MUST know topics
Ophthalmology
Dr Sourabh Sharma
MBBS, MD (AIIMS), DNB, FICO, FRCS
Fellow - Singapore National eye Center and Research Institute
Faculty Ophthalmology - DAMS
Consultant – Bharti Eye Hospital, Delhi
Ocular injuries
Ocular injuries Perforation repair ASAP in OT
-Removal of toxic foreign body
(Fe, Cu, Hg)
Closed globe injuries Open globe injuries
BLUNT trauma Penetrating trauma
Blow- out # BLUNT trauma
Tear-drop sign
En-ophthalmous
Infra-orbital anaesthesia
Inferior rectus entrapped Difficulty in elevation
Sub-conjunctival hemorrage hyphema Irido-dialysis
ecchymosis
Vossius ring Rosette cataract Berlin edema
# anterior cranial fossa
Globe rupture Open globe injuries
Embryology
Remnant of hyaloid vessel
Anterior Posterior
Mittendorf dot Bergmister papilla
Persistent Hyperplastic
Primary vitreous
Failure of closure of embryonic fissure - coloboma
Lens
Nuclear sclerosis
Second sight phenomeon
Induced myopia
Posterior Subcapsular
Post cataract surgery
LOW IOP HIGH IOP
shallow AC
Wound leak- Siedel test positive
Pupil block GLAUCOMA
AQUEOUS MISDIRECTION SYNDROME/ MALIGNANT GLAUCOMA
Vision loss, corneal haze, intraocular inflammation post cataract surgery
TASS (Toxic anterior chamber syndrome) Acute postoperative endophthalmitis
Posterior capsular opacification
Management of congenital cataract
Lens aspiration + Posterior capsulorhhexis + Anterior vitrectomy + IOL
Zonular Blue-dot
Executive bifocals – pediatric pseudophakia/aphakia
Congenital cataract
Afetr Sx
Accomodation is lost
Near glasses are needed
Accomodative esotropia
To assist Accomodation
Near glasses are needed
19
M Marfans
Subluxated lens
A Aniridia
Trauma
T
Hyperlysimeia
H Homocystinuria
S Stickler
Suplite oxidase deficiency
Retina
Foveola Fovea
Inner limiting
Inner limiting
Outer plexiform/Henle layer
Outer nuclear
Outer nuclear
Outer limiting
Outer limiting
Cones
Cones
Retinal Pigment Epithelium
OPTICAL COHERENCE TOMOGRAPHY (OCT)
Retinal Pigment Epithelium
Macular hole Cystoid Macular edema
Central serous retinopathy
Inner blood retinal barrier-
NFL retinal vascular endothelium
OPL
Outer blood retinal barrier - RPE
Flower petal Microaneurysms
Ink blot/smoke stack Cystoid Macular edema Mild NPDR
Central serous retinopathy
PDR
Ganglion layer edema
Central retinal vein occlusion
Central retinal artery occlusion
Young patient
Symptom – night blindness
Signs
EGG YOLK - Lipofuscin Vision - Normal
RPE dystrophy
Vision - poor
Scrambled egg , Vision loss
Pseudohypopyon
Cornea Conjunctiva
Farmer
Young patient
Trauma – vegetable matter
Soft contact lens
Mild symptoms
– tap water
Excruciating pain
Dry ulcer
Rough texture
Feathery rolled margins
Ring infiltrates Satellite lesions
Pseudo-dendrites Fixed hypopyon
non sterile
Resembles viral Resembles Nocardia
Herpes simplex dendritic ulcer
Corneal stromal dystrophies
LATTICE TYPE GRANULAR TYPE MACULAR TYPE
Lattice – amyloid – Congo red
Granular – hyaline – Masson trichome
Macular – mucopolysaccharoid – Alcian blue
Copper Descment
Bowman
membrane Calcium membrane Drugs Epithelium
Amiodarone
NSAIDS
Chloroquine
KAYSER FLEISHER ring BAND shaped keratopathy
VORTEX KERATOPATHY
Wilson disease
Chalcosis
resembles
Orbit and eyelids
Proptosis Rule out pseudo-proptosis - (Myopia/lid retraction,C/l ptosis)
Lid lag, EOM belly enlargement, soft tissue signs –
Rule out Thyroid eye disease(Thyroxine levels is not important)
Female child, features of NF1
Painless axial, RAPD Optic glioma
Abaxial, painful, gradual vision loss Female middle aged, psammoma bodies
sign of Optic nerve meningioma
inflammation- Painless axial, gradual visual loss
Orbital cellulitis/ Benign intraconal tumour – Cavernous hemangioma/Schwannoma
pseudotumour/
malignancy Abaxial, painless, look for direction of proptosis
Lacrimal gland tumours
41
3, 4, v1, v2, 6
Pulsatile proptosis
High eyelid crease
Drooping of eyelid with absence of eyelid crease
Left Congenital ptosis Left Aponeurotic ptosis
Mild – LPS plication Aponeurosis repair
Modrate – LPS resection
Severe – Frontalis sling
43
Tensilon/ice pack test
Patient with variable ptosis, diplopia, restriction of eye movements
Myasthenia gravis
Neuro-ophthalmology
AND
Glaucoma
Right Optic tract lesion
Left visual field Right visual field
Left honomymous hemianopia
Wernicke hemianopic pupil
Chiasmal – heteronymous
Retrochiasmal - homonymous
Anterior pathway defects
CAN be Incongruous
(asymmetrical)
Posterior pathway defects
ARE Congruous
(symmetrical)
Optic chiasma lesion
Left temporal lobe lesion
Left visual field Right visual field
Right homomymous sup. quadrantanopia
50
Near/Accomodation pathway
Convergence
Bilateral pupil constriction
Near Vision/Accomodation
Ciliary body contracts
Zonules relax
mm mm 6
mm
6
mm
Anterior lens curvature ↑
51
PUPIL examination
Slit lamp examination
Check near constriction
Anisocoria increases in bright light
Light Torn pupillary border 0.125% Pilocarpine test
Sluggish near constriction
No Constriction Constricts
Dark Damage to iris sphicter Tonic near constriction
1% Pilocarpine test Adie pupil
Adie pupil
3rd nerve palsy
Constriction occurs No Constriction
Damage to iris sphincter
Pharmacological mydriasis 3rd nerve palsy Pharmacological mydriasis
PUPIL examination
Slit lamp examination
Signs of posterior synechia etc
10% Cocaine test
Mechanical miosis
Dilatation lag
No lag
Anisocoria increases in dark light
Dilatation with cocaine Lag+
Light Physiological miosis No dilatation
Horner pupil
Dark
Amphetamine test
Horner pupil
Mechanical miosis Dilatation occurs No Dilatation
Physiological miosis Horner pupil – Preganglion lesion Horner pupil – Postganglion lesion
Pharmacological miosis
Types and Management of glaucoma
Gonioscopy
Open angle Closed angle
IOP
IOP
Normal High Normal High
Optic disc/Field Optic disc/Field Optic disc/Field Optic disc/Field
Changes Changes Normal
Normal Normal
Normal Changes
NTG POAG OHT PACS PAC PACG
Medical Mx Laser iridotomy
Laser trabeculoplasty Medical Mx
Surgical Mx Surgical Mx
Goldmann applanation tonometer
Tonopen – combined
Indentation and applanation principle Rebound tonometer- self tonometer
55
Primary Congenital glaucoma
Squint and optics
Superior rectus – elevator in abducted position
Right eye
Superiors – intorters
Rectii - adductors
58
Deviation measured = 30° Deviation measured = 45°
Primary deviation Secondary deviation
Incomitant squint Right esotropia, Left normal
- Down and out eye
(Hypotropia and exotropia)
- Ptosis
- Pupil dilatation
- Direct and consensual light
reflex absent in that eye
Left 3rd nerve palsy
60
Horizontal BINOCULAR DIPLOPIA
CROSSED UN-CROSSED
eXophoria/ esophoria/
eXotropia esotropia
Interpretation as if patient’s view
Normal
UN-CROSSED
CROSSED
Diplopia--- Eso
Diplopia--- Exo
61
Emmetropia
FAR POINT
Far point is infinity
Hypermetropia
Far point is behind eye
Myopia
Far point in front of eye
-4 D Myopia -2 D Myopia
Far point ¼ m= 25 cm in front of eye Far point ½ m= 50 cm in front of eye
62
NEAR POINT PRESBYOPIA
↑Age > 40 Years = near glasses (+ glasses)
↓Accomodation = ↑Near point
63
+-44D
D
-6+ D
1D
Compound Hpermetropic Astigmaism
Against the rule
More myopic axis – more steeper axis 64
Keratometry
47D
-4 D
-6
44DD Vertical steeper – with the rule astigmatism
More cornea power - More myopic axis – more steeper axis
+2 D sphere with -1D cylinder @ 90
+2 D +2
-490°
D -4 D
D
0/180° -6 DD -1 D = +1D
+2 -6
+1DD
Compound Hypermetropic Astigmatism
against the rule
66
Uveitis
Non-
Idiopathic
HLA B27 related
- Ankylosing spondylitis
- Reiter syndrome
- Psoriasis
Juvenile idiopathic arthritis
Bechet’s disease
Immunity
recognises
uveal tissue
antigen –
Retinal S antigen
Penetrating trauma Panuveitis - granulomatous
2 weeks to 3 months
Exciting eye Sympathising eye
1st symptom – loss of near vision
1st sign – Retrolental flare
DALEN FUCH nodules – sub retinal
Rx – i.v. steroids
VISION
Minimal angle of resolution (MAR)
Snellen’s chart
Each segment of letter subtends Total letter subtends
60/6 = 10 minutes of arc 10✖5= 50 minutes of
arc
6/36 = 6 minutes of arc 6✖5= 30 minutes of
arc
6/6 = 1 minutes of arc
Each letter has 5 segments
71
Direct ophthalmoscopy Indirect ophthalmoscopy/Fundoscopy
Entire retina
Optic disc, macula Real inverted image
Virtual erect image
Field of view – 8 disc dioptre
Field of view – 2 disc dioptre
Magnification =
Magnification = Power of eye/4 Power of eye/power of lens (+20D,+30D)
72
Magnification in
emmetropic eye
= 60/4
= 15 times
Magnification in
Direct ophthalmoscopy myopic eye of -4 D
= (60+4)/4
= 16 times
73
Best Wishes
Dr Sourabh Sharma Ophthalmologist
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