2. Primary Care Practitioners
See variety of eye problems
Discuss treatment options
Facilitate referrals
Positioned to explain
optometry's role as
primary eye care providers
10. Space between
cornea and iris
Filled with aqueous
humor produced by
ciliary body
Anterior Chamber
11. Iris gives eye color
2 muscles:
o Dilator—opens
o Sphincter—constricts
Iris
12. Allows light to enter
Enables view to back
of eye and eye health
evaluation
Pupil
13. Located behind iris
Focuses light on
retina
Allows for
accommodation
Normally transparent
Where cataracts form
Lens
14. Primary functions
o Pulls on lens for
accommodation
o Epithelium secretes
aqueous fluid that
fills anterior chamber
Ciliary Body
15. Red Reflex
Light reflection off
retina
Useful for assessing
media clarity
Affected by any
opacity of cornea, lens,
vitreous
White reflex = leukocoria
Refer immediately!
16. Vitreous Humor
Gel-like fluid that
fills back cavity
Serves as support
structure for blood
vessels while eye
formed—before birth
After birth, just
‘hangs out’ in there
Where floaters are located
18. Optic Nerve Head
Collection of nerve
fibers and blood
vessels from retina
Transfers info to
brain’s visual cortex
Slightly yellow-pink
when healthy
White ‘full moon’
appearance can
mean trouble!
19. Optic Nerve Head
Cup is natural
depression in center
of nerve
Cup size varies
between people
Very large cup, or
change in appearance
over time, can
indicate glaucoma
Physiologic Cup
Optic Disc
Optic Nerve
20. Macula
Dense collection
of cone photoreceptors
Fine detail and
color vision
Macular degeneration
affects this area
21. Retinal Vessels
Include arteries and veins
Only place in body
where you can directly
visualize blood vessels
Excellent indicators
of systemic diseases
o HTN
o Diabetes
o High cholesterol
o Carotid disease
22. Peripheral Retina
Can only be evaluated
with dilated pupil
Important to evaluate
periodically to fully
assess eye health
27. Hyperopia
Blurry image on retina
Lens focuses to compensate
Hyperopes often
asymptomatic much
their of lives
Can cause headaches or
eyestrain with extended
reading
These problems can
get worse after age 40
28. Astigmatism
Surface of cornea is
irregular or misshapen
Light focuses at
various points causing
distorted vision
Often combined with
nearsightedness and
farsightedness
31. Turned Eyes - Strabismus
Eye misalignment
o One or both turn
in, out, up or down
Caused by muscle
imbalance
3 Kinds of Strabismus
o Esotropia
o Exotropia
o Hypertropia
33. 3 Types of Esotropia
Infantile (congenital)
o Develops in first 3 months of life
o Surgery usually recommended—
along with vision therapy and glasses
Accommodative
o Usually noted around age 2
o Child typically farsighted
o Focusing to make images clear can
cause eyes to turn inward
o Treated with glasses but
vision therapy may also be needed
34. 3 Types of Esotropia
Partially Accommodative
o Combination of
accommodative dysfunction and
muscle imbalance
o Glasses and vision therapy
won’t completely correct
eye turn
o Surgery may be required
for best binocularity
35. If you see Esotropia
Refer to pediatric
optometrist or
ophthalmologist
Sooner the better for
best chance of good
vision
36. 2. Exotropia
Eye turns outward
Congenital—present
at birth
Surgery usually needed
to re-align
Many exotropias are
intermittent
o May occur when patient is tired or not paying attention
o Concentration can force eyes to re-align
o Vision therapy and/or glasses can help
37. 2. Exotropia
When intermittent
o Brain sometimes receives
info from both eyes
(binocular)
o Less chance of amblyopia
o However, important to be
seen by eyecare provider
when deviation noted
38. 3. Hypertropia
One eye vertically
misaligned
Usually from paresis
of an extra-ocular
muscle
Typically much more
subtle for patient to
describe and provider
to diagnose
39. 2 Types
Congenital
o Most common type
o Patients can compensate for
years by tilting head
o Can be discovered by looking at
childhood photos
40. 2 Types
Acquired
o Trauma—
Extra-ocular muscle ‘trapped’
by orbital fracture
o Vascular infarct—
Systemic diseases that affect
blood supply to nerves can
cause temporary nerve palsy
Diabetes and HTN most
common
Palsies tend to resolve over
weeks or months
o Neurological—
In rare cases a tumor or
aneurysm can cause symptoms
42. Lazy Eye - Amblyopia
Decreased vision
uncorrectable by glasses
or contacts—not due to
eye disease
For some reason, brain
doesn’t fully acknowledge
images seen
43. Lazy Eye - Amblyopia
3 Types of Amblyopia
o Strabismic
o Anisometropic
o Stimulus deprivation
44. 1. Strabismic Amblyopia
One eye deviates from other and
sends conflicting info to brain
Brain doesn’t like to see double—
so “turns off” info from deviated
eye
Results in under developed visual
cortex for that eye
Can usually be reversed or
decreased if treated during first
9 years
Need to visit eyecare provider
ASAP to determine cause
45. Treatment
If caught early,
treatment can teach
brain how to see better
o Vision therapy/patching
o Glasses
o Surgical re-alignment
Early vision screenings
are critical!
46. 2. Anisometropic Amblyopia
Anisometropia—significant
difference in Rx between eyes
Commonly one eye more
farsighted
Farsighted eye works hard to
see clearly—and sometimes
gives up
Brain relies on info from
other eye
47. 2. Anisometropic Amblyopia
If not caught, one eye
won’t learn to see as well
as other
Vision therapy and glasses
are both beneficial
Sooner the better
48. 3. Deprivational Amblyopia
Any opacity in visual
pathway can be devastating
to developing visual system
o Congenital cataracts
o Corneal opacities
o Ptosis (droopy eyelid)
o Other media opacities
50. Common External Ocular
Conditions
Blepharitis
Hordeolum—stye
Preseptal cellulitis
Orbital cellulitis
Pterygium
Corneal ulcer
Conjunctivitis
o Viral “pink eye”
o Adenovirus
o Bacterial
o Allergic
o Hyperacute
o Chlamydial
51. Blepharitis
Inflammation of
eyelids (anterior or
posterior)
Symptoms
o Itching
o Burning
o Crusting
o Dry eye sensation
o Foreign body
sensation
52. Blepharitis
Signs
o Crusts on lid margins
o Thickened, reddened
eyelids
o Plugged or inspisated
meibomian glands
along eyelid
Treatment
o Warm compresses,
10 minutes 1-2 x/day
o Lid scrubs with
diluted baby
shampoo
o Artificial tears
o Erythromycin
ointment at night
54. Hordeolum
Signs
o Raised nodule
protruding out from
or under lid
o Red, swollen lid
o Capped glands at
site of infection
Treatment
o Warm compresses,
BID-TID for 10 mins
o Topical meds don’t
penetrate abscess
o Oral antibiotics if no
response to traditional
treatment
55. Preseptal Cellulitis
Bacterial infection of
eyelid anterior to
orbital septum
Can arise from
o concurrent sinus
infection
o penetrating lid trauma
o dental infection
o hordeolum
o insect bite
56. Preseptal Cellulitis
Signs
o Painful, swollen lid
extending past
orbital rim
o May be unable to
open eye
o No decreased vision,
restricted ocular
motility or proptosis
o White conjunctiva
Treatment
o Amoxicillin
(augmentin) 500 mg
PO TID
o Treat infection
quickly to minimize
risk of orbital
cellulitis
57. Orbital Cellulitis
Serious infection of soft
tissues behind orbital
septum
Can be life-threatening
Causes
o Sinus infection
o Extension of preseptal
cellulitis
o Dental infection
o Penetrating lid injury
o After ocular surgery
58. Orbital Cellulitis
Signs
o Tender, warm
periorbital lid edema
o Proptosis
o Painful
ophthalmoplegia
o Decreased vision
o Severe malaise, fever
and pain
Treatment
o Medical emergency
o Hospitalization with
IV antibiotics
o Consider orbit/head
CT to look for
abscess
o Consult pediatrician
or infectious disease
specialist
59. Preseptal vs. Orbital Cellulitis
Preseptal
o Painful, swollen lid
extending beyond
orbital rim
o Normal vision
o Full EOMs
o White conjunctiva
o No proptosis
o No fever
Orbital
o Painful, swollen lid
that stops at orbital
rim
o Decreased vision
o Restricted ocular
motilities
o Proptosis
o Fever/malaise
61. Pterygium
Signs
o Dry eye
o Irritation
o Redness
o Blurred vision
Management and
Treatment
o UV tint on glasses
o Avoid irritating
environments
o Artificial tears
o Topical vasoconstrictor
or mild steroid
o Surgery
62. Corneal Ulcer
Infection of cornea
o Bacterial
o Fungal
o Acanthamoeba
Causes
o SCL wearer
o Trauma
o Compromised
cornea from pre-
existing condition
63. Corneal Ulcer
Signs
o Pain
o Photophobia
o Blurred vision
o Discharge
o Hypopyon
Treatment:
o Start immediately
Fortified antibiotics
Fluoroquinolones
o Culture may not be
necessary if ulcer is
small
o Must be monitored
daily!
65. Conjunctivitis
Signs
o Irritation
o Burning/stinging
o Watering
o Photophobia
o Pain or foreign body
sensation
o Itching
Discharge
o Watery
o Mucoid
o Mucopurulent
o Purulent
66. 1. Viral Conjunctivitis (pink eye)
Most viral infections are fairly mild
and self-limiting
Signs & Symptoms
o Watering
o Redness
o Photophobia
o Discomfort/foreign body sensation
o Palpable preauricular node
67. 1. Viral Conjunctivitis
Patients often have recent history of URI
Treat symptoms
o Cool compresses
o Artificial tears
o Topical vasoconstrictors or mild anti-
inflammatory
Frequent handwashing
Usually runs course in
1-3 weeks
68. 2. Adenoviral Conjunctivitis
Highly contagious
Most common types
o Pharyngoconjunctival fever (PCF)—
can be caused by adenovirus
types 3, 4 & 7
o Epidemic keratoconjunctivitis (EKC)—
caused most commonly by adenovirus
types 8 & 19
69. 2. Adenoviral Conjunctivitis
Signs
o Watering
o Conjunctival follicles
o Subconjunctival
hemorrhages
o Chemosis
o Pseudomembranes
o Lymphadenopathy
o Keratitis
70. 3. Bacterial Conjunctivitis
Common, especially in
children
Usually self-limiting
Signs/symptoms
o Acute redness
o Burning/grittiness
o Mucopurulent
discharge
o Lids stuck shut in
morning
71. 3. Bacterial Conjunctivitis
Common organisms: S. aureus, S. epidermidis,
S. pneumonia, H. influenza (esp. peds)
Usually self-limiting
But important to use broad-spectrum antibiotic
until discharge cleared (5-7 days)
Antibiotics
o Tobramycin
o Polytrim—polymyxin + trimethoprim
o Fluoroquinolones like
Ocuflox or Ciloxan
72. 5. Hyperacute Conjunctivitis
Cause
o Sexually transmitted
o Neisseria gonorrhoeae
Signs
o Swollen, tender lids
o Copious purulent
discharge
o Significant conjunctival
redness and swelling
o Lymphadenopathy
73. 5. Hyperacute Conjunctivitis
Treatment
o Lavage
o Take scrapings for culture and sensitivity
testing
o Patients usually hospitalized and started on
IM Ceftriaxone
o Topical antibiotics not effective
74. 6. Chlamydial Conjunctivitis
Cause
o Sexually transmitted ocular infection
Signs
o Patients typically have mild but persistent
follicular conjunctivitis non respondent to
topical antibiotics
o Any conjunctivitis lasting longer than 3
weeks despite therapy should be suspect
75. 6. Chlamydial Conjunctivitis
Patients can have concomitant genital
infection (could be asymptomatic)
o Refer for work-up if necessary
Treatment
o Oral—Azithromycin 1g, doxycycline 100mg
bid x 7 days, erythromycin 500mg qid x 7
days. Also need to tx partners!
o Topical—erythromycin, tetracycline, or
sulfacetamide ung bid-tid x 2-3 weeks
76. 4. Allergic Conjunctivitis
Can be seasonal or
acute
Signs/symptoms
o Itching is hallmark
o Conjunctival redness
o Chemosis
o Lid edema
o Thin, watery discharge
o No palpable preauricular
nodes
77. 4. Allergic Conjunctivitis
Treatment
o Eliminate offending agent
o If mild
Cool compresses
Artificial tears/vasoconstrictors
o If moderate or severe
Topical antihistamine/mast-cell stabilizer (ie. Patanol)
Topical NSAID
Topical steroid
Oral antihistamine
80. Glaucoma
Progressive loss of Nerve
fiber layer at ONH
(increased cupping)
Can lead to peripheral
visual field loss
Sometimes caused by
elevated intraocular
pressure
81. Glaucoma
Pathophysiology of progression not well
understood
Increased IOP
o Damages nerves as they leave eye, causing cell death
o Reduces blood supply to ONH, indirectly destroying
cells by starving them of oxygen and nutrients
Abnormal levels of neurotransmitter (glutamate)
cause cells to die off
82. Glaucoma
Monitoring
o IOP
o ONH appearance
o Visual field testing
o Newer methods include
HRT (Heidelberg Retinal
Tomograph II)
GDx Nerve Fiber Analyzer
Genetic testing
83. Glaucoma
IOP reduction is mainstay
of treatment
Decrease aqueous production
o B-blockers
o Alpha-agonists
o Carbonic anhydrase inhibitors
Increase uveoscleral outflow
o prostaglandin analogs
84. Cataract
Clouding of natural
lens
Patients experience
o Blurred/dim vision
o Glare, especially
at night
o Halos around lights
o Doubling or ghost
images of objects
85. Etiology
Everyone develops them if
they live long enough!
Types of cataracts
o Age-related—senile
o Trauma—blunt or perforating
injury
o Systemic conditions—diabetes
o Medications—steroids
86. Main Types
Age-related
o Nuclear sclerotic
o Cortical spokes
o Posterior sub-
capsular
o Mature cataract
87. Treatment
Surgery
When loss of vision interferes
with daily activities
o Driving
o Reading
o Hobbies
88. Outpatient Surgery
5-10 minutes with skilled
surgeon
o Incision through cornea
or sclera under upper lid
o Circular tear in anterior
capsule
o Lens broken up with ultra
sound instrument
o Fragments suctioned out
o Lens implant inserted
89. Secondary Cataract
Cloudiness forms on
posterior capsule after
cataract surgery
30-50% of patients
YAG laser used to
create opening
Vision quickly restored
91. Pathophysiology
Causes not well understood
Theorized link to
o UV light exposure
o subsequent release of free
radicals
o oxidation within retinal tissues
Another theory—areas of
decreased vascular perfusion
in retina, lead to cell death
92. Two Types
Dry (atrophic)
o 90% of those diagnosed
Wet (exudative)
o 10% of those diagnosed
o But accounts for 90% of
blindness caused by
disease
93. Symptoms
None
Blurred vision
Metamorphopsia—
straight lines appear
wavy or distorted
Scotomas—missing
areas in vision
94. Dry Form
Slow, progressive loss of
central vision
Breakdown of underlying
retinal tissues, resulting in
mottling or clumping of
normal pigment
Drusen begin to accumulate
Geographic atrophy can also
occur
95. Wet Form
Can quickly degrade
central vision
Break in underlying
tissues allows new blood
vessels or fluid to come
through
New blood vessels are
weak so frequently break
and bleed
96. Treatment for Dry Form
Regular eye exams
Careful discussion regarding
family history
Education
UV protection
Antioxidants
o AREDS
o PreserVision
Stop smoking
97. Treatment for Wet Form
Refer to retinal specialist
Photocoagulation
Photo-dynamic therapy
(PDT)
Submacular surgery
Macular translocation
Anti-angiogenic drug
therapy
98. Retinal Detachment
Several types
o Rhegmatogenous—
caused by break in retina
o Exudative—caused by
fluid accumulation
beneath retina
o Tractional—proliferative
fibrovascular vitreal
strands
99. Signs & Symptoms
Flashing lights in peripheral vision
New floaters—black spots or ‘cobwebs’
Peripheral scotoma—dark shadow or
“curtain” blocking vision
100. Emergency
Patients with these
symptoms must see eyecare
provider immediately
Additional risk factors
o Highly nearsighted
o Diabetic
o Recent trauma/injury
101. Treatment
Laser photocoagulation
or cryotherapy
Pneumatic retinopexy—
gas bubble to
tamponade retina back
into place
Scleral buckle
Silicone oil
104. Progression
Over time, elevated and fluctuating blood sugar
damages vessel walls
Vessels leak fluid, lipids or blood into retina
New vessels grow to bring more oxygen to
retina
