtual in nature.
Principal focus (F) of a spherical mirror is a point on the principal axis of the mirror at which, ray incident on the mirror in a direction parallel to the principal axis actually meet (in concave mirror) or appear to diverge (as in convex mirror) after reflection from the mirror.
Focal length (f) of the mirror is the distance of principal focus from the pole of the spherical mirror. Images formed by a concave mirror As a summary, Table 3.1 gives the position, size and nature of images formed by a concave mirror for different positions of the object. Figures 3.4 a, b, c, d, Fig. 3.2. Image formation with a plane mirror. e and f illustrate various situations.  OPTICS AND REFRACTION 21 Table 3.1. Images formed by a concave mirror for different positions of object No. Position of Position of Nature and size Ray diagram the object the image of the image 1. At infinity At the principal focus (F) Real, very small and inverted Fig. 3.4 (a) 2. Beyond the centre Between F & C Real, diminished in size, and Fig. 3.4 (b) of curvature (C) inverted 3. At C At C Real, same size as object and Fig. 3.4 (c) inverted 4. Between F & C Beyond C Real, enlarged and inverted Fig. 3.4 (d) 5. At F At infinity Real, very large and inverted Fig. 3.4 (e) 6. Between pole of the Behind the mirror Virtual, enlarged and erect Fig. 3.4 (f) mirror (P) and focus (F) Fig. 3.4. Images formed by a concave mirror for different positions of the object : (a) at infinity; (b) between infinity and C; (c) at C; (d) between C and F; (e) at F; (f) between F and P. 22 Comprehensive OPHTHALMOLOGY Refraction of light Critical angle refers to the angle of incidence in the Refraction of light is the phenomenon of change in denser medium, corresponding to which angle of the path of light, when it goes from one medium to refraction in the rare medium is 90°. It is represented another. The basic cause of refraction is change in by C and its value depends on the nature of media in the velocity of light in going from one medium to the contact. other. The principle of total internal reflection is utilized in many optical equipments; such as fibroptic lights, Laws of refraction are (Fig. 3.5): applanation tonometer, and gonioscope. 1. The incident and refracted rays are on opposite sides of the normal and all the three are in the same plane. 2. The ratio of sine of angle of incidence to the sine of angle of refraction is constant for the part of media in contact. This constant is denoted by the letter n and is called ‘refractive index’ of the medium 2 in which the refracted ray lies with respect to medium 1 (in which the incident ray sin i lies), i.e., sin r = 1n2. When the medium 1 is air (or vaccum), then n is called the refractive index of the medium 2. This law is also called Snell’s Fig. 3.6. Refraction of light (1-1'); path of refracted law of refraction. ray at critical angle, c (2-2'); and total internal reflection (3-3'). Prism A prism is a refracting medium, having two plane surfaces, inclined at an angle. The greater the angle formed by two surfaces at the apex, the stronger the prismatic effect. The prism produces displacement of the objects seen through it towards apex (away from the base) (Fig. 3.7). The power of a prism is measured in prism dioptres. One prism dioptre (∆) produces displacement of an object by one cm when kept at a distance of one metre. Two prism dioptres of displacement is approximately equal to one degree of arc. Fig. 3.5. Laws of refraction. N1 and N2 (normals); I (incident ray); i (angle of incidence); R (refracted ray, bent towards normal); r (angle of refraction); E (emergent ray, bent away from the normal). Total internal reflection When a ray of light travelling from an optically- denser medium to an optically-rarer medium is incident at an angle greater than the critical angle of the pair of media in contact, the ray is totally reflected back into the denser medium (Fig. 3.6). This phenomenon is called total internal reflection. Fig. 3.7. Refraction by a prism.  OPTICS AND REFRACTION 23 Uses. In ophthalmology, prisms are used for : lens power is taken as negative. It is measured 1. Objective measurement of angle of deviation as reciprocal of the focal length in metres i.e. P (Prism bar cover test, Krimsky test). = 1/f. The unit of power is dioptre (D). One 2. Measurement of fusional reserve and diagnosis dioptre is the power of a lens of focal length one of microtropia. metre. 3. Prisms are also used in many ophthalmic Types of lenses equipments such as gonioscope, keratometer, Lenses are of two types: the spherical and cylindrical applanation tonometer. (toric or astigmatic). 4. Therapeutically, prisms are prescribed in patients with phorias and diplopia. 1. Spherical lenses. Spherical lenses are bounded by two spherical surfaces and are mainly of two types : Lenses convex and concave. A lens is a transparent refracting medium, bounded (i) Convex lens or plus lens is a converging lens. It by two surfaces which form a part of a sphere may be of biconvex, plano-convex or concavo-convex (spherical lens) or a cylinder (cylindrical or toric lens). (meniscus) type (Fig. 3.9). Cardinal data of a lens (Fig. 3.8) 1. Centre of curvature (C) of the spherical lens is the centre of the sphere of which the refracting lens surface is a part. 2. Radius of curvature of the spherical lens is the radius of the sphere of which the refracting surface is a part. Fig. 3.9. Basic forms of a convex lens: (A) biconvex; (B) plano-convex; (C) concavo-convex. Identification of a convex lens. (i) The convex lens is thick in the centre and thin at the periphery (ii) An object held close to the lens, appears magnified. (iii) Fig. 3.8. Cardinal points of a convex lens: optical centre When a convex lens is moved, the object seen through (O); principal focus (F); centre of curvature (C); and principal axis (AB). it moves in the opposite direction to the lens. Uses of convex lens. It is used (i) for correction of 3. The principal axis (AB) of the lens is the line hypermetropia, aphakia and presbyopia; (ii) in oblique joining the centres of curvatures of its surfaces. illumination (loupe and lens) examination, in indirect 4. Optical centre (O) of the lens corresponds to the ophthalmoscopy, as a magnifying lens and in many nodal point of a thick lens. It is a point on the other equipments. principal axis in the lens, the rays passing from where do not undergo deviation. In meniscus Image formation by a convex lens. Table 3.2 and Fig. lenses the optical centre lies outside the lens. 3.10 provide details about the position, size and the 5. The principal focus (F) of a lens is that point on nature of the image formed by a convex lens. the principal axis where parallel rays of light, after (ii) Concave lens or minus lens is a diverging lens. It passing through the lens, converge (in convex is of three types: biconcave, plano-concave and lens) or appear to diverge (in concave lens). convexo-concave (meniscus) (Fig. 3.11). 6. The focal length (f) of a lens is the distance between the optical centre and the principal focus. Identification of concave lens. (i) It is thin at the centre 7. Power of a lens (P) is defined as the ability of the and thick at the periphery. (ii) An object seen through lens to converge a beam of light falling on the it appears minified. (iii) When the lens is moved, the lens. For a converging (convex) lens the power is object seen through it moves in the same direction as taken as positive and for a diverging (concave) the lens. 24 Comprehensive OPHTHALMOLOGY Fig. 3.10. Images formed by a convex lens for different positions of the object, (a) at infinity ; (b) beyond 2F1 ; (c) at 2F1; (d) between F1 and 2F1; (e) at F1; (f) between F1 and optical centre of lens Table 3.2. Images formed by a convex lens for various positions of object No. Position of Position of Nature and size Ray the object the image of the image diagram 1. At infinity At focus (F2) Real, very small and inverted Fig. 3.10 (a) 2. Beyond 2F1 Between F2 and 2F 2 Real, diminished and inverted Fig. 3.10 (b) 3. At 2F1 At 2F2 Real, same size and inverted Fig. 3.10 (c) 4. Between F 1 and 2F1 Beyond 2F2 Real, enlarged and inverted Fig. 3.10 (d) 5. At focus F1 At infinity Real, very large and inverted Fig. 3.10 (e) 6. Between F1 and On the same side of Virtual, enlarged and erect Fig. 3.10 (f) the optical centre lens of the lens Uses of concave lens. It is used (i) for correction of myopia; (ii) as Hruby lens for fundus examination with slit-lamp. Image formation by a concave lens. A concave lens always produces a virtual, erect image of an object (Fig. 3.12). Fig. 3.11. Basic forms of a concave lens: biconcave (A); plano-concave (B); and convexo-concave (C).  OPTICS AND REFRACTION 25 Identification of a cylindrical lens. (i) When the cylindrical lens is rotated around its optical axis, the object seen through it becomes distorted. (ii) The cylindrical lens acts in only one axis, so when it is moved up and down or sideways, the objects will move with the lens (in concave cylinder) or opposite to the lens (in convex cylinder) only in one direction. Fig. 3.12. Image formation by a concave lens. Uses of cylindrical lenses. (i) Prescribed to correct astigmatism (ii) As a cross cylinder used to check the 2. Cylindrical lens. A cylindrical lens acts only in one refraction subjectively. axis i.e., power is incorporated in one axis, the other Images formed by cylindrical lenses. Cylindrical or axis having zero power. A cylindrical lens may be astigmatic lens may be simple (curved in one meridian convex (plus) or concave (minus). A convex cylindrical only, either convex or concave), compound (curved lens is a segment of a cylinder of glass cut parallel to unequally in both the meridians, either convex or its axis (Fig. 3.13A). Whereas a lens cast in a convex concave). The compound cylindrical lens is also cylindrical mould is called concave cylindrical lens called sphericylinder. In mixed cylinder one meridian (Fig. 3.13B). The axis of a cylindrical lens is parallel to is convex and the other is concave. that of the cylinder of which it is a segment. The Sturm's conoid cylindrical lens has a power only in the direction at right angle to the axis. Therefore, the parallel rays of The configuration of rays refracted through a toric light after passing through a cylindrical lens do not surface is called the Sturm’s conoid. The shape of come to a point focus but form a focal line (Fig. 3.14). bundle of the light rays at different levels in Sturm's conoid (Fig. 3.15) is as follows:
At point A, the vertical rays (V) are converging more than the horizontal rays (H); so the section here is a horizontal oval or an oblate ellipse.
At point B, (first focus) the vertical rays have come to a focus while the horizontal rays are still converging and so they form a horizontal line.
At point C, the vertical rays are diverging and their divergence is less than the convergence of the horizontal rays; so a horizontal oval is formed here. Fig. 3.13. Cylindrical lenses: convex (A) and concave (B). Fig. 3.14. Refraction through a convex cylindrical lens. Fig. 3.15. Sturm's conoid. 26 Comprehensive OPHTHALMOLOGY
At point D, the divergence of vertical rays is exactly equal to the convergence of the horizontal rays from the axis. So here the section is a circle, which is called the circle of least diffusion.
At point E, the divergence of vertical rays is more than the convergence of horizontal rays; so the section here is a vertical oval.
At point F, (second focus), the horizontal rays have come to a focus while the vertical rays are divergent and so a vertical line is formed here.
Beyond F, (as at point G) both horizontal and vertical rays are diverging and so the section will always be a vertical oval or prolate ellipse.
The distance between the two foc (B and F) is called the focal interval of Sturm. OPTICS OF THE EYE As an optical instrument, the eye is well compared to a camera with retina acting as a unique kind of 'film'. The focusing system of eye is composed of several refracting structures which (with their refractive indices given in parentheses) include the cornea (1.37), the aqueous humour (1.33), the crystalline lens (1.42), and the vitreous humour (1.33). These constitute a homocentric system of lenses, which when combined in action form a very strong refracting Fig. 3.16. Cardinal points of schematic eye (A); and system of a short focal length. The total dioptric reduced eye (B). power of the eye is about +60 D out of which about +44 D is contributed by cornea and +16 D by the
The principal points P1 and P2 lie in the anterior crystalline lens. chamber, 1.35 mm and 1.60 mm behind the anterior surface of cornea, respectively. Cardinal points of the eye
The nodal points N1 and N2 lie in the posterior Listing and Gauss, while studying refraction by lens part of lens, 7.08 mm and 7.33 mm behind the combinations, concluded that for a homocentric anterior surface of cornea, respectively. lenses system, there exist three pairs of cardinal points, which are: two principal foci, two principal The reduced eye points and two nodal points all situated on the Listing's reduced eye. The optics of eye otherwise is principal axis of the system. Therefore, the eye, very complex. However, for understanding, Listing forming a homocentric complex lens system, when has simplified the data by choosing single principal analyzed optically according to Gauss' concept can point and single nodal point lying midway between be resolved into six cardinal points (schematic eye). two principal points and two nodal points, Schematic eye respectively. This is called Listing's reduced eye. The The cardinal points in the schematic eye as described simplified data of this eye (Fig. 3.16b) are as follows : by Gullstrand are as follows (Fig. 13.16A):
Total dioptric power +60 D.
Total dioptric power is +58 D, of which cornea
The principal point (P) lies 1.5 mm behind the contributes +43 D and the lens +15 D. anterior surface of cornea.
The principal foci F and F lie 15.7 mm in front
The nodal point (N) is situated 7.2 mm behind the 1 2 of and 24.4 mm behind the cornea, respectively. anterior surface of cornea.  OPTICS AND REFRACTION 27
The anterior focal point is 15.7 mm in front of the Optical aberrations of the normal eye anterior surface of cornea. The eye, in common with many optical systems in
The posterior focal point (on the retina) is 24.4 practical use, is by no means optically perfect; the mm behind the anterior surface of cornea. lapses from perfection are called aberrations.
The anterior focal length is 17.2 mm (15.7 + 1.5) Fortunately, the eyes possess those defects to so and the posterior focal length is 22.9 mm (24.4 – small a degree that, for functional purposes, their 1.5). presence is immaterial. It has been said that despite Axes and visual angles of the eye imperfections the overall performance of the eye is The eye has three principal axes and three visual little short of astonishing. Physiological optical angles (Fig. 3.17). defects in a normal eye include the following : 1. Diffraction of light. Diffraction is a bending of Axes of the eye light caused by the edge of an aperture or the rim of a 1. Optical axis is the line passing through the lens. The actual pattern of a diffracted image point centre of the cornea (P), centre of the lens (N) produced by a lens with a circular aperture or pupil is and meets the retina (R) on the nasal side of the a series of concentric bright and dark rings (Fig. 3.18). fovea. At the centre of the pattern is a bright spot known as 2. Visual axis is the line joining the fixation point the Airy disc. (O), nodal point (N), and the fovea (F). 3. Fixation axis is the line joining the fixation point (O) and the centre of rotation (C). Fig. 3.17. Axis of the eye: optical axis (AR); visual axis (OF); fixation axis (OC) and visual angles : angle alpha Fig. 3.18. The diffraction of light. Light brought to a focus (ONA, between optical axis and visual axis at nodal point does not come to a point,but gives rise to a blurred disc N); angle kappa (OPA, between optical axis and pupillary of light surrounded by several dark and light bands (the line – OP); angle gamma (OCA, between optical axis and 'Airy disc'). fixation axis). 2. Spherical aberrations. Spherical aberrations occur Visual angles (Fig. 3.17) owing to the fact that spherical lens refracts peripheral 1. Angle alpha. It is the angle (ONA) formed rays more strongly than paraxial rays which in the between the optical axis (AR) and visual axis case of a convex lens brings the more peripheral rays (OF) at the nodal point (N). to focus closer to the lens (Fig. 3.19). 2. Angle gamma. It is the angle (OCA) between the The human eye, having a power of about optical axis (AR) and fixation axis (OC) at the +60 D, was long thought to suffer from various centre of rotation of the eyeball (C). amounts of spherical aberrations. However, results 3. Angle kappa. It is the angle (OPA) formed from aberroscopy have revealed the fact that the between the visual axis (OF) and pupillary line dominant aberration of human eye is not spherical (AP). The point P on the centre of cornea is considered equivalent to the centre of pupil. aberration but rather a coma-like aberration. Practically only the angle kappa can be measured 3. Chromatic aberrations. Chromatic aberrations and is of clinical significance. A positive angle kappa result owing to the fact that the index of refraction of results in pseudo-exotropia and a negative angle any transparent medium varies with the wavelength kappa in pseudo-esotropia. of incident light. In human eye, which optically acts 28 Comprehensive OPHTHALMOLOGY 6. Coma. Different areas of the lens will form foci in planes other than the chief focus. This produces in the image plane a 'coma effect' from a point source of light. ERRORS OF REFRACTION