This document provides information on ocular disease and proptosis (forward displacement of the eyeball). It discusses various types and causes of proptosis including unilateral (affecting one eye), bilateral (affecting both eyes), acute, intermittent, and pulsating proptosis. Common causes listed include congenital defects, trauma, infections, circulatory issues, cysts, tumors, and sinus mucoceles. The anatomy of the eyelids is also reviewed including the positions, structures, lashes, and glands. Key diseases of the conjunctiva are defined like conjunctivitis, pinguecula, and pterygium along with their symptoms and causes. Opthalmia neonatorum as a type

1. OCULAR DISEASE

2. PROPTOSIS

3. Forward displacement of eyeball
beyond the orbital margins.
Exophthalmos is synonymous, but
used for the displacement associated
with thyroid d/s.
*

4. *
*U/l proptosis
*Bilateral proptosis
*A/c proptosis
*Intermittent proptosis
*Pulsating proptosis

5. *
*Unilateral Proptosis
• Congenital: dermoid cyst
congenital cystic eyeball
orbital teratoma
• Traumatic: orbital hemorrhage
retained intraorbital FB
traumatic aneurysm
emphysema of orbit

6. • Inflammatory Lesions:
A/c: orbital cellulitis
abscess
panophthalmitis
thrombophlebitis
cavernous sinus thrombosis
C/c: pseudotumours
tuberculoma
gumma
sarcoidosis

7. • Circulatory Disturbances & Vascular Lesions:
angioneurotic edema
orbital varix
aneurysms
• Cysts of orbit:
hematic cyst
implantation cyst
parasitic cyst (hydatid cyst & cysticercus cellulosae)
• Tumors:
primary, secondary or metastatic
• Mucocele of PNS:
frontal(most common), ethmoidal, maxillary sinuses

8. *Bilateral Proptosis
• Developmental Anomalies of Skull:
craniofacial dysostosis (oxycephaly(tower skull))
• Osteopathies:
osteitis deformans
rickets
acromegaly
• Inflammatory Conditions:
Mikulicz’s syndrome
late stage of cavernous sinus
thrombosis

9. • Endocrinal Exophthalmos:
thyrotoxic or thyrotropic.
• Tumors:
symmetrical lymphoma or lymphosarcoma
secondaries from neuroblastoma
Ewing’s sarcoma
leukemic infiltration
• Systemic Disease:
histiocytosis
systemic amyloidosis
Wegener’s granulomatosis.

10. *Acute Proptosis
Develops with extremely sudden onset.
•Common Causes
orbital emphysema
fracture of medial orbital wall
orbital hemorrhage
rupture of ethmoidal mucocele

11. *Intermittent Proptosis
Appears & disappears on its own.
•Common Causes:
periodic orbital edema
orbital varix
recurrent orbital hemorrhage
highly vascular tumors

12. *Pulsating Proptosis
•Causes:
1. Pulsating vascular lesions
(caroticocavernous fistula and saccular aneurysm
of ophthalmic artery)
2. Transmitted cerebral pulsations
associated with deficient orbital roof
(congenital meningocele or meningoencephalocele,
neurofibromatosis, traumatic or operative hiatus)

13. Anatomy of the Eyelids

14. Introduction to the Eyelids
• An eyelid is a thin fold of skin that covers and
protects an eye.
• Protects against the dust, injury and excessive
light by its closure.
• It spread the tears on the eye surface to keep it
moist, since the cornea must be continuously
moist.
• Also involve into exit of tears into drainage
system at medial canthus.
• They keep the eyes lubricated when asleep.

15. GROSS ANATOMY

17. Position of eyelid
– When eye is open, the upper lid covers about 1/6th of the
cornea & the lower lid just touches the limbus.
– When eye closed, it covers the whole cornea

18. Palbebral fissure or aperture
• There is the elliptical space b/w the upper and
the lower lid called Palbebral fissure.
• When the eyes are opened, it measures about
10-11mm vertically in the centre and about
28-30mm horizontally.

19. Palbebral fissure or aperture
• There is the elliptical space b/w the upper and
the lower lid called Palbebral fissure.
• When the eyes are opened, it measures about
10-11mm vertically in the centre and about
28-30mm horizontally.

20. Canthi or angles of eyelids
• The two lids meet each other at medial and
lateral angles(or outer & inner canthi).
• Lateral canthus is directly in contact with the
eye ball
• Medial angle is rounded and 5mm medial to
the eye ball.
• The medial canthus is about 2mm higher than
the lateral canthus.

21. Medial canthus
• Medially eyelids are separated by a small
triangular space called lacus lacrimalis.
• In the centre there is pinkish elevation called
caruncula lacrimalis.
• On the lateral side of the caruncula there is
semilunar skin fold called plica semilunaris

23. THE LID MARGIN
• It is About 2mm broad and is divided into two
parts by punctum.
• The medial 1/6th, the lacrimal portion is
rounded and devoid of lashes or glands.
• The lateral 5/6th of eyelid margin is the ciliary
portion consist of rounded anterior border, a
sharp posterior border and an inter-marginal
strip.

24. Conti…
• 5mm from the medial angle there is small
elevation called papilla lacrimalis
• On the papilla there is small hole called
punctum lacrimalis.
• Punctum varies from 0.4 to 0.8mm in size
• It is the part of lacrimal apparatus for the
drainage of the tears.

25. Conti…
• 5mm from the medial angle there is small
elevation called papilla lacrimalis
• On the papilla there is small hole called
punctum lacrimalis.
• Punctum varies from 0.4 to 0.8mm in size
• It is the part of lacrimal apparatus for the
drainage of the tears.

26. Eye lashes
• Short curved hairs are present on the margins of
the eye lids from the lateral angle of the eye to
the papilla.
• More numerous in upper lid and curved upward
• And those of lower lid curved downward.
• In front of the posterier edge of the margin of the
lids there are the openings of the tarsal gland
seen as yellowish line on the inner surface of the
everted eye lid.

28. DISEASES OF CONJUCTIVA

29. CONJUCTIVA

30. Types of conjunctive diseases
 Allergic conjunctivitis.
 Conjuntivitis bacteriana.
 Conjuntivitis irritates the toxic
 .
 Pinguecula.
 Pterygium.
 Tumors of the conjunctiva.

31. Conjunctivitis
• Definition: is inflammation of the thin, clear covering of the white of
the eye and the inside of the eyelids (conjunctiva).
• Synonym: Pink eye
• Conjunctivitis can have several causes, but many eye doctors use the term
"pink eye" to refer only to viral conjunctivitis.
• When small blood vessels in the conjunctiva become inflamed, they're
more visible. This is what causes the whites of your eyes to appear
reddish or pink.

32. Pinguecula
• Definition: The term “pinguecula” refers to a pyramid-like
growth that appears as a yellow discoloration on the
conjunctiva
• A pinguecula (pin-GWEK-yoo-lah) is a yellowish, slightly
raised thickening of the conjunctiva on the white part of
the eye (sclera), close to the edge of the cornea.
• Pingueculae are non-cancerous bumps on the eyeball and
typically occur on top of the middle part of the sclera, the
part that's between your eyelids and therefore is exposed
to the sun.
• Usually pingueculae affect the surface of the sclera that's
closer to the nose, but they can occur on the outer sclera
(closer to the ear) as well.

33. Pinguecula

34. • Causes:
• In fact, the word “pinguecula” comes from a Latin word that
originally means “fatty.”
• A pinguecula forms when the tissue in your conjunctiva changes
and creates a small bump. Some of these bumps contain fat,
calcium, or both.
• Risk factors:
• Ultraviolet radiation from the sun is the primary cause of the
development of pingueculae,
• frequent exposure to dust and wind also appear to be be risk
factors.
• For this reason, pinguecula is sometimes known as “surfer’s eye,”
• Dry eye disease also may be a contributing factor and can promote
the growth of pingueculae

35. • Sign & Symptoms:
• It is seen as a yellow-white deposit on the conjunctiva adjacent to
the limbus (the junction between the cornea and sclera).
• In most people, pingueculae don't cause many symptoms. But
when they do, those symptoms usually stem from a disruption of
the tear film. Because a pinguecula is a raised bump on the eyeball,
the natural tear film may not spread evenly across the surface of
the eye around it, causing dryness. This can cause dry eye
symptoms, such as a burning sensation, stinging, itching, blurred
vision and foreign body sensation.
• Another symptom of pingueculae is the appearance of extra blood
vessels in the conjunctiva that covers the sclera, causing red eyes.
• In some cases, pingueculae can become swollen and inflamed. This
is called pingueculitis.

36. Pterygium
• Definition: A pterygium (tuh-RIJ-ee-uhm) is a growth of
the conjunctiva or mucous membrane that covers the
white part of your eye over the cornea.
• The cornea is the clear front transparent covering of the
eye.
• This benign or noncancerous growth is often shaped like a
wedge.
• A pterygium is a pinkish, triangular tissue growth on
the cornea of the eye. It typically starts on the cornea near
the nose.
• It may slowly grow but rarely grows so large that
the pupil is covered.
• Often both eyes are involved.

37. Pterygium

38. • Cause:
• The exact cause is unknown,
• but it is associated with excessive exposure to wind, sunlight, or sand.
• Therefore, it is more likely to occur in populations that inhabit the areas
near the equator (tropical regions), as well as windy locations.
• In addition, pterygia are twice as likely to occur in men than women.
• Some research also suggests a genetic predisposition due to an expression
of vimentin, which indicates cellular migration by the keratoblasts
• embryological development, which are the cells that give rise to the
layers of the cornea. Supporting this fact is the congenital pterygium, in
which pterygium is seen in infants.
• These cells also exhibit an increased P53 (tumor protein) expression likely
due to a deficit in the tumor suppressor gene.
• These indications give the impression of a migrating limbus because the
cellular origin of the pterygium is actually initiated by the limbal
epithelium

39. • Symptoms:
• Pterygia usually occur on the side of the eye closer to the nose, but
they can also develop on the side closer to the ear as well and can
affect one eye or both eyes.
• Many people with mild surfer's eye may not experience symptoms
or require treatment.
• But large or growing pterygia often cause a gritty, itchy or burning
sensation or the feeling something is "in" the eye (called a foreign
body sensation).
• Also, these pterygia often become inflamed, causing
unattractive red eyes.
• If a pterygium significantly invades the cornea, it can distort the
shape of the front surface of the eye, causing blurred vision
and higher-order deviations that affect vision.

40. • Diagnosis:
• Pterygium (conjunctiva) can be diagnosed without need for a specific exam,
however corneal topography is a practical test (technique) as the condition
worsens
• The diagnosis is made by slit-lamp examination of the typical limbal growth at the
characteristic location within the palpebral fissure. The diagnosis is most often
clear clinically, but histopathologic confirmation is performed routinely.
• Physical examination
• External examination (lids,
lashes, lacrimal apparatus)
•Examination of bulbar
and palpebral conjunctiva
as well as fornices
• Topography : the distribution of parts or features on the surface of or within an
organ or organism.

41. Difference between Pterygium &
pinguecula
Pterygium
• Pterygia have a flesh-
colored (pink) appearance
and are round, oval, or
elongated.
• Pterygia are more likely to
grow over the cornea,
• Pterygia is the growth of
fleshy tissue that can start
as a pinguecula, but it grows
large enough to cover the
cornea and affect vision
Pinguecula
• A pinguecula is yellowish in
color and typically has a
triangular shape.
• Less likely to grow on
cornea & when pinguecula
that grows onto the cornea
is known as a pterygium.
• Pinguecula do not grow, do
not cover the cornea, and
do not affect vision.

42. Similarities between
Pterygium &
Pinguecula
• Both pterygium and a
pinguecula are abnormal
growths that form on the
surface of the eye.
• Pingueculae and pterygia are
both benign and grow near
the cornea.
• They’re both linked to
exposure to the sun, wind,
and other harsh elements.
• Redness, irritation, grittiness
Abnormal growth
Benign tumor
Cause
Symptoms

43. Opthalmia neonatorum
• Definition: is defined as conjunctival
inflammation occurring within the first 30
days of life.
• Synonym: Neonatal conjunctivitis
a type of neonatal
infection contracted
by newborns during
delivery.

44. Opthalmia
neonatorum

45. INFLAMATION OF CORNEA

46.  Inflammation of the cornea (keratitis) is
characterized by corneal oedema, cellular
infiltration and ciliary congestion.
 It is defined as a complex vascular response that
results in the accumulation of the cellular exudates

47.  KERATITIS
- central
 Superficial , deep
- non ulcerative , ulcerative
- Peripheral
 Superficial , deep
- non ulcerative , ulcerative

48. CORNEAL ULCER
 Localized necrosis of sup. Stroma with destruction
of overlying epithelium
 corneal ulcer may develop when:
 either the local ocular defence mechanism is
jeopardized, or
 there is some local ocular predisposing disease, or
host's immunity is compromised
 the causative organism is very virulent

49.  1. Corneal epithelial damage
 Corneal abrasion due to small foreign body,
 Epithelial drying as in xerosis and exposure
keratitis.
 Necrosis of epithelium
 Epithelial damage due to tropic changes as in
neuroparalytic keratitis.

50.  Causative organisms.
 Common bacteria associated with corneal
ulceration are:
 Staphylococcus aureus, Pseudomonas pyocyanea,
Streptococcus pneumoniae, E. coli, Proteus,
Klebsiella, N. gonorrhea, N. meningitidis and C.
diphtheria.

51. PATHOLOGY OF LOCALIZED CORNEAL ULCER
 1. Stage of progressive infiltration
 infiltration of polymorph nuclear and/or lymphocytes
into the epithelium from the peripheral circulation
supplemented by similar cells from the underlying
stroma if this tissue is also affected

52. 2. STAGE OF ACTIVE ULCERATION
 Active ulceration results from necrosis and
sloughing of the epithelium, Bowman's membrane
and the involved stroma.

53. 3. STAGE OF REGRESSION
 Regression is induced by the natural host defence
mechanisms
 A line of demarcation develops around the ulcer,
which consists of leucocytes that neutralize and
eventually phagocytes the offending organisms and
necrotic cellular debris

54. 4.STAGE OF CICATRIZATION
 In this stage healing continues by progressive
epithelization which forms a permanent covering.
 When ulcer involves Bowman's membrane and few
 superficial stromal lamellae, the resultant scar is called a
'nebula‘
 Macula – one third
 leucoma – more than one third of stroma

56. Keratoconus

57. DEFINITION
• Progressive,
•
•
•
Non inflammatory,
Bilateral (usually asymmetrical)
Cone like anterior protrusion of the
cornea involving the central and the
inferior paracentral areas that results in
corneal ectasia, astigmatism, & decreased
vision.
• Incidence of 1 in 2000 of general
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58. • Usually seen after puberty
• No gender predominance
• No race predominance
• The patient becomes myopic but the error
of refraction cannot be satisfactorily
corrected with ordinary glasses owing to
parabolic nature of the curvature which
leads to irregular astigmatism.

59. • sub clinical keratoconus is seen in family
members or the fellow eye.
• No frank clinical sign
• The cornea is at risk of developing
keratoconus at a later stage and can be
diagnosed only by videokeratography.

60. • B: Based on keratometry
•
•
•
mild <48D
moderate 48 -54D
severe: >54D
• C: Based on morphology
•
•
•
nipple cones(central <5mm)
oval/sagging cones(5-6mm)
globus cones(>6mm)

61. Systemic associations
•
•
•
•
•
•
•
•
•
•
•
•
•
Atopy
Down syndrome
Turner syndrome
Ehlers –danlos syndrome
Marfans syndrome
Osteogenesis imperfecta
Floppy eyelid syndrome
Oculodentodigital syndrome
Rieger's syndrome
Focal dermal hypoplasia
Nail -patella syndrome
Apert's syndrome
craniofacial dysostosis (Crouzon's syndrome)

62. Crouzon syndrome
Marfan syndrome Osteogenesis imperfecta
Atopic dermatitis Down syndrome Ehlers-Danlos
syndrome

63. Symptoms
•
•
•
•
•
•
•
Progressive visual blurring and/or distortion
Rapidly changing spectacle prescription
Eye rubbing
Photophobia
Glare
Monocular diplopia
Sudden onset of pain, redness, loss of
vision, and photophobia suggests hydrops

64. • The onset of keratoconus occurs
predominantly in the late teens.
• Symptoms usually appear bilaterally, but
asymmetric presentation.
• During the first 5-7 years of onset, the
condition generally worsens with
intermittent periods of remissions

65. SIGNS KKKKKK
• Munson’s sign is a V-shaped conformation of the lower
lid produced by the ectatic cornea in downgaze.
• Rizzuti’s sign is a sharply focused beam of light near
the nasal limbus, produced by lateral illumination ofthe
cornea in patients with advanced keratoconus.
• Charleux”s sign: Dark reflex in the centre of cornea
with DDO in dilated pupils..
• Pulsations of mires on applanation tonometry
• Pulsations of reflected images in keratometry.

66. Slit lamp examination
• Prominent corneal nerves

67. Slit lamp examination
• Fleischer's Ring
– The Fleischer ring is a
yellow-brown to olive-
green ring of pigment
which may or may not
completely surround
the base of the cone
– Formed when
hemosiderin (iron)
pigment is deposited
deep in the epithelium
– Fleischer's ring often
becomes thinner and
more discrete with
progression

69. Corneal Thinning:
• Significant thinning (up to 1/5th cornea
thickness) in the advanced stages of the disease
and
•
•
• A diagnostic criterion based on comparison of
central and peripheral corneal thickness has
been proposed.
Additionally, as the disease progresses, the
cone is often displaced inferiorly.
The steepest part of the cornea (apex) is
generally the thinnest.

71. Corneal Scarring
• Sub-epithelial corneal
scarring, not generally
seen early, may occur as
keratoconus progresses
because of ruptures in
Bowman's membrane
which is then filled with
connective tissue
Deep opacity of the
cornea are also common
in keratoconus.
•

72. Corneal Hydrops:
• Corneal hydrops occurs in advanced cases,
• when Descemet's membrane ruptures, aqueous flows
into the cornea and reseals
• Keratoconus patients who are having an acute episode
of corneal hydrops report a sudden loss of vision and a
visible white spot on the cornea.
• Corneal hydrops causes edema and opacification.

73. • As Descemet's regenerates, edema and
opacification diminish.
• Occasionally, hydrops can benefit keratoconus
patients who have extremely steep corneas.
• If the cornea scars, a flatter cornea often
results, making it easier to fit with a contact lens.
• An increased incidence of hydrops has also
been reported in keratoconus patients with
Down's syndrome.

76. Episcleritis is inflammation of the superficial, episcleral
layer of the eye. It is relatively common, benign and
self-limiting.
Scleritis is inflammation involving the sclera. It is a
severe ocular inflammation, often with ocular
complications, which nearly always requires systemic
treatment

77. How is scleritis different from episcleritis?
Scleritis is characterized by significant pain, pain with
eye movement, vision loss, and vessels that do not
blanch with phenylephrine.
Episcleritis is typically less painful with no vision loss.
Vessels blanch with phenylephrine drops and can be
moved by a cotton swab

80. Scleritis

81. Episcleritis

83. Endophthalmitis is a purulent inflammation of the
intraocular fluids (vitreous and aqueous) usually due to
infection. Serious intraocular inflammatory disorder
resulting from infection of the vitreous cavity.
The inflammation is typically due to infection by
bacteria (eg. Staphylococcus species, Streptococcus
species, Gram-negative bacteria) or fungi (eg. Candida,
Aspergillus).

84. Symptoms
Endophthalmitis symptoms may be severe and include
severe eye pain, redness in the white of the eye,
extreme sensitivity to bright light, decreased vision,
and occasionally swelling of the eyelid.
Treatment
Endophthalmitis cases can be treated successfully if
properly managed, and useful vision can be retained.
However, in severe cases of bacterial endophthalmitis,
significant vision loss can occur rapidly, despite
prompt and proper treatment.

85. Endophthalmitis

86. *