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Adrian - Pemicu 1
Adrian - Pemicu 1
Vitreous humor
watery fluid enclosed in the meshes of the vitreous body;
transparent jelly-like substance in the posterior four fifths of the
eyeball posterior to the lens
holds the retina in place and supports the lens
Extraocular muscles of the orbit
Levator Palpebrae Superioris
broadens into a wide bilaminar aponeurosis as it approaches its
distal attachments
superficial lamina attaches to the skin of the superior eyelid
deep lamina to the superior tarsus
opposed most of the time by gravity
antagonist of the superior half of the orbicularis oculi, the
sphincter of the palpebral fissure
The deep lamina includes smooth muscle fibers, the superior
tarsal muscle additional widening of the palpebral fissure
during a sympathetic response (e.g., fright)
Fascial Sheath of the Eyeball
~fascia bulbi, Tenon capsule
envelops the eyeball from the optic nerve nearly to the
corneoscleral junction, forming the actual socket for the
eyeball
is pierced by the tendons of the extraocular muscles and is
reflected onto each of them as a tubular muscle sheath
The muscle sheaths of the levator and superior rectus
muscles are fused; thus, when the gaze is directed
superiorly, the superior eyelid is further elevated out of the
line of vision
Triangular expansions from the sheaths of the medial and
lateral rectus muscles, called the medial and lateral check
ligaments, are attached to the lacrimal and zygomatic bones
limit abduction and adduction
blending of the check ligaments with the fascia of the inferior
rectus and inferior oblique muscles forms a hammock-like sling
suspensory ligament of the eyeball
potential episcleral space between the eyeball and the fascial
sheath allows the eyeball to move inside the cup-like sheath
similar check ligament from the fascial sheath of the inferior
rectus retracts the inferior eyelid when the gaze is directed
downward
Arteries of the orbit
Veins of the orbit
LO 2
Menjelaskan histologi mata
Layers of the eye
Fibrous layer
Sclera
protects the more delicate internal structures and provides sites
for muscle insertion
0.5 mm in thickness, is relatively avascular, and consists of tough,
dense connective tissue containing flat type I collagen bundles,
moderate amount of ground substance and scattered fibroblasts
adjacent to the choroid slightly less dense, with thinner
collagen fibers, more fibroblasts, elastic fibers, and melanocytes
Cornea
colorless, transparent, and completely avascular
an external stratified squamous epithelium
an anterior limiting membrane (Bowman's membrane, the
basement membrane of the stratified epithelium)
the stroma
a posterior limiting membrane (Descemet's membrane, the
basement membrane of the endothelium)
an inner simple squamous endothelium
Corneo-scleral junction
Sclera, choroid, & retina
-. Choroid
highly vascular tunic in the posterior
two-thirds of the eye, with loose,
well-vascularized connective tissue
rich in collagen and elastic fibers,
fibroblasts, melanocytes,
macrophages, lymphocytes, mast
cells, and plasma cells
Cilliary body
anterior expansion of the choroid at the level of the lens
has a stroma of loose connective tissue, rich in
microvasculature, elastic fibers, and melanocytes,
surrounding much smooth muscle
ciliary muscle important in visual accommodation
Iris
the most anterior extension of the uvea (middle layer) that
partially covers the lens, leaving a round opening in the
center called the pupil
anterior surface of the iris, not covered by epithelium,
but consists of an irregular, discontinuous layer of
fibroblasts and melanocytes
posterior surface of the iris is smooth, with a two-layered
epithelium continuous with that covering the ciliary body
and its processes
Lens
transparent biconvex structure immediately behind the iris,
used to focus light on the retina
Lens casule
homogeneous capsule rich in proteoglycans and type IV
collagen
Lens epithelium
homogeneous capsule rich in proteoglycans and type IV
collagen
Lens fibers
Developing from stem cells in the lens epithelium, the
differentiating lens fibers eventually lose their nuclei and other
organelles, fill the cytoplasm with a group of proteins called
crystallins
Vitreous body
transparent connective tissue containing mostly (99%)
water (vitreous humor), bound to hyaluronate, and a small
amount of collagen
contained within the vitreous membrane composed of type
IV collagen and other proteins of external laminae
few macrophages and a small population of cells near the
membrane called hyalocytes, which synthesize the
hyaluronate and collagen
Retina
neural retina, contains the neurons and photoreceptors
The outer pigmented layer is an epithelium resting on
Bruch's membrane just inside the choroid, function:
serve as an important part of the blood-retina barrier
absorb light passing through the retina to prevent its reflection
phagocytose shed components from the adjacent rods and cones
remove free radicals
isomerize and regenerate the retinoids used as chromophores
by the rods and cones
Specialized Areas of the Retina
(fovea centralis, macula lutea, optic disc)
Conjunctiva & eyelids
Lacrimal glands
produce fluid continuously for the tear film that moisturizes
and lubricates the cornea and conjunctiva and supplies O2
to the corneal epithelial cells
contains various metabolites, electrolytes, and proteins,
including lysozyme, an enzyme that hydrolyzes the cell
walls of certain species of bacteria
LO 3
Menjelaskan fisiologi penglihatan
Function of the parts of the eye
Refraction
Light rays travel through air at a velocity of about
300,000 km/sec, but they travel much slower through
transparent solids & liquids
When light rays traveling forward in a beam strike an
interface that is perpendicular to the beam, the rays enter
the second medium without deviating from their course
If the light rays pass through an angulated interface, the
rays bend if the refractive indices of the two media are
different from each other (refraction)
Because the direction in which light travels is always
perpendicular to the plane of the wave front
“Depth of focus” of the lense system
if the retina is moved forward or
backward to an out-of-focus
position, the size of each spot
will not change much in the
upper eye, but in the lower
eye the size of each spot will
increase greatly, becoming
a “blur circle.”
Pathology features
Elevation of intraocular pressure is a consequence of obstruction
of aqueous outflow by occlusion of the trabecular meshwork by
the peripheral iris
Risk factors
age, female gender, family history of glaucoma, and South-East
Asian, Chinese, or Inuit ethnic background
Diagnosis
examination of the anterior segment and careful gonioscopy
primary angle closure has resulted in optic nerve damage and
visual field loss
Diabetic Retinopathy
Risk factor & epidemiology
Chronic hyperglycemia, hypertension,
hypercholesterolemia, and smoking
Young people with type I (insulin-dependent) diabetes do
not develop retinopathy for at least 3–5 years after the
onset of the systemic disease
Type II (non–insulin-dependent) diabetics may have
retinopathy at the time of diagnosis
Screening
should be performed within 3 years from diagnosis in type I
diabetes, on diagnosis in type II diabetes annually
thereafter in both types
Digital fundal photography has been proven to be an effective
and sensitive method for screening
Seven-field photography is the gold standard
Mydriasis is necessary for best quality photographs, especially
if there is cataract
Symptoms
night blindness (nyctalopia) and gradually progressive
peripheral visual field loss as a result of increasing and
coalescing ring scotomas
Diagnosis & examination
Fundoscopic findings
attenuated retinal arterioles, waxy pale optic disc, mottling of
the retinal pigment epithelium, and peripheral retinal pigment
clumping, referred to as "bone-spicule formation"
Treatment
should be referred to specialized centers for genetic
counseling and selective mutation analysis
Genetic analysis is useful to identify female carriers in
families with X-linked disease and to diagnose dominant
disease
Refraction disorder
Presbyopia
The loss of accommodation that comes with aging to all
people
inability to read small print or discriminate fine close
objects
About age 44-46 increase until about age 55, when they
stabilize but persist
worse in dim light and usually worse early in the morning
or when the subject is fatigued.
Therapy
corrected by a plus lens make up for the lost automatic
focusing power of the lens
Fine for reading but blurred for distant objects leaving the
top open and uncorrected for distance vision
Myopia
When the image of distant objects focuses in front of the retina
in the unaccommodated eye or nearsighted
If the eye is longer than average, the error is called axial
myopia
If the refractive elements are more refractive than average, the
error is called curvature myopia or refractive myopia
Prognosis high degree of myopia susceptibility to
degenerative retinal changes, including retinal detachment
Concave spherical (minus) lenses are used to correct the image
in myopia
Hyperopia
the state in which the unaccommodated eye would focus the
image behind the retina
A young person may obtain a sharp distant image by
accommodating, as a normal eye would to read
The young hyperopic person may also make a sharp near
image by accommodating more
Classification
reduced axial length (axial hyperopia) in certain congenital disorders
reduced refractive error (refractive hyperopia), as exemplified by
aphakia
Prognosis esotropia , monocular amblyopia
Astigmatism
the eye produces an image with multiple focal points or lines
regular astigmatism two principal meridians, with constant
power and orientation across the pupillary aperture, resulting in
two focal lines
astigmatism with the rule greater refractive power is in the
vertical meridian
astigmatism against the rule the greater refractive power is in the
horizontal meridian
Oblique astigmatism regular astigmatism in which the principal
meridians do not lie within 20 degrees of the horizontal and vertical
irregular astigmatism the power or orientation of the
principal meridians changes across the pupillary aperture
Etiology abnormality of corneal shape
corrected with cylindrical lenses, frequently in combination
with spherical lenses
Anisometropia
Anisometropia is a difference in refractive error between
the two eyes
major cause of amblyopia because the eyes cannot
accommodate independently and the more hyperopic eye
is chronically blurred
Refractive correction of anisometropia is complicated by
differences in size of the retinal images (aniseikonia)
Correction
Spectacle difference in retinal image size of approximately
25%, which is rarely tolerable
Contact lens difference in image size to approximately 6%,
which can be tolerated
Intraocular lens difference of less than 1%
LO 5
Menjelaskan gangguan penglihatan mata tenang +
penurunan visus mendadak
Retinal detachment
Definition
the separation of the sensory retina, ie, the photoreceptors
and inner tissue layers, from the underlying retinal pigment
epithelium
3 types
Rhegmatogenous
Traction
Hemorrhagic
Rhegmatogenous Retinal Detachment
most common type of retinal detachment
usually preceded or accompanied by posterior vitreous
detachment and is associated with
myopia, aphakia, lattice degeneration, and ocular trauma
Characteristics
full-thickness break in the sensory retina
variable degrees of vitreous traction
passage of liquefied vitreous through the break into the
subretinal space
Binocular indirect ophthalmoscopy with scleral depression
elevation of the translucent detached sensory retina with one or
more full-thickness sensory retinal breaks
such as a horseshoe tear,
most common in the superotemporal quadrant
round atrophic hole,
temporal quadrants
anterior circumferential tear (retinal dialysis)
inferotemporal quadrant
Treatment
Principal aim treat all the retinal breaks
cryotherapy or laser being applied to
create an adhesion between the pigment epithelium and the sensory retina,
preventing any further influx of fluid into the subretinal space,
to drain subretinal fluid, internally or externally,
relieve vitreo-retinal traction
Surgery techniques:
pneumatic retinopexy
air or expandable gas is injected into the vitreous to maintain the retina in
position, while the chorioretinal adhesion induced
Scleral buckling
maintains the retina in position, while the chorioretinal adhesion forms, by
indenting the sclera with a sutured explant in the region of the retinal break
Pars plana vitrectomy
relief of vitreo-retinal traction, internal drainage of subretinal fluid,
Traction Retinal Detachment
most commonly due to proliferative diabetic retinopathy
can also be associated with proliferative vitreoretinopathy,
retinopathy of prematurity, or ocular trauma
Characteristics
has a more concave surface and is likely to be more localized,
usually not extending to the ora serrata
tractional forces actively pull the sensory retina away from the
underlying pigment epithelium toward the vitreous base
Traction is due to formation of vitreal, epiretinal, or subretinal
membranes consisting of fibroblasts and glial and retinal pigment
epithelial cells
Treatment
Pars plana vitrectomy allows removal of the tractional elements
followed by removal of the fibrotic membranes
Retinotomy and/or injection of perfluorocarbons or heavy
liquids may be required to flatten the retina
Gas tamponade, silicone oil, or scleral buckling may be used
Serous & Hemorrhagic Retinal Detachment
occurs in the absence of either retinal break or
vitreoretinal traction
form as a result of accumulation of fluid beneath the
sensory retina and are caused primarily by diseases of the
retinal pigment epithelium and choroid
Degenerative, inflammatory, and infectious diseases
subretinal neovascularization serous retinal detachment
may also be associated with systemic vascular and
inflammatory disease
Amaurosis fugaks
Definisi, etiologi, & gambaran klinis
Buta sekejap satu mata yg berulang
Etiologi
Hipotensi ortostatik, spasme pemb darah, aritmia, migrain
retina, anemia, arteritis, koagulopati
Clinical appearances
a few small scattered retinal hemorrhages
cotton-wool spots to a marked hemorrhagic appearance with
both deep and superficial retinal hemorrhage
rarely may break through into the vitreous cavity
Classification
Central Retinal Vein Occlusion
Macular dysfunction
persistent decreased central vision as a result of chronic macular
edema
Th/
Intravitreal triamcinolone has limited effect
Trials of intravitreal injections of depot steroid or anti-VEGF agents
have shown promising results
Branch Retinal Vein Occlusion
occurs at the site of an arteriovenous crossing
Reduction in visual acuity only occurs if the macula is affected
Retinal neovascularization may develop if retinal capillary
nonperfusion exceeds five disk diameters in area
Th/
peripheral retinal neovascularization develops sectoral retinal laser
photocoagulation to the area of ischemic retina
reduces the risk of vitreous hemorrhage by one-half
vision loss due to macular edema persists for several months without
spontaneous improvement grid-pattern macular argon laser
photocoagulation
Intravitreal injection of steroids or anti-VEGF agents may be useful in
macular edema unresponsive to laser treatment
Central retinal artery occlusion
Sign & symptoms
painless catastrophic visual loss occurring over a period of
seconds
afferent pupillary defect can appear within seconds, preceding
the fundus abnormalities by an hour
Branch retinal artery is usually embolic in origin and results in
visual field loss
Fundoscopy
superficial retina becomes opacified due to ischemia
foveal cherry-red spot is evident
visualization of the choroidal pigment and retinal pigment epithelium
through the extremely thin retina overlying foveola
resolves within 4–6 weeks, leaving a pale optic disk as the major ocular
finding
Treatment
Irreversible retinal damage occurs after 90 minutes of
complete central retinal artery occlusion in the subhuman
primate model quick therapy
anterior chamber paracentesis and intravenous
acetazolamide
Sudden decrease in intraocular pressure resulting in increased
retinal perfusion
Inhaled oxygen–carbon dioxide mixture induces retinal
vasodilation and increases the PO2 at the retinal surface
Thrombolytic therapy
infused directly into the ophthalmic artery or administered
systemically, continues to be evaluated
Neuritis optik
Etiologi & epidemiologi
Etiologi
Idiopatik
Sklerosis multipel sedang pada anak o/ morbili, cacar air,
parotitis
Dapat merupakan gejala dini penyakit multipel sklerosis
Epidemiologi
Perempuan >, 20-40 thn bersifat unilateral
Klasifikasi
Neuritis unilateral
e/ Multipel sklerosis; th/ steroid (< peradangan &
memperpendek periode akut penyakit)
Dapat sembuh spontan dalam 4-6 mg
Neuritis bilateral
e/ tidak diketahui pasti, penyakit Devic, atrofi papil herediter
Leber, keracunan alkohol/tembakau, kelainan metabolik (DM),
neuropati tropik, kurang gizi, neuritis optik bilateral pd anak
Tanda & gejala
Rasa sakit di sekitar mata terutama bila mata digerakkan
Pegal & sakit bila dilakukan perabaan pada mata yg sakit
Kehilangan penglihatan beberapa jam – hari pd 1/kedua
mata pd usia khusus 18-45 thn
Sakit pd rongga orbita terutama pd pergerakan mata
Penglihatan warna terganggu
Tahda Uhthoff (penglihatan < setelah olahraga atau suhu >)
Perjalanan penyakit
Turunnya tajam pengllihatan mendadak intermiten (maksimal 2
minggu) & sembuh kembali dgn sempurna atrofi papil saraf optik
parsial/total
Pada 1 mata terlihat defek pupil aferen relatif (Marcus
Gunn pupil)
Terdapat sel dalam badan kaca
Edem papil dengan perdarahan lidah api (anak &
pemuda)
Papil normal pada proses retrobulbar
DD
Iskemik otak neuropati (tidak sakit, skotoma altitudinal)
Edema papil akut
Hipertensi berat
Toksik neuropati
Pengobatan
Pengobatan sesuai kausa
Kortikosteroid / ACTH
+ antibiotik
Vasidiltasia & vitamin
Etiologi
Sklerosis multipel, penyakit mielin saraf, anemia pernisiosa, DM,
intoksikasi