Cornea 2019/2020

Contents
Cornea 3
Uvea 10
Glaucoma 16
Retina 22
Optic Nerve 29
Errors of refraction 33
Eye lid 36
Conjunctiva 43
Lens 50
Orbit 62
Injuries 66
Tumors 74
Squint 79
Instruments 85

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Cornea 2019/2020

Red eye

Uvea - Cornea- Glaucoma

Circum Corneal Ciliary Injection (CCCI)
Pain- Pressure- Pupil

Uvea Cornea Glaucoma

Pain Dull aching Stitching Bursting
pressure ↓ ↓ in perforation ↑
Pupil Normal or festooned Normal Dilated

Hypopyon

Disease in Uvea = Uveitis Cornea = Keratitis Orbit =Endo/Pan

Pan Opthalmitis
Other ± (KPs, festooned pupil, ± (Active Corneal Ulcer, ± (Yellow reflex, Sutures,
signs floaters) Dendritic ulcer) Post-surgical
surgical)

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Cornea 2019/2020

Cornea

Keratitis 4
Herpes simplex keratitis (Dendritic ulcer) 5
Neurotrophic ulcer 6
Herpes Zoster Ophthalmicus 6
Keratoconus 7
Corneal Foreign Body 8
Band Keratopathy 8
Arcus Senilis 8
Exposure Keratitis 8
Corneal Perforation 9

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Cornea 2019/2020

Keratitis
 Pneumococcus (Hypopyon Corneal Ulcer)
Ulce
• Pseudomonas (most common with Contact Lens)
• Acanthamoeba (Contact Lens + Water)
• Fungal (Wood or plant trauma) → farmers
Symptoms PDR
• Pain (sharp – stitching) with reflex refle BLPH
(Blepharospasm, Lacrimation, Photophobia, Headache) Corneal Ulcer with Hypopyon
• Defective vision.
• Redness.
Signs
• Ciliary injection.
• Ulcer (loss of luster, Grayish White
infiltration, +ve fluorescein test)
• 2ry uveitis (flare & cells, miosis)
Complications Corneal Ulcer +ve Fluorescein
• Corneal Scar (Nebula / Leucoma) →Vascularization
‫أﺷﻮف ﻣﻦ وراﻫﺎ‬ ‫ﻣﺎﺷﻮﻓﺶ ﻣﻦ وراﻫﺎ‬ Opacification
• Hypopyon
• 2ry open angle glaucoma Leucoma
• Descemetocele (ttt BCG “Bandage C.Lens +
cyanoacrylate/Graft)
• Perforation → slit lamp ‫ﯾﺼﻮره ﺑﺎﻟﺠﻨﺐ ب‬
+ history of pain then water gush with relief of pain
• 2ry closed angle glaucoma
• Resistant ulcer: if no response to Treatment
for 2 weeks
• Amblyopia if central scar in a child <6 years.
Confirm→ fluorescein stain test
Treatment:  Atropine & AB  scar: PTK
Leukoma: PKP
 If with ↑IOP → 2ry Glaucoma
Don’t stop original ttt
Don’t give Pilocarpine Descemetocele
But give β Blockers + Diamox

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Cornea 2019/2020

N.B: Corneal ulcer in Red eye while Leucoma in

healed eye (clear eye)
linear branched
with terminal knobs
Herpes Simplex Keratitis “HSV1”
(Dendritic Ulcer)
Organism Dendritic ulcer
+ve fluorescein
HSV-I
Symptoms
• Pain that decreases with recurrence with reflex
BLPH
(blepharospasm, lacrimation, photophobia, headache)
• Defective vision if central
Dendritic ulcer
• Redness +ve fluorescein
Signs
• Ciliary injection.
• Ulcer (loss of luster, +ve fluorescein test,
Disci-form
form stromal keratitis Roun
+ve ROSE BINGALE) 2ry uveitis (flare & cells, d
miosis). lesion
result
No ing
Complications (DARK) desmatocel from
e strom
• Uveitis al
No and
• 2ry open angle glaucoma epith
elial
• Scar: nebula infla
mmat
• Disci-form keratitis ion
and
edem
• Amoeboid ulcer (Geographical ulcer) Stop
• Recurrence Old Steroids!
• Keratitis meta-herpetica
name tica (Neurotrophic Ulcer)
Management
• Atropine Corneal beam
Iris beam
showing edema
• Acyclovir (Ointment 3%, 5 mes/day for 2 weeks)
• Avoid Hot Fomentations, Steroids except in
Disciform keratitis → Steroids under umbrella
of Antiviral

Geographical ulcer
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Cornea 2019/2020

Neurotrophic Ulcer
Cause
• 5th C.N affection as in HSV infection
• Trauma
Symptoms
• No pain
• Defective vision
• Redness
Signs
• Decreased corneal sensation
• Central ulcer with punched out edges
Treatment
• Lubricants - Median Tarsoraphy
• If on Steroids → Stop

Herpes Zoster Ophthalmicus

(+hutchinson)
Organism
Varicella zoster

Hutchinson's sign
Affection of tip of nose increases as it means Nasociliary
nerve is affected which
the risk of corneal affection. also supplies the cornea
Ocular affection (Itis)
• Conjunctivitis
• Scleritis
• Keratitis
• Uveitis
• Retinitis
• Neuritis
Treatment
Systemic Acyclovir within in 2 days of rash onset

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Cornea 2019/2020

Keratoconus (manson) More in

Symptoms ♀
 Frequent change of distant glasses
 Intolerance to Contact Lens
• Gradual painless drop of vision due to:
o Progressive myopia
o Irregular astigmatism
• Mono-ocular diplopia Manson's sign
If boy presents with KC and itching → evert lid
for cobble stone papillae, as KC is associated with
spring catarrh, which is common in ♂

Signs
• Oil droplet reflex with ophthalmoscope.
• Fleischer ring deposition of Fe
• Manson's sign
• Vogt’s striae
• Progressive corneal thinning
• Deepening of A.C
• Rotatory reflex with retinoscopy
Investigations
 Corneal Topography Oil droplet reflex
• Placido Disc (Irregular rings)
Complications
Associations Placido
• Corneal scar (PTK)
• Ectopia lentis Disc
• Acute hydrops • spring catarrh
Treatment • retinitis pigmentosa
• Marphan $
• Hard Contact lens
• Intra-corneal rings
• Collagen cross linking
• Penetrating keratoplasty Types of Corneal
• Deep Lamellar Keratoplasty graft

Corneal Topography
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Cornea 2019/2020

Band Keratopathy
Causes
 Scraping with EDTA
• Chronic anterior uveitis  PTK “ penetrating keratoplasty”
• Hypo-calcemia ttt  LKP “ lamellar keratoplasty “
• Idiopathic  Treat the cause

Arcus Senilis
Pathology
Lipid & cholesterol deposition in the stroma.
Signs
Whitish non-vascularized
vascularized ring at the periphery of the cornea
with clear interval from sclera
 In young (arcus juveniles) indicates
indicate high cholesterol

Exposure Keratitis
Cause
• Ectropion.
• Exophthalmos.
• Coloboma
• Lagophthalmos
Lagophthalmos
Symptoms PDR
Pain, Defective vision, Redness.. Bell’s palsy
Signs
Bell's phenomenon (lower marginal ulcer with upper straight border)
Treatment
• Lubricants
• Lateral tarsoraphy Exposure Keratitis

Corneal Foreign Body

Signs & complications
Pain with reflex (blepharospasm,
blepharospasm, lacrimation, photophobia
photophobia).
Corneal ulcer & scar. ttt:: Removal

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Cornea 2019/2020

Corneal Perforation +ve Seidel’s test

Symptoms
““River sign”
Sharp pain followed by gush of fluid.

Signs
• Perforation site is seen.
• Sudden hypotony.
• Shallow anterior chamber.
• Positive Seidel’s test.

Complications
• 2ry infec on (Endo/Pan ophthalmi s)
Descematocele
• Ectopia lentis
• Expulsive hemorrhage
• Leucoma adherent
or non-adherent
adherent if small perforation
• Large perforation → Staphyloma
(Blind, painful, ugly eye)
Treatment
• Hospitalization - Swab
• Atropine - Antibiotic
• Hot foments
• Bandage C.Lens (± Cyano--acrylate)
• Analgesics
Partial Anterior Staphyloma

Indications for
Keratoplasty Complications
• Keratoconus • Rejection
• Corneal Scar • Glaucoma
• Resistant Ulcer • Cataract
• Desmatocele • Astigmatism
• Perforation • Endo/Pan Ophthalmitis

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Uvea 2019/2020

Uvea
Irido- cylitis (Uveitis) 11
Endophthalmitis & Panophthalmitis 14

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Uvea 2019/2020

Irido cylitis (Uveitis)

Irido-
Etiology
A. Non-infective:
 Auto-immune
immune (Arthritis)
 Behcet's Disease (oral & genital ulcers)
 Idiopathic (25%)
 2ry uveitis:
2ry to Ectopia lentis, Hypermature
Hyper cataract,
Trauma
 Vogt Koyanagi Harada Vogt Koyanagi Harada
(Poliosis,
Poliosis, vitiligo, alopecia
alopecia)
 Sarcoidosis ‫ﺷﻌﺮ اﻟﺮﻣﻮش‬ ‫ﺑﮭﺎق‬ ‫ﺻﻠﻊ أﺟﺰاء ﻣﻦ‬
‫أﺑﻴﺾ‬ ‫ﻓﺮوة اﻟﺮاس‬
B. Infective: as Syphilis, Toxoplasma most abundant
inflammatory cell
is macrophage

Symptoms PDR
1. Dull aching Pain with reflex BLPH (Blepharospasm,
Blepharospasm, Lacrimation, Photophobia, Headache
Headache)
2. Drop of vision d.t:
Acute: Plasmoid aqueous, myopic shift, corneal edema, toxic maculopathy
Chronic: Complications (Cyclitic membrane – Occlusio pupillae - RD)

Treatment: (5C)
 Atropine (Cycloplegic, Mydriatic)
 Corticosteroids
 Of the Cause
 Of Complications:
• Cataract:: Cataract extrac on a er 6 months of free period
• 2ry Glaucoma:
Don’t stop original ttt
Don’t give Pilocarpine
But give β Blockers + Diamox

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Uvea 2019/2020

Uveitis showing Ciliary injection, Uveitis showing Ciliary Mutton fat Keratic precipitates
festooned pupil injection, festooned pupil,
+ Fine keratetic percipitates Hypopyon
Case: ttt follow up

Aqueous flare & cells Lenticular precipitates

Signs
1. Ciliary injection
2. Flare & cells in anterior & posterior chamber
chambers (in severe cases there might be hypopyon or Hyphema)
3. Muddy iris
4. Miosis (sphincter spasm)
5. Myopic shift (ciliary spasm)
6. Keratic precipitates (if large → Mutton fat)
7. Lenticular precipitates
8. Early there is Hypotony due to ciliary shut down
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Uvea 2019/2020

Complications
 Organization
 Peripheral anterior synechia
 Occlusio-pupillae
 Cyclitic membrane
 Posterior synechia:
Occlusio-pupillae
• partial: festooned pupil
• annular: seclussio-pupillae
pupillae
 2ry Glaucoma
 2ry OAG in acute phase d.t Plasmoid aqueous,
trabeculitis, steroids.
 2ry CAG in chronic phase due to:
• Pupillary block by occlusio
occlusio/seclussio pupillae
• Peripheral anterior synechia
• Neo-vascular
vascular glaucoma Atrophia Bulbi
 2ry Cataract (posterior sub-capsular)
sub
 Retina
 Cystoid Maculopathy (Macular
( edema)
 Tractional Retinal Detachment (Cyclitic membrane)
 Exudative
tive Retinal Detachment (Choroiditis)
 Band keratopathy
 Atrophia Bulbi Seclussio-pupillae

Investigations
Posterior synechia:: history of recurrent eye
 CBC inflammation
 HLA typing ttt: follow up for exacerbation
 MRI, CT, X-ray

Treatment
• Cataract:: cataract extrac on a er 6 months of free period
• 2ry Glaucoma:
Don’t stop original ttt
Don’t give Pilocarpine
But give β Blockers + Diamox
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Uvea 2019/2020

Endophthalmitis
& Panophthalmitis

Yellow Reflex + Hypopyon

Etiology Causative Organism

 Postoperative (Intraocular surgery) • Bacteria: Staph Albus - Pseudomonas
 Open globe injury • Fungal (candida)
 Perforated corneal ulcer
Signs
 As uveitis PDR but more severe:
severe
• Vision up to no PL
• Hypopyon is common,
common infected
• Vitreous abscess → Yellow Reflex
N.B. hypopyon is sterile except in Endo
Endo/pan ophthalmitis
Investigations
 Aqueous & vitreous sample for culture & sensitivity
 US to confirm diagnosis & exclude retinal detachment & intra ocular foreign body

Complications
 Healing by fibrosis (phthisis bulbi)
 Spread → Orbital cellulitis
cellulitis, Cavernous Sinus Thrombosis
 Endophthalmitis → Panophthalmitis

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Uvea 2019/2020

Management
Hospitalization & :
A. Endophthalmitis
Light perception or better: Vitrectomy & intravitreal drugs & Systemic Antibiotic
No light perception: Evisceration (better) - Enucleation
B. Panophthalmitis
Evisceration & systemic antibiotics
 Never Enucleation in Panophthalmitis to avoid spread of infection

N.B. Endophthalmitis affects middle & inner coat

coats while Panophthalmitis affects all
three coats.

From history; in Endo/Pan ophthalmitis there is 5P

1. Fever (Pyrexia)
2. No perception of light
3. Pus
us in cornea leads to perforation
4. Plegia of extra ocular muscles
5. Proptosis Sure signs of
Panophthalmitis

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Glaucoma 2019/2020

Acute Congestive glaucoma 17

Buphthalmos 18

Glaucoma

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Glaucoma Pupil ‫ واﺳﻊ‬+ ‫ﻋﯾن ﺣﻣرا‬ 2019/2020

Acute Congestive Glaucoma

- Darkness Sudden complete angle
PACG:: high axial hypermetropia + - Mydriatics closure by peripheral iris,
- Ciliary body not followed by re-opening
re
d.t sphincter ischemia
congestion

How to identify:
 Ciliary injection
 Pupil: Semi-dilated,
dilated, Blue-green,
Blue vertically oval

Hints in case (symptoms): ( PDR with reflex BLPH)

 Sudden bursting pain with reflex BLPH
 Defective vision
 Vomiting & Acute abdomen
Signs: (‫)ﻣﻦ ﺑﺮا ﻟﺠﻮا‬
 CCCI
 IOP: stony hard by digital method
 Pupil: semi-dilated unreactive
reactive, vertically oval
 Shallow anterior chamber
 Corneal edema
lines of Treatment: Complications if not treated
Surgical after Medical preparation • Lost vision due to Optic Nerve atrophy
1. Hospitalization: • Medical only: progress to chronic stage
• 20% mannitol I.V. • Patches of Iris atrophy
• CAEI & βB • Pigment dispersion
• Miotics (Pilocarpine) • Glaucomoflecken (Anterior Subcapsular Cataract)
• Steroids & analgesics
2. Gonioscopy:
a. If Peripheral ant synechia less than 50% → Iridotomy
b. If Peripheral ant synechia more than 50% → Sub-scleral
scleral trabeculectomy
3. Prophylactic iridotomy in the other eye

MCQ: MCQ:
What is the first thing to do to this patient? What is the first thing to give to this patient?
Gonioscopy Oral Mannitol
IOP measurement by applanation Pilocarpine drops
tonometer (or other method)
method false answer
false answer

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Glaucoma 2019/2020

Buphthalmos
How to identify:
 Megalocornea
 White pupil

Symptoms:
(BLP) Blepharospasm, Lacrimation, Photophobia,
large globe, blue sclera.

Signs:
 Cornea: thin & flat & large ( Horizontal Diameter)
 Corneal Edema - Haab’s striae
 Sclera: thin and blue
 Anterior Chamber: Deep
 Tremulous iris DD of Large Cornea
 Lens: flat • Buphthalmos
 IOP: High but reversible • Megalocornea
cornea
 Fundus: Cupping • Congenital high axial myopia

Investigations :
 Bilateral Fundus Examination, if opaque media → US to exclude Retino
Retinoblastoma
 Horizontal corneal diameter, IOP (Confirm Diagnosis)
 Axial length by A scan US

Treatment: (Surgical)
A. Clear cornea: Goniotomy. if failed: Re-Goniotomy
Re
B. If Failed or Opaque cornea: sub-scleral
sub trabeculectomy

Complications:
1. Corneal scar
2. Ectopia lentis
3. Amblyopia
4. Glaucomatous optic atrophy
5. Cataract

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Glaucoma 2019/2020

Glaucomatous optic Cupping

Identification:
 Vessels: Kinking, limbing, nasal shift
 Cup: wide & deep, ↑ Cup/Disc ra o
 Well defined disc edges

Hints in case:
 No color nor light perception
 Afferent pupillary defect
 Increase intra-ocular
ocular pressure
Causes ttt
Investigations  Buphthalmos • Medical: βB
  Field, IOP, Angle, OCT  OAG • Laser: Trabeculoplasty
 CHRONIC closed angle • Surgery: Trabeculectomy

Scotoma in Primary open angle glaucoma

 Nerve fibers never cross the horizontal raphe
raphe.
 Para-central → siedle → arcuate → double arcuate → tubular vision
Treatment of primary open angle glaucoma:
A. Medical
1. βB # in Bronchial asthma-HB
asthma
2. CAEI # in Sulpha allergy
3. Miotics
4. PG “Latanoprost” # in Uveitis
5. Alpha-2 agonists
B. Surgical: Sub-scleral
scleral trabeculectomy

 Glaucomatous optic atrophy

 CRVO (Central retinal vein occlusion)
 Complicated cataract

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Glaucoma 2019/2020

Apparatuses and their uses

Goldmann three mirror contact lens: Applanation tonometer:

 Angle examination  Measure intra-ocular

intra pressure
(Accurate)

Gonioscopy:

 Angle examination

Automated perimetry Indentation Schoitz tonometer

 Field examination  Intra-ocular
ocular pressure (Inaccurate)
for rigidity factor

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Retina 2019/2020

Diabetic Retinopathy (with or without maculopathy) 23

Hyper tensive retionapthy 24
Central retinal artery occlusion 25
Central retinal vein occlusion 26
Retinitis pigmentosa 27
Retinal detachment 28
Retina

Optic Nerve
Papillitis 30
Papillidema 31
Optic atrophy 32
Errors of refraction
Myopic Temporal Crescent 33

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Retina 2019/2020

Retina Slides
• ill defined margin → Disc edema
• New vessels → NVD
• Cupping → Glaucma
• Cresent→ High axial myopia
Disc • Atrophy

• Attenuated arteries
• Tortous veins
• Crossed → Atheroscelrosis
Vessesls

•Yellow dots → Diabetic retinopathy

•Blood → CRVO
•Infarction → CRAO "cherry red spot"
•Dark pigmentation → Retinitis pigmentosa
Background •Macular star → Malignant HTN,, Papilledema"rare"
•Retinal detachment

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Retina 2019/2020

Diabetic Retinopathy (±Maculopathy)

±Maculopathy)

N.B. most
important risk
is duration of
DM

Non-Proliferative
Proliferative Proliferative Diabetic
Diabetic Retinopathy Retinopathy (PDR)
(NPDR)
Proliferative D.R.: Neovascularization at the disc
How to identify = Signs: or elsewhere (NVD--NVE) due to ischemia
 Haemorrhage
 Hard exudates
 Micro-aneurysm

Hints in case (symptoms):

 Diabetic patient
 Rapid painless drop of vision
 Foggy vision not improved with glasses
 Most important factor is duration Vitreous Hemorrhage

In advanced DR
Complications - what else to examine?
examine
1- Vitreous Hemorrhage  Tractional Retinal Detachment
2- Iris for Rubeosis
3- Pressure for Glaucoma
4- Lens for Cataract
5- Macula for Maculopathy

D.D of Rubeosis Iridis

PDR - CRVO - Uveitis - Chronic Retinal detachment -
Intraocular tumor NVI = Rubeosis iridis
Investigations Complications 
FA – OCT – US – blood sugar Hyphema – NVG – Corneal staining
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Retina 2019/2020

Lines of Treatment:
A. Control DM
B. Diabetic Maculopathy:: (with NPDR or PDR)
 Focal edema: focal laser
+ Anti VEGF
 Diffuse edema: Grid laser
 Cystoid edema: intra
intra-vitreal Triamcinolone(CS) + Anti VEGF
C. Proliferative diabetic retinopathy:
 Pan retinal photocoagulation(PRP) & intraintra-vitreal
vitreal (Avastin + Triamcinolone)
D. Complications:
 Vitreous hemorrhage & Tractional retinal detachment: vitrectomy + silicone oil + PRP
 Neovascular glaucoma:
aucoma: βB & Diamox

Investigations :
 Random blood Sugar, H HbA1c
 Fluorescein angiography (for type of lesion) and ocular coherence tomography
(OCT)) for amount of leakage
 US (to exclude retinal detachment)
NPDR, no Maculopathy → follow up
Investigation of choice? Fluorescein angiography

Hypertensive Retinopathy(Malignant
Retinopathy
HTN)
How to identify:
 Disc edema
 Macular star
 Cotton wool spots

Causes: ttt
 Preeclampsia Refer to cardiologist
Macular
 Pheochromocytoma Star
 Renal artery stenosis
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Retina 2019/2020

Central retinal artery occlusion (CRAO)

How to identify:
Cherry red spot

Hint in case - Symptoms:

Sudden painless drop of vision up to no PL

Causes:
 Embolism
 Giant cell arteritis (scalp tenderness-
tenderness headache-
jaw claudication), SLE
 Spasm (Migraine)
 Atherosclerosis, Hypertension, DM.DM
Branch retinal
Signs:
1. Drop of vision up to no perception of light
artery occlusion
2. Afferent pupillary defect
(BRAO)
3. Cherry red spot - Milky white retina
4. Attenuated arteries - Segmented Veins

Complications:
 Death (by emboli)
 Blindness - If with chorio-retinal
retinal bundle: Tubular vision
 Rubeosis iridis (rare)
 Sectorial field defect (BRAO)
causes Sectorial Field defect
Treatment:: (CRAO or BRAO)
 Refer to Cardiologist
 If < 30 min: Flat position, Firm massage, sublingual Nitrate and IV Diamox.

D.D:
1. Commo o Re nae
2. Iaysach disease
3. Quinine toxicity
4. sphingolipidosis: deposited in the ganglion cells and the CNS.

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Retina 2019/2020

Central retinal vein occlusion

occlusion(CRVO)
How to identify:
Extensive hemorrhage (Pizza ketchup appearance)

Hint in case - Symptoms:

Rapid painless drop of vision

Causes:
 Increased blood viscosity: oral
Branch Retinal Vein
contraceptive pills, increase in any Occlusion
blood element. MCQ:
 Primary open angle glaucoma (e.g in ttt of BRVO:
case: on topical drugs for 5 years)  vasodilator
 Behcet's disease (Orogenital ulcers)  aspirin

 Atherosclerosis, Hypertension, DM.

refer to internist
 PRP
Signs:
 Rapid painless drop of vision specially in  causes sectorial field loss
the morning Refer to Internist
 Afferent pupillary defect Treatment:
“Primary open
angle glaucoma”

 Dilated & tortuous veins A. of Cause: Stop oral contraceptive - POAG

 Extensive flame shaped hemorrhage B. of Macular edema
edema:
 Disc and macular edema - Intravitreal Triamcinolone / anti VEGF
 Cotton wool spots
- Laser (PRP in CRVO, scatter or focal in
Complications: (as DR) BRVO) after hemorrhage resolution.
 100 Day Glaucoma = neovascular C. of Complications
Complications:
glaucoma  Vitreous hemorrhage & Tractional retinal
 Vitreous hemorrhage detachment: Vitrectomy + silicone oil
 Tractional retinal detachment  Neovascular glaucoma: Atropine + steroids
 Hyphaema  Neovascularization: PRP after hemorrhage
 Macular edema resolution
 Maculopathy
Investigations :
As Diabetic retinopathy
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Retina 2019/2020

Retinitis Pigmentosa
Causes:
X-linked recessive

Symptoms:
 Nyctalopia
 Progressive contraction of field
 Decrease color & visual acuity

Signs: ABC
 Attenuated arteries
 Black brown- bone corpuscle like pigment
present at midperiphery
 (Colour): Waxy yellow disc

Q complications/ what else to examine/ Association

 Cataract  Keratoconus
 Open angle Glaucoma  Consecutive optic atrophy
 Maculopathy

D.D: Siderosis

Investigations
 Electroretinogram “ERG””
 Field (Ring scotoma → Contraction
Cont of field → Tubular field )
 Electrooculogram “EOG””

Treatment
 Low visual Aids
 ttt of complication
 Genetic & Premarital counseling

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Retina 2019/2020

Rhegmatogenous Retinal Detachment (RD)

Hints in case:
High axial myopia / Trauma `
(since childhood)
Symptoms:
A. Break
 Flashes: photopsia
 Floaters: Musca volitans
 Drop of vision
B. Retinal detachment
 Rapid painless drop of vision
 Field defect: black curtain

Signs:
 Drop of vision if macula is affected
Treatment:
 Pupillary afferent defect if total
A. Break;; Sealing by:
retinal detachment
 Laser
 Field defect corresponding to site of
 Cryo-therapy
therapy
detachment
 Diathermy
 Red reflex becomes grayish due to
B. Retinal detachment
detachment:
sub-retinal fluid
 Drain sub retinal fluid
 Hypotony, uveitis, Rubeosis and
tobacco dust.  Sealing
 Fundus (elevated è tortuous blood  Scleral buckle
vessels) C. Retinal detachment with Proliferative
vitreoretinopathy
vitreoretinopathy:
Complications:  Vitrectomy + silicone oil injection
 Complicated Cataract  Macular hole
 2ry uveitis  High Myopia
 Proliferative vitreoretinopathy  Trauma
 Total RD – Atrophia bulbi  Senile
 Robeosis Iridis

Page
29
Optic nerve 2019/2020

Optic Nerve
Disc edema
(Cup disc –elevated - ill-defined margin)

Papilledema or Papillitis?

Papilledema Papillitis MCQ:

“Showing 2 images of both

History of  Rapid
eyes, one fundus is normal,
• Headache ↓ Vision other is hyperemic with
• Diplopia ↓ Color perception edema”. Patient complains of
• Amaurosis fugax  Painless pain on moving eye up and in.
• Projectile vomiting (If Painful? → RBN) RBN or Papillitis?
• Persistent headache On moving eye
up and in
Papillitis

 in RBN fundus is normal

Signs:
Function (Vision, color, pupil)
Field
Fundus

Page
30
Optic nerve 2019/2020

Optic Neuritis (Papillitis)

Cause
 Non-infective: multiple
ultiple sclerosis in young female
female,, toxic (anti TB drugs)
 Infective
 Ischemic (GCA -DM/HTN/Atherosclerosis)
DM/HTN/Atherosclerosis) : pale disc + old age

Symptoms
Rapid painless drop of vision & color perception (painful only in retro bulbar neuritis)
* In RBN: Pain with muscle movement (up and in) & normal fundus and abnormal pupil RAPD
If there's disc edema even associated with pain on moving eye = Papillitis

Signs
A. Functions
Acute drop
rop of vision &color perception with relative afferent pupillary defect (Marcus
Gun Pupil)
B. Fundus (normal in retro bulbar neuritis)
Blurry disc margin ,leakage
kage around disc , tortious vein
Cup obliteration
Vitreous flare & cells → (Papilledema‫)ﻣﻣﯾزة ﻋن‬
C. Field
Central Centrocecal scotoma for red & green
Non-Arteritic: (HTN-DM-atherosclerosis):
atherosclerosis): Altitudinal field defect

Investigations
 MRI for (M.S)
 Field examination
 Visual evoked potential

Treatment:
Refer to Neuro
If Multiple sclerosis: IV steroids-interferon
steroids
If ischemic: IV steroids in arteritic type
Complications 
Papillitis: 2ry optic atrophy Disc Edema

Retro bulbar neuritis: primary optic atrophy (MRI, maybe RBN or tumor)
Page
31
Optic nerve 2019/2020

Papilledema (Bilateral)
Cause: (SBSB)
 Space occupying lesion (brain tumor
until proved otherwise)
 Benign
nign increase in intra cranial tension
in obese female on OCP
 Subarachnoid hemorrhage
 Block of ventricular system

Symptoms
A. General
• Persistent Headache
• Projectile vomiting
• Galactorrhoea - amenorrhea
• history of brain tumor
B. Ocular Advanced
• Amaurosis Fugax (Transient painless Papilledema
loss of vision)
• Gradual painless drop of vision Investigations
• Diplopia (6th nerve palsy) 1. Field
• Late 2ry op c atrophy Bilateral enlarged blind spot →
Contraction of field → Tubular field
Signs
2. CT or MRI Brain “Cause”: tumor
 Function:
o Vision normal early Treatment:
o Relative afferent pupillary defect only  Treat the cause + Refer to neuro
if asymmetrical
 If idiopathic:
o Central scotoma for blue
• Optic nerve decompression if there is
 Fundus:
drop of visual acuity (# in brain tumor)
o Blurring of disc margin
• Shunt surgery to relieve headache
o Tortuous Dilated veins
o Leakage around the disc that Results:
Macular If early → resolution
o Might extend to the macula →fan or star
o Champaign cork like gliotic If late→ 2ry op c atrophy “Complica on”
If -ve CT , MRI for brain tumor →Benign increased tension
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32
Optic nerve 2019/2020

Optic Atrophy

Post Glaucomatous
Primary optic atrophy 2ry optic atrophy
optic atrophy
• Cause:  Cause:  Cause:
Cause
Damage behind the Damage at the disc Absolute Glaucoma
disc (tumor e.g glioma) (Papillitis)
- RBN - Drugs
 Signs:
Signs white disc with
• Signs: white disc with  Signs: grayish yellow well-defined
well edge, wide
well-defined edge waxy disc with ill- deep cup. Kinking,
defined edges, limbing, nasal shift of
• Investigations: obliterated cup & blood vessels
MRI Brain sheathed retinal vessels
INCREASED Intra-ocular
Intra
• ttt: Refer to neuro
pressure

Clinical Picture:
 No light perception, No color perception
 Afferent pupillary defect
 Pale disc

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33
Errors of refraction 2019/2020

Myopic Temporal Crescent

Crescen
Causes:
High axial myopia

Signs:
• Choroidal sclerosis
• Tigroid retina
• Temporal crescent

Complications
• Retinal break (flash + floater
floaters)
• Rhegmatogenous Retinal Detachment (flash + floater + drop of vision)
• Fuchs spot (neo- vessels at fovea)
• OAG
• Cataract

Treatment: -ve Lens

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34
Eye lid and conjunctiva 2019/2020

Eye lid
Seborrheic blepharitis 36
Stye 36
Chalazion 37
Blepharophemosis 37
Trichiasis 38
Distichiasis 38
Ectropion 39
Entropion 40
Coloboma 40
Epicanthus 40
Ptosis 41

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35
Eye lid and conjunctiva 2019/2020

Follicles + Papillae(finger like)

Cobble stone Active trachomatous follicles
in Spring catarrah and papillea

Inverted upper
Eyelid

White band Foreign body

Healed trachomatous scar TTT: Removal

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36
Eye lid 2019/2020

Seborrheic (Scaly) Blepharitis

How to identify:
Scales on lid margin and lashes
Symptoms:
Discomfort & severe itching
Complications:
 2ry Bacterial infection
 Eczema → Cicatricial Ectropion
Treatment:
Anti-seborrheic ttt (erythromycin – tetracycline)

Stye (External hordeulum)

How to identify:
Pus pointing to skin along lash line infront of the grey line.
Predisposing factors:
 DM
 Uncorrected error

Causative organism & site:

Staph in sebaceous & sweat glands
complications:
 Cavernous sinus thrombosis
 Trichiasis
 Recurrence & multiplicity
Investigations if recurrence:
 Blood sugar (DM) – Retinoscopy (errors)
 Examine for staph blepharitis
Treatment:
A. Diffuse stage: Antibiotics + hot fomentation
B. Localized stage
 Small: Epilating the affected lash
 Large: Drain through horizontal skin incision
Moraxella lacunata causes Angular blepheritis

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37
Eye lid 2019/2020

Chalazion
Cause:
Meibomian gland duct obstruction due to seborrhea or
Vit A deficiency.

Hints in case:
 Better felt than seen & better seen from conjunctival side.
 Decrease in size with forcible closure of lid.
 Causes of recurrence: Errors of refraction-
refraction DM- seborrhea

Complications
A. Mechanical effect:
 Upper lid: Mechanical ptosis & astigmatism
 Lower lid: Mechanical Ectropian
B. Infection (internal hordeulum) : Antibiotic then excision
C. Rupture through conjunctiva→Chalazation
conjunctiva Granuloma
D. Recurrence:: old age in same position : biopsy to exclude
malignancy
Treatment:
 Incision vertical from conjunctival site & curette operation
 Excision

Blepharo-phimosis
Findings: (peln)
1. Ptosis
2. Epicanthus
3. Lower lid ectropion
4. Narrow fissure
5. Apparent esotropia

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38
Eye lid 2019/2020

Trichiasis(± Corneal Ulcer)

Cause:
Localized scaring of the lash follicles due trachoma, chemical injury, ulcerative Blepharitis

Hints in case = Symptoms:

Foreign body sensation + Blepharospasm, lacrimation, photophobia (BLP)
Complications:
Affects cornea & conjunctiva by:
 Ulceration
 Vascularization
 Opacification
 Keratinization
Lines of Treatment:
 Epilation
 Laser photocoagulation
 Z-plasty

Distichiasis
Definition: congenital extra raw of eye lashes from the white line (opening of tarsal glands)
behind gray line

Treatment: cryotherapy

Complications: corneal ( 4 ation):

 Ulceration
 Opacification
 Vascularization
 keratinization

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39
Eye lid 2019/2020

Ectropion
Clinical Picture:
 Epiphora: over-watering
watering of the eye
 Eczema
 Exposure keratitis
A. Upper lid:
Cause is always Cicatricial as burns
& vertical wounds

B. Lower lid:
i. Cicatricial Senile lower lid Ectropion
ii. Mechanical: as Chalazion
iii. Senile
iv. Paralytic (facial nerve): if he has bell's phenomena refer to Neurologist

Treatment:
 If mild Z-plasty
 If extensive skin graft

To prevent exposure keratitis

(due to Lagophthalmos):
 Lubricants at night
 Lateral tarsoraphy
 Lower lid support by fascia lata or sutures
 Lateral tarsal sling

Cicatricial lower lid Ectropion

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40
Eye lid 2019/2020

Entropion Lower Lid Entropion

Symptoms & complications:
As Trichiasis
Upper lid:
Cicatricial (Only cause): Trachoma - Diphtheria - Chemical injury
Lower lid:
(young (old
Congenital
age) - Senile
age)
Cicatricial: Trachoma - Diphtheria - Chemical injury
Treatment (according to tarsus scarring):
 Mild: resection
 Extensive: tarsal graft

Coloboma of eyelid Epicanthus

Complication 
exposure keratitis (Lagophthalmos
Lagophthalmos ulcer)
ulcer
Treatment: Surgery Treatment
Treatment: Follow up

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41
Eye lid 2019/2020

Ptosis
Causes:
 Mechanical (chalazion)
 Congenital
 Senile
 III nerve palsy (+ divergent squint)
 Myasthenia gravis (intermittent)
 Horner’s syndrome

Consequences of ptosis:
 Overaction of frontalis: Astonished look
 Compensatory Head & Body Posture
 Amblyopia:
d.t. Defective vision before 6 years (severe ptosis)
Treatment: Surgery
Levator function test: if poor → sling
iff good → resection

Congenital ptosis
Associations:
1. hypotropia due to levator & superior rectus palsy(paresis) both by same nerve => squint
2. has same myotome 3. blepharo-phimosis
blepharo 4. Marcus Gun jaw winking 5. Epicanthus
Marcus Gun Jaw Winking Phenomenon
Due to III and V cranial nerves Synkinesis

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42
Eye lid 2019/2020

Ptosis +

Ectropian + ‫ﻗﺎﻓل‬
Exotropia +Plen
‫ﻋﯾﻧﯾﮫ‬

III nerve Pulsy Blepharaphemosis

Facial Palsy
" induce lagophthalmos and paralytic ectropion "

Conjunctiva
Conjunctivitis Head lines 43
Pterygium 45
Trachomatous Pannus 46
Mucopurulent Conjunctivitis 47
Phlycten Conjunctivitis
ctivitis 48
Spring Catarrh 49

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43
Conjunctiva 2019/2020

Conjunctivitis Head lines

How to identify:
 Conjunctival injection
 Discharge
Hints in case = symptoms: DDR
 Discharge
 Discomfort
 Redness
 BLPH (Trachoma – Spring Catarrh)
Catarrh
 Severe itching + Papillae (Spring
( Catarrh)
Mechinacal ptosis
Signs:
Conjunctival Injection – Lid edema – chemosis (conj. Edema) – discharge – conjunctival
reaction – lymph node enlargement (as in viral infections and severe bacterial infections eg
:gonococcus) Types of conjunctival reaction:

1- Follicular reaction 2- Papillae reaction

Absent before 3 months Spring catarrhal action

Either viral or toxic Ophthalmianeonatorum
Giant Papillae in contact lens

3- Both follicular & Papillae in Chlamydia (Trachoma).

4-Pannus (Trachoma) 5-Nodule

Nodule (Phlycten)

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44
Conjunctiva 2019/2020

Conjunctival
Discharge

Watery Mucoid Muco-purulent Purulent

Scanty Profuse MPC

Viral Allergy Gonococcus
(Trachoma) (Bacterial)

Complications of conjunctivitis:
A. Secondary corneal ulcer (Investigation:
(Investigati Fluorescein)
B. Scar: (Trachoma) Trachoma Trichiasis
 Trichiasis Diphtheria Entropian Trichiasis
Conjunctival
 Entropion Trichiasis scar Xerosis
Chemical injuries
 Xerosis Symblepharon
syndromes
 Symblepharon
C. Systemic spread (In Ophthalmia neonatorum)
neonatorum

Treatment:
A. Bacterial
 Broad spectrum Antibiotic drops / Ointment
 Bath the discharge by Boric acid lotion
 Never bandage
B. Viral
 Acyclovir
 Cold foments
C. Chlamydial
 Azithromycin: single dose
 Atropine in corneal ulcer
 Erythromycin in ophthalmia neonatorum

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45
Conjunctiva 2019/2020

Pterygium
Definition:
Fibro- vascular encroachment of conjunctiva on cornea due to chronic exposure to UV rays &
dust in soldiers & farmers.

Site:
Nasal, bilateral, triangular

Types:
Progressive or stationary
Fleshy & membranous

Clinical presentation:
Disfigurement, drop of vision, sense of irritation

Treatment:
 Follow up if small and no symptoms
If symptomatic:
omatic: surgical excision with limbal stem cells transplantation
NB: pseudopterygium: a part of conjunctiva is used as a corneal graft (positive hook test)

Sub-conjunctival
conjunctival Diffuse Episcleritis
Hemorrhage

- Blunt trauma - Cough More common in middle aged females

- Spontaneous - Bleeding tendencies - Tender

- Hypertension - Infection (viral) - Immobile

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46
Conjunctiva 2019/2020

Trachomatous pannus
Causative organism:
Chlamydia Trachomatous types A, B, C
Symptoms:
 Discomfort, Discharge, Redness
Blepharospasm, lacrimation, photophobia

Signs:
Active:
 Herbet's rosettes
 Active pannus ( Vascular, Cellular, Annular, tenuis )
 Mature follicles + Papillae ( Pink, Projectile, Fleshy, Finger like)

Inactive: Healed Trachomatous Pannus

 Herbet's pits
 Healed pannus
 Arlet's line
 Post Trachomatous degeneration
 Post Trachomatous
us concretions
 Healed Trachoma

N.B no solid immunity (there may be both active & inactive signs at the same time)

Complications due to scar:

 Dry eye
 Corneal ulcer
 Conjunctival scar
 Trichiasis
 Entropion
 Symblephron
 xerosis
Treatment: Post Trachomatous fibrosis
A. Active: (if there is ulcer)
Azithromycin+ atropine.
B. Inactive :( Of complications: as dry eye, Trichiasis)
Surgical removal of projecting Post Trachomatous degenerations.

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47
Conjunctiva 2019/2020

Herbet’s pits

Mucopurlent Conjunct
Organism:
Bacteria (staph)

C/P
as before +
 Red fornix
 Mucopurulent discharge
 Lids sticked together
 Lashes glued

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48
Conjunctiva 2019/2020

Ophthalmia Neonatorum
Causative organism:
 Chlamydial oculu-genetalis
genetalis (D~K)(most common)
 Neisseria Gonorrhea (most serious)
 Herpes simplex virus watering discharge
 Other Bacteria

Symptoms:
 Discharge (type according to cause)
 Redness
 Papillae only
Investigations:
Complications: Conjunctival swap
 Secondary corneal ulcer up to perforation Treatment:
 Systemic spread Topical &Systemic
Systemic erythromycin +
parent examination

Phlyctenular keratoconjunctivitis
Cause: (type IV hypersensitivity)

Endogenous: staph in lids, strept in tonsils ,TB in the

lung
Symptoms:
No discharge unless infected
D.D: Nodular Episcleritis (Non motile- tender) Limbalphlycten

Signs: Types:
 Yellow nodule surrounded by hyperemic zone  Conjunctival Phlyctenular pannus
 Non tender  Limbal
 Mobile with conjunctiva D.D: Nodular Episcleritis
Treatment:  Corneal
 Cause Complications:
 N-SAID / SAID (topical and short term) 1. Pannus
 broad spectrum antibiotic eye drops 2. Ulcer: Marginal Fascicular
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49
Conjunctiva 2019/2020

Spring Catarrah
Hints in case + symptoms:
 Seasonal (spring, summer)
 More frequent in boys
 Positive family history
 Age between 5-25
 Limbal gelatinous nodules
 Ropy discharge + (redness, discomfort, blepharospasm, lacrimation, photophobia)
 Sever itching
 Cobble Stone “palpebral “
 Tranta spots “limbal “

Cause:(typeype I hypersensitivity reaction

reaction)
UV rays
Pollen, dust, fumes
Complications:
 Pannus
Tranta spots in bulbar SC
 Ulcer (keratitis superficialis vernalis of Tobgy)
 Keratoconus
 Cataract
 Glaucoma
 Mechanical ptosis

Treatment:
A. During attack
N-SAID
SAID (topical for short term)
B. In-between Cobble stone in palbebral SC
Mast cell stabilizer
Anti-histaminic = Giant papillae maybe due to :
C. Symptomatic Contact lens wearer
Dark glasses Protruding sutures
Cold foments Most important spring catarah
D. TTT of Complications

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50
Lens 2019/2020

Spring catarrh phlycten

Type I hypersensitivity Type IV hypersensitive
(atopy) (delayed/ cell mediated)
Exogenous antigen Endogenous antigen
Examples Staph in lid
Ultra violet rays Strept in tonsils
Fumes TB in lung
Pollen grains parasite in intestine

Lens
Congenital Cataract……………………………………………………………………………………………………………..
…………………………………………………………………………………………………………….. 52

Senile cataract……………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………….. 53

Others …………………………………………………………………………………………………………………………………56
…………………………………………………………………………………………………………………………………

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51
 Lens 2019/2020

Abnormal position Sublaxation

Congenital
3H. 3M Senile Lens Dislocation (Ant.,post.)
Hypoxia Mental
Hypocalcaemia Malnutrition
Hereditary Maternal ds Opacity (Cataract)
“rebella”

Peripheral ∆ Central Special shape The whole pupil

Incipient immature
cortical cataract
White wrinkled 2 colors other (± KPs ,
Night vision Y Synechea,..)
+ Riders In Iris
Fixed Musca Ant.
Lamellar Nuclear Rosette
Polar YAG Vossiu Sutural Mature Hyper-- Morgagnion Complicated
Haloes around light Congenital Senile shaped Cap. Senile mature
Congenital cataract
cataract cataract traumatic cataract cataract
cataract
Astigmatism and riders cataract

Uniocular diplopia If with slit

lamp
Hypermetropic shift
Post.
Polar
Congenital
cataract Page
52
Lens 2019/2020

Congenital cataract

Q mention 2 causes:
 Hypoxia
 Hypocalcemia specially in lamellar type Leucocoria

 Malnutrition
 Rubella
 Galactosemia

Symptoms: by Mother
 Leukocoria DD : most common congenital cataract
Most serious: Retinoblastoma
Posterior polar cataract
 Drop of vision

Management:
A. Preoperative:
 Full pediatric examination
 Fundus by US or ophthalmoscope depending on
intensity of opacity Lamellar or zonular cataract with
 Biometry riders(most important cause is hypocalcemia )

 Pupillary light reflex

 Electro-physiology (Electro-retinogram,
(Electro electro-
oculogram, visual evoked potential)
B. Surgery
Irrigation aspiration
Lensectomy with posterior capsulotomy
Lamellar cataract against red reflex
C. Visual rehabilitation
Younger than 2 years use contact lens
Older than 2 years use intra
intra-ocular lens or glasses
N.B. Glassess are contraindicated in unilateral cases

Complications:
Amblyopia especially if opacity is dense, central, posterior,
Senile cataract Anterior polar catarct
asymmetric, affecting fixation.. Squint
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53
Lens 2019/2020

Nuclear cataract Mature cataract

Immature cortical Incipient cataract against

cataract (incipient) red reflex

Hypermature cataract Morgangnian cataract

Blue dot cataract

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54
Lens 2019/2020

Symptoms
 Gradual painless drop of vision
 White pupil
 Incipient: Halos,, fixed Musca, diplopia

Signs:
A. Posterior sub-capsular
On miosis decreased near vision, day blindness
B. Nuclear
Myopic shift:
i. Increase near vision (no reading glasses)
ii. Day blindness
C. Cortical
i. Incipient & immature
Night blindness + hypermetropic shift
Present red reflex with spoke like sectorial wedge in incipient
Iris shadow
Grayish white pupil
ii. Mature re &Hypermature
Hypermetropic shift
White pupil
Absent red reflex
Iris shadow only in hypermature
In hypermature anterior chamber is deep, iris is tremulous, and capsule is
wrinkled
Complications:
 Morgagnian cataract (pupillary block glaucoma)
 Phacolytic (secondary open angle glaucoma)
 Ectopia lentis:
Sub-laxation:
laxation: uveitis, diplopia(Uniocular)with clear lens IF cataracts Astigmatism
Anterior dislocation: Glaucoma inversus
Posterior dislocation (pupillary block glaucoma)
 Glaucoma from all types

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55
Lens 2019/2020

N.B. treatment of lens induced glaucoma is just cataract surgery after control of intra-
intra
ocular pressure

Management:
A. Preoperative
 Fundus by US or ophthalmoscope depending on intensity of opacity
 Biometry (axial length, kerato-metry)
kerato
 Pupillary light reflex
 Electro-physiology
physiology (Electro-retinogram,
(Electro electro-oculogram,
oculogram, visual evoked potential)
 Color perception to assess macula
 Light projection to assess field
B. Surgery
a. Large incision
Intra-capsular
capsular cataract extraction (only in sever sub
sub-laxation
laxation or dislocation)
Extra-capsular
capsular cataract extraction
b. Small incision
Phaco-emulsification:
emulsification: contraindicated in hard nucleus
C. Visual rehabilitation
Intra-ocular lens is of choice
D- post dislocation ttt : vitrectomy & lens extraction to avoid RD
E- Ant dislocation ttt : immediate
immediat extraction
complications of surgery: Indication of surgery:
 Posterior capsule Opacification 1- If the cataract to this patient
atient is visually handicapping
2- If causing glaucoma = mandatory
 Endophthalmitis
 Secondary glaucoma / Astigmatism

2ry / complicated cataract: cataract + ocular / systemic disease

Case example: young age (25 y) with lower than hand mo on in VA test which indicate defect in re na

Ectopia lentis :

Blunt trauma – hypermature cataract - pseudo exfoliation – collagen affecting diseases (marfan’s SS)

Page
56
Lens 2019/2020

Anterior dislocation of clear Sub-laxation

laxation
lens (oil droplet)

Complicated
plicated cataract

Traumatic cataract

A 66 -year- old male with Insulin Dependent DM presents

with gradual deteriora on of vision of 1 year dura on on, vision
is Hand Motion
otion,, the following investigation is of value :
ultrasonography
ultrasonography

How to asses retinal functio ?

light projection and color perception
light

Page
57
Lacrimal 2019/2020

Lacrimal
Chronic Dacryocystitis 58
Acute Dacryocystitis 60
Dry Eye 61

Page
58
Lacrimal 2019/2020

Chronic Dacryo-cystitis
Dacryo

Etiology:
A. Obstruction of nasolacrimal duct:
duct
 Congenital
 Acquired
Occluded lumen by concretions as eye lash
Pressure from outside as tumor
Stricture in the wall
Nose as polyp
B. Infection:
Pneumococcus 80%
Symptoms:
 Watery eye
 Discharge
 Swelling

Signs: Chronic Dacryo-cystitis

Dacryo with
 Epiphora positive regurge sign

 Positive regurge test

 Swelling below medial canthal tendon

Complications:
A. Spread,
Septic focus
Corneal ulcer
postoperative endophthalmitis

B. Eczema → Ectropion congenital dacryo

dacryo- cystitis
C. Acute on top of chronic
D. Mucocele or pyocele (swelling below medial canthal tendon with negative regurge
test)

Page
59
Lacrimal 2019/2020

Investigations & tests:

 Fluorescein John's dye test

 Regurge test
 Diagnostic syringing with saline

- Regurge from same punctum means canalicular obstruction

- Regurge from other & same punctum means nasolacrimal duct obstruction
 X-ray, CT Scan
 ENT consultant
 Congenital (Delayed
Delayed canalization: imperforate Hassner's
Hassner valve) : massage & AB
 A er 9 months: probing can be done

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60
Lacrimal 2019/2020

Treatment of chronic Dacryocystitis:

A. Acquired
 Dacryocystorhinostomy
 Dacryocystectomy only in contraindications of
Dacryocystorhinostomy

Treatment of complications:
 Lacrimal fistula: Dacryocystorhinostomy with fistulectomy
 Mucocele & pyocele: Dacryocystorhinostomy with silicone tube

Acute Dacryocystitis

Causative organism:
Pneumococcus or staph

Clinical picture:: fever, anorexia, headache,

malaise along with red, hot, tender lacrimal sac area
Complications
 Lacrimal abscess & fistula
 Cavernous sinus thrombosis Acute Fistula in Acute dacryocystitis
 Chronicity

Treatment
 Medical: hot foments & antibiotics
 Surgical: drain abscess if present
 DCR

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Lacrimal 2019/2020

Dry eye
Causes of dry eye:
 Contact lens use
 Lagophthalmos
 Sjogren's syndrome
 Sarcoidosis
 Distichiasis

Symptoms:
 Discomfort
 Defective vision
 Redness
 Dryness improve with blinking
Schirmer test
Signs:
 Dull lustreless cornea & conjunctiva
 Bitot spots

Special tests:
 Schirmer
chirmer test: dry eye if less than 5mm in 5 min (Sicca $)
 Fluorescein break up time
 Rose Bengal Dye

Treatment of dry eye:

 Treat the cause
 Replacement therapy:
Tear substitutes as hypotonic tears, lubricants
Punctal occlusion in severe cases

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Orbit 2019/2020

Orbit
Orbital Cellulitis 63
Preseptal Cellulitis 63
Thyrotoxic Proptosis 64

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 Orbit 2019/2020

Etiology: Orbital cellulitis

 Sinusitis
 Trauma
 History of EO surgery { squint – buckle }

Clinical picture:
A. General:
Fever, anorexia, headache,, malaise
{FAHM}
B. Local:
 Proptosis
 Lid edema Complications:
 Severe pain A. Spread
 Hot tender skin  Eye: panophthalmitis
 Limited motility  Optic neuritis, central retinal
Investigations : vein occlusion
 Brain: Cavernous sinus
 CBC
thrombosis
thrombosis, meningitis
 CT Scan
B. Exposure keratitis
Treatment: C. Healing by fibrosis (frozen orbit)
 Hospitalization
 Antibiotics
 Hot foment & analgesics
 If abscess : drain { diagnosed by CT}

Preseptal cellullitis
Differentiated from orbital celliulitis
(orbita lcelliulitis →proptosis and plegia)

Preseptalcelluitis (eye white)

Treatment:
Abs and hot foment

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Orbit 2019/2020

Thyrotoxic Proptosis
Cause:
It is due to thyroid gland dysfunction
leading to extra-ocular
ocular muscle enlargement.

N.B. the commonest muscle affected is

inferior rectus leading to limited up-gaze.
up

Signs:
 Proptosis & limited motility
 Lid retraction & lid lag
 Corneal exposure
 Hyperemia along recti muscles

Complications: Treatment:
 Exposure keratitis  Treatment of thyrotoxicosis
 Systemic steroids + radio therapy
 Compressive optic neuropathy
 2ry glaucoma  Surgical:
Orbital decompression:
decompression if severe exposure
Investigations : or compressive optic neuropathy
 Thyroid func on (T3, T4, TSH) Extra-ocular
ocular muscle recession:
recession if diplopia
 CT, MRI
Hertel's exophthalmometer

Used to measure degree of Proptosis

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Injuries and trauma 2019/2020

Injuries and trauma

Hyphema 66
Ectopia lentis 66
Sub conjunctival haemorrahage 67
Iridodialysis 67
Open globe injuries 70
Chalcosis 71
Chemical injuries 72
Comotio retenea 76

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Injuries and trauma 2019/2020

Hyphaema
Causes:
 Trauma
 Rubeosisiridis
 Spontaneous (leukemia, blood diseases)
 UVEITIS

Complications:
 2ry Glaucoma either open angle or closed angle {
The blood cells trabed in the angle, so hyphema
is worse with sickle cell anemia }
 Corneal blood staining

 Rebleeding
 Uveitis
 Fibrosis { synechia }

Treatment:
 Bed rest in a semi-sitting
sitting position
 Follow up of intra-ocular
ocular pressure
 Topical steroids
 Eye shield
 Surgical evacuation

Iridodialysis
Symptoms:
Ectopia lentis
Uniocular diplopia

Signs:
Sublaxation – Anterior dislocation –
D shaped pupil & double red
Posterior reflex
dislocation
Treatment:
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Injuries and trauma 2019/2020

Sublaxation
Cause (same for all):
 Congenital (Marfan syndrome)
 Traumatic
 Hypermature cataract
 Buphthalmos

Signs:
 Drop of vision
 Uni-ocular diplopia
 Tremulous iris
 Irregular anterior chamber

Complications:
 Uveitis
 Cataract
 2ry Glaucoma
 Dislocation

Treatment:
 Glasses in case of no complications
 Lens extraction + Anterior Vitrectomy

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Injuries and trauma 2019/2020

Anterior dislocation

Signs:
 Myopic shift
 Spherical globule of oil in anterior chamber

Complications:
 Uveitis
 Cataract
 Glaucoma inversus
 Corneal endothelial damage{edema)
damage

Treatment: Immediate lens extraction with IOL

Posterior dislocation

Signs:
 Hypermetropic shift
 Signs of aphakia (jet black pupil,
tremulous iris, deep anterior chamber)
 Lens is seen in fundus

Complications:
 Uveitis
 Cataract
 2ry glaucoma
 Rosette shaped cataract
TTT :
• CL for non complicated cases
• If Complicated: Vitrectomy & silicon oil injection + Lens Extraction
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Injuries and trauma 2019/2020

Sub-conjunctival
conjunctival haemorrahage
Causes:
Ocular trauma or fracture base of skull

How to differentiate from slide & case:

Ocular trauma Fracture Base of skull

Onset Immediate Delayed

Laterality Unilateral Usually Bilateral

Color Bright red Dark red

Shape Base towards limbus Base towards fornix

Investigations :
Blow out fracture of orbital
 X-ray.
floor complications:-
 Ct-scan.
 Enophthalmos. Treatment
 Hypotropion.  Bone repair or bone implant.
 Restriction
estriction of muscles  If Endophthalmos
ndophthalmos or diplopia →
limited up gaze. Surgical Treatment.
Treatment
 Vertical diplopia.  Infra-orbital
orbital anathesia.
Blunt trauma to the eye  corneal edema, vitreous  Surgical emphysema.
Hge, acute ant. uveitis retinal bone specules cannot be
attributed to the trauma,, if limited eye elevation
elevation can
be fractured orbital floor CT orbit to confirm diagnosis
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Injuries and trauma 2019/2020

Open Globe injuries

Clinical picture:
 Sudden drop of vision
 Pain, redness, watering
 Shallow anterior chamber
 Hypotony
 Sometimes intra-ocular
ocular foreign body
 Sometimes uveal prolapse

Management:
 Immediate sterile patching
 Prophylactic systemic antibiotics
 Anti-tetanus
 Imaging CT (avoid MRI in suspected metallic intra-ocular
intra ocular foreign body)
 Surgical repair
 Prophylactic Enucleation if blind or to avoid sympathetic ophthalmitis

Foreign Body
Symptoms
 Pain, defective vision, redness
 Reflex blepharospasm, lacrimation, photophobia

Complications
As Trichiasis Foreign body in
palpebral conjunctiva
Management
 Removal of the foreign body
on cornea
 Treatment of complications

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Injuries and trauma 2019/2020

Chemical injuries

N.B. Alkali burns are more dangerous than acid burs because they have greater degree of
penetration, while acid burns set up barriers against deeper penetration.

Symptoms
Pain, defective vision, redness, Blepharospasm, lacrimation, photophobia

Signs
 Lid &conjunctivaledema
 Conjunctival&ciliary injection
 Uveitis
 Corneal ulcers
 Corneo-scleral
scleral melting in severe cases
 COOKED FISH APPERANCE

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Injuries and trauma 2019/2020

Complications
 Scarring (Trichiasis, ectropian, entropian,
entropian, Symblepharon, corneal scar)
 Perforation

Management
A. Immediate Management
 Copious energetic thorough wash
with water or saline regurgitation
 Water is avoided in lime injury
 Removal of causative organism if
present Posterior
B. Subsequent Management Symblepharon
Topical antibiotic, steroid to avoid
symplepharon
Pain medication
Diamox & ΒB to decrease any rise of intra-ocular
intra pressure
Surgical (grafts)
C. Treatment of complications
Tarsoraphy for lagophthalmos
Penetrating keratoplasty if there is a corneal scar

Chalcosis
Ocular reaction due to retained intra-
intra
ocular copper alloy

Clinical presentation
 Kayser-Fleisher ring
 Sunflower cataract

Must be differentiated from wilson disease

N.B. Retained intra-ocular

ocular iron causes Siderosis Bulbi

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Injuries and trauma 2019/2020

Commotio retinae (Berlin's edema)

Traumatic macular oedema

Diagnosis:

 OCT
 FUNDUS
Treatment:

 Self follow up
 small amount of steroids
Complications:

Lamellar macular hole { degeneration of macula }

DD:
Cherry red Spot
Central retinal artery occlusion

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Tumors 2019/2020

Tumors
Retinoblastoma…………………………………………………………………………….75
Retinoblastoma…………………………………………………………

Malignant melanoma………………………………………………………..
melanoma………………………………………………………..…………..77

RETINOBLASTOMA MALIGNANT
MELANOMA
3-5 YEAR 50-60
60 YEAR

30% Bilateral multifocal Unilateral, unifocal

Stage 1
lucocorrhea drop of vision

squint field defect

uveitis uveitis

Stage 2
glaucoma (buphthalmos) glaucoma
Stage 3
proptosis
Stage 4
neuronal spread to the brain throw the
blood spread
optic nerve

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Tumors 2019/2020

Retinoblastoma
N.B. Retinoblastoma is a genetic disease presented
presented in children below 3 years of age with

equal incidence for both

oth sexes, present bilaterally.

Symptoms (Quiescent Stage): Leucocoria ( white pupil )

 Leukocoria 60% (amaurotic
amaurotic cat's eyes)
 Retinoblastoma (most serious )
 Squint  Congenital cataract (most common)
 2ry uveitis  Retinopathy of prematurity
 2ry Buphthalmos  Cyclitic membrane

Diagnosed by :
Complications
 Fundus examination for cataract
 Extra-ocular: Proptosis
 US for retinoblastoma
 Distant spread
 Amblyopia

N.B. In any case of Buphthalmus fundus examination has to be done to exclude

retinoblastoma.

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Tumors 2019/2020

Signs
Fundus

 Endo-phytic:
Cottage cheese appearance
 Exo-phytic:
2ry exudative retinal detachment
N.B. Both eyes have to be examined & other family members below 6 years.

Investigations
 Fundus
 US, CT Scan, MRI
 Lumbar puncture
 MRI brain

Treatment
A. Quiescent stage:
Laser photocoagulation
Trans-scleral cryotherapy
Radiotherapy
Transpupillary thermotherapy
B. Glaucomatous stage: Enucleation NEVER Evisceration
C. Extra-ocular stage: Exenteration
D. Distant spread: Palliative

Differential Diagnosis of Leukocoria

 Retinoblastoma
 Congenital cataract
 Cyclitic membrane
 Retinopathy of prematurity

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Tumors 2019/2020

Malignant Melanoma
Symptoms:
 Field Defect if peripheral
 Drop of visual acuity if central
 Asymptomatic
 2ry Uveitis

Complications:
 2ry Glaucoma
 Proptosis
 Pigmented epibulbar mass in ciliary body
melanoma
 Blood metastasis

Signs:
 Fundus
Mushroom shaped (collar stud) 2ry exudative
retinal detachment
 Gonioscopy in iris &Ciliary body melanoma

Q mention 2 Investigations :
 US, CT Scan, MRI
 Liver enzymes
 CT chest & abdomen
 Bone Scan

Treatment:
Same as Retinoblastoma

Mushroom shaped
malegnant melanoma

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Tumors 2019/2020

Why tumors cause 2ry Glaucoma:

 Space occupying lesion
 Direct angle invasion
 Tumor growth push the iris
 Tumor necrosis release toxins that cause toxic uveitis
 Neovascular Glaucoma due to consumption of blood supply causing ischemia
 Ghost cell glaucoma due to vitreous hemorrhage
 Blockage of the angle by pigment shedding in melanoma
 Closure of vortex veins

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Squint 2019/2020

Squint
(Strabismus)

True squint Apperent

Manifest Latent
squint Squint

Paralytic

Non -paralytic
paralytic

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Squint 2019/2020

Apparent Squint
Person shows squint but it is not true as the visual axis are parallel and no recovery movement
is detected by the cover test
Example: Epicanthus

About:
A fold of skin that covers the medial
canthus giving the appearance of a
convergent squint
Treatment:
Follow up: (with time, nasal bridge will develop dragging the skin fold to its normal position
away from the medial canthus)
If persists: surgical

True squint
1- Latent squint (Heterophoria)
Deviated visual axis in relation to the other eye ffrom normal
ormal direction (parallel) when
binocular vision is dissociated (e.g by cover or alternate cover test)

Types:
a. Esophoria (in) \ exophoria (out)
b. Hyperphoria (up) \ hypophoria (down)
c. Cyclophoria (rotational in or out)
Causes:
 bilateral hypermetropia
Errors of refraction :eso
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Squint 2019/2020

Exo bilateral myopia

Cyclo oblique astigmatism
Signs:
a. Error of refraction
b. No primary angle of deviation
c. Cover test (2ry angle of deviation)
d. Maddox wing or rod

Treatment:
a. Correction of errors of refraction
b. Orthoptic Treatment by synaptophore
c. Exercising prism
d. Surgical (if previous Treatment fails)

2- Manifest squint (Heterotropia)

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Squint 2019/2020

Non-Paralytic (Concomitant)
Types:
1- Unilateral with one eye fixating‫ﻟو رﺟﻌت ﺣدﻓت ﺑﻌد ﻣﺎ ﻛﺎﻧت اﺗﻌدﻟت‬
2- Alternating ‫ﻟو اﻟﻠﻰ ﻛﺎﻧت ﺳﻠﯾﻣﺔ ھﻰ اﻟﻠﻰ ﺣدﻓت‬
3- Horizontal deviation (most common) (eso (eso\exotropia)
4- vertical deviation (hyper\\hypotropia)
Causes:
a. Defective vision in one eye (e.ganisometropia, organic lesions, .. )
b. Accommodation and convergence abnormal relationship
c. Central causes

Symptoms:
a. Cosmetic disfigurement
b. No Binocular Diplopia

Signs:
a. No Limitation of movement
b. No Face turn or head tilt (since there is no diplopia)
c. 2ry angle of devia on is equal to the primary
d. Past pointing of objects

Treatment (have to be done before 6 years to avoid amblyopia)

a. Medical ttt (glasses
asses and drugs)
b. Orthoptic exercises for small degrees of squint
c. Surgical (last step and usually for unilateral squint when the cause is not refractive
error,, Cosme c especially a er 6 years of age)
age

 Exotropia Case + pupil not affected, no ptosis → not paralytic squint

ttt:: weakening of lateral rectus
 Head Trauma + Squint → inves gate for cause and conserve for 6
months,, if squint of 1 eye: Alternate covering

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Squint 2019/2020

Paralytic Squint

Causes (VITAMIN)
a. Traumatic
b. Metabolic \ Vascular (DM/HTN)
c. Myogenic \ neuromuscular
euromuscular
d. Mythania
e. Neoplastic
f. Idiopathic
g. Anurysm(as artery have a common course ē nerve)
h. M.S

Types
 III nerve →Divergent
Divergent (EXO) (pupil ex. If dilated ;need MRI as the cause is compresive so
need surgery while if pupil is constricted then medical ttt)
 IV nerve→ Hypertropia
 VI nerve→ Convergent (ESO)

Symptoms
a. Binocular Diplopia
b. Vertigo with nausea Treatment:
a. Treatment of the cause
Signs (3p +motility)
b. Refer to neuro
a. Limitation of movement
c. Alternate occlusion to avoid diplopia
b. Face turn or head tilt (posture)
osture)
d. Relieving
ing prism
c. 2ry angle of devia on is greater
e. Surgical
than the primary
d. Ptosis
tosis in case of 3 nerve palsy N.B: what else to examine?
a. Past pointing of objects Pupill in case of 3 nerve Pulsy

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Squint 2019/2020

Cardinal positions of gaze

N.B. Measurement of angle deviation of squint by corneal light reflex

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Instruments 2019/2020

Instruments and
Their uses

Maddox wing
An instrument that dissociates the two eyes for near fixation and measure the amount of
heterophoria.

Maddox rod

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Instruments 2019/2020

An Instrument
nstrument that dissociates the two eyes for Far

Synaptophore Optokinetic Drum

It is a rotating instrument to test vision in

young children

Binocular vision assessment

Uses:
Orthoptic exercise
The easy-to-operate
operate variable manual controls
enable the complete examination of
binocular potential, within one instrument. It
allows for the assessment of; simultaneous
perception, positive and negative fusional
fusiona
amplitudes and gross stereopsis.

Visual evoked potential

Uses:
Page
VEPs are used primarily to measure the87 functional integrity of the visual pathways from
retina via the optic nerves to tthe
he visual cortex of the brain.
Instruments 2019/2020

Fluorescein stain Rose Bengal stain

Use in corneal ulcer

+ve in dendritic ulcer

Fluorescein angiography:

We use it to diagnose new vessel formation at disc or elsewhere

(retinal vasculature for leakage or occluosion

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Instruments 2019/2020

slit lamp photokeratoscopy

Use: Use to assess shape of anterior surface of
cornea
1. Anterior segment examination
2. Posterior segment examination with help Diagnoses
of oher lens  Keratoconus
3. Routine observation of ocular adenxia  irregular astigmatism
4. Fluorescine dye may use during
examination to make it easier to detect a
foreign body
5. a camera maybe attached to silt lamp to
take photographs of different part of eye

Perimetry
Field examination (detect defect in visual field)
In retinitis pigmontosa (ring scotoma )
-glaucomatous cupping

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Instruments 2019/2020

Goniolens : Applantion tonometer

Use: in conjunctiva with slit lamp or Use for measure IOP
operating microscope to gain aview of AC
angle

Importance: Diagnosing
iagnosing & monitoring
various eye condition associate with
glaucoma

Autorefractometer
Device for measurement of an index of
Ishara colour test
refraction (refractectometry) for colour vison

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Instruments 2019/2020

Ocular ultrasonography:

A -scan
scan is used in cataract surgeries for IOL calculation
B-scan :
 To detect depth of AC
 To assess vitero-retinal
retinal disorder
 Detect tumor as malignant melanoma
 Thyroid opthalmopathy

Direct & indirect opthalmoscope

use to examine posterior segment of the eye (Fundus)

indirect opthalmoscope Direct opthalmoscope

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 2019/2020

New born

Epicanthus Blepharo Colobma Leucocoria Buphthalmos Ophthalmia Neonatorum

phemosis
Retinoblastoma

‫اﻟﻨﻈﺮ؛؛ ﺑﺤﻴﺚ ﺗﺜﻖ ﺑﺎﻟﻨ ﻴﺠﺔ اﻟ ﺎﺋﻴﺔ ؛ ﻌ ان ﺗﻨﻈﺮ ا اﻟﺸﻮﻛﺔ و ﺗﺮى اﻟﻮردة‬
‫ ﺑﻞ ﻌ ان ﺗ ﻮن ﻌﻴﺪ اﻟﻨﻈﺮ‬، ‫ﻻ ﻌ اﻟﺼ ان ﺗﺘﺤﻤﻞ اﳌﺼﺎﻋﺐ ﺳﻠﺒﺎ‬

‫ﺗﻤﺖ ﺑﺤﻤﺪ‬

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