Ophthalmology secrets 3rd ed

Vander, MD Attending Surgeon, Retina Service Wills Eye Institute Clinical Professor of Ophthalmology Thomas Jefferson University Philadelphia, Pennsylvania Janice A.. Gault, MD, FACS Ass

IN COLOR

IN COLOR

Third Edition

James F Vander, MD

Attending Surgeon, Retina Service

Wills Eye Institute

Clinical Professor of Ophthalmology

Thomas Jefferson University

Philadelphia, Pennsylvania

Janice A Gault, MD, FACS

Associate Surgeon, Cataract and Primary Eye Care Service

Wills Eye Institute

Assistant Clinical Professor of Ophthalmology

Thomas Jefferson University

Philadelphia, Pennsylvania

Eye Physicians PC

Voorhees, New Jersey

1600 John F Kennedy Boulevard, Suite 1800

Philadelphia, PA 19103-2899

Copyright 2007, 2002 by Elsevier Inc All rights reserved

No part of this publication may be reproduced, stored in a retrieval system, or transmitted inany form or by any means, electronic, mechanical, photocopying, recording, or otherwise,without prior permission of the publisher (Mosby, 1600 John F Kennedy Boulevard, Suite

1800, Philadelphia, PA 19103-2899)

NOTICEKnowledge and best practice in this field are constantly changing As new research andexperience broaden our knowledge, changes in practice, treatment and drug therapymay become necessary or appropriate Readers are advised to check the most currentinformation provided (i) on procedures featured or (ii) by the manufacturer of eachproduct to be administered, to verify the recommended dose or formula, the methodand duration of administration, and contraindications It is the responsibility of thepractitioner, relying on his or her own experience and knowledge of the patient, to makediagnoses, to determine dosages and the best treatment for each individual patient,and to take all appropriate safety precautions To the fullest extent of the law, neitherthe Publisher nor the Editor assumes any liability for any injury and/or damage to persons

or property arising out or related to any use of the material contained in this book

Library of Congress Cataloging-in-Publication Data

Ophthalmology secrets in color / [edited by] James F Vander, Janice A Gault – 3rd ed.p.; cm – (The secrets series)

Rev ed of: Ophthalmology secrets

Includes bibliographical references and index

ISBN 0-323-03469-1

RE48.O666 2007

2006046682Senior Acquisitions Editor: James Merritt

Developmental Editor: Stan Ward

Project Manager: Mary Stermel

Marketing Manager: Alyson Sherby

Printed in China

To Caroline Anna, William Henry, and Eliza Avery

DEDICATION

v

Brandon D Ayres, MD

Corneal Associates PC, Wills Eye Institute, Philadelphia, Pennsylvania

Augusto Azuara-Blanco, MD, PhD, FRCS(Ed)

Consultant Ophthalmic Surgeon and Honorary Senior Lecturer, Aberdeen Royal Infirmary,University of Aberdeen, Aberdeen, United Kingdom

Robert S Bailey, Jr., MD

Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University;Attending Surgeon, Wills Eye Institute; Attending Surgeon, Chestnut Hill Hospital, Philadelphia,Pennsylvania

Marc S Cohen, MD

Associate Surgeon, Wills Eye Institute, Philadelphia, Pennsylvania

Mary Jude Cox, MD

Instructor, Glaucoma Service, Wills Eye Institute, Philadelphia, Pennsylvania; Eye Physicians PC,Voorhees, New Jersey

Janice A Gault, MD, FACS

Associate Surgeon, Cataract and Primary Eye Care Service, Wills Eye Institute; Assistant ClinicalProfessor of Ophthalmology, Thomas Jefferson University, Philadelphia, Pennsylvania; EyePhysicians PC, Voorhees, New Jersey

Roberta E Gausas, MD

Department of Ophthalmology, University of Pennsylvania Medical School; Scheie Eye Institute,Philadelphia, Pennsylvania

Kenneth B Gum, MD

Section Chief, Department of Ophthalmology, Munson Medical Center,

Transverse City, Michigan

Philip G Hykin, FRCS, FRCOphth

Surgeon, Medical Retina Service, Moorfields Eye Institute, London, United Kingdom

Anup Khatana, MD

Cincinnati Eye Institute, Cincinnati, Ohio

xii CONTRIBUTORS

Joseph I Maguire, MD, FACS

Assistant Professor, Thomas Jefferson University Hospital; Wills Eye Institute,

Associate Professor of Ophthalmology, Jefferson Medical College of Thomas Jefferson

University; Codirector of Oculoplastic Surgery Department, Wills Eye Institute;

Chief of Ophthalmology, Lankenau Hospital, Philadelphia, Pennsylvania

Ophthalmology, Thomas Jefferson University School of Medicine; Clinical Associate Professor

of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania

Much of the information in this book can be found in a number of other

ophthalmology textbooks The table of contents is similar to that of many other books already in print So why bother to write a new ophthalmology text? The value of the book is in the unique manner in which the material is presented, continuing the tradition the Secrets SeriesWhas established in numerous other specialties The question-and-answer ‘‘Socratic method’’ format reflects the process by which a large portion of clinical medical education actually takes place Our purpose is not to displace the comprehensive textbooks of ophthalmology from the shelves of

clinicians and students Instead, we hope that we have filled a useful spot beside them We greatly appreciate the efforts of the talented contributors who have shared their wisdom and experiences to help fill this void.

We have received much positive feedback on the first two editions of this book This third edition includes many more color figures as well as the helpful study aids

of the Top 100 Secrets and Key Points We have enjoyed updating Ophthalmology Secrets, and we hope that clinicians and students will enjoy this book and find it valuable.

James F Vander, MD Janice A Gault, MD, FACS

PREFACE

xvii

1 Corneal opacification in a neonate has a differential diagnosis of STUMPED: sclerocornea,trauma, ulcers, metabolic disorder, Peter’s anomaly, endothelial dystrophy, and dermoid.

if there is more than a 0.3 mm difference between the two eyes For each 1 mm in error, thecalculation is off by 2.5 diopters (D) Recheck keratometry readings if the average K power is

<40 D, >47 D, or if there is a difference of more than 1 D between eyes For every 0.25 D error,the calculation is in error of 0.25 D

whereas optic nerve diseases affect red-green discrimination

diagnosis of a choroidal melanoma and differentiate it from other choroidal lesions

superotemporal field defect and is caused by compression of the contralateral optic nervenear the chiasm

errors cause a visual field to look better than it actually is

papillary defect, and color abnormalities The optic disc may also have asymmetric cuppingand pallor

Asymmetrically low intraocular pressure may be an important clue to a potential ruptured globe

will blanch) and scleritis (these vessels do not)—two entities with very different prognoses andevaluations Because 50% of patients with scleritis have systemic disease, referral to aninternist is necessary for further evaluation

TOP 100 SECRETS

These secrets are100 of the top board alerts.They summarize the concepts, principles,

and most salient details of ophthalmology

1

15 A patient with a corneal abrasion from a dirty source (contact lens use, tree branch) is at risk for

a corneal ulcer and should not be patched while healing

checking visual acuity

hypertension or blood dyscrasias

any ulcer not responding to therapy should be recultured

conjunctivitis due to the potential for serious disseminated disease The mother and her sexualpartners must be evaluated for other sexually transmitted diseases

conjunctivitis include 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline Silver nitrate israrely used, however, due to its potential for causing chemical conjunctivitis

administration

dexamethasone This risk is higher in patients with known glaucoma or a family history ofglaucoma

discernible cause Vitamin A deficiency may be the reason

will show signs of dry eye earlier than fluorescein stain

findings of the same, look for an underlying dystrophy, specifically epithelial basementmembrane dystrophy

clinically significant cataract, consider staging the cataract extraction a few months after thecorneal transplant, offering the patient the advantage of better intraocular lens power calculationand postoperative refractive result Alternatively, Descemet stripping endothelial keratoplasty(DSEK), which does not alter corneal contour, may be combined with cataract surgery with apredictable refractive outcome

to eye rubbing All keratoconus patients should be advised to avoid eye rubbing

transplantation is highly successful in treating keratoconus patients whose visual needs cannot

be satisfied by spectacle or contact lens correction

refractive surgery in the fellow eye on the same day

2 TOP 100 SECRETS

30 As many as 30–50% of individuals with glaucomatous optic nerve damage and visual field losshave an initial intraocular pressure measurement less than 22 mmHg.

aims to preserve vision and quality of life through the lowering of intraocular pressure

Except for cases of marked anisometropia, the fellow eye should have a similar anteriorchamber depth and narrow angle If it does not, consider other nonrelative papillary blockmechanisms of angle closure

lens-particle glaucoma

associated with 25% of cases

medications, have a favorable side-effect profile, and are easy to use However, prostaglandinanalogs and miotics are contraindicated in any type of inflammatory glaucoma

during office visits, think noncompliance

Apraclonidine should be used only as a last resort in healthy infants

avoided: those with angle-closure glaucoma, shallow anterior chambers, very high preoperativeIOP, or elevated episcleral venous pressure or high myopia Hemorrhagic choroidals andexpulsive hemorrhages are more likely

retinal detachments in the future They need ongoing ophthalmic evaluation for the rest oftheir lives

cataract surgery is indicated

decreases the risk of some complications compared with retrobulbar anesthesia

sulcus, remember to lower the power of the implant approximately 0.5 D from what was chosenfor capsular fixation to compensate for the more anterior location of the lens

TOP 100 SECRETS 3

47 If amblyopia is associated with an afferent pupillary defect, a lesion of the retina or optic nerveshould be suspected and ruled out.

at older ages if compliance is good Atropine penalization can be as effective as patching in thetreatment of mild and moderate amblyopia

vision Be certain that a patient with a partial accommodative esotropia is wearing the maximumtolerated hyperopic prescription

is in the appropriate place and there is no refixation on cover testing, the patient is orthophoric

insufficiency) as well as checking his or her cycloplegic refraction for undercorrected hyperopia(accommodative insufficiency)

rule out heart block These patients may need a pacemaker to prevent sudden death

headache; and decreased vision must be immediately placed on intravenous steroids andreferred to neurosurgery for pituitary apoplexy

lethargy, asymmetric eye redness, eyelid swelling, and fever

illumination

patients who presented with visual acuity of less than 20/200 were still 20/200 or less at

6 months

sclerosis (MS) Fifty-six percent of patients with optic neuritis and a white matter lesion on MRIwill develop MS at 10 years

helpful in determining a malingering patient

steroids to prevent involvement of the other eye even if the temporal artery biopsy cannot bedone beforehand

4 TOP 100 SECRETS

64 The primary causes of tearing are dry eyes, lower eyelid laxity, and blockage of the lacrimalsystem.

delineation

ophthalmopathy)

edema should have immediate neuroimaging followed by an orbital biopsy to rule out

rhabdomyosarcoma

inflammation of the eyes even if there is no history of a systemic thyroid imbalance

multiple office visits

response to antibiotics is poor by 48–72 hours, vision decreases, or an afferent pupillary defectpresents

artery dissection, prompting an urgent workup

pupil-involving third-nerve palsy A dilated pupil requires neurologic evaluation for a

compressive aneurysm

because of invasion to the orbit and brain via the lacrimal drainage system, prior radiationtherapy, or clinical neglect

margin to prevent permanent deformity

carcinoma

hypercholesterolemia

posterior segment disease

have uveitis that does not respond to treatment Uveitis in patients with AIDS is almostinvariably part of a disseminated systemic infection Lymphoma may masquerade as retinitis

TOP 100 SECRETS 5

81 Early signs of chloroquine retinopathy are perifoveal retinal pigment epithelium changes.

disease unless retinoblastoma has been absolutely ruled out

dissolution, and macular holes

surgical site

world The leading epidemiologic risk factors for ARMD are increasing age, smoking, andgenetic predisposition

modalities to physiologic pharmacologic therapies such as inhibitors of vascular endothelialgrowth factor (VEGF)

clock hours of stage 3 ROP in zone I or II in the presence of plus disease

screened for ROP at 4–6 weeks after birth or 31–33 weeks postconceptual age

within 500 microns of the center of the fovea, hard yellow exudate within 500 microns of thefovea and adjacent retinal thickening, or at least one disc area of retinal thickening, any part ofwhich is within 1 disc diameter of the center of the fovea

are embolic Systemic disease must be ruled out in any patient with retinal artery obstruction

occlusion Neovascular glaucoma is the most feared complication of a central retinal vein occlusion

vitreous strongly suggests the possibility of a retinal break

degeneration, and myopia

in the United States and developed nations survive due to early detection and propermanagement

bilateral retinoblastoma are managed with chemoreduction

an underlying ciliary body or peripheral choroidal tumor

6 TOP 100 SECRETS

98 Uveal melanomas with epithelioid cells have a poorer prognosis Seventy percent of uvealmetastases are from breast or lung cancer.

thyroid-related ophthalmopathy (Graves’ ophthalmopathy)

radiotherapy

TOP 100 SECRETS 7

1 Name the seven bones that make up the bony orbit and describe which location

is most prone to damage in an orbital blow-out fracture

The seven orbital bones are the frontal, zygoma, maxillary, sphenoid, ethmoid, palatine,

and lacrimal A true blow-out fracture most commonly affects the orbital floor

posteriorly and medially to the infraorbital nerve The ethmoid bone of the medial wall is

often broken

2 Which nerves and vessels pass through the superior orbital fissure? Whichmotor nerve to the eye lies outside the annulus of Zinn, leaving it unaffected byretrobulbar injection of anesthetic?

The superior orbital fissure transmits the third, fourth, and sixth cranial nerves as well as thefirst division of the fifth cranial nerve, which has already divided into frontal and lacrimalbranches The superior ophthalmic vein and sympathetic nerves also pass through this fissure.The fourth cranial nerve, supplying the superior oblique muscle, lies outside the annulus Thisposition accounts for residual intorsion of the eye sometimes seen during retrobulbar

3 A 3-year-old is referred for evaluation of consecutive exotropia after initial

bimedial rectus recessions for esotropia performed elsewhere Review of theoperative notes discloses that each muscle was recessed 4.5 mm for a 30-prismdiopter deviation Unfortunately, the child had mild developmental delay andpresents with a 25-prism diopter exotropia You decide to advance the recessedmedial rectus of each eye back to its original insertion site Where is this site inrelation to the limbus? Identify the location of each of the rectus muscle

insertion sites relative to the limbus

Reattach each medial rectus muscle 5.5 mm from the limbus Insertion of the inferior rectus is6.5 mm from the limbus; the lateral rectus is 6.9 mm from the limbus; and the superior rectus,7.7 mm The differing distances of rectus-muscle insertions from the limbus make up the spiral

of Tillaux An important caveat in developmentally delayed children is to postpone musclesurgery until much later, treating any amblyopia in the interim Early surgery frequently leads toovercorrection

4 What is the most common cause of both unilateral and bilateral proptosis inadults?

Thyroid orbitopathy is the most common cause Many signs are associated with thyroid eyedisease, which is probably caused by an autoimmune reactivity toward the epitope of thyroid-stimulating hormone (TSH) receptors in the thyroid and orbit The order of frequency of

extraocular muscle involvement in thyroid orbitopathy is as follows: inferior rectus, medialrectus, lateral rectus, superior rectus, and obliques There is enlargement of the muscle bellywith sparing of the tendons

CLINICAL ANATOMY OF THE EYE

I GENERAL

9

5 You have just begun a ptosis procedure A lid crease incision was made, and theorbital septum has been isolated and opened horizontally What importantlandmark should be readily apparent? Describe its relation to other importantstructures.

The orbital fat lies directly behind the orbital septum and directly on the muscular portion of

years

6 To what glands do the lymphatics of the orbit drain?

There are no lymphatic vessels or nodes within the orbit Lymphatics from the conjunctivae andlids drain medially to the submandibular glands and laterally to the superficial preauricularnodes

7 What is the orbital septum?

The septum is a thin sheet of connective tissue that defines the anterior limit of the orbit In theupper lid it extends from the periosteum of the superior orbital rim to insert at the levator

extends from the periosteum of the inferior orbital rim to insert directly on the inferiortarsal border

nasociliarynerve

inferior divisionoculomotor nerve

ophthalmicarteryoptic nerve

Figure 1-1 The annulus of Zinn and surrounding structures (From Campolattaro BN, Wang FM:Anatomy and physiology of the extraocular muscles and surrounding tissues In Yanoff M, Duker JS[eds]: Ophthalmology, 2nd ed St Louis, Mosby, 2004.)

10 CLINICAL ANATOMY OF THE EYE

8 A 70-year-old patient presents

with herpes zoster lesions in the

trigeminal nerve distribution

Classic lesions on the side and

tip of the nose increase your

concern about ocular

involvement Why?

This sign, called Hutchinson’s sign,

results from involvement of the

infratrochlear nerve The infratrochlear

nerve is the terminal branch of the

nasociliary nerve, which gives off the

long ciliary nerves (usually two) that

supply the globe

9 Where is the sclera the thinnest?

Where are globe ruptures after

blunt trauma most likely to

occur?

The sclera is thinnest just behind the

insertion of the rectus muscles (0.3

mm) Scleral rupture usually occurs

opposite the site of impact and in an arc

parallel to the limbus at the insertion of

the rectus muscles or at the equator

The most common site of rupture is

near the superonasal limbus

10 Describe the surgical limbus and

Schwalbe’s line

The surgical limbus can be differentiated

into an anterior bluish zone that extends

from the termination of Bowman’s layer

to Schwalbe’s line, which is the

termination of Descemet’s membrane The posterior white zone overlies the trabecular meshworkand extends from Schwalbe’s line to the scleral spur

11 You are preparing to do an argon laser trabeculoplasty Describe the

gonioscopic appearance of the anterior chamber angle

The ciliary body is a visible concavity anterior to the iris root The scleral spur appears as a whiteline anterior to the ciliary body Above this are the trabecular meshwork and canal of Schlemm.Treatment is applied to the anterior trabecular meshwork

12 After a filtering procedure, your patient develops choroidal effusions Explain thedistribution of these fluid accumulations based on uveal attachments to the sclera

The uveal tract is attached to the sclera at the scleral spur, the optic nerve, and the exit sites ofthe vortex veins The fluid dissects the choroid from the underlying sclera but retains theseconnections

13 Describe the structure of Bruch’s membrane Name two conditions in whichdefects develop in this structure spontaneously

Bruch’s membrane consists of five layers: internally, the basement membrane of the pigmentepithelium, the inner collagenous zone, a central band of elastic fibers, and the outer

B A

G H

N M J

K K I

O Q P R D C

E

F R

W P

Q

F C

D G

Q

S

U

W V

H

T

Figure 1-2 Schematic cross-section of eyelids andanterior orbit A, skin; B, frontalis muscle; C,orbicularis muscle (orbital portion); D, orbicularismuscle (preseptal; portion); E, orbicularis muscle(pretarsal portion); F, orbicularis muscle (muscle ofRiolan); G, orbital septum; H, orbital fat; I, superiortransverse ligament; J, levator muscle; K, levatoraponeurosis; L, Mu¨ller’s muscle; M, superior rectusmuscle; N, superior oblique tendon; O, gland ofKrause; P, gland of Wolfring; Q, conjunctiva; R,tarsus; S, inferior rectus muscle; T, inferioroblique muscle; U, inferior tarsal muscle; V,capsulopalpebral ascia; W, peripheral arterialarcade (From Beard C: Ptosis, 3rd ed St Louis,Mosby, 1981.)

CLINICAL ANATOMY OF THE EYE 11

collagenous zone; externally, the basement membrane of the choriocapillaris Pseudoxanthomaelasticum and myopia may cause spontaneous defects in this membrane, making the patientprone to development of choroidal neovascularization.

KEY POINTS: BRUCH’S MEMBRANE

1 Composed of five layers

2 Spontaneous breaks can occur in pseudoxanthoma elasticum and myopia

3 Defect in Bruch’s membrane in age-related macular degeneration may lead to the exudativeform

4 Trauma may cause a break in the membrane, leading to a choroidal neovascular membrane

14 Less laser power is required for photocoagulation in darkly pigmented fundi.What determines this pigmentation?

The pigmentation of the fundus seen ophthalmoscopically is largely determined by the number

of melanosomes in the choroid The darker macular area results from taller pigment epithelialcells that contain more and larger melanosomes than the periphery

15 What is the blood-retinal barrier?

The inner blood-retinal barrier consists of the retinal vascular endothelium, which isnonfenestrated and contains tight junctions The outer blood-retinal barrier is the retinal pigmentepithelium Bruch’s membrane is permeable to small molecules

16 Name the 10 classically described anatomic layers of the retina and the cells thatmake up the retina

The retina may be divided into 10 layers, starting just above the choroids and extending to thevitreous:

&Retinal pigment epithelium

&Outer segments of the photoreceptors

&External limiting membrane

&Outer nuclear layer

&Outer plexiform layer

&Inner nuclear layer

&Inner plexiform layer

&Ganglion cell layer

&Nerve fiber layer

&Internal limiting membrane

Within these layers lie the photoreceptors, horizontal cells, bipolar cells, amacrine cells, retinalinterneurons, ganglion cells, and the glial cells of the retina, the Mu¨ller cells

17 Which retinal layer is referred to as the fiber layer of Henle in the macularregion?

The outer plexiform layer, which is made up of connections between photoreceptor synapticbodies and horizontal and bipolar cells, becomes thicker and more oblique in orientation as itdeviates away from the fovea At the fovea this layer becomes nearly parallel to the retinalsurface and accounts for the radial, or star-shaped, patterns of exudate in the extracellularspaces under pathologic conditions causing vascular compromise, such as hypertension

12 CLINICAL ANATOMY OF THE EYE

18 What are three clinically recognized remnants of the fetal hyaloid vasculature?

Mittendorf’s dot, Bergmeister’s papilla, and vascular loops (95% of which are arterial)

19 A patient presents with a central retinal artery occlusion and 20/20 visual acuity.How do you explain this finding?

Fifteen percent of people have a cilioretinal artery that supplies the macular region Thirtypercent of eyes have a cilioretinal artery supplying some portion of the retina These areperfused by the choroidal vessels, which are fed by the ophthalmic artery and thus are notaffected by central retinal artery circulation

20 Where do branch retinal vein occlusions occur? Which quadrant of the retina ismost commonly affected?

Branch retinal vein occlusions occur at arteriovenous crossings, most commonly where the veinlies posterior to the artery The superotemporal quadrant is most often affected because of ahigher number of arteriovenous crossings on average

21 Discuss the organization of crossed and uncrossed fibers in the optic chiasm

Inferonasal extramacular fibers cross in the anterior chiasm and bulge into the contralateraloptic nerve (Willebrand’s knee) Superonasal extramacular fibers cross directly to the oppositeoptic tract Macular fibers are located in the center of the optic nerve Temporal macular fiberspass uncrossed through the chiasm, whereas nasal macular fibers cross posteriorly However,

in albinism, many temporal fibers also cross

22 Describe the location of the visual cortex

The visual cortex is situated along the superior and inferior lips of the calcarine fissure This area

is called the striate cortex because of the prominent band of geniculocalcarine fibers, termed thestria of Gennari after its discoverer

23 What is the most likely anatomic location of pathology associated with

downbeat nystagmus?

Downbeat nystagmus is usually indicative of cervicomedullary structural disease The mostcommon causes are Arnold-Chiari malformation, stroke, multiple sclerosis, and platybasia Anypatient with this finding should have neuroimaging studies done

24 A patient presents with a chief complaint of tearing and ocular irritation As shedumps the plethora of eye drops from her purse, she explains that she has seenseven different doctors and none has been able to help her The exam showsmild inferior punctate keratopathy but a normal tear lake and normal Schirmer’stest Of interest, she had blepharoplasty surgery 6 months previously What isthe diagnosis?

You are already patting yourself on the back as you ask if the irritation is worse in the morning orevening She replies emphatically that it is much more severe upon awakening You ask her toclose her eyes gently and see two millimeters of lagophthalmos in each eye This is a frequentlyoverlooked cause of tearing in otherwise normal eyes

25 During orbital surgery, a patient’s lacrimal gland is removed Afterward, there is

no evidence of tear deficiency Why not?

Basal tear production is provided by the accessory lacrimal glands of Krause and Wolfring.Krause’s glands are located in the superior fornix, and the glands of Wolfring are located abovethe superior tarsal border They are cytologically identical to the main lacrimal gland

CLINICAL ANATOMY OF THE EYE 13

26 Describe the anatomy of the macula and fovea.

The macula is defined as the area of the posterior retina that contains xanthophyllic pigment andtwo or more layers of ganglion cells It is centered approximately 4 mm temporal and 0.8 mminferior to the center of the optic disc The fovea is a central depression of the inner retinalsurface and is approximately 1.5 mm in diameter

27 Fluorescein angiography typically shows perfusion of the choroid and anycilioretinal arteries prior to visualization of the dye in the retinal circulation Why?

Fluorescein enters the choroid via the short posterior ciliary arteries, which are branches of theophthalmic artery The central retinal artery, also a branch of the ophthalmic artery, provides amore circuitous route for the dye to travel, resulting in dye appearance in the retinal circulation1–2 seconds later

28 Explain why visual acuity in infants does not reach adult levels until

approximately 6 months of age, based on retinal differentiation

The differentiation of the macula is not complete until 4–6 months after birth Ganglion cellnuclei are initially found directly over the foveola and gradually are displaced peripherally,leaving this area devoid of accessory neural elements and blood vessels as neural organizationdevelops to adult levels by age 6 months This delay in macular development is one factor in theinability of newborns to fixate, and improvement in visual activity parallels macular

30 Describe the innervation of the lens

The lens is anatomically unique because it lacks innervation and vascularization It dependsentirely on the aqueous and vitreous humors for nourishment

31 Describe the innervation of the cornea

The long posterior ciliary nerves branch from the ophthalmic division of the trigeminal nerve andpenetrate the cornea Peripherally, 70–80 branches enter the cornea in conjunctival, episcleral,and scleral planes They lose their myelin sheath 1–2 mm from the limbus The network justposterior to Bowman’s layer sends branches anteriorly into the epithelium

32 What are the three layers of the tear film? Where do they originate?

&The mucoid layer coats the superficial corneal epithelial cells and creates a hydrophilic layerthat allows for spontaneous, even distribution of the aqueous layer of the tear film Mucin issecreted principally by the conjunctival goblet cells but also from the lacrimal gland

&The aqueous layer is secreted by the glands of Kraus and Wolfring (basal secretion) and thelacrimal gland (reflex secretion) The aqueous layer contains electrolytes, immunoglobulins,and other solutes, including glucose, buffers, and amino acids

&The lipid layer is secreted primarily by the meibomian glands and maintains a hydrophobicbarrier that prevents tear overflow, retards evaporation, and provides lubrication for the lid/ocular interface

33 What are the differences in the structure of the central retinal artery and retinalarterioles?

The central retinal artery contains a fenestrated internal elastic lamina and an outer layer ofsmooth muscle cells surrounded by a basement membrane The retinal arterioles have no

14 CLINICAL ANATOMY OF THE EYE

internal elastic lamina and lose the smooth muscle cells near their entrance into the retina.Hence, the retinal vasculature has no autoregulation.

34 Where is the macula represented in the visual cortex?

Macular function is represented in the most posterior portion at the tip of the occipital lobe.However, there may be a wide distribution of some macular fibers along the calcarine fissure

35 What is macular hole formation?

Macular hole formation is a common malady that can result in rapid loss of central vision.Approximately 83% of cases are idiopathic, and 15% are due to some sort of trauma

36 Describe the stages of macular hole formation as proposed by Gass, as well asthe changes in our understanding of the disease process since the development

of optical coherence tomography (OCT)

Gass’s theory proposed that the underlying causative mechanism was centripetal tangentialtraction by the cortical vitreous on the fovea He also proposed the following stages:

&Stage 1a: Tractional elevation of the foveola with a visible yellow dot

&Stage 1b: Enlargement of the tractional detachment with foveal elevation A yellow ringbecomes visible

&Stage 2: Full-thickness retinal defect less than 400 mm

&Stage 3: Full-thickness retinal defect larger than 400 mm

&Stage 4: Stage 3 with complete posterior vitreous detachment

OCT analysis has revealed that some patients have perifoveal vitreous detachment with aremaining attachment of the fovea Occasionally patients may develop an intraretinal split withformation of a foveal cyst This cyst may evolve into a full-thickness hole with disruption of theinner retinal layer and opening of the foveal floor These findings suggest a complex array ofboth anterior-posterior and tangential vector forces as an etiology for molecular hole formation.Clearly the classification of macular holes will need to be reworked in light of these new findings

BIBLIOGRAPHY

1 American Academy of Ophthalmology: Basic and Clinical Science Course, Section 2 San Francisco, AmericanAcademy of Ophthalmology, 1993–1994

2 Burde RM, Savino PJ, Trobe JD: Clinical Decisions in Neuro-ophthalmology St Louis, Mosby, 1985

3 Fine BS, Yanoff M: Ocular Histology, 2nd ed Hagerstown, MD, Harper & Row, 1979

4 Gass JDM: Stereoscopic Atlas of Macular Diseases, 4th ed St Louis, Mosby, 1997

5 Guyer DR, Yannuzzi LA, Chang S, et al: Retina-Vitreous-Macula Philadelphia, W.B Saunders, 1999

6 Jaffe NS: Cataract Surgery and its Complications, 5th ed St Louis, Mosby, 1990

7 Justice J, Lehman RP: Cilioretinal arteries: A study based on review of stereofundus photographs and

fluorescein angiographic findings Arch Ophthalmol 94:1355–1358, 1976

8 Miller NR: Walsh and Hoyt’s Clinical Neuro-Ophthalmology, vol 1, 4th ed Baltimore, Williams & Wilkins, 1982

9 Spaide RF: Optical Coherence Tomography: Interpretation and Clinical Applications Course #590, AAO AnnualMeeting, Chicago, 2005

10 Stewart WB: Surgery of the Eyelid, Orbit, and Lacrimal System Ophthalmology Monographs, vol 1 SanFrancisco, American Academy of Ophthalmology, 1993

11 Weinberg DV, Egan KM, Seddon JM: The asymmetric distribution of arteriovenous crossing in the normalretina Ophthalmology 100:31–36, 1993

CLINICAL ANATOMY OF THE EYE 15

1 Name the bones of the orbit

&Medial wall: Sphenoid, ethmoid, lacrimal, maxillary

&Lateral wall: Zygomatic, greater wing of sphenoid

&Roof: Frontal, lesser wing of sphenoid

&Floor: Maxillary, zygomatic, palatine

SeeFig 2-1

2 What are the weak spots of the orbital rim?

&Frontozygomatic suture

&Zygomaticomaxillary suture

&Frontomaxillary suture

3 Describe the most common location of blow-out fractures

The posteromedial aspect of the orbital floor

4 What is the weakest bone within the orbit?

The lamina papyracea portion of the ethmoid bone

5 Name the divisions of cranial nerve V that pass through the cavernous sinus

&Ophthalmic division (V1)

&Maxillary division (V2)

6 What is the annulus of

Zinn?

The circle defined by the

superior rectus muscle,

inferior rectus muscle,

lateral rectus muscle, and

medial rectus muscle (see

Fig 2-1)

7 What nerves pass

through the superior

orbital fissure but

outside the annulus of

of palatine bone

Zygomaticomaxillary suture Maxillary bone

Intraorbital glove Zygoma

Interior orbital tissues

Sphenoid bone

Frontal bone

Intraorbital foramen

Figure 2-1 Anatomy of the orbit (From Kanski JJ: ClinicalOphthalmology: A Systematic Approach, 5th ed New York,Butterworth-Heinemann, 2003.)

16

8 List the factors responsible for involutional entropion

&Lower lid laxity

&Override of the preseptal orbicularis oculi muscle onto the pretarsal orbicularis oculi muscle

&Dehiscence/disinsertion of the lower lid retractors

&Orbital fat atrophy

9 Describe the sensory nerve supply to the upper and lower eyelids

&The ophthalmic nerve (V1) provides sensation to the upper lid

&The maxillary nerve (V2) provides sensation to the lower lid

10 What are the surgical landmarks in locating the superficial temporal arteryduring temporal artery biopsies?

The superficial temporal artery

lies deep to the skin and

subcutaneous tissue but

superficial to the temporalis

fascia

11 What structures would you

pass through during a

12 What is meant by the term

lower lid retractors?

The lower lid retractors consist

of the capsulopalpebral fascia

and the inferior tarsus

muscle The capsulopalpebral

fascia of the lower lid is

analogous to the levator complex

in the upper lid The inferior

tarsus muscle of the lower lid is

analogous to Mu¨ller’s muscle

in the upper lid

13 What structures would be

cut in a full-thickness

lower-lid laceration 2 mm

below the lower tarsus?

&Skin

&Preseptal orbicularis oculi muscle

&Conjoint tendon (fused orbital septum and lower lid retractors)

&Palpebral conjunctiva

OrbitalseptumLevatoraponeurosisMüller'smuscle

Lower lidretractors

Figure 2-2 Eyelid structures (From Kanski JJ: ClinicalOphthalmology: A Systematic Approach, 5th ed New York,Butterworth-Heinemann, 2003.)

ANATOMY OF THE ORBIT AND EYELID 17

14 What structures would be cut in a full-thickness lower-lid laceration 6 mm belowthe lower tarsus?

&Skin

&Preseptal orbicularis oculi muscle

&Orbital septum

&Fat

&Lower lid retractors (capsulopalpebral fascia and inferior tarsus muscle)

&Conjunctiva

15 Discuss the bony attachments of Whitnall’s superior suspensory ligament

Medially, it attaches to the periosteum of the trochlea Laterally, the major attachment is to theperiosteum at the frontozygomatic suture It also sends minor attachments to the lateral orbitaltubercle

16 What structure separates the medial fat pad from the central (also called thepreaponeurotic) fat pad in the upper eyelid?

The superior oblique tendon

17 Lester Jones divided the orbicularis oculi muscle into three portions Name them

&Orbital portion

&Preseptal portion

&Pretarsal portion

18 What portions of the orbicularis oculi muscle are important in the lacrimal pumpmechanism?

The preseptal and pretarsal portions

BIBLIOGRAPHY

1 Anderson R, Dixon R: The role of Whitnall’s ligament in ptosis surgery Arch Ophthalmol 97:705–707, 1979

2 Bedrossian EH Jr: Embryology and anatomy of the eyelids In Tasman W, Jaeger E (eds): Foundations of ClinicalOphthalmology Lippincott, Williams & Wilkins, 1998, pp 1–22

3 Bedrossian EH Jr: Surgical anantomy of the eyelids In Della Rocca RC, Bedrossian EH Jr, Arthurs BP (eds):Opthalmic Plastic Surgery: Decision Making and Techniques Philadelphia, McGraw-Hill, 2002, pp 163–172

4 Dutton J: Atlas of Clinical and Surgical Orbital Anatomy Philadelphia, W.B Saunders, 1994

5 Gioia V, Linberg J, McCormick S: The anatomy of the lateral canthal tendon Arch Ophthalmol 105:529–532,1987

6 Hawes M, Dortzbach R: The microscopic anatomy of the lower eyelid retractors Arch Ophthalmol100:1313–1318, 1982

7 Jones LT: The anatomy of the lower eyelid Am J Ophthalmol 49:29–36, 1960

8 Lemke B, Della Rocca R: Surgery of the Eyelids and Orbit: An Anatomical Approach Norwalk, CT, Appleton &Lange, 1990

9 Lemke B, Stasior O, Rosen P: The surgical relations of the levator palpebrae superioris muscle Ophthal PlastReconstr Surg 4:25–30, 1988

10 Lockwood CB: The anatomy of the muscles, ligaments and fascia of the orbit, including an account of thecapsule of tenon, the check ligaments of the recti, and of the suspensory ligament of the eye J Anat Physiol20:1–26, 1886

11 Meyer D, Linberg J, Wobig J, McCormick S: Anatomy of the orbital septum and associated eyelid connectivetissues: Implications for ptosis surgery Ophthal Plast Reconstr Surg 7:104–113, 1991

12 Sullivan J, Beard C: Anatomy of the eyelids, orbit and lacrimal system In Stewart W (ed): Surgery of the Eyelids,Orbit and Lacrimal System American Academy of Ophthalmology Monograph no 8, 1993, pp 84–96

13 Whitnall SE: The levator palpebrae superioris muscle: The attachments and relations of its aponeurosis.Ophthalmoscope 12:258–263, 1914

14 Whitnall SE: The Anatomy of the Human Orbit and Accessory Organs London, Oxford Medical Publishers,1985

18 ANATOMY OF THE ORBIT AND EYELID

1 What is the primary focal point (f)?

The point along the optical axis at which an object must be placed for parallel rays to emerge

2 What is the secondary focal point (f0)?

The point along the optical axis at which parallel incoming rays are brought into focus It is equal

3 Where is the secondary focal point for a myopic eye? A hyperopic eye? Anemmetropic eye?

The object must be moved forward from infinity to allow the light rays to focus on the retina

eye focuses light rays from infinity onto the retina

4 What is the far point of an eye?

The term far point is used only for

the optical system of an eye It is

the point at which an object must

be placed along the optical axis for

the light rays to be focused on the

retina when the eye is not

accommodating

5 Where is the far point for a

myopic eye? A hyperopic

eye? An emmetropic eye?

The far point for a myopic eye is

between the cornea and infinity

A hyperopic eye has its far point

beyond infinity or behind the eye

An emmetropic eye has light rays

focused on the retina when the

object is at infinity

6 How do you determine which

lens will correct the

refractive error of the eye?

A lens with its focal point coincident

with the far point of the eye allows

the light rays from infinity to be

focused on the retina The image at

the far point of the eye now

becomes the object for the eye

OPTICS AND REFRACTION

Figure 3-2 The secondary focal point (F2), which also has

an object at infinity (From Azar DT, Strauss L: Principles ofapplied clinical optics In Albert DM, Jakobiec FA [eds]:Principles and Practice of Ophthalmology, vol 6, 2nd ed.Philadelphia, W.B Saunders, 2000, pp 5329–5340.)

Figure 3-1 The primary focal point (F1), which has an image

at infinity (From Azar DT, Strauss L: Principles of appliedclinical optics In Albert DM, Jakobiec FA [eds]: Principles andPractice of Ophthalmology, vol 6, 2nd ed Philadelphia, W.B.Saunders, 2000, pp 5329–5340.)

19

7 What is the near point of an eye?

The point at which an object will be in focus on the retina when the eye is fully accommodating.Moving the object closer will cause it to blur

8 Myopia can be caused in two ways What are they?

&Refractive myopia is caused by too much refractive power due to steep corneal curvature orhigh lens power

&Axial myopia is due to an elongated globe Every millimeter of axial elongation causes about

3 D of myopia

9 The power of a proper corrective lens is altered by switching from a contact lens

to a spectacle lens or vice versa Why?

Moving a minus lens closer to the eye increases effective minus power Thus, myopes have aweaker minus prescription in their contact lenses than in their glasses Patients near presbyopiamay need reading glasses when using their contacts but can read without a bifocal lens in their

Thus, hyperopes need a stronger plus prescription for their contact lenses than for their glasses.They may defer bifocals for a while The same principle applies to patients who slide theirglasses down their nose and find that they can read more easily They are adding plus power.This principle works for both hyperopes and myopes

10 What is the amplitude of accommodation?

The total number of diopters that an eye can accommodate

11 What is the range of accommodation?

The range of clear vision obtainable with accommodation only For an emmetrope with 10 D ofaccommodative amplitude, the range of accommodation is infinity–10 cm

12 How does a diopter relate to meters?

A diopter is the reciprocal of the distance in meters

13 What is the near point of a 4-D hyperope with an amplitude of accommodation of 8?

overcome hyperopia and focus the image at infinity on the retina Thus, he or she has 4 D to

wearing a þ4.00 lens, he or she has the full amplitude of accommodation available The near

20 OPTICS AND REFRACTION

14 What is the near point of a

4-D myope with an amplitude

of accommodation of 8?

of the eye The patient can

accommodate 8 D beyond this point

The near point is 12 D, which is 8.3

15 When a light ray passes from

a medium with a lower

refractive index (n) to a

medium with a higher

refractive index (n0), is it bent

toward or away from the

normal?

It is bent toward the normal

(Fig 3-4)

16 What is the critical angle?

The incident angle at which the

angle of refraction is 90 degrees to

normal The critical angle occurs

only when light passes from a

more dense to a less dense medium

17 What happens if the critical angle is

exceeded?

Total internal reflection The angle of

incidence equals the angle of reflection

(Fig 3-5)

18 Give examples of total internal

reflection

Total internal reflection at the tear-air

interface prevents a direct view of the

anterior chamber To overcome this

limitation, the critical angle must be

increased for the tear-air interface by

applying a plastic or glass goniolens to the

surface Total internal reflection also

occurs in fiberoptic tubes and indirect

ophthalmoscopes

19 What is the formula for vergence?

U þ P ¼ VWhere U is the vergence of light entering the lens, P is the power of the lens (the amount ofvergence added to the light by the lens), and V is the vergence of light leaving the lens All areexpressed in diopters By convention, light rays travel left to right Plus signs indicate anything

to the right of the lens, and minus signs indicate points to the left of the lens

Figure 3-4 When light passes from a medium with lowerrefractive index (ni) to a medium of higher refractive index(nr), it slows down and is bent toward the normal to thesurface Snell’s law determines the amount of bending

i ¼ angle of incidence, r ¼ angle of refraction (From Azar

DT, Strauss L: Principles of applied clinical optics In Albert

DM, Jakobiec FA [eds]: Principles and Practice ofOphthalmology, vol 6, 2nd ed Philadelphia, W.B

Saunders, 2000, pp 5329–5340.)

Figure 3-5 Total internal reflection occurs whenthe critical angle is exceeded (From Azar DT,Strauss L: Principles of applied clinical optics InAlbert DM, Jakobiec FA [eds]: Principles andPractice of Ophthalmology, vol 6, 2nd ed

Philadelphia, W.B Saunders, 2000,

pp 5329–5340.)

OPTICS AND REFRACTION 21

20 What is the vergence of parallel light rays?

Zero Parallel light rays do not converge (which would be positive) or diverge (which would benegative) Light rays from an object at infinity or going to an image at infinity have zero vergence

21 What is the image point if an object lies 25 cm to the left of a +5.00 lens?

Everything must be expressed in diopters: 25 cm is 4 D (1/0.25 m) Because the image is to theleft of the lens,

U ¼
4 D

P ¼ þ5 D

4 þ 5 ¼ 1The vergence of the object is þ1 D Converted to centimeters, the object lies 1 m to the right of the lens(1/1 D ¼ 1 m ¼ 100 cm)

22 Draw the schematic eye with power

(P), nodal point (np), principal

plane, primary (f) and secondary

(f0) focal points, refractive indices

(n, n0), and respective distances

labeled

SeeFig 3-6

23 How is the power of a prism

calculated?

The power of a prism is calculated in

prism diopters (D) and is equal to the

displacement in centimeters of a light ray

passing through the prism measured 100

cm from the prism Light is always bent

toward the base of the prism Thus, a

prism of 15 D displaces light from infinity

15 cm toward its base at 100 cm

24 What is Prentice’s rule?

D ¼ hDThe prismatic power of a lens (D) at any

point on the lens is equal to the distance

of that point from the optical axis in

centimeters (h) multiplied by the power of

the lens in diopters (D) It follows that a

lens has no prismatic effect at its optical

center; a light ray will pass through the

25 How is Prentice’s rule used in real

life?

In a patient who has anisometropia, the

reading position may cause

hyperdeviation of one eye due to the

prismatic effect

Figure 3-6 The reduced schematic eye (FromAzar DT, Strauss L: Principles of applied clinicaloptics In Albert DM, Jakobiec FA [eds]: Principlesand Practice of Ophthalmology, vol 6, 2nd

ed Philadelphia, W.B Saunders, 2000,

pp 5329–5340.)

Figure 3-7 Prismatic effect of a lens according toPrentice’s rule d ¼ induced prism (measured inprism diopters), h ¼ distance from optical center

in centimeters, and D ¼ power of lens in diopters.(From Azar DT, Strauss L: Principles of appliedclinical optics In Albert DM, Jakobiec FA [eds]:Principles and Practice of Ophthalmology, vol 6,2nd ed Philadelphia, W.B Saunders, 2000,

pp 5329–5340.)

22 OPTICS AND REFRACTION