CHAPTER I

INTRODUCTION

1.1 Background
Sensory and Integumentum System is the 16th block on semester 5 of
Kurikulum Berbasis Kompetensi (KBK) system in Medical Faculty of
Muhammadiyah Palembang University. One of the strategy from these
curriculum is Problem Based Learning (PBL). Case tutorial is one of the
implementation of this PBL methode. In this section, Students are divided into
small groups and every groups will be guided by a mentor or a lecturer as a
facilitator who will guide the students to solve the case.
Tutorial process is a part of student’s evaluation exactly as a formative
evaluation. These evaluation helps the students to reach the aim of study.
Tutorial process is also requirment for students to join the block’s exam called
OSOCA (Objective Structure Oral Case Analysis) which is included in
summative evaluation. The aim of summative evaluation is assesing the
student’s achievement in order to determine the competencies that have been
achieved. Summative assessment is done by referring to the learning taxonomy
proposed by Bloom that consist of cognitive, psychomotor, and affective
assessment.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah Palembang University.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II
DISCUSSION

2.1 Tutorial’s Data

Tutor : dr.
Moderator :
Secretary :
Notulis :
Date and Time :
1. Tuesday, November 27th 2018
Time : 08.00 to 10.30 a.m
2. Thursday, November 29st 2018
Time : 08.00 to 10.30 a.m
Rules :
1. Everyone in the group should express their opinion
2. Gadget should be in silent mode.
3. Ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 Case Scenario

“My Eyes”
Mr. Santo, 22 years old, as a “Hojex” driver, came to “Puskemas” with
blurred vision in left eye since 2 days ago. Since 10 days ago, he complained
left eyes of redness, pain, and yellowish white thick discharge. He didn’t come
to doctor and only used eyes drop from market. He used minus glasses since 7
years ago. His friend complain about the same symptom.
Physical Examination
General Examination: Compos mentis
Vital sign: Blood Pressure: 120/80 mmHg, Pulse Rate: 92x/minute, Respiratory
Rate: 18x/minute, Temperature: 36,7oC.

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 Spesific Examination
Eyes:
OS: VOS 4/60, pinhole insignificantly improve vision, mixed injection,
yellowish white thick discharge, blepharospasm, infiltrate punctate form.
OD: VOD 6/60, with correction: Spheris-2.00 become 6/6.

2.3 Clarification of Terms

Table 1. Clarification of Terms

No Terms Clarifications
Yellowish white thick Excretion from caruncula lacrimale that
1.
discharge contained bacterial & mucous.
Sudden contraction involunter muscle of
2. Blepharospasm
eyelid.
The lost of sharpness of eye sight making
3. Blurred vision
object appear out of focus and hazy.
Excessive of blood in an eye that doe to
4. Redness
local of general relaxtation of arteriole.
An effort from someone to improve
5. Pinhole in signification
sharpness of eyesight shringking.
Combination of two injections ciliary and
6. Mixed injection
conjunctiva injection.
Infiltrating substante or a number of
7. Infiltrate
infiltration cell in punctate lacrimale.
Lens range in frame as aid to vision
- Ciliary: Vasodilataton of ciliary of
9. Minus glasses artery
- Conjunctiva: Vasodilataton of ciliary
posterior conjunctiva artery.

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2.4 Identification of Problems
1. Mr.
2. He
3. Specific Examination
Eyes:
OS: VOS 4/60, pinhole insignificantly improve vision, mixed injection,
yellowish white thick discharge, blepharospasm, infiltrate punctate form.
OD: VOD 6/60, with correction: Spheris-2.00 become 6/6.

2.5 Analysis dan Synthesis of Problem

1. Mr..
a. What are organs involve in this case?
Answer:
The organ involve in this case is Eyes.

b. How is the anatomy, physiology, and histology that involved in this

case ?
Answer:
Anatomy
- Palpebra
Palpebra is in front of eyes, protect eyes from injury or trauma
and excessive light. Palpebra superior is bigger and easier to move
than palpebra inferior. Both of palpebra meet each other in medial
angle and lateral. Fissura palpebra is a hole that has elips shape
between palpebra superior and inferior, it is a place to entry saccus
conjunctivae. If eyes is closed, palpebra superior will close cornea
perfectly. If eyes is open and staring straight ahead , palpebra
superior just close upper edge of cornea. Palpebra inferior is in the
right below of cornea if eyes is open and will up just a bit if eyes is
closed (Snell, 2011: 614).

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 In superficial surface of palpebra is cover by skin and inner
surface is contains of membrana mucosa that called conjuntivae.
cilia, short and curved is in freely edge of palpebra that composed
by two or three lines at the limit of mucocutaneus. There is sebacea
gland, ciliaris gland and also tarsalis gland (Snell, 2011: 614).

Figure 1.1 Anatomy of Palpebra

Source: Sobotta, 2006: 352

Lateral angle fissura of palpebra is more shar than medial and the
location is connected with eyeball. Medial angle is globular and
separated by narrow cavity that called lacus lacrimalis. In the middle
of this cavity there is a small bulge that has reddish yellow that called
plica seminularis is in lateral caruncula (Snell, 2011: 614).
Near medial angle of eyes, cilia and tarsalis gland suddenly
stopped and there is a small bulge that called papilla lacrimalis. Apex
of papilla there is a small hole, punctum lacrimale, that connected
with canaliculus lacrimalis. Papilla lacrimalis sticking into lacus,
punctum and canaliculus will wetting tears into nose (Snell, 2011:
614).

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 Figure 1.2 Palpebra and conjunctiva
Source: Sobotta, 2006: 352

- Conjunctiva
The conjunctiva is a thin, transparent mucous membrane
overlying the anterior-most portion of the sclera and lining the inner
surfaces of the eyelids. The conjunctiva is divided into the limbal,
bulbar, forniceal, and palpebral regions. Associated with the
conjunctiva are goblet cells, which produce mucus and eccrine
glands: the conjunctival glands (of Krause) and the accessory
lacrimal glands (of Wolfring). The conjunctival glands (of Krause)
are concentrated in the upper fornix, whereas the accessory lacrimal
glands (of Wolfring) are associated with the tarsus (Snell, 2011:
614).
Conjuntiva is thin membrana mucosa that covered palpebra.
Conjuntiva consists of :
- Tunica conjuntiva bulbi
- Tunica conjuntiva palpebrum
- Plica semilunaris
- Fornix conjuntivae
- Lacrimal Gland and the Nasolacrimal System
The lacrimal gland is nestled within the fossa of the frontal bone
located in the anterior superotemporal quadrant of the orbit. The
gland is divided into the orbital lobe and the palpebral lobe by the
tendon of the levator palpebrae superioris. Ducts from both lobes
traverse through the palpebral lobe and empty into the conjunctival

6
fornix temporally. Lacrimal fluid is collected by 2 lacrimal
canaliculi, which drain into the lacrimal sac at the medial canthus of
the eye. These tears then drain into the inferior nasal meatus via the
nasolacrimal duct (Snell, 2011: 614).

Figure 1.3 Lacrimal Apparatus

Source: Sobotta, 2006: 357

Lacrimal gland consists of big pars orbitalis and small pars

palpebralis. Both of that connected each other of the end lateral
aponeurosis M. Levator palpebrae superior. This gland is above
eyeball, anterior and superior orbita, posterior of septum orbitale. It
is about 12 duct out from botton surface of gland and will boils down
lateral fornix superior conjuntiva. Tears will flow and wetting cornea
and will gather in lacus lacrimalis. From here, tears will enter to
canaliculi lacrimales by puncta lacrimalia. Canaliculi lacrimalis
walk to medial and boils down into saccus lacrimalis is in lacrimalis
path behind ligamentum palpebra medial and it is the block upper
edge from nasolacrimalis duct (Snell, 2011: 614).
Lacrimalis duct has lenght is about 1,3 cm and out from the botton
edge saccus lacrimalis. Duct will walk to botton, behind and lateral

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 in canalis osseosa and will boils down to meatus nasi inferior. This
estuary will protect membrana mucosa layer that called plica
lacrimalis. This layer prevent the air enter by duct to saccus
lacrimalis at the time of snot (Snell, 2011: 614).

Anatomy of Eyeball
The adult eyeball measures about 2.5 cm in diameter of its total area,
and only the anterior one-sixth is exposed; the remainder is recessed
and protected by the orbit, into which it fits. Anatomically, the wall of
the eyeball consists of three layers: fibrous tunic, vascular tunic, and
retina (Tortora&Derrickson, 2007: 582-3).
- Fibrous Tunic
The fibrous tunic is the superficial coat of the eyeball and consists
of the anterior cornea and the posterior sclera. The cornea is a
transparent coat that covers the colored iris. Because it is curved, the
cornea helps focus light onto the retina. Its outer surface consists of
nonkeratinized stratified squamous epithelium. The middle coat of
the cornea consists of collagen fibers and fibroblasts, and the inner
surface is simple squamous epithelium. Since the central part of the
cornea receives oxygen from the outside air, contact lenses that worn
for long periods of time must be permeable to permit oxygen to pass
through them. The sclera, the “white” of the eye, is a layer of dense
connective tissue made up mostly collagen fibers and fibroblasts.
The sclera covers the entire eyeball except the cornea; it gives shape
to the eyeball, makes it more rigid, and protecrs its inner parts. At
the junction of the sclera and cornea is an opening known as the
scleral venosus sinus (canal of Schlemm). A fluid called aqueous
humor drains into the sinus (Tortora&Derrickson, 2007: 583).

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 Figure 1.4 Structure of the Eyeball
Source: Sobotta, 2006: 362

- Vascular Tunic
The vascular tunic or uvea is the middle layer of the eyeball. It is
composed of three parts: choroid, ciliary body, and iris. The highly
vascularized choroid, which is the posterior portion of the vascular
tunic, lines most of the internal surface of the sclera. Its numerous
blood vessels provide nutrients to the posterior surface of the retina.
The choroid also contains melanocytes that produce the pigment
melanin, which cause this layer to appear dark brown in color.
Melanin in the choroid absorbs stray light rays, which prevents
reflection and scattering of light within the eyeball. As a result, the
image cast on the retina by the cornea and lens remains sharp and
clear (Tortora&Derrickson, 2007: 583).
In the anterior portion of the vascular tunic, the choroid becomes
the ciliary body. It extends from the ora serrata, the jagged anterior

9
margin of the retina, to a point just posterior to the junction of the
sclera and cornea. Like the choroid, the ciliary body appears dark
brown in color because it contains melanin-producing melanocytes.
In addition, the ciliary body consist of ciliary processes and ciliary
muscle. The ciliary processes are protrusions or folds on the internal
surface of the ciliary body. They contain blood capillaries that
secrete aqueous humor. Extending from the ciliary process are
zonular fibers (suspensory ligaments) that attach to the lens. The
ciliary muscle is acircular band of smooth muscle. Contraction or
relaxation of the ciliary muscle changes the tightness of the zonular
fiber, which alters the shape of the lens, adapting it for near or far
vision (Tortora&Derrickson, 2007: 583).

Figure 1.5 Iris

Source: Sobotta, 2006: 364
The iris, the colored portion of the eyeball, is shaped like a
flattened donut. It is suspended between the cornea and the lens and
is attached at its outer margin to the ciliary processes. It consists of
melanocytes and circular and radial smooth muscle fibers. The
amount of melanin in the iris determines the eye color
(Tortora&Derrickson, 2007: 583).

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 A principal function of the iris is to regulate the amount of light
entering the eyeball through the pupil, the hole in the center of the
iris. The pupil appears black because, as you look through the lens,
you see heavily pigmented back of the eye (choroid and retina).
However, if bright light is directed into the pupil, the reflected light
is red because of the blood vessles on the surface of the retina. It is
for the reason that person’s eyes appear red in photograph (“red
eye”) when a bright light is directed to the pupil. Autonomic reflexes
regulate pupil diameter in response to light levels. When bright light
stimulates the eye, parasympathetic fibers the occulomotor (III)
nerve stimulate the circular muscles (sphincter pupillae) of the iris
to contract, causing a decrease in the size of the pupil (constriction).
In dim light, sympathetic neurons stimulate the radial muscles
(dilator pupillae) of the iris to contract, causing an increase in the
pupil’s size (dilatation) (Tortora&Derrickson, 2007: 583).
- Retina
The third and inner coat of eyeball, the retina, lines the posterior
three-quarters of the eyeball and is the beginning of the visual
pathway. The optic disc is the site where the optic (II) nerve exits the
eyeball. Bundled together with the optic nerve are the central retinal
artery, a branch of opthalmic artery, and the central retinal vein.
Branches of the central retinal artery fan out to nourish the anterior
surface of the retina; the central retinal vein drains blood from the
retina through the optic disc. Also visible are the macula lutea and
central fovea (Tortora&Derrickson, 2007: 583-4).
The retina consists of a pigmented layer and a neural layer. The
pigmented layer is a sheet of melanin-containing epithelial cells
located between the choroid and the neural part of the retina. The
melanin in the pigmented layer of the retina, like in the choroid, also
helps to absord stray light rays. The neural layer of the retina is
multilayered outgrowth of the brain that processes visual data

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extensively before sending nerve impulses into axons that form the
optic nerve (Tortora&Derrickson, 2007: 855).

Figure 1.6 Optic Nerve

Source: Sobotta, 2006: 368

Three distinct layers of retinal neurons: the photoreceptor layer,

the bipolar cell layer, and the ganglion cell layer, are separated by
two zones, the outer and inner synaptic layers, where synamptic
contacts are made. Note that light passes through the ganglion and
bipolar cell layer and both synaptic layers before it reaches the
photoreceptor layer. Two other types of cell present in the bipolar
cell layer of the retina are called horizontal cells and amacrine cells.
These cells from laterally directed neural circuits that modify the
signals being transmitted along the pathway from photoreceptor to
bipolar cells to ganglion cells (Tortora&Derrickson, 2007: 855).
The macula lutea is in the exact center of the posterior portion of
the retina, at the visual axis of the eye. The central fovea, a small
depression in the center of macula lutea, contains only cones cells.
In addition, the layers of bipolar and ganglion cells, which scatter

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 light to some extent, do not cover the cones here; these layers are
displaced to the periphery of the central fovea. As a result, the central
fovea is the area of highest visual acuity or resolution
(Tortora&Derrickson, 2007: 855).
- Lens
Behind the pupil and iris, within the cavity of the eyeball, is the
lens. Proteins calles crystallins, arranged like the layers of an onion,
make up the lens, which normally is perfectly transparent and lacks
blood vessles. It is enclosed by a clear connective tissue capsule and
held in position by encircling zonular fibers, which attach to the
ciliary processes. The lens helps focus images on the retina to
facilitate clear vision (Tortora&Derrickson, 2007: 855).

Figure 1.7 Lens

Source: Sobotta, 2006: 366
Interior of the Eyeball
The lens divides the interior of the eyeball into two cavities: the
anterior cavity and vitreous humor. The anterior cavity, the space
anterior to the lens, consists of two chambers. The anterior chamber lies
between the cornea and the iris. The posterior chamber lies behind the
iris and in front of the zonular fibers and lens. Both chamber of the

13
anterior cavity are filled with aqueous humor, a watery fluid that
nourishes the lens and cornea. Aqueous humor continually filters out of
blood capillaries in the ciliary processes and enters the posterior
chamber. It then flows forward between the iris and the lens, through
the pupil, and into the anterior chamber. From the anterior chamber,
aqueous humor drains into the scleral venosus sinus (Canal of
Schlemm) and then into the blood. Normally, aqueous humor is
completely replaced every 90 minutes (Tortora&Derrickson, 2007:
855-6).
The second, and larger, cavity of the eyeball is the vitreous chamber,
which lies between the lens and the retina. Within the vitreous chamber
is the vitreous body, a jellylike substance that holds the retina flush
against the choroid, giving the retina an even surface for the reception
of clear images. It is formed during embryonic life and consists of
mostly water plus collagen fibers and hyalaronic acid. The vitreous
body also contains phagocytic cells that remove debris, keeping this
part of the eye clear for unobstructed vision (Tortora&Derrickson,
2007: 856).

Vascular Supply and Drainage of Eyes

The arterial input to the eye is provided by several branches from the
ophthalmic artery, which is derived from the internal carotid artery.
These branches include the central retinal artery, the short and long
posterior ciliary arteries, and the anterior ciliary arteries. Venous
outflow from the eye is primarily via the vortex veins and the central
retinal vein, which merge with the superior and inferior ophthalmic
veins that drain into the cavernous sinus, the pterygoid venous plexus
and the facial vein. In some species (e.g., rodents and lagomorphs), the
orbital veins form a sinus (Kiel, 2011).
The iris and ciliary body are supplied by the anterior ciliary arteries,
the long posterior ciliary arteries and anatosmotic connections from the

14
anterior choroid. The anterior ciliary arteries travel with the extraocular
muscles and pierce the sclera near the limbus to join the major arterial
circle of the iris. The long posterior ciliary arteries (usually two) pierce
the sclera near the posterior pole, then travel anteriorly between the
sclera and choroid to also join the major arterial circle of the iris. The
major arterial circle of the iris gives off branches to the iris and ciliary
body. Most of the venous drainage from the anterior segment is directed
posteriorly into the choroid and thence into the vortex veins (Kiel,
2011).

Figure 1.8 Opthalmic Artery

Source: Sobotta, 2006: 376

The arterial supply of the conjunctiva arteries from the two

palpebras arches in eash eyelid and from anterior cilliary arteries. The
palpebral arches are the large marginal and smaller peripheral, running
respectively along the marginal and peripheral borders of the tarsal
plates. The large marginal arch run 3mm from the free border of the
eyeid between tarsal plate and the orbicularis is oculi muscle branches
pass from one arch to the other in front and behind the tarsal plates. It
is the arteries on the posterior surface of the tarsal plat that supply the
palpebral cinjunctiva (Snell, 2011).

15
 Branches from the peripheral arch supply the supperiois and inferior
conjunctival fornics. Many then run under; the bulbar conjunctiva,
forming the posterior conjunctival arteries, to supply the bulbar
conjunctiva; these arteries, the proceed toward the cornea. At the limbus
they anatomose with the anterior conjunctival arteries, which are
branches of the anterior cilliary arteries. The anterior cilliary arteries
arise from th emuscular branches of the ophtalmis artery to the rectus
muscles. Some person have no peripheral arterial arch to the lower lid.
In these subjects the margial arch supplies the conjunctiva along with
the anterior cilliary arteries (Snell, 2011).

Figure 1.9 Opthalmic Vein

Source: Sobotta, 2006: 376

The conjunctival veins are more numerous that the arteries. They
accompany the arteries and drain into the palperbral veins or directly
into the superior and inferior ophtalmic nerve. The retina is supplied by
the central retinal artery and the short posterior ciliary arteries. The
central retinal artery travels in or beside the optic nerve as it pierces the
sclera then branches to supply the layers of the inner retina (i.e., the
layers closest to the vitreous compartment). There are marked species
differences in the inner retinal vascularization, with primates having a
complex 4-zone arrangement and an avascular zone at the fovea,

16
lagomorphs having a rather simple narrow band of superficial vessels,
rodents having a wagon-wheel spoke-like arrangement and guinea pigs
having no inner retinal vessels. Retinal venules and veins coalesce into
the central retinal vein, which exits the eye with the optic nerve parallel
and counter-current to the central retinal artery (Snell, 2011).
The short posterior ciliary arteries (typically 6-12) pierce the sclera
around the optic nerve then arborize to form the arterioles of the dense
outer layer of conduit vessels of the choroid. The arterioles the give off
roughly perpendicular terminal arterioles that supply lobules of
choriocapillaries that comprise the sheet-like layer of the
choriocapillaris adjacent to Bruch’s membrane, the retinal pigment and
the outer segments of the photoreceptors (Kiel, 2011).
The vascular supply of the optic nerve is complex. The optic nerve
has three zones referenced to the lamina cribosa, the connective tissue
extension of the sclera through which the optic nerve axons and the
central retinal artery and vein pass. The prelaminar (i.e., inside the eye
relative to the lamina cribosa) optic nerve is supplied by collaterals from
the choroid and retina circulations. The laminar zone is supplied by
branches from the short posterior ciliary and pial arteries. The post
laminar zone is supplied by the pial arteries. Venous drainage is via the
central retinal vein and pial veins. For the optic nerve vessels, the
laminar zone marks the transition from exposure to the IOP to the
cerebral fluid pressure within the optic nerve sheath (Kiel, 2011).

Histology
Fibrous Layer
This layer includes two major regions, the posterior sclera and
anterior cornea, joined at the limbus (Mescher, 2013).
- Sclera

17
 The fibrous, external layer of the eyeball protects the more
delicate internal structures and provides sites for muscle insertion.
The white posterior five-sixths of this layer is the sclera, which
encloses a portion of the eyeball about 22 mm in diameter in adults.
The sclera averages 0.5 mm in thickness and consists mainly of
dense connective tissue, with flat bundles of type I collagen parallel
to the organ surface but intersecting in various directions;
microvasculature is present near the outer surface. Tendons of the
extraocular muscles which move the eyes insert into the anterior
region of the sclera. Posteriorly the sclera thickens to approximately
1 mm and joins with the epineurium covering the optic nerve. Where
it surrounds the choroid, the sclera includes an inner suprachoroid
lamina, with less collagen, more fibroblasts, elastic fibers, and
melanocytes (Mescher, 2013).
- Cornea
In contrast to the sclera, the anterior one-sixth of the eye—the
cornea—is transparent and completely avascular. A section of the
cornea shows five distinct layers according to Mescher (2013):
- An external stratified squamous epithelium;
- An anterior limiting membrane (Bowman’s membrane),
which is the basement membrane of the external stratified
epithelium;
- The thick stroma;
- A posterior limiting membrane (Descemet’s membrane),
which is the basement membrane of the endothelium; and
- An inner simple squamous endothelium.
The stratified surface epithelium is nonkeratinized, five or six cell
layers thick, and comprises about 10% of the corneal thickness. The
basal cells have a high proliferative capacity important for renewal
and repair of the corneal surface and emerge from stem cells in the
corneoscleral limbus that encircles the cornea. The flattened surface

18
cells have microvilli protruding into a protective tear film of lipid,
glycoprotein, and water. As another protective adaptation, the
corneal epithelium also has one of the richest sensory nerve supplies
of any tissue. The basement membrane of this epithelium, often
called Bowman’s membrane, is very thick (8-10 μm) and contributes
to the stability and strength of the cornea, helping to protect against
infection of the underlying stroma (Mescher, 2013).

Figure 1.10. Histology of Cornea

Source: Mescher, 2013

The stroma, or substantia propria, makes up 90% of the cornea’s

thickness and consists of approximately 60 layers of parallel
collagen bundles aligned at approximately right angles to each other
and extending almost the full diameter of the cornea. The uniform
orthogonal array of collagen fibrils contributes to the transparency

19
 of this avascular tissue. Between the collagen lamellae are
cytoplasmic extensions of flattened fibroblast-like cells called
keratocytes). The ground substance around these cells contains
proteoglycans such as lumican, with keratan sulfate and chondroitin
sulfate, which help maintain the precise organization and spacing of
the collagen fibrils (Mescher, 2013).
The posterior surface of the stroma is bounded by another thick
basement membrane, called Descemet’s membrane, which supports
the internal simple squamous corneal endothelium. This
endothelium maintains Descemet’s membrane and includes the most
metabolically active cells of the cornea. Na+/K+ ATPase pumps in
the basolateral membranes of these cells are largely responsible for
regulating the proper hydration state of the corneal stroma to provide
maximal transparency and optimal light refraction (Mescher, 2013).
- Limbus
Encircling the cornea is the limbus, a transitional area where the
transparent cornea merges with the opaque sclera. Here Bowman’s
membrane ends and the surface epithelium becomes more stratified
as the conjunctiva that covers the anterior part of the sclera (and lines
the eyelids). As mentioned previously, epithelial stem cells located
at the limbus surface give rise to rapidly dividing progenitor cells
that move centripetally into the corneal epithelium. The stroma
becomes vascular and less well-organized at the limbus, as the
collagen bundles merge with those of the sclera (Mescher, 2013).
Also at the limbus Descemet’s membrane and its simple
endothelium are replaced with a system of irregular endothelium-
lined channels called the trabecular meshwork. These penetrate the
stroma at the corneoscleral junction and allow slow, continuous
drainage of aqueous humor from the anterior chamber. This fluid
moves from these channels into the adjacent larger space of the
scleral venous sinus, or canal of Schlemm, which encircles the eye.

20
 From this sinus aqueous humor drains into small blood vessels
(veins) of the sclera (Mescher, 2013).

Vascular Layer
The eye’s more vascular middle layer, known as the uvea, consists
of three parts, from posterior to anterior: the choroid, the ciliary body,
and the iris (Mescher, 2013).
- Choroid
Located in the posterior two-thirds of the eye, the choroid consists
of loose, well vascularized connective tissue and contains numerous
melanocytes. These form a characteristic black layer in the choroid
and prevent light from entering the eye except through the pupil.
Two layers make up the choroid according to Mescher (2013):
- The inner choroido-capillary lamina has a rich microvasculature
important for nutrition of the outer retinal layers.
- Bruch’s membrane, a thin extracellular sheet, is composed of
collagen and elastic fibers surrounding the adjacent
microvasculature and basal lamina of the retina’s pigmented
layer.
- Ciliary Body
The ciliary body, the anterior expansion of the uvea that encircles
the lens, lies posterior to the limbus. Like the choroid, most of the
ciliary body rests on the sclera. Important structures associated with
the ciliary body include the following according to Mescher (2013):
- Ciliary muscle makes up most of the ciliary body’s stroma and
consists of three groups of smooth muscle fibers. Contraction of
these muscles affects the shape of the lens and is important in
visual accommodation (see Lens).
- Ciliary processes are a radially arranged series of about 75 ridges
extending from the inner highly vascular region of the ciliary
body. These provide a large surface area covered by a double

21
 layer of low columnar epithelial cells, the ciliary epithelium. The
epithelial cells directly covering the stroma contain much melanin
and correspond to the anterior projection of the pigmented retina
epithelium. The surface layer of cells lacks melanin and is
contiguous with the sensory layer of the retina.
Cells of this dual epithelium have extensive basolateral folds
with Na+/K+-ATPase activity and are specialized for secretion of
aqueous humor. Fluid from the stromal microvasculature moves
across this epithelium as aqueous humor, with an inorganic ion
composition similar to that of plasma but almost no protein.
Aqueous humor is secreted by ciliary processes into the posterior
chamber, flows through the pupil into the anterior chamber, and
drains at the angle formed by the cornea and the iris into the
channels of the trabecular meshwork and the scleral venous sinus,
from which it enters venules of the sclera.
- The ciliary zonule is a system of many radially oriented fibers
composed largely of fibrillin-1 and 2 produced by the
nonpigmented epithelial cells on the ciliary processes. The fibers
extend from grooves between the ciliary processes and attach to
the surface of the lens, holding that structure in place.
- Iris
The iris is the most anterior extension of the middle uveal layer
which covers part of the lens, leaving a round central pupil. The
anterior surface of the iris, exposed to aqueous humor in the anterior
chamber, consists of a dense layer of fibroblasts and melanocytes
with interdigitating processes and is unusual for its lack of an
epithelial covering (Mescher, 2013).
Deeper in the iris, the stroma consists of loose connective tissue
with melanocytes and sparse microvasculature. The posterior surface
of the iris has a two-layered epithelium continuous with that
covering the ciliary processes, but very heavily filled with melanin.

22
The highly pigmented posterior epithelium of the iris blocks all light
from entering the eye except that passing through the pupil.
Myoepithelial cells form a partially pigmented epithelial layer and
extend contractile processes radially as the very thin dilator pupillae
muscle. Smooth muscle fibers form a circular bundle near the pupil
as the sphincter pupillae muscle. The dilator and sphincter muscles
of the iris have sympathetic and parasympathetic innervation,
respectively, for enlarging and constricting the pupil (Mescher,
2013).

Figure 1.11 Aqueous Humor

Source: Mescher, 2013
Melanocytes of the iris stroma provide the color of one’s eyes. In
individuals with very few lightly pigmented cells in the stroma, light
with a blue color is reflected back from the black pigmented
epithelium on the posterior iris surface. As the number of
melanocytes and density of melanin increase in the stroma, the iris
color changes through various shades of green, gray, and brown.
Individuals with albinism have almost no pigment and the pink color

23
 of their irises is due to the reflection of incident light from the blood
vessels of the stroma (Mescher, 2013).

Lens
The lens is a transparent biconvex structure suspended immediately
behind the iris, which focuses light on the retina. Derived from an
invagination of the embryonic surface ectoderm, the lens is a unique
avascular tissue and is highly elastic, a property that normally decreases
with age. The lens has three principal components according to Mescher
(2013):
- A thick (10-20 μm), homogeneous lens capsule composed of
proteoglycans and type IV collagen surrounds the lens and provides
the place of attachment for the fibers of the ciliary zonule. This layer
originates as the basement membrane of the embryonic lens vesicle.
- A subcapsular lens epithelium consists of a single layer of cuboidal
cells present only on the anterior surface of the lens. The epithelial
cells attach basally to the surrounding lens capsule and their apical
surfaces bind to the internal lens fibers. At the posterior edge of this
epithelium, near the equator of the lens, the epithelial cells divide to
provide new cells that differentiate as lens fibers. This process
allows for growth of the lens and continues at a slow, decreasing rate
near the equator of the lens throughout adult life.
- Lens fibers are highly elongated, terminally differentiated cells that
appear as thin, flattened structures. Developing from cells in the lens
epithelium, lens fibers typically become 7 to 10 mm long, with cross-
section dimensions of only 2 by 8 μm. The cytoplasm becomes filled
with a group of proteins called crystallins, and the organelles and
nuclei undergo autophagy. Lens fibers are packed tightly together
and form a perfectly transparent tissue highly specialized for light
refraction.

24
 The lens is held in place by fibers of the ciliary zonule, which extend
from the lens capsule to the ciliary body. Together with the ciliary
muscles, this structure allows the process of visual accommodation,
which permits focusing on near and far objects by changing the
curvature of the lens. When the eye is at rest or gazing at distant objects,
ciliary muscles relax and the resulting shape of the ciliary body puts
tension on the zonule fibers, which pulls the lens into a flatter shape. To
focus on a close object the ciliary muscles contract, causing forward
displacement of the ciliary body, which relieves some of the tension on
the zonule and allows the lens to return to a more rounded shape and
keep the object in focus. In the fourth decade of life presbyopia (Gr.
presbyter, elder + L. opticus, relating to eyes) normally causes the
lenses to lose elasticity and their ability to undergo accommodation
(Mescher, 2013).

Vitreous Body
The vitreous body occupies the large vitreous chamber behind the
lens. It consists of transparent, gel-like connective tissue that is 99%
water (vitreous humor), with collagen fibrils and hyaluronate, contained
within an external lamina called the vitreous membrane. The only cells
in the vitreous body are a small mesenchymal population near the
membrane called hyalocytes, which synthesize the hyaluronate and
collagen, and a few macrophages (Mescher, 2013).

Retina
The retina, the innermost tunic of the eye, develops with two
fundamental sublayers from the inner and outer layers of embryonic
optic cup according to Mescher (2013):
- The outer pigmented layer is a simple cuboidal epithelium attached
to Bruch’s membrane and the choroidocapillary lamina of the

25
 choroid. This heavily pigmented layer forms the other part of the
dual epithelium covering the ciliary body and posterior iris.
- The inner retinal region, the neural layer, is thick and stratified with
various neurons and photoreceptors. Although its neural structure
and visual function extend anterior only as far as the ora serrata,
this layer continues as part of the dual cuboidal epithelium that
covers the surface of the ciliary body and posterior iris.

- Retina Pigmented Epithelium

The pigmented epithelial layer consists of cuboidal or low
columnar cells with basal nuclei and surrounds the neural layer of
the retina. The cells have well-developed junctional complexes, gap
junctions, and numerous invaginations of the basal membranes
associated with mitochondria. The apical ends of the cells extend
processes and sheath-like projections that surround the tips of the
photoreceptors. Melanin granules are numerous in these extensions
and in the apical cytoplasm. This cellular region also contains
numerous phagocytic vacuoles and secondary lysosomes,
peroxisomes, and abundant smooth ER (SER) specialized for retinal
(vitamin A) isomerization. The diverse functions of the retinal
pigmented epithelium include the following according to Mescher
(2013):
- The pigmented layer absorbs scattered light that passes through
the neural layer, supplementing the choroid in this regard.
- With many tight junctions, cells of the pigmented epithelium
form an important part of the protective blood-retina barrier
isolating retina photoreceptors from the highly vascular choroid
and regulating ion transport between these compartments.
- The cells play key roles in the visual cycle of retinal
regeneration, having enzyme systems that isomerize all-trans-

26
 retinal released from photoreceptors and produce 11-cis-retinal
that is then transferred back to the photoreceptors.
- Phagocytosis of shed components from the adjacent
photoreceptors and degradation of this material occurs in these
epithelial cells.
- Cells of pigmented epithelium remove free radicals by various
protective antioxidant activities and support the neural retina
by secretion of ATP, various polypeptide growth factors, and
immunomodulatory factors.

Figure 1.12 Retina

Source: Mescher, 2013
- Neural Retina
True to its embryonic origin, the neural retina functions as an
outpost of the CNS with glia and several interconnected neuronal
subtypes in well-organized strata. Nine distinct layers comprise the
neural retina, described here with their functional significance
(Mescher, 2013).

27
 Three major layers contain the nuclei of the interconnected
neurons:
- Near the pigmented epithelium, the outer nuclear layer (ONL)
contains cell bodies of photoreceptors (the rod and cone cells).
- The inner nuclear layer (INL) contains the nuclei of various
neurons, notably the bipolar cells, amacrine cells, and horizontal
cells, all of which make specific connections with other neurons
and integrate signals from rods and cones over a wide area of the
retina.
- Near the vitreous, the ganglionic layer (GL) has neurons
(ganglion cells) with much longer axons.
These axons make up the nerve fiber layer (NFL) and converge
to form the optic nerve which leaves the eye and passes to the brain.
The GL is thickest near the central, macular region of the retina but
it thins peripherally to only one layer of cells. Between the three
layers with cell nuclei are two fibrous or “plexiform” regions
containing only axons and dendrites connected by synapses:
- The outer plexiform layer (OPL) includes axons of the
photoreceptors and dendrites of association neurons in the INL.
- The inner plexiform layer (IPL) consists of axons and dendrites
connecting neurons of the INL with the ganglion cell.
The rod and cone cells, named for the shape of their outer
segments, are polarized neurons with their photosensitive portions
aligned in the retina’s rod and cone layer (RCL) and their axons in
the IPL. As shown schematically, both rod and cone cells have
highly specialized outer and inner segments. All neurons of the
retina are supported physically by glial cells called Müller cells.
With their nuclei in the INL, Müller cells extend fine processes and
branching lamellae that serve as a scaffold for the neurons and their
fibers. Müller cells also organize two boundaries that appear as very
thin layers within the retina according to Mescher (2013):

28
 - The outer limiting layer (OLL) is a faint but well-defined series
of tight and adherent junctions that form at the level of the rod
and cone inner segments between the photoreceptors and Müller
cell processes. The OLL forms one side of the compartment that
encloses the rods and cones.
- The inner limiting layer (ILL) consists of terminal expansions
of other Müller cell processes that cover the collagenous
membrane of the vitreous body.

Figure 1.13 Layers of Retina

Source: Mescher, 2013
Rod Cells
The human retina has on average 92 million rod cells. They are
extremely sensitive to light, responding to a single photon, and allow
some vision even with light low levels, such as at dusk or nighttime.
Rod cells are thin, elongated cells (50 μm X 3 μm), composed of two
functionally distinct segments. The outer segment is a modified primary

29
cilium, photosensitive and shaped like a short rod; the inner segment
contains glycogen, mitochondria, and polyribosomes for the cell’s
biosynthetic activity (Mescher, 2013).
The rod-shaped segment consists mainly of 600 to 1000 flattened
membranous discs stacked like coins and surrounded by the plasma
membrane. Proteins on the cytoplasmic surface of each disc include
abundant rhodopsin (or visual purple) which is bleached by light and
initiates the visual stimulus. Between this outer segment and the cell’s
inner segment is a constriction, the connecting stalk, which is part of
the modified primary cilium arising from a basal body (Mescher, 2013).
The membranous discs form by repetitive in-folding of the plasma
membrane near the connecting stalk and insertion of rhodopsin and
other proteins transported there from the inner segment. In rod cells the
newly assembled discs detach from the plasma membrane and are
displaced distally as new discs form. Eventually the discs arrive at the
end of the rod, where they are shed, phagocytosed, and digested by the
cells of the pigmented epithelium. Each day approximately 90
membranous discs are lost and replaced in each rod, with the process of
assembly, distal movement, and apical shedding taking about 10 days
(Mescher, 2013).

Cone Cells
Less numerous and less light-sensitive than rods, the average 4.6
million cone cells in the human retina produce color vision in
adequately bright light. There are three morphologically similar classes
of cones, each containing one type of the visual pigment iodopsin (or
photopsins). Each of the three iodopsins has maximal sensitivity to light
of a different wavelength, in the red, blue, or green regions of the visible
spectrum, respectively. By mixing neural input produced by these
visual pigments, cones produce a color image (Mescher, 2013).

30
 Like rods cone cells are elongated, with outer and inner segments, a
modified cilium connecting stalk, and an accumulation of mitochondria
and polyribosomes. The outer segments of cones differ from those of
rods in their shorter, more conical form and in the structure of their
stacked membranous discs, which in cones remain as continuous
invaginations of the plasma membrane along one side. Also, newly
synthesized iodopsins and other membrane proteins are distributed
uniformly throughout the cone outer segment and, although iodopsin
turns over, discs in cones are shed much less frequently than in rods
(Mescher, 2013).

Figure 1.14 Rod and Cone Cells

Source: Mescher, 2013
Accessory Structures of the Eye
- Conjunctiva
The conjunctiva is a thin, transparent mucosa that covers the
exposed, anterior portion of the sclera and continues as the lining on
the inner surface of the eyelids. It consists of a stratified columnar

31
 epithelium, with numerous small goblet cells, supported by a thin
lamina propria of loose vascular connective tissue. Mucous
secretions from conjunctiva cells are added to the tear film that coats
this epithelium and the cornea (Mescher, 2013).
- Eyelids
Eyelids are pliable structures containing skin, muscle, and
conjunctiva that protect the eyes. The skin is loose and elastic, lacks
fat, and has only very small hair follicles and fine hair, except at the
distal edge, where large follicles with eyelashes are present.
Associated with the follicles of eyelashes are sebaceous glands and
modified apocrine sweat glands. Beneath the skin are striated
fascicles of the orbicularis oculi and levator palpebrae muscles that
fold the eyelids. Adjacent to the conjunctiva is a dense fibroelastic
plate called the tarsus that supports the other tissues. The tarsus
surrounds a series of 20 to 25 large sebaceous glands, each with
many acini secreting into a long central duct that opens among the
eyelashes. Oils in the sebum produced by these tarsal glands, also
called Meibomian glands, form a surface layer on the tear film,
reducing its rate of evaporation, and help lubricate the ocular surface
(Mescher, 2013).
- Lacrimal Glands
The lacrimal glands produce fluid continuously for the tear film
that moistens and lubricates the cornea and conjunctiva and supplies
O2 to the corneal epithelial cells. Tear fluid also contains various
metabolites, electrolytes, and proteins of innate immunity such as
lysozyme. The main lacrimal glands are located in the upper
temporal portion of the orbit and have several lobes that drain
through individual excretory ducts into the superior fornix, the
conjunctiva-lined recess between the eyelids and the eye. The
lacrimal glands have acini composed of large serous cells filled with

32
 lightly stained secretory granules and surrounded by well-developed
myoepithelial cells and a sparse, vascular stroma (Mescher, 2013).
Tear film moves across the ocular surface and collects in other
parts of the bilateral lacrimal apparatus: flowing through two small
round openings (0.5 mm in diameter) to canaliculi at the medial
margins of the upper and lower eyelids, then passing into the
lacrimal sac, and finally draining into the nasal cavity via the
nasolacrimal duct. The canaliculi are lined by stratified squamous
epithelium, but the more distal sac and duct are lined by
pseudostratified ciliated epithelium like that of the nasal cavity
(Mescher, 2013).

Physiology
- Eyelashes and eyebrows
The eyelashes, which project from the border of each eyelid, and
the eyebrows, which arch transversely above the upper eyelids, help
protect the eyeballs from foreign objects, perspiration, and the direct
rays of the eyelashes, called sebaceous cilliary glands, release a
lubricating fluid into the follicles (Tortora&Derrickson, 2007).
- The Lacrimal Apparatus
The lacrimal apparatus is a group of structures that produces and
drains lacrimal fluid, or tears. The lacrimal glands, each about the
size and shape of an almond. Secrete lacrimal fluid which drains into
6-12 excretory lacrimal ducts that empty tears onto the surface of
conjunctiva of the upper lid. From here the tears pass medially over
the anterior surface of the eyeball to enter two small openings called
lacrimal puncta. Tears then pass into two ducts, the lacrimal canals,
which lead into the lacrimal sac and then into the nasolacrimal duct.
This duct carries the lacrimal fluid into the nasal cavity just inferior
to the inferior nasal concha. An infection of the lacrimal sacs is
called dacryoscystitis. It is usually caused by a bacterial infection

33
 and results in blockage of the nasolacrimal ducts. The lacrimal
glands are supplied by parasympathetic fibers of the facial (VII)
nerves. The lacrimal fluid produced by these glands is a watery
solution containing salts, some mucus, and lysozyme, a protective
bactericidal enzyme. The fluid protects, clens, lubricates, and
moistens the eyeball. After being secreted from the lacrimal gland,
lacrimal fluid is spread medially over the surface of the eyeball by
the blingking of the eyelids. Each gland produces about 1 mL of
lacrimal fluid per day (Tortora&Derrickson, 2007).
Normally, tears are cleared away as fast as they are produced,
either by evaporation or by passing into the lacrimal canals and then
into nasal cavity. If an iritating substance make contact with
conjunctiva, however, the lacrimal glands are stimulated to
oversecrete, and tears accumulate. Lacrimation is a protective
mechanism, as the tears dilute and wash away the irritating substance
(Tortora&Derrickson, 2007).
- Phototransduction
The stacked membranous discs of rod and cone outer segments
are parallel with the retinal surface, which maximizes their exposure
to light. The membranes are very densely packed with rhodopsin or
one of the iodopsin proteins; one rod contains about a billion
rhodopsin molecules. Each of these visual pigments contains a
transmembrane protein, the opsin, with a small, light-sensitive
chromophore molecule bound to it. The vitamin A derivative called
retinal acts as the chromophore of rhodopsin in rods (Mescher,
2013).
Phototransduction involves a cascade of changes in the cells
triggered when light hits and activates the chromophore, a basically
similar process in both rods and cones. As diagrammed for a rod, in
darkness rhodopsin is not active and cation channels in the cell
membrane are open. The cell is depolarized and continuously

34
releases neurotransmitter at the synapse with the bipolar neurons.
When retinal on rhodopsin absorbs a photon of light, it isomerizes
within one picosecond from 11-cis-retinal to all-trans--retinal. This
causes a configuration change in the opsin, which in turn activates
the adjacent membrane-associated protein transducin, a
heterotrimeric G protein to which opsin is coupled (Mescher, 2013).

Figure 1.15 Phototransduction

Source: Mescher, 2013

Transducin activity then indirectly closes cGMP-gated Na+

channels, causing hyperpolarization which reduces the synaptic
release of neurotransmitter. This change in turn depolarizes sets of
bipolar neurons, which send action potentials to the ganglion cells of
the optic nerve. causes the chromophore to dissociate from the opsin,

35
 a process called bleaching. The free all-trans-retinal is transported
from the rod into the adjacent pigmented epithelial cell where it is
converted back to 11-cis-retinal, then transported back into a
photoreceptor for reuse. This cycle of retinal regeneration and
rhodopsin recovery from bleaching may take a minute or more and
is part of the slow adaptation of the eyes that occurs when moving
from bright to dim light (Mescher, 2013).
- Specialized Areas of the Retina
The blind spot of the retina, or optic disc, lacks photoreceptors
and all conducting neurons. It occurs in the posterior area of the
retina where axons in the NFL converge to produce the optic nerve
which leaves the retina. The central artery and vein of the retina enter
at the optic disc (Mescher, 2013).
Near the optic disc, within the portion of retina directly opposite
the pupil, lies a specialized area about 1.5 mm in diameter called the
fovea centralis, where visual acuity or sharpness is maximal. The
fovea (L. fovea, a small pit) is a shallow depression with only cone
cells at its center; ganglion cells and other conducting neurons are
located only at its periphery. Cone cells in the fovea are long, narrow,
and closely packed. Blood vessels do not cross the fovea and light
falls directly on its cones. The locations and structural adaptations of
the fovea together account for the extremely precise visual acuity of
this region (Mescher, 2013).
Surrounding the fovea centralis is the macula lutea (L. macula,
spot; lutea, yellow), or simply macula, 5 mm in diameter. Here all
layers of the retina are present and the two plexiform layers are rich
in various carotenoids, which give this area its yellowish color. The
carotenoids have antioxidant properties and filter potentially
damaging short-wavelength light, thus helping to protect the cone
cells of the fovea (Mescher, 2013).

36
 Within the GL of the entire retina a subset of ganglion cells serve
as nonvisual photoreceptors. These neurons contain 11-cis-retinal
bound to the protein melanopsin and serve to detect changes in light
quantity and quality during each 24-hour dawn/dusk cycle. Signals
from these cells pass via axons of the retinohypothalamic tract to the
suprachiasmatic nuclei and the pineal gland, where they help
establish the body’s physiologic circadian rhythms (Mescher, 2013).

c. What are the possible diseases with blurry vision with redness,
pain, and yellowish white thick discharge?
Answer:
According to Alteveer (2012), the possible disease are:
1. Blurry vision with redness:
- Keratoconjunctivitis
- Keratitis
- Uveitis
- Endopthalmitis
- Acute Glaukoma
- Eye allergies, etc
2. Blurry vision with pain:
- Keratoconjunctivitis
- Optic neuritis
- Blepharitis
- Keratitis
- Eye allergies, etc
3. Blurry vision with yellowish white thick discharge :
- Keratokonjungtivitis
- Conjunctivitis
- Keratitis
- Blepharitis
- Eye allergies, etc

37
d. What is the relation between the age and gender and job with the
complain in this case?
Answer:
There is no corelation between age and gender. Everyone and every
age can suffer this complain. His job as hojex driver is risk factor. He
often exposed by dust and discharge.

e. How is the mechanism of blurred vision and whole symptom in this

case?
Answer:
The surface tissues of the eye and the ocular adnexa are colonized
by normal flora such as streptococci, staphylococci,
and corynebacteria. Alterations in the host defense, in the bacterial
titer, or in the species of bacteria can lead to clinical infection.
Alteration in the flora can also result from external contamination (eg,
contact lens wear, swimming, dust), the use of topical or systemic
antibiotics, or spread from adjacent infectious sites (eg, rubbing of the
eyes). In this case one of the risk factor from external contamination is
dust and polution from vehicle. The primary defense against infection
is the epithelial layer covering the conjunctiva. Disruption of this barrier
can lead to infection. Secondary defenses include hematologic immune
mechanisms carried by the conjunctival vasculature, tear film
immunoglobulins, and lysozyme and the rinsing action of lacrimation
and blinking (Yeung, 2017).
Due to the infection, there will be inflammation reaction.
Inflammation is a response of vascularized tissues to infections and
tissue damage that brings cells and molecules of host defense from the
circulation to the sites where they are needed, to eliminate the offending
agents. The external manifestations of inflammation, often called its
cardinal signs, are heat (calor in Latin), redness (rubor), swelling

38
(tumor), pain (dolor), and loss of function (functio laesa). After the
microbe is recognized by the machropage, machropage will release
some pro-inflammatory mediators such as TNF, IL-1, IL-2, IL-6,
histamine, and prostaglandin that lead to the process of dilatation of
small vessels, leading to increase in blood flow and emigration of the
leukocytes from the microcirculation (Abbas, et al., 2015: 60).
In this case, the artery that vasculate the conjunctiva that is posterior
conjunctiva artery become dilate and show as redness in the eye
(Abbas, et al., 2015: 60). In response to the tissue injury of the
conjunctiva, it wil activate the peripheral pain receptors and their
specific A delta and C sensory nerve fibers (nociceptors) through the
sensory nerve of opthalmica division from trigeminus nerve. Then the
pain fibers enter the spinal cord at the dorsal root ganglia and synapse
in the dorsal horn. From there, fibers cross to the other side and travel
up the lateral columns to the thalamus and then to the cerebral cortex,
and this process manifest as pain in the eye (Sherwood, 2014).
Emigration of the leukocytes from the microcirculation, their
accumulation in the focus of injury, and their activation to eliminate the
offending agent leading to the formation of discharge. In this case, the
formation of yellowish white thick discharge is caused by the
leukocytes which phagocytes the microbes (bacteria) (Abbas, et al.,
2015: 60).
During the infection, Mr.Santo didn’t get adequate treatment, leads
to another infection of the eye structure that is cornea. The infection
spread diffusely through the epithelial of conjuctiva bulbi to the
epithelial of cornea. So the interruption of an intact corneal epithelium
and/or abnormal tear film permits entrance of microorganisms into the
corneal epithelium to cause infection. Virulence factors may initiate
microbial invasion, or secondary effector molecules may assist the
infective process. The inflammation of the cornea makes the cornea
become cloudy and distrub the refraction function of the cornea. The

39
 cornea can not refract incoming light rays to focus them on the retina
and show as blurry vision (Deschenes, 2017).

f. What is the relation between Mr. Santo complained in 10 days ago

and 2 days ago?
Answer:
Ten days ago Mr. Santo complained his left eyes red, pain, and have
yellowish white thick discharge. Probably because of conjunctivitis due
to bacterial infection but because of inadecuate treatment, the bacterial
spread to deeper organ such as cornea and blurry vision since two days
ago is a sign of infection in cornea (Deschenes, 2017).

2. He didn’t come to doctor and only used eyes drop from market. He
used minus glasses since 7 years ago. His friend complain about the
same symptom.
a. What is the meaning of he didn’t come to doctor and only used eyes
drop from market?
Answer:
The meaning Mr. Santo didn’t come to doctor and only used eyes
drop prom masket is to tell us that Mr. Santo never get doctor treatment
before, and never get doctor treatment before can make bad progression
like Mr. Santo complain 2 days ago.

b. How is the pharmacology of eyes drop?

Answer:
Frequently used eye drops contain Tetrahydrozoline Hydrochloride.
Tetrahydrozoline is applied topically to the conjunctiva to temporarily
relieve congestion, itching, and minor irritation, and to control
hyperemia in patients with superficial corneal vascularity. Ocular
decongestants are ineffective in the treatment of delayed
hypersensitivity reactions such as contact dermatoconjunctivitis. The

40
 vasoconstrictor effect of tetrahydrozoline may be used during some
ocular diagnostic procedures (NCBI, 2017).
The mechanism of action of tetrahydrozoline has not been
conclusively determined. Most pharmacologists believe that the drug
directly stimulates a-adrenergic receptors of the sympathetic nervous
system and exerts little or no effect on beta-adrenergic receptors.
Following topical application of tetrahydrozoline to the conjunctiva,
small arterioles are constricted and conjunctival congestion is
temporarily relieved, but reactive hyperemia may occur. The drug also
may produce mydriasis when applied to the conjunctiva, but this effect
is usually minimal with the concentrations used as ocular
decongestants. Intranasal application of tetrahydrozoline results in
constriction of dilated arterioles and reduction in nasal blood flow and
congestion. In addition, obstructed eustachian ostia may be opened.
Nasal ventilation and aeration are improved temporarily (NCBI, 2017).
Following topical application of tetrahydrozoline hydrochloride
solutions to the conjunctiva or nasal mucous membranes, local
vasoconstriction usually occurs within a few minutes and may persist
for 4-8 hours. Occasionally, enough tetrahydrozoline may be absorbed
to produce systemic effects (NCBI, 2017).

c. What is the meaning of Mr. Santo used minus glasses since 7 years
ago?
Answer:
It means that Mr.Santo has a refractive disorder, which is myopia.
People with myopia will be corrected with spheris minus lens
(Ilyass,2013).
Synthesis:
Myopia known as nearsightedness. Myopia occurs when the eye
grows too long from front to back. Instead of focusing image on the
retina-the light-sensitive tissue in the back of the eye- the lens of the

41
 eye focuses in the image in front of the retina. Myopia also can be the
result of a cornea-the eye’s outermost layer- that is too curved for the
length of the eyeball or a lens that is to thick. The risk factor people
with myopia are genetics factor and enviroment factor. The genetic
factor is take the biggest role in the incident of myopia (Sherwood,
2013). Myopia occurs when the eyeball is too long, relative to the
focusing power of the cornea and lens of the eye This causes light rays
to focus at a point in front of the retina, rather than directly on its
surface. Nearsightedness also can be caused by the cornea and/or lens
being too curved for the length of the eyeball. In some cases, myopia is
due to a combination of these factors (Sanjay, 2015).

d. What is the relation between used minus glasses since 7 years ago
with Mr. Santo complain?
Answer:
In this case, there is no relation between used minus glasses since 7
years ago with Mr. Santo complain.

Synthesis:
Risk factors that would have made patient susceptible to develop
eyes infection such as keratitis according to Deschenes (2017), are:
- Wearing contact lens
- Trauma (including previous corneal surgery)
- Use of contaminated ocular medications
- Decreased immunologic defenses
- Use of immunosuppresive agents such as steroid drops that may
predispose to infection
- Aqueous tear deficiencies
- Structural alteration or malposition of the eyelids

42
 So there’s no actual relation between Mr. Santo uses minus glasess
(Miopia) with the main complain. The keratitis just makes Mr. santo’s
visions become worse than before.

e. What is classification of refractive disorder?

Answer:
1. Myopia
Myopia known as nearsightedness. Myopia occurs when the eye
grows too long from front to back. Instead of focusing image on the
retina-the light-sensitive tissue in the back of the eye- the lens of the
eye focuses in the image in front of the retina. Myopia also can be
the result of a cornea-the eye’s outermost layer- that is too curved
for the length of the eyeball or a lens that is to thick. The risk factor
people with myopia are genetics factor and enviroment factor. The
genetic factor is take the biggest role in the incident of myopia
(Sherwood,2013).

Figure 2.1 Refraction in Myopia

Source: Sherwood, 2013: 220

Myopia occurs when the eyeball is too long, relative to the

focusing power of the cornea and lens of the eye This causes light
rays to focus at a point in front of the retina, rather than directly on

43
 its surface. Nearsightedness also can be caused by the cornea and/or
lens being too curved for the length of the eyeball. In some cases,
myopia is due to a combination of these factors (Sanjay, 2015).
2. Hyperopia
Hyperopia also known as farsightedness, is a common type of
refractive error where distant objects may be seen more clearly than
objects that are near. Hyperopia develops in eyes that focus images
behind retina instead of retina, which can result blurred vision. This
occurs when the eyeball is too short, which prevents incoming light
from focusing directly on the retina. It may also be caused by an
abnormal shape of the cornea or lens. People whose parents have
hyperopia may also be more likely to get the condition
(Sherwood,2013).

Figure 2.2 Refraction in Hyperopia

Source: Sherwood, 2013: 220

Farsightedness (Hyperopia) is the result of the visual image being

focused behind the retina rather than directly on it. It is mainly cause
by two reasons:
- Low converging power of eye lensbecause of weak action of
ciliary muscles.

44
 - Eyeball being too short because of which the distance between
eye lens and retina decreases.
Farsightedness is often present from birth, but children have a
veryflexible eye lens, which helps make up for the problem. As aging
occurs, glasses or contact lenses may be required to correct the
vision. Farsightedness is hereditary (Sanjay, 2015).
3. Astigmatism
Astigmatism is a common type of refractive disoreder. It is
conditio which the eye does not focus light evenly onto the retina.
Astigmatism occurs when the light is bent differently depending on
where it strikes the cornea and passes throught the eyeball. The
cornea of normal eye is curved like a basketball, with the same
degree of roundness in all areas. An eye with astigmatism has a
cornea that is curved more like a football, with some areas that are
steeper or more rounded than other. This can cause images to blurry
and stecthed out (Sherwood,2013).
Astigmatism is an optical condition in which the refracting power
of lens is not same in all meridians. Astigmatism is a natural and
commonly occurring cause of blurred or distorted vision that is
usually associated with an imperfectly shaped cornea. The exact
cause in not known. A person's eye is naturally shaped like a sphere.
Under normal circumstances, when light enters the eye, it refracts,
or bends evenly, creating a clear view of the object. However, the
eye of a person with astigmatism is shaped more like a football or
the back of a spoon. For this person, when light enters the eye it is
refracted more in one direction than the other, allowing only part of
the object to be in focus at one time. Objects at any distance can
appear blurry and wavy (Sanjay, 2015).

Synthesis:

45
 The normal eye, known as an emmetropic eye can sufficiently refract
light rays from an object 6m (20 feet) away so that a clear image is
foccused on the retina. Many people however, lack this ability beacuse
of refraction abnormalities among these abnormalities are myopia or
near sigthdness, which occurs when the eyeball is too long relative to
the focusing power of the cornea and lens, or when the lens is thicker
than normal, so an image converges in front of the retina. Myopic
individuals can see close objects clearly, but not distant objects. In
hypermetropia the eyeball length is short relative to the focusing
power of the cornea and lens, or the lens is thinner then normal, so in
image converges behind the retina. Hyepermetropia individuals can see
distant objects clearly, but not close ones (Sherwood, 2013).

Figure 2.3 Emetropia

Source: Sherwood, 2013: 220

Astigmatism in which either the cornea or the lens has an irregular

curvature. With aging, the lens loses elasticity and thus its abillity to
curve to focus on objects that are close. Therefore, older people cannot
read print at the same close range as can young sters. This condition
called presbyopia (Tortora&Derrickson, 2007).

f. What is the meaning his friend complain about same symptom?

Answer:

46
 The meaning is risk factor of conjunctivitis cause conjunctivitis
spread through hand-to-eye contact by hands or objects that are
contaminated (Vaughan, 2014).

3. Specific Examination
Eyes:
OS: VOS 4/60, pinhole insignificantly improve vision, mixed injection,
yellowish white thick discharge, blepharospasm, infiltrate punctate
form.
OD: VOD 6/60, with correction: Spheris-2.00 become 6/6.
a. What is the interpretation of physical examination?
Answer:
Oculi Sinistra
Table 2. Interpretation of Eyes Specific Examination
Examination Meaning
VOS 4/60 Patient are only able to see as 4 meters on the
snellen chart. While others are able to see as 60
meters on the snellen chart.
Pinhole Patient has no refractive disorder.
insignificantly
Mixed Ciliary and conjunctival injection occurs indicate
injection the vasodilatation of anterior ciliary artery and
posterior conjunctival artery (Inflammation in
cornea and conjunctiva).
Discharge Mucopurulent (Indicate bacterial infection)
Infiltrate Keratitis
punctate

Oculi Dextra

47
 Table 3. Interpretation of Eyes Specific Examination
Examination Meaning
VOD 6/60 Patient are only able to see as 6 meters on the snellen
chart. While others are able to see as 60 meters on the
snellen chart.
Spheris -2.00 Myopia

b. How the abnormal mechanism of physical examination?

Answer:
VOS 4/60
The transmition of this infection throught hand to eye from
contaminated friend before. Which will lead to infection in Mr. Santo
conjunctiva bulbi. After conjunctivitis that was not treat inadequate.
The infection spread to cornea that infected the cornea also. The
infection that happens in cornea will make the inflammation in cornea
which make the cornea cloudy because of infiltrate punctate form in
cornea. Cornea is one of the refractive media that has a main role in
refractive which about 40 dioptri. It will make a symptom such as
lowering the vision (Ilyas dan Yulianti, 2017).

Mixed injection
The transmition of this infection throught hand to eye from
contaminated friend before. Which will lead to infection in Mr. Santo
conjunctiva bulbi. After conjunctivitis that was not treat inadequate.
The infection spread to cornea that infected the cornea also. The
infection that happens in both conjunctiva and cornea will make the
vasodilation of artery conjunctiva posterior and artery cilliaris anterior
That will manifestated as mixed injection (Ilyas dan Yulianti, 2017).

Infiltrate punctate form

48
 The transmition of this infection throught hand to eye from
contaminated friend before. Which will lead to infection in Mr. Santo
conjunctiva bulbi. After conjunctivitisthat was not treat inadequate. The
infection spread to cornea that infected the cornea also. When the
infection come there will be an inflammation which make inflammation
cell will be infiltrate in cornea (Ilyas dan Yulianti, 2017).

Yellowish thick discharge and blepharospasm

The transmition of this infection throught hand-to eye from
contaminated friend before. Which will lead to infection in Mr. Santo
conjunctiva bulbi. Goblet cell in caranculu lacrimales will excrete
mucous that contains microorganism. It makes the discharge
mukopurulen(yellowish thick discharge) and will be blepharospasm
(Ilyas dan Yulianti, 2017).

c. What is the classification of glasses for refractive disorder?

Answer:
- Myopia : Concave lens
- Hyperopia : Convex lens
- Astigmatism : Hard contact lens if epitel is not fragile or soft contact
lens if causes by infection, trauma and distrofi to give an irregular
effect in surface.
- Presbyopia : Convex lens

d. How to perform spesific examination object?

Answer:
Pinhole test
This test perform to to determine whether a decrease in vision occurs
due to refractive disorder or organic abnormalities in eyes. First asked
patient to remove their glasses or contact lenses and stand or sit 20 feet
(6 meters) from snellen chart. Cover one eyes with the occuler lenses.

49
 After that patient asked to read the snellen chart from the biggest letter
until the smallest letter thet can be read cleary,with that we can also
determine patient’s visus. Put the pinhole in front of patient eyes if the
pinhole significantly improve the vision so that means patient have a
refractive disorder but if not probably patient have organic abnormality
(Ilyas dan Yulianti, 2017).

e. What is the classification of injection?

Answer:
1. Conjunctiva Injetion
Conjunctiva injection is the dilatation posterior conjunctiva
artery. The etiology of conjunctiva injection usually caused by
alergy, conjunctiva infection and mecanical factor. The
characteristic of conjunctia infection according to Ilyas and Yulianti
(2017), are:
- Fotofobia (-)
- Normal pupil
- Normal refraction
- Fresh red color
2. Ciliary Injection
Ciliary injecton is the dilatation of anterior cilliary artery.
Usually, ciliar injection caused by keratitis, uveitis, glucoma. The
characteristic according to Ilyas and Yulianti (2017), are:
- Red colour
- Pupil irregular
- Fotofobia
- Small size beside cornea

f. What are the possible causes of injection?

50
 Answer:
The possible causes of injection according to Ilyas and Yulianti
(2017) are:
1. Conjunctival injection usually caused by mechanical influences,
allergic, infection of the conjunctival tissue.
2. Ciliary injection usually caused by inflammation of the cornea
(keratitis), corneal ulcer, a foreign object in the cornea, inflammation
of uvea (uveitis), glaucoma, endoftalmitis.

4. What disturbances might happen in this case?

Answer:
Based on the analysis above, the disturbances that might be happen in
this case, are:
- Keratoconjunctivitis
- Anterior uveitis
- Acute glaucoma

5. What investigations are needed to diagnose this case?

Answer:
- Slit Lamp
Slit lamp photography can be useful to document the progression of
the keratitis, and, in cases where the specific etiology is in doubt, it is
used to obtain additional opinions, particularly in indolent and chronic
cases not responding to antimicrobial therapy (Ilyas dan Yulianti,
2017).
- Bacterial Culture
Though pathogens can be identified within 12-15 hours of
inoculation, most aerobic bacteria in microbial keratitis appear only
within 48 hours on standard culture media. The plates should be
examined on daily basis and liquid media observed for turbidity. Blood
agar is best for isolation of aerobic bacteria. Anaerobes are slow

51
 growing; therefore, cultures should be incubated for at least 10 days.
The most common combination found in polymicrobial keratitis is
aerobic Gram-positive coccus plus Gram-negative rod, followed by
fungus plus bacteria. There are no established criteria for true diagnosis
of corneal infections. One of the authentic criteria was put forward by
Jones which includes clinical signs of infection and isolation of ten or
more colonies of bacteria on one solid medium and one additional
medium in presence of a positive smear (Al-Mujaini, 2009).

6. What disturbances are most likely to occur in this case?

Answer:
Keratokonjunctivitis sinistra and myopia oculi dextra.

7. What is the etiology of keratitis?

Jawab:
- Bacterial infection
- Fungal infection
- Viral infection
- Allergies

8. How does the comprehensive management for this case?

Answer:
Pharmacology
If it caused by bacterial infection: chloramfenicol drop as much as 1 drop
6x/day or eye ointment 3x/day for 3 days.
Non-pharmacology
- Before and after use ointment patient have to wash their hand
- Ask patient to keep personal hygiene and environment
- Don’t use the same towel or duster

52
9. What will happen if these circumstances are not manage
comprehensively?
Answer:
- Cornea Ulcer
- Blepharitis

10. Is this disorder can be overcome thoroughly, how the odds?

Answer:
- Quo ad Vitam: bonam
- Quo ad Fungsionam: bonam
- Quo ad Sanationam: bonam

11. How does the competence of general practitioner for this case?
Answer:
The competence of general practitioner for Keratitis is 3A and
Conjunctivitis is 4A (KKI, 2012).

Synthesis:
3A. Non-emergency case
General practitioner are able to make clinical diagnoses and provide
preliminary therapy in non-emergency cases, to determine the most
appropriate referral for the next patient's treatment and also able to
follow up after returning from referrals (KKI, 2012).
4A.General practitioner are able to make clinical diagnoses and treatments
independently and throughtly (KKI, 2012)

53
 12. How does the Islamic point of view of this case?
Answer:
Q.s Al-Mu’minun (23:78)

“And it is He who produced for you hearing, vision, and heart, little are
you grateful”.

2.6 Conclusion
Mr. Santo, 22 years old complained with blurred vision, eyes of redness,
pain & yellowish white thick discharge due to keratoconjunctivitis oculi
sinistra with myopia oculi dextra.

2.7 Conceptual Framework

1. Keratoconjunctivitis concept

Risk Factor (Contact from contaminated friend

Injection in the conjunctiva bulbi

Eye redness
Pain
Inadequate Conjunctivitis
treatment Discharge
Infection spread to cornea

Keratoconjunctivitis

Blurry vision

54
2. Myopia concept

- Length of eye ball its to long

- Cornea is to corved

The light fall in the front of the retina

Myopia Dextra

55
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