this presentation is tell about what structural changes occur in eyes with increasing age.

1. UTTAR PRADESH UNIVERSITY OF
MEDICAL SCIENCES
Presented by- RAJAT BANSAL Guided by- GAURAV SIR
B.OPTOM 3RD YEAR

2. ANATOMICAL AND
STRUCTURAL CHANGES OF
EYES

3. CONTENT
 Introduction to geriatric optometry
 Importance of anatomical and structural changes in geriatric optometry
 Structural changes in lid
 Structural changes in Eyelashes and Lid margin
 Structural changes in Tear Film
 Structural changes in Cornea
 Structural changes in Conjunctiva
 Structural changes in Pupil/Iris
 Structural changes in Crystalline lens
 Structural changes in Vitreous
 Structural changes in Choroid
 Structural changes in Retina

4. WHO IS A GERIATRIC PATIENT
 Senior citizen or Elderly person who is age of 60 years or above.
 The elderly population ( aged 60 years or above ) accounts for
7.4% of total population.

5. GERIATRIC OPTOMETRY
 It is a branch of optometry that deals with the issue and management
relating to primary vision and eye care in elderly population.
 Elderly population is divided into three segments-
Young old ------ 65 to 74 years
Middle old ------ 75 to 84 years
Old Old ------ 85 years or greater
This field is focus on the health care of elderly patient.
The main aim is to promote health by preventing and treating disease and
disabilities in older people

7. STRUCTURAL CHANGES IN THE LID
With age orbicular oculi muscles (which squeeze the lid
shut) decrease in strength.
 Senile Ectropion.
 Spasm of orbicular oculi muscle may cause the lid margin
to turn in ( Entropion).
 Trichiasis resulting in chronic Irritation.
 The lid contain many gland which secrete sebum and
sweat with aging.
Deposition of fat.

8. BLEPHAROCHALASIS
 Blepharochalasis is an inflammation of the eyelid that is characterized
by exacerbations and remissions of eyelid .
 Affects only the upper eyelids, and may be unilateral as well as
bilateral.
 It may occur due to orbital fat which convert into lumps of fat in the
skin of lid under the eyes.
 This often result in the redundancies of skin of the lid called
blepharochalasis.
 It is a normal part of ageing

9. DERMATOCHALASIA
 Defined as an excess of skin in the upper or lower eyelid, also
known as "baggy eyes.
 Dermatochalasis often also have blepharitis a condition caused by
the plugging of glands in the eye that produce lubricating fluid
(meibomian glands).
 Dermatochalasis is caused by a loss of elasticity in the connective
tissue supporting the structure of the front portion of the eyelid.

11. PTOSIS
 It is defined as dropping or falling of the upper or lower eyelid.
 Also called Lazy eyes.
 occurs due to dysfunction of the muscles that raise the eyelid or their nerve supply
(oculomotor nerve for levator palpebrae superioris and sympathetic nerves
for superior tarsal muscle).
 Can affect one eye or both eyes and is more common in the elderly,
 In old age due to decrease in palpebral aperture width by 10 mm at 40 age to 9 mm
by age 80 result In Mechanical Ptosis.
 Result in reduction in superior visual field.

13. ENTROPION
 Inward turning of eyelid.
 The most common type is involutional seen in elder age.
 Mainly effect the lower eyelid.
 It can also be mechanical.
SYMPTOMS -- Trichiasis
Rubbing of eyelashes on cornea
Foreign body sensation
Pain
Diagnoses-- The “SQUEEZE TEST” may be performed. In this patient is asked to close
their eyes forcibly , if entropion present the lid margin invert.

15. ECTROPION
 Outward turning of eyelid margin.
 The most common type is Involutional seen in elderly patient affecting the
lower eyelid.
 Epiphora is chief complain.
 Mild photophobia and irritation due to chronic conjunctivitis.
Diagnoses--- It can be done by “SNAP BACK TEST” in which lid is pulled down with
finger resting on the inferior orbital rim. On release, the lid should snap
back into contact with the globe, if not than the lid is lax.

17. XANTHELESMMA
 There is a creamy yellow lipid deposit near the medial canthus and upper and
lower eyelid.
 Mostly seen in middle age women.
 They represents lipid deposit in histocytes in dermis of skin of lids.
 Associated with diabetes and high cholesterol level.

18. BLEPHARITIS
 inflammation of the eyelid margin.
 Caused by bacterial infection.
 Uncorrected refractive error is also cause this
 It is of two types-- 1- Anterior Blepharitis
2- Posterior Blepharitis
 Symptoms-- Sticky eye lids, fluid discharge, swelling, redness, pain etc.
 Diagnoses is done by using SLIT LAMP and TORCH LIGHT.
 The best way to treat blepharitis is with good eyelid hygiene, including regularly
cleaning the lids and lashes.

19. MADAROSIS
 Loss of eyelashes or eyebrows.
 Madarosis is not a critical or severe condition.
 Symptom - loss of hair from the eyelids, eyebrows, or eyelashes.
Swollen, itchy, red, burning eyelids.
 Causes- 1. Blepharitis an infection of the eyelid.
2. Dermatologic conditions
 Diagnosis- The main diagnosis technique is observing the area

20. POLIOSIS
 Whitening of eyelashes
 Arises due to absence of melanin pigment

21. STRUCTURAL CHANGES IN TEAR FILM
 Tear production by the lacrimal gland may decrease with age.
 Abnormalities of lacrimal system may result in decrease or increase tear production.
 Variety of change occur in tear film with aging.
 Inadequate tear film or function result in unstable tear film.
 Aging cause a decrease in Goblet cell number along with lacrimal gland mass result in
decrease tear production.
 biochemical makeup of tears changes with age such as Lactoferrin and lysozyme conc
are decreased with age.
 Symptoms- dryness, grittiness, burning sensation, blurred vision etc.
 Diagnoses - SCHIRMER TEST are mainly use to test the tear production.

23. STRUCTURAL CHANGES IN CORNEA
 The most important refractive element of eyes.
 Corneal sensitivity decreases with age.
 There is a increase in ATR corneal cylinder with aging.
 Corneal toricity shifts dramatically from youth to old age.
 Aging changes seen in stroma include increased fluorescence and light scatter.

24. ARCUS SENALLIS
 It is an old age syndrome where there is a white, grey, or blue opaque ring in the
corneal margin (peripheral corneal opacity), or white ring in front of the
periphery of the iris
 Peripheral annulus of opacity separated from limbus.
 It Is bilateral.
 Arcus Senallis is common in persons above 60 years or more.
 it may occur due to the increased permeability of blood vessel to lipids.
 Causes - It results from cholesterol deposits
it may occur due to the increased permeability of blood vessel to lipids.

26. VOGT WHITE LIMBAL GIRDLE
 It is a degeneration of cornea.
 Consist of white fine radial lines
 Usually seen in nasal cornea. In this area there is no peripheral clear zone between
the limbus and the cornea.
 It is present in normal eyes in people aged between 40-60 years.
 Present in all patient over 80 years of age.

28. CROCODILE SHAGREEN CORNEA
 Age related change occur in central cornea.
 It is due to change in the collagen lamellae

29. STRUCTURAL CHANGES IN CONJUNCTIVA
 Conjunctiva is a semi transparent non keratinizing mucous membrane.
 Epithelium consist of squamous cells
 With aging there is a reduction in number of goblet cell
 With aging conjunctiva shows a reduction in transparency, a yellowish discoloration,
increased discoloration of fat pads .
 With age number of mucus cell decreases which cause dry eyes.

30. PINGECULA
 It is a degenerative condition.
 It is a yellow white elevation of bulbar conjunctiva at the limbus.
 Degeneration of stromal collagen fibres accompanied by epithelial thining.

31. PTERYGIUM
 Also known as fibrovascular growth.
 It is also a degenerative condition.
 Extend to cornea at 3 o’ clock or 9 o’ clock position
 It result into destruction of Bowman's membrane.
 Pterygium can invade the cornea to the pupillary area and mechanically
block the light path into eyes.
 Also cause distortion of cornea and induce irregular astigmatism.
 Treatment is by surgical removal.

33. STRUCTURAL CHANGES IN THE PUPIL/ IRIS
 Pupil size decreases with aging
 The iris contain two set of muscle that work together to regulate pupil size and
reaction to light.
 With age these muscle weakens, and the pupil becomes smaller, react more
sluggishly to light, and dilates more slowly in dark.
 Person above age of 60 may complain that object are not as bright as outdoor.
 They also experience difficulty when going from a bright light environment to dark
light.
 Hyperpigmentation on iris are also seen in old age patient.

35. STRUCTURAL CHANGES IN CRYSTALLINE
LENS
 The crystalline lens grows continuously throughout the life cycle.
 with ageing the thickness of lens and weight of the lens increase concomitantly.
 Nuclear portion of lens become denser with age and hence increase in R.I.
 Lens of older adult become yellow or yellow brown appearance called Brunescence.
 Light loss as a result of scatter increase significantly with ageing.
 Older people has face problem while driving at night due to disability glare.
 Loss of accommodation is the common problem of lens in old age.
 this arises due to 1- Lenticular sclerosis
2- decrease elasticity of lens capsule
3- decreased zonular contractility.
 Formation of cataract (opacification) due to sun exposure, steroid use, hypertension, diabetes, smoking
etc.

36. Between the age of 40 and 50 years the lens usually
Become so inelastic that close object can no longer be
Brought into focus without the assistance of corrective lens
and this condition is called Presbyopia.

37. STRUCTURAL CHANGES IN CHOROID
 Choroid changes with age.
 Reduced cohroidal blood flow has been suggested by Doppler’s ultrasound
technique.
 Change in Bruch membrane with age are a hallmark of the ageing eye.
 The most obvious sign of ageing in Bruch’s membrane is the accumulation of
deposit waste material probably from the RPE and consist of Lipofuscin.
 Lipofuscin is seen from the age of 45 onwards and is strongly age related.

38. STRUCTURAL CHANGES IN VITREOUS
 The vitreous humor is normally clear, but with age , discrete opacities or
structural changes leading to the general haziness may develop.
 The vitreous undergo liquefaction with ageing and also posterior vitreous
detachment.
 R.I of vitreous with age may account for the problem in the retinoscopy reflex .

39. STRUCTURAL CHANGES IN RETINA
 The retina is difficult to examine in elderly patient because of their small size pupil, increase random eye
movement and iris opacities.
 The retina which seen glister in younger age become duller with age.
 The important are of retina that change with age is RPE and PHOTORECEPTOR CELL.
 Loss of ganglion cell layer.
 Loss of foveal reflex seen with age due to loss of inner limiting membrane.
 Also loss of melanin granule which are antioxidant and are responsible for detoxifying the antioxidant.
 With age the number of photoreceptor cell do changes. Cone number appear fairly stable but parafoveal rods
do reduce by 30%.
 Reduced dark adaptation is seen clearly elder patient due to reduction in rods.
 The optic nerve tend to have less distinct margin and slightly pale.
 In older age macula does not show bright foveal reflex.
 Yellowish white spot (drusen) are seen in macular area.

40. Lipofuscin
Change in Bruch’s membrane

41. Dull retina
Normal retina

42. Dull macula with decreased fovel reflex