This document appears to be a slide compilation for ophthalmologists covering various topics in ophthalmology. It includes an introduction and acknowledgements section, as well as slides on topics like the spirit of Bali, visual functions and their examination, equipment used in examinations like the slit lamp and optotypes, embryology of ocular tissues, and advanced examination equipment and techniques. The compilation is meant as an educational reference for ophthalmologists.

1. 2014’s
2014’
MataPedia
M t P di
TM
for Ophthalmologist
(Slides Compilation)
Gede Pardianto
Sumatera Eye Center
Medan Indonesia
M d -I d
i

2. The information provided within this book is for educational and
scientific purposes only and it should not be construed as
commercial advice.
Author thanks all of our teachers, fellow ophthalmologists,
publishers, sponsors, and all manufacturers for their works those
all being cited in this handout book.
FREE COPY
NOT FOR SALE
2

3. • Being an ophthalmologist doesn’t mean you can
be the rich person or you can do everything. As
a little light, the sincerity you can perform in your
meaningful life is giving a humble tribute to
humanity by serving the people against
blindness.
Gede Pardianto
May 20, 2008
3

4. Gede Pardianto
•
Graduate from
–
–
–
•
Office
–
–
–
•
Doctor of Medicine  Airlangga University
Ophthalmologist  Airlangga University
Doctor of Philosophy  Sumatera Utara University
p y
y
Dr. Komang Makes Hospital
Sumatera Eye Center
Sumatera Utara University, Medical School
y
Member of
–
–
–
–
–
–
–
–
IOA
InaSCRS
APACRS
ESCRS
ASCRS
EuCornea
AAO
ICO
4

5. Here are awarded to the souls
of the valiant who gave their
lives in the service of their
country and who sleep in
unknown graves…
All Indonesian heroes…
Some there be which have no
sepulchre.
Airlangga University - Medical School 1913
But their name liveth for
evermore.
Dedicated to 100 Years of the Spirit of Nationality 1908 – 2008
y
y
and 1 Century of Medical Education in Surabaya 1913 – 2013
5

6. Basic and Latest
Spirit of Bali
Only one on earth

7. Visual functions including :
•
•
•
•
•
•
Visual acuity
Visual fi ld
Vi
l field
Color vision
Dark adaptation
Contrast sensitivity
Binocular single vision
7

8. Examination
Which one goes wrong ?
8

9. Examination : Finger
•
•
•
•
Finger counting
Confrontation t t
C f t ti test
Digital tonometry
Open the eye lid
9

10. Confrontation Visual Field testing
• Technique
– Examiner sated about 1 meter opposite patient
– Patient directed to cover one eye and fixate on
y
examiner’s opposite or nose
– Patient asked whether examiner’s entire face is
visible or specific portions are missing
– Patient asked to identify a target of 1,2 or 5 presented
at the midpoint of each of four q
p
quadrants in a p
plane
halfway between the patient and examiner
American Academy of Ophthalmology
10

11. Confrontation Visual Field testing
– Patient is asked to add total number of fingers
g
presented in opposing quadrants (double
simultaneous stimulation)
– A h i uncooperative, sedated i t b t d or very
Aphasic,
ti
d t d intubated
young patient can use finger mimicry, pointing, visual
tracking or reflex blink to respond and allow gross
appraisal of VF integrity. If a patient saccades to a
visual stimulus in a given quadrant, the visual field
area can be considered to be relatively intact
– Check patient’s ability to distinguish color of red
object when looking directly at it
American Academy of Ophthalmology
11

12. Examination : At least
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Optotypes charts
Phoropter and/or Trial lens and frame
Torch
Slit lamp
Jaegger’s reading chart
Lensometer
L
t
Color test  Ischihara’s pseudoisochromatic plates
Tonometer
Fluorescein for Defect and Siedel’s test
Siedel s
Ophthalmoscope
Amsler grid and Red dots
Ruler
Placido disc keratoscope
Whatman No. 41 paper by 5x30mm for Schirmer test
12

13. Examination : Phoropter
• A device containing different lenses used
for refraction of the eye during sight testing
• The instrument used to measure refractive
status of the eyes.
• It contains many lenses which are then
changed in front of the eyes while the
p
patient is looking at an eye chart.
g
y
• This is when the doctor usually asks,
"Which is better, one or two?"
13

14. Examination : Optotypes
• High contrast visual acuity
– Snellen chart
– Bailey Lovie chart
Bailey-Lovie
• Low contrast visual acuity
– Reagan chart
14

15. Examination : Torch
• Light perception
• Projection of Illumination / Light projection
• Macula Photostress Recovery Test
–
–
–
–
–
Measure visual acuity first
Place torch 2 cm from eye
10 seconds illumination
Measure visual acuity again
Record th ti
R
d the time needed f recovery b k t previous visual
d d for
back to
i
i
l
acuity
– 55 seconds  normal
– Larger (90 180)  macular dysfunction
(90-180)
• Pupil examination
• Crude anatomical screening
Deborah Pavan-Langston
15

16. Examination : Slit lamp
• How to adjust
– Up and down
– Horizontal move
– Pupil distance
– Light
– Angle
– Slit maneuver and rotation
d t ti
– Color option
16

17. Slitlamp examination
anterior
cornea
p
posterior
cornea
anterior
lens
limbus
anterior
iris
17

18. Examination : Ophthalmoscope
• How to use :
– Power switch
– Size of illumination
– Diopter
– Color  Red free
– Placido disc  Crude
18

19. Dilating drops
• Mydriatic
– Phenylephrine 2.5%, 10%  20 min  3 hours
• Cycloplegics
–
–
–
–
–
Tropicamide 0.5%, 1%  20-30 min  3-6 hours
Cyclopentolate 0.5%, 1%, 2%  20-45 min  24 hours
Homatropine 2%, 5%  20-90 min  2-3 days
Scopolamine 0.25%  20-45 min  4-7 days
Atropine 0.5%, 1%, 2%  30-40 min  1-2 week(s)
Will’s Eye Manual, 2004
19

20. Examination : Amsler grid
• Boldly cross-hatched paper
• Will b mandatory i :
be
d t
in
– Metamorphopsia
– Central scotoma
– Discomfort “perfect” vision
– Color vision disturbance
20

21. Amsler grid
21

22. 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 may find it convenient to attach the grid to a wall at
eye level and stand 12 inches to 14 inches away
(comfortable reading distance)
• If you wear glasses, keep them on. If you wear bifocals,
use the bottom or reading portion of the lens
• Cover one eye completely
• Stare with your other eye at the central dot on the grid.
While doing this, observe the pattern of vertical and
horizontal lines
• Repeat the test with the other eye
22

23. Schirmer test I
•
•
•
•
•
•
•
•
Whatman No. 41 paper
p p
Filter strip 5x30mm, folded 5mm
Dimly light room
Place l
Pl
lower palpebral conjunctiva at it l t l 1/3
l b l
j
ti
t its lateral
Eye kept open and look upward
Blinking is permissible
Remove after 5 minutes
10-30 mm wet  normal or basal secretion may be low
but compensated for by reflect secretion
• Less than 5 mm wet  repeated  hyposecretion of
basic tearing
Deborah Pavan-Langston, 2008
23

24. Examination : Add 1
•
•
•
•
•
•
•
•
•
•
•
76 or 90 D lens
Goldmann’s 3 mirrors lens
Hruby lens
Indirect hth l
I di t ophthalomoscopy
Manual or automatic keratometry
Standard A-Scan biometry
A Scan
Retinometer
WFDT
Prisms
Streak retinoscopy
Hertel s
Hertel’s exophthalmometer
24

25. Examination : Goldmann s 3 Mirrors
Goldmann’s
•
•
•
•
Central
Oval
O l
Trapezium
Square
: Posterior pole
:G i
Gonioscopy
: Equator
: Periphery
25

26. Examination : Add 2
• Visual field test 
–
–
–
–
Bjerrum’s tangent screen
Goldmann’s perimetry
SAP, SWAP, FDT, HPRP
For AMD  Preferential Hyperacuity Perimeter (PHP) 
Foresee PHP (Notal Vision)
– For Retina  Micro Perimeter MP-1 (Nidek)
• Advanced biometry
– Partial Co e e ce Laser Interferometer
a t a Coherence ase te e o ete
– Non-contact Optical Coherence Biometry
– Laser Interferometry Technique
• Advanced High Definition AB-Scan USG
g
– Aviso (Quantel Medical)
– VuMax II (Sonomed)
• Standard digital fundus camera with FFA
g
– VisuCam (Carl Zeiss Meditec AG), AFC-330 (NIDEK)
26

27. Visual Field Analyzers
FDT Perimetry
Octopus 101
Perimetry
Goldmann
Perimetry
Humphrey
Perimetry
27

28. Examination : Add 2
• Advanced anterior examination
– Pachy-Autorefrakto-Keratometer
• PARK 1 (OCULUS Optikgeräte GmbH)
• Galilei G4 (Ziemer)  Placido and Dual Scheimpflug
– Anterior Optical Coherence Tomography
• Visante OCT (Carl Zeiss Meditec AG)
• SL OCT (Heidelberg Engineering)
• TOMEY SS-1000 (TOMEY GmbH)
– Scheimpflug Camera Pentacam  Keratometry Corneal
Keratometry,
topography, Pachimetry, Corneal wavefront, AC and angle
analyzer, Lens analyzer, Phakic IOL and Post refractive surgery
biometry
y
• Pentacam HR (OCULUS Optikgeräte GmbH)
28

29. Examination : Add 2
• Advanced anterior examination
– Keratograph  Oculus Keratograph (OCULUS
Optikgeräte GmbH)
– E d th li
Endothelium S
Specular Mi
l Microscope
– Advanced High Definition Ultrasound Biomicroscopy
(
(UBM)
)
• P60 UltrasoudBioMicroscope (Paradigm)
• Aviso (Quantel Medical)
• VuMax (Sonomed)
– Very high frequency (VHF) ultrasound eye scanner 
Artemis (ArcScan, Inc)
– HRT3 with Cornea Module (Heidelberg Engineering)
29

30. Advanced anterior examination
Artemis (ArcScan, Inc)
P60 UltrasoudBioMicroscope
(Paradigm)
Visante OCT (Carl Zeiss Meditec AG)
Pentacam HR
(OCULUS
Optikgeräte GmbH)
30

31. Examination : Add 2
• Advanced posterior examination
– Posterior Optical Coherence Tomography
• St t OCT (C l Z i M dit AG)
Stratus
(Carl Zeiss Meditec
• 3D OCT 2000 FA Plus Swept-Source SS OCT and
DRI (TopCon)
( p
)
• 3D OCT-1 Maestro OCT (TopCon)
• RS3000 Advance (Nidek)
• RTV FD OCT (O t
RTVue
(Optovue)
)
• High Definition Cirrus + SmartCube HD OCT (Carl
)
Zeiss Meditec AG)
• SOCT Copernicus (Reichert)
• HRA OCT Spectralis (Heidelberg Engineering)
• E i P di t i SDOCT (bi ti
Envisu Pediatric
(bioptigen)
)
31

32. Examination : Add 2
• Advanced posterior examination
– Scanning Laser Ophthalmoscopy
• OCT-SLO (Opko Instrumentation)
• O t Ultra Widefield I
Optos Ult Wid fi ld Imaging S t
i System (O t )
(Optos)
– Scanning Laser Polarimetry
• GDxVVC  Glaucoma Diagnosis - Variable
g
Corneal Compensation (Carl Zeiss Meditec AG)
– Confocal Scanning Laser Tomography
3
e de be g et a o og ap y
• HRT3  Heidelberg Retinal Tomography
(Heidelberg Engineering)
32

33. Stratus OCT (Carl Zeiss Meditec AG)
RTVue FD OCT (Optovue)
HRA-OCT Spectralis
(Heidelberg Engineering)
HRT3 (Heidelberg Engineering)
GDxVCC (Carl Zeiss Meditec AG)
Cirrus HD OCT
(Carl Zeiss Meditec AG)
33

34. Examination : Add 2
• Pediatric visual examination
– Pictures cards  Allen card
– Letter  HOTV
– Matching games  Lea symbols
• Binocular vision test
– Titmus, TNO, Lang, Madox’s Rod,
– Bargolini striated test
– Hering-Bielschowsky afterimage test
• Al f t t
Also for teatment 
t
– Synophtophore
– Holme’s stereoscope
• H
Hess S
Screen
• ERG and EOG
• Visual Evoked Potential (VEP)
34

35. Contrast sensitivity tester
• Aberrometry
• Glare
– Letter  Pelli-Robson Chart
Pelli Robson
– Grating 
•
•
•
•
•
Functional Acuity Contrast Test (FACT) Chart
Contrast Sensitivity Tester 1800
Landolt-C based Miller Nadler Glare Tester
Frankfurt-Freiburg Contrast and Acuity Test System (FF-CATS)
Grating-based Charts CSV-1000 (Vector Vision)
– Scotopic testing  lower than 0.032 cd/m
0 032 cd/m²
• Rodenstock Nytometer (Rodenstock)
• Mesoptometer (Oculus Optikgeräte GmbH)
• Scatter
– Van den Berg Stray Lightmeter
• Haloes
– Tomey G a e a d Halo So t a e ( o ey)
o ey Glare and a o Software (Tomey)
Kohnen T, Koch DD, 2005
35

36. Examination equipment
•
•
•
•
•
•
•
•
Well accepted
pp
Well approved
Well proven
Easy to learn its manual
Easy to use
Easy and comfortable for patient
Easy to make accurate and reliable interpretation
Reproducible
36

37. EMBRIOLOGY
The Marshall
dr. Norman Tagor Lubis, Sp.M
37

38. American Academy of Ophthalmology
Neuroectoderm
-Neuresonsory retina
-Retinal p g e t ep t e u
et a pigment epithelium
-Pigmented ciliary epithelium
-Nonpidmented ciliary epithelium
-Pigmented iris epithelium
-Sphincter and dilator muscles of iris
-Optic nerve, axons, and glia
-Vitreous
DERIVATIVES
OF
EMBRYONIC
TISSUES :
ECTODERM
Cranial Neural Crest cells
-Corneal stroma and endothelium
-Trabecular meshwork
-Sheaths and tendons of extraocular muscles
Sheaths
-Connective tissues of iris
-Ciliary muscles
-Choroidal stroma
-Melanocytes (uveal and ephitelial)
g
p
-Meningeal sheaths of the optic nerve
-Schwann cells of ciliary nervers
-Ciliary ganglion
-All midline and enferior orbital bones, as well as part of orbital roof and lateral rim
-Cartilage
-Connective tissues of orbit
-Muscular l
M
l layer and connective ti
d
ti tissues sheaths of all ocular and orbital vessels
h th f ll
l
d bit l
l
Surface Ectoderm
-Ephitelium, glands, cilia of skin of eyelids and caruncle
-Conjuntivital ephiyelium
-Lens
-Lacrimal glan
-Lacrimal drainage system
-Vitreous
38

39. DERIVATIVES
OF
EMBRYONIC
TISSUES :
MESODERM
• Fibers of extra ocular
muscles
• Endothelial lining of all
orbital and ocular blood
vessels
l
• Temporal portion of sclera
• Vitreous
American Academy of Ophthalmology
39

40. American Academy of Ophthalmology
22 days Optic primordium appears in neural folds (1 5-3 0 mm)
(1.5-3.0 mm).
25 days Optic vesicle evaginates. Neural crest cells migrate to surround vesicle
28 days Vesicle induces lens placode.
Second Invagination of optic and lens vesicles.
month Hyaloid artery fills embryonic fissure.
Closure of embryonic fissure begins.
Pigment granules appear in retinal pigment epithelium
epithelium.
Primordial of lateral rectus and superior oblique muscles grow anteriorly
Eyelid folds appear.
Retinal differentiation begins with nuclear and marginal zones.
Migration f ti l ll begins.
Mi ti of retinal cells b i
Neural crest of corneal endothelium migrate centrally.
Corneal stroma follows.
y
Cavity of lens vesicle is obliterated.
Secondary vitreous surrounds hyaloid system.
Choroidal vasculature develops.
Axons from ganglion cells migrate to optic nerve.
Glial lamina cribrosa forms
forms.
Bruch’s membrane appears.
40
.

41. Third
Precursors of rods and cones differentiate.
month Anterior rim of optic vesicle grows forward
Ciliary body starts to develop.
Sclera condenses.
Vortex veins pierce sclera.
Eyelid folds meet and fuse.
Fourth Retinal vessels grow into nerve fiber layer near optic disc.
month Choroidal vessels form layers.
Iris t
I i stroma is vascularized.
i
l i d
Eyelids begin to separate.
Sixth
Ganglion cells thicken in macula.
g
month recurrent arterial branches join the choroidal vessels.
Dilator muscle of iris forms.
Seventh Outer segments of photoreceptors differentiate
differentiate.
month Central fovea starts to thin.
Fibrous lamina cribrosa forms.
Chorodial melanocytes produce pigment.
Circular muscle forms in ciliary body
American Academy of Ophthalmology
41

43. Oculoplastic
43

44. Eye lid layer
y
y
• Anterior lamellar
– Skin and subcutaneus tissue
– Muscles of protraction  Ocular orbicular muscle
• Medial lamellar
– O bit l septum
Orbital
t
– Orbital fat
– Muscles of retraction
• Palpebral levator muscle
• Muller’s muscle
• Posterior lamellar
– Tarsus
– Conjunctiva
American Academy of Ophthalmology
44

45. OP : Ptosis
1. PSEUDOPTOSIS
2. CONGENITAL
3. ACUIRED
–
MYOGENIC
•
BLEPHAROPHIMOSIS SYNDROME
•
MYASTHENIA GRAVIS
•
PROGRESSIVE EXTERNAL
•
OPHTHALMOPLEGIA
–
NEUROGENIC PTOSIS
•
HORNER’S SYNDROME
•
MARCUS GUNN JAW WINKING
•
THIRD NERVE PALSY
•
BOTULISM
•
CEREBRAL PTOSIS
–
APONEUROTIC PTOSIS
•
INVOLUTIONAL PTOSIS
•
POST CATARACT SURGERY
•
POST EYELID TRAUMA
•
POST EYELID OEDEMA
•
POST CONTACT LENS WEAR
–
MECHANICAL PTOSIS
•
EYELID TUMOURS
•
ORBITAL LESIONS
•
CICATRIZING CONJUNCTIVAL DISORDERS
•
ANOPHTHALMOS
45

46. Diagnostic keys
g
y
•
•
•
•
•
•
Levator Function
Margin reflex distance (MRD)
Margin limbal distance (
g
(MLD)
)
Inter palpebral fissure
Lid lag
Bell’s phenomenon  Eye lid closing
failure without moving eye ball upward or
outward at the SAME time
• Ocular motility
46

47. Levator function
• The most practical measure of the strength of the
levator muscle
• Excursion of the upper lid from extreme down-gaze
to extreme up-gaze
• Normally 15 mm
47

48. 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 f
from th corneal
the
l
light
• MRD 2 = distance of the
lower eye lid from the
corneal light reflex
48

49. 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 mm
– Women  8-10 mm, Asia  7-8 mm
• A weak levator muscle  creates less pull
on the skin the crease is weak
• MLD  Normal 9-10 mm
49

50. System for Ptosis surgery
Levator function
> 10 mm
< 10 mm
Degree of ptosis
Levator function
< 2 mm
> 2 mm
> 2 mm
< 4 mm
Fasanella
servat
Aponeurosis
surgery
Levator
resection
Brow
suspension
Collin JRO, 1989
50

51. System for myogenic ptosis
Collin JRO, 1989
51

52. Collin JRO, 1989
52

53. Collin JRO, 1989
53

54. Collin JRO, 1989
54

55. 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 undermine
dull d
i
Find the white fascia
Take 3 X 1.5 cm of fascia
Suture the edge of fascia
Suture sub cutan and skin
55

56. OP : Entropion
CLASSIFICATION :
–C
Congenital
it l
• Entropion
• Epiblepharon
– Acquired :
• Involutional
• Spastic
y
• Cycatrical
56

57. Entropion : Involutional
• Overriding of lower lid protractor muscle
• Horizontal eye lid laxity  lateral and
medial canthus ligament
• Disinsertion or weakness of lower lid
retractor muscle
t t
l
• Fat atrophy enophthalmos
• Anteriorly prolapse of orbital fat
57

58. Involutional Entropion : Examination
• Horizontal laxity
– Pi h / Distraction t t
Pinch Di t ti test
– Snap back test
• Medial canthal laxity
• Lateral canthal laxity
y
• Vertical laxity  Retractor dehisence
58

59. Pinch / Distraction test
• Distant between globe and lower lid
g
pull
margin after full lower lid p out
• None  5 mm
• Mild  5 7 mm
5-7
• Moderate  10-12 mm
• Severe  more than 12 mm
59

60. Snap back test
• Dynamic test  Pull downward lower lid
margin then rapidly released
• Normal  Lid margin back on its position
spontaneous without blinking
t
ith t bli ki
• Laxity  Not spontaneous back on
position
60

61. Medial canthal laxity
• Lateral distraction test  Position shift of
inferior lacrimal punctum
• Normal  The punctum must be stable on
semilunar plica while pulled to lateral
– 1 2 mm shift i youth
1-2
hift in
th
– 3-4 mm shift in elderly
• If any greater position shift  Laxity
61

62. Medial canthal laxity
0
1
2
3
4
5
6
Grade of Lancrimal punctum position shift
62

63. Cycatrical Entropion
Pathophysiology
p y
gy
• Cycatric at posterior lamellar  Posterior
lamellar shortening  lid margin inversion
to the globe  Entropion  Trichiasis
63

64. System for upper lid entropion
Lid closure possible?
Yes
No
Keratinisation of marginal
tarso-conjunctiva?
Corneal graft considered?
Yes
Lashes abrading
cornea?
Rotation of
terminal
tarsus
No
Posterior
lamellar
graft
Yes
No
Tarsal
excision
No
Yes
Anterior lamellar
reposition
Tarsus thickened?
Yes
No
Tarsal wedge resection
Lamellar division +/- MM graft
Collin JRO, 1989
64

65. Collin JRO, 1989
65

66. Congenital Entropion : Surgery
• Congenital epiblepharon
– Could be disappear by age
– If there any punctate keratopathy Tarsal
fixation
66

67. Involutional Entropion : Surgery
• Without lid laxity
– Everting suture
g
– Wies procedures
• With lid laxity
– Wies procedures with tarsal strip
67

68. Cycatrical Entropion : Surgery
• Mild to Moderate
– Anterior lamellar reposition (ALR)
– Tarsotomy
• S
Severe
– Posterior lamellar graft
– Terminal tarsus rotation
68

69. OP : Ectropion
CLASSIFICATION :
– Congenital
– Acquired :
• Involutional
• Paralytic
• Mechanical
• Cycatrical
69

70. Ectropion : Principal surgery
• Laxity
– Tarsal strip
– Pentagonal excision  Medial Canthal
Medial, Canthal,
Lateral
– Medial canthus ligament shortening
• Cycatrix
– Ski graft
Skin
ft
70

71. System of acquired
ectropion
p
Shortage of skin?
No
Yes
Normal eyelid closure?
Cicatricial ectropion
Yes
Localized defect?
No
Paralytic t i
P l ti ectropion
Yes
No
Z - plasty
Skin
replacement
Medial canthal tendom laxity?
Yes
Y
No
N
Lump in lid
Medial ectropion only?
Yes
No
Involutional
ectropion
Mechanical
ectropion
t i
Medical canthal
resection
No
Yes
Medical canthoplasty
+ lat canth. sling
lat. canth
Medical
canthoplasty
Ectropion mainly medial?
Collin JRO, 1989
Yes
No
Horizontal lid laxity?
Exess skin?
No
Horizontal lid
shortening
h t i
Yes
Horiz .lid short. +
blepharoplasty
bl h
l t
No
Yes
Excision of
diamond of
tarso-conjunctiva
t
j
ti
Med.canth. tendom lax?
No
Lazy - T
Yes
Med.canth. tendom
placation or resection
71

72. Collin JRO, 1989
72

73. OP : Trichiasis
• Cilia emerge from their normal anterior
lamellar location
• Associated with cicatrizing processes of
the conjunctiva
73

74. OP : Blepharospasme
• Eye lid squeezing disorders
• L
Long standing  association with :
t di
i ti
ith
– Eye lid and brow ptosis
– Dermatochalasis
– Entropion
– Canthal tendon abnormalities
74

75. OP : Blepharophimosis
- G
Generalized narrowing of the palpebral
li d
i
f th
l b l
fissure
- A CONGENITAL ANOMALY
- EPICANTHUS INVERSUS
- MICROBLEPHARIA PTOSIS AND
- VERTICAL STRETCHING OF THE BONY ORBIT
75

76. COLOBOMA PALPEBRA or
BLEPHAROSCHIZIS
• FULL THICKNESS DEFECTS OF THE EYELIDS
• RARE. UNILATERAL OR BILATERAL
• THE CONFIGURATION  TRIANGULAR OR
QUADRILATERAL
• THE CORNEA EXPOSE  CORNEAL OPACITY
• THE RISKS ARE GREAT INVOLVES THE CENTER
OF THE LID
76

77. OP : Blepharochalasis
p
• Thin and wrinkled eyelid skin
• Familial variant of angioneurotic edema
• Idiopathic episodes of inflammatory edema of
the eyelid
• Most frequently in young females
• Younger patient than dermatochalasis
• Different with Dermatochalasis 
• Redundancy of eyelid skin
• Often associated with orbital fat protrusion or prolapse
• Upper eye lid  indistinct or lower than normal eyelid crease
American Academy of Ophthalmology
77

78. Contracted sockets
• Causes of
– Radiation
– Extrusion of an enucleation implant
– Severe initial injury
– Poor surgical technique
– Multiple socket operations
–P l
Prolonged periods of conformer or prothesis
d
i d f
f
th i
removal
American Academy of Ophthalmology
78

79. Collin JRO, 1989
79

80. Collin JRO, 1989
80

85. Prof. dr. Mardiono Marsetio, Sp.M(K)
and
Prof. dr. Wisnujono Soewono, Sp.M(K)
Ocular surface
85

86. Tear film : Functions
• Maintains optical clear for cornea
• Moistening, lubricating and protecting
surface of conjunctiva and cornea
• Inhibits microorganism growth by
mechanism processes and anti-microbial
h i
d ti i bi l
actions
• Feeding the cornea
Vaughn GD, 2000
86

87. Tear film : Layers
y
•
Monomolecular lipid layer
–
–
–
–
•
Superficial
Origin from Meibomian glands
Inhibits evaporation
Closed palpebra  Water-tight barrier
Aqueous layer
– Origin from major and minor lacrimal glands
– Water soluble salts and proteins
•
Mucin layer
– Secreted principally by conjunctival goblet cells
– Glycoprotein  coating conjunctiva and cornea
– Absorbed by hydrophobic corneal epthelial cells membrane  on
microvilio
– Normally on 15-45 seconds of Break-up time test
– Abnormally on less than 10 seconds of Break-up time test
Vaughn GD, 2000
87

88. Tear film : Formations
•
•
•
•
•
•
Thickness  7-10 µm
7 10
Volume  7 + 2 µL each eye
pH  7 35  vary from 5 20 8 35
7.35
5.20-8.35
Isotonic  295-309 m osmol/L
Albumin
Alb i  60% t t l protein
total
t i
Defence mechanism by  Lisozym, Ig A,
Ig
I G and Ig E
dI
Vaughn GD, 2000
88

89. Tear dynamics
• Tear volume is 10 µ L or less
• The maximum volume of fluid that can be contained in
the “cul-de sac” without overflow is 30 µL.
• Th eye d
The
drop volume i approximately 40 µL
l
is
i
l
L
• The excess fluid instilled is rapidly removed by spillage
j
from the conjunctiva sac  until the tear fluid returns to
its original volume
• The reflex tearing after the instillation of an irritating drug
may produce up to 400 µL excess tears
tears.
• Dilution of 5–50 fold usually occurs in the first 2 minutes,
depending on the irritating power of the substance
Cornea, 2002
89

90. Ocular surface : Hyperemia
• Conjunctival
j
• Corneal
• Scleral
90

91. Ocular surface : Red eye
•
•
•
•
Conjunctivitis
Uveitis
Keratitis
K titi
Glaucoma
91

92. Acute
Conjunctivitis
Acute Iritis
Acute
Glaucoma
Acute
Keratitis
Incidence
++
+
+/-
+
Secret
++
-
-
+
VA
-
+/-
++
+
Pain
-
+
++
+/++
Injection
Diffuse, to
fornices
Circum cornea
Circum cornea
Circum cornea
Cornea
C
Clear
Cl
Usually clear
U
ll l
Cloudy
Cl d
Clearance
Cl
change
Pupil
Normal
Small
Oval dilated
Normal or Small
Light response
Normal
Decrease
None
Normal
IOP
Normal
Normal
Increase
Normal
Organism +
No organism
No organism
Only in ulcers
Swap
92

93. Sign
Injection
Hemorrhage
Chemosis
Secret
Pseudo
membrane
Bacterial
Viral
Allergic
Toxic
Trachoma
Marked
Moderate
Mild/ Moderate
Mild/ Moderate
Moderate
+
+
-
-
-
++
+/-
++
+/-
+/-
Purulent
Scant/
Watery
String/ White
-
Scant
+/-
+/-
-
-
-
Streptococcus/
Corynebacterium
Papillae
+/-
-
+
-
-
Follicles
-
+
-
+
+
(Medication)
Peri auricular
node
+
++
-
-
+/-
Pannus
-
-
-
-
+
(Except
Vernal)
93

94. Staining : Gram
g
• Older technique
–
–
–
–
–
3 seconds of Carbol Gentian Violet on fixated object glass
¾ seconds Lugol solution
1 second 90% Alcohol
Wash by water
y
3 seconds Watery Fuhcin
• New technique
q
–
–
–
–
–
–
–
½ - 1 second(s) Ammonium oxalate crystal violet
Wash by water
1-2 seconds Lugol solution
Wash by water
1 second Acetate alcohol
Wash by water
1 second S ff
d Sofframin
i
94

95. Staining : Giemsa and KOH
• Giemsa
– Giemsa solution : Aquadest  1 : 10
– 2 seconds Methanol on Fixated object glass
– Waste and add 10-15 seconds Giemsa stain
– Wash by water and make it dry
y
y
• KOH
– 1-2 drops 10% KOH on object g
p
%
j
glass
– Place specimens on object glass
– Covered with coverglass
g
95

96. Ocular surface : Conjunctiva
j
• Follicle
– Focal lymphoid nodule
y p
– With accessory vascularization
• Papilla
– Dilated, talengiectatic conjunctival blood vessels
,
g
j
– Anchoring septa
– Dot like changes to enlarged tufts, surrounded by edema and
inflammatory cells
• G
Granuloma
l
– Nodule of chronic inflammatory cells
– With fibrovascular proliferation
• Phl t
Phlyctenule
l
– Nodule of chronic inflammatory cells
– Often at or near the limbus
American Academy of Ophthalmology
96

97. Follicle and Papilla
p
Area to be examined
Follicles
Papillae
97

98. Follicle and Papilla
p
Papilla
Follicle
American Academy of Ophthalmology
98

99. Phlycten and Phlyctenule
y
y
Phlycten
Phlyctenule
Staphylococcus
Delayed hypersesitivity
Good
Poor
+
-
Limbus
Without progression
Limbus
To central
All ages
g
Children
Cycatrix
-
+
Recurrence
-
+
Triangular
Base at limbus
Triangular
Apex at limbus
Topical antibiotic
Steroid based on
Underlying disease
Etiology
General condition
Conjunctivitis
Location
Age
Shape
Therapy
py
99

100. Ocular surface: Cornea
• Epithelium
– 5-6 layer structure
– 50 100 µm thickness
50-100
– Great sensitivity
– Composed
• Basal cells layer
• Wing cells layer
• Surface cells layer
Deborah Pavan-Langston, 2008
100

101. Ocular surface : Cornea
• Bowman’s layer
Bowman s
– Homogenous condensation of anterior
stromal lamellae
• Stroma
– 90% of corneal thickness
– Bundles of collagen fibrils of uniform
thickness enmeshed in mucopolysaccharide
subtance
bt
– Maintain corneal clarity
Deborah Pavan-Langston, 2008
101

102. Ocular surface : Cornea
• Dua’s Layer
Dua s
– Discovered by examining the separation that
often occurs along the last row of keratocytes
during the big bubble (BB) technique
– Attached to the deep stroma
– is not "residual stroma."
– Distinct layer that is 10 15 ± 3 6 microns thick
10.15 3.6
between stroma and descemet membrane
EuroTimes, 2013
102

103. Ocular surface : Cornea
• Descemet membrane
– Basement membrane of the endothelial cells
– Can be easily stripped
– Homogenous glasslike structure
– Anterior  Composed of stratified layers of
very finecollagenousfilaments
– Posterior  Amorphous layers that increases
with age
Deborah Pavan-Langston, 2008
103

104. Ocular surface : Cornea
• Endothelium
– Single layer
– 5 18 µm size of approximately 500 000
5-18
500,000
polygonal cells
– Maintain corneal deturgescence
– Contributes the formation of Descemet
membrane
Deborah Pavan-Langston, 2008
104

105. Ocular surface : Cornea
• Blood supply
– Predominantly from
• Conjunctival vessel
• Episcleral vessel
• Scleral vessel
– Arborize about the corneoscleral limbus
• Innervation
– Sensory  mostly  ophthalmic division of the
trigeminal nerve
g
– Is via long ciliary nerves that branch in the outer
choroid near ora serrata region
Deborah Pavan-Langston, 2008
105

106. Ocular surface : Keratititis
Location
Marginal
keratitis
k titi
Peripheral
Bacterial
keratitis
k titi
Central
Size
< 1 mm
> 1 mm
Epithelial defect Small or absent Present
Uveitis
Absent
Present
Kanski JJ, 2007
106

107. Chemical trauma : Hudge Grade
I
II
III
IV
Good
Good
Intermediate
Poor
Epithelial
Epithelial
Epithelial loss
Hazy
Iris/Pupil
detail
Visible
Visible
Blurred
Very blurred
Ischemia
None
<1/3 limbus
1/3 -1/2
limbus
> 1/2 limbus
Prognosis
Broken
cornea
107

108. Corneal endothelial layer
• Normal  2 000 – 3 000 cells / mm²
2,000 3,000
mm
• Stressed  800 -1,500 cells / mm²
• D
Decompensate  < 500 cells / mm²
t
ll
²
108

109. Keratoplasty
• Penetrating Keratoplasty (PK)
• Barron’s Keratoplasty
• Sterile Cornea Allograft  VisionGraft
(TBI/Tissue Bank International)
• Deep Anterior Lamellar Keratoplasty (DALK)
• Femtosecond laser-assisted Anterior Lamellar
Keratoplasty (FALK)
• Femtosecond laser-assisted Descemet Stripping
Endothelial Keratoplasty (
dot e a e atop asty (F-DSEK)
S )
109

110. Keratoprostheses: Boston K Pro
EuroTimes 2006
110

111. Keratoprostheses: AlphaCor
EuroTimes 2006
111

112. Keratoprostheses: Pintucci
IJO 2011
112

113. 113

114. 114

115. Refraction
Prof. Dr. dr. Admadi Soeroso, Sp.M, MARS
115

116. Visual acuity
• Vi
Visual threshold
l th h ld
– Light discrimination
•
•
•
•
Brightness sensitivity (minimum visible)
Brightness di i i ti ( i i
B i ht
discrimination (minimum perceptible)
tibl )
Brightness contrast
Color discrimination
– Spatial discrimination
• Minimum separable
• Vernier acuity (hyperacuity) 
– Separated by little as 3 5 seco ds o a c
Sepa a ed
e
3-5 seconds of arc
– Considerable less than the diameter of single foveal cone
– The basis of Amsler’s grid
• Minimum legible acuities
• Di t
Distance di i i ti
discrimination
• Movement discrimination
– Temporal discrimination
• Flickering light
American Academy of Ophthalmology
116

117. Some basic acuity
Type
Description
Point acuity ( arc minute)
y (1
)
The ability to resolve two distinct point targets.
y
p
g
Grating acuity (1-2 arc minutes)
The ability to distinguish a pattern of bright and dark
bars from a uniform grey patch.
Letter acuity (5 arc minutes)
The ability to resolve a letter. The Snellen eye chart
is a standard way of measuring this ability. 20/20
vision means that a 5-minute letter target can be
seen 90% of the time
Stereo acuity (10 arc seconds)
The ability to resolve objects in depth. The acuity is
measured as the difference between two angles
for a just-detectable depth difference.
just detectable
Vernier acuity (10 arc seconds).
The ability to see if two line segments are collinear
Healey CG, 2005
117

118. Visual acuity in different notation
FEET
METERS
MINIMUM ANGLE OF
RESOLUTION
LOGMAR
DECIMAL
NOTATION
20/10
6/3
0.50
-0.3
2.0
20/15
6/4.5
6/4 5
0.75
0 75
-0 1
0.1
1.5
15
20/20
6/6
1.00
0.0
1.0
20/25
6/7.5
1.25
0.1
0.8
20/30
6/9
1.50
1 50
0.2
02
0.7
07
20/40
6/12
2.00
0.3
0.5
20/50
6/15
2.50
0.4
0.4
20/60
6/18
3.00
3 00
0.5
05
0.3
03
20/80
6/24
4.00
0.6
20/100
6/30
5.00
0.7
20/120
6/36
6.00
6 00
0.8
08
20/150
6/45
8.00
0.9
20/200
6/60
10.00
1.0
0.1
20/400
6/120
20.00
20 00
1.3
13
0.005
0 005
American Academy of Ophthalmology
0.2
118

119. Visual acuity : Development
y
p
Age
Visual acuity
2 months
20/400 (6/120)
6 months
20/200 (6/60)
1 year
20/100 (6/30)
2 years
20/60 (6/18)
3 years
20/30 (6/9)
y
4-5 years
20/20 (6/6)
( )
Duke Elder
119

120. 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 looking
Fixation behavior
Allen pictures
HOTV
E-Game
Snellen h t
S ll chart
NORMAL
20/30
20/30
CSM
CSM*
20/40-20/20
20/40-20/20
20/40 20/20
20/40-20/20
20/30-20/20
20/30 20/20
* CSM Method : Refers to Corneal light reflex, Steadiness of fixation and
Maintain alignment
American Academy of Ophthalmology
120

121. Light : Basic
• Wavelength of visible light  380-760nm
380 760nm
• Velocity of light waves 
– 300 000 k /
300.000 km/second or
d
– 86.000 mils /second
• Character of light
– Hue
– Saturation
– Brightness or Luminance
121

122. Illumination
• Radiometry
– Measures term of power
– Irradiance = watts per square meter, lamberts
• Sunny day = 10,000 – 30,000 foot lamberts
• Photometry
–
–
–
–
–
Measures units based on the response of the eye
1 candela = 12.6 lumens
Illuminance = lumens per square meter
Luminance of surface is amount of light that reflected or emmited
Apostlib  surface perfectly emitting or reflecting 1 lumen per
square meter
– Ideally 100 watt lamp bulb provides about minimum
• 600 foot candles 3 feet away
• 150 foot candles 6 feet away
American Academy of Ophthalmology
122

123. Photobiology
gy
• Scotopic vision is the monochromatic vision of the eye
in low light. Since cone cells are nonfunctional in low
light, scotopic vision is produced exclusively through rod
cells so therefore there is no color perception. Scotopic
vision occurs at luminance levels of 10-2 to 10-6 cd/m².
cd/m .
• Mesopic vision occurs in intermediate lighting
conditions (luminance level 10-2 to 1 cd/m²) and is
effectively a combination of scotopic and photopic vision
vision.
This however gives inaccurate visual acuity and color
discrimination.
• Ph t i vision  I normal light (l i
Photopic i i
In
l li ht (luminance l
level 1 t
l to
106 cd/m²), the vision of cone cells dominates  good
visual acuity (VA) and color discrimination
Lars Olof Björn, 2002
123

124. The cone cells
• Sharp photoreceptor
• A human eye can see wavelengths in the range of 380 to
760nm. This range is called the visible region
y
yp
,
• Trichromatic Theory  3 types of cones, each with a
different iodopsin (a photosensitive pigment)
• Each type of iodopsin can absorb and respond to a
range of wavelengths
• Photosensitive pigments 
– Erythrolabe  maximum absorption at 565nm (red)
– Chl l b  maximum absorption at 535
Chlorolabe
i
b
ti
t 535nm (
(green)
)
– Cyanolabe  maximum absorption at 440nm (blue)
124

125. Visible light
Hue
Wavelength (nm)
Indigo
g
400-450
Blue
450-480
Cyan-Blue
480-510
Green
510-550
Yellow-Green
550-565
Yellow
565 590
565-590
Orange
590-630
Red
630-700
125

126. Chromatic aberration
• The type of error in an optical system in which the
formation of a series of colored images occurs, even
though only white light enters the system.
system
• Chromatic aberrations are caused by the fact that the
refraction law determining the path of light through an
optical system contains the refractive index which is a
index,
function of wavelength.
• Thus the image position and the magnification of an
optical system are not necessarily the same for all
wavelengths, nor are the aberrations the same for all
wavelengths
126

127. Chromatic aberration
• Short wavelength light focused
more anterior than long
wavelength li ht
l
th light
• Violet focused more anterior
than Red
127

128. Spherical aberration
• A blurred image that occurs when
light from the margin of a lens or
g
g
mirror with a spherical surface comes
to a shorter focus than light from the
central portion.
• Also called dioptric aberration
128

129. Spherical aberration
•
•
•
•
A perfect lens (top) focuses all
incoming rays to a point on the
optic axis
A real lens with spherical
surfaces (bottom) suffers from
spherical aberration
It focuses rays more tightly if
they enter it far from the optic
axis than if they enter closer to
the axis
It therefore does not produce a
perfect focal point
129

130. Spherical aberration
• Mirror spherical
aberration
• Reflective Caustic
generated f
d from a
circle and parallel
rays
130

131. 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
1.9
55
1.3
Vaughan DG
131

132. Refractive index (Helium D Line)
•
•
•
•
•
•
Air
Water
Cornea
Aqueous and vitreous
Spectacle crown glass
PMMA
1.000
1.333
1.376
1.336
1 336
1.523
1.492
1 492
American Academy of Ophthalmology
132

133. Refracting power (D)
• Corneal system
43.05
– Anterior surface
– Posterior surface
48.83
- 5.88
• Lens system
– Relaxed
– Maximum accommodation
19.11
33.06
33 06
• Complete optical system
– Relaxed
– Maximum accommodation
58.64
70.57
American Academy of Ophthalmology
133

134. DIOPTER CONVERTION - MILIMETER
K
K
Reading
(D)
Radius
(mm)
Reading
(D)
Radius
(mm)
47.57
47.50
47 50
47.25
47.00
47 00
46.75
46.50
7.07
7.11
7 11
7.14
7.18
7 18
7.22
7.26
46.25
46.00
46 00
45.75
45.50
45 50
45.25
45.00
7.30
7.34
7 34
7.38
7.42
7 42
7.46
7.50
134

135. Pinhole visual acuity measurement
• If visual acuity improves  refractive error
usually present
• Disease of macula 
– Unable to adapt to amount of light through the
pinhole
– Visual acuity can decrease markedly
• M t useful  1 2 mm
Most
f l
1.2
– Refractive error – 5.00 to + 5.00 D
American Academy of Ophthalmology
135

136. 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
-6.00 and above
6 00 d b
Diopters
Hyperopia
+1.00 to +2.00
Diopters
+2.00 to +4.00
Diopters
+4..00 and above
Diopters
Astigmatism
-1.00 to –2.00
Diopters
-2.00 to -4.00
Diopters
-4.00 and above
Diopters
Myopia
Mild
136

137. Refraction
• Myopia (Nearsightedness)
– Pathophysiology
• Axial Curvature Increased index of refraction
Axial, Curvature,
– Severity
• Mild Moderate High
Mild, Moderate,
– Clinical
• Simplex/Stationary, Progressive, Malignant
Deborah Pavan-Langston, 2008
137

138. Myopia
y p
•
•
Children born myopic  small percentage  not become
emmetropic by age 6-8 years
Previously emmetropic children or h
P i
l
t i hild
hyperopic may b
i
become myopic
i
– Hyperopes greater than +1.50 D rarely become myopic and may
become more hyperopic
•
•
Prevalence of myopia begins to increase at about age of 6 y
y p
g
g
years
Juvenile-onset myopia
– 7-16 years of age
– Primarily due to growth in globe axial length
– L
Largest i
t increase i girls at age 9 10 years and i b
in i l t
9-10
d in boys at age 11 12
t
11-12
years
– Usually stops in middle teen years, 15 for girls and 16 for boys
•
•
Myopia starting after 16 is less severe and less common
y p
g
Adult-onset myopia
– Begins at about 20 years of age
– Risk factor  extensive near work
American Academy of Ophthalmology
138

139. Significant myopia in childhood
g
y p
•
•
•
•
Cycloplegic refraction are mandatory
Full refractive error, including cylinder, should be corrected
Young children tolerate cylinder well
On theory  prolonged accommodation increase development of
myopia
– Some  undercorrection myopia
– S
Some use bif
bifocal, with or without At i
l ith
ith t Atropine
•
Parents should be educated about
– Progression of myopia
– Need for frequent refraction
– Possible prescription changes
•
•
•
Contact lenses  older children  avoid problem of image
magnification by high minus lenses
Intentional undercorrection f myopic esotrope  d
I t ti
l d
ti for
i
t
decrease th
the
angle of deviation  well tolerated
Intentional overcorrection for myopic error  controlling
(
)
exodeviation (some value)
American Academy of Ophthalmology
139

140. Refraction
• Hypermetropia (Farsightedness)
– Structural
• Axial, Curvature, Index of refraction
– Accommodative
• Latent, manifest, total
– Severity
Uncorrected can causes
• Strabismus  Esotropia
• Ambliopia
Deborah Pavan-Langston, 2008
140

141. Correcting hyperopia in childhood
• No esodeviation and reduced vision  NOT
necessary correcting low hyperopia
• Significant astigmatic error must be fully
corrected
d
• Hyperopia coexists esotropia  full correction of
the cycloplegic refractive error
• In a school age child  full correction may
cause b u ed vision
blurred s o
– Because inability to relax accommodation fully
– A short course of cycloplegia may help
American Academy of Ophthalmology
141

142. Clinical refraction
• Refraction approach  ARK
• Subjective  Trial and error by trial optical
lenses
• Objective  Streak retinoscopy
– Characteristic of reflex
• Speed
• Brilliance
• Width
– Four characteristic of STREAK reflex
•
•
•
•
Break
Width
Intensity
Skew
American Academy of Ophthalmology
142

143. Streak retinoscopy
Neutralization
With
Against
ga s
143

144. Finding Neutrality
•
•
•
•
•
•
•
In against movement, the far point is between the examiner and the
perfect therefore, to bring the far point to the examiner’s pupil, minus,
lenses should be placed in front of the patient’s eye.
patient s
Similarly, in the case of with movement plus lenses should be placed in
front of the patient’s eye.
Similarly, in the case of with movement, plus lenses should be placed in
front of the patient s eye
patient’s eye.
This leads to the simple clinical rule: if you see with motion, add plus
lenses (or subtract minus); if you see against motion, add minus lenses
(or subtract plus). Lens power should be added (or subtracted) until
neutrality is reached
y
Since it is considered easier to work with the brighter, sharper with image, it
is preferable to overminus the eye and obtain a with reflex and then reduce
the minus (add plus) until neutrality is reached.
,
Be aware that the slow, dull reflex and then reduce the minus
refractive errors may be confused with the pupil-filling neutrality reflex
or with dull reflexes (as seen in patients with hazy media).
Place high-power plus and minus lens over the eye and look again.
American Academy of Ophthalmology
144

145. Finding Neutrality
g
y
145

146. Finding the cylinder axis
g
y
• Before retinoscope is used to measure the powers in
each of the principal meridians, the axes of the
p
p
meridians must be determined.
• Characteristics of the streak reflex can aid in determining
axis.
– Break. A break is seen when the streak is not parallel to one of
the meridians. The are projecting the line is discontinuous, or
broken. The break disappears (ie, the line appears continuous)
g
when the streak is rotated on to the correct axis. The correcting
cylinder should be placed at this axis.
– Width. The width of the streak varies as it rotated around the
correct axis. It appears narrowest when the streak aligns with
the axis
– Intensity. The intensity of the line is brighter when the streak is
on the correct axis. (This is a subtle finding, useful only in small
cylinders)
American Academy of Ophthalmology
146

147. Finding the cylinder axis
g
y
American Academy of Ophthalmology
147

148. Finding the cylinder axis
g
y
148

149. Finding the cylinder axis
g
y
American Academy of Ophthalmology
149

150. Finding the cylinder axis
g
y
American Academy of Ophthalmology
150

151. Finding the cylinder axis
g
y
American Academy of Ophthalmology
151

152. Finding the cylinder power
•
•
Once the two principal meridians are identified, the axis separately
in turn.
With two spheres
spheres.
– Neutralize one spherical lens. If the 90º axis is neutralize with a +1.50
sphere and the 180º axis is neutralized with a +2.25 sphere, the gross
retinoscopy would be +1.50 + 0.75 x 180. The examiner’s working
distance should be subtracted from the sphere to obtain the refractive
correction.
•
With a sphere and cylinder.
– Neutralize one axis with spherical lens. To continue working using with
reflexes,
reflexes neutralize the lens plus axis first Then with this spherical lens
first. Then,
in place, neutralize the axis 90º away by adding a plus cylindrical lens
directly from the trial lens application. The spherocylindrical gross
retinoscope can be read directly from the trial lens application.
•
It is also possible to use two cylinders at right angles to each other
for this gross retinoscopy ; however, this variant does not seem to
provide any advantages over the other methods.
American Academy of Ophthalmology
152

153. Aberrations of the Retinoscopic Reflex
•
•
•
•
•
With irregular astigmatism, almost any type of aberration may
appear in the reflex.
Spherical aberration tend to increase the brightness at the center or
periphery of the pupil, depending on whether the aberrations are
positive or negative.
As the point of neutrality is approached one part of the reflex may
approached,
be myopic while the other is hyperopic relative to the position of the
retinoscope. This will produce the scissors reflex.
Sometimes a marked irregular astigmatism or optical opacity
produces confusing, distorted shadows that can markedly reduce
confusing
the precision of the retinoscopic result. In such as subjective
refraction should be used.
All of these aberrant reflexes become more noticeable with larger
papillary di
ill
diameters. I these cases, considering the central portion
In h
id i
h
l
i
of the light reflex yields the best approximation.
American Academy of Ophthalmology
153

154. Summary of retinoscopy
1.
2.
3.
4.
5.
The steps below summarize how to performing streak retinoscopy using
a plus cylinder phoropter. Set the phoropter to 0 D sphere and 0 D
cylinder.
cylinder Use cycloplegia if necessary Otherwise fog the eyes or use a
necessary. Otherwise,
non accommodative target.
Hold the sleeve of the retinoscope in the position that produces a
divergent beam of light. (If the examiner can focus the linear filament of
the retinoscope on a wall, the sleeve is in the wrong position)
wall
position).
Sweep the streak of light (the intercept) across the pupil perpendicular to
the long axis of the intercept and watch the papillary light reflex. Sweep in
several different meridians. Use the right eye to examine the patient’s
right eye, and use the left eye to examine the patient’s left eye.
patient s
Add minus sphere (dial up on a phoropter) until the retinoscopic reflex
shows with motion in all meridians. Add a little extra minus sphere if
uncertain. If the reflex are dim or indistinct, consider high refractive errors
and make large changes in sphere ( D, -6 D, -9 D, etc).
g
g
(-3
)
Add plus sphere (dial down on a phoropter) until the retinoscopic reflex
neutralizes or shows a small amount of residual with motion in one
meridian. If all meridians neutralizes simultaneously, the patient’s
refractive error is spherical. Proceed to step 9.
American Academy of Ophthalmology
154

155. Summary of retinoscopy
y
py
6.
7.
8.
9.
10.
Rotate the streak 90º and set the axis of the correcting plus cylinder
parallel to the streak. Sweep this meridian to reveal additional with
motion. Add plus cylinder power until the remaining with motion is
neutralized.
neutralized Now the retinoscopic reflex should be neutralized in all
meridiens simultaneously.
Refine the correcting cylinder axis by sweeping 45º to either side of it.
Move in slightly closer to the patient to pick up with motion. Rotate the
axis of the correcting plus cylinder a couple of degrees toward the “guide”
guide
line, the brighter and narrower reflex. Repeat until both reflexes are
equal.
Refine the cylinder power by moving in closer to the patient to pick up
with motion in all directions. Back away slowly, observing how the
reflexes neutralize. Change sphere or cylinder power as appropriate to
make all meridians neutralize simultaneously.
Subtract the working distance. If working at 67 cm, subtract 1.5 D. if the
examiner’s arms are short or the examiner prefers working closer, the
p
g
,
appropriate dioptric power for the distance chosen should be subtracted.
Record the streak retinoscopy findings and, if possible, check the
patient’s visual acuity after he or she has had time to wear the
prescription and readjust to ambient room light.
American Academy of Ophthalmology
155

156. Retinoscopy: Final correction
•
•
If we use working lenses  Another
correcting lenses  Final correction
If for example in 50 cm working distance,
we use S +2.00 working lenses, and we
2.00
get: Horizontal S -6.00 and Vertical S 3 00, t e
3.00, the Final correction:
a co ect o
– S -6.00 C +3.00 A 90 or,
– S -3 00 C +3 00 A 180
3.00 +3.00
156

157. Lenses
• Meniscus Lens or Curve Lens  Lens with
one spherical convex surface and the other
spherical concave. Meniscus lenses often have
a base of 6 D for the surface of lesser curvature.
• Polarizing Lens A lens that transmits light
waves vibrating in one direction only. In the
other direction perpendicular to it, the light
waves are absorbed In this way reflected glare
absorbed.
is reduced.
157

158. The Basic Lenses
(A), biconvex; (B), biconcave; (C), planoconvex; (D), plano concave;
(E),concavoconvex, periscopic convex, converging meniscus;
(F), convexoconcave, periscopic concave, diverging meniscus;
(G, H), cylindrical lenses, concave and convex.
MedDict 2007
158

159. Sphere lenses
159

160. Sphere Lens
Biconvex Lenses
CaF2 Lenses
Plano Concave Lenses
Biconcave Lenses
Meniscus Sphere
Lenses
Changch Jixiang 2006
hun
g,
Plano Convex Lenses
160

161. Spheric correction
• Least minus for myopia
– More minus forces contraction of cilliary
muscles for unnecessary accommodation 
Fatigue
• Most plus for hyperopes
– Less plus retains accommodation
161

162. Spherical aberrations
• More peripheral rays focused anteriorly
• Exacerbates myopia in low light (night
myopia) about – 0.50 D
• Increase as fourth power of pupil diameter
– Small pupil can cause better vision
• Can also occurs following refractive
surgery
– Aspheric cornea becomes more spherical
American Academy of Ophthalmology
162

163. Achromatic lenses
•
•
•
•
•
Achromatic Lenses consist of two or more elements, usually of
crown and flint glass that have been corrected for chromatic
aberration with respect to two selected wavelengths.
Most company provides achromatic lenses consisting of two
elements.
These lenses have considerably reduced not only chromatic
aberration bust also spherical aberration and coma aberration.
These are designed with respect to three wavelength 480nm,
546.1nm
546 1nm and 643 8nm
643.8nm.
They are best used in replacing singlet where improved
performance is required.
– Positive Achromatic Lenses
– Negative Achromatic Lens
Changchun Jixiang, 2006
163

164. Achromatic lenses
Positive Achromatic Lenses
Negative Achromatic Lenses
Changchun Jixiang, 2006
164

165. Astigmatism
g
• Classified as
– Sh
Shape
• Regular astigmatism
– With the rule
» Common in children
» Vertical meridians is steepest
» A i near 90º
Axis
– Against the rule  opposite
» Older adult
• Irregular astigmatism
– Rigid contact lenses may be useful
American Academy of Ophthalmology
165

166. Circle of least confusion
Conoid of Sturm
166

167. Cylinder lenses
y
167

168. Cylinder lenses
Plano Convex Cylindrical Lenses
Plano Concave Cylindrical Lenses
Biconvex Cylindrical Lenses
Biconcave Cylindrical Lenses
Changchun Jixiang, 2006
Meniscus Cylindrical Lenses
168

169. Cylinder axis
American Academy of Ophthalmology
169

170. Astigmatic dial technique
• Obtain best visual acuity using SPHERES only
y
g
y
• FOG the eye to about 20/50 by adding PLUS
sphere
• Note the BLACKEST and SHARPEST line of
the astigmatic dial
• Add MINUS CYLINDER with axis
PERPENDICULAR to the blackest and sharpest
line (Rotate minus cylinder if necessary) until all
lines APPEAR EQUAL
es
QU
• REDUCE plus sphere or ADD minus until best
acuity is obtained with the visual acuity chart
American Academy of Ophthalmology
170

171. Astigmatic correction
g
• For children  full correction with correct axis
• For adult  adaptable full correction
• Reduce distortion
–
–
–
–
Use minus cylinder
y
Minimize vertex distance
Rotate axis toward 180º or 90º
Reduce cylinder power and use spherical equivalent
• Spatial distortion is binocular phenomenon 
occlude one eye to verify
• If fail to reduce distortion  use contact lenses
or iseikonic corrections
American Academy of Ophthalmology
171

172. Toric lenses
American Academy of Ophthalmology
172

173. Toric lenses
• Shaped like a section through a rugby ball
• P
Prescribed t correct astigmatism 
ib d to
t ti
ti
contact lenses and IOLs
• Toric lenses can be plus, minus, one
principle meridian plus with the other
minus
p
y
• Referred as Spherocylinder lenses
173

174. Prism lenses
174

175. Prisms aberration
• In addition to chromatic aberration
• Producing colored fringes at the edges of
objects viewed through the prism
• Other aberration
– Asymmetrical magnification of field
– Asymmetrical curvature of field
• Usually insignificant but  produce
symptoms even with low-power
p
prisms.
ophthalmic p
American Academy of Ophthalmology
175

176. Prismatic effect of decentred lens
• Convex lens  two
prisms cemented
together at their
BASEs
BASE
• Concave lens  two
prisms cemented
together at their
APEXs
• Decentred lens 
Prism effect  Base
in or Base out
Decrease convergence
Increase convergence

177. Bifocals
• A lens having one
section that
corrects for distant
vision and another
section that
corrects for near
vision.
vision
177

178. Bifocals
The dot indicates the optical centre of the near portion
A, executive-type segment; B, flat-top segment; C, round segment;
D,
D curved segment
d
MedDict 2007
178

179. Trifocals
•
Three prescription powers: a distance power, a mid-range power, and a
near power.
•
The distance power helps to see things at a distance, the mid-range
power helps to see things at intermediate distances and the near power
distances,
corrects vision close up.
•
Tri-focal lenses are available in a variety of options, including thin and
light lenses, impact resistant lenses and transition lenses (lenses that
change from light to dark).
MedDict 2007
179

180. Progressive Lens
•
Characterized by a gradient of
increasing lens power added to
power,
the wearer's correction for the
other refractive errors.
•
The gradient starts at a
minimum, or no addition power,
at the top of the lens and
reaches a maximum addition
power, magnification, at the
bottom of the lens.
•
The length of the progressive
power gradient on the lens
surface is usually between 15
and 20 mm with a final addition
power between 1 00 to 3 00
1.00 3.00
dioptres.
MedDict 2007
180

181. Transposition
181

182. 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
- 3.00
- 3.00
- 6.00
182

183. Transposition
• New sphere is the ALGEBRAIC SUM of old sphere and
cylinder
• New cylinder is same value with old cylinder but with
cylinder,
OPOSITE sign
• Change axis of cylinder by 90º
S - 6 00 C + 3 00 A 90º
6.00
3.00 90
S - 3.00 C - 3.00 A 180º
IS IT SAME OR EQUAL ???
183

184. 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
184

185. 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
– Smaller, darker, farther away or any such change
• Duochrome test  RAM-GAP
– Red add minus, green add plus
Binocular balance
• Fogging
• Prism dissociation
• Cycloplegics
American Academy of Ophthalmology
185

186. Refraction : Correction
•
•
•
Spectacle / glass
Contact lenses
Keratorefractive surgery
–
–
–
–
–
–
–
–
RK  Radial keratotomy
PRK  Photo Refractive Keratotomy / Keratectomy
Laser Thermal Keratoplasty
LASIK (Laser-assisted in-situ Keratomileusis), EpiLASIK
SBK  Sub-Bowman Keratomileusis
LASEK  Laser-assisted Sub-Epithelial Keratomielusis
LaserACE  Restoring accommodative ability
CK  Conductive Keratoplasty  Radio-frequency-based Collagen
shrinking procedures
– Arcuate keratotomy
– Intrastromal corneal ring
•
IOL
– AC Lens, Claw lens (25-6)  Artisan (Ophtec), Verisyse (
,
(
)
( p
),
y (Abbott
Medical Optics), STAAR Visian ICL and Toric ICL
– Posterior lens by CLE / RLE (>13)
186

187. Corneal Collagen Cross-Linking
g
g
• Corneal thermal remodeling  (also) can be induced by
Microwave Keratoplasty
Micro a e Keratoplast  treat Keratocon s and
Keratoconus
Refractive Errors
• UV radiation  accelerates corneal stiffening by
riboflavin
• Cross-linking occurs between collagen helix,
aminoglycans and other substances in corneal substrate
• D li i “Controlled I
Delivering “C t ll d Insult” t St
lt” to Stromal C ll
l Collagen Fib
Fibers
bellow epithellium and Bowman’s layer  change shape
without cutting.
• Fatten the cornea  after Lasik or incisional surgery
• Achieve corneal rigidity equivalent to 600 years of
natural ageing
Marshall J, 2010
187

188. Corneal Collagen Cross-Linking
g
g
•
•
Older procedure  30 minutes riboflavin soaks and 30 minutes UV
p
exposure  potential endothelial damage, complication to lens and retina
Newer procedure  2 minutes riboflavin soaks and 3 minutes UV exposure
with mask-covered protection at peripheral and central of the cornea 
protecting endothel, corneal stem cells, lens and retina  Keraflex KCL
(Avedro)
(A d )
Marshall J, 2010
188

189. Contact Lenses Fitting
189

190. Contact lenses : Materials
1.
1 HEMA (Hydroxyethyl methacrylate)
2. Non HEMA  Hydrogel lenses  Hydrophyllic
3. HEMA + PVP (Polyvinylpyrrolidone)
( y y py
)
- To increase water holding ability ,
- PVP  Yellowing by age / heat disinfection
4.
4 HEMA + MMA (Methylmethacrylate)
(M th l th
l t )
- To increase stiffness.
- Lens more durable
durable.
- The pores are smaller than any known
bacterium or virus
190

191. Contact Lenses Fitting
•
Base curve
–
–
–
–
–
•
Radius of curvature to be cut on the posterior surface of the lens
Minimal apical clearance
Guided by the K measurements along two principal meridians
Selected to ensure a comfortable and healthy fit for patients
Range from 8.40 mm (40.25 D) to 7.00 (48.25 D)
Diameter
– Optical zone range between 6.0 – 8.0 mm
– Central thickness  less than 0.10 mm
•
Peripheral curve
– Curve radii range between 8 40 – 13 00 mm
8.40 13.00
– Curve width  0.10 – 0.45 mm
•
•
Power
Lens surface design
–
–
–
–
Spherical lens
Back surface toric lens
Front surface toric lens
Bitoric
Bit i
American Academy of Ophthalmology
191

192. The Contact Lenses
Peripheral curve width
Optic zone
Base curve
Peripheral curve radii
Peripheral curve width
Center thickness
192

193. VERTEX DISTANCE CORRECTION
Vertex Distance (mm)
Spectacle
Power (D)
10
11
12
13
10
12
13
Contact Lens Power
Minus Lenses
4.00
4.50
5.00
5.50
6.00
6.50
7.00
7.50
8.00
11
3.87
4.25
4.75
5.25
5.62
6.12
6.50
7.00
7.37
3.87
4.25
4.75
5.12
5.62
6.00
6.50
6.87
7.37
3.87
4.25
4.75
5.12
5.62
6.00
6.50
6.87
7.25
Plus Lenses
3.75
4.25
4.75
5.12
5.50
6.00
6.37
7.25
7.62
4.12
4.75
5.25
5.75
6.37
7.00
7.50
8.12
8.75
4.12
4.75
5.25
5.87
6.37
7.00
7.62
8.12
8.75
4.25
4.75
5.25
5.87
6.50
7.00
7.62
8.25
8.87
4.25
4.75
5.37
5.87
6.50
7.12
7.75
8.25
8.87
193

194. FITTING STEPS
Good fit
1. Sufficient movement
2. Proper centration
3. Stable vision
4.
4 Sharp retinoscopic reflex
5. Clear keratometry mires
194

195. FITTING STEPS
Tight fit
1.
1 Vision fluctuates (clears briefly after blink)
2. Bubbles trapped under the lens
3. Declining comfort over a span of hours as the lens is worn
4. A burning sensation following by redness or an indication
appearing around the corneal circumference
5. Restricted or no movement of the lens
6. Keratometry mires that are distored, but clear on blinking
7. A fuzzy retinoscope reflex that clears on blinking
195

196. FITTING STEPS
Loose fit
1. Variable vision (briefly clears after blinking)
2.
2 Bothersome lens awareness
3. Lack of centration
4. Too much movement
5. Lens edge stand off l
5 L
d
t d ff lens d
decenter onto th sclera
t
t the l
7. Bubbles forming under the lens edge
8. Keratometry mires that are clear, but blurs on blinking,
and than clear
9. A clear retinoscopic reflex, that blurs after blinking
196

197. 197

198. Toric contact lenses
• An astigmatic eye is not perfectly round (like a
soccer ball) but more shaped like a rugby ball.
• O i f
One-in-four people with l
l
i h low amounts of
f
astigmatism can get away with wearing normal
(spherical) contact lenses
lenses.
• A person with higher amounts of astigmatism
needs to wear special contact lenses called
toric lenses
198

199. 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, that ‘rugby ball’ is
y
y
g y
,
g y
positioned at a certain angle in the eye socket.
• In order for the contact lens to correct astigmatism, it
needs to lie at that same angle in front of the eye
eye.
• Usually contact lenses rotate on the eye with each blink.
A toric contact lens is designed in such a way, that it
won t
won’t rotate on the eye
eye.
• Most toric lenses are made slightly thicker at the bottom
of the lens.
• The thicker part will weigh the lens down at the bottom,
preventing it from turning on the eye.
199

200. Radial Keratotomy
200

201. Laser Thermal Keratoplasty
201

202. Laser assisted
Laser-assisted in situ Keratomileusis
202

203. Laser-assisted Sub-Epithelial Keratomileusis
203

204. Arcuate Keratotomy
204

205. Intrastromal Corneal Ring
205

206. Aniseikonia
• Translated from Greek aniseikonia means
"unequal images".
• It is a binocular condition so the image in
condition,
one eye is perceived as different in size
compared to the image in the other eye
eye.
• Two different types of aniseikonia can be
differentiated: static and dynamic
diff
ti t d t ti
dd
i
aniseikonia
206

207. Aniseikonia
• Static aniseikonia or
aniseikonia in short means that
in a static situation where the
eyes are gazing in a certain
direction
• The perceived (peripheral)
images are different in size
207

208. Aniseikonia : Static
208

209. Aniseikonia
• Dynamic aniseikonia or (optically
induced) anisophoria means that
the
th eyes h
have t rotate a different
to t t
diff
t
amount to gaze (i.e. look with the
sharpest vision) at the same point in
space
p
• This is especially difficult for eye
rotations in the vertical direction
209

210. Aniseikonia : Dynamic
210

211. Aniseikonia
Schematic presentation of the different steps to get to a perceived
image size and the visualization of a field angle α
211

212. Aniseikonia
Features : a) Example of a single aniseikonia test image, b) same aniseikonia
test image as on the left, but now with an (exaggerated) vertical fixation
g
,
(
gg
)
disparity compensation (click on image to enlarge).
212

213. Anisophoria
• Is a condition in which the balance of the
vertical muscles of one eye differs from
that of the other eye  the visual lines do
not lie in the same horizontal plane
• Eye muscle imbalance  the horizontal
visual plane of one eye is different from
that of the other
213

214. Amblyopia
y p
Type :
• St bi i amblyopia
Strabismic
bl
i
– Frequently  in esotropia patients
• A i
Anisometropic (R f ti ) amblyopia
t i (Refractive)
bl
i
– Difference in refraction greater than 2.50 D
• Isoametropic amblyopia
– Bilateral refractive error grater than + 5.00 or – 10.00 D
• Deprivation amblyopia
– Caused by such as media opacities
Deborah Pavan-Langston, 2008
214

215. CyberSight, 2003
215

216. 216

217. Strabismus
217

218. Position of gaze
g
• Primary position
– Straight ahead
• Secondary position
– Straight up, straight down
– Right gaze, left gaze
• Tertiary position  Four oblique position
– Up and right, up and left
– Down and right, down and left
• Cardinal position
American Academy of Ophthalmology
218

219. Cardinal position and Yoke muscles
RSR
LIO
Right Gaze
LSR
RIO
RLR
LMR
LLR
RMR
RIR
LSO
LIR
RSO
Left Gaze
American Academy of Ophthalmology
219

220. Eye movement
• Agonist
– Primary muscle moving the eye in a GIVEN direction
• Synergist
–
–
–
–
–
Muscle in the same eye
As the agonist
That can act with agonist
Produce a GIVEN movement
E.g Superior rectus with I f i oblique  elevate the eye
E :S
i
t
ith Inferior bli
l
t th
• Antagonist
–
–
–
–
Muscle in the same eye
As the
A th agonist
i t
That can act with in the direction opposite
E.g : Medial rectus and lateral rectus
American Academy of Ophthalmology
220

221. Basic
• Sherrington’s law for reciprocal innervation
– Increased innervation and contraction of GIVEN
EOM 
– Accompanied by reciprocal decrease of innervation
and contraction of its antagonist EOM
f
O
• Yoke muscle
– Two muscle (one in each eye)
– Are Prime mover of their respective eyes
– In GIVEN position gaze
– E.g : right gaze  RLR and LMR simultaneously
innervated and contracted  to be “yoked” together
yoked
American Academy of Ophthalmology
221

222. Basic
• Hering’s law of motor correspondence
Hering s
– The state  equal and simultaneous
innervation flow to Yoke muscle
– Concerned with the desired direction of the
gaze
American Academy of Ophthalmology
222

223. EOM : Functions
Muscle
Primary
Secondary
Lateral rectus
Abduction
None
Medial rectus
Adduction
None
Superior rectus
Elevation
Adduction
Intorsion
Inferior rectus
Depression
Adduction
Extorsion
Superior oblique
Intorsion
Depression
Abduction
Inferior oblique
Extorsion
Elevation
Abduction
Vaughan DG
223

224. EOM : Origin
g
Muscle
Origin
Functional
origin
i i
Lateral rectus
Annulus of Zinn
Annulus of Zinn
Medial
M di l rectus
t
Annulus of Zi
A
l
f Zinn
Annulus of Zi
A
l
f Zinn
Superior rectus
Annulus of Zinn
Annulus of Zinn
Inferior rectus
Annulus of Zinn
Annulus of Zinn
Superior oblique
Orbit apex above
Annulus of Zinn
Trochlea
Inferior oblique
Behind lacrimal fossa
Behind lacrimal fossa
American Academy of Ophthalmology
224

225. EOM : Insertion from limbus
•
•
•
•
Medial rectus
Lateral rectus
Superior rectus
Inferior rectus
5.5
5 5 mm
6.9 mm
7.7 mm
6.5 mm
American Academy of Ophthalmology
225

226. EOM : Wide and Length
•
•
•
•
•
Superior Rectus  5.0 mm and 41.8 mm
Inferior Rectus  4.2 mm and 40 mm
Lateral Rectus  6 5 mm and 40.6 mm
6.5
40 6
Medial Rectus  4.0 mm and 40.8 mm
Superior Oblique  1 2 mm and 
1-2
– Muscle part 40 mm
– Tendineus part 20 mm
• Inferior Oblique  1-2 mm and 37 mm
Kumar SM 2007
226

227. EOM : Gazes
Up and right
RSR - LIO
Up and left
LSR – RIO
Right
RLR – LMR
Left
LLR - RMR
Down and right
RIR - LSO
Down and left
LIR - RSO
Vaughan DG
227

228. Eye movement
• Versions
– Eyes move in the same direction
• Vergences  Disconjugate binocular eye
movement
–
–
–
–
–
Convergence  15-20 ∆ distance and 25 ∆ for near
Divergence  6-10 ∆ distance and 12-14 ∆ for near
Incyclovergence  2-3º
Excyclovergence
y
g
Vertical vergence  2-3 ∆
American Academy of Ophthalmology
228

229. Eye movement : Supranuclear control system
•
Saccadic system
– G
Generates all fast eye movements or refixation
t
ll f t
t
fi ti
– Up to 400-500º/sec
•
Smooth pursuit
– Generates all following, or pursuit eye movements
following
pursuit,
– Pursuit latency is shorter than for saccades
– Maximum velocity 30-60º/sec
•
The vergence system
– Controls disconjugate eye movements
•
The position maintenance
– Maintains a specific gaze position
– Allowing an object to interest to remain on the fovea
•
The non optic reflex
– Integrated eye movement with the body movement
– Most important system is Labyrinthine system
American Academy of Ophthalmology
229

230. Variation of deviation
With gaze position or fixating eye
• Comitant (Concomitant)
– Deviation doesn’t vary in size with direction of gaze or
fixating eye
• Incomitant (Noncomitant)
– Deviation varies in size with direction of gaze or
fixating eye
– Most  paralytic or restrictive
– In acquired condition  may indicate neurologic or
orbital problems or diseases
American Academy of Ophthalmology
230

231. Grades of binocular vision
• 1st Grade
– Simultaneous perception
• 2nd Grade
– Fusion
• 3rd Grade
– Stereopsis
Kanski JJ, 2007
231

232. Fusion
•
•
Cortical unification of visual object into a single percept
Made by simultaneous stimulation of corresponding retinal areas
Sensory fusion
– Relationship between retina and visual cortex
– Corresponding retinal points project to same cortical locus
– Corresponding adjacent retina points have adjacent cortical
representations
Motor fusion
–
–
–
–
Vergence movement
Causes similar retinal i
C
i il
i l image
Fall and be maintained on corresponding retinal areas
Disparities can be induced by, E.g : phoria, etc
American Academy of Ophthalmology
232

233. Stereopsis and Depth perception
• Stereopsis
p
– Binocular sensation
– Relative or subjective ordering of visual objects in
depth or 3 dimensions
• Depth perception
–M
Monocular clues i l d
l
l
include
•
•
•
•
•
Object overlap
Relative object size
Highlight and shadow
Motion parallax
Perspective
American Academy of Ophthalmology
233

234. AC/A Ratio
•
Accommodative Convergence / Accommodation Ratio
– Normal is between 3:1 to 5:1
– AC/A = PD +
∆n – ∆o
D
Gradient method
– PD = pupil distance (millimeter)
– ∆n = near deviations (prism diopter)
– ∆o = distance deviations (prism diopter)
sign convention :
– Esodeviation +
– Exodeviation -
– D = diopter of accommodation
– Distance 6 m
– Near 0.33 m
American Academy of Ophthalmology
234

235. ESODEVIATION
• Esodeviation
– Esophoria
• Controlled by fusion under condition of normal
y
binocular vision
– Intermittent esotropia
• C t ll d b f i under condition of normal
Controlled by fusion d
diti
f
l
binocular vision
• Spontaneous becomes manifest
• Particularly with fatigue or illness
– Esotropia
American Academy of Ophthalmology
235

236. Esotropia
•
•
Pseudoesotropia
Congenital esotropia
– Classic essential
– Nystagmus and esotropia
y g
p
•
Accommodative esotropia
– Refractive (Normal AC/A ratio)
– Non refractive (High AC/A ratio)
– Partially accommodative
•
Non-accommodative acquired esotropia
–
–
–
–
–
–
•
Basic
Acute
Cyclic
Sensory depriviation
Divergence insufficiency and divergence paralysis
Spasm of near synkinetic reflex
Incomitant esotropia
– Sixth nerve paresis
– Medial rectus restriction  Thyroid and trauma
y
– Duane’s syndrome and Möbius syndrome
American Academy of Ophthalmology
236

237. Pseudoesotropia
• Infant often have a wide, flat nasal bridge
with prominent medial ep ca a folds a d
po
e
ed a epicanthal o ds and
a small interpupillary distance.
• May appear esotropic
• I fact their eyes are straight.
In f t th i
t i ht
• No real deviation exists
• Both corneal light reflex and cover testing
results are normal.
237

238. Congenital Esotropia
•
•
•
•
Large constant esotropia (usually > 40 PD)
Onset birth to 6 months of age
Amblyopia common (50%-60%)
Associated motor phenomenon (
p
(usually
y
present after 1 year of age) :
– Inferior Oblique Over Action (IOOA)
– Dissociated Vertical Deviation (DVD)
– Latent nystagmus
238

239. Non-surgical treatment
Congenital esotropia
•
•
•
•
•
•
•
Abduction should be full or only slightly limited. Mild (-1) limitation of
abduction is common and does not necessarily indicate a lateral rectus
paresis.
Try the dolls head maneuver or spinning the child (vestibular stimulation) to
elicit full abduction in infants
Check for inferior oblique overaction and V-pattern
Check fixation preference: strong fixation preference for one eye indicates
amblyopia in the fellow eye.
Cross-fixate  fixing with right eye for objects in the left visual field and with
left eye for objects in the right visual field
Cross-fixate  indicate no significant amblyopia.
Measure deviation :
– Prisms Alternate Cover Test (PACT) is the BEST.
– KRIMSKY test  if PACT i unobtainable
t t
is
bt i bl
•
Cycloplegic refraction
– Use cyclopentolate 0.5% in infant < 24 year of age and 1% for older children
– If cycloplegic refraction shows > 3 D  prescribe full hyperopic correction.
– If ET > 10 to 15 PD persist after prescribe full hyperopic correction 
SURGERY is required
239

240. Accommodative esotropia
• CLINICAL FEATURES
– Usually acquired around 2 to 4 years of age
– Moderate to large esotropia (20 to 50 PD)
– Variable angle that is often intermittent
– Associated with hyperopia usually +2 to +6 D
– Classify as
• R f ti (Normal AC/A ratio)
Refractive (N
l
ti )
• Non refractive (High AC/A ratio)
• Partially accommodative
240

241. Non surgical treatment
•
Refractive accommodative esotropia
– Corrective lenses
• Full amount of hyperopia as determined under cycloplegia
• Full time spectacle wear  instill Atropine 1% at bed time to make initial
compliance
• Esotropia fully corrected distance and near
–
–
–
–
Full hypermetropic correction
ET < 8 to 10 PD
Single vision spectacle (without bifocal)
Surgery is not needed.
needed
• Distance corrected, but there is residual esotropia at near (high AC/A ratio)
–
–
–
–
–
Full hypermetropic correction
Distance deviation resulting fusion (i.e, < 10 PD ET)
Residual ET at near that can not be fused (i e > 10 PD ET)
(i.e
Prescribe a flat-top bifocal add. (start : + 2.50 to + 3.00 D)
Prescribe the least amount of near add to obtain fusion while leaving a
small near esophoria (E < 5 PD)
• Residual esotropia distance and near (
p
(Partially Accommodative esotropia)
y
p )
– With full hypermetropic correction
– Distance esotropia persist can not be fused (usually > 10 PD).
 SURGERY is INDICATED
– Miotic agent  subtitutes for glasses
American Academy of Ophthalmology
241

242. Non surgical treatment
• Non-refractive accommodative esotropia
– Bifocals
•
•
•
•
•
Flat-top design preferred
+2.50 to +3.00 D
Top of the segment should CROSS the pupil
Vertical height not exceed distance portion of the lens
Progressive lens must be fitted higher of 4 mm than adult fitting
with maximum bifocal power of +3.50 D
• Give detail to opticians
• Acceptance value 
– Fusion at distance
– L
Less th 10 ∆ residual esotropia at near
than
id l
t i t
– Long-lasting cholinesterase inhibitors  0.125% echothiophate
iodide both eye one time daily for 6 weeks
American Academy of Ophthalmology
242

243. Bifocal for Deviations
243

244. Order for surgery
• Surgery between 6 months and 2
years of age (most reference
recommend)
• Surgery between 6 months and 1 year
of age (standard approach).
• Early surgery between 3 and 5 months
of age (controversial, but may improve
sensory outcome)
outcome).
244

245. Surgical Approach
• The procedure of choice  bilateral medial
rectus muscle recession
g
g
• Near deviation as the target angle.
• In older patients with irreversible amblyopia
 recession medial rectus and resection
lateral
l t l rectus t amblyopic eye
t to
bl
i
• The surgical goal  not to operate the
patients out of glasses but to achieve
glasses,
alignment and fusion with full hypermetropic
correction
245

246. Non accommodative
Non-accommodative esotropia
• CLINICAL FEATURES :
–
–
–
–
–
Usually emmetropic, may be myopic
Onset after 2 years, even in late adulthood
Full duction
Late onset ET of unknown etiology
Surgery is the treatment of choice
• Bilateral lateral rectus recession
• Often undercorrection increase the amount of recession
• Try using prism adaptation to determine the full target angle
angle,
especially if there is a disparity between the distance and
near deviation.
• Operate for the full prism adapted angle
246

247. Sensory Esotropia
• Associated with a monocular blindness
or dense amblyopia
amblyopia.
• Treatment : recession lateral rectus
and resection medial rectus muscle is
performed on the eye with poor vision
• To obtain Cosmetic appearance of
straight eyes.
247

248. EXODEVIATION
• Exodeviation
– Pseudoexotropia
• An appearance of exodeviation when in fact the
pp
eyes are properly aligned
• Positive angle kappa
• Wide interpupillary distance
– Exophoria
• Controlled by fusion u de co d o o normal
Co o ed
us o under condition of o a
binocular vision
– Intermittent exotropia
American Academy of Ophthalmology
248

249. Intermittent exotropia
•
Classified by
– Difference distance and near between alternating prism and cover test
measurement
– Change in near measurement by unilateral occlusion or +3.00 D lenses
•
Clinical features
–
–
–
–
–
–
Most common form of exotropia
Usually present after 1 year of age
Large exophoria that spontaneusly becomes to a tropia
g
p
p
y
p
High grade stereopsis when fusing; suppression when tropic
Squint one eye to bright sun light
The exotropia is typically manifest when the patient is fatigued,
daydreaming or ill
– Symptoms  blurred vision, asthenopia, visual fatigue and rarely
diplopia in older children and adults
American Academy of Ophthalmology
249

250. Intermittent exotropia
• Basic type
– Same at near and distance
• Divergence excess
– Greater at distance
– True divergence excess
• Greater at distance even after a periods of monocular occlusion
• High gradient AC/A ratio at near by +3.00 D lenses
– Simulated divergence excess
• Greater than distance
• Same after one eye is 1 hour occluded  to remove the effect of
tenacious proximal fusion
• Convergence insufficiency
– Greater at near than distance
– Excludes isolated convergence insufficiency
American Academy of Ophthalmology
250

251. Non surgical treatment
•
Corrective lenses
– Improve retinal image clarity
•
Additional minus lens power
– Usually 2-4 D beyond refractive error correction
– Temporarily stimulate accommodative convergence
•
Part time patching
– Passive orthoptic treatment
– 4-6 hours per day or alternate daily patching
– Treatment for small to moderate-sized deviation
•
Active orthoptic treatment
–
–
–
–
•
Anti suppression therapy / diplopia awareness
Fusional convergence training
Alone or in combination with patching, minus lenses and surgery
Good for deviations of 20∆ or less
Base in prism
– Promote fusion
– Not recommended for long term treatment  cause a reduction in
fusional vergence amplitudes
f i
l
lit d
American Academy of Ophthalmology
251

252. Surgical treatment
•
•
•
•
•
Deviation of 15 ∆ or more
Nearly constant exotropia
Still i t
intermittent
itt t
Before 7 years of age
Before 5 years of strabismus duration
American Academy of Ophthalmology
252

253. NOTE
• Children under 4 years of age are at
risk f d
i k for developing postoperative
l i
t
ti
amblyopia and losing binocular vision.
• It is probably best to postpone surgery
until 4 years of age unless the patient
demonstrates progressive loss of
fusion control.
253

254. Another exodeviation
• Constant exodeviation
– Congenital exotropia
– Sensory exotropia
– Consecutive exotropia
– Exotropia Duane’s retraction syndrome
– Neuromuscular abnormalities
– Di
Dissociated h i
i t d horizontal d i ti
t l deviation
American Academy of Ophthalmology
254

255. 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 difference compares to down gaze
• V P tt
Pattern
– Eyes closer together in down gaze
– 15 PD difference compares to up gaze
Deborah Pavan-Langston, 2008
255

256. A Pattern
• Etiology
– Most f
frequent  overaction of SO
f
– With or without underaction of IO
– As SO acts abduction in downward gaze
• Esotropia decreases
• Exotropia increases
– If no overaction of SO  suspect underaction of LR
• Treatment
– Deviation more than 10 PD
– Bilateral weakening  Tenotomy with silicone expander
– Horizontal surgery
g y
• With upward displacement of MR
• With downward displacement of LR
– Bilateral SO surgery  avoided in patient with foveal bifixator
Deborah Pavan-Langston, 2008
256

257. V Pattern
•
Etiology
– Most frequent  overaction of IO
– Primary underaction of SO
– As IO acts abduction in upgaze
• Esodeviation decreases
• Exodeviation increases
– Overaction of LR  V exotropia
•
Head position
– V esodeviation  chin held down close work
– V exodeviation  chin held up
•
Treatment V esotropia
– Recession or disincertion of overacting IO
– Recession or downward the MR if obliques are normal
•
Treatment V esotropia
– Recession or disincertion of LR if IO overacts
Deborah Pavan-Langston, 2008
257

258. Strabismus : Position test
Measurement of deviation
• Hiscberg test
• C
Cover t t
test
• Cover uncover test
• Krimsky test
• Prisms Cover test
• Prisms Alternate Cover Test (PACT)
American Academy of Ophthalmology
258

259. 259

260. 260

261. 261

262. 262

263. 263

264. Strabismus : Sight test
• WFDT
• Maddox’s rod
264

265. 265

266. 266

267. 267

268. 268

269. Approach to Recession surgery
Minimal (mm)
Average
maximum (mm)
Maximum
ever (mm)
LR
4
8 - 10
MR
2.5
7 adult
6 children
5 - 5.5
6-7
14 for nystagmus
SR
2.5
5
IR
2.5
10
5
Eugene M. Helvestone
269

270. Approach to Resection surgery
Minimal (mm)
Average
maximum (mm)
Maximum
ever (mm)
LR
5
8 infant
10 children and adult
-
MR
5
8 infant
10 children and adult
-
SR
2.5 - 3
5
-
IR
2.5 - 3
5
-
Eugene M. Helvestone
270

271. Prisms Muscle
Prisms-Muscle length conversion
• 5 ∆ Di t f 1 mm MR recession
Diopter for
i
• 2.5 ∆ Diopter for 1 mm LR recession
• 2.5 ∆ Diopter for 1 mm MR and LR
resection
271

272. Both eye surgery for Esodeviation :
Angle of esotropia (∆)
Recess MR OU (mm)
OR
Resect LR OU (mm)
10
3.0
4.0
20
3.5
35
5.0
50
25
4.0
6.0
30
4.5
7.0
35
5.0
8.0
40
5.5
9.0
50
6.0
9.0
American Academy of Ophthalmology
272

273. Monocular surgery for Esodeviation
Angle of esotropia (∆)
Recess MR OU (mm) AND Resect LR OU (mm)
10
3.0
4.0
20
3.5
35
5.0
50
25
4.0
6.0
30
4.5
7.0
35
5.0
8.0
40
5.5
9.0
50
6.0
9.0
American Academy of Ophthalmology
273

274. Both eye surgery for Exodeviation :
Angle of exotropia (∆)
Recess LR OU (mm)
OR
Resect MR OU (mm)
15
4.0
3.0
20
5.0
50
4.0
40
25
6.0
5.0
30
7.0
6.0
40
8.0
6.0
American Academy of Ophthalmology
274

275. Monocular surgery for Exodeviation :
Angle of exotropia ( )
g
p (∆)
Recess LR OU (mm) AND Resect MR OU (mm)
(
)
(
)
15
4.0
3.0
20
5.0
4.0
25
6.0
5.0
30
7.0
6.0
40
8.0
6.0
50
9.0
7.0
60
10.0
10 0
8.0
80
70
10.0
9.0
80
10.0
10.0
American Academy of Ophthalmology
275

276. Strabismus : Exercise
Synophthophore
Holme’s stereoscope
276

277. Glaucoma
277

278. Glaucoma : Basic
• Definition
– Optic neuropathy
– Visual field defect
– Rise of IOP as major risk
278

279. 279

280. Glaucoma : Basic
•
•
•
•
•
•
•
•
IOP measure
Angle examination
Optic nerve head examination
Vascular change
RNFL examination
i ti
Visual field examination
Central corneal thickness and rigidity
General eye examination*
280

281. IOP : Basic
•
•
•
•
•
•
•
Normal IOP  10-20 mmHg
10 20
Average  15 mmHg
Fluctuation
Fl t ti  2 56 mmHg
2.56
H
Diurnal Variation  3-6 mmHg
Peak period  Morning
Decrease during the night
Hypotony < 5-6 mmHg
Gumansalangi MNE, 2003
281

282. IOP : Determining factors
F = C (P – P )
(Po Pe)
• F
• C
= rate of aqueous outflow (normal 2 µl/min)
= facility of aqueous outflow (normal 0.2
µl/min/mmHg
• Po = IOP in mmHg
• Pe = episcleral venous pressure (normal 10 mmHg)
Kanski JJ, 2007
282

283. How to measure the IOP
• First line
– Applanation tonometer  Nowadays Gold standard  AT 900D
(Haag-Streit International)
– Dynamic contour tonometer  E g : PASCAL (Ziemer)
E.g
• Second line
– Air-puff non-contact tonometer
– Corvis ST Air-puff non-contact tonometer with Scheimpflug
Camera Cornea Monitoring (OCULUS)
– Tono-Pen, The Pachmate DGH 55, Diaton, Schiotz tonometer
– iCare ONE tonometer, SOLX IOP sensor*  IOP monitoring
283

284. IOP : Flow
•
•
•
•
•
Cilliary body
Posterior chamber
Pupil
P il
Anterior chamber
Delivery
– Trabecular pathway (85-95%)
(85 95%)
– Uveo-scleral pathway (5-15%)
– Iris (Kanski)
284

285. IOP : Flow
• Aqueous come in to eye by :
– Diff i
Diffusion
– Ultrafiltration
–C
Carbonic Anhydrase II activity
– Active secretion
American Academy of Ophthalmology
285

286. Glaucoma: Vascular dysregulation
y g
• Endhotelial dysfunction
– Impaired endothelium-derived nitric oxide
activity
– Abnormalities of the endothelin system 
altered Endothelin-1 (ET1) vasoreactivity
• Defective auto regulation of ocular blood
flow
• Instable blood supplies to the tissue
Henry E, 2006; Araie M, 2010
286

287. Glaucoma : Angle
•
•
•
•
•
•
•
Torch
Von Herrick Slit-lamp
Gonioscopy
Ultrasound Biomicroscopy (UBM)
Anterior
A t i OCT
Scheimpflug Camera Pentacam
Very high frequency (VHF) ultrasound eye
scanner  Artemis (ArcScan, Inc)
287

288. Angle : Observation
288

289. Angle Examination : Torch
289

290. Angle Examination : Van Herick
Von Herrick and Shaffer grades
Grade
Ratio of aqueous gap/cornea
Clinical interpretation
Shaffer angle degrees
4
>½/1
Closure impossible
45-35
3
½-¼ /1
Closure impossible
35-20
2
¼/1
Closure possible
20
1
<¼/1
Closure likely with full dilation
10 or less
0
Nil
Closed
0
290

291. Angle Examination : Gonioscopy
291

292. Identification of Schwalbe’s Line
Schwalbe s
Thomas R, 2006
292

293. Shaffer’s Intepretation
Classification
Angle Width
Visible Structure
Clinical Intepretation
Grade 0
Closed
Schwalbe’s line is not visible
Totally closed angle
Grade I
10°
Schwalbe’s line visible
Considerable risk of closure
Grade II
20°
Anterior trabeculum is visible
Bear watching
Grade III
30°
Scleral spur is visible
No risk of angle closure
Grade IV
40°
Ciliary body is visible
No risk of angle closure
293

294. PAS look alike
Thomas R, 2006
294

295. Rubeosis
Thomas R, 2006
295

296. Angle Recession
g
Thomas R, 2006
296

297. Angle Examination : UBM
297

298. Angle Examination : UBM
Normal eye’s angle
Angle : Pupillary block
298

299. Angle Examination : Anterior OCT
Visante OCT (Carl Zeiss Meditec AG)
299

300. Scheimpflug Camera Pentacam
300

301. Artemis ( Ultralink)
50 MHz ArcScan
301

302. The Angle
302

303. Shaffer s
Shaffer’s Intepretation
Classification
Cl
ifi ti
Angle
A l Width
Visible St
Vi ibl Structure
t
Clinical I t
Cli i l Intepretation
t ti
Grade 0
Closed
Schwalbe’s line is not visible
Totally closed angle
y
g
Grade I
10°
Schwalbe’s line visible
Considerable risk of closure
Grade II
20°
Anterior trabeculum is visible
Bear watching
Grade III
30°
Scleral spur is visible
No risk of angle closure
Grade IV
40°
Ciliary body is visible
No risk of angle closure
303

304. Optic disc
A. Surface
B. Pre Laminar
C. Laminar
D. Retro Laminar
304

305. GON : Evaluation
• Indirect ophthalmoscope*
• Direct ophthalmoscope
• Slit lamp : stereoscopic view
• H b or El B
Hruby
Bayadi l
di lens
• 60, 78, 90 D
• Contact lens
Thomas R, 2006
305

306. GON : Evaluation
•
•
•
•
•
•
•
Disc  Generally
Cup
Neuro R ti l Ri (NRR)
N
Retinal Rim
Peripapillary hemorrhage
Circum Linear Vessels (CLV)
Para Papillary Atrophy (PPA)
Retinal Nerve Fiber Layer (RNFL)
306

307. GON : Evaluation
Generalized
Large optic cup
L
ti
Asymmetry of the cup
Progressive enlargement
of the cup
Focal
Narrowing ( t hi ) of th rim
N
i (notching) f the i
Vertical elongation of the cup
Cupping to the rim margin
Regional palor
Splinter hemorrhage
S li t h
h
Nerve fiber layer loss
Less specific
Exposed l i cribosa
E
d lamina ib
Nasal displacement of vessels
Baring of circumlinear vessels
Peripapillary crescent
(TJ et al, 2003)
al
307

308. Cup and Disc
308

309. Disc Excavasion
309

310. Definition of Cup : Disc Ratio
• Disc Diameter
• Cup Diameter
• CDR = c / d
c d
• Horizontal > Vertical
Thomas R, 2006
310

311. Thomas R, 2006
R
311

312. 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 Splinter Hemorrhages
d. Cup enlarge to Superior and show
Inferior Bayoneting Sign
e. Advance Cupping Oval Disc
enlarge to superior and inferior
f. Pale Papil with deep excavasion
312

313. CDR Asymmetry
Thomas R, 2006
313

314. Asymmetric cupping
314

315. Cup Depth
•
•
•
•
Not of much importance
In normal : depends on disc area
In glaucoma : type & level of IOP
Deepest with high IOP
– Juvenile POAG
– Angle recession
Thomas R, 2006
315

316. Neuro Retinal Rim (NRR): Shape
• Sloping rim in small and intermediate discs
• Steep or over hanging with oblique insertion
• Supero nasal tilt in normal
• Nasal tilt in myopes
Thomas R, 2006
316

317. NRR in Glaucoma
• Loss of physiological shape
• ISNT rule i b k
l is broken
• Vertical cup enlarges
Thomas R, 2006
317

318. Jonas ISNT Rule
•
Less marked in large discs
•
Rim more evenly distributed
•
Punched out well defined
cup in large discs
•
p
Also compare Inferior &
Superior to temporal rim
•
Inferior to Temporal 2 : 1
•
Superior to Temporal 1.5 : 1
Thomas R, 2006
318

319. NRR : I S N T
• Partially depends on exit of central retinal
vessels
l
• Rim furthest away is more affected
• May explain unusual configuration of rim
Thomas R, 2006
319

320. Temporal Portion of Rim
• Papillo macular bundle
• Preferential cupping temporally with field
loss near fixation
• POAG with Myopia and NTG
Thomas R, 2006
320

321. Glaucoma & Contour of Rim
• May cause a backward bowing of the rim
tissue
• Deep extension of the cup in one meridian
• Gentler sloping backward : Saucerization
Thomas R, 2006
321

322. Rim contour : Normal
Thomas R, 2006
322

323. Saucerization
• Slight backward
bowing : like
saucer
• Periphery or a
portion
ti
• Or whole disc
• May be first
change
Thomas R, 2006
323

324. Shelving : No Field Defect ?
Thomas R, 2006
324

325. Excavation : Field Defect
Thomas R, 2006
325

326. Excavation : Field Defect
Thomas R, 2006
326

327. Excavation : Superior and Inferior
Thomas R, 2006
327

328. Notching
Thomas R, 2006
328

329. Disc Hemorrhage
• Rare in normals (1%)
• 4 -7 % in glaucoma
7
• > In “NTG”
• Lasts 10 weeks (1035)
Thomas R, 2006
329

330. Disc Hemorrhage
• Splinter or flame
shaped
• Border of disc
• Inferior or superior
temporal region
• RNFL defects,
Notching, Focal
perimetric loss
Thomas R, 2006
330

331. Circum Linear Vessels (CLV)
• Vessel hugging
gg g
the NRR
• Exits disc for
macula
• Normally present
in 50 % of eyes
Thomas R, 2006
331

332. Circum Linear Vessels (CLV)
Thomas R, 2006
332

333. Circum Linear Vessels “Bared” in Glaucoma
• N
Normal CLV
l
• As rim is lost : gap
between vessel and
rim
– Implies loss of rim
• F i l specific
Fairly
ifi
• Superficial or deep
CLV normally present in 50 % of eyes
Thomas R, 2006
333

334. Para Papillary Atrophy (PPA)
• Central beta zone
• Peripheral alpha zone
• Rare nasally or
circumferential
• Correlate with myopia
and age
Thomas R, 2006
334

335. Para Papillary Atrophy In Normals
• Beta zone : 20 %
• Alpha zone : 95 + %
Thomas R, 2006
335

336. PPA : Alpha Zone
•
•
•
•
Peripheral to beta or disc margin
Irregular Hyper and Hypo pigmentation
Thinning of RPE
Relative scotoma
Thomas R, 2006
336

337. PPA : Beta Zone
•
•
•
•
•
Central to alpha
Peripheral to disc margin
Marked atrophy of RPE
Visible choroidal vessels & sclera
Absolute scotoma
Thomas R, 2006
337

338. PPA in Glaucoma
• Central beta zone
more important
• Peripheral alpha
zone
Thomas R, 2006
338

339. PPA in POAG
• B t larger in hi h
Beta l
i high
myopic POAG
• Next in age
related POAG
• Less in SOAG
• ? NTG and POAG
Thomas R, 2006
339

340. Disc Hemorrhage a d Para Papillary Atrophy
sc e o age and a a ap a y t op y
• PPA associated
with h
ith hemorrhages
h
• PPA  marker for
old hemorrhages
Thomas R, 2006
340

341. Axonal distribution
341

342. Glaucoma : RNFL Defect
342

343. Normal RNFL :
Axons Bundled by Mueller Cell Processes
Bright fine striations
• Best seen 
Inferior and
superior temporal
p
p
(Inferior > Superior)
• Bright Dark Bright
• Fans off the disc to
periphery
Thomas R, 2006
343

344. RNFL Visibility
•
•
•
•
Clear media
Without yellowing of lens
Deeply pigmented RPE
Decreases with age
D
ith
– Loose 4000 - 5000 per year
Thomas R, 2006
344

345. RNFL : Normal ?
• “Obscures”
normal vessels
• Slit like or groove
like defects
• Narrower than
retinal vessels
Thomas R, 2006
345

346. Localized RNFL Defects
•
•
•
•
•
Dark wedge
Larger than vessel
Touching disc
Fan out
Broad at temporal
raphe
Thomas R, 2006
346

347. Localized RNFL Defects
• Not seen in normal
• 20% of Glaucoma eyes
– Less with early glaucoma
– Touch the disc
• Other causes of atrophy
– Drusen, Toxoplasmosis,
Ischemia, Papiledema,
Optic Neuritis
Thomas R, 2006
347

348. Localized RNFL Defects a d Disc Hemorrhage
oca ed
e ects and sc e o age
• Disc hemorrhage
• Localized defect
– 6 - 8 weeks
• Localized type of
disc damage : Notch
Thomas R, 2006
348

349. Diffuse RNFL Defects
• I f i less visible
Inferior l
i ibl
than Superior
• Bright Dark, Bright
Bright, Dark
pattern lost
g
• Macula as bright
as Superior and
Inferior
• “N k d” vessels
“Naked”
l
Thomas R, 2006
349

350. Frequency of RNFLD in Glaucoma
• More with focal NTG
• Less with
– Age related POAG
– Highly myopic OAG
–J
Juvenile OAG
il
Thomas R, 2006
350

351. Importance of Localized RNFL
p
Defects in Early Diagnosis
• E
Eyes with normal
ith
l
IOP and Visual
Fields
• Show field loss on
follow up
• “Pre perimetric”
Glaucoma
• J t’ R l # 2
Jost’s Rule
Until proved otherwise, all glaucoma (suspects) have a RNFL defect
Thomas R, 2006
351

352. Subtle Retinal Nerve Fib L
S btl R ti l N
Fiber Layer D f t
Defect
Thomas R, 2006
352

353. With Experience :
Thomas R, 2006
353

354. With More Experience :
Thomas R, 2006
354

355. Re check
Re-check !
Thomas R, 2006
355

356. Many Optic Disc Changes Have
Been Described in Glaucoma
Loss of ISNT pattern
Localized notch in the rim
Acquired Pit
Disc Hemorrhage
Wedge / diffuse loss of retinal
nerve fibers
 Absent rim inferiorly,
superiorly, temporally & or
nasally
 Increase in cupping over time









•
•
•
•
•
•
Asymmetry in CDR > 2
y
y
Cup large for disc size
Vertically oval cup
Baring of CL vessels
Over pass phenomenon
Large CDR
CDR of > 0.7
Deep cup
Laminar dot sign
g
Thinned retinal arterioles
Don t
Don’t Just Use The Cup : Disc Ratio !
Thomas R, 2006
356

357. Once more
357

358. RNFL Examination
• Ophthalmoscope (Red free light)
• R dF
Red Free Ph t
Photographs
h
• HRT, OCT, GDxVCC
Slit lamp (Green light)
358

359. SLP, OCT and CSLO/T
•
•
•
Pre Perimetric Glaucoma Detection
Non Perimetric Glaucoma Progression Analysis
RNFL analysis over Optic disc analysis
359

360. Scanning laser polarimetry
– GD VCC (Carl Zeiss Meditec AG)
GDxVCC (C l Z i M dit
360

361. GDxVCC
361

362. OCT
Normal retina OCT
Glaucomatous retina OCT
362

363. OCT : Symmetric optic discs with C/D ratio of 0.3
Optic Nerve Head Analysis Results
Vert. Integrated Rim Area (Vol.)
Horiz. Integrated Rim Width (Area)
Disk Area
Di k A
Cup Area
Rim Area
Cup/Disk Area Ratio
Cup/Disk Horiz. Ratio
p
Cup/Disk Vert. Ratio
.321 mm3
1.717 mm2
2.53
2 53 mm2
2
.938 mm2
1.592 mm2
0.371
0.647
0.593
Optic Nerve Head Analysis Results
Vert. Integrated Rim Area (Vol.)
Horiz. Integrated Rim Width (Area)
Disk Area
Cup Area
Rim Area
Cup/Disk Area Ratio
Cup/Disk Horiz. Ratio
Cup/Disk Vert. Ratio
.313 mm3
1.706 mm2
2.217 mm2
.764 mm2
1.453 mm2
0.345
0 345
0.622
0.586
RNFL analysis demonstrates a typical p
y
yp
pattern in the OD and flattening of the RNFL p
g
pattern in the OS.
Thinning of the superior RNFL is consistent with the visual field defect and the diagnosis of glaucoma.
This was later confirmed by visual field with infero-nasal defect, OS
363

364. OCT : OD appears within normal limits with a C/D ratio of 0.5. OS has
large cup with C/D ratio of 0.7. Visual fields within normal limits
Optic Nerve Head Analysis Results
Vert. Integrated Rim Area (Vol.)
Horiz. Integrated Rim Width (Area)
Disk Area
Di k A
Cup Area
Rim Area
Cup/Disk Area Ratio
Cup/Disk Horiz. Ratio
p
Cup/Disk Vert. Ratio
.327 mm3
1.578 mm2
1.998
1 998 mm2
2
.646 mm2
1.352 mm2
0.323
0.538
0.58
Optic Nerve Head Analysis Results
Vert. Integrated Rim Area (Vol.)
Horiz. Integrated Rim Width (Area)
Disk Area
Cup Area
Rim Area
Cup/Disk Area Ratio
Cup/Disk Horiz. Ratio
Cup/Disk Vert. Ratio
.188 mm3
1.597 mm2
2.973 mm2
1.766 mm2
1.207 mm2
0.594
0 594
0.775
0.791
Anatomic large nerve head with normal RNFL. Only distinguished with Stratus OCT Crossg
y
g
sectional imaging is vital in the analysis of RNFL thickness in vivo, particularly in differentiating
healthy RNFL from glaucomatous RNFL
364

365. Glaucoma RNFL scanning on Cirrus OCT
NEW Optic Disc cube 200 X 200 scan pattern
365

366. Optic Disc Cube 200 X 200 scan pattern
Auto Center™
Center of ONH automatically identified.
Measurement of TSNIT graph thickness is
automatic. Less operator dependant and crucial
for
f repeatibility
tibilit
366

367. Cirrus HD-OCT
Normal OU RNFL
printout
i t t
Similar to Stratus OCT RNFL
thickness reporting format
thi k
ti f
t
RNFL thickness map
RNFL thickness
deviation map (
p (LSO
fundus)
RNFL thickness values
ISNT and Average
Multi-ethnicity (Including
Asian Eye) NDB
367

368. Cirrus HD-OCT
RNFL thickness report
OS RNFL
loss at 6
o’clock
368

369. Cirrus HD-OCT
OU nerve loss
RNFL printout
p
369

370. RTVue
3D SD-OCT
with Ganglion
Cells Analyzer
370

371. Confocal scanning laser topography
– HRT3 (Heidelberg Engineering GmbH)  provides
objective measurements of the optic nerve head and
surrounding RNFL
– High quality stereo photographs of the optic disk
371

372. HRT
372

373. The Moorfields Regression Analysis
HRT measurements have been shown to have high diagnostic accuracy for
detecting glaucoma.
glaucoma
The Moorfields Regression Analysis had a sensitivity and specificity of 84% and
96% respectively.
An analysis based on the shape of the optic disc and surrounding RNFL resulted
in a sensitivity and specificity of 89% and 89%.
A sophisticated type of neural network analysis called a Support Vector Machine
373
resulted in a sensitivity and specificity of 91% and 90%

374. VISUAL FIELD (VF)
( )
• Isopter /isop·ter/ (i-sop´ter) a curve
/isop ter/ (i sop ter)
representing areas of equal visual acuity in
the field of vision
• A curve of equal retinal sensitivity in the
visual field
– Designated by a fraction
– The numerator being the diameter of the test
object
– The denominator being the testing distance
MedWeb, 2008
374

375. Indication of Visual field test
•
•
•
•
•
•
•
•
•
•
Raised IOP
Suspected GON
Asymmetric C/D Ratio  > 0.3
3 mmHg IOP difference on both eyes
H
diff
b h
Glaucoma on other eye
Previous retinal detachment
Unexplained low visual acuity
Discomfort “perfect” vision
sco o t pe ect s o
Unexplained headache and migraine
Injured eye
Gumansalangi MNE, 2003
375

376. Visual field : Normal
• The field of vision is defined as the area that is perceived
simultaneously by a fixating eye.
• The limits of the normal field of vision are 60° into the superior
60
field, 75° into the inferior field, 110° temporally, and 60°
nasally.
• An island of vision in the sea of darkness
• The island represents the perceived field of vision, and the
sea of darkness is the surrounding areas that are not seen.
• In the light-adapted state, the island of vision has a steep
light adapted state
central peak that corresponds to the fovea, the area of
greatest retinal sensitivity.
MedWeb, 2008
376

377. THE NORMAL VISUAL FIELD
377

378. THE NORMAL VISUAL FIELD
• The contour of the island of vision relates to both
the anatomy of the visual system and the level of
retinal adaptation.
• The highest concentration of cones is in the
fovea, and most of these cones project to their
own ganglion cell.
• This one-to-one ratio between foveal cone and
ganglion cell results i maximal resolution i the
li
ll
l in
i l
l i in h
fovea.
MedWeb, 2008
378

379. KINETIC PERIMETRY
• In kinetic perimetry a stimulus is moved from a nonseeing
perimetry,
area of the visual field to a seeing area along a set meridian.
• The procedure is repeated with the use of the same stimulus
along other meridians usually spaced every 15°.
meridians,
15
• In kinetic perimetry, one attempts to find locations in the
visual field of equal retinal sensitivity.
• By j
y joining these areas of equal sensitivity, an isopter is
g
q
y,
p
defined.
• The luminance and the size of the target is changed to plot
other isopters.
• In kinetic perimetry, the island of vision is approached
horizontally.
• Isopters can be considered the outline of horizontal slices of
the island of vision.
vision
MedWeb, 2008
379

380. STATIC PERIMETRY
• In static perimetry the size and location of the test
perimetry,
target remain constant.
• The retinal sensitivity at a specific location is
determined by varying the brightness of the test
target.
• The shape of the island is defined by repeating the
threshold measurement at various locations in the
field of vision.
MedWeb, 2008
380

381. STATIC PERIMETRY
381

382. MANUAL PERIMETRY: THE GOLDMANN VISUAL FIELD
• The Goldmann perimeter is the most widely
used instrument for manual perimetry.
• It is a calibrated bowl projection instrument with
a background intensity of apostilbs (asb), which
is
i well within th photopic range.
ll ithi the h t i
• The size and intensity of targets can be varied to
plot different isopters kineticall and determine
kinetically
local static thresholds.
MedWeb, 2008
382

383. THE GOLDMANN VISUAL FIELD
•
•
•
•
First in 1945 by Hans Goldmann
Photopic background ( 10 cd/m² )
Moving and static circular targets
The stimuli used to plot an isopter are identified by a
Roman numeral, a number, and a letter.
p
j
• The Roman numeral represents the size of the object,
from 0.05º Goldmann size 0 (1/16 mm2) to 1.7º
Goldmann size V (64 mm2) .
• Each size increment equals a twofold increase in
diameter and a f f ld i
di
d fourfold increase i area
in
• Visual angle + 90º
MedWeb, 2008
383

384. GOLDMANN VISUAL FIELD
MedWeb, 2008
384

385. GOLDMANN VISUAL FIELD
• The number and letter represent the
intensity of the stimulus.
5 db
• A change of one number represents a 5-db
(0.5 log unit) change in intensity, and each
letter represents a 1-db (0.1 log unit)
change i i t
h
in intensity.
it
• The dynamic range of the Goldmann
perimeter from the smallest/dimmest target
(01a) to the largest/brightest target (V4e) is
greater than 4 log units, or a 10,000-fold
change.
h
MedWeb, 2008
385

386. GOLDMANN VISUAL FIELD
• The number and letter represent the intensity of
p
y
the stimulus. A change of one number
represents a 5-db (0.5 log unit) change in
intensity,
intensity and each letter represents a 1 db (0 1
1-db (0.1
log unit) change in intensity.
• The dynamic range of the Goldmann perimeter
from the smallest/dimmest target (01a) to the
largest/brightest target (V4e) is greater than 4
log it
l units, or a 10 000 f ld change.
10,000-fold h
MedWeb, 2008
386

387. GOLDMANN VISUAL FIELD
• Isopters in which the sum of the Roman numeral (size) and
number (i t
b (intensity) are equal can b considered equivalent.
it )
l
be
id d
i l t
For example, the I4e isopter is roughly equivalent to the II3e
isopter.
• A change of one number of intensity is roughly equivalent to a
change of one Roman numeral of size.
• The equivalent isopter combination with the smallest target
size usually is p
y preferred because detection of isopter edges is
p
g
more accurate with smaller targets.
• One usually starts by plotting small targets with dim intensity
(I1e) and then increasing the intensity of the target until it is
maximal before increasing the size of the target
target.
• The usual progression then is I1e (ARW1) I2e (ARW1) I3e
(ARW1) I4e (ARW1) II4e (ARW1) III4e (ARW1) IV4e (ARW1)
V4e
e
MedWeb, 2008
387

388. GOLDMANN VISUAL FIELD
388

389. AUTOMATED PERIMETRY
• The introduction of computers and automation
heralded a new era in perimetric testing.
• St ti testing can be performed in an objective
Static t ti
b
f
di
bj ti
and standardized fashion with minimal
p
perimetrist bias.
• A quantitative representation of the visual field
can be obtained more rapidly than with manual
testing.
testing
• The computer allows stimuli to be presented in
a pseudorandom, unpredictable fashion.
MedWeb, 2008
389

390. AUTOMATED PERIMETRY
• Patients do not know where the next stimulus will
appear, so fixation is improved, thereby increasing
the reliability of the test.
• Random presentations also increase the speed
with which perimetry can be performed by
bypassing th problem of l
b
i the
bl
f local retinal adaptation,
l ti l d t ti
which requires a 2-second interval between stimuli
if adjacent locations are tested
tested.
MedWeb, 2008
390

391. Static suprathreshold and threshold testing
• Is processes to determine sensitivity of the retina to light
stimulus
• In addition to plotting isopters kinetically, static
suprathreshold and threshold testing can be performed
manually.
ll
• Once an isopter is plotted, the stimulus used to plot the
isopter is used to statically test within the isopter to look
for localized defects.
• In this way, it acts as a suprathreshold stimulus.
• Static thresholds also can be determined along set
meridians to obtain profile plots of the visual field, but like
any multiple thresholding task, it is time consuming.
MedWeb, 2008
391

392. Visual Fields : Advanced Concepts
•
The Threshold Strategy
– The threshold strategy defines the threshold as being that level of light intensity
that the patient responds to 50% of the time
– Th most common example i th H
The
t
l is the Humphrey Vi
h
Visual A l
l Analyzer 24 2 th h ld
24-2 threshold
strategy for glaucoma.
– In this strategy, a grid of 54 points is tested in the central 24 degrees
•
Swedish Interactive Thresholding Algorithm (SITA)
– Designed to reduce testing time while still providing an adequate test of visual
sensitivity.
– Reduced test time should increase attentiveness and result in a more reliable
test
– There are two different SITA programs :
• SITA Standard  designed to replace the Full Threshold program
(e.g. Full Threshold 30-2  a grid of 76 test points).
• SITA Fast  designed to replace Fastpac, which is a simplified Threshold program
•
The Suprathreshold or Screening Strategy
– Screening strategies use knowledge of the normal threshold values to present
only suprathreshold stimuli that are just above the normal threshold values.
– If the patient misses a significant number of these stimuli then the program is
stimuli,
considered to have detected a defect that warrants further testing
392

393. Visual Field Analyzer
y
• Standard Achromatic Automated Perimetry (SAP)
–
–
–
–
–
–
–
–
White-on-white perimetry
Whit
hit
i t
First established 1972 by Franz Frankhauser et al
Mesopic to Photopic background (1.27 cd/m² or 10 cd/m²)
Static test targets with 0.43º Goldmann size III for Standard test
1.7º Goldmann size V for low vision testing
Standardized-high availability-wide dynamic range
Feasible visual range usually ± 30º, theoretically up to ± 90º
SAP :
• Humphrey Visual Field Analyzer II (Carl Zeiss Meditec AG),
program 24 2 software version 3 4 and the SITA testing
24-2, f
i 3.4.7, d h
i
algorithm
• Centerfield 2 Compact Perimetry (Oculus Optikgeräte GmbH)
Survey of Ophthalmology, 2007
393

394. Automated perimetry : Indicator
• Fixation errors: the number of times the patient looks
away from the central target. This is a key indicator of
patient cooperation or fatigue
fatigue.
• False positives: the number of times the patient pushes
the button when, in reality, a light source is not illuminated.
• False negatives: the number of times the patient fails to
push the button when, in reality, there is a light source
illuminated. These spots can be repeat tested by the
onboard computer at exactly the same spot to best
understand the patient's ability to produce an accurate fi ld
d
d h
i ' bili
d
field
test.
• Points tested: indicates the total number of separately
illuminated testing points and therefore data points
points,
presented to the patient for testing. Reliable patients can
produce a very useful field with a limited number of test
po ts
points.
MedWeb, 2008
394

395. Automated perimetry : Indicator
• Reliability index : the overall reliability of the patient's
testing for each eye. Poor reliability may indicate patient
fatigue,
fatigue insufficient understanding of the test or poor
test,
vision for other reasons such as cataracts. Visual field
tests can also be used to ferret out malingerers.
• Standard deviation: the difference in peripheral field
acuity when compared to a normative data base, or
simply put, a large group of similar normal patients. This
tells the doctor whether or not a particular p of the
p
part
peripheral field is normal, depressed, or absent.
• Visual field map: the final basic report indicating the
patient's visual field anywhere from the central 10
degrees all the way out to the farthest reaches of the
field at 90 degrees. Altered patterns in the field map from
reliable patient testing are often extremely useful in the
diagnosis of ocular or neurological disorders
disorders.
MedWeb, 2008
395

396. ASSESSING RELIABILITY
False-Positive Catch Trials
• A sound cue is given before each stimulus is presented in automated
tests.
• Periodically, the sound cue is given but no test stimulus is presented.
• Af l
false-positive result occurs if th patient responds t th sound cue
iti
lt
the ti t
d to the
d
alone.
False-Negative Catch Trials
• A false-negative catch trial is recorded if a patient does not respond at a
location that had a measurable threshold earlier in the examination.
g
g
y
patient
• A high number of false-negative catch trials may indicate p
inattentiveness and an unreliable visual field.
• The false-negative response rate is higher in eyes with extensive visual
field defects than in those with normal visual fields.
MedWeb, 2008
396

397. How to Interpret : HFA
Single Field Analysis (
g
y
(SFA) p
) print out :
• Test parameter
• Patient’s data
• Reliability indices
• dB graph
• Gray scale pattern
• Total deviation
• Localized pattern deviation
• Glaucoma Hemifield Test (GHT)
• Global indices
397

398. HFA Interpretation : Acceptability
• Right test data
• Correct patient’s data
398

399. HFA Interpretation : Reliability
• Fi ation Loss < 20 %
Fixation
• False positive < 33 %
• False negative < 33 %
399

400. Normality : dB Graph
• The dB test by HFA
range between “0” and
“50” dB
50
• A typical “normal”
reading is around 30
dB
• A value at or above 40
dB is very unusual
400

401. Normality : Gray scale
• The actual threshold value
on the dB graph converted
to a Gray scale
• The value less than or equal
to 0 dB represented b solid
d by lid
black
• The value above 40 dB are
represented by total white
• Commonly  we can not
make a diagnosis based on
g y
the gray scale
• The gray scale format quite
useful when the patients to
be explained about their
visual field status
401

402. Total deviation : Numerical plot
• The numeric plot is the actual decibel
deviation at each point as compared to
normative data
– Zero  Threshold
– Positive  More sensitive
– Negative  Depressed
402

403. Total deviation : Probability plot
• The probability plot indicates the statistical
significance and predicts the possibility of
such an normality in normal population
• Gray scale pattern
– “ < 5 % “ means l
less th 5 of 100 normal
than
f
l
people (control) have this result
– “ < 0.5 % “ means less than 5 of 1000 normal
05
people (control) have this result
403

404. Total deviation
• The Total deviation plot
p
highlights any overall
depression of visual field
– Generalized loss
– Localized loss (scotoma)
• The generalized field loss
is caused by
–
–
–
–
–
Cataract
Corneal opacities
Media opacities
Miosis
Refractive errors
404

405. Pattern deviation
• Shows sensitivity
y
losses after an
adjustment to
remove any
generalized
depression
• Primarily
highlights only
significant
localized visual
l
li d i
l
field loss
• The most
useful analysis
405

406. Deviation : Normality
Total Deviation
Pattern Deviation Interpretation
No symbol
No symbol
Normal
Some symbols
Same pattern
Pure localized loss
Many symbols
No symbols
Pure generalized loss
Many symbols
Fewer symbols
Mixed loss
No or fewer
Many symbols
Trigger happy
406

407. Glaucoma Hemifield Test (GHT)
• It compares points on the upper field to
corresponding points on lower one
• The GHT based on :
– The sensitivity of field should be similar on both
hemifield
– In Glaucoma the upper and lower hemifield are often
significantly different
• Sensitivity difference between the upper
and lower hemifield are hallmark of
glaucomatous field loss
407

408. GHT : Approach
408

409. GHT : Result
•
•
•
•
•
Outside normal limits
Borderline
General Reduction of sensitivity
Abnormally hi h sensitivity
Ab
ll high
iti it
Within normal limits
409

410. Global indices
• Mean Deviation (MD)
• Pattern Standard Deviation (PSD)
410

411. Mean Deviation (MD)
• Th average measure of how much elevation or
The
fh
h l
i
depression the patient’s visual field compared to
a normal person of the same age
• Derived from the Total deviation
• Shows how much the whole field departs from
normal
• Very sensitive to generalized loss
• A small defect will not affect MD significantly
411

412. Pattern Standard Deviation (PSD)
• It is a measure of th d
i
f the degree t which th
to hi h the
shape of the patient’s field differs from the
normal age-corrected reference fi ld
l
t d f
field
• An index of localized non uniformity of the
surface of the hill of vision
f
f th
f i i
• Strongly sensitive to the localized defect
• I not affect by purely generalized d f t
Is t ff t b
l
li d defect
• Very helpful in diagnosing early glaucoma
412

413. Global indices : Summary
MD
PSD
Interpretation
Normal
Normal
Probably Normal
y
Abnormal Normal
Generalized loss
Normal
Abnormal Small localized defect
Abnormal Abnormal Large defect with significant
Localized component
413

414. Normality : Definitively Abnormal
• GHT  Outside normal limits
• PSD  p < 5 %
414

415. Visual Field Loss : Indicator
• Mean Deviation  < - 5 dB
• Mean Deviation  p < 10%
415

416. Defect identification
•
•
•
Type
Pattern
Tendency
416

417. Defect identification : Type
•G
Generalized
li d
• Localized
• Mixed
417

418. Defect identification : Pattern
•
•
•
•
•
•
•
Paracentral scotoma
Nasal step
Arcuata
Temporal wedge
T
l
d
Altitudinal
Hemianopsia
Etc
418

419. Defect identification : Tendency
•
•
•
•
Glaucoma
Retinal disorders
Neurological problems
Artifact
419

420. Anderson s
Anderson’s criteria
It must be Glaucoma
• GHT  Outside normal limits
• PD  Cluster of 3 or more non-edge
points p < 5% with one of p < 1%
• PSD  p < 5 %
420

421. GLAUCOMATOUS VISUAL FIELD DEFECTS
• Any clinically or statistically significant
deviation from the normal shape of the
hill of vision can be considered a visual
field defect.
• In glaucoma, these defects are either
diffuse depressions of the visual field
or localized defects that conform to
p
nerve fiber bundle patterns.
MedWeb, 2008
421

422. Glaucomatous VF Defect
Most appearances
• Paracentral
• Arcuate
• Nasal step
• Temporal wedge
• Altitudinal defect
American Academy of Ophthalmology
422

423. GON and VF Defect Progression
Community Eye Heath 2012
423

424. PARACENTRAL DEFECTS
• Circumscribed paracentral defects are an early
sign of localized g
g
glaucomatous damage.
g
• The defects may be absolute when first
discovered, or they may have deep nuclei
,
y
y
p
surrounded by areas of less dense involvement.
• The dense nuclei often are numerous along the
course of the nerve fiber bundle
MedWeb, 2008
424

425. PARACENTRAL DEFECTS
MedWeb, 2008
425

426. ARCUATE SCOTOMAS
• More advanced loss of arcuate nerve fibers
leads to a scotoma that starts at or near the
blind spot, arches around the point of fixation,
and terminates abruptly at the nasal horizontal
meridian .
• An arcuate scotoma may be relative or
absolute.
• In the temporal portion of the field, it is narrow
because all of the nerve fiber bundles converge
onto the optic nerve.
nerve
• The scotoma spreads out on the nasal side and
may be very wide along the horizontal meridian.
MedWeb, 2008
426

427. ARCUATE SCOTOMAS
•
•
•
A notch at the inferior pole of
the optic disc (A) reflects
damage to retinal nerve fibres
projecting in an arcuate pattern,
(B) resulting in an arcuate field
defect.
Section through the optic disc
(C) illustrates that nerve fibres
from peripapillary areas (red
arrow) are located centrally in
the optic nerve while fibres from
peripheral areas (green arrow)
are located near the nerve
sheath.
Damage occurring midway
between sclera and cup yields a
paracentral d f t (blue arrow).
t l defect (bl
)
427

428. Differential Diagnosis of Arcuate Scotomas
MedWeb, 2008
428

429. NASAL STEP DEFECTS
• Because of the
anatomy of the
horizontal raphe, all
complete arcuate
scotomas end at the
nasal horizontal
meridian.
• A steplike defect along
the horizontal meridian
results from
asymmetric loss of
nerve fiber bundles in
the superior and
inferior hemifields.
MedWeb, 2008
429

430. NASAL STEP DEFECTS
• Nasal step defects may be evident in some
isopters but not in others, depending on which
nerve fiber bundles are damaged.
• The width of the nasal step also varies. Nasal
f
steps frequently occur in association with
arcuate and paracentral scotomas, but a nasal
p
,
step also may occur in isolation.
• Approximately 7% of initial visual field defects
are peripheral nasal step defects
defects.
MedWeb, 2008
430

431. TEMPORAL WEDGE-SHAPED DEFECTS
WEDGE SHAPED
• Damage to nerve fibers on the nasal side of the
optic disc may result in temporal wedge-shaped
defects.
• These defects are much less common than
defects in the arcuate distribution.
• Occasionally, they are seen as the sole visual
field defect.
• Temporal wedge defects do not respect the
horizontal meridian.
MedWeb, 2008
431

432. TEMPORAL WEDGE-SHAPED DEFECTS
WEDGE SHAPED
Community Eye Heath 2012
432

433. Altitudinal Scotoma
Altit di l S t
• A more extensive arcuate defect
• Involving 2 quadrants in either the superior
or inferior field
American Academy of Ophthalmology
433

434. Altitudinal Scotoma: Causes
•
RETINAL CAUSES
– B
Branch R ti l A t
h Retinal Artery O l i
Occlusion
– Branch Retinal Vein Occlusion
– Retinal Coloboma
•
OPTIC NERVE LESION
– Ischemic optic neuropathy (both arteritic and non-arteritic types)
– Papil edema
– Optic disc coloboma
•
LESION IN CEREBRAL CORTEX
–
–
–
–
Superior or Inferior calcarine cortex lesion
Temporal lobe lesion
Parietal lobe lesion
Tumors affecting both occipital lobe may produce bilateral superior or
inferior ltit di l field defect.
i f i altitudinal fi ld d f t
434

435. GLOBAL INDICES
• The mean deviation (HFA) or mean defect
(
)
(Octopus) reflects the overall depression or
elevation of the visual field.
• The deviation from the age-matched normal
value is calculated at each location in the visual
field.
• Th mean deviation i simply th average
The
d i ti is i l the
(Octopus) or the weighted average (HFA) of the
deviation values for all locations tested.
• Like the mean sensitivity, the mean deviation is
most sensitive to diffuse changes and is less
sensitive to small localized scotomas
scotomas.
MedWeb, 2008
435

436. GLOBAL INDICES
• Pattern standard deviation (HFA). Such
(
)
irregularities can be due to a localized visual
field defect or to patient variability.
• Th corrected l
The
d loss variance or corrected pattern
i
d
standard deviation provides a measure of the
irregularity of the contour of the hill of vision that
is not accounted for by patient variability (shortterm fluctuation).
• It is increased when localized defects are
present
MedWeb, 2008
436

437. INTEREYE COMPARISONS
• The difference in the mean sensitivity between a
patient s
patient's two eyes is less than 1 dB 95% of the
time and less than 1.4 dB 99% of the time.
• Intereye differences greater than these values
are suspicious if they are unexplained by non
g
glaucomatous factors, such as unilateral
,
cataract or miosis.
MedWeb, 2008
437

438. New opinions in VF analyzing
• Nowadays SAP armed by Visual field
progression software, E.g :
i
ft
E
PROGRESSOR GPA software package
for
f HFA (C l Z i M dit AG)
(Carl Zeiss Meditec
438

439. Glaucoma Progression Analysis (GPA)
• Advancing the Science of Progression Analysis with
improved GPA d i  d t
i
d
design
determine th stage of disease
i the t
f di
and the rate of progression, and assess your patient’s
risk of future vision loss  all at a glance
• N
New single-page G id d P
i l
Guided Progression A l i (GPA)
i Analysis
report delivers current exam results, trends the entire
visual field history and projects future vision loss.
• New Visual Field Index (VFI)  an improved measure of
a patient’s visual function status and is optimized for
glaucoma progression analysis.
• New software reporting offers guidance for severely
depressed visual fields
• New GPA algorithm allows GPA analysis to be run on
more patients right away by allowing a mix of Full
Threshold and SITA exams.
439

440. New opinions in VF analyzing
• But still SAP can only detect the visual
field defect after about 50% loss of the
ganglion cells
• How to detect earlier ?
440

441. Weinreb’s Structural/ Functional Relationship
in Glaucoma as the Disease Progresses
g
VF
Early
% Loss
s
As compared to
GCC, RNFL is still
most widely used
and accepted by
thought leaders and
Drs worldwide
orld ide
Moderate
Severe
Time
Adapted f
Ad t d from Professor Robert N. Weinreb
P f
R b tN W i
b
Hamilton Glaucoma Center, University
California San Diego
441

442. 442

443. Latest generation :
g
Ganglion cell VF Analyzer
• Short-Wavelength Automated Perimetry (SWAP)
–
–
–
–
First 1986 by Pam Sample et al
Photopic background
Static test targets with 1.7º Goldmann size V and 440 nm Blue color
In SWAP, a 440-nm, narrow-band, 1.8° target is presented at 200ms duration on a bright 100 cd/m2 yellow background and
selectively tests the short-wavelength–sensitive cones and their
connections
– Selecti e test for Koniocell lar path a  Bl e sensitive cones
Selective
Koniocellular pathway
Blue sensiti e
– Feasible visual range + 30º
– Detecting glaucoma 5 years earlier than white on white perimetry
Survey of Ophthalmology, 2007
443

444. Latest generation :
Ganglion cell VF Analyzer
• F
Frequency-Doubling Technology Perimetry
D bli
T h l
P i t
(FDT)
– First 1966 by Don Kelly et al
– FDT was measured with the frequency-doubling
visual field instrument (Carl Zeiss Meditec AG) using
Welch-Allyn technology (Skaneateles Falls, NY) and
the N-30 program, software version 3.00.1
– Magnocellular  Motion detecting sensitivity
– The targets consist of a 0.25-cyc/deg sinusoidal
g
grating that undergoes a 25-Hz counterphase flicker
g
g
p
Survey of Ophthalmology, 2007
444

445. Latest generation :
Ganglion cell VF Analyzer
• Frequency Doubling Technology Perimetry
Frequency-Doubling
(FDT)
– The test involves a modified binary search staircase
y
threshold procedure with stimuli presented for a
maximum of 720 ms. FDT measures the contrast
needed for detection of the stimulus
– Each grating target is a square subtending
approximately 10° in diameter.
– Targets are presented in one of 18 test areas located
within the central 20° radius of the visual field
temporally and 30° nasally
Survey of Ophthalmology, 2007
445

446. Latest generation :
Ganglion cell VF Analyzer
• High-Pass Resolution Perimetry (
g
y (HPRP)
)
– First introduced 1987 by Lars Frisen
– In HPRP, ring-shaped vanishing optotypes which vary
in size are used to assess resolution ability in the
central 30° of the visual field
– The optotypes used in HPRP are high-spatialfrequency filtered targets where the inner and outer
portions of the rings are darker (15 cd/m2), whereas
the
th center portion of the rings i b i ht (25 cd/m2)
t
ti
f th i
is brighter
d/
– Parvocellular Color, Form, Long wavelength
sensitivity
446

447. Latest generation :
Ganglion cell VF Analyzer
• Hi h P
High-Pass R
Resolution Perimetry (HPRP)
l ti P i t
– The space-averaged luminance of the entire ring is equal to the
luminance of the photopic background (20 cd/m2)
– Th f
Therefore, when the edges of the ring cannot b resolved, th
h th d
f th i
t be
l d the
rings blend into the background, that is, the targets are either
resolved (seen) or they are invisible
– The target consists of rings of different sizes presented at 50
sizes,
locations within the central 26-30°
– No stimuli are presented within the central 5° of the visual field
– The subject responds when the target is large enough to resolve
– E.g : HPRP is with the Ophthimus High-Pass Resolution
Perimeter, version 2.0, software version 2.51 (HighTech Vision,
Malmö, Sweden).
447

448. Examples of visual field pattern deviation display for SAP, SWAP, FDT, and the small and deep
dent display for HPRP in a patient with GON. Each plot shows the location and number of stimulus
test locations as designated by either a box or a dot Dot: within normal limits The shading in the
dot.
limits.
boxes denotes the probability of abnormality relative to the internal normative database of each
device. Probabilities are shown in the corresponding key.
448

449. VF Defect :
Charts and Facts
449

450. Source of error in VF Analyzing
•
•
•
•
Miosis
Lens or media opacities
Uncorrected refractive error
Spectacles
S
l
– Decrease of sensitivity up to about 1.2 dB per Diopter
– Boundary scotoma caused by the frame
• Ptosis
• Inadequate retinal adaptation
• Fatigue
Kanski JJ, 2007
450

451. Another VF Analyzer
•
•
•
•
•
•
•
Matrix
PULSAR
Flicker Perimetry
Fli k P i t
Motion Detection Perimetry (MDP)
Motion Automated Perimetry (MAP)
Motion Coherence Perimetry (MCP)
Rarebit Perimetry
Survey of Ophthalmology, 2007
451

452. Endothelial
cell loss
Trabecular
damage /
PAS
Iris atrophy
Primary
angle
closure
Lens damage
Ischemic
Optic
Glaucomatus
Neuropathy
Optic
Neuropathy
Damage to ocular tissue in angle-closure glaucoma
angle closure
Foster PJ 2001
452

453. CLASSIFICATION OF GLAUCOMA
(JAPAN GLAUCOMA SOCIETY, GUIDELINES FOR GLAUCOMA)
ANTERIOR CHAMBER ANGLE
NORMAL OPEN ANGLE
GON
NO
GVFD
NO
YES
IOP
NORMAL
ELEVATED
NORMAL
YES
IOP
IOP
NORMAL
ELEVATED
NORMAL-TENSION
GLAUCOMA (SUSPECT)
NORMAL
ELEVATED
NORMAL-TENSION
GLAUCOMA
OCULAR HYPERTENSION
PRIMARY OPEN-ANGLE
GLAUCOMA (SUSPECT)
PRIMARY OPEN-ANGLE
GLAUCOMA
453

454. Steroid-induced glaucoma
g
• Uncertain
• Steroid  excessive deposit of acid
mucopolysaccharide or
glycosaminoglycan (GAG)
• It present in trabecular meshwork 
ti t b
l
h
k
abnormal function
Trans Am Ophthalmol Soc,1977
454

455. Newest term of POAG and NTG
• Developmental and degenerative ocular
problems
– Degenerative of entire ocular vascular and trabecular
meshwork*
– Regression failure of hyaloid artery in third trimester
of gestation  facilitating the high IOP to directly hits
the optic nerve head
– Previously “ fragile “ optic nerve head and RNFL
y
g
p
* Does not occur in NTG
455

456. Glaucoma : T t
Gl
Treatment
t
•
•
•
•
•
Causes  Trauma, New vessels etc
Medical
Laser
Surgery
Others
Others*
456

457. Gaucoma : Medical
Class
Dosage
IOP
decrease
Time to peak effect/ washout
1.  blockers
Timolol Maleat
bid
20-30%
20 30%
2-3
2 3 hours/1 month
Betaxolol
bid
15-20%
2-3 hours/1 month
bid, tid
20-30%
2 hours/7-14 days
2. Alpha 2 adrenergic agonist
Brimonidine
3. Carbonic Anhidrase inhibitor
Dorzolamid
D
l id
bid,
bid tid
15-20%
15 20%
2-3 hours/48 h
23h
/48 hours
Brinzolamide
bid, tid
15-20%
2-3 hours/48 hours
4. Prostaglandin analogues & Prostamides
ostag a d a a ogues
osta des
Latanoprost
qd
25-32%
10-14 hours/4-6 weeks
Travoprost
qd
25-32%
10-14 hours/4-6 weeks
p
Bimatoprost
q
qd
27-33%
10-14 hours/4-6 weeks
Unoprostone
Tafluprost
bid
qd
13-18%
18-22%
Unknown
Unknown
457

458. Glaucoma : Pathways to IOP reduction
458

459. Target IOP
g
Target IOP may be defined as a pressure, rather a
range of intraocular pressure levels within which
the progression of glaucoma and visual field
loss will be delayed or halted
• Advanced POAG  12 mmHg
• Early g
y glaucoma  17 mmHg
g
• NTG  11 mmHg
Gumansalangi MNE, 2002
459

460. AAO GUIDELINES: TARGET IOP
GUIDELINES
• Open angle glaucoma with IOP in the
mid to high 20s  Target IOP range 1418 mmHg
• Advanced Glaucoma  Target IOP is
< 15 mmHg
• OHT whose IOP > 30 mmHg with no
sign of optic nerve damage  Target
IOP < 20 mmHg
Survey of Ophthalmology, 2003
460

461. Factors to be considered
•
•
•
•
•
•
•
•
Efficacy: Maximal IOP reduction
Minimum required drug
Easy to use and compliance
Giving flat diurnal curve
Ocular tolerability
Systemic safety
Cost effective
Quality of life
Gumansalangi MNE, 2002
461

462. Glaucoma : Laser
• Argon laser trabeculoplasty
p
y
y
• Selective laser trabeculoplasty  Primary
Glaucoma Therapy?
• Laser gonioplasty
• Nd:YAG laser iridotomy
y
• Diode laser cycloablation
• Endoscopic cyclo laser photocoagulation
462

463. Glaucoma : Surgery
•
•
•
•
•
•
•
•
•
•
•
Inflow procedures
p
Vitrectomy
Lens extraction
Pupil
P il reconstruction
t ti
Iridectomy
Trabeculectomy
Tubes and Shunting
Canaloplasty
Viscocanalostomy
Deep sclerotomy
Crosslinked NaHA  surgery enhancer
enhancer*
463

464. Glaucoma: Surgery
464

465. Glaucoma Devices, Tubes and Shunting
•
•
•
•
•
•
•
•
•
•
•
•
Molteno Implant
Pressure Ridge Molteno Implant
Ahmed Valve
Baerveldt Tube Shunt
SOLX Gold Shunt
iScience Microcatheter Canaloplasty
GLAUCOLIGHT C
Canaloplasty D i (DORC)
l l t Device
ExPress Mini-Shunt (Alcon Inc)
iStent (Glaukos)
Hydrus (Ivantis)
Stegmann Canal Expander
AqueSys Collagen Tube Implant
465

466. Glaucoma : Cilliary body ablation
• Cyclocryo therapy
• Ultrasound
• Diode laser
466

467. 467

468. Is there more to glaucoma
treatment than l
h lowering IOP ?
i
• Inhibition of activation of Astrocytes
• Inhibition of Nitric-Oxide-Syntase 2 (NOS-2)
• Reduces nocturnal overdipping
– Fludrocortisone 0.1 mg 2 times per week
•
•
•
•
•
Improvement of vascular regulation and autoregulation
Combat of oxidative stress
Inhibition of Metalloproteinase-9 (MMP-9)
Stimulation of Heat Shock Protein (HSP) production
Neuroprotection
– Memantine  N-Methyl D-Aspartate (NMDA) receptor
g
antagonist
Survey of Ophthalmology, 2007
468

469. Lens and cataract
L
d t
t
The Pioneer
Prof. dr. Istiantoro Sukardi, Sp.M(K)
Sukardi, Sp.M(K)
469

470. Lens fluid dynamics
470

471. Lens Opacities Classification System III
(LOCS III)
471

472. Opt ca o et y ased Cata act C ass cat o
Optical Biometry Based – Cataract Classification
• No Cataract (NC) 
• For Refractive Lens Extraction (RLE)
Phacoemulsification Plan
• Optical Biometry Examinable Cataract (OBEC) 
• For Low Energy Phacoemulsification Plan
• For learning Phacoemulsification and for transition to
MICS and Femtosecond Laser Cataract Surgery
• Optical Biometry Un-examinable Cataract (OBUC) 
• For High Energy and More Maneuver
Phacoemulsification Plan
Pardianto G ESCRS 2010
472

473. Paradigm of lens surgery
• Avoid advanced cataract complications 
prevents avoidable bli d
t
id bl blindness
• Restores visual function
• Nowadays  refractive surgery 
p
improves visual function 
Phacoemulsification or more*
Eurotimes, 2009
473

474. Refractive Surgery
• Optical synergy  Sharper vision
– Zero spherical aberration
– Reduced chromatic aberration
– Full visible light transmission
– Glistening free
– Limited Lens Epithelial Cells (LEC) migration
Eurotimes, 2009
474

475. Cataract surgery : State of the Art
• More comfort, faster and reliable
,
advanced examination
• Minimal invasion
• Minimal manipulation
• Minimal complication
• Better result
• Better outcome
• More improved visual function
475

476. Intraocular materials
•
•
•
•
•
•
Sterile
Inert
I t
Non toxic
Non allergenic
pH Balanced
Long lasting stable
476

477. Crystalline Lens vs IOLs
•
•
•
•
200 250
200-250 vs 20 mm3 volume
11 vs 12-13 mm overall diameter
4.5
4 5 vs 1 mm thi k
thickness
10 vs 5-6 mm front surface radii of
curvature
• 6 vs 5-6 mm back surface radii of
curvature
Eurotimes, 2010
477

478. Spherical vs Aspheric Lens
Spheric
478

479. Spherical vs Aspheric Lens
Aspheric
479

480. Spherical vs Aspheric Lens
Changchun Jixiang, 2006
480

481. IOL : Biometry
• A Scan biometry
– Very dense cataract
– Use different keratometry analyzer
• 3rd and 4th generation formulated biometry  Phakic IOL
and post refractive surgery biometry
– Partial Coherence Laser Interferometer or Non-contact Optical
Coherence Biometry or Laser Interferometry Technique
C h
Bi
t
L
I t f
t T h i
• IOL Master 5.0 (Carl Zeiss Meditec AG),
• Lenstar LS 900 (Haag-Streit International)
• Pentacam HR (OCULUS Optikgeräte GmbH)
(
p g
)
• IOL Station (NIDEK)
– Advanced Immersion A Scan biometry
• Aviso (Quantel Medical)
481

482. Aviso (Quantel Medical)
IOL Master 500 (Carl Zeiss Meditec AG)
Lenstar LS 900 (Haag Streit International)
(Haag-Streit
482

483. IOL Calculation Formulas
• 1st Generation
– SRK  Sanders, Retzlaf and Kraff
• 2nd Generation
– Binkhort, Hoffer, SRK II, Holladay
• 3rd Generation
– SRK/T, Hoffer-Q
• 4th Generation
– Holladay 2, Haigis, Camellin-Calossi
– Double K technique  Post LASIK
483

484. IOL calculation formulas
• SRK  P = A - (2.5L) - 0.9K
– L in millimeter
– K in Diopter
• Older guidance (Axial length approach)
– > 26 mm
– 24.4 – 26 mm
– 22 – 24 5 mm
24.5
» or 
– < 22 mm
SRK-T, Optimized Haigis
Holladay
Holladay 2 Haigis
2,
Average of SRK/T, Holladay,
Hoffer-Q
Hoffer-Q, Optimized Haigis
484

485. Reevaluated IOL Calculation :
• Less than 22 mm or more than 25 mm
axial length
• Less than 40.00 D or more than 47.00 D of
K Reading
• Difference in both eyes :
– More than 1.00 D K Reading
– More t a 0 3 mm a a length
o e than 0.3
axial e gt
– More than 1 D IOL Power in target of
emmetropia
485

486. The IOLs
•
•
•
•
•
360
360º barrier edge
Corrects spherical aberration to essential zero
Increases contrast sensitivity
Reduces harmful blue lights
g
p
Significant improvement of visual function
486

487. IOL: Spheric vs Aspheric
IOL Spherical aberration correction by Spherical IOL vs Aspheric IOL
Alcon, 2010
487

488. Lens and Cataract : IOLs
Aberration counter
Aberration-counter Aspheric IOLs
• Acrysof IQ Aspheric Natural IOL (Alcon, Inc)
• enVista Glistening-free Aspheric IOL (
g
p
(Bausch & Lomb
Incorporated)
• Akreos MI60 Microincision Lens with Aspheric Aberration-Free
Optics IOL (Bausch & Lomb Incorporated)
•
•
•
•
TECNIS 1-Piece Aspheric IOL (Abbott Medical Optics)
C-flex and Superflex Aspheric IOL ( y )
p
p
(Rayner)
HOYA’S Aspheric ABC Design IOL (HOYA)
Afinity Collamer Aspheric IOL (Staar)
y
488

489. Multifocal IOL : Refractive
• Designed with several optical zones on the
intraocular l
i t
l lens.
• These zones provide various focal points,
allowing for an improvement in distance,
intermediate, and near vision.
489

490. Multifocal IOL : Diffractive
• Gradual diffractive steps on the intraocular
lens implant that create a smooth
transition between focal points.
• Th IOL also b d i
The
l bends incoming li ht t th
i light to the
multiple focal points to increase vision in
various lighting sit ations
ario s
situations.
490

491. Apodization
• Is the gradual reduction or blending of diffractive
step heights.
• Distributes the appropriate amount of light to
pp p
g
near and distant focal points  regardless of the
lighting situation.
• The apodized diffractive optics are also
designed to improve image quality and minimize
visual di
i
l disturbances – a significant i
b
i ifi
improvement
over traditional multifocal technologies
Alcon, 2010
491

492. Multifocal :
Multifocal*: Accommodative
• An accommodative intraocular lens implant only
p
y
has one focal point, but it acts as if it is a
multifocal lenses.
• Th IOL was designed with a hi
The
d i
d i h hinge similar to the
i il
h
mechanics of the eye’s natural lens.
• Using the eye’s muscles the single focal point of
eye s muscles,
an accommodative intraocular lens can shift to
bring objects at varying distances into focus.
– Change in SHAPE of the lens in the eye
– Change in POSITION of the lens in the eye
492

493. Multifocal, Accommodating IOLs
,
g
493

494. Multifocal IOLs
• AcrySof ReSTOR Diffractive Apodization
Aspheric IOL
(Alcon Inc)
(Alcon,
• ReZoom TECNIS Multifocal IOL (Abbott
Medical Optics)
• TECNIS 1 Diffractive Aspheric 1-piece
Multifocal IOL (Abbott Medical Optics)
• Acriva Reviol Multifocal IOL (VSY
Biotechnology)
• AT Lisa (Carl Zeiss Meditec AG)
• MF4 (Ioltech  Carl Zeiss Meditec AG)
• M-flex (Rayner)
( y )
• Versario (CROMA)
494

495. Accommodating IOLs
• Crystalens AT-45 Accommodating IOL
(C&C Visions)
• KH-3500 (Lenstec)
• Bi C
BioComFold 43A (M h )
F ld
(Morcher)
495

496. Toric IOLs
• AcrySof Toric Natural IOL (Alcon, Inc)
• Acri.LISAToric IOL (Acri.Tec  Carl Zeiss
(
Meditec AG)
• AA4203TF (Staar)
• MicroSil (H manOptics)
(HumanOptics)
• T-flex (Rayner)
• M-flex-T  Toric Multifocal (Rayner)
M flex T
496

497. Photochromic IOLs
•
•
•
•
•
Colorless UV-Blocking at night
Changes to a yellow outdoor during the day
Does not compromise scotopic vision at night
Provides additional protection from blue light
E.g : MATRIX Acrylic AURIUM (Medennium)
497

498. MICS IOL
•
•
•
•
MI60 (Bausch and Lomb)
AT Lisa (Carl Zeiss Meditec AG)
AT S
Smart 48S (C l Z i M dit AG)
t
(Carl-Zeiss-Meditec
ThinLens UltraChoice 1.0 (Technomed
GmbH)
• Lentis L-303 (Oculentis GmbH)
(
)
• CareFlex (w2o Medizintechnik AG)
498

499. Hydrophilic vs Hydrophobic IOL
• Hydrophilic IOL
–
–
–
–
Less Uveitis
Less Anterior Capsule Contraction
Less Glaucoma
Less Capsular Block
• Hydrophobic IOL
– More adhesiveness to posterior capsule
– Less PCO
• New design  Anterior surface hydrophilic and
posterior surface hydrophobic  Bi Flex 1.8
(Medicontur)
(M di
t )
499

500. Haptic
• Three-piece
Three piece
– Less PCO  if square-edged optic IOL
– Less space  if in posterior chamber / sulcus
fixation  less glaucoma
• One piece
One-piece
– Less PCO  if design as 360-degree squareedged IOL
– Not recommended fixated in the sulcus
500

501. Hi-end Operating microscope
•
Excellent in
–
–
–
–
–
–
–
–
Bright illumination
Red reflex
Depth perception
Outstanding Beam splitter  Assistance, Teaching and Recording
Smooth X-Y-(Z)
Great i
G t in zoom and focus maneuver
df
UV barrier
Blue filter
•
•
•
•
Carl-Zeiss OPMI Lumera i and Lumera T
MÖLLER Hi-R 900 and Hi-R 1000
Leica M844 F40
Alcon LuxOR™ Surgical Microscopes with Q-VUE™ 3-D assistant
•
Do not forget : How to adjust your microscope
microscope.
501

502. Cataract surgery : Phacotechnique
• 1st Generation
– Kelman tecnique 
• Can-opener capsulotomy
• Anterior chamber
• 2nd Generation
– Can-opener capsulotomy
p
p
y
– Posterior chamber Phaco
– Sculpting
• 3rd Generation
– Continuous Curvilinear Capsulorrhexis (CCC)
– In-situ Phaco  Endo-capsular
– E.g : Divide and Conquer, Sheperd’s Phaco Fracture
Technique, Fine’s Chip and Flip Technique, Fine and
colleagues’ Crack and Flip Technique, Nagahara’s
Phaco C
Ph
Cop, Pf iff ’ Q i k Ch and K h’ St
Pfeiffer’s Quick Chop d Koch’s Stop
and Chop
502

503. Cataract surgery : Phacotechnique
• 4th Generation
– CCC
– Supracapsular
– E.g : Fine, Parker and Hoffman’s Choo Choo Chop
and Flip
– Revolution in
•
•
•
•
•
Micro incision  1 7 - 1 8mm
1.7 1.8mm
Cooler Phaco
Phaco-tip
IOLs
Improvement in uncorrected post-operative day one visual
acuity
503

504. Cataract surgery : Anesthesia
• Nowadays trend  Topical, and some  add
y
p
,
by Viscoelastic-borne intra cameral anesthesia
• But please do not forget and keep your ability to
perform
f
–
–
–
–
–
Akinesia  the absence (or poverty) of movement
Retrobulbar
Peribulbar
Sub-tenon
Sub-conjunctiva
• In special case  General anesthesia
504

505. Cataract surgery : Incision
•
•
•
•
•
Clear Corneal Incision recomended
Small to Micro
(
)
Micro to 1.6 - 1.8 mm incision (MICS)
But  size is not everything
Factors to be considered
–
–
–
–
–
Shape and contour of incision
Well sealed and water tight
Depend on cataract density and hardness
Depend on instruments to perform
Depend on surgeon ability
p
g
y
505

506. Avoid incision leak
•
•
•
•
•
•
•
•
Square incision
Proper size
2-3
2 3 steps direction
Avoid incision burns
Good t h i
G d technique phaco and IOL i
h
d
insertion
ti
Good tip and cartridge
Checking incision at end of surgery
Stromal hydration
506

507. Limbal relaxing incision
• With the rule  CCI and superior limbal
relaxing i i i
l i incision
• Against the rule  temporal CCI and
limbal relaxing incision
Vajpayee RB 2005
RB,
507

508. Cataract surgery : “Peri-phaco”
Peri phaco
• CCC  Continuous Curvilinear
Capsulorrhexis
Caps lorrhe is
• Tools:
– N dl
Needle
– Forceps
–F t
Femtosecond Laser 
dL
•
•
•
•
Alcon LenSx (Alcon LenSx Laser Inc)
LensAR Laser System (LensAR Inc)
Catalys Precision Laser System (OptiMedica)
CUSTOMLENS TECHNOLAS (Perfect Vision)
EuroTimes, 2010; EyeWorld, 2010
508

509. Cataract surgery : “Peri-phaco”
Peri phaco
• Hydrodissection  Injection of a small
amount of fluid into the capsule of the lens
to separate the nucleus from cortex
• H d d li
Hydrodelineation  I j ti of fl id
ti
Injection f fluid
between the layers of the nucleus of the
lens using a bl t needle  G ld Ri
l
i
blunt
dl
Golden Ring
509

510. Hydrodissection : Be careful
•
•
•
•
Posterior pole cataract
Traumatic cataract
Hard brown cataract
Post vitrectomy cataract
Rajan M, Mehta C, 2009
510

511. Phacomachine and instrumentation
•
•
•
•
•
•
•
•
Well contour micro incision
Surge free anterior chamber maintenance
Cooler phaco tips
Smoother vacuum and phaco power
Endothelial friendly
E d th li l f i dl
Reduce dropping nucleus
Less edema, less astigmatism
Better outcome
511

512. Phacomachines
a. Peristaltic Pump
A pump which fluid is forced along by waves of
contraction produced mechanically on flexible
tubing
512

513. Phacomachines
b. Venturi Pump
This pump is driven by compressed gas (nitrogen or
air) that is directed through chamber B
513

514. Phacomachines
c. Diaphragm Pump
A flexible diaphragm A is alternately pushed in and
pulled out by a rod connected to an electric motor
rotating as indicated
514

515. Comparison of p p
p
pumps
Peristaltic
Venturi
Flow based
Vacuum based
Vacuum created on occlusion of phaco tip
Vacuum created instantly via pump
Flow is constant until occlusion
Flow varies with vacuum level
Drains into a soft bag
Drains into a rigid cassette
Devgan U, 2008
515

516. Phaco Pump Comparison
Pump
Pro
Contra
Vacuum
e.g. Venturi
Less posterior occlusion surge
Better for vitreous removal
Material comes to tip easily
Need source of compressed gas
Need rigid cassette
Flow
Fl
e.g. Peristaltic
Better f
B tt for sculpting
l ti
No need for compressed air
Post
P t occlusion surge
l i
Need occlusion for vacuum to build
Siebel BS, 2008
516

517. Lens and Cataract : Phacomachines
Newest phacomachines :
• WHITESTAR SignatureTM System with FusionTM
Fluidics and ELLIPSTM Transversal Ultrasound
(Abbott Medical Optics)
• Th Stellaris MICSTM Vi i E h
The St ll i
Vision Enhancement S t
t System
with EQ FluidicsTM Technology (Bausch & Lomb
Incorporated)
• INFINITI Vision S
System with INTREPIDTM Fluidics
Management System and the OZil® IP Intelligent
Phaco Torsional Handpiece (Alcon, Inc)
• The CENTURION® Vision System (Alcon, Inc)
• Qube Smart System (CROMA)
• Faros OS3 and CataRhex3 (Oertli)
517

518. Micro Incision Sleeve Development
Support smaller incisions
– Reduce shaft diameter
Optimize performance
– Maximize chamber
stability
– Wound protection
– Minimize wound leakage
Alcon Inc
518

519. Infusion Sleeve Technology
Translucence
– Maximize visualization
Thin Walls
– Maximize Flow
– Minimize bulk
Large Holes
– Maximize Flow
Smooth Profile
– Ease of insertion
– MicroSmooth Technology
Tight Tolerances
– Consistency
– Quality
Alcon Inc
519

520. Older Footswitch Positions
1. Irrigation
2.
2 Irrigation
Aspiration + Vacuum
3. Irrigation
Aspiration + Vacuum
U/S Power
520

521. Footswitch Positions
1.
1 Irrigation can set
always ‘On’
2. Irrigation
g
Aspiration + Vacuum
3. Irrigation
Aspiration + Vacuum
U/S Power
521

522. Phacodynamics : Fundamentals
• Ultrasound (U/S): Repulsive forces  Power (percent)
and also  Ph
d l
Phaco ti
time (
(second)  A
d)
Average U/S,
U/S
Effective U/S and Absolute U/S
• Aspiration Flow Rate: (cc/min); is the magnetic action
Rate:
in system to ATTRACT lens material at a specific speed.
• Vacuum: (mmHg) is negative pressure in system used
to HOLD the pieces
• Bottle height: (cm)  Estimate IOP (mmHg) = Bottle
height X 0.74  now automated by compressor
gy
technology
522

523. Ultrasound: Phaco power
• Absolute phaco time (APT) and Effective
phaco time (EPT)
• Equivalent phaco time at 100% power
• APT = total phaco time (seconds)
• EPT = phaco time (seconds) X average
phaco power (percents)
Devgan 2004
523

524. Power Delivery
• Duty cycle: The ratio of working time to
total time of U/S  usually expressed as a
percent
• P l per second (PPS) A
Pulse
d (PPS): Amount of pulse
t f l
those are delivered in one second.
524

525. Power modulation
Devgan 2004
525

526. AFR and Vacuum
• Aspiration Flow Rate (Attracts)
• Vacuum (negative holding pressure)
Alcon Inc
526

527. ASPIRATION FLOW RATE (AFR)
• What does it do?
– Attracts material to the tip
– Determines how fast material is
drawn to the phaco tip
Alcon Inc
527

528. ASPIRATION FLOW RATE (AFR)
• Fluid moving through the tubing toward the
collection b i referred t as A i ti Fl
ll ti bag is f
d to
Aspiration Flow,
or Aspiration.
• Aspiration starts when the pump starts .
ASPIRATION
FLOW
-Pump rotation pushes fluid out
TO DRAIN BAG
PERISTALTIC PUMP
-More fluid moves in
-That is Aspiration Flow
-Speed of flow is Aspiration Flow Rate
-Pump speed controls AFR
Alcon Inc
528

529. AFR: FOLLOWABILITY
• WHAT DOES THIS TERM APPLY TO?
– The ability to attract material to the tip
• WHAT CONTROLS IT?
– Aspiration Flow Rate
Alcon Inc
529

530. VACUUM
–Negative Pressure or
Negative
Holding Force
–Measured in mmHg
–Holds material onto the tip
–The higher the vacuum the
greater the holding force
Alcon Inc
530

531. Vacuum: OCCLUDE
• Occlusion refers to an obstruction of the
phaco tip
Alcon Inc
531

532. Vacuum: Purchase
• The grip of the vacuum on the occluding
material.
• The higher the vacuum the greater the
vacuum,
purchase.
Alcon Inc
532

533. Rise Time
• WHAT IS IT?
– The measurement of how fast
vacuum builds upon occlusion
– Rise Time is directly related to AFR
– The faster the AFR the shorter the
Rise Time
Alcon Inc
533

534. COMPLIANCE
• WHAT IS IT?
“The ability of an object
to yield elastically
when a force is
applied”
• WHAT IMPACT DOES
IT HAVE?
The more compliance,
the slower the
responsiveness and
performance
Alcon Inc
534

535. NON-COMPLIANCE
Non-Compliance is “the ability
of an object to maintain
rigidity when a force is
applied”.
The more Non-compliant a
p
fluidic system is, the more
responsive it’s performance
will be (ie: “True Control”)
Alcon Inc
535

536. Vacuum: VENTING
Vacuum  Back to neutral
Alcon Inc
536

537. Vacuum: REFLUX
V
• Push fluid flow
•R l
Release material that attached on th
t i l th t tt h d
the
phacotip after complete venting
process
Alcon Inc
537

538. Vacuum: SURGE
FLUIDIC
IMBALANCE
• Outflow
• Exceeds
• Inflow
Alcon Inc
538

539. Vacuum: SURGE
539

540. ULTRASOUND (U/S)
(
)
• Refers to frequencies above the range of
human audibility, or above 20,000 vibrations
per second
second.
• In phacoemulsification, the term “ultrasound” is
used because the phaco needle moves back
and forth in excess of 20,000 times per second
 MICS is in 28,500 times per second
,
p
• There are no “sound waves” associated with
phacoemusification.
Alcon Inc
540

541. U/S: FREQUENCY
•How
FAST the phaco needle moves back and forth
Frequency
q
y
WHAT IS THE FREQUENCY RANGE?
•The frequency of ultrasonic handpieces is between
27,000 d 60,000
2 000 and 60 000 cycles per second
l
d
Alcon Inc
541

542. U/S: STROKE
• WHAT IS IT?
The tip travels 3.5 mils at maximum power
Stroke
How FAR the phaco tip moves back and forth
p
p
Alcon Inc
542

543. U/S POWER
• U/S Power is the percent of the maximum
stroke length traveled b th phaco ti
t k l
th t
l d by the h
tip.
• Phaco tip moves in and out in linear fashion.
• Some handpieces have a maximum
excursion (Stroke) of 3.2 mils , or 3.2
thousands of an inch (0 001 inch) which
(0.001 inch),
would represent 100% power.
• Lower power settings are some portion of the
maximum stroke, e.g., 60% would be 1.92
mils of travel.
Alcon Inc
543

544. PIEZOELECTRIC HANDPIECE
• The forward and back linear (in a straight
line) motion of a U/S handpiece is
generated by piezoelectric crystals.
• Th
These crystals, which are l
t l
hi h
located i th
t d in the
handpiece, vibrate at a known frequency
when electricit r ns thro gh them
hen electricity runs through them.
Alcon Inc
544

545. PIEZOELECTRIC HANDPIECE
•
Motion is generated when a tuned, highly refined crystal is deformed
by the electrical energy supplied from the console.
t l
i il to the
t h
• Th
These crystals are similar t th ones i a watch.
in
• The phaco tip is attached to the vibrating crystals.
Alcon Inc
545

546. CHATTER
• WHAT IS IT?
– Fragments rebounding from the tip
WHAT CAUSES IT?
• Chatter occurs when stroke overcomes Vacuum and AFR
Alcon Inc
546

547. •
•
•
•
•
U/S: LOAD
WHAT IS IT?
Occurs when the tip encounters nuclear material
WHAT HAPPENS?
Requires more power to maintain stroke
Load is constantly changing
No Load
Load
Alcon Inc
547

548. CAVITATION
WHAT IS IT?
• The formation of vacuoles in a liquid by a swiftly moving solid
body (an ultrasonic tip)
• The collapse of the vacuoles produces energy which will
erode solid surfaces
Alcon Inc
Boat Propeler Example of Cavitation
548

549. CAVITATION
Kelman tip
Implosion f
I l i of vacuoles produces:
l
d
Nine (9) ATA of pressure
l
5000° F destructive energy release
This takes place on a microscopic scale
Alcon Inc
549

550. TUNING
• The method used to match up the driving
frequency of the console with the operating
frequency of the phaco handpiece and tip.
Alcon Inc
550

551. U/S: Power modulation
• Continuous
– Continuous delivery of power
– Phaco is on in position three
– Usually increasing ultrasound power with
depth into foot position
– Used for partial-occlusion sculpting
Chang DF, 2004; Oetting T, 2005
551

552. U/S: Power modulation
• Pulse
– Allows surgeon to vary the power with linear control
with a fixed number of pulse per second (pps)
– Ranges from 1 to 20 pps
– With a 50% duty cycle and linear control of power
– Phaco pulses with duty cycle on and off
– Usually with equal on and off time or 50% duty cycle
(time on/cycle time)
– Usually the rate (or inverse of duty cycle) is fixed (Hz)
– Usually increasing ultrasound power with depth into
foot positi
Chang DF, 2004; Oetting T, 2005
552

553. U/S: Power modulation
• Burst
– Allows surgeon to vary the number of burst of power
per unit time
– With Constant amount of power
– Duration  varied widely  5-600 ms
– Reduce in thermal and exposure time of energy
– Bursts of power come with off time that decreases
with depth into foot position
– Usually when floored in position 3 -- ultrasound power
becomes continuous
b
i
– Ultrasound power is fixed
Chang DF, 2004; Oetting T, 2005
553

554. U/S: Power modulation
• Hyperpulse
– Uses short on time pulses e.g. 25% on; 75%
off
– Fixed duty cycle; fixed pulse rate
– Usually increasing ultrasound power with
depth into foot position
Oetting T, 2005
554

555. Advantages & Disadvantages
of Various U/S Modes
Mode
Advantages
Disadvantages
Applications
Continuous
Simple
- Repels nuclear
material
- Hot
Sculpting
Pulse
Less hot
- Can repel nuclear
material
- Choo choo chop
- Segment removal
Burst
B t
- L
Less h t
hot
- Holds material
well
Chopping
Ch
i
Hyperpulse
- Followability with
long off cycle
- Cool with long off
y
cycle
- Sculpting
- Bimanual small
incision
Siebel BS, 2008
555

556. U/S: Amount of Power
• Early phacomachine
– Available in pedal position 3
– Power level was set on the machine panel
• Over a decade
–S
Surgeon able to vary the power
– In LINEAR fashion
– By modulating pedal travel in position 3
Chang DF, 2004
556

557. Laws of Phaco Physics
 Smaller tips occlude easier
 The smaller the tip, the more precise
p,
p


ultrasonic control
The smaller the tip, the easier to
p
maneuver
The larger the tip, the better it holds
Alcon Inc
557

558. Laser Phacoemulsification
• 2940 nm Erbium:YAG Laser
– Erbium:YAG Phacolase (Carl Zeiss Meditec AG)
• Neodymium:YAG Laser
– Neodymium:YAG Photon Laser PhacoLysis System (Paradigm
Medical)
– Dodick Q-Switched Neodymium:YAG laser (ARC GmbH)
• Femtosecond Laser
– Vi t (TECHNOLAS P f t Vi i )
Victus
Perfect Vision)
– Alcon LenSx (Alcon Inc)  Rhexis, Incision, Nuclear
fragmentation, Limbal Relaxing Incision (LRI)
– L
LensAR
AR
– Catalys (OptiMedica)
– Femto LDV Z Models (Ziemer-S)*
Kohnen T, Koch DD, 2005; Auffarth G, 2010; EyeWorld 2010; Salz JJ, 2010
558

559. Femtosecond Laser Cataract Surgery
•
•
•
•
Data collection
Docking
OCT or S h i fl S
Scheimpflug Scan
Laser works:
– CCC
– Lens softening
g
– Clear corneal incision
– Limbal relaxing incision
g
559

560. Docking and OCT guide scan
• Diagram of the optical
and mechanical
interface between the
laser system and the
y
eye.
• The femtosecond laser
and OCT beam share
the same optical path,
p
providing an exact
g
co-registration of the
OCT image with the
laser segmentation
patterns.
560

561. Femtosecond Laser Cataract Surgery
561

562. Tips in Zonular weakness
p
• Full dilated pupil
• M i t i d b BSS d
Maintained by BSS-adrenaline (1 1 000 or 0 5
li (1:1,000 0.5
ml in 500 ml)
• Viscoadaptive ophthalmic viscosurgical devices
(OVD)
• 2 4 to 2.75 mm incision
2.4 2 75
• Large capsulorhexis ( 5mm or more)
• Cortical cleaving hydrodissection*
• Use a Capsular tension ring (CTR)
Chee SP 2009; Kim WS 2009; Pangputhipong P 2009
562

563. Tips in Zonular weakness
p
•
•
•
•
Groove long, wide and deep or triangular groove
Bevel ti d
B
l tip downward
d
Long horizontal chop
Utilize Triangular cracking technique  chop
both distal corner without any nuclear rotation*
• I i ti pole as l
Irrigation l
low as possible ( b t 70mm –
ibl (about 70
75 mm)  reduce any BSS misdirection
• Implant Three piece foldable IOL with PMMA
Three-piece
haptics
Chee SP 2009; Kim WS 2009; Pangputhipong P 2009
563

564. Small Pupil Management Devices
• Malyugin’s Ring Pupil Expander
• Behler’s Iris Retractor
• Iris Hooks
564

565. Viscoelastic materials
•
•
•
•
•
•
•
•
Maintains space
Spreads and protects tissues
Coats tissues and instruments
Non-toxic
Non-inflammatory
N i fl
t
Optically clear but visible
Neutral effect on IOP
Protects the endothelium
American Academy of Ophthalmology
565

566. Viscoelastic : Rheology
•
•
•
•
•
Viscosity
Pseudo plasticity
Elasticity
Cohesion and Dispersion
Rigidity
Kohnen T, Koch DD, 2005
566

567. Viscoelastic materials
• Sodium Hyaluronate (SH)
– Healon Healon GV Healon 5 (Abbott Medical
Healon,
GV,
Optics)
– Provisc (Alcon, Inc)
(
,
)
– AmVisc Plus (Bausch & Lomb Incorporated)
– VisThesia (Ioltech – Carl Zeiss Meditec AG) 
Plus 2% Lidocain HCl
• Chondroitin sulfate (CS)
– Vi
Viscoat (Al
(Alcon, I )
Inc)
– DisCoVisc (Alcon, Inc)
Kohnen T, Koch DD, 2005
567

568. Viscoelastic materials
• Hydroxypropyl methyl cellulose (HPMC)
– Ocuvis (CIMA Technology)
– OcuCoat (Bausch & Lomb Incorporated)
• Colagen IV
– Removed from market  world-wide fear of possible
prior contamination of human-sourced protein
• Polyacrylamide
– Formation of microgel  clogged the trabecular
meshwork  could not b eliminated  idl
h
k
ld
be li i
d rapidly
removed from the market in Europe and USA
Kohnen T, Koch DD, 2005
568

569. 569

570. Cohesive vs Dispersive
• C h i  Vi
Cohesive
Viscoadaptives, Vi
d ti
Viscouscohesive viscoelastics
–
–
–
–
–
–
–
Heavy molecular weight
High concentration
Create and preserve space
Displace and stabilize tissues
Pressurize the anterior chamber
Clear view of posterior capsule
Easy to remove
– E.g : 2.3% SH  Healon 5 (Abbott Medical Optics (Abbott
Medical Optics), SH 1 6%  Amvisc (Bausch and Lomb)
Optics)
1.6%
Lomb),
1.4% SH  Healon GV (Abbott Medical Optics), SH 1.2% 
StaarVisc II (Staar Surgical), and SH 1%  ProVisc (Alcon,
)
Inc)
Kohnen T, Koch DD, 2005
570

571. Cohesive vs Dispersive
• Dispersive  Medium viscosity, Very low
viscosity Very-low
viscosity
– Coating tissues
– Partition spaces
– Prolonged retention
– E.g : 3.0% SH  Viscoat (Alcon, Inc), Healon D (Abbott Medical
g
(
,
),
(
Optics), HPMC 2%  Ocucoat (Bausch and Lomb)
• Dual Characters  Viscous-Dispersive
Viscous Dispersive
– Cohesive and Dispersive in one
– E.g :
• Healon D + G ( bbott Medical Opt cs)
ea o
GV (Abbott ed ca Optics)
• Duovisc (Alcon, Inc)
– The proven protection of Viscoat
– The ease to removal of ProVisc
Kohnen T, Koch DD, 2005
571

572. Rojanapongpun P, 2010
572

573. Soft shell technique
– Protects compromised
corneal endothelium and
posterior capsular bag
– Injects dispersive
viscoelastic materials
– Followed by cohesive
viscoelastic materials
injection
– P h di
Push dispersive viscoelastic
i
i
l ti
materials anteriorly 
coating the endothelium
– Or  also push dispersive
viscoelastic materials
i
l ti
t i l
posteriorly  coating the
posterior capsular bag 
safer in-the-bag IOL
implantation
573

574. Vasavada A, 2009
574

575. Steroid cataract formation
• Glucocorticoids are convalently bound to
lens proteins
• Resulting in  destabilization of the
protein structures
• All i f th modification, i : oxidation
Allowing further
difi ti
ie
id ti
• Leading to cataract
Experimental Eye Research, 1997
575

577. Vitreoretina
577

578. Retinal Layers
American Academy of Ophthalmology
578

579. Retinal Layers
American Academy of Ophthalmology
579

580. Retina : Basic
• Strongest j
g
junction
– Ora serrata
– Optic nerve head
• Retinal vessel
– Inner 2/3 by Central retinal artery
– Outer 1/3 by Choriocapillaris  also supply
• Fovea
• RPE
– Cilioretina artery
• In 50% of persons it supplies 30% parts of inner retina
• In 15% of persons it contributes to some of macular
circulation
580

581. Retinal vessels
581

582. Retina : Blood Ocular Barrier
• Blood Retinal Barrier
– Retinal Blood Vessel  analogous to Cerebral Blood
Vessels  maintain Inner Blood-Retina Barrier
–I
Inner Blood-Retina B i performed b
Bl d R ti Barrier
f
d by
• Single Layer of Non Fenestrated Endothelial Cells  TightJunction (zonulae occludens)
• Basement Membrane, pericytes (Interupted layer)
• Internal Elastic Lamina & Smooth Muscle (Near Optic Head )
– Outer Blood-Retina Barrier performed by RPE in
RPE,
which adjacent cells are similarly joined by zonulae
occludens
American Academy of Ophthalmology
582

583. Retina : Blood Ocular Barrier
• Blood Aqueous Barrier
–I
Inner non-pigmented cilliary epithelium
i
t d illi
ith li
– Tight-junctions between epithelial and
endothelial cells
American Academy of Ophthalmology
583

584. RPE : Function
•
•
•
•
•
•
•
•
Vitamin A metabolism
Maintenance of outer blood-retina barrier
g y
photoreceptor outer segment
p
g
Phagocytosis of p
Absorption of light (reduction of scatter)
Heat exchange
Formation of basal lamina
Production of mucopolysaccharide matrix
Active transport of material in and out of the
RPE
American Academy of Ophthalmology
584

585. Clinical Facts
• The outer Blood retinal barrier the RPE
barrier,
RPE,
and the retinal vascular endothelium utilize
the same receptor-ligand pairing to control
receptor ligand
lymphocyte traffic into the retina
• The outer Blood retinal barrier is a
common site for inflammatory attack, often
resulting in breakdown of barrier functions
and choroidal neovascularization
Penfold PL, Provis JM, 2005
585

586. Blue Light toxicity to RPE
• Over time  RPE accumulates Fluorescent
material  Lipofuscin
• Lipofuscin absorbs blue light  Lipofuscin
Fluorophore A2E  in presence of Oxygen 
generate A2E Epoxides
• A2E Epoxides toxic to RPE and induces
Apoptosis
poptos s
• RPE can no longer nourish photoreceptor cells
 adversely affect the vision
586

587. Fundus : Examination
•
•
•
•
Optic nerve head
Retinal appearance
Vascular shape
Macula
587

588. Fundus : Optic nerve head
•
•
•
•
•
•
•
•
Margin
Color
Disc, Cup,
Disc Cup Rim shape
Para papil
Vascular change
V
l
h
Hemorrhage
Myeline
Membrane
588

589. Fundus : Retina
• RNFL
• Hard exudates
– Intra retinal lipoprotein deposits
• Soft exudates  Cotton Wool Spot (
p (CWS)
)
– Fuzzy or ill-defined edges as retinal ischemia to infarction 
cotton-wool spot
• Microaneurysm  around areas of capillary non perfusion
• Hemorrhage
–
–
–
–
Pre-retinal
Retinal  Flame-shaped
Sub-retinal  Fluids level
Roth spot  hemorrhages with white center  Leukemia
• Degeneration
589

590. Fundus : Vascular
• AV ratio
• AV crossing
– Sallus
– Gunn
– Banking
• Axial reflect
– Copper wire
– Silver wire
• Malformation
590

591. Fundus : Macula
• Reflect
• Malformation :
– Edema
– Hole
– Drusen  deep or dull yellow deposit
• Located in the outer retina of posterior pole
• Histologically corresponds to abnormal thickening of the inner
aspect of Bruch’s membrane
• Basal laminar deposits  long-spacing collagen between the
plasma membrane and basement membrane of the RPE
• B
Basal li
l linear d
deposits  d
it
deposits of electron-dense granules and
it f l t
d
l
d
phospolipid vesicles in the inner parts of Bruch’s membrane
– Pigment
– Cicatrix
American Academy of Ophthalmology
591

592. American Academy of Ophthalmology
592

593. The 1.5 mm Macula
Penfold PL, Provis JM, 2005
The central human retina or macula,
with an idealized view of its bl d vessels.
ith
id li d i
f it blood
l
The optic disc (OD) is to the left. The
macula is subdivided into the central-most
foveola, which is surrounded in turn by the
,
y
0.35 mm fovea, parafovea and wider
perifovea in 5.5 mm of posterior pole. Each
is indicated by concentric circles. Blood
vessels form a ring outlining the foveal
avascular zone, which marks the inner
593
limits of the foveal pit

594. Drusen
•
•
•
•
•
•
•
Drusen
– Hard drusen  appear clinically as small yellow punctate
small, yellow,
deposits
– Soft drusen  paler, larger deposits
Is presence of cellular debris
Located in the outer retina of posterior pole, underneath the RPE
Histologically corresponds to abnormal thickening of the inner
aspect of Bruch’s membrane
Consist of extracellular deposit  that aggregate between RPE and
Bruch’s membrane
Basal laminar deposits  long-spacing collagen between the
plasma membrane and basement membrane of the RPE
Basal linear deposits  deposits of electron-dense granules and
phospolipid vesicles in the inner parts of Bruch’s membrane
Penfold PL, Provis JM, 2005 ; Eurotimes 2009
594

595. Macula : HRA OCT Spectralis (Heidelberg E i
M
l HRA-OCT S
li (H id lb
Engineering)
i )
595

596. Simple test for macular function
•
•
•
•
Colour test
Photostress Recovery test
Amsler grid
g
Heyne Retinoscopy
596

597. Distribution of photoreceptor
cells and ganglion cells on the
g g
macula
Penfold PL, Provis JM, 2005
597

598. The cone cells
• Sharp photoreceptor
• A human eye can see wavelengths in the range of 380 to
760nm. This range is called the visible region
• Trichromatic Theory  3 types of cones, each with a
different iodopsin (a photosensitive pigment)
• Each type of iodopsin can absorb and respond to a
range of wavelengths
• Photosensitive pigments 
– Erythrolabe  maximum absorption at 565nm (red)
– Chlorolabe  maximum absorption at 535nm (green)
– Cyanolabe  max. absorption at 440nm (blue)
598

599. Color test
•
•
•
•
Color naming
Yarn test
Lantern test
Plate test
– Hardy-Rand-Rittler plates  Red/Green and Bleu/Yellow
– Ischihara’s Polychromatic or Pseudoisochromatic plates 
Ischihara s
Red/Green
• Arrangement test  Hue discrimination test
• Anomaloscopes test
• Panel test  Farnsworth Panel D-15 and FarnsworthMunsell 100-Hue test
599

600. Deficient Color Vision
• Dichromacy (Color blindness)
– Red / Green deficiencies
• Protanopes
– Confusion  at a point at the red end (right end) of the
spectrum l
locus
– Reds also appear darker to protonopes than to normals
• Deuteranopes
– Confusion lines  an extraspectral point (off the chart to the
lower right, in these coordinates) and their brightness vision is
more like that of color-normals
– T it
Tritanopia and T it
i
d Tritanomaly  Y ll
l
Yellow / Bl
Blue
deficiencies
– The third class  Achromacy
Birch, 2001
600

601. Ischihara’s Pseudo-isochromatic plates
p
• Standard illumination
– Daylight
y g
– 20-60 foot candles
• 75-100 cm reading distance
75 100
• 3-5 seconds observation time per plate
• N color contact l
No l
t t lens wear
Deborah Pavan-Langston, 2008
601

602. Dark-adaptation test
p
• The Goldman-Weekers machine
• Used to plot the dark-adaptive curve
• In bright light 10 minutes and then all lights are
extinguished
• Interval 30 seconds  make a measurement of light
threshold in one area of visual field
• By presenting a gradually increasing light stimulus
• U til b l visible t th patient
Until barely i ibl to the ti t
• The graph of decreasing retinal threshold against time :
– Initial steep slope  cone adaptation
– Subsequent gradual slope  rod adaptation
• Depression of the dark-adaptation  affecting outer
retina and RPE, E.g : Retinitis pigmentosa
Deborah Pavan-Langston, 2008
602

603. Retina : How to draw the retina
• Central  Macula
• Ora Serrata
– Temporal
– Nasal  Thinner
• Color :
–
–
–
–
–
Red
R d
Blue
Red with blue margin
Brown
Black
603

604. RD : Basic
• RETINAL DETACHMENT (RD) :
A SEPARATION OF THE SENSORIC RETINA
FROM THE RETINAL PIGMENT EPITHELIUM
• RETINAL BREAK :
A FULL-THICKNESS DEFECT IN THE
SENSORY RETINA
604

605. RD : Classification
I. RHEGMATOGENOUS R.D. (RRD)
( PRIMARY R D )
R.D.
II. NON-RHEGMATOGENOUS R.D.
( SECONDARY R D )
R.D.
1. TRACTIONAL R.D.
2.
2 EXUDATIVE R D
R.D.
605

606. RD : Classification
•
MINIMAL
– Vitreous haze
– Vitreous pigment clumps
pg
p
•
MODERATE
–
–
–
–
•
Wrinkling of inner retinal surface
Rolled edge of retinal breaks
Retinal stiffness
Vessel tortousity
MARKED full thickness fixed retinal folds
– C1, C2, C3 (1,2,3 quadrant(s))
•
MASSIVE fixed retinal folds in four quadrant
q
– D1 wide funnel shape
– D2 narrow funnel shape
– D3 closed funnel  invisible optic disc
American Academy of Ophthalmology
606

607. RD : Rhegmatogenous
Kanski JJ, 2007
607

608. RRD : Principle of management
• First : find all breaks
• Second : create a chorioretinal irritation
surrounding each breaks
• Finally : bring the retina and choroid into contact
for sufficient time  produce chorioretinal
adhesion  permanently close the breaks
American Academy of Ophthalmology
608

609. RD : Management
• Break only : Laser Photocoagulation
• With Detachment
– Si l
Simple
•
•
•
•
Scleral buckle  Local and Encircling
Sub retinal fluid drainage
Pneumoretinopexy
Cryoretinopexy  Limited due to PVR formation
– Vitrectomy
609

610. Buckle vs Vitrectomy
• Vitrectomy
– More expensive*
– More equipments and technology
– Longer learning curve to perform
– Induce more complication
– Need specific positioning
– S l more diffi lt case
Solve
difficult
610

611. Buckle vs Vitrectomy
y
• Buckle
– Cheaper and faster
– Less equipments and technology
– Longer learning curve to perform
– Less complication
– Better mobilization
– Need more skill to identifying break location
and placing buckle precisely on it
– More painful
– Myopic shift
611

612. Vitrectomy is prefer : When?
•
•
•
•
•
•
•
•
Unclear media
Unsolved traction
Not indented breaks by buckle
Posterior breaks
Need of membrane peeling
PVR
Multiple or spreading breaks
Combined with anterior segment surgery
612

613. Buckle
• Make indentation to close and prevent
breaks
• Silicone
– Band
– Tire
– Sponge
• Sleeve for adjust the tightening
• Suture to sclera with non absorbable
material
613

614. Vitrectomy
•
Machines  1,000 up to 7,500 cuts per minute  face to Microincision Vitroretinal Surgery (MIVS)
– Examples :
• CONSTELLATION Vision System (Alcon, Inc)
• Stellaris PC Phacoemulsification and Vitrectomy System (Bausch & Lomb
Incorporated)
• Oertli OS3 and Faros Ophthalmic Micro-incision Surgery System (Oertli
Instruments)
• The Associate 6000 Ophthalmic Microsurgical System (DORC)
g
y
• eva Ophthalmic Microsurgical System (DORC)
• The VersaVIT and Core Essentials Vitrectomy Machine System and
Vitrectomy Packs (Synergetics)
•
New  Vitreoretinal Endoscopic
– Micro endoscopy for vitrectomy and endophotocoagulation
– Examples :
p
• Endo Optiks
• 23 g tapers to 27 g probe and 25 g tapers to 30 g probe IRIDEX EndoProbe
614

615. Vitrectomy
• Microscope enhancement system 
Retinal wide angle observation tools
– Examples :
•
•
•
•
•
•
RESIGHT Fundus Viewing System (Carl Zeiss)
MERLIN Surgical Viewing System (Volk)
Oculus SDI 4 (OCULUS Optikgeräte GmbH)
Oculus BIOM 5 (OCULUS Optikgeräte GmbH)
EIBOS 200 (Platinum Medical)
SUPER VIEW Wide Angle (Insight Instruments)
615

616. Vitrectomy
y
• Endo Laser
– Example :
p
• PUREPOINT Laser (Alcon, Inc)
• Instruments
– Example :
• 23 and 25+ gauge Micro-Incision Vitrectomy Surgery 
MIVS (Alcon, Inc)  ULTRAVIT® High Speed Vitrectomy
Probes with Duty Cycle Control
• 25+ and 27+ Probe TotalPLUS Paks (Alcon Inc)  7,500
cpm Ultra-High Speed Cutting
• Hi-speed 23 and 25 g g NovitreX3000 and
p
gauge
OertliKatalyst (Oertli Instruments)
• Intraocular pressure stabilizer  Autoseal PMS (Oertli
Instruments)
• 27 gauge MIVS system pack (DORCH and Synergetics)
• GRIESHABER® Instrumentation (Alcon Grieshaber AG)
616

617. Vitrectomy : Illumination
•
•
•
•
•
•
Halogen  Yellow Dimmer Light
Xenon  Bright White
Metal Halide  Bright Natural
Photon
Ph t  G
Green Yellow
Y ll
Light-Emmiting Diode (LED)
29/30 g Chandelier Fiber Optics
(Synergetics)
617

618. Gas d Liquid
G and Li id
Purpose :
p
1. MECHANIC MANIPULATION OF RETINA
2. TEMPORARY INTERNAL TAMPONADE OF RETINAL BREAK
3.
3 TO FLATTEN RETINAL DETACHMENT
4. TO MAINTAIN  CLEAR VIEW- RETINA
5. TO MAINTAIN OCULAR TONE
618

619. The Gas
NONEXPANSILE GASES
–
AIR (NOT PURE GAS)  20% OXYGENE +
80% NITROGENE  < 5 DAYS
–
OXYGENE ( O2 )
–
CARBON DIOXIDE (CO2 )
EXPANSILE GASES
–
SULFUR HEXAFLUORIDE (SF6)  2x
 10 – 14 DAYS
–
PERFLUOROPROPANE (C3F8)  4x
55 – 65 DAYS
619

620. The Liquid
q
BSS – PLUS
GLUTATHIONE  ANTI OXIDANT
SILICONE OIL
VISCOSITY  1,000 – 5,300 cSt
HEAVY LIQUIDS
- PERFLUORODECALIN (C10F18)
- SURFACE TENSION 16 – 21.6 dyne/cm
- VISCOSITY  2.6 – 8.03 cSt
HEAVY SILICONE OIL
- MIXTURE OF :
- ULTRAPURE POLYDIMETHYLSILOXAN
(CH3)3SiO-n-Si(CH3)3 AND
- PERFLUOROHEXYLOCTANE (C6F8)
620

621. Heavy Liquid
621

622. The Laser
TO MANAGE THE BREAKS
– ARGON GREEN (532 nm)
• PREFFERED
– KRIPTON RED (647 nm)
• HAZY MEDIA
• DEEP BURNS
• LESS CHANCE OF RNFL DAMAGE
– DIODE (810 nm)
• VITREORETINAL TRACTIONS
622

623. Precaution
• Excessive cryoretinopexy  Risk of PVR
• Heavy laser burn 
– Iatrogenic break
g
– Pain and inflammation
– Retinal ede a
et a edema
• Long time heavy fluid  Toxic to retina
• Long time silicone oil  More difficult to
manage  Risk of inferior PVR
• St id i oil fill d eye  N
Steroid in il filled
Necrotic retina
ti
ti
623

624. PVR : Classification
•
Grade A
– Vitreous haze
– Vitreous pigment clumps
– Pigment cluster on inferior retina
•
Grade B
–
–
–
–
–
•
Wrinkling of inner retinal surface
Rolled and irregular edge of retinal breaks
Retinal stiffness
Vessel tortousity
Decreased mobility of vitreous
Grade CP 1-12
– Posterior to equator : focal, diffuse or circumferential full thickness folds
– Sub retinal strands
•
Grade CA 1-12
–
–
–
–
Anterior to equator : focal, diffuse or circumferential full thickness folds
Sub retinal strands
Anterior di l
A t i displacement
t
Condensed vitreous with strands
American Academy of Ophthalmology
624

625. Diabetic Retinopathy (DR)
Basic of disease
– Hyperglicemia  EPO, IGF  PKCβ, VEGF
– Basal membrane thickening
– Pericyte death
– Mild endothel proliferative (Microaneurysm)
with plasma leakage
Ong SG, 2009
625

626. Diabetic Retinopathy (DR)
Basic of disease
– Lost of intramural pericytes
– Compromised blood-retinal barrier by defect in the
p
y
junction between abnormal vascular endothelial cells
– Increased vascular permeability  dot and blot
hemorrhages,
hemorrhages edema and hard exudates
– Extensive capillary closure in tripsin-digest flat
p p
preparations of the retina
– Retinal rendered ischemic by capillary closure
elaborates VEGF  stimulates neovascularization
American Academy of Ophthalmology
626

627. Diabetic Retinopathy (DR)
Muller cells
–
–
–
–
–
–
Uptake glutamate  toxic to neurotransmitter
Maintain the synaps  release of neurotrophic agents
y p
p
g
Control extracellular ion concentration
Regulate water transport out of retina  Aquaporin 4
Responsive to VEGF  Express VEGFR1
Responsive to Glucocorticoids  Only one* 
Express Glucocorticoid receptors
Ong SG, 2009
627

628. DR : Basic
Haematologic and biochemical abnormalities
– Increased platelet adhesiveness
– Increased erytrocyte aggregation
– Abnormal serum lipids
– Defective fibrinolysis
– Abnormal level of growth hormone
– Ab
Abnormal serum and whole blood viscosity
l
d h l bl d i
it
American Academy of Ophthalmology
628

629. DR : Highlight
1. No Diabetic Retinopathy
2. Non
2 N proliferative Di b ti R ti
lif ti Diabetic Retinopathy
th
A. Background Diabetic Retinopathy
B. Preproliferative Diabetic Retinopathy
3. Proliferative Diabetic Retinopathy
4. Diabetic maculopathy
Deborah Pavan-Langston, 2008
629

630. DR : Non proliferative
Non-proliferative
•
•
•
•
•
Dilated veins
Dot d blot intra ti l hemorrhages
D t and bl t i t retinal h
h
Microaneurysms
Hard exudates
Edema and CWS
Deborah Pavan-Langston, 2008
630

631. Progression from NPDR to PDR
• Diffuse intra retinal hemorrhages and
mycroaneurysms in 4 quadrants
y
y
q
• Venous beading in 2 quadrants
• IRMA in 1 quadrant
American Academy of Ophthalmology
631

632. DR : Pre-proliferative
Pre proliferative
• Intra retinal hemorrhages
• Microaneurysm
• Intra retinal microvascular abnormalities (IRMA)
 dilated vessel within the retina
• Venous beading
• Widespread capillary closure
• 10-50% develop to proliferative within a year
Deborah Pavan-Langston, 2008
632

633. DR : Proliferative
• New vessel on surface the retina and optic
nerve head  usually attached of
posterior hyaloid of vitreous body
• C
Cycatrical stage  vitreous hemorrhages
ti l t
it
h
h
and traction retinal detachment
Deborah Pavan-Langston, 2008
633

634. Diabetic maculopathy
• Result from increased vascular
permeability
bilit
• With or without hard exudates
• Less commonly  result from ischemia
due to closure of foveal capillaries
p
• May NOT be seen in early background DR
Deborah Pavan-Langston, 2008
634

635. DME : Type of Thickening
• Uniform speckled
– Extra cellular fluid  Vasogenic mechanism
• Cystic
– Swollen of Muller’s cells  Toxic mechanism
– Not extra cellular fluids
Ong SG, 2009
635

636. DME : Clinical variations
• Vasogenic
– Localized leakage from microaneurism
• Toxic - Non vasogenic
– Leakage from poorly identifiable sites
– Massive leakage
• Mechanical
– Vitromacular tractions
– Epiretinal membrane (ERM)
• T id - VEGF mediated
Toxid
di t d
– Perpheral ischemia  VEGF over expression
Ong SG, 2009
636

637. DR : CSME
Clinically Significant Macular Edema
• Thickening of the retina at or within 500 µm of
center of the macula
• Hard exudates at or within 500 µm of center of
the macula
• A zone of retinal thickening one disc area or
larger  any p of which is one disc diameter
g
y part
of center of the macula
American Academy of Ophthalmology
637

638. DR : CSME
American Academy of Ophthalmology
638

639. DR : CSME
American Academy of Ophthalmology
639

640. DR : CSME
American Academy of Ophthalmology
640

641. DR : High risk PDR
• Mild Neovascularization on disc (NVD) with
vitreous hemorrhages
• Moderate to severe NVD  larger than ¼ to ⅓
disc area with or without vitreous hemorrhages
• M d t N
Moderate Neovascularization at elsewhere
l i ti
t l
h
(NVE) ½ disc area or more with vitreous
hemorrhages
American Academy of Ophthalmology
641

642. DR : High risk PDR
• At least 3 of :
– Vitreous or pre retinal hemorrhages
– New vessels (NV)
– Location of new vessel on or near optic disc
– Moderate or severe extent of new vessels
American Academy of Ophthalmology
642

643. DR : Approach
•
•
•
•
•
•
•
Reduce blood sugar
Monitoring Hba1c
Laser photocoagulation
L
h t
l ti
Steroids
Anti-VEGF
Rapamycin (Sirolimus)*
(Sirolimus)
Surgery
Ong SG 2009; Blumenkranz, 2009; Eurotimes 2009
643

644. DR & DME: Clinical Trial Update
•
•
•
•
•
•
•
N acetylcarnosine
N-acetylcarnosine Eye Drops
Nepafenac Eye Drops
Fenofibrate Oral
F
fib t O l
Dextromethorphan Oral
Danazol Oral
Ranibizumab (Advance Clinical Trial)
Dexamethasone Implant
Retinal Physician 2013
644

645. DR : Laser rationale
Retina
•
•
•
•
•
•
Thinning of retina
Destruction of ischemic retina
Reduction of VEGF release
Proliferation f d th li l ll
P lif ti of endothelial cells
Increase blood flow
Improve auto regulation
Ong SG, 2009
645

646. DR : Laser rationale
RPE
•
•
•
•
Destruction of RPE  new growth
Increase transmission of metabolism
Increase Oxygen transmission
yg
Improve “pump”
Ong SG, 2009
646

647. DR : Laser rationale
Bruch s
Bruch’s membrane
• Altered permeability
• Lipid destruction
Choriocapillary
• Destruction of choriocapillary
Ong SG, 2009
647

648. DR : Laser
Grid Laser Photocoagulation
g
• Macular application  500 µm up to 3000 µm from
foveal center
• Excluded  area of PMB
• Grid Lens / +78 and +90 D Lens
• Start at 100mW power  increments of 10-20mW
10 20mW
• 50-100 µm spot size
• 0.100 second or less duration
• Spots spaced at least one burns apart
• Supplemental treatment considered at least 3-4 month
after initial coagulation  up to 300 µm
648

649. DR : Laser
Focal L
F
l Laser Ph t
Photocoagulation
l ti
• Grid Lens / +78 and +90 D Lens
• Start at 100mW power  increments of 1020mW
• 50-100 µm spot size
• 0.100 second or less duration
• Attempt to whiten or darken microaneurysms
649

650. Laser : PRP
Pan-Retinal Photocoagulation
/ Scatter Laser Photocoagulation
• NVD or / and NVE
• PRP L
Lens
• Start at 180mW power  increase gradually to achieve
the end point
• 500 µm spot size
• 0.100 to 0.200 second duration
• 1800 total applications
pp
• 1 – 1.5 burns width apart
• 3 sessions complete  10 days to weeks apart
• Usually inferior half of retina coagulated first
Usually,
650

651. DR : Laser
• Poor visual outcome after
photocoagulation associated with :
– Diffuse macular edema with center involved
– Diffuse fluorescein leakage
– Macular ischemia  extensive perifoveal
capillary non perfusion
– Hard exudates in the fovea
– Marked Cystoid Macular Edema (CME)
American Academy of Ophthalmology
651

652. DR : Laser
• Side effect and complication
– Paracentral scotomata
– Transient increased edema  decreased
vision
– Choroidal Neovascularization (CNV)
– Subretinal fibrosis
– Scar expansion
p
– Inadvertent foveolar burns
American Academy of Ophthalmology
652

653. Laser in Retina: Nowadays
•
•
•
•
•
•
•
•
Highly focused
Adjustably patterned
Burn effectively  Speed and accuracy
Surrounding area safety
OCT guided with high transparency
Navigated and tracked
Real time information and comfort for patient
Better result and less side effect
653

654. DR : IVTA Consideration
• Edema refractory to Laser photocoagulation
treatment
• Proximity of leakage to the fovea
• Difficult to laser or more exacerbate of
edema  High risk PDR, Cataract with DME
• Hard exudates with heavy leak close to
fovea
• Extreme exudation
Ong SG, 2009
654

655. DR : IVTA to Muller s cells
Muller’s
• M ll ’ cells are t
Muller’s ll
target of St id
t f Steroids
treatment
• Increase in Adenosin mediated fluid
resorption
• Reducing the cystic thickening DME
Ong SG, 2009
655

656. DR : Steroids
• Slow released injectable non-erodible
non erodible
intravitreal steroids
• Fluocinolone Acetonide  Medidur (Bausch &
Lomb)  18 to 36 months
• Oral treatment
– Danazol  Optina (Ampio Pharmaceuticals)
Cousins SW, 2009; Retina Today 2012
,
;
y
656

657. Vitreous hemorrhages
• Major cause
– Diabetic retinopathy (39-54%)
– Retinal break without detachment (12-17%)
– Posterior vitreous detachment (7.5-12%)
(
)
– Rhegmatogenous retinal detachment (7-10%)
– Retinal NV following BRVO or CRVO (3.5-10%)
(3.5 10%)
American Academy of Ophthalmology
657

658. DR: Vitrectomy Indications
American Academy of Ophthalmology
658

659. Central Serous Chorio-Retinopathy (CSCR)
•
Sensory detachment of the sensory retina, resulting from
S
d t h
t f th
ti
lti f
– Altered barrier function
– Deficient pumping function at level of the RPE and may also involving
the choriocapillaris
p
•
•
Preferentially in 30-50 years old healthy men
Sudden onset of
–
–
–
–
•
Blurred and dim vision
Micropsia
Mi
i
Metamorphopsia
Decreased color vision
FFA
– Expansile dot  most common
• Focal hyperfluorescent leak from RPE
• Appear in early phase
• Increase in size and intensity as angiogram processes
– Smokestack
• Leakage of fluorocein into sub retinal fluid pocket
• Produce a pattern of sub retinal pooling of dye
– Mushrooms Umbrella
Mushrooms,
American Academy of Ophthalmology
659

660. Infrared CSCR : HRA OCT Spectralis (Heidelberg Engineering)
660

661. Sub retinal fluid in elderly
CSCR
CNV associated
with AMD
Pin point leak relative to a large
area of sub retinal fluid on FFA
Sub retinal fluid corresponds closely
to area of leakage on FFA
Multifocal RPE abnormalities
- Small serous PED
Large drusen
Absence of blood and significant
lipid
Presence of blood and significant
lipid
American Academy of Ophthalmology
661

662. CSCR : Laser indication
• Persistent serous detachment 3-4 months
34
• Recurrences in eye with visual deficit from
previous episodes
• Presence of permanent visual deficit from
previous episodes in fellow eye
• Development of chronic signs 
– Cystic changes
– Widespread RPE abnormalities
• Occupational
American Academy of Ophthalmology
662

663. Retina : AMD
International Classification (1995)
(
)
• Age-related maculopathy (
Ageg
p y (ARM)
)
– Drusen
• Small, intermediate, large
• Hard, soft, confluent
Hard soft
– Hyper or hypopigmentation of RPE
• Age-related macular degeneration (AMD)
Age– Exudative
– N -exudative
NonNon
d ti
Koh A, 2005
663

664. AMD : Exudative
• Choroidal Neovascularisation (CNV)
• Pigment E ith li l D t h
Pi
t Epithelial Detachment (PED)
t
• Glial/scar tissue (disciform scar)
Koh A, 2005
664

665. AMD : Non-Exudative
Non Exudative
• RPE hypopigmentation >175 m diameter
(Geographic atrophy)
(G
hi t h )
Koh A, 2005
665

666. AMD : Signs
•
•
•
•
•
•
•
GreenishGreenish-gray or Yellow-green lesion
YellowPigmented halo around lesion
Subretinal hemorrhage
S b ti l h
h
Hard lipid exudates
Sensory retinal detachment
RPE detachment
Cystoid edema
Koh A, 2005
666

667. AMD : Symptoms
•
•
•
•
•
•
•
Monocular vision loss
p p
Metamorphopsia
Decreased contrast sensitivity
Scotoma
Decreased color vision
Micropsia
Nowadays level of vision early detection and
monitoring  ForeseeHome (NOTALVISION)
Koh A 2005, Retina Today 2013
667

668. AMD : RF, IF, AF, FA, ICGA
Red Free
Infrared
Fluorescein
Angiography
Autofluorescence
ICG Angiography
HRA Spectralis (Heidelberg Engineering)
668

669. AMD : HRT and OCT
HRT3 Heidelberg Engineering
Cirrus HD OCT (Carl Zeiss Meditec AG)
669

670. CNV : Morphology
• Vascular
• Hypervascular
• Fib
Fibrovascular
l
Cousins SW 2009
SW,
670

671. CNV : Diverse cell types
•
•
•
•
•
•
•
Endothelial
Smooth muscle cells
Pericytes
Myofibroblasts
RPE cells
ll
CD34 progenitor cells
Macrophages
Cousins SW 2009
SW,
671

672. CNV : FFA
Classic (Type 1) CNV
•
•
Bright area of fluorescence surrounded
by hypofluorescent margin in early phase
Leakage of fluorescein at boundaries of
bright area in late phase
Koh A, 2005
672

673. CNV : FFA
Occult (Type 2) CNV
• Fibrovascular PED
– Irregular elevation of the RPE
– Stippled fluorescence within 1 to 2 minutes
– Persistent staining or leakage in late phase frames
• Late Leakage Undetermined Source
– Leakage at level of RPE
–A
Areas of leakage d not correspond t an area of
fl k
do t
d to
f
classic CNV or fibrovascular PED in early or mid
phase frames to account for leakage
Koh A, 2005
673

674. Occult (Type 2) CNV
Hagerman GS 2008
H
GS,
674

675. CNV : ICG
• Components
p
– Subretinal fibrovascular complex
– Intrachoroidal “Feeder Artery”
– Intrachoroidal “Draining Vein”
• Patterns
– Capillary pattern
– Arteriolar pattern
p
– Mixed pattern
Cousins SW, 2009
675

676. Occult CNV
• More than one lesion
• Sub RPE low flow and poor defined
vascularity
• High flow arteriolarized
• Atypical polypoidal choroidal vasculopathy
• Retinal angiomatous p
g
proliferation
Cousins SW 2009
SW,
676

677. AMD : Major Risk Factor
• Molecular Biology :
– H Gene (Known as CFH of HFI)  Located
(
)
on Human Chromosome Iq31
– Less of Particular Non-Coding SNP Variant
(Allele A)  Found in Intron 6 of the Serping 1
Gene
Eurotime, 2009
E ti
677

678. AMD : Approach
• Laser photocoagulation
• Signal  Anti VEGF
OSI Eyetech (Pegabtanib)  Selective
y
g
)
VEGF165 Inhibitor
– Lucentis® Genentech (Ranibizumab)
– Avastin™ Genentech (Bevacizumab)
– Macugen®
g
– ALG-1001Allegro Ophthalmic (Anti Integrin Oligo Peptide) 
Signaling and Regulating
Cousins SW 2009; Eurotimes 2009, Retina Today 2013
678

679. AMD : Approach
• Signaling pathway  Steroids
– Anecortave
– Triamcinolone
• Formation  PDT
– Verteporfin dye (Visudyne)
p
y (
y )
• Liposome-encapsulated Benzoporphyrin
• Maximum absorption  light near 689 nm wavelength
– Others :
• Tin Ethyl Etiopurpurin (SnET2, Purytin)
• Lutetium (Lu-Tex)
Cousins SW 2009; Eurotimes 2009, Retina Today 2013
679

680. AMD : Approach
• E10030 – A ti PDGF Aptamer (Ophthotech)  Synthetic
Anti
A t
RNA molecules  bind protein similar to antibody
•
•
•
•
•
Implantable Miniaturized Telescope (MT)*
p
p ( )
The Lipshitz Macular Implant (LMI)*
The IOL-VIP System*
Gene Therapy  Small interfering (si)RNA*
Membrane Differential Filtration (MDF)  Rheopheresis
 Dry AMD*
AMD
Eurotimes, 2009, 2011
680

681. AMD : Approach
• I t
Integrin P tid Therapy
i Peptide Th
• ALG-1001
• Topical Therapies*:
–
–
–
–
–
ATG3 (coMentis)
OT-551 (Othera Ph
OT 551 (Oth
Pharm)
)
TG100801 (TargeGen)
Pazopanib (GlaxoSmithKline)
OC-10X (OcuCure)
Eurotimes, 2010; Retina Today 2012
681

682. AMD : Approach
pp
• Brachytherapy
• Source of radiation is placed close to the
surface of targeted therapeutic area
• Beta radiation targeted at abnormal or leaking
vessels
• Stereostatic Radiotherapy  Oraya Therapy
(Oraya Inc)
(O
I )
Retina Today, 2011, 2012
682

683. Dry AMD : Approach
y
pp
• Anti oxidants
– Vitamin C, Vitamin E, Beta-Carotene, Zinc and Copper
– Lutein and Zeaxanthin
– Omega 3 fatty acid
•
•
•
•
•
Visual cycle inhibition
Anti inflammatory agents
Complement inhibitor
Targeting amyloid
Neuroprotector
Retina Today, 2011
683

684. Response to Anti-VEGF
Anti VEGF
• C ill
Capillary-dominated CNV  W ll
d i t d
Well
response
• Mixed CNV  variable response depends
on  Ratio of feeder artery caliber and
length to capillary area
• Arteriolarized CNV  Poor response
p
Cousins SW, 2009
684

685. Remember
•
•
•
•
PDT induces hypoxia in tissue
yp
PDT induces formation of oxygen free radical
After 1 day  Strong VEGF expression
After 1 month PDT increases expression of
– CD 34 ( marker of endothelial cell)
– CD 105 ( marker of activated endothelial cell)
– KI-67 ( marker of proliferation )
Eurotimes, 2009
685

686. PDT : Post procedure
• Inflammatory cells observed
y
–
–
–
–
–
Monocytes
Macrophages
Platelets
Mast cells
Leukocytes
• Release angiogenic factors  VEGF, bFGF
IL 1β, IL-2,
• Release cytokines  IL-1β, IL 2, TNFα
• Release vasoactive mediators  Thromboxane,
TNFα, Histamine
Koh A, 2009
686

687. Remember
• Fundus fluorescein angiography remains an
g g p y
indispensable tool in diagnosis and
management of AMD
• Indocyanine green angiography is useful in
certain situations
• Optical coherence tomography is very popular
because of ease of use and interpretation,
b
f
f
di t
t ti
particularly useful for follow-up
follow• Newer tec ques suc as S O a g og ap y
e e techniques such
SLO angiography
and autofluorescence not so essential for clinical
practice
Koh A, 2005
687

688. Wet AMD: Clinical Trial Update
•
•
•
•
•
•
•
•
•
•
Proton Beam Irradiation
Slidenafil
Zeaxanthin Oral (Advance Clinical Trial)
Aflibercept Intravitreal injection
Squalamine Lactate Eye Drops
Ranibizumab (
(Advance C
Clinical Trial)
)
LFG316 Intravitreal injection
AGN-150998
AGN 150998 Intravitreal injection
ESBA 1008 Microvolume injection
E10030 Intravitreal administration
Retinal Physician 2013
688

689. Occult CNV AF and OCT : HRA OCT Spectralis (Heidelberg Engineering)
689

690. Polypoidal Choroidal Vasculopathy (PCV)
• Also as "idiopathic p yp
p
polypoidal choroidal vasculopathy")
p y)
• A distinct form of choroidal neovascularization (CNV)
• Disorder characterized by vessel networks and
polypoidal lesions
• Specifically, an inner choroidal vascular abnormality
with two distinct components:
– A network of branching vessels predominantly external to the
choriocapillaris, and
– Aerminal aneurysmal dilatations
Nakashizuka H, 2008; Cousins SW, 2009
690

691. Polypoidal Choroidal Vasculopathy (PCV)
• Sometimes clinically seen as reddish-orange
y
g
spheroidal, or polypoidal, vascular lesions.
• Location  Peripapillary, Sub foveal,
Juxtafoveal, E
J
f
l Extra f
foveal
l
• Formation  Single, Cluster (more than 2
polyps in a group) or String (more than 3 polyps
in a line )
S e
µ
• Size  in µm
• Area  Single, Multiple
Nakashizuka H, 2008; Cousins SW, 2009
691

692. Polypoidal Choroidal Vasculopathy (PCV)
•
•
•
(A) Color fundus
photograph showing a
white fibrin-like lesion
(arrow) adjacent to
subretinal h
b ti l hemorrhage
h
(arrowhead) and serous
retinal detachment in the
macula.
(B) Fluorescein fundus
angiography showing
granular hyperfluorescence
in the early phase (arrow).
(C) IGA showing polypoidal
lesions resembling grape
clusters
Nakashizuka H, 2008
692

693. Polypoidal Choroidal Vasculopathy (PCV)
•
•
•
(A) Color fundus photograph
shows orange lesions (arrow)
surrounded by a white lesion.
These findings are consistent with
PCV (i.e., a polypoidal lesion
accompanied b fib i )
i d by fibrin).
(B) Fluorescein fundus
angiography showing two small
round hyperfluorescent lesions
near the fovea (arrow) and a
hyperfluorescent lesion indicating
pigment epithelial detachment
(arrowhead).
(C) IGA showing polypoidal
lesions corresponding to
hyperfluorescent lesions on
fluorescein fundus angiography.
Nakashizuka H, 2008
693

694. PCV : Management
• Focal laser photocoagulation
• PDT
• Anti VEGF
Cousins SW 2009
SW,
694

695. Macular hole
•
•
A, Standard StratusOCT image of the normal human macula. Most of the major
intraretinal layers can be visualized in the Stratus OCT image and correlated with
intraretinal anatomy.
B, Ultrahigh-resolution optical coherence tomography (Cirrus HD OCT?) image of
normal human macula. Ultrahigh-resolution OCT has an improved ability to visualize
smaller structures such as the external limiting membrane (ELM) and ganglion cell
layer (GCL) INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS =
(GCL).
photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer
nuclear layer; OPL = outer plexiform layer; RPE = retinal pigment epithelium
695
Fujimoto J, 2006

696. Macular hole : Lamellar
•
Lamellar hole. A, Fundus photograph depicting the direction of optical
,
p
g p
p
g
p
coherence tomography (OCT) scans. StratusOCT (B) and ultrahighresolution OCT (UHR-OCT) (C) images. D, Two-times magnification of the
UHR-OCT image in the region of the hole. ELM = external limiting
membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = inner
plexiform layer; IS/OS = photoreceptor inner and outer segment junction;
NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform
layer; RPE = retinal pigment epithelium.
696
Fujimoto J, 2006

697. Macular hole : Stage 1
•
Stage 1 macular hole. A, Fundus photograph depicting the direction of
g
,
p
g p
p
g
optical coherence tomography (OCT) scans. Stratus OCT (B) and ultrahighresolution OCT (UHR-OCT) (C) images. D, Two-times magnification of the
UHR-OCT image in the region of the hole. ELM = external limiting
membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = inner
plexiform layer; IS/OS = photoreceptor inner and outer segment junction;
NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform
layer; PR OS = photoreceptor outer segment; RPE = retinal pigment
697
epithelium. *Henle’s fibers of the OPL.
Fujimoto J, 2006

698. Macular hole : Stage 2
•
Fujimoto J, 2006
Eccentric stage 2 macular hole.
A, Fundus photograph depicting
the hole before surgery and the
direction of optical coherence
tomography (OCT) scans. B C
t
h
B, C,
Stratus OCT (B) and ultrahighresolution OCT (UHR-OCT) (C)
images of the hole before
surgery. D, Two-times
g
magnification of the UHR-OCT
image in the region of the hole.
E, Fundus photograph depicting
repair of the hole after surgery.
F, G, StratusOCT (F) and UHROCT (G) images of the repair of
the hole after surgery H Twosurgery. H, Two
times magnification of the UHROCT image in the region of the
hole repair. ELM = external
limiting membrane; GCL =
ganglion cell layer; INL = inner
nuclear layer; IPL = inner
plexiform layer; IS/OS =
photoreceptor inner and outer
segment junction; NFL = nerve
fiber layer; ONL = outer nuclear
layer; OPL = outer plexiform
layer; PR OS = photoreceptor
l
h t
t
outer segment; RPE = retinal
pigment epithelium.
698

699. Macular hole : Stage 3
•
Stage 3 macular hole. A, Fundus photograph depicting the direction of
g
,
p
g p
p
g
optical coherence tomography (OCT) scans. B, C, Stratus OCT (B) and
ultrahigh-resolution OCT (UHR-OCT) (C) images. D, Two-times
magnification of the UHR-OCT image in the region of the hole. ELM =
external limiting membrane; GCL = ganglion cell layer; INL = inner nuclear
layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer
segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL
= outer plexiform layer; PR OS = photoreceptor outer segment; RPE =
retinal pigment epithelium.
Fujimoto J, 2006
699

700. Macular hole : Stage 4
•
Fujimoto J, 2006
Stage 4 macular hole. A, Redfree fundus photograph depicting
the direction of optical
g p y (OCT)
)
coherence tomography (
scans. B, C, Stratus OCT (B)
and ultrahigh-resolution OCT
(UHR-OCT) (C) images of the
hole before surgery. D, Twotimes magnification of the UHROCT image in the region of the
hole. E, Fundus photograph
depicting repair of the hole after
surgery. F, G, StratusOCT (F)
and UHR-OCT (G) images of the
repair of the hole after surgery.
H, Two-times
H Two times magnification of
the UHR-OCT image in the
region of the hole repair. ELM =
external limiting membrane; GCL
= ganglion cell layer; INL = inner
nuclear layer; IPL = inner
plexiform layer; IS/OS =
photoreceptor inner and outer
segment junction; NFL = nerve
fiber layer; ONL = outer nuclear
layer; OPL = outer plexiform
layer; PR OS = photoreceptor
outer segment; RPE = retinal
pigment epithelium.
700

701. Hole Form Factor ‘HFF’
HFF
Pullifiato, 1999; Ullrich S, 2002
701

702. Hole Form Factor ‘HFF’
HFF
• ‘HFF’ > 0,9
• ‘HFF’ < 0,5
• Higher ‘HFF’



80% success rate
25% success rate
Better visual outcome
Pullifiato, 1999; Ullrich S, 2002
702

703. Vitreo Macular
Vitreo-Macular Adhesion (VMA)
• Symptomatic VMA is which  the vitreous gel
adheres i an abnormally strong manner t th
dh
in
b
ll t
to the
retina
• VMA can lead to vitreomacular traction (VMT)
and subsequent loss or distortion of visual acuity
• Anomalous posterior vitreous detachment (PVD)
is linked to several retinal disorders including
macular pucker, macular hole, age-related
age related
macular generation (AMD), macular edema, and
retinal tears and detachment
Retina Today 2012; Retina Physician 2012
703

704. Vitreo Macular
Vitreo-Macular Adhesion (VMA)
• Approach  Pars Plana Vitrectomy (PPV)
is used to surgically induce PVD and
release the traction on the retina for
selected cases
• PPV may result in incomplete separation
separation,
and it may potentially leave a nidus for
vasoactive and vasoproliferative
substances, or it may induce development
of fibrovascular membranes
Retina Today 2012; Retina Physician 2012
704

705. Vitreo Macular
Vitreo-Macular Adhesion (VMA)
• Approach
pp
– Ocriplasmin 2.5mg/ml, a vitreolysis agent  JETREA
(TromboGenics)
– ALG-1001 (Allegro)
ALG 1001
• Pharmacologic vitreolysis has the following advantages
g
y
g
g
over PPV: It induces complete separation, creates a
more physiologic state of the vitreomacular interface,
prevents the development of fibrovascular membranes
membranes,
is less traumatic to the vitreous, and is potentially
prophylactic
Retina Today 2012; Retina Physician 2012
705

706. CME
• Intraretinal edema contained honeycomb-like
cystoid spaces
• Abnormal perfoveal retinal capillary permeability
• FFA  because of Henle’s fiber layer  Flowerpetal pattern
• Irvine-Gass syndrome
–
–
–
–
High as 60% after ICCE
Lower when posterior capsule remains intact
Occurs 6-10 weeks post operatively
Uncomplicated cases  95% spontaneous resolution
after 6 months
American Academy of Ophthalmology
706

707. Hypertensive retinopathy
• Grade 0
• Grade 1
• Grade 2
• Grade 3
• Grade 4
No changes
Barely detectable arterial narrowing
Obvious arterial narrowing with focal
irregularity
Grade 2 plus retinal hemorrhages and
or exudates
Grade 3 plus disc swelling
p
g
American Academy of Ophthalmology
707

708. CRAO
•
•
•
•
Sudden
Severe
Painless
Retina
R ti  opaque, edematous, thi k t nerve fib l
d
t
thickest
fiber layer
and ganglion cell layer in the posterior pole
• Cerry-red spot  orange reflex  intact choroidal
vasculature beneath the fovea  stands out in contrast
to surrounding opaque neural retina
• Iris neovascularization 18% in 1-12 weeks after
1 12
onset with mean time 4-5 weeks
American Academy of Ophthalmology
708

709. BRVO
In BRVO, the blockage
occurs in one of the smaller
branch vessels th t connect
b
h
l that
t
to the central retinal vein.
Allergan
709

710. BRVO : Cause of poor vision
•
•
•
•
•
•
Macular edema
Macular pigmentation
Epi ti l
E i retinal membrane (ERM)
b
Macular ischemia
Vitreous haemorrhage
Tractional retinal detachment
Yeo KT, 2009
710

711. CRVO
•
Non-ischemic
– Milder form
•
•
•
•
•
Mild dilatation and tortuosity of central retinal veins
y
Dot and flame hemorrhages
Macular edema  decreased visual acuity
Mild optic disc swelling
FFA  prolongation of circulation time with breakdown of permeability but minimal
areas of non perfusion
– Sometimes referred as partial, perfused or venous stasis retinopathy
•
Ischemic
–
–
–
–
–
80% CRVO progress to be
Marked venous dilatation at least 10 disc areas
Cotton wool spot
Decrease visual acuity
FFA 
• Retinal capillary non perfusion on posterior pole  non perfused, complete or
hemorrhagic
• Widespread capillary non perfusion
– Iris neovascularization 60% in 3-5 months after onset
American Academy of Ophthalmology
711

712. CRVO : Approach
Hypoxia Induced
yp
VEGF
Increased Hydrostatic
y
Pressure
Increased Hydrostatic
Pressure
Rheopheresis*
Grid Laser
Inflammatory Vascular
y
Leak
Increased Hydrostatic
Pressure
Cousins SW, 2009
712

713. CRVO
In CRVO, the blockage
occurs in the central retinal
vein, which is the main
drainage line for blood
leaving the retina
Allergan
713

714. Allergan
714

715. Macular Edema
Allergan
715

716. CRVO : Anti-VEGF and Steroids
Anti VEGF
• Anti-VEGF*
• Intra Vitreal Injection  Preservative-free
Triamcinolone
• Slow-released Drug Delivery System
– Fluocinolone  Retisert (Bausch & Lomb) 
(
)
30 months
– Dexamethasone 
• Posurdex (Allergan)
• Ozurdex (Allergan)
Cousins SW, 2009; EuroTimes, 2010
716

717. Retinal Vascular Disease : Surgery
• CRAO  Decompression
• BRVO  Arteriovenous Sheatotomy (AVST) 
Reduce compression artery-venous 
p
y
– Persistent CME
– ERM with Vitreous traction
– Significant retinal ischemia  more than 5 discdiameter of capillary non-perfusion with or without NV
–M
Macular i h i
l ischemia
• CRVO  Radial Optic Neurotomy (RON)
Yeo KT, 2009
717

718. ROP : Indirect ophthalmoscopy
•
•
•
•
Stage 1: Demarcation line
Stage 2: Ridge : height, width, volume
Stage 3 N
St
3: New vessels growing out of ridge
l
i
t f id
Stage 4: Partial retinal detachment
– 4 a. Extra fovea
– 4 b. Involving fovea
g
• Stage 5: Total retinal detachment with
funnel
American Academy of Ophthalmology
718

719. Zone and clock hours
719

720. Stage 1:
St
1
Demarcation
Line
Stage 2 : Ridge
Stage 3: Neo
Vascularization
720

721. ROP : Screening
g
Indirect ophthalmoscopy
• All infants with a birth weight of ≤ 1500 g
• All infants with a gestational age of ≤ 28 weeks
• Infants over 1500g if unstable clinical co rse
o er
nstable
course
• Timing: 4-6 weeks after birth or 31 to 33 weeks
after conception
• Treat < 72 hours after diagnosis of threshold
disease
New approach  RetCam Di it l I
N
h
Digital Imaging (Cl it )
i (Clarity)
721

722. ROP : Treatment
• Laser photocoagulation
• C th
Cryotherapy
• Retinal detachment surgery
American Academy of Ophthalmology
722

723. Intravitreal Antibiotics ( / 0 1 ml )
0.1
•
•
•
•
•
•
Gentamycin
G t
i
Vancomycin
Amikacin
Chlorampenicol
Amphotericin B
Ceftazidime
Cefta idime
0.1
0 1 mg
1.0 mg
0.4 mg
1.0 mg
5.0 µg
2.0-2.25
2 0 2 25 mg
American Academy of Ophthalmology
723

724. Intravitreal Steroids ( / 0.1 ml )
01
• Dexamethasone
• Triamcinolone
0.4 mg
4 mg
American Academy of Ophthalmology
724

725. Consideration : Anatomy
• Limbus identification
• Lens existence
– Ph ki  3 5 – 4 mm
Phakic
3.5
– Aphakic / Pseudophakic  3 mm
• Cilliary body  2.5 mm
• Widest Pars plana and Ora  Temporo
p
p
inferior  Safest area
725

726. Retina : VEGF Session
• VEGF is
– Survival factor
– Neuro protector
– Fenestration
• New vessels  Endothelial tubes
Eurotimes, 2009
726

727. Angiogenesis factors
•
•
•
•
•
VEGF
bFGF
Angiopoietin
A i
i ti
PGE2
Erythropoietin
Cousins SW 2009
SW,
727

728. The VEGF
• A sub-family of growth factors
sub family
• More specifically of platelet-derived growth
factor family of cystine-knot growth factors.
cystine knot
• They are important signaling proteins
involved in both of
– Vasculogenesis (the de novo formation of the
embryonic circulatory system)
– Angiogenesis (the growth of blood vessels
from pre-existing vasculature)
728

729. The VEGF : Production
• VEGFxxx production can be induced in cells that
p
are not receiving enough oxygen.
• When a cell is deficient in oxygen  it produces
Hypoxia Inducible Factor (HIF)  a transcription
factor.
• HIF stimulates the release of VEGFxxx 
among other functions (including modulation of
th f
ti
(i l di
d l ti
f
erythropoeisis).
• Circulating VEGFxxx t e b ds to VEGF
C cu at g
G
then binds
G
Receptors on endothelial cells  triggering a
Tyrosine Kinase Pathway  leading to
angiogenesis
729

730. The VEGF
Type
Function
VEGF-A
• Angiogenesis
• Migration of endothelial cells
• Mitosis of endothelial cells
• Methane mono oxygenase activity
• αvβ3 activity
• Creation of blood vessel lumen
• Creates lumen
• Creates fenestrations
• Chemo tactic for macrophages and granulocytes
• Vasodilatation (indirectly by NO release)
VEGF-B
Embryonic angiogenesis
VEGF-C
Lymph angiogenesis
VEGF-D
Needed for the development of lymphatic vasculature
surrounding lung bronchioles
PlGF
Important for Vasculo genesis, Also needed for
angiogenesis during ischemia, inflammation, wound
healing, and cancer.
730

731. VEGF A
•
•
•
•
•
Located on Chromosome 6
Consist of 8 exons and 7 introns
Diffusible
Tightly bound to intracellular matrix
Isoforms
–
–
–
–
A121
A165
A185
A206
Eurotimes, 2009
731

732. VEGF 165
• Moderate difusible
• Potent inducer of angiogenesis 
–N
Neovascularization
l i ti
– Inflammation
– Increase permeability
Eurotimes, 2009
732

733. AMD : Intravitreal injections
Drug
Structrure Dosage
Bevacizumab
(Avastin))
Complete
p
immunoglobulin
2.5 mg/0.1 ml
g
Ranibizumab
(Lucentis
Antibody
fragment
0.3–0.5 mg/0.1 ml
Pegaptanib
(Macugen)
Aptamer
(oligonucleotide)
0.3–1.0 mg/0.1 ml
Williamson TH, 2008
733

734. Potential Methods
1. Adult 
1. Phakic
: 4 mm
2. Aphakic
: 3.5 mm
3.
3 Pseudophakic
: 3.5 mm
35
2. Infant  1 – 1.5 mm
Krieglstein GK, Weinreb RN, 2005
734

735. Retinal Artery Occlusion: Approach
• Vasodilators: Increase blood oxygen
content
– Sublingual isosorbide mononitrate
– Systemic pentoxifyline
– Carbogen inhalation
– Hyperbaric oxygen
Retinal Physician 2013
735

736. Retinal Artery Occlusion: Approach
• Reduction retinal edema
– IV methylprednisolone (suspected areteritic
CRAO)
• IOP reducers
– Acetazolamide
– Mannitol
– T i l anti glaucoma
Topical ti l
– Paracentesis
Retinal Physician 2013
736

737. Retinal Artery Occlusion: Approach
• Dislodge the emboli
– Ocular massage
– Nd:YAG laser embolectomy
Retinal Physician 2013
737

738. 738

739. Neuro-ophthalmology
739

740. The optic nerve
•
Intra ocular
– 1.0 mm length
– 1 5 X 1 75 mm diameter
1.5 1.75
– Supplied by retinal arterioles and branches of posterior ciliary arteries
•
Intra orbital
– 25 mm length
– 3-4 mm diameter
– Supplied by intraneural branches of central retinal artery
•
Intra canalicular
– 4-10 mm length
– various diameter
– Supplied by Ophthalmic artery
•
Intra cranial
– 10 mm length
– 4-7 mm diameter
– S
Supplied b b
li d by branches of i t
h
f internal carotic and ophthalmic artery
l
ti
d hth l i
t
American Academy of Ophthalmology
740

741. Optic nerve : Intra ocular
• Surface
• Prelaminar
• Laminar
– Scaffold for optic nerve axons
– Point of fixation for central retinal artery and vein
– Reinforcement of posterior segment of the g
p
g
globe
• Retrolaminar
American Academy of Ophthalmology
741

742. Optic disc
A. Surface
B. Pre Laminar
C. Laminar
D. Retro Laminar
742

743. Vascularization
Surface : branches of central retinal artery
Prelaminar and laminar : posterior cilliary artery
Retrolaminar : central retinal artery and
y
posterior cilliary artery anastomosis
743

744. Euro ophthalmic
Euro-ophthalmic examination
•
•
•
•
•
•
•
•
History
Visual acuity
Color vision
Pupil reactions
Ocular
O l motility
tilit
Discs
Visual fields
Advanced intracranial examination
Cullen JF, 2007
744

745. Neurologic and imaging : Indication
•
•
•
•
•
•
•
•
Progressive visual loss more than 4 weeks
No recovery of vision and fields after 10 weeks
Head or periocular pain for more than 4 weeks
Patient older than 50 year
Quadrantic or Hemianopic fields defect
Development of field defect in fellow eye
Atypical features
History of paranasal sinus disease
Kumar SM 2007
745

746. Neuro imaging
Neuro-imaging : Which?
•
•
•
•
•
Brain
Anterior visual pathway
p
y
Pituitary area
Orbit + Coronal view ?
Base of skull
Cullen JF,
C ll JF 2007
746

747. Visual pathway
Temporal
Retina
R
L
R
Temporal
Retina
Nasal
Retina
Optic
Nerve
L
Optic
Chiasm
Optic
Tract
LGN
Optic
Radiations
Primary
Visual Cortex
747

748. Visual cortex
• The term visual cortex refers to
– The primary visual cortex  Striate cortex or V1
– Extrastriate visual cortex  V2, V3, V4, and V5.
• The primary visual cortex is anatomically
equivalent to Brodmann Area 17 or BA17
748

749. Visual pathway and VF defects
Miller-Keane 2003
749

750. Intracranial hypertension and VF
defects
d f
(a) Enlarged blind spot.
(b)Nasal step.
(c) Biarcuate scotoma.
(d)Severe visual field
constriction
Kedar, Gathe and Corbett
2011
750

751. The pupillary light reflex pathway
p p
y g
p
y
751

752. Afferent pupillary pathway
• Light stimulates p
g
photoreceptors
p
• Signal conveyed to a special set of ganglion cells 
send nerve impulses through the axons in similar
topographic distribution
• Carrying signal to optic nerve
• Decussation occurs at the optic chiasm
• Afferent fibers NOT enter lateral geniculate bodies
• BUT instead exit and pass the brachium of of the
superior colliculus  its synapse on the protectal olivary
nuclei (pontine olivari and sublentiform nuclei)
• This nuclei project bilaterally to Edinger-Westphal nuclei
Kourouyan and Horton, 1997
752

753. Efferent pupillary pathway
• Efferent parasympathetic response
p
y p
p
– The Edinger-Westphal nuclei send fiber to join the
cranial nerve III
– Follow that course on dorsomedialsurface of the
nerve
– After coursing through the cavernous sinus, fibers
emerge to enter orbit with the inferior oblique branch
of cranial nerve III
– Fibers synapse at ciliary g g
y p
y ganglion
– Enter the eye through short posterior ciliary nerves to
distribute fiber to choroid, ciliary body and iris
Kourouyan and Horton, 1997
753

754. Efferent pupillary p
p p
y pathway
y
• Efferent sympathetic response
– This believed to start in the hypothalamus and project in an
uncrossed fashion with synapses in mesencephalon and pons
– These neurons project to and synapse upon intermediolateral
cell column from C8-T2 in spinal cord
– These exit the spinal cord and p
p
pass through stellate g g
g
ganglion to
synapse in the superior cervical ganglion
– Fibers go with internal carotic artery
– Enter the cavernous sinus
– G with cranial nerve VI
Go ith
i l
– Enter superior orbital fissure with cranial nerve V
– Go with the nasociliary branch of cranial nerve V
– Pass through the ciliary ganglion without synapsing
– Pass through the long ciliary nerves
– Terminate the dilator muscle
– Some fibers diverge in the superior orbital fissure to innervate
Muller’s muscle
Kourouyan and Horton, 1997
754

755. Swinging flashlight test
755

756. RAPD: Grading Scale
g
•
Grade 1+:
– A weak initial pupillary constriction f ll
k i iti l
ill
t i ti followed b greater redilation
d by
t
dil ti
– Minimally detectable
•
Grade 2+:
– An initial pupillary stall followed by greater redilation
– Pupil fails to constrict or dilate slightly when the light swings to weaker
eye
•
Grade 3+:
– An immediate pupillary dilation
– Pupils dilate or “escape” readily
•
Grade 4+:
– No reaction to light – Amaurotic pupil
– Non reactive mydriatic pupil
Kumar SM 2007; Uhwi 2011
756

757. RAPD
•
•
•
•
•
Dark
D k room
Bright light  torch
2 eyes
Patient fixation is at distance
2-3 seconds per eye  longer may create an
p
y
g
y
iatrogenic RAPD
• Check by your self  do not rely on others
Burton B, Golnik K, 2010
757

758. Cause of light-near dissociation
• Unilateral
–
–
–
–
Afferent conduction defect
Adie pupil
HZO
Aberrant degeneration of the cranial nerve III
• Bilateral
–
–
–
–
–
–
–
Neurosyphilis
Type I diabetes
T
di b t
Myotonic distrophy
Parinaud dorsal midbrain syndrome
Familial amyloidosis
Encephalitis
Chronic alchoholism
Kanski JJ, 2007
758

759. Anisocoria
•
Good light reaction
–
–
Physiologic
Horner s
Horner’s Syndrome
•
•
•
•
•
Sympathetic chain disruption
Miosis, Ptosis, Anhydrosis
Anisocoria worse in the dark
Dilatation Lag
Poor light reaction
–
Adie’s tonic
•
•
•
•
•
•
–
–
–
Post ganglionic parasympathetic  usually idiopathic
No ptosis, No ophthalmoplegia
Mydriatic pupil
Segmental iris contraction
Slow (tonic) redilation
Light – Near dissociation
3rd nerve palsy
Pharmacologic
Sphincter damage
•
•
•
Trauma
Surgery
Herpes Zoster
Burton B, Golnik K, 2010
759

760. Papilledema : Walsh & Hoyt’s
•
Early
E l manifestations
if t ti
–
–
–
–
•
Late
L t manifestations
if t ti
–
–
–
•
As the papilledema continues to worsen, the nerve fiber layer swelling eventually obscures
the normal disc margins and the disc becomes grossly elevated.
Venous congestion develops, and peripapillary hemorrhages become more obvious, along
with exudates and cotton-wool spots.
The
Th peripapillary sensory retina may d
i
ill
ti
develop concentric or, occasionally, radial f ld k
l
ti
i
ll
di l folds known
as Paton lines. Choroidal folds also may be seen.
Chronic manifestations
–
–
•
Disc hyperemia
Subtle edema of the nerve fiber layer can be identified with careful slit lamp biomicroscopy
and direct ophthalmoscopy. This most often begins in the area of the nasal disc. A key
finding occurs as the nerve fiber layer edema begins to obscure the fine peripapillary
vessels.
vessels
Small hemorrhages of the nerve fiber layer are detected most easily with the red-free (green)
light.
Spontaneous venous pulsations that are normally present in 80% of the individuals may be
obliterated when the intracranial pressure rises above 200 mm water.
If the papilledema persists for months, the disc hyperemia slowly subsides, giving way to a
gray or pale disc that loses its central cup.
With time, the disc may develop small glistening crystalline deposits (disc pseudodrusen).
Atrophic manifestations
–
–
Blurred-border and pale disc
Atrophic vessels
Giovannini J, 2005
760

761. 761

762. Papilledema : Lars Frisen’s Scale
•
Stage 0
– Normal disc with blurring of nasal and temporal disc; no
obscuration of the vessel and the cup is maintained.
p
•
Stage 1
– C shaped blurring of the nasal, superior and inferior borders.
Usually the temporal margin is normal
•
Stage 2
– Elevation of the temporal margin
•
Stage 3
– Elevation of the entire disc with obscuration of the retinal
vessels at the disc margin
•
Stage 4
– Complete obliteration of the cup and obscuration of the vessels
on the surface of the disc.
•
Stage 5
– Dome shaped appearance with all vessels being obscured
Lars Frisen, 2004
762

763. Stage 0
Lars Frisen, 2004
763

764. Stage 1
Lars Frisen, 2004
764

765. Stage 2
Lars Frisen, 2004
765

766. Stage 3
Lars Frisen, 2004
766

767. Stage 4
Lars Frisen, 2004
767

768. Stage 5
Lars Frisen, 2004
768

769. Differentiating Papilledema from Pseudopapilledema
Papilledema
Pseudopapilledema
Physiologic cup usually present
Central cup often absent, disc diameter small
Vessels arise normally
Vessels from central apex of disc
Arterioles bifurcate
Anomalous branching, trifurcation
Hyperemia due to dilation of the disc capillaries
Absence of superficial capillary telangectasia
C shaped blurring of RNFL in peripapillary region
Disc margins irregular with pigmentary derangement
Diffuse elevation of the disc
Irregular elevation, refractile masses which glow
Peripapillary NFL radial hemorrhage
Rare 'blot' subretinal hemorrhage
Dilation of the retinal veins
No venous dilation
Exudates in chronic situations
p
No exudates or cotton-wool spots
Not usually familial
Familial
Absence of SVP
SVP usually present
Lars Frisen, 2004
769

770. Optic Neuropathies
p
p
•
•
•
•
Trauma ocular, orbit and skull
• Single or multiple nerve defect
Metabolic
• Early diabetic  Insufficient in vascular to nourish the optic
nerve
Toxic
• Methanol, Ethambutol, Isoniazid
Neuritis
• Primary inflame
• Secondary inflame
• Giant Cell Arteritis
• Multiple Sclerosis
• t th and paranasal sinus i fl
teeth d
l i
inflammation or nearby ti
ti
b tissue
inflammation
770

771. AION : Symptoms
•
•
•
•
•
Giant cell arteritis
Sudden, painless, non progessive visual loss
Initially unilateral may rapidly bilateral
unilateral,
Older than 60 years, Women greater than Men
Antecedent or simultaneous headache jaw
headache,
claudication or chewing pain, scalp or hair
co b g tenderness, proximal muscle a d jo t
combing te de ess, p o
a usc e and joint
ache, anorexia, weight loss and fever may occur
Will’s Eye Manual
771

772. AION : Signs
g
• Critical
– Aff
Afferent pupillary defect
ill
d f
– Devastating worse visual loss
– Pale swollen disc with flame shape hemorrhages 
Pale,
atrophy
– Erythrocytes Sedimentation Rates, C Reactive
Protein and platelets may be markedly increased
• Other
– Visual field defect  altitudinal, involving central field
– Non pulsatile temporal artery
– CRAO an cranial nerve palsy may occur
Will’s Eye Manual
772

773. NAION : Symptoms
• Sudden, painless, non progressive visual
loss of moderate degree
• Initially unilateral, may become bilateral
• 45 65 years, commonl younger than
45-65 ears commonly o nger
AION
Will’s Eye Manual
773

774. NAION : Etiology
• Idiopatic
– Arteriosclerosis
– Diabetes
– Hypertension
– Hyperhomocystinemia
– Anemia
– Sl
Sleep apnea  risk f t
i k factor
– Relative nocturnal hypotension
Will’s Eye Manual
774

775. NAION : Risk factors
•
•
•
•
•
Hypertension
Hyperlipidemia
H
li id i
Diabetes mellitus
Smoking
Obesity
Deborah Pavan-Langston, 2008
775

776. NAION : Signs
g
• Critical
– Afferent pupillary defect
– Pale, swollen disc involving only a segment of the disc with
flame shape hemorrhage
– Normal Erythrocytes Sedimentation Rates
– Non-progressive  sudden decrease of VA and VF, which
stabilized
– Progressive  sudden decrease of VA and VF, followed with
another decrease of VA and VF
• Other
– Visual field defect  altitudinal, involving central field
– Reduced color vision proportional to decrease in acuity
Will’s Eye Manual
776

777. AION
PION
ON
Symptoms
Sudden i
S dd visual l
l loss, often
ft
on awakening
Sudden i
S dd visual l
l loss, often
ft
on awakening
Rapid loss of vision over
R id l
f i i
several days to 1 week
VA
Can be good if central
field maintained
Can be good if central field
maintained
Good to no perception of
light
CV
Normal in unaffected field
Normal in unaffected field
Disproportionate loss of
color vision
Pupils
Relative afferent pupil
defect
Relative afferent pupil
defect
Relative afferent pupil defect
VF
Most commonly
inferonasal loss, or
altitudinal defects, but
other patterns possible
More commonly central
scotoma seen
Central visual field loss
relatively common, nerve
fiber bundle defects also
possible
Disc
-Hyperemic disc swelling
in early phase
-Pallor developing 3-6
weeks after onset
-However arteritic AION
usually causes chalky
white disc infarction from
onset
-Disc appear normal at
onset
-Pallor develops about 6
weeks after onset
-Hyperemic disc swelling in
early phase
-Pallor developing from
about 6 weeks after onset
Cullen JF, 2007
777

778. Acquired optic atrophy in childhood
•
•
•
•
•
•
•
Craniopharyngioma
Optic nerve / Chiasmal glioma
Retinal degenerative di
R ti l d
ti disease
Hydrocephalus
Optic neuritis
Post papil edema
Hereditary
Cullen JF, 2007
778

779. Optic Pit
• Often appear as small, hypopigmented, y
pp
yp p g
yellow
or whitish, oval or round excavated defects.
• Most often within the inferior temporal portion of
the optic cup
cup.
• Approximately 20 to 33 percent are found
centrally, with an average size of 500µm (onethird disc diameter).
thi d di di
t )
• Typically, optic pits occur unilaterally (85
pe ce t)
percent).
• The optic disc in these patients appears larger
than normal, and 60 percent of discs with optic
pits also have cilioretinal arteries
arteries.
779

780. Optic Pit
780

781. Optic Disc Drusen
p
• The classic appearance involves bilaterally elevated
optic discs with irregular or "scalloped" margins, a small
scalloped
or nonexistent cup, and unusual vascular branching
patterns that arise from a central vessel core.
• Often there are small, refractile hyaline deposits visible
,
y
p
on the surface of the disc and/or in the peripapillary area.
• Most often manifests on the nasal disc margin, but can
yp
be found within any part of the nerve head.
• In younger patients, the disc elevation tends to be more
pronounced and the drusen less calcific, making them
less visible ophthalmoscopically, and hence offering a
more challenging diagnostic dilemma.
• Unlike true disc edema, its very rarely presents with
juxtapapillary nerve fiber edema, exudate, or cotton-wool
spots.
t
781

782. Optic Drusen : Pathophysiology
• There is no histopathological correlation between drusen
of the optic nerve head and retinal drusen; the former
represent acellular l i t d concretions, often partially
t
ll l laminated
ti
ft
ti ll
calcified, possibly related to accumulation of axoplasmic
derivatives of degenerating retinal nerve fibers.
• Optic disc drusen are globules of mucoproteins and
mucopolysaccharides that progressively calcify in the
optic disc.
• They are thought to be the remnants of the axonal
transport system of degenerated retinal ganglion cells.
• Optic disc drusen have also been referred to as
congenitally elevated or anomalous discs
discs,
pseudopapilledema, pseudoneuritis, buried disc drusen,
optic nerve head drusen and disc hyaline bodies.
• They may be associated with vision loss of varying
degree
782

783. Optic Disc Drusen
783

784. VF Defects in Optic neuropathies
•
Central scotoma
–
–
–
–
•
Demyelination
y
Toxic and nutritional
Leber disease
Compression
Enlarged blind spot
– Papil edema
– Congenital anomalies
– AIBSE (Acute Idiopathic Blind Spot Enlargement)  with flashing light
(
p
p
g
)
g g
seen, normal retina, normal imaging
– AZOOR (Acute Zonal Occult Outer Retinopathy)  with flashing light
and other field loss, normal retina, normal imaging
•
Respecting horizontal meridian
p
g
– Anterior Ischemic Optic Neuropathy
– Glaucoma
– Disc drusen
Kanski JJ, 2007; Burton B, 2010
784

785. Unexplained visual loss
• Miss the real diagnosis
• Munchausens
– Factitious disorder, or mental illness  repeatedly acts as has a
physical or mental disorder when
– People with factitious disorders act this way because of an inner
need t be seen as ill or i j d not t achieve a concrete
d to b
injured, t to hi
t
benefit
• Hypochondriac
– Health phobia or health anxiety
– Excessive preoccupation or worry about having a serious illness
• Hysteria (Conversion disorder)
– Exacerbation of symptoms during psychological stress
– Relief from tension (primary gain)
– Gain of outside support or attention (secondary gains)
• Malingering
Burton B, Golnik K, 2010
785

786. Nystagmus
• Clinician’s notes
– Amplitude
– Frequency
– Direction of gaze that induces nystagmus
– Null point  Gaze location where nystagmus at least evident
p
y g
• Concerns
– Congenital or acquired
– Specific lesion location
– True nystagmus or nystagmoid movements (saccadic oscillations)
• Characteristics
– I it conjugate  symmetrically affecting both eyes
Is
j
t
t i ll ff ti b th
– Slow or fast, equal speed or different speed
– Movement  horizontal, vertical, torsional or mixed
American Academy of Ophthalmology
786

787. Nystagmus : Type
•
•
•
•
•
•
Latent nystagmus
Pendular nystagmus
Congenital motor nystagmus
Spasmus nutan
Acquired pendular nystagmus
Acquired jerk nystagmus
– Gaze paretic nystagmus
– Vestibular nystagmus
Deborah Pavan-Langston, 2008
787

788. Nystagmus : Other nystagmus form
•
•
•
•
•
•
•
•
Endgaze (physiologic) nystagmus
Upbeat nystagmus
Downbeat motor nystagmus
Rotary nystagmus
Dissociated nystagmus
ssoc a ed ys ag us
Seesaw nystagmus
Optokinetic nystagmus
Other nystagmoid-like oscillations
– Ocular myoclonus
– Ocular bobbling
– Ocular flutter  One plane of ‘Back to Back Saccades’ without inter
saccadic interval
– Opsoclonus  Multi directional of ‘Back to Back Saccades’ without inter
saccadic interval
Deborah Pavan-Langston, 2008
788

789. Nystagmus : Medical treatment
y g
•
Cyclopentolate 1%
– One drop bid  Latent nystagmus  60 % reduce the amplitude,
p
y g
p
velocity and frequency
– With occlusion  improve visual acuity
•
Baclofen
– 5 mg po tid starting dose  acquired periodic alternating nystagmus
– Dosage increased every 3 days  80 mg maximum per day
•
Botulinum A
– Dampened acquired nystagmus and oscillopsia
– 66%  improve visual acuity
•
Other drugs
–
–
–
–
Gabapentin/Memantine  dampen nystagmus/oscillopsia
Clonazepam  downbeat nystagmus
Carbamazepin  SO myokymia
Propanolol  Opsoclonus
Deborah Pavan-Langston, 2008
789

790. Nystagmus : Optical treatment
•
Glasses or contact lenses
– Decrease nystagmus in bilateral aphakia
•
Stimulating accommodative convergences
– Overcorrecting with minus lenses  dampening nystagmus at distance
fixation
– Improve visual acuity
p
y
•
Galilean arrangement
– Stabilizing retinal images
•
Base-out prisms
– Promote covergence and dampen nystagmus in Congenital motor
nystagmus
•
Fresnel stick-on prisms
– Displace image at null p
p
g
point in Congenital motor nystagmus
g
y g
– Vertically correct head position in Vertical nystagmus and Acquired
downbeat nystagmus
– Combination prisms  help in Oblique head turns
Deborah Pavan-Langston, 2008
790

791. Nystagmus : Surgical treatment
• Kestenbaum Anderson procedures
– Recession of horizontal muscles
– The versions are blocked
• F d operation
Fade
ti
– Acts like recession  by creation of a more
posterior attachment
t i
tt h
t
– Reducing the area of contact
Kumar SM 2007
791

792. Optic Ataxia
•
•
•
•
•
•
Is lack of coordination between visual inputs and hand movements,
resulting in inability to reach and grab objects
objects.
Optic ataxia may be caused by lesions to the posterior parietal
cortex.
p
parietal cortex is responsible for combining and
p
g
The posterior p
expressing positional information and relating it to movement.
Outputs of the posterior parietal cortex include the spinal cord, brain
stem motor pathways, pre-motor and pre-frontal cortex, basal
ganglia and the cerebellum
cerebellum.
Some neurons in the posterior parietal cortex are modulated by
intention.
Optic ataxia is usually part of Balint's syndrome, but can be seen in
isolation ith injuries to the
i l ti with i j i t th superior parietal l b l as it represents
i
i t l lobule,
t
a disconnection between visual-association cortex and the frontal
premotor and motor cortex.
792

793. Visual Agnosia
• Is an inability of the brain to make sense of or make use
y
of some part of otherwise normal visual stimulus
• Typified by the inability to recognize familiar objects,
people or faces.
• This is distinct from blindness, which is a lack of sensory
input to the brain due to damage to the eye, optic nerve,
or primary visual systems in the brain such as the optic
radiations or primary visual cortex.
• Visual agnosia is often due to damage, such as stroke,
in the
i th posterior occipital and/or t
t i
i it l d/ temporal l b ( ) i th
l lobe(s) in the
brain.
793

794. Horner Syndrome
794

799. Uvea and Immunology
In
I remembrance:
b
dr. Muhammad Anie, Sp.M
799

800. Choroid : Layers
• Th choriocapillaris
The h i
ill i
• Small vessels
• Large vessels
800

801. Uveitis
• How to avoid complication
– Fi t  C l l i agents
First
Cycloplegic
t
• Complication
– Acute  Cell
– Chronic  Synechiae
801

802. U ets
Uveitis
Non-granulomatous
Onset
O
Granulomatous
Acute
A
Chronic Hidden
Ch i – Hidd
Pain
Marked
+/-
Photophobia
Marked
Mild
Moderate
Obvious
Marked
Mild
Keratic precipitate
White - smooth
Big – grey / Mutton fat
Pupil
Small - irregular
Small – irregular (vary)
Posterior synechiae
+/-
+/-
Iris nodule
+/-
+/-
Anterior uvea
Anterior and posterior uvea
Often
+/-
Blur vision
Circumcorneal injection
Predilection
Recurrent
Vaughan DG, 2000
802

803. Flare and Cell
• Flare  Resulting of extra protein in the
aqueous
• Cell  White Blood Cell in the aqueous
– Hallmark of Iritis
– Ob
Observed under Hi h M
d d High-Magnification Slit L
ifi ti
Lamp
examination by 1 X 3 mm field of light
– If its clustering on corneal endothelium 
it l t i
l d th li
Keratic Presipitate
803

804. Grading anterior chamber cells
g
Grade
Cells in field
0
0
0.5+
0 5+ (Trace)
1-5
15
1+
6-15
2+
16-25
3+
26-30
26 30
4+
> 50
Kanski JJ, 2007
804

805. Grading anterior chamber flare
g
Grade
Description
0
Nil
(Completely Absent)
1+
Faint
(Barely Present)
2+
2
Moderate
(Iris and lens detail clear)
3+
Marked
(Iris and lens detail hazy)
4+
Intense
(Fibrinous exudates)
Kanski JJ, 2007
805

806. Type of Allergy
806

807. Type of Allergy
807

808. HLA Immunogenic test
g
• Specific ocular inflammatory :
–
–
–
–
–
–
–
–
–
Acute anterior uveitis : HLA-B27, HLA-B8
Adamantiades-Behçet disease : HLA B-51
Birdshot retinopathy : HLA A29
HLA-A29
Multiple sclerosis, uveitis and optic neuritis : DR2
Ocular pemphigoid :HLA-B12, DQw7
:HLA B12,
Presumed ocular histoplasmosis : HLA-B7, DR2
Reiter syndrome : HLA-B27
Sympathetic ophthalmia :HLA-A11, DR4, Dw53
VKH disease : DR4, Dw53, DQw3
Deborah Pavan-Langston, 2008
808

809. Lipid mediators
809

810. Lipid mediators : Basic activities
810

811. Vasoactive amine
• Containing amino groups
• Breakdown of amino acids. Many natural
neurotransmitters like epinephrine
epinephrine,
norepinephrine, dopamine, serotonine,
histamine
• Acts on the blood vessels to alter vascular
permeability or t cause vasodilation.
bilit
to
dil ti
811

812. Cytokines
• Small secreted proteins which mediate and regulate
p
g
immunity, inflammation, and hematopoiesis.
• Produced de novo in response to an immune stimulus.
• Generally (although not always) act over short distances
and short time spans and at very low concentration.
• Act by binding to specific membrane receptors, which
then i
th signal th cell via second messengers, often
l the ll i
d
ft
tyrosine kinases, to alter its behavior (gene expression).
y
g
g
• Responses to cytokines include increasing or decreasing
expression of membrane proteins (including cytokine
receptors), proliferation, and secretion of effector
molecules.
812

813. Selected Immune Cytokines and Their Activities*
Cytokine
Producing Cell
Target Cell
GM-CSF
Th cells
progenitor cells
Function**
growth and differentiation of
monocytes and DC
Th cells
IL-1
monocytes
macrophages
B cells
DC
co-stimulation
B cells
maturation and proliferation
IL-2
Th1 cells
IL-3
Th cells
NK cells
NK cells
activation
various
IL-1
inflammation, acute phase
response, fever
activated T and B cells
cells,
NK cells
growth, proliferation,
growth proliferation
activation
Th2 cells
growth and differentiation
mast cells
growth and histamine release
activated B cells
IL-4
stem cells
proliferation and differentiation
IgG1 and IgE synthesis
macrophages
h
T cells
MHC Cl
Class II
proliferation
813

814. IL-5
Th2 cells
IL-6
monocytes
macrophages
Th2 cells
stromal cells
activated B cells
proliferation and differentiation
IgA synthesis
activated B cells
differentiation into plasma cells
plasma cells
stem cells
various
antibody secretion
differentiation
acute phase response
IL-7
marrow stroma
thymus stroma
y
stem cells
differentiation into progenitor B and
T cells
IL-8
macrophages
endothelial cells
neutrophils
chemotaxis
IL-10
IL 10
Th2 cells
macrophages
B cells
cytokine production
activation
differentiation into CTL
(with IL-2)
macrophages
B cells
activated Tc cells
NK cells
activation
IFN-
leukocytes
various
viral replication
MHC I expression
IFN-
fibroblasts
various
viral replication
MHC I expression
IL-12
814

815. various
macrophages
IFN-
Th1 cells,
Tc cells, NK cells
Viral replication
MHC expression
activated B cells
Th2 cells
macrophages
Ig class switch to IgG2a
proliferation
pathogen elimination
MIP-1
macrophages
monocytes, T cells
chemotaxis
MIP-1
lymphocytes
monocytes, T cells
chemotaxis
monocytes, macrophages
chemotaxis
activated macrophages
activated B cells
TGF-
IL-1 synthesis
IgA synthesis
T cells, monocytes
various
TNF
macrophages, mast cells, NK
cells
macrophages
proliferation
CAM and cytokine expression
cell death
phagocytes
TNF-
tumor cells
phagocytosis, NO production
tumor cells
cell death
Th1 and Tc cells
815

816. Reactive Oxygen Intermediate
• Including both radicals and non-radicals.
non radicals.
• Constantly formed in the human body and
have been shown to kill bacteria and
inactivate proteins, and have been
p
implicated in a number of diseases.
• Produced by inflammatory phagocytes to
p
cancer development.
• Important signals controlling cell growth
and cell death
816

817. Reactive Oxygen Intermediate
817

818. Immune Systems
Systems  exhibit fascinating complexity and
y
g
p
y
interrelationships that allow them to fine-tune immune
reactions to almost any antigen, or molecule that
p
stimulates an immune response
• Humoral immunity
– Deals with infectious agents in the blood and body tissues
– Managed by B-cells (with help from T-cells)
• C ll
Cell-mediated immunity 
di t d i
it
– Deals with body cells that have been infected.
– Managed by T-cells.
818

819. Immune Systems : Humoral
y
•
The humoral system of immunity is also called the antibody-mediated
system because of its use of specific immune-system structures called
antibodies.
•
Activation phase
– The first stage in the humoral pathway of immunity is the ingestion
(p g y
(phagocytosis) of foreign matter by special blood cells called macrophages.
)
g
y p
p g
– The macrophages digest the infectious agent and then display some of its
components on their surfaces.
– Cells called helper-T cells recognize this presentation, activate their immune
response, and multiply rapidly
•
Effector phase
– Involves a communication between helper-T cells and B-cells.
– Activated helper-T cells use chemical signals to contact B-cells, which then begin
to multiply rapidly as well B cell descendants become either plasma cells or B
well. B-cell
memory cells.
– The plasma cells begin to manufacture huge quantities of antibodies that will
bind to the foreign invader (the antigen) and prime it for destruction.
– B memory cells retain a "memory" of the specific antigen that can be used to
y
y
p
g
mobilize the immune system faster if the body encounters the antigen later in life.
These cells generally persist for years.
819

820. Immune Systems : Cell-Mediated
•
•
•
•
•
•
•
•
The cell-mediated immune response involves cytotoxic T-cells, or
killer-T cells.
Body cells that have been infected by foreign matter often present
components of that material on their surfaces.
Killer-T cells recognize these displays and respond by ingesting or
otherwise destroying the infected cell.
Killer-T cells are also important in the body's defenses against
parasites, fungi, protozoans, and other larger cells that might have
found their way into the body.
The killer T cells recognize these large invaders by their foreign
killer-T
proteins and then destroy them.
Killer-T cells also produce T memory cells which "remember" a
specific protein or antigen.
The
Th combination of T ll and B ll memory assures the b d of
bi ti
f T-cell d B-cell
th body f
familiarity with any antigens or foreign agents that have been
present in the body within the last few years.
p
g
g
y
y
A response to an agent against which the body has already formed
memory cells is called a secondary response. All other responses
are primary responses.
820

821. Inflammatory cascade: Steroids vs NSAID
Cervantes-Coste G et al 2009
821

822. Retinal arteritis
• Causes
– SLE
– Polyarteritis nodosa
– Churg-Strauss
– Microscopic polyangitis
– Frosted branch angitis
– S hili
Syphilis
– Herpetic viruses
Retinal Physician 2011
822

823. Retinal phlebitis
• Causes
– Sarcoidosis
– Paraviral
– Toxoplasmosis
– Birdshot
– HIV
– E l di
Eales disease
Retinal Physician 2011
823

824. Mixed retinal vasculitis
• Causes
– Multiple sclerosis
– Behçet’s disease
Behçet s
– Wegener’s granulomatosis
Retinal Physician 2011
824

825. Non infectious uveitis: Approach
• ANTIMETABOLITES
– Methotrexate (MTX)
– Azathioprine (AZA)
– Mycophentolate Mofetil (MMF)
Retinal Physician 2013
825

826. Non infectious uveitis: Approach
pp
• BIOLOGIC RESPONSE MODIFIERS
– Adalimunab
– Interferon 2a
– Anakinra
• ALKYLATING AGENTS
– Cyclophosphamide
– Clorambucil
– Mycophentolate Mofetil (MMF)
Retinal Physician 2013
826

829. dr. Bakri Abdus Syukur, Sp.M
Orbit and Tumor
829

830. The orbit
• 7 bones make the bony orbit :
– Frontal
– Zygomatic
– Maxillary
– Ethmoidal
– Sphenoid
–L i l
Lacrimal
– Palatine
American Academy of Ophthalmology
830

831. The orbit : Margin
g
• Superior by frontal bone, interrupted
p
y
,
p
medially by Supraorbital notch
• Medial above by frontal bone
• Medial bellow by
– P t i l i l crest of l i l b
Posterior lacrimal
t f lacrimal bone
– Anterior lacrimal crest of maxillary bone
• Inferior by maxillary and zygomatic bone
• Laterally by zygomatic and frontal bone
American Academy of Ophthalmology
831

832. The orbit : Roof
• Orbital plate of frontal bone
• L
Lesser wing of sphenoid b
i
f h
id bone
American Academy of Ophthalmology
832

833. The orbit : Medial wall
•
•
•
•
Frontal process of maxilla
Lacrimal bone
L i lb
Orbital plate of ethmoid
Lesser wing of sphenoid
American Academy of Ophthalmology
833

834. The orbit : Lateral wall
• Formed by
– Zygomatic
– Greater wing of sphenoid
• Lateral orbital tubercle of Whitnall
– Check ligament of the lateral rectus muscle
– Suspensory ligament of the eyeball
– Lateral palpebral ligament
– Aponeurosis of the levator muscle
American Academy of Ophthalmology
834

835. The orbit : Floor
• Formed by
– Maxillary
– Palatine
– Orbital plate of zygomatic
• Very fragile to orbital blunt trauma
American Academy of Ophthalmology
835

836. The Orbit : Superior orbital fissure
• Above the ring
– Lacrimal nerve of V-1
– Frontal nerve of V-1
– Cranial nerve IV
• Within the ring (Heads of 4 rectuses)
–
–
–
–
–
Superior and inferior division of cranial nerve III
Nasociliary b
N
ili
branch of cranial nerve V 1
h f
i l
V-1
Sympathetic root of ciliary ganglion
Cranial nerve VI
Superior ophthalmic vein
• Bellow the ring
– Inferior ophthalmic vein
American Academy of Ophthalmology
836

837. The orbit : Cavernous sinus
• Posterior to orbital apex
• Lateral to the sphenoidal air sinus and
pituitary fossa
• Structures located within are :
– Internal carotic artery that
that,
– Surrounded by sympathetic carotid plexus
– Cranial nerves III, IV and VI
– Ophthalmic and maxillary divisions of cranial
nerve V
American Academy of Ophthalmology
837

838. Orbital surgical space
•
•
•
•
Sub periorbital
Extra
E t conal
l
Intra conal
Episcleral
American Academy of Ophthalmology
838

839. Retinoblastoma
• Most common primary intraocular malignancy of
p
y
g
y
childhood
• 30-40% occurs bilaterally
– If associated with ectopic intracranial retinoblastoma
 Trilateral retinoblastoma  pineal gland and para
sellar region
• Most abnormal finding
– Leukocoria (50-62%)
– Strabismus (20%)
• Esotropia : Exotropia  50:50
– Redness, painful, glaucomatous, decreased vision,
etc
American Academy of Ophthalmology
839

840. Retinoblastoma : Histopathology
840

841. Basalioma
•
•
•
•
•
•
•
•
Basal cell carcinoma
Most common eye lid malignancy  90-95%
y
g
Lower eyelid margin  50-60%
Near medial canthus  25-30%
Upper eyelid  15%
Lateral canthus  5%
Most common  Nodular
Less common  Morpheaform of Fibrosing type
 more aggressive
American Academy of Ophthalmology
841

842. Basalioma : Managements
• Localized to the adnexa
– 3-5mm excision from macroscopic margin  frozen
section
• Invasion to the orbit
– Exenteration
– Radiation therapy
• Only a palliative treatment
• Generally be avoided for periorbital lesions
• Invasion to intracranial or paranasal sinuses
– Palliative
842

843. Squamous Cell Ca
• 40 times less common than basalioma 
biologically more aggressive
• Metastasize through :
– Lymphatic transmission
– Bl d b
Blood-borne t
transmission
i i
– Direct extension  often, along nerves
American Academy of Ophthalmology
843

844. Squamous Cell Ca : Eyelid
•
Localized to the adnexa
– 6 7 mm excision f
6-7
i i from macroscopic margin  f
i
i
frozen section
ti
•
Invasion to the orbit
– Without regional lymphatic nodes involvement
• Exenteration
• Radiation therapy
– With regional lymphatic nodes involvement
• Exenteration
• Lymphatic nodes disection  joint surgery
• Radiation therapy
•
Invasion to intracranial or paranasal sinuses or far metastasizing
– Palliative
844

845. Squamous Cell Ca : Conjunctiva
• 1-2 mm diameter of tumor
12
– 6-7 mm excision from macroscopic margin
– 70 degree subzero cryotherapy
• 2-5 mm diameter of tumor
– If excision not available  Enucleation or
f
Excenteration
• M
More than 5 mm diameter of t
th
di
t
f tumor
– Excenteration
845

846. Sebaceous Adeno Ca
•
•
•
•
Highly malignant and potentially lethal tumor
Tarsal plate  meibomian glands
Eyelash  Glands of Zeis
Or,
Or sebaceous glands of caruncle eyebrow or
caruncle,
facial skins
• Patient commonly older than 50 years of age
American Academy of Ophthalmology
846

847. Sebaceous Adeno Ca : Managements
•
Less than 1 mm diameter of tumor
– wide excision f
id
i i from macroscopic margin  f
i
i
frozen section
ti
•
More than 1 mm diameter of tumor
– Without regional lymphatic nodes involvement
• Exenteration
– With regional lymphatic nodes involvement
• Exenteration
• Lymphatic nodes disection  joint surgery
• Radiation therapy
•
Invasion to intracranial or paranasal sinuses or far metastasizing
–
–
–
–
Exenteration and joint surgery if possible
Lymphatic nodes disection  joint surgery
Radiation therapy
py
Palliative
847

848. Malignant melanoma
• 5% of cutaneous cancers
• 1% of eyelid malignancies
• Develop de novo or from preexisting
melanocytic nevi or lentigo maligna
• Four clinicopathologic forms
– Lentigo maligna
– Nodular
– Superficial spreading
– Acro-lentiginous
Acro lentiginous
American Academy of Ophthalmology
848

849. Malignant melanoma : Managements
•
Localized
– Incision biopsy
– 6-7mm full thickness excision from macroscopic margin  frozen
section
•
Invasion to the orbit
– Without regional lymphatic nodes involvement
• Exenteration
• Radiation therapy
• Cytostatic agent and immune therapy
– With regional lymphatic nodes involvement
• Exenteration
• Lymphatic nodes disection  joint surgery
• Cytostatic agent and immune therapy
•
Invasion to intracranial or paranasal sinuses or far metastasizing
–
–
–
–
Exenteration and joint surgery if possible
Lymphatic nodes disection  joint surgery
y p
j
g y
Cytostatic agent and immune therapy
Palliative
849

850. Epithelial tumors of Lacrimal gland
• 50% of epithelial tumor  malignant
p
g
• Types
– Pleomorphic adenoma (Benign mixed tumor)
– Malignant mixed tumor
– Adenoid cystic carcinoma
• Half of the carcinomas
• Grow in tubules, solid nest or cribiform Swiss cheese pattern
Swiss-cheese
• Management
–
–
–
–
–
Percutaneous biopsy
Permanent section
Radical orbitectomy
High dose radiation with surgical debulking
Palliative
Palliati e
American Academy of Ophthalmology
850

851. Secondary orbital tumor
• Lung  40% in male
• Breast  68 % in female
• Leukemia
–
–
–
–
Ocular involvement  80%
Choroid is more often affected
Also found in retina, optic disc and vitreous
Retinal hemorrhages and pseudo Roth spots are
common
American Academy of Ophthalmology
851

852. Thyroid orbitopathy : Classification
Class Mnemonic Suggestion
0
N
No physical signs or symptom
1
O
Only signs
2
S
Soft tissue involvement
3
P
Proptosis o 3 mm o more
op os s of
or o e
4
E
Extra ocular muscle involvement
5
C
Corneal i
C
l involvement
l
t
6
S
Sight loss (due to optic nerve)
Werner, 1963
852

853. Thyroid orbitopathy : Classification
• Soft tissue involvement
– 0 : Absent
– A : Minimal
– B : Moderate
– C : Marked
Werner, 1963
853

854. Thyroid orbitopathy : Classification
• Proptosis of 3 mm or more
– 0 : Absent
– A : 3 – 4 mm
– B : 5 – 7 mm
– C : 8 mm or more
Werner, 1963
854

855. Thyroid orbitopathy : Classification
• Extra ocular muscle involvement
– 0 : Absent
– A : Limitation of motion at extremes of gaze
– B : Evident restriction of motion
– C : Fixation of globe
g
Werner, 1963
855

856. Thyroid orbitopathy : Classification
• Corneal involvement
– 0 : Absent
– A : Punctate lesions
– B : Ulceration
– C : Necrosis or perforation
p
Werner, 1963
856

857. Thyroid orbitopathy : Classification
• Sight loss (due to optic nerve)
– 0 : Absent
– A : 20/20 – 20/60
– B : 20/70 – 20/200
– C : Worse than 20/200
Werner, 1963
857

858. Staging of Disease
• Rundle’s Curve – Disease Activity
– Active (Dynamic) Stage  Proptosis and Lid
retraction
– Static (Partial regression) Stage  Stable
disease with littl i
di
ith little improvement
t
– Inactive (Burnt out) Stage  Spontaneous
relative i
l ti improvement
t
Sanjeev Y, 2010
858

859. Disease Activity (EUGOGO)
Proptosis
Diplopia
Neuropathy
Mild
19-20 mm
Intermittent Subclinical
Moderate
21 23
21-23 mm
Inconstant
6/9 -6/12
6/12
Marked
> 23 mm
Constant
(Primary)
(P i
)
6/12 and
worse
• Severe disease
– 1 Marked
– 2 Moderate
– 1 Moderate + 2 mild
Sanjeev Y, 2010
859

860. Auto antibodies
Auto-antibodies
• Anti-TSH.R
• A tit id P
Antityroid Peroxidase
id
Sanjeev Y, 2010
860

861. Blow out fracture : Signs
• Major signs
– Enophthalmos
– Diplopia
– Hypoesthesia
• Also
– Positive forced duction test
– Cloudiness and fluid level in the maxillary
sinus
861

862. Le Fort fractures
•
Le Fort I
– Low transverse maxillary fracture above the teeth
– No orbital involvement
•
Le Fort II
– Pyramidal configuration
– Nasal, lacrimal and maxillary bones  medial orbital floor
•
Le F t
L Fort III
– Disjunction of craniofacial bones
– Suspended only by soft tissues
– Orbital floor, medial and lateral
orbital walls are i
bit l
ll
involved
l d
American Academy of Ophthalmology
862

863. Painful ophthalmoplegia
• Think  Life saving first  Infection ??
– Orbital cellulitis
• Tumor
• Tolosa-Hunt-Syndrome
– High dose steroids usually produce rapid and
dramatic resolution
863

864. Painful blind eye
•
•
•
•
Think  Life saving first  infection ??
Relieving the pain immediately
Cryo-therapy ?
Enucleation  Last choice that strongly to be
avoided
• Remember :
– Incisional intra ocular surgery strictly contra indicated
in blind eye and in eye with severe decreased vision.
864

865. Community Ophthalmology
865

866. What is blindness?
• WHO classification of visual impairment
Criteria
Normal
Vision
6/6 to 6/18
Visual impairment (1)
<6/18 to 6/60
Severe visual impairment (2)
<6/60 to 3/60
Blind (3)
Blind (4)
Totally blind (5)
< 3/60
Or Visual Field 5 10
5-10º
1/60
Or Visual Field < 5º
No light perception
866

867. Legal Blindness
• Best corrected of visual acuity both eyes
20/200 or less (USA)
• Or, Visual fields in both eyes of less than
10 degree centrally (USA)
Deborah Pavan-Langston, 2008
867

868. Decreased vision percentage
Distance vision
20/20
20/25
20/40
20/50
20/80
20/100
20/160
20/200
20/400
Decrease (%)
0
5
15
25
40
50
70
80
90
Vaughan DG
868

869. Decreased vision percentage
Near vision
1
2
3
6
7
11
14
Decrease (%)
0
0
10
50
60
85
95
Vaughan DG
869

870. Trachoma
• Initially  Chronic follicular conjunctivitis
• Marked on upper tarsal plate
• Pannus
– Usually pronounced on upper half of the cornea
– Corneal infiltrates
– Superficial vascularization
• Art line
– Transverse band of scar  Fine linear
– Occurring on superior tarsal conjunctiva
• Herber pits
– Regression of the follicles formation
– Locate at the limbus
– Sharply defined depression at the base of the pannus
American Academy of Ophthalmology
870

871. Trachoma : WHO
SIGN
DEFINITION
TF
Trachoma Follicullar
5 or more follicles on superior tarsal
conjunctiva
TI
Trachoma Intense
Pronounced inflammatory thickening of the
upper tarsal conjunctiva  obscures more
than ½ the normal deep tarsal vessels
TS
Trachomatous
T h
t
Scarring
The presence of scarring in the tarsal
conjunctiva
TT
Trachomatous
Trichiasis
At least one eyelash rubbing on the
eyeball
CO
Corneal opacity
Easily visible corneal opacity over the pupil
American Academy of Ophthalmology
871

872. Trachoma : MacCallan
• Trachoma I
– Immature follicles on upper tarsal plate
– Including in central area
– Without scarring
• Trachoma II
– Mature follicles on upper tarsus  necrotic or soft
– Obscuring tarsal vessels
– Still without scarring
• Trachoma III
– Follicle presents on tarsus
– Definite scarring of the conjunctiva
• Trachoma IV
– No follicles on tarsal plate
– Marked scarring of the conjunctiva
872

873. Vitamin A deficiency
Xerophthalmia (WHO 1996)
•
•
•
•
•
(XN)
(X1A)
(X1B)
(X2)
(X3A)
•
(X3B)
•
•
(XS)
(XF)
: Nyctalopia
: Conjungtival xerosis
: Conjungtival xerosis + Bitot spot
: Corneal xerosis
: Keratomalacia or corneal ulceration
with < 1/3 corneal involvement
: Keratomalacia or corneal ulceration
with > 1/3 corneal involvement
: Corneal scar
: Xerophthalmia fundus
American Academy of Ophthalmology
873

874. Fortified topical antibiotics
• Fortified Tobramycin (or Gentamycin)
– Inject 2 ml of 40mg/ml Tobramycin
– Directly into a 5 ml – 0 3% Tobramycin
0.3%
ophthalmic solution
– This gives a 7 ml fortified Tobramycin 
approximately 15 mg/ml
– Refrigerate
– Expires after 14 days
Will’s Eye Manual, 2004
874

875. Fortified topical antibiotics
• Fortified Vancomycin
– Add non preservative sterile water to 500 mg of
Vancomycin dry powder to form 10 ml of solution
– This provides a strength of 50 mg/ml solution
– To achieve a 25 mg/ml solution  take 5 ml of 50
mg/ml solution
– Add 5 ml sterile water
– Refrigerate
– Expires after 4 days
Will’s Eye Manual, 2004
875

876. Fortified topical antibiotics
• Fortified Cefazolin
– Add non preservative sterile water to 500 mg
of Cefazolin dry powder to form 10 ml of
solution
– This provides a strength of 50 mg/ml solution
– Refrigerate
– Expires after 7 days
Will’s Eye Manual, 2004
876

877. Fortified topical antibiotics
• Fortified Bacitracin
– Add non preservative sterile water to
50,000
50 000 U of Bacitracin dry powder to form
5 ml of solution
– This provides a strength of 10,000 U/ml
solution
– Refrigerate
g
– Expires after 7 days
Will’s Eye Manual, 2004
877

878. Intracameral Antibiotics
• Glycopeptide
– Vancomycin  Use Millipore powder filter
• Cephalosporins
– Cefuroxime
– Cefazolin
• Fluoroquinolones
– Gatifloxacin
– Moxifloxacin
EyeWorld 2009
878

879. Intravitreal antibiotics ( / 0 1 ml )
0.1
•
•
•
•
•
•
Gentamycin
G t
i
Vancomycin
Amikacin
Chlorampenicol
Amphotericin B
Ceftazidime
Cefta idime
0.1
0 1 mg
1.0 mg
0.4 mg
1.0 mg
5.0 µg
2.0-2.25
2 0 2 25 mg
American Academy of Ophthalmology
879

883. The Laser
883

884. Laser
•
•
•
•
Light Amplification
By
Stimulating
The Emission of Radiation
884

885. Laser : Effect
•
•
•
•
Photochemical
Thermal
Photovaporization
Ionizing effects
885

886. Laser : Type
• GAS ION LASERS
- Argon, Krypton
• SOLID STATE LASERS
- R b C t l Nd YAG
Ruby Crystal, Nd:YAG
• LIQUID LASERS
-D e
Dye
• DIODE LASERS
886

887. Laser for Eye
• Photocoagulation  Proteindenaturating processes
– Argon Blue Green
– Argon Green
– Krypton Red
– Diode
– Tunable Dye
– Frequency Doubled Nd:YAG
–X
Xenon Arc
A
887

888. Laser for Eye
• Photodisruption  Cutting by
optical break down  10,000° K
– Q-switched Frequency Doubled
Nd:YAG Laser
888

889. Laser for Eye
• Photodecomposition  Carving
 C tti th molecular b d
Cutting the
l
l bond
– UV short wavelength
– Excimer (Excited Dimmer) Laser
889

890. Laser for Eye
• Photoevaporation  Infra Red
– CO2 Laser
–H l i
Holmium:YAG L
YAG Laser Shorter Long
Wavelength
– Erbium:YAG Laser
Laser
890

891. MODERN LASERS
• Continuous Wave ( CW )
p
accurate selection of power & emission time
• Efficiency
- lower power and energy consumption
- lower space consumption
- lower cost
- long term use
891

892. The Lasers
•
•
•
•
•
integrepro multicolor laser (ellex)
PUREPOINT Laser (Alcon Inc)
MicroPulse Fovea-Friendly Laser (IRIDEX)
VISULAS 532s VITE (Carl-Zeiss)
(Carl Zeiss)
PASCAL (Pattern Scan Laser) Photocoagulator
(OptiMedica, now: TopCon)
• Novus Varia multicolor photocoagulator
(Lumenis)
• MC-500 Vixi Multi-Colour Laser (NIDEK)
MC 500
Multi Colour
• Vitra Multispot Laser (Quantel Medical)
892

895. Laser on Retina
My teacher, my mentor, my friend:
dr.
dr Tjuk Suparjadi Sp M
Suparjadi, Sp.M
895

896. Laser on Retina : Photocoagulation
• L
Lenses
– PRP Lens
– Goldmann 3 mirror Lens
• 59°, 67°, 73°
–F
Focal and G id L
l d Grid Lens
– +78 and +90 D Lens
– PDT Lens
896

897. 897

898. LASER ON RETINA
• GREEN LASER : 532 nm
Produced by :
- Gas ( Argon )
- Diode Pumped Solid State (DPSS)
F
Frequency doubled Nd YAG
d bl d Nd:YAG
898

899. LASER ON RETINA : Argon
g
• 514 nm and 532 nm wavelength
• Clear media  safe and proven effective
• Indications :
– DR
– Veins occlusions
– CNV
– Retinal breaks
899

900. LASER ON RETINA : Dye Yellow
•
•
•
•
•
577 nm wavelength
Better than Argon for microaneurism
Preferred for Coats disease
Not acceptable in hemorrhage
Macula  absorbed by haemoglobin, unabsorbed b
M
l
b b db h
l bi
b b d by
Xanthophil
900

901. LASER ON RETINA : Krypton Red
•
•
•
•
•
•
•
647 nm wavelength
Less absorption by blood
Hazy media
Deep b
D
burns
Less NFL damage
Not preferable for Coats disease and Retinal angioma
Indications :
–
–
–
–
DR with vitreous hemorrhage
Veins occlusions with vitreous hemorrhage
Vitreoretinal tractions
CNV  General Peripapillary, Near PMB with pre-retinal
General, Peripapillary
PMB,
pre retinal
membrane
901

902. LASER ON RETINA : Diode
•
•
•
•
•
•
810 nm wavelength
Deep burns
Less NFL damage
Less absorbed by blood
Not preferable for Coats disease and Retinal angioma
Indications :
–
–
–
–
DR with vitreous hemorrhage
Veins occlusions with vitreous hemorrhage
Vitreoretinal tractions
CNV  General, Peripapillary, Near PMB, with pre-retinal
membrane
b
902

903. HOW to OPERATE
• TECHNICAL SPECIFICATION
p
1. Laser Specification
2. Electrical Requirement
3. Visualization
- Slit Lamp
- Aiming Beam
- Laser Safety Eye Wear
MPE = maximum permissible exposure
903

904. How to select the mode
• Type of Laser : Wavelength
• Power : 0 3 - 1 7 W ( DPSS )
0.3 1.7
0.5 - 4.0 W ( Gas )
• S t Size: 50 - 2000 um
Spot Si
• Exposure time : 0.01 - 4.0 s ( DPSS )
0.01 - 1.0 s ( Gas )
• Pulse Interval : 0.1 - 1.0 s
904

905. Nice to know
• Xantophyl, Oxyhaemoglobin and Melanin
• Indirectly mechanism
• Exposure time :
< 0 1 sec : mechanical effect
0.1
h i l ff t
> 0.1 sec : thermal effect
• Energy Density  inversely proportional to
the focal spot size
905

906. Applications
• Diabetic retinopathy
– Non-perfusion
– Edema
– Neovascularization
•
•
•
•
•
•
Venous occlusion
Retinal breaks
Retinal degeneration
Retinal vasculitis
CSCR
AMD
• G id
Grid
• Focal
• Pan retinal
906

907. Applications : Grid LPC
• Grid Laser Photocoagulation
• Macular application  500 µm up to 3000 µm from
foveal center
• Excluded  area of PMB
• Grid Lens / +78 and +90 D Lens
• Start at 100mW power  increments of 10-20mW
• 50-100 µm spot size
• 0.100 second or less duration
• S t spaced at least one burns apart
Spots
d tl
t
b
t
• Supplemental treatment considered at least 3-4 month
after initial coagulation  up to 300 µm
907

908. Applications : Focal LPC
Focal Laser Photocoagulation
•
•
•
•
•
Grid Lens / +78 and +90 D Lens
Start at 100mW power  increments of 10-20mW
50-100 µm spot size
0.100 second or less duration
Attempt to whiten or darken microaneurysms
908

909. Applications : PRP
Pan-Retinal Photocoagulation
/ Scatter Laser Photocoagulation
•
•
•
•
•
•
•
•
•
NVD or / and NVE
PRP Lens
Start at 180mW power  increase gradually to achieve the end
point
500 µm spot size
0.100 to 0.200 second duration
1800 total applications
1 – 1.5 burns width apart
3 sessions complete  10 days to weeks apart
Usually, inferior half of retina coagulated first
y,
g
909

910. Applications : Others
•
•
•
•
•
•
•
•
ROP
Retinoblastoma
Coats disease
Vitreolysis
Retinal cavernosus hemangioma
Choroidal hemangioma
Optic Disc Pit – Maculopathy
Idiopathic Juxtafoveal Retinal talengiectasis
910

911. Chorioretinal burn intensity
• Light
– Barely visible retinal blanching
• Mild
– Faint white retinal burn
• Moderate
– Opaque, dirty white retinal burn
• Heavy
– Dense-white retinal burn
911

912. Laser on Retina : PDT
•
•
•
•
•
Systemic administration
Use photosensitizing drugs
Followed b li ht application
F ll
d by light
li ti
Particular wavelength to affected tissue
Incite a localized photochemical reaction
912

913. Laser on Retina : PDT
• CW beam  500 - 590 µm of low thermal energy
laser
• Extend at least 500 µm beyond lesion margin
y
g
• 50 J/cm2 laser energy
• 600 mW/cm2 dose rate
• 15 minutes after start the infusions
913

914. Laser on Retina : PDT
• Liposome-encapsulated Benzoporphyrin
 Verteporfin dye (Visudyne)
– Maximum absorption  light near 689 nm
wavelength
• Others :
– Tin Ethyl Etiopurpurin (SnET2, Purytin)
– Lutetium (Lu-Tex)
914

915. Laser on Retina : PDT
• 30 ml Verteporfin via 10 minutes infusion pump
injection, plus
• 5 ml D5W injected simultaneously via Y tube
• Filtered by 1.2 um filter to venflon catether into
Cubiti vein
915

916. Laser on Retina : TTT
• Transpupillary Thermotherapy
– Alt
Alternative th
ti therapy f S bf
for Subfoveal CNV
l
– Rise intralession temperature of 4-9° C
•
•
•
•
•
Infra Red Diode laser 810 nm
Within 72 hours of recent FFA
Diode-coated
Diode coated Volk QuadrAspheric Lens
0.8 mm, 1.2 mm, 2.0 mm, 3.0 mm spot size
200 – 600 mW power
W
916

919. Laser for Glaucoma
919

920. A Tribute to
Prof. dr. Ratna Kentjana, Sp.M(K)
Prof. d MNE G
P f dr. MNE. Gumansalangi, S M(K)
l
i Sp.M(K)
920

921. ALT
• Argon Laser Trabeculoplasty
921

922. ALT : Aims
• I
Increase aqueous outflow
tfl
• By burning the trabecular meshwork
• By applying a low energy of laser
922

923. ALT : Mechanism
• Absorption of laser by Pigmented TM
• Produces thermal energy
• Shrinkage of collagen of trabecular lamellae
– Probably opens un intratrabecular space in untreated
region
– Trabecular tightening  pulling meshwork centrally 
opens Schlemm’s canal
• Attract phagocytes that clean up debris
• Allows aqueous to flow better
923

924. ALT : Preparations
• CW Argon laser :
– Bichromatic Blue-Green
– Monochromatic Green
• Krypton Red
• Frequency doubled Nd:YAG laser
q
y
• Diode
– Lesser pain
– Lesser PAS
– Lesser disruption of Blood Aqueous Barrier
• Gonio lens
924

925. ALT : Protocol
1. Pre-Treatment
● Alpha-adrenergic antagonist (Apraclonidine 1%) and topical anesthetic
2. Treatment
● G i i
Gonioprisms
● Focus aiming beam to target the entire height of TM
● 180° or 360° of TM can be photocoagulated in single or two sessions
● Goniolens rotated clockwise and make 25 burns for each 90°
3. Post-Treatment
●
●
●
●
Alpha-adrenergic antagonist
Topical steroid or NSAID for 3 to 5 days (optional)
1 hour IOP check after treatment
Regular follow-up routine
925

926. ALT : Indications
•
•
•
•
POAG
Exfoliation syndrome
Pigmentary glaucoma
Glaucoma in aphakia and pseudophakia
926

927. ALT : Contraindications
•
•
•
•
•
•
Closed or Extremely narrow angle
Corneal haze and diminished aqueous clarity
Vitreous in anterior chamber
Neovascular glaucoma
Active uveitis
Poor responsiveness glaucoma  Congenital
glaucoma and Angle recession glaucoma
927

928. ALT : Complications
•
•
•
•
•
•
Elevated IOP
Progressive visual fi ld l
P
i
i
l field loss
Iritis
PAS
Hemorrhage
Corneal complications
928

929. SLT
• Selective Laser Trabeculoplasty
929

930. SLT : Mechanism
• Uses specific wavelength
• Absorption of laser by Pigmented TM 
selective t
l ti targets  no d
t
damage on N
Nonpigmented TM
Non thermal
• Produces Photothermolysis  Non-thermal
• Trabecular tightening
• Allows aqueous to flow better
930

931. SLT : Preparations
• 532nm Wavelength Q-switched frequency
doubled Nd:YAG laser
(Neodymium: Yytrium-Aluminum-Garnet)
• 63
635nm W
Wavelength Di d l
l
h Diode laser
• Goldmann, Thorpe or Latina lens
(0° magnification)
ifi ti )
931

932. SLT
• Allerex
• Ellex
932

933. SLT : Protocol
1. Pre-Treatment
● Alpha-adrenergic antagonist and topical anesthetic
2. Treatment
● G ld
Goldmann, Th
Thorpe or Latina lens (0° magnification)
L ti l
ifi ti )
● Focus aiming beam to target the entire height of TM
● Set laser to 0.8 mJ (average) and then increase in 0.1 mJ steps until
champagne bubbles appear approximately 50%-70% of the time
50% 70%
● Approximately 50 shots are placed onto the TM in the same pattern as ALT
3. Post-Treatment
3 P
T
●
●
●
●
Alpha-adrenergic antagonist
Topical steroid or NSAID for 3 to 5 days (optional)
1 hour IOP check after treatment
Regular follow-up routine
933

934. SLT is not ALT
Spot size comparison:
ALT
50µm
SLT
400µm
ALT SLT
ALT
SLT
50 micron
SPOT SIZE
400 micron
500 – 1,000 mW
720 – 1,200 mW
ENERGY OUTPUT
0.8 – 1.5 mJ
10 ms
PULSE DURATION
3 ns
60,000 mJ/cm2
FLUENCE
600 mJ/cm2
934

935. SLT is not ALT
The SLT technique is much less traumatic to the eye than ALT
ALT,
and evokes a gentle response of the auto-immune system to begin
clearing the TM without the coagulative damage of ALT.
TM tissue after ALT
TM tissue after SLT
935

936. SLT : Processes
SLT is a non-thermal treatment which uses short pulses of relatively low energy 532nm
light to target and irradiate only the melanin-rich cells in the trabecular meshwork (TM);
the laser pulses affect only these melanin-containing cells, and the surrounding structure
of the TM is unaffected.
During the procedure approximately 50 confluent spots are applied along the meshwork
in order to treat a 180° angle.
Animation
936

937. 1. SLT is selective
SLT selectively targets only the melanin-rich cells of the trabecular
meshwork.
2. SLT is non-thermal
The short pulse duration of SLT is below the thermal relaxation time of
the TM tissue, thereby eliminating the incidence of thermal damage.
3. SLT is repeatable
SLT treatment can be repeated without causing harm or further
p
complications.
937

938. SLT : Indications
Open Angle Glaucoma
•
•
•
•
POAG
OHT
Pigmentary Glaucoma
Pseudo-exfoliative glaucoma
Poorly compliant to drug therapy
Intolerant or unresponsive to drug therapy
I l
i
d
h
Failed ALT (either 180˚ or 360˚)
Inflammatory glaucoma
Patients currently undergoing drug therapy who wish to use SLT in
conjunction with glaucoma medications
938

939. SLT represents a whole new approach to managing open-angle glaucoma
Compliance issues minimized
Gentle, non-invasive treatment
SLT does not cause thermal damage of the
trabecular meshwork
No systemic side effects
SLT can be used in conjunction with medicine
to enhance the overall IOP lowering effect
IOP-lowering
Non-penetrating glaucoma surgery is not
compromised as with ALT
The latest in ‘Primary Glaucoma Therapy
Primary
Therapy’
939

940. ALPI
• Argon Laser Peripheral Iridoplasty
940

941. ALPI : Aims
•
•
•
•
•
Laser energy placed near iris root
Separate Iris from TM
S
t Ii f
For PACG
Reopening of closed angle
Widening of narrow angle
941

942. ALPI : Preparations
• 532nm Wavelength Q-switched frequency
doubled Nd:YAG laser
(Neodymium: Yytrium-Aluminum-Garnet)
• Ab h
Abraham contact lens +55 to +66 D
l
66
942

943. ALPI : Indications
• Plateau iris syndrome
• Unbreakable attack of angle close
glaucoma  laser iridotomy not possible
• Phacomorphic glaucoma
• Adjunct to laser trabeculoplasty
• R t ti peripheral i i stuck
Retracting
i h l iris t k
• Rare case of nanophthalmos
943

944. ALPI : Contraindications
•
•
•
•
Advanced corneal edema / opacity
Flat anterior chamber
Extensive PAS
Creeping angle glaucoma  not effective
ALPI : Complications
•
•
•
•
Iritis
Corneal endothelial burns
Hemorrhage
Transient IOP rise
944

945. Nd:YAG Laser Iridotomy
• R li
Relieve th pupillary bl k
the
ill
block
• 532nm Wavelength Q-switched frequency
doubled Nd:YAG laser
(Neodymium: Yytrium-Aluminum-Garnet)
• Abraham contact lens +55 to +66 D
945

946. Nd:YAG Laser Iridotomy
• Indications :
– PACG :
• A t / Sub acute angle closure
Acute S b
t
l l
• Creeping angle closure
– Fellow eye of ACG
– Non-pupillary block angle closure
• Plateau iris
• Forward lens position
– Narrow or closed angle
946

947. Nd:YAG Laser Iridotomy
y
• Complications :
–
–
–
–
–
–
–
–
–
Corneal epithelial / endothelial burns
Iritis
Pigment dispersion
Hemorrhages
g
Lens opacities
Retinal burns
Raised IOP
Posterior synechiae
Monocular di l i
M
l diplopia
947

948. Laser for Glaucoma and Others
•
•
•
•
•
Nd:YAG Laser C
Nd YAG L
Capsulotomy
l
Diode Laser Cyclophotocoagulation
Endoscopic Cyclo Photo Coagulation
Nd:YAG Laser Iridolenticular Synechiolysis
Cyclophotocoagulation
–
–
–
–
•
Transpupillary CP
Endo CP
Nd:YAG Trans-scleral CP  Contact and Non-contact
Diode laser CP (DLCP)
Excimer Laser Trabeculotomy (ELT)
– 308 nm X Cl l
XeCl laser, power 35 55 mJ/mms spot size 200 um, d ti 10
35-55 J/
t i
duration
sec, freq 20Hz
•
Excimer Laser Assisted Deep Sclerotomy
– Argon Fluoride XL 193 nm at 180 mJ x sq cm fluence
g
q
948

949. Laser for Refractive Surgery
•
•
•
•
•
•
PRK
LASIK
Epi LASIK
SBK
LASEK
LaserACE
949

950. LASIK : Wood carving
• W dC
Wood
Cornea
• Equipment  Laser
• Carver  Ophthalmologist
950

951. Argon Fluorine (ArF)
•
•
•
•
•
•
193 nm
Above th h ld t b k molecular b d
Ab
threshold to break
l
l bond
Ablative photodecomposition
Neighboring tissue <10º C (Cold laser)
Minimal collateral damage
Maximal accuracy & precision
951

952. Solid State UV 213
•
•
•
•
•
213 nm
DPSS Nd YAG P l
Nd:YAG Pulzar 21 (C t Vi )
(CustomVisc)
Less absorbed by neighboring tissue
Much better penetrating
Less sensitive to environmental factor
952

953. Solid State UV 210
•
•
•
•
•
210 nm
DPSS L
LaserSoft (K t
S ft (Katana T h l i )
Technologies)
Less inflammations
Less pain
Faster visual recovery
953

954. Lasik
• Pre Lasik
– General Examination
– Mapping  Topography and pachymetry, Aberration
measurement and collecting data
– Making algorithm for laser treatment
• Durante
– Flapping  Micokeratome or Femtosecond
– Eye-tracked Laser treatment
– Recovery management
• Post Lasik
954

955. Corneal Topography, Corneal
Pachymetry and Aberrometry System
955

956. Femto and Excimer Laser System
956

957. Pre Lasik
• Topography - Keratometry
• Ab
Aberrometry
t
957

958. Topography
3 types
– Placido-based systems
Placido– Elevation-based systems
Elevation– Interferometric system
y
Bausch and Lomb
958

959. Topography
Provide topography of the cornea, like a map
Bausch and Lomb
959

960. ORBSCAN II z
Combination of :
• Placido based-system
• Scanning slit imaging (elevation
based system)
Bausch and Lomb
960

961. Reflective and Slit-Scan Technologies
•
•
•
One image, one surface.
Angle-dependent specular
A l d
d t
l
reflection.
Measures slope (as a
function of distance).
f
ti
f di t
)
•
•
•
Multiple images, multiple
surfaces
Omni-directional diffuse
backscatter
Triangulates elevation
Ti
l t
l
ti
The overwhelming advantage Placido reflective systems is
that they can measure curvature
curvature.
Bausch and Lomb
961

962. How corneal shape relates to shape factor
962

963. LASIK  Fit the cornea
Data surface
(cornea)
Fit-zone
Reference surface (Best Fit Sphere)
(
p
)
Bausch and Lomb
963

964. 3D Corneal Topography
BFS
BFS : Reference surface (Best Fit Sphere)
Bausch and Lomb
964

965. Major points
•
•
•
•
•
Anterior Elevation
Posterior Elevation
Pachymetry Thickness
Keratometry - Surface Curvature
Statistics and Data
•
•
•
•
•
•
•
•
Sim K
Steep and Flat Axis
White to White
Pupil diameter
Thinnest point
Anterior Chamber Depth (ACD)
Angle Kappa
g
pp
Kappa Intercept
Bausch and Lomb
965

966. Anterior Elevation Map
Curvature M
C
Map
Posterior Elevation Map
Statistics d D
S i i and Data
Pachymetry Map
P h
M
Bausch and Lomb
966

967. Elevation (f
El
ti (from a reference surface)
f
f
)
Max
Red
• High
• Anterior to the
reference surface
(+)
reference
f
(-)
level
l
l
• Low
• Posterior to the
reference surface
Min
Blue
Bausch and Lomb
967

968. Elevation Map Reading
• Warmer colors are above “sea level”
sea level
• G
Green i “
is “sea l
level” ( t h with a
l” (match ith
sphere that best matches the cornea)
• Cooler colors are below “sea level”
• Both Anterior and Posterior are read in
the same way
y
Bausch and Lomb
968

969. Eye #1
Highest Point
Lowest Point
Bausch and Lomb
969

970. Eye #1
Highest Point
Lowest Point
Bausch and Lomb
970

971. Pachymetry Maps
• Warmer colors are THINNER
• Cooler colors are THICKER
Pre-Op
Pre Op eyes are usually thinnest in the
temporal and inferior quadrant
Bausch and Lomb
971

972. Thickness
Min
Red
(+)
• Thin
(+ +)
• Thi k
Thick
Max
Blue
Bausch and Lomb
972

973. Pachymetry Thickness
THINNEST Area
THICKER Area
Bausch and Lomb
973

974. Pachymetry map
y
y
p
• Thinnest point  obtain from data sheet
Bausch and Lomb
974

975. Pachymetry map
• Orbscan pachymetry measurements 
5% to 8% more compared to ultrasonic
– Orbscan measures from epithelium to
endothelium
– Ultrasonic pachymetry : Stroma
Bausch and Lomb
975

976. High and Low is not always
directly related to Steep and Flat
High Tissue is usually flatter, but not always
g
y
,
y
Low Tissue is usually steeper, but not always
Color coded in elevation map >< curvature map (keratometric)
Ablation requires Elevation Data because
tissue that needs to be removed is high
Bausch and Lomb
976

977. Color-coded scales
Colors :
– Warm (red, orange, yellow) for steeper
portions of cornea
– Green denotes intermediate portions
– Cool (blue, dark blue) depict flatter
portions
Bausch and Lomb
977

978. Surface Curvature
S rface C r at re
(+ +)
Max
Red
• Sharp
• Fast bend
• Short radius
• Flat
• Slow bend
• Long radius
(+)
Min
Blue
Bausch and Lomb
978

979. Bausch and Lomb
979

980. Orbscan topography prior to refractive surgery
•
•
•
•
•
•
•
•
•
•
•
Ultrasound pachimetry > 475 µm
Residual bed thickness (RBT) > 250 - 300 µm
Posterior elevation < 50 µm
Posterior bed fit sphere < 50 D
Anterior/Posterior Radii-Ratio 1.21 – 1.27
Irregularity (3mm) < 1.5 D
Irregularity (5mm) < 2 0 D
2.0
Peripheral-Central Pachimetry < 20 µm
SimK (Max) < 47 D
Astigmatism variance between eyes < 1.0 D
Symetric bowtie
EyeWorld 2009; Joo CK 2009
980

981. ANY CAUTIONS
981

982. Keratoconus
Refractive surgery makes early diagnosis of
corneal abnormalities more important
Bausch and Lomb
982

983. Close-Fitting Reference Surfaces
Topographic maps of terrestrial landscapes are displayed in
the form of constant-elevation contours, measured from the
“mean sea level” of the earth.
mean sea-level
earth
Data surface
(cornea)
Reference surface (sphere)
Corneal topography differs from terrestrial topography in
that the reference surface is not some fixed “mean sealevel”, but is movable.
Bausch and Lomb
983

984. Close-Fitting Reference Surfaces
For th
F the cornea, a reference surface (typically, a sphere) i
f
f
(t i ll
h ) is
constructed by fitting the reference surface as close as
p
possible to the data surface.
Data surface
(cornea)
Fit-zone
Reference surface (sphere)
A best-fit minimizes the square difference (always a
p
positive number) between the two surfaces, but only within
)
,
y
a specified region known as the fit-zone.
Bausch and Lomb
984

985. Elevation Topology: Central Hill
Bausch and Lomb
Sharp center
Flat periphery
The normal cornea is prolate meaning that meridional curvature
prolate,
decreases from center to periphery.
Prolateness of the normal cornea causes it to rise centrally above the
reference sphere. The result is a central hill.
f
h
Th
lt i
t l
Immediately surrounding the central hill is an annular sea where the
cornea dips below the reference surface.
In the far periphery, the prolate cornea again rises above
the reference surface, producing peripheral highlands.
985

986. Elevation Distortion
Bausch and L b
B
h d Lomb
Spherical
reference surface
Post Lasik
profile
Relative
elevation
p
profile
As an example of distortion, consider the corneal surface following
p
g
myopic lasik correction. It is centrally flattened by the surgery.
To see surface features, elevation must be measured with respect to
some reference surface.
This relative elevation peak is NOT the highest point on the cornea.
This apparent central "concavity" does NOT exist.
986

987. Normal Post LASIK Anterior Elevation
Bausch and Lomb
Lower in the Center - OD
Lower in the Center - OS
987

988. Elevation (sphere)
Elevation (sphere)
These are pre-op (left) and post-op (right) elevation maps of
a myopic with-the-rule astigmatic eye corrected with LASIK.
y p
g
y
The post-operative central “sea” is not a concavity but a
central flattening.
The ring of relatively highest terrain is not absolutely higher
(more anterior) than the “sea” bottom near the map center.
988

989. Abnormal Post LASIK Posterior Elevation
Bausch and Lomb
Abnormally High but
High & De centered - Poor Vision
De-centered
Centered - Moderately Good Vision
• Diplopia at night
989

990. Normal Band Scale
Bausch and Lomb
Accentuates anomalies
990
Filters small irregularities

991. Normal B d S l
N
l Band Scale
• Elevation Maps (Anterior & Posterior)
– + 0.25 microns of Best Fit Sphere
• Total Cornea Power
– 40 to 48 Diopter
• Pachymetry
– 500 to 600 microns
Bausch and Lomb
991

992. Posterior Keratoconus
The normal band scale on the left indicates very small changes on the
anterior corneal surface and a relatively small area of corneal
steepening above 48 D.
These findings are indicative of milder disease than the contra-lateral
contra lateral
eye but probably represents an earlier forme fruste of keratoconus.
Bausch and Lomb
992

993. The CRS-Master
How d you plan your t t
H
do
l
treatments ?
t
Wavefront
Patient Data
Microkeratome
Refraction
Corneal C
C
l Curvature
t
Pachymetry
• Modern refractive excimer surgery is based on a complex
data set
• I must take into account not only wavefront data, b all
It
k i
l
f
d
but ll
relevant parameters of each individual patient.
Bausch and Lomb
993

994. Aberrometry
• Collecting aberration data
• Make algorithm for laser treatment
• Minimizing aberration post surgery
Bausch and Lomb
994

995. Aberration : Category
• Two categories of aberrations commonly are used to
describe vision errors, including:
– Lower-order aberrations consist primarily of nearsightedness
and farsightedness (defocus), as well as astigmatism. They
make up about 85 percent of all aberrations in an eye.
– Higher-order aberrations comprise many varieties of
aberrations. Some of them have names such as coma, trefoil
p
,
y
and spherical aberration, but many more of them are identified
only by mathematical expressions (Zernike polynomials). They
make up about 15 percent of the total number of aberrations in
an eye.
• Order refers to the complexity of the shape of the
wavefront emerging through the pupil — the more
complex the shape the higher the order of aberration
shape,
aberration.
Vessel M, 2008
995

996. Aberration : What Exactly
y
• A higher-order aberration is a distortion acquired by a
wavefront of light when it passes through an eye with
irregularities of it refractive components (t
i
l iti
f its f ti
t (tear fil
film,
cornea, aqueous humor, crystalline lens and vitreous
body
• Abnormal curvature of the cornea and crystalline lens
may contribute to the distortion acquired by a wavefront
of light.
• Serious higher order aberrations also can occur from
higher-order
scarring of the cornea from eye surgery, trauma or
disease.
• Cataract clouding the eye's natural lens also can cause
eye s
higher-order aberrations. Aberrations also may result
when dry eye diminishes your eye's tear film, which
p
g
y
helps bend or refract light rays to achieve focus
Vessel M, 2008
996

997. Aberration : How to diagnose
•
•
•
•
Higher-order aberrations are identified by the types of distortions
acquired by a wavefront of light as it passes through your eye.
Because light travels in bundles of rays a common way of
rays,
describing an individual wavefront involves picturing a bundle of light
rays. The tip of each light ray in the bundle has its own point. We
create the wavefront or wavefront map by drawing lines
perpendicular to each point
point.
The shape of a wavefront passing through a theoretically perfect eye
with no aberrations is a flat plane known, for reference, as piston
(see next chart). The measure of difference between the actual
wavefront shape and the ideal flat shape represents the amount of
aberration in the wavefront.
Because no eye is absolutely perfect (emmetropic), a wavefront
passing through an eye acquires certain three-dimensional, distorted
shapes. S f more th 60 diff
h
So far,
than
different shapes, or aberrations, h
t h
b
ti
have
been identified.
Significant amounts of aberrations can pose vision problems
y
y
y
because they interfere with the eye's ability to see clear and distinct
images (focus).
Vessel M, 2008
997

998. Aberration : Visual quality
• The impact of higher-order aberrations on vision quality
depends on various factors, including the underlying cause of
the aberration.
• People with larger pupil sizes generally may have more
problems with vision symptoms caused by higher-order
aberrations, particularly in low lighting conditions when the
pupil opens even wider.
il
id
• But even people with small or moderate pupils can have
significant vision problems when higher-order aberrations are
caused by conditions such as scarring of the eye's surface
eye s
(cornea) or cataracts that cloud the eye's natural lens.
• Also, specific types and orientation of higher-order aberrations
have been found in some studies to affect vision quality of
q
y
eyes with smaller pupils.
• Large amounts of certain higher-order aberrations can have a
severe, even disabling, impact on vision quality.
Vessel M, 2008
998

999. Aberration : Symptoms
• An eye usually has several different
higher-order aberrations i t
hi h
d
b
ti
interacting
ti
together.
• Th f
Therefore, a correlation between a
l ti b t
particular higher-order aberration and a
specific symptom cannot easily be drawn
drawn.
• Nevertheless, higher-order aberrations are
generally associated with double vision
vision,
blurriness, ghosts, halos, starbursts, loss
of contrast and poor night vision
vision.
Vessel M, 2008
999

1000. TERMS OF WAVEFRONT
SO
O
Aberrometry
Provide information, h
P id i f
i
how b d the
bad h
Aberrations of the rays inside the eye
gy
 Wavefront technology
1000

1001. What is Wavefront?
• Wavefront Technology is the latest generation of laser
vision correction.
• Light travels in a flat uniform beam.
• When there is nothing disturbing it, such as light going
through space, it is perfectly flat without error.
• This pattern of a straight beam of light is called a
wavefront.
• As light g
g goes through objects, the light beam becomes
g
j
,
g
distorted or becomes more like a wave.
• When light enters the eye, the light rays become
distorted because of the many components of the eyes
optical system.
• Some of these components include the cornea, lens and
aqueous fluid, although the greatest amount of distortion
occurs when light enters th
h li ht t
through th cornea.
h the
1001

1002. What is Wavefront?
Perfect beam
Imperfect beam
p
Wavefront E e
Wa efront in Eye
1002

1003. How does Wavefront Work?
• As the light rays touch the retina, the Wavefront
Analyzer measures the amount of distortion that has
occurred prior to the light entering the eye and after
going through the eye.
• As with the diagram the simulation grid would be
diagram,
considered the ideal or perfect optical grid.
• This grid is projected on to the back of the eye and
is measured.
measured
• The measurement is compared to the original grid
producing what is called a wavefront map.
• This wavefront map calculates the specific
aberrations of the cornea precisely measuring each
section of the cornea to provide the most accurate
p
and detailed information about our vision.
1003

1004. How does Wavefront Work?
• Once the information is collected, it is
,
transferred to the laser.
• The laser then does a customized treatment that
is
i specific to the patient and i not b
ifi
h
i
d is
based on
d
general guidelines of treatment.
• No two wavefront maps are identical therefore a
identical,
customized treatment is specific to that patient,
enhancing the opportunity for superior quality of
vision, reduced or eliminated night vision and
improved uncorrected visual acuity.
1004

1005. Why wavefront technology ?
To reshape corneal surface to
compensate for optical
t f
ti l
aberrations
Real eye:
rays do not intersect
retina
Ideal eye:
all rays intersect in image plane
Determine actual shape
p
of wavefront
Bausch and Lomb
retina
1005

1006. Wavefront methods
• Hartman-Shack
• Tscherning
• Optical Path Difference (OPD) Scan
Deborah Pavan-Langston, 2008
1006

1007. Measurements & Terminology
•
•
•
•
•
•
Zernike polynomials
Point S
P i t Spread F
d Function (PSF)
ti
Root Mean Square (RMS)
Strehl Ratio
Diffraction
Convolution
Bausch and Lomb
1007

1008. Zernike polynomials
• Prof. Frits Zernike
Groningen, Holland
Awarded Nobel prize in Physics 1953
•
The complex shape of wavefront
is approximated by a sum of
function to give a special
geometrical mode
ti l
d
Bausch and Lomb
1008

1009. 1009

1010. Zernike polynomials
Bausch and Lomb
1010

1011. LowerLower-order aberrations
2nd
Bausch and Lomb
1011

1012. 3 common higher order aberrations
g
most patients suffer from
3rd
3rd
4th
Bausch and Lomb
1012

1013. Aberrations of the eye
Bausch and Lomb
1013

1014. Aberrations of the eye
Bausch and Lomb
1014

1015. Understanding Aberrations
Second Order
Myopia
Cylinder
Bowl Shape
Saddle Shape
Third Order
Fourth Order
Coma
Trifoil
Sph Aber
Bump & Dip
Napoleon’s Hat
Sombrero
Plant Stand
1015
Bausch and Lomb
Quadrafoil

1016. Understanding Aberrations
g
Coma (3rd order)
(
)
Spherical Aberration
(4th order)
Bausch and Lomb
1016

1017. Point Spread Function (PSF)
Normal eye
Monocular Diplopia
Bausch and Lomb
1017

1018. Point Spread Function (PSF)
Bausch and Lomb
1018

1019. Root Mean Square (RMS)
• Single value
• Measure the magnitude of a set of number
• Example :
– Set of no : -2 +5 -6 +4 -1
– Average = 0  not informative
– We want to know the variation, disregard the
signs  average = 3.6
g
g
Bausch and Lomb
1019

1020. Root Mean Square (RMS)
Another way to know the variation :
1. Square all values
2.
2 Take average of the squares
3. Square root of average
Smaller RMS = Less aberrations
General agreement : RMS < 0.38 plano LASIK
Bausch and Lomb
1020

1021. Strehl Ratio
• A metric calculated from :
Actual
A t l peak PSF
k
Diffraction-limited peak PSF
Results closer to 1  less aberration
Bausch and Lomb
1021

1022. Strehl ration
H eye
Strehl ratio 
H dl
Diffraction limited PSF
Aberration free
H dl
Actual PSF with aberrations
Bausch and Lomb
H eye
1022

1023. Diffraction
• Diffraction causes light to bend perpendicular to
the direction of the diffracting edge
• Spreading of light waves as they p
p
g
g
y pass through a
g
small opening. (Christiaan Huygens, 1678)
• Cause the light imaged not as a single sharp
g
g
g
p
point  AIRY DISK
• Smaller apertures generates more diffraction
Bausch and Lomb
1023

1024. Convolution
• Method to portray blur, using PSF in every p
p
y
,
g
y point of
object to stimulate retinal image
Bausch and Lomb
1024

1025. Wavefront Analyzers
•
•
•
•
•
Zywave (Bausch & Lomb Incorporated)
(
)
CRS Master (Carl Zeiss Meditec AG)
WaveScan (Abbott Medical Optics)
g
p y
(WaveLight, Alcon)
g
)
Allegro Topolyzer Vario (
MAXWELL (Ziemer)
1025

1026. Glare
• Glare can be described as “extreme brightness”
from the presence of excessive visible light.
• Glare can be distracting and even dangerous
and can occur day or night in a number of ways.
• Gl
Glare can cause you to squint, resulting i eye
t
i t
lti in
strain and eye fatigue. In extreme cases, glare
can even result in temporary blindness
blindness.
1026

1027. • Distracting glare
– Distracting glare can be caused by car headlights or streetlights
at night.
– It can also be as simple as light being reflected off the front of
your lenses making it difficult for others to see your eyes.
ff
f
– Similarly, it may be from light reflected off the back – or inside –
of your lenses so that you see the distracting reflection of your
own eyes of objects behind you in your forward field of vision.
– As a result, this kind of glare may cause eye fatigue, annoyance
and distraction.
1027

1028. • Discomforting glare
– Glare can be caused by everyday, normal sunlight conditions.
– D
Depending upon one’s li ht sensitivity, thi glare can
di
’ light
iti it this l
be discomforting regardless of weather or time of day.
– It can be present in any level or intensity of light, or when moving
from one lighting condition to another.
– Discomforting glare often causes squinting and eye fatigue
1028

1029. • Disabling glare
– Straylight
– This type of glare comes from excessive, intense light that can
occur when you face directly into the sun.
– Disabling glare can block vision because the intense light can
g
y
g
cause significantly reduced contrast of the retinal image.
– The latent effects can last well beyond the time of exposure.
– It can occur by light scattering from IOL edge, glistenings or
calcifications.
calcifications
1029

1030. • Blinding or reflected glare
– This comes from light reflected off smooth, shiny
g
,
y
surfaces such as water, sand or snow.
– It can be strong enough to block vision.
– Reflected light is polarized and requires polarized
lenses to reduce it optimally.
1030

1031. All being measured to make an
an…
Eye of the Thief
Eye of the Eagle
1031

1032. Another Pre-LASIK examination
Pre LASIK
• Understand the Cornea  Measuring the biomechanical
g
properties of the cornea
• Is to quantify various corneal conditions by means of a
measurable and repeatable metric.
• Low Corneal Hysteresis (CH) demonstrates that the
cornea is less capable of absorbing (damping) the
energy of the air pulse.
pulse
• The differences in CH between normal and
compromised corneas are highly evident, and lead some
experts to theorize that normal eyes exhibiting
t t th i th t
l
hibiti
significantly lower than average CH may be at risk of
developing corneal disorders in the future.
1032

1033. How does it work?
• The Ocular Response Analyzer utilizes a rapid
air impulse, and an advanced electro-optical
system to record two applanation pressure
d
l
i
measurements; one while the cornea is moving
inward,
inward and the other as the cornea returns
returns.
• Due to its biomechanical properties, the cornea
resists the dynamic air puff causing delays in the
inward and outward applanation events,
resulting in two different pressure values
1033

1034. How does it work?
• The average of these two p
g
pressure values
provides a repeatable, Goldmann-correlated IOP
measurement (IOPG).
• Th difference b
The diff
between these two pressure
h
values is Corneal Hysteresis (CH); a new
measurement of corneal tissue properties that is
a result of viscous damping in the corneal tissue.
• The ability to measure this effect is the key to
understanding the biomechanical properties of
the cornea.
1034

1035. How does it work?
Ocular Response
Analyzer (Reichert)
1035

1036. How does it work?
• The CH measurement also provides a basis for
two additional new parameters: CornealCompensated Intraocular Pressure (IOPCC) and
Corneal Resistance Factor (CRF). IOPCC is an
Intraocular Pressure measurement that is less
affected by corneal properties than other
ff t d b
l
ti th
th
methods of tonometry, such as Goldmann
(GAT).
(GAT) CRF appears to be an indicator of the
overall “resistance” of the cornea
1036

1037. Standard vs Customized LASIK
STANDARD
CUSTOMIZED
• No data necessary
y
• Correct defocus only
(Sphere & Astigmatism)
y ()
• Contrast sensitivity (-)
• Use aberration data
• Correct both defocus
and High order
aberration
• Contrast sensitivity
(++)
1037

1038. Aberrometer Zywave
Complete Wavefront Analysis
Zylink 
Generation of optimized Laser
Treatment
OrbScan IIz
Corneal architecture
Laser System
1038

1039. Eye registration
The integrated procedure
•
Ease of Use: Fully automated imaging with online data quality check
WASCA
WASCA
MEL 80
Wavefront
Acquisition
Reference
Image
Surgical
Image
1039

1040. Microkeratomes
•
•
•
•
•
•
Hansatome (Bausch & Lomb)
Moria Evolution 3E (Moria)
Gebauer SL (Gebauer Medizin)
G b
(G b
M di i )
Zyopic XP (Bausch & Lomb)
ML7 (Med Logics Inc)
(Med-Logics,
Amadeus II (AMO, Inc 
Ziemer)
• Make ‘Hinged Flap’
• Take 110 – 180 um
corneal thickness
1040

1041. Microkeratome
Animation
1041

1042. Some kind of older microkeratomes : A Hansatome (Ba sch & Lomb);
A.
(Bausch Lomb)
B. LSK-one (Moria); C. Amadeus (Abbott Medical Optics); D. MK-2000
(Nidek)
1042

1043. Hinged flap
Animation
1043

1044. Femtosecond Laser
• A femtosecond is one millionth of a
nanosecond or 10-15 of a second and is
a measurement used in laser technology
• Procedure of laser corneal flap making
– Increased accuracy and predictability for
corneal flap thickness
– Faster
– Better visual outcomes
1044

1045. Femtosecond Laser
•
Range of uses
– Flap creation 
•
•
•
•
•
IntraLase FS (Abbott Medical Optics)
CUSTOMFLAP TECHNOLAS (Perfect Vision)
FEMTO LDV CrystalLine(Ziemer)
VisuMax (Carl Zeiss Meditec AG)
WaveLight FS200 (Alcon Inc)
g
(
)
– Presbyopia surgery  INTRACOR TECHNOLAS (Perfect Vision)
– CUSTOMSHAPE TECHNOLAS (Perfect Vision)
•
•
•
•
•
•
Astigmatic Keratotomy (AK)
Limbal Relaxing Incisions (LRIs)
Penetrating and Lamellar Keratoplasty (PK/LK)
Endothelial Keratoplasty (FL-EK)
Intrastromal segment insertion  ring implantation (ICRS)
Cross-linking
– Even for glaucoma patient and Cataract surgery
1045

1046. Femtosecond Laser
• Pulse of energy
– Low  Less than 1 µJ
– High  1 µJ and above
• Pulse of frequency
– Low  Bellow 80 kHz
– High  Above 100 kHz
1046

1047. Femtosecond Laser
• High pulse energy and Low pulse
frequency
– IntraLase FS (Abbott Medical Optics)
– TECHNOLAS (Perfect Vision)
• Low pulse energy and High pulse
q
y
frequency
– FEMTO LDV CrystalLine(Ziemer)
– VisuMax (Carl Zeiss Meditec AG)
su a (Ca e ss ed tec G)
1047

1048. Femtosecond : The IntraLase FS
The IntraLase laser
produces tiny bubbles
to be able to lift up the
surface of the cornea
The ability to precisely place
the bubbles up to the edge of
cornea enables an exact
preparation of the flap
The corneal flap is
opened up in order to
treat the deeper layers
of cornea
f
EuroEyes, 2008
1048

1049. Another “Flaps”
Flaps
• Hinged Flap 
– Lasik
– Epi-Lasik  Epi-K (Moria)
– SBK  One Use-Plus SBK (Moria)
• Smaller flap diameter  8 5 mm
8.5
• 100-115 microns flap thickness
• 50% fewer fibers being cut than a 150 microns flap
• Epithelial Scrubber  PRK
– Amoils Epithelial Scrubber
1049

1050. Eyetracker
1050

1051. Decentered ablations : Causes
•
•
•
•
•
•
•
Saccadic eye movements
Improper head alignment
Cyclotorsion
Pupil shift
p
Centroid shift
Eye rolling
Technical misalignment of the laser beam
1051

1052. Cyclotorsion
Diagnostic
Treatment
1052

1053. Cyclotorsion
•
•
•
•
Eye rotates 3.7° + 2.3°
y
Some until 9.1°
60% counter clockwise
counter-clockwise
40% clockwise
1053

1054. Cyclotorsion
•
•
•
•
Iris Recognition
Iris Registration
Eye-Tracker
Dynamic Rotational Eye-Tracker (DRET)
1054

1055. JUST FOR YOU AND SAFETY
Iris structure
i
finger print
fi
i
•Safe
S f
•Compensate pupil center shift & cyclotorsion
1055

1056. SAFETY
• Adapted for medical use from military technology
utilized for high l
tili d f hi h level security control
l
it
t l
1 out of 3,493..E24 or
1 out of 3 493 000 000 000 000 000 000 000
t f 3.493.000.000.000.000.000.000.000
There are not more than 10.000.000.000 people or
20.000.000.000
20 000 000 000 eyes on earth
th
1056

1057. Eyetracker : Ability
y
y
• Not all eyetrackers are created equally.
• The new generation e etracker has a sampling rate
ne
eyetracker
faster than 200 Hertz.
• The reason why this is so important is because your eye
can twitch at a rate of 60 Hz
Hz.
• If the eye twitches faster or at the same speed as the
eyetracker then the eyetracker may not be able to get
the appropriate readings of the movement of the eye
eye.
• In turn, the laser may not be able to place the right pulse
of the laser in the appropriate section of the cornea
because of the lack of information.
information
• What is also extremely important is the ability of the laser
to react to the information being sent to it from the
eyetracker.
eyetracker
1057

1058. Eyetracker : Ability
y
y
• What is also extremely important is the ability of the laser
to react to the information being sent to it from the
eyetracker.
t k
• The response time of the laser must be very fast to
ensure that each laser pulse is placed exactly on the
appropriate part of the cornea
cornea.
• Even if the laser can sample the movement of the eye
1000 times but the laser reacts slowly to this information,
the result is that the laser may be placing pulses on
areas of the cornea based on old information.
• The best example of the relationship between the
eyetracker and the laser is to try and imagine throwing a
ball at a moving object that is going 200 miles an hour.
• Although we can see the moving object, our reflexes are
too slow to adjust to the constant changes of the moving
object.
1058

1059. Eyetracker : Ability
• As a result, every time you throw the ball you are
,
y
y
y
missing the moving object. Slow or older lasers
work on the same principle.
• Al h
Although the eyetracker can see the eye
h h
k
h
moving, it is too slow to react and may miss the
targeted area of the cornea
cornea.
• Eyetracker with the ability to react between 4 to
8 ms  optimizes the ability of each pulse being
placed on the appropriate spot on the cornea
reducing erroneous misplaced pulses of the
laser more common on older laser technology
1059

1060. Laser ablation
1060

1061. Laser ablation
•
•
•
•
Extremely p ec se ab a o s
e e y precise ablations
Disrupting molecular bonds
Vaporising material
Without generating heat
1061

1062. ArF Laser (Photoablation)
• Laser energy ArF = 6.0 eV
• Tissue inter-molecular bond = 3.5 eV
• Ablation  Cut the bond
Laser 6.0 eV
3.5 eV
1062

1063. 0.25 um
1063

1064. Energy distributions
Heterogen
Homogen
1064

1065. Beam Size and Profile
• A small diameter laser beam or also known as spot
p
size is very important for both accuracy and
smoothness.
• An ideal beam size is approximately 1mm or less.
less
• If the size of the laser beam is larger the result is that
the beam is too large to make fine adjustments
throughout the cornea.
• Imagine filling a fishbowl with marbles compared to
filling is with sand.
• The marbles allow gaps while the sand contours and
fills the fishbowl exactly.
1065

1066. Beam Size and Profile
1 mm vs 2 mm
1066

1067. Laser Beam Profile
• Gaussian Beam
• Flat Top
• T
Truncated Gaussian Beam
t dG
i B
1067

1068. Gaussian Beam
• Energy not well homogene distributed
• Hi h energy on central
Higher
t l
• Lower energy on peripheral
Energy
Ablation Threshold
Heat sensation
1068

1069. Gaussian Beam
• Advantage : Smoother ablation profile
• Disadvantage : Heat sensation
Energy
Ablation threshold
Absorbed as heat
1069

1070. 1070

1071. Flat Top Beam
p
• Homogen energy distribution
• No heat
• Less smooth ablation profile
Energy
Ablation threshold
1071

1072. Truncated Gaussian Beam
• Bausch & Lomb Combine all benefits of Gaussian
Beam + Flat Top Beam
• Smooth ablation surface
• No heat no residual energy
heat,
Energy
Ablation threshold
1072

1073. Gaussian Beam
Flat Top Beam
Truncated Gaussian Beam
u c ed G uss
e
1073

1074. Laser treatment
• WaveLight EX500 (Alcon Inc)
• VISX Star S4 IR Advanced CostumVue (Abbott
Medical Optics)
• MEL 80 and MEL 90 (Carl Zeiss Meditec)
(Carl-Zeiss
• TECHNOLAS Perfect Vision
– SUPRACOR is a new corneal approach to treating
pp
g
presbyopia with TECHNOLAS Excimer Workstation
217P
•
•
•
•
Z LASIK (Ziemer)
(
)
Pulzar ZI (CustomVisc)
LaserSoft (Katana Technologies)
Schwind Amaris (Schwind Eye-Tech)
1074

1075. Laser treatment
Animation
1075

1076. Rinse and Fl closing
Ri
d Flap l i
Animation
1076

1077. Special Laser Vision Correction
• Reduce aberrations
• Improve contras sensitivity
– Scotopic
– Intermediate Mesopic
– Photopic
• Improve reading speed
• Improve the ability to special task force 
p
y
p
Astronauts and Fighter-Pilots
– NASA, US Navy Aviation and US Air Force
– Using :
• iDesign Advanced WaveScan (Abbott Medical Optics)
• 5th Generation Femtosecond IntraLase FS 
iFS Advanced Femtosecond Laser (Abbott Medical Optics)  10
seconds only
• VISX Advanced CustomVue Technology (Abbott Medical Optics)
1077

1078. Once more : Lasik
1078

1079. Flap & Stromal Thickness Analysis
1079

1080. Presby LASIK
y
• Monovision LASIK
• Pseudo-accommodative cornea 
PAC Nidek EC 5000 Excimer Laser (Nidek Co Ltd)
• Aspheric-multifocal cornea 
VISX CustomVue STAR S4 IR Aspheric (Abbott
Medical Optics)
• Lens Femtosecond laser treatment  100
microns thi k
i
thickness th t corresponds t 2 3
that
d to 2-3
Diopters 
INTRACOR (TECHNOLAS Perfect Vision)
1080

1081. Non LASIK Presby Laser
Illuminating LaserACE
• Bladeless microsurgical procedures
• Ablate scleral tissue  Restoring Eye’s natural
Eye s
accommodative ability
• VisioLite Er:YAG Ophthalmic laser system 
LaserACE (ACE Vision Group, USA)
• Laser ablations made in 3 Scleral critical zones
EyeWorld, June 2008
1081

1082. Laser : Miscellaneous Application
• Femtosecond laser assisted Descemet stripping
Endothelial keratoplasty (FS-DSEK)
• Laser suturolysis
• Bleb remodeling
Go opu ctu e
• Goniopuncture
• Laser in DCR
Lids,
• Lids Trichiasis and Punctal occlussion
1082

1083. Laser : Miscellaneous Application
• Deep sclerotomy
• Anterior hyaloidotomy
• Persistent pupilary membrane
removal
• Lysis of vitreous strand
1083

1084. Laser Phacoemulsification
• 2940 nm Erbium:YAG Laser
– Erbium:YAG Phacolase (Carl Zeiss Meditec AG)
• Neodymium:YAG Laser
– Neodymium:YAG Photon Laser PhacoLysis System (Paradigm
Medical)
– Dodick Q-Switched Neodymium:YAG laser (ARC GmbH)
• Femtosecond Laser
– Vi t (TECHNOLAS P f t Vi i )
Victus
Perfect Vision)
– Alcon LenSx (Alcon Inc)  Rhexis, Incision, Nuclear
fragmentation, Limbal Relaxing Incision (LRI)
– L
LensAR
AR
– Catalys (OptiMedica)
– Femto LDV Z Models (Ziemer-S)*
Kohnen T, Koch DD, 2005; Auffarth G, 2010; EyeWorld 2010; Salz JJ, 2010
1084

1085. Laser Phacoemulsification
1085

1086. Acknowledgement
• All My Teachers in Department of Ophthalmology,
Airlangga University, Medical School, 1913
• All My Friends in Laser and Advanced Eye Care Team of
Sumatera Eye Center
• All My Teachers from IOA/Perdami, InaSCRS, ESCRS,
Euretina, APAO, APACRS, ASCRS, EuCornea, AAO,
IIRSI, ICO, AIOS, Cicendo Eye Hospital Bandung,
Jakarta Eye Center, SN Feodorov MSC Moscow, Yale
Eye Center and Yale School of Medicine, Beijing
Tongren Hospital, Mitsui Hospital Tokyo, and Singapore
National Eye Center
1086

1087. And also special thanks to
•
•
•
•
•
•
•
•
•
Alcon, Inc
Bausch & Lomb Incorporated and TECHNOLAS
Abbott Medical Optics
Carl Zeiss Meditec AG
Heidelberg E i
H id lb
Engineering
i
OCULUS Optikgeräte GmbH
Haag Streit
Ziemer
Allergan
g
© May 20, 2008 – 2014
See also: gedepardianto blogspot com
gedepardianto.blogspot.com
Any suggestions : gedepardianto@yahoo.com
1087

1088. Main references
• American Academy of Ophthalmology, Basic and Clinical
Science Course
• Kanski JJ Clinical Ophthalmology
JJ,
• Deborah Pavan-Langston, Manual of Ocular Diagnosis and
Therapy
• Will’s Eye Manual
y
• Vaughan DG, General Ophthalmology
• Kohnen T, Koch DD, Cataract and Refractive Surgery
• Journal of Cataract and Refractive Surgery, Ophthalmology,
g y, p
gy,
American Journal of Ophthalmology, British Journal of
Ophthalmology, Clinical Ophthalmology
• ESCRS, EUROTIMES
• ASCRS EyeWorld USA
ASCRS, E W ld
• APACRS, EyeWorld Asia-Pacific
• Retina Today
• Retina Physician
1088

1089. Support Team
• Sight for a Lifetime.TM
• Bi h
Bring hope t th li ht TM
to the light.
• ACT-G.TM
1089

1090. Sail across Pacific Ocean of the 150 years of Gold Rush in
California ,USA, 1999
USA
© 2008-2014.
100 tahun Kebangkitan Nasional…
KRI Dewaruci : Duta antar bangsa dan lambang kejayaan bangsa bahari