JCabarrubias

ORBITAL DISEASES
Thyroid eye disease (TED) Most common cause unilateral & Ocular signs: Dx: Control underlying thyroid abnormality
●​Graves bilateral proptosis in adults ●​Eyelid protraction 90% ●​Immune-related Systemic steroids (Methylpred)
Ophthalmopathy Autoimmune ●​Proptosis 68% thyroid dysfunction Biologic agents (Monolonal AB)
●​Thyroid-Assoc Women (8-10x) > Men (1) ●​Von Graefe’s sign ●​Ocular signs (1 or Orbital radiation
Ophthalmopathy Tendon sparing ●​Lagophthalmos more) Surgery- 6 mos of dse inactivity & euthyroid
Pts can be hyper, hypo or euthyroid ●​Diplopia ●​Radiographic state
Severity: evidence ●​Orbital decompression- relieve proptosis
Patho: ●​Presumed self-limiting ●​Strabismus surgery- correct ocular
-Activation of orbital fibroblast ●​Active course of NO SPECS- classification deviations; eye occlusion helpful until
-Inc. pdxn mucopolysach-> exacerbations & condition stable for 6mos
accumulate in EOM remissions ●​Eyelid surgery- address malposition
-Fibroblast -> Adipocytes & Myoblast ●​Mild GO: ocular
surface, controlled w/
topical lubricants
●​Mod-severe GO:
immunosuppression
may be required; sight
threatening
Non-specific Orbital Idiopathic Pain, proptosis, diplopia, periocular edema, diffuse Steroids- 1st line
Inflammation (NSOI) Unilateral, rapid onset or localized inflam Immunosuppressants- alt (cyclophos, inflixim)
“Orbital pseudotumor” Tendon involving Myositis, Dacryoadenitis, or Optic Perineuritis Surgery-> biopsy
Orbital infections:
●​Orbital Cellulitis ●​POSTERIOR to orbital septum ●​Arise from ACUTE (S.aureus) or CHRONIC ●​Immediate tx is essential (IV antibiotics;
-most common cause of proptosis SINUSITIS (anaerobic); critical -> extend to consult w/ ENT, surgical drainage of
children cavernous sinus & CNS; preseptal ssxs +chemosis, abscess)
proptosis, limited EOM, Leukocytosis
●​Preseptal cellulitis ●​ANTERIOR to orbital septum; ●​RF: Skin trauma; CA: S.aureus; edema, erythema, ●​Oral antibiotics, may be discharged
spares the globe pain, fever
Dermoid and epidermoid Dermoid- epithelial structures Benign choristomas CT scan: round bony defect En-bloc surgical removal w/ preservation of
cyst (keratin, hair, teeth) Originate from ectoderm MRI: well defined round cyst wall- TOC
Epidermoid- keratin w/o dermal Loc: lateral brow at mass
appendage frontozygomatic suture
Cavernous hemangioma Most common benign tumor of orbit Loc: w/in muscle cone DO NOT REGRESS Surgery- if symptomatic
in adulthood spontaneously
Women > Men
Capillary hemangioma Most common benign tumor of orbit Anastomosing vascular 30% present at birth Systemic B blockers: Propranolol 1st line
and periorbital area in childhood channels 90% apparent before 6 Systemic/ Intralesional steroid: Bleomycin
Girls (3) > Boys (1) Strawberry nevi- superficial mos Surgery- for refractory or compromised vision
Bluish nevi- deeper Enlarge rapidly 1st yr
REGRESS slowly 6-7yrs
Rhabdomyosarcoma Most common primary malignant Loc: superonasal quadrant Presents before 10 yrs Radiotherapy- produce many cx
tumor of orbit in children Rapid growth w/ proptosis 90% survival rates if w/ Chemotherapy- appropriate for children
May destroy adj bone & tx Surgery- high mortality; biopsy
spread into brain
Metastatic tumors Reached thru hematogenous spread Loc: Poor life expectancy Radiation
(choroid >orbit ) ●​Adults: breast, lung, Chemotherapy
prostate Surgery- excised if small and localized
●​Children:
neuroblastoma
-spont. periauricular hemorrhage
EYELIDS INFECTION AND INFLAMMATION
Hordeolum/ Stye ACUTE inflamm of meibomian PAINFUL, redness and Fluctuant nodular mass Warm compress
glands (internal) or glands of Moll/ swelling Loc: Near lid margin Topical antibiotics- if w/ discharge
Zeis (external) -> preseptal cellulitis Incision and drainage- unresolving
Chalazion Sterile, focal, CHRONIC inflamm Firm, PAINLESS, Persistent Assoc w/ rosacea and Warm compress
from obstruction of Meibomian over wks or mos post. Blepharitis Antibiotic-steroid ointment
gland -> Lipogranuloma formation Incision and Curettage- if not amenable to warm
Initially present as Internal Dome-shaped nodule compress, distorts vision or aesthetically unacceptable
hordeolum (absence of Loc: Area above lashes Biopsy -persistent & recurring; to r/o CA
acute inflam signs)
Blepharitis Chronic inflammation of eyelid Irritation, burning & itching CA: Lid hygiene- warm compress, cleansing
MARGINS w/ frequent exacerbation of eyes & lids; discharge on ●​S.aureus (most gel/shampoo, removal of scales, meibomian
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eyelid & lashes common) gland expression

Most common cause external ocular ●​Malassezia furfur
irritation (seborrheic)
Avoid eyeliners, mascara, false eyelash or
“COLLARETES”/ extension
●​Posterior Blepharitis ●​Moraxella
scales/scurf: fibrin crust at
-​ Lid inflam sec to dysfunction of base of lashes ●​Herpes simplex Antibiotic ointment
Meibomian glands -> ●​Demodex (parasite) Anti inflammatory
Meibomianitis (inspissated
secretions upon pressure)
-​ Hyperemia, telangiectasia,
rounded/rolled inward, tears
frothy filled w/ debris
Other Eyelid abnormalities:
●​ Ectropion- outward turning of lid margin
●​ Entropion- inward turning of lid margin
●​ Trichiasis- misdirection of eyelashes toward cornea
●​ Distichiasis- accessory or extra row of eyelashes
●​ Ptosis- eyelids abnormally low position
Benign tumors:
●​Squamous papilloma ●​“Skin tag”; focal hyperplasia of SSE of epidermis, single or multiple, fleshy color, ●​Observed or excised
sessile or pedunculated; irregular surface
●​Seborrheic keratosis ●​Middle aged to older indivs; Dome shaped or Verrucoid; “greasy” or “stuck on”; gray to ●​Excision if aesthetically bothersome
brown, crusty surface
*Verruca vulgaris: HPV 6/11; TOC excision/cryotherapy; digitated surface; known to recur
●​Keratoacanthoma ●​Low grade tumor; resembles SCC, rapidly growing single nodule; umbilicated w/ ●​Surgical incision- TOC
distinct crater filled w/ keratin plug-> atrophic scar; involution after 6 mos
Malignant epithelial tumors:
●​BCC ●​most common eyelid malignancy ●​Firm, painless indurated ●​Blue basaloid tumor ●​Incisional or excisional biopsy; wide
90% nodule w/ pearly, rolled arranged in nests excision; cryotherapy or radiation,
Loc: Lower lid, medial canthus border & telangiectatic and cords; Exenteration if w/ orbital extension
(poorest prognosis), upper lid, outer surface vessels; rarely Peripheral
canthus metastasize Palisading
●​SCC ●​Flat, keratinized ulcerated ●​Slow growing, painless ●​Pink dyskeratotic ●​Incisional or excisional biopsy; wide
erythematous plaque in lower lid hyperkeratotic nodule; cells; keratin pearls; excision entire lesion then reconstruction;
more aggressive; mets by cordlike atypical cryotherapy or radiation, exenteration if
lymphatics or hema anaplastic cells w/ orbital extension
●​Sebaceous cell CA ●​From sebaceous glands ●​Painless nodule from ●​Frequently ●​Biopsy; wide surgical excision;
Tarsus or diffuse misdiagnosed as radiotherapy (palliative not curative)
thickening of the lid; lash chalazion/blepharitis
loss (Madarosis)
LACRIMAL APPARATUS DISORDERS
DacryoAdenitis Inflammation of Lacrimal gland
●​ Acute ●​less common; usually in children; cx of VIRAL infection (mumps, measles, influenza)
●​ Chronic ●​>1 mo; bilateral and often painless; assoc w/ SYSTEMIC INFLAMMATORY DSES
DacryoCystitis Infection of Nasolacrimal SAC Warm compress
CAs: staph, strep, pseudomonas Oral (effective) Topical (limited) antibiotics
Distension below medial canthus Incision and drainage- localized abscess
DCR (dacryocystorhinostomy)- obstruction
Nasolacrimal duct Women>Men Silicone tube intubation
obstruction (NLDO) Involutional stenosis of NLD -> inflamm infiltrates compress duct -> fibrosis -> stenosis DCR
Congenital NLDO- membranous blockage of Valve Hasner; open spontaneously w/in
4-6 wks after birth; 2-6% full terms at 3-4wks; 90% resolves w/in 1 yr
Periorbital contusion ●​Closed globe injury sec blunt force XRay Cold compress 15-30 mis x 24 hrs then warm
hematoma ●​Causes (mauling contact sport, falls) CT Scan compress
●​Blunt trauma delivers shock wave throughout the globe Frank or occult globe Povidone iodine/ Antibiotic oint- abrasions
●​Spontaneous bleeding -> Bleeding disorder rupture Analgesics
●​Reddish blue (fresh) -> greenish to pale yellow (healing) TT, TIg
Subconjunctival ●​Caused by spontaneous or traumatic rupture of conjunctival blood vessels (Valsalva, HPTN, bleeding dx, anticoagulant)
hemorrhage ●​Unilateral, sudden onset, bright red appearance, asymptomatic
●​Benign & self limiting; investigate if recurrent
●​Consider open globe injury if: due to trauma, >270 degrees, assoc w/ prominent chemosis
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Orbital floor fracture Dx: Mgt:

●​Indirect (blowout) ●​Hx of trauma ●​Majoritity do not require surgery
-​ No involvement ●​PE ●​Observe 1-2 wks
orbital rim ○​Eyelids signs (ecchymosis, edema) ●​Oral steroids 1mg/kg x 7days
●​Direct ○​Diplopia w/ up and down gaze limitations ●​Pedia- urgent repair if IR tightly trapped, vertical globe excursion,
-​ From inferior ○​Enophthalmos & ptosis oculocardiac reflex (bradycardia & vomiting on EOM)
orbital rim ○​Hypoesthesia in distribution of infraorbital nerve Surgical indications:
fractures ○​White-eyed blowout fracture- children ●​Functional entrapment of inferior rectus- diplopia, gaze limitations,
○​Limited EOM (+) force duction test, radio confirmation
■​Inferior rectus entrapment- limitation and pain ●​Large floor fracture: >50% floor involvement
vertical movement ●​Enophthalmos > 2 mm
■​Forced duction test (Traction test)- limitation ●​Cosmetically unacceptable
passive movement
●​Radiograph CT Scan FOR LIMITED EOM:
Repair w/in 2wks
Infraciliary/ Conjunctival incision
-​ Elevation of periorbital
-​ Release of prolapsed tissue
-​ Placement of implant
Mini / Microplating ; Mesh Nylon
Orbital roof fracture Observe for protrusion/displacement intraocular contents Plating, mesh, nylon foil implant
Otorrhea, rhinorrhea, CSF leaks Observe and coordinate w/ neuro dept
CORNEA AND EXTERNAL DISEASE
Microbial Keratitis Major cause visual loss throughout the world
RF: contact lens wear, ocular surface disease, trauma, ocular surgery
●​Bacterial Keratitis
○​most common form corneal infection causing central MK
○​Trauma- most common predisposing factor
○​Developed countries RF- contact lens & pre existing surface dse
○​CAs: Pseudomonas- most rapid course <5-7 days, attention to ulcer borders, corneal scraping before starting meds; Moraxella;
S. pneumoniae (“PMS”)
○​Features: corneal epithelial defect, hypopyon, corneal thinning perf.
○​Mgt: DC contact lens use, NEVER patch eye, empiric therapy (FQs), systemic antibiotics (if ulcers >6mm)
●​Fungal Keratitis
○​Common in agricultural setting
○​CAs: Candida, Fusarium, Aspergillus
○​Feature: Indolent ulcers, irregular edges and satellite lesions
○​Dx: corneal scraping, KOH smear
○​Mgt: topical or systemic antifungal meds; Corticosteroid is CONTRAINDICATED
●​HSV Keratitis
○​Most common infectious cause of unilateral corneal blindness in developed countries (3rd in PH)
○​HSV1- eye infection & face, HSV2- genitals
○​Primary infection -> latency in trigeminal ganglion -> reactivation (triggered by fever, uv exposure trauma, menstruation,
immunocompromised) -> LIFELONG!
○​Features: irritation, photophobia, tearing (1st sxs); Pain is NOT prominent
○​Dx: test for corneal sensation (hypoesthesia); fluorescein staining
■​ HSV Stromal keratitis- disciform; Tx: topical antiviral + steroids, topical cycloplegic
■​ HSV Endothelial keratitis- disciform w/ AC findings; Tx: same to HSV Stromal Keratitis
■​ HSV Epithelial keratitis- dendritic; Tx: topical antiviral, debridement, NO STEROIDS
Herpes zoster Reactivation of latent VZV Pain and abn sensation of Hutchinson sign- rash on Systemic antiviral (Valacyclovir, acyclovir)
Ophthalmicus (HZO) Ophthalmic branch CN 5 skin over affected tip of nose; strong start w/in 3 days from onset skin lesions
Higher incidence >60 yo dermatome predictor of ocular Antibiotic-steroid oint
1 out 5 experience reactivation -> Unilateral vesico-papular inflam and corneal Clean skin lesions
10-25% will have HZO skin eruption ff denervation Antibiotic eye drops
dermatomal distribution Analgesics
Adenoviral conjunctivitis Most common cause of conjunctivitis Cold compress PRN
Tears & discharge highly contagious; Transmitted by contact Membrane removal
Self limiting 7-14 days Eye drops
Epidemic keratoconjunctivitis (EKC) -​ artificial tears
-​ caused by adenovirus types 8, 19, 37 -​ Vasoconstrictors
-​ assoc w/ corneal subepithelial lesions -​ Antibiotic-steroid drops- severe inflam,
-​ Often unilateral (1st eye more severe) epithelial defect & bacterial superinfectx
-​ Tender preauricular node For EKC- topical steroids ONLY when there is
-​ Resolves 3-4 wks subepithelial central opacities resolves mos- yrs significant dec vision
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Gonococcal conjunctivitis Hyperacute purulent- occurs w/in 1-2 days Irrigate and remove discharge
CA: N. Gonorrhea Ceftriaxone 1g IM x 1 dose ;
Transmission: Autoinoculation by contaminated fingers, sexual activity, infected urine, Neonate 125-250 mg IM 1 DOSE
direct contact in birth canal Oral ofloxacin/Ciprofloxacin- alt
Features: Copious purulent discharge, Corneal ulceration, Matted eyelash Topical fluoroquinolone or erythromycin oint
Dx: Conjunctival swab & scraping for gram stain NO STEROIDS
Tx infected sexual partners and parents
Tx Delay -> Corneal Melt and Perforation
Chlamydial conjunctivitis Most common cause of sexually transmitted ocular infection Oral azithromycin, erythromycin or
CA: C. trachomatis tetracycline
Transmission: contact by genital-to-eye, hand-to-eye, passage in birth canal, prom Topical fluoroquinolones or erythromycin oint
Features: Beefy red conjunctiva, mucopurulent discharge esp in morning NO STEROIDS
Dx: Conjunctival swab & scraping for Giemsa stain Treat sexual partners or parents
Allergic conjunctivitis Features: Sudden and rapid onset of itching (cardinal sx), clear stringy discharge Avoidance allergens and triggers
●​ Seasonal or hay fever- mild Cold compress
●​ Perennial conjunctivitis “CHRONIC”; throughout the yr Antihistamine
●​ Vernal keratoconjunctivitis: uncommon, bilateral, prepubertal onset Others: Mast cell stabilizers, steroids
-​ Cobblestone papillae, shield ulcer
Pinguecula Degenerative lesion of bulbar conjunctiva sec to chronic sunlight exposure Not necessary
Probable precursor pterygium if symptomatic/inflamed
Loc: Interpalpebral zone, medial & lateral sides ●​ topical lubricating drops
Features: yellow-white amorphous subepithelial deposit/nodule; asymptomatic but may ●​ weak topical steroid for
cause irritation and FB sensation pingueculitis
*see below for classification EXCISION NOT RECOMMENDED
Pterygium Actinic degeneration of conjunctiva & cornea caused by UVB Lubricating drops PRN
Irritative phenomenon due to envi factors (light, drying, wind) Topical vasoconstrictor- congested
Loc: from conjunctiva -> encroaches cornea Steroid- inflamed
Features: Triangular wing-shaped fibrovascular mass, asymptomatic if small Excision- only effective tx; indications:
Cx: astigmatism, scarring, recurrence -​ Recurrent congestion & irritation
-​ Dec visual acuity
-​ Induced astigmatism
-​ Threat to visual axis
-​ Cosmesis
Pyogenic granuloma Granulation tissue ff ruptured hordeolum or surgical trauma Excision at base
Features: Red, soft, fleshy pedunculated mass outgrowth w/ narrow stalk at base attached Topical antibiotic-steroid ointment
to conjunctiva
LENS AND CATARACTS
Nuclear cataract Some nuclear sclerosis & yellowing is normal in pts >50 yo
Interferes minimally w/ visual fxs, progress slowly; “second sight”
Patho: Central opacity inc light scattering -> inc refractive index of lens -> myopic shift -> Lenticular myopia
Vision impairment Distance > Near
Brunescent Cataract: Progressive yellowing or browning -> poor color discrimination
Cortical cataract Wedged-shaped, cortical spokes or cuneiform opacities
Forms in the periphery w/ pointed end towards center
Patho: Membrane integrity compromised -> essential metabolites lost -> extensive protein oxidation & precipitation
Vision impairment depends to loc of opacity relative to visual axis
Features: vacuoles & water clefts (1st sign); glare
●​ Mature- entire cortex from capsule to nucleus becomes opaque
●​ Intumescent- lens absorb water becoming swollen & enlarged
●​ Hypermature- degenerate cortical materials leak thru the lens capsule -> capsule wrinkles & shrink
●​ Morgagnian- further liquefaction of cortex -> free movement of nucleus w/in the bag
Posterior subcapsular Result of trauma, corticosteroid, inflammation, ionizing radiation, prolonged alcohol use
cataract (PSC) Patho: Posterior migration of lens epithelial cells to visual axis -> aberrant enlargement -> Wedl or Bladder cells
Younger pts
Visually significant when they become axial
Feature: Subtle iridescent sheen (1st sign); glare and poor vision under bright light; Vision impairment: Near > Far
Congenital cataract Visually significant if <2-3 mos; >3 mm in size; central and/or posterior dense
●​Lamellar zonular: most common; bilateral & symmetric; disc shaped configuration
●​Polar- lens opacities involve subscapular cortex & capsule
○​Anterior Polar- small, bilateral, symmetric; non progressive opacities
-​ don't impair vision & don't require tx but cause Anisometropia
○​Posterior Polar- larger, closer to nodal point; familial (bilateral), sporadic (unilateral)
-​ more visual impairment; assoc w/ capsular fragility
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●​Congenital rubella syndrome- maternal infec w/ Rubella virus; Ist trimester

○​Features: Cardiac defects, deafness, mental disability, pearly white nuclear opacifications; live virus may be in lens
Acquired Cataract Visual system more mature -> do not require same urgent care as congenital
●​Traumatic Cataract- lens damage caused by mechanical injury, physical, chemical, electric current
○​Stellar or rosette shaped calcification involving posterior lens capsule- 1s t sign
○​Vossius ring- ring of pigment on anterior surface, insignificant, indicates prior blunt trauma
○​Assoc w/ ectopia lentis, perforating/penetrating inj, intraocular procedure, intraocular FB, chemical inj, electrical inj
●​Metabolic cataract (DM)- acute myopic shift -> undiagnosed or poorly controlled DM
○​Inc BG = inc aq. Glucose -> sorbitol pathway change in hydration & inc nonenzymatic glycosylation -> oxidative stress
○​Snowflake cataract- bilateral widespread posterior subcapsular lens change
●​Drug-induced lens changes
○​Corticosteroid- may cause PSC; dose & duration related; may resolve after cessation in children
○​Phenothiazine- psychotropic; dose & duration related
-​ pigmented deposits in anterior lens epithelium, axial configuration;
○​Miotics- topical anticholinesterases; tx for glaucoma; 20% after 55 mos of pilocarpine
-​ small vacuoles w/in & posterior to anterior lens capsule -> cortical & nuclear cataracts
○​Amiodarone- antiarrhythmic drug; rarely visually significant; other SE: corneal epithelial deposits, optic neuropathy
-​ Stellate pigment deposition in anterior cortical axis
○​Statins- contradicting (protective & risk factor); simvastatin + erythromycin -> inc statin levels, 2-fold risk cataract
○​Tamoxifen- breast Ca drug; crystalline maculopathy may occur
Congenital aphakia Very rare; Lens is absent
●​ Primary- lens fail to form
●​ Secondary- more common, developing lens absorbed
Microspherophakia Developmental anomaly of the secondary lens fibers
Lens is small in diameter and spherical -> inc refractive power -> highly myopic
Seen in Weill-Marchesani syndrome
Assoc w/ secondary angle closure glaucoma, aggravated by miotics
Tx:
●​ Cycloplegics- TOC
●​ Laser iridotomy- relieve angle closure
Ectopia lentis Displacement of lens
Congenital, developmental or acquired (trauma)
●​ Subluxated lens- partially displaced from normal position, remains in pupil area
●​ Luxated or dislocated lens- completely displaced from pupil
○​ Dislocation to AC -> pupillary block -> sec angle-closure
○​ Dislocation to VC -> error of refraction
Assoc diseases:
●​ Marfan syndrome- mutation in fibrillin gene
○​ Ectopia lentis (50-80%; superotemporal)
○​ Lens extraction- high rate cx
○​ Spectacles- provides satisfactory VA
●​ Weil-Marchesani syndrome- AR trait
○​ GEMMS syndrome: Glaucoma, Ectopia lentils (50%; downward & anterior), Microspherophakia,
Musculoskeletal/Joint stiffness, Short stature & stubby fingers
●​ Homocystinuria- inborn error of Methionine metabolism; cysteine deficiency
○​ healthy at birth then develops seizure & osteoporosis; tall & light colored hair
○​ Lens subluxation (80% by 15 yrs old; inferonasally)
●​ Ectopia lentis et pupillae- AR trait, lens and pupil displaced in opposite direction; pupils irregular, slit shaped, iris dilates
poorly, usually bilateral but not symmetric
GLAUCOMA
Primary Open angle Blacks & Latinos (4&6) > White (1)
glaucoma (POAG) Patho: inc resistance to aq. outflow -> reduction on aq drainage -> Inc IOP
Feature: chronic, insidious, painless, central vision relatively UNaffected
Dx: Glaucomatous optic disc or field changes, elevated IOP, Normal appearing AC angles, no other reason IOP elevation
Rf: Elevated IOP, Reduced perfusion pressure, Advanced age, Thin central cornea, Racial background, Family hx, DM (controversial),
Myopia, Retinal vein occlusion
Normal tension glaucoma Controversial if distinct/ POAG w IOP - Glaucomatous disc/ visual field w IOP < 21 mmHg 60% progressive field loss
(NTG) w/in ave. range - Bilateral often asymmetrical Decreasing IOP is beneficial w progressive
- High prev in vasospastic d/o visual field loss
Must EXclude: - CHARACTERISTIC DISC HEMORRHAGE
-​ Prior episode of raised IOP
-​ Large diurnal variation
(elev in morning)
-​ Postural changes IOP
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-​ Intermitt. IOP elevations

-​ Underestimation of IOP
due to Corneal thickness
-​ Other causes of optic disc
& field changes
Ocular hypertension Elevated IOP but absence of Optic RF: aging, inc. IOP, fam history , dses (DM and HTN) Lowering IOP reduces risk of progression
disc, RNF layer or VF abn Check corneal thickness
Majority NEVER devp glaucoma Thicker —> higher IOP
1-2% devp glaucoma

Primary Angle Closure Inuits (20-40) > Whites Obstruction of outflow facility Ciliary injection; Steamy cornea; Fixed mid
Glaucoma (PACG): RF: female (shallower AC, smaller Pupillary block dilated pupil; Shallow AC; Inc. IOP
eye), age, hyperopia Occlusion of TM by periph iris
Asymptomatic until visual loss occurs Hallmark:
-leading cause of Bilat. Blindness Primary patho: anatomical Periph iris adhesion, impedes access of
worldwide Aq.humor to TM
-develops in HYPEROPIC eyes Stuff IRIS BOMBE → blockage of aqueous → rapid
-exacerbated by enlarging crystalline inc. IOP → pain, redness & blurring of vision DEFINITIVE TX:
LENS LASER IRIDOTOMY
-attack is precip. By Pupillary Dilation Sudden onset visual loss, excruciating pain, halos,
IOP control
N&V, headache, BOV Trabeculectomy
-​ Filtering surgery
-​ Ostium is created into anterior chamber
from underneath partial thickness
scleral flap to ALLOW aqueous flow out
of the eye
Glaucomatous optic Sine qua non of all forms of - progressive degen.of RGC (retinal ganglion cell); Early glau cupping, loss of:
neuropathy glaucoma major mech. of visual loss -​ Axons
-​ Blood vessels
Glaucoma: - loss of tissue starts at LAMINA CRIBROSA - more -​ Glial cells
Cupping > area of pallor prominent in Sup and Inf. poles
Generalized Enlargement of cup
Non Glaucomatous -​ Earliest sign
- Area of pallor > cupping -​ Thinning of retinal Nerve fiber layer
-Optic neuritis -​ Normal: Vertical CDR 0.1-0.4
-Ant. Ischemic Optic neuropathy -​ Asymmetry >0.2 ; occurs 1% normal eyes
Visual Field Defect Not specific Nerve fiber bundle defect - hallmark
Pattern, nature of progression and Superior and Inferior poles - susc.
correlation
Glaucomatous field loss; mainly
CENTRAL 30 degree
Glaucomatous field ●​ Generalized depression
defects ●​ Paracentral scotoma: Island of relative/absolute vision loss; w/in 10 degrees of fixation
●​ Arcuate/ Bjerrum scotoma: 10-20 degree from fixation; Single area of relative loss → becomes larger, deeper and multifocal
●​ Full form -> Arches from blind spot to nasal raphe
●​ Nasal Step: Relative depression of 1 horizontal hemifield
●​ Kinetic perimetry ; discontinuity of 1 or more nasal isopters near horizontal raphe
●​ Altitudinal defect: Moderate to advanced optic neuropathy
●​ Temporal wedge
Childhood glaucoma ●​ Congenital glaucoma
○​ Classic triad: epiphora, photophobia, blepharospasm
○​ Haab striae
○​ Buphthalmos
●​ Juvenile glaucoma
○​ 5-35 yo; AD traut
Lens Induced glaucoma ●​ Phacolytic glaucoma: due to mature or hypermature cataract
●​ Lens particle glaucoma: lens cortex obstruct ™; hx of cataract surg or ocular trauma
●​ Phacomorphic glaucoma: due to intumescent lens; pathological angle narrowung sec to acquired mass of lens
Neovascular glaucoma
Steroid induced glaucoma
REFRACTIVE ERRORS
●​ Presbyopia: dec ability to focus near objs but distance vision normal; develops Hyperopia- converging lens ‘+ lens’
progressively w/ age Myopia- diverging lens, ‘- lens’
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●​ Emmetropia: no refractive error

●​ Ametropia: has refractive error Spectacles- safest
●​ Hyperopia: farsightedness, BEHIND THE RETINA; more severe eye fatigue ●​ sphere- corrects myopia/hyperopia
○​ Refractive hyperopia: reduced refractive power ●​ cylinder- corrects astigmatism
○​ Axial hyperopia- shorter eyeball ●​ axis- rep degree of angle at w/ch cylinder is placed on
●​ Myopia: nearsightedness, IN FRONT OF RETINA; inc risk to retinal detachment corrective lenses
○​ most babies slightly hyperopic -> myopic shift as gets older -> Contact lens
emmetropic ●​ Rigid- change curvature of ant surface; overcome corneal
○​ Refractive myopia: more refractive power astigmatism; correct irregular astigmatism
○​ Axial myopia- longer eyeball ○​ more initial discomfort, allows o2 to pass, good
●​ Astigmatism: MULTIPLE FOCAL POINTS; abn of corneal shape durability, for extended wear, easily dislodged,
○​ residual astigmatism- lens contribute longer adaptation
●​ Anisometropia: difference in refractive error bet 2 eyes ●​ Soft- flexible, adopt corneal shape, correct lil astigmatism
○​ Amblyopia: 1 eye has refractive error either myopic or hyperopic ○​ greater initial comfort, less durability, cause more
○​ Aniseikonia: both eyes either myopic or hyperopic dry eye, intermittent wear, adheres to corneal
○​ Mixed: one eye myopic and other hyperopic shape, shorter adaptation
Refractive surgeries
●​ LASIK- change curvature of ant surface
●​ Intraocular lens- replace natural lens; cataract surgery

Orbital Exam 6 Ps
●​ Pain
●​ Palpation
○​ Resistance to retrodisplacement -> retrobulbar tumor or diffuse inflammation
●​ Pulsation
●​ Proptosis- inc in orbital volume -> globe displacement (forward protrusion)
○​ Exophthalmos- Graves DSE
○​ Pseudoproptosis- absence of an orbital dse/globe displacement
●​ Progression
●​ Periorbital changes

Imaging
●​ XRay- most common and readily available; Rule out metallic FB
○​ Waters view- orbital roof and floor
○​ Caldwell view- superior, lateral orbital rim, medial wall, ethmoid and frontal sinuses
●​ CT scan- better bone detail, shorter imaging time, less expensive than MRI
○​ Sagittal
○​ Axial
○​ Coronal
○​ 3D reconstruction
○​ With contrast- to differentiate vascular DSEs; better used if suspecting tumors
●​ MRI- better for soft tissues; poor bony detail, longer imaging time, more expensive
○​ CI: metallic FB, pacemaker, aneurysm clip

NO SPECS- Class of TEDs

●​ No signs or symptoms (0)
●​ Only signs (1)
●​ Soft tissue involvement (2)
●​ Proptosis (3)
●​ EOM involvement (4)
●​ Corneal involvement (5)
●​ Sight loss (optic nerve compression) (6)

Eyelids (7 layers)
●​ Skin
●​ Muscles of protraction
○​ Orbicularis oculi- closes eyelid, CN 7
●​ Orbital septum
●​ Orbital far
●​ Muscles of retraction
○​ Levator palpebrae superioris- upper lid opening, CN 3
○​ Capsulopalpebral fascia- lower lid opening
●​ Tarsus
●​ Conjunctiva - adheres firmly to tarsus
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Eyelid crease
-​ levator aponeurosis fibres
●​ Caucasian: mid upper eyelid
●​ Asians: lower or absent

Anophthalmic procedures
●​ Evisceration- removal cornea and globe contents; leaving scleral shell, muscles & tissues intact
○​ Indications: Endophthalmitis; Pt can't tolerate long procedure
○​ Adv: Less disruption of orbital anatomy, Better prosthesis motility, Simpler
○​ Disadv: risk of sympathetic ophthalmia not decreased; not for tumors
●​ Enucleation- removal of globe; muscles & tissues spared
○​ Indications: Primary intraocular malignancy; Painful blind eye; Severe ocular trauma
○​ Disadv: cancer cannot be R/O
●​ Exenteration- removal infraorbital contents, involves bones and eyelids
○​ Indications: Destructive orbital malignancy; Tumors w/ extension into orbit; Malignant lacrimal gland
tumors; Orbital sarcomas; Fulminating fungal infections

Pterygium classification:
THICKNESS SIZE/ GRADE
T1 (Atrophic)- episcleral vessels unobscured G1- extends up to ¼ diameter cornea
T2 (Intermediate)- episcleral vessels partly obscured G2- extends up to ¼-½ diameter cornea
T3 (Fleshy)- episcleral vessels totally obscured G3- extends beyond visual axis

Orbital fractures:
●​ Zygomatic- “tripod fracture”, 4 articulation: lateral wall, inferior rim, zygomatic arch and lateral maxilla
●​ Roof- common in young children due to unpneumatized frontal sinus; most do not require repair
●​ Apex- occur in assoc w/ other fractures; may involve optic canal, sup orbital fissure & structures passing thru it
●​ Medial- direct or indirect; involves Maxilla, Lacrimal & Ethmoid (LEM)
○​ Le Fort 1- Transverse fracture through the maxillary sinuses, lower nasal septum, pterygoid plates​
○​ Le Fort 2- Oblique fracture crossing zygomaticomaxillary suture, inferior orbital rim, nasal bridge
○​ Le Fort 3- Fracture above the zygomatic arch, thru the lateral & medial orbital walls and nasofrontal suture

RED EYE
SIGNS SYMPTOMS
●​ Reduced VA ●​ Mattering of lashes
●​ Ciliary Flush ●​ Itching
●​ Corneal Opacification ●​ Blurring vision
●​ Corneal Epithelial disruption ●​ Severe Pain
●​ Pupillary Abnormalities ●​ Photophobia
●​ Shallow AC ●​ Colored Halos
●​ Increased IOP
●​ Proptosis
Eye redness patterns:
●​ Subconjunctival Hemorrhage
●​ Conjunctival Injection
●​ Ciliary Flush
●​ Chemosis
Acute Painful Red eye
●​ Disruption of corneal epithelium
●​ Due to trauma or infections
●​ Corneal abrasions, FB injuries, keratitis
Discharge:
●​ Serous - watery, clear
●​ Purulent - creamy white, yellowish
●​ Stringy - scant, ropy, white
Conjunctivitis
-​ Inflam of conjunctiva
-​ Most common red eye dse worldwide
-​ Severity is variable; mostly caused by an exogenous, rarely endogenous
-​ Duration:
-​ Hyperacute: 1-2 days
-​ Acute: 2-4 days
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-​ Subacute: 5-14 days

-​ Chronic: >14 days
-​ Cardinal sx: Redness and Discharge
-​ Mechanism to protect the eye:
-​ Tear film
-​ Aqueous dilutes infectious material
-​ Mucus traps debris
-​ Lids flushes tears
-​ Tears contain antimicrobial substances

DRY EYE
-​ Multifactorial disease of the tears and ocular surface. Accompanied by increased osmolarity of the tear film and
inflammation of the ocular surface (Dry Eye Workshop)
-​ Multifactorial chronic disease characterized by unstable tear film accompanied by ocular surface damage (Asia Dry
Eye Society)
-​ Most common form of ocular surface disease world wide
-​ Occurs if there is inadequate tear volume or fx -> unstable tear film & ocular surface dse
-​ Extremely common particularly elderly & postmenopausal
-​ Keratoconjunctivitis sicca (KCS)- Any eye with some degree of dryness
-​ Xerophthalmia- Dry eye disease associated with Vitamin A deficiency
-​ Xerosis- Extreme ocular dryness and keratinization with severe conjunctival cicatrisation
-​ Sjogren Syndrome- Autoimmune inflammatory disease which features dry eyes
-​ Symptoms:
-​ Foreign body sensation - most frequent
-​ Burning sensation (gets worse later in the day)
-​ Accumulation of mucus
-​ Redness
-​ Photosensitivity
-​ Tearing- eyes become dry enough to stimulate reflex tearing
-​ Mechanism
-​ Tear instability - lack of function or lack of amount of tears
-​ Tear Hyperosmolarity - same as inflammation but is a laboratory finding
-​ Inflammation- inflammation in the conjunctiva, accessory glands and ocular surfaces is present in 80% of
patients with KCS
-​ Ocular Surface Damage- lead to tear film instability
-​ Classification:
AQUEOUS DEFICIENT EVAPORATIVE
●​ Sjogren Syndrome ●​ Intrinsic (Meibomian Gland Deficiency)
●​ Lacrimal deficiency ○​ May be the leading cause of dry eye
●​ Lacrimal gland obstruction ○​ Disorders of the lid Aperture
●​ Reflex hyposecretion ○​ Low blink rate
○​ Drug action
●​ Extrinsic
○​ Vit. A deficiency
○​ Topical drugs
○​ Contact lens wear
○​ Ocular surface disease
-​ Investigation:
-​ Tear Break up Time (TBUT)- stability of the tear film
-​ Estimate MUCIN content of tear fluid
-​ Apply fluorescein strip to lid margin-> ask pt to blink -> observe under cobalt filter
-​ Dry spot <10 sec is suspicious; normal >15 secs
-​ Tear production or SCHIRMER TEST - Amount of wetting measure for 5 mins. Mucin is not affected
-​ Schirmer 1: without anesthesia, Measures Reflex tearing by Lacrimal gland
-​ Schirmer 2: with anesthesia; Basal Secretion by accessory gland
-​ Abnormal <10 mm schirmer 1; <5 mm schirmer 2
-​ Possible 10-15 mm
-​ Normal >15 mm
-​ Ocular Surface Staining
-​ Fluorescein: Stains corneal epithelium and tear meniscus, Identifies eroded and denuded areas
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-​ Rose Bengal: Affinity for dead/devitalized conjunctival epithelial cells, lost or altered mucus layer
-​ Lissamine Green: Similar to Rose bengal; Less irritation
*There is NO clinical test to confirm the diagnosis of EVAPORATIVE DRY EYE. It is therefore a presumptive diagnosis based on
associated clinical findings.
-​ Management
-​ Understand the diseases: Chronic condition, complete relief is unlikely unless mild
-​ Establish type and severity of the dry eyes disease: Treatment of the underlying disease is essential
-​ Lifestyle and environment modifications
-​ Lubricants and Artificial tears - MAINSTAY TREATMENT
-​ Short course topical steroids
-​ Surgery - punctal plugs, punctual and canalicular closure
Tears
-​ Thin layer of fluid covering the cornea and conjunctival epithelium
-​ Functions:
-​ Makes the cornea a smooth optical surface by abolishing epithelial irregularities
-​ Lubricates and protects the corneal and conjunctival epithelium
-​ Inhibits growth of microorganism by flushing and anti-microbial properties
-​ Provides nutrition
-​ Tear film:
-​ Mucin- secreted by Goblet cells, improves tear adhesion
-​ Aqueous- secreted by main & accessory lacrimal glands; lubricates eye and washes away particles
-​ Lipid- secreted by Meibomian glands, seals and slows down evaporation
-​ Composition:
-​ 60% Albumin
-​ 40% Immunoglobulins (A,G,E)
-​ Lysozymes
-​ Important defense mechanism
-​ Act together with gamma globulins and other antibacterial factors
-​ Electrolytes, Glucose and Urea
-​ pH 7.35 ISOTONIC, NORMAL pH

Lens
●​ Biconvex, avascular, transparent, no innervation
●​ Nutrition is from aqueous humour
●​ Clear in young; Yellowish/amber in adults
●​ Fx: refract light, Visual clarity, Accommodation
●​ Posterior to iris, supported by zonular fibers from ciliary body
●​ Parts:
○​ Capsule- basement membrane
○​ Cortex- younger and less compact fibers
○​ Nucleus- central, older and compressed fibers
●​ Physiology:
○​ Metabolism: anaerobic glycolysis -> low level o2 in aq
■​ Sorbitol pathway: aldose reductase
■​ Oxidative stress: free radicals gen in normal cellular metabolism; inc O2 levels w/in eye ->
cataract
○​ Water & electrolytes: critical to lens transparency; if disrupted -> lens opacification
■​ 66% water, 33% protein
○​ Pump leak theory: K and Amino acids predominate in the lens
Cataract
-​ Any opacity of the lens
-​ Aging- most common cause; trauma, toxin, systemic dse, smoking, hereditary
-​ As lens age, mass & thickness inc, accommodative power dec, nucleus compresses & hardens -> nuclear sclerosis
-​ Protein aggregates scatter light & reduce transparency
-​ Protein alterations -> discoloration
-​ Oxidative damage, UV light, malnutrition
-​ Age related lens changes, pathology is multifactorial and not completely understood
-​ Management:
●​ Non surgical (TIMe Ref)
○​ Refraction
○​ Tint
○​ Illumination
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○​ Medication
●​ Surgical
○​ Goal: removal of cataract, placement of IOL; evolve into a refractive procedure
○​ Phacoemulsification: end result-> Pseudophakic
○​ Complications:
■​ Permanent vision impairment
■​ Perioperative intraocular hemorrhage- most serious, rare
■​ Post operative infection- endophthalmitis
■​ Posterior capsular tear (PCT) - main INTRAoperative cx; “dropped nucleus”, vitreous prolapse
■​ Posterior capsular opacification (PCO)- “second cataract”
●​ Proliferation epithelium -> multiple layers -> opacification -> fish egg appearance
(Elschnig's pearls) -> contraction -> wrinkles posterior capsule -> visual distortion
●​ Tx laser surgery (Capsulotomy)
○​ Childhood surgery
■​ stronger anterior capsule, cataracts less dense, removed by irrigation & aspiration (Lensectomy)
■​ Opening posterior capsule -> removal part of vitreous -> reduce incidence PCO
■​ Cx: post-op refraction

Glaucoma
-​ Acquired chronic optic neuropathy characterized by optic disc cupping & visual field loss
-​ Most frequent cause preventable blindness in US, incidence inc w/ age and + fam hx
-​ Much peripheral vision is lost before visual disability noticeable
-​ Optic nerve & visual field changes determined by
-​ IOP level
-​ Impaired outflow of Aqueous
-​ Impaired access of Aqueous to drainage system
-​ Resistance of Optic Nerve to damage
-​ 2 classifications
-​ Primary: no identifiable underlying anatomical or pathologic cause
-​ Secondary- abn identified & presumed role in pathogenesis can be ascribed

Aqueous humor
-​ Clear liquid, fills anterior and posterior chamber
-​ 250 uL
-​ Produced by ciliary body (2-2.05 uL/min), supplied by major arterial circle of iris
-​ Outflow system
-​ Trabecular outflow- TM > schlemm > venous
-​ Uveoscleral outflow
Episcleral venous pressure
-​ 8-10 mmHg
-​ Relatively stable except with sudden alterations in body positions, head and neck that obstructs venous return

Tonometry
-​ Measurement IOP
-​ Goldmann Applanation Tonometer (gold standard)
-​ Applanation tonometry (most widely used)
-​ Corneal thickness affects measurement
-​ Thick = overestimate; Thinner = underestimate
-​ Corneal edema -> falsely LOW IOP; Corneal Scar -> falsely HIGH IOP
-​ Dec.aqueous flow → risk of ON damage
-​ ANGLE- formed by jxn of periph cornea & iris; lies the trabec meshwork
Gonioscopy
-​ Method to visualize structures of AC
-​ Goniolens
-​ Config: wide, narrow, closed

Optic Nerve (ON)

-​ Neuroretinal rim; directly affected; more impt > cup; size/CDR
-​ ONH round/slightly oval
-​ Central/ Physio cup (bending of vessels)

IOP
-​ Determined by rate of aqueous pdxn and resistance
-​ approx 15.5 mmHg, SD 2.6 mmHg
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-​ Normal: 10-21 mmHg

-​ 21 mmHg ; define w/c px require ocular hypotensive therapy

OPTICS AND REFRACTION

Optics- science of vision
●​ Physical- properties of light
●​ Geometric- focusing of light onto retina; Refraction
●​ Physiologic- processes in retina producing stimuli
●​ Neuro-ophthalmic- conduction of stimuli to occipital visual center

Vergence- measure diverging or converging light; diopters

●​ Negative vergence- Diverge
●​ Positive vergence- Converge
●​ Zero vergence- Parallel

Index of refraction
-​ higher index, slower speed, greater refraction
-​ Snell’s law
-​ from lower to higher index = TOWARDS from normal
-​ from higher to lower index= AWAY from normal
-​ refractive surfaces of eye
-​ Cornea= 43D; 1.37
-​ Lens = 19D; 1.42
-​ Aqueous = 1.34
Pinhole- minimize scattering of light and reduce blurring induced by refractive error; improve vision if NO pathology aside RE;
allows to estimate potential VA

Accommodation
NEAR VISION: ciliary muscle contracts, central lens thickness inc, inc its refractive power

Glaucoma meds
●​ PGAs- inc uveroscleral and TM outflow
○​ Latanoprost, travoprost
○​ Se: darkening of iris and periocular skin, trichiasis, distichiasis, hair gorwth
●​ Beta blockers- inh CAMP prodxn -> reduc aq humor prodxn
○​ Timololo, betazolol
○​ Se: bronchospasn, bradycardia, hypotension, heart block, reducced exercise tolerance, reduced gluc
tolerance, masking hypoglycemia
○​ Ci: asthma, COPD
●​ Alpha 2 agonist- dec aq prodxn, episcleral venous pressure
○​ Apraclonidine, brimonidine
○​ Se: blepharoconjunctivitis, ectropion
●​ Carbonic anhydrase inh- dec aq prodxn; Antagonize ciliary epithelial carbonic anhydrase
○​ Acetazolamide
●​ Parasympatomimemtics- inc TM outflow, contraction cilary muscle
○​ Miotics
●​ Hyperosmotic agents- inc blood osmolarity
○​ Mannitol, glycerol