Ophthalmology Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 14)

Ophthalmology Review
A Free Booklet Series by Dr. Aryan

Preface:
• This is the study material designed by Dr. Aryan with creation and compilation of the best
of the best and the most finest slides on the subject. I would like to offer a billion heartily
thanks for everyone who contributed directly or indirectly to the creation of the material
through creation and dissemination of the scientific information.
• Covering everything in one study material is next to impossible. Hence, refer to gold
standard textbooks for building solid concepts or in case of any doubt. Textbooks are
acknowledged at the end of the presentation. If any source has been missed to
acknowledge, it doesn’t lessen their impact and contribution in any way.
• Don’t keep searching for pattern between the consecutive slides. You won’t find many.
Rather to boost your recall and review, I have constructed many slides and are deliberately
placed with no much relation between the preceding and the succeeding ones.
• The main rule of a review material is that it must make you recall or learn maximum
amount of information in minimum amount of time and space.
• Motivational quotes and articles are included within the slides. Always remember that
every good idea, nice piece of information and everything else is literally and absolutely
worthless unless you execute.
• If you know everything in the slides in much detail, you probably wouldn’t need this
material.
Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

Clinical Distinction
Bacterial conjunctivitis Viral conjunctivitis
Congestion is marked Congestion is moderate
Chemosis (conjunctiva swelling) is marked Chemosis may or mayn’t be present
Discharge is purulent or mucopurulent Discharge is watery
Follicles are absent Follicles are present
Papillae may or mayn’t be present Papillae is absent (@Pakalu Papito red)
Swollen lymph nodes present Lymph nodes swelling is more marked
Pseudomembranes may or mayn’t be present Pseudomembranes may or mayn’t be present
Subconjunctival hemorrhage may or mayn’t be present Subconjunctival hemorrhage may or mayn’t be present
No pannus formation No pannus formation
No itching No itching
Dr. Aryan (Anish Dhakal)

Cytological features: Conjunctivitis
Bacterial: Neutrophils & microorganisms present. Eosinophils,
lymphocytes, plasma cells, inclusion bodies and multinuclear cells
absent
Viral: Neutrophils (early stages), lymphocytes, inclusion bodies and
multinuclear cells present. Microorganisms, eosinophils, and plasma
cells absent
Allergic has eosinophils, rest all absent
Chlamydial: Neutrophils, lymphocytes, plasma cells and inclusion
bodies present rest absent

Trachoma: Chronic keratoconjunctivitis

Anterior uveitis
• Inflammation of iris and ciliary body.
Anterior
uveitis
Iritis Iridocyclitis Cyclitis

Components of Visual Pathway

• Large/Medium/Small light source: Ophthalmoscopes usually have 2 or 3 sizes
of light to use depending on the level of pupil dilation. The small light is used
when the pupil is very constricted (i.e. well lit room, no pupil dilators used). The
large light is best if using mydriatic eye drops to dilate. Most commonly in a
dark, non-dilated pupil, the medium sized light is used.
• Half light: If, for example, the pupil is partially obstructed by a lens with
cataracts, the half circle can be used to pass light through only the clear portion
of the pupil to avoid light reflecting back
• Red free: Used to visualize the vessels and hemorrhages in better detail by
improving contrast. This setting will make the retina look black and white.
• Slit beam: Used to examine contour abnormalities of the cornea, lens and
retina.
• Blue light: Some ophthalmoscopes have this feature that can be used to
observe corneal abrasions and ulcers after fluorescein staining.
• Grid: Used to make rough approximations of relative distance between retinal
lesions.

CORNEA
• transparent part covering anterior 1/6th of the eyeball
• Upper eyelid covers 1/6th or 2mm of cornea (lower just touches the limbus)
• Clinical Significance: Ptosis & Lid retraction

@ OMU: Oblique Medial Ulto

Blood-ocular barrier

Morphological Classification of cataract
• Capsular cataract
• Sub-capsular cataract
• Cortical cataract
• Supra-nuclear cataract
• Nuclear cataract
• Polar cataract

Senile cataract
• Cortical (soft cataract): decreased level of crystalline lens proteins &
potassium
increased sodium and hydration of lens
coagulation of proteins
• Nuclear (hard cataract): age related nuclear sclerosis associated with
dehydration & compaction of lens

Stages of maturation of Cortical cataract:
1. Stage of lamellar separation
2. Stage of incipient cataract
3. Immature senile cataract
4. Mature senile cataract
5. Hypermature senile cataract

Complications of Cataract:
• Phacoanaphylactic uveitis
• Lens induced glaucoma
• Phacomorhic /phacolytic/phacotopic glaucoma
• Subluxation/ Dislocation of lens

Types and choice of Surgical Techniques
1.Intracapsular cataract extraction (ICCE)
2. Extracapsular cataract extraction techniques
 Conventional Extracapsular cataract extraction (ECCE)
 Manual small incision cataract surgery (SICS)
 Phacoemulsification
 Microincision cataract surgery(MICS)
 Femtosecond laser assisted cataract surgery(FLACS)

Extracapsular cataract extraction techniques
• Major portion of anterior capsule with epithelium, nucleus and cortex
are removed; posterior capsule intact
• Indications: Surgery of choice for almost all type of
adulthood/childhood cataracts unless CI
• CI : markedly subluxated or dislocated lens
ICCE entire cataractous lens along with intact capsule removed,nowadays done
only for markedly subluxated and dislocated lens

Postoperative management after cataract
operation
1. Pt. asked to lie quietly upon the back for abt 2-3 hrs, nil orally
2. Diclofenac sodium for pain
3. Next morning bandage/eyepatch removed and inspected for any
complication
4. Antibiotic eyedrops, 4 times for 2 weeks
5. Topical steroids, ketorolac, timolol, cytoplegic-mydriatic like homatropine
eye drops used
6. After 6-8 weeks, corneoscleral suture removed
7. Spectacles prescribed for 4-8 wks after surgery

Complications of cataract surgery
• Preoperative
• Anxiety, nausea ,gastritis ,allergic conjunctivitis ,corneal abrasion ,LA
complications
• Operative
• Superior rectus muscle laceration ,excessive bleeding, incision related,
injury to cornea and iris, posterior capsule rupture, zonular
dehiscence, vitreous loss, nucleus drop into the vitreous cavity,
posterior loss of lens fragments, expulsive choroidal hemorrhage

Post-operative complications of cataract
surgery
• Early post operative
• Hyphaema,Iris proplapse,flat/shallow anterior chamber,anterior uveitits,
Toxic anterior segment syndrome
• Late postoperative
• Cystoid macular edema,delayed postoperative endophthalmitits,bullous
keratopathy,retinal detachment etc
• IOL-related complications
• Corneal damage,2ndary glaucoma,uveitits,UGH syndrome,malpositions of
IOL,pupillary capture of IOL ,TASS

Management
Treatment of central retinal artery occlusion is unsatisfactory, as retinal
tissue cannot survive ischaemia for more than a few hours
The emergency treatment should include:
• Immediate lowering of intraocular pressure by intravenous mannitol
and intermittent ocular massage- It may aid the arterial perfusion
and also help in dislodging the embolus

Management contd..
• Vasodilators and inhalation of a mixture of 5 % carbon dioxide and 95 % oxygen (practically patient
should be asked to breathe in a polythene bag) may help by relieving element of angiospasm
• Intravenous steroids are indicated in patients with giant cell arteritis.
• Anterior chamber paracentesis:
1. Under LA and withdraw fluid until ant chamber shallow (0.1-0.2cc)
2. Decrease in IOP – allow greater perfusion – pushing the emboli further down
Inhalation of amyl nitrite produces vasodilation
Immediate lowering IOP: acetazolamide 500mg
Anticoagulants may be helpful in some cases

Digital ocular massage
• Apply direct pressure for 5-15
seconds, then release. Repeat
several times.
• Increased IOP causes a
reflexive dilation of retinal
arterioles by 16%.
• A sudden drop in IOP with
release increases the volume
of flow by 86%.
• Ocular massage dislodges the
embolus to a point further
down the arterial circulation
and improves retinal perfusion.

Development of Lens
• Lens is developed from surface ectoderm -Lens placode and lens vesicle formation
• Surface ectoderm in contact with optic vesicle elongate and form lens placode
• Lens placode invaginates and develops into lens vesicle
• During 5thweek, lens vesicle lose contact with the surface ectoderm and lies in the
mouth of the optic cup
• By the end of the 7th week, elongating cells form the primary lens fibers

Development of Lens
• Primary lens fibers:
• Elongation of the posterior cells into the cavity towards the anterior cell layer
• Secondary lens fibers:
• Cells at the top and bottom edges
• Primary lens fibres are formed upto 3rd month of gestation and are preserved as
the compact core of lens, known as embryonic nucleus

Identifying Lens in a Nutshell
Concave lens (Spherical) Convex lens (Spherical) Cylindrical lens
Thin center, Thick periphery Thick center, Thin periphery
Movement with the motion of
lens
Movement against the motion
of lens
Rotate the lens, image will
rotate too (scissor reflex in
cross chart)
Minification Magnification
@ Copper color/Red with
handle
Sliver color/Black with handle No handle (+ or – lens)
Power same throughout 360
degrees
Power same throughout 360
degrees
Power only in one axis and zero
across others

Clinical features
• Similar to hordeolum externum, but pain is more intense
On examination
Can be differentiated from hordeolum externum by
Point of maximum tenderness and swelling is away from the lid margin
Pus usually points on the tarsal conjunctiva (seen as yellowish area on
everting the lid) and not on the root of cilia

Chalazion: Introduction
• Chronic, non-infective, lipogranulomatous
inflammation of meibomian gland.

Management
•Intralesional triamcinolone acetonide injection (0.2 mL
of 10 mg/dl) or incision and curettage is the treatment
of choice.
Incision and curettage:
2 % xylocaine solution dropped in eye and lid in the
region of chalazion.
Incision made with sharp blade should be vertical on
the conjunctival side and horizontal on skin side.
Content curetted out with chalazion scoop.

Clinical Features: Congenital Dacryocystitis
•Mild grade chronic inflammation with
• Epiphora  usually after 7 days of birth followed by
mucopurulent eye discharge
• Regurgitation Test +ve  when pressure applied near lacrimal
sac area, purulent discharge regurgitates from lower punctum
• Swelling on the sac area

Treatment
• Depends upon the age of the child
• Lacrimal sac massage and topical antibiotics
• mainstay of treatment
• >4 times a day
• Cure rate  90% infants upto 6-9 months
• Lacrimal syringing (irrigation) with NS and antibiotic soln
• Added with conservative t/t if not cured w/i 3 months
• Once a week or once in 2 weeks
• Probing of NLD with Bowman’s Probe
• If not cured by 6 months (sometimes 9-12 months)
• Under GA
• Single probing is sufficient in majority but if not repeated after 3-4 weeks

Adult Dacrocystitis: Clinical Features
4 stages
1. Stage of Chronic Catarrhal Dacrocystitis
2. Stage of Lacrimal Mucocele
3. Stage of Chronic Suppurative Dacryocystitis
4. Stage of Chronic Fibrotic Sac
Clinical picture in acute dacrocystitis:
1. Stage of cellulitis
2. Stage of lacrimal abscess
3. Stage of fistula formation

Treatment
•Conservative:
• Probing, syringing
•Dacrocystorhinostomy (DCR)
•Dacrocystectomy (DCT)

Treatment of Preseptal Cellulitis:
• Systemic antibiotics
• Mild to moderate cases:
• Co-amoxiclav 500/125mg TDS or Flucloxacillin 500mg QID for 10 days
• Severe cases:
• Needs hospitalization
• IV Ceftriaxone 1-2 g/day for 5 days
• Then treat as mild cases
• Systemic analgesics and anti-inflammatory drugs
• Warm compression: 2-3 times a day; soothing effect
• Surgical exploration & debridement:
• If fluctuant mass or abscess, or when retained foreign body is suspected

Complications of Orbital cellulitis:
• Ocular complications: exposure keratopathy,
optic neuritis, central retinal artery occlusion
• Orbital complications
• Subperiosteal abscess
• Pus between orbital bony wall & periosteum
• Signs: eccentric proptosis
• Orbital abscess
• Pus within orbital soft tissue
• Signs: severe proptosis, chemosis, complete
ophthalmoplegia, pus point below conjunctiva
• Temporal and parotid abscess
• Intracranial complications:
• Cavernous sinus thrombosis, meningitis, brain
abscess
• Septicemia or pyemia

Surgical Intervention of Orbital Cellulitis:
• Indications
• Unresponsiveness to antibiotics
• Decreasing vision
• Presence of abscess
• Immediate canthotomy/cantholysis:
• if optic neuropathy is present or severely elevated IOP
• Incision and drainage of abscess
• Subperiosteal abscess: drained by 2-3 cm curved incision in upper medial
aspect
• In most cases, need to drain both the orbit and infected paranasal sinuses

Findings Preseptal Cellulitis Orbital Celulitis
Fever Present Present
Lid edema Moderate to severe Severe
Chemosis Absent or mild Moderate or marked
Proptosis Unusual Present
Pain on eye movement Absent Present
Ocular mobility Normal Decreased/ limited
Vision Normal Diminished vision +/-
diplopia
RAPD Absent May be seen
Leukocytosis Minimal or moderate Marked
Adenopathy Absent May be seen
ESR Normal or elevated Very elevated
Additional Findings Skin infection Sinusitis, dental abscess

Trichiasis
• Refers to inward misdirection of the cilia
• Eye lid is normal
Inward turning of eye lashes along with lid margin = Pseudotrichiasis

Lagopthalmos
This is the condition characterized by inability to close the eyelid voluntarily.
Nocturnal Lagopthalmos: Physiologically
some people sleep with their eyes open

Classification
Benign tumours Pre-cancerous condition Malignant tumors
Simple papilloma
Naevus
Angioma
Haemangioma
Neurofibroma
Sebaceous Adenoma
Solar keratosis
Carcinoma in-situ
Xeroderma pigmentosa
Squamous cell carcinoma
Basal cell carcinoma
Malignant melanoma
Adenocarcinoma

In male orbits are square shaped with rounded borders whereas in females it is rounded,
set lower and has sharp borders. @ 7 bones: EF LMP SZ

Clinical features
Lid signs
• Darlrymple’s
sign: retraction
of upper lids
producing the
characteristic
staring and
frightened
appearance (90%
cases)
Primary target in Thyroid Eye Disease is orbital fibroblasts. Secondary is EOM

• Lid lag (von Graefe’s sign) : when globe is moved
downward, upper lid lags behind (50% cases)

• Enroth’s sign: fullness
of eyelids due to puffy
oedematous swelling
(@Bilroth)
• Gifford’s sign: difficulty
in eversion of upper lid
• Stellwag’s sign:
infrequent blinking
(@Still)
Enroth’s sign

Class 0: No sign and symptoms
Class 1: Only sign, no symptoms (signs  limited to lid
retraction, with or w/o lid lag and mild proptosis)
Class 2: Soft tissue involvement with signs and symptoms
including lacrimation, photophobia, lid or conjunctival swelling
Class 3: Proptosis is well established
Class 4: Extraocular muscle involvement ( limitation of
movement and diplopia)
Class 5: Corneal involvement (exposure keratitis)
Class 6: Sight loss due to optic nerve involvement with
disc pallor or papiloedema and visual field defects
NO SPECS Grading of TED (Werner’s Classification)

Xerophthalmia:
• All the ocular
manifestations of
vitamin A deficiency
including not only the
structural changes
affecting conjunctiva,
cornea and
occasionally retina, but
also the biophysical
disorders of retinal
rods & cones functions.

Clinical types
• Acute catarrhal conjunctivitis
• Most common type
• Fiery red eye
• Peak at 3-4 days
and cured in 2 weeks
• Complicated by corneal
ulcer, keratitis,
dacryocystitis
• Topical antibiotics
• No steroids

• Acute purulent
conjunctivitis
• Commonest cause is
Gonococcus infection
• Stage of infiltration
• Stage of blenorrhoea
• Stage of slow healing
• Corneal involvement
• Systemic therapy
• Norfloxacin
• Cefotaxime

• Acute membranous
conjunctivitis
• Formation of true membrane
• Corynebacterium diptheriae
• Corneal ulceration
• Topical therapy
• Penicillin
• Antidiptheric serum (ADS)
• Atropine sulfate
• Antibiotic
• Systemic therapy
• Crystalline penicillin
• ADS

• Acute
pseudomembranous
conjunctivitis
• Formation of
pseudomembrane
• Variable etiology
• Features similar to
mucopurulent
conjunctivitis
• Treat as
mucopurulent
conjunctivitis

Clinical types of Allergic Conjunctivitis
1. Simple allergic conjunctivitis
• Hay fever conjunctivitis
• Seasonal allergic conjunctivitis(SAC)
• Perennial allergic conjunctivitis(PAC)
2. Vernal Conjunctivitis(VKC)
3. Atopic conjunctivitis(AKC)
4. Giant papillary conjunctivitis(GPC)
5. Phlyctenular keratoconjunctivitis(PKC)
6. Contact dermoconjunctivtis(CDC)

Chalazion in a Nutshell
Chalazion is chronic, non-infectious
lipogranulomatous infection of meibomian gland
Complications: pressure on cornea leading to
astigmatism, fungating mass of granulation tissue, secondary
infection, calcification, mebomian gland adenocarcinoma
Symptoms: painless
swelling , epiphora,
heaviness, blurred vision
Signs: nodule, reddish
purple area, projection to
skin side & marginal
chalazion
Common in children,
young adults; habit of
rubbing eyes, high
carbohydrate, alcohol

Incision & Curettage: Vertical on conjunctival side (to avoid injury to other
meibomian glands) and horizontal on skin side ( to have invisible scar)
Carbolic acid cautery followed by neutralization with methylated spirit to avoid
reoccurrence
Complications of chalazion surgery: Scar, injury to
soft tissue or other meibomian glands, blepharitis,
LA complications (pain, sloughing, necrosis)
Chalazion clamp: fix chalazion & achieve hemostasis
Intralesional long acting
steroid (triamcinolone):
esp. near puncta where
I & C produces damage
Diathermy for marginal
chalazion
Conservative treatment:
hot fomentation, topical
antibiotic & oral anti-
inflammatory drugs
Oral tetracycline
especially if associated
with acne rosacea or
seborrheic dermatitis

Examination of Corneal Abrasion:
Small abrasion seen in the center of cornea
It take stain on fluorescein staining
Narrowing of the palpebral aperture.
Distortion of corneal reflex
Tender eye
Visual acuity should be assessed
If examination is limited by pain, minimal topical
anesthetic can be used

Treatment of Corneal Abrasions:
• Heals with time
• Treatment depends on many factors (cause, severity of injury and degree
of pain, location of injury)
• Prophylactic topical antibiotic in abrasion from contact lens
• Diclofenac or ketorolac drops for pain relief along with soft contact lens
• Ice compression for 24-28 hours reduces edema in small abrasions
followed by then warm compressions
• Removal of FB

X3A & X3B
Pathology of localized
corneal ulcer
A. Stage of progressive
infiltration
B. Stage of active
ulceration
C. Stage of regression
D. Stage of cicatrization

Complications of Corneal Ulcer:
Toxic iridocyclitis: due to absorption of toxins
Secondary glaucoma: due to fibrinous exudates
blocking the angle of anterior chamber
Descemetocele
Perforation of corneal ulcer
Corneal scarring

Retinoblastoma Treatment

• Raised IOP is frequently associated but neither the necessary nor
essential condition for glaucoma
• Normal IOP: 10 to 21 mmHg
• Ocular HTN : Persistent raised IOP without glaucomatous changes
• Normal/Low Tension Glaucoma (NTG/LTG): cupping of discs and
visual field defects w normal or low IOP

Medical Therapy for Glaucoma
• Single drug therapy:
1. Topical beta-blockers
- Reduce the aqueous secretion due to their effect on beta 2 receptors in
the ciliary processes lower IOP
Timolol maleate (0.25, 0.5%: 1-2times/day)
Betaxolol (0.25%: 2times/day)
Levobunolol (0.25, 0.5%: 1-2 times/day)
Carteolol (1%: 1-2 times/day)

2. Prostaglandin analogues:
- Increase uveo-scleral outflow of aqueous decrease IOP
- Drug of choice for treatment of POAG (if pt can afford it)
- Very good adjunctive to beta blockers, dorzolamide, pilocarpine
Latanoprost (0.005%), HS
Travoprost (0.004%), HS
Bimatoprost (0.03%, a prostamide), HS
Unoprostone (0.15%), BID

3. Adrenergic drugs:
• Increase aqueous outflow by stimulating alpha receptor lower IOP
• Epinephrine hydrochloride (0.5, 1, 2%: 1-2 times/day),
• Dipivefrine hydrochloride (0.1%: 1-2 times/day)
• High allergic reaction rate
Brimonidine (0.2%: 2times/day)
• Selective alpha-2 adrenergic agonist
• Decrease uveo-scleral outflow  lowers IOP
• Increased allergic reactions and tachyphylaxis

4. Dorzolamide (2%, 2-3 times/day)
- Topical CAase inhibitor
- Alter ion transport along the ciliary process epithelium  decrease
aqueous production lower IOP
- Second line drug and adjunct drug also

5. Pilocarpine (1, 2, 4%: 3-4 times/day)
- Very effective and useful in management of POAG for a long time
-MOA: contracts longitudinal muscle of ciliary body and open spaces in
trabecular meshwork mechanically increase aqueous outflow
- In younger pt it causes problem due to spasm of accommodation and
miosis

• Combination topical therapy:
- If one drug is not effective
- One drug which decreases aqueous production (b-blocker, brimonidine,
dorzolamide) and other drug which increases aqueous outflow (latanoprost or
brimonidine or prilocarpine)

• Oral CAase inhibitors in POAG
- Acetazolamide, methazolamide
- Only for short term; acetazolamide 250 mg, TDS
• Hyperosmotic agents
- Mannitol 1-2 gm/kg body wt, initially when pt present with very high IOP
(>30 mmHg)
Laser trabeculoplasty

Provocative tests: other is mydriatic drug
administration

VISION 2020
• This is a global initiative launched by the WHO in Feb 1999. It is
based on the concept that every living persons has a right to sight
and aims to eliminate avoidable blindness (preventable + curable)
worldwide by the year 2020
• Target diseases are: cataract, glaucoma, refractive
error, childhood blindness, corneal blindness,
diabetic retinopathy, onchocerciasis

Top causes of blindness in developed countries
• Age related macular diseases
• Diabetic retinopathy
• Glaucoma
• Refractive error, etc
Top causes of blindness in developing/ under developed countries :
• Cataract
• Glaucoma
• Age related macular degeneration
• Xerophthalmia
• Diabetic retinopathy, etc.
Common causes of blindness in Nepal (2012):
• Cataract 65%
• Retina diseases 9%
• Corneal cause 6%
• Glaucoma 5%
• Refractive error and ARMD 4% each
• Diabetic retinopathy 0.25%.

Emergency Management of Ocular Chemical
Injuries:
• Copious irrigation
• Topical anesthetic instilled prior to irrigation
• Sterile balanced buffer solution (NS,RL) for 15-30 minutes or until pH is measured
• Double eversion of upper eyelid
• Debridement
• Admission
• Grade III or IV to insure adequate preservative free eye drop instillation

Medical Treatment
Steroids
Must be tailed off after 7-10 days when sterile corneal ulceration is most likely to occur
Cycloplegics
Topical antibiotics
Ascorbic acid (topical sodium ascorbate 10% 2 hourly in addition to a systemic dose of 1-2
gm vitamin C QID)
Citric acid
Topical sodium citrate 10% 2 hourly for 10 days or 2 gm orally QID
Tetracyclines (topical ointment QID or Doxycycline 100 mg twice daily tapering to once
daily)
Symblepharon formation can be prevented by lysis of developing adhesions with
sterile glass rod or damp cotton bud
Oral acetazolamide may be needed if Intraocular pressure is increased

Anatomical classification of uveitis
-Anterior (Iritis, ant. Cyclitis, iridocyclitis)
-Intermediate (post.cyclitis, pars planitis)
-Posterior ( choroiditis, chorioretinitis)
-Panuveitis (inflammation of uvea as a whole)
Based on onset/duration
-Acute (<3 weeks)
-Chronic (>3 weeks)
-Recurrent (inflammation occur after complete control)

Depending on clinical picture;
I. Suppurative uveitis
II. Non-suppurative uveitis
-Granulomatous and non granulomatous uveitis
Etiological classification
i. Infective- Bacterial, viral, Fungal, parasitic
ii. Immune related
iii. Traumatic
iv. Idiopathic
v. Toxic
vi. Associated with non infective systemic diseases

TED: Thyroid eye disease is the eye condition in which the eye muscles and fatty
tissues behind the eye became inflamed.
Inflammation of EOM
Increased secretion of
glycosaminoglycans and inhibiton of
water
Muscle enlarges, compresses optic
nerve
Muscle degeneration, fibrosis and
restrictive myopathy and diplopia
Inflammatory cellular infiltration
Accumulation of glycosaminoglycans
and retention of fluid
Elevation of IOP
Further fluid retention within the
orbit

Signs of anterior uveitis:
• Lid oedema
• Circumcorneal congestion
• Corneal signs:
1.Corneal edema d/t toxic endothelitis & increased IOP
2. Keratic precipitates:
Proteinaceous cellular deposits occurring at the back of cornea
Mutton fat, Small, medium, red, old
3. Posterior corneal opacities

Anterior chamber signs:
• Aqueous cells: early features of iridocyclitis.
• Aqueous flare: due to leakage of protein praticles into the
aqueous humor from damaged vessels.

Hypopyon: when exudates are thick and heavy, they settle
down in lower parts of AC.

Complication and sequelae of uveitis:
• Complicated cataract
• Cyclitic membrane
• Choroiditis
• Retinal complication (cystoid macular edema)
• Papilloedema
• Band- shaped keratopathy
• Hypotony/Phthisis bulbi
• Secondary glaucoma

Non-Specific Treatment: Local Therapy
• Cycloplegics
• Corticosteroids
• Systemic Therapy:
• Corticosteroids: when administered systemically have a definite role in
nongranulomatous iridocyclitis.
• Non-Steroidal Anti-inflammatory Drugs(NSAIDS):
o Used when steroid are contraindicated or not tolerated.
oPhenylbutazone & oxyphenylbutazone
• Immunosupressives: In corticosteroid resistant or intolerant cases

Differentials for Leukocoria (White Eye Reflex)
Congenital cataract
Retinoblastoma
Retinopathy of prematurity (ROP)
Persistent hyperplastic primary vitreous (PHPV)
Endophthalmitis
Coloboma
Toxocoriasis
Massive vitreous hemorrhage

Fundoscopy in papilledema:
Early Fully developed Chronic Atrophic
Obscured disc margin (1st
nasal then superior,
inferior and temporal)
Disc edema (forward
elevation above plane of
retina)
Peripapillary edema,
exudates & hemorrhages
resolved
Pale optic disc due to
atrophy
Blurring of peripapillary
never fiber layer
Physiological cup and disc
obliterated
Atrophic changes begins Prominance of optic disc
decreases despite high
ICP
Absent spontaneous
venous pulsation at disc
Hyperemic disc with
blurred margins
Optic disc gives
champagne cork
appearance
Narrow retinal arterioles
Mild hyperemia of disc Cotton wool spots &
superficial hemorrhages
White sheathing around
vessels
Tortuous and engorged
veins

Keith-Wagener-Barker classification of
hypertensive retinopathy
• I: Thickening of arterioles & diffuse arteriolar
narrowing
• II: Focal arteriolar constriction (spasms). AV nicking
present.
• III: Hemorrhages (flame shaped), cotton wool
exudates(ischemia) and hard waxy exudates (lipid
deposition)
• IV: Papilledema

Refraction varies in different meridian, light instead of converging to a point
instead forms many focal lines.

Not an error of refraction but a condition of physiological insufficiency leading to
progressive fall in near vision

Decreased IOP Differentials:
• Wound leak
• Retinal detachment
• Blunt trauma
• Cilliay body insufficiency
• Iridocyclitis
• Myotonic dystrophy
• Cyclodialysis

Adverse effects:
Pilocarpine
Local ADRs: Systemic ADRs:
Spasm of accommodation CNS disturbance
Cataract Profuse sweating and
salivation
Ciliary spasm Nausea, Vomiting
Myopic shift Constipation
Brow pain Bronchospasm
Bradycardia

Tropicamide plus: Tropicamide + dilator pupillae stimulator Phenylephrine

Hydroxypropyl-methyl
cellulose (HPMC)
• Hypromellose (HPMC) solutions were patented
as a semisynthetic substitute for tear-film.
• Post-application, celluloid attributes of good
water solubility reportedly aid in visual clarity.
• When applied, a hypromellose solution acts to
swell and absorb water, thereby expanding the
thickness of the tear-film.
• Hypromellose augmentation therefore results in
extended lubricant time presence on the cornea,
which theoretically results in decreased eye
irritation, especially in dry climates, home, or
work environment

Used after any ocular surgery, uveitis, scleritis, vernal keratoconjunctivitis, cystoid
macular edema, allergic keratitis, etc.
Local ADRs: secondary glaucoma, cataract, flaring up of infections, dry eyes, ptosis

LOSS OF VISION
Sudden Painless Loss of Vision Gradual Painless Loss of Vision
Unilateral Bilateral Age < 40 years Age > 40 years
Retinal detachment B/L occipital infarction Refractive error Presbyopia
Retinal vascular occlusion Diabetic retinopathy Keratoconus Senile cataract
Massive vitreous
hemorrhage
Severe hypertensive
retinopathy
Developmental cataract Age related macular
degeneration
Optic neuritis Methyl alcohol poisoning Juvenile glaucoma Diabetic retinopathy
Subluxation or dislocation of
lens
Posterior uveitis Corneal dystrophy Chronic open angle
glaucoma

Sudden Painful Loss of Vision Gradual Painful Loss of Vision
Acute iridocyclitis Chronic iridocyclitis
Acute congestive glaucoma Chronic open angle glaucoma
Chemical / Mechanical injuries to eye Corneal ulceration
Endophthalmitis Sarcoidosis

Epilation forceps & Syringing canula

Universal Eye speculum:

Key Drugs in Ophthalmology

With anesthesia abnormal value is less than 5 mm after 5 minutes.

This is a type of corneo-scleral forceps:
Colibri forceps. Other type is Lim’s forceps

Myopia can cause primary open angle glaucoma & hypermetropia can cause angle closure glaucoma.

Cyclopentolate: A Milder mydriatic &
cycloplegic alternative to atropine

Cycloplegics & Mydriatics:
Paralyze sphincter pupillae: mydriatics
Paralyze ciliary muscles: cycloplegics
Uses:
 Cycloplegic refraction, relieve ciliary spasm in corneal ulcer, prevent
posterior synechiae formation in uveitis, ophthalmoscopy
ADRs:
 Photophobia, Blurring of vision, Dizziness, Dry mouth, Flushing,
Dermatitis

Acknowledgements:
Best of the best slides, pictures and information on the web. Special
thanks to all those brilliant minds for their act of creation and
compilation of scientific material without which this work would not
be possible
• Sihota R, Tandon R, Parson’s diseases of the Eye
• AK Khurana, Comprehensive Ophthalmology
• Kanski’s Clinical Ophthalmology

Will waking up early makes me successful as so
many self help gurus proclaim?
• https://medium.com/@anishdhakal718/against-the-ubiquitious-
advice-of-waking-up-early-a9870c9af0e2

Ophthalmology Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 14)

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