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2014’s
2014’

MataPedia
M t P di

TM

for Ophthalmologist
(Slides Compilation)
Gede Pardianto
Sumatera Eye Center
Medan In...
The information provided within this book is for educational and
scientific purposes only and it should not be construed a...
• Being an ophthalmologist doesn’t mean you can
be the rich person or you can do everything. As
a little light, the sincer...
Gede Pardianto
•

Graduate from
–
–
–

•

Office
–
–
–

•

Doctor of Medicine  Airlangga University
Ophthalmologist  Air...
Here are awarded to the souls
of the valiant who gave their
lives in the service of their
country and who sleep in
unknown...
Basic and Latest
Spirit of Bali
Only one on earth
Visual functions including :
•
•
•
•
•
•

Visual acuity
Visual fi ld
Vi
l field
Color vision
Dark adaptation
Contrast sens...
Examination

Which one goes wrong ?
8
Examination : Finger
•
•
•
•

Finger counting
Confrontation t t
C f t ti test
Digital tonometry
Open the eye lid

9
Confrontation Visual Field testing
• Technique
– Examiner sated about 1 meter opposite patient
– Patient directed to cover...
Confrontation Visual Field testing
– Patient is asked to add total number of fingers
g
presented in opposing quadrants (do...
Examination : At least
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Optotypes charts
Phoropter and/or Trial lens and frame
Torch
Slit lamp...
Examination : Phoropter
• A device containing different lenses used
for refraction of the eye during sight testing
• The i...
Examination : Optotypes
• High contrast visual acuity
– Snellen chart
– Bailey Lovie chart
Bailey-Lovie

• Low contrast vi...
Examination : Torch
• Light perception
• Projection of Illumination / Light projection
• Macula Photostress Recovery Test
...
Examination : Slit lamp
• How to adjust
– Up and down
– Horizontal move
– Pupil distance
– Light
– Angle
– Slit maneuver a...
Slitlamp examination
anterior
cornea
p
posterior
cornea

anterior
lens

limbus

anterior
iris
17
Examination : Ophthalmoscope
• How to use :
– Power switch
– Size of illumination
– Diopter
– Color  Red free
– Placido d...
Dilating drops
• Mydriatic
– Phenylephrine 2.5%, 10%  20 min  3 hours

• Cycloplegics
–
–
–
–
–

Tropicamide 0.5%, 1%  ...
Examination : Amsler grid
• Boldly cross-hatched paper
• Will b mandatory i :
be
d t
in
– Metamorphopsia
– Central scotoma...
Amsler grid

21
To use the grid
g
• Sit in an area with good lighting, and hold the chart at
eye level and at a comfortable distance
• You...
Schirmer test I
•
•
•
•
•
•
•
•

Whatman No. 41 paper
p p
Filter strip 5x30mm, folded 5mm
Dimly light room
Place l
Pl
lowe...
Examination : Add 1
•
•
•
•
•
•
•
•
•
•
•

76 or 90 D lens
Goldmann’s 3 mirrors lens
Hruby lens
Indirect hth l
I di t opht...
Examination : Goldmann s 3 Mirrors
Goldmann’s
•
•
•
•

Central
Oval
O l
Trapezium
Square

: Posterior pole
:G i
Gonioscopy...
Examination : Add 2
• Visual field test 
–
–
–
–

Bjerrum’s tangent screen
Goldmann’s perimetry
SAP, SWAP, FDT, HPRP
For ...
Visual Field Analyzers

FDT Perimetry
Octopus 101
Perimetry

Goldmann
Perimetry

Humphrey
Perimetry

27
Examination : Add 2
• Advanced anterior examination
– Pachy-Autorefrakto-Keratometer
• PARK 1 (OCULUS Optikgeräte GmbH)
• ...
Examination : Add 2
• Advanced anterior examination
– Keratograph  Oculus Keratograph (OCULUS
Optikgeräte GmbH)
– E d th ...
Advanced anterior examination

Artemis (ArcScan, Inc)

P60 UltrasoudBioMicroscope
(Paradigm)

Visante OCT (Carl Zeiss Medi...
Examination : Add 2
• Advanced posterior examination
– Posterior Optical Coherence Tomography
• St t OCT (C l Z i M dit AG...
Examination : Add 2
• Advanced posterior examination
– Scanning Laser Ophthalmoscopy
• OCT-SLO (Opko Instrumentation)
• O ...
Stratus OCT (Carl Zeiss Meditec AG)
RTVue FD OCT (Optovue)

HRA-OCT Spectralis
(Heidelberg Engineering)
HRT3 (Heidelberg E...
Examination : Add 2
• Pediatric visual examination
– Pictures cards  Allen card
– Letter  HOTV
– Matching games  Lea sy...
Contrast sensitivity tester
• Aberrometry
• Glare
– Letter  Pelli-Robson Chart
Pelli Robson
– Grating 
•
•
•
•
•

Functi...
Examination equipment
•
•
•
•
•
•
•
•

Well accepted
pp
Well approved
Well proven
Easy to learn its manual
Easy to use
Eas...
EMBRIOLOGY

The Marshall
dr. Norman Tagor Lubis, Sp.M

37
American Academy of Ophthalmology

Neuroectoderm
-Neuresonsory retina
-Retinal p g e t ep t e u
et a pigment epithelium
-P...
DERIVATIVES
OF
EMBRYONIC
TISSUES :
MESODERM

• Fibers of extra ocular
muscles
• Endothelial lining of all
orbital and ocul...
American Academy of Ophthalmology
22 days Optic primordium appears in neural folds (1 5-3 0 mm)
(1.5-3.0 mm).
25 days Opti...
Third
Precursors of rods and cones differentiate.
month Anterior rim of optic vesicle grows forward
Ciliary body starts to...
Oculoplastic

43
Eye lid layer
y
y
• Anterior lamellar
– Skin and subcutaneus tissue
– Muscles of protraction  Ocular orbicular muscle

• ...
OP : Ptosis
1. PSEUDOPTOSIS
2. CONGENITAL
3. ACUIRED
–

MYOGENIC
•
BLEPHAROPHIMOSIS SYNDROME
•
MYASTHENIA GRAVIS
•
PROGRES...
Diagnostic keys
g
y
•
•
•
•
•
•

Levator Function
Margin reflex distance (MRD)
Margin limbal distance (
g
(MLD)
)
Inter pa...
Levator function

• The most practical measure of the strength of the
levator muscle
• Excursion of the upper lid from ext...
MRD
• A simple way to measure
the height of the upper lid.
• N
Normally 4 5 mm
ll 4-5
• MRD 1 = distance of the
upper lid ...
Skin
Ski crease height and strength
h i ht d t
th
• The distance from the lid margin to crease
– Men  6-8 mm, Asia  5-6 ...
System for Ptosis surgery
Levator function

> 10 mm

< 10 mm

Degree of ptosis

Levator function

< 2 mm

> 2 mm

> 2 mm

...
System for myogenic ptosis

Collin JRO, 1989

51
Collin JRO, 1989

52
Collin JRO, 1989

53
Collin JRO, 1989

54
Fascia lata : How to get
•
•
•
•
•
•

Mark outside of thigh 1/3 distally
Skin incision 4-5
Ski i i i 4 5 mm  d ll undermi...
OP : Entropion
CLASSIFICATION :

–C
Congenital
it l
• Entropion
• Epiblepharon

– Acquired :
• Involutional
• Spastic
y
• ...
Entropion : Involutional
• Overriding of lower lid protractor muscle
• Horizontal eye lid laxity  lateral and
medial cant...
Involutional Entropion : Examination
• Horizontal laxity
– Pi h / Distraction t t
Pinch Di t ti test
– Snap back test

• M...
Pinch / Distraction test
• Distant between globe and lower lid
g
pull
margin after full lower lid p out
• None  5 mm
• Mi...
Snap back test
• Dynamic test  Pull downward lower lid
margin then rapidly released
• Normal  Lid margin back on its pos...
Medial canthal laxity
• Lateral distraction test  Position shift of
inferior lacrimal punctum
• Normal  The punctum must...
Medial canthal laxity

0

1

2

3

4

5

6

Grade of Lancrimal punctum position shift

62
Cycatrical Entropion
Pathophysiology
p y
gy
• Cycatric at posterior lamellar  Posterior
lamellar shortening  lid margin ...
System for upper lid entropion
Lid closure possible?
Yes

No

Keratinisation of marginal
tarso-conjunctiva?

Corneal graft...
Collin JRO, 1989

65
Congenital Entropion : Surgery
• Congenital epiblepharon
– Could be disappear by age
– If there any punctate keratopathy ...
Involutional Entropion : Surgery
• Without lid laxity
– Everting suture
g
– Wies procedures

• With lid laxity
– Wies proc...
Cycatrical Entropion : Surgery
• Mild to Moderate
– Anterior lamellar reposition (ALR)
– Tarsotomy

• S
Severe
– Posterior...
OP : Ectropion
CLASSIFICATION :

– Congenital
– Acquired :
• Involutional
• Paralytic
• Mechanical
• Cycatrical

69
Ectropion : Principal surgery
• Laxity
– Tarsal strip
– Pentagonal excision  Medial Canthal
Medial, Canthal,
Lateral
– Me...
System of acquired
ectropion
p

Shortage of skin?
No

Yes

Normal eyelid closure?

Cicatricial ectropion

Yes

Localized d...
Collin JRO, 1989

72
OP : Trichiasis
• Cilia emerge from their normal anterior
lamellar location
• Associated with cicatrizing processes of
the...
OP : Blepharospasme
• Eye lid squeezing disorders
• L
Long standing  association with :
t di
i ti
ith
– Eye lid and brow ...
OP : Blepharophimosis
- G
Generalized narrowing of the palpebral
li d
i
f th
l b l
fissure
- A CONGENITAL ANOMALY
- EPICAN...
COLOBOMA PALPEBRA or
BLEPHAROSCHIZIS
• FULL THICKNESS DEFECTS OF THE EYELIDS
• RARE. UNILATERAL OR BILATERAL
• THE CONFIGU...
OP : Blepharochalasis
p
• Thin and wrinkled eyelid skin
• Familial variant of angioneurotic edema
• Idiopathic episodes of...
Contracted sockets
• Causes of
– Radiation
– Extrusion of an enucleation implant
– Severe initial injury
– Poor surgical t...
Collin JRO, 1989

79
Collin JRO, 1989

80
Prof. dr. Mardiono Marsetio, Sp.M(K)
and
Prof. dr. Wisnujono Soewono, Sp.M(K)

Ocular surface
85
Tear film : Functions
• Maintains optical clear for cornea
• Moistening, lubricating and protecting
surface of conjunctiva...
Tear film : Layers
y
•

Monomolecular lipid layer
–
–
–
–

•

Superficial
Origin from Meibomian glands
Inhibits evaporatio...
Tear film : Formations
•
•
•
•
•
•

Thickness  7-10 µm
7 10
Volume  7 + 2 µL each eye
pH  7 35  vary from 5 20 8 35
7....
Tear dynamics
• Tear volume is 10 µ L or less
• The maximum volume of fluid that can be contained in
the “cul-de sac” with...
Ocular surface : Hyperemia
• Conjunctival
j

• Corneal
• Scleral

90
Ocular surface : Red eye
•
•
•
•

Conjunctivitis
Uveitis
Keratitis
K titi
Glaucoma

91
Acute
Conjunctivitis

Acute Iritis

Acute
Glaucoma

Acute
Keratitis

Incidence

++

+

+/-

+

Secret

++

-

-

+

VA

-
...
Sign
Injection
Hemorrhage
Chemosis
Secret
Pseudo
membrane

Bacterial

Viral

Allergic

Toxic

Trachoma

Marked

Moderate

...
Staining : Gram
g
• Older technique
–
–
–
–
–

3 seconds of Carbol Gentian Violet on fixated object glass
¾ seconds Lugol ...
Staining : Giemsa and KOH
• Giemsa
– Giemsa solution : Aquadest  1 : 10
– 2 seconds Methanol on Fixated object glass
– Wa...
Ocular surface : Conjunctiva
j
• Follicle
– Focal lymphoid nodule
y p
– With accessory vascularization

• Papilla
– Dilate...
Follicle and Papilla
p
Area to be examined

Follicles

Papillae
97
Follicle and Papilla
p
Papilla

Follicle

American Academy of Ophthalmology

98
Phlycten and Phlyctenule
y
y
Phlycten

Phlyctenule

Staphylococcus

Delayed hypersesitivity

Good

Poor

+

-

Limbus
With...
Ocular surface: Cornea
• Epithelium
– 5-6 layer structure
– 50 100 µm thickness
50-100
– Great sensitivity
– Composed
• Ba...
Ocular surface : Cornea
• Bowman’s layer
Bowman s
– Homogenous condensation of anterior
stromal lamellae

• Stroma
– 90% o...
Ocular surface : Cornea
• Dua’s Layer
Dua s
– Discovered by examining the separation that
often occurs along the last row ...
Ocular surface : Cornea
• Descemet membrane
– Basement membrane of the endothelial cells
– Can be easily stripped
– Homoge...
Ocular surface : Cornea
• Endothelium
– Single layer
– 5 18 µm size of approximately 500 000
5-18
500,000
polygonal cells
...
Ocular surface : Cornea
• Blood supply
– Predominantly from
• Conjunctival vessel
• Episcleral vessel
• Scleral vessel

– ...
Ocular surface : Keratititis
Location

Marginal
keratitis
k titi
Peripheral

Bacterial
keratitis
k titi
Central

Size

< 1...
Chemical trauma : Hudge Grade
I

II

III

IV

Good

Good

Intermediate

Poor

Epithelial

Epithelial

Epithelial loss

Haz...
Corneal endothelial layer

• Normal  2 000 – 3 000 cells / mm²
2,000 3,000
mm
• Stressed  800 -1,500 cells / mm²
• D
Dec...
Keratoplasty
• Penetrating Keratoplasty (PK)
• Barron’s Keratoplasty
• Sterile Cornea Allograft  VisionGraft
(TBI/Tissue ...
Keratoprostheses: Boston K Pro

EuroTimes 2006

110
Keratoprostheses: AlphaCor

EuroTimes 2006

111
Keratoprostheses: Pintucci

IJO 2011

112
113
114
Refraction

Prof. Dr. dr. Admadi Soeroso, Sp.M, MARS
115
Visual acuity
• Vi
Visual threshold
l th h ld
– Light discrimination
•
•
•
•

Brightness sensitivity (minimum visible)
Bri...
Some basic acuity
Type

Description

Point acuity ( arc minute)
y (1
)

The ability to resolve two distinct point targets....
Visual acuity in different notation
FEET

METERS

MINIMUM ANGLE OF
RESOLUTION

LOGMAR

DECIMAL
NOTATION

20/10

6/3

0.50
...
Visual acuity : Development
y
p
Age

Visual acuity

2 months

20/400 (6/120)

6 months

20/200 (6/60)

1 year

20/100 (6/3...
Visual acuity : Various test in children
AGE (Years)
0-2
0-2
0-2
02
2-5
2-5
25
2-5
5+
5

VISION TEST
VEP
Preferential look...
Light : Basic
• Wavelength of visible light  380-760nm
380 760nm
• Velocity of light waves 
– 300 000 k /
300.000 km/sec...
Illumination
• Radiometry
– Measures term of power
– Irradiance = watts per square meter, lamberts
• Sunny day = 10,000 – ...
Photobiology
gy
• Scotopic vision is the monochromatic vision of the eye
in low light. Since cone cells are nonfunctional ...
The cone cells
• Sharp photoreceptor
• A human eye can see wavelengths in the range of 380 to
760nm. This range is called ...
Visible light
Hue

Wavelength (nm)

Indigo
g

400-450

Blue

450-480

Cyan-Blue

480-510

Green

510-550

Yellow-Green

55...
Chromatic aberration
• The type of error in an optical system in which the
formation of a series of colored images occurs,...
Chromatic aberration
• Short wavelength light focused
more anterior than long
wavelength li ht
l
th light
• Violet focused...
Spherical aberration
• A blurred image that occurs when
light from the margin of a lens or
g
g
mirror with a spherical sur...
Spherical aberration
•
•
•

•

A perfect lens (top) focuses all
incoming rays to a point on the
optic axis
A real lens wit...
Spherical aberration
• Mirror spherical
aberration
• Reflective Caustic
generated f
d from a
circle and parallel
rays

130
Accommodation table
Age (years)

Rate of Accommodation (Diopters)

8

13.8

25
5

99
9.9

35

7.3

40

5.8
58

45

3.6

50...
Refractive index (Helium D Line)
•
•
•
•
•
•

Air
Water
Cornea
Aqueous and vitreous
Spectacle crown glass
PMMA

1.000
1.33...
Refracting power (D)
• Corneal system

43.05

– Anterior surface
– Posterior surface

48.83
- 5.88

• Lens system
– Relaxe...
DIOPTER CONVERTION - MILIMETER
K

K

Reading
(D)

Radius
(mm)

Reading
(D)

Radius
(mm)

47.57
47.50
47 50
47.25
47.00
47 ...
Pinhole visual acuity measurement
• If visual acuity improves  refractive error
usually present
• Disease of macula 
– U...
Refraction
Common
Disorder

Moderate

Severe

-1.00 t – 4 00
1 00 to 4.00
Diopters

-4.00 t – 6 00
4 00 to 6.00
Diopters

...
Refraction
• Myopia (Nearsightedness)
– Pathophysiology
• Axial Curvature Increased index of refraction
Axial, Curvature,
...
Myopia
y p
•
•

Children born myopic  small percentage  not become
emmetropic by age 6-8 years
Previously emmetropic chi...
Significant myopia in childhood
g
y p
•
•
•
•

Cycloplegic refraction are mandatory
Full refractive error, including cylin...
Refraction
• Hypermetropia (Farsightedness)
– Structural
• Axial, Curvature, Index of refraction

– Accommodative
• Latent...
Correcting hyperopia in childhood
• No esodeviation and reduced vision  NOT
necessary correcting low hyperopia
• Signific...
Clinical refraction
• Refraction approach  ARK
• Subjective  Trial and error by trial optical
lenses
• Objective  Strea...
Streak retinoscopy

Neutralization
With
Against
ga s
143
Finding Neutrality
•
•
•
•

•
•
•

In against movement, the far point is between the examiner and the
perfect therefore, t...
Finding Neutrality
g
y

145
Finding the cylinder axis
g
y
• Before retinoscope is used to measure the powers in
each of the principal meridians, the a...
Finding the cylinder axis
g
y

American Academy of Ophthalmology

147
Finding the cylinder axis
g
y

148
Finding the cylinder axis
g
y

American Academy of Ophthalmology

149
Finding the cylinder axis
g
y

American Academy of Ophthalmology

150
Finding the cylinder axis
g
y

American Academy of Ophthalmology

151
Finding the cylinder power
•
•

Once the two principal meridians are identified, the axis separately
in turn.
With two sph...
Aberrations of the Retinoscopic Reflex
•
•
•
•

•

With irregular astigmatism, almost any type of aberration may
appear in...
Summary of retinoscopy
1.

2.
3.

4.

5.

The steps below summarize how to performing streak retinoscopy using
a plus cyli...
Summary of retinoscopy
y
py
6.

7.

8.

9.
10.

Rotate the streak 90º and set the axis of the correcting plus cylinder
par...
Retinoscopy: Final correction
•
•

If we use working lenses  Another
correcting lenses  Final correction
If for example ...
Lenses
• Meniscus Lens or Curve Lens  Lens with
one spherical convex surface and the other
spherical concave. Meniscus le...
The Basic Lenses

(A), biconvex; (B), biconcave; (C), planoconvex; (D), plano concave;
(E),concavoconvex, periscopic conve...
Sphere lenses

159
Sphere Lens

Biconvex Lenses

CaF2 Lenses

Plano Concave Lenses

Biconcave Lenses

Meniscus Sphere
Lenses

Changch Jixiang...
Spheric correction
• Least minus for myopia
– More minus forces contraction of cilliary
muscles for unnecessary accommodat...
Spherical aberrations
• More peripheral rays focused anteriorly
• Exacerbates myopia in low light (night
myopia) about – 0...
Achromatic lenses
•
•
•
•
•

Achromatic Lenses consist of two or more elements, usually of
crown and flint glass that have...
Achromatic lenses

Positive Achromatic Lenses

Negative Achromatic Lenses

Changchun Jixiang, 2006

164
Astigmatism
g
• Classified as
– Sh
Shape
• Regular astigmatism
– With the rule
» Common in children
» Vertical meridians i...
Circle of least confusion

Conoid of Sturm

166
Cylinder lenses
y

167
Cylinder lenses

Plano Convex Cylindrical Lenses

Plano Concave Cylindrical Lenses

Biconvex Cylindrical Lenses

Biconcave...
Cylinder axis

American Academy of Ophthalmology

169
Astigmatic dial technique
• Obtain best visual acuity using SPHERES only
y
g
y
• FOG the eye to about 20/50 by adding PLUS...
Astigmatic correction
g
• For children  full correction with correct axis
• For adult  adaptable full correction
• Reduc...
Toric lenses

American Academy of Ophthalmology

172
Toric lenses
• Shaped like a section through a rugby ball
• P
Prescribed t correct astigmatism 
ib d to
t ti
ti
contact l...
Prism lenses

174
Prisms aberration
• In addition to chromatic aberration
• Producing colored fringes at the edges of
objects viewed through...
Prismatic effect of decentred lens
• Convex lens  two
prisms cemented
together at their
BASEs
BASE
• Concave lens  two
p...
Bifocals
• A lens having one
section that
corrects for distant
vision and another
section that
corrects for near
vision.
v...
Bifocals

The dot indicates the optical centre of the near portion
A, executive-type segment; B, flat-top segment; C, roun...
Trifocals

•

Three prescription powers: a distance power, a mid-range power, and a
near power.

•

The distance power hel...
Progressive Lens
•

Characterized by a gradient of
increasing lens power added to
power,
the wearer's correction for the
o...
Transposition

181
S - 6.00 C + 3.00 A 90º
0.00

- 6.00

- 6.00

- 6.00

+3.00

+3.00

0.00

- 6.00

- 6.00

Make the
transposition
of it

- ...
Transposition
• New sphere is the ALGEBRAIC SUM of old sphere and
cylinder
• New cylinder is same value with old cylinder ...
S - 3.00 C -3.00 A 180º
- 3.00

- 3.00

0.00

0.00

- 3.00

- 3.00

- 3.00

- 3.00

- 6.00

EQUAL

- 3.00

- 3.00

- 6.00
...
Is your correction correct?
y
• Duke Elder  add + 0.25 or – 0.25 D
– I it bl
Is i blurred or still clear ?
d
ill l
– Smal...
Refraction : Correction
•
•
•

Spectacle / glass
Contact lenses
Keratorefractive surgery
–
–
–
–
–
–
–
–

RK  Radial kera...
Corneal Collagen Cross-Linking
g
g
• Corneal thermal remodeling  (also) can be induced by
Microwave Keratoplasty
Micro a ...
Corneal Collagen Cross-Linking
g
g

•
•

Older procedure  30 minutes riboflavin soaks and 30 minutes UV
p
exposure  pote...
Contact Lenses Fitting

189
Contact lenses : Materials
1.
1 HEMA (Hydroxyethyl methacrylate)
2. Non HEMA  Hydrogel lenses  Hydrophyllic
3. HEMA + PV...
Contact Lenses Fitting
•

Base curve
–
–
–
–
–

•

Radius of curvature to be cut on the posterior surface of the lens
Mini...
The Contact Lenses

Peripheral curve width

Optic zone

Base curve

Peripheral curve radii

Peripheral curve width

Center...
VERTEX DISTANCE CORRECTION
Vertex Distance (mm)
Spectacle
Power (D)

10

11

12

13

10

12

13

Contact Lens Power
Minus ...
FITTING STEPS
Good fit
1. Sufficient movement
2. Proper centration
3. Stable vision
4.
4 Sharp retinoscopic reflex
5. Clea...
FITTING STEPS
Tight fit
1.
1 Vision fluctuates (clears briefly after blink)
2. Bubbles trapped under the lens
3. Declining...
FITTING STEPS
Loose fit
1. Variable vision (briefly clears after blinking)
2.
2 Bothersome lens awareness
3. Lack of centr...
197
Toric contact lenses
• An astigmatic eye is not perfectly round (like a
soccer ball) but more shaped like a rugby ball.
• ...
What makes a to c co tact lens d e e t
at a es toric contact e s different?
• If you think of the eye as a rugby ball, tha...
Radial Keratotomy

200
Laser Thermal Keratoplasty

201
Laser assisted
Laser-assisted in situ Keratomileusis

202
Laser-assisted Sub-Epithelial Keratomileusis

203
Arcuate Keratotomy

204
Intrastromal Corneal Ring

205
Aniseikonia
• Translated from Greek aniseikonia means
"unequal images".
• It is a binocular condition so the image in
cond...
Aniseikonia
• Static aniseikonia or
aniseikonia in short means that
in a static situation where the
eyes are gazing in a c...
Aniseikonia : Static

208
Aniseikonia
• Dynamic aniseikonia or (optically
induced) anisophoria means that
the
th eyes h
have t rotate a different
to...
Aniseikonia : Dynamic

210
Aniseikonia

Schematic presentation of the different steps to get to a perceived
image size and the visualization of a fie...
Aniseikonia

Features : a) Example of a single aniseikonia test image, b) same aniseikonia
test image as on the left, but ...
Anisophoria
• Is a condition in which the balance of the
vertical muscles of one eye differs from
that of the other eye  ...
Amblyopia
y p
Type :
• St bi i amblyopia
Strabismic
bl
i
– Frequently  in esotropia patients

• A i
Anisometropic (R f ti...
CyberSight, 2003
215
216
Strabismus

217
Position of gaze
g
• Primary position
– Straight ahead

• Secondary position
– Straight up, straight down
– Right gaze, le...
Cardinal position and Yoke muscles
RSR
LIO

Right Gaze

LSR
RIO

RLR
LMR

LLR
RMR

RIR
LSO

LIR
RSO

Left Gaze

American A...
Eye movement
• Agonist
– Primary muscle moving the eye in a GIVEN direction

• Synergist
–
–
–
–
–

Muscle in the same eye...
Basic
• Sherrington’s law for reciprocal innervation
– Increased innervation and contraction of GIVEN
EOM 
– Accompanied ...
Basic
• Hering’s law of motor correspondence
Hering s
– The state  equal and simultaneous
innervation flow to Yoke muscle...
EOM : Functions
Muscle

Primary

Secondary

Lateral rectus

Abduction

None

Medial rectus

Adduction

None

Superior rect...
EOM : Origin
g
Muscle

Origin

Functional
origin
i i

Lateral rectus

Annulus of Zinn

Annulus of Zinn

Medial
M di l rect...
EOM : Insertion from limbus

•
•
•
•

Medial rectus
Lateral rectus
Superior rectus
Inferior rectus

5.5
5 5 mm
6.9 mm
7.7 ...
EOM : Wide and Length
•
•
•
•
•

Superior Rectus  5.0 mm and 41.8 mm
Inferior Rectus  4.2 mm and 40 mm
Lateral Rectus  ...
EOM : Gazes
Up and right

RSR - LIO

Up and left

LSR – RIO

Right

RLR – LMR

Left

LLR - RMR

Down and right

RIR - LSO
...
Eye movement
• Versions
– Eyes move in the same direction

• Vergences  Disconjugate binocular eye
movement
–
–
–
–
–

Co...
Eye movement : Supranuclear control system
•

Saccadic system
– G
Generates all fast eye movements or refixation
t
ll f t
...
Variation of deviation
With gaze position or fixating eye
• Comitant (Concomitant)
– Deviation doesn’t vary in size with d...
Grades of binocular vision
• 1st Grade
– Simultaneous perception

• 2nd Grade
– Fusion

• 3rd Grade
– Stereopsis

Kanski J...
Fusion
•
•

Cortical unification of visual object into a single percept
Made by simultaneous stimulation of corresponding ...
Stereopsis and Depth perception
• Stereopsis
p
– Binocular sensation
– Relative or subjective ordering of visual objects i...
AC/A Ratio
•

Accommodative Convergence / Accommodation Ratio
– Normal is between 3:1 to 5:1

– AC/A = PD +

∆n – ∆o
D

Gr...
ESODEVIATION
• Esodeviation
– Esophoria
• Controlled by fusion under condition of normal
y
binocular vision

– Intermitten...
Esotropia
•
•

Pseudoesotropia
Congenital esotropia
– Classic essential
– Nystagmus and esotropia
y g
p

•

Accommodative ...
Pseudoesotropia
• Infant often have a wide, flat nasal bridge
with prominent medial ep ca a folds a d
po
e
ed a epicanthal...
Congenital Esotropia
•
•
•
•

Large constant esotropia (usually > 40 PD)
Onset birth to 6 months of age
Amblyopia common (...
Non-surgical treatment
Congenital esotropia
•
•
•
•
•
•
•

Abduction should be full or only slightly limited. Mild (-1) li...
Accommodative esotropia
• CLINICAL FEATURES
– Usually acquired around 2 to 4 years of age
– Moderate to large esotropia (2...
Non surgical treatment
•

Refractive accommodative esotropia
– Corrective lenses
• Full amount of hyperopia as determined ...
Non surgical treatment
• Non-refractive accommodative esotropia
– Bifocals
•
•
•
•
•

Flat-top design preferred
+2.50 to +...
Bifocal for Deviations

243
Order for surgery
• Surgery between 6 months and 2
years of age (most reference
recommend)
• Surgery between 6 months and ...
Surgical Approach
• The procedure of choice  bilateral medial
rectus muscle recession
g
g
• Near deviation as the target ...
Non accommodative
Non-accommodative esotropia
• CLINICAL FEATURES :
–
–
–
–
–

Usually emmetropic, may be myopic
Onset aft...
Sensory Esotropia
• Associated with a monocular blindness
or dense amblyopia
amblyopia.
• Treatment : recession lateral re...
EXODEVIATION
• Exodeviation
– Pseudoexotropia
• An appearance of exodeviation when in fact the
pp
eyes are properly aligne...
Intermittent exotropia
•

Classified by
– Difference distance and near between alternating prism and cover test
measuremen...
Intermittent exotropia
• Basic type
– Same at near and distance

• Divergence excess
– Greater at distance
– True divergen...
Non surgical treatment
•

Corrective lenses
– Improve retinal image clarity

•

Additional minus lens power
– Usually 2-4 ...
Surgical treatment
•
•
•
•
•

Deviation of 15 ∆ or more
Nearly constant exotropia
Still i t
intermittent
itt t
Before 7 ye...
NOTE
• Children under 4 years of age are at
risk f d
i k for developing postoperative
l i
t
ti
amblyopia and losing binocu...
Another exodeviation
• Constant exodeviation
– Congenital exotropia
– Sensory exotropia
– Consecutive exotropia
– Exotropi...
A-V Patterns in horizontal strabismus
A V P tt
i h i
t l t bi
• A Pattern
– Eyes closer together in up gaze
– 10 PD differ...
A Pattern
• Etiology
– Most f
frequent  overaction of SO
f
– With or without underaction of IO
– As SO acts abduction in ...
V Pattern
•

Etiology
– Most frequent  overaction of IO
– Primary underaction of SO
– As IO acts abduction in upgaze
• Es...
Strabismus : Position test
Measurement of deviation
• Hiscberg test
• C
Cover t t
test
• Cover uncover test
• Krimsky test...
259
260
261
262
263
Strabismus : Sight test
• WFDT
• Maddox’s rod

264
265
266
267
268
Approach to Recession surgery
Minimal (mm)

Average
maximum (mm)

Maximum
ever (mm)

LR

4

8 - 10

MR

2.5

7 adult
6 chi...
Approach to Resection surgery
Minimal (mm)

Average
maximum (mm)

Maximum
ever (mm)

LR

5

8 infant
10 children and adult...
Prisms Muscle
Prisms-Muscle length conversion

• 5 ∆ Di t f 1 mm MR recession
Diopter for
i
• 2.5 ∆ Diopter for 1 mm LR re...
Both eye surgery for Esodeviation :
Angle of esotropia (∆)

Recess MR OU (mm)

OR

Resect LR OU (mm)

10

3.0

4.0

20

3....
Monocular surgery for Esodeviation
Angle of esotropia (∆)

Recess MR OU (mm) AND Resect LR OU (mm)

10

3.0

4.0

20

3.5
...
Both eye surgery for Exodeviation :
Angle of exotropia (∆)

Recess LR OU (mm)

OR

Resect MR OU (mm)

15

4.0

3.0

20

5....
Monocular surgery for Exodeviation :
Angle of exotropia ( )
g
p (∆)

Recess LR OU (mm) AND Resect MR OU (mm)
(
)
(
)

15

...
Strabismus : Exercise

Synophthophore

Holme’s stereoscope

276
Glaucoma

277
Glaucoma : Basic
• Definition
– Optic neuropathy
– Visual field defect
– Rise of IOP as major risk

278
279
Glaucoma : Basic
•
•
•
•
•
•
•
•

IOP measure
Angle examination
Optic nerve head examination
Vascular change
RNFL examinat...
IOP : Basic
•
•
•
•
•
•
•

Normal IOP  10-20 mmHg
10 20
Average  15 mmHg
Fluctuation
Fl t ti  2 56 mmHg
2.56
H
Diurnal ...
IOP : Determining factors
F = C (P – P )
(Po Pe)
• F
• C

= rate of aqueous outflow (normal 2 µl/min)
= facility of aqueou...
How to measure the IOP
• First line
– Applanation tonometer  Nowadays Gold standard  AT 900D
(Haag-Streit International)...
IOP : Flow
•
•
•
•
•

Cilliary body
Posterior chamber
Pupil
P il
Anterior chamber
Delivery
– Trabecular pathway (85-95%)
(...
IOP : Flow
• Aqueous come in to eye by :
– Diff i
Diffusion
– Ultrafiltration
–C
Carbonic Anhydrase II activity
– Active s...
Glaucoma: Vascular dysregulation
y g
• Endhotelial dysfunction
– Impaired endothelium-derived nitric oxide
activity
– Abno...
Glaucoma : Angle
•
•
•
•
•
•
•

Torch
Von Herrick Slit-lamp
Gonioscopy
Ultrasound Biomicroscopy (UBM)
Anterior
A t i OCT
S...
Angle : Observation

288
Angle Examination : Torch

289
Angle Examination : Van Herick

Von Herrick and Shaffer grades
Grade

Ratio of aqueous gap/cornea

Clinical interpretation...
Angle Examination : Gonioscopy

291
Identification of Schwalbe’s Line
Schwalbe s

Thomas R, 2006

292
Shaffer’s Intepretation

Classification

Angle Width

Visible Structure

Clinical Intepretation

Grade 0

Closed

Schwalbe...
PAS look alike

Thomas R, 2006

294
Rubeosis

Thomas R, 2006

295
Angle Recession
g

Thomas R, 2006

296
Angle Examination : UBM

297
Angle Examination : UBM

Normal eye’s angle

Angle : Pupillary block

298
Angle Examination : Anterior OCT

Visante OCT (Carl Zeiss Meditec AG)
299
Scheimpflug Camera Pentacam

300
Artemis ( Ultralink)
50 MHz ArcScan

301
The Angle

302
Shaffer s
Shaffer’s Intepretation
Classification
Cl
ifi ti

Angle
A l Width

Visible St
Vi ibl Structure
t

Clinical I t
C...
Optic disc
A. Surface
B. Pre Laminar
C. Laminar
D. Retro Laminar

304
GON : Evaluation
• Indirect ophthalmoscope*
• Direct ophthalmoscope
• Slit lamp : stereoscopic view
• H b or El B
Hruby
Ba...
GON : Evaluation
•
•
•
•
•
•
•

Disc  Generally
Cup
Neuro R ti l Ri (NRR)
N
Retinal Rim
Peripapillary hemorrhage
Circum L...
GON : Evaluation
Generalized
Large optic cup
L
ti
Asymmetry of the cup
Progressive enlargement
of the cup

Focal
Narrowing...
Cup and Disc

308
Disc Excavasion

309
Definition of Cup : Disc Ratio
• Disc Diameter
• Cup Diameter
• CDR = c / d

c d

• Horizontal > Vertical

Thomas R, 2006
...
Thomas R, 2006
R
311
a. Normal C/D Ratio 0.2
b. Same Disc 1 year later with C/D
Rasio 0 5
R i 0.5
c. Cup enlarge to Infero Temporal
and Splinte...
CDR Asymmetry

Thomas R, 2006

313
Asymmetric cupping

314
Cup Depth
•
•
•
•

Not of much importance
In normal : depends on disc area
In glaucoma : type & level of IOP
Deepest with ...
Neuro Retinal Rim (NRR): Shape
• Sloping rim in small and intermediate discs
• Steep or over hanging with oblique insertio...
NRR in Glaucoma
• Loss of physiological shape
• ISNT rule i b k
l is broken
• Vertical cup enlarges
Thomas R, 2006

317
Jonas ISNT Rule
•

Less marked in large discs

•

Rim more evenly distributed

•

Punched out well defined
cup in large di...
NRR : I S N T
• Partially depends on exit of central retinal
vessels
l
• Rim furthest away is more affected
• May explain ...
Temporal Portion of Rim
• Papillo macular bundle
• Preferential cupping temporally with field
loss near fixation
• POAG wi...
Glaucoma & Contour of Rim
• May cause a backward bowing of the rim
tissue
• Deep extension of the cup in one meridian
• Ge...
Rim contour : Normal

Thomas R, 2006

322
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Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
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Gede Pardianto - MataPedia2014 for Ophthalmologist
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Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
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Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
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Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
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Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
Gede Pardianto - MataPedia2014 for Ophthalmologist
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