Contents

Anatomy ................................................................................................................................... 2

Eyelid ........................................................................................................................................ 4

Orbit & Oculoplasty ................................................................................................................. 5

Conjuctiva ................................................................................................................................. 7

Corneal ...................................................................................................................................... 8

Retina ........................................................................................................................................ 9

Lens & Cataract ...................................................................................................................... 11

Pediatric oculopathy .............................................................................................................. 12

Optic neuropathy ................................................................................................................... 13

個輪 ......................................................................................................................................... 14

1
 Anatomy
-

Conjunctiva & Cornea Retina 10 層

5層 光
Epithelium Stratified squamous 1. Inner limiting
epitherlium, 2. Optic nerve fiber
Basal epithelium cells 分泌 3. ganglion cell layer
a basement membrane 4. inner plexiform layer
Bowman’s Acellular (not epithelium 5. inner nuclear layer
layer BM) 6. outer plexiform layer
Stroma 最厚 (含 collagen & 7. cell bodies of rods & cones
proteoglycan) 8. outer limiting
Descemet’s 厚度改(出生 3um成人 9. photoreceptor layer
membrane 10~12um) 10. pigment cells
Endothelium BM Chroid
Endothelium Pump, Not proliferate in
vivo
Tear film layer
Lipid layer 分泌 by Meiboman gland
Aqueous Main & accessory lacrimal
layer gland
Mucin layer Conjunctival goblet cell

2
Normal Retina--Right Eye Normal retina- Left eye

Optic Monocular field defect,

disc/ respect to horizontal
Optic .n midline
Ceco-central
scotoma
Central scotoma
Arcuate scotoma
Altudinal scotoma
2.chiasmal Bitemporal hemianopia
原因:pituitary tumor
3.optic Homonymous
tract hemianopia
(more posterior, more
congruous)
4.optic Temporal lobe: denser
radiation superiorly
Parietal lobe: denser
inferiorly
3
 5.occipital 伴 macula sparing
lobe
@Stoke 造成 90%的 isolated
homonymous hemianopia

Eyelid

Hordeolum 分類 位置
別名
External ant.eyelid(gland of Zeis Staphylococcus Stye / ext.
lash follicle) infection hordeola
Internal Meibormand gland 感染 or sterile Int. hordeola
Chalazion Chronic granuloma(zonal granulomatous inflammation around lipid) in 無症狀: lid
位置: meiboman gland or Zeis gland massage,
If recurrent 需 biopsy 排除 sebaceous cell carcinoma moist heat
topical mild
steroid
drops.
預防:
tetracycline
治療: I & C
Blepharitis -
Ant Eyelashes & follicles
post Meibomian gland & orifices

-
Pre-malignant Actinuc keratosis
epidermal lesions Bowen dis.
考 Keratocanthoma
Lentigo maligna30~50% malignant melanoma
Malignant eyelid 流行: Basal cell ca.> Squamous cell.ca. > sebaceous adenocarcinoma >
tumors malignant melanoma
預後: Basal cell ca> squamous cell > sebaceous adenocarcinoma

Hordeolum Chalazion Blepharitis

4
Ptosis DDx
Trichiasis 倒睫;倒
生毛
Entropion,
Ectropion Entropion 位置: 下眼瞼>上 Tapping
眼瞼內反, 眼瞼 原因: 老化(常), (lower)
外反 先天, acute spastic(好犯下眼瞼) eyelids to
(機轉:lower eyelid laxity, disinsertion of te cheek
eyelid retraction, 或
overriding of pretasal orbicularis(inf. botulinum
eyelid)) inj(暫時
Cicatrical: scarring of taral conjunctiva(trachoma) 性) 或
後遺症: corneal erosion even to ulcer op
Ectropion 位置: 下眼瞼
Lacrimal drainage 分類
abnormality Congenital 90% resolve in 1st year <6mantibiotics +
nasolacrimal duct massage
obstruction >6mprobing
Acquired ~~ 流炳: 中年女性 Dacryocystorhinostomy
Involutional cause

Orbit & Oculoplasty

Proptosis DDx
(Exophthalmus) 雙 小 ① metastatic neuroblastoma ,leukemia ②
凸眼 眼 孩 pseudo-tumor
成 ①Graves opthalmopathy
人 ②inflammation: pseudo-tumor, wegener’s
granulomatosis
③Neoplasm
單 成 Graves opthalmopathy
眼 人
Bruit proptosis 成因: C-C fistula, neurofibromatosis, orbital roof fracture,
Bruit + 凸眼 meningocele
Graves 症狀: eyelid retraction > exophthalmus 突眼> restrictive 如果需要
opthalmopathy extraocular myopathy(Inf.rectus.m 最常見) Orbital
>optic.n dysfunction (crowding phenomenon) decompressionstrabismus
@ severity of ophthalmopathy ≠ systemic thyroid function, surgeryeyelid retraction
some irrevisible

5
Neurofibromatosis 分類
Type 1, 17q,AD ①café au lait spots Meningioma
象人= ≥6 個 (兒童>5mm)
Von
Recklinghausen dis (大人>15mm)
②Lish nodule
③皮膚,神經周圍的
fibrosarcoma
Type 2, 22q,AD ①Bilateral acoustic 可併 nerve
neuroma system 的
②multiple ca. (脊椎神
meningioma 經瘤)
③Juvenile cataract

Rhabdomyosarcoma 症狀: sudden onset, rapid unilateral proptosis, edema &

小孩 Orbital 腫瘤 discoloration of the eyelid
最常見 來源: mesenchymal elemesnts in orbital soft tissue
4 subtype: frequency: embryonal > alveolar> plemorphic>
botryoid
預後: pleomorphic > embryonal> alveolar(最差)
Lacrimal gland 原 80% idiopathic inflammatory dacryoadenitis
tumor 因 20% 50% lymphoproliferative
50% epithelial 50% benign mixed tumor
neoplasia (pleomorphic adenoma)
50% 50% carcinoma
50% adenoid cystic.ca
Blowout fracture 原因: Orbital floor fracture: 最常見 治療
凹眼 medial orbital wall fracture Trapdoor fracture 立即 op
症狀: 1. Eyelid ecchymosis & edema (小孩常見)
2. enophthalmus 凹眼 其他 blowout 建議 repair within
3. diplopia (forced duction test to fracture 2wks (/p edema
check muscle entrapment) resolution)
4. hypoesthesia in the distribution of 適應症: 1. Diplopia with limition within 30°
infraorbital nerve 2. enophthalmus over 2mm
5. emphysema (medial wall) 3. large fracture involve >1/2 orbital
診斷: orbital CT(有效), water’s view(少 floor
用)

6
 Conjuctiva

Dry eye
(keratoconjunctivitis 分類: 1. Lipid layer def Meiboman gld dysfunction
sicca) 2. Aqueous tear def. Contact lens wear, Sogren synd, 其他先天異常
3. Mucin layer def Vit A def, conjunctiva scarringgoblet cell disorder
DDx 原因/特徵
治療
Epicleritis simple 或 nodular, blanch with topical phenylephrine(會變白) 自癒
scleritis 與 connective tissue dis 或 autoimmune 有關
分 1.Ant. a. Nodular 常
類 scleritis b. Diffuse 見
c. Necrotizing with 少 全身性自
inflammation (necrotizing) 體免疫有
d. Necrotizing w/o 關
inflammation n
2.Post. sclritis
考凡具 scleritis 要照會 風濕免疫科
考 DDx scleritis & episcleritis 方法: 點眼 10% phenylephrine
依照 鞏膜血管的收縮與否
Ocular infection Virus
Adenovirus Epedemic keratoconj~: Type 8, 11, 19
keratoconjunctivitis Pharyngoconj~ : Type 3, 4, 7
Acute hemorrhagic kerato~ Enterovirus 70, Coxackievirus A24
Corneal ulcer/ ulcerative Herpes simplexdendritic ulcer
keratitits Vit A def
Bacterial
Bacterial keratitis G(+):α-hemolytic strep.
G(-): P.aeruginosa—症狀 mucopurulent
exudate
Trachoma 砂眼 自己 又稱 granular conjunctivitis/ Egyptian
opthalmia
感染源: Chlamydia trachomatis
Criteria 符合 2/4
上眼瞼結膜濾泡
2. 輪部濾泡 or 其後遺症 Herbert’s pit
3.典型瞼結膜疤痕: 上瞼結膜大濾泡破裂,
結痂呈線性疤, 稱 Arlt’s line; 於輪部稱
Herbert’s pit.
4. Pannus
Fungal
Fungal keratitits 症狀: filamentous 或 feathery edge
Satellite infiltration
Endothelial plaque
Amoeba
7
 Acanthamoeba keratitis 原因: 隱性眼鏡 use homemade water 對抗生素
棘 症狀: ring ulcer 無效
需長期用
Autoimmune
Mooren ulcer 原因:autoimmune
症狀: peripheral ulcerative keratitis
Allergy
conjunctivitis Vernal keratoconj~ 症狀: palpebral, Papillary hypertrophy
cobble stone in upper tarsus lumbal,
Horner trantas dots
考 有 shield ulceration
Giant papillary conjunctivitis 原因: 隱性眼睛 (soft> RGP)
Papillary hypertrophy : central fibrovascular
core
Follicular hypertrophy: lymphoid hyperplasia

Corneal
-
Stroma Corneal 原因: recurrent corneal erosion
dystrophy 症狀: epithelium irregularity, stromal haze
1. Granular AD Hyaline 最常見
dystrophy
2. Lattice dystrophy AD Amyloid 預後最差
3. Macular AR glycosaminoglycan
dystrophy
Endothelial Fuchs endothelial dystrophy: cornea guttata, corneal decompensation
dystrophy
Band calcific 症狀:Superficial cornea(Bowman’s layer) calcification Chelation
keratopathy degenerationchronic ocular disease solution(EDTA),
PTK(不用 PK)
keratoconus 症狀: onset on puberty
progressive thinning & bulging, inf. Paracentral thinning at apex,
iron ring(Fleischer ring), scarring striae(Vogt of line).

Corneal surgery Penetrating keratoplasty

Myopic surgery Op 種類
近視 RK -1~ -4D myopia Diurnal fluctuation of vision
Hyperopic shift
ALK -4.5~ -22.75D
myopia
PRK < -6D myopia Epithelium scdraping with
spatula
Use laser to reduce the

8
 thickness
LASIK 最常 對象: -3~ -15D 9mm/130~160μm lamellar flap
用 myopia Excimer laser
RK=radial keratotomy;

Corneal abrasion in fluorescein in green &

blue light

Retina

Diabetic Duration of diabetes: most determined risk factor 治療

retinopathy Non-prroliferative ①microaneurysm ②hard exudates Laser
(Background stage) ③intra-retinal hemorrhage photocoagulant 改
Pre-proliferative ①soft exudates (NFL infarcts, cotton wool 善黃斑部水腫
stage spot)
Proliferative stage ①neovascullization ②vitrous hemorrhage
③tractional Retina detachment
@ Macular edema 可發生 at any stage
@ associated systemic condition : Pregnancy, HT, diabetic renal
disease, anemia,
severe carotid vascular dis.
Hypertensive Scheie classification
retinopathy Grade 1 Barely detectable arterial narrowing
Grade 2 Obvious arterial narrowing with focal
irregularities
Grade 3 Grade 2 + retinal hemorrhage &
exudates
Grade 4 Grade 3 + disc swelling
Central retinal 原因: atherosclerosis-related thrombosis, emboli, giant cell 預後差
artery occlusion arthritis(又稱 temporal artritis) Irreversible damage to
(CRAO) 見: cherry red spots (intact choroidal vasculature) the sensory retina
Central retinal vein Ischemic form: more extensive 4-quadrant hemorrhage & retinal
occlusion (CRVO) edema, cotton-wool spots,
widespread capillary non-perfusion
 60% neovasculization
Branch retinal vein 原因: occur at arteriovenous crossing
occlusion (BRVO) Predispose 因子: HTN, DM, arteriosclerosis 或 hyperopia
位置: superotemporal quadrant 最常見
Age-related Non-neovascular type: basal lamina deposits & basal linear
macular deposits(drusen)atrophic changeRPE geographic
9
degeneration atrophychoroidal neovasculization(CNV)
(ARMD 或 AMD) 原因: 可發生在 myopic degeneration, angioid streaks
有關疾病: HTN, DM, artherosclerosis heart dis.
Retinitis 遺傳
Pigmentosa 症狀: vision ↓ in dim light, constricted visual field(VF)
(Rod-Cone 見: arteriolar narrowing, waxy pallor of disc, bone-spicule-like pigment
dystrophy) change
ERG chage: photoreceptor (Rod>cone) dysfunction I
Pathologic Myopia 原因: abnormal elongation of eye
見: Fuch’s spots, atrophy of RPE & choroid, post staphyloma, choroid
NV
Retinal 分類 治療:
Detachment (RD) 1. Rhegmatogenous Breakliquid vitreous separate sensory Break
RD retina & RPE FRP, RD
2. Tractional RD 原因:DM, prematurity, penetrating trauma, Sclera buckle, parplane
sickle cell dis virectomy
 造成 proliferative membrane
3. Exudative RD 原因: malignant, HTN, eclampsia, renal
failure
造成 retinal 或 choroid disleakage fluid
& accumulate fluid beneath the retina

Retinoblastoma 基因: chromosome 13q14 Enucleation (excise

小孩 ocular 腫瘤 生長: endophytic growth/ exophytic growth longest section of optic
最常見 症狀: leukocoria(最常見)> strabismus nerve,CN2)
影像: calcification in CT
Risk of developing –2nd non-ocular tumors(orbital osteosarcoma/ soft
tissue sarcoma) later in life

CRAO CRVO BRVO 正長 macula AMD—Dry type & Wet type

Hypertensive Glaucoma
retinopathy

10
 Lens & Cataract

Cataract 解釋:lens opacity (ant. 手術選擇:

Capsule—cortex—nucleus—cortex—post.capsule) 1.intracapsular cataract extraction
Classification 1 Nucleus opacity Myopic shift 2. Extra-capsular catatact
2. Cortical extraction(常用)
3. Posterior Early blurred Phacoemulsification
capsular 常見 vision , glare 手術方法: IOL insertion position:
4.Congenital ▼amblyopia 弱視 Bag(protect posterior capsule
rupture), sulcus  PCIOL anterior
chamber  ACIOL
併發症: Irvine-Gass
syndrome(macular edema)
Lens dislocation 原因: Marfan’s syndrome(sup.dislocation), trauma(最常
考原因 見)
Homocystiurea, hyperlysinemia,
Weil-marchesani’s syndrome

IOL= intra-ocular cataract lenses

11
 Pediatric oculopathy

Gonococcal 產道感染—Neisseria gonorrhea (GNC 雙球) Penicilin G

conjunctivitis 會失明
Stabismus 斜 分類 必須處理,不然
視 Esotropia 小 種類 vision damage
內斜/ 孩 1.Pseudo-esotropia 原因:Wide epicanthic If >7y/o 變
convergent 最 2.Accommodative a. 後天 permanent
squint 常 esotropia refractive 原因:hyperopia(+4D)& 處理方法: 3O’s
見 insufficient fusional -Optical,
divergence Orthoptics, Op
症狀: onset 時
(intermittent)constant
併發: 常 amblyopia 弱
視
b.Non- (high AC/A) abnormal
refractive relationship between
accommodation &
accommodative
convergence
3.Basic esotropia
Exotropia 小
外斜/ 孩
Divergent Age
squint 大
分類
Non-paralytic 從小就有
squints
Paralytic -Diplopia 當見於此 paralysed.m 的作用方向.
squints -whn the separation between the 2 images is greatest
the image from the paralysed eye is furthest from the
midline & faintest.

診斷: Cover test

Amblyopia 症狀: abnormal visual experience in life

弱視 Crowding phenomenon
2~4% Classification
12
 1.Strabismus amblyopia
2.Anisometropic amblyopia
3.Isometropic ablyopia
4.Deprivation Amblyopia
Mild hyperiopia & astigmatism 散光
severe myopia
Hyperiopia>5D, myopia>-10D
Dense congenital cataract, severe
ptosis

Optic neuropathy

1.Ant. 原因: occlusion of Post. Ciliary artery

Ischemic 症狀: Painless vision loss (altitudinal field loss), 預後差
optic Classification Arteritic AION Giant cell arteritis
neuropathy Non-arteritis 伴 HTN
(AION) AION
@contra-lateral optic disc: frequent small (second eye:40%)
2.Optic 症狀: 年輕 P’t
Neuritis 考 2008 最常見的視野變化= central scotoma 中心盲點
rapid vision loss with periorbital pain or painful eye movement;
vision return to normal over weeks~months
Uhthoff symptom: -為 Multiple sclerosis 的神經症狀,當遇見熱,發燒,運動時
出現.
-residual symptom of brightness & color desaturation &
diminished vision with exertion
診斷: central scotoma, dyschomatoopsia & RAPD(+), VEP↓
3.Leber 原因: mitochondrial gene mutation at codon 11778
Hereditary 症狀: Bilateral (asymmetry)optic atrophy,
Optic Mild to severe vision loss (Male > F)
Neuropathy Telagiectasia microangiopathy, prominent NFL, hyperemicoptic atrophy

13
 個輪

Glaucoma 循環: Ciliary process(post.chamber)pupillaryant.chamber(a)(b)

(a) 80% trabecular meshwork schlemm’s canal (venous system)
(b) 20% uveoscleral outflowciliary musclesupraciliary & suprachoroidal
space
分類: 藥物
1.Primar 症狀少 併發症: Myopia 近視, DM, CV disease, Laser
open-angle 有 paracentral retinal vein occlusion trabeculoplasty
glaucoma 盲點 op
2.Angle closure 症狀明顯 機轉: Laser iridotomy
glaucoma Iris pushed forwad(原因: papillary block(LI), (Peripheral
plateau iris, tumors, choroidal hemorrhage iridotomy)
or tumor) +藥物
2.iris pulled forward(retinal hypoxiaretinal Op
hypoxiaCRVO/CRAO) (trabeculectomy)
3.Normal 原因: vascular factors
tension
glaucoma Op
4.Children AR with 時機: 80% before 1y/o; 70% bilateral
glaucoma incomplete 症狀: ①photophobia ②ephoria
penetration ③blepharospasm
診斷: bulphthalmus>12mm, Habb’s
striae(tear of Descemet’s membrane) 治療:
①β-blocker
機轉: cellular 或 membranous abnormality in
②Adrenergiagonist
the trabecular meshwork
(Brimonidine)
症狀:
③
Generalized sign: Focal sign:
Para-sympathomimetic
1.Large optic cup 1.Narrowing of rim 4.Splinter agent
2.Asymmetry of cups 2.Vertical elongation hemorrhage
(pilocarpine)
3.Progressive of the cup 5.Nerve fiber layer
④ Carbonic
enlargement of cup 3.Regional pallor lost
anhydrase inhibitors
(Diamox, topical
診斷: Dorzolamide)
⑤Hyper-osmotic
Visual field(VF) Test Nasal step VF test (manitol)
1.Para-central scotoma 1.Temporal wedge ⑥PG analog (Xalatan,
2.arcuate 或 Bjerrum 2.Central island of vision Travatam, Lumigan)
scotoma 較不會 central scotoma

藥物 Antifirotic agents:
①β-blocker ↓aqueous humor 分泌 禁 asthma, ①5-FU
heart block, ②Mitomycin-C
MG

14
 ②Adrenergiagonist Brimonidine ↑convetional&
uveoscleral outflow
③ Para- pilocarpine ↑trabecular meshwork
sympathomimetic outflow
④ Carbonic Diamox, ↓aqueous humor 分泌
anhydrase topical by ↓carbonic anhydrase
inhibitors Dorzolamide in ciliary body
⑤Hyper-osmotic manitol ↑blood osm.-->osm gradient between
vitrous & blooddrawing water from
vitreous
⑥PG analog Xalatan, ↑convetional&
Travatam, uveoscleral outflow
Lumigan
Uveitis AC cells : AC inflammatory cell
葡萄膜炎 AC flares : protein influx
未完 Keratic precipitate (KP): white, round precipitate in endothelium
Mutton-fat KP : granulomatous
Iris nodule : granulomatous
考-與全身性疾病有關
容易復發
容易視力傷害
可用免疫抑制劑

AIDS AIDS ophthalmic complication >70%

HIV retinopathy 最 Cotton-wool spots, retinal hemorrhage, microaneurysm 像 DM
常見’
2.Oppotunistic
ocular infection CMV retinitis 時機:CD4 cell<50cells/mm3
最常見 症狀: full thickness retinal opacification with hard
exudates & hemorrhage
Periphlebitis with some retinal necrosi
治療: ganciclovir, foscarnet & cidofovir
Herpes zoster 症狀: progressive outer retinal nerosis
Toxoplasma Toxoplasma retinochoroiditis
gondi
Mycobacterium
tuberculosis
etc
-
3.External eye Kaposi sarcoma
menifestation

15
 運動
EOM
abnormality Palsy 右邊 支配 症狀 原因
CN3, Sup br: sup.rectus, 往下往外, ptosis, Papillary dilate, loss of 最常見
oculomotor levator.m(張 3 閉 7) accomadation aneurysm,
Inf br : inf.rectus , vascular
med.rectus cauase
CN4, Sup. Oblique 往上(無法往下),Vertical diplopia
trochlear 症狀: ipsilateral hypertropia (▼extortion)
& worsen on contralateral Extortion 造成無法看書, 無法下樓梯
horizontal gaze & ipsilateral 改善方法:頭斜向患側的
head tilt 相反方向
CN6, Lat.rectus 往中(medially)directed eye, diplopia
abducent horizontal
改善方法:頭轉向患側(R’t), (讓 L’t 眼外移,
與 R’t 平行)
CN7, Orbicularis.m
facial 張3閉7

Internuclear Horizontal diplopica

ophthalmolegia MLF 損壞(Pons horizontal gaze
centervertical gaze center)
Ipsilateral eye: adduct delay
Contralateral eye: abduct nystagmus
Convergency(+)

Pupil
2進3出 Horner synd 原因: sympathetic lesion (dilator .m)
Triad:①Ptosis ②miosis(pupil 縮小) ③無汗 unilateral
anhydosis
Anisocormia worse in dark(瞳孔大小不等),
light reflex(+)
?heterochromia (congenital)
Adie’s synd 原因: Post-ganglion para-sympathetic damage
(iris sphincter) 症狀: Pupil light reflexsluggish, segmental
contraction, better response too near effort followed
by slow redilation
Marcus Gunn 原因: Optic.n (CN2)damage 或 severe retinal disease

16
pupil(RAPD) 症狀: pupil 等大,但
Abnormal swinging-flash light test
Argyll Robertson 原因: syphilis 3°
pupil 症狀: small pupil & irregular., light reflex(-),
some iris atrophy & poor dilation of mydriatics 瞳
孔放大劑
Near reflex(+)

17
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