`Sanjay Sebastian

SURGERY 2 – OPHTHALMOLOGY NOTES

ANATOMY OF THE EYE
3 layers of the eye:

1. Fibrous layer
a. Sclera (white)
b. Cornea (clear) ,
2. Vascular layer (Uvea)
a. Pupil
b. Iris
i. Sphincter pupillae muscle
ii. Dilator pupillae muscle
c. Ciliary body (controls the lens to make it flatter or rounder)
d. Choroid (contains blood vessels)
3. Neural layer
a. Retina
i. Outer pigmented layer
ii. Inner neural layer (Inner neural layer  photoreceptors absorb light 
neural signals  optic nerve  brain for visual processing
`Sanjay Sebastian
`Sanjay Sebastian
 `Sanjay Sebastian
GLAUCOMA
Glaucoma is a condition that causes damage to the optic nerve due to mainly increased
intraocular pressure (IOP) that can lead to blindness.

 Normal intraocular pressure: 10-21 mmHg

 Increased intraocular pressure (Intraocular hypertension): >21 mmHg

Types of Glaucoma
1. Open Angle Glaucoma (most common) Gradual ONSET
a. Clogging of the trabecular meshwork leads to the angle between cornea and
iris to get big  leading to increased IOP  damaged optic nerve.

2. Closed Angle Glaucoma (aka. Angle Closure Glaucoma & Narrow Angle Glaucoma)
Fast ONSET
a. Lens pushes against iris causing angle between iris and cornea to get small 
leading to increased IOP  damaged optic nerve.

3. Normal Tension Glaucoma (aka. Low Tension Glaucoma)

a. Normal IOP, but hypoperfusion (low vascularity) to the optic nerve 
damaged optic nerve.
 `Sanjay Sebastian

GLAUCOMA RF:
 Have high IOP
 Age > 60 years
 Family Hx
 Being black, Asian, or Hispanic
 Medical conditions: HBP, heart conditions, diabetes

GLAUCOMA Symptoms:
 Intense eye pain
 Redness
 Decreased or blurred vision
 Tunnel vision (loss of peripheral
vision, but central vision
remains)
 Headache
 Nausea & Vomiting
 `Sanjay Sebastian
GLAUCOMA Dx:
Physical examination
1. General eye inspection: redness, symmetry
2. Visual acuity
3. Visual field
4. Fundoscopy
Additional studies TGPKPFSSSCA
1. Tonometry (measures IOP)
2. Gonioscopy (measures the angle between cornea and iris)
3. Pachymetry (measure corneal thickness)
4. Keratometry: (measure the radius and curvature of the cornea)
5. Perimetry (measures loss of visual field)
6. Fluorescein angiography (dye is injected into the vein of your arm, to make it easier
to see where the rupture of blood vessels in your eye are)
7. Stratus Optical Coherence Tomography (OCT): (measures retinal thickness)
8. Slit lamp
9. Stereo disc photography (detects cupping)
10. Colour fundus photography (takes photo of the interior surface of the eye)
11. Analysis of fluid from the eye

GLAUCOMA Tx: NO CURE

Normal tension glaucoma is a type of open angle glaucoma. Therefore, the treatment of
normal tension glaucoma is the same as open/closed angle glaucoma, by varieties of way to
decrease the IOP.
Medications:
1. If the underlying cause is increased IOP:
a. Decrease production of aqueous humor
i. Beta-adrenergic blockers
ii. Carbonic anhydrase inhibitors
b. Increase outflow of aqueous humor
i. Prostaglandin analogs
ii. Cholinergic or Miotics
 `Sanjay Sebastian
Laser:
1. Open Angle Glaucoma:
a. Trabeculoplasty: open trabecular meshwork
2. Closed Angle Glaucoma:
a. Laser Iridotomy: punches hole in iris

Surgical:
1. Glaucoma filtration surgery (Trabeculectomy): surgery to create a new drainage
system of aqueous humor.
 `Sanjay Sebastian
DIABETIC RETINOPATHY
Diabetic retinopathy is the
damage of blood vessels
that supply the retina,
leading to blindness and is
caused by high blood
sugar (diabetes).

Types of Diabetic Retinopathy (DR)

1. Non-proliferative Diabetic Retinopathy (Early Diabetic Retinopathy)
When you have non-proliferative DR, weakened areas in the blood vessels supplying the
retina form aneurysm that rupture and bleed in the retina.

2. Proliferative Diabetic Retinopathy (Advanced Diabetic Retinopathy)

As NPDR progresses, damaged blood vessels close off causing the growth of new, abnormal
vessels in the retina. These newly formed blood vessels are weak and can rupture and fill
the vitreous humour with blood  eventually leading to the detachment of the retina,
increased IOP leading to glaucoma, & macular degeneration.
 `Sanjay Sebastian
DR RF:
 Diabetes 1 or 2
 Uncontrolled diabetes
 High BP
 High cholesterol

DR Symptoms:
 Floating dark spots/strings
 Eye pain
 Redness
 Macular edema  blurry/double vision
 Cotton wool spots  due to poor blood supply

DR Dx:
Comprehensive dilated eye exam (eye drops to dilate the pupils) followed by:
1. Fluorescein angiography: dye is injected into the vein of your arm to view where the
blood vessels are ruptured in your eye.
2. Stratus OCT: provides cross-sectional images of the thickness of retina (e.g., picture
below)
 `Sanjay Sebastian
DR Tx:
Non-proliferative Diabetic Retinopathy Tx:
1. Controlling blood sugar levels

Proliferative Diabetic Retinopathy Tx:

1. Vascular Endothelial Growth Factor (VEGF)
inhibitors: injected into the vitreous of the eye
to help stop the growth of new blood vessels &
decrease fluid build-up.

2. Photocoagulation (focal laser treatment): laser

beams are used to seal the leakage from the
new abnormal blood vessels.

3. Pan-retinal photocoagulation: laser beams to

shrink new abnormal blood vessels.

4. Vitrectomy: the damaged vitreous humor is

removed and replaced with new fluid.
 `Sanjay Sebastian
CATARACTS
Cataracts is the clouding of the lens in your eye.

CATARACTS Causes:
Lens of the eye is made up of water and proteins. As proteins break down, some remain in
the lens causing the cloudiness.

CATARACTS Types & RF:

1. Congenital infections: TORCH
a. Toxoplasma
b. Other infectious agents (e.g., syphilis)
c. Rubella
d. Cytomegalovirus
e. HSV

Other congenital causes include:

f. Galactosemia (inability to convert galactose
into glucose)
g. Trisomy 13, 18, 21
h. Marfan Syndrome
 `Sanjay Sebastian
2. Acquired
a. Age > 60yrs
b. Smoking
c. Alcohol/drug abuse
d. Eye trauma & infections
e. UV light exposure
f. Diabetes

CATARACTS Symptoms:
 Clouded, blurred vision
 Vision at night is worse  better brighter light for reading and activities.
 Seeing halos around lights

CATARACTS Dx:
1. Visual acuity (via Snellen chart)
2. Fundoscopy (aka., ophthalmoscopy)
3. Slip lamp examination (special microscope that lets you see the lens clearly)
 `Sanjay Sebastian
CATARACTS Tx:
Mild cataracts can be treated with new prescription glasses or contact lens. But, because
cataracts can worsen over time that can lead to blindness, surgery is often done.

Surgical:
1. Phacoemulsification cataract surgery (more common surgery): small incision is made
in the eye, then using sound waves the surgeon breaks down the lens into pieces
before suctioning it out and replacing it with a new plastic lens.

2. Extracapsular cataract surgery: this surgery is done in advanced stages when the lens
is too dense. An incision is made in the eye to remove the lens in one whole piece
before replacing it with a new plastic lens.
 `Sanjay Sebastian
REFRACTIVE ERRORS
Axial length: distance between cornea and retina

1. Emmetropia: perfect 20/20 vision

2. Myopia: near-sightedness (axial length is too long for the refractive power of the
cornea and lens)
 Corrected with concave (diverging) lens
The degrees of myopia: Myopia is measured in dioptres (D)
 Mild myopia: 0 to - 1.5 D
 Moderate myopia: - 1.5 to - 6 D
 Severe myopia: - 6 D or more

3. Hyperopia: farsightedness (axial length is too short for the refractive power of the
cornea and lens)
 Corrected with convex (converging) lens

4. Astigmatism: abnormal curvature of the cornea, resulting in >1 focal point. Patient
can’t see close or far.
 Corrected with cylindrical lens
 `Sanjay Sebastian
Presbyopia: as you age, elasticity of the lens and the strength of the ciliary muscle that
control the lens to make it flatter or rounder decreases. Similar to hyperopia!
 Corrected with convex reading glasses

REFRACTIVE ERRORS Dx:

1. Visual Acuity (via Snellen chart)
2. Fundoscopy
3. Slit lamp
4. Refractometry: refractometer helps identify refractive errors in your vision
5. Pachymetry: measures corneal thickness
6. Keratometry: measures corneal radius and curvature

REFRACTIVE ERRORS Tx:

1. Lens (concave, convex, cylindrical)
2. Refractive eye surgery
 `Sanjay Sebastian
UVEITIS
Uvea (aka., vascular layer) is the middle layer of
the eye. Uvea consists of the pupil, iris, ciliary
body & choroid.
Uveitis is the inflammation of the uvea.

UVEITIS Causes or RF:

 Idiopathic
 Injury or Iatrogenic
 Autoimmune or inflammatory disorders (e.g., juvenile arthritis, psoriasis, rheumatoid
arthritis, crohn’s disease, ulcerative colitis, HIV/AIDS)
 Infections (e.g., Toxoplasmosis, Syphilis, Herpes)

UVEITIS Types
Anterior uveitis (aka. iritis) (most common & least serious): affects the cornea, iris & ciliary
body.
Intermediate uveitis: affects retina, blood vessels & vitreous.
Posterior uveitis: affects the back of the eye; retina & choroid.
Pan uveitis: all layers of the uvea are affected from the back to the front of the eye.

UVEITIS Symptoms
 `Sanjay Sebastian
 Redness
 Pain
 Light sensitivity
 Blurred vision
 Dark, floating spots
 Decreased vision

UVEITIS Dx:
Physical examination

1. General eye inspection: redness, symmetry

2. Visual acuity
3. Fundoscopy

Imaging studies TGPKPFSSSCA

1. Tonometry (measures IOP)

2. Gonioscopy (measures the angle between cornea and iris)
3. Pachymetry (measure corneal thickness)
4. Keratometry: (measure the radius and curvature of the cornea)
5. Perimetry (measures loss of visual field)
6. Fluorescein angiography (dye is injected into the vein of your arm, to make it easier
to see where the rupture of blood vessels in your eye are)
7. Stratus Optical Coherence Tomography (OCT): (measures the thickness of retina)
8. Slit lamp
9. Stereo disc photography (detects cupping)
10.Colour fundus photography (takes photo of the interior surface of the eye)
11. Analysis of fluid from the eye
 `Sanjay Sebastian
UVEITIS Tx: CASI
1. Corticosteroids (prednisone): anti-
inflammatory drug & immunosuppressants (if
causative factor is autoimmune)

2. Antibiotics or Antivirals: if causative factor is

infection

3. Steroid injection: injected into the eye

4. Implant: Surgical implant placed in your eye that slowly releases steroid into your
eye.
 `Sanjay Sebastian
CONJUNCTIVITIS (Pink eye)
The outer surface of the sclera & the inner
surface of the eyelids is covered by a mucous
layer known as conjunctiva. When the small
blood vessel in the conjunctiva become
inflamed, they present as reddish/pink eye.

Conjunctivitis is the inflammation of the

conjunctiva, mainly caused by infectious or
non-infectious.

CONJUNCTIVITIS Types:
1. Infectious

2. Non-infectious
 `Sanjay Sebastian
CONJUNCTIVITIS Symptoms:
 Unilateral or bilateral eye redness
 Itchiness & pain
 Conjunctival swelling
 Light sensitivity
 Excessive lacrimation
 If the causative factor is viral or non-infectious
related, discharge will be: watery or mucoid
 If the causative factor is bacterial, discharge will
be: purulent white, yellow, or green.

CONJUNCTIVITIS Dx:
1. Medical hx & Symptomatic dx
2. Analysis (culture) of the fluid that drains from your eye
3. Slit-lamp examination

CONJUNCTIVITIS Tx:

1. Viral conjunctivitis: NO ANTIVIRAL MEDICATION (self-resolving)

 Clean with saline
 Artificial tears
 Cold/warm compress
 Pain relief

2. Bacterial conjunctivitis:
 Antibiotics administered in the form of eye drops or ointments. Azithromycin,
Erythromycin & Ceftriaxone

3. Allergic conjunctivitis:
 Minimize exposure to allergens
 Antihistamines
 Anti-inflammatory drops
 `Sanjay Sebastian
EYELID DISORDERS
1. CHALAZION
2. HORDEOLUM (STYE)
3. BLEPHARITIS
4. ECTROPION
5. ENTROPION
6. TRICHIASIS
7. DISTICHIASIS

1. CHALAZION

Chalazion is a red bump on your eyelid (upper or lower).

Chalazion is known as an eyelid cyst or meibomian cyst.
Chalazion is formed when an oil gland (meibomian) becomes
blocked.
Chalazion is painful in the beginning but becomes painless
later on.
Chalazion Dx: Eyelid examination
Chalazion Tx:
Initial Tx:
1. Hygiene therapy
2. Warm compress
(melts the fat)
3. Massage

Surgery to drain the

chalazion (if initial
therapy does not work)
 `Sanjay Sebastian
2. HORDEOLUM (STYE)

Hordeolum is red bump on your eyelid. Hordeolum occurs when an oil gland becomes
infected, mainly by bacteria.
Hordeolum Sx:
 Painful mass on the eyelid usually at the base of an eyelash
 Redness and swelling
 Discharge & crusting (not found in chalazion)
 Excessive tearing
 Light sensitivity

Hordeolum Dx: Clinical evaluation & Eyelid examination

Hordeolum Tx:
Initial Tx:
1. Hygiene therapy
2. Warm compress (melts the fat)
3. Massage
4. Antibiotics (topical + oral) e.g., doxycycline
Surgery to drain the hordeolum (if initial therapy does not work)
 `Sanjay Sebastian
3. BLEPHARITIS

Blepharitis is the inflammation of the eyelids. Blepharitis occurs when the oil gland located
at the edge of the eyelids become clogged or irritated, resulting in red eyes.

BLEPHARITIS Types:
 Anterior Blepharitis: inflammation affecting the exterior eyelids
 Posterior Blepharitis (more common): inflammation also affecting the meibomian
gland
 `Sanjay Sebastian
Blepharitis Causes: ACIDOA
1. Allergic: drugs
2. Chemical: eye drops
3. Infectious: bacterial (S. aureus) or viral
4. Dermatologic: meibomian gland dysfunction
5. Ocular: chalazion, conjunctivitis
6. Autoimmune: SLE, Sjogren’s syndrome

Blepharitis Sx:
 Red eyes & surrounding tissues
 Watery eyes
 Greasy, crusty, itchy, sticky eyelids
 Flaky skin around eyes
 Loss of eyelashes
 Light sensitivity

Blepharitis Dx:
1. Examination of eye & eyelids
2. Slit lamp
3. Analysis of the oil/crust

Blepharitis Tx:
1. Hygiene therapy
2. Warm compress (melts the fat)
3. Massage
4. Antibiotics (topical + oral) e.g., doxycycline
5. Corticosteroids (ant inflammatory and immunosuppressant)
 `Sanjay Sebastian
4. ECTROPION

Ectropion is when your lower eyelid turns outwards. This can be congenital but often
acquired due to impaired orbicularis oculi muscle as you age.
Sx: excessive tearing as the eyelid cannot hold normal tear volume, dry/ irritated eyes
Tx: Surgery

5. ENTROPION

Entropion is when your lower eyelid turns inwards. This can be congenital but often
acquired due to impaired orbicularis oculi muscle as you age.
Sx: eyelashes irritate the eye from friction, red eye, light sensitivity, watery eyes
Tx: Surgery
 `Sanjay Sebastian
6. TRICHIASIS
Trichiasis is the condition in which the eyelashes
grow inwards towards the eye. The eyelashes
irritate the cornea & conjunctiva.
Cause:
 Idiopathic
 Secondary to: SJS, blepharitis, infection, or
trauma
Dx:
1. Examination of the eyes & eyelids
2. Slit lamp
Tx:
Surgical:
1. Electrolysis: electricity to fry the hair follicles
2. Cryotherapy: freezing (nitrous oxide)
 `Sanjay Sebastian
7. DISTICHIASIS
Distichiasis is the condition in which an extra row
of eyelashes grow from the meibomian gland.
Distichiasis can be congenital or acquired
(inflammation or trauma)
Dx:
1. Examination of the eyes & eyelids
2. Slit lamp
Tx:
Surgical:
1. Electrolysis: electricity to fry the hair follicles
2. Cryotherapy: freezing (nitrous oxide)
 `Sanjay Sebastian
ADDITIONAL INFORMATION
Keratoconus: occurs when the cornea
bulges out into a cone shape, caused by
loss of collagen in the cornea.
All people who have keratoconus have
astigmatism, but not all people who have
astigmatism have keratoconus.
Tx:
1. Prescription lens
2. Keratoplasty: Corneal transplant surgery

Dry eye syndrome (aka., keratoconjunctivitis sicca (KCS)): condition of having dry eyes
caused by decreased tear production or increased tear absorption.
Dx:
1. Schirmer test: test to see if eye is producing enough tears
2. Tear break up time (TBUT): measures the time it takes for the first dry spot to appear
on the cornea after a blink.
Tx:
1. Artificial tears
2. Tear duct plugs: stop the tears from draining
 `Sanjay Sebastian
Macula is a structure of the retina that is responsible for central vision. The macula has high
concentration of photoreceptor cells that detect light.
Age-related Macular Degeneration (AMD):
eye disease that can blur your central
vision.
 Dry AMD: slow deterioration of the
cells of macula that make it thinner.
 Wet AMD: growth of abnormal
blood vessels into the macula.

Dx:
 `Sanjay Sebastian
Tx:
Dry AMD: No Tx, take vitamins & supplements
Wet AMD:
1. Vascular Endothelial Growth Factor (VEGF) inhibitor
2. Photocoagulation