JCabarrubias

BASIC OPHTHALMOLOGY ANATOMY

ORBIT
●​ 7 Bones
○​ Frontal ○​ Zygomatic
○​ Sphenoid ○​ Palatine
○​ Ethmoid ○​ Lacrimal
○​ Maxillary
●​ 4 Walls: Converge posteriorly, Medial wall parallel, Lateral & Medial walls 45 degrees apart
○​ Roof
■​ Bones involved: Frontal, Lesser wing of Sphenoid
■​ Trochlear fossa: site of pulley of SO muscle
■​ Supraorbital foramen: where Supraorbital Nerve (branch of Ophthalmic N- CN5) pass thru
■​ Lacrimal gland: lateral aspect of the roof
○​ Lateral
■​ Bones involved: Zygomatic, Greater wing of Sphenoid
■​ Thickest & strongest
■​ Whitnall tubercle: landmark of attachment
○​ Floor
■​ Bones involved: Maxillary, Zygomatic, Palatine
■​ Infraorbital Groove & Canal: where Infraorbital Nerve (branch of Maxillary N- CN5) pass thru
​ ​ ​ *Superior Orbital Fissure: separates roof & lateral wall; bet greater & lesser wing of sphenoid
​ ​ ​ *Inferior Orbital Fissure: separates floor & lateral wall
○​ Medial
■​ Bones involved: Maxillary, Lacrimal, Ethmoid, Sphenoid
■​ Weakest
■​ Lamina papyracea: thinnest bone in the orbit (paper thin); seen in ethmoid
■​ Lacrimal sac: located on the lacrimal groove
●​ Volume: 30 cc
●​ Eyeball occupies ⅕ of the orbit (6-7 cc)
●​ Orbital Apex: main portal for all nerves & vessels of eye; site of origin of all EOM except IO muscle
○​ Annulus of Zinn: tendon of all rectus muscle
○​ Optic canal: hole at the center of annulus of zinn; CN II & Ophthalmic Artery pass thru
○​ Superior Orbital Fissure: CN III-VI
○​ Inferior Orbital Fissure: CN V2 (Maxillary), Inferior Ophthalmic vein
●​ Arterial supply:
○​ Ophthalmic artery: 1st major branch of ICA, thru optic canal & accompanies optic nerve
1.​ Central retinal artery: 1st intraorbital branch, most impt
2.​ Posterior ciliary arteries: short & long
3.​ Muscular
4.​ Laminar
●​ Venous Drainage:
1.​ Superior ophthalmic vein: drains to cavernous sinus
2.​ Inferior ophthalmic vein: grains to pterygoid plexus
ADNEXA
-​ Structures outside the eye
1.​ Brows: folds of the thickened skin covered w/ hair
2.​ Eyelids: modified folds of skin
●​ Protects eyeball
●​ Blinking: spread tear film, prevent dehydration
●​ Upper lid ends at the eyebrow, Lower lid merges into the cheek
●​ Palpebral fissure: horizontal-> 27-30 mm; vertical-> 8-11 mm
●​ 2 segments
○​ Anterior margin
■​ Glands of Zeis: modified sebaceous gland, beneath the eyelashes, gives moisture
■​ Glands of Moll: modified sweat glands
○​ Posterior margin
■​ Meibomian gland ■​ Tarsal gland
●​ 7 layers: SPOORT C
○​ Skin & Subcutaneous tissue: thin, loose & elastic
■​ Thinnest of the body
■​ Few hair follicles, No subcutaneous fat-> readily distended by edema & blood
○​ Muscles of Protraction: Orbicularis oculi
■​ 3 portions: Orbital, Preseptal, Pretarsal
■​ Closes eyelids, innervated by CN 7
 JCabarrubias

○​ Orbital septum: fascia; barrier to blood, infection & inflammation

○​ Orbital fat: found posterior to septum
​ *trauma or laceration, (+) fat-> septum is damaged
○​ Muscles of Retraction
■​ Opens the eyelids, innervated by CN 3
■​ Upper lid: Levator palpebral superioris, Superior tarsal/muller muscle
■​ Lower lid: Capsulopalpebral fascia; Inferior tarsal muscle
○​ Tarsus: dense, fibrous tissue; main supporting structure
○​ Palpebral Conjunctiva: posterior layer of mucous membrane, adheres firmly to tarsus
3.​ Lacrimal apparatus
a.​ Lacrimal gland: located at the temporal part of frontal bone
●​ Exocrine glands, serous secretion (watery)
●​ Supplied by Lacrimal artery
●​ Innervated by Lacrimal (sensory), Great petrosal (secretory), Sympathetics (excretory)
b.​ Accessory lacrimal gland: located in palpebral conjunctiva; 10% of total lacrimal secretory mass
●​ Krause ●​ Wolfring
Tear drainage system:
1.​ Lacrimal gland- produces tears
2.​ Fornix
3.​ Upper & Lower Puncta
4.​ Canaliculi
a.​ Type A: 2 canaliculus form common canaliculi (most common, 90%)
b.​ Type B: directly to lacrimal sac
c.​ Type C: different entry point to lacrimal sac
5.​ Valve of Rosenmuller: bet canaliculi & lacrimal sac
6.​ Lacrimal sac
7.​ Nasolacrimal duct
8.​ Valve of Hasner: bet NLD & inferior meatus, more impt-> Congenital NLDO
9.​ Inferior meatus
​ ​ Tear/tear film- outer coating of cornea & conjunctiva
●​ Mucin- goblet cells; improve adhesion of tears
●​ Aqueous: lacrimal & accessory gland; lubricate & wash away particles
●​ Lipid/oil- meibomian gland; seals & slows down evaporation of tears
THE EYEBALL
-​ AKA Globe; NOT a true sphere
-​ Axial length: 23 mm; Volume: 6-7 mL
1.​ Conjunctiva: thin, transparent mucous membrane
●​ Stratified columnar & squamous epithelium; numerous goblet cells
●​ Rich vascular network - anterior ciliary & palpebral arteries
●​ Receives innervation from ophthalmic nerve of CN5
1.​ Palpebral conjunctiva: directly behind tarsus
2.​ Fornix: transition bet palpebral & bulbar
3.​ Bulbar conjunctiva: covering of sclera
2.​ Tenon’s capsule: fascia bulbi; envelope of fibrous membrane; cavity w/in which globe moves
●​ Fuses from limbus to ON sheath
●​ Check ligaments: continuous w/ muscle fascia, tough & limit EOM fx
3.​ Sclera: fibrous outer protective coating
●​ Almost entirely collagen; dense & white; thinnest at EOM insertions (0.3 mm)
●​ Episclera: thin layer of elastic tissue, outer surface of anterior sclera, contains BV to nourish sclera
4.​ Cornea: transparent tissue; inserted into the sclera at the limbus
-​ Main refractive component (43D)
-​ Optically clear, reflective
-​ Dimension: 11 x 12 mm (VxH)
-​ Central thickness: 550 um < Peripheral thickness: 1000 um
-​ Layers: EBSDE
●​ Epithelium: Anteriormost; Continuous w/ conjunctiva
○​ 5-6 layers of basal wing & surface cells -> Physiologic barrier
●​ Bowman’s layer: Acellular portion of stroma (DO NOT regenerate)
○​ Tough layer of collagen fibrils
○​ Replaced by scar tissue post injury
●​ Stroma: composed of collagen fibrils, ground substance of proteoglycans & keratocytes
○​ Regular intertwining arrangement; 60% corneal thickness
●​ Descemet’s membrane: Basal lamina of endothelium
○​ TRUE basement membrane; Attaches the endothelium to stroma
 JCabarrubias

●​ Endothelium: Single layer of Hexagonal cells

○​ Continuous cell loss w/ aging (DO NOT regenerate)
○​ Enlarge/slide to fill space; *endothelial dysfx-> corneal edema
○​ Contains Na-K ATPase Pump- regulate electrolytes & water
○​ Responsible for deturgescence- relative state of dehydration
-​ Clarity
●​ Uniform structure
●​ Avascularity
●​ Deturgescence
-​ Source of nutrition:
●​ Limbal vessels ●​ Tears
●​ Aqueous ●​ O2 from atmosphere
-​ Innervation: Ophthalmic nerve of CN V
5.​ Uveal tract: Middle vascular layer protected by cornea & sclera; Contributes to retinal blood supply
●​ 3 parts: ICC
1.​ Iris: in front of the lens; central round aperture
○​ Divides anterior & posterior chamber
○​ Pupil (hole): Controls amount of light entering the eye
■​ Constriction/Miosis: parasympathetic
■​ Dilation/Mydriasis: sympathetic
○​ Made of BV & connective tissues
○​ Melanocytes + pigments = Iris/eye color
2.​ Ciliary body: Triangular x-section; Extends from anterior choroid to iris root
○​ Processes: produce aqueous humour
○​ Muscle: contract/relax lens zonular fibers
3.​ Choroid: posterior segment of uveal tract; located bet. retina & sclera
○​ Composed of 3 layers of BV: Choriocapillaris- internal portion of BV
○​ Nourish the outer portion of the retina
*Aqueous humor- produced by ciliary body
-​ clear fluid that nourishes & inflates the eye
-​ enter the anterior chamber through the pupil
-​ exits the eye thru Trabecular meshwork + Schlemm canal- outflow apparatus
6.​ Lens: biconvex, avascular, colorless, almost completely transparent
●​ Suspended by zonules of zinn-> controlled by ciliary body
●​ Consists of 65% H2O, 34% protein
●​ Receives nutrition from aqueous and vitreous
●​ Refractive fx: 20D power
●​ 3 Parts: CCN
1.​ Capsule: outside, elastic, transparent layer; Type 4 collagen
-​ Subcapsular epithelium: located anterior & at the equator; Mitotic; Cell division
continues throughout life -> continued growth of the lens
2.​ Cortex: Outermost, softer
3.​ Nucleus: Innermost, harder
-​ No cells are lost, Crowd/move on; Older cells are centrally located
-​ No morphologic distinction over time
*Vitreous- clear, avascular, gelatinous structure
-​ 2/3rd of volume & wt of the eye -​ Becomes more fluid with age
-​ 99% H2O, 1% Collagen + Hyaluronan -​ Provides a route for metabolites
-​ Adheres to the retina
7.​ Fundus
a.​ Retina: thin, semitransparent, neural tissue; Inner, posterior ⅔ of the eye
●​ Neurosensory fx: receives light-> neural signal-> optic nerve-> brain -> visual recognition
●​ Blood supply: Choriocapillaris (outer 3rd), Central Retinal Artery (inner 2/3rd )
●​ 10 layers
1.​ ILM 5.​ INL
2.​ NFL 6.​ MLM
3.​ GCL 7.​ OPL
4.​ IPL 8.​ ONL
9.​ Photoreceptors- Light sensitive cells
■​ Rods- detect light in dim light, enabling night vision (Rhodopsin)
■​ Cones - detect colors (red, green, blue cones)
10.​ RPE
b.​ Macula: “Area centralis”, 5.5-6.0 mm in diameter; provides fine visual fx, optimal visual acuity
i.​ Macula lutea: 3 mm diameter; Xanthophyll- yellow luteal pigments
 JCabarrubias

ii.​ Fovea: 1.55 mm diameter

iii.​ Foveola: 0.33 mm diameter; thinnest area of retina, at 0.25 mm
c.​ Optic nerve: consists more than 1 million axons
-​ Arise from retina, forms the NFL, Exits posteriorly
-​ Myelinated, Organization similar to white matter
-​ 4 topographic areas
●​ Intraocular: optic disc-> 1 mm in size
○​ Optic nerve head- principal site of many ocular DSE
○​ Diameter: 1.76 1.92 mm (HxV); pink in color
○​ Physiologic cup: cup-to-disc ratio (Normal 0.3-0.5)
○​ Blindspot: area of ON head w/ no photoreceptors
●​ Intraorbital: w/in muscle cone, 25-30 mm
●​ Intracanalicular: w/in optic canal; prone to injury; 4-9 mm
●​ Intracranial: ends in optic chiasm; 10 mm
​ ​ *ON longer than distance of globe to optic canal allowing it to be loose and move freely
Visual physiology
*Cornea bends light ray for focusing-> Pupil determines amt of light entering the eye-> Lens bend light to help focus,
change shape-> Retina sends electrical impulse-> ON carries signals to the brain to be interpreted into images
*ON -> Chiasm -> Tract -> Lateral Geniculate Body -> Optic radiations -> Occipital lobe/Visual cortex
●​ Magnocellular (M) cells- info about dim illumination & motion
●​ Parvocellular (P) cells- color & fine detail
●​ Koniocellular (K) cells- modulate info
8.​ Extraocular muscles
●​ Origin
○​ Annulus of Zinn: tendons, ALL rectus muscles
○​ Spiral of Tillaux: imaginary line connecting the insertions of the recti muscles of the eye
○​ Body of Sphenoid bone: SO
○​ Maxillary bone: IO
○​ Lesser wing of sphenoid: LPS
●​ Action ​
PRIMARY SECONDARY TERTIARY
MR ADduction - -
LR ABduction - -
IR Depression Extorsion ADduction
SR Elevation Intorsion ADduction
IO Extorsion Elevation ABduction
SO Intorsion Depression ABduction
LPA Elevation of upper eyelid - -
●​ Insertion
○​ SO- underneath SR
○​ IO- posterior inferior temporal quadrant
○​ LPS- upper tarsal plate
●​ Blood supply: ophthalmic, lacrimal, infraorbital arteries
●​ Innervation
○​ All EOMs- CN3 except LR- CN 6, SO- CN 4

BASIC OPHTHALMOLOGY EXAM

●​ Eye is most accessible to direct exam
●​ External anatomy is visible to inspection
●​ Interior eye examined w/ advanced instruments
●​ Visual fx can be quantified
●​ Eye is the only body part where BVs & Nervous system can be viewed directly
Patient’s History
●​ CC ●​ PMH & FH
●​ Ocular history ●​ Evaluate visual complaints
3 Common Ocular Symptoms: VAS
●​ Abnormalities of Vision
○​ Anywhere along the eye: Anterior (Adnexa, Cornea), Posterior (Neurologic)
○​ Central acuity vs Peripheral
○​ Duration: Transient, Acute, Chronic/Prolonged
○​ Degree of Visual loss
○​ Visual aberrations
●​ Abnormalities of Appearance
 JCabarrubias

○​ Red eye & other color abnormalities (jaundice, pigmentation, opacities)

○​ Lesions, tumors, inflammation, deformities, displacements
●​ Abnormalities of Sensation
○​ Eye pain: periocular, ocular, retrobulbar, poorly localized
○​ Irritation: dryness, itchiness, tearing/secretions, burning, grittiness, FB sensations
○​ Nonspecific complaints
Examination: VATEF
●​ Visual Acuity
●​ Adnexa
●​ Tonometry
●​ Extraocular motility
●​ Fundoscopy
Vision
●​ Vital sign- measured in every ocular exam whether w/ glasses or not
●​ Quantified by visual acuity & visual fields- subjective
●​ Good vision: intact neuro pathway, structurally healthy eye, proper focus
VISUAL ACUITY
●​ Measurement of smallest obj a person can identify at a given distance
●​ Tested for Far & Near
○​ Oculus dexter (OD)- right eye ○​ CC- corrected VA; w/ aids
○​ Oculus sinister (OS)- left eye ○​ SC- uncorrected VA; w/o aids
○​ Oculus uterque (OU)- both eyes
●​ Recorded as fraction:
○​ Numerator- distance bet. pt & eye chart
○​ Denominator- distance of smallest letters pt can read; distance at w/c person w/ normal VA can read
Far distance
-​ 20 ft or 6 meters
-​ Test 1 eye @ a time. By convention, OD first. Read smallest line w/ more than half letters/optotype distinguished
-​ Consider crowding effect
■​ Snellen Chart
■​ ETDRS chart: for diabetic pts, research purposes
■​ HOTV
■​ LEA & Allen: drawings, for children
■​ Tumbling E & Landolt “C”- for illiterate
●​ If VA 20/30 or less, do Pinhole; Test w/ & w/o glasses
●​ Pinhole: estimates corrected VA; prevents misfocused light rays from entering the eye; only centrally aligned
focused rays reach the retina resulting in a sharper image
-​ If pt cant see largest letter
●​ Reduce testing distance: record new distance as numerator
-​ Unable to read at 3ft
●​ Counting finger
-​ Can't do CF
●​ Hand motion
-​ No HM
●​ Light perception and projection: ability to identify directions of light source; dim the room, light @ 4 quadrants
○​ 4 = Good
○​ 2-3 = Fair
○​ 0-1 = Poor
Near distance
-​ Performed if pt has complaint about near vision or distance testing is difficult/impossible (eg. Bedside)
-​ 14-16 in or 35-40 cm, Rosenbaum chart
-​ Test 1 eye at a time. Use spectacles. Same with far but NO Pinhole; Noted as jaeger notation
VA in children- can be difficult, uncooperative
●​ Newborn:
○​ Corneal light reflex
○​ Pupillary testing
○​ Red reflex, fundus exam
●​ Infants- 2 yo
○​ Assess visual fx instead of acuity
○​ CSM, fixates & follows
●​ 2-5 yo
○​ Test acuity, may not reach 20/20, as long as VA equal in both eyes
●​ Non verbal or Pre verbal children: CSM method
○​ Central: centrality of corneal light reflex
 JCabarrubias

■​ Esotropia (ET): inward deviation

■​ Exotropia (XT): outward deviation
○​ Steady: steadiness of eye
■​ Nystagmus
○​ Maintained: maintain fixation after removal of occlusion
Confrontation Visual Field: grossly examines for any significant visual field defects
-​ 1 m or 1 arms length from pt
-​ Cover 1 eye of pt, examiner covers opposite eye. Maintain fixation on eyes.
-​ Use CF instead of finger movement. Test 4 quadrants
EXTERNAL EXAM
●​ General exam of Adnexa
○​ Eyelids ○​ Orbit
○​ Globe ○​ Lymph nodes, sinuses, skin
●​ Performed before evaluating the eye under magnification
●​ Gross inspection & palpation
○​ Lesions ○​ Malposition, asymmetry
○​ Inflammation
Adnexa
●​ Penlight is an impt tool
●​ External inspection: eyelids, surrounding tissues & palpebral fissure; conjunctiva and sclera
●​ Upper eyelid eversion: search for FB or conjunctival signs, topical anestheisia helps facilitate exam
●​ Pupillary reaction testing
○​ Size & shape assessed
○​ Direct & consensual reflex
○​ Relative afferent pupillary defect (RAPD)-> Swinging penlight Test *if left eye impaired, right eye normal; if the
light is shone right to left, BOTH eyes will not constrict. But if light is shone left to right, both will constrict.
○​ May reveal indications of neuro DSE
●​ AC depth assessment
○​ Torchlight method
○​ Normally AC is deep & iris w/ flat contour-> iris is well illuminated
○​ If AC is shallow, iris is bent forward-> Nasal iris seen in a shadow when light is directed from temporal side
■​ Grade 1: less than ⅓ illuminated
■​ Grade 2: ⅓ to ⅔ illuminated
■​ Grade 3: more than ⅔ illuminated
■​ Grade 4: fully illuminated
TONOMETRY
●​ IOP measurement; Normal= 10-21 mmHg
●​ Goldmann applanation tonometry: gold standard; uses fluorescent dye; “yin yang”
○​ High IOP: away
○​ Low IOP: overlap
○​ Normal: close together
●​ Digital tonometry- estimates IOP using fingers
○​ Instruct pt to look down (do not close eyes-> falsely high), palpate/indent globe thru upper eyelid using 1
index finger. Feel for the rebound pressure w/ the other index finger
○​ Normal: firm (soft, tip of nose)
○​ Low IOP: hypotonic (ear lobe/lips) -> retinal detachment, trauma
○​ High IOP: hard (forehead)-> glaucoma
OCULAR MOTILITY TESTING
●​ Follow an object in 6 directions, cardinal fields of gaze *no up & down
●​ Enables to test each muscle in its primary action
●​ Indicare restrictions or over-actions (rare)
○​ Grade -1: 25% restriction ○​ Grade +1: 25% overaction
○​ Grade -2: 50% restriction ○​ Grade +2: 50% overaction
○​ Grade -3: 75% restriction ○​ Grade +3: 75% overaction
○​ Grade -4: 100% restriction ○​ Grade +4: 100% overaction
FUNDOSCOPY
●​ Direct ophthalmoscopy; Uses magnifying lens & light to check fundus
●​ To visualize optic nerve head & retinal structures in posterior pole of the fundus
●​ Patient side
○​ Viewing window- light ○​ Diopter dial
○​ Filter switch- what filter to use ○​ Rheostat- controller
○​ Aperture dial- change size/shape of light
●​ Practitioner side
○​ Brow rest ○​ Viewing window
 JCabarrubias

○​ Diopter power display (0-20) ○​ On/off switch

●​ Aperture dial/focus wheel
○​ 0- no refractive error ○​ Green/Plus- hyperopic/farsighted
○​ Red/Minus- myopic/nearsighted
●​ Apertures & filters
○​ Crossed linear polarizing filter/red-free filter switch: 18 possible apertures
○​ Micro spot aperture: allows quick visual entry in very, small undilated pupils
○​ Small aperture: provides easier fundus thru undilated pupil
○​ Large aperture: standard aperture for dilated pupil & general exam of the eye
○​ Fixation aperture: for measuring eccentric fixation or for locating lesions & other abnormalities
○​ Cobalt filter: blue filter w/ fluorescein dye for easy viewing of small lesions, abrasions, & foreign objects
○​ Slit: determine various levels of lesion & tumors
○​ Red-free filter: excludes red rays from exam field for easy identification of veins, arteries & nerve fibers
●​ Technique
○​ Pt’s OD-> MD’s OD/ right hand-> “right, right, right”
○​ Dim or dark room to inc mydriasis, instruct pt to look away to avoid miosis
●​ Elicit Red Orange Reflex (ROR): BVs -> confluence -> optic disc -> macula
-​ if no ROR, may have poor or no view of fundus-> lens opacity, dull
●​ Recording findings
○​ ROR: red-orange reflex ○​ AV: arteriovenous ratio
○​ CM: clear media ○​ Hge: hemorrhage
○​ DDB: distinct disc borders ○​ Exud: exudate
○​ CDR: cup-to-disc ratio ○​ FR: foveal reflex
●​ Abnormal optic disc (papillopathy)
○​ Optic atrophy ○​ Glaucoma
○​ AION ○​ DM ret
●​ Retinopathy
○​ CRAO- cherry red sports
○​ CRVO: diffuse flame shape
○​ BRVO: segment of retina has flame shaped hemorrhages
●​ Maculopathy
○​ Dry macular degeneration- yellow deposits accumulate in macula
○​ Wet macular degeneration: blood underneath macula
○​ Macular hole

OCULAR EMERGENCIES AND TRAUMA

OPHTHALMIC EMERGENCIES
●​ Crucial: prompt recognition & tx
○​ Prevent unnecessary visual impairment
○​ Pain (intensity & duration) and visual loss (onset & severity)
○​ Gross appearance & ophthalmoscopic abnormalities
●​ Ocular emergencies
○​ True emergencies: tx initiated w/in minutes
○​ Urgent situations: require tx to be instituted w/in few hours; discussion w/ ophthalmologist; usually from
trauma or infections
TRUE OCULAR EMERGENCIES
Chemical Eye ACID SSxs: Examples Treatment
Injury -​ Denatures & precipitates ●​Pain ●​Sulfuric acid: battery, -​ should be instituted immediately unless
tissue proteins ●​Injection- inflamm of the industrial cleaner open globe injury is suspected
-​ Immediately conjunctiva ●​Acetic acid: vinegar ●​Copious irrigation of conjunctival sac
-​ Cause a barrier effect ●​Photophobia ●​HCl: chem lab, muriatic ○​At least 20 minutes
ALKALI ●​Blepharospasm- acid, swimming pools ○​At least 2L of running water/NSS soln
-​ Causes more damage involuntary twitching ●​Ammonia: fetilizer, cleaning ○​Away from unaffected eye
-​ Penetrate deeply & rapidly-> agents ○​Use eyelid tractors to expose eye
Alkali
-​ Linger in conjunctival tissues ●​Lye: drain cleaner ○​Attach tubings to control flow of
●​Symblepharon: contracture
-​ Fatty acid saponification-> ●​Lime: mortar, cement, irrigation, allows to hit where we want
of conjunctiva; palpebral
destructx of collagen fibers, plaster to wash the eye
adhere directly to bulbar
damage for hours or days-> ●​MgOH: sparkers, ○​Irrigate all surfaces (all direction)
conjunctiva
corneal penetration firecrackers ●​Solid materials should be removed
●​Corneal scarring: forms
●​Sulfurous acid: bleach, mechanically
white tissue opacity,
refrigerant, preservatives ●​Do NOT use chemical antidotes
hinders clarity
●​Hydrofluoric acid: glass ●​Irrigate until pH normalize (7-7.4)
*see table below for ropper etching, metal cleaning, ●​Complete hx & PE after irrigation
hall classification electronic manufacturing -Severity of ocular injury depends on 4 factors
 JCabarrubias

○​Toxicity
Poor prognosis: ○​Duration of contact
●​Severe conjunctival & ○​Depth of penetration
corneal burns ○​Area of involvement
●​Corneal scarring Further treatment:
●​Antibiotic eye drops
Surgical intervention: ●​Topical cycloplegics: stop ciliary spasm &
●​Corneal transplant dec pain
●​Grafting ●​Topical steroids: dec swelling
●​Conjunctival reconstructx ●​IOP lowering meds
●​Ascorbic acid: faster healing
Central retinal Diminished flow thru CRA leading Sudden, painless, severe Dx: No proven treatment
artery occlusion to retinal ischemia & infarction unilateral vision loss ●​Fluorescein angiography ●​Attempt to dislodge embolus w/in 24 hrs
(CRAO) “Amaurosis Fugax” ●​Visual field exam ●​Ocular massage ASAP
Embolus (20%): Hollenhorst AV ratio: 2:3 ●​Optical coherence ●​IOP lowering meds
plaques -> glistening yellow tomography ●​AC Paracentesis
crystals seen in bifurcation of ●​CVS embolic workup ●​Refer to IM
veins & arteries
Fundus appearance:
Golden period: 60-90 mins
●​Venous stasis & box
scarring: minutes
●​Retina opaque, macula
“cherry red spot”: hours
●​Pale optic nerve: months
NOT A TRUE OCULAR EMERGENCY
Acute Angle Occlusion of AC angle by Sxs: Dx: Mgt:
Closure peripheral iris ●​Excruciating pain Shallow- nasal side of iris is in -​ break the attack thru initial
Aqueous flow block-> IOP rise -> ●​HA darkness lowering IOP 20-30%
SSxs ●​N&V ●​IOP lowering meds
●​Halos Cxs: ○​B blockers
Likely to occur when pupils are ●​Sudden BOV ●​Anterior synechiae: ○​CAI
mid dilated Signs: irreversible occlusion of ○​Mannitol
Pupillary block- most common ●​Red, teary eye angle ●​Analgesics
cause ●​Hazy cornea ●​Optic nerve damage ●​Pilocarpine- constrict pupils
RFs: ●​Fixed mid dilated pupil ●​Steroids
●​Aging: AC angle narrowing, ●​Elevated IOP >21 mmHg ●​Laser iridotomy- definitive tx
crystalline lens enlargement *Fellow eye is treated prophylactically due to
●​Hyperopic eyes: eyeballs high risk of developing glaucoma as well
shorter-> narrower AC ●​Iridectomy: alt if iridotomy not effective
OPHTHALMOLOGIC TRAUMA
Foreign bodies Common reasons for ER consult Sxs: Dx: Mgt:
Corneal or conjunctival FB sensation, tearing, Evaluate location & depth Remove FB
redness, BOV Fluorescein staining Topical antibiotics
Commonly due to: Trauma, Metal Signs:
grinders, Welders, Construction, +FB, corneal epithelial
Organic FB defect, rust ring, discharge,
eyelid edema
Corneal Loss of epithelium Severe eye pain Mgt: Promote healing:
abrasions Secondary to scratching/scraping ●​Remove offending agents ●​Bandage contact lens
Exposed sensory corneal nerve Cx: Chronic Neutrophilic ●​Topical antibiotics ●​Pressure Eye Patch:
endings Corneal Ulcer ●​Lubricating drops *make sure unlikely infection before putting
-​ Periodic exam: evaluate bandage contact lems/Eye patch
healing & assoc infection
-​ No steroids & top.
anesthetic
Microbial Major cause visual loss RFs: (+) corneal opacities Mgt:
keratitis throughout the world ●​Contact lens wear (+) eye pain ●​Discontinue contact lens
●​Ocular surface dse ●​NEVER patch the eye
Prevention, early diagnosis, ●​Truma ●​Antibiotics (if ulcer >6mm: oral)
prompt mgt- essential ●​Ocular sugery ●​Steroids- do not start w/o antibiotic
Red eyes ●​Ophthalmia neonatorum: Conjunctivitis in neonates; Tx pt & parents
●​Gonococcal conjunctivitis: Hyperacute and purulent; Can cause corneal melt; Tx IV ceftriaxone
●​Subconjunctival haemorrhage: Rupture of conjunctival blood vessels; Alarming but asymptomatic; Usually benign condition
Hyphema Blood in the anterior chamber Causes: Mgt: Surgical indications:
 JCabarrubias

Damage to the iris blood vessels ●​Trauma ●​Bed rest ●​Uncontrolled glaucoma
Readily visible ●​Neovascular glaucoma ●​Head elevation ●​Corneal blood staining
●​Intraocular lens related ●​Limit physical and ●​Persistent large or total hyphema
Fresh: bright red blood -> recent problem strenuous activities w/ ●​Active bleeding / Rebleeding: most
bleeding ●​Systemic bleeding eyeshields common cx
Deoxygenated 8 ball: hyphema abnormalities Meds: Surgical intervention prevents:
prolonged period of time Sxs: ●​Topical cycloplegic ●​Vision loss
●​Ocular discomfort ●​Topical steroid ●​Optic nerve damage
●​Photophobia ●​Oral anaslgesics ●​Corneal blood staining
●​Blurry vision ●​Manage elevated IOP ●​Anterior synechiae
*see table below for *Avoid aspirin and NSAIDs
hyphema grading system
Monitoring + medical mgt->
resolution
Eyelid Subset of facial trauma ●​Canalicular involvement: Repair laceration Tx:
lacerations Accompanied by ocular injuries medial, close to canthus -​ Wound irrigation w/ saline ●​Direct closure: Superficial lacerations
●​Contact w/ sharp objects ●​Orbital fat prolapse: -​ Removal of FB visible on ●​6-0 or 7-0 non absorbable or absorbable
●​Blunt trauma exposure of fate, orbital surface sutures
septum violated; inc risk -​ Clean wound w/ povidone *Avoid non-absorbable in noncompliant pts
●​Partial thickness: only a portion infectx iodine ○​ Children
○​ Homeless
of skin & exposure of cutaneous ●​Extensive tissue -​ Exploration ○​ Poor ff up
tissue & muscle exposed damage: needs plastic -​ Anatomical alignment & ●​Surgery eyelid repair
●​Full thickness: entire layer eyelid reconstructive surgery closure ●​Oral & ointment antibiotics
splits; able to see the Imaging: check for FB before ●​Oral analgesics
globe/eyeball closure; multiple views ●​Tetanus & rabies prophylaxis
Open globe ●​Most common indication of Classification: Evaluation: Mgt:
injuries ocular trauma ●​Corneal laceration ●​Always do NON-CONTACT ●​Protect the eyes: glasses/googles
●​Intraocular contents exposed to ●​Scleral lacerations EXAM 1st ●​Antibiotics: topical broad spectrum/
external environment ●​Ruptured globe ●​AVOID OVER Systemic
●​May be assoc w/ lenticular MANIPULATION or pressure ●​Cycloplegics
problems Weak points: on the globe ●​Tetanus & Rabies prophylaxis
●​Result in full thickness defect ●​Incisions of previous ●​Imaging: intraocular or ●​Analgesics, antiemetic
Cornea or Sclera ocular surgeries orbital FBs ●​NPO
●​caused by sharp objects or high ●​Posterior insertions of *if metallic FB suspected, MRI is Surgical mgt:
velocity projectiles EOM contraindicated ●​Small self sealing wounds
●​Seidel test: check for -​ antibiotics, ff up
Sight threatening wound/ aqueous leak ●​Large self sealing wounds
Ocular morbidity Bacillus sp.: rapid deterioration -​ add bandage contact lens
of vision & related to puncture ●​Leaking wounds:
by dirty stick -​ suture wounds w/ nylon 10-0
-​ Reposition clean & viable iris, remove if
dirty or macerated
-​ Remove ruptures lens/cataract
-​ Evisceration/enucleation for severely
disorganised eye & infection w/o no
visual potential
Orbital cellulitis Infection involving structuresOrganisms: Course: Mgt:
behind the orbital septum ●​S. aureus 1.​Delay in treatment Immediate action
●​MRSA 2.​Compressive optic neuropathy ●​Admit
Most common cause proptosis in
●​Strep spp. -​ Dec vision, impaired color ●​Blood culture
children
●​H. influenzae vision, restricted visual ●​CT scan
Sinusitis: most common cause ●​Anaerobic field & pupillary ●​Broad spectrum IV antibiotics
Mucormycosis: diabetics, CMs: abnormalities ●​Abscess drainage
immunocompromised ●​Fever 3.​Cavernous sinus thrombosis ●​Otolaryngologist consultation
●​Leukocytosis 4.​Cranial neuropathy
●​Proptosis 5.​Brain abscess
●​Chemosis 6.​Death
●​EOM restriction
●​Ocular pain
Periorbital Most common orbital trauma in Damage facial bones & adj tissues. Fractures can involve: Mgt
contusion CNS ●​Orbital contents ●​Control inflammation
hematoma ●​Intracranial structure ●​Treat injuries
Common in VA, fall and fights ●​Paranasal sinus ●​Consider imaging
High incidence of concomitant intraocular injuries
 JCabarrubias

Traumatic optic Uncommon Concussive head trauma CT Scan/MRI or orbital apex, Tx:
neuropathy Unilateral decreased vision shears the blood supply to optic canal & cavernous sinus is Crash trial: high dose IV steroids in 1st 8 hrs
(+) RAPD ON causing blindness essential after initial injury if no comorbidities or
No clear ocular origin Nerves are normal looking -​ Fracture at/near optic canal traumatic brain injury present
upon initial exam -​ Damage at optic nerve’s
Pallor occurs after a month course
-​ Open globe injury is NOT
necessary to cause TON
Bilateral optic Papilledema: Sec ro inc ICP; finding for HA; Requires urgent Inc ICP or malignant systemic Requires urgent investigation & tx
disc swelling head imaging to r/o intracranial mass HPTN: characteristic feature
HPTN- gradual BP control to avoid optic nerve infarction

ROPPER HALL CLASSIFICATION

GRADE Prognosis Limbal ischemia Corneal involvement
I Good None Epithelial damage
II Good <⅓ Haze, iris details visible
III Guarded ⅓-½ Total epithelial loss, Haze, Iris
details obscured
IV Poor >½ Opaque, iris & pupils obscured

Hyphema grading system

GRADE AC filling Best prognosis for 20/50 vision or better
Microhyphema circulating RBC by slit lamp only 90%
I <33 % 90%
II 33-50 % 75%
III > 50% 50%
IV 100% 50%