REVALIDA REVIEW

Ophthalmology
ALLAN KENNETH WONG
Department of Ophthalmology
University of Santo Tomas Hospital
Ophthalmology Must-Haves during
Revalida:
-OPHTHALMOSCOPE –spare
batteries
-penlight
-small ruler
-Jaeger chart
 Outline

1. Anatomy of the Eye

2. Visual Pathway
3. Basic Ophthalmic Examination
4. Basic Ophthalmic Instruments
5. Common Eye Diseases
Anatomy of the Eye -
External
 Ocular Adnexa

Eyebrows
Eyelids – upper and lower
Palpebral Fissure
Lacrimal Lake – caruncle, plica semilunaris
Lid Margins – anterior and posterior
Orbital Septum –barrier b/w lid and orbit
Mullers muscle – sympathetic innervation, thyroid problem
Anatomy of the Eye –
Globe and its parts
 Eyeball

Conjunctiva – thin, transparent

a. palpebral

b. bulbar
 Layers of the Cornea

A – Anterior Epithelium *43 Diopteric power

B – Bowmans capsule
C – Corneal Stroma
D – Descemets membrane
E – Endothelium
Transparency of the cornea is due to:
1. Avascularity
2. Uniformly arranged fibers
3. State of relative dehydration
 Eyeball

Sclera – fibrous coating of the eye

Uvea – composed of iris, ciliary body, choroid
Lens – biconvex, avascular, colorless, 20D
*cataract
Vitreous – 2/3 of vol of eye
Aqueous Humor – sl. alkaline liquid
Anatomy of the Eye -
Fundus

Cup to
Disc
Ratio
0.2-0.4
AV ratio
2:3
Retina
(color::
transpar
 Layers of the Retina

Retinal Pigment Epithelium

Cones and Rods
External Limiting Membrane
Outer Nuclear Layer
Outer Plexiform Layer
Inner Nuclear Layer
Inner Plexiform Layer
Ganglion Cell Layer
Nerve Fiber Layer LIGHT
Internal Limiting Membrane
 Fundus

Macula Lutea –
central vision
(fovea)
Optic Nerve –
physiologic
blind spot
Artery and Vein
 Extraocular Muscles

- Innnervated by CN III, IV, VI (SO4,

LR6) Primary Origin
Muscle Insertion
Medial Adduction Annulus of Medially 5.5mm from
Rectus Zinn limbus
Lateral Abduction Annulus of Laterally 6.9mm from
Rectus Zinn limbus
Superior Elevation Annulus of Superiorly 7.7mm from
Rectus Zinn limbus
Inferior Depressio Annulus of Inferiorly 6.5mm from
Rectus n Zinn limbus
Superior Incycloduc Medially to Under the superior rectus
Oblique t’n optic foramen
Inferior Excyclodu Depression on Post inferotemporal
Oblique ct’n orbital floor quadrant at level of
 Extraocular Muscles

YOKE MUSCLES
RSR, LIO
LSR,RIO

RLR, LMR
LLR,RMR
Visual Pathway

Retina
Optic nerve
Optic tract
Lateral
geniculate body
Optic radiation
Calcarine
fissure
Visual cortex
(Brodman’s
area 17, 18,19)
Visual Acuity
SNELLEN Acuity (20ft)
– distance tested (numerator) :
distance that a normal person
can see that letter
(denominator) (20/20)

Jaeger Chart – near vision

(14 in)
Pinhole effect – clearer
vision d/t lesser influx of
light through the hole
ERROR OF REFRACTION
Myopia (near-sighted)

Concave (-) lenses

Hyperopia (far-sightedness)

Eye focuses the image behind the retina

Convex (+) lenses

Astigmatism

Eye produces an image with multiple focal

points or lines
Cylinder lenses
 Presbyopia
Loss of
accommodation
associated with
aging (usually
starts at age 40)

Reading Glasses
Convex (+)lenses
 Afferent Pupillary Defect
• The intensity of the direct and consensual response to light is
directly proportional to the light-carrying ability of the stimulated
optic nerve.
• If an optic nerve lesion is present , the direct light response in the
involved eye is less intense than the consensual response evoked
when the normal eye is stimulated – Relative Afferent Pupillary
Defect (RAPD)
 RAPD
SWINGING FLASHLIGHT
TEST
- Pupils must react to light
- Tests optic nerve function
- Relies on the difference
between 2 optic nerves –
one must be different from
each other
 Complete Eye Exam

History of Present Illness (chief

complaint) – BOV, pain, trauma
Past Medical History – HPN, DM,
allergy, asthma, PTB, goiter, cancer,
glaucoma
Visual Acuity – most important
External Eye Exam
 Complete Eye Exam

Extraocular Muscles Movement

Biomicroscopy / applanation
tonometry
Funduscopy
 Visual Acuity
Snellen Acuity Chart
OD OS
Sc 20/200 J12 20/100-2 J2
Ph 20/40+3 20/25
Cc 20/20 J1 20/20 J1
What if illiterate? Illiterate E chart, Picture chart, Number Chart
What if children not yet studying? Picture chart
What if babies? Lid popping, CSM (central steady maintained)
 Visual Acuity

Snellen Acuity Chart

20/20 – 25 – 30 – 40 – 50 -70 -100 – 200 – 400
15/200 – 10/200 – 5/200 – CF4ft – 3ft – 2ft -1ft
Hand Movement – Light Projection – Light Perception-
No Light Perception
Jaeger Chart
J12 – 10 – 8 – 6 – 4 – 3 – 2 – 1
Amsler Test
Detects macular
problems especially those
with hypertensive and
DM retinopathy
Abnormalities:
(+)scotoma –black spot
middle or periphery
(+)metamorphopsia –
distortion of lines
Amsler Test

(+)scotoma –black spot

middle (central) or
periphery
Amsler Test

(+)metamorphopsia –
distortion of lines
 External Eye Examination
OD OS
Lids Not swollen Swollen
Lashes Not matted Matted
Conjunctiva Non hyperemic Slightly hyperemic
Sclera Anicteric Icteric
Cornea Clear Hazy
AC Deep Shallow
Iris Pigmented Nonpigmented
Pupil 3-4 mm RTL SRTL/NRTL
Lens clear Opaque
EOMs

Motility

Full and equal

Look up, down (raise eyebrows), left, right, up right,

down right (raise eyebrows), up left, down left (raise
eyebrows)
Slitlamp Biomiscroscope

Used to view
problems of the eye
externallly/macrosc
opically; can also
be used internally
with the help of
special (adjunctive)
lenses
Applanation Tonometer

Used to detect
intraocular pressure
(glaucoma);
NV=10-20mm/Hg
Mounted on the
slitlamp;
Mires lines
 Direct
Ophthalmoscopy/Funduscopy

Clear media
Distinct disc
margins
(+) ROR
CDR 0.2-0.4 (-) ROR

Clear Media
AV 2:3
Proper use of Ophthalmoscope – adjust diopters,
eye of same side, ROR, optic nerve, blood vessels
Common Eye Diseases
 CONJUNCTIVITIS
• - inflammatory process involving surface of
the eye
• - vascular dilation
• - cellular infiltration
• - exudation
• Maybe: a. INFECTIOUS
b. NONINFECTIOUS
 Symptoms of Conjunctivitis

• Foreign body sensation

• Scratching or burning sensation
• Itching
• Photophobia
 Signs of Conjunctivitis
• Hyperemia- most conspicuous sign
• Tearing
• Exudation
• Chemosis
• Papillary hypertrophy- bacterial, vernal
• Follicles- viral
• Pseudomembrane and membrane
• Granulomas
• Phlyctenules- represent delayed hypersensitivity
to microbes
• Preauricalar lymphadenopathy*
Allergic Conjunctivitis
 Allergic Conjunctivitis

Diffuse papillary hypertrophy, most marked on superior tarsus

 Allergic Conjunctivitis

Formation of cobblestone
papillae

Rupture of septae - giant papillae

 Allergic Conjunctivitis
• Noninfectious
• Itchiness
• Hyperemia
• Ropy, white viscous/muco watery discharge
• Lacrimation
• Chemosis
• Follicles/papillae
• TREATMENT: anti-allergy medications
 Bacterial Conjunctivitis
-Infectious
-Hyperemic
-Bleeding (sometimes)
-Purulent discharge
-(+)crusts
-(+) papillae
- fever (sometimes) chemosis
- (+) chemosis Acute, profuse, purulent discharge,
hyperaemia and chemosis
 Bacterial Conjunctivitis

TREATMENT: Antibiotic eye drops / eye ointment

 Viral Conjunctivitis
• Infectious
• Hyperemic (sometimes)
• Bleeding (sometimes)
• Watery discharge
• Lacrimation
• Swollen lymph nodes
 Viral Conjunctivitis

TREATMENT: supportive
HORDEOLUM
and
CHALAZION
 External Hordeolum

-Acute bacterial infection of one or more eyelid glands

- EXTERNAL HORDEOLUM: glands of Zeis and Moll
 External Hordeolum
• Painful nodule w/
central core of pus
- Eyelid margin
- Swelling

- TREATMENT:
Oral antibiotic,
Antibiotic ointment,
Surgical: Incision and Drainage
Warm compress
 Internal Hordeolum

INTERNAL HORDEOLUM – meibomian glands

TREATMENT: oral antibiotic, antibiotic ointment, warm
compress
 Chalazion

- Chronic granulomatous inflammation from meibomian

gland
- Asymptomatic, painless nodule
TREATMENT: incision and curettage
SUBCONJUNCTIVAL
HEMORRHAGE
 Subconjunctival Hemorrhage

-CAUSES:
-Spontaneous
-exercise (coughing, sneezing,
pressing, bending over,
defecation of hard stools, lifting
heavy objects)
-Trauma or surgery
-Recurrent arteriosclerosis
(elderly)
- Extensive bleeding under the -Impaired coagulation
conjunctiva (hemophilia, aspirin)
- Harmless
Subconjunctival Hemorrhage

TREATMENT: resolves spontaneously in 2 weeks

 Pinguecula
• Harmless, grayish yellow
thickening of conjunctiva
epithelium in palpebral
fissure

- d/t advanced age,

exposure to sun, wind,
dust
Pinguecula

No treatment needed
 Pterygium
- Triangular fold of conjunctiva
that grows from medial portion
of palpebral fissure toward
cornea

-Believed to be d/t
sunlight, dust, and wind
exposure

- Asymptomatic
(sometimes, blurring of
vision)
 Pterygium

TREATMENT: Surgical excision

* Recurrence very likely
 Preseptal Cellulitis
- Infection anterior to orbital septum
-Eyelid Swelling
-Eye pain
-Absent chemosis
-no limitation of eye movement
 Preseptal Cellulitis

TREATMENT:
-high-dose intravenous antibiotic therapy
* Children mostly affected
 Caustic Injury
Common chemicals
involved:
-Acids
-Alkalis
-Detergents
-Solvents
•Ocular emergency !!! -Adhesives

-Alkalis more destructive than -Irritants like tear gas

acids
CAUSTIC INJURY
-Epiphora
-Blepharospasm
-Severe eye pain
-Corneal abrasion
-Conjunctival abrasion
-Red eye
-Blurring of vision
 Caustic Injury
• FIRST AID:
Copious irrigation to
affected eye!!!
- TREATMENT:
topical antibiotics,
lubricants,
patching if necessary
CORNEA
 Corneal Abrasion
• Surface of the cornea
• Maybe due to trauma: fingernail, spiked-
leaf or branch that snaps back to the eye
• Severe foreign body
sensation; severe pain
-Tearing
-Eyelid swelling
-Conjunctival injection
 Corneal Abrasion (Staining
with fluorescein sodium dye)

*Blue light is used to see epithelial defect

 Corneal Abrasion
(Patching)

TREATMENT:
- Antibiotic eyedrops

- Heals in 24-48 hours

- Patching done (especially in large epithelial defects) to
prevent manipulation and infection from outside
 Corneal Foreign Body
• Airborne foreign body,
• Metal splinters from
grinding
- Foreign body sensation
with every blink of the eye
- Epiphora
- Blepharospasm
- TREATMENT: removal of foreign body through
slitlamp; antibiotic eye drops
Corneal Foreign Body Limbal Foreign Body

Rust Ring
 Cataract
-lens opacity (white)
-gradual or progressive
blurring of vision

Stages:
1. Intumescent (swollen)
2. Mature (moderately dense)
3. Hypermature (white opaque)
4. Morgagnian (brown dehydrated)
 Cataract
Types:
Senile
Juvenile
Congenital
Acquired

Tx: surgery – Extracapsular cataract extraction

(ECCE) or Phacoemulsification with intraocular
lens implantation
 Diabetic Retinopathy

Clinical Stages
a. Background or Nonproliferative DM
Retinopathy
-microaneurysms, dot blot hemorrhage, flame
shaped hemorrhages, hard exudates (outer
plexiform layer)
b. Pre Proliferative DM Retinopathy
-cotton wool spots (soft exudates, nerve fiber
layer)
 Diabetic Retinopathy

Clinical Stages
c. Poliferative DM Retinopathy
- neovascularization into vitreous&optic disc,
vitreous hemorrhge, tractional RD

Tx: Panretinal Photocoagulation (principle:

destruction of ischemic retina to reduce
oxygen demand hence reduce angiogenic
stimulus for neovascularization
Diabetic Retinopathy

Hard exudates
Soft exudates
Dot-blot
hemorrhage
Clinically
significant macular
edema
 Diabetic Retinopathy

Clinical Stages
a. Nonproliferative DM Retinopathy, Minimal
b. Nonproliferative DM Retinopathy, Mild
c. Nonproliferative DM Retinopathy, Moderate
d. Nonproliferative DM Retinopathy, Severe
e. Nonproliferative DM Retinopathy, Very
Severe
f. Proliferative DM Retinopathy, Early
g. Proliferative DM Retinopathy, High Risk
h. Proliferative DM Retinopathy, Advanced
 Hypertensive Retinopathy

Scheie Grading:
I- Slight generalized attenuation retinal
arterioles
II. Obvious attenuation/further narrowing
III. Changes in I and II + exudates and
hemorrhages
IV. I, II, III + optic disc edema

Tx: BP control, PRP if necessary

Hypertensive Retinopathy
Eye Trauma

Severe burn
 PERFORATING Injury
• Sharp objects that
penetrate cornea
and sclera
- Trauma (mauling,
stabbing)
- Accident (vehicular,
falling debris,
hammering)
 PERFORATING Injury
• FIRST AID:
Sterile bandage
Tetanus injection
Prophylactic antibiotic

*Do not remove foreign

object in the eye!
 PERFORATING Injury

TREATMENT: surgical removal of foreign object (refer to

ophthalmologist)
 EYELID LACERATION
-Involves all skin layers

TREATMENT:
-Surgical closure

Eyelid avulsion, puncture,

cuts d/t trauma
 Bones of the Orbit

Ethmoid
Frontal
Palatine
Lacrimal
Maxillary
Sphenoid
Zygomatic
ORBITAL FRACTURE
 Orbital Fracture
• Usually from blunt
trauma (mauling)
- Double vision
- Eye pain
- Enophthalmos
- Hypesthesia of facial
skin
- swelling
Periorbital hematoma
 Orbital Fracture

Orbital Xray and CT scan are very important diagnostic

tools
 Orbital Fracture
TREATMENT:

- Surgical restoration of
normal anatomy

-Tetanus injection

-Oral antibiotics
*enophthalmos
 Glaucoma

- Severe eye pain, blurring of vision

Criteria:
1. Increased intraocular pressure (NV 10-
20mmHg)
2. Optic nerve cupping (0.5 above)
3. Visual field defects (perimetry)

Tx: anti-glaucoma eyedrops, laser

iridotomy, trabeculectomy
 Strabismus

Esotropia OS
Exotropia OD
Diagnostic Procedure: Use Prisms to measure
deviation
Treatment: prescription glasses or squint surgery
 Different Diagnoses of Red
Eye
Acute Acute Acute Corneal
Conjunct Iritis Glaucom Trauma
ivitis a
Incidence Very common uncommom Common
common
Discharge
Mod to none none Watery to
copious purulent
Vision/Pain No BOV or Sl. blurred, Markedly Usu
pain mod pain blurred; blurred,
severe pain mod to
Conjunctival severe pain
injection Diffuse circumcorne Diffuse Diffuse
toward al
Cornea fornices
Pupils clear clear Hazy/steam Related to
y cause
IOP
Normal Small Dilated Normal
 Different Diagnoses of
Blurring of Vision

CORNEA (abrasion, keratitis, edema)

ANTERIOR CHAMBER (uveitis, glaucoma)
LENS (error of refraction, cataract)
VITREOUS (hemorrhage, vitritis)
RETINA (DM/HPN Retinopathy, RD, ARMD)
 Different Diagnoses of
White Pupil (Leukocoria)

Hypermature Cataract
Retinoblastoma
Retinopathy of Prematurity
Persistent Hyperplastic Primary Vitreous
Coats Disease
 Final Words

Sleep well
Prepare your things properly –
stroller, books, med bag, etc
Be confident – be honest if you don’t
know the answer rather than
bluffing…tell your tribe that you will
still do further reading/studying
PRAY – it works! (Manaoag, StJude,
StaClara, etc)