Gede Pardianto - MataPedia2014 for Ophthalmologist

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

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

• 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

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

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

Basic and Latest
Spirit of Bali
Only one on earth

Visual functions including :
•
•
•
•
•
•

Visual acuity
Visual fi ld
Vi
l field
Color vision
Dark adaptation
Contrast sensitivity
Binocular single vision
7

Examination

Which one goes wrong ?
8

Examination : Finger
•
•
•
•

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

9

Confrontation Visual Field testing
• Technique
– Examiner sated about 1 meter opposite patient
– Patient directed to cover 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

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

11

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

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

Examination : Optotypes
• High contrast visual acuity
– Snellen chart
– Bailey Lovie chart
Bailey-Lovie

• Low contrast visual acuity
– Reagan chart

14

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

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

Slitlamp examination
anterior
cornea
p
posterior
cornea

anterior
lens

limbus

anterior
iris
17

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

18

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

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

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

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

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

Examination : Goldmann s 3 Mirrors
Goldmann’s
•
•
•
•

Central
Oval
O l
Trapezium
Square

: Posterior pole
:G i
Gonioscopy
: Equator
: Periphery

25

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

Visual Field Analyzers

FDT Perimetry
Octopus 101
Perimetry

Goldmann
Perimetry

Humphrey
Perimetry

27

Examination : Add 2
• Advanced anterior examination
– Pachy-Autorefrakto-Keratometer
• PARK 1 (OCULUS Optikgeräte GmbH)
• 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

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

Advanced anterior examination

Artemis (ArcScan, Inc)

P60 UltrasoudBioMicroscope
(Paradigm)

Visante OCT (Carl Zeiss Meditec AG)

Pentacam HR
(OCULUS
Optikgeräte GmbH)

30

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

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

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

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

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

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

EMBRIOLOGY

The Marshall
dr. Norman Tagor Lubis, Sp.M

37


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

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


39

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
.

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

41

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

44

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

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

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

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

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

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

System for myogenic ptosis

Collin JRO, 1989

51

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

OP : Entropion
CLASSIFICATION :

–C
Congenital
it l
• Entropion
• Epiblepharon

– Acquired :
• Involutional
• Spastic
y
• Cycatrical
56

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

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

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

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

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

Medial canthal laxity

0

1

2

3

4

5

6

Grade of Lancrimal punctum position shift

62

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

63

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

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

66

Involutional Entropion : Surgery
• Without lid laxity
– Everting suture
g
– Wies procedures

• With lid laxity
– Wies procedures with tarsal strip

67

Cycatrical Entropion : Surgery
• Mild to Moderate
– Anterior lamellar reposition (ALR)
– Tarsotomy

• S
Severe
– Posterior lamellar graft
– Terminal tarsus rotation

68

OP : Ectropion
CLASSIFICATION :

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

69

Ectropion : Principal surgery
• Laxity
– Tarsal strip
– Pentagonal excision  Medial Canthal
Medial, Canthal,
Lateral
– Medial canthus ligament shortening

• Cycatrix
– Ski graft
Skin
ft

70

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

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

73

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

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

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

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

77

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

78

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

Ocular surface
85

Tear film : Functions
• Maintains optical clear for cornea
• Moistening, lubricating and protecting
surface of conjunctiva 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

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

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

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

Ocular surface : Hyperemia
• Conjunctival
j

• Corneal
• Scleral

90

Ocular surface : Red eye
•
•
•
•

Conjunctivitis
Uveitis
Keratitis
K titi
Glaucoma

91

Acute
Conjunctivitis

Acute Iritis

Acute
Glaucoma

Acute
Keratitis

Incidence

++

+

+/-

+

Secret

++

-

-

+

VA

-

+/-

++

+

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

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

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

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

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

96

Follicle and Papilla
p
Area to be examined

Follicles

Papillae
97

Follicle and Papilla
p
Papilla

Follicle


98

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

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

100

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

101

• 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

• 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

103

• 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


104

• 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

105

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

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

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

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

Keratoprostheses: Boston K Pro

EuroTimes 2006

110

Keratoprostheses: AlphaCor

EuroTimes 2006

111

Keratoprostheses: Pintucci

IJO 2011

112

Refraction

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

Visual acuity
• Vi
Visual threshold
l th h ld
– Light discrimination
•
•
•
•

Brightness sensitivity (minimum visible)
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

116

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

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


0.2

118

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

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

120

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

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


122

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

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

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

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

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

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

•
•
•

•

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

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

130

Accommodation table
Age (years)

Rate of Accommodation (Diopters)

8

13.8

25
5

99
9.9

35

7.3

40

5.8
58

45

3.6

50

1.9

55

1.3
Vaughan DG

131

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


132

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


133

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

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

135

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

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

– Severity
• Mild Moderate High
Mild, Moderate,

– Clinical
• Simplex/Stationary, Progressive, Malignant


137

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

138

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)

139

Refraction
• Hypermetropia (Farsightedness)
– Structural
• Axial, Curvature, Index of refraction

– Accommodative
• Latent, manifest, total

– Severity

Uncorrected can causes
• Strabismus  Esotropia
• Ambliopia

140

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

141

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

142

Streak retinoscopy

Neutralization
With
Against
ga s
143

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.


144

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)

146

g
y


147

g
y

148

g
y


149

g
y


150

g
y


151

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.


152

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.


153

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.

154

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.

155

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

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

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

Sphere Lens

Biconvex Lenses

CaF2 Lenses

Plano Concave Lenses

Biconcave Lenses

Meniscus Sphere
Lenses

Changch Jixiang 2006
hun
g,

Plano Convex Lenses

160

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

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

162

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

Achromatic lenses

Positive Achromatic Lenses

Negative Achromatic Lenses


164

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

165

Circle of least confusion

Conoid of Sturm

166

Cylinder lenses

Plano Convex Cylindrical Lenses

Plano Concave Cylindrical Lenses

Biconvex Cylindrical Lenses

Biconcave Cylindrical Lenses

Meniscus Cylindrical Lenses

168

Cylinder axis


169

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

170

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

171

Toric lenses


172

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

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

175

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

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

177

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

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

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

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

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

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

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

185

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

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

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

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

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

191

The Contact Lenses

Peripheral curve width

Optic zone

Base curve

Peripheral curve radii

Peripheral curve width

Center thickness

192

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

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

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

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

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

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

Laser Thermal Keratoplasty

201

Laser assisted
Laser-assisted in situ Keratomileusis

202

Laser-assisted Sub-Epithelial Keratomileusis

203

Intrastromal Corneal Ring

205

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

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

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

Aniseikonia

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

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

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

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

214

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

218

Cardinal position and Yoke muscles
RSR
LIO

Right Gaze

LSR
RIO

RLR
LMR

LLR
RMR

RIR
LSO

LIR
RSO

Left Gaze


219

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

220

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

221

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


222

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

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


224

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


225

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

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

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 ∆


228

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

229

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

230

Grades of binocular vision
• 1st Grade
– Simultaneous perception

• 2nd Grade
– Fusion

• 3rd Grade
– Stereopsis

Kanski JJ, 2007
231

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


232

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

233

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


234

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

235

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

236

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

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

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

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

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

241

• 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

242

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

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

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

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

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

248

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


249

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

250

•

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

251

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


252

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

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


254

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


255

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

256

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

257

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)

258

Strabismus : Sight test
• WFDT
• Maddox’s rod

264

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

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

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

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


272

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


273

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


274

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


275

Strabismus : Exercise

Synophthophore

Holme’s stereoscope

276

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

278

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

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

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

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

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

IOP : Flow
• Aqueous come in to eye by :
– Diff i
Diffusion
– Ultrafiltration
–C
Carbonic Anhydrase II activity
– Active secretion


285

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

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

Angle Examination : Torch

289

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

Angle Examination : Gonioscopy

291

Identification of Schwalbe’s Line
Schwalbe s

Thomas R, 2006

292

Shaffer’s Intepretation

Classification

Angle Width

Visible Structure

Clinical Intepretation

Grade 0

Closed

Schwalbe’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


293

PAS look alike

Thomas R, 2006

294

Angle Recession
g

Thomas R, 2006

296

Angle Examination : UBM

Normal eye’s angle

Angle : Pupillary block

298

Angle Examination : Anterior OCT

Visante OCT (Carl Zeiss Meditec AG)
299

Scheimpflug Camera Pentacam

300

Artemis ( Ultralink)
50 MHz ArcScan

301

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


Grade IV

40°

Ciliary body is visible


303

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

304

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

Thomas R, 2006

305

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

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

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

c d

• Horizontal > Vertical

Thomas R, 2006

310

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

CDR Asymmetry

Thomas R, 2006

313

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

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

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

317

Jonas ISNT Rule
•

Less marked in large discs

•

Rim more evenly distributed

•

Punched out well defined
cup in large discs

•

p
Also compare Inferior &
Superior to temporal rim

•

Inferior to Temporal 2 : 1

•

Superior to Temporal 1.5 : 1

Thomas R, 2006

318

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

Temporal Portion of Rim
• Papillo macular bundle
• Preferential cupping temporally with field
loss near fixation
• POAG with Myopia and NTG

Thomas R, 2006

320

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

Rim contour : Normal

Thomas R, 2006

322

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