Frequently Asked Questions (FAQ)

CATARACT

Prof Dr.A.M.RAJA
 1.What is your diagnosis?

• RE / LE / BE

• Senile / congenital

• Immature / mature / hypermature

• Cortical / Nuclear cataract

 2.What are the points favour for your
diagnosis?
• Senile cataract – usually occurs after the age of 40years
• Congenital cataract – occurs at birth / Developmental cataract – from
infant to adult life

• Immature cataract – lens colour – greyish white opacity

Iris shadow – present
(in IMC some of the lens fibres are clear not opaque …when we pass the
light from one end which will pass through the normal lens cortex and
form the shadow of the iris near the pupillary margin in same side)
Vision is not improving through pin hole(size 1.2mm)
• Mature Cataract (MC)
Lens colour – pearly white
Iris shadow – absent (all the lens fibres are opaque ..
so light will not enter into the eye and will not form any shadow)
Vision – only Hand Movents (HM)
Fundus examination – no view

• Hyper Mature Cataract (HMC)

Lens colour – milky white
Iris shadow – absent
Vision – HM / PL +
Fundus – no view
How will you manage this patient ?
First we have to do investigations then management
• What are the investigations needed for cataract sugery?

Systemic investigations
• Blood sugar
• Blood pressure
• to rule out focal sepsis like active dental carries/ active
CSOM / active sinusitis – for preventing Endophthalmitis

Ocular investigations
• Syringing for lacrimal duct patency – to r/o dacryocystitis
which is one of the risk factor for endophthalmitis
• Intra ocular pressure measurement
Goldman’s applanation tonometry is gold standard method for
measuring IOP
raised IOP is one of the risk factor for developing Expulsive
choroidal haemorrhage which may occur during cataract surgery

.IOL BIOMETRY
SRK formula – P = A- 2.5L-0.9K
SRK – Sanders , Retzlaff , Kraff
A – constant
L – axial length ( Normal axial length = 22 – 24mm which is measured by A scan)
K – keratometry reading ( Normal k reading = 42 – 44D which is measured by
Keratometer)
Dilated Fundus examination
• seen by ophthalmoscopy
• if there is any problem in fundus which will affect the cataract surgery
prognosis
• common fundus problems like ARMD , Glaucoma , optic atrophy , Retinal
detachment, CRVO, CRAO are commonly occurred in cataract aged patients.

When fundus examination is not possible in Mature & Hypermature cataract

other two investigations are must

• B – scan ( other uses of B scan – to confirm the diagnosis like

Endophthalmitis , Intra ocular Foregin Body, Retinal Detachment)
 Macular Function Tests
• Maddox rod test
• Two light discrimination
• Entoptic visualisation
• Laser interferometry
• To asses PL / PR
• To check Colour vision
• Electro physiological tests like ERG , EOG , VEP
• What is the treatment of choice in IMC/?
Phaco emulsification with Posterior Chamber Intra Ocular Lens

Why phaco? / advantages of phacoemulsification?

- smaller incision 2.8 – 3.2mm length so quick healing period ( 3-4weeks)
- no need of suturing so surgically induced astigmatism s only 0.5 D

Why Posterior Chamber IOL?

bcoz Anterior Chamber IOL will cause long term complications like
- Bullous Keratopathy
- UGH syndrome (Uveitis,Glaucoma,Hyphema)
In case of Mature cataract / Hyper mature / Nuclear cataract what is
your treatment of choice?
• bcoz of the nucleus hardness pahco will cause complications like
nucleus drop, zonular dehiscence and posterior capsular rupture … so
Small Incision Cataract Surgery (SICS) is the choice…

What are the advantages of SICS?

• smaller length (6-8 mm) compared to ECCE ( 10 – 12mm)
• healing period is faster 4 – 6weeks compared to ECCE(6-8weeks)
• post op astigmatism (1-2D) is less compared to ECCE (2-3D)
• no suturing compared to ECCE (5suturing)
When conventional Extra Capsular Cataract Extraction (ECCE) is
indicated ?
In this method length of incision is 10 – 12 mm ..so 5sutures ( nylon /
silk material,size 10-0) are needed which will create problems like
• long healing period (6-8weeks)
• high post op astigmatism ( 2- 3D)
• Infections & suture related irritation

• ECCE is only indicated in black nuclear cataract and mature cataract

Why Intra Capsular Cataract Extraction (ICCE) is not indicated
nowadays?

in ICCE posterior capsule is removed along with nucleus .so IOL can
not be placed…so vision will not be improved even after surgery.

it is indicated only in

• Traumatic cataract
• Zonular dehiscence
How will you classify cataract surgeries?

I – ICCE ( without posterior capsue II – ECCE ( with posterior capsue

support) Intra Capsular Cataract
Extraction
support) Extra Capsular Cataract
Extraction
1. conventional ECCE
2.SICS
3.Phacoemulsification
 What is phakoNIT?
• phacoemulsification performed with a Needle opening via
an Incision (only 0.9mm) using the Tip of phacoprobe.
• this method is invented by Prof Amar Agarwal indian
ophthalmologist who is a chairmen of Agarwal group of eye hospitals

What is the recent technique used for cataract surgery?

• Laser Assisted Cataract Surgery (LACS) in this technique
capsulorrehexis and nucleus fragmentation done by laser then
fragmented nucleus emulsified by phacoemulsification
Cataract pathogenesis
always bilateral , but asymmetrical
Why smoking is the major risk factor for cataract formation?

- accumulation of pigmented molecules like

3-hydroxykynurinine and chromophores and cyanates
in the lens which leads into formation of nuclear cataract

- 20% of risk is higher in smokers when compared to non smokers

What are all the morphological types of cataract?
I Cortical cataract
Cueniform cataract
• wedge shaped opacity starts
from periphery
• vision will not be affected in
early stages
• sugery is indicated in later stages
Cupuliform cataract
• opacity starts from center in
posterior subcapsular cataract and
posterior polar cataract
• vision will be affected in early
stage so surgery is indicated
II Nuclear cataract
Based upon colour
• Grade I- greenish yellow
• Grade II – yellow
• Grade III – amber
• Grade IV- brown
• Grade V – black
• Colour changes d/t
• deposition of pigments like
urochrome &melanin which is derived
from the aminoacids in the lens
 What are the clinical stages of cataract formation?
Stage of lamellar separation
• entry of water into lens fibers
• no symptoms
• diagnosed by SLE not with torch light

Stage of incipient cataract

• coloured halos is the symptom
• Cuneiform type and cupuliform type
• diagnosed by SLE not with torch light
 Stage of ImMature Cataract (IMC)
• symptoms – defective vision, coloured halos, polyopia, glare
• signs – diagnosed with torch light
• greyish opacity
• iris shadow

• Intumescent cataract – sudden swollen of lens

d/t hydrated lens fibres which will cause the pupillary block and
secondary glaucoma
 Mature cataract (ripe cataract)

• vision is only Hand Movements (HM)

• Lens colour is pearly white
• Iris shadow is absent
• Fundus view is absent
 Hyper Mature Cataract (HMC)
• vision is only HM
• Lens color is milky white
• Iris shadow is absent / Fundus view aslo absent
• presence of anterior capsular wrinkling and calcified spots in the
anterior capsule is the specific sign of hypermature cataract

Morgagnian cataract
• the whole lens cortex is liquefied and converted into bag of milky
fluid in which nucleus is settled into the bottom of the bag

Sclerotic type
• d/t shrinkage of lens ,anterior chamber becomes deep and
iridodonesis (iris tremulous) will be seen
Difference between the cortical and Nuclear cataract

Cortical cataract Nuclear cataract

• Colour greyish white brown / black
• Defective vision night blindness day blindness

(Cortical cataract opacities are in the periphery, In the night bcoz of physiological
mydriasis, pupillary dilatation will cause more defective vision in cortical cataract.
Nuclear cataract opacity is the central opacity, in the day time bcoz of sunlight
induced pupillary miosis nuclear cataract will cause more defective vision in the day
time)
• Consistency soft Hard

• Surgery of choice phacoemulsification SICS

 Difference between IMC and MC
Immature cataract Mature cataract
• vision HM < 6/12 < HM+
• Colour greyish white pearly white

• Iris shadow + -

• Fundus view possible not possible

• Distant direct dark shadow against red glow no red glow

Ophthalmoscopy
• Surgery of choice phaco SICS
Difference between MC and HMC

Mature cataract Hypermature cataract

• colour pearly white milky white

• Vision HM+ PL+

• Others - anterior capsular wrinkling

calcified spots in the anterior capsule
What are the causes for Pre Senile cataract ?
cataract occurs before the age of 40years
causes :
• Hereditary
• Diabetes
• Myotonic dystrophy
• Atopic dermatitis
• Fuchs heterochromic iridocyclitis
• Traumatic cataract
• Drug induced cataract ( systemic steroids/Pilocarpine drops)
 Named morphological type of cataracts
• Snowflake cataract – Diabetes

• Sunflower cataract – Wilson’s disease

• Oil drop cataract – Galactosemia

(Oil drop sign – Keratoconus)

• Rosette cataract – Traumatic cataract

• Christmas tree cataract – Myotonia dystrophy

• Shield cataract – Atopic dermatitis
(Shield ulcer – VKC)
 What is Complicated Cataract?
since lens is a avascular structure which gets nutrition from aqueous
humour and vitreous.
if any conditions affecting lens nutrition will form the complicated cataract.
Causes
• Iridocyclitis
• RD, RP, Pathological myopia
• Secondary Glaucoma
• Intra ocular tumors

Slit lamp examination showed

• Bread & Crumb appearance
• Poly chromatic lustre
 What is After cataract / secondary cataract / PCO ?
usually after 4-6months of cataract surgery , left out
anterior epithelial cells in the anterior capsule will proliferate over the
posterior capsule (Posterior Capsular Opacification) and form the white
membrane which appears like cataract (after cataract)
Types
• Soemmering’s ring – seen in periphery , no treatment needed

• Elschnig’s pearl – seen in centre , treated with Nd:YAG laser

(Neodymium: Yttrium, Aluminium, Garnett)

• Dense membranous type – Nd:YAG Lase / surgical removal

 What is Second Sight in cataract?
in Nuclear cataract, bcoz of nuclear hardening will increase
the refractive index of the lens and form the index myopia .
so patient can read the newspaper without glasses and thought he got
good vision after cataract

What is congenital cataract?

Congenital cataract – occurs at birth

Developmental cataract – from infant to adult life

 What are the types of congenital cataract?
• Capsular cataract – anterior & posterior
• Polar cataract - anterior & posterior
• Nuclear cataract
• Lamellar (Zonular) cataract
• Sutural & axial cataract
• Blue dot cataract
• Total congenital / membranous cataract
What is the most common type of congenital cataract?
Blue Dot cataract
• punctate bluish dot opacities seen in the periphery
• stationary / no progression
• no need of treatment
Which type of congenital cataract will affect the vision?
Lamellar (Zonular) cataract
• bilateral
• d/t heredity / vit D def / Rubella
• it forms spokes of a wheel (riders) like opacity, will affect the vision always
 What is the triad of congenital Rubella syndrome?
• Congenital cataract
• Deafness
• PDA

When will you advice cataract surgery for congenital cataract?

Unilateral congenital cataract

• cataract surgery immediately after birth to prevent Amblyopia

Bilateral congenital cataract

• cataract surgery is advisable 6-8 weeks after birth
Which type of cataract surgery is advisable in congenital cataract?
• lens aspiration by phacoemulsification method
• posterior capsulorrhexis is mandatory to prevent pco
How will you calculate IOL power in congenital cataract?
• < 2years – reduce 20% from actually calculated IOL power to
compensate myopic shift when child grows up
• 2years to 7 years – reduce 10% from actually calculated IOL
power
• > 7 years – no reduction
What are the commonest post op complications in congenital
cataract surgery?
• thickened Posterior Capsular Opacification (PCO)
• secondary Glaucoma
Cataract II
What are all the complications of Cataract?

• after Hyper mature stage – lens proteins leaked into anterior

chamber and block the trabecular mesh work – Phacolytic Glaucoma

• Phacoanaphylactic Uveitis

• Intumescent cataract block the pupillary area- Phacomorphic

Glaucoma
What are the types of ocular anaesthesia?
I – Local Anaesthesia
1.Topical anaesthesia ( 4% lignocaine) – Phacoemulsification

2.Peribulbar block – Best anaesthesia used for cataract surgery nowadays. In

this technique anaesthetic solution is injected parallel to the eyeball and will reach
the muscle cone slowly and block the III IV VI V nerve

3.Retrobulbar block- in this method anaesthetic solution is injected directly

into the muscle cone. Globe perforation,Optic nerve injury,Retro bulbar
haemorrhage are the complications.so not used nowadays.

4.Facial block – to block the facial nerve at neck of the mandible to block the
orbicularis oculi muscle action and lid squeezing. This is a very painful procedure
and not used nowadays
 II General Anaesthesia
1.children
2.psychiatric patients
3.toxic to lignocaine

What are the components of anaesthetic solution?

1. 2% lignocaine
2. Hyaluronidase 5IU/ml (anaesthetic drug penetration is better)
3.Adrenaline 1/100000 (vasoconstriction- prolonged drug
action)
 What are the surgical steps of SICS?
•  aseptic precaution Ocular anaesthesia
• after eye speculum Bridle suturing (temporary suturing to Superior
Rectus muscle to control eye movement)
• Scleral incision around 6 – 8mm size which extents into cornea and
makes sclero corneal tunnel
• after entry into anterior chamber anterior Capsulotomy (can opener
method / capsulorrhexsis method)
• Hydrodissection and Nucleus prolapse into AC
• Nucleus delivery by sandwitch method
• Cortical aspiration
• IOL implantation
• After each and every step , viscoelastic substance is injected into AC
to protect the corneal endothelium . At the end of surgery visco has
to be aspirated to prevent secondary glaucoma.

What is the name of nucleus delivery method in ECCE and SICS?

• ECCE – Pressure & counter pressure technique

• SICS – Sandwitch technique

 What are the common intra operative complications occurred during
cataract surgery?

• Premature entry and Iris prolapse

(in SICS making sclerocorneal tunnel is a three step incisional
procedure will maintain the valve mechanism in the tunnel.sudden
entry (premature ) into the AC by single incision step will lost the valve
effect and will prolapse the iris out)

• Posterior Capsular Rupture (PCR) – occurred during capsulotomy /

cortical aspiration/IOL implantation
• Vitreous prolapse – after PCR vitreous is prolapsed from posterior
chamber into anterior chamber and demage the corneal endothelium
– vitreous touch syndrome

• Nucleus drop / IOL drop – d/t large zonular dehiscence or PCR

• Hyphaema (iris bloodvessels injury) Iridodialysis (separation of iris

from root)

• Expulsive Choroidal Haemorrhage

What are features of Expulsive Choroidal Haemorraghe?
- bleeding comes from choroidal vessels
- common in HT/ Glaucoma patients
- sudden severe pain / stony hardness of the eye ball
- wound gapping / expulsion of all intra ocular contents
- absence of Red glow
- treatment stop the surgery / iv mannitol
- Sclerotomy and drain the subchoroidal blood
- Evisceration
 What is Oculo Cardiac reflex?
• sudden bradycardia / arrhythmia / hypotension will occur
during retrobulbar block or suturing in the superior rectus muscle
• d/t afferent stimulus from ophthalmic division of Trigeminal
nerve and efferent stimulus from Vagus nerve
What are the early post operative complications after cataract surgery?

1.Striate Keratopathy

2.Shallow anterior chamber

3.Iris prolapse

4.Hyphaema

5.IOL drop

6.Endophthalmitis
 What is Striate Keratopathy? (SK)
• corneal edema with DM folds (descemet’s membrane)
• occurs d/t damage of corneal endothelium
• treated with 5% Hypersol eye drops (sodium chloride)
4times/day and 6% Hypersol eye ointment at night time

What is the normal endothelial cell count?

• 2500 – 3000 which is measured by Specular microscope
 What is the reason for shallow AC after cataract surgery?
• usually d/t wound leak (hypotony is a main feature)
• sometimes d/t choroidal detachment / pupillary block
• diagnosed with Seidel’s test
• treatment – pad & bandage / oral acetazolamide / suturing

What is Siedel’s test?

• after applying fluorescein dye ask the patient to blink his
eye,then see with slit lamp..at the site of leakage fluorescein will be
diluted by aqueous.
 What is the reason for Iris Prolapse?
• d/t wound leak
• small iris prolapse – iris reposition with wound suturing
• large iris prolapse – iris abscission with wound suturing

Where is the source for Hyphaema?

• bleeding comes from iris vessels / scleral vessels
• indications for aspiration of blood through paracentesis
- secondary Glaucoma
- Blood staining cornea
- defective vision d/t blocking the pupillary area
 Why IOL drop occurs after cataract surgery?
• d/t large posterior capsular rupture / zonular dehiscence

What is Endophthalmitis?
• inflammation of all the layers of the eyeball except Tenon’s
capsule ( if it is involved – Panophthalmitis )
• dreaded complication of cataract surgery
• sudden pain , defective vision ,
• Hypopyon , Yellow reflex (exudative membrane) in pupillary
area , absence of fundal red glow
• confirmed by B –scan ( choroidal thickening)
 Clinical Types
• very early Endophthalmitis – occurs within 1week after surgery
• Early Endophthalmitis – within 1month
• Late Endophthalmitis – 1 month to 1year
• (mc organism – Propionobacterium acne / Staph.epidermidis)
Treatment
Intra vitreal injections
• Vancomycin 1 mg / 0.1 ml
• Ceftazidime 2.25 mg / 0.1 ml
• Amikacin 0.4mg / 0/1 ml
• Topical & systemic antibiotics
• Pars plana vitrectomy
What are late post op complications?
1.Cystoid macular edema

2.After cataract

3.Retinal Detachment

4.Pseudophakic Bullous keratopathy

5.Delayed post operative Endophthalmitis

Why CME occurs after cataract surgery?

• during cataract surgery inflammatory mediators like prostaglandin E -

2 ,I - 2 are released which will be settled into macular area and forms
cystic spaces in the macular region.

• Fundus – Honeycomb appearance

• FFA – flower petal pattern

• Treatment – anti prostaglandin drugs like – Bromfenac / Nefafenac /

Flur / Ketoralac eye drops
 What is After cataract / secondary cataract / PCO ?
usually after 4-6months of cataract surgery , left out
anterior epithelial cells in the anterior capsule will proliferate over the
posterior capsule (Posterior Capsular Opacification) and form the white
membrane which appears like cataract (after cataract)
Types
• Soemmering’s ring – seen in periphery , no treatment needed

• Elschnig’s pearl – seen in centre , treated with Nd:YAG laser

(Neodymium:Yttrium,Aluminium,Garnett)

• Dense membranous type – Nd:YAG Lase / surigical removal

 Why Retinal Detachment is common in pseudophaic patients?
• vitreous loss in posterior capsule rupture / vitreous
liquefication ( normally vitreous is a gel like structure) is the
predisposing factor for RD formation in pseudophakia
• RD is confirmed with B-scan

What is Pseudophakic Bullous Keratopathy (PBK)?

• occurs d/t severe damage of corneal endothelium
• normally 2500 – 3000 endothelial cells
• count is less than 750 bullous keratopathy occurs
• treated with 5% sodium chloride eye drops/ anti glaucoma
drops / penetrating keratoplasty
 Who invented Intra Ocular Lens (IOL)?
• Harold Ridley

What are the parts of the IOL?

• 1.Optic
• 2.Haptics
• 3.Dialling holes (only in rigid PCIOL)
(in ACIOL – no dialling holes,haptics are larger than PCIOL)

What are the types of IOL implantation?

• Primary IOL implantation – cataract removal & IOL implantation in same
sitting
• Secondary IOL implantation – cataract removal in one sitting & IOL
implantation in another sitting
 How will you classify IOLs?
Based on the site of implantation
• ACIOL (Kelman multiflex Anterior Chamber IOL) – implanted in
front of the Iris
• PCIOL (Posterior Chamber IOL) – implanted behind the Iris
• Iris claw lens (Singh & Worst’s) – clipped into iris
• SFIOL (scleral fixation IOL) – haptics sutured into sclera by holes in
the haptics

Based on the material

• Rigid IOL – PMMA (Poly Methyl Metha Acrylate)
• Foldable IOL – Silicone, acrylic,hydrogel
• Rollable IOL - Hydrogel
 Based on the refractive status
• Monofocal IOL – to correct only distant vision (most commonly used
IOLs in cataract surgery.since it will correct only distant
vision have to prescribe near vision glasses after cataract surgery)

• Multifocal IOL- this will correct both distant and near vision ( this IOL
can be identified by presence of multiple circles seen on the optics .
but colour contrast sensitivity is the problem of this IOL.)

• Accommodative IOL (Crystalens) – artificial IOL accommodates like

normal lens.This IOL corrects near vision and colour contrast also
good
 Which type of IOL has best prognosis?
• Posterior Chamber IOL

What are the indications of Iris Claw/SFIOL/ACIOL?

• large posterior capsular rupture / Zonular dehiscence

What are complications of ACIOL?

• UGH syndrome(Uveitis,Glaucoma,Hyphaema)
• Bullous Keratopathy
What are the PCIOL related complications occurred after cataract surgery?
it occurs d/t Zonular dehiscence

• Sun set syndrome – inferior IOL subluxation

• Sun rise syndrome – superior IOL subluxation
• Lens lost syndrome – complete IOL dislocation into vitreous cavity
• Windshield wiper syndrome – when smaller optic IOL is placed in
the sulcus (space between posterior part of iris and anterior capsule)
superior haptic moves when patient head moves right and left

• Optic capture
 What is the pre op and post op treatment protocol for cataract?
• Broad spectrum antibiotic drops like Moxifloxcin eye drops
6times/day 3-5 days prior to the surgery
• Dilating drops like Tropicamide with Phenylephrine eye drops every
15mts once 2hrs before to the surgery
• Tab.Acetazolamide 250mg st on the day of surgery

Post op treatment
• Antibiotic – steroid (Moxifloxcin with Dexamethasone/prednisolone)
eye drops for 4 – 6weeks in SICS
• Every week taper the steroid drops dose
 What is the post op follow up schedule?
• First post op day then after one week after that every 2weeks till
the healing period is over (SICS – 6-8 weeks/ Phaco -3-4 weeks)
• Every visit check vision / IOP (steroid will increase the IOP)
• After the healing period advise BIFOCAL glasses ( distant vision
(astigmatism) + near vision)

How long gap will be advisable between two eyes cataract surgery?
• Both eyes cataract surgery in same sitting is not advisable for the fear
of endophthalmitis
• Usually one month gap (to r/o very early (3days) and early (1month)
endophthalmitis) is advisable between two eyes surgery
 What is Ectopia Lentis?
• displacement of lens from its normal patellar fossa d/t zonular
weakness
Types
• Subluxation – partial displacement
• Dislocation – complete displacement
Causes
• Marfan’s syndrome- upwards & temporal subluxation
• Homocystinuria – downwards & nasal subluxation
• Weil-Marchesani syndrome
• Ehlers-Danlos syndrome
 What is Lenticonus?
• conical shape protrusion of central part of the lens
• Anterior Lenticonus – Alport’s syndrome
• Posterior Lenticonus – Lowe’s syndrome

What is Microspherophakia?
• Lens becomes spherical shape and smaller size which will cause
pupillary block angle closure Glaucoma .in this type cyloplegics is the
drug of choice which is usually contraindicated in other type of angle
closure glaucoma.This is called inverse Glaucoma

• Weil Marchesani syndrome / Marfan’s syndrome

Cataract - III
 Qns from patient’s profile data
Age related ocular problems
• ARMD after 60 years
• Cataract after 40 years
• Glaucoma after 40 years
• Refractive Error (school going
children)
Ocular problems common in Females
• Glaucoma
• Episcleritis / Scleritis
• Keratoconus
• Diabetic / Hypertensive retinopathy
Males
• Allergic conjunctivitis
• Pigmentary Glaucoma
• Coat’s disease
• Congenital Glaucoma
 Occupation related ocular problems

• Computer Vision Syndrome (CVS)

eventhough tear is secreted from Lacrimal gland in
lateral side which travel into medial side and reaches lacrimal sac by
blinking.Normal person blinking rate is 16-18 times/mt but it comes
only 8-10 times /mt in IT workers which will cause corneal dryness and
asthenopic symptoms
• Radiation cataract
• Occular injuries in industrial workers
• Pre senile presbyopia in watch workers
• Pterygium is common in farmers
 What are the chief complaints in ophthalmology?
• Defective vision
• Ocular pain
• Coloured halos
• Redness
• Discharge
• photophopia
• Diplopia
• Floaters
 Defective vision
Sudden painless loss of vision
• CRAO
• RD
• Vitreous Haemorrhage
• Ischemic CRVO
Sudden painful loss of vision
• Acute congestive Glaucoma
• Acute iridocyclitis
• Chemical injuries
Gradual painless loss of vision
• Cataract
• Corneal dystrophies
• Pterygium
• Refractive error
• Optic atrophy
• ARMD
Gradual painful loss of vision
• Chronic congestive Glaucoma
• Chronic iridocyclitis
• Chronic corneal ulcer
 Night Blindness
watering
• Vit A deficiency
• dacryocystitis (d/t blockage in
• RP the lacrimal drainage system)
• Pathological myopia • Corneal pathology (d/t increased
• CSNB (Congenital Stationary reflex secretions)
Night Blindness) • Allergic conjunctivitis
Discharge
Itching
Mucpurulent – bacterial
• Allergic conjunctivitis
conjunctivitis
• Severe Dry eyes
Watery – allergic /viral
conjunctivitis
 Photophobia
• d/t abnormal sensitivity to
normal light
• Corneal pathology
Glare
• d/t entry of high amount of light
or reflection of light
• After cycloplegics
• cataract
Acute RED EYE
• Acute congestive Glaucoma
• Acute iridocyclitis
• Acute conjunctivitis
Floaters
• Block spots infront of the eye
• Vitreous Haemorrhage
• Vitreous degeneration
• Pathological myopia
• After cataract surgery
Coloured halos Diplopia
• IMC (d/t scattering of light d/t
hydrated lens fibres) Uni ocular diplopia
• Acute congestive Glaucoma (light • Incipient cataract
scattering d/t corneal edema)
• Subluxated IOL
• Acute mucopurulent conjunctivitis
(light scattering d/t mucus • Keratoconus
deposition) Binocular Diplopia
• Fincham stenopaeic slit test • Paralytic Squint
• Ask the patient to see the light • Myasthenia Gravis
source through this slit • Thyroid eye disease
• Broken light – IMC • Anisometropia
• Intact light - Glaucoma • Blow out fracture of orbital floor
 Qns from past h/o,personal h/o,treatment h/o
Ocular manifestation of Diabetes Hypertension & EYE
• Xanthelesma • SCH
• Recurrent stye / chalazion • POAG
• SCH • CRAO / CRVO
• Fungal corneal ulcer • Hypertensive retinopathy
• Nonhealing corneal ulcer
• Hypertensive choroidopathy
• POAG
• AION
• Rubeosis iridis
• Snowflake cataract
• Vitreous haemorrhage
• Diabetic retinopathy
• III ,IV,VI nerve palsy
 Ishcemic Heart Disease Drug induced cataract
• To stop Aspirin 7-10 days prior to Systemic drugs like
the surgery • Amiodarone
• Busulphan
Asthmatic cataract patient • Corticosteroids
• to avoid NSAIDS and beta • Chlorpromazine
blockers like anti glaucoma drugs
• golD(treatment for Gout)

• Topical – Pilocarpine drops

 Alcohol & EYE Smoking & EYE
• Telengectasia of conjunctival • cataract
vessels
• Glaucoma
• Fungal corneal ulcer
• Crvo
• Glaucoma
• Toxic amblyopia
• Optic neuritis
• Optic atrophy
 QNS from Ocular Examination

• Abnormal Head Posture • Facial asymmetry

Paralytic Squint (head turns to the Bell’s palsy
direction of the action of
paralysed muscle to avoid
diplopia) • Forehead wrinkling
Increased – ptosis (d/t overaction
of frontalis muscle)
• Chin elevation
Ptosis
Absent – Facial nerve palsy
• Orthophoria – normal alignment of the eyeball
• Squint (Heterophoria/Heterotropia) – malalignment of the eyeball
• Heterophoria – Latent squint
• Heterotropia – manifest squint
Esotropia (convergent squint)
Exotropia (divergent squint)

How will you check orthophoric?

to ask the patient to fix the distant object ,then light pass on to the
glabella and observe the light reflex on centre of the pupil in both eyes in
normal patients.
if the reflex is deviated from the centre of pupil indicates squinting of
that eye.
• If the reflex is on medial side – Exotropia
• Reflex is on lateral side – Esotropia

Hirschberg corneal reflex test

• Approximately to measure the amount of squint
• light reflex on centre of the pupil – normal
edge of the pupil - 15
iris surface - 30
limbus - 45
 EOM
• Uniocular movements – Ductions (elevation,depression.adduction,
abduction,intorsio,extorsion)

• Binocular movements
• Versions – both eyes movements in same direction (dextroversion,
levoversion,dextroelevation,levoelevation,dextrodepression,levodepr
ession,supraversion,infraversion,dextro&levo cycloversion)

• Vergences - both eyes movements in opposite direction

(convergence,divergence)
• Extorsion – rotatory movement along the anteroposterior axis in which
superior pole of the cornea at 12p moves laterally (external rotation) –
Inferior Oblique muscle

• Intorsion – rotatory movement along the anteroposterior axis in which

superior pole of the cornea at 12p moves medially (internal rotation) –
Superior Oblique muscle

Restricted EOM
• Paralaytic squint
• III,IV,VI nerve palsy
• External ophthalmoplegia – lesions at the level of motor nucleus
• Inter Nucleur Ophthalmoplegia(INO) – lesions at Medial Longitudinal
Fasciculus(MLF) – defective action of medial rectus on same side of lesion
 LIDS
• Madarosis – loss of eyebrows & lateral onr third of eye lashes
Leprosy,Myxoedema,chronic blepharitis
• Trichiasis – misdirected eye lashes – trachoma,blepharitis,stye
• Distichiasis – abnormal etra rows of eye lashes
• Poliosis – graycoloured eye lashes – old age ,albinism,VKH syndrome
• Entropion - inward turning of lid margin
• Ectropion – outward turning of lid margin
• Ankyloblepharon – abnormal adhesions of the two lids at angles –
ulcerative blepharitis , chemical burns
• Symblepharon - abnormal adhesions of palpebral and bulbar
conjunctiva – chemical burns
• Blue sclera – Osteogenesis imperfect , pseudoxanthoma elasticum,
marfan’s syndrome

• Megalocornea- horizontal diameter > 13mm (normal – 11.7) or adult

size at birth (at birth normal diameter 10mm)
Marfan’s syndrome , Ehlersdanlos,down syndrome
• Microcornea - <10 mm at birth
Nanophthalmos (normal small eyeball)
Microphthalmos (abnormal small eyeball)

• Reduced corneal sensation – viral keratitis / neuroparalytic keratitis/

absolute glaucoma / leprosy / diabetes
 Anterior chamber
• Normal anterior chamber depth 2.5 – 3mm
• Measured clinically by torch light / SLE – Van Herrick method
• By instrument – A-scan / UBM (Ultra Bio Microscopy)
• Eclipse sign – when torch light shows from temporal side will form the
crescent like illumination into the nasal part of iris which indicates shallow
anterior chamber
• Hyphaema – collection of blood in the anterior chamber
trauma, after cataract surgery,herpes zoster iridocyclitis, retinoblastoma
• Hypopyon – collection of pus in the anterior chamber
• Infective causes – corneal ulcer , endophthalmitis,uveitis
• Noninfective (pseudo hypopyon) – phacolytic glaucoma,silicone oil in RD
sugery , retinoblastoma
 Deep anterior chamber Shallow anterior chamber
• Myopia • Angle closure glaucoma
• Aphakia • Phacomorpic glaucoma
• Posterior dislocation of lens into • Hypermetropia
vitreous cavity • After cataract surgery d/t wound
• Keratoconus leak
• Buphthalmos • Anterior subluxation of lens into
anterior chamber
IRIS
• Normal colour – light brown/dark brown
• Normal pattern – peculiar pattern is d/t presence of Collarette,Crypts and
radial striations on its anterior surface

• Heterochromia Iridium – different colour between two iris

• Heterochromia Iridis – different colour pattern in same iris
Causes – Horner’s syndrome,Fuch’s heterochromic iridocyclitis,
malignant melanoma of iris
• Iridodonesis – tremulousness of the iris – Aphakia

• Rubeosis iridis – abnormal new vessels formation on the iris

Diabetic Retinopathy,CRVO,chronic uveitis,Retinoblastoma
Synechiae
Abnormal adhesions of iris into other structures
• Anterior synechiae – iris adhesions into the cornea (adherent leucomatous
corneal opacity)
• Posterior synechiae – iris adhesions into the lens (iridocyclitis)
• Ring (annular) synechiae - 360 posterior synechiae – pupillary block angle
closure glaucoma

Horner’s syndrome – d/t oculo symphathetic paresis

• Components (MAPLE)
• Miosis
• Anhydrosis
• Ptosis
• Loss of cilio spinal reflex
 Pupil
• Single/circular/3mm size/centrally placed
• Reacting to both direct (same eye pupil constriction) and indirect
(other eye pupil constriction) light reflex
• Normal pupil size – 3-4mm

Miosis - < 3mm size

• Parasympathomimetic drugs – Pilocarpine
• Horner syndrome
• Pontine haemorrahage
• Iridocyclitis – irregular miotic pupil
 Mydriasis – size > 4mm
• Parasympatholytic drugs – atropine,homoatropine,cyclopentolate
• Sympathomimetic drugs – adrenaline,phenylephrine
• III nerve palsy
• Optic atrophy
• RD

• POLYCORIA – more than one pupil

• ANISOCORIA – difference between the SIZE of teo pupil
• Jet black pupil – aphakia
• Festooned pupil– after mydriatics in iridocyclitis
• D shaped pupil – blunt trauma induced iridodialysis
• Mid dilated fixed pupil – acute congestive glaucoma
 Leucocoria – white reflex in pupil
• Retinoblastoma
• ROP(Retinopathy Of Prematurity)
• PHPV (Persistent Hyperplastic Primary Vitreous)
• Congenital cataract
• Coat’s disease
• Toxocara endophthalmitis

Marcus Gunn pupil

• RAPD (Relative Afferent Pupillary Defect)
• When light shown to the affected eye pupil will be dilated instead of
constriction – Swinging Flash light test
 Causes
• Optic atrophy
• Optic neuritis
• Ischemic CRVO
• CRAO
• Longstanding RD

Argyll Robertson Pupil (ARP)

• Accommodation reflex present
• Pupillary reflex absent
• Neuro syphilis
 Purkinje images
• Normally 4images but 4th image is not visible which is inverted and
minified image
• 1 & 2 images – anterior & posterior surfaces of cornea
• 3 & 4 images – anterior & posterior surfaces of lens

• IMC – normal images

• Mature cataract – 4th image is absent
• Aphakia – 3 & 4 images are absent
• Pseudophakia – prominent 3rd image
• Exophthalmos(proptosis) – forward displacement of the eyeball
Thyroid,orbital cellulitis,cavernous sinus thrombosis
Optic nerve glioma,meningioma,haemangioma
• Enophthalmos – inward displacement of the eyeball
Horner’s syndrome,blow out fracture of floor of the orbit

• Nanophthalmos- normal small eyeball

• Microphthalmos – abnormal small eyeball

• Phthisis bulbi – shrunken eyeball & anatomically disorganised intra ocular

contents
• Atrophic bulbi – shrunken eyeball but anatomically differentiate intra
ocular contents