Getachew K.

(MD)
 Ophthalmology cont..

Outline Basic anatomy & physiology of the eye

Examination of the eye

Diagnosis & managements of ocular disorders

Preventive ophthalmology
a) Orbit h) Vitreaus
b) Eye ball (globe) i) Retina & optic nerve
c) Lids & lacrimal apparatus j) Extra cular muscles (ocular
d) Conjunctiva motility)
e) Cornea k) Visual pathways

f) Sclera
g) Uveal tract
h) Lens
 The orbits are bony cavities contain the globes, extra ocular muscles,
nerves, fat, and blood vessels
 Each bony orbit is pearl (cone) shaped.
 Dimensions:
o Volume 30 cc
o Width – 35mm x 45mm, variable.
o Length (Ap) – 40 to 45mm.
 The orbital walls are composed of seven bones:
o Ethmoid bones
o Frontal bones o Palatine bones
o Sphenoid bones
o Lacrimal bones
o Zygomatic bones
o Maxillary bones
There are several
foramina & two
fissures that are
used by nerves,
arteries & veins to
pass through.
 Four walls of the orbit
oRoof of Orbit  Frontal bone, Lesser wing of sphenoid
oLateral wall of orbit  Zygomatic bone and greater wing of the
sphenoid bone.
oMedial wall of the orbit  Ethmoidal bone, lacrimal bone, lesser
wing of the sphenoid bone, maxillary
oFloor of Orbit  Maxillary bone, zygomatic bone and palatine
bone
 Has three layers and three cavities:
 1. The three layers (Coats) of eye ball:
a) The fibrous (outer) layer Cornea/sclera.
i. Cornea transparent
ii. Sclera opaque representing the white appearance of the eye ball
 Function:
o Along with the IOP, maintains the Shape, stability of the eye ball
o Optical
b) The vascular (Middle) layer  Iris/Ciliary body/Choroid------Uveal tissues.
o Brown to dark-brown in appearance.
o e.g. -The iris represent the brown appearing part behind the transparent cornea.
o Functions:
o Nutrition for the inner layers of the eye ball.
o Provide dark environment of the eye ball cavity to avoid image degradation. E.g. film developing
c) Neuro Sensory (inner) layer Retina/ RPE.
o Functions:- transducers the electromagnetic form of image to neuronal impulse to be dispatched to
the brain.
• The eye is a fluid-filled sphere
enclosed by three layers of
tissue:

1) The outer layer is composed of

the sclera(posterioly) and the
cornea(anterioly).

2) The middle layer includes

the iris, the ciliary body, and
the choroid.

3) The inner layer is the

actual retina containing the
photoreceptors.
 The three cavities of eye ball are:
a) Anterior chamber
oBetween the Cornea and anterior face of the Iris filled with the
Aqueous-fluid.
b) Posterior chamber:
oBetween the posterior face of the Iris and lens. Is also filled with the
aqueous.
o A and B communicate through the pupil.

c) Vitreous cavity
oBetween the Lens and retina Filled with Vitreous (jelly fluid)
o The iris contains a musculature
controlling the pupil size.
o Its function is to modulate the amount
of light that enters the eyes.

o This control originates from the brain

stem.
 Circular muscles under
parasympathetic control reduce
pupils size.
 Radial muscles under
sympathetic control increase
pupil size.
The ciliary body encircles the lens. It
contains a musculature that adjusts
the refractive power of the lens.
Together with the cornea, the lens
help focusing the image on the
retina.
The choroid is a capillary bed.
It supplies oxygenation &
metabolic substance to the
cells in the retina, including
the photoreceptors.
The aqueous humor is a clear,
watery liquid in the anterior
chamber produced by the ciliary
body in the posterior chamber.
It regulates the intraocular
pressure.
The vitreous humor is a thick
gelatinous substance between the
back of the lens and the retina. It
accounts for the size and shape of
the globe.
Retina:
Retinal Image Formation
The ability to focus an image on the retina depends on
the refractive power of both the cornea lens
as well as on the shape of the eye globe.
When an object is distant, the light
rays are essentially parallel and
brought to a focus on the retina.

If the object moves closer, the focal

point then moves behind the retina.

To bring the image into focus on the

retina, the lens refractive power
must be increased. This is the
process of accommodation.
 Eye color is determined by the relative number of melanocytes
in the stroma and of course the density of melanin granules
produced.
 Few cells give a blue color, whereas many melanin- containing
cells produce a dark brown color; gray and green are the
intermediate colors.
 It has a circular aperture (pupil) that can be opened and closed by
the action of groups of smooth muscle. Contraction of the pupil
reduces the amount of light entering the eye and thereby reduces
the glare from light scattered from the periphery of the lens.
 There are seven extra-ocular muscles that are used for movement of the
eyes.
 Four rectus muscles –
o Medial rectus
o Lateral rectus
o Superior rectus
o Inferior rectus
 Two oblique –
o Superior oblique
o Inferior oblique.
 Levator palpebrae superioris.
 The pupil may be considered to have three major optic functions:
1) To regulate the amount of light reaching the retina;
2) To diminish the chromatic and spherical aberrations produced by the
peripheral imperfections of the optical system of the cornea and lens;
and
3) To increase depth of field (analogous to the f-stop setting of a camera).
Pupillary Light Reflexes:
 Shining a light into each eye can elicit a direct and a consensual
pupillary light reflex.
 This light reflex tells us about the state of a patient’s visual
pathways and helps identify the cause of structural coma.
 Visual Pathways:
The optic tract projects primarily to the thalamus
(lateral geniculate nucleus), which projects to
the visual cortex in the occipital lobe.
En route to the retina, light
successively travels through:

1) the cornea
2) the aqueous humor of the
anterior chamber
3) the pupil
4) the lens
5) the vitreous humor
Conjunctiva:
 Named so because it conjoins the eyeball to the lids

 Is a thin, transparent mucous membrane that lines the

posterior surface of the lids, and is then reflected forwards
on the eye.
 Conjunctiva is continuous anteriorly with the epithelium of
the cornea.
 Recessed in the eyelids, the conjunctiva forms a cul de sac,
which is open in front at the palpebral fissure, and only
closed when the eyes are shut.

 Although all parts of the conjunctiva are continuous each

has been given its own name to emphasize anatomic
differences.
 The regional variation of the conjunctiva
start with an overview in a photograph in
which the patient is looking up.
 The limbus (1) is the junction of the
conjunctiva and cornea.
 The bulbar conjunctiva (2) covers the eyeball
and extends into the recess created by
forniceal conjunctiva (3).
 The tarsal conjunctiva (4) covers the tarsus.
 The marginal conjunctiva (6) is at the eyelid
margin where the epithelium will begin to be
keratinized.
 The punctum (5) is also shown.
Cornea
Dimensions - in the adult typically measures
10.5 mm vertically and 11.5 mm from
horizontally.
Centrally the cornea is about 500 microns
(515-539) in thickness and peripherally it is
about 650 microns thick.
The cornea is more curved than the eye and
protrudes anteriorly.

The cornea has five layers.

The five layers of cornea .

1. Epithelium
2. Bowman’s capsule
3. Stroma
4. Descemets
memebrane
5. Endothelium
The sclera
• The sclera is the white tunic that covers and protects the eye,
made of collagen.
At the insertion of the rectus muscles (posteriorly) it is thinnest
0.3mm.
At the equator it measure 0.4-0.5 mm and at the posterior pole
in measures 1.0 mm.
The thickness of the sclera is relevant to areas prone to
rupture. Blunt trauma most frequently results in rupture of the
eye at the thinnest site, behind the insertions of the rectus
muscles.
At the entry site of the optic nerve, the sclera is perforated in a
sieve like structure to admit optic nerve bundles, axons of
ganglion cells. This sieve of sclera is called the lamina cribosa.
In addition there are other channels through the sclera called
emissaria. Posteriorly there are aperatures around the optic
nerve through which the long and short posterior ciliary arteries
and nerves pass.
About 4 mm posterior to the equator apertures permit the
passage of the vortex veins. Anteriorly, anterior ciliary vessels,
branches of vessels to the rectus muscle, and nerves pass.
Lacrimal gland:-
Lacrimal gland-human
• How many lacrimal glands are there in each
orbit?
Main (orbital and palpebral portions) + Glands of
Krause (50) + Glands of Wolfring (5) + caruncle (1)
= About 57!

• What is the blood supply to the lacrimal glands?

The arterial blood supply originates from the
ophthalmic artery via the lacrimal artery.

• What is the innervation of the lacrimal gland?

The lacrimal nerve provides sensory innervation.
1. Visual acuity examination
2. Alignment and motility examination
3. Pupillary examination
4. Visual field examination
5. Intraocular pressure measurement
6. External examination
7. Biomicroscopy
8. Ophthalmoscopy
12/29/2017 44
To provide an assessment of ocular adnexa, external globe and anterior
chamber

 Inspection
 Palpation
 Examination by flashlight !
Visual acuity:- the ability to discern fine visual detail.
Distance visual acuity:-
 Snellen Chart!
 Distance 6 meters
 Numeric notation at the left of each line of the snellen characters
e.g. 6/12
The numerator= the distance at which the test was performed
The denominator = the distance at which the letters could be
seen by a person with “normal” visual acuity.
OD = Oculus Dexter = it is a Latin word for “visual acuity in
the right eye”
OS = Oculus Sinister = visual acuity in the left eye
OU = Visual acuity in both eyes
e.g.VOD=6/60 , VOS= 6/24
For those who are not able to see the largest snellen letter
 Repeating the visual acuity at shorter distances
 Count the number of fingers
 Hand motions
 Detect light
The ability to see clearly at a normal reading distance (i.e. 33cm)
=>Near acuity card (distance equivalent)
Snellen chart

 The chart is designed so that the top line can be read by

someone with normal vision at 60 metres, the next at 36
metres, the next at 24, the next at 18, the next at 12, the
next at 9, and the next at 6 metres. Acuity is recorded as
6/60, 6/36, 6/24, 6/18, 6/12, 6/9, 6/6 to indicate the last
line accurately read (6/6 vision is normal). For acuities
<6/60 patients can be brought forward to 5, 4, 3, 2 and 1
metre from the chart to read the top line. If he can read it
then acuity is expressed as that distance, eg 5/60, 4/60,
3/60, 2/60 or 1/60. If the vision is below 1/60 ask the
patient to count your fingers at 50cm distance.
Snellen chart cont..

 This is recorded as CF (count fingers). If unable to count

your fingers move your hand in front of the eye at a
distance of 25cm. If the patient can appreciate that your
hand moves, record HM (hand movement). If the patient
cannot appreciate hand movement, dim the light in the
examination room and shine a torch light into the eye. If
the patient perceives light, record PL. If there is no
perception, record no PL (the eye is blind). NB: in
practice, if nothing on the Snellen chart can be read, it is
common to go straight to finger counting.
Snellen chart cont..

 If the patient sees less than 6/6 with or without

glasses, examine again with a pin-hole in front of the
eye: a narrow beam removes the need for focus. In
simple refractive errors, acuity will improve through
the pin-hole.
 Admits only central rays of light, which do not require
refraction by the cornea and the lens
 If vision improves with PH test, the patient has
refractive error; but in case of high myopia i.e.>-8, the
vision may not improve.
 If no improvement with PH test, the visual problem is
due to a cause other than refractive error, so additional
test is necessary.
 Color vision defects may be hereditary or acquired.
 Most hereditary defects are transmitted by the mother and usually affect male
offspring;
 Hereditary color blindness occurs in 8% - 10% of males and in less than 0.5% of
females. Because the defective gene is recessive, many more females carry the gene
than actually have a color vision defect.
 Acquired color blindness occurs when the macular photoreceptors, the cones, have
been damaged by optic nerve or macular disorders.
 For normal colour vision we require cone photo-pigments sensitive to blue,
green, and red light.
 The commonest hereditary colour vision defect is X-linked failure of red-green
discrimination.
 Blue-yellow discriminatory failure is more commonly acquired and sexes are
affected equally.
Eye movement:-
 In six directions to test the function of the six extra ocular muscles
 May reveal weakness /paralysis or restriction
Eye Alignment:-
 Corneal light reflex
Four procedures in pupillary evaluation:
 Measurement of pupil size in dim illumination
 Speed of pupillary constriction to a bright light
 Pupillary response to a near target
 Swinging light test (direct and consensual pupillary reaction)

May reveal:-
- Iris muscle/ nerve damage
- optic nerve/retinal pathology
- diseases of the visual pathway and the brain.
 Measures the expanse of vision surrounding the direct line of sight
(peripheral vision)
 Disturbances could be due to diseases of the retina, optic nerve or
structures of the visual pathway in the brain.
=> Confrontation field test
 Tonometry, Tonometer
 Principles:- - Digital
- Applanation e.g -Goldmann
-Tonopen
- Indentation e.g Schiotz
Slit lamp biomicroscope!!
A magnified view of the patient’s adnexa &
anterior segment structures.
- Lid margins and lashes
- conjunctiva
- sclera
- cornea and tear film
- anterior chamber, iris, lens and
vitreous
- retina, macula & optic nerve head
 Direct
 Indirect
The normal one DDx:
Refractive errors
Strabismus
 DDx
Lens problems e.g:- cataract, etc.
Retinal problems e.g:- retinal detachment
V. humer problem like any mass lesions
The normal one
 Refractive errors
 Cataract
 Presbyopia
 Glaucoma
 Strabismus  Trachoma
 Amblyopia
 Red eye
Refractive Errors:
Refractive states of the eye

 Measured looking in the distance(usually 6mts) so

that the ciliary muscle is relaxed (that is not
accommodated)
 Emmetropia
 A normal condition
 Parallel rays of light from infinity come to a focus on
the retina (fovea)
=> no error of refraction/visual acuity is normal
 Ametropia
 Abnormal condition/absence of emmetropia
 Parallel rays of light from infinity do not come to
a focus on the retina (fovea)
=>error of refraction:
* Myopia or short/Near-sightedness
* Hyperopia or long/Far-sightedness
* Astigmatism
* Presbyopia
Anisometropia

 Unequal refractive power of the eyes

e.g :-
1. one eye emmetropic, the other one myopic

2. OD;- 0, OS:- -3.0 D

3. OD:- +1.5 D, OS:- +3.5 D

 Pinhole test:

 Any patient with defective visual acuity

should be tested again with a pinhole
 If visual acuity improves with pin hole,
 refractive error
 If no improvement  the loss of vision is
is due to other causes.
 Ametropia cont…
 Axial ametropia:-
- the eye ball is either unusually long
(Hyperopia) or short (Myopia)
 Refractive ametropia:-
-The length of the eye is normal
- Excessive power in myopia, inadequate in hyperopia
Myopia = Short-sightedness
 Short-sightedness
 A condition where the light rays from a distance
object are focused in front of the retina.
 Therefore the image at the retina is blurred and
the vision is poor for distance objects, but good
for near objects.
 The greater the degree of myopia, the closer
the patient has to hold things to see them
clearly without any spectacles
 Treatment of myopia
 Concave(-) spherical glasses
 Contact lenses (concave)
 Laser surgery
 Hyperopia / Hypermetropia
= long-sightedness
 An error of refraction in which parallel rays of light
from infinity come to a focus behind the retina, so
they are blurred at the retina.
 Visual acuity is decreased except for young people
who can use their accommodation to focus on the
retina.
 With age the power of accommodation decreases.
 Symptoms of Hyperopia
 Blurring of near vision
 Not much compliant regarding distance vision, as
distance vision does not need accommodation that
much.
 Headache due to constant strain on accommodation
 Treatment
 Convex (+)spherical glasses
 Convex contact lenses
 Laser surgery
 Presbyopia
 Usually becomes at age beyond 40 years
 Part of the natural ageing process in the
lens
 With age lens becomes harder=>loss of
elasticity of the lens=>loss of
accommodative response
 The eye can still see distant objects
clearly, but cannot focus on near objects.
Symptoms of Presbyopia

 Blurring of vision while reading books/carry out

near- vision tasks.
 Vision improves if the object is held further away
from the eye.
 Those doing close work feel the symptoms earlier.
Treatment of presbyopia

 Convex (+) spherical lenses, which is added on

glasses if any for distant vision.
 Strabismus

- Strabismus = a Latin word for squint

- Squint = eyes are looking in different
direction
- Many possible causes for a squint to
develop  a cause should be looked for
- For a squint to develop, Binocular
reflexes should fail.
 Strabismus cont…
 Esotropia:- inward deviation

 Exotropia:- outward deviation

 Hypertropia:- upward deviation

 Hypotropia:- downward deviation

Esotropia
 Inward turning of the eye
 The most common form of childhood strabismus
 Usually associated with hyperopia
 Types:
– congenital
– Acquired:
 Accommodative
 Nonaccommodative
 Incomitant e.g VI nerve palsy
Management of Esotropia

 Convex (+) glasses

-Accommodative esotropia
 Surgery
- Congenital Esotropia
- Acquired nonaccommodative esotropia
- Paralytic esotrpia
 Parasympathomimetics
 Exotropia:
 Outward deviation of the eye
 Types:-
– Congenital
– Acquired
 nonparalytic

 paralytic e.g III nerve palsy

Management of Exotropia

 Nonsurgical
Corrective glasses espe. Myopia
Overminusing!
 Surgical
Vertical Strabismus

 Hypertropia, hypotropia
 Types:-
-Comitant:-usually accompanies horizontal
strabismus
-Incomitant - muscle restriction
- paralytic e.g IV nerve palsy
Management of Vertical strabismus:

Surgery!
Management of Strabismus
 In children:-
1. Find the cause
2. Correct refractive errors with spectacles
3. Treat Amblyopia
4. Straighten the eyes with surgery
 In adults:-
- If the squint started in childhood = cosmetic surgery
- If the squint is recent
-look for a cause
-wait 6 mons.before considering surgery
Amblyopia

 Poor vision caused by abnormal visual experience early in life.(i.e

in the immature visual system)
Visual development

 Latent period in first 6 months of life

 Followed by critical or sensitive period (6 months - 2 years)
 Continues until 7/8 years
 Affected by disease/visual deprivation in sensitive period
f
Amblyopia

 Amblyopia: a Greek term

Amblyos: dull/blunt
Opia: vision
 Occurs in 2-4% of the general population

 The most common cause of decreased vision in childhood

(birth-7/8 yrs.)
Definition of amblyopia:

 A unilateral/bilateral reduction of best corrected visual acuity that

can’t be attributed to the effect of any structural abnormality of
the eye or posterior visual pathway.

 If best corrected vision in one eye is at least two lines worse in the
snellen chart than the other eye or a vision of 6/12 or worse in
both eyes
Amblyopia: Pathophysiology

i. Abnormal binocular interaction

ii. Retinal image blur
iii. Both

Causes: Three “D”s

i. Deviated strabismus
ii. Defocused anisometropia, ametropia
iii. Deprived Ptosis, cataract, corneal opacity
Management:

 One of the most time consuming tasks in pediatric ophthalmology

,but if successful it is one of the most rewarding!

 Basic Strategies:-
1. Provide a clear retinal image-(refraction)
2. Correct ocular dominance-(occlusion)
Management cont..

1. Occlusion: gold standard

Principle:- cover the sound eye to force the poorer
eye to see better
2. Penalization (pharmacologic)
Blurring of the sound eye to force fixation with the
amblyopic eye
Occlusion
Red eye:

Definition
Common causes
Differential diagnosis
Urgent causes of red eye
Red eye - ocular hyperemia:
Red eye cont..
The DDx for red eye are numerous ranging from trivial conditions like
sleeplessness & fatigue to life threatening conditions as cavernous
sinus thrombosis and carotid cavernous fistula.
Clinically simple and conventional way of categorizing causes of red
eye:
1) Painless red eye
– Conjunctivitis
– Pterygium and others
2) Painful red eye
– Keratitis and corneal ulcer
– Iridocyclitis
– Angle closure glaucoma
– Episcleritis and Scleritis
PAINLESS RED EYE

Causes of painless red eye are mostly self

limiting .
If they are neglected and mismanaged they will
complicate to the extent of sight threatening
condition.
Appropriate evaluation and management is
recommended.
Those patients who will not have improvement in
less than 48 hrs need referral to a better center
for better management.
Conjunctivitis
Def. Conjunctivitis is a general term for any inflammation of
the conjunctiva.
Commonest cause of red eye and most common infectious
eye disease

Epidemiology
The prevalence of each is different in pediatric and adult
population. The vast majority of pediatric cases are
bacteria, while in adult’s bacterial and viral causes are
equally common.
Bacterial conjunctivitis
Commonly caused by staphylococcus aureus,
streptococcus pneumonia, Hemophilic influenza, and
moraxella catarrhalis
S. aureus is common in adults
Highly contagious from secretions or with contaminated
objects and surfaces
Symptoms

Patients typically complain of redness and discharge in one eye;

although it can also be bilateral.
The affected eye often is “stuck shut” in the morning
Purulent discharge continues through out the day.
The discharge is thick; it may be yellow, white or green.
No real pain as the conjunctiva has few sensory nerve supplies but
complain of irritation, itching and discomfort
Vision is almost always normal.
Sign
On examination, patients will typically have purulent
discharge at the lid margins and in the corners of the eye.
More purulent discharge appears within minutes of wiping
the lids
Red eye – due to dilatation of superficial blood vessels as
apart of inflammation
Edema of the conjunctiva (chemosis) and eyelids swelling
Cornea is mostly clear; but if it is involved, there will be
different degree of corneal opacity it is common special in
untreated and delayed patients
Diagnosis
Mostly clinical
Gram stains
Course
It lasts for 1 - 2 weeks and then it usually resolves spontaneously.
Treatment: Broad spectrum antibiotics-
Chloramphenicol eye drop or ointment QID
Ciprofloxacillin eye drop QID
If the above drugs are not available, one can use tetracycline eye
ointment BID
Evaluate the patient after 48 hrs and if no improvement, refer to
ophthalmic center for better evaluation
N.B. Don’t use steroid or steroid containing antibiotic as they
will reduce local immunity and encourage micro organism to
multiply
Ophthalmia neonatorum and conjunctivitis in operated eyes are
considered as urgent and are best handled by an ophthalmologist.
Viral conjunctivitis
It is highly contagious, spread by direct contact with
the patient and his or her secretions or with
contaminated objects & surface
Patient usually presents with watering, photophobia,
irritation and mostly associated with upper
respiratory tract infection
Treatment
Self limiting
Prophylactic topical antibiotics ,Chloramphenicol eye
drop TID
Never use steroid or steroid containing antibiotics.
Allergic conjunctivitis

Is caused by air borne allergy contacting the eye.

With specific IgE, causes local mast cell degranulation and the
release of chemical mediators including histamines, eosinophil
chemo tactic factors and platelets activating factors.
Symptoms
Red eye
Severe and persistent itching of both eyes
Mucoid eye discharge
No visual reduction
 Allergic conjunctivitis cont..
Signs
V/A is normal
Papillary reaction to hypertrophy on tarsal
conjunctiva
Treatment
Cold compress
vasoconstrictor-antihistamine like cromolyn sodium
Topical steroid –Terracortril eye suspension
Allergic conjunctivitis
Trachoma

Chronic cicatrizing kerato conjunctivitis

Follicular reaction
Neonatal Conjunctivitis (Ophthalmia
Neonatorum)
Defn: is conjunctivitis in a newborn (in the first 28 days of life)
Etiology: Gonococcus and Chlamydia are the commonest cause of which
gonococcal is most serious
Symptoms - profuse thin to thick purulent eye discharge
Sign - purulent eye discharge, eye lids are swollen
- If cornea is involved, ulcer, scarring, lately
cornea will shrink.
Ophthalmia Neonatorum cont..
Treatment
It is sight threatening condition that needs systemic
antibiotic and close follow up in better ophthalmic center
start with tetracycline eye ointment 3-4 times a day
Urgent referral to ophthalmic center for further evaluation
and management
Prevention
The eye lids should be cleaned with saline swabs as soon
as the head was born and before the infant‘s eyes
opened
Then apply TTC eye ointment
should be applied routinely whenever there is a risk
that the mother had these infection during pregnancy.
Painful Red Eye
Those causes of painful red eye are so severe and
sight threatening conditions.
The Dx of such diseases need experienced
ophthalmic worker, appropriate instruments and
especial diagnostic tests and procedures.
They should be evaluated by the ophthalmologist.
Their visual out come highly depends on the time
interval between onset of the disease and initiation
of treatment and subsequent close follow up.
So early referral to best center may salvage their
vision.
Keratitis and corneal ulcer

The cornea is exposed to the atmosphere, and

so often suffers from injury, inflammation or
infection.
Common terms used in corneal disease.
Keratitis -is the general word for any type of
corneal inflammation.
Corneal ulcer -is loss of some of corneal
epithelium and inflammation in surrounding
cornea.
Corneal scar is white and opaque cornea, which
is the final result of any serious inflammation.
 Etiology
Virus, bacteria, fungi.
Symptoms
Pain - sharp, and severe.
Blurred vision - because the ulcer makes the corneal
surface
Irregular and less transparent.
Photophobia
Red eye
Signs
Red eye -circumcorneal injection
Cornea - grayish to whitish infiltrate, hazy
with loss of clarity and opacity of different
degree

Treatment
– Start with gentamycin or ciprofloxacillin eye
drop frequently
– For proper diagnosis, it needs slit lamp
examination and culture.
Iridocyclitis

Definition: inflammation of the iris and ciliary body.

Classification:
Etiology
Associated with systemic diseases
Infection
Mostly idiopathic
Duration
. Acute duration less than six
weeks
. Chronic duration above six weeks
Symptoms
Painful red eye.
Photophobia
Reduction of vision
Sign
V/A may be reduced
Cornea is relatively clear
Circum corneal injection
Miosis (small pupil), may be irregular
Anterior chamber may be hazy or loss of clarity
 Symptoms
Pain
Photophobia
Ocular redness
Epiphora
Blurred vision
Refractive error
Cataract
Floaters
Macular edema
Treatment

Start with topical steroids

E.g.-Dexamethasone eye drop _QID

Atropine eye drop 1% BID to prevent adhesion and to

reduce pain
Refer as soon as possible to ophthalmic center
ACUTE ANGLE CLOSURE GLAUCOMA

Definition: - it is an elevation of IOP as a result of obstruction of

aqueous outflow.
Symptoms
Painful red eye
Sudden reduction of vision
Rapid progressive visual impairment.
Periocular pain
Nausea and vomiting, ipsilateral headache
Rain –bow (haloes)vision around light
Signs
V/A is decreased
Firm to hard eyeball on digital palpation
Circum corneal injection
Cornea is hazy or loss of its clarity
Anterior chamber will be shallow
Pupil is mid dilated, sluggish and fixed
Difficult to evaluate the fundus due to cornea edema.
Treatment
Timolol eye drop 0.25% every 30 minutes
Acetazolamide (Diamox) 500mg PO stat and then 250
mg po QID
With the above treatment, urgent referral to ophthalmic
center
Episcleritis
Inflammation of the episclera below the
conjunctiva.
Ocular redness without irritation or pain and the
redness typically persists for 24to 72 hours then
resolves spontaneously
May be localized or diffuse
Treatment
not sight threatening
self limiting process
topical vasoconstricting
agent may reduce redness
Scleritis
Inflammation of the sclera.
Symptoms
Painful disorder-typically a constant severe boring pain
that worsens at night or in the early morning hours and
radiates to the face and periorbital region. Pain is severe
enough to limit activity and often to prevent sleep.
Watering, redness, and photophobia
Highly associated with systemic disease like rheumariod
arthritis,SLE,etc
Signs
Sclera edema
Tenderness
Treatment – steriod,P.O.and/or systemic
-Early referral for better management.
Scleritis
Ulcer and abscess
Slit Lamp Examination of the A/S
Herpetic keratitis
 DDX of Red Eye
conjunctivitis keratitis uveitis PACG Episcleritis/scleritis
(Primary
angle closure
glaucoma)

symptom Discomfort/painl Pain/photop Pain/photoph Severe Dull ache

ess hobia obia pain

discharge Watery-purulent watery watery watery Slightely watery

vision Never altered blurry blurry blurry normal

hyperemia diffuse cilliary cilliary cilliary localized

cornea normal altered altered steamy normal

pupil normal +/-miosis miosis Mid dilated normal

IOP normal normal +/- normal elevated normal

 Cataract cont..
Objective:
 Definition
 Normal anatomy and function of the lens.
 Risk factors for the development of cataract.
 Sign and symptom of cataract.
 Examination of patients with cataract
 Refer patients to a centre where they can undergo definitive
treatment (i.e. surgery).
 Complications of untreated cataract.
 Normal crystalline lens is transparent, biconvex structure.
 It is derived from the surface ectoderm.
 It is composed of:– Capsule
Lens epithelium
Cortex and nucleus
 It has no blood supply or nerve supply after fetal development.
 Lies posterior to iris and anterior to vitreous.
 Suspended in position by the zonular fiber.
 It depends on aqueous humor to meet its metabolic requirement
and carry off its wastes.
 It grows continuously throughout life.
Measures at birth adulthood
 Equatorially 6.4mm 9mm.
 Ap 3.5mm 5mm.
 Weighs 90mg 255mg
 Functions:
 To maintain its own clarity.
 Provides accommodation.
 To refract light (the lens contributes about 15-20 diopters
of the refractive power of the eye).
 As age increases, lens increase in:
Density
Hardness
Size
Opacity
 Any congenital or acquired opacity in the lens or lens capsule is called as
cataract
 Cataracts remain the leading cause of blindness.
 The commonest cause of cataract is old age
 Age-related cataract is responsible for 48% of world blindness, which
represents about 18 million people
 Cataracts are also an important cause of low vision in both developed and
developing countries.
 Cataract surgery is the most frequently performed surgical procedure
 50% of those over 65 develop vision impairing cataracts.
 Age
 Congenital (genetic, metabolic)
 Trauma
 Inflammation within the eye (Uveitis)
 Metabolic
 Surgery
 Drugs (eg steroids)
 Cataract in down's syndrome

Bilateral cataracts in an infant due to

Congenital rubella syndrome
 Also called as age related cataract
 Usually above the age of 50 yrs
 Usually bilateral, but almost always one eye is affected earlier
than the other
Classified according to:
 Morphological Classification
• Nuclear
• Cortical
• Subcapsular

 Maturity classification
• Immature Cataract
• Mature Cataract
• Hypermature Cataract
 Most common type
 Age-related
 Occur in the center of the lens
 Occur on the outer edge of the lens (cortex).
 Begins as whitish, wedge-shaped opacities or streaks.
 It’s slowly progresses, the streaks extend to the center and
interfere with light passing through the center of the lens.
 Problems with glare are common with this type of cataract.
• Lens is completely opaque.
• Vision reduced to just perception of light

Right eye mature cataract, with obvious white

opacity at the center of pupil
This may take any of two forms:
1. Liquefactive/Morgagnian Type
2. Sclerotic Cataract
 Cortex undergoes auto-lytic liquefaction and turns uniformly
milky white.
 The nucleus loses support and settles to the bottom.
 The fluid from the cortex gets absorbed
and the lens becomes shrunken.
 There may be deposition of calcific
material on the lens capsule.

 The zonules become weak, increasing

the risk of subluxation / dislocation of
lens.
 A cataract usually develops slowly,  Reduced visual acuity (near and distant
so: object)
◦ Causes no pain.
◦ Cloudiness may affect only a small part of  Glare in sunshine or with street/car lights.
the lens  Distortion of lines.
◦ People may be unaware of any vision loss.
 Over time, however, as the cataract  Monocular diplopia.
grows larger, it:  Altered colours ( white objects appear
◦ Clouds more the lens yellowish)
◦ Distorts the light passing through the lens.
◦ Impairs vision  Not associated with pain, discharge or
redness of the eye
  Bright Colors Become Dull

 Halos Around Lights

 Reduced visual acuity

 Lens opacity
 Surgical removal (The definitive treatment ).
 Indications:-
◦ Visual improvement
◦ Medical indications
◦ Cosmetic indications
• Steroid drops (inflammation)
• Antibiotic drops (infection)
• Avoid
• Very strenuous exertion (rise the pressure in the eyeball)
• Ocular trauma.
 Infective endophthalmitis infection)
 Bleeding or haemorrhage
 Uveatis (Inflammation)
 Glaucoma
 Vitreous loss
 Cystoid macula
 Retinal detachment . . .
 Occur in about 3:10000 live birth.
 2/3 of case are bilateral
 It can cause ambylopia in infants.
 Bilateral congenital cataract require urgent surgery (lensectomy and vitrectomy) and
the fitting of the contact lens to correct the aphakia
 Uniocular congenital cataract treatment remains controversial.
 Follow-up for children with congenital cataract should continue because of the risk
for developing
◦ Glaucoma
◦ Amblyopia
◦ Strabismus
Complications of untreated cataract:

- Blindness
- Glaucoma
- Uveitis
- Subluxation and dislocation.
 Is a chronic severe keratoconjunctivitis leads to corneal abrasion,
ulceration, and scarring.
 Caused by Chlamydia trachomatis (obligate intracellular bacterium) that
primarily affects the superior and inferior tarsal conjunctiva and cornea.
 Trachoma is related to poor hygiene, and is a disease of poverty.
 Leading infectious cause of blindness in the world
 The most common cause of preventable blindness.
 Vary contagious
 Always affected both eyes
 Affects84 million people worldwide:
About 8 million visually impaired.
 55 countries
 once endemic in north America and Europe
 Endemic in Africa, Asia, the Middle East, Latin America, the Pacific Islands,
and the aboriginal communities in Australia.
 Most common in pre-school children
 2-4 times more common in adult women than men.
Epidemiology cont..
How common is trachoma in Ethiopia?
 The major causes of blindness
 9 million children (1-9yr) are affected by active
trachoma(AT) and 1.2 million people(>15yr) are
sufferring from trachomatous trichiasis (TT)
 AT is 4 fold in the rural than urban population
( 42.5% Vs 10.7%)
 TT is higher in female than male.
(4.1% Vs 1.6%)
70

60

50

40
AT
30 TF
20 Series 3

10

0
Tigray Afar Amhara Oromia Somali Addis Gambella
Abeba
 Blindness; 3.6million people are blind because of trachoma
 Increased risk of mortality.
 Destroys families
 Affect economy
(Globally, trachoma results in an estimated US $2.9 billion in lost
productivity per year. )
 Trachoma is caused by serotypes A, B, Ba and C of C.trachomatis.
 Chlamydiae are gram negative, obligate intracellular bacteria.
 Typically infects columnar epithelial cells.
 Mild inflammation of the sub tarsal conjunctiva lining the inner eyelid surface.
 Repeated episodes of infection results in sub-epithelial follicles.
 Scarring of the sub tarsal conjunctiva
◦ deterioration of epithelium
◦ depletion of goblet cells
◦ replacement of loose type 1 and 3 collagen with tougher more compact
type 4 and 5 collagen.
 The scarred inner lining deforms the eyelid margin to fold inwards.

 Eyelashes in contact with cornea

 Scratching with each blink or movement of the eye painful (Trachomatous

Trichiasis).
Course of the disease:
 Active phase:
repeated episode of infection

chronic follicular conjunctivitis

 Scaring phase:
Entropion

Trichiasis

Blindness
 Vary contagious
 Direct contact
 Indirect contact
Fomites i.e. shared towels, handkerchiefs, bedclothes etc
 Eye-seeking flies
 Coughing or sneezing.
 Vector: synathropic Muscid flies

Muscid flies
Mode of transmission of trachoma
 Primary :
person-to-person (fig. a&b)
towel or handkerchiefs (fig.c)
 Secondary:
mechanical vectors, flies. (fig. a)
 Risk Factors
 Poverty
 Crowded living conditions
 Poor sanitation
 Age
 Sex
 Poor access to water
1) Active trachoma with follicles- TF
-Mild disease
-Conjunctival blood vessels visible
2) Active trachoma intense- TI
-Intense
-Conjunctival blood vessels not visible
3) Trachoma scarring- TS
4) Trachoma trichiasis- TT
5) Corneal opacity- CO
 Most patients with active trachoma are asymptomatic
 Non specific symptom like, foreign body sensation, redness, tearing and
mucopurulent discharge.
 Progressive conjunctival follicular hyperplasia
 Conjunctival scarring
 Entropion of the eyelid and trichiasis
 Corneal neovascularization and opacity.
 Two phases of the disease process exist.
◦ Active phase
◦ Scarring (cicatricial) phase
 Active phase:
◦ Active trachoma is characterized by mucopurulent keratoconjucivitis.
◦ The conjuctival surface of upper eyelid shows a follicular and inflammatory
response.
◦ Resembles many of the causes of follicular conjunctivitis
◦ Diagnosis solely based on the clinical appearance of active trachoma.
Scarring (cicatricial) phase:
 unique clinical features
 Conjuctival scarring alone asymptomatic
 Trichiasis causes an intensely irritating foreign body
sensation, as well as blepharospasm
 Corneal opacities that cover any part of the pupil
impair the patients vision.
 Clinical
 Gram stain
 Immunofluorescent cytology
 Culture
 PCR
 WHO advocates SAFE strategy.

S = Surgery for complications (TT & CO)

A = Antibiotics for active (inflammatory) trachoma (TF & TI)
F = Face washing, particularly in children
E = Environmental improvement including provision of clean water
The Antibiotics for active (inflammatory) trachoma (TF & TI):
1) Active trachoma with follicles- TF
First line:- Tetracycline, single strip of ointment applied BID for 6 weeks, OR asintermittent
treatment BID for five consecutive days per month, OR QD for 10 consecutive
days, each month for at least for six consecutive months.
Alternative:- Erythromycin, single strip of ointment applied BID for 6 weeks

2) 2. Trachomatous Inflammation – Intense (TI)

Topical First line & Alternative as above
PLUS
 Tetracycline, 250mg P.O., QID for 3 weeks (only for children over 7 years of age
and adults). OR
Doxycycline, 100mg P.O., QD for 3 weeks (only for children over 7 years of age
and adults). OR
Erythromycin, 250mg P.O., QID for 3 weeks. For children of less than 25kg,
30mg/kg daily in 4 divided doses.
Definition
A group of diseases that have in common a characteristic of optic
neuropathy with associated visual field loss for which elevated IOP is
one of primary risk factors.
Glaucoma is characterized by progressive optic nerve head damage and
visual field loss, for which raised intra-ocular pressure (IOP) is a primary
risk factor.
 Optic neuropathy means death of the neurons of the retina.
 Glaucoma may occur as a primary condition or secondary to other
ocular conditions or systemic diseases.

205
 It is usually a bilateral disease, but may be unilateral or
asymmetrical
 Normal IOP: 10-22 mmHg.
 Three risk factors determine the IOP:
1. Rate of aqueous humor production by ciliary body

2. Resistance to aqueous outflow across the Trabecular meshwork-

Schlemm’s canal system
3. The level of episcleral venous pressure

206
 Glaucoma cont..
 Second leading cause of blindness worldwide
 Around 50% of patients do not know that they have the disease, because
of which it is called

◦ “The silent Blinder” or

◦ “The Sneak Thief of Sight”

20
7
Aqueous Production
◦ Active secretion
 80%, NPE ciliary body

◦ Passive secretion
 20% , ultrafiltration, diffusion
 Dependent on capillary pressure, plasma oncotic pressure, IOP

 Aqueous drainage
◦ Trabecular meshwork (convetional), 90%
◦ Uveoscleral(unconventional), 10%

20
8
Glaucoma cont..

20
9
Clinical evaluation:
1. History
In general symptoms include
• Pain
• Redness
• Haloes around lights
• Alteration or loss of vision
• Alteration of visual field
• Family history of glaucoma
• History of DM, trauma
• Past surgical history
• Medication history

21
0
Physical examination
1-Visual acuity: The VA of glaucoma patient ranges from normal to NLP in
advanced or terminal disease. A normal VA does not rule out glaucoma
2-Tonometry:
•The normal IOP ranges from 10-22 mmhg
• But normal tension range does not always rule out glaucoma
• Conversely, high measurement of IOP (greater than 22) does not always
tell a glaucoma (especially when IOP is less than 30)
3-Slit lamp microscopy;
Ciliary injection in AACG
Cornea could be steamy (cloudy) in AACG
 Anterior chamber reaction
Anterior chamber could be shallow in AACG
Pupil could be dilated and fixed

21
1
4. Gonioscopy:

2.1 Gonioscopy:
-Is a mechanism by which the anterior chamber
angle (360 degree) is inspected and assessed for the following
conditions using gonioscope and SLM;
 Angle status (open, closed narrow)
 Inspect vessels, pigmentation, etc

21
2
Gonioscopic assessment

21
3
 Clinical evaluation
5. The optic nerve:
Glaucomateous optic neuropathy:
Clinical evaluation
normal disc: neural rim : ISN’T rule
color : orange to pink
Sign of glaucoma
Generalized
- large optic cup
- Asymetrical of the cup
- Progressive enlargement of cup
- splinter hemorrhage
Examination:
- slit lamp combined with 60,78 or 90 D lens

21
4
21
5
What is optic neuropathy?
Optic neuropathy means death of the neurons of
the retina.

21
6
Glaucomateous optic neuropathy

21
7
Characteristic pattern to loss of visual field

Rim of optic nerve

becomes thinner as disc
caves in and becomes
more cupped

21
8
 Based on duration:
◦ Acute Vs Chronic
 Based on angle status:
◦ Open- Vs closed-angle
 Based on cause:
◦ Primary Vs Secondary
 Combination
 Congenital Vs Acquired
 Classification of glaucoma

1 . Primary open angle glaucoma

2. Primary angle closure glaucoma

3. Secondary glaucoma

4. Infantile or Congenital glaucoma

Assignment:- Read on each of them

22
0
 I. Treatment of glaucoma
Medical management of glaucoma
Goal of treatment: - lowest risk
- fewest side effect
- least disruption of patient’s life
Target IOP: - severity of the damage
- life expectancy
- associated risk factor
Medical agents: 1. Beta-adrenergic antagonists
2. Parasympathomimetic ( miotic ) agent
3. Carbonic anhydrase inhibitors
4. Adrenergic agonist
5. Hypotensive lipids
6. Combination medications
7. Hyperosmotic agents
22
1
 Surgical therapy for glaucoma:

Trabeculectomy
Angle closure glaucoma:
1. Laser iridectomy:
2.Incisional Peripheral iridectomy
3. Cataract extraction

Congenital glaucoma:
Goniotomy: clear cornea
Trabeculotomy: cloudy cornea
Tube shunt implantation

22
2
 Flat anterior chamber
 Leak
 Excessive filtration
 Choroidal detachments
 Hypotony
 Suprachoroidal haemorrhage
 Encapsulated blebs

22
3
 Pilocarpine and timolol
 Atropine and dexamethasone
 Retrobulbar alcohol injection
 Enucleation

22
4
 Chapter four:
Preventive ophthalmology:

• Global & regional status of blindness

• Prevalence & major cause of blindness in Ethiopia
• Preventive measures of “avoidable blindness”
 Blindness:
• Def:
• Although the word blind suggests inability to perceive light, a person is said to be
blind (WHO def.) if their acuity is less than 3/60 (or if >3/60 but with substantial
visual field loss {as in glaucoma}) and/or inability of FC {counting finger from ≤ 3
meters away from the patient.
• A person is said to be partially sighted if acuity is <6/60 (or >6/60 with visual field
restrictions).
• Visual impairment is a significant health problem worldwide.
• WHO estimates that globally 285million people are visually impaired of whom 39
million are blind. Over 80% of global Visual impairment is preventable or
treatable.
• 90% of the world's blind live in developing countries and 80% would not be blind
if trained eye personnel, medicines, ophthalmic equipment, and patient referral
systems were optimized.
• Color blindness Vs visual acuity related blindness
• a
Epidemiology:
 Common causes of impaired vision & blindness:
• Cataract (any congenital or acquired opacity in the lens or lens capsule)  It
is the leading causes of blindness in Ethiopia and worldwide.
• AMD (age-related macular degeneration)  The most common cause of
irreversible blindness and partial sight in developed countries.
• Diabetic retinopathy  In patients of working age, it is the leading cause of
blindness.
• Eye injury  Leading cause of unilateral blindness
• Vit. A deficiency Young children b/n the age of 6 months and 3 years are
at a higher risk
• ICSOL (including Brain tumor) & ocular tumors
 Common causes of blindness cont..
• Infectious causes:
– Bacterial e.g.
• Neonatal Conjunctivitis (ophtalmia neonatorum)  Neisseria gonorrhoeae
or/& Chlamydia trachomatis.
• Trachoma which is caused by Chlamydia trachomatis. It:
– Is the leading infectious cause of ocular morbidity.
– The most common cause of preventable blindness.
– The second most common cause of blindness worldwide.
– Viral e.g. Herpes zoster can involve the eye and cause corneal scarring
and blindness.
– Parasitic e.g. Onchocerciasis (river blindness) is most frequent
cause of blindness in Africa.
• Refractive errors  are a common, correctable cause of
impaired vision throughout the world.
• Stroke
• Etc..
 Preventive measures of “avoidable blindness”

• Vaccination
• Balanced diet
• Personal & environmental hygiene
• Know glycemic status & tight glycemic control in case of DM
• Properly diagnosing & treating eye problems
• Take care of eyes from injury
• Optimizing trained eye personnel, medicines, ophthalmic equipment,
and patient referral systems.
• Etc…