Oftalmo 1st test Flashcards
Dimensions of the eye?
23.5mm x 23mm (vertical), 22-24mm (AP)
Size matters for refraction
weight of the eye
7.5g
2 poles of the eye
○ An equator - maximum circle perpendicular to AP axis
○ 2 meridianos: § Anterior pole - □ center of the cornea, □ transparent □ Most external layer □ avascular
§ Posterior pole □ Retina and optic nerve □ Most internal part □ To see these parts have to dilate the pupil
What are the 3 cameras of eye?
to have good vision all cameras need to be transparent
anterior
posterior
vitrea
anterior camera
between iris (color) and cornea
○ the aperture of iris = pupila, ○ Contains aqueous humor ○ Measures 3mm deep ○ Volume of 250 µL. ○
posterior camera
medial to iris and ciliary body, anterior to crystalline lens and vitreal cavity,
○ 60uL volume
○ 4.5mm deep
○
○ (No hay medio acuoso casi, solo lente).
vitrea
constitutes > 2/3 of volume of eye
○ Contains vitreal gel
○ 5-6ml
○ Gives form to eye
What happens When there is an increase in production of aqueous humor or when there is no proper drainage?
–> increase in intraocular pressure and affection of II
Define catarats?
- when in this (post camera ) area, crystalline lens opacifies
What do zonulas do?
- Permit accomadation of lense
- With age this decreases –> presbicia
The zonule of Zinn (Zinn’s membrane, ciliary zonule) (after Johann Gottfried Zinn) is a ring of fibrous strands connecting the ciliary body with the crystalline lens of the eye. These fibers are sometimes collectively referred to as the suspensory ligaments of the lens.
Only thing that detaches?
Retina
How to see II?
neuroimages
embryological development of the eye
- Formed in day 25 from optic fossettes
- Derived from prosencefalus
- Differentiates in days 26-28 in optic vesicles
sturctures of the eye from the neuroectoderm?
retina, II, sphincter muscles, dilator of iris, posterior iridian epithelium, epithelial ciliar body
sturctures of the eye from the superficial ectoderm?
crystalline, corneal epithelium, eyelid epidermis, lagrimal gland and tarsal/eyelid conjuntiva (covers eyelids, bulbar conjuntiva which covers sclera)
sturctures of the eye from the neural crest or ectomesenquim?
keratocytes, scleral fibroblasts, trabeculum endothelium, coiroid stroma, iridian, ciliar SM, meninges, orbital fibroadipous tissue, carillage, and orbitary bones
sturctures of the eye from the mesoderm or mesenquime?
extraocular muscles and vascular endothelium
3 layers of the eye
external: cornea sclera
middle: uvea
internal: retina
cx of cornea
§ Most external
§ Normally transparent
§ avascular
§ 6 layers (stratified)
§ Trigeminal innervation § : ○ 90% del espesor corneal: colágeno y queratocitos, .
cx of sclera
§ Continues with meninges and DM
§ CT , dense, similar to cartilage
§ Avascular
§ Insertion of extraocular muscles § Lamina cribosa at posterior part - exit of optic nerve fibers
uvea cx
§ Anterior: iris and ciliar body
§ Posterior: coroides
Only part of eye transplanted? Only part that hurts?
cornea
6 layers of the cornea
stratirifed
○ se descubrió una sexta capa que se encuentra entre descemet y el endotelio, la capa dua.
Epithelium.
Bowman’s.
Stroma. ○ Lesion here or deeper –> leocoma = scar
Dua’s layer.
Descemet’s.
Endothelium.-: maintaines corneal dehydration (avoid blurry vision).
function of sclera
structural support of eye
what forms the sclera
§ Formed by external episclera (very vascularized) and stroma (avascular without innervation)
What gives nutrition to cornea?
- Pelicular lagrimal
What causes scar of cornea?
- Lesion of endothelium
What causes corneal edema?
- Lesion of endothelium
Mientras más acentuado el edema, mayor disminución de la agudeza visual, dado que este es el que mantiene la deshidratación corneal
Corneal Pannus
@ rheumatological process –> Ag/Ac @ conjuntiva so conjuntival vessels invade cornea
vascularization of avascular cornea
innervation of eye
- Opthalmic
- Some penetrate thru subconjuntival and episcleral
- Most penetrate thru sclera
irrigation of eye
- Peripheral cornea are irrigated by conjuntival , episcleral and scleral vessels
- Avascular cornea
- Perforations for vorticose veins, short ciliar arteries and large ones –> irrigation to sclera
3 layers of sclera
- Episclera
○ CT, rotation- Stroma/fibrous layer
○ Avascular
○ Densely innervated by branches of posterior ciliary nerves - Fuscia Lamina
○ Most internal - abundant vessels
- Stroma/fibrous layer
How is endocraneal HTN seen ?
papiledema
Name of transition zone between cornea and sclera?
clercorneal limbo
- With structures that drain acuous humor or trabecular malla - Localized in irido-corneal angle where humoracuous passes to schlemm canal - Arrives to collector channels of episcleral veins - Causes that increase humoral pressure (aysmptomatic --> irreversible damage)
what is pterigon
growth of conjunctiva that invades cornea
- Hipertrophy of conjuntiva that invades the córnea - Not all are operated , the younger the px the more chance of scarring - Are removed if grow too fast, if irregular , if irritate, if inflame frequently, if px doesn’t want it - Can become malignant, with conjuntival CA which confuse, differentiate them by rapid growth, coloration and border irregularity, should biopsu
most vascularized part of eye
uvea
what is the ciliar body
part of iris and is what allows it to open or close
what produces aqueous humor
Aqueous humor is produced by the ciliary body and it flowsfrom the posterior chamber through the pupil into the anterior chamber
part of eye that gives color
iris
Central opening of the iris?
pupilla
innervation of pupila
- Sympathetic - midriasis
- Parasympathetic - miosis
Vascularized layer between sclera and retina?
coroides
layers of coroides
- External layer w/ grand coroid vessels
- Internal layer = coricocapilaris - gives nutrients to external third of retina
- Internal limiit is Bruch membrane that seperates coriocapilaris from retinal epithelium.
what makes up ciliary body
§ Made of ciliar muscle (fibras musculares lisas radiales y circulares )that allow accomodation of crystalino/lens (ZOOM)
cx of iris
§ Made of lax stroma with pigmentated cells and smooth muscle
§ Surrounded by anterior epithelium and posterior one (pigmentary) from which come the melanocytes.
□ Albino have pink eyes - no melanin iris is so clear
cx of coroides
§ Below retina
§ Extends forward with ciliar body
§ Abundant melanocytes
cx of retina
- Transforms light in nerve impulse
has cones and bastones
10 layers of retina
- Epitelio pigmentario
- Capa fotorreceptora
- Membrana limitante externa: sostén
- Granulosa externa: Núcleos fotorreceptores
- Plexiforme externa: sinapsis entre bipolares y fotorreceptores.
- Granulosa interna: núcleos de células bipolares
- Plexiforme interna: sinapsis entre las células ganglionares y células bipolares y de las células amácrinas entre ambas
- Capas células ganglionares: núcleos de estas
- Capa de fibras nerviosas axones células ganglionares
- Membrana Limitante interna: Membrana basal
pars plana vs pars plicata
- Pars plana - [posterior part with ciliar muscle) –> pars planitis or intermediate uveitis
(Latin: flat portion) is part of the ciliary body in the uvea (or vascular tunic), the middle layer of the three layers that comprise the eye.
As a part of the ciliary body, it is about 4mm long, located near the point where the iris and sclera touch and is scalloped in appearance.
The pars plana may not have a function in the post-fetal period, making this a good site of entry for ophthalmic surgery of the posterior segment (pars plana vitrectomy).- Pars plicata - (anterior part with ciliar processes) –> anterior uveitis
(Latin: folded portion) is the folded and most anterior portion of the ciliary body of an eye.
The ciliary body is a part of the uvea, one of the three layers that comprise the eye. The pars plicata is located anterior to the pars plana portion of the ciliary body, and posterior to the iris. The lens zonules that are used to control accommodation are attached to the pars plicata.
The pars plicata is the portion of the ciliary body that is responsible for producing aqueous humor, the fluid of the anterior chamber.
The production of too much aqueous humor, or reabsorption that occurs too slowly, can lead to increases in the pressure within the eye.
- If it affects both = pan uveitis Panuveitis: a serious inflammation of the uveal tract of the eye. The uveal tract includes the iris, the ciliary body, and the choroid. Panuveitis also typically involves the retina and the vitreous humor. Panuveitis can be caused by infections, chronic inflammatory diseases, or its cause may be unknown.
cones vs bastones
- Has specilized cells called cones to discriminate sight and color, in fovea
Cones?- Contain rodospine making them sensible to light
- Rodopsine is the aldehyde form of vitamine A (absorbs light)
- Cones - detect form and color, occupied in diurnal vision and their loss causes legal blindness
- Bastones - regulate nocturnal vision
- Has bastones to discriminate between light and darkness
Queratitis
- Inflamations of the cornea
- Can be bacterial, viral, micotic, actinic (from radiation)
MC of corneal lesions?
- Red eyes,
- Pain
○ The only thing that hurts in eye is the cornea due to trigeminal innervation ,
○ Ocular pain from spasms of ciliar muscles and iridian sphincter - fotofobia,
- blefarospasm
- ciliary injections
○
Can have corneal ulcers: - Hipopion - pus in anterior camera -
○ don’t drain only
○ topical ATB and systemic - hospitalize px - Hipema - blood in anterior camera - drain
- Pain
causes of infectious queratitis
bacterial
fungal
virus
bacterial queratitis
§ No drop steroids - delays recoverey?
○ Contact lenses
○ Edema of cornea, grey borders vascularized, hipopion
○ Staph, aureus, neumococo, streptococous, pseudomona, moraxella
○
viral queratitis
○ High association with HSV I (95%) - facial?
○ Vesicular lesions in eyelid , nose, mouth maybe
○ Epithelial affection mostly
○ Dendtritic lesions - clinical determination for dx
○ NO STEROIDS - get worse
fungal queratits
○ Associated with vegetal trauma ○ Aspergillus ○ Satelite lesions ○ Little inflamation ○ Acanthamoeba: in contact lense users
management of viral queratitis
§ Topical & oral aciclovir 5x/d
§ Cycloplejics
§ Ocular lubricants
what is a geographic ulcer
○ When a dendritic ulcer grows losing lineal aspect
○ Associated with inadecuate use of steroids which favor viral replication
○ En estos casos, existe un defecto amplio que tiñe con fluorosceína.
non infectious queratits
- Traumatic - secondary to abrasion or simple erosion, burning, FBs, recidivant erosion
- Chemical toxic substances
- Physical (UV rays, sun, soldadura)
- Exposure Queratitis - due to bad eyelid closure usually from ectropion
management of noninfectious queratits
○ Frequent lubrication
○ Ocular parchado
○ Qx - SOS
○ Midriatic SOS
○ Topic steroids - if there is no epithelial lesion
§ Fluor-negative - steroids to disinflame
§ Fluor- possitive - no steroids
corneal dystrophies
- Bilateral anomalies,
- progressive,
- hereditary,
- painless,
- no systemic illness
- Opacity of cornea due to degeneration –> agudez visual
what are queratocones
- A type of dystrophy like a cone (not concave)
- Contact lenses to flatten or transplant
- Operate after 8yrs when eye reaches appropriate size
”) es una condición no habitual, en la cual la córnea (la parte transparente en la cara anterior del ojo) está anormalmente adelgazada y protruye hacia adelante.
Arco senil o gerontoxon:
- Deposit of lipids in the cornea - normal - in old px agining - if young must investigate lipid profile
Gerontoxon is an abnormal change in the perilimbal areas involving both cornea and sclera, consisting of lipid deposition into the spaces between cells and intracellularly in advanced instances
ciliary injections
Ciliary injection involves branches of the anterior ciliary arteries and indicates inflammation of the cornea, iris, or ciliary body.
○ VC in ciliar injection px --> gets white ingurgitated deep vessels remain § (VISINE CI until dx because uveitis or FB white but inflammation continues and you lose alarm signs)
you have an infectious process
hiperemia
Hiperemia - red eyes –> gets white with VC
estas te enrojecen el ojo pero no te ingurgitan los vasos,
VC generally used
fenilefrine,
nafazoline in drops
To dx cornea epithelial ulceration
○ Flurozine - green = active
if not its old
§ White lesion with flurosceine and remaines = scar - px ulcerated and remains with a leucoma
Management of bacterial corneal ulcers?
§ Cycloplejic - □ apart from dilating pupils □ Paralyze ciliar body □ Last 48-72hr vs midriatics last 4-6hr § Antibiogram § Fortified ATBs - Tobramycin drops with ampolla of ATB § Subconjuntival injections § Oral analgesics § Ocular lubricants
Scleral pathologies are associated with?
- RA
- Steven Johnson
- Lupus
Epiescleritis is?
inflamation of episclera (between insertion of rectus and the limbo) that generally affects 30-40yr women.
- Seen as a circunscrit hiperemic elevation - More diffuse
Tx of epiescleritis?
○ Topical and oral AINES
- If you put a VC in eye it will clear up even tho inflammaed part /ingurgitation will stay circunscrit, its what will allow you to differentiate something superficial or something deep like this pathology
Difference with Scleritis?
- Pain
- Bilateral
- More localized
- Don’t whiten with VC
- More tendency to recidivar
- Between 40-60yr, women
- Diffuse or nodular
- 70% unknown etiology
Tx of scleritis?
topical steroids or oral ones
Necrotizing Scleretis?
has a plaque of severe thinning of sclera
Anterior Uveitis?
- Affects the iris and anterior part of ciliar body (pars plicata)
- Management of AU?
○ Infectious analytics
○ Odontological evaluation
○ PA thorax x ray
○ Topical steroids
○ Cycloplejics - relax ciliar body and iris and pain foes away
§ Don’t put midriatics, shorter 4-6hr, only opens iris but doesn’t affect ciliar body
§ Cylclo alone - takes away pain but puil still dilated, still inflammed
§
What are sinequia?
- Affection of eye in the iris presents adherences to cornea (anterior sinequia) or lens (sinequiq posterior)
Called seclusion when?
They are 360 degrees, occurs when musculature sticks to iris or lens
Intermediate Uveitis?
- Usually with vitiritis
- Cx by decrease much higher in visual acuity
- Most difficult to dx because cant know if just vitro or other also affected
Posterior Uveitis?
- Affect suprajacent retina, coroidis
- Lower acuity
- Present floculos = copos de neives
○ . - Celularity and vitreal opacity
○ Same as anterior uveitis but in this case its in the vitreo
○ If manges to become so severe can present “Copos de nieves” - Vascularity
associated with rheumtalogical diseases
- Coroiditis: these have yellow grey focuses , differentiating itself from opacity of uveitis which is white - Uveitis has to progress to get coroiditis
floculos
Floating flies or artefacts , can be hilos
○ Most are not pathological, only says that vitreo detached a protein but when it happens wit decrease In visual acuity that’s when we think its pathological
What is the conjuntiva?
- Mucosal transparent membrane that tapizas the eye from limbo to conjuntival fondos de saco
- Covers sclera = conjuntiva bulbar
- Covers posterior surface of eyelids = palpebral conjuntiva
Limits of the conjunctiva?
- Eyelid border: skin
- Limbo: cornea
- Lagrimal points: nasal mucus (inf. And sup inner pink part)
3 parts of palpebral conjuntiva?
- Marginal
- Tarsal
- Orbitary
Bulbar conjuntiva
- Anterior surface of eye (conjuntiva scleral)
- Thinnest conjuntiva covers Tennon and unites with it 3mm from limbo (limbal conjuntiva)
- Allows visualization of BVs
- When reaches cornea continues with corneal epithelium
Fondo de saco conjuntival
- inferior: 8mm of limbo
- superior: 8-10mm of limbo
- lateral: 14mm of limbo
- medial: has carúncula y pliegue semilunar o plica semilunar
○ Function: it’s a rompe olas so tears don’t go directly yo lagrimal conduct).
Conjuntival accesory glands?
- Krause
- Wolfring
- Criptas Henle
- Manz
- Caliciformes
- All have functions to avoid pelicula lagrimal evaporates faster secreting mucus or oil (fat)
- If any of these are infected –> orzuelo –> painful
○ Tetrad: de celso
Vascularization/Irrigation of conjuntiva:
- Palpebral branches: nasal arteries
- Lagrimal branches of eyelids
- Anterior ciliary branches
a. Arcada palpebral marginal:
i. Of perforating arteries that cross the tarso
b. Arcada palpebral periférica:
i. Gives perforating ones that perforate muscle of Muller irrigating the conjuntival fornix
c. Autolimiting bleeds, use compression
Venous drainage?
- Zona bulbar plexo venoso post-tarsal de los parpados
- Zona tarsal venas oftálmicas superior e inferior
- Parte profunda del plexo epiescleral, venas de los músculos intrínsecos
- Opthalmic vein stuck to II so infections can esparcirse por continuidad and infect II
Lymphatic Drainage?
2 systems: superficial (conjuntiva) , profound (fibrous layer
bacterial vs viral conjunctivitis vs allergic?
If you have a conjuntivitis and don’t know if tis viral or bacterial the differences because the bacterial will have more secretions without ganglios and follicles, but remember that folliculos are more viral
Bacterial are gross, and fast clinical cuadro
Viral have elevated ganglio
Allergy have allergic papilas - vessels cross thru middle vs folliculos which are viral - vessels surround them
Cx of onjuntival innervation
- Doesn’t hurt
- Only bothers
- Sensitive
○ Nerves of eyelid: innervate majority of mucosa
Ciliary nerves: innervate limbo zone
@ tarsal conjunctival can see if ptosis is neurological or mechanical
Phenylafrine simpatomimetic +
§ Not better - neurological
MC of conjuntivitis:
- Sensation of a FB
- Sensation of burning - inflmmation
- Secretion
○ Not in allergic - more tears
What is quemosis?
- Accumulation of liquid under conjuntiva
- Inflammation of eyellid and conjuntiva, irritation of eye
- Can be infectious, allergic (worse), or due to renal failure
- Kid < 2yr - ATB only
- Tx normally is steroids + ATBs
edema en la conjuntiva bulbar (conjuntiva que recubre el globo ocular) que puede estar o no asociada a inflamación en el polo anterior del ojo.[citarequerida]
No se trata de una enfermedad, sino de un signo clínico que puede aparecer en muchos procesos diferentes.
hinchazón de la membrana que cubre la porción externa del ojo o conjuntiva. La quemosis leve solo produce sensación de malestar, pero cuando es intensa impide el cierre de los parpados.
foliculos
○ hiperplasia (increase in cell number ) of lymphoid tissue inside the conjuntival stroma, especially in fondo de saco although can be found in tarsal conjuntiva and limbo. Appear as multiple lesions, discrete, and slightly eveated in small diameter.
○ Every folluclo is surrounded by a small blood vessel and its size osscilates in function of severety and duration of inflmaation between 0.5mm y 5mm.
○ Produced by viral infection, chlyamidia, oculoglandular syndrome of Parinaud, molluscum contagiosum, e hipersensibility to topical medication .
○ Vessels around = viral
papilas
- Balls
- Vasos go thru
- Less dx value
- Hiperplasia and hipertrophy (increase in size of cells) of conjuntival epithelium.
- Contain central vessels and an infiltrate of chronic inflammatory cells; lymphocytes, plasma cells and eosinophils.
- Can develop in palpebral conjuntiva normally superior y in the bulbar conjuntiva in limbo nivel.
- Observed with mosaic patter with elevated polygonal hyperemic areas that with prolonged inflammation can reach great diameters
Pinguecula
- Conjuntival hyaline tissue that hasn’t invaded cornea
- It’s a degeneration of elastic subconjuntival fibers with deoposit of amorpha hyaline substance
- Once it invades cornea = pterigium
Simblefaron
- por procesos autoinmunes, la conjuntiva se hipertrofia y se pega la conjuntiva tarsal de la bulbar, no logrando mirar por arriba totalmente,
- Can cause diplopia
- Need to qx
Causes of acute bacterial conjuntivitis
- Staph
- Strep
- Haemophilus influenzae
MC of bacterial conjunctivitis?
- Sticky eyelids
- FB sensation
- Mucosal or purulent exudates
- Eyelid edema
Purulent conjuntivitis are generally produced by:
- Neisseria Ghonorreae
- Neisseria Meningitidis
Viral conjuntivitis
- Adenovitus (3,4,7) –> faringoconjuntival fever
- MC:
○ Fever, faringitis, cervical and preauricular adenopathy, folicular conjuntivitis, pseudomembranes
- MC:
*generally are preceded by febrile process
what is blefaritis?
inflammation of eyelid
Hemorragic conjuntivatis
- enterovirus (picorna - 70)
Epidemic queratoconjunctivitis
- Unilateral
- Adenovitus 8
Chronic Conjuntivitis:
- Persistent conjuntival inflmation
- MC
○ Conjuntival injection
○ Exudation
○ Irritation
○ Fotofobia
○ Buring sensaiton
○ Eyelid heavy
○ Remision periods and exacerbation
- MC
Triquiasis
everted eyelashes –> conjuntivitis.
Pseudofaquia?
When u remove lens have to put intraocular lens
Afaquia?
- period that px has no lens
Iridogonesis
El cristalino se bambolea due to rupture of zonulas .
Leucocorea
when crystalline lens is totally blank
If in RN first must do is discart retinoblastoma.
actual qx to operate catarats is done with
facoemulsificador
conjuntival sensitive innervation - nerves of eyelid that innervate most of the mucus
Lagrimal nerve
§ Infraorbitary nerve
§ Supratroclear branches and frontal nerve of orbit
§ Infratroclear branch of naso-ciliar nerve
General ideas of the orbits?
- 2 cavities situated in both sides of midline of face for the eyeballs
- Floor contains optic canal for optic nerve
- @ lesions of optic nerve –> vitreal hemorrage = direct trauma
Cx of Orbit?
- 40-45mm deep (35mm high)(40 wide)
○ Max width 1cm behind anterior orbital border- 30ml vol
○ Formed by eyeball, II, extraocular musculature, VAN, lagrimal gland, periorbital fat - Lacrimal gland in superexternal part - put drops here
○ Eye can only receive simultaneous 1ml of solutions - more than one drop pointless
- 30ml vol
Bones of the orbit?
- Frontal
- Sphenoid
- Ethmoids
- Palatine
- Maxillary
- Zygomatic
- Lagrimal
Superior border of orbit?
- Formed by frontal bord, interrupted medially by supraorbital escotadura where supraorbital nerve runs
- Nerve comes out of there which carries trayectary in hemiface from mastoid apofisis
- If u are tense mastoids compress nerve at this level and will give neuralgia due to contraction of deltoid and supraspinal
- Pinzamiento of this nerve is behind but youll feel in front
What urts in eye
- Optic neuritis, glaucoma and corneal ulcer
Medial border?
- Formed above by frontal bone
- Below by lagrimal crest posterior to lagrimal bone and anterior lagrima crest of maxillary bone
Inferior border?
- Formed by maxiallary bones and zygomatic bones
Laterally
- Zygomativ bones and frontal complete reborde
- Thickest , strongest of walls formed by zygomatic bones and major wing of sphenoid
- Here we find lateral orbital tubercule (whitnall)
Orbital roof?
- Lagrimal gland fosa localized anterolateral behind zygomatic apofisis of frontal bone
- Medilally troclear fossa localized in frontal bone approx 4mm from orbital border
- Weakest part of orbit is internal wall where ethmoidal celdillas are and second plane of orbital floor
Medial wall of roof?
- formed by frontal Apófisis of maxilar
- Lagrimal bone
- Minor wings of sphenoid
- Oribital plaques of ethmoids - this bone forms most of medial part
Orbital floor formed by?
- Orbital plaque of zygomatic
- Palatine
- maxilar
Foramens of the orbit?
- Etmoidal foramens
- Superior orbitary fissure
○ - inferior orbitary fissures
○ - Lagrimonasal canal
○ - Optic conduct
- Zygomatic foramen
- Superior orbitary fissure
superior orbitary fissure
Hendidura esfenoidal - between major and minor wings of sphenoid ○ Crossed by: § III,IV,V1, VI § Sympathetic nerve fibers § Superior opthalmic vein
inferior orbitary fissures
Hendidura esfenomaxilar ○ Crossed by: § V2 § Zygomatic nerve § Branches of inferior opthalmic vein § Infraorbitary nerve
optic conduct
Optic nerve
○ Ophthalmic artery
○ Sympathetic fibers of carotid plexus
lagrimonasal canal
Directed downwards from lagrimal fosa –> inferior meato of nose
○ If obstructed –> epifora
Ciliary ganglion
- Posterior part of orbit between optic nerve and external rectus muscle
- Sensorial root
- Motor root
○ originates from inferior root of III
○ Iris sphincter with PS fibers - Sympathetic root
○ Comes from plexus that surrounds internal carotid artery
○ Ocular BVs and possibly dilator muscle
III innervates?
- Superior rectus
- Elevator of eyelid
- Inferior rectus
- Internal rectus
- Inferior oblique
IV innervates?
- Superior oblique
VI innervates?
- External rectus
Orbital irrigation?
- Opthalmic artery and branches
- Vorticose veins which drain in venous system of coiroide of iris
What are paranasal sinuses?
- Prolongations of nasal cavity towards neighboring bones of cranium –> pair cavities existing in grand variability between individuals
How many paranasal sinuses?
- 8 (4 per side covered with thin mucusoal ciliated epithelium)
Paranasal sinuses?
- Maxillary
- Anterior and posterior ethmoidal
a. Etmoidal cedillas continue with paranasal sinuses which any process here can affect them - Frontal
- Sphenoidal
- Anterior and posterior ethmoidal
Functions of paranasal sinuses?
- Lift weigh from bones
- Heat and humidify aspirated air
- Secrete mucus
- Seves as resonance box for voice
Expulse FB which penetrate in inhalation
Measurements of eyelids?
- Long - 7-30mm`
- Wide - 8-11mm
Ambliopia? -
- It’s a decrease in visual acuity without organic lesion that justifies it
- poor visual development where visual strucure of the eye is formed
- After 8yr old vision is no longer developed regardless
Segments of the eyelid?
- Skin
- Margen
- Subcutaneous CT
- Orbicularis muscle
- Oculi
- Orbital septum
- Elevator of eyelid muscle
- Superior tarsal, Muller Muscle
- Tarsus
- Eyelid Conjuntiva
○
tarsus
Dense CT laminas (cartilage) ○ Insertion tendones cantales internos and externos ○ In espesor can find meibomio glands ○ Superior: 30-40 glands ○ Inferior: 20-30 glands
eyelid conjuntiva
Transparent , vascularized membrane
○ Non keratinized stratified epithelium
○ Posterior face of every eyelid and anterior surface of eyeball until sclerocorneal limbo (bulbar conjuntiva)
○ Mucosal calciforme cells
○ Mucosal secretions are generally due to dryness
Eyelid alterations are not necessarily ophthalmological because there can be systemic alteration that can affect them such as?
- Thyroid - w/ proptosis
- Miastenia gravis
○ If ocular, affects mostly rectus and eyelids
○ Only 20% become severe
○ Ptosis , alteration, affection of rectus muscle mobilization - Congenital ptosis - >3mm must qx, cover visual axis
- Horner syndrome - ptosis
- Miastenia gravis
Distriquiasis
: an additional line of eyelashes in eyelid
- Can be due to scarring tracomas
Subcutaneous CT
- No fat
- Blood and fluids accumulate
Lagoftalmos
inferior eyelid is removed from internal and external canto, leaving the eye entreabierto when closing.
- Depending on severity have to put gel before sleeping or put a gold pesita
Irrigation of eyelids
- Internal carotid –> opthalmic –> marginal superior arcade –> superior eyelid
- External carotid –> facial –> angular –> marginal inferior arcade –> inferior eyelid
innervation of eyelid
- Sensorial
○ V1: opthalmic
○ V2: maxilar
ptosis
- Any defect that prevents vision before 8yr
- Operate to improve vision
- But if after 8 yr, born with , asthetic qx wont see better
:
External Orzuelo
- Infectious
- Celso signs
- No pus, fat
Chalazion
- Sebaceous cysts without inflmmation
- Same as an orzeulo but reticular system sends macrophages and encapsualtes it
- If small can put steroids in unguento inside eye so that it passes thru conjuntiva for 21 days, doesn’t come off just opiana
Blefaritis are usually in which eyelid and why?
- superior eyelid with more glands
Localization of lagrimal gland? -
- Depression in orbital part of frontal part
Measurements of lagrimal system?
- 20mm long
- 10mm wide
types of lagrimal cells
- Acinar
- Myoepithelial
lagrimal glands
- Krause - - Wolfring -
wolfring
usually ones that get most infected
○ Localized in border of tarso
○ 3 glands in superior border of superior tarso
○ 1 in inferior border of inferior tarso
krause
loocalized at conjuntival fornix
○ 20-40 superior fornix
○ 6-8 in inferior fornix
Dacriocystitis
- Infection of lagrimal sac
- ## Staph. Aureus
Dacrioadenitis
- Inflammation of principal lagrimal gland
- Associated with parotiditis, cold, measels
-
- Associated with parotiditis, cold, measels
Ret HTA –>
deshicence of hematoretinal barrier which increases PERM
Retinal HTA on fundoscope
Fondoscope cx by- VC, extravascion and arteriosclerosis
- VC obstructs precapilary arterioles bland exudates or cottony
- More exudate - more liekely to be glaucoma
- Veins 2x thicker than arteries
- Extravasation - caused by abnormal vasc. PERM –> hemorrages en llamas, retinal edema and hard exudates
○ When its around in Henle capa = macular star
- Causes thickening of vasc wall = hialinization of intima layer with hypertrophy of media and endothelial hyperplasia
- Manifested by AV pathological crosses
○ Deeper it is , bigger the grade
- Fundamentally vascular diff from diabetes which is microangiopathic
salus sign
pathological arteriole croses ; more accentuated the corsis there is interruption between artery and vein
Classification of hypertensive retinopathy
- Grade 1
○ Generalized arteriolar attenuation mild with some venous ocultamiento- 2
○ Arteriolar constriction worse that is local or generalized associated with deflexion of veins in AV cruces (Salus sign) - 3
○ Presence of copper hilos (Bonnet sign) and decrease in vein calibrre, hard exudates and bland and hemmorages in llamas - 4
○ All above + silver hilos and papilar edema (blurry)
- 2
Risk factors for Diabetic Retinopathy?
- Duration of DM
- Metabolic control
- HTA?
- Pregnancy
- Anemia
- Renal damage
What is DR?
- A microangiopathy that affects precapillary arterioles, capillaries and retinal venules (seen in fundux exam)
- Causes microvascular occlusion with thickening of BM of cap, lesion and prolif of endothelial cells allowing formation of new vessels
- Alteration in hematies and platelet aggregation
- In normal conditions, veins are 2x bigger than arteries
- First changes seen
- If its hypertensive after arteries thin –> hilos de cobre
- Elemental lesions of retina (retinal signs)
Classification of DR?
nonprolifetaive (mild, moderate, severe)
proliferative (not high risk, HR, advanced)
nonprolif DR
○ Mild
§ microaneurismas, mild retinal hemorragias, hard and bland exudates.
§ Bland exudates represent isquemic zonas.
○ Moderate
§ More advanced lesions but less than 4-2-1 rule.
○ Severe
§ uno cualquiera de la regla 4-2-1.
§ 1) Microaneurisms/Severe Hemorrages in 4 cuadrants
§ 2) Arrosariamiento venoso (vascular anomalies) in at least 2 quadrants
§ 3)moderate or extense microvasculares intrarretinal anomalies (AMIR) in at least 1 quadrant
2 / 3 of the 3 previous cx determines severe RDNP
prolif DR
○ w/out cx of high risk
§ Neovasos extrapapilares (NVE): of any extension without vitreal hemorrage /preretinal hemorrage (HV/HP).
§ Neovasos in disk (NVD): of any inferior extension to 4th part of papilar area. (<1/4
○ w/ cx of HR
§ Neovasos in disk (NVD): of major extension or iqual to 4th part of papilar area. (>1/4)
§ HV/HP with neovasos in disc in any extensión.
○ Advanced
§ Extense Hemorragias of vítreo (don’t allow evaluation of neovasos).
§ Neovascular glaucoma
§ Detachement of traccional macular retina .
§ Ptisis bulbi.
□ One eye that doesn’t have well defined structure - all is emplastronado
neovessels
: newly formed vessels that have a weak layer of muscle and allow extravasation
2 types of hemorrages?
- llamas
- puntiformes.
2 types of exudates?
- Hard due to deposition of proteins
- Blands look like copos of cotton
vitreal hemorrage
if it clots it forms a membrane of fibirin which receives name of vitreal band
- If you give laser it can detach that retinal band and cause a traccional retinal detachment - Traccional are secondary to this condition - Can be traumatic as well
localization of microaneurysms
- Microaneurysms - internal nuclear layer
localization of hemorrages
- Hemorrages : middle layer and hemorragias en llama: layer of nerve fibers.
localizations of hard exudates vs bland exudates
- Hard Exudados: between internal plexiforme and nuclear interna.
- Bland Exudados : are isquémicos seen as llama b/c they are on top of coroide
Components of rodospine?
- 11 cis retinal
- Opsina (protein)
what is rodopsine
- Rodopsine is the aldehyde form of vitamine A (absorbs light)
What is produced by vitamin A deficiency?
- Nictalopia - night blindness
Cones are only found where vs bastones?
- In macular vs. bastones in the rest of the retina
Rincón del Vago:
- Sensorial layer of the fovea is composed of only cells with cone form while que en torno a ella also can fine bastone form cells
- As we separate from sensible area, cells with cone form become less and in external borders of retina only baston form cells
interneurons
- Bipolar cells - connect rec with GCs
- Ganglionar cells - retinal neuron projections that carry info to SNC
- Horizontal cells - interact between rec and bipolar cells
- Amacrine cells - interaction between bipolar cells and ganglionar cells
Optic system composed of 2 convergent lenses?
- Cornea
- Cristaline/lens
fovea
retinal area of more spacial resolution, more accentuated in foveloa where photorec are concentrated
accomodation
capacity that eye has to increase its refraction power to focus on nearby objects
○ An AP increase in thickness occurs and crystalline convexity due to contracction of miliar muscle
miopia
- Don’t see far
- Defect in refraction of eye in which light rays paralel from infinite converge on focal pooint infront of retina
If eye is too big need concave lense
- Defect in refraction of eye in which light rays paralel from infinite converge on focal pooint infront of retina
hipermetropia
- Don’t see up close
- Refraction defect where rays converge behind retina
- Some of these px with excess accomopdation u put +3 and cant take it
- With -5 if u get 20/20 but uncomfortable put -3
- Discomfort is due to feeling floor sink or all spins, nausea, vvomit, cant walk
- Common in px with a lot increaese in one eye
- NO MORE than 3 dioptrias difference between eyes - brain cant tolerate that
- When eye is smaller than normal, images fall behind retina, need convex spheres = hypermetropia
astigmatism
- Don’t focus
- Defect with different refraction between two ocular meridians which prevents clear focus of objects and is generally due to an alteration in anterior curve of cornea
- Different between a curvature or corneal and crystallin and need cyllinders to correct both
presbicia
- Physiological defect , cant read
- An ocular defect in which by 40yrs causing difficulty to see up close
- Due to reduction of power of accomodatin causing less capacity to focus on nearby objects.
how to know type of refraction?
lensetest
- Objective test with retinoscope
Subjective test - px tells u
- Miopes trying to do a estenopeic foramen squint eyes to see better - If with glasses move to right side and image moves to left = engative (concave for miopes) same side + (convex for hipermetropes) To know if they have astigmatism move from one side to another or roate and if image disvirtues or se desdobla has aan added cylinder and has asygmatism if not it’s a sphere doesn’t have astigmatism .
LASIK
- Es un queratómetro,
- Put anesthesia, open cornea 360 degrees
- Program based on alteration
- Laser reduces stroma
- Close cornea
requirements of LASIK
○ 18 yr
○ 2 yrs without vatation in defect
○ Appropriate endothelial count
○ >1.5 of refractory defect that u want
types of glasses
- Intraocular glasses go inside eye
- When you operate px with catarats have to extrat crystaline must substitue for an intraocular lens to no leave afaquico
- Before to old ppl they put glasses de fondo de botealla beause crystaline wasn’t replaced
- These are multifocal pic - right is rigid for extracapsular qx left is plegable for facoemulsifcation
- Haptics are patics which fixate it
- Progressive intraocular glasses correct presbicia not anterior ones
multifocal
- Used to otorgar a clear focus point close or far but can only choose one
- Need complementation with glasses
- Intraocular give 2 or more points of focus but at expense of clarity
causes of anterior uveitits
- Can be acute or chronic
Generally idiopathic or secondary to systemic disease (infectious or immunological)
MC of anterior uveitits
Pain, photophobia, marked redness, tearing, decrease in visual acuity, fibrin network between pupilar margin and cristaline causing posterior sinequias
TEARS cx of obstruction of tear drainage conducts, due to a severe rhinitis
tx for dacrioadentitis
Tx: NSAIDs, topical antibiotics (NOT ORAL), can give oral as prophylaxis
dacriocystitis MC
Has epifora, supuration por los puntos
- Due to mechanical compression --> pseudoobstruction - Tumefaccion in internal canto of inferior eyelid , eritema, ,painful at palpation - Can observe drainage point in cutaneous surface
tx for dacriocystitis
Tx: oral doxicycline and topic antibiotics
conjunctival sensitive innervation of the limbo
ciliar nerves
sympathetic conjunctival innervation arrives to eye with
ophthalmic artery
causes of sinequia
- Can be caused by ocular traumatism, iritis (inflammation of iris) or iridociclitis (inflamation of iris and ciliary body, synonym of anterior uveitits) and can lead px to some types of glaucoma
only horner type with anyhydrosis
preganglionar
no laser tx
neovessels, macula, II
