PiPU

EYE Ophthalmology

,
, guideline

PiPU
...
Pipu Tavornshevin
pipu@edu.vajira.ac.th (PBook Vajira BM19)
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Introduction / Physical examination / Eye Symptomatology / Orbit Eyelid Lacrimal system / Lens&Cataract / Glaucoma /
Visual field loss / Neuro-ophthalmology / Cornea&Sclera / Retina / Conjunctiva / Uvea / Ocular therapeutic /
Medical ophthalmology / Eye emergency / Refractive error / Strabismus / / OPD case
_______________________________________________________________________________________________________

Introduction
- eye create steropsis( 3D) ; )

intro disease
1. Cornea 5-6
:
lysozyme
: Endothelium injury
>> Tx : penetrating keratoplasty( ; )
Infect : hypopion(wbc), bleed : hyphema(rbc)
2. Conjunctiva > infect : (injection from vasodilate)
3. Lens : nucleus - cortex - capsule cortex/nucleus
>> Tx : Phacolensemulsification intraocular lens
4. Retina : choroid, Vitreous body (bleed from retinal vessel ; DM >
angiogenesis )
Retina : a,v > hemorrhage/occlusion, infect ex. CMV retinitis, detachment(vitreous retina )
5. Eyelid Hordeorum, Chalazion
> infect/abscess > drain
6. Extraocular muscle : nerve palsy (CN3), (CN7)

- Anatomy

1. Lens 20 diopter + Cornea() 40diopter

> condense > focus at Macula lutea ; (= )
zonule Ciliary body, Accommodation(lens focus )

Accommodation : distance > near image

by Ciliary muscle contract > zonule tension > Lens spherical ; Presbyopia
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Diopter D 1 D = 1 /100 100

= -100 D
+100 D
Refractive error :
Myopia, Hyperopia, Astigmatism(), Anisometropia(2 refractive power )

2. 3
1. Cornea Sclera()
2. Ciliary body/Iris + Choroid = Uvea >> Uveitis
3 , vessel metas
3. Retina : macula , 10 , nerve fiber

1. Eyelid/lashes
2. injection (dilate vessel > )
3. Ant chamber = aqueus humor( Ciliary body, drain by trabecular meshwork)
4. Iris
5. Pupil : diameter , react to light(=CN2)
6. = Lens > Cataract ; =
7. Visual acuity 6m Snellen chart
20mmHg(tension > Glaucoma > tension to retina)
Ocular motility synchronize ,
convergence
Myopia > lens
40 presbiopia > accomodate
()

8. Ophthalmoscope - retina : direct( ), indirect(resident)

Disc
Fundus - papilledema, blood vessel( a : v diameter = 2:3 ; 1:3 artery )
macula = fovea reflex
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Physical examination
1. Eye vital sign
1. VA(with glass, with pinhole scattering light)
- Target() , Allen card() , E game, Snellen chart
2. Refraction
3. ocular pressure/tension error

Snellen chart : recognition acuity, spatial frequency(space)

(6/6)/(20/20) in 6yr

>> ( )/()
VA record form : UCVA (Uncorrected Visual Acuity), BSCVA (Best Spectacle Corrected Visual Acuity), VA cc,
VA with PH( refractive error ) pinhole 6/6 = in refractive >5.0 diopter,
organic disease in eye, central media opacity, macular disease
- 20/200(6/60) >>
2 = 2/60 2 3
1 = 1/60

Counting finger > hand movement > light project > light perception(confirm with strong light) > blindness

2. Lid : ectropion , entropion, Hordeolum(internal/external),

3. Orbit > proptosis >2mm difference (grave = exophthalmos ) lateral/bird eye view,
enophthalmos(trauma, metas bone lysis)

4. Lacrimal passage ,
> Epiphora from NLDO : positive Dye disappearance Test fluores 5
: regurgitation test mucopurulent reflux pressing at medial canthus cotton bud

> eyelid retraction sign - early thyroid
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5. Position of eye : corneal light reflex ( Phoria )

> Hirschberg test , Cover test
- Nystagmus : steady fixation at 6wk age

6. CN3,4,6 CN3 palsy (LR6), , pupil dilate

CN4 palsy - chin depress, head tilt head turn

7. Cornea : clear eye power (40/60 diopter)

8. Conjunctiva : Bulbar > pinguecula, pterygium nasal

Tarsal/palpabrae
> renal fail
> Subconj hemorrhage : benign 1wk > vitamin C

9. Sclera : scleritis Awakening pain, conj

10. Ant chamber : hypopyon, hyphema

11. Iris : shape color contour

Aniridia( > disease) cause reduction in the sharpness of vision (visual acuity) and increased sensitivity to
light (photophobia).

12. Pupil : direct light reflex CN2 : consensual light reflex CN3(parasym 2 )
: RAPD swinging flash light test ; 2
: reverse RAPD in post dilation( fixed dilate MCA lesion ) optic neuropathy (nerve
pulse methylpred ??) lesion

13. Lens : clear(clear, cataract), position(dislocation, subluxation), type

14. Intraocular pressure (10-20)

: digital palpation 2 tense
: Schiotz tonometer Goldmann tonometry = gold standard

15. Visual field testing : Confrontation test 2 5

16. Fundus exam : direct ophthalmoscope 15

- Ant segment : +5 - +7 dye staining on blue light
- Bruckner's test : red reflex (reflection of light from choriocapillary
)
2
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- Post exam : dim light, pupil dilation >

red reflex optic disc , vessel , macular( ) 3
1. Disc : cupping color margin
Cup - = cup ; 0.3 ratio

glaucoma cup to disc ratio ( cell ) optic artrophy

Bilat disc edema = papilledema LR6 bilat limitation, no spontaneous venous pulsatile
2. Vessel(artery, vein) : artery temporal to vein, a : v 2:3
Hypertension 1:3 Vein occlusion > tortious

Retina : exudate, dot blot hemorrhage, CMV retinitis(pizza appearance)

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3. Macula : chloroquine Bulls eye maculopathy

**steroid Scotoma > Amsler Grid test macula

17. Color vision testing - Ishihara plate

Plate 2-13 : pseudoisochromatic plate > high sense for congenital red-green deficiency

Eye Symptomatology
Visual DDx
1. Blurred Vision 1st R/O Refractive error
vision Central > Snellen chart
/ (physiologic)
Peripheral > visual 2 opaque media 1st corneal scar,
field(confrontation test) 2nd lens cataract, aq humor/vitreous body, bleed
3. neuroretinal disorder : optic neuritis, optic
Color/contrast sensitivity atrophy, brain tumor

4. malingering patho
2. Diplopia Binocular EOM
Monocular
1. Astigmatism 2. Cataract(lens ) 3. Polycoria( scatter)

3. Ent optic /delusion
phenomenon - Floater clinical sig,
- Flashing vitreous retraction, retinal tear > RD,
occipital cortex
- Halo > spectrum /
- Purkinje tree ( retina )
- Metamorphopsia macular edema, senile macular degen,
Astigmatism
4. Night retinitis pigmentosa, vit A def, cataract, glaucoma, post laser
blindness
in DM
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Non-visual
1. Red eye Subconj Hemorrhage , Hx trauma ///HTN
> Tx : 2-3wk ,

Conj injection(dilate blood vessel) 3
1. Ciliary type Uveitis, Glaucoma
2. Conj type conjunctivitis,
episcleritis(immune not infect)
3. mixed type
2. Painful 1. Asthenopia muscle EOM >
2. Inflame/infect
: Ant > Uveitis scleritis keratitis
Post > optic neuritis
orbital cellulitis, Hordeolum
3.IOP : acute glaucoma >20mmHg
3. Itching >> Allergy
Irritation
( ,) Trichiasis,
Lithiasis(calcium lipid )
: conjunctivitis keratitis Pinguecula/Pterygium

4. Tearing : Allergy Inflam Irritation

(punctum, canaliculi, NLD) NL
5. Discharge ( mucus )
- Dry eye :
- mucus : purulent/watery/mucus discharge
6. Lid ptosis, blepharospasm,
Lashes
Lagophthalmos > cornea exposure keratitis
Pt Neuro
Trichiasis/Ectropion, Entropion
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Orbit Eyelid Lacrimal system

Eyelid
: 2 part - orbital, tarsal part , Canthus

: 5 layer skin , muscle > trauma ;

superior palpebral muscle symp > Horner syndrome ; pupil (

)
- gland : sebaceous - Meibomian, Zeis( ) gland, sweat, accessory lacrimal gland

Orbit

1. Thyroid orbitopathy : upper lid retraction, lid lag, diplopia, proptosis(Worn eye view
, limit EOM
), exposure keratopathy(), compressive optic neuropathy

2. Infection (sinus), trauma

: !!
: acute limit EOM pain on eye motion +|-VA drop RAPD+ve >>
= orbital cellulitis, subperiosteal abscess, ...
Preseptal cellulitis( septum = ) oral ATB, no admit
orbital cellulitis EOM limited, Optic n compress( RAPD+ve), proptosis
- Tx : Orbital cellulitis >> admit, IV ATB, drain source infect CT abscess

3. Orbital trauma /

: Blow out (floor/medial ) = proptosis/enophthalmos + limit EOM(orbital fat entrapment) +|- diplopia

: Le Fort (Maxillary) type 2,3

: Zygoma fx - floor orbit

4. Retrobulbar hemorrhage
[concept orbital cellu 2 optice nerve, EOM]

: > retinal artery/optic nerve compress

- Tx : med ,

Sx - Lateral canthotomy and cantholysis

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Eyelid disease

1. Congenital : Coloboma( ),

congenital ptosis( occlusional Amblyopia ),

Blepharophymosis

2. Infect Hordeolum (acute infect gland Zeis/Meibomian)

Chalazion(chronic> focal granuloma inflam)

Blephalitis - inflam infect, seb derm(seborrhea), ...
Cellulitis

Eyelid shape disease

1. Trichiasis > reflex tear(irritation), corneal abrasion/ulceration

Tx : prevent corneal complication(by lubrication), remove lashes
Entropion ( stabilize)

Ectropion > > eye discomfort, irritation, photophobia

Tx : prevent corneal comp - topical lubricant, temporary tarsorrhaphy

2. Ptosis - congenital amblyopia

- acquired systemic MG, muscle dystrophy

1) myogenic ptosis
2) aponeurotic : stretch/dehiscence levator aponeurosis aging

3) neurogenic : CN3 palsy( aneurysm PComA nerve ), Horner,

Marcus Gunn jaw winking
4) Mechanical : edema, tumor, mass at upper eyelid NF
5) traumatic : to levator aponeurosis/muscle

3. Dermatochalasisrelax excess skin upper/lower eyelid gravity, loss elastic

4. Lagophthalmos > dry/irritate

- Bell palsy
- Tx : taping lid, tx related dry eye, nighttime moisture google

5. Tumor eyelid - benign : Xanthelasma( ass with Chol level )

Papiloma(Wart) - benign growing exophytic
Hemangioma - 1-4wk
- malignant : BCC SCC Sebaceous cell CA
: clinical suggest for malignancy
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> Ulceration, lack of tenderness, induration, irregular, telangiectasia, pearly border(tumor

keratin ), loss margin, loss cutaneous wrinkle( )

Lacrimal system

1. Tearing

- (Lacrimation) : irritation/inflam infect/emotion

- (Epiphora) : decrease pump of orbicularis oculi, punctum stenosis, canaliculi obstruct, NLDO
NLDO > congenital NLDO : membrane obstruction at valve of Hasner at distal end of NLD
1 , lacrimal sac pressure
> Dx by Dye disappearance test(in children 15
), Irrigating test
- Tx : Probing (congenital), Dacryocystorhinostomy(DCR)

2. Dacryocystitis : inflam of NL sac by NLDO

DDx - (
NLDO )
- Tx : control infect oral drain ) + fistula( )
: Dacryocystorhinostomy(DCR) lacrimal sac-nasal cavity

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Lens and Cataract

-
VA with PH :
cataract
Lens iris Iriodonesis
: protein 33% water insoluble

: 1. Water 2. Electrolyte balance epithelium pump

aq humor /
** Steroid ( ), DM > glucose > , Trauma > FB into lens

1. Type of age-related cataract >40

Cortical cataract incidental finding

No Sx
Nuclear sclerosis , VA Oph scope fundus
NS1-3+

Posterior (pupil constrict) Oph scope ,
subcapsular cataract
red reflex

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Stage of Senile cataract

1. Intumescent /immature : iris > glaucoma
2. Mature : red reflex >>
hypermature comp
3. Hypermature : comp
- comp : Lens induced glaucoma ER dilate pupil
N/V + cornea /
onset comp IOP (optic n )
1) Phacomorphic glaucoma : lens
2) Phacolytic glaucoma : lens > uveitis TM
>> Cataract tx only
4. Morgagnian : , cortex nucleus !!

Indication for Sx 3 1. Improve visual function VA

2. complication A/C ( IOP )
3. P/S laser

Sx : 1. Intracapsular cataract extraction RD

2. Extracapsular cataract extraction posterior capsule
- Nuclear expression : comp ,
- Phacoemulsification : Hydrodissection capsule, nucleus
> comp : corneal edema( ), wound leakage, post capsule rupture (
), RD( post capsule )
> post op infect, wound leakage

LASIK + + cornea
3. Pars plana vitrectomy sclera retina
** lens > Len dislocation hypermature > reaction,
glaucoma,
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2. Traumatic Cataract :
iris

3. Secondary cataract drug, DM

- Diabetic cataract : criteria 1) DM type1

abrupt onset
2) 2 bilat snowflake ant&post subcapsular opacity

3) (>40 = Senile cataract)

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Glaucoma
3 : optic neuropathy + VF loss + IOP

- IOP Aqueous dynamic : Ciliary body >> TM >> Epislceral vein

normal IOP = 10-22 mmHg ; by Tonometry(Goldmann, Air puff, Schiotz)

- VF : perimetry (manual confrontation test, automated Goldmann kinetic, Static perimetry)

Blind spot = optic nerve (macula field)

Glaucoma VF ( )

[nasal step > arcuate scotoma blind spot > central field]

- Optic nerve : oval shape : = neural rim, cup =

normal : C/D ratio 0.3 symmetry
>>>>> Glaucoma : C/D >0.5 asymmetry >0.2, thin neural rim, deep cup, +/- disc hemorrhage
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Fundoscopy 3 : Direct/Indirect ophthalmoscope, Slit lamp with high power lens

Gonioscopy : slit lamp

Open Closed angle =
Trabecular meshwork(TM) ; = Open
= Peripheral anterior synechiae(PAS) : iris

: !! Angle depth

>> A/C ?? = , = ; iris shadow

>60 Glaucoma >> screen glaucoma ( late stage )

Screen by 1. IOP 2. optic nerve() 3. VF 1-2

Primary open angle glaucoma (POAG) acute, chronic most common

: glaucomatous cupping, VF loss, open angle, IOP>21mmHg(<21mmHg = NTG)

- risk : IOP, myopia, FHx, old age, (HTN, migraine, DM+/-)

- S/S : insidious onset, slow progressive, painless, bilateral
Late = VF defect, decrease vision, blind
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Treatment

1. Drug 6
mechanism Eyedrop S/E
Beta blocker Timolol(Timodrop)
1st line
Betaxolol(1 antag
- BP, CHF, bronchospasm, mask
IOP 20-30% hypoglycemic sign
pulmonary
sparing eff )
CA inhibitor aq humor Pill : Acetazolamide Fewer systemic S/E
(Diamox) acute - paresthesia, renal stone, allergy(sulfa
angle drug), hypoK
Eye : Dorzolamide,
Brinzolamide
Adrenergic Selective Alpha2 Nonselective
agonist : Epi, Dipivefrin, : HA, BP, tachycardia, arrhythmia,
Alphagan allergic conjunctivitis
Selective
: burning, fatigue, HA, drowsiness
Cholinergic Miosis > Pilocarpine Constrict pupil > dim vision
IOP 15-25% drainage TM
Ciliary constrict > induce myopia, HA

PG analog drain Xalatan, Travatan, Local S/E

uveoscleral Lumigan, Rescula
pathway Darkening iris, periocular skin
, burning, eye redness
Hyperosmotic blood osmolarity Glycerine oral Hyperglycemia DM, ketosis,
Control acute >vitreous volume diuresis
IOP > IOP Mannitol(more S/E )

**NTG IOP ( 20-30% baseline) > progress 30%

Guideline
- 1st Heart/Lung disease ?? >> Beta blocker then F/U 1 mo q 6 mo

Monotherapy ( hyperosmotic)
- combination therapy Beta block or PG

- Laser/Sx

2. Laser trabeculoplasty open angle

3. Surgery : indication = max tolerate med fail to IOP

1) Trabeculectomy : standard

- flap conjunctiva

- filtering bleb
conjunctiva vessel
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2) Glaucoma drainage device A/C drain

- indication : fail trabeculec, poor prog for trabeculec(active uveitis, neovascular glaucoma, aphakia)

3) Cyclodestructive surgery : indication = absolute glaucoma

( no vision) )
Ciliary body - Cyclocryotherary/cyclophotocoagulation

Primary open angle glaucoma (POAG) acute, chronic

Primary angle close glaucoma (PACG) : acute angle closure glaucoma

chronic angle closure glaucoma
pathophysio angle closure
> IOP
= 1. Pushed iris from behind : 90% Pupillary block, ant displaced lens, plateau iris(iris )
2. Pulled iris into angle : contraction fibrovas tiss, iris incarceration into corneal wound

close angle screen

st
1 primary angle closure suspect Narrow angle Laser PI
Primary angle closure Peripheral anterior synechiae (PAS)
10 Iris peripheral cornea
Primary angle close glaucoma

Acute angle closure glaucoma = rapid block TM

- Symptom : acute severe ocular pain, blurred vision, rainbow-color halo around light, N/V/HA
Sign : VA drop( IOP > cornea ), high IOP 40-60, conj ciliary injection, corneal edema,
shallow A/C, lens glaukomflecken, optic nerve swell
( sign )
Glaukomflecken simply means glaucoma flecks. associated with focal epithelial infarct from
past acute angle closure glaucoma (opacity of len ant lens)

Tx emer!! : initial tx medical IOP 1-2

1. Acetazolamide 250mg 2tab stat
2. Hyperosmotic : 50%Glycerine 1-2 mg/kg/dose, 20% Manitol 1-2 g/kg/dose
Tx definite : Sx Peripheral iridectomy(PI) Laser,Sx mech iris TM
>> IOP Trabeculectomy
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Chronic angle closure glaucoma

: IOP asymptomatic gradually / = open angle
Tx definite : Sx same acute (PI, Trabeculec)

Secondary Glaucoma Mx
Open angle Lens induced cataract Anti-inflam
- Phacolytic Leakage lens protein through acute Anti-glaucoma
capsule > obstruct TM glaucoma
Cataract removal Sx
Lens cortex in A/C lens
- Lens particle Lens cortex obstruct TM and inflame,
IOP, corneal
edema
Steroid induced Systemic topical ( tx uveitis,
allergy, )
> resistance to aq outflow
Traumatic angle > iris Fn TM Iridodialysis
Close angle Lens induced Anti-inflam
- Phacomorphic Mature cataract Anti-glaucoma
Cataract removal Sx
lens
Neovascular NVG Hypoxia/ischemic > neovas Tx U/D, control IOP
M/C from DR, CRVO Prophylactic
panretinal
photocoagulation
(PRP) for NV
Anterior lens
dislocation

Childhood glaucoma

1. Primary congenital glaucoma

- Congenital glaucoma : M/C,, sporadic
75%bilat, triad(epiphora,photophobia,blepharospasm
), Buphthalmos( corneal diameter>12mm), Corneal haze(), Haab striae(break descemet
membrane)

sclera/cornea IOP ( )
2. Developmental glaucoma Iridocorneal dysgenesis fn TM

- Neural crest development, ass with abnormal cornea and iris

Tx : Sx , medical congenital

Sx Goniotomy( TM), Trabeculotomy( Sclem canal) , Trabeculectomy(

)

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Visual loss
6
1. Ocular media opacity 2. Sensory process(retina/optic nerve)

3. Motor control(nystagmus ) 4. Refractive error

5. Cerebral cortex(cerebral palsy, Amblyopia) 6. Psycho(functional visual loss, Malingering)

History visual loss

: blurred onset, uni/bilat, sudden/gradual, temporary, near/far, double vision, floater/flashing
: when, associate symptom(pain, red eye, swell, itching)

- present status of vision(, contact lens), past ocular history, past Hx med, FHx ocular disease

Visual loss DDx disease Key

Painful Red eye Keratitis, acute glaucoma, acute Infect/inflam
uveitis
Non red eye Optic neuritis
Non painful Sudden Retinal vascular disease Retina
Retinal detachment
progressive Cataract, Glaucoma, Chronic disease
Retinopathy(DR, AMD)
=

1. Lens - Caratact lens PSC cortex

> posterior capsular opacity (PCO)

Aftercataract Laser capsule

2. Glaucoma
- AACG : sudden, severe pain, red eye, blurred vision
ciliary injection, fix/dilated pupil, shallow A/C 2
corneal edema : , iris
, light reflex scatter cornea
Tx : emer, Laser

- COAG : medication eye drop, laser, Sx

3. Retinal detachment
; Vitreous detachment
- S/S : floater/flashing are common
- VA : variable invole macula = VF defect VA drop
- Mx : Sx sealing the retinal break(cryo, laser), relieving vitreous traction
scleral buckling, PPV ????
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4. CRAO/BRAO
- arteriosclerotic, embolus >> sudden painless visual loss(complete or partial vessel)
: reduce VA in CRAO but maybe normal in BRAO
RAPD+ve, narrow retinal artery, cherry-red spot(CRAO)/white infarct retina(BRAO), emboli may seen
- Mx : immediate refer in <6hr,
tx IOP( flow ; IV Acetazolamide, globe massage, paracentesis, carbogen therapy)
manage U/D

5. DR : NPDR, PDR(neovas/hypoxia)
- Mx : control blood glucose, annual check up, photocoagulation in severe NPDR
PPV in PDR with TRD or VH

Other cause of visual loss Management

Conjunctiva Pterygium Excision Conjunctival autograft(CAG)
(amniotic membrane)
inflame , cosmetic
Cornea Corneal ulcer
Corneal scrap ATB
Ciliary inject Refer / perforate/blind
trauma/ CL
Dendritic keratitis
Herpes simplex/zoster
Corneal scar Corneal transplant
Corneal abrasion ATB 7 heal
// - 1
+ Hx
FB : 27-30
abrasion
/ rupture globe

A/C Hyphema (microscopic ) 90% med case,

10% Sx case uncontrol glaucoma,
Comp : glaucoma
corneal blood stain
Lens Dislocation = visual axis Lens removal with IOL
subluxation zonule

Retina AMD

Drusen yellow deposits under the
retina are one of early signs of
Age-related Macular Degeneration

hard exudate

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Optic nerve Optic atrophy : cup , neural rim ,

Glaucoma : cup ,
, neural rim
Disc swell : 2 = Papilledema ( ICP )
> enlarge blind spot ( )

Neuro-ophthalmology
- lateral geniculate body > pretectal midbrain > CN3 pupil reflex

- Pupillary reflex = direct/consensual,

RAPD = Marcus Gunn pupil(optic n lesion or retinal disease) by Swinging flashlight test

VF defect of optic n. lesion : Central scotoma, Arcuate scotoma , Altitudinal

Ex. Lt eye Glaucomatous field defect

Disease of optic nerve - Sign : VA drop, RAPD +ve, Dyschromatopsia , VF defect

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Disease of optic appearance Clinical DDx

nerve
Optic neuropathy Atrophy pale disc, Inflame : optic neuritis
damage optic n. flat disc, clear Vascular : ischemia(arteritic, non-arteritic ex. DM)
margin Toxic
Compression
Trauma
Papilledema Swell, almost Sign ICP : N/V/HA, 1.Space occupying lesion of CNS
IOP> axoplasmic always bilateral diplopia(CN6 pressed)
flow stasis > axon
VA normal, no VF 2.Pseudotumor cerebri(idiopathic
swell Blurred disc
margin, disc defect( enlarge intracranial hypertension)
RAPD ve swell/hyperemia, blind spot Pt > risk
no optic cup
2 )

Papilledema may be asymptomatic or present with headache in the early stages. However it may progress to
enlargement of the blind spot, blurring of vision

Tx papilledema : R/O other cause of disc swelling, imaging find U/D

prog : resolve normal disc 6-10wk, chronic papilledema > optic atrophy

Optic neuropathy
1. Optic neuritis inflame
: idiopathic, demyelination(ass with multiple sclerosis, NMO), infect, autoimmune
typical : young female <40yr, subacute, unilat loss VA, 90% periocular pain with eye movement, RAPD+ve
60% normal disc(retrobulbar optic neuritis) - 40% swollen disc(ant optic neuritis)

VF defect(M/C central scotoma), recovery 2-3wk complete in 6mo

- Tx : IV methypred 250mg q 6 hr x3days then oral pred 1 MKD x11days
(steroid recurrence attack)
prog : 30% recurrence , 40% develop MS in 10 yr

2. Ischemic optic neuropathy(ION)

- PION : no disc swell ;

- AION(ant) : disc swell, peripapillary hemorrhage

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> arteritic : Giant cell/Temporal arteritis(triad : HA, Jaw claudication, visual disturbance)

>70 , Tx steroid
non-arteritic NAION : DM HT DLP OSA ; common Tx : none
3. Toxic optic neuropathy
: Ethambutol(Pt TB with ), Amiodarone, vit B12 def

common : Tobacco, Isoniazid, Chloram, Arsenic, Digitalis, Chloroquine

- S/S : bilat and simultaneously VA drop Methanol acute onset, severe visual loss

VF defect(cecocentral scotoma spec )

> Methanol ingestion : ( ethanol ) acute, life threaten, irrev visual loss
- S/S : N/V, respi distress, HA, Metabolic acidosis, abdominal pain, weakness
VA drop to any level(to no LP)
disc gradually pale, swell, hyperemic
- Dx by methanol level >20 mg/dl
- Tx : Ethanol ingestion, HCO3 and Hemodialysis eliminate metabolic acidosis

> Ethambutol : met to Disulfiram/DL-penicillamine > toxic optic neuropathy

- dose related >25MKD, visual loss 2mo, renal TB

- S/S : dyschromatopsia( red-green color blindness), insidious bilat sym visual loss, normal fundus,
vary VF defect
- Tx : ; E in TB baseline (VA/ VF/ Color vision)

4. Compressive optic neuropathy (tumor infect inflam)

1) Lesion of the orbit : infect - abscess(orbital cellulitis)

inflam - idiopathic orbital inflam(pseudotumor oculi)

compress proximal optic nerve, visual loss, pain, proptosis, disc swell
2) Thyroid ophthalmopathy
: bilat, symmetric, gradual onset, VA drop with central scotoma and arcuate defect
CT : enlarge EOM at orbital apex
3) Intracanalicular and intracranial lesion : aneurysm/tumor ex. Meningioma

triad = progressive visual loss, optic disc pale + optociliary shunt vein( drain )

5. Infiltrative optic neuropathy : primary >> secondary tumor

6. Traumatic optic neuropathy(TON) : RAPD +ve, pupil 2 dilate brain

- Direct / Indirect blunt

- by anatomical
1. Optic disc avulsion >>>>>>>>>>>>>>>>>>
: partial ring hemorrhage at optic nerve head
2. Anterior optic neuropathy - injury to prox optic nerve 10 mm of globe
: fundus finding = CRAO/BRAO, CRVO, AION ;
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3. Posterior optic neuropathy

: fundus finding = disc normal at least 3-5wk then become pale
: assess VA, Color vision, VF no defect, RAPD +ve
palpation of orbital rim > iden fracture ; TON optic ? CT

- Mx : high dose methyprednisolone risk-benefit acute spinal cord injury study

tx within 8hr with MP 30mg/kg bolus then 5.4 mg/kg/hr for 24hr

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Cornea
: transparent, avascular organ fibrous trauma

rich nerve supply > reflex >> /

+ light refraction 2/3 of total refractive power of eye

- Anatomy 5

> Epithelium 4 turnover rate 7-14days(healing )

sensory nerve CN5-1 >> pain, reflex lacrimation

> Bowman layer > Stroma 90%

> Descemets membrane(true basement membrane)

> Endothelium( active transport

)

Precorneal tear film : lubricate ocular surface, smooth optical surface( focus ), ,

lysozyme(antiseptic )

ex. > > > focus

Filamentary keratitis is a condition in which strands (filaments) composed of degenerated epithelial cells and
mucus develop on and adhere to the corneal surface causing pain and foreign body sensation, move with each
blink
= Corneal filament

Special investigation : corneal pachometry(), esthesiometry( sensation), specular photomicroscopy,

 PiP BM19 23

Corneal disease
1. Congenital anomaly corneal&sclera
size 2 ass with congenital glaucoma
: microcornea/megacornea, cornea plana, posterior embryotoxon, sclerocornea, CHED

2. Corneal degeneration
: Corneal arcus , Calcific band keratopathy, Terrien marginal degeneration

3. Corneal infection Corneal ulcer = bact

1) Bacterial keratitis contact lens, trauma, contaminate,
- rapid onset, conj injection, photophobia, decrease vision,
>> tx cornea 2-3 (Pseudomonas esp contact lens)
2) Fungal keratitis Hx expose /
tx
>> Mx : Corneal scraping G/S, KOH, C/S bact, C/S fungus
3) Acanthamoeba keratitis
: severe pain inappropriate with lesion, Hx wear contact lens,
perineuritis(enlarge corneal nerve - pathognomonic)

4) HSV keratitis : HSV cornea, zoster

:
- primary ocular infection : Blepharoconjunctivitis, Dendritic epithelial keratitis
- Mx : antiviral EO/oral 7 days
**Steroid fungal / Herpes

4. Corneal inflam(non infect)

- Peripheral ulcerative keratitis

5. Corneal dystrophy Corneal ectasia

Keratoconus
3-4

6. Corneal tumor cornea avascular

7. Trauma : Corneal FB >> remove by needle 26G, ATB ED
Corneal abrasion
>> pressure patch, ATB, artificial tear(lubricant), bandage CL
24hr CL 2-3

Corneal edema > scar

 PiP BM19 24

Sclera
: nontransparent tissue, cornea

- 3 vascular layer 1. Conjunctival vv

2. Superficial episcleral vv
3. Deep vascular plexus
: , retina cornea

Scleral disease
1. Episcleritis : immune mediated vasculitis to destruct sclera, ass with autoimmune

S/S ocular pain, deep violaceous hue
2. Scleritis : self limited, benign inflam
S/S redness, mild irritation
Tx no, irritation > NSAID ED/oral

Retina
Retinal vascular dz blurred vision Fundus Tx
Hypertensive HT 5-10 yrs retinal hemorrhage,
retinopathy hard exudates,
Pre-eclampsia cotton-wool spots
BRVO CRVO Mostly old age with HT flame-shape hemorrhage with scatter photocoagulation
retinal edema laser neovas
retina
-cotton wool spots
-macular edema
neovascularization
BRAO/CRAO Cherry red spot Tx in 90 min : paracentesis,
macula ocular massage( emboli
Emer Pale, whitish edematous retina disrod), acetazolamide,
carbogen(vasodilate)
Diabetic retinopathy NPDR = MA, venous beading microaneurysm( dot blot NPDR = F/U observe,
slit lamp), dot-blot control DM/HT,
DR flame shape PDR = retinal neovas
macula edema
(NVD,NVE), Vitreous hemorrhages, hard
vein occlusion exudates, cotton wool spots antiVEGF
hemorrhage
, Clinical sig macular
edema(CSME) PDR = Laser photocoag
- grid laser
macular edema, VA drop
- PRP(Panreti photocoag)

Retinopathy of premature, low birth ischemic peripheral avascular cryotherapy or laser

prematurity(ROP) weight, oxygen therapy retina photocoagulation
> fibrovascular proliferate
> tractional RD
- retinal vasoobliteration
Screening : indirect
ophthalmoscope
periphery
 PiP BM19 25

Macular disease central vision loss Fundus Tx

Macular hole Mostly old woman with Tangential traction Vitrectomy with gas
central vision loss between posterior hyaloid tamponade membrane
macula face and macula

Macular common cause of macular drusen hard dry AMD

degeneration blindness in old age
exudate : F/U, no tx
= Age related macular
degeneration(AMD) Central scotoma
= macula wet AMD
geographic atrophy of RPE : Photodynamic
Dry AMD = severe in Dry AMD therapy(PDT)
Wet submacular : Intravitreal injection of
choroidal neovas, disciform Anti-VEGF
hemorrhage scar

Retinal detachment Fundus Tx

(detachment between sensory retina
and RPE)
RRD retinal break(vitreous ) Scleral buckling procedure
Rhematous (SBP) break
retina choroid

PPV

TRD Causes no retinal break Vitrectomy and peeling
traction : Trauma,Diabetic membrane
retinopathy
Vitreoretinal membrane, membrane traction
fibrous traction PDR
(neovas > fibrous > TRD)
ERD Causes Exudates collected under sensory
- exudative : choroidal tumor, retina
choroidal inflam

Infection Fundus Tx
HIV retinopathy Immune complex Cotton wool spots M/C
retinal manifest in HIV+

Retinal hemorrhages
CMV Most common OI of Pizza pie apperance Gancyclovir
retinitis(CMVR) the retina (pathognomonic) - intravitreal injection or
- necrotizing retinitis iv infusion
Low CD4 <50 (white fluffy infiltrate)
- retinal hemorrhage
 PiP BM19 26

Conjunctiva
cornea
: palpebral/tarsal( tarsal plate),
bulbar( cornea limbus corneal stem cell ),
fornix /(superior/inferior) / contact lens
> ,
caruncle( semilunar fold)
cyst/ 2

Blood supply
Anterior ciliary artery : superficial > bulbar conj, >> Conjunctival injection
deep > cornea, iris, ciliary body >> Ciliary injection
>

ex. Conjunctivitis > conj injection

acute glucoma, ant uveitis > limbus conj
> severe!! emer tx (glucoma > peripheral iridectomy)
Tx glaucoma definite : Sx Peripheral iridectomy(PI) Laser,Sx

mech iris TM >> IOP Trabeculectomy

Sign of inflam conjunctivitis papillae, follicle

: papillae : vascular core+ tissue edema + mixed inflam cell
: follicle : cluster lymphocyte
palpebral conj, lower fornix
Chemosis
: pseudomembrane : inflam coagulum conj >
- membrane membrane

Conjunctivitis /
- keratinization vit A ,
- scar trachoma(),
- Symblepharon conj lid >
> 2wk
 PiP BM19 27

Degenrative Disease
1. Pinguecula limbus interpalpebral zone ; yellow white conjunctival nodule
Risk :
: tearing irritation pain
Tx : vasoconstrictor, antiHis,
steroid eyedrop
; comp glaucoma, cataract
risk factor + (/)
2. Pterygium
: fibrovascular tissue invade cornea nasal /
pupil/ blurred vision, > astigmatism(cornea )
- Tx : med same pinguecula, excision in blurred vision, chronic inflam, cosmetic
> simple excision bare sclera
3 indication : /, steroid , cosmetic
risk factor + 3-6mo
; recurrent fibroblast

Disease infect
1. Viral conj : benign spread bact ; 2wk
- all have acute follicular(cluster lymphocyte) + LN

1. Adenoviruses - most common acute viral infections of conjunctiva, epidemic / sporadic throughout all seasons.
4 syndromes, 1 epidemic keratoconjunctivitis EKC 2 pharyngoconjunctival fever PCF

1) adenovirus 8,11,19,37 >> EKC(epidemic keratoconjunctivitis)

direct/indirect contact /
mild-mod
: acute redness, tearing, conj inject, foreign body sensation, follicle lower lid(upper tracoma), membrane

Comp : epithelial keratitis (wk-mo) steroid immune = superficial punctate keratitis SPK???
- Tx : prevent transmission viral shed 10-14 >>
>>
self limited > supportive Cold compress,
lubricant,
topical vasoconstrictor-antiHis,
topical NSAID or topical steroid
*Topical steroid controversy acute follicular conj HSV (steroid in HSV keratitis)
( severe conjunctival membrane or pseudomembrane conj scar
 PiP BM19 28

Pt epithelial keratitis steroid recurrent )

conjunctival membrane forceps/ q2-3day + conj scar

2) Pharyngoconjunctival fever PCF : adenovirus 3,4,7 keratitis

: fever, pharyngitis(upper respi infect), acute follicular conjunctivitis, enlarged preauricular adenopathy.
- Tx EK

2. Acute hemorrhagic conjunctivitis

: coxsackie A24 , enterovirus 70 / highly contagious share cosmetic
- adeno, Tx EKC

3. Molluscum contagiosum : DNA poxvirus

- elevate Pearly umbilicated nodule lid margin,
- chronic follicular conj viral particle ,
- cornea punctate epithelial erosion(PEE), Pannus ( upper conj cornea > cornea
)
- Tx : - curettage, excision

2. Bacterial

1. Bact conjunctivitis - acute bact conj : incubation 3-4wk

foreign body sensation, tearing, photophobia, Lid edema, conj injection, chemosis(conj edema),
purulent/mucopurulent discharge , Subconj hemorrhage, conj membrane,
SPK(Superficial punctate keratitis) cornea death of small groups of cells on the surface of the cornea ,
corneal ulcer
H. influ = pharyngitis, otitis media > oral ATB
- Tx : topical ATB(Neomcin, polymyxin B, gramicidin = PolyOp : broad spectrum), ChlorOph

2. Hyperacute : Neisseria 2 invade cornea (GC mening)

- incubation
, Hx STD > Neiserria
1. GC conjunctivitis
: copious purulent discharge , pain, tender preauricular LN,
cornea keratitis 15-40% > cornea perforation , swab > G/S culture
 PiP BM19 29

- Tx : admit , copious irrigation q 30-60 min, off,

Topical ATB - Ciproflox, Erythro, Gentamicin
systemic ATB - Ceftri Cefixime(400-800mg ),
GC conj no involve cornea > Ceftri 1g IM
keratitis/dissem GC infect > Ceftri 1g IV or IM q12-24hr x3days
- Cipro/Oflox Pen : Cipro 500mg or Levo 400mg bid x5days
Tx
Tx Concurrent chlamydia 33%. > Azihro 1g , Doxy 100mg bid x7day
Tetra 500mg qid x7day, Erythro 250mg qid x7day
2. Neonatal GC conjunctivitis : Ophthalmia neonatorum
: 3-5 GC conj , 75% 2
Chloram ointment, Rare dissem
- Tx :
Ceftri 25-50mg/kg( 125mg) IM or IV Cefotaxime 50-100 mg/kg
3. Neisseria meningitidis : clinical GC, younger , bilateral icu
secondary meningococcal conj meningococcemia/meningitis
- Tx same GC

3. Chronic bact conj : 3-4wk non specific

- risk factor lid malposition, dry eye, chronic blepharitis, eye prosthesis, chronic steroid,
poor hygiene
- S.aureus, E coli, S.pyogenes, S.pneumo, Moraxella lacunata( angular blepharitis, chronic follicular
conjuctivitis)
- Tx : conjunctival swab G/S C/S, nasal/throat swab colonize
respi mucosa

Chlamydial infection serotype

1. Trachoma - Chlamydia upperlid poor hygiene

> preventable blindness ;
chronic follicular conjunctivitis
 PiP BM19 30

Stage of Trachhoma MacCallan class

1 Incipient trachoma
2 established
2A Follicular hypertrophy
predominant
2B Papillary hypertrophy
predominant
3 Cicatrical = scar
4 Healed
acute inflam,
3 wk immature follicle on UTC(upper tarsal conj),
follicle mature , keratitis, pannus
follicle papillae
scarring, trichiasis( =Entropion) ,
Pathognomonic : Limbal follicle necrosis/scar > Herbert's pit
limbus > ,
UTC horizontal scar > Arlt's line(upperlid)
No inflame, scar , corneal opacity, lid complication
complication

- Criteria Dx : 1. Conjunctival follicle at UTC 2. Limbal follicle

(Herbert pit)
3. Conj scarring 4. Vascular pannus superior cornea
- Tx : topical/oral , triple sulfa, cornea
oral tetracycline 1-2g/day qid 3-4wk, oral Erythro 250mg qid 3-4wk
topical Tetra or Erythro EO bid 2month

2. Adult inclusion conjunctivitis

: oculogenital disease, ass with urethritis/cervicitis contact ,
- subacute follicular conjunctivitis 2d-2wk Mucopurulent discharge lowerlid trachoma
- Tx : + tx pathner ; scar

3. Neonatal inclusion conjunctivitis : birth canal 5 , mucopulurent discharge

conjunctiva papillae follicle immune system 6-12wk
systemic infect > pneumonia 10-20%
 PiP BM19 31

3. Allergic conjunctivitis
1. Hay fever conj(seasonal allergic conj) - hypersense type1, airborne allergen spore
other atopic condition Itching tearing burning Chemosis
- Tx : avoid allergen, cold compress, topical vasocon/antiHis/NSAID/steroid
topical mast cell stabilizer 2-3wk
2. Vernal keratoconj(VKC) onset 10 bilat
, Hay fever conj
: hypersens type1,4 Hx atopy blepharospasm
2 form: palpebral > giant papillae UTC>LTC 'Cobblestone' ,
limbus > opalescent nodule
> trachoma(Herbert pit) eosinophil

3. Atopic keratoconjunctivitis hypersense type1/3 atropic dermatitis

4. Contact lens induced conj
(giant papillae conj : hypersense type 4 , soft rigid contact lens
machanical trauma or contact lens Papillae small to giant
Tx : , refitting with new CL, daily wear, disposable CL, improve lens hygiene, topical

4. Adverse reaction to topical medication

1) allergic reaction acute onset : hypersense type 1 anaphylaxis
delay onset : hypersense type 4 Contact blepharoconjunctivitis
> 24-72
Tx : , , lubricant eye drop/ointment, topical vasoconstrictor-antiHistamine
topical steroid
2) Toxic reaction allergic wk-month
2.1) Toxic papillary conjunctivitis direct chemical irritation preservative
2.1) Toxic follicular conjunctivitis
Tx : > preservative-free artificial tear/ointment

_______________________________________________________________________________________
 PiP BM19 32

Uvea
Anterior uvea = Iris + Ciliary body

: Ant border layer iris melanocyte ,

Iris 4

circular m(parasym), radial m(symp),

post pigment epi

Ciliary body : Pars plicata(ciliary process + zonule

)
Pars plana

Posterior = Choroid

Choroid : 5 4 = choriocapillaries

5 = Bruchs membrane
collagen elastin RPE
> Drusen AMD = hyaline excresence in Bruch layer Hard exudate

Blood supply

Nerve : long and short ciliary n(CN5-1)

symp short ciliary >> iris dilator m

parasymp = short ciliary >> iris circular m,
>> ciliary m(accommodation)

Approach

Onset : Acute VS chronic

Type of inflammation : Granulomatous( epithelioid )

: nongranulomatous

Causative : infection, noninfection, masquerade( uveitis lymphoma, leukemia)

Location : anterior( systemic , HLA-B27),

intermediate, posterior, panuveitis
PiP BM19 33
 PiP BM19 34

Corectopia
1cm
Heterochromia irides 2 Congenital Horners syndrome

Traumatic midriasis :
(sphincter m )
 PiP BM19 35

Posterior uveitis : TB choroiditis, Toxoplasma retinochoroiditis

Complication uveitis

Secondary ocular hypertension/glaucoma

Complicated cataract - lens opacity occurring due to a local or systemic disease

Rubeosis iridis neovas retina ischemia

Cystoid macular edema : macula uveitis

Pthisis bulbi : severe uveitis

_______________________________________________________________________________________
 PiP BM19 36

Ocular therapeutic
Pharmacokinetic
1. Eye Drop : cul de sac 30 L 1 (50L)

; 1

>1 5 ( reflex )
2. Eye oint penetrate

Pilocarpine, Tetracycline, Fluorescine

3. Subconjunctival injection Ant segment

, OPD case
4. Systemic : /
5. Intraocular : intracameral, intravitreous

Local anesthesia drug S/E

Topical cornea, conjunctiva Proparacaine Disrupt tight jc > corneal
permeability
/ , onset 15 20

Corneal epithelial
Benoxinate, Tetracaine
toxicity
Local retrobulbar, anesthesia akinesia 2%Lidocaine onset 5min CNS toxic drowsiness,
peribulbar,
intraocular, orbital Sx 1-2hr max dose 15ml tremor, convulsion
lid block
0.75%Bupivacaine onset
CVS toxic MI, respi
8hr max depress
dose 25ml
Mydriatic and Cycloplegic
> Pupil dilate > fundus,lens
> Cycloplegic > relax ciliary muscle
1 ciliary blood flow > pain
2 inhibit accommodation refraction

3 pain ciliary spasm iridocyclitis

4 iris-lens adhesion(post synechiae) contact

Mydriatic and Cycloplegic Drug

1 agonist Iris dilator m > Phenylephrine systemic absorb BP
no Cycloplegia
Muscarinic Mydriatic Cycloplegia 1%Atropine - 7-10d recover
antagonist
complete cycloplegia
0.5-1%Tropicamide(Mydriacyl) 6hr , 6hr
Homatropine, Cyclopentolate
recover fundus


 PiP BM19 37

Antiglaucoma 6 mechanism Eyedrop S/E

Beta blocker Timolol(Timodrop)
1st line - BP,HR, CHF, bronchospasm, mask
IOP 20-30% hypoglycemic sign

CA inhibitor Pill : Acetazolamide Fewer systemic S/E

aq humor (Diamox) acute angle - paresthesia, renal stone, allergy(sulfa
drug), hypoK, metabolic acidosis
Eye : Dorzolamide,
Brinzolamide
Adrenergic ago uveoscleral Nonselective
agonist outflow : HA, BP, tachycardia, arrhythmia, allergic
: Epi Dipivefrin conjunctivitis
Selective
: burning, fatigue, HA, drowsiness
Selective A2 :
Apraclonidine,
Brimonidine(Alphagan)
Cholinergic Mitotic Pilocarpine Constrict pupil > dim vision
IOP 15-25% drainage TM Carbachol
Ciliary constrict > induce myopia, HA, RD

PG analog drain uveoscleral Latanoprost(Xalatan), Local S/E

pathway Travatan, Lumigan, Darkening iris, periocular skin
Rescula
hypertrichosis, burning, eye redness
Hyperosmotic blood osmolarity Glycerine oral 1-1.5g/kg Hyperglycemia DM, ketosis, diuresis
Control acute >vitreous
IOP
volume > IOP SAH
Mannitol 1.5-2 g/kg (more
S/E ) CVS overload

1. Beta blocker 1st line Timolol(Timodrop) : punctate keratitis

Betaxolol(1 antag
pulmonary sparing eff )
Carteolol nonselective antag timolol partial ago HR,dyspnea
Timolol

2. Adrenergic agonist
ago uveoscleral outflow : Epi Dipivefrin
Selective A2 : Apraclonidine, Brimonidine(Alphagan)> S/E lid retraction

3. Cholinergic ago
Carbachol(Miostat) intraop intracameral
1-4%Pilocarpine qid IOP
 PiP BM19 38

4. CA inhibitor : HCO3 non pigmented epi aqueous

Oral Acetazolamide(Diamox), Meyjazolamide(Neptazane)
Topical Dorzolamide(Trusopt), Brinzolamide(Azopt)

5. Osmotic agent
Glycerine oral 1-1.5g/kg hyperglycemia DM, ketosis, diuresis
Mannitol 1.5-2 g/kg (more S/E ) SAH rapid volume overload, rapid
shrinkage > traction to subarachnoid vessel
CVS overload esp Pt CHF, angina,HT, recent MI
6. PG analog

Anti-inflam drug use S/E

Steroid (-dex oph) PSC Cataract, glaucoma,
Fluorometholone
NSAID Diclofenac, Flurbiprofen, pain, photophobia Topical : ocular irritation,
Indomethacin tear, burn, superficial
intraop miosis
systemic punctate keratits
(Timolol )
Anti-histamine Hista-Oph(Antazoline + allergic conjunctivitis
vasoconstrictor
Tetrahydrozoline)
Mast cell stabilizer Cromolyn sodium Olopatadine(Patanol)
prophylactic antiHis, MCS
wk
effective
Anti-metabolite Mitomycin, 5FU - success rate of filtering Sx in difficult
glaucoma case

Antibiotic Drug
Bact FQ : corneal ulcer, post op Sx(broad spec)
AG : Genta bact conj, GNB( Pseudo)
Fusidic : bacteriostatic > GPB, S. aureus
Chloram : GP GN
Polymyxin B : non severe superficial eye infect ;
> PolyOph = Neomycin + Polymyxin + Gramicidin
Fungus Polyene 5%Natamycin, Ampho filament ex. Asper
Imidazole 1%Miconazole filament/yeast ex. Asper,crypto
Flucytosine 5-FC 50-150MKD q6hr combine Ampho
asper,candida
Viral HSV keratoconjunctivitis or Epithelial keratitis CMV : IV Gancyclovir, Foscarnet
- HSV >> Acyclovir 400x5d
- VZV >> Acyclovir 800x5d
Acanthamoeba Polyhexamethylene biguanide (PHMB) combined regimen 3-6mo
 PiP BM19 39

Misc
1. Artificial tear : dry eye ED > polyvinyl alcohol, cellulose
ointment > petrolatum, oil
** preservative ; non-preservative
2. Diagnostic agent : 1%roose Bengal, 2%fluorescein external ocular disease ex. Abrasion
3. Viscoelastic agent : protect corneal epithelium, facilitate tissue manipulation

_______________________________________________________________________________________

Medical Ophthalmology
( systemic disease )

1. Hypertensive retinopathy : control HT , GA pre-eclampsia

Grade HT change Tx
1 Generalized arterial spasm Med : antiHTN drug
2 Localized spasm, A-V crossing(a OB : term > terminate

spasm vein) Comp : BRVO, CRVO, AION,

3 Exudate, hemorrhage, cotton wool NVG(neovas glaucoma hyphema TM)
4 Optic disc swelling

2. Diabetic retinopathy
: duration ; >15 60-75%
1. Pericyte(capillary wall) > hold fluid > leak > Hard exudate

2. Plt aggregation > intraretinal microangiopathy

> budding new capillary > Microaneurysm

> dot blot hemorrhage
> rupture(intraretinal hemorrhage) Pt DM

3. Microinfarction of nerve fiber layer > Cotton wool spot( leakage)

4. Retinal vein engorgement > irregular dilate > bleed > VH

5. VH > fibrous > TRD
> Epiretinal membrane > MH

NPDR : microaneurysm, dot-blot hemorrhage, hard exudate, macular edema, cotton wool spot
PDR : neovas NVD/NVE, fibrous proliferation, VH, TRD

Other DM comp
1. Refractive error - lens / > Aqueous(myopia, hyperopia)

- retina glare(edematous retina)

2. Cataract PSC ; senile cataract nuclear sclerosis

3. Neovascular glaucoma = Rubeosis iridis
4. Optic neuritis
 PiP BM19 40

- Tx : medical, PDR photocoagulation laser PRP retina

Sx PPV, Endolaser photocoagulation

3. Ophthalmic Graves disease

: Thyroid-related immune orbitopathy(TRIO) immune reaction

Staging
1 Lid retraction upper limbus 1st sign
lid lag upper eyelid
2 Soft tissue involvement
3 Proptosis
4 EOM involvement vertical diplopia
horizontal or vertical
5 Corneal involvement Ulcer, dry eye eye shield
6 Optic nerve involvement nerve
- ischemia, compression
Tx : med antithyroid drug
steroid

Sx Tarsorhaphy , optic nerve decompression,

correction of diplopia(muscle Sx) 6 mo /

4. AIDS
- non infect : peripheral ulcerative keratitis
- CMV retinitis : floater, VF defect, visual loss /
Toxoplasma retinitis

Eye Emergency
True emer : Chemical burn , CRAO ; tx minute

1. CRAO unilateral, sudden, painless loss of vision

VA : FC to PL in 90%case ; ophthalmic artery no PL , no cherry red
Cilioretinal a retina choroid macula
Fundus : disc , a:v 1:3 attenuation of retinal a,
Cherry red spot( macula choroid, retina ) - pathog ,
disc, Box carring of vessel
 PiP BM19 41

cause
: Atherosclerosis >> emboli,
CNTD( Giant temporal arteritis triad - scalp tender/neck pain/jaw claudication
steroid high dose biopsy, SLE APS > ),
drug abuse - >
migraine
Pseudo-CRAO deposit cherry red

- Tx : golden period 90 min, ocular massage, Ant chamber paracentesis,

IOP drug(acetazolamide/diamop 2 tab, glycerine 50cc),
O2 95% + 5% CO2. = Carbogen 45 15 24 vasodilate,
vasodilator(NTG CCB), ASA grain 5
Consult med cardio

**CRVO thrombosis systemic disease flame-shaped hemorrhage , Cotton wool

spot /

2. chemical burn
: ; : protein precipitation
: NH4OH > NaOH > KOH > CaOH( )
, fluorescen
degree : Corneal haziness , limbus
limbal ischemia( stem cell cornea )
- Long term complication : Corneal pannus, persistent epithelial defect, corneal thinning/perforation

- Tx : immediated copious irrigation

[ syringe 50 cc push/IV set NSS, LRS 2-3L 5
test pH 3-5L > consult]
CaOH2 injury rod upper fornix EDTA
- supportive tx vasoconstrict : histaoph, phenylephrine, efemoline
preservative

Urgency
1. acute angle closure glaucoma
( angle ) FHx
Acute painful visual loss , Halos( edema), Ciliary injection
cornea, tense
- Tx : oral acetazolamide/ Diamox, 50% glycerine
>> refer for iridectomy for bypass
 PiP BM19 42

2. orbital cellulitis
: , periorbital structure > consult ENT film , trauma/Sx, hematogenous

Preseptal > no admit, admit in 5yr old H influ

Orbital > admit for ATB Ceftri clinda 2wk, consult ENT
CT for abscess(comp)

3. Endophthalmitis
: post op Sx - esp Glaucoma , posttraumatic, endogenous liver abscess
painful visual loss, ciliary inject, chemosis, corneal edema, eyelid edema Cell in A/S, vitreous

4. Lid injury Periorbital ecchymosis - stepping, Laceration of eyelid

- 3 gray line (tarsus ), Lash line, Meibomian line canuliculi
> Fat prolapse in lid laceration fat = Levator injury test

5. Orbital injury blunt trauma > orbital wall

Blow out Fx inf rectus trap > , diplopia
damage infraorbital nerve > cheek numbness
- Tx : Sx spontaneous improve 1-2wk > Trapdoor fx ( vagovagal reflex)

6. Orbital compartment syndrome

Triad : tense orbit , proptosis with RAPD+ve
Proptosis in CT 2/3
Tx : Lat cantotomy/cantholysis

Globe injury
1. Corneal abrasion
Mx : Fluorescein staining , topical ATB, tears, pressure eye padding

2. Subconj hemorrhage vulsava

3. Hyphema corneal abrasion, FB

Mx : bed rest with head elevation clot lysis glaucoma
admit sedate
4. Cornea FB Rust ring
- Mx : > 27 > ATB drop > pressure eye padding > F/U

Intraocular foreign body IOFB > X ray intraocular FB > refer

 PiP BM19 43

Sign occult scleral rupture

Prolapse of intraocular contents

Marked conjunctival edema (chemosis) with extensive subconjunctival hemorrhage
Abnormal depth of the anterior chamber with or without fluid flow
Pupil not round or peak
Hypotony

UV keratoconjunctivitis : UVB/C exposure hr (DDx for FB)

- painful from epithelial defect mostly both eye
- Tx : ATB ointment, pressure patch, tears with steroid

_______________________________________________________________________________________

Refractive error
: Blurred vision

- Emmetropia primary position 20

Refractive power = 2/3 Cornea, 1/3 Lens
Accommodation : refractive power

( autofocus) , parasympathetic > contract ciliary muscle > lens refractive power ;
40 = Presbyopia

1. Myopia
: 1) longer AP diameter(axial length) M/C

> retina stretch defect/detachment

2) greater curvature of cornea/lens

- keratoconus, cataract(lens > curve)

presbyopia cataract > lens

- DM hyperglycemia : lens fructuate > curve cataract/DR

( /)
Fundus : disc atrophy peripapillary optic disc atrophy, background

Classification
1. Simple myopia :
15-20 -10D
2. Congenital myopia : associated anomaly ex. Congenital cataract,
lenticonus, aniridia
3. Progressive myopia
1

- S/S : blurred vision ( pinhole effect), eye strain(

), strabismus, floater( vitreous degeneration warning sign of RD )

 PiP BM19 44

- Tx : concave lens full correction ; full correction Normal

accommodation-convergence reflex( 2
Amblyopia)
Laser LASIK(Laser in situ keratomileusis) cornea (20 )
; manual cornea astigmatism

2. Hyperopia risk for acute angle glaucoma

: 1) short AP diameter
2) smaller curvature

3) aphakia lens( lens )

Accommodation in hyperopia : accommodation

+3D
10 , Accom = blur vision
> Latent hyperopia = accom

>> Cycloplegic/Miosis = Antichol Atropine( 2-3wk), Mydriacyl(action )

Cycloplegic refraction

- Tx :
full correction , no correction symptom ( undercorrection
)

3. Presbyopia 40 accom /

accom ()

4. Aphakia : lens :

( + lens accom)
lens dislocation ex. Marfan syndrome, Homocystinuria,
- slit lamp
= Iridodonesis lens

5. Astigmatism

: cornea toric spheric >> refractive power

>> focus 1 focus

, corneal disease/scar/contracture
- S/S : blurred vision, distortion /, head tilt/turning, squinting( ) pinhole effect

Snellen ,
- Tx : cylinder lens refractive power

6. Anisometropia : 2

> full correction Amblyopia suppressed diplopia

- Tx : tolerate lens power 3D

 PiP BM19 45

Strabismus
squint = visual axis cannot direct at the same point of fixation
: Tropia , Phoria ; Eso / Exo / Hyper / Hypo

- primary position = optical axis 23

Axis of Fick(rotation) : Z >> abduct/adduct , X >> elevate/depress , Y >> incyclo/excyclo

- primary action : muscle

primary position

subsidiary action(secondary/tertiary action) : additional effect

EOM origin Annulus of Zinn(ligament optic foramen) IO maxillary bone

> horizontal rectus : MR, LR primary action

> vertical rectus : SR IR 23 action

> oblique : SO IO 51 action ; SO primary incyclo, subsidiary abduct/depress

Cardinal position of Gaze

Supranuclear control by by
Saccadic Frontal lobe Position maintenance -
system fovea
Smooth Persuit Parieto-occipital Nonoptic reflex system Semicircular canal,
utricle, saccule inner ear

Vergence Midbrain

Eye movement
: Sheringtons law of reciprocal innervation = agonist muscle + inhibit antagonist

Yolk muscle 2
LR MR
Herings law of motor correspondence version() innervation

synergist muscle()
2

1. Idiopathic M/C , 50% FHx

2. Paretic muscle
- systemic disease ex. DM(microvascular > LR6 ), Thyroid, MG(NMJ )
- trauma ex. Birth trauma forceps extraction
3. Refractive error > power > accom
4. Accommodation/ accommodative convergence abnormality(accom convergence
)
5. Ocular disease sensory deprivation Retinoblastoma(fovea
) >> DDx Rb
 PiP BM19 46

- Inspection : pseudostrabismus ex. Pseudoestropia( epicanthal fold ),

Pseudoexotropia(hyperteleorism )

Corneal light reflex/pupillary light reflex

Hirschberg test : cornea light reflex pupil temporal displacement of light reflex

Cover test : /

1. Cover-uncover test tropia

- fix (uncovered)
shift in/out for fixation
2. Alternate cover test phoria

- prevent binocular fixation

Measure deviation
1. Hirschburg test decentration

2. Krimskys method (Hirshburg + Prism) co-operate vision

: prism corneal light reflex deviating eye pupil

prism

Level of single binocular function SBF Worth 4 dots test

detect abnormal sensory adaptation

: tropia diplopia cortical adaptation

1) Suppression 8 > Amblyopia (anatomy function)

monocular function Worth 4 dots test

2) ARC abnormal retinal correspondence

: 2 fovea = normal retinal correspondence NRC

fovea

Tx : 1) function single binocular vision(SBV) <8 function

2) cosmetic for cosmetic
- Patching Amblyopia( )
- Correct significant refractive error with glasses
- Cycloplegic refraction accom

_______________________________________________________________________________________
 PiP BM19 47

1. Eye trauma : Close globe > blunt
Open > penetrating( ), perforate( )

24hr enophthalmitis
2. conjunctiva > = active infect

> = corneal scar

3. Uveitis > ciliary spasm > > Atropine(cycloplegic)

4. Topical steroid > glaucoma(topical), infect, delay healing, cataract(oral - PSC),
dry eye( )

5. refractive index
6. Soft contact lens > >
Hard >
7. M/C cause trichiasis : inflam Blepharitis
8. Cataract sx - IOL > glaucoma V degen

dead space V
9. Snowflake cataract pt DM type1
A special type of cataract, is seen predominantly in young type 1 DM Pt and tends to progress rapidly.
10. Myopic shift
11. Rubella - cataract(NS white pearl)
12. Glaucoma : retinal damage at ganglion cell
> 3 = IOP, visual loss - paracentral scotoma VA ,
glaucomatous optic nerve damage
Glaucoma suspected : Ocular HT, NTG suspect progress
13. Congenital glaucoma
: triad - epiphora, photophobia, blepharospasm()
14. CRVO/BRVO - M/C cause HT, ocular HT
15. Photopsia flashing
: temporal ,
movement ,
>> DDx 3 1. Symptomatic Posterior Vitreous Detachment (PVD)
2. Migraine
3. Uveitis - choroiditis
16. Metas CA - uvea, bone(lesser sphenoid bone) enophthalmos

17. CN3 5 7 - muller muscle(CN5) Superior tarsal muscle

18. Typical optic neuritis
- 20-30 , ( MS), pain on eye movement 2-3 , , VA drop, RAPD+ve, Color
vision loss
MRI : MS > white area at periventricular
**atypical = NMO , cord paralysis, poor visual prog
 PiP BM19 48

19. Papilledema : enlarged blind spot, disc swell, flame shape hemorrhage, CN6 > LR palsy limbus

, loss spontaneous venous pulsation

Acute : VA, color vision drop 6 wk

20. Beta block - heart block

21. Pilocarpine : cholinergic agonist inflam > NVG

22. TRAUMA > 6

23. CN3 palsy (LR6), , pupil dilate
CN4 palsy - chin depress, head tilt head turn
24. Post op VA(V/S). corneal ?, A/C space, lens IOL , pupil ?

25. IOP <10, >20 direct contact

26. Case Pt 22 2wk flashing
VA central scotoma, lid swell -, RAPD+ve Rt eye( pupil size 2 ;

reverse RAPD = consensual light reflex)

EOM
lid retraction >> Worm eye view ( )
>> proptosis CT orbit with contrast (X ray ) = , nerve

: infiltrative mass >> Bx : chronic inflam, IHC : no lymphoma

>>>> Dx : optic neuritis, Tx by steroid

autoimmune infiltrative lesion

27. Optic nerve > visual

> RAPD+ve ; cataract nerve

28. Red reflex

= ex. Cataract
29. Crescent mass at palpebral conjunctiva > /itching
Dx : Lipodermoid benign >> Tx : incisional Bx and reconstruct
Dermoid cyst canthus suture site > Mx imaging

30. Tear : normal, emotional, reflex(for inflam)

>> irritate = Entropion

involution = senile stabilize

31. PDR + Cataract >> PPV
PDR = neovas retinal ischemia ischemia

[ vitreous shearing force > VH ]

VH > Epiretinal membrane(ERM) macula > MH

> fibroblast > TRD
PDR PRP panretinal photocoagulation NPDR visual field
 PiP BM19 49

32. Macular hole = PPV with fluid gas exchange

fibrous tissue (DM ) , M/C in old

risk : aftercataract, DM, HT, myopia, intraocular Sx

33. Legally blindness

= 3/60 with correction VA visual field <10

34. Retinal detachment

1. RRD retinal break V

: liquefaction( floater Weiss ring esp. myopia, )

V base > light flashing

: Tx Laser/Cryotherapy break( )

2. TRD : DM fibrous

3. ERD : chronic renal fail , choroidal tumor

: choroid subretinal fluid

35. Anti VEGF Avastin , neovas ex. PDR,AMD

36. Vitreous hemorrhage DDx ; Vitreous = hyarulonic + collagen fiber

1. PDR most common
2. BRVO neovas

3. AMD neovas choroid >

4. Retinal break RRD retinal a.

5. PVD post vitreous detachment retinal a. aging

6. Trauma
approach VH : normal vessel = PVD
abnormal vessel = BRVO, wet AMD

37. Pterygium : degenerative disease <40

indication for Sx 1. VF loss (>3mm)

2. Horizontal diplopia (globe restriction)

2. Astigmatism >100(cornea )

3. Active inflame inflam

4. Cosmetic
Mx : UVB > Macular degen, cataract, pterygium [UVC > UV keratitis]

38. ROP : Retinopathy of prematurity
O2 VEGF vessel
 PiP BM19 50

vessel retina O2 neovas

screen
ROP screen 1. BW<1,500 2. GA<32
3. BW<2,000 + risk factor (cyanosis, on high Oxygen, )

39. Hordeolum : Tobrex q 2hr + Augmentin 1wk (tobramycin ophthalmic ointment)

Chalazion visual axis >

40. Leukocoria : abnormal white reflection from the retina

DDx : Rb, ROP, Coats disease(vessel exudate ), PFV(persistent fetal vasculature),

Toxocariasis() Endophalmitis

41. Convergence insufficiency = Accom spasm , computer

S/S : diplopia, HA, , eye strain, Asthenopia, Pseudomyopia

>> Tx : rest, muscle exercise Accom 10cm >10cm =
42. Painless progressive visual loss
DDx : refractive error, cataract, macular degeneration, glaucoma
43. Smoking >> AMD
44. Immature cataract Antioxidant aging
 PiP BM19 51

OPD case
1. >> DDx : NLDO, dry eye()
2. >> ; Trichiasis

>> Meibomian plug/gland dysfunction MGD lipid

Mx :
5-10
chronic blepharitis cause chronic meibomian gland dysfunction, will cause dry eye. But blepharitis should not be confused with meibomian gland dysfunction.
Keep in mind that you may clear up the bleph and still have MGD.

3. : Acute conjunctivitis ( )
Tx : HistaOph ; ELC + follicle

4. Flashing( retina), Floater 2

DDx : 1. Retinal tear/detach
2. Vitreous hemorrhage vv retina

3. Vitreous detachment/opacity

Mx : advice , floater/flashing

5. 2 , >> Presbyopia

6. Allergic conjunctivitis : follicle (palpebral conjunctiva) vessel

> Trichiasis >> Epilation

7. > Pterygium
Tx : topical steroid Fluorometholone(FML)

8. Subconjunctival hemorrhage >> trauma , ASA, //

Tx : self limited, symp tx > HistoOph

9. Dry eye Fluorescein tear film break up time >10sec ; <10sec = dry eye
10. CN7 palsy > Lagophthalmos > exposure keratitis, corneal abrasion
11. Artificial tear = VISLUBE no preservative

12. Style = Cravit(FQ Levoflox) ED + Dicloxa(500)1x4 x5days