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A TEXTBOOK OF OPHTHALMOLOGY, 2nd ed.

by E. Ahmed

© 2001 by Prentice-HaJI of India Private Limited, New Delhi. All rights reserved. No part of this book
may b e reproduced in any form, by mimeograph or any other m eans, without permission in writing from
the publisher.

ISBN-81 -203-1916-8

The export rights of this book are vested solely with the publisher.

Published by Asoke K. G hosh, Prentice-Hall of India Private Limited, M-97, Connaught Circus,
New Delhi-110001 and Printed by Rajkamal Electric Press, B-35/9, G.T. Kamal Road Industrial Area,
Delhi-110033.
Brief Contents

Preface XXV

A cknowledgemertts xxvii
Ahhrpviatinns xx ix

PART ONE—ANATOMY AND EMBRYOLOGY 1-51


1. Anatomy of the Oribit 3-11
2. Anatomyof the Eyelid 11-15
3. Anatomy of the Lacrimal Apparatus 15-18
4. Anatomyof the Conjunctiva 18-21
5. Anatomy of the Cornea 21-24
6 . Anatomy of the Sclera 24-25
7. Anatomy of the Uveal Tract 25-29
8 . Anatomyof the Crystalline Lens and Suspensory Ligament 29-30
9. Anatomy of the Vitreous Humour 30-31
10. Anatomy Related to Glaucoma 31-33
11. Anatomy of the Retina 33-88
12. Anatomy of the Visual Pathways 38-43
13. Anatomy of Extraocular Muscles of the Eye 43-46
14. Embryology and Postnatal Development of the Eye 46-51

PART TW Q-=QCULAR.PHYS1QLQGY_______________________________________________ 53=7.4


15. The Aqueous Humour 55-56
LfL__ The Intraocular Pressure_
17 Ornlar Pirfiilafirms S7—5Q
18. Physiology of the Cornea 59-61
19. Physiology of the Crystalline Lens 61-62
20. Physiology of the Vitreous Humour and Retina 62-63
2L__ Accommodation_63-65
22. Convergence 65-67
23 Binocular Vision_67=68
24. The Reactions of Light on the Eve 68-70
2 1 Colour Vision_2Q=12
26. Visual Sensation and Adaptation 72-73
27. Neurology of Vision 73-74

PART THREE—MICROBIOLOGY____________________________________________________ 75=8?


2&__ Bacterial Infections_77- 80
29. Viral and Chlamydial Infections 80-82
30. Mycotic and Parasitic Infections 82-87
PART F O U R — OCULAR THERAPEUTICS. OPTICAL DEFECTS
AND OCULAR EXAMINATIONS_______________________________ *9=146
31. Ocular Therapeutics 91-104
32. Optics and Refractions 104-128
33. The Examination o f the Eyes 128-146

[S
Ю-SYSXEMIC DISEASES 147=441
34A_ D iseases o f the Orbit_L49=1.64
35. Diseases of Eyelids 164-180
36. Diseases o f the Lacrimal Apparatus 180-189
37. Diseases of the Conjunctiva 189-211
38. Diseases o f the Cornea_21.1-240
39. Diseases of the Sclera 241-244
4Q,_P iseaseg_Qf_the_Uyeal_Tracl_244r:264
41. Pupillary Disorders 264-269
42. Diseases o f the Crystalline Lens 269-277
41._Diseases o f the Vitreous__277-282
44. Glaucoma 282-309
45. Diseases o f the Retina 309-355
46. Diseases o f the Visual Pathways 355-366
47. Strabismus 366-390
48. Ocular Manifestations of Systemic Diseases 390-420
49. Tumours 420-4 29
50. Ocular Injuries 429-441

PA R T.SIX =3U R G 1C A L PROCEDURES_____________________________________________ 443=499


51. Ophthalmic Surgery 445-499

PART SEVEN—MISCELLANEOUS ASPECTS 501-545


52. Genetics and Paediatric Ophthalmology 503-512
53. Immunology Related to Ocular Disorders 512-515
54. Prevention and Rehabilitation o f Blindness__515-517
55. Eye Hygiene 517
56. Modem Advances in Ophthalmology 518-537
57. Syndromes in Ophthalmology 537-545

Appendix I: Formulary o f Topical Ophthalmic Preparations 547-549


Appendix II: Ophthalmic Instruments 550-558
Glossary'___________________________________________________________________________ 559-571
Index 573^600
Contents

Preface_________________________________________________________________________________ xxv
A cknowledgements xxvii
Abbreviations xxix

PART ONF— ANATOM Y AND FM BRYOI.OGY 1-51


1. Anatomy of the O rbit 3-11
Walls o f the Orbit 3
Ophthalmic Artery 5
Superior Ophthalmic Vein 6
Inferior Ophthalmic Vein 6
Ciliary Ganglion 7
Surgical Spaces in the Orbit 7
Tenon’s Capsule or the Fascia Bulbi 7
Cranial Nerves in the Orbit 8
Sphenopalatine (Pterygopalatine) Ganglion 11
Paranasal Sinuses in Relation to the Orbital Walls__ LI
Further Reading 11
2. Anatomy of the Eyelids 11-15
Muscles of the Eyelids 13
Glands o f the Eyelids 13
Further Reading 14
3. Anatomy of the Lacrim al A pparatus 15-18
The Lacrimal Gland 15
The Lacrimal Passages 17
Further Reading 18
4. Anatomy of the Conjunctiva 18-21
The Palpebral Conjunctiva 18
The Bulbar Conjunctiva 19
The Fornix 19
Further Reading 21
5. Anatomy of the C ornea 21-24
Structure of the Cornea 22
The Epithelium 22
Bowman’s Membrane 22
Substantia Propria 22
Descemet’s Membrane 23
Endothelium 23
Limbus 23
Further Reading 24
vii

V
—1^. ул^
6. Anatomy of the Sclera____________________________________________________________24-25
Further Reading 24
7. Anatomy of the Uveal T ract______________________________________________________ 25-29
Iris 25
Ciliary Body 26
Choroid__22
Further Reading. 28
8. Anatomy of the Crystalline Lens and Suspensory Ligament______________________ 29-30
Suspensory Ligament of the Lens 30
Petit’s Canal 30
Further Reading 30
9. Anatomy of the Vitreous H um our 30-31
Further Reading 31
10. Anatomy Related to Glaucoma 31-33
Anterior Chamber__U
Posterior Chamber__I I
Angle o f the AC or the Filtration Angle 32
The Outflow Apparatus 32
Inner Canals or Afferent Communications__13
Further Reading 33
11. Anatomy of the Retina___________________________________________________________ 33-38
Optic Disc 33
Central Retina or Macula Lutea__34
Peripheral Retina 34
Further Reading 38
12. Anatomy of the Visual Pathways__________________________________________________ 38-43
Optic Nerve 39
Localization of the Fibres in the Visual Pathways 40
Optic Chiasma 41
Optic Tract 42
Lateral Geniculate Body 42
Optic Radiations 42
Striate Cortex__43
Extrastriate System 43
Further Reading 43
13. Anatomy of Extraocular Muscles of the Eye________________________________________43-46
Extrinsic Muscles—43
Basic Eye Movements 45
Further Reading 45
14. Embryology and Postnatal Development of the Eye_________________________________ 46-51
Embryology of the Eye 46
Embryology of Neuroectodermal Structures 48
Embryology of Mesodermal Structures 49
Further Reading 5 /
ГЛЛ1 _L«U ---WLULAR rilXaiVlASLiX
15. The Aqueous H um our 55-56
Further Reading 56
16. The Intraocular Pressure 56-57
Physiological Variations 56
Nervous Control o f the IOP 57
Normal IOP and Hypertensive Eyes 57
Further Reading 57
17. O cular Circulations 57—59
Pulsation in the Retina 57
Measurement o f Ocular Blood Flow 58
Control of Ocular Circulation 58
Further Reading 59
18. Physiology of the Cornea 59-61
Nutrition o f the Cornea 59
Metabolism o f the Cornea 59
Comeal Permeability 60
Transparency of the Cornea 60
Further Reading 61
19. Physiology of the Crystalline Lens 61-62
Lens Metabolism 61
Further Reading 62
20. Physiology of the Vitreous H um our and Retina 62-63
Physicochemical Properties o f Vitreous 62
Metabolism of the Vitreous__62
Transparency o f the Vitreous 63
Retinal Pigment Epithelium (RPE) 63
Metabolism o f the Retina__61
Further Reading 63
21. Accommodation__________________________________________________________________6 3 -6 5
Theories of Accommodation__64
Physical and Physiological Accommodation 64
Range and Amplitude of Accommodation 64
Anomalies of Accommodation__64
Further Reading 65
22. Convergence_____________________________________________________________________6 5 -6 7
Pathway for Convergence 65
Measurement of Convergence 65
Range and Amplitude of Convergence 66
Association between Accommodation and Convergence 66
Anomalies of Convergence 66
Presbyopia 66
Further Reading 67
23«_Bino.cuiar_yisjon SbSSt
Anatomical Factors__62
Physiological Factors 67
Grades of Binocular Vision__62
lestS-foiLBinocular Vision__ 6&
Depth Perception 68
Further Reading 68
24. The Reactions of Light on the Eye_________________________________________________68-70
Light 68
Transmission, Reflection and Absorption o f Light 69
Effects o f Radiant Energy 69
Photochemistry of Vision 69
Visual Pigments 69
Electrical Changes in the Retina 70
Further Reading 70
25. Colour Vision____________________________________________________________________7Q-72
Purkinje Phenomenon 70
Scotopic Luminosity Curve 70
Theories of Colour Vision__10
Colour Cells 71
Colour Deficiency 71
Tests for Colour Vision__11
Further Reading 72
26. Visual Sensations and Adaptation__________________________________________________72-73
Visual Sensations__22
Light Threshold 72
Successive Contrast__22
Simultaneous Contrast or Spatial Induction 73
Further Reading 73
21. Neurology of Vision______________________________________________________________ 73-74
Visual Pathways^ 73
Pupillary Pathways 73
Sympathetic Pupillary Pathways 74
Further Reading 74

PART THREE—MICROBIOLOGY 25=37.


28*_Bacterial Infections 7.7=80
Staphylococci 77
Streptococci 77
Pneumococci 78
Neisseria 78
Mycobacteria 78
Haemophilus 79
Treponema 79
Comybacterium 79
Diphtheroids 79
Pseudomonas (Ps.) Pyocyanea 79
Morax-Axenfeld Diplobacilli 80
Further Reading 80
29. V iral and Chlamydial Infections__________________________________________________ 80-82
Viral Infections 80
Chlamydial Infection 81
Further Reading 82
30. Mycotic and Parasitic Infections 8 2 -8 7
Mycotic Infections 82
Rhinosporidiosis 83
Aspergillosis 83
Sporotrichosis 83
Moniliasis or Candidosis 84
Actinomycosis 84
Streptothrix 84
Parasitic Infections 84
Parasites causing Ocular Affections 85
Toxoplasmosis 85
Acanthamoebiasis 86
Malaria 86
Leishmaniasis 86
Giardiasis 86
Taeniasis and Cysticercosis 86
Echinococcosis 86
Toxocariasis 86
Onchocerciasis
Raj-p Hplminthir Tnfprtions 87
Further Reading 87

PART F O U R -O C U L A R THERAPEUTICS, OPTICAL DEFECTS


AND OCULAR EXAMINATIONS 89-146
31. O cular Therapeutics 91-104
Autonomic Drugs 91
Miotics__91
Mydriatics 93
Anaesthesia in Ophthalmology 93
Chemotherapeutic Agents and Antibiotics 94
Sulphonamides 95
Antibiotics__95
Antiviral Agents 95
Antifungal Agents 98
Steroids__

II
Enzymes in Ophthalmology 100
Anticoagulant Therapy 100
Carbonic Anhydrase Inhibitors (CAIs) 100
Hyperosmotic Agents 100
Immunosuppressive Agents 101
Nonsteroidal Antiinflammatory Drugs (NSAIDs) 102
Viscoelastic Agents 102
Toxic Effects o f Ocular Drugs 102
Toxic Effects o f Systemic Drugs 103
Other Therapeutic Measures 103
Further Reading 104
32. Optics and Refraction__________________________________________________________ 104-128
Geometrical Optics 104
Reflection at Uniformly Curved Surfaces: Spherical Mirrors 104
Spherical Lens 106
Astigmatic Lens 106
Meniscus Lens__102
Transposition o f Spherocylindrical Lenses 108
Ш
Vergence and Dioptre 109
Front and Back Vertex Powers__LQ9
Aberrations in Lenses__110
Prismatic Effects o f the Lenses__Ш
Dccentration of the Lenses__110
Homocentric or Coaxial Lens System 111
Refraction in the Normal Eye 111
Reduced Eye or Schematic Eye 111
Optical Aberrations o f the Eye 111
Catoptric Images (Purkinje-Sanson Images) 112
Hypermetropia or Hyperopia 113
Myopia 114
Astigmatism 116
Anisometropia 119
Aniseikonia__119
Aphakia 119
Transient Changes in Refraction 120
Contact Lens__120
Visual Aids__122
Special Lenses 123
Tinted Glasses 124
Frames— 125
Verification of Spectacle Lenses 125
Optical Centre of the Lens 125
Instruments used in Refraction Work__ 126
Further Reading 127
33. The Exam ination of the Eyes___________________________________________________ 128-146
Basic Equipments 128
History o f the Case 128
External Examinations 129
Examination in Dark Room 131
Visual Acuity 135
Functional Examinations 135
Special Examinations 135
Visual Field 139
Hemianopia 142
Quadrantanopia 142
Scotomata 143
Visual Field Changes in Different Ocular Disorders 143
Toxic Effects on the Retina and Optic Nerves 144
Optic Nerve Affections 144
Chiasmal Affections 144
Infrachiasmatic Lesions 145
Suprachiasmatic Lesions 145
Vascular Lesions 145
Retrochiasmal Lesions 145
Further Reading 146

PART FIVE— O CULAR DISEASES AND O CULAR AFFECTIONS


IN SYSTEM IC DISEASES 147-441
34. Diseases of the Orbit 149-164
Proptosis or Exophthalmos 149
Investigations 150
Special Radiological Techniques 151
Enophthalmos 152
Acute Orbital Cellulitis (Postseptal Cellulitis) 152
Preseptal (Periorbital) Cellulitis 152
Chronic Orbital Cellulitis 153
Tenonitis 153
Osteoperiostitis 153
Cavernous Sinus Thrombosis 153
Nasal Sinusitis__154
PseudotumQurs of the Orbit__L54
Dysthyroid Exophthalmos 155
Thyrotoxic Exophthalmos (Graves’ Disease) 156
Orbital Tumours__ LSI
Primary Tumours 157
Tumours of the Optic Nerve Sheaths 158
Superior Orbital (Sphenoid) Fissure Syndrome 159
Meningioma of the Sphenoid Ridge 159
Metastatic Tumours— 15.9
Manifestations in General Diseases 159
Orbital Cysts 160
Dermoid Cysts 160
Vascular Disturbances__Ш1
Caroticocayemous Fistula__ Ш
Orbital Varix L61
Developmental Anomalies o f the Orbit 162
Dysostoses of the Skull 162
Facial Dystrophies 162
Orbital Meningocele and Cephalocele 163
Further Reading 163

35. Diseases of Eyelids 164-180


Diseases of the Lacrimal Gland 180
Diseases of the Skin of Eyelids 164
Disorders o f the Eyebrows and Eyelashes 167
Tumours o f Eyelids 174
Carcinoma of the Lid 175
Neurofibromata or von Recklinghausen’s Disease 177
Malignant Melanoma o f the Eyelid 177
Abnormal Lid Movements 178
Abnormalities of the Palpebral Aperture 179
Developmental Abnormalities of Eyelids and Palpebral Fissure 179
Oedema of the Lids 180
Further Reading 180

36. Diseases of the Lacrim al A pparatus 180-189


Diseases of the Lacrimal Gland 180
Hypersecretion o f Tears 181
Paradoxic Lacrimation 181
Dry Eye 181
Acute Dacryoadentitis 181
Chronic Dacryoadentitis 182
Atrophy of the Lacrimal Gland 182
Dislocation of the Lacrimal Gland__ L&2
Tumour of the Lacrimal Gland__152
Benign Mixed Tumour of the Lacrimal Gland 182
Miscellaneous Tumours__ L83
Cysts of the Lacrimal Gland 183
Sjogren’s Syndrome 183
Diagnostic Tests for Dry Eye 183
Diseases of the Lacrimal Passages 184
Tumours of the Lacrimal Sac 186
Developmental Abnormalities of the Lacrimal Apparatus 187
Anomalies of Secretory System 188
Anomalies of Excretory System 188
Congenital Obstruction of the Nasolacrimal Duct 188
Further Reading 189
37. Diseases of the Conjunctiva_____________________________ 189-211
Anomalies o f the Vascular System 189
Conjunctivitis 190
Bacterial Flora of the Conjunctival Sac 191
Acute Infective Conjunctivitis 191
Acute Purulent Conjunctivitis 192
Membranous Conjunctivitis 193
Chronic Catarrhal Conjunctivitis 194
Rare Types of Conjunctivitis 195
Follicular Conjunctivitis 195
Beal’s Syndrome 196
Epidemic Viral Keratoconjunctivitis 196
Epidemic Haemorrhagic Conjunctivitis 196
Adenoviral Keratoconjunctivitis 197
Epidemic Keratoconjunctivitis 197
Pharyngoconjunctival Fever 197
Nonspecific Follicular Conjunctivitis 197
Other Viruses causing Conjunctivitis 197
Tuberculosis o f the Conjunctiva 201
Ulceration o f the Conjunctiva 202
Allergy of the Conjunctiva 202
Allergic Conjunctivitis 202
Keratoconjunctivitis Associated with Diseases of the Skin and
Mucous Memhrancs__205
Degeneration of the Conjunctiva 205
Transposition o f Pterygium 207
Conjunctival Cysts 209
Tumours of the Conjunctiva 209
Pigmentation of the Conjunctiva 210
Developmental Anomalies of the Conjunctiva 210
Further Reading 2 /0
38 ,_Diseases of the Cornea_________________________________ 211=240
Equipments and Methods of Examination 212
Injury to the Cornea 212
Healing of Corneal Wounds 213
Keratitis__213
Bacterial Corneal Ulcer__214
Hypopyon Comeal Ulcer 217
Rosacea Keratitis__219
Diffuse Superficial Keratitis 219
Herpes Simplex 220
Herpes Zoster Ophthalmicus 222
Adenoviral Keratitis 221
Molluscum Contagiosum 223
Thygeson's Superficial Punctate Keratitis 223
Theodore's Superior Limbic Keratoconjunctivitis 223
Exposure Keratitis (Keratitis Lagophathalmo) 224
Neurotropic Keratitis 224
Neuroparalytic Keratitis 224
Nutritional Ulcers__225
Keratitis Sicca (Keratoconjunctivitis Sicca) 225
Interstitial Keratitis (IK) 225
Disciform Keratitis__226
Mycotic Comeal Ulcer 226
Noninfectious Comeal Ulcers__222
Comeal Degenerations 227
Keratoconus or Ectatic Comeal Dystrophy or Conical Cornea 233
Comeal Pigmentations 235
Comeal Deposits 236
Comeal Oedema__216
Secondary Oedema 236
Essential Oedema (Diffuse Epithelial Keratopathy) 237
Bullous Keratopathy 237
Filamentary Keratopathy 237
Folds in.B owman’s Membrane__211
Ruptures in Bowman’s Membrane 237
Folds in Dcscemct’s Membrane__235
Ruptures in Descemet’s Membrane 238
Developmental Anomalies o f the Comea 238
Further Reading 239
39. Diseases of the Sclera 241-244
Episcleritis 241
Scleritis 241
Scleromalacia Perforans 243
Necrosis of the Sclera 243
Further Reading 244
40. Diseases of the Uveal T ract 244-264
Uveitis 244
Iridocyclitis (Anterior Uveitis) 250
Acute Iritis__21Q
Chronic Iridocyclitis 251
Cyclitis 251
Choroiditis__251
Pars Planitis__252
Panophthalmitis 252
Uveitis in Bacterial Infections__253
Tuberculosis of the Uveal Tract—253
Syphilis of the Uveal Tract 254
Gonococcal Iritis 254
Herpetic Keratoiridocyclitis 254
Herpes Zoster Uveitis 254
Toxoplasmosis 254
Uveitis in Noninfective Systemic Diseases 255
Uveitis due to Hypersensitivity 256
I^ns-induced Uyeitis__256
Idiopathic Specific Uveitis Syndrome 256
Uveitis in Children__258
Heterochromic Cyclitis o f Fuchs 258
Pseudoglioma 259
Endophthalmitis 259
Iris Cysts 260
DisturfaanceS-QiLCkc.ulatip.n__260
Riibeosis-Iridis__260
Masquerade Syndromes 260
Uveal E ffusion_260
Neovascularization in the Posterior Segment 261
Haemorrhage in the Uvea 261
Degenerative Changes in the Uvea 261
Congenital Anomalies of the Uvea 262
Further Reading 263
41. Pupillary Disorders
Pupillary Pathways 264
Pupillary Reflexes 265
Abnormal Pupillary Reflexes 265
Neurologic Significance of the Abnormalities in the Pupil 266
Further Reading 269
42. Diseases of the Crystalline Lens 269-277
Developmental Abnormalities of the Lens 269
Cataract 270
Cataract Associated with Systemic Diseases 275
Iatrogenic Cataract 276
Aftercataract 276
Displacement of the Lens 276
Further Reading 277
43. Diseases of the Vitreous 277-282
Fluidity o f the Vitreous 211
Vitreous Opacities 278
Muscae Volitantes or yitreous_Floaters__278
Asteroid Hyalopathy or Benson’s Disease 278
Synchysis Scintillans 279
Vitreous Haemorrhages 279
Vitreous Degenerations 280
Vitreous Detachments__280
Proliferative Vitreoretinopathy 280
Congenital Deformities in the Vitreous 281
Massive Vitreous Retraction (MVR) 281
Further Reading 281
. Glaucoma 282-309
Investigation o f Glaucoma 282
Chronic Simple Glaucoma (Simple Glaucoma, Open-angle Glaucoma) 289
Closed-angle Glaucoma 293
Treatment of Glaucoma 297
Congenital Glaucoma 301
Absolute Glaucoma__302
Secondary Glaucomas 302
Lens-induced Glaucomas__ЗШ
Secondary Glaucomas following Ocular Trauma 304
Neovascular Glaucoma (Haemonhagic Glaucoma) 304
Glaucoma in Aphakia and Pseudophakia 305
Malignant Glaucoma 305
Iatrogenic Glaucoma 306
Pigmentary Glaucoma 306
Glaucoma Capsulare 306
Epidemic Dropsy Glaucoma (Bengal Glaucoma) 306
Juvenile-onset Open-angle Glaucoma 307
Normal-tension (Low-tension) Glaucoma 307
307
Glaucoma in Developmental Disorders 307
Further Reading 308
4S. Diseases of the Retina________________________________ 309-3SS
The Normal Fundus__109
Investigations for Retinal Diseases 310
Miscellaneous Diagnostic Procedures 311
Electrodiagnostic Methods in Retinal Disorders 311
Common Developmental Abnormalities of the Fundus 314

Central Serous Retinopathy (CSR) 317


Central Chorioretinopathy 317
Cystoid Macular Oedema 317
Haemorrhages in the Fundus 318
Anomalies o f Retinal Blood Vessels 319
Exudates 319
Central Retinal Artery Obstruction (CRAO) 320
Ophthalmic Artery Occlusion 322
Central Retinal Vein Thrombosis (CRVT) 322
Neovascularization of the Fundus Oculi__325
Inflammation of the Retina__325
Senile Changes in the Retina 328
Retinal Degenerations 328
Developmental Variations in the Peripheral Part of the Fundus 330
Disorders oLBmch.^-Membrane__130
Macular Lesions Secondary to Choroidal Vascular Affections 332
Circinate Retinopathy 332
Macular Disorders__133
Retinal Dystrophies 334
Flecked Retina Syndrome 339
Vascular Retinopathies 339
Retinal Manifestations of Vascular Disease__339
Involutionary Sclerosis or Senile Arteriosclerosis 340
Diabetic Retinopathy 342
Chronic Arteriolar Capillaropathies in Retina 345
Retinal Changes in Blood Diseases 345
Retinal Changes in Hyperlipidaemia 347
Inflammatory Retinopathy 347
Anomalies of Fundus Pigmentation 347
Retinal Detachment__342
Coats* Disease__351
Phakomatoses or Hamartomous Syndromes 351
IuteiQy&_5cleiQsis or Bowncville.!s-Disease._35 1
Neurofibromatosis or von Recklinghausen’s Disease 352
Sturge-Weber Syndrome 352
von Hippel-Lindau Disease 352
Cysts of the Retina 353
Further Reading 353
46. Diseases of the Visual Pathways_________________________________________________355-366
Optic Neuritis 355
Optic Atrophy 359
Compressive Optic Neuropathy 362
Disorders o f Optic Chiasma and Optic Tract 362
Disorders o f Optic Radiations and Visual Cortex 363
Symptomatic Visual Disturbances 363
Further Reading 365
47. Strabism us 366-390
Strabismus or Squint 368
Diplopia 368
Confusion 369
Suppression 369
Amblyopia 369
Abnormal Retinal Correspondence (ARC) 372
Investigations for Squint 372
Paralysis of the Ocular Muscles 374
Ophthalmoplegia 375
Paralytic Squint 376
Cranial Nerve Palsy 377
Palsy Involving Extrinsic Ocular Muscles 378
Congenital Paralytic Strabismus 378
Concomitant Squint 379
Extropia 380
Vertical Squint 382
Gaze Palsy 384
Orthoptic Instruments 384
Pleoptic Instruments 387
Nystagmus 387
Further Reading 389

48. O cular Manifestations of Systemic Diseases______________________________________ 390-420


Ocular Involvement in Affections of the Nervous System 390
Intracranial Tumours 391
Demyelinating Diseases 394
Inflammatory Diseases of the Brain and Meninges 395
Vascular Disorders 396
Cervical Vascular Diseases 399
Metabolic Disorders 400
Disorders o f Lipoprotein 403
Sphingolipidoses 403
Disorders o f Glycoprotein Metabolism 404
Disorders o f Mineral Metabolism 405
Senile Changes in the Eyes 405
Tuberculosis 405
Syphilis 407
Parasitic Infection of the Eyes 408
Toxoplasmosis 408
Acquired Immuno Deficiency Syndrome (AIDS) 410
Diseases o f the Blood and Reticuloendothelial System 411
Skin and Mucous Membrane Diseases Related to Ophthalmology 411
Connective Tissue Disorders 413
Diseases of the Muscles 415
Miscellaneous Disorders 419
Further Reading 419

49. Tum ours 420-429


Tumours of the Cornea 420
Pigmented Tumours 421
Tumours o f the Uveal Tract 422
Tumours o f the Retina 426
Secondary Tumours of the Retina 428
Tumours of the Optic Nerve and Sheaths 428
Further Reading 429

SO. O cular Injuries 429-441


Contusion and Concussion Iniuries 430
Posttraumatic Retinal Detachments 432
Perforating Iniuries 433
Nonmechanical Injuries 437
Orbital Fractures 439
Further Reading 440
p a r t ^ l x ^ u r g i c a l p E -Q C e d u r e s ________________ .Ш =429-
51. Ophthalmic Surgery___________________________________________________________ 445-499
Surgery o f the Eyelids 446
Entropion 447
Ectropion 448
Ptosis__449.
Canthotomy 451
Canthoplasty 451
Surgery o f the Lacrimal Passages 451
Other Operations 454
Surgery o f the Conjunctiva 455
Corneal Surgery 456
Keratoplasty or Comeal Transplantation 457
Eye Bank 457
Postoperative Treatment 460
Lamellar Keratoplasty 461
Surgery o f the Iris 462
Iridotomy 464
Surgery for Iridodialysis 464
Cataract Surgery 464
Ocular Diseases Posing Problems for Surgery 465
Intracapsular Extraction o f the Lens 468
Discission for Developmental Cataract 476
Cmett£-Evacuation or Linear Extraction__417
Intraocular Lens Implantation 477
Phacoemulsification 479
Operations for Glaucoma 480
Surgery on the Trabeculum 484
Operations for Squint 487
Retinal Detachment__42Q
Cryosurgery in Ophthalmology 492
Photocoagulation 493
Intravitreal Procedures__495
Pars Plana Surgery 495
Vitreous Surgery 496
Enucleation o f the Eyeball 496
Further Reading 498

PART SEVEN—MISCELLANEOUS ASPECTS 501-545


52. Genetics and Paediatric Ophthalmology 503-512
Basic Aspects of Genetics and Inheritance 503
Sex-linked or X-linked Disorders and Ocular Affections 503
Chromosomal Aberrations 504
Paediatric Ophthalmology 504
Defects_oLtheJjlQb.e_a&-a-WliQle__506
Abnormal Skull and Face Development 506
Abnormalities o f the Vitreous 508
Abnormalities o f the Optic Disc 508
Abnormalities of the Choroid and Retina 508
Paediatric Inflammations 509
Inherited Metabolic Disorders__5Ш
Miscellaneous Disorders__509
Glaucoma in Cfaildhood 510
Tumours in Childhood__510
Prematurity and Ocular Abnormalities 510
Further Reading 512
53. Immunology Related to O cular Disorders________________________________________ 512-515
Cellular Components 512
Human Leucocyte Antigens 512
Immunologic Responses 513
Autoimmune Diseases 514
Immunologic Aspects o f Certain Ocular Affections 514
Further Reading 515
54.-Prevention and Rehabilitation of Blindness_______________________________________ 515-51?
Preventive Ophthalmology 515
Blindness in India__516
Further Reading 517
55. Eye Hygiene 517
The Visual Tasks 517
The Environment 517
Further Reading 517
56. M odern Advances in Ophthalmology_____________________________________________ 518-537
Improved Diagnostic Facilities 518
Pachometry (Pachymetry) 518
Fluorophotometry 518
Specular Microscopy 519
Computer-assisted Kcratomctry 519
Specialized Contact Lenses in Fundus Examinations 519
High-power Plus Lenses 519
Transillumination Ophthalmoscopy 519
Equator Plus Ophthalmoscope and Camera 519
Scanning Laser Ophthalmoscope 519
Confocal Scanning Laser Ophthalmoscope 520
Optic Nerve-head Imaging 520
Sensory Diagnostic Tests in Strabismus 520
Fundus Fluorescein Angiography 521
Indocyanine Grean Angiography 525
Ultrasonography 525
Computed Tomography 528
Magnetic Resonance Imaging 528
Improved Modes o f Treatments 528
Laser Therapy 529
Automated Perimetry 531
Keratorefractive Surgery 531
Adhesives in Ophthalmology 534
Pneumatic Retinopexy 535
Further Reading 535
57. Syndromes in Ophthalmology 537- 545
Further Reading 545

Appendix I: Formulary o f Topical Ophthalmic Preparations 547-549

Appendix II: Ophthalmic Instruments 550-558


Glossary 559-571

Index 573-600
Preface

This book was originally published in 1993. Since the first edition, many important advances have been
made in the science o f ophthalmology. The primary objective o f bringing out the second edition remains
still the same as the original edition. It is to provide an accurate, complete and up-to-date textbook on the
subject of ophthalmology for the students both at the undergraduate and postgraduate levels. The second
edition takes due account o f the developments in ophthalmology, and records state-of-the-art advances in
all aspects of this science—basic, investigative, clinical, and management.
Today, diagnostic techniques such as automated perimetry, fluorescein fundus angiography, digital
imaging, computer-assisted procedures, specialized lenses and ophthalmoscopes are being increasingly
employed. Newer drugs are available with better therapeutic results. Intraocular lens implantation,
phacoemulsification, keratorefractive surgery, vitreoretinal procedures are also being increasingly practised.
All these new techniques and practices have been fully described in this completely revised and updated
edition. The book can thus also fulfil the need for a valuable work of reference of lasting usefulness to
practising ophthalmologists.
The text, as in the first edition, is organized into several parts dealing with anatomy and embryology,
ocular physiology, microbiology, ocular therapeutics, optical defects and ocular examinations, ocular diseases
and ocular affections in systemic diseases, and surgical procedures, etc. This organization o f the book is
based on the premise that the aetiopathological processes and the fundamental principles o f optics and
refraction should be understood first. Next, it is essential to be familiar with the methods o f clinical
examinations. Finally, it is the study o f different ocular diseases and their differentiation from allied
disorders. The treatment, depending on the case may be medical or if necessary surgery may have to be
resorted to.
I gratefully acknowledge, as in the first edition, many authors, editors and publishers o f textbooks
from which I have collected text matters and some illustrations.
I express my sincere thanks to Prof. Ranabir Mukheijee, Prof. I.S. Roy, Prof. K.S. Mehra,
Prof. K.N. Sahoo, Prof. P.K. Mukheijee, Dr. G.N. Rao, and many others for their helpful criticism o f the
first edition of the book, which has resulted in significant improvements in this edition. I am thankful to
my younger colleagues and to my son, Dr. Imtiaz Ahmed, for assisting me in creating this new edition.
I also owe a debt o f gratitude to Appasamy Associates o f Chennai and Modem Surgical o f Kolkata for
allowing me to use a number of quality photographs of several eye equipment and instruments.
I gratefully acknowledge the sincere support and help received from the staff o f my publishers,
Prentice-Hall of India, New Delhi. I am indebted to all o f them for their unending patience and courtesy.
Finally, I express my deep appreciation and heartfelt thanks to my family members for their patience,
perseverance and encouragement, and for supporting me throughout the fulfilment of this arduous task of
revision.

E. AHMED
Acknowledgements

The author gratefully acknowledges the authors, editors and publishers o f the following textbooks from
which some illustrations have been borrowed. Parsons' Diseases o f the Eye: Churchill Livingstone, London;
M ay’s Manual o f the Diseases o f the Eye: Williams and Wilkins, Baltimore; May and Worth’s Manual o f
the Diseases o f the Eye: Bailliere Tindall and Cashell, London; Wolffs Anatomy o f the Eye and Orbit, H.K.
Lewis, London; Philps and Foster: Ophthalmic Operations, Bailliere, Tindall and Cox, London;
Cunningham's Manual o f Practical Anatomy: Oxford University Press, London; Pauchet and Dupret's
Pocket Atlas o f Anatomy: Oxford University Press, Hong Kong; Reed: The Essentials o f Perimetry, Oxford
University Press, London; Duke-Elder and Wybar: Duke-Elder's System and Ophthalmology, Vol. 6 .
Ocular Motility and Strabismus, Kimpton, London; Sorsby: Modem Ophthalmology, Butterworths, London;
Lombardi: Radiology in Neuro-Opthalmology, Williams and Wilkins, Baltimore; Wybar: Ophthalmology,
Bailliere-Taindall, London; Mann: Developmental Abnormalities o f the Eye, British Medical Association;
Mcpherson: New and Controversial Aspects o f Retinal Detachment, Harper and Row, New York; Scheje
and Albert: Textbook o f Ophthalmology, W.B. Saunders, Philadelphia; Berens and Zuckerman: Diagnostic
Examination o f the Eye; J.B. Lippincott, Philadelphia; Whittington: The Art o f Clinical Refraction, Oxford
University Press, London; Perkins: Uveitis and Toxoplasmosis, J&A Churchill, London; Stallard’s Eye
Surgery, John Wright and Sons, London; Trevor-Roper: The Eye and Its Disorders, Blackwell Scientific
Publications, Oxford; Trever-Roper: Lecture Notes in Ophthalmology, Blackwell Scientific Publications,
Oxford; Gifford's Textbook o f Ophthalmology, W.B. Saunders, Philadelphia; Parr: Introduction to
Ophthalmology, Oxford University Press, New Zealand; Galbraith: Basic Eye Surgery, Churchill Livingstone,
Edinburgh; Brian and Walton: Brain’s Diseases o f The Nervous System, Oxford University Press, London;
Whitnall: The Anatomy o f the Human Orbit, Oxford Medical Press, London; Hollwich, F.: Ophthalmology,
2nd revised ed., English translation by F.C. Blodi, Thieme and Sttraton, 1985; Peyman, G.A., Sanders,
D.H. and Goldberg, M.F. (Eds.): Principles and Practice o f Ophthalmology, W.B. Saunders, Philadelphia,
1980; Snell, R.S. and Lewp, M.A.: Clinical Anatomy o f the Eye, 2nd ed., Blackwell Science, 1998.
The author is thankful and he also acknowledges permission to reproduce certain illustrations as follows:
A.J. Bron of University of Oxford for some illustrations in The Unquiet Eye published by Glaxo Laboratories;
American Cyanamid Company, for two coloured photographs; Nicholas division of Indian Schering Ltd;
Appaswamy Associates, Chennai and Ankur Metal Works, West Bengal. The author’s gratitude is no less
in the case of help received from his esteemed colleagues.
Although every effort has been made to trace copyright holders of material printed in this book, in some
cases it has not proved possible. The publisher will be glad to hear from such copyright holders, which
will be acknowledged in the next edition.

E. AHMED
Abbreviations

А Accommodation С Candida
А Angstrom, a unit of measurement C/D ratio Cup/disc ratio
АС Anterior chamber c* Cervical vertebra 8
AC/A ratio Accommodation-convergence/accommo- CAB Cellulose acetate butyrate
dation ratio CAI Carbonic anhydrase inhibitor
АСЕ Angiotensin-converting enzyme CAT Computerized axial tomography
АСТН Adrenocorticotrophic hormone CCC Continuous curvilinear capsulorrhexis
ACV Acyclovir CCT Computerized coronal tomography
ADCC Antibody-dependent cell-mediated СБА Carcinoembryonic antigen
cytotoxic CF Complement fixation
AIDS Acquired immuno deficiency syndrome CFF Critical fusion frequency
AION Anterior ischaemic optic neuropathy CHED Congenital hereditary endothelial dystrophy
АК Astigmatic keratotomy CLV Corrected loss variance
АКС Atopic keratoconjunctivitis CMI
ALT Argon laser trabeculoplasty response Cell-mediated immunity response
АМР Adenosine monophosphate CMO Cystoid macular oedema
ANA Antinuclear antibodies CMV Cytomegalovirus
АРМРРЕ Acute posterior multi-focal placoid pigment CNS Central nervous system
epitheliopathy Coryn Corynbactcrium
Ага-А Adenine arabinoside CP angle Cerebellopontine angle
ARC Abnormal retinal correspondence CPC Central posterior curve, of the cornea
ARMD Age-related macular degeneration CPK Combined epithelial and subepithelial
AS Ankylosing spondylitis punctate keratitis
Asb Apostilbs, a term used in automated CR length Crown-rump length
perimetTy CRAO Central retinal artery occlusion
ASFA Anterior segment fluorescein angiography CRVT Central retinal vein thrombosis
ATP Adenosine triphosphate CSLO Confocal scanning laser ophthalmoscope
AV crossing Arteriovenous crossing CSMO Clinically significant macular oedema
AZT Azidothymidine CSR Central serous retinopathy
CT Computerised tomography
Cyl Cylinder
В Bacillus
B-cells Lymphocytes, bone-marrow derived
BCG Bacille Calmette-Guerine D Dioptre, unit of a lens
BDR Background diabetic retinopathy dB Decibel, term used in automated perimetry
BMR Basal metabolic rate DCG Dacryocystography
BP Blood pressure DCR Dacryocystorhinostomy
BRVT Branch retinal vein thrombosis DEAE-D Diethyl aminoethyl-dextran
BSS Balanced salt solution DEK Deep epithelial keratopathy
BSV Binocular single vision DFP Diisopropyl fluorophosphate
BUT Breakup-time of tear DHPG 9-{l ,3-dihydroxy-2-propoxymcthyl guanine
BVA Binocular visual acuity DIT Diniodotyrosine
BVDU 5-(2-bromovinyl)-2-deoxyuridine DLT Differential light threshold
DMSO Dimethyl sulphoxide
DNA Deoxyribonucleic acid
‘C Coefficient of aqueous outflow DOCA Deoxycorticosterone acetate
DSG Dacryoscintillography
xxix
E Emmetropia HLA Human leucocyte antigen
EBV Epstein-Barr virus НМ Hand movements
ECCE Extracapsular cataract extraction Hm Hypermetropia, manifest
ECF Eosinophil chemotactic factor HMS Hexose monophosphate shunt
ED glaucoma Epidemic dropsy glaucoma HSV Herpes simplex virus
EDMA Ethylene glycol dimethacrylate Ht Hypermetropia, total
EDTA Ethylenediamine tetraacetic acid HZO Herpes Zoster ophthalmicus
EEG Electroencephalography
EHC Epidemic haemorThagic conjunctivitis
EIA Enzyme immuno assay la antigen Immune-associated antigen
EKC Epidemic keratoconjunctivitis ICCE Intracapsular cataract extraction
EKP Epikeratoprosthesis ICG Indocyanine green
ELISA Enzyme-linked immuno assay IDDM Insulin dependent diabetes mellitus
EMBP Eosinophil major basic protein IDU 5-iodo-2-deoxyuridine
EMG Electromyography IF Immunofluorescene
EOG Electrooculography IFA Indirect fluorescent antibody
EPS Exophthalmos-producing susbstance Ig Immunoglobulin
ERG Electroretinography IHA Immune adherence haemoagglutination
ERP Early receptor potential IK Interstitial keratitis
ESR Erythrocyte sedimentation rate INH Isonicotinic acid hydrazide
ETDRS Early treatment diabetic retinopathy study 10 Inferior oblique
IOL Intraocular lens
IOP Intraocular pressure
5-FU 5-fluorouracil IPK Interstitial punctate keratitis
Fb F2 Focal points IR Inferior rectus
F3T Trifluorothymidine IRBP Interphotoreceptor retinal binding protein
Fab Fragment antigen binding IRMA Intraretinal microvascular abnormalities
FAMA Fluorescent antibody to membrane antigen
FAZ Foveal avascular zone
FC Finger counting i.,i2 Sizes of the print in Jaeger's near vision
Fc Fragment crystallisable chart
FFA Fluorescein fundus angiography JCA Juvenile chronic arthritis
FNAB Fine-needle aspiration biopsy JOAG Juvenile open-angle glaucoma
FTA-ABS Fluorescein treponemal antibody absorption JRA Juvenile rheumatoid arthritis

G Gutta, i.e. drop *K* Reading in keratometry indicating the


GANDA Guanethidine + adrenaline radius of the curvature of the front surface
GCV Gancicyclovir of the cornea
GHPC Geographic helicoid peripapillary K-cell Killer cell
choroidopathy KP Keratic precipitate
GM Gangliosidosis KW
GMP Guanosine monophosphate syndrome Kimmelstiel-Wilson syndrome
GPC Giant papillary conjunctivitis KWC Koch-Weeks' conjunctivitis

H Hypermetropia Laser Light amplification by stimulated emission


H. Haemophilus of radiation
HA Haemoagglutination LASIK Laser-assisted keratomileusis
HEMA Hydroxy ethyl methacrylate LATS Long-acting thyroid stimulator
HI Haemoagglutination inhibition LCAT Lecithin cholesterol acyl transferase
HIV Human immunodeficiency virus LDH Lactic dehydrogenase
HI Hypermetropia, latent LED Light emitting diode
LGV Lymphogranuloma venereum OU Oculus uterque (both eyes)
LK Lamellar keratoplasty
LR Lateral rectus
LRP Late receptor potential pp, Punctum proximum (near point)
LTF Long-term fluctuations pr, Punctum remotum (far point)
P0 Initial intraocular pressure in tonography
P, and P2 Principal points
M Myopia P, Resultant elevated pressure in tonography
m.a. Metre angle PABA Paraamino benzoic acid
mA Milliampere PACG Primary angle-closure glaucoma
MAO Monoamine oxidase PAF Platelet-activating factor
MD Mean defect PAM Potential acuity meter
MDCG Macrodacryocystography PAS Paraamino salicylic acid
MEWDS Multiple evanescent white dot syndrome Pas Peripheral anterior synechia
M1F Microimmunofluorescence PBI Protein-bound iodine
MIT Monoiodotyrosine PCF Pharyngoconjunctival fever
MK medium McCarey-Kaufman medium PCM Protein-calorie malnutrition
ML Mucolipidosis PD Pupillary distance
MLD Margin limbal distance PDMS Polydimethyl seloxane
MMC Mitomycin С PDR Proliferative diabetic retinopathy
MPP Massive preretinal proliferation PEE Punctate epithelial erosions
MPR Massive preretinal retraction РЕК Panctate epithelial keratitis
MPS Mucopolysaccharidoses PHEMA Polydihydroxymethyl methacrylate
MR Medial rectus PHPV Persistent hyperplastic primary vitreous
MRD Margin reflex distance PI Peripheral iridectomy
MRI Magnetic resonance imaging PK Penetrating keratoplasty
MVR Massive vitreous retraction PL Perception of light
Myco. Mycobacterium PMMA Polymethyl methacrylate
POAG Primary open-angle glaucoma
POB Punctate opacification of Bowman's
N. Neisseria membrane
N,&N2 Nodal points PPDR Preproliferative diabetic retinopathy
N5 to Nw 5-point to 48-point sizes of near vision chart PR Projection of rays
standardized by Faculty of PRK Panretinal photocoagulation
Ophthalmologists Ps. Pseudomonas
NADPH Nicotinamide adenine dinucleotide PSK Punctate subepithelial keratitis
phosphate PTK Phototherapeutic keratectomy
NANA N-acetyl neuraminic acid PUGH
NCL Neuronal ceroid lipofuscinosis syndrome Pigment-uveitis-glaucoma-hyphaema
NIDDM Non-insulin-dependent diabetes mellitus syndrome
NK cells Natural killer cells PVD Posterior vitreous detachment
nm Nanometer PVP Polyvinyl pyrrol idone
NPA Near point of accommodation PVR Proliferative vitreoretinopathy
NPC Near point of convergence
NRC Normal retinal correspondence
NSA1D Nonsteroidal antiinflammatory drug RA Rheumatoid arthritis
NVD Neovascularization at the disc RAI Radioactive iodifte
NVE Neovascularization elsewhere RAPD Relative afferent pupillary defect
RB inj. Retrobulbar injection
RBN Retrobulbar neuritis
OA Optic atrophy RBP Retinol-binding protein
OD Oculus dexter (right eye) RD Retinal detachment
OS Oculus sinister (left eye) RLF Retrolental fibroplasia
RMS Root mean square, a tenn in automated T-cell Thymus-derived cell
perimetry ТЕМ Triethylene melamine
RNA Ribonucleic acid TF Total fluctuations
RNFL Retinal nerve fibre layer THIOTEPA Triethylene thiophosphoramide
ROP Retinopathy of prematurity TL Total loss, a term in automated perimetry
RPE Retinal pigment epithelium TRD Traction retinal detachment
TRH Thyrotropin-releasing hormone
TRIC Trachoma inclusion conjunctivitis virus
Sc.inj. Subconjunctival injection TSCA Tumour-specific cytoplasmic antigen
SLE Systemic lupus erythematosus TSH Thyroid-stimulating hormone
SLO Scanning laser ophthalmoscope TSTA Tumour-specific transplantation antigen
SO Superior oblique
Sph Spherical
SPK Superficial punctate keratitis UGH
SR Superior rectus syndrome Uveitis-glaucoma-hyphacma syndrome
SRF Subretinal fluid Ung. Unguentum (ointment)
SRK formula Sanders, Retzlaff and Kraff formula
SRNVM Subretinal neovascular membrane
SRS-A Slow release substance of anaphylaxis VA Visual acuity
Staph. Staphylococcus VDRL Venereal disease research laboratory
STF Short-term fluctuations VER Visual evoked response
Strepto. Streptococcus VF Visual field
V1SC Vitreous infusion suction cutter
VSR Venous stasis retinopathy
T|,T2 etc. Thoracic vertebrae 1,2, etc. VZV Varicella-Zoster virus
TAA Tumour-associated antigens
ТВ Tuberculosis
TCA cycle Tricarboxylic acid cycle YAG laser Yttrium-aluminium-gamet laser
Part One
Anatomy and Embryology

T~? ach eyeball or globe, with the anteroposterior, vertical and horizontal
XJ/diameters of 24 mm, 23 mm and 23.5 mm respectively, occupies
the anterior part of the bony orbit. The eyeball comprises three concentric
coats— outermost, middle and innermost. The outermost coat, protective
in function, contains the opaque sclera in its posterior five-sixth portion
and the transparent cornea in its anterior part. The anterior part of the
sclera is covered by the conjunctiva which also covers the back surface
of the eyelids. The middle coat of the globe, vascular and nutritive, is
made up o f the iris, ciliary body and choroid—all three constituting the
uveal tract. The innermost coat is the retina. The ocular appendages are
the eyelids, eyebrows, conjunctiva and lacrimal apparatus. There are
two sets of muscles—extrinsic, six in number, and intrinsic, three in
number. The extrinsic muscles comprise four recti and two obliques,
while the intrinsic muscles are the sphincter pupillae, dilatator pupillae
and ciliary muscle. Aqueous humour, the intraocular fluid, occupies the
anterior and posterior chambers. The posterior four-fifth of the globe is
occupied by the vitreous humour. The crystalline lens is placed behind
the iris and in front of the vitreous body.
This section deals with the orbit and its contents, eyelids, lacrimal
apparatus, conjunctiva, cornea, sclera, uveal tract, retina, visual pathways,
extrinsic muscles and with the parts involved in glaucoma.
Certain basic aspects of the embryology of the eye should also be
understood since there are lot of developmental anomalies in each tissue
of the eyeball and its appendages.
V_____________________________________________________________ -
1. ANATOMY OF THE ORBIT13 Orbital index. It is the ratio of the height to the
width x 100. There are three types o f orbital index:
Seven bones contribute to the formation of the pear- (i) mesosemes (intermediate): index between
shaped orbit: the frontal, sphenoid, maxillary, 83-89
palatine, zygomatic, ethmoid and lacrimal. It has a (ii) megasemes (large): index more than 89
base, margin, apex and four posteriorly converging (iii) microsemes (small): index less than 83.
walls. The orbital cavity is directed forward,
outward and slightly downward. Walls of the Orbit (Fig. 1.1)
Base. The base of the orbit represents the anterior Roof. This is approxim ately triangular and
open end. consists, anteriorly of the orbital plate of the frontal
Margin. This is made up o f three bones: the bone—the major contribution; and posteriorly, the
frontal, zygomatic and maxilla. There are four lesser wing of the sphenoid bone.
portions: superior, inferior, medial, and lateral. Floor. This is roughly triangular and consists
Apex. The apex corresponds to the optic foramen. centrally, o f the orbital plate o f the maxilla,
anterolaterally o f the zygom atic bone, and
Average dimensions. Table 1.1 indicates average posteriorly of the orbital process of the palatine
dimensions of the orbit. bone.

Table 1.1 Medial wall. This is quadrangular and is the


Average Dimensions of the Orbit thinnest of all the walls, 0.2-0.4 mm. It consists,
in the main central part, of the lamina papyracea
Each orbital margin 40 mm of the ethmoid; superoanteriorly, of the frontal
Width of orbital opening 40 mm process of the maxilla; inferoanteriorly, o f the
Height of orbital opening 35 mm lacrimal bone; and posteriorly, of the lateral aspect
Interorbital distance 25 mm of the body of the sphenoid.
Extraorbital distance 100 mm
Length of sphenoid fissure 22 mm Lateral wall. This in triangular is shape and is
Distance between the strongest of all the walls. Both lateral walls
intracranial openings of 2opticcanals 25 mm
orbital openings of 2 opticcanals 30 mm form an angle of about 90° to each other. Each
Orbital volume 30 ml wall forms an angle of about 45° with the median

Optic foramen, transmitting optic


Supraorbital notch for supraorbital vessels and nerve and ophthalmic artery
Superciliary arch
. Frontal bone
F ossa for lacrimal Anterior ethmoidal foramen for anterior
Superior orbital fissure ethmoidal vessels and nerve
transmitting:
Lacrimal nerve
Frontal nerve Orbital plate of ethmoid (Lamina papyracea)
4th or trochlear nerve - Lacrimal bone
3rd or oculomotor nerve
Nasociliary nerve • Nasolacrimal canal
6th or abducent nerve
Superior and inferior ophthalmic Posterior ethmoidal foramen for posterior
veins ethmoidal v essels and nerve
Inferior orbital fissure; ** Foram en rotundum for maxillary nerve
Zygomatic bone * ; Infraorbital foramen and canal for
Maxilla infraorbital v essels and nerve
Fig. 1.1 Right orbit (Pauchet and Dupret).
3
sagittal plane. Each is made up of the orbital surface roof and the lateral wall of the orbit, having two
o f the zygomatic in the anterior one-third, and that segments. The wide medial segment communicates
of the greater wing of the sphenoid in the posterior with the middle cranial fossa, while the narrow
two-thirds. lateral segment is closed by the dura mater.
Relations are shown in Table 1.2. Through the wide part the following structures pass:
(a) the three branches of the ophthalmic division
Table 1.2
of the trigeminal nerve, (b) the III, IV and VI
Relations o f the O rbit
cranial nerves, (c) the ophthalmic vein or veins,
Relations Structures (d) the orbital branch of the middle meningeal
artery and the recurrent meningeal branch of the
Superior Anterior cranial fossa
Frontal sinus lacrimal artery and (e) the sympathetic fibers from
Supraorbital sinuses the cavernous plexus. A tendinous ring known as
Medial Ethmoid air cells annulus tendinous communis ofZinn surrounds the
Nasal cavity optic canal and part of the medial segment of the
Sphenoid sinus superior orbital fissure.
Inferior Maxillary antrum Optic foram en and canal. The optic foramen is
Palatine air cells
the vertically oval opening at the apex of the orbit
Lateral Middle cranial fossa and marks the orbital end o f the optic canal. The
Temporal fossa
Pterygopalatine fossa optic canal, about 4-9 mm long and 4-6 mm wide,
lies between the two roots of the lesser wing of the
sphenoid bone. It is directed posteromedially and
L a n d m a rk s
makes an angle of about 36° with the median
Superior orbital or sphenoid fissure (Fig. 1.2). sagittal plane. The canal transmits (a) the optic
Between the greater and lesser wings o f the nerve, (b) the ophthalmic artery, (c) the branches
sphenoid there lies an anterolaterally directed of the sympathetic carotid plexus, and (d) the
oblique gap about 2 cm long, situated between the prolongations of the optic nerve sheaths.
Frontal n. Trochlear

Sup. ophthalmic v.

Recurrent meningeal a.

Oculomotor n.,
upper division
Nasociliary n.
Sympathetic n.
Abducent
Ophthalmic a.
Oculomotor n.,
lower division Inf. ophthalmic v.
Fig. 1.2 Anatomical relations at the apex o f the right orbit (Reed).
Fossa fo r the lacrimal gland. This is on the C o n te n ts
frontal bone and is situated at the anterolateral angle
Apart from the eyeball which occupies most of its
of the orbit.
space the orbit contains the following:
Trochlear fossa. This is on the frontal bone,
(a) Muscles. Six extrinsic, lid muscles and
5 mm behind the anteromedial angle o f the orbit.
plane muscles o f the orbit.
It contains the pulley of the superior oblique
muscle. (b) Arteries. Two sources—ophthalmic and
terminal branch of the external carotid.
Zygomaticofrontal suture. This lies between the
roof and the lateral wall of the orbit. (c) ( Veins. Superior ophthalm ic, inferior
ophthalmic and central retinal.
Supraorbital notch and canal. This is at the
junction of the medial third and lateral two-third (d) Nerves. И, П1, IV, VI, first two divisions
of the superior ©rbital margin and transmits the of the V cranial; sympathetic fibres to the eyeball,
supraorbital nerve and vessels. the lacrimal gland, the plane muscle of the orbit
and to the blood vessels; and parasympathetic fibres
Orbital tubercle o f the zygomatic bone. This is to the lacrimal gland through the VII cranial.
11 mm below the frontozygomatic suture. The
structures attached to it are: (a) the check ligament (e) Orbital fascia.
o f the lateral rectus, (b) the suspensory ligament (f) Ciliary ganglion.
o f the eyeball, (c) the lateral palpebral ligament
and (d) the aponeurosis of the levator palpebrae Ophthalmic Artery (Fig. 1.3)
superioris. The combined attachment o f these
structures is called the lateral retinaculum. Ophthalmic artery arises from the anteromedial
aspect o f the internal carotid artery, just medial to
Zygomatic canal. This is in the lateral wall. It the anterior clinoid process. The artery has three
transmits the zygomatic nerve and branches of the parts: one part lying inferolateral to the optic nerve;
infraorbital artery. the second crossing the optic canal to lie on the
M eningeal foramen. This is in the lateral wall.
Medial palpebral Lateral palpebral
It transmits the orbital branch o f the middle
meningeal artery with the accompanying vein. Supratrochlear
Dorsal nasal
Lacrimal fossa. This lodges the lacrimal sac in
Infratrochlear N.- Supra-orbital
the medial wall, and is situated between the anterior
Anterior ethmoidal
and posterior lacrimal crests. A. and
Inferior orbital or sphenomaxillary fissure. This Posterior ciliary Arteria retinae
is about 2 cm long and is situated between the Posterior centralis
ethmoidal Posterior ciliary
floor and posterior two-third of the lateral orbital
Ophthalmic
wall. It transmits these structures: (a) the maxillary Muscular
division of the V cranial nerve; (b) the infraorbital
Lacrimal
artery; (c) the zygomatic nerve; (d) the branches
^ •O p h th alm ic
of the inferior ophthalmic vein to the pterygoid
plexus; and (e) the branches of the sphenopalatine Nasociliary N.
ganglion. Internal carotid
Fossa at the anteromedial angle o f the floor. The Fig. 1.3 Illustration of the ophthalmic artery and its
inferior oblique muscle originates from this fossa. branches (Cunningham).
lateral side of the optic nerve; and the last lying Table 13
medial to the optic nerve. Leaving the dural sheath, Branches of the Ophthalmic Artery
it lies within the muscle cone, crosses the optic
nerve usually above, and runs towards the medial Central retinal
side o f the orbit. Running forward between the superior and inferior papillary
nasal and temporal branches
superior oblique and the medial rectus, ophthalmic
artery ends by sp littin g into two term inal Lacrimal
branches—the frontal and the dorsal nasal. lateral palpebral
zygomatic
The branches of the ophthalmic artery are listed
recurrent meningeal
in Table 1.3.
Muscular (7)
anterior ciliary
Superior Ophthalmic Vein (Fig. 1.4) Posterior ciliary
It is the largest vein in the orbit and originates at long (2 )—medial and lateral
short (15-20)
the junction of the angular and supraorbital veins. Anterior ethmoidal
It runs alongside the ophthalmic artery and receives Posterior ethmoidal
several tributaries such as the inferior ophthalmic,
Pial
the central retinal, the anterior ciliary via the
m uscular veins, the anterior and p o sterio r Supraorbital
ethmoidal, two vorticose and the lacrimal. It finally Medial palpebral
drains into the cavernous sinus. Anterior meningeal
Central artery o f the optic nerve
Inferior Ophthalmic Vein Supratrochlear (frontal) л
n___/ ___ i f terminal branches
This vein (Fig. 1.4) arises in the floor o f the orbit

Fig. 1.4 Diagramatic representation of the orbital veins: I, cavernous sinus: 2, vein of Vesalius; 3, pterygoid
venous plexus; 4, deep facial vein; 5, facial vein; 6, nasal vein; 7, angular vein; 8, frontal vein, 9, supraorbital vein;
10, frontal sinus; 11, maxillary sinus; 12, superior ophthalmic vein; 13, inferior ophthalmic vein; and 14, optic nerve.
as a plexus, runs alongside the inferior rectus, and ophthalmic artery. Essentially, a cell-station of the
joins either the superior ophthalmic vein or drains parasympathetic elements of the III cranial nerve,
directly into the cavernous sinus. it has three roots which enter its posterior aspect:
(a) the short motor or parasympathetic—from the
Ciliary Ganglion (Figs. 1.5 and 1.6) nerve to the inferior oblique, (b) the long sensory—
from the nasociliary branch o f the ophthalmic
A small, rectangular body 2 mm horizontally and
division of the V cranial, and (c) the sympathetic—
1 mm vertically situated at the apex of the orbit
from the internal carotid plexus.
within the loose fatty tissue, it lies about 1.5 cm Variations in the ciliary ganglion are common,
behind the globe, nesting between the optic nerve e.g. multiplicity or absence of a root.
and the lateral rectus and on the lateral side o f the
Superior branch of the
Accessory ciliary ganglia. Thirty or more in
oculomotor nerve number, these are associated with the ciliary nerves
i Inferior branch of the
\ oculomotor nerve and may be concerned with the contraction of the
*•0*0 cilian, nefVpc
\ \ pupil or convergence.
.Lacrimal nerve
Frontal nerve
Nasociliary nerve Surgical Spaces in the Orbit
Ophthalmic nerve
1. Subperiosteal space is situated between the
orbital wall and the periorbita.
Short ciliary W 2. Peripheral space is bound internally by the
nerves 12 3 Gassenan extrinsic muscles with their fascial expansions,
ganglion
peripherally by the periorbita, anteriorly by the
Fig. 1.5 R oots o f ciliary ganglion 1, short root; septum orbitale, and it merges posteriorly with
2, sym pathetic root and 3, long root (Hollwich).
the retrobulbar space.
3. Retrobulbar (central) space, also called muscle
cone, is a cone-shaped space limited anteriorly
by the globe, posteriorly by the annulus
tendinous communis of Zinn and laterally by
the extraocular muscles.
4. Episcleral (Tenon) space lies round the eyeball
between the sclera and Tenon’s capsule.

Tenon’s Capsule or the Fascia Bulbi


(Fig. 1.7)
Tenon’s capsule or fascia bulbi is a thin fibrous
membrane consisting of the outer parietal and inner
visceral layers. It extends from the limbus to the
optic nerve and blends anteriorly with the
subconjunctival connective tissue and posteriorly
with the dural sheath of the optic nerve. It is
attached to three structures: the globe, the extrinsic
Fig. 1.6 A lateral view of the orbit showing the muscles, and the sclera and is picrccd by three
position of the needle when the injection commences.
major sets of structures: six extrinsic muscles, venae
(Note that the cxtraocular muscles and lateral wall of
the orbit have been removed in this model. (Courtesy: voFticosae, and the optic nerve with surrounding
J.E.K. Galbraith) ciliary arteries and nerves. Each extrinsic muscle

b
The optic nerve. The anatomy of the optic nerve
has been described under anatomy of the visual
pathways (see Chapter 12).
The thirdt fourth and sixth nerves (Fig. 1.8). The
nuclei of the third and fourth nerves lie in the mid-
brain just anterior to the cerebral aqueduct at the
level of the superior colliculi. The nuclei of the
sixth nerve lie in the pons beneath the floor of the
upper part o f the fourth ventricle. The third nerve
nucleus is divided as follows (Fig. 1.9).
Table 1.4 and Fig. 1.9 give a brief account of
this nuclear complex.

Table 1.4
Subdivisions of the Oculomotor Nuclear Complex

Parts o f the nucleus Supply to


Pairded
Dorsolateral ipsilateral inferior rectus
Fig. 1.7 Schematic view of a horizontal section Intermediate ipsilateral inferior oblique
through the right orbit to illustrate the fascia of the orbit. Ventromedial ipsilateral medial rectus
The fascia bulbi or Tenon’s capsule, is shown by A, its Unpaired
anterior part, and P, its posterior part. The fascial sheaths Caudal central levator palpcbrac supcrioris
of the muscles are marked by S, and their offshoots Edinger-Westphal prcganglionic parasympathetic
form the lateral, C, and the medial, H, “check ligaments.” fibres in ciliary ganglion
The drawing also illustrates certain points in the anatomy Pcrlia possible role in convergence
of the eyelids. MT, the medial palpebral ligament with Large multipolar contralateral superior rectus
its two limbs passing in front of and behind the fossa
for the lacrimal sac; LR, the lateral palpebral ligament; The third nerve emerges from the brain and
and the lateral palpebral raphe (Whitnall: Anatomy of passes between the superior cerebellar and posterior
the Human Orbit. Oxford Medical Press, London). cerebral arteries. It runs forward and pierces the
dura mater on the lateral side of the posterior clinoid
is clothed by a tubular reflection from Tenon’s
process. It traverses the lateral wall of the cavernous
capsule. The lateral and medial recti receive such
sinus and divides into superior and inferior divisions
capsular expansion which partly limits some action
which enter the orbit through the superior orbital
of either of the two muscles. This is known as the
fissure. The plan of the oculomotor nerve has been
check ligament. The reflection from the superior
shown in (Fig. 1.10).
oblique and the inferior oblique muscles are
The fourth nerve is the largest cranial nerve.
respectively attached to the trochlear pulley and
The fibres of this most slender nerve first run
the outer part of the floor of the orbit.
downward and laterally through the tegmentum and
The lower part of Tenon’s capsule, the ligament
then turn backward and at the anterior medullary
o f Lockwood, is especially thickened forming a
velum the nerve fibres decussate w ith the
hammock in which the globe rests.
corresponding fibres of the other side and cross
the median plane to emerge just behind the inferior
Cranial Nerves in the Orbit12
colliculi. The nerve passes round the cerebral
O f the 12 cranial nerves, the following are the main peduncle just above the pons and pierces the
nerves concerned with the structures in the orbit. tentorium cerebelli to enter the cavernous sinus. It
then enters the orbit through the superior orbital The fifth (trigeminal) nerve. This arises from the
fissure, and runs along the orbital roof to supply undersurface of the pons on its lateral aspects by
the SO. two roots—a large sensory and a small motor and

Fig. 1.8 Nerves to the muscles of the eyeball: HI. IV and VI cranial nerves 1. orbital cavity; 2, trochlear nerve,
to superior oblique; 3. oculomotor nerve, superior division; 4, nasociliary nerve: branch of ophthalmic nerve, giving
the sensory root (radix longa ganglii ciliaris) to the ciliary ganglion; 5, sympathetic root; 6. internal carotid artery;
7, sympathetic root; 8, oculomotor nerve; 9, trochlear nerve; 10. abducent nerve; 11. trigeminal nerve; 12. trigeminal
ganglion (g. semilunars); 13, maxillary nerve; 14, mandibular nerve; 15, communicating branches of ophthalmic
nerve; 16, ophthalmic nerve; 17, N. to levator palpebrae superioris; 18, N. to superior rectus; 19, N. to medial rectus;
20, ciliary ganglion; 2 1 , efferent branches from the ganglion (short ciliary nerves, upper group); 22 , intra-ocular course
of ciliary nerves; 23, eyeball (bulbus oculi); 24, optic nerve, cut across; 25, short ciliary nerves, lower group; 26, N.
to inferior oblique; 27, motor or short root of ciliary ganglion; 28, N. to lateral rectus; 29, N. to inferior rectus; 30,
inferior division of oculomotor nerve; 31, sympathetic root (Pauchet and Dupret).

Dorsal aspect
Fig. 1.9 Topographic organization within the
oculomotor nucleus. 1 , viseeral nucleus; 2 , inferior rectus;
3, medial rectus; 4, inferior oblique; 5, superior rectus; Fig. 1.10 Distribution of the oculomotor nerve. UD,
6, levator palpebrae superioris. L = left; R = right; CCN upper division; LD, lower division; CG, ciliary ganglion;
= caudal central nucleus; D = dorsal nucleus; VN = LPS, nerve to levator palpebrae superioris; MR. nerve to
ventral nucleus; IC = intermediate nucleus; IV = trochlear medial rectus; SR. nerve to superior rectus; IR. nerve to
nucleus (Warwick). inferior rectus; and 10. nerve to inferior oblique.
passes forward in the posterior fossa to pierce the four groups of branches: (a) in the cranium, (b) in
dura mater to reach the apex of the temporal bone. the pterygopalatine fossa, (c) in the infraorbital
The sensory root expands and forms the trigeminal canal, and (d) on the face.
ganglion (Gasserian ganglion) which splits into The mandibular nerve is made up of two roots—
three divisions: (a) the ophthalm ic, (b) the the large sensory and the small motor. It descends
maxillary, and (c) the mandibular. The motor root through the foramen ovale of the sphenoid bone.
em erges under the ganglion and becom es It supplies the teeth and gums of the mandible,
continuous with the mandibular division. Table 1.5 skin o f the temporal region, lower part o f the face,
enumerates the branches. muscles o f mastication, etc., as also mucous
Table 1.5 membrane of the anterior two-third of the tongue
and floor o f the mouth.
Branches of the Trigeminal Nerve
The sixth nerve. The fibres leave the nucleus just
Ophthalmic division (sensory) below the floor of the fourth ventricle, and pass
Nasociliary
Long ciliary forward through the pons to emerge at its lower
Infratrochlear border. The nerve follows a long course along the
Anterior ethmoidal base of the brain and pierces the dura matera lateral
Posterior ethmoidal to the dorsum sellae to enter the cavernous sinus.
Long root of ciliary ganglion
Frontal (largest branch) It then follows the same route as that of the third
Supratrochlear and fourth nerves.
Supraorbital
Lacrimal (smallest branch) The facial (W ith) nerve [Fig. 1.11]. The facial
nerve has got two roots—the motor and the sensory.
Maxillary division (sensory)
Infraorbital
Middle superior alveolar
Anterior superior alveolar
Middle meningeal
Zygomatic
Zygomaticofacial
Zygomaticotemporal
Pterygopalatine•

Mandibular division (sensory and motor)


Sensory
Auriculotemporal
Inferior alveolar
Lingual
Buccal
Motor
Supply to muscles of mastication
Fig. 1.11 The relation of the facial nerve to the neck
The ophthalmic nerve lies in the lateral wall of
of the mandible shown on a model (Courtesy: J.E.K.
the cavernous sinus, and then it enters the orbit Galbraith).
through the superior orbital fissure. It supplies the
skin of the face and scalp, and supplies sensory The two roots arise at the lower border of the pons.
fibres to the conjunctiva, comea, iris and possibly The nerve passes laterally and anteriorly (with the
secretory fibres to the lacrimal gland. The lacrimal, auditory nerve) to the internal auditory meatus. It
frontal and nasociliary are its three branches. enters the facial canal and finally descends to reach
The maxillary nerve passes through the foramen the stylomastoid foramen. It continues to the
rotundum into the pterygopalatine fossa and enters substance of the parotid gland and divides behind
the orbit through the inferior orbital fissure. It has the ramus of the mandible into branches.
The branches are listed in Table 1.6. each side there are three groups: the anterior and
middle groups enter the middle meatus, while the
Table 1.6 posterior groups open into the superior meatus,
Branches of the Facial Nerve forming a medial relation to the optic canal.
Sphenoidal sinuses. These two sinuses lie within
Within the facial canal
the body of the sphenoid bone and relate superiorly
Greater petrosal nerve
Tympanic to the optic chiasma and the pituitary body laterally
Nerve to stapedius to the internal carotid artery and the cavernous
Chorda tympani sinus.
A t Ihe exit fro m the stylom astoid foram en
Posterior auricular Maxillary sinuses. These are the largest accessory
Nerve to digastric paranasal sinuses situated in the body o f the
Nerve to stylohyoid maxilla. The roof of the sinus is often ridged by
On the face the infraorbital canal.
Temporal
Zygomatic
Buccal F u rther R eading
Mandibular
Cervical 1. Bron, A.J., Tripathi, R.C., Tripathy, B.J. (Eds.),
Wolff's Anatomy o f the Eye and Orbit ( 8th ed.),
Chapman and Hall, London, 1997.
Sphenopalatine (Pterygopalatine) 2. Duke-Elder, S., System o f Ophthalmology,
Ganglion Vol. II: The Anatomy o f the Visual System,
The largest p erip h eral ganglion o f the Duke-Elder, S. and Wybar, K. (Eds.), Kimpton,
parasympathetic system, connected functionally London, 1961.
with the seventh nerve, is situated just below the 3. Gray, H. G ray’s Anatomy (35th ed.), Warwick,
maxillary nerve and is deeply placed in the R. and W illiam s, P.L. (Eds.), Longman,
p tery g o p alatin e fossa. It has two roots, London, 1973.
parasympathetic and sympathetic.
Parasympathetic fibres derived from lacrimatory
nucleus of the facial nerve are preganglionic and
relayed in this ganglion. They follow a complicated
2. ANATOMY OF THE
course and supply secretomotor fibres to the EYELIDS13
lacrimal gland. Postganglionic sympathetic fibres
The eyelids (Fig. 2.1) are movable folds to protect
reach this ganglion and follow also a complicated
the eye from external injury, excessive light and
course.
undue exposure, to facilitate the distribution of tear
and glandular secretions, and to help in the
Paranasal Sinuses in Relation to the regulation of the amount of light reaching the retina.
Orbital Walls The palpebral fissure is an elliptical space, 30 mm
long x 10 mm wide, between the upper and lower
Frontal sinuses. The septum between the two
lid margins when the eye is open.
frontal sinuses is frequently not strictly median.
The eyelids unite laterally at an acute angle lying
The sinus opens into the anterior part of the middle
in direct continuity with the globe (lateral canthus)
meathus.
and medially at a rounded angle (medial canthus)
Ethmoidal sinuses. These are numerous thin- in which there are two structures namely the
walled sinuses within the ethmoid bone and on caruncle and plica semilunaris.
O rbital Tarsal
portion portion
Septum Fat Levator
Upper palpebral furrow Muscle of Muller

Gland of Krause
Intermargm al sulcus
Upper punctum
Orbicularis

Plica sem ilunaris


Caruncle
Penpheral arcade
W $ —
Lower punctunv

Openings of Glands of
tarsal glands- Wolfnng
palpebral Sweat gland —
1 ■x stt
$ $ —

furrow Meibomian gland


Ш in the tarsal plate
Naso jugal furrow
Marginal arcade
Fig. 2.1 The surface anatomy of the eye and eyelids Lash with gland of
Zeis running into Opening of
(Trevor-Roper and Curran). this duct of Moll’s Meibomian gland
gland
The eyelid margin, 2 mm broad, is divided by
the lacrimal punctum into the large ciliary portion, Fig. 2.2 Structures seen in a vertical section of the
upper lid: 1, skin; 2, eyelashes with gland of zeis; 3,
of the anterior border from which the eyelashes
orbicularis oculi; 4, levator palbebrae superioris; 5,
arise and the small lacrimal portion, having neither Meibomian glands; 6, opening of Meibomian gland; 7,
cilia nor Meibomian ducts. The posterior border of Krause’s glands; 8, glands of Wolfring; and 9, conjuctiva.
the lid margin is sharp and is in contact with the
globe. Grey line is midway between the anterior is loose and delicate, containing no fat. The
and posterior borders of the lid margin and lies palpebral fibres o f the orbicularis oculi run parallel
anterior to the openings o f Meibomian ducts and to the palpebral fissure. The submuscular areolar
through it lid—halving between the orbicularis and tissue communicates with the subaponeurotic layer
the tarsus is possible. of the scalp. It is traversed by the fibres of the
levator, palpebrae superioris and the nerves to the
S tr u c tu re (Fig. 2.2)
eyelids, and through this plane the lid can be halved
The layers o f an eyelid are disposed into an anterior and posterior portion. The fibrous
anteroposteriorly as follows: layer consists of the thickened tarsal plate and
1. The skin peripheral part, the palpebral fascia {septum orbitale).
Septum orbitale (palpebral fascia) arises at the
2. The subcutaneous areolar layer orbital rim from the thickened periosteum called
3. The layer of striated muscle—orbicularis oculi arcus marginale. It is attached to the anterior and
4. The submuscular areolar tissue posterior lacrimal crests. It is fused above with the
lev ato r aponeurosis and below w ith the
5. The fibrous layer made up of tarsus and capsulopalpebral fascia. This fascia is pierced by
septum orbitale the following structures: (i) lacrimal vessels and
6 . The layer o f unstriated muscle—M uller’s nerve, (ii) supratrochlear nerve, (iii) supraorbital
muscle vessels and nerve, (iv) frontal arte ry , (v)
7. The palpebral conjunctiva. infratrochlear nerve, (vi) anastomosis between
angular and ophthalmic veins, (vii) superior
The skin is extremely thin and is marked by palpebral arteries, (viii) inferior palpebral arteries,
furrows—the superior and inferior palpebral sulci— (ix) levator palpebrae superiories, and (x) expansion
when the eyes are open. The subcutaneous tissue of inferior rectus.
The fusion of this fascia with the fibres of the The orbicularis is subdivided into three
orbicularis oculi on the lateral side forms the lateral parts.
palpebral raphe.
(a) Palpebral part
The tarsus constitutes the form and support of
the eyelid and is made up o f thickened fibrous Pretarsal or marginal (muscle of Riolan)
tissues encircling the acini o f the tarsal or Preseptal or peripheral
Meibomian glands. About 29 mm long and 1 mm
(b) Orbital part
thick, its shape resembles the letter “D” placed
on its side. It is made up of two surfaces—the (c) Lacrimal part (Homer’s muscle).
anterior and posterior, two borders—the attached The palpebral part forms two half ellipses, one on
is continuous with the septum orbitale, and each lid. It arises from the medial palpebral
the free and two extremities—the medial and ligament and the bone immediately above and
lateral. below this ligament and sweeps across the eyelids
The superior unstriped muscle (Muller’s muscle) to finally form the lateral palpebral raphe. Its action
takes origin from the levator fibres, while the is essentially a sphincter of the eyelid. The other
inferior is from the inferior rectus; they are inserted actions of the muscles are variable depending upon
to the corresponding tarsus and supplied by the the part o f the muscle brought into play, e.g. the
sympathetic. orbital part acts during forcible closure of the
The palpebral conjunctiva is subdivided into eyelids and causes expansion o f the lacrimal sac
three portions—marginal, tarsal, and orbital. during stretching of the lacrimal diaphragm in a
lateral direction.
Muscles of the Eyelids
L evator palpebrae superioris. The muscle MUller's muscle. This consists of the unstriped
originates from the undersurface of the lesser wing muscle fibres derived from the expansion o f the
o f the sphenoid bone, above and in front of the levator in the upper lid and that of the inferior
optic foramen. The muscle ends anteriorly in a rectus in the lower lid. Each muscle is inserted
wide aponeurosis, the extremities being called the into the proximal edge of the tarsus and is supplied
lateral and medial “horns”. by the sympathetic. This muscle causes 2-mm
The muscle is intersected by three slips: (a) elevation of the upper lid.
anteriorly it traverses between the fibres of the
orbicularis and these muscle fibres are attached to Glands of the Eyelids
the skin, (b) centrally it is inserted at the upper Meibomian glands. These are about 20 to 40
border of the tarsus, and (c) posteriorly, it is inserted highly developed sebaceous glands within the tarsus
at the upper fornix. The lateral horn is attached to extending from its upper to lower border, and each
the orbital tubercle of the zygomatic bone and opens by a single vertical duct on the free margin
lateral palpebral ligament. The medial horn is of the eyelid. The lower lid has lesser glands than
attached to the frontonasal suture and medial the upper. The oily meibomian secretion mixes
palpebral ligament. The muscle is supplied by the with tear and does not allow it to overflow, thus,
oculomotor nerve. It acts as an elevator (10 mm) guarding against xerosis of the conjunctiva and
o f the upper lid and as a direct antagonist of the cornea.
orbicularis oculi.
Zeis *5 glands. These are minute sebaceous glands
Orbicularis oculi. This is a broad, flat, elliptical
connected with the eyelashes.
sheet of concentric muscle fibres covering the
eyelids and circumference of the orbit. It spreads Moll*s glands. These are minute sweat glands
over the temporal region downward toward the opening between the two eyelashes or into the duct
cheek. It is supplied by the facial nerve. of Zeis’s gland.
The deep or posttarsal drains into the orbital
which drains into the cavernous sinus and the deep
The superficial structures of the eyelids are supplied
facial which drains into the pterygoid plexus.
by a free anastomosis derived from two sources. The two systems of veins meet in the angular
Supraorbital Supraorbital Frontal artery vein, the nodal point of the entire venous system
artery vein of the eyelids. The angular vein is situated at the
inner canthus 8 mm away from the medial angle
Frontal of the lids and lateral to the corresponding artery.
vein
Frontal
Lacnmal artery L y m p h a tic c ra in a g e
artery
Angular From the lateral side, the lymph vessels drain into
Superficial
temporal vein and the preauricular and parotid lymph glands. From
artery
the medial side, the lymph vessels drain into the
submaxillary lymph nodes.
acial
vein and
artery N erve su p p ly (Fig. 2.4)
EVi
It is divided into three groups: (a) motor—the facial
v--------------- Г and oculom otor, (b) the sensory— from the
T ransverse facial artery infraorbital artery
trigeminal and (c) the sympathetic—supplying
Fig. 2.3 The blood supply of the eyelids (Wolff). Muller’s muscle.

The facial system is composed of (a) the facial Supraorbital


artery, (b) the superficial temporal artery consisting
o f the transverse facial, the frontal and the
zygomaticoorbital, and (c) the infraorbital artery.
The orbital system or the branches of the
ophthalmic artery consists of (a) the dorsal nasal
artery, (b) the frontal artery, (c) the supraorbital
artery, and (d) the lacrimal artery.
The deeper structures are supplied by four
palpebral arcades, two in each lid and one at either
border of the tarsus: (a) the medial palpebral—
from the dorsal nasal branch of the ophthalmic
artery, and (b) the lateral palpebral—from the
lacrimal artery, branch of the ophthalmic.
Both anastomose and form two arterial arcades
in each lid. Of the marginal and peripheral arcades, Fig. 2.4 Sensory supply to the eyelid: 1, lacrimal
nerve; 2, Supraorbital nerve; 3. supratrochlcar nerve; 4,
the former is the larger and runs 3 mm from the
infratrochlear nerve; and 5. infraorbital nerve (Snell and
free border of the lid.
Lemp).

V enous d ra in a g e
F urther Reading
The supeificial or pretarsal vein drains into the
anterior facial which in turn drains into the internal 1. Bron, A.J., Tripathy, R.C. and Tripathy, B.J.
jugular and the superficial temporal which in turn (Eds.), W olff s Anatomy o f the Eye and Orbit,
drains into the external jugular. ( 8th ed.). Chapman and Hall, London, 1997.
2. Duke-Elder, S., System o f Ophthalmology,
Vol. II: The Anatomy o f the Visual System,
The lacrimal gland consists of the major—the
Duke-Elder, S. and Wybar, K. (Eds.), Kimpton,
orbital part, and the minor— the palpebral part
London, 1961.
which is about one-third of the size of the orbital
3. Gray, H. Gray’s Anatomy (35th ed.), Warwick, part, the two parts being continuous behind and
R. and W illiam s, P.L. (E ds.), Longm an, separated in front by the expansion o f the
London, 1973. aponeurosis of the levator muscle. The palpebral
part can be seen after everting the upper lid while
the eye looks down.
The orbital part. The orbital part has two
3. ANATOMY OF THE surfaces—the superior and inferior, two borders—
LACRIMAL APPARATUS14 the anterior and posterior and two extremities—
the medial and lateral. Relations are as follows:
The lacrimal apparatus consists of the lacrimal (a) The superior surface connects the fossa for
gland that is the secretory part and the lacrimal the lacrimal gland with the intervening
passages which form the collecting part. periosteum.

Fig. 3.1 Lacrimal apparatus: 1, lacrimal gland; 2, superior portion; 3, lacrimal ducts opening in superior fom ix;
4. palpebral portion o f lacrimal gland; 5, eyeball covered with conjuctiva; 6. inferior tarsus; 7, inferior fom ix;
8. palpebral fascia o f low er lid; 9. low er lacrimal canaliculus opening at punctum lacrim ale on papilla lacrimalis;
10. horizontal portion o f same; 11. portion formod by upper and lower canaliculi, opening into the lacrimal sac;
12. levator palpebrae superioris; 13. palpebral fascia o f upper lid; 14. superior tarsus; 15. superior lacrimal canaliculus;
16. tendon o f orbicularis oculi. posterior part; 17, tendon o f orbicularis oculi. anterior part; 18. lacrimal sac; 19. upper
orifice o f naso-lacrimal duct, which runs in a bony canal; 20. middle nasal concha; 21. septum nasi: 22. inferior nasal
concha; 23. low er opening o f naso-lacrimal duct in anterior quarter o f inferior m eatus o f nose; 24. right nasal cavity
(Pauchet and Dupret).
(b) The inferior surface is related to the levator, reach the lacrimal gland. The infraorbital sometimes
expansion o f the levator and the lateral contributes.
rectus in this order.
(c) The anterior border is related to the septum N erv e su p p ly (Fig. 3.2)
orbitale. Nerve supply consists of two groups of nerves—
(d) The posterior border is related to the orbital the afferent or sensory, from the trigeminal, and
fat. the efferent or motor, which is contributed by both
(e) The medial extremity is related to the sympathetic and parasympathetic.
levator palpebrae superioris.
Superior cervical sympathetic ganglion
(f) The lateral extremity is related to the lateral
rectus. Pterygopalatine
ganglion Lacfima,
The palpebral p a rt Since all the 10 to 12 lacrimal gland
ducts, at first intralobular, then extralobular and ______ £ / ) Nerve of /
finally lacrim al ducts traverse this part to Lacrimatory
nucleus of facial nerve
finally reach the superolateral aspect o f the
conjunctival sac, excision of this part of the gland
virtually leads to complete nonfunctioning o f the Maxillary nerve
gland. G reater
Accessory lacrimal glands are described under Facial petrosal nerve
nerve
the conjunctival glands. Zygomaticotemporal
nerve

S tru c tu re Fig. 3.2 Sym pathetic and parasym pathetic supply to


the lacrimal gland (Snell and Lemp).
Lacrimal gland is a branched tubuloalveolar type
of gland. Each tubule when cut in section forms an
acinus. The acini are lined by pyramidal secretory The afferent or sensory supply to the lacrimal
cells, the cells containing many secretory granules gland is from the lacrimal nerve, a branch of the
toward the lumen. The secretory tubules are ophthalmic division of the trigeminal nerve.
surrounded by a dense basement membrane and The lacrimal nerve continues to run along the
they converge to form an intralobular duct, the lateral wall of the orbit. After entering the gland it
latter emptying into larger interlobular duct. The divides into superior and inferior divisions—the
interlobular and interacinous connective tissue inferior division joins the zygomaticotemporal
contains many vessels, non-myelinated nerves and branch of the maxillary division of the trigeminal.
plasma cells. Most o f the plasma cells secrete Sympathetic. The sympathetic fibres are derived
immunoglobulin A into the interstitial space. from the postganglionic fibres associated with the
internal carotid artery. The fibres then run in the
Ultramicroscopy. Each acinar cell contains a
nerve of the pterygoid canal (vidian nerve) which
well-defined basal nucleus and number of electron-
is formed by the junction of the deep petrosal nerve,
dense secretory granules. The secretory cells are
from the internal carotid plexus, with the greater
joined near their lumen by junctional complexes
petrosal nerve, from the facial nerve to the
and they have many microvilli projecting into the
lumen. sphenopalatine ganglion, from the latter the nerve
fibres reach the lacrimal gland either with the
A rte ria l su p p ly zygomatic nerve or along with the lacrimal artery.
The lacrimal artery runs along the lateral orbital Parasympathetic. The fibres are derived from the
wall at the upper margin o f the lateral rectus to facial nerve nucleus, superior lacrimal, in the brain­
stem. Leaving the brain stem the fibres depart the nasolacrimal duct is due to relaxation o f the
facial nerve in the greater superficial petrosal nerve negative pressure within the sac when the eyes are
and reach the sphenopalatine ganglion. A relay open.
takes place in the ganglion and the postganglionic In the lacrimal secretory system, there are two
fibres reach the lacrim al gland through the types of secretors.5
zygomatic branch o f the maxillary nerve or directly Basic—the fundamental and indispensable part.
to the gland.
(i) Mucin secretors
Tear.6 Tear, which is slightly alkaline, is Goblet cells
composed of 98.2 per cent water and 1.8 per cent Crypts of Henle
solids. The solid components of tear have been Glands of Manz
listed in Table 3.1. (ii) Lacrimal secretors
Glands o f Krause
Table 3.1
Glands o f Wolfring
The Solid C om ponents o f Tear
(iii) Oil secretors
G lucose approx. 5 mg/dL Meibomian glands (sebaceous)
Proteins 0.6% Glands of Zeis (sebaceous)
Tear-specific prealbum in Glands o f Moll (sweat)
Albumin
Im m unoglobulins Reflex—the lacrimal gland.
Lysozym e Tear film6 is made up o f three layers:
Lactoferrin
G lycoprotein (a) external lipoid produced by Meibomian
Potassium glands
Sodium in higher concentrations than in plasma
Chloride (b) middle aqueous formed primarily by the
Urea 0.04 mg/dL lacrimal and accessory lacrimal glands
(c) innermost mucous secreted by the goblet
Tear is secreted by the lacrimal gland and cells.
collected by 10 to 12 lacrimal ducts extending
toward the superior conjunctival fornix. Table 3.2 lists important measurements.

M echanism o f secretion.2 Two pathways are Table 3.2


involved in the secretion of water and electrolytes: M easurem ents Related to T ear Film 3
cholinergic-activated, and vasoactive intestinal
peptide-activated. Three pathways involved in the External lipoid layer 0.1 micron
M iddle aqueous layer 7 m icrons
secretion of protein are: cholinergic agonist-
Innerm ost m ucous layer 0.02-0.05 m icrons
activated, alpha adrenergic agonist-activated and T hickness o f tear film 7 -9 m illim icrons
AMP-dependent. V olume o f tear film 7 m icrolitres
Normal secretion is sufficient to keep the eyeball O sm olarity o f tear film 3 0 3 -6 mOsm/L
moist. The collection near the inner canthus, lacus Average tear flow 0 .5 -2 .2 microlitres/m in
lacrimalis, and movement into the lacrimal passages
are caused by: (a) capillarity, (b) gravity,
The Lacrimal Passages (Fig. 3.1)
(c) blinking due to orbicularis contraction,
(d) dilatation of the lacrimal sac occurs due to pull The lacrimal passages begin at each punctum and
on the lacrimal fascia owing to the contraction of terminate at the inferior meatus of the nose. These
Homer’s muscle and tear is drawn into the resulting are made up of the puncta, canaliculi, lacrimal sac,
vacuum and (e) m ovement o f tear into the nasolacrimal duct and inferior meatus of the nose.
The punctum. This is a patent ring of dense N erve su p p ly
fibrous tissue around which are the fibres o f the
Nerve supply is divided in three groups: (a) the
orbicularis oculi. It is relatively pale because of its sensory—from the trigeminal, (b) the motor—from
avascularity and is situated on each lid margin.
the facial, and (c) the sympathetic outflow to the orbit.
The upper and the lower ones are 6 and 6.5 mm
away from the medial canthus. It is normally not F u rther R eading
visible unless the lid is averted.
1. Bron, A.J., Tripathy, R.C. and Tripathy, B.J.
The canaliculus. This consists of vertical, about (Eds.), Wolff’s Anatomy o f the Eye and Orbit
2 mm, and horizontal, about 6 to 8 mm, portions. ( 8th ed.), Chapman and Hall, London, 1997.
It is lined by stratified epithelium, and both
2. Dartt, D.A., Signal transduction and activation
canaliculi join to form a small diverticulum just
of the lacrimal gland. In Principles and Practice
before opening into the sac.
o f Opthalmology: Basic Sciences, Albert, D.M.
The lacrimal sac. The membranous sac, 15 mm and Jacobiec, F.A. (Eds.), W.B. Saunders,
long vertically and 5 mm wide when distended, is Philadelphia, 1994, p. 458.
situated in the lacrimal fossa. It is closed above
3. Gilbard, A.P., Dry eye disorders. In Principles
but continuous below with the nasolacrimal duct,
and Practice o f Ophthalmology: Clinical
and has three parts—the fundus, the body and the
Practice, Albert, D.M. and Jacobiec, F.A. (Eds.),
neck.
W.B. Saunders, Philadelphia, 1994, p. 257.
Relations are as follows:
4. Gray, H., Gray’s Anatomy (35th ed.), Warwick,
Medially—where the ethmoid air cells and the
R. and W illiam s, P.L. (Eds.), Longm an,
middle meatus are situated and laterally it is related
London, 1973.
to the skin, the orbicularis muscle, the medial
palpebral ligament (across the fundus o f the sac) 5. Jones, L.T., The lacrimal secretory system and
and the lacrimal fascia and posteriorly—to the its treatment, Am. J. Ophthalmol., 62: 47, 1966.
lacrimal fascia and Homer’s muscle. 6 . Lamberts, D.W., Physiology of the tear film,
The lacrimal sac has a fibroelastic coat lined in The Cornea, Smolin, G. and Thoft, R.A.
internally by mucous membrane, the latter being (Eds.), Little, Brown and Co., Boston, 1983.
continuous with the conjunctiva through the
canaliculi and with the nasal cavity through the
nasolacrimal duct. 4. ANATOMY OF THE
The nasolacrimal duct. This is a membranous CONJUNCTIVA12
canal, 12 to 24 mm long and consists o f two
portions, the intraosseous— w ithin the bony The conjunctiva (Lat. conjunctivus, serving to
nasolacrim al canal, and the intram eatal connect) is a thin and transparent mucous
membranous portion. membrane, conjoining the eyelid to the globe and
The mucous lining o f the lacrimal sac and the its epithelium is continuous with that of the cornea.
duct is covered w'ith columnar epithelium. It is divided into three parts: palpebral, bulbar and
fomix.
A rte ria l supply
The Palpebral Conjunctiva (Fig. 4.1)
The sources of supply are from the ophthalmic
through its superior and inferior medial palpebral The palpebral conjunctiva is subdivided into three
branches—the angular branch of the facial artery; parts.
the maxillary through its infraorbital branch; and (a) The marginal which is the transition zone
the nasal branch of the sphenopalatine artery. between the skin and the conjunctiva
cul-dc-sac interrupted on the medial side by (a)
the caruncle (Lat. caro, flesh) which is a small,
fleshy ovoid, modified skin containing sebaceous,
sudorific and modified lacrimal glands; and (b)
the plica semilunaris (Lat. plica, to fold) contains
the plain muscles and thickened epithelium having
many goblet cells. The inferior, superior and lateral
fomices are 8 mm 9 mm and 14 mm from the
limbus respectively.

S tru c tu re

Histologically, the layers are the epithelium and


the substantia propria, which is subdivided into
the superficial, i.e. adenoid layer and the deep, i.e.
the fibrous layer. The structure varies in different
portions.
Fig. 4.1 Schcm c o f a sagittal section through the
eyelids and eyeball to show the conjunctival sac and the The epithelium. The free margin of the lid is
position o f its glands. SF, IF, the conjunctiva o f the covered by keratinized stratified epithelium. The
superior and inferior fom iccs respectively. B, the bulbar
mucocutaneous junction lies at the level o f the
conjunctiva. P, the palpebral conjunctiva. LAC, the
lacrimal gland proper. K, the accessory lacrimal glands posterior margin of the openings of Meibomian
o f Krause, and W , those o f W olfring. H, the crypts o f glands and at this region there are about five layers
Henle. M, the glands o f M anz, (A fter Dubreuil, 1908. of non-keratinized squamous epithelium, the most
From W hitnall: Anatomy o f the Human Orbit. Oxford superficial cells being nucleated.
Medical Press, London.)
The tarsal conjunctiva of the upper lid has two
layers, the deeper cubical and the superficial
proper, extending from the anterior lid
cylindrical. The tarsal conjunctiva of the lower lid
margin to a groove, sulcus subtarsalis,
is rarely two-layered as in the upper, but contains
situated 2 mm behind the posterior lid
three or four layers of cells. Sometimes there may
margin.
be five layers. There are three sets of cells—
(b) The tarsal which is thin, vascular and deepermost cubical, polygonal and superficial cone-
intimately adherent to the underlying tarsus. shaped.
The fornix shows three layers, the deepermost
(c) The orbital which is loose with horizontal
folds overlying Miiller’s muscle. layer contains cubical, intermediate polyhedral and
superficial cylindrical cells.
The bulbar conjunctiva consists of several layers
The Bulbar Conjunctiva including additional polyhedral layers between the
The bulbar conjunctiva is a loose sheet overlying superficial and deep cells. The superficial cells are
the episclera and the tendons of the four recti. flatter and the deep cells taller.
Because of its looseness, chemosis commonly In the limbus, there are several layers. The
affects this zone. deepest of them are basal cells containing melanin
pigment. A few layers o f polygonal cells are also
present. Superficially, one or two layers of flattened
The Fornix
cells are noticed. Conjunctival polygonal cells do
The fornix represents the junction between the not show any prickle while corneal polygonal cells
palpepral and bulbar conjunctiva and is a circular show prickles.
The substantia propria. The adenoid layer is
absent at birth, starts developing about the third
The deeper structures of the eyelid and the whole
month of life and is most developed in the fomix
o f the conjunctiva barring 3 to 6 mm of the
conjunctiva.
paralimbal zone are supplied by four palpebral
The fibrous layer, form ed m ainly by the
arcades, two in each lid, one at either border of the
expansions of muscle tendons and Tenon’s capsule,
tarsus. The medial palpebral is formed from the
contains the blood vessels and nerves.
dorsal nasal and the lateral palpebral from the
U ltram icroscopy. The follow ing im portant lacrimal arteries.
characteristics are seen.
1. The superficial cells are joined at their anterior
contiguous borders by junctional complexes.
2. The apical cytoplasm of the surface cells
contains numerous subsurface vesicles.
3. The cell membrane is anchored to the
cytoskeleton by actin filaments passing from
the microvilli to the horizontal condensation Orbicularis ciliary artery rectus
(terminal web).
arcade Ant. dliary artery

C o n ju n c tiv a l g la n d s branch major


The distinguishing features o f the conjunctival
glands are indicated in Table 4.1.
Ascending branch

Table 4.1
D istinguishing Features o f Conjunctival G lands

Krause’s Glands o f Henle s glands С = Conjunctiva


glands Wolfring F ig . 4.2 Section o f the upper lid and anterior portion
o f the eye to show the blood supply to the conjunctiva
Nature o f Acccssory Accessory Not true
glands lacrimal lacrimal glands but (W olff).
transversely
cut mucous
Along each border of the tarsal plate two arterial
folds arcades, the marginal and the peripheral are formed.
Number 42 in the 2 to 5 in the The marginal arcade is the larger of the two arcades
upper and upper, and 2 in
and runs 3 mm from the free border of the eyelid.
6 to 8 in the the lower lids
lower lids The peripheral arcade is smaller and inconstant. It
Situation In subconjunc­ A t both borders is situated at the peripheral margin of the tarsus,
tival connec­ o f the tarsus i.e. the upper border of the upper tarsus and the
tive tissue
lower border of the lower tarsus. Small twigs pass
from the marginal to the peripheral arcade and vice
G oblet cells. These occur throughout the versa, and two arterial plexuses, the pretarsal and
conjunctiva, more abundant in the fomices and the the posttarsal, are formed in front and behind the
plica semilunaris. They decrease as the limbus is tarsus. The posttarsal plexus supplies the major
approached. They are large, oval, fat-looking cells, part of the conjunctiva. The ascending branches of
unicellular mucous glands which secrete mucin the peripheral arcade run upwards to the fomix,
which moistens and protects the epithelium of the bend round it and pass under the bulbar conjunctiva
conjunctiva and cornea. as the posterior conjunctival arteries.
The anterior ciliary arteries are continuation of the upper and lateral two-third o f the lower
the muscular arteries to the recti and are derived conjunctiva drain into the submaxillary, while the
from the ophthalmic artery. These arteries give off remaining portions drain into the preauricular gland.
the anterior conjunctival arteries. The anterior
ciliary arteries on the surface o f the sclera divide N erv e su p p ly
into three branches, the episcleral, the intrascleral
and the perforating. The episcleral twigs give off There are three groups: (a) the sensory, branches
two sets o f branches, terminal and recurrent; the of the ophthalmic division o f the V cranial, (b) the
terminal branches run anteriorly into the limbus, sympathetic supplying the conjunctival glands and
while the recurrent branches run away from the (c) the parasympathetic supplying the accessory
cornea as the anterior conjunctival arteries and lacrimal glands.
anastomose with the terminal branches o f the The sensory supply is as follows:
posterior conjunctival arteries. • upper palpebral and fomix from the frontal
The arterial supply o f the entire conjunctiva
(Table 4.2) is derived from three sources: (a) the • outer part o f bulbar conjunctiva from the
marginal arterial arcade, having marginal and tarsal lacrimal
branches, (b) the peripheral arterial arcade, having • remaining part of bulbar conjunctiva from
descending and ascending branches or the posterior the long ciliary branches of the nasociliary
conjunctival and (c) the episcleral twigs of the nerve
anterior ciliary arteries having two sets—terminal • lower fomix from the infraorbital nerve.
and recurrent branches.

Table 4.2 F urther R eading


Details o f the Arterial Supply o f the Conjunctiva 1. Bron, A.J., Tripathy. R.C. and Trepathy, B.C.
(Eds.), W olff s Anatomy o f the Eye and Orbit
Zone o f conjunctiva A rterial supply
(8th ed.), Chapman and Hall, London, 1997.
Marginal M arginal branches o f the
2. Duke-Elder, S. System o f Opthalmology, Vol.
marginal arcade
Tarsal Tarsal branches o f the II: The Anatomy o f the Visual System, Duke-
marginal and descending Elder, S. and Wyber, K. (Eds.), Kimpton,
branches o f the peripheral arcade London, 1961.
Orbital, fom ix and A scending branches o f the
bulbar (except peripheral arcade, i.e. the
3 -6 mm paralimbal posterior conjunctival arteries
zone) 5. ANATOMY OF THE
Paralimbal 3 -6 mm A nterior conjunctival derived
zone from the episcleral tw igs o f the CORNEA13
anterior ciliary arteries
The shiny and transparent cornea, having slightly
greater curvature than the rest o f the globe,
V enous d ra in a g e constitutes the anterior one-sixth of the outer coat
The conjunctival veins are larger, darker and more of the eyeball. The horizontal diameter, 11.7 mm
tortuous than the corresponding arteries. is greater than the vertical diameter, 10.6 mm. The
cornea is more curved and thinner 0.58 mm
L y m p h a tic d ra in a g e centrally, while its peripheral part is less curved
and thicker, i.e. 1 mm. Anteriorly it looks elliptical,
There are two groups of lymphatic networks, the while it is circular posteriorly. The radii o f
superficial and the deep. The medial one-third of curvature of the anterior and posterior surfaces are

A r autortiesibam aizsargats materials


7.8 mm and 6.6 mm respectively. The cornea can The wing or umbrella cells. These are 2-3 layers
be divided into the cornea proper—transparent and of polyhedral cells and have concave bases fitted
avascular and the limbus— 1 mm transition zone, over the rounded heads o f the basal cells. These
richly vascular [Limbus, seam, i.e. the line of rounded heads project anteriorly. Each cell has an
junction between two edges]. oval nucleus whose long axis is parallel to the
comeal surface. They are so named because o f the
Structure of the Cornea (Fig. 5.1) presence of intercommunicating processes, the
wings, between them.
The cornea proper shows five layers disposed
anteroposteriorly behind the precorneal tear film. The surface cells. These constitute the most
superficial layer. The cells are flattened and
nucleated. They do not show any keratinization
normally.
It must be stressed that there are lymph spaces
between the cells, best distinguished between the
basal cells and gradually disappearing between the
surface cells.
Basal membrane. A part of the epithelium, it is
o f even thickness and is osmophilic. This merges
with Bowman’s membrane.

Bowman’s Membrane
Bow m an’s m embrane is a 8-14 m illim icron
hom ogeneous sheet interposed betw een the
basement membrane and the substantia propria,
separated from the epithelium by a sharply defined
border. It is demarcated from the stroma by an ill-
defined line. Peripherally, it terminates in a rounded
border. It does not regenerate if it is damaged. It
does not contain any elastic tissue.

Fig. 5.1 T he m icroscopic appearance o f the cornea: Substantia Propria


1, epithelium ; 2, B ow m an’s m em brane; 3, strom a; 4,
The substantia propria is made up of a modified
D escem et’s m em brane; and 5, endothelium .
connective tissue whose components have almost
The Epithelium the same refractive index. T here are three
components.
The epithelium is the forward extension o f the
conjunctival epithelium. It is 50 millimicron thin The lamellae. These are made up o f 200 to 250
and consists of three types of cells disposed in fine collagen fibrils arranged parallel to the comeal
5-6 layers. surface. Each lamella is about 2 millimicron thin
and 10 to 25 millimicron wide. Only a few of the
The basal cells. This is a single layer of cells,
fibres are oblique, probably in relation with the
the germinal cell layer, standing in a palisade-like
entrance of the comeal nerves. They are clearly
manner on the basement membrane. The cells are
distinguished by electron microscopy.
columnar with rounded heads and flat bases and
have an oval nucleus near the head. The cells are The cells. These are o f two types, ‘fixed’ or
interconnected by fine denticulations. keratocytes and ‘wandering’ or histiocytes.

A r autortiesibam aiz
The ground substance. This is made up of acid E pithelial cells. They contain: (i) usual
mucopolysaccharides. It holds the cells and the organelles o f activ ely m etabolizing cells,
fibres and forms a gel. (ii) tonofibrils, (iii) desmosomes, (iv) zonulae
occludentes (tight junctions), (v) microvilli and
Descemet’s Membrane microplicae (fused microvilli), and (vi) dendritic
Descemet’s membrane is a strong, homogeneous cells.
membrane of 10-12 millimicron. There is a line of Basal membrane. Two layers are seen, lamina
demarcation between it and the stroma, the line densa and lamina lucida. This membrane is
being utilized during lamellar keratoplasty. At its anchored to the underlying Bowman’s membrane
periphery the posterior surface of the membrane by short filaments.
shows some round elevations, H assall-H enle
bodies, having a tendency to increase with age. Bowman's membrane. It consists o f felted
meshwork of fine collagen fibrils o f uniform size
Endothelium 24 to 27 nm.
The endothelium is the posteriormost layer and Stroma. Each lamella contains a band o f
consists of a single layer of flattened epithelium­ collagen fibrils (64 nm) arranged in parallel rows.
like cells, continuous round the angle of the anterior The lamellae cross each other approximately at
chamber with the endothelium of the iris. It can be right angles. Keratocytes are mostly interlamellar
visualized by a slit-lamp. and occasionally intralamellar.
Specular microscopy, first used by Maurice in
Descemet's membrane. There are two portions:
1968, can evaluate the m orphological and
anterior, banded showing interdigitations between
functional aspects of the endothelium. The cells
the fine filaments, the foetal part, constituting one-
can be examined at a very high magnification
third portion. The posterior two-third, the postnatal
(x500). The examination is possible with corneas
part, forms the nonbanded zone showing a granular
in vitro and in vivo. The introduction of noncontact
appearance.
and wide-angle instrum ents has widened its
sophistication. Endothelium. There are 500.000 cells, each of
The study of corneal endothelium is of vital 5 millimicron thin and 10-20 millimicron wide.
significance because: (a) comeal transparency is These are extremely metabolically active cells.
dependent on the integrity of the endothelium, (b) Large num bers o f m itochondria are found
the endothelium is the site of metabolic process particularly around the nucleus. The lateral borders
which maintains the deturgescent state of the of the cells show marked convolutions forming
comea, (c) the efficacy o f drug therapy and (d) the complex interdigitations with the neighbouring
success o f keratoplasty. cells. The anterior (basal) cell membrane is
anchored to Descemet’s membrane by modified
Limbus desmosomes. The posterior (apical) cell membrane
There are two layers only: (a) the epithelium, shows m icrovilli projecting into the anterior
having ten or more layers o f irregularly disposed chamber and pinocytic vesicles.
cells and (b) the stroma which lacks the uniformity
of the structure that is present in the comea proper, Nerve supply
but contains numerous capillary loops. The comea is richly supplied by the long ciliary
nerves from the nasociliary branch o f the
Ultramicroscopy ophthalmic division of the trigeminal. Most of the
The ultram icroscopic features have been nerves enter the comea from the sclera and, the
summarized below. remaining from the subconjunctival and episcleral
tissues 70 to 80 nerves run radially into the stroma Variation in colour. In childhood and in
and most of them lose their myelin sheaths 0.3- pathological state, the sclera appears bluish owing
0 .5 .mm from the limbus. These nerves form to the visibility of the uvea through the thinned-
plexuses within the epithelium, under Bowman’s out sclera. In old age it may appear yellowish due
membrane and within the stroma. There is no to the deposition of fat.
innervation o f Descemet’s membrane.
S tr u c tu r e (Fig. 7.3)
F u rther R eading The sclera is relatively avascular, almost acellular,
1. Bron, A.J., Tripathy, R.C and Tripathy, B.J. and it consists o f highly compact thick collagen
(Eds.), Wolff’s Anatomy o f the Eye and Orbit bundles o f varying sizes between 400 and 3300 A
( 8th ed.), Chapman and Hall, London, 1997. and easily separable with the intervening elastic
tissues.
2. Hogan, M.J., Alvarado, J.A. and Weddell, J.E.,
Histology o f the Human Eye, W.B. Saunders Orientation o f the fibres. The anterior part is
Co., Philadelphia, 1971. strictly circular at the insertions o f the extrinsic
3. Smelser, G.K. and Ozanics, V., New concepts muscles. There are two strata at the posterior part:
in anatomy and histology o f the cornea, in The the outer like a net around a balloon and the inner
Cornea: World Congress, King, J.H. and fanwise. Hence, owing to the increased ocular
McTigue, J.W. (Eds.) Butterworths, London, tension the elastic fibres become tense, while the
1965. wavy connective tissues become straight.
Dense cross-linking of the large diameter fibrils
results in greater tensile strength o f the sclera. The
scleral resistance is due to greater surface area of
6. ANATOMY OF THE contact with the encircling matrix and greater
amount of interaction with proteoglycans by the
SCLERA1”3 small-diameter fibrils3.

The dull-white and inelastic sclera form the tough A rte ria l su p p ly
posterior five-sixth of the outermost protective coat The sclera is almost avascular except for the vessels
o f the eyeball. Anteriorly, it is continuous with the which pass through it. Two vascular networks are
cornea; and posteriorly, it is continuous with the present: the circle of Zinn-Haller (Chapter 11, p.
dural sheath of the optic nerve. The outer surface 37 o f Part One) and the episcleral plexus situated
is covered by Tenon’s capsule and the conjunctiva, at the insertions of the recti.
connected by a loose connective tissue, i.e. the
episclera. The inner surface is covered by the N erv e su p p ly
lamina fusca of the choroid. The average thickness
is 0.8 mm. It is thickest at the posterior part, 1 The sclera is innervated by the branches of the
mm, thinner anteriorly and thinnest at the insertions short posterior ciliary nerves posteriorly behind the
o f the recti, 0.3 mm. equator, and by those of the long posterior ciliary
nerves.
Week spots in the sclera. As 3 mm medial to
and slightly above the posterior pole, the sclera F urther R eading
becomes sieve-like, lamina cribrosa, through the
holes of which traverse the fibre of the optic nerve. 1. Duke-Elder, S., System o f Ophthalmology, Vol
At this weakest spot, excavation of the optic disc II: The Anatomy o f the Visual System, Duke-
occurs typically in long-standing chronic simple Elder, S. and Wybar. K. (Eds.), Kimpton,
glaucoma. London, 1961.
2. Gray, H., Gray's Anatomy (35th ed.), Warwick, Pigment
R. and W illiam s, P.L. (Eds.), Longman,
London, 1973. Pupillary
zone
3. Marshall, G.E., Konstas, A.G.P. and Lee, W.R.
Collagens in ocular tissues. Br. J. Ophthalmol. Collarette
77: 515, 1993.

7. ANATOMY OF THE
UVEAL TRACT1'3 Contraction
furrow
The middle coat of the eyeball is presumed to be a
dark sphere (Gk. uva) hanging from the optic nerve.
The middle coat, which is also vascular and
nutritive, consists of three portions: the choroid or
the posterior uvea, the iris, and the ciliary body
which together form the anterior uvea.

Iris crypt

The iris is a thin average 3-4 mm in diameters, Fig. 7.1 The surface anatom y o f the front o f the iris
(W olff).
circular, coloured disc depending upon the amount
o f pigm ent, w ith a cen tral, slightly nasal,
C h o ro id
perforation called the pupil. It is attached at its
periphery or root, i.e. the thinnest part to the middle
of the anterior surface of the ciliary body. The Ciliary
pupillary margin is free and it glides over the r \ p ro c -
anterior capsule of the lens. i esses
The iris has two surfaces:

(a) Anicrior— Ciliary zone Innerm ost— sm ooth area L ens


\ > MMi iddle— furrow ed area
O uter— cribiform zone
Ciliary
Pupillary zone z o n u le

(b) Posterior

Sclera
Between the ciliary and pupillary zones, about
1.5 mm from the pupillary margin, there lies the Fig. 7.2 A nterior h alf o f the interior o f the eyeball
view ed from behind after rem oval o f the vitreous
collarette or iris frill (Fig 7.1), the thickest part.
(Cunningham ).
Posterior. This is relatively smooth surface
(Fig. 7.2). 1. Anterior border layer
2. Stroma
Structure 3. Anterior epithelium
The layers of the iris from anterior to posterior are: 4. Posterior pigment epithelium.
The anterior border layer is a condensation of This is made up of two layers: narrower anterior
connective tissue and pigment cells of the anterior and w ider posterior, connected laterally by
stroma. This contains fibroblasts, melanocytes, desmosomes. The apical surfaces of the epithelial
collagen fibres, nerve filaments and capillaries. This cells form microvilli interdigitating with those of
layer exhibits crypts where it is not continuous. the anterior epithelium.
The colour of the iris depends on the thickness of
this layer and the number of melanocytes. The Ciliary Body
fibroblasts project their microvilli and cilia into
The ciliary body is the region beyond the ora
the anterior chamber.
serrata, the jagged line marking the termination of
The stroma forms the bulk of the iris. This is a
the retina and the beginning of the ciliary body. It
loosely arranged collagenous network containing
forms a ring 5.9 mm wide nasally and 6.7 mm
blood vessels, nerves, pigmented and nonpigmented
temporally. Its colour is black. Its inner surface
cells, and sphincter pupillae.
which faces the vitreous can be divided into two
Blood vessels are radial with a slightly sinuous
zones: the peripheral part or the pars plana which
course to allow movements of the pupil. They
is relatively the smooth two-third part, and the inner
straighten during constriction and become wavy
part, the pars plicata or the corona ciliaris which
during dilatation of the pupil.
shows about 70 longitudinal ridges of various sizes
Nerves are derived from the long and short
called the ciliary processes, each 0.8 mm high x 1
ciliaries and they accompany the corresponding arteries.
mm wide. On the sagittal section the ciliary body
Melanocytes are distributed around the vessels
appears trian g u lar w ith these three sides
along with fibroblasts. Clump cells are mostly
(Fig. 7c. 1)
pigment-laden macrophages found especially near
the pupillary margin. Mast cells are also seen. (a) The anterior side from whose middle the
Sphincter pupillae constitutes a 0.75-mm wide iris arises. The outer part contributes to the
and 0.17-mm thick, smooth, annular band of muscle formation o f the angle of the anterior
fibres encircling the pupillary margin. The muscle chamber, and the remainder opens in the
fibres are separated by collagenous septa containing posterior chamber.
blood vessels and nerves. (b) The lateral side is adjacent to the sclera
The anterior epithelium is 12.5 millimicron thick and corresponds to the ciliary muscle.
and essentially containing smooth muscle, dilatator
(c) The medial side corresponds to the ciliary
pupillae.
processes.
Dilatator pupillae 60 millimicron long and
7 millimicron wide, is a radially oriented smooth
Structure
muscle. At places this muscle merges with the
sphincter pupillae or the iris stroma causing The suprachoroidal space intervenes between the
pigmented projections (spurs) as follows. sclera and ciliary body proper.
(i) Fuchs’ spur—in the vicinity of the sphincter From outside to inwards the layers are as
pupillae follows:
(ii) M ichel’s spur—at the periphery of the The ciliary muscle 6 mm broad, is a circular
sphincter pupillae band of unstriped fibres. It constitutes the main
framework of the ciliary body and has mainly two
(iii) Grunert's spur—by the fusion of dilator
groups of fibres, longitudinal (Brucke’s muscle)
fibre with the stroma at the root of the iris.
and circular, each 0.8 mm high x 1 mm wide
The posterior pigment epithelium is the forward (Muller’s muscle) and some junctional oblique
continuation of the ciliary epithelium and pars fibres. The outer, longitudinal fibres originate from
ciliaris retinae. The cells are heavily pigmented. the scleral spur and extend posteriorly even beyond
the equator ending in ‘muscle-stars’-branched, star Ciliary epithelium. The cells are rich in
shaped figures. The inner, circular fibres from a organelles. The cytoplasm o f the cells of the
sort of ring. pigment epithelium is more electrondense than that
The ciliary muscle has two important actions: o f nonpigm ented ep ith elial cells. Z onulae
(a) the pull of the muscle fibres slackens the occludentes occlude the lateral surfaces of the
suspensory ligament and there is decreased tension nonpigmented cells close to their apieces. Gap
on the lens capsule following which the anterior junctions connect the lateral surfaces o f both
surface of the lens becomes more convex during pigmented and less frequently nonpigmented cells.
accommodation, and (b) backward pull on the Desm osom es attach the lateral sides o f the
scleral spur opens up the trabecular spaces and nonpigmented cells to each other.
facilitates the drainage o f the aqueous humour.
The ciliary process consists essentially of the Choroid
blood vessels and constitutes the most vascular
The dark-brown choroid, nourishing the outer part
region of the whole eye.
of the retina, extends from the margin of the optic
Bruch's membrane is the forward continuation
nerve to the ora serrata. Because o f its extreme
of that o f the choroid. In the choroid there are two
vascularity, its thickness cannot be assessed
strata, the outer elastic and inner cuticular; while
accurately, although it is thicker posteriorly, 1/4
in the ciliary body there are three strata: the outer
mm than anteriorly, 1/10 mm. There are two sites
elastic, intermediate connective tissue and inner
at which the choroid is adherent, at the margin of
cuticular.
the optic nerve, and at the scleral spur.
The epithelium consists of two layers, the outer
pigmented cells and inner nonpigmented cells.
Retinal detachment does not spread beyond the Structure (Fig. 7.3)
ora serrata because here the pigm ented and From outside to inward the layers are as follows.
nonpigmented layers are firmly united.
The internal limiting membrane is said to be absent - epithelium
over the pars plana. -S m aller
It must be emphasized that the structure of the Bruch’s
choroidal
ciliary body is the continuation o f the layers of the vessels
choroid and the retina. The ciliary muscle, ciliary
processes and B ru ch ’s m em brane are the Larger
continuation of the choroid. The epithelium and choroidal
internal limiting membrane continue with those of v essels
the retina.
Ultramicroscopy. The features are summarized
below. Suprachoroid

Ciliary muscle. The characteristic features are Fig. 7.3 C horoid, transverse section (W olff).
as follows:
(a) The suprachoroid or epichoroid is a potential
1. There is abundance o f m itochondria and
space between the sclera and the choroid, consisting
endoplasmic reticulum.
of interwining flattened laminae through which run
2. More well-developed Golgi apparatus is seen. or lie: (i) the long and short posterior ciliary arteries
3. Muscle cells are arranged in bundles surrounded and nerves; (ii) the elastic fibres; (iii) the
by a sheath of fibroblasts. chromatophores; (iv) the muscle-stars; and (v) the
4. The fibres are filled with actin filaments, and multipolar ganglia at the nerve endings, probably
many pinocytic vescles. vasomotor.
(b) The layer o f large vessels, Haller's layer. with branches o f the long posterior ciliary arteries
(c) The layer o f medium-sized vessels, Sattler's to form the major arterial circle of the iris—the
layer. circulus arteriosus iridis major. The major arterial
circle gives off muscular—to the ciliary muscle,
(d) The choriocapillaris are capillaries of unusual ciliary—to the ciliary processes, recurrent ciliary—
bore, packed closely together. They end at the ora the other recurrent branches are from the long
serrata, whereas the other layers continue on the posterior ciliary and perforating branches of the
the ciliary body. anterior ciliary arteries, and branches to the iris.
(e) Bruch's membrane or the lamina vitrea is a The majority of the arterial branches run to the
thin 1.5 micron membrane firmly attached to the pupillary margin, while others divide and subdivide
pigment epithelium of the retina. It acts as a filtering to finally form an incom plete circle at the
meshwork for the metabolic exchange between the collarette—the minor arierial circle o f the iris or
choriocapillaris and the pigment epithelium o f the Circulus arteriosus iridis minor.
retina. The venous return of the uveal tract is practically
Electronmicroscopically, it is found to be made through four to seven venae vorticosae, so named
up o f five layers :4 (i) the basement membrane of because of its whorled appearance. The radial veins
the retinal pigm ent epithelium; (ii) the inner o f the iris run posteriorly, receive tributaries from
collagenous zone; (iii) the elastic layer; (iv) the the ciliary processes, and finally reach the choroid
outer collagenous zone; and (v) the basement to form large anterior tributaries o f the venae
membrane o f the capillaries. vorticosae. The veins from the outer part o f the
ciliary body run anteriorly and unite to form the
Blood supply to the uveal tract (Fig. 7c.2) ciliary venous plexus. This plexus drains into the
anterior ciliary and episcleral veins.
Blood is supplied to the uveal tract by these two
arterial systems: Nerve supply
(a) The posterior ciliaries— Short, Long Parasympathetic. The postganglionic fibres from
(b) The a n te rio r c ilia rie s— through the the ciliary ganglion run in 8 to 10 short ciliary
perforating branches. nerves, p en etrate the sclera to reach the
suprachoroidal space and supply the sphincter
The short posterior ciliary arteries. Ten to twenty
pupillae and ciliary muscle.
arteries perforate the sclera in a circular zone
around the optic nerve-head. T hey divide Sympathetic. The postganglionic fibres from the
dichotom ously and eventually break up into superior cervical ganglion run along the internal
choriocapillaris. carotid artery via the nasociliary-»tw o long
posterior ciliary nerves—»and finally penetrate the
The long posterior ciliary arteries. The nasal and
sclera to reach the dilator pupillae and possibly
temporal arteries pierce the sclera on either side of
also the ciliary muscle.
the optic nerve anterior to the short posterior ciliary
arteries. They pass through the scleral canal, reach Sensory. The supply is through the long ciliary
the suprachoroidal space and end into the ciliary nerves.
muscle. They do not give off any branch till they
reach the ciliary muscle. F u rther R eading
The perforating branches o f the anterior ciliary 1. Bron, A.J., Tripathy, R.C. and Tripathy,
arteries. These perforate the sclera about 5 mm B.J. (Eds.), W olff s Anatomy o f the Eye and
away from the limbus, enter the ciliary body, and Orbit ( 8 th ed.), Chapman and Hall, London,
at the anterior end of the ciliary muscle anastomose 1997.
2. Duke-Elder, S., System o f Ophthalmology,
Vol III: The Anatomy o f the Visual System,
Duke-Elder, S. and Wybar, K. (Eds.). Kimpton,
London, 1961. Nucleus

3. Gray, H., Gray’s Anatomy, (35th ed.), Warwick,


R. and W illiam s, P.L. (Eds.), Longm an,
London, 1973. Cortex

4. Hogan, M.J. Bruch’s membrane and diseases


of the macula: role o f elastic tissue and
collagen, Tr. Ophthalmol. Soc. UK, 87: 113, Cape iilo
1967.

Fig. 8.1 Pans of the human lens, diagramatic.


8. ANATOMY OF THE
CRYSTALLINE LENS AND
SUSPENSORY LIGAMENT Structure
The crystalline lens is comprised of the following.
The crystalline lens in the adult is transparent,
(a) The capsule is an elastic, homogeneous
biconvex and semisolid. It is spherical and soft in
envelope with varying thickness at different
the fetus, and flattened and sclerosed in the old. It
regions, thicker anteriorly, thickest at the equator
is placed behind the pupillary border of the iris
and thinnest at the posterior pole. It has two
and on the anterior surface of the vitreous to which
portions: superficial, i.e. the delicate zonular
it is attached by W ieger’s hyaloideocapsular
lamellae and the deep, i.e. capsule proper, which
ligament, with the intervening hyaloid fossa and
is homogeneous. With an increase of age the
the retrolental space o f Berger which is a capillary
capsule becomes thicker.
space behind the lens. The lens is suspended from
the ciliary body by the suspensory ligament or (b) The anterior epithelium which consists of a
zonule o f Zinn. It is enclosed by a capsule. Its single layer of cubical cells interposed between
axial thickness is 3.6 mm and has a variable the anterior capsule and the main substance of the
diameter between 9 and 10 mm. The radius of the lens. There is no posterior epithelium, since the
anterior surface is 9 mm, while that of the posterior cells of this portion have developed into lens fibres
surface is 5.5 mm. Its refractive index is 1.39. during intrauterine life.
The crystalline lens (Fig. 8.1) has: (a) two parts,
(e) The cement substance is present in different
the central or nucleus and the peripheral or cortex;
places: subcapsular, subepithelial and central.
(b) two surfaces, the anterior and posterior; and
(c) two poles, the anterior and posterior. (d) The lens fibres are hexagonal, 2100 to 2300
The equator of the lens having a dentate in number, flat, 5 to 7 millimicron wide and 8 to
surface corresponds to the junction between two 12 millimicron long. During development they run
surfaces and is about 0.5 mm behind the ciliary from one pole to another initially, and from the
processes. equator to the anterior epithelium at a later stage.
The lens is avascular and its nutrition is Newly-formed fibres are successively laid upon
maintained by the metabolic exchange between it the older ones, pushing the older fibres towards
and the aqueous humour. the centre.
Ultramicroscopy. Electron microscopy o f the micron is made up of microfibrils of 8 to 40 nm
cells of the lens epithelium shows few organelles diameter.
lying in a coarse cytoplasm, endoplasmic reticulum,
ribosomes, small mitochondria and golgi complex. Petit’s Canal
The cytoskeletal elements o f the cells include
Petit’s canal is the triangular space between the
proteins, actin, intermediate filaments, microtubular
protein, spectrin, alpha actin and myosin. The basal crystalline lens and the zonular fibres.
aspects of the cells are attached to the anterior
capsule by hemidesmosomes, while their lateral F urther R eading
aspects are attached to each other by desmosomes.
The superficial lens fibres are roughly hexagonal 1. Bron, A.J., Tripathy, R.C. and Tripathy, B.J.
having two long and four short sides. The fibres (Eds.), W olffs Anatomy o f the Eye and Orbit
meet forming a series of ‘ball and socket-like’ ( 8 th ed.), Chapman and Hall, London, 1997.
joints. In the deepest layers o f the cortex and 2. Nema, H.V., Anatomy o f the Eye and Its
nucleus, the ball and socket-like jo in ts are Adnexae (2nd ed.), Jaypee Bros, New Delhi,
supplemented by ‘tongue and groove’ joints. 1991.
These interlockings are essential for continuing
transparency of the lens and accommodation.

Suspensory Ligament of the Lens12 9. ANATOMY OF THE


(Syn. Ciliary zonule or zonule of Zinn) VITREOUS HUMOUR13
Suspensory ligament suspends the crystalline lens
and allows the ciliary muscle to act on it particularly The vitreous humour is a perfectly transparent,
during accommodation. Most o f the fibres appear roughly spherical and gelatinous structure
triangular in a meridional section having apex, base, occupying the posterior four-fifth of the globe. The
anterior (outer) and posterior (inner) surfaces. The volume of the vitreous is about 4 ml.
apex corresponds to a point on the ora serrata. The Its outerm ost condensation is called the
base is at the equator 01 the lens spreading towards hyaloid membrane. The base o f the vitreous is
both anterior and posterior surfaces. The anterior the region where it is attached to the pars plana
surface forms part of the posterior wall o f the and ora serrata, and is 1.5 mm broad. The potential
posterior chamber, while the posterior surface lines space between the posterior lens surface and the
the anterior limiting membrane of the vitreous. anterior hyaloid membrane is called Berger's space
There are two types of fibres: the main and the and the connections between the two is by
auxiliary. hyaloideo- capsular ligament o f Weiger. Cloquet’s
The main fib re s are subdivided into four canal or the hyaloid canal indicates the potential
groups depending upon the site o f attachment, and space running from the funnel-shaped space
these are: in fron of the optic disc (area o f Martegiani) to
the posterior lens capsule, left behind by the hyaloid
1. Orbiculoposterior capsular artery.
2. Orbiculoanterior capsular
3. Cilioposterior capsular Structure (Fig. 9.1)
4. Cilioequatorial fibres.
A combination of gel containing 99% water and
The auxiliary fibres are fine and they anchor cells the vitreous humour consists of these major
the main fibres providing strength to the latter. macromolecular components: (a) the collagen—
A zonular fibre having a diameter of 0.35 to 1 which is the main structural basis and is filled up
F urther R eading

1. Bron, A.J., Tripathy, R.C. and Tripathy, B.J.


(Eds.), Wolff*.s Anatomy o f the Eye and Orbit
( 8 th ed.), Chapman and Hall, London, 1997.
2. Duke-Elder, S., System o f Ophthalmology. Vol.
11: The Anatomy o f the Visual System. Duke-
Elder, S. and Wybar, K., (Eds.), Kimpton,
London, 1961.
3. Nema, H. V., /4natomy o f the Eye and Its Adnexae
(2nd ed.), Jaypee Bros., New Delhi, 1991.

10. ANATOMY RELATED TO


GLAUCOMA12
Fig. 9.1 Electron m icrograph showing drying pattern
Anterior Chamber
o f vitreous acid m ucopolysaccharidcs, MP, between the
aggregates o f dclicate collagenous filaments, C, o f the The anterior chamber (AC) is bound in front by
vitreous framework. Below lies the inner surface o f the the posterior surface o f the comea and peripherally
reting (arrow s) (x24,000) (Courtesy: B.S. Fine; Scheie by the angle recess. The apex of the angle is formed
& Albert).
by the anteriormost part of the ciliary body. It is
also limited behind by the anterior surface of the
with hyaluronic acid, (b) hyaluronic acid which
iris and the lens exposed in the pupillary area. The
protects the gel against cellular invasion and is
average diameter is 1 1 to 12 mm and its average
condensed at the periphery as a surface layer and
axial depth is 3 to 3.5 mm. Its volume is 0.2 to 0.3
(c) soluble proteins. In the normal eyes, the vitreous
mm. The shallowest part is at the iridocorneal
cells called the hyalocytes which are mainly
junction and the deepest part is in the pupillary
histiocytes, appear to help in the synthesis of acid
area.
mucopolysaccharides and vitreous fibrils.
The causes of deep AC include (a) aphakia; (b)
It acts as an intervening medium in the light­
buphthalmos; (c) sometimes myopia; and (d)
pathway between the lens and the retina.
vitreous degeneration.
The causes o f shallow AC include (a)
Vitreous attachm ents
intumescence of lens; (b) closed-angle glaucoma;
The vitreous is firmly adherent at certain regions, (c) sometimes hypermetropia; and (d) old age.
viz., the vitreous base, margin of the optic disc AC is deep in the centre and shallow at the
and m acula, and overlying retinal vessels. periphery as in iris bombe. AC is deeper at one
Elsewhere the attachment is loose. side than on the other as in subluxation o f the lens.

Ultramicroscopy. The fibrils in the cortical


Posterior Chamber
vitreous insert into the internal limiting membrane
of the retina posteriorly, blending with the basal The posterior chamber is the space demarcated in
lamina of Muller's cells or with that of the ciliary front by the iris, at the back by the lens and the
body anteriorly. The hyalocytes show large suspensory ligament. Its base is formed by the
electron-dense inclusions. ciliary processes, while its apex is formed by the
pupillary margin o f the iris. The volume of this interlace but tapering anteriorly. The sheets
chamber is 0.06 ml. converge anteriorly and join the periphery of
This chamber consists o f three compartments: Descemet’s membrane, inner part o f Schwalbe’s
prezonular (posterior chamber proper), zonular and ring and corn eo scleral trab ecu lae. The
retrozonular. corneoscleral meshwork is made up of 8 to 15
The prezonular part is triangular on cross- layers with a total width of 120 to 150 millimicrons.
section. Its apex is formed by the point o f contact
Ultramicroscopy. The trabeculae are made up of
between the pupillary margin o f the iris and the
central core, middle layer o f basement membrane
anterior surface o f the lens. The base is formed by
and the surrounding endothelial layer containing
the ciliary processes. The anterior and posterior
numerous pinocytic vesicles. The central core is
walls are respectively formed by the pigment
formed by collagen types I, II and IV, fibronectin,
epithelium o f the iris and by the lens with zonules.
chondroitin sulphate, elastic tissue, etc. The
The zonular compartment lies within the zonule
trabecular cells made up of basal laminar, collagen
o f Zinn.
and glycosaminoglycans (mucopolysaccharides
The retrozonular compartment (Petit’s canal)
have important functions like secretion and pigment
is situated in between the posterior aspect of
phagocytosis).
the zonular fibres and the anterior hyaloid
face. Canal o f schlemm. It is a slightly irregular,
annular, endothelial-lined canal. This is about 36
mm in circumference and is situated in the outer
Angle of the AC or the Filtration Angle portion o f the internal scleral sulcus. This canal
This is bound behind by the root o f the iris and in conducts the aqueous humour from the trabecular
front by the co rn eo scleral trabeculum and meshwork to the episcleral venous network via the
anteriorm ost part o f the ciliary body. The collector channels. Microscopically there are zones:
corneoscleral trabeculum or the meshwork o f the the endothelial lining, basement membrane, and
angle is made up o f three structures: (i) Descemet’s pericanalicular connective tissue.
membrane breaking up into bundles; (ii) scleral
Ultramicroscopy. There is direct communication
meshwork; and (iii) uveal meshwork. Descemet’s between the extracellular spaces o f the trabeculum
m em brane connects the scleral and uveal and S chlem m ’s canal. The sin g le-lay ered
meshworks. endothelial spindle cells line the canal. These cells
are connected to each other by poorly tight
The Outflow Apparatus ju n ctio n s and their cytoplasm show s usual
The outflow apparatus consists of the trabecular organelles. The luminal surface of the cells show
m eshw ork, canal o f Schlem m and collector sparse microvilli, but the prominent feature is the
channels. presence o f giant vacuoles. These vacuoles are
globular invaginations of the basal plasmalemma
The trabecular m eshwork (Fig. 7c.2). This o f en d o th elial cells. The vacuoles are 25
spongework connective tissue beams are arranged millimicron long x 6 millimicron wide. About 2%
as superimposed perforated sheets. It arises just o f these vacuoles communicate with Schlemm’s
before the apparent termination of Descemet’s canal via a luminal pore (transcellular channels).
membrane. The beams run posteriorly to the Following aqueous drainage there is occlusion of
anterom edial border o f the scleral spur and the basal infoldings resulting in a nonvacuolated
junctions of the iris and ciliary body. It shows two state.
p o rtio n s: inner uveal m eshw ork and outer
corneoscleral meshwork. The uveal meshwork The collector channels. They originate at irregular
contains one or two layers which branch and intervals from the outer wall o f Schlemm’s canal.
They are 25 to 35 in number. They drain into: (i) extends into the ciliary body. Posteriorly, all the
deep scleral plexus, (ii) intrascleral (midscleral) retinal layers except the nerve fibre layer terminate
plexus and (iii) episcleral plexus. The deep plexus at the optic disc and being separated from the disc
made up o f branches o f the anterior ciliary veins by a layer of glial tissue, the intermediary tissue o f
drains into the intrascleral plexus. The intrascleral Kuhnt. The retina and the vitreous humour are in
plexus drains posteriorly into the episceleral plexus, intimate contact especially at the ora serrata and in
and the latter finally into the anterior ciliary veins. a 4 mm zone posterior to the ora serrata.
Aqueous veins are those 8 collector channels
that directly drain into the episcleral plexus. They Optic Disc
are seen with a slit-lamp biomicroscope either as
clear vessels showing bilaminar flow of blood and The optic disc is round or vertically oval, 1.5 mm
in diameter with a depression at the centre. The
aqueous, about 2 mm away from the limbus usually
located anteromedially. depression is due to atrophy of the fetal vascular
elements called the physiologic cup. At this region
the nerve fibres become continuous with the optic
Inner Canals or Afferent
nerve and the central retinal artery with its branches
Communications
enters here. The central retinal vein with its
These are fine, tortuous, endothelial-lined, oblique tributaries exits here. It is made up of axons of the
spaces within the meshwork. ganglion cells of the retina. The term ‘papilla’ used
as a synonym is a misnomer since the disc is not
F u rther R eading raised from the surface but at the same level as
that of the rest of the retina. While charting the
1. Bron, A .J., Tripathy, R.C. and Tripathy, visual field the ‘blind spot’ corresponds to the
B.J. (Eds.), Wolff’s Anatomy o f the Eye and optic disc, because of absence o f the rods and
Orbit (8th ed.), Chapman and Hall, London, cones. The optic disc is considered the retinal
1997. aspect o f the head or intraocular portion of the
2. Sugar, H.S., The Glaucomas, Paul B. Hoeber, optic nerve.
New York, 1957. Table 11.1 gives an account of retinal elements.

Table 11.1
11. ANATOMY OF THE The Elem ents o f the Retina

RETINA'-7 N euroepithelial layer


Rods
The retina (Lat. rete. net) is the innermost (nervous) C ones
coat of the eyeball which is the receptor of the Cerebral layer
Direct conducting elements
light stimuli. It is a delicate, transparent membrane,
Bipolar cells
purplish red in colour due to rhodopsin. It is very
Ganglion cells
thin approximately 0.5 mm at the posterior pole, A ssociation and sustentacular elem ents
0.2 mm at the equator and 0.1 mm at the ora serrata. M ailer’s cells
It is thickest near the optic disc and becomes thinner Horizontal cells
towards the periphery. It is attached at two places— Amacrine cells
the ora serrata and the optic disc. Externally, the O ther cells like astrocytes and spongioblasts
retinal pigment epithelium is in contact with
Bruch’s membrane of the choroid. The internal There are three neurons and the layers of
limiting membrane o f the retina separates it from the retina are grouped under them as indicated in
the vitreous. Anteriorly, the pigment epithelium Table 11.2.
The m id periphery. It is 3 mm wide. It is
Three N eurons in the Retina characterized by interrupted ganglion cells and
thicker cones, the cones being separated from each
N euron I (percipient elements)
other by at least three rods.
Layer o f rods and cones
External limiting mem brane The fa r periphery. This is 9 to 10 mm wide
O uter nuclear layer temporally and 16 mm wide nasally. At this region
O uter plexiform layer
there are large and widely-spaced ganglion cells
N euron II (conduction and association elem ents)
Inner nuclear layer and the number of cones reduced, the cones having
Inner plexiform layer shorter outer segments.
Neuron III (purely conduction elem ents) The ora serrata. The ora serrata is 2 mm wide
G anglion cell layer
temporally and 0.7 mm wide nasally. There is
Nerve fibre layer
Internal lim iting membrane gradual disappearance of the rods and replacement
with malformed cones, disappearance of the outer
molecular layer and fusion of the rods and cones.
The retina proper can be broadly subdivided
At 0.5 mm before the termination of the retina the
into two parts: the central or macular and the
rods and cones, ganglion cells and nerve fibre layer
peripheral.
cease.
Ora serrata is the anteriormost end of the retina
Central Retina or Macula Lutea
where it continues as the nonpigmented ciliary
Macula lutea (Lat. macula a spot; lutea, yellow, epithelium o f the pars plana. The serrated
the specialized region o f the retina is 3 mm or 2- appearance is due to anteriorly directed projections,
disc diameter temporal to the optic disc. Since this about 40 in number. These projections are called
area is avascular, its nutrition is derived from the dentate processes or oral teeth. Hie scalloped areas
choroid. The central retina can be subdivided into between them are called oral bays.
three areas, the fovea, parafovea and perifovea.
The fovea centralis (Lat .fovea, pit) is a central Structure (Fig. 11.1)
depression in the macula lutea. It shows a bright The retina has ten layers from outside to inwards.
reflex seen by the ophthalmoscope. It is the most These are as follows:
sensitive part of the retina and contains only conces.
The parafovea is a 2.1 mm wide area all round
the fovea and contains both rods and cones arranged
Pigment cells Pgment
alternately. layer
Rod and cooc
The perifovea is 1.5 mm wide area around the processes
Rod and
cone layer
parafovea and at this region there are two rods Outer
Nuclei o f rod
between each cone. and cone cells
nuclear
layer
Plexus between
I^Oirter plexiform layer
Peripheral Retina photoreceptors and
nerve cells
Bipolar horizontal Inner nuclear
The peripheral retina may be divided into four and amacrine cells layer
Mullers fibre
zones: (a) the near periphery; (b) the mid periphery;
Plexus beNveen Inner plexiform
(c) the far periphery; and (d) the ora serrata or bipolar and amacrine layer
extreme periphery. and ganglion cefts
cells
Ganglion cells Stratum
The near periphery. The near periphery is the 1.5 and
their processes
opticum
Am aatne cell Ganglion cell
mm wide area around the macula characterized by
the absence of Henle’s fibre layer and the presence Fig. 11.1 D iagram o f the structure o f the retina
of thicker cones surrounded by a collar of rods. (Sorsby)
The pigment epithelium. This consists of a single The distinguishing features o f the photoreceptors
layer of flattened hexagonal cells (each cell consists (rods and cones) are listed under Table 11.3.
o f a dome, base and fine contractile pigment
processes insinuating between adjacent rods and Table 113
cones), each cell having a nucleus and large amount D istinguishing Features o f the Retinal R ods and C ones
of dense pigment, fuscin. In senile eyes there is
less dense pigment, lipofuscin. Points Rods Cones
Electron microscopically, the cytoplasm shows
three zones: (a) the outermost which contains the Total num ber 77.9 -1 0 3 .3 m illions 4 .0 8 -5 .2 9 m illions
D istribution A bsent at fovea M axim a] at fovea
mitochondria and basal membrane infoldings; O uter segm ent Lesser in num ber M ore, 10 0 0 - 1200/cone
(b) the intermediate which contains the nucleus discs
and endoplasmic reticulum; and (c) the innermost Ending Spherule Feet
w hich co n tain s m elanin granules and Plasm a Discs w ithin it Discs n o t separated
m em brane from it
ribonucleoprotein particles.
R elation with No Y es
Layer o f rods and cones. This represents the true colour vision

light-perceiving layer. The rods are maximum at %

the periphery, and at the fovea there are only cones. Electron microscopy shows (Fig. 11.3) the
Each visual cell, either a rod or a cone, has the essential structure of the outer segments of both
following components (Fig. 11.2): (a) an outer rods and cones consisting o f about 600 to 1200
segment, which is thicker than the inner one, (b) a highly regular lamellae packed in a columnar
cilium connecting the outer and inner segments, manner. In a cone the discs have a greater diameter.
The inner segment is connected to the outer by a
Outer -------------- ft « short area o f relatively featureless cytoplasm. The
m em ber It IV------ Outer inner segment contains many mitochondria, Golgi
II II member apparatus and a granular endoplasmic reticulum,
Ellipsoid along with ribosomes and neurotubules.
Ellipsoid------
Inner The external limiting membrane. This is fomied
member
Inner m em ber — by Muller’s fibres and fenestrated by the fibres of
Myoid
Limitans externa the rods and cones. The cone openings are larger
Cone
Rod fib re ------------- nucleus than the rod openings.
Cone fibre The outer nuclear layer. This layer consists
Rod n u c le u s ------
essentially of the nuclei of the rods and cones.
V aricosity----------
End bulb ----------------- J ----- Cone foot
The outer plexiform (molecular) layer. This
a b contains the axons of the rods and cones arborizing
Fig. 11.2 D iagram sh o w in g parts o f (a) rod and with the dendrites of the bipolar cells, as well as
(b) cone o f the human retina. with those of the horizontal cells and amacrine
cells. This layer is thickest at the macula, but almost
(c) an inner segment which consists of the ellipsoid
disappears at the fovea.
containing the m itochondria and the myoid
containing glycogen, (d) a connecting fibre between The inner nuclear layer. This layer consists of:
the inner segment and the cell body, (e) the cell (a) the bipolar cells, (b) the nuclei o f Muller's
body contains the large nucleus and small amount fibres, (c) the horizontal cells, (d) the amacrine
of cytoplasm, and (0 the inner rod or inner cone cells, and (e) the capillaries of the central retinal
fibre: the rod fibre ends in a spherule and the cone vessels.
fibre in feet. The bipolar cells (Table 11.4) are o f two types.
vesicles
Stnations o f c iia ry
rootlets

Mitochondrion
Ciliary filaments

Cytoplasmic cofiar
(calyx)

extension!, of lameJlas into m embrane of


longitudinal furrows

Cross-section

Terminal bar
endoplasmic
reticulum
Pig m en!

Fig. 1 1 3 (a) Electron micrograph showing external limiting membrane made up o f terminal bars, ТВ. Internally,
M uller’s cell cytoplasm , M U is easily distinguished from the photoreceptor ceils, PH. in the outer unclear layer
( ' 7.000). (b) Diagram showing parts o f the photoreceptors that extend beyond (are external to) the external limiting
m em brane (Courtesy: В S Fine; M cPherson).

T ab le 11.4 Classification o f B ipolar Cells midget bipolar cells and monosynaptic ganglion
cells, and this arrangement causes one-to-one
Rod or m op bipolar connections between the cones and the optic nerve
Cone bipolar
fibres.
M onosynaptic (midget)
Invaginating Ultramicroscopy. Ultrastructures of all types of
Flat
bipolar cells are similar. They contain round or
Diffuse
Invaginating (brush) oval nucleus, prom inent G olgi apparatus,
Flat ribosomes, endoplasmic reticulum, mitochondria
Giant and microtubules.
R at The horizontal cells connect the cones of one part
of the retina with the rods and cones of adjacent parts.
diffuse and midget or monosynaptic; the diffuse The am acrine c e lls are also laterally
bipolar again may be subdivided into mop and communicating neurons like the horizontal cells.
brush types. The mop bipolar cells connect with The name ‘amacrine’ was given to these cells from
both rods and cones. The brush bipolar cells the incorrect assumption that they had no axons.
connect with the cones only. The axons of the In fact, these cells have single processes.
midget bipolar run into the inner plexiform layer Muller's fibres are the main supporting elements
and connect with the dendrites of the midget of the retina and they extend throughout the retina
ganglion cells. There are equal number of cones. except at the fovea. Each fibre has a nucleus, cell
body and long processes. They have the capacity from the macula itself run straight towards the outer
o f storage and synthesis of glycogen. side of the optic disc, the papillomacular bundle.
The fibres from the outer side of the disc arch
The in n er p lex ifo rm layer. This consists
above and below the macula, the arcuate fibres,
essentially o f the arborizations o f the axons of the
while those from the inner side reach the disc
bipolar cells with the dendrites of the ganglion
without any interruption.
cells along with Muller’s fibres, distal processes of
The nerve fibre layer is thinnest in the zone of
the amacrine cells and branches o f the retinal
the papillomacular bundle, next in thickness are
vessels.
the outer quadrants followed by the thickest inner
The ganglion cell layer. It consists of Muller’s quadrants. The relative thickness is the factor which
fibres, neuroglia, branches of the retinal vessels determ ines the onset o f papilloedem a, and
and a single row of ganglion cells except near the papilloedema initially involves the inner quadrant.
fovea where 8 layers are present.
The internal limiting membrane. This separates
Ganglion cells are flask-shaped consisting of
the retina from the vitreous and is formed by the
the axons, forming the nerve fibre layer, and the
terminal expansions of Mtiller's fibres. It merges
dendrites, extending into the inner plexiform layer.
at the optic disc and becomes continuous with the
Each cell is multipolar with a large nucleus, several
neuroglia constituting the connective tissue
nucleoli and Nissl granules. The ganglion cells are
meniscus of Kuhnt. Neuroglia are derived from
the neurons of the second order. Their axons make
both ectoderm and mesoderm. It may be broadly
a cell station in the lateral geniculate body.
divided into astrocytes and oligodendrocytes
The nerve fibre layer. This consists essentially derived from the ectoderm, and microglia derived
o f the axons o f the ganglion cells. The other from the mesoderm.
elements of this layer are the centrifugal fibres,
Miiller’s fibres, the neuroglia and the retinal blood Arterial supply (Fig. 45c. 1)
vessels.
The arrangement of the nerve fibres (Fig. 11.4) The retina gets its main arterial supply from the
is an important consideration while dealing with central retinal artery, a branch of the ophthalmic
papilloedema and various field defects. All the artery. The central artery of the retina is divided
fibres converge towards the optic disc. The fibres into four branches: superior temporal, superior
nasal, inferior temporal, and inferior nasal.
The branches arise in the physiologic cup of
the optic disc, then they divide in a dichotomatous
manner and all the four quadrants of the retina
receive the blood supply in an even manner. The
retinal arterioles are end-arteries.
The cilioretinal artery is an inconstant branch
appearing at the temporal side of the disc coursing
Tem poral Nasal towards the macula. It is derived from the circle of
Zinn-Haller, called the circulus vasculosus nervi
optici which is the circular anastomosis between
2,4 or more of the short posterior ciliary arteries,
the circle lying close to the optic nerve.
The retina has a double blood supply. The
central retinal artery extends between the internal
bundle limiting membrane and the inner nuclear layer. The
Fig. 11.4 Distribution o f the retinal nerve fibres. outer plexiform layer is fed partly from the retinal
arterioles and the choriocapillaris. The remaining 4. Fine, B.S., Retinal Structure: light and electron
layers namely the outer nuclear layer, the layer of m icroscopic observations. In N ew and
rods and cones, the external limiting membrane, Controversial Aspects o f Retinal Detachment,
and the pigment epithelium are supplied by the McPherson, A. (Ed.), Hoeber, Harper & Row,
choriocapillaris. New York, 1968.
5. Hogan, M.J., Alvarado, J.A. and Weddell, J.E.,
Venous drainage Histology o f the Human Eye, W.B. Saunders,
The veins at the retinal periphery do not follow Philadelphia, 1971.
the course of the arteries, but in the central part the 6. Pahwa, J.M. and Billore, O.P., Retinal Diseases,
veins follow the course of the arteries. Four veins, Oxford and IBH, New Delhi, 1978.
the superior temporal, superior nasal, inferior 7. Roof, D.L. and Heth, C.A., Photoreceptors and
temporal and inferior nasal unite to form the central retinal pigment epithlium transduction and
retinal vein. The central retinal vein drains into the renewal mechanism. In Principles and Practice
cavernous sinus, and sometimes into the superior o f Ophthalmology: Basic Sciences, Albert, D.M.
and inferior ophthalmic veins. and Jacobiec, F.A. (Eds.), W.B. Saunders,
Philadelphia, 1994, p. 309.
Capillary distribution
Basically, there are two networks, superficial and
deep—the former is in the outer parts of the nerve 12. ANATOMY OF THE
fibre layer and the latter in the zone intervening
between the inner nuclear layer and the outer VISUAL PATHWAYS1'3
plexiform layer. This basic pattern of distribution
is modified at the following regions: (a) at the The visual pathway from the retina has been
extreme margin of the retina, the avascular zone; divided into six parts (Fig. 12.1): (a) the optic nerve,
(b) at the retinal periphery, the single capillary net; (b) the optic chiasma; (c) the optic tract, (d) the
(c) at the equator, the double capillary net;
(d) around the macula, the triple capillary net and
most superficial retinal net disappears; and (e)
around the disc, four layers, the superficial net
becomes three-dimensional.

F urther R eading
1. Bron, A.J., Tripathy, R.C. and Tripathy, B.J.
(Eds.), Wolff's Anatomy o f the Eye and Orbit
(8th ed.) Chapman and Hall, London, 1997.
2. Dacheux, R.P. and Raviola, E., Functional
anatomy of the neural retina. In Principles and
Practice o f Ophthalmology: Basic Sciences,
Albert, D.M. and Jacobiec, F.A. (Eds.), W.B.
Saunders, Philadelphia, 1994, p. 285.
3. Duke-Elder, S., System o f Ophthalmology, Vol.
II: The Anatomy o f the Visual System, Duke- Fig. 12.1 A n a to m y o f th e v isu a l p a th w a y s : 1, re tin a ;
Elder, S. and Wybar, K. (Eds.), Kimpton, 2 , o p tic n e rv e ; 3 , o p tic c h ia s m a : 4 . o p tic tra c t; 5 , la te ra l
London, 1961. g e n ic u la te b o d y ; 6 , o p tic ra d ia tio n s ; a n d 7, v isu a l c o rte x .
lateral geniculate body, (e) the optic radiations, lateral rectus. The posterior ciliary arteries gradually
and (f) the visual cortex. surround the nerve when it is approaching the
In the visual path, the end-organ is the sensory eyeball.
epithelium of the rods and cones. Three sensory
Intraosseous or canalicular. The ophthalmic
neurons can be recognized between the retinal
artery crosses below the nerve in the dural sheath
receptors and the visual cortex and they start as
to the lateral side and leaves the dura near the
follows.
canal. The sphenoidal air sinus is separated from
The first neuron. The bipolar cell in the retina
the optic nerve by a thin plate o f bone.
one cone receptors are connected with a single
bipolar cell. Intracranial The nerve lies successively on the
The second neuron. The ganglion cells of the retina. diaphragma sellae and the anterior part o f the
The third neuron. The axons o f the lateral cavernous sinus, and below the anterior perforated
geniculate body. substance and the medial root o f the olfactory tract.
The internal carotid artery, as also the ophthalmic
Optic Nerve artery, is at first below and then lateral to the
intracranial part of the nerve. Between the two optic
Ontogenetically, morphologically and functionally nerves in front of the chiasma, there is a variable
a tract of the central nervous system, the optic part o f the pituitary gland covered by the
nerve extends from the retina to the chiasma, and diaphragma sellae.
it has the following characteristics: (a) no sheaths The other important structures are described in
and cells of Schwann are present, (b) neuroglial connection with the sphenoidal fissure.
cells in the interstices are seen, and (c) it is clothed
by coverings of the brain. The length varies
between 35 and 55 mm, and the diameter of the Type o f fibres
intracranial part is between 4 and 7 mm and that There are over one million axons and five types of
of the intraorbital part is between 3 and 4 mm.
fibres: (a) the visual (afferent), 80%, the fibres
The optic nerve is divided in several parts. reaching the lateral geniculate body, (b) the
(a) The intraocular or head, 1 mm in length. pupillary (afferent), the fibres running to the tectum,
This is subdivided into three parts: retinal, (c) the efferent fibres (of unknown function) to the
choroidal and scleral. retina, (d) the photostatic fibres to the superior
colliculus, and (e) the autonomic fibres.
(b) The intraorbital, 25 mm in length, after
leaving the retina through the lamina
cribrosa. Arterial supply

(c) The intraosseous or canalicular, 4 to 10 mm The intraocular part (Fig. 12.2). Arterial supply
in length. to the intraocular part of the optic nerve is derived
from these.
(d) The intracranial, 10 to 23 mm in length.
From the ciliary circulation: (a) the circle of
The part starting beyond the optic foramen
Zinn, (b) the anterior part of the arterial plexus in
is the intracranial portion.
the pia mater, (c) the short posterior ciliary arteries,
and (d) the choroidal arteries.
Relations
From the retinal circulation: (a) the intraneural
These are extremely important. part of the central retinal artery: and (b) the anterior
division of the central artery of the optic nerve.
Intraorhital. It is surrounded by the origin of
the extrinsic muscles. The ciliary ganglion is The intraorbital part. The peripheral system is
situated lateral to the nerve between it and the derived from the pial plexus o f vessels
Pial brs. from post.

Pial
network a.

Ant. central optic artery centraJ optjc artery

Central retinal artery


Fig. 12.2 B lood supply o f the optic nerve (Reed).

supplemented by the ophthalmic, posterior ciliary,


circle o f Zinn and central retinal artery; and the
axial system is derived from the central retinal, e
central artery of the optic nerve and central retinal Fig. 123 Diagram to show the posterior view of the
collateral branches. distribution of the visual fibres in (a) right optic nerve
The intracanalicular p a r t It is supplied by the near the disc; (b) the region midway between the right
optic nerve-head and the optic chiasma; (c) the optic
ophthalmic artery. The axial system disappears
chiasma; (d) the right optic tract; (e) the right striate
proximal to the optic foramen. area. U, upper; L, lower; T, temporal; N, nasal;
The intracranial p a rt The supply is derived from P, peripheral; M, macular; B, binocular; and
the pial plexus and supplemented by the internal U, uniocular.
carotid, anterior cerebral, ophthalmic and anterior In the chiasma. There is partial decussation of
communicating arteries. the fibres of both optic nerves. The temporal fibres
pursue a direct ipsilateral course, while the fibres
Localization of the Fibres in the from the nasal hemiretina cross over to the optic
tract of the opposite side. The arrangement of the
Visual Pathways (Fig. 12.3)
fibres has been described on p. 42 and shown in
It is essential to be familiar with the arrangement Fig. 12.5.
o f the fibres in the visual pathways as it is helpful
In the optic tract. The macular fibres both
in the localization of a lesion.
crossed and uncrossed, are placed dorsolaterally.
In the retina. This has already been described The lower peripheral fibres occupy the lateral
{see Fig. 11.4 on p. 37). position and the upper peripheral fibres occupy
the medial position.
In the optic nerve. In the distal part, the macular
fibres, about one-third o f the nerve occupy a In the lateral geniculate body. The upper retinal
wedgeshaped area in the lateral part of the nerve. fibres reach the medial part of the lateral geniculate
The peripheral fibres from the temporal side and body. The macular fibres occupy the posterior two-
those from the nasal side occupy the same side. In third.
the proximal part, i.e. the part near the chiasma the In the optic radiations (Fig. 12.1). The upper
macular fibres occupy the central position of the and lower retinal fibres form corresponding parts
nerve. of the radiations and reach the upper and lower
lips o f the calcarine fissure. The macular fibres
occupy the middle position.
In the visual cortex. There is a point-to-point
localization of the retina in the visual cortex.

Optic Chiasma
Optic chiasma it is a transversely oval structure 12
mm in transverse diameter, 8 mm sagittally and 3
to 5 mm dorsoventrally covered by pia mater and
represents the junction between the termination of
the optic nerves anteromedially and emergence of
the optic tracts.

Relations
T hey are im portant and o f m uch clinical
significance.
Superiorly. They are the lamina terminalis and
floor o f the third ventricle. The chiasma is also
related to the hypothalamus. Fig. 12.4 Parts o f the visual pathw ays and their
arterial supply. 1, central retinal artery; 2, optic nerve;
Inferiorly. Relations vary according to its
3, ciliary arteries; 4, anterior cerebral artery; 5, central
position. It usually rests on the diaphragma sellae artery o f the optic nerve; 6, anterior com m unicating
and is related closely to the pituitary gland. artery; 7, ophthalm ic artery; 8, internal carotid artery; 9,
However, the optic chiasma may be prefixed 5% m iddle cerebral artery; 10, optic chiasma; 11, posterior
or postfixed 4% depending upon whether the com m unicating artery; 12 anterior choroidal artery; 13,
chiasma is lying in front or behind the pituitary basilar artery; 14, optic tract; 15, choroid plexus; 16,
gland. posterior choroidal artery; 17, middle cerebral artery;
18, laterial geniculate body; 19, thalam us; 20 posterior
Laterally. It is related especially to the termination cerebral artery; 21, optic radiations; 22, deep optic branch
o f the internal carotid artery. to middle cerebral artery; 23, calcarine artery; 24, cerebral
cortex.
Posteriorly. It is related to the tuber cinereum and
the infundibulum which connects the pituitary to
the base of the brain. Arrangem ent o f the fibres (Fig. 12.5)
The fibres, from the nasal half of each retina
A rterial supply including the nasal half of the macula decussate
Arterial supply is by the vessels on all free aspects. and cross over to the contralateral optic tract. The
It should be remembered that these are the main temporal fibres pursue a direct ipsilateral course.
branches (Fig. 12.4). The fibres, coming from the lower medial
(a) The superior part is supplied from the: (i) quadrant of the retina, cross in the lower part of
a n te rio r cereb ral and (ii) the an terio r the front of the chiasma. The uncrossed fibres, after
communicating arteries. crossing, loop forward into the terminal portion of
(b) The inferior part is supplied from the: (i) opposite nerve before reaching the inferomedial
the internal carotid (ii) the anterior superior part of the tract. The fibres, coming from the upper
hypophysial and (iii) the posterior communicating medial quadrant o f the retina, cross in the middle
arteries. and posterior parts of the chiasma, while the more
Right optic nerve
Ant. knee of Wilbrand
Inf. peripheral fibres

Temporal fibres

Macular crossing

Post, knee of Wilbrand


Sup. peripheral fibres
Left optic tract

Fig. 12.5 Arrangement of the fibres in the optic chiasma

posteriorly disposed fibres cause a detour at the ‘geniculate’ because of its configuration, i.e. it is
commencement of the ipsilateral optic tract before bent upon itself so that its dorsal surface is convex
reaching the contralateral optic tract. m edially and the ventral surface is concave
medially. It has two nuclei, dorsal and ventral, the
Optic Tract former being phylogenetically more recent. Six
layers are described, o f which 1, 4 and 6 receive
The optic tract originates at the posterolateral angle contralateral optic fibres, while the other layers
of the optic chiasma, appears round at first between
receive ipsilateral optic fibres.
the tuber cinereum and the anterior perforated
substance, and flat subsequently. It sweeps round
Arterial supply
the side o f the cerebral peduncle and finally divides
into two roots: (a) the larger lateral, and (b) the Lateral geniculate body is supplied mainly by the
sm aller m edial. The m ajority o f the former posterior cerebral and to some extent by the anterior
terminates into the lateral geniculate body and some choroidal arteries.
reach the pretectal region and superior colliculus, The external striate artery termed the ‘artery of
and the latter into the medial geniculate body. The cerebral haem orrhage’ passes near the lateral
superior colliculus is the part o f the midbrain and geniculate body.
serves possibly as a centre of vertical gaze in man.
Optic Radiations
Arterial supply (Fig. 12.4)
Fresh relay o f fibres originates in the lateral
Optic tract is supplied by the pial network, the geniculate body, pass forward and laterally forming
vessels derived from: (a) the anterior choroidal, the optic peduncle. It lies anterior to the lateral
(b) the m iddle cereb ral, (c) the p o sterio r ventricle and in the retrolenticular part o f the
communicating, and (d) the posterior cerebral internal capsule behind the sensory and medial to
arteries. the auditory radiations. It fans out to form the
medullary optic lamina and then terminates into
Lateral Geniculate Body the fourth layer o f the ipsilateral visual cortex. The
Lateral geniculate body acts as the ‘relay station’ lower fibres spread out forward around the inferior
in the afferent visual pathway, and derives its name fom o f the lateral ventricles (Meyer's loop).
Extrastriate System
Opticradiations receive their supply from: (a) the This includes visual association with the parastriate
anterior choroidal through the perforating branches, or area 18 of Brodmann and peristriate or area 19
(b) the calcarine branch of the posterior cerebral, of Brodmann. These two are: the visuopsychic,
and (c) the middle cerebral arteries through the area, and the area anterior to the former, i.e. in the
deep optic branches. region o f the angular and supramarginal gyri and
the temporal lobe. Area 18 does not show stria of
Striate Cortex Gennari. Area 19 does not show pyramidal cells in
Striate cortex is also called primary>visual area or layer 5. The frontal eye fields, superior colliculus,
area 17 of Brodmann. This is characterized by oculomotor and other nuclei are connected with
white lines o f Gennari. There are six layers in the area 19.
cerebral cortex:
F u rth er R eading
Layer 1—molecular layer
Layer 2—outer granular layer 1. Bron, A .J., T ripathy, R.C. and Tripathy
Layer 3—pyramidal layer B.J. (Eds.), Wolff’s Anatomy o f the Eye and
Oribit (8th ed.), Chapman and Hall, London,
Layer 4— inner granular layer
1997.
Layer 5—ganglion layer 2. Duke-Elder, S., System o f Ophthalmology,
Layer 6—polymorphous layer. Vol. II: The Anatomy o f the Visual System,
Duke-Elder, S. and Wybar, K. (Eds.), Kimpton,
In the striate cortex the layer 4 (inner granular
London, 1961.
layer) is enormously expanded and the layer 5
(ganglion layer) contains solitary pyramidal cells 3. Gray, H., Gray’s Anatomy (35th ed.), Warwick,
o f Meynert. R. and W illiams, P.L., (Eds.), Longman,
The primary visual area (area 17) is situated London, 1973.
mainly in the medial aspect of the occipital lobe,
around and in the calcarine sulcus with extensions
into the lingual and conous gyrus. It is the main
receptor area for the optic radiation from the lateral 13. ANATOMY OF
geniculate body. There is a p o in t-to -p o in t EXTRAOCULAR
localization o f the retina in the visual cortex and
pyramidal association areas.
MUSCLES OF THE EYE13
The functions o f the visual cortex are: (a) to The extraocular muscles are divided into three
appreciate visual sensation, (b) to differentiate major groups: extrinsic muscles, muscles of the
colours, (c) to fuse two separate images in binocular eyelid, and plane muscles of the orbit.
vision, (d) to perceive form and contour, and (e) to
coordinate relative localization in space. Extrinsic Muscles
For descriptive purpose these are described under
Arterial supply
five headings: origin, insertion, course, actions and
Striate cortex receives its blood supply chiefly from nerve supply (Table 13.1).
the occipital branch of the posterior cerebral artery
through its calcarine branches and to a less extent O rig in
through the temporal and parieto-occipital branches The four recti originate from a tendinous ring
o f the posterior cerebral arteries. surrounding the optic foramen and part of the
Table 13.1
D etails and A ctions o f the Six Extrinsic M uscles o f the Eye

M uscle Length o f D istance o f Length o f the N erve supply Actions


m usicle insertion from tendon (cranial nerve) --------------------------------------
(in m m ) the cornea (in m m ) M ain Subsidiary
(in mm)
Medial 40.8 5.5 3.7 Ill Adduction None
rectus
Lateral 40.6 6.9 8.8 VI Abduction None
rectus
Superior 41.8 7.7 5.8 III Elevation Adduction and
rectus intorsion
Inferior 40.0 6.5 5.5 III Depression A dduction and
rectus extorsion

Superior 60.0 ----- — IV Intorsion Depression and


oblique (40 direct and 20 abduction
reflected part)

Inferior 37.0 --- --- III Extorsion Elevation and


oblique abduction

medial end of the superior orbital fissure. The ring The inferior rectus (IR) similarly passes in the
is known as annulus tendinous communis o f Zinn. same direction as the SR but along the floor o f the
The origin of the superior oblique is by a narrow orbit, and also makes an angle of 25°. The medial
tendon above and medial to the optic foramen, (MR) and lateral rectus (LR) pass forward along
partially overlapping that o f the levator palpebrae the corresponding walls.
superioris. The superior oblique (SO) about 10 mm behind
The inferior oblique originates from a rounded the trochlea or pulley forms a rounded tendon
tendon from a depression on the orbital plate of which hooks round the trochlea, passes downward,
the m axilla ju st outside the passage o f the backw ard and outw ard at an angle o f 55°
nasolacrimal duct. (Fig. 13.1)
The inferior oblique (10) passes backward and
Insertion outward lying below the IR.

The recti are inserted into the sclera in an area Actions o f the muscles
lying anterior to the equator, while the obliques
Rotation of an eyeball is possible around three
are inserted into the sclera in an area lying posterior
axes: vertical, transverse and anteroposterior—
to the equator.
whose centre of rotation corresponds roughly to
The inserted tendons can be distinguished from
the centre o f the eyeball.
the scleral fibres. The tendons have parallel
In elevation the SR and 10 act together; the SR
arrangement of fibres and the scleral fibres at this
is responsible for elevation of the abducted eye,
region show more irregular pattern.
and the IO for elevation of the adducted eye
(Fig. 13.2).
Course In depression the IR and SO act together.
The superior rectus (SR) passes forward and Intorsion is produced by the SO and SR. Extorsion
outward lying under the levator forming an angle is produced by the IO and IR. During abduction
o f 25° with the visual axis. the main action of the vertical recti (SR and IR)
V Frontal air sinus
Superior oblique muscle
Optic nerve, cut across Pulley (trochlea) lor tendon of
Levator palpebrae superior^ superior oblique
Superior rectus
Anterior or cutaneous tendon of
levator palpebrae superioris
Right anterior dinoid process

Atlactment of tendinous ring ^ Posterior or tarsal tendon


Optic foramen
Eyeball
Tendinous ring —
Groove for lacrimal sac
Foramen rotundum
' Laterial rectus
Inferior oblique
Lateral rectus
Orbital margin
Medial rectus
Interior retcus

Fig. 13.1 M uscles o f the right orbit (Pauchet and Dupret).

Table 13.2
RIO RSR
Classification of Basic Eye Movements3

Reflexive
RLR R M R LMR LLR
Vestibuloocular reflex
Opticokinetic nystagmus
Voluntary
Saccades
RSO RIR LIR LSO
Smooth persuit
R ig h t e y e Left e y e

Fig. 13.2 Diagram showing possible actions o f the Opticokinetic nystagmus is a reflexive ocular
extrinsic muscles. The direction tow ards which the eye movement in response to a large moving stimulus,
m oves is indicated by the straight arrows, w hile the and can be elicited in newborn infant.
torsional m ovem ent is shown by the curved arrows. Saccades are eye movements of short, 20 to
100 m seconds’, duration and o f high velocity, 20
increases, while during adduction the main action
to 600 degrees/second peak velocity. They shift
o f the obliques (SO and 10) increases. The
the direction of gaze from one target to another.
subsidiary actions of the vertical recti increase
Both saccades and smooth pursuit movements
during adduction, while those o f the obliques
depend largely on attention.
increase during abduction.
Smooth pursuit movements are low velocity
Basic Eye Movements (Table 13.2) ocular movements.

Vestibuloocular reflex has a latency of 15 m,


F urther R eading
seconds and it starts in three pairs of semicircular
canals. It shows two phases: a phase interrupted 1. Duke-Elder, S., System o f Ophthalmology, Vol
by a quick phase (saccadic) and resets the eye II: The Anatomy o f the Visual' System, Duke-
in more central position. .This reflex is present at Elder, S. and Wybar, K. (Eds.), Kimpton,
birth. London, 1961.
2. May, C. and Worth, C., Manual o f the Diseases Table 14.1
o f the Eye (13th ed.), Keith Lyle, Т., Cross, Principal Landm arks in O cular G row th (M ann)3
A.G., and Cook, C.A.G. (Eds.), Bailliere,
Tindall and Cashell, London, 1968. Structures undergoing change Approximate
age at end of
3. Hansen, R.M., Development o f oculomotor period
control systems. In Principles and Practice o f
O ptic p it changing in to optic vessicle 3 -4 weeks
Ophthalmology: Basic Sciences, Albert, D.M.
(a) A ppearance o f lens p it and vesicle
and Jacobiec, F.A. (Eds.), W.B. Saunders,
(b ) Form ation o f the optic cup by end o f 4th
Philadelphia, 1994, p. 608.
invagination o f the optic vesicle w eek
(c) A ppearance o f pigm ent in the outer
layer o f the optic cup
14. EMBRYOLOGY AND (a) C losure o f the foetal tissue
POSTNATAL DEVELOPMENT (b ) Form ation o f prim ary lens fibres 6th w eek

OF THE EYE13 (c) B eginning o f retinal differentiation


(d ) B eginning o f tunica vasculosa lentis

The two eyes develop from the pair o f diverticula (a) B eginning o f secondary lens fibres

from the sides of the forebrain and the neighbouring (b ) C om pletion o f tunica vasculosa lentis 3rd m onth
mesodermal and ectodermal elements. A short (c) D evelopm ent o f lid folds
discussion about the development o f the central (d) B eginning o f ectoderm al layers o f the iris
nervous system (CNS) and the brain in this (a) B eginning o f retrogression o f posterior
connection is thus important. vascular capsule o f the lens
The ectoderm of the embryonic plate anterior (b) A ppearance o f ciliary m uscles, 5th m onth
to the prim itive streak is the source o f the m uscles o f the iris and outer layer o f
development o f the major part of the CNS. It runs the choroid

longitudinally over the caudal part of the dorsal (a) R etrogression o f pupillary m em brane 7th m onth
surface. The neural plate is formed at this region (b) B eginning o f m edullation o f the
by proliferation and thickening o f the cells. The optic nerve
neural groove is the median longitudinal groove (a) D isappearance o f hyaloid artery 9th m onth
in the neural plate and the two parallel neural folds (b) M edullation reaching lam ina cribrosa
are the result o f proliferation of the neural ectoderm Full differentiation o f m acula lutea 4 - 6 m onths
one on each side of the groove. Along the margin after birth
of each neural fold a ridge of ectodermal cell, G row th o f w hole eye 25 years

neural crest, is formed. Posteriorly, the neural folds


fuse in the midline to conert the neural groove into dorsolateral aspects o f the cephalic end o f the neural
the neural tube during the fourth w eek o f tube and cause a depression on either side known
intrauterine life. Prior to the closure of the neural as the optic pit, the first evidence of the rudiments
tube, the neural folds expand in the cephalic end o f the eyes. The peripheral cells o f the optic pits
to outline the primordial brain and subsequent become thickened to form the optic plates. The
expansions form the three parts, the hindbrain, the optic plates themselves grow outward towards the
midbrain, and the forebrain. surface to form the primary optic vesicle. The
prim ary optic vesicles are connected to the
Embryology of the Eye (Tables 14.1 forebrain on each side by the optic stalk.
The two eyes develop from the primary optic
and 14.2 and Fig. 14.1)
vesicles along with the neighbouring mesodermal
The cells o f the neural crests migrate to the and ectodermal structures. At the 4 to 5 mm stage
the primary optic vesicle begins to invaginate the
A pproxim ate Relationship between Age and Crown- surface ectoderm simultaneously from below and
R um p Length (C R L) o f the Embryo and Fetus laterally thus forming the optic cup or the secondary
(D uke-Elder)1 optic vesicle, and the groove foetal, embryonic or
choroidal fissure— at the lower part. The fissure
Age CR length • allows the passage o f the vascular mesoderm to
(in weeks) (in mm) eventually form the hyaloid system. The inner layer
Embryo 4th 1-25 Somites of the optic cup forms the main structure of the
5th 3 -8 retina, while the outer layer of the cup forms the
6th 8-15 pigment epithelium. From the anterior border of
7th 15-22 the narrow space representing the original optic
8th 2 2 -3 0 vesicle between the two layers o f the cup, parts of
Foltus 9th 3 0 -4 0 the iris and ciliary body develop. The mesoderm
10th 4 0 -5 0 surrounding the cup differentiates to form coats of
11th 50-60 the eyes and the structures within the orbit. The
12th 6 0 -7 0 development o f the crystalline lens occurs from
16th 70-110 the lens vesicle.
20th 110-150 Table 14.3 gives an account of the embryonic
24th 150-200
origins o f various ocular tissues.
28th 200-230
32th 230-265 Table 14.3
36th 265-300 Em bryonic O rigins o f D ifferent O cular Tissues
40th 300-335
Neural ectoderm
•T h e C RL is the end-to-end length w ithout considering Neural retina
the curvature and w ithout taking account o f the legs. O ptic nerve
Epithelium o f iris and ciliary body
Pupillary muscles
Combined ectoderm and mesoderm
V itreous hum our
Surface ectoderm
Epithelium o f
Conjunctiva
C om ea
Lacrimal gland
Lacrimal sac and nasolacrim al duct
Eyelid epiderm is and lashes
Crystalline lens
Mesoderm
Stroma, D escem et’s m em brane and endothelium o f
com ea
Sclera
Stroma o f iris and ciliary body
Choroid
1 2 3 Ciliary muscle
Extraocular muscles
Fig. 14.1 D raw ings to depict the developm ent o f the Schlem m ’s canal
hum an eye. 1, pigm ent layer o f the retina; 2, nervous Trabecular meshwork
layer o f the retina; 3, lens pit; 4, neural ectoderm; 5, Vascular endothelia
optic cup; 6, surface ectoderm; 7, lens; 8, m esoderm ; 9, M eninges o f optic nerve
developing anterior surface o f the eyelids and cornea. Orbital cartilages and bones
Embryology of Neuroectodermal The primary stage (3-6 weeks). This stage or
Structures the hyaloid vitreous develops from the extensions
o f the protoplasmic conical processes o f both lens
The retina. This develops from two layers o f the cells and retinal cells, the latter group being
optic cup, the inner one forming the nervous predominant. As the lens capsule develops, the lens
elements and the sustentacular fibres, while the cells lose contact with the vitreous. At the same
outer layer gives rise to the pigment epithelium time, the hyaloid artery enters and empbryonic
There are four stages in the development o f the fissure along with mesodermal fibrils.
retina.
The secondary stage (6-10 weeks). In this stage
Stage I (4th-5th week). Initial differentiation of
die secondary vitreous is avascular and is secreted
two zones—outer nucleated and inner nonnucleated
from the inner layers o f the optic cup. This
m a rg in a l.
surrounds the primary vitreous and gradually
Stage II (6th-l2th week). Differentiation into increases in volum e. The thickening o f the
three temporary zones o f the inner non-nucleated secondary vitreous forms the hyaloid membrane.
zone and inward migration o f the outer nucleated The remnants o f the primary vitreous surrounding
zone. the hyaloid artery persists as the hyaloid canal,
Stage III (3rd-7th month). Differentiation into extending from the retrolental space towards the
various layers. The m arginal zone has been optic disc.
subdivided into three layers: the inner neuroblastic; The tertiary stage (10 weeks onwards). The
the intermediate (layer o f Chievitz); and the outer tertiary vitreous is secreted from the ciliary
neuroblastic. The inner neuroblastic layer gives rise epithelium appearing as fibrils extending from the
to the ganglion cells; the amacrine cells; and ciliary body to the equator of the lens. The zonule
Mtiller’s fibres. The intermediate layer disappears. of Zinn in adult is formed from these fibrils.
The outer neuroblastic layer gives rise to the
horizontal cells; and the nuclei o f rods and cones. Epithelium o f the iris, o f the ciliary body and
The processes extending from the ganglion cells pupillary muscles. During the third month the rim
constitute the nerve fibre layer. The terminal o f the optic cup grows forward in front o f the lens.
expansions o f Mtiller’s fibres develop into the two The inner layer forms the nonpigmented epithelium
limiting membranes. of the ciliary body and the posterior epithelial layer
o f the iris. The outer layer gives origin to the
Stage IV (7th-13th month). Final organization
anterior epithelial layer of the iris. The sphincter
of layers occurs. All the layers of the adult retina
pupillae and dilator pupillae (after 6th month)
are formed by the fifth month. Vascularization in
develop from the anterior epithelial layer of the
the inner retinal layers develops at the eighth month.
iris.
Macula develops between 3 and 8 months.
Conjunctival and corneal epithelium. The lens
The optic nerve. The optic nerve is formed by the vesicle perhaps induces a differentiation o f the
growth o f nerve fibres from the axons o f the surface ectoderm into the comeal epithelium by
ganglion cells o f the retina into the cavity of the means o f thin protoplasm ic bridges running
optic stalk and its subsequent obliteration at the 25 between the lens vesicle and the epithelium. The
mm stage. They consist mostly of centripetal fibres epithelium at the 14 mm stage is seen to have two
from the retina and a few centrifugal fibres from cell layers. By the 30 mm stage, three o f the five
the nerve cells of the brain. layers o f the epithelium are fairly well diffemtiated.
The vitreous humour. It is developed from both Epithelium o f the lacrimal gland. This is derived
the ectoderm and mesoderm. The development is from the ectoderm o f the superior conjunctival
in three stages: fomix.
The lacrimal sac and the nasolacrimal duct At
first a solid cord o f ectodermal cells, evident at 6
weeks in the embryo, becomes buried in the
mesoderm at the junction o f the maxillary and
lateral nasal processes. By the twelfth week,
canalization starts at the upper end by disintegration
o f its central cells and gradually descends
downward towards the inferior meatus. At about
the second week of life, the communication at the
inferior meatus is fully established by lysis of cells
of opposed mucosal lining of the nasal cavity and
the lower end of the nasolacrimal duct.
Other structures developing from the surface Fig. 14.2 D evelopm ent o f crystalline lens. A, lens
ectoderm are the eyelashes and the lining cells of plate; B, lens pit; C, lens pit closing; D, lens vesicle; E,
the tarsal and other glands opening on the lid prim ary lens fibres beginning; F, prim ary lens fibres
margin. complete; and G, secondary lens sutures (Ida Mann).

The crystalline lens (Table 14.4). This is developed


development of primary lens fibres, secondary lens
(Fig. 14.2) from the invagination o f the surface
fibres start forming. Y-sutures (upright anterior *Y*
ectoderm whose communication with the surface
and inverted posterior ‘Y ’) are seen when the
is cut off.
opposing fibres meet along these lines.
Table 14.4 In the embryonic life, the lens is enclosed by a
vassular capsule, tunica vasculosa lentis, which
Im portant Phases o f Lens D evelopm ent (M ann3)
totally disappears at or before birth.
The lens capsule develops from two sources—
Lens plate— 2 weeks
Lens vesicle— 4 weeks the deeper layer from the cells of the lens vesicle,
Prim ary lens fibres, beginning— 5 weeks and the superficial layer from the suspensory
Secondary lens fibres, beginning— 7 weeks ligament of the lens.
Y -sutures, recognizable— 81/2 weeks
V ascular capsule fully developed— 9 weeks
Retrogression o f vascular capsule complete— at or before
Embryology of Mesodermal
birth Structures (Fig. 14.3)
Lens capsule— 3 months
Nuclei o f the lens The cornea. The endothelium , D escem et’s
(i) Em bryonic— 1 to 3 months membrane and stroma of the comea originate from
(ii) Foetal— 2 to 6 months the mesodermal cells growing between the surface
(iii) Infantile— continues up to puberty ectoderm and the lens vesicle. At the 12 mm stage
(iv) A dult— 20 to 25 years the mesodermal cells give rise to the corneal
Cortex-form s throughout life
endothelium. The second layer of the mesodermal
cells then grows between the surface ectoderm and
The lens pit deepens to form the lens vesicle
the cells destined to develop into the corneal
which is attached to the surface by the lens stalk.
endothelium. This forms the stroma between 25
Subsequently, the lens vesicle separates. Primary
and 30 mm stage. By the fifth month. Bowman’s
lens fibres begin to form from the cells o f the
membrane appears. Subsequently Descem et’s
posterior subcapsular epithelium of the lens vesicle.
membrane elaborated by the endothelium develops.
These fibres obliterate the lumen of the vesicle
and meet its anterior wall which persists as the The sclera and extraocular muscles. They develop
anterior epithelium . After the com pletion o f from the condensed mesoderm encircling the optic
Large venous channels make their appearance
during the third month. By the fifth month
chromatophores appear.
The ciliary body and iris. During the third month
Edgeof the paraxial mesoderm outside the anterior rim of
optic cup
the optic cup shows a tendency for condensation.
Primordium
of comea The mesoderm external to the epithelial layers fills
Edgeof the spaces behind the folds and ridges produced
Opeccup
by the epithelial layer, and forms the stroma of the
retinae
corona ciliaris. The posterior leaf of the mesodermal
portion of the iris is formed, while there is forward
and axial extension of the neural ectoderm.
Ora senate
The ciliary m uscle is developed by the
Para cikans retinae
sp ecialized condensation o f the m esoderm
Fig. 143 Section through the eye and foetal fissure encircling the optic cup.
of 13.5 mm embryo (xl57). Note the eversion of the
inner layer of the optic cup at the posterior (proximal) Hyaloid system o f vessels. This constitutes an
end of the foetal fissure (After Fischel; Wolff). important aspect in the embryology of the eye.
The hyaloid artery, a branch o f the primitive dorsal
cup and at the 20 mm stage the differentiation sets ophthalmic artery, reaches the posterior pole of
in. By the fifth month development o f these the lens vesicle (6 to 7 mm) through the foetal
structures is well marked. fissure. At the posterior pole of the lens vesicle it
unites with the tunica vasculosa lentis.
The eyelids. The lid buds appear at the 16 mm
Soon.after the 10 mm stage the hyaloid system
stage in front o f the growing eye where they fuse
communicates with the annular vessel to form the
at the 37 mm stage. During the fifth month they
capsulopupillary portion of the tunica vasculosa
separate, while the ectodermal structures of the
lens. The annular vessel develops at the 8 to 9 mm
eyelids, i.e. the eyelashes and lining cells of
stage along the anterior margins of the foetal
different glands, develop.
fissure. At the 2.5 mm stage small buds appear in
Anterior and posterior chambers. A thin cleft the annular vessel to form the anterior portion of
appears in the mesoderm separating the future the tunica vasculosa lentis.
corneal endothelium and the iris stroma and forms The hyaloid system starts disappearing at the
the anterior chamber (AC). After the fifth month 60 mm stage of differentiation.
there is marked deepening and development of the
anterior ocular segment. Schlemm’s canal is present Postnatal developm ent
after the second m onth and the trabecular Postnatal development occurs through first few
meshwork starts appearing in the sixth month. years of life.
The choroid. At the 5 to 6 mm stage with the Eyeball. The anterior segment of a neonatal eye
appearance o f the en d o th elial spaces is about 75 to 80 per cent of that in adult, while
ch o rio cap illaris develop in the m esoderm the posterior segment at birth is less than 50 per
surrounding the optic vesicle. The cuticular layer cent o f the size of a normal adult eye. The size
of Bruch’s membrane appears at the 14 to 18 mm increases due to expansion of the scleral surface
stage. The elastic layer of this membrane is seen at area of the posterior segment and this continues
the 70 mm stage. The inner cuticular layer is till 13 years of age, but most dramatic changes
ectoderm al and the o u ter elastic layer is involving 50 per cent increase occur within first
mesodermal in origin. six months of life.
The length of an eyeball in a neonate is 16 mm, The size o f the pupil is 3.6 ± 0.9 mm and there
but this is 22.7 mm in the age group of 5 to 13 is no pupillary response to light.
years.
Intraocular pressure (IOP) in an infant is lower
Orbit. With the growth and development of the than in an adult.
skull and facial bones orbital anatomy undergoes
Extraocular muscles. Their development continues
significant changes. The roof becomes flatter and
after birth. The insertions o f the medial rectus and
larger in infants than in adults. The inner angle
lateral rectus are quite close to the equator, and
becomes more divergent as age advances.
those o f the superior oblique and inferior oblique
Palpebral fissure. The length and height are 18.5 are closer to one another than in the adult eye.
to 19 mm and 10 mm respectively, while those in
Retina. The macula lutea is least well-developed
an adult eye they are 28 to 30 nun and 14 to 15
at birth. The foveal reflex is fully established by
mm respectively.
42 weeks of gestational age.
Lacrimal apparatus. Both secretory and excretory
Crystalline lens. At birth it is almost spherical
functions are operational at birth. The development
and soft in consistency.
of the nasolacrimal duct is complete at birth.
Refractive error. About 80 per cent o f children
Conjunctiva is thicker and tougher in a child.
are bom hypermetropic. Seventy-one per cent of
There is a gradual increase in size over 10 years of
them have + cylinder at 180°.
age.
Cornea. The newborn child has a relatively large F urther Reading
cornea which reaches adult size by 2 years of age.
1. Duke-Elder, S., System o f Ophthalmology,
D uring the first year the changes include
enlargement, flattening, thinning and increase in Vol. Ill: Normal and Abnormal Development,
Part I: Embryology, Duke-Elder, S. and Cook,
transparency.
C. (Eds.), Kimpton, London, 1963.
Anterior chamber (AC). The angle of the AC
2. E ustis, H .S ., P ostnatal developm ent.
undergoes differentiation during first year of life.
In P ed ia tric O phthalm ology, W right,
Shortly after birth the endothelial cell lining of the
K.W. (Ed.), C.V. Mosby, St. Louis, 1995,
angle becomes fenestrated.
p. 45.
Iris and pupil. At birth, the anterior surface of the 3. Mann, I., The Development o f the Human Eye
iris shows very little or no pigment. The colour of (3rd ed.), British Medical Association, London,
the iris changes within first 6 months of life. 1964.
O ops, p a g e PA 53 w a s not y e t d o w n lo ad ed :(
Part Two
Ocular Physiology

he eye is the organ o f vision. To enable the eyes to do so, its parts
T must be in perfect condition to attain perfect vision. The physiology
o f the eye differs from that o f the other organs o f the body. The
particular aspects related to the eyes include the formation of the
intraocular fluid, maintenance o f the intraocular pressure, metabolism
of the avascular tissues of the eyeball, accommodation and convergence.
15. THE AQUEOUS HUMOUR13 o f ions by the enzymes: carbonic anhydrase,
sodium-potassium ATPase, and others. This occurs
The aqueous humour comprises about 4 per cent in the region of nonpigmented cells of the ciliary
of the total volume of the eye and represents the body containing numerous mitochondria.
ocular tissue fluid. It maintains the intraocular Ultrafiltration means dialysis in the presence of
pressure and supplies nutrition to the avascular hydrostatic pressure. When a combined protein and
structures, namely the comea and lens. It has a salt solution is separated from pure water by means
specific gravity of 1.005, slightly higher than water o f membrane impermeable to protein, transference
and a low refractive index o f 1.336. The aqueous o f salt and water through the membrane occurs.
humour is a refractive medium. It is composed of The passage o f water into the protein-containing
water— 99.69 per cent and solids. The solid solution is called dialysis.
constituent is as follows: (a) diffusible crystalloids In the eye, protein-free filtrate derived from the
made of electrolytes containing positively-charged plasma passes inward and outward between the
or cations—sodium, potassium, magnesium and uveal and retinal capillaries and form s the
calcium and negatively-charged or anions— intraocular fluid. Because o f the anatom ical
chlorides, phosphates, sulphates and bicarbonates, peculiarity in the ciliary body, the most vascular
n o n electro ly tes— glucose, urea, lactate and region of the eye, the transference is largely carried
pyruvate; (b) nondiffusible colloids made of out by this region.
proteins, immune bodies and enzymes as well as Diffusion is the process of uniform molecular
(c) ascorbic acid and hyaluronic acid. The cations distribution o f a gas or solution throughout the
are in lesser concentrations and the anions in higher space in which it is present.
concentrations in the aqueous humour than in In the eye, diffusion of nonelectrolytes occurs
blood plasma. This is due to the retention of cations across the blood—aqueous barrier, i.e. the walls of
by the negatively-charged blood colloids. the capillary beds act as semipermeable membrane
The concentrations o f glucose and urea are and separate the blood from the ocular cavity.
higher in blood plasma. The aqueous humour has Diffusion of electrolytes occurs according to the
a higher concentration o f lactate. It contains 0.02 ‘Gibbs-Donnan theory’. According to the theory,
gm/pcr cent o f proteins in comparison to that of the product of the diffusible ions on one side of
blood which is 7 gm/per cent. ТЪеге is a low the membrane is equal to the product o f the
concentration of immune bodies and only traces of diffusible ions on the other side, and the sum of
enzymes. The presence o f ascorbic acid, in the the cations on any one side is equal to the sum of
region o f 12 to 20 mg per 100 ml, is 18 times the anions on the same side.
higher than that of blood plasma.
Hyaluronic acid is present only in the aqueous Circulation
and not in the blood.
The aqueous humour, formed by the ciliary body,
comes to the posterior chamber, flows between the
Formation
iris and lens into the anterior chamber, and finds
Aqueous humour is formed by the ciliary body its exit at the angle of the anterior chamber.
and the following mechanisms arc responsible: There are two types of circulation: the small
mass movements of aqueous humour due to change
• Secretion—approximately 80 per cent
in the hydrostatic-osmotic pressure relationship, e.g.
• Ultrafiltration
during eye movements, compression of the lids,
• Diffusion.
etc., and thermal circulation due to the difference
Secretion is the active transport o f certain in temperature. Aqueous humour is constantly
substances from the blood into the posterior heated by the blood in the iris vessels and so it
chamber. It is an active energy-dependent transport tends to rise. When it comes in contact with the
back surface o f the cornea, which is cooled by fluid flows from whichever vessel is at a higher
evaporation and the precorneal tear film, it tends pressure into the other, i.e. the glass-rod
to sink. Thus, a constant cycle is established. phenomenon. Depending on the higher pressure,
there is either ‘blood influx’ into the aqueous vein
Drainage
seen in the rising phase o f high ocular tension, or
There are two modes of drainage:
‘aqueous influx’ into the blood vein, seen in the
• Conventional or pressure-dependent—85 to falling phase o f ocular tension.
95%
• Uveoscleral or pressure-independent— 5 to Further R eading
15% 1. Adler, F.H., Physiology o f the Eye (6th ed.),
Conventional It is principally dependent on the Moses, R.A., (Ed.), C.V. Mosby, S t Louis, 1975.
relationship between the intraocular pressure (IOP) 2. Parsons, J.H., Diseases o f the Eye (18th ed.),
and pressure in the exit veins situated at the angle Miller S J.H . (Ed.), Churchill Livingstone,
of the AC, in the vorticose veins, and in the veins London and ELBS, 1990.
at the optic disc. The walls o f the veins traversing 3. Podos, S.M. and Yanoff, M. (Eds.), Textbook
the sclera are quite compressible, thus, when the o f Ophthalmology, Vol. VII, Glaucoma, C.V.
IOP rises above the venous pressure the veins are Mosby, St. Louis, 1994, p. 1.23, 1.30.
constricted, the venous pressure behind the
4. Tripathi, R.C., Mechanism o f aqueous outflow
constriction rises until it reaches above the IOP.
across the trabecular wall o f Schlemm’s canal,
The venous pressure in the exit veins normally
Exp. Eye Res., II: 111, 1971.
remains just above the IOP, and there is a sudden
fall of pressure beyond these points.
The aqueous from the angle o f the AC filters
through the trabecular meshwork.4 It reaches the 16. THE INTRAOCULAR
canal of Schlemm, showing a vacuolization cycle, PRESSURE14
and then the aqueous veins and flows into the
venous system at a point beyond which there is a The factors responsible for the maintenance of the
rapid drop o f pressure. Free drainage is thus normal intraocular pressure are: (a) elasticity of
established. It is estimated that about 1% o f the the sclera and cornea—a rigid coat gives rise to
fluid in the AC drains away per minute. When the higher pressure; (b) the volume of the intra-ocular
IOP rises, there is concomitant rise o f venous contents which is composed of solid i.e. the lens,
pressure within the sclera. There is also a bigger vitreous, uvea and retina and fluid i.e. the aqueous
difference o f venous pressure betw een the humour; the volume of the aqueous humour is the
intrascleral and episcleral veins, and hence there is principal determinant o f normal IOP; and (c) the
enhanced aqueous drainage. difference in the osmotic pressure o f plasma and
aqueous humour— if the osmotic pressure o f the
Uveoscleral. The drainage occurs through the aqueous is raised or that of the blood lowered,
stroma and vessels o f the iris root and ciliary body, there is a rise of the IOP.
and flows backward to leave the eye via supraciliary Prolonged changes in the maintenance of IOP
and suprachoroidal spaces to finally reach the are chiefly due to two factors— variation in the
orbital vessels. formation o f the aqueous, and variation in the
G lass-rod or com pression p h en o m en o n . A resistance to the outflow.
laminated stream is often found in a confluent
vessel made up of a blood vein and an aqueous Physiological Variations
vein. When such a confluent vessel is compressed, Physiological variations have been subdivided by
stratification is present after the compression. The Duke-Elder2 into two groups:
Ocular Circulation 57

Rhythmic variations, (a) Cardiovascular— 1 to 2 Normal IOP and Hypertensive Eyes


mm, (b) respiratory— as much as 5 mm and
The mean average IOP measured by applanation
(c) diurnal—normally not in excess of 5 mm.
tonometer is 15.4 mm with a standard deviation of
A cute variations, (a) Blinking, (b) action of ±2.5 mm Hg. The normal eye will tolerate an IOP
extraocular and intrinsic muscles, and (c) physical 20 mm of Hg indefinitely without any bad effect,
effort. but in high myopia, such normal IOP may produce
pathological effects.
Diurnal variation. The normal IOP is highest in
The IOP which can be higher than the normal
the early morning and lowest in the evening hours.
range, may not produce any pathological signs or
The cause of this variation is still not clear, but is
symptoms. If there is no rise o f pressure on
probably either due to change in the secretory
provocation then those eyes with normal aqueous
activity o f the ciliary body or to extrinsic factors
outflow facility are hypertensive.
like action of extraocular muscles, postural changes
involving vascular factor, intake of food and drink
and loss o f fluid throughout the day. F urther Reading
1. Adler, F.H., Physiology o f the Eye (6th ed.),
Nervous Control of the IOP Moses, R.A. (Ed.), C.V. Mosby, St. Louis,
1975.
It is known that the stimulation o f the para­
sympathetic causes raised intraocular pressure (IOP) 2. Duke-Elder, S., System o f Ophthalmology\ Vol.
while that of the sympathetic reduces IOP. IV: The Physiology o f the Eye and o f Vision,
In addition, there is also local nervous control Duke-Elder, S., Gloster, J. and Weale, R.A.
mediated through axon reflexes from the trigeminal (Eds.), Kimpton, London, 1968.
nerve, an action resembling the triple response of 3. Krupin, Т., Manual o f Glaucoma: Diagnosis
Lewis. and Management, Churchill Livingstone, New
The intraocular pressure may be raised or York, 1988.
lowered in several conditions (Table 16.1).
4. Sugar, H.S., The Glaucomas, Paul B. Hoeber,
New York, 1957.
Table 16.1
V arious Conditions Influencing Intraocular Pressure3

Those causing raised pressure 17. OCULAR CIRCULATION12


Elevated episcleral venous pressure
Squeezing o f the eye
There are two systems of blood vessels in the
interior of the eye—retinal and uveal. These have
Elevated body temperature
already been described.
M ydriatics
Steroids
Pulsation in the Retina
D ysthyroid exophthalm os
Depolarizing m uscle relaxants It can be classified as under
Ketamine— dissociative anaesthesia
Pulsation in the retina
Those causing reduced pressure
General anaesthesia
arterial venous capillary
Prolonged physical exercise
System ic acidosis
Alcohol
expansile serpentine or locomotor
Arterial pulsation. This is due to the rhythmic 3. Laser Doppler velocimetry
variations o f pressure within the artery. In the 4. Blue field entoptoscopy.
expansile pulsation, the artery itself enlarges and
collapses during the systole and the diastole F luorescein angiography. W ith this,
respectively. This pulsation is due to transmission measurements of various aspects of local retinal
of a pressure-pulse from the heart through the large blood flow can be done.
arteries to the retinal arterioles. Two factors favour Indocyanine angiography is more suitable for
its appearance, namely the fall in the BP and rise studying choroidal circulation.
in the IOP. Laser doppler velocimetryк A bidirectional system
In the serpentine or locomotor pulsation, there has been introduced for absolute measurements of
are rhythmic side-to-side movements of the part of flow velocity in large retinal vessels.
the artery at each heartbeat. The factors that favour
its appearance include tortuosity, dilatation and Blue fie ld entoptoscopy provides a retinal
pliable wall o f the arteries, high systolic pressure shadow due to leucocytes flowing through the
and low peripheral resistance. paramacular capillaries.

Venous pulsation. This occurs at the optic disc Control of Ocular Circulation
and is viewed by an ordinary ophthalmoscope. It The blood flow is influenced by vascular pressure,
is perhaps due to transmission of pulse from the tone in the vasoactive nerves, vasoactive substances
arteries to the veins. In a large number of normal and metabolic activity.
eyes there is spontaneous venous pulsation, which Perfusion pressure is the difference between the
is exhibited by the slightest pressure on the eyeball. pressure in the arteries and the veins. The pressure
It is made to stop by compression o f the jugular in the ocular arteries can be reco rd ed by
veins. ophthalmodynamometry, while that in the veins
Capillary pulsation. This has also been reported. leaving the eye can be assessed by tonometry. The
Average pressure in vessels o f the eye has been ocular perfusion pressure (Pa - Pv) can be reduced
indicated in Table 17.1. by either reduction o f arterial pressure or increase
in intraocular pressure.
Table 17.1
N ervo u s control. B oth sym pathetic and
A verage Pressure in D ifferent Vessels o f the Eye parasympathetic nerves innervate various ocular
vessels, though the role of the latter is less clear.
Pressure in the central retinal artery systolic, 6 5 -7 0 m m Hg
diastolic, 3 5 -4 5 m m Hg
The sympathetic system helps autoregulation
Pressure in the retinal arterioles systolic, 88 m m Hg system in maintaining the intraocular flow and
diastolic, 64 m m Hg volume-constant.
Pressure in the intraocular veins about 2 m m Hg higher
than IOP
Vasoactive substances. The vascular endothelium
Pressure in the intrascleral veins 7 to 8 m m Hg is involved in the regulation of vascular tone,
Pressure in the vortex vein 8.5 m m Hg platelet activity and vascular permeability. This
Pressure in the episcleral veins 11 m m Hg endothelium maintains vascular tone by releasing
Pressure in the choroid capillaries about 55 m m Hg
potent vasoactive agents.
Pressure in the retinal capillaries lesser than 55 m m Hg
M etabolic activity. B reathing pure oxygen
Measurement of Ocular Blood Flow constricts the retinal vessels and increases the
oxygen tension o f choroidal venous blood.
Only the clinical methods are mentioned below: Inhalation of 7 per cent carbon dioxide and 21 per
1. Fluorescein angiography cent oxygen moderately dilates the retinal blood
2. Indocyanine green angiography vessels.
(e) Ascorbic acid. It is indirectly responsible
for formation of collagens, and hence, is effective
1. A im , A., O cular circulation. In A d le r ’s
in the healing o f deep comeal ulcer. It is twice
Physiology o f the Eye (9th ed.), Hart, W.M.,
greater in the epithelium, 47 to 94 m g/100 gm,
Jr. (Ed.), Mosby Year Book, 1992, p. 198.
than in the stroma.
2. Trevor-Roper, P.D. and Curran, P.V., The Eye
(f) Glutathione. The possible functions include:
and Its D isorders (2nd ed.), B lackw ell
(i) its involvement in hexose monophosphate shunt
Scientific, Oxford, 1984.
and in regulation o f adenosine triphosphatase
activity as in endothelium pump function as well
as (ii) removal of toxic peroxides.
18. PHYSIOLOGY OF THE
CORNEA1-6 Nutrition of the Cornea
The normal water content of the comea is between Nutrition of the comea is derived from three
75 to 80 per cent. sources: (a) aqueous humour; (b) exudation from
The solid constituents are as follows: the perilimbal vessels; and (c) precorneal tear film.
(a) Proteins— 18 to 20 per cent.
(i) Collagen is present in large quantities in Precorneal tear film . The optical interface between
the comeal lamellae, although reported to the anterior surface o f the comea and the air is
be present in Bowman’s membrane and formed by the tear film. Oxygen is derived from
Descemet’s membrane. It is essential in the the tear film by diffusion.
healing of wound.
(ii) Mucopolysaccharide (MPS) forming 4 per Metabolism of the Cornea
cent o f the corneal dry weight is the
Metabolism o f the comea is modified by the
polysaccharide o f mucoid. Mucoid is an
structural peculiarities in the comea and they are:
ester of hyaluronic acid and is hydrolyzable
(a) avascularity of the comea proper, while the
by hyaluronidase. Polysaccharide present in
limbus is richly vascular; (b) bathing of comeal
interlamellar spaces plays an important role
surfaces by fluids; and (c) three sources of comeal
in the maintenance o f transparency and
nutrition. The metabolism of glucose is the chief
swelling pressure of the comea. There are
source of energy required for transparency, cellular
three fractions of MPS: (a) keratan sulphate
activity and growth of the comea. Glucose is stored
(50% ); (b) ch o n d ro itin (25% ) and
in the epithelium as glycogen which in state of
(c) chondroitin sulphate A (25%).
emergency, e.g. wound healing, breaks down again
(iii) Elastin.
into glucose.
(iv) N ucleoprotein is found m ostly in the
There are two different processes of catabolism
epithelium as DNA and RNA.
o f glucose: (a) aerobic, through—(i) K rebs’
(v) Albumin and globulin.
tricarboxylic acid (TCA) cycle, and (ii) hexose
(b) Lipids are in greater concentration: 5.4 per monophosphate shunt (HMS); (b) anaerobic.
cent o f the dry weight of the epithelium, about
Aerobic. TCA cycle is not very active because
100 times more in the epithelium than in the stroma.
o f less abundant mitochondria in the comeal
(c) Minerals, e.g. sodium, potassium, copper, epithelium , since this cycle takes place in
iron, zinc, etc. mitochondria. About 35 per cent of glucose used
(d) Enzymes, necessary for different pathways by the epithelium passes through the HMS.
o f corneal metabolism, are mostly seen in the The breakdown of glucose produces adenosine
epithelium and endothelium. triphosphate (ATP) and nicotinamide adenine
dinucleotide phosphate (NADPH), high energy resistance to water flow. The movement of the
elements utilized in cellular processes. ions is restricted, because of unusual resistance
of the epithelium, which is about 200 times
Anaerobic glycolysis produces pyruvate and
that of the stroma, to ions, and hence the
lactate and these under aerobic condition break
resulting osmotic pressure retains the water in
down into carbon dioxide and water. Carbon
the comeal stroma.
dioxide is eliminated across both epithelium and
endothelium. Lactate is unable to permeate the 3. Balance of normal swelling tendency o f the
epithelium but diffuses through the stroma and comea caused by excretion o f the fluid and
endothelium into the aqueous humour. There is dehydration by evaporation. This tendency is
accumulation of lactate during hypoxia or other called stromal swelling pressure.
comeal stress causing comeal oedema. 4. Relatively slow movement of the fluid from
Glycolysis, i.e. the breakdown of glucose into the comea.
lactic or pyruvic acid, the process may be aerobic 5. The comeal endothelium has a pump activity.
or anaerobic, e.g. use of tight contact lens. If this is decreased there is stromal swelling.
Respiration, i.e. oxidation o f lactic acid into 6. Intraocular pressure can only produce oedema
carbon dioxide and water is always aerobic. of the epithelium in presence o f defective
In the comea, glucose derived mainly from the endothelium.
aqueous humour is utilized mainly by anaerobic or
Embden-Meyerhofpathway, 65 per cent and partly Transparency of the Cornea
by aerobic or phosphogluconate pathway, i.e.,
‘shunt’, 35 per cent. Transparency is dependent on two factors, viz.
Glycolysis occurs both in the comeal epithelium anatomical and physiological.
and strom a. R espiration only occurs in the The anatomical factors are:
epithelium . The strom a contains chiefly a (a) Avascularity.
dehydrogenase system and the epithelium contains (b) Regular arrangement of epithelial layers on
cytochrome oxidase. its outer surface and absence o f its
comification.
Protein synthesis
(c) Single layer o f endothelium.
There are two types o f proteins in the comea—
(d) Stromal collagen fibres disposed regularly
structural and enzymes.
and in parallel strata. Maurice reported
Ribonucleic acid (RNA) acts as a template for that they form a lattice structure, so
protein synthesis, the two other constituents are arranged that scattering of light is eliminated
amino acids and adenosine triphosphate (ATP). by mutual interference from individual
fibrils.
Corneal Permeability3,6 More recent view indicates that regular lattice
Normally, comeal hydration in vivo is maintained arrangement of collagen fibres is not necessary for
by the following factors. transparency. The comeal stroma does not scatter
light because its collagen fibrils are small in
1. Structural rigidity due to presence of the comeal
diameter (300 A) and closely packed.
layers and restriction o f swelling by sclera.
2. The epithelium and endothelium act as barriers (e) Presence of mucopolysaccharide gel in
to rapid fluid passage, especially by high which the stromal fibres are immersed.
resistance to diffusion of electrolytes rather than (f) Absence of pigment.
The physiological factors are: The amount of beta-crystallin is double that of
alpha-crystallin. As the lens ages, alpha-erystallin
(a) The state of deturgescence. The stroma has
is gradually converted into insoluble albuminoid.
a tendency to swell, which is counteracted
The minor group consists of nucleoprotein,
by a process of fluid transport through the
phosphoprotein, and mucoprotein.
limiting membranes.
The lens protein is organ-specific and not
(b) Metabolic process. species-specific. An animal immunized against lens
protein reacts to the subsequent injection of the
Further Reading same irrespective of the species from which it is
obtained.
1. Adler, F.H., Physiology o f the Eye ( 6th ed.),
Moses, R.A. (Ed.) C.V. Mosby, S t Louis, 1975. (c) Salt content. This is 0.5 to 0.75 per cent of
the weight o f the lens. The salts include sodium,
2. Arffa, R.C. (Ed.), Grayson's Diseases o f the
potassium, calcium, magnesium and chloride.
Cornea (4th ed.), C.V. Mosby, St. Louis, 1997.
Sodium and chloride are present chiefly in the fluid
3. Dohlman, C.H., Physiology of the comea: surrounding the lens fibres, while potassium is
comeal oedema. In The Cornea, Smolin, G. found within the fibre. As the lens ages potassium
and Thoft, R.A. (Eds.), Little, Brown and Co., content decreases. C alcium helps in the
Boston, 1983. permeability of the cell membrane.
4. Friend, J., Physiology of the comea: metabolism (d) Lipids. These include phospliolipids and
and biochemistry. In The Cornea, Smolin, G. cholesterol.
and Thoft, R.A. (Eds.), Little, Brown and Co.,
(e) Ascorbic acid. This is present in both
Boston, 1983.
oxidized and reduced forms, 30 m g/100 gm of
5. Maurice, D.M., The Structure and transparency lens. The source o f ascorbic acid is by direct
o f the comea. J. Physiol. 136: 263, 1957. synthesis by the lens and by the ciliary epithelium.
6 . M aurice, D.M., The regulation o f corneal Dihydroascorbic acid oxidizes glutathione and
hydration. In The Comea: World Congress, hydrogen thus released reduces nicotinamide
K ing, J.H . and M cTigue, J.W . (E ds.), adenine dinucleotide phosphate (NADP) or
Butterworths, London, 1965. diphosphopyridine nucleotide (DPN).
( 0 Glutathione. G am m a-glutam ylcysteinyl
glycine is synthesized by the crystalline lens. It
19. PHYSIOLOGY OF THE protects the lens enzymes and proteins against
oxidative damage. It is decreased in advanced age
CRYSTALLINE LENS12 and cataract.
The chemical composition of the normal lens is:
Lens Metabolism
(a) Water. The water content in the adult lens
is 65 per cent of its total weight. There is relative The lens subserves the following functions which
dehydration o f the lens as age advances. are dependent on the lens metabolism.
(a) Maintenance o f transparency. 'Ibis depends
(b) Proteins. They form the 34 per cent balance on the physiochemical state o f the lens proteins.
of the composition and are divided in two groups: (b) Development and growth of new lens fibres.
(c) Maintenance o f elasticity of the capsule.
alpha-crystallin—55%
S o lu b lc-8 5 % bcta-crystallin-15% (d) Permeability, diffusion and transport.
M ajor g am m a-cry stallin -1 5 %
There are two elem ents involved in lens
Insoluble or alb u m in o id -1 5% metabolism.
Lens proteins. Electrophoretic study reveals Vitreous cells
d ifferen t types o f proteins w ith d ifferen t
They are chiefly histiocytic and they normally help
electrophoretic motility, antigenicity and structure.
in the synthesis of acid mucopolysaccharide,
Carbohydrates. The metabolic pathways of
pathologically they behave as phagocytes.
carbohydrate metabolism are:
(a) Anaerobic glycolysis. It accounts for about Composition
85 per cent of glucose metabolism of the lens.
The vitreous has a near similar composition as the
G lucose is phosphorylated by ATP to form
aqueous but for the following differences: (a) an
glucose-6 -phosphate —» through various steps —»
excess of collagen; (b) an excess of hyaluronic
pyruvic acid -» oxidized —» which in the lens is
acid; and (c) a slightly less amount of glucose.
reduced to lactic acid.
(b) The hexose m onophosphate pathw ay. Physicochemical Properties of
Glucose is phosphorylated —> oxidized —» oxidative Vitreous
decarboxylation —> production of carbon dioxide. There are three macromolecular components:
(c) The citric acid cycle. Glucose —> pyruvic (a) collagen—which is the main structural basis;
acid —> some enters Krebs citric acid cycle. (b) soluble proteins; and (c) hyaluronic acid, which
occupies the intervening spaces o f interlacing
(d) The sorbitol pathway. If glucose is excessive
collagen fibrils. It acts as a stabilizer which protects
it is converted into sorbitol with the help of enzyme
the gel against cellular invasion. The concentration
aldose reductase coupled with diphosphopyridine
of low molecular weight constituents is usually
nucleotide and then to fructose.
similar to that in aqueous humour.
The energy of the lens is derived from glucose
According to B alazs 1 there are four basic
matabolism.
physicochem ical properties: (a) frictio n al
The maintenance of constant water-content is
interaction; (b) vitreous expansion and contraction;
also an energy-consuming process.
(c) the excluded volume concept; and (d) the
molecular sieve concept.
Further Reading
A precise balance between the collagen and
1. Adler, F.H., In Physiology o f the Eye (6th ed.), hyaluronic acid (acid MPS) is responsible for:
Moses, R.A. (Ed.), C.V. Mosby, St. Louis, (a) the maintenance of the integrity of the structure
1975. of the vitreous; (b) viscoelasticity of the vitreous
gel; (c) volume change characteristics; (d) cell
2. Newell, F.W., Ophthalmology: Principles and
Concepts ( 8th ed.), C.V. Mosby, St. Louis, distribution and (e) its transport. Any breakdown
of the delicate balance between the two can cause
1997.
a lesion.

Metabolism of the Vitreous


20. PHYSIOLOGY OF THE The vitreous hum our serves the follow ing
VITREOUS HUMOUR functions:
AND RETINA‘S 1. It is a repository for the retina, hyalocytes and
surrounding tissues
The vitreous body is a medium which maintains
the light path between the lens and the retina. It is 2. It is a depository for metabolic wastes like lactic
jelly-like occupying the major cavity of the globe. acid
It is essentially acellular and has a low metabolic 3. It plays an important role in the movements of
activity. solutes and solvents within the eye
Accommodation 63

4. Hyaluronic acid offers the major resistance Metabolism of the Retina3 4


against the transvitreal flow o f water and
The retina has got an unusual active metabolism.
decreases tran sv itreal tran sp o rt of
It has d ifferen t p h y sio lo g ic activ ities like
macromolecules.
biosynthesis of cellular elements, ion transport and
axonal transport. Retinal capillaries supply glucose
Transparency of the Vitreous and oxygen which are metabolized in the inner
Transparency o f the vitreous is due to the presence layers. The retinal photoreceptors receive these two
o f an extemely low concentration of macromole- from the choroidal vessels. M u lle r’s cells
cular solutes. containing glucose- 6-phosphatase activity have
some glycogen. Most of the oxygen utilized in the
retina are consumed. Most o f the ATP are produced
Retinal Pigment Epithelium (RPE)4
by combustion of pyruvate into carbon dioxide and
The functions of the RPE are as follows: water. The excess pyruvate is converted into lactic
acid.
1. It plays a major role in maintenance of the
blood-retinal barrier
Further Reading
2. It cooperates with the photoreceptor to maintain
the light sensitivity of the retina 1. Balazs, E.A., The Molecular biology of the
Vitreous. In New and Controversial Aspects
3. It is involved in the removal of photoreceptor
o f Retinal Detachment, McPherson, A. (Ed.),
protein and membrane components.
Harper & Row, New York, 1964.
Disc shedding and phagocytosis. Each RPE cell
2. Duke-Elder, S., System o f Ophthalmology, Vol.
is in contact with as many as 200 photoreceptor
IV: The Physiology o f the Eye and o f Vision,
outer segments. Phagocytosis of the rod outer
Duke-Elder, S., Gloster, J. and VVeale, R.A.
segment is mediated by a specific receptor present
(Eds.), Kimpton, London, 1968.
on the apical membrane o f the RPE. This is
followed by generation of a transmembrane signal 3. Marmour, M.F., Clinical physiology of the
across the plasma membrane of the RPE with retina. In P rin cip les and P ractice o f
production o f a second messenger. Finally the shed Ophthalmology. Peyman, Sanders and Goldberg
disc membranes are pulled into the RPE cell (Eds.), W.B. Saunders, Philadelphia, 1980.
cytoplasm as phagosomes. The phagosomes quickly 4. Roof, A.J. and Heth, C.A., Photoreceptors and
fuse with lysozomes forming phagolysosomes. The retinal pigment epithelium: transduction and
process o f disc shedding, phagocytosis and renewal mechanism. In Principles and Practice
formation of phagolysosomes is complete within 5 o f Ophthalmology: Basic Sciences. Albert, D.M.
minutes of exposure to light. and Jacobiec, F.A. (Eds.), W.B. Saunders,
Disc synthesis and assembly. The molecular Philadelphia, 1994, p. 309.
mechanism is obscure, but some facts are known.
The discs o f the outer segment of the rods arise by
evaginations o f the plasma membrane of the 21. ACCOMMODATION1^
connecting cilium region. The disc assembly is
Accommodation is the mechanism o f an eye by
initiated within one hour of exposure to light and
which the rays coming from a near object are
continues throughout the light period.
brought to a focus on the retina.
Axoplasmic transport. Axoplasmic transport is The changes that occur during accommodation
the passage of the metabolic substances from the are: (a) an increase in the thickness of the lens
body of the nerve cell to its axon. causing diminution of the diameter of the lens;
(b) the anterior surface o f the lens moves towards Physical and Physiological
the comea, making the AC shallow, while its Accommodation
posterior surface remains comparatively stationary;
Though contraction of the ciliary muscle chiefly
(c) contraction of the ciliary muscle; (d) relaxation
determines the activity of accommodation, the lens
of the zonule o f Zinn and (e) the lens capsule
also takes part in it. The physical accommodation
becomes lax and folds upon itself.
is an expression of the physical deformation o f the
lens expressed in dioptres, while the physiological
Theories of Accommodation
accommodation is related to the contractile power
The Helmholtz theory o f relaxation states that the of the ciliary muscle expressed in myodioptres.
zonule is relaxed on contraction o f the ciliary Decreased physical accommodation is seen in
muscle and diminishes the tension on the capsule. p resb y o p ia, w hile decreased p h y sio lo g ical
The lens now freed of any compressing force accommodation occurs in a state of debility.
becomes spherical. The objections to this theory
are that the lens is not an elastic body, but a Range and Amplitude of
semisolid mass. The choroid being a vascular Accommodation
structure cannot constantly stretch without showing
The furthest distance at which an object' can be
pathologic changes. So, it is unlikely that the
seen clearly is called the far point or punctum
choroid can act as a counteracting force. When the
remotum. The nearest point at which an object can
ciliary muscle contracts the choroid is pulled
be seen clearly exerting maximum accommodation
forward which releases the tension of the zonule.
is called the near point or punctum proximum. The
To overcom e the objections o f this theory,
distance between the far point and the near point
Henderson suggested that the traction of the zonule
is called the range o f accom m odation. The
is bome by both the radial and longitudinal fibres
amplitude o f accommodation is the difference of
of the ciliary muscle. Fincham supported the theory
refractivity o f the eye in two different conditions—
but postulated that the lack o f uniform thickness
static and dynamic refraction, expressed by the
throughout its entire extent determines the increased
formula A = P - R, where
curvature of the lens and the conoidal form assumed
by the lens. A = amplitude of accommodation,
The Tscherning’s theory o f increased tension, P = refractive power of the fully accommodated
rejected by m any, assum es that follow ing eye, and
R = refractive power of the eye at rest.
compression o f the lens at the equator there
is increased curvature especially o f the anterior In emmetropia, R is nil.
pole. AC/A ratio is the ratio between accommodative
convergence and accom m odation. It is an
Nervous pathway expression o f how much convergence the subject
associates with a given amount of accommodation.
The parasympathetic supply is the main effector,
and the sympathetic perhaps plays only a minor
Anomalies of Accommodation
part. The peripheral cell station is the ciliary
ganglion and perhaps also in the accessory ciliary The following are the anomalies of accommodation:
ganglion. The fibres run along the short ciliary (a) excessive accom m odation; (b) spasm o f
nerves. The stimulation of the accommodation accommodation; (c) insufficiency of accommoda­
centre located near or in Brodmann’s area 22 in tion; (d) ill-sustained accommodation; and (e)
the cerebral cortex. paralysis of accommodation.
Excessive accommodation. It occurs in young Paralysis is caused by drugs, e.g. cycloplegics, and
hypermetropes to gain clear vision, myopes doing infections like diphtheria, toxic conditions, etc.
too much close work, in early presbyopia, using Treatment o f the cause is essential.
ill-fitted glasses or in debility. Cardinal symptoms
are blurring of vision and those of accommodative Further Reading
asthenopia, i.e. headache, feeling of discomfort,
1. Adler, F.H., Physiology o f the Eye ( 6th ed.),
etc.. The latter is caused by excessive
Moses, R.A. (Ed.), C.V. Mosby, St. Louis, 1975.
accommodation and marked dissociation between
accommodation and convergence. Normally, the 2. A garw al, L.P. P rinciples o f O ptics and
refractio n becom es +1 D after com plete Refraction, Medical Publication, New Delhi,
cycloplegia, but in excessive accommodation there 1962.
is a greater difference than normal. 3. Duke-Elder, S., The Practice o f Refraction, 9th
Treatment. Close work should be forbidden ed. R evised by A bram s, D. C hurchill
initially and curtailed thereafter, general health Livingstone, Edinburgh, 1978.
should be attended to.
4. Trevor-Roper, P.D. and Curran, P.V. The Eye
Spasm o f accommodation. True spasm of the and Its D isorders (2nd ed.), B lackw ell
ciliary muscle is rare and may occur in hysteria or Scientific, Oxford, 1984.
following instillation of eserine. Treatment involves
complete cycloplegia for about 4 weeks.
Insufficiency o f accommodation. In childhood the 22. CONVERGENCEu
amplitude of accommodation is 14 D, the near point
at 7 cm; at 36 years the amplitude is 7 D, near Pathway for Convergence
point at 14 cm; at 45 years amplitude is 4 D and
near point at 25 cm . In insufficiency, the The path is not definitely known. The centre for
accommodation is always below the lower limit of voluntary convergence is situated in the oculogyric
normal variation. This is due to lental sclerosis area, i.e. area 8 . Afferent fibres from the medial
and/or weakness of the ciliary muscle. All the recti run centrally, probably by the oculomotor
features o f asthenopia and eye strain are present. nerve to the mesencephalic nucleus of the fifth
Asthenopia is due to enhanced muscular work and nerve, to a presumptive convergence centre.
eye strain is caused by fatigue. Near vision is Perlia’s nucleus, the lower convergence centre, is
blurred and test of amplitude of accommodation connected by the occipitom esencephalic and
reveals insufficiency. corticomesencephalic tracts. From Perlia's nucleus,
Treatment. Rectifying glasses, which also the fibres run to Edinger-Westphal nucleus. The
provide weakest convex glass give adequate vision efferent path is through the parasympathetic fibres
and near correction, are essential. Proper base-in in the oculomotor nerve.
prism s are added in associated convergence
insufficiency. Exercises with the help o f an Measurement of Convergence
accommodation card are also beneficial, e.g. a black Measurement of convergence is done by using
vertical line over a white card. metre angle, i.e. та unit. When the eyes are directed
Ш-sustained accommodation. It is essentially the to an object situated at 1 metre distance, the visual
same as insufficiency but less accentuated. axes make an angle with this line. This angle is
called the metre angle. This angle is inversely
Paralysis o f accommodation. It may be static, i.e. proportional to the distance in metres.
presbyopia and dynam ic. The failure of The convergence can also be measured in prism
accommodation may be inertia or total paralysis. dioptres.
Clinically, it can be measured roughly by asking Insufficiency o f convergence. The causes include
the patient to look at a pencil or finger which is anatomical, e.g. wide interpupillary distance,
gradually brought nearer to the eyes in the middle un co rrected refractiv e erro rs, i.e. m yopia,
line. hypermetropia and presbyopia. In the former, it is
caused by lack of use of accommodation and in
Range and Amplitude of Convergence the latter tw o due to in su fficien cy o f
accommodation, systemic diseases and -weakness
The range of accommodation is the distance
o f the m edial recti, e.g. m yasthenia gravis.
betw een the far point and near point o f
Diagnosis is clinched by remoteness of the near
convergence. The amplitude of convergence is the
point, beyond 9.5 cm, in the presence o f
difference in convergence between the far point orthophoria in the distance. Treatment comprises
and the near point. The amplitude o f convergence correction o f refractive error, orthoptic exercises
consists of: and advice in the training of voluntary convergence.
(a) the positive, i.e. that part of the range of Occasionally base-in prisms are advocated.
convergence between the eye and infinity, and
(b) the negative, i.e. that part beyond infinity. This C onvergence excess. There are three types:
is also called relative divergence. (a) associated with increased accommodation,
(b) associated with attempted clear near vision, and
Association between Accommodation (c) primary or irritative lesion, e.g. meningitis.
and Convergence Symptoms in mild cases include headaches and
blurring of the prints. In severe cases close work
Accommodation, convergence and contraction of is impossible and diplopia occurs. The principles
the pupil form normally a synkinesis. o f treatment are elimination o f the causative factor,
In emmetropia, the eye needs for each distance curtailing o f close work, orthoptic exercises and
o f binocular vision, as many dioptres of accom­ divergence exercises with the amblyoscope.
modation as it does metre angles of convergence,
e.g. to see an object placed at 1 metre, one metre Presbyopia
angle o f convergence and 1 dioptre of accom­
modation are needed. Presbyopia is the decreased ability of the eye to
Near reflex consists of two parts, convergence alter its focus as age advances, because o f
reflex and accommodation reflex. progressive diminution of power of accommoda-
The different types o f convergence are: tion.The process is considered physiological unless
(a) voluntary— that can be induced at will; it is premature, e.g. in premature sclerosis o f the
(b) reflex, which may be (i) tonic—not dependent lens or development of cataract.
upon fusion or proxim ity o f fixation Close work is usually done about 28 to 30 cm
(ii) proximal—dependent on proximity o f fixation from the eyes and when the near point is about 40
(iii) fusional—related with fusion o f disparate to 50 cm there is onset of presbyopia.
stimuli (iv) accommodative; (c) tonic—that part of The onset of presbyopia depends on the age
convergence which is not dependent on fusion or and the state of refractive error. In hypermetropia
p ro x im ity of the fixation and it usually sets in earlier than 40 years of age, in
(d) fusional—that is related with fusion of disparate emmetropia later than 40, and much later in
retinal stimuli. myopia.
The symptoms are as follows:
Anomalies of Convergence (i) small prints appear indistinct especially in
A nom alies o f convergence may be either relative lack of bright light,
insufficiency or excess of convergence. (ii) running together of the lines,
Binocular Vision 67

(iii) holding of the book more distally to get a a state of ‘diminished flux,’ and in ‘fixed’ state by
clear view, and the age of 8 years.
(iv) tiring of the eyes, etc. Binocular reflexes are as follows:1

Treatment. This consists of the provision of At birth. Compensatory fixation reflex keeps the
convex lenses depending on the age, state of eye in a fixed position in spite of movement of the
refraction and working habits of the individual. head and neck.
In general the following schedule may be At 2 to 3 months, (a) Orientational reflex; (b)
followed: re-fixation reflex relates to the eyes to take up
40 years +1 D original orientational point, i.e. passive re-fixation
45 years +1.5 D or new orientational point, i.e. active re-fixation;
50 years +2 D (c) pupillary reflex—direct and consensual; and
55 years +2.5 D (d) vergence reflex is established by the age of
6 months
Further Reading At 2 to 3 years, (a) Accommodation reflex, and
(b) fiisional vergence reflex.
1. A garwal, L.P., Principles o f O ptics and
Refraction, Medical Publication, New Delhi, Grades of Binocular Vision
1962. Binocular vision was divided by Worth into three
2. Parsons, J.H., Diseases o f the Eye (18th ed.), grades (Fig. 23.1).
Miller, S.J.H. (Ed.), Churchill Livingstone,
Edinburgh and ELBS, 1990.

23. BINOCULAR VISION13


Binocular vision is the coordinated use of both
eyes so as to produce a single mental impression.
It depends on anatomical and physiological factors.
I I
<
1)
f
if t
Under normal conditions, the binocular vision
becomes established during the fust few years of life.

Anatomical Factors
There is poor visual perception, because there is
no full development of the retina and fovea just
after birth. The child attains 6/6 vision at about the (»

©©
age of 5. At 6 months there is enough structural
development in the eye to have rudimentary
binocular vision.

Physiological Factors
At birth the single unconditioned reflex links the
two eyes. As the child grows, they are linked by
(c)
a series of conditioned reflexes—from 6 months Fig. 23.1 Slides for testing: (a) simultaneous macular
to 2 years in a state of ‘flux’, from 2 to 5 years in perception, (b) fusion and (c) stereopsis.
Grade I. Simultaneous perception, i.e. the faculty dot test. The degree o f stereopsis is estimated by
to view two im ages, one on each retina measuring the disparity required to produce the
simultaneously. This grade, i.e. the simultaneous impression of depth. Two tests may be employed:
foveal, macular or paramacular, of binocular vision Titmus stereo test for near, and vectograph used
is proved by the presence o f normal retinal for distance.
correspondence (NRC).
NRC is the fusion o f two monocular images, Depth Perception
and the two foveae are the corresponding points,
Depth perception is the third-dimension in space,
i.e. they are points on the two retinae from which
and this is dependent on a number of factors. Apart
images are projected to the same place in the
from stereopsis there are other clues, monocular
common visual pathway. In NRC the subjective
and binocular.
and objective angles o f deviation are the same.
The angle o f deviation is the difference between Monocular clues. These include apparent size,
the visual and optic axes. The horopter is an interposition of one object in front of another, aerial
imaginary line is space, all points on which perspective, shading, geometric perspective, relative
stimulate corresponding retinal elements. Around velocity and motion parallax.
the horopter is ‘Panum’s fusional space', narrow
Binocular clues include stereopsis, efforts of
at the centre and wider at the periphery.
convergence and accommodation.
Grade II. Fusion—faculty o f viewing two
similar images and blending them as one. F urther Reading
Grade III. Stereopsis—ability o f seeing two
1. Cashell, G.T. and Durran, I.M., Handbook o f
slightly dissimilar images and blending them as
O rthoptic P rin c ip le s, E&S L ivingstone,
one along with an appreciation o f depth.
Edinburgh 1967.
The advantages of binocular vision, are: (a) the
field o f vision is larger; (b) the combined binocular 2. Tycheson, L. Binocular vision. In Adler's
visual acuity is slightly greater than the visual acuity Physiology o f the Eye (9th ed.), Hart, W.M.,
o f one eye; (c) optical defects present in one eye Jr. (Ed.), Mosby Year Book, St. Louis, 1992,
are made less evident by the normal image of the p. 773.
opposite, involving the use o f the blind spot of 3. W alonker, A .F., C lin ical assessm ent o f
each eye; and (d) stereoscopic vision and depth binocular vision. In Adler s Physiology o f the
perception occur accurately. Eye (9th ed.), Hart, W.M., Jr. (Ed.), Mosby
S tereo p sis can be subdivided into two Year Book, St. Louis, 1992, p. 183.
components: fine parvocellular or static and coarse
magnocellular o^ motion. The location o f static
stereopsis is foveal and it persists in the presence 24. THE REACTIONS OF
of chromatic equiluminance. The parvocellular
stream o f retinal ganglion cells (beta cells), LIGHT ON THE EYE13
concentrated in the fovea are concerned with static
Light
stereopsis. The location o f motion stereopsis is
parafoveal. It is not colour sensitive. This is related Light is the energy spectrum in wavelengths that
to magnocellular stream o f retinal ganglion cells evokes a retinal response to cause a sensation.
(alpha cells), found more toward the near periphery.
Light sense
Tests for Binocular Vision The faculty to see the gradations of intensity is
The presence of fusion is detected by Worth’s four- called light sense.
Light minimum Fluorescence. This is caused by the larger
ultraviolet rays.
Light minimum is the gradual reduction of the
intensity o f light reaching the retina to a point which Specific effects. The specific effects cause: (i)
can be just perceived. structural changes in the retina; (ii) bleaching of
the visual pigments; and (iii) electrical changes in
Lum inous intensity the retina.

Luminous intensity is the amount of light radiated. It Photochemistry of Vision (Fig. 24.1)
is estimated in units of candles. A foot candle is one
lumen per square foot. Lumen is the unit of luminous The stimulation of the visual pigments of the retina
flux. A lambert is one lumen per square cm. by light causes photochemical, photomechanical
or stru ctu ral and e lectric al ch an g es. The
Transmission, Reflection and photomechanical change is insignificant in man.
Absorption of Light
Rhodopsin
The visible spectrum has a span o f 400 to 700
millimicrons (m|i) or roughly 400 nm at the violet
end and 700 nm at the red end. One millimicron II-cis retinene + scotopsin Lum irhodopsin
or one m illim icrom illim etre is equal to one
nanometer (nm), i.e. 10-6. Beyond the red end are \
i
M eta rhodopsin
infrared rays known as heat rays which cause a
rise o f temperature. Beyond the violet end are A ll-trans.retinene +
ultraviolet rays capable of causing chemical action scotopsin
such as ultraviolet burn.
The ocular media uniformly allow the visible II-cis Vitamin A
I
A ll-trans v tam in A
rays at 390 to 660 nm to permeate, whereas the
nonvisible spectrum is reflected maximally. The
comea absorbs rays shorter than 295 nm, and the Fig. 24.1 Breakdown and reform ation o f shodopsin
lens rays shorter than 350 nm. Ordinary spectacle
glasses absorb rays beyond 350 nm. Thus, it
Visual Pigments1
appears that only a few of the longest ultraviolet
rays reach the retina and are relatively harmless. (a) Rhodopsin. It is a magenta-coloured pigment.
Infrared rays at 700 to 1100 nm can almost On exposure to light, it is converted into retinene,
uninterruptedly reach the retina, and ‘eclipse bum ’ which in turn is converted to vitamin A. Retinene
at the macula occurs. is an aldehyde of vitamin A and opsin is the protein
component. When opsin is found in rods, it is called
Effects of Radiant Energy3 scotopsin. Photopsin is found in cones.
(b) Idopsin. Retinene, combined with photopsin
The effects can be grouped as:
is found in cones.
Thermal. These effects are caused by infrared rays.
(c) Porphyropsin. Retinene 2 combined with
They especially involve the pigmented structures,
scotopsin is found in rods.
i.e. the iris and retinal pigment epithelium causing
necrosis. (d) C yanopsin. R etinene com bined w ith
photopsin is found in cones.
Chem ical. This results usually from short
ultraviolet rays, i.e. below 300 nm. (e) Xanthophyll. Yellow carotenoid pigment of
vegetable origin also enters the human body 2. Roof, D.J. and Heth, C.A., Photoreceptors and
through food products. retinal pigment epithelium: transduction and
There are three types of cone pigments: blue renewal mechanism. In Principles and Practice
( cya n o la b e), red (eryth ro la b e) and green o f Ophthalmology: Basic Sciences, Albert, D.M.
(chlorolabe). and Jacobiec, F.A. (Eds.), W.B. Saunders,
Philadelphia, 1994, p. 309.
Electrical Changes in the Retina 3. Trevor-Roper, P.D. and Curran, P.V., The Eye
The process by which the light is converted to an and Its D isorders (2nd ed.), B lackw ell
electrical signal is called phototransduction, which Scientific, Oxford, 1984.
is prim arily performed by photoreceptors and
assisted by the retinal pigment epithelium. The outer
part of the photoreceptor in the light (photon)— 25. COLOUR VISION
capturing p a rt The rod cells are highly sensitive
even in a single incident photon under dim The three important factors in colour vision are :1
illumination .2 (a) wavelength; (b) luminosity or brightness; and
There are three types of potential differences: (c) saturation or calorimetric purity which indicates
(a) action potential in the optic nerve fibres, the ratio of mixing with white light. Pure colour
(b) steady comeoretinal potential; and (c) phasic means unmixed white. When red, green and violet
potential produced by light stimulus. portions of the spectrum mix and evoke a sensation
The fleeting electrical disturbances following of white, they are called primary colours.
excitation o f a nerve or muscle by action currents Certain colours admix to produce white and
are called action potentials. these are known as complementary colours, e.g.
Recordings show a single fibre o f the crab red + greenish blue, greenish-yellow + violet
‘limulus' in which each of the light-sensitive cells
is connected to a single nerve fibre. This ends into Purkinje Phenomenon
a central ganglion without any intervening neuron. Purkinje phenomenon is the shift in relative colour
Hartline recorded intermittent and evenly spaced values from photopic to scotopic vision, e.g. a red
impulses o f the same height in all o f them. He light may be strong enough to permit reading as
found three types of fibres in frog’s eye: well as to allow unimpaired dark adaptation. Rods
1 . simple intermittent response, i.e. 20 per cent are much more sensitive to low illumination than
‘on-fibre’ as in limulus; cones, while in bright illumination cones come into
play, and under the respective states the vision is
2 . initial outburst to onset and final outburst
called ‘scotopic’ and ‘photopic’. In man, they are
to cessation o f illumination, i.e. 50 per cent both present.
‘on- and off-fibres’; and
3. response only to cessation of illumination, Scotopic Luminosity Curve
i.e. 30 per cent ‘off-fibres’.
The curve obtained by measuring the minimal
It has been found that in mammals ‘on-fibres’ amount o f energy of light from the different
are present in rod-rich retinae and. ‘on-off fibres' portions o f the spectrum just perceptible to a dark-
in cone-rich retinae. adapted subject is called scotopic luminosity curve.

Further Reading Theories of Colour Vision


1. Pahwa, J.M. and Billore, O.P., Retinal Diseases, The Young-Helmholtz theory states the existence
Oxford and IBH, New Delhi, 1978. of three colour-transmitting mechanisms. This is

nts
Colour Vision 71

really the basis of trichromatic theory of colour Developmental


vision. A. Anomalous trichromats
In human, the presence o f three kinds of (a) Protanomalous— 1-1.5%
pigments in the cones has been established which (b) Deuteranomalous—2-4%
lends support to this theory. (c) Tritanomalous—0.0001%
The Hering's opponent-colour theory proposes B. Dichromats
the presence of three photochemical substances in (a) Protanopia—one colour is defective, 1 per
the retina that can be both broken down and re­ cent, red-blind, confusing blue-green with
synthesized by three sets of complementary colours red.
(white-black, red-green and yellow-blue). The
theory is against the doctrine that the same nerve (b) Deuteranopia—two colours are defective,
fibre cannot signal two different sensations to the 1.4 per cent, green-blind, confusing blue-
green with purple.
brain.
The Granit’s theory proposes that the rods, i.e. (c) Tritanopia—three colours are defective,
the ‘dominators’ respond in the dark only, and both 0.0001 per cent, confusing yellow with blue.

‘dom inators’ and ‘m odulators’, i.e. the three (d) Tetratanopia—in which the confusion runs
groups—red, green and blue come into play in between yellow and blue.
light adaptation. C. Monochromats
There are several other views regarding the These are very rare, rod monochromatism in 0.003
mechanism of colour vision. The trichromatic per cent and cone monochromatism in 0.000001
theory may account for the phase of reception. per cent
Hering’s theory may explain the neural interaction Blue blindness is acquired.
at the higher visual levels.
Tests for Colour Vision
Colour Cells3
Most commonly by Ishihara’s pseudoisochromatic
Both opponent and double opponent colour cells chart (Fig. 25.1) which contains bold numerals
are found in the visual pathways, the former in the shown in dots of various tints which are not
ganglion cells of the retina and lateral geniculate confusing to the trichromat but to those whose
body, and the latter in the striate cortex. The colour vision are defective.
opponent colour cells are involved in successive $
co n trast and the double opponent cells in
simultaneous contrast.

Colour Deficiency2,3,4
The normal subject who needs a minimum of three
primary colours is a trichromat. Those who need
two primary colours to match the spectrum are
dichromats, and those who need only one are
monochromats. In the anomalous trichromat, the
colour mixtures differ from those o f the normal
trichromat.

Classification
Fig. 25.1 Ishihara’s pseudoisochrom atic colour vi­
This may be classified into: sion chart.
For precise diagnosis, an anomaloscope is more alternation of three positive and three negative
suitable. This is a device wherein a variable mixture images becoming progressively longer and less
o f two coloured lights is compared with and intense.
matched with another colour.
Effects o f intermittent stim uli When the rate of
The Famsworth-Munsell 100 hue test involves
alternation is increased, a flickering occurs, and
the discrimination of hue o f specially prepared
on further increase, the difference between
coloured disces.
successive sensations lessens and suddenly ceases
The Edridge-Green lantern test is practical test
at a certain rate. This is the criticalfusion frequency
cases where recognition o f colour signals is
(CFF).
required. Other tests include electroretinograph and
microspectrophotometry.
Visual Sensations
Further Reading Visual sensations consist o f three senses: (a) light;
(b) form; and (c) colour.
1. Adler, F.H., Physiology o f the Eye, ( 6th ed.),
Moses, R.A. (Ed.), C.V. Mosby, S t Louis, Light sense. Light sense is the property to perceive
1975. gradations in intensity o f illumination and can be
tested by determining light minimum and light
2. Majji, A.R., Sharma, Y.R., Rajsekhar, Y.L., et
difference. Light minimum or intensity threshold
al. Colour vision and colour blindness. In
for light is the lowest limit o f illumination at which
Modern Ophthalmology, Dutta, L.C. (Ed.),
an object is discernible. Light difference or
Jaypee Bros., New Delhi, 1994, p. 777.
differential threshold for light is the faculty of
3. Duke-Elder, S., System o f Ophthalmology, distinguishing different intensities of light.
Vol IV: The Physiology o f the Eye and o f
Vision, Duke Elder, S., Gloster, J. and Weale, F orm sense. Form sense is the faculty o f
R.A. (Eds.), Kimpton, London, 1968. perceiving the form or shape of an object and is
expressed in terms o f visual acuity.
4. Рагт, J., Introduction to Ophthalmology, (2nd Visual acuity is a measure of the smallest retinal
ed.), O xford University Press and ELBS, image o f which the form can be appreciated. It is
Oxford, 1982. dependent on factors like area o f the retina
stimulated, intensity and distribution of illumination
and spectral nature of illumination.
26. VISUAL SENSATIONS Colour sense. Colour sense is the faculty of
AND ADAPTATION1' 3 differentiating between colours.
The effects o f a single flash of light of moderately
high intensity (Fig. 26.1) causes a retinal response.
Light Threshold
The response has :1 (a) a latent period o f 50 to Light threshold depends on several factors like:
200 m seconds; (b) a primary image of 50 to 200 (i) nature, duration and size o f the stimulus;
m. seconds; and (c) after-images, consisting of (ii) quadrant of the retina stimulated; (iii) state of
adaptation; and (iv) nature of the surrounding field.
The peripheral rays that reach the retina most
obliquely are less effective in stimulating vision.
This is called the Stiles-Crawford effect.

Fig. 26.1 Afterim ages. Following fading o f primary Successive Contrast


image there are three positive and three negativeaftrim. The single stimulus evoking after-images inhibits
subsequent similar stimuli and enhances dissimilar Loss of 7 per cent rhodopsin causes cone function
stimuli. This phenomenon is called successive to play its role.
contrast or temporal induction. The familiar
example is the appearance of a dark square when Further Reference
a white square is briefly projected on the white
wall. 1. Hart, W.M., Jr. (Ed.), A dler’s Physiology o f
the Eye (9th ed.), Mosby Year Book, St. Louis,
1992, p. 502.
Simultaneous Contrast or Spatial
Induction 2. Marmour, M.F. Clinical physiology o f the
retina. In P rin cip les and P ractice o f
Simultaneous contrast or spatial induction improves Ophthalmology, Peyman, G.A., Sanders, D.R.
the definition o f the contour of the visual image and Goldberg, M.F. (Eds.), W.B. Saunders,
and is the result of a single stimulus. An example Philadelphia, 1980, p. 823.
is the appearance of a grey square as almost white
3. Trevor-Roper, P.D. and Curran, P.V., The Eye
and alm ost black against black and w hite
and Its D isorders (2nd ed.), B lackw ell
backgrounds respectively.
Scientific, Oxford, 1984, p. 146.
Adaptation
The adjustability of the eye to light of different
intensities is called adaptation, either dark or light 27. NEUROLOGY OF VISION1
adaptation. The rods operate best at low The neurology of vision is associated with the study
illumination, scotopic vision. The cones are more of visual pathways and pupillary pathways and
sensitive to light and act effectively in bright reflexes.
illumination, photopic vision. These two types,,
scotopic and photopic, form the basis for duplicity Visual Pathways1
theory of vision.
Three neurons link the retina to the occipital cortex.
Dark adaptation. The visual sensitivity increases The sensory end-organs, the rods and cones of the
when the eyes remain in darkness. The pupil dilates retina respond to adequate light stimulus. The first
and there are neural and biochemical changes. neuron is the bipolar cell with its axon in the inner
There are two phases: the initial phase lasting for plexiform layer. The second neuron starts at the
5 to 9 minutes and the second lasting for 30 to ganglion cell of the retina and runs to the lateral
45 minutes; the first phase is rapid and the second geniculate body. The third neuron transmits the
slower. In the first phase there is regeneration of impulse from the lateral geniculate body to the
cone pigments, while regeneration of rhodopsin occipital cortex. Each neuron is made up o f a cell
occurs in the next phase. The bleaching and body containing the nucleus, dendrites and an axis
regeneration can be m easured by reflection cylinder or axon. The terminal ramifications are
densitometry. The dark adapted retina is most called teledendrones. The teledendrones synapse
sensitive in the region 2.5 mm away from the fovea. with the dendrites of the other cells.
Dark adaptation can be tested by Goldmann- The nerve m essage received through the
Weekers’ adaptometer. dendrites is transmitted by the cell body and is
discharged to the next receiving neuron through
Light adaptation. The visual sensitivity decreases
the teledendrones.
when the eye is exposed to a strong source of
light. This is primarily a neural phenomenon and
Pupillary Pathways
is complete within 2 to 3 minutes, but whole
process of light adaptation takes about 30 minutes. There are two separate pathways that control
pupillary constriction and dilatation, the former by convergence is described on p. 65, and for
the p arasy m p ath etic and the latter by the accommodation is described on p. 63.
sympathetic pathways. Parasympathetic pupillary
pathways (light, near and accommodation reflexes). Sympathetic Pupillary Pathways
There are three neurons: central, preganglionic and
Afferent pathway. The afferent pupillary fibres
postganglionic. Central neuron originates in the
start in the photoreceptors —» pass through the retina
posterior hypothalamus. The fibres pass caudally
to reach the optic nerve partially decussate in
and ipsiiaterally through the brain stem into the
the optic chiasma like the visual fibres -» run along
upper spinal cord to synapse in the ciliospinal
with the visual fibres to reach the posterior third of
centre o f Budge.
the optic tract - » then leave the tract as a separate
Preganglionic neuron leaves the spinal cord
bundle of fibres to enter the brachium o f the
by ventral roots o f C 8 to T2 to reach the
superior colliculus —» pass into the midbrain to
sympathetic chain and finally the superior cervical
reach the pretectal nucelus —» partially cross to
ganglion.
reach Edinger-Westphal nucleus.
Postganglionic neuron has the following course:
Efferent pathway. The fibres start in Edinger- the fibres enter the skull with the carotid plexus -»
Westphal nucleus. This nucleus is linked with the reach the cavernous sinus —> pass over Gasserian
frontal cortex, occipital cortex and hypothalamic ganglion —> run along the ophthalmic nerve
sympathetic centre. There is excitatory control nasociliary nerve -» long ciliary nerve -»
from the frontal and occipital cortex. The inhibitory sympathetic root of the dilatator ganglion —» short
control is from the frontal cortex and the ciliary nerve —» reach the dilatator pupillae.
hypothalamic centre. The course of the efferent
Pupillary reflexes (See p. 265)
pathway is sum m arized as follows: Edinger-
Westphal nucleus —» the oculomotor nerve —> the
Further Reading
nerve to the inferior oblique —» short root of the
ciliary ganglion -> sphincter pupillae. Three 1. Parsons, J.H., Diseases o f the Eye (18th ed.),
p ro cesses, viz, m io sis, convergence and Miller, S.J.H. (Ed.), Churchill Livingstone,
accommodation occur together. The pathway for Edinburgh, ELBS, 1990.
Part Three
Microbiology

he eye is vulnerable to infection—especially exogenous. There are


T three chief groups o f infection: bacterial, viral and fungal. A
description o f the offending organisms causing ocular lesions is helpful
in understanding the pathogenesis.
Table 28.1
28. BACTERIAL INFECTIONS1"2
T oxins and Enzym es Produced by Staphylococci
Bacterial infections in the eyes (Figs. 28c. 1-7)
are caused by cocci or bacilli, both of them are Toxins
gram-positive or gram-negative organisms. H aem olytic: alpha, beta, delta and gam m a
E nterotoxins— А, В, С and E
Epiderm olytic
Staphylococci T oxic shock syndrom e toxin I

Staphylococci are among the most common group Enzymes


C oagulase
of human bacteria, normally found on the mucous
H yaluronidase
membranes and skin surfaces. Lysozym e
Fibrinolysin
Microscopic appearance. Staphylococcus (Staph.)
O thers— lipase, protease, gelatinase, nuclease, etc.
is a coccus o f about 1 m icron in diameter,
nonsporing, nonmotile, usually noncapsulate,
g ra m -p o sitiv e, and they are arran g ed in Alpha-haemolytic toxin (dermatonecrotoxin) is
grapebunch-like clusters from which it derives its found to be associated with chronic staphylococcal
name. conjunctivitis. Beta-haemolytic toxin is cytotoxic
to different types of cells and damaging to plasma
Cultural characteristics. They grow abundantly membrane of RBCs.
on all ordinary media under aerobic condition. O f the enzym es, coagulase is the m ost
There are also facultative anaerobes. The colonies im portant. H yaluronidase probably helps in
on blood-agar may have white (Staph, albus), d issem in atio n o f stap h y lo co cci. The other
lemon yellow (Staph, citreus) or golden (Staph, significant enzyme is lysozyme.
aureus) pigmentation. The Staph, epidermidis Staph, aureus causes several local infections
strain s are u su ally n o n h aem o ly tic and such as boils, carbuncles and wound infection.
nonpigmented.
Ocular infections. Staphylococci are present as
C oagulase test. The pathogenic strain s o f commensals in the healthy conjunctival sac, usually
staphylococcus produce a prothrom bin-like Staph, albus. In more than 50 per cent o f the
enzyme. population, the anterior nares are the reservoir of
The test is done as follows. To 0.5 ml of citrated Staphylococcus from where they spread to the skin
rabbit or human plasma diluted 1 : 1 0 in sterile of the lids especially the lower.
saline, 0.1 ml o f an overnight broth culture of the The various forms of exogenous staphylococcal
Staphylococcus is added. The mixture is incubated conjunctivitis are: (a) chronic catarrhal; (b) chronic
at 37°C for 6 to 12 hours, and is inspected hourly allergic; (c) blepharo-conjunctivitis; and (d) rarely,
for coagulation. purulent or pseudomembranous conjunctivitis.
C o ag u lase-p o sitiv e stap h y lo co cci are Staph, pyogenes can also cause central comeal
pathogenic and are called Staph, pyogenes i.e. ulcer or superficial punctate keratitis due to
Staph, aureus, and occasionally Staph, albus and staphylococcal hypersensitivity, the latter variety
Staph, citreus. being accompanied by blepharo-conjunctivitis.
There are three species o f coagulase-positive
and 13 sp ecies o f co ag u lase-n eg ativ e Streptococci
staphylococci.
Microscopic appearance. They are approximately
Pathogenecity. This is dependent on the presence 1 micron in diameter, spherical, arranged in chains
of toxins and enzymes liberated by staphylococcus o f varying lengths, gram-positive, nonmotile,
(Table 28.1). nonsporing, capsulate in certain conditions and
they stain well with basic aniline dyes. Pathogenic O cular in fectio n s. The lacrim al sac, when
streptococci are usually arranged in long chains. infected, is said to be a potent reservoir of
pneumococci. The other ocular lesions are: (a) the
Cultural characteristics. Streptococci (Strepto.) are
v ario u s c lin ic a l types o f c o n ju n c tiv itis—
aerobes and facultative anaerobes. They grow best
acute c a ta rrh a l, h aem o rrh ag ic, p u ru len t,
on 5 per cent blood agar and cause three types of
pseudomembranous, ulcerative and lacrimal; and
haemolysis. When Streptococcus is surrounded by
(b) the central corneal ulcer. A haemolytic toxin
a narrow halo o f greenish grey discolouration it is
that can cause toxic effect on the comea has been
called alpha-haemolysis (Strepto. viridans). When
reported.
Streptococcus is surrounded by a wider zone of
clearing o f the red cells it is called beta-haemolysis
Neisseria (N.)
and when there is nonhaemolysis it is called
gamma-haemolysis. The genus Neisseria comprises a few members
which are commensals in the nasopharynx. Two
Pathogenecity. There arfe three toxins liberated
o f them are of ophthalmologic importance, namely
by Strepto. p y o g e n e s: (a) strep to ly sin 0 ,
N. catarrhalis, and N. gonorrhoeae (gonococci).
(b) streptolysin S, and (c) erythrogenic toxin, the
first two being cytolytic. Two o f the enzymes, Microscopic appearance. Less than 1 micron in
hyaluronidase and streptokinase are related to diameter, they are arranged in pairs with the long
pathogenicity. axes parallel and concavity o f their opposed
Strepto. p yo g en es the b eta-h aem o ly tic surfaces. They are gram-negative, noncapsulate
streptococci, has the characteristic property o f and nonsporing.
extrem e in v asiv en ess p ro b ab ly because of
Cultural characteristics. They grow on ordinary
production of hyaluronidase and streptokinase, the
agar, but their growth is much improved by adding
latter causing fibrinolysis.
blood or serum.
Ocular infections. Streptococci are present in 1 Biochem ical reactions. All Neisseriae give a
to 4 per cent o f normal eyes. It may cause positive oxidase reaction, which is especially
erysipelas, woud infection and conjunctivitis. They needed to detect N. gonorrhoeae. 1 per cent freshly
may give rise to endogenous infection. prepared oxidase reagent is applied over the culture
plate, the colonies o f N. gonorrhoeae rapidly turn
Pneumococci (Streptococcus a deep purple colour.
pneumoniae)
O cular infections. N. catarrhalis may cause
Pneumococci are commensals in the nasopharynx chronic conjunctivitis, but is rarely found in acute
and throat in about 40 per cent o f the population
conjunctivitis.
and in the nose in about half this number. N. gonorrhoeae causes typically ophthalmia
M icroscopic appearance. These are about 1 neonatorum, acute purulent conjunctivitis and
micron in length, arranged in pairs. They are gram- comeal complications. Rarely it causes a metastatic
positive, nonmotile, capsulate and nonsporing. conjunctivitis associated with arthritis in adults.
Cultural characteristics. They grow poorly on
ordinary media, but can grow well on blood or Mycobacteria (Myco.)
serum media. They are facultative anaerobes. Two o f the species of the genus Mycobacterium
Biochemical reactions. Of which bile solubility are o f im portance in ophthalm ology:
and optochin sensitivity are important. Mycobacterium tuberculosis and Myco. leprae.
Antigenic structure. Over 70 different types of Myco. tuberculosis. The human and bovine types
pneumococcus have been identified. of Myco. tuberculosis cause human tuberculosis.
M icro sco p ic appearance. T hey are and C. hofmanni, o f cornybacteria are called
approximately 3 microns by 0.3 microns, straight diphtheroids.
or slightly curved bacilli, arranged like small
Microscopic appearance, C. diphtheroid are very
‘Chinese letters’. They are nonmotile, nonsporing
pleomorphic. They are usually slender, slightly
and noncapsulate. Ziehl-Neelson stain shows that
curved, with club-shaped ends and show ‘chinese
they are acid-fast and alocohol-fast. When stained
letter’ arrangement. They are gram-positive bacilli,
they resist d eco lo n isatio n with 25 per cent
nonmotile, noncapsulate and nonsporing. Stained
sulphuric acid.
with methylene blue, they stain irregularly with
Cultural characteristics. They are strictly
metachromatic granules at either end o f the
aerobic. They grow on enriched media—egg yolk
bacteria.
or serum.
Cultural characteristics. Their growth occurs in
M y со. leprae
enriched media such as Loffler’s semm medium.
Microscopic appearance. They are similar in size
and shape to My со. tuberculosis. They are acid- Diphtheroids
fast but n o n -alc o h o l-fast. The b acilli are
Diphtheroids rarely show metachromatic-granules.
intracellular and are arranged in bundles. The
They readily grow on ordinary media and on
bacilli cannot be cultivated.
Tellurite media. C. xerosis produces jet black and
C. hofmanni produces greyish-white colonies.
Haemophilus (H.)
This genus comprises o f 13 species including H. Pseudomonas (Ps.) Pyocyanea
influenzae and H. aegyptius or Koch-Weeks bacilli.
Ps. pyocyanea (Ps. aeruginosa) occurs as
H. aegyptius. is for all practical purposes identical commensal in the human intestine or on the skin.
with H. influenzae. They are gram-negative, M icro sco p ic a p p ea ra n ce. T hey are sm all,
slender rods 1.5 microns by 0.5 microns in size, nonsporing, gram-negative bacilli, 1.5 microns to
nonmotile, noncapsulate and nonsporing. They 3 microns in length, motile and flagellate.
require blood-containing media (haemophilic) for
growth and are aerobic. It produces ‘pink eye’. Cultural characteristics. They grow readily on
ordinary media at room temperature.
Treponema (T.) The pigm ents and toxins produced by
pseudomonas are listed in Table 28.2.
T. pallidum is a purely human parasite and the
T a b le 28.2
causative agent for syphilis.
Pigm ents and T oxins Produced by Pseudom onas
M icroscopic appearance. They are delicate
spiralled filaments of about 0.2 microns by 4 to Pigments
14 microns with pointed and tapering ends. In the Pyocyanin— blue
Pyo vcrdin— yellow
unstained preparation, they require dark-ground
Pyomclanin— brown
illumination. They cannot be cultivated. Fluorescein— yellowish
S ero lo g ica l reaction. They give a positive Toxins
complement-fixation test or Wassermann reaction. Haem olysin
E xotoxin-A , В and С

Cornybacterium (C.) Pyocyanin inhibits oxygen uptake by tissue cells,


Comybacterium has been so named because of its haem olysin contributes to invasiveness, and
club-like shape. The commensal species, C. xerosis exotoxin A can destroy polymorphs.
Morax-Axenfeld Diplobacilli (Moraxella) Table 29.1
V iruses C ausing V arious O cular A ffections4
There are three species which are important in
ophthalmology: M. lacunata, M. liquefaciens and DNA viruses RNA viruses
M. catarrhalis. Papovavirus
They are human parasites and cause angular O rthom yxovirus
conjunctivitis. A denovirus Influenza
H erpes virus Param yxovirus
Microscopic appearance. They are diplobacilli 1 H erpes sim plex M easles
by 2 to 3 microns, nonsporing, noncapsulate and V a rie d la-zos ter M um ps
C ytom egalovirus N ew castle disease
gram-negative.
E pstein-B arr Picom avirus
Cultural characteristic. It grows best on serum Pox virus Enterovirus 70
Sm all pox C oxsackie virus
media.
V accinia T ogavirus
M olluscum contagiosum Rubella
F u rth e r R e a d in g Arbo
Retrovirus
1. Brinser, J.H., Ocular bacteriology. In Infections Human im muno
o f the Eye, Tabbara, K.F. and Hyndiuk, R.A. deficiency virus
(Eds.), Little, Brown and Co., Boston, 1986,
p. 115. P ro life ra tio n o f v iru ses involves com plex
relationships with their host cells. They do not
2. B urd, E .M ., B acterial k e ra titis and
grow in non-living culture media.
conjunctivitis: bacteriology. In The Comea:
Scientific Foundations and Clinical Practice L ife cycle o f a virus. The following stages are
(3rd ed.), Smolin, G. and Thoft, R.A. (Eds.), generally evident.
Little, Brown, Boston and Co., 1994, p. 115. (a) Penetration. There is specific attachment
between the virus protein and ‘surface receptor*
on the cell membrane, following which nucleic
acid goes to the interior o f the cell leaving the
29. VIRAL AND CHLAMYDIAL protein envelope outside.
INFECTIONS (b) ‘Eclipse phase’. True viruses always pass
through this phase in which the intracellular nucleic
acid loses its identity.
Viral Infections2,4 (Table 29.1) (c) M atu ratio n and rep licatio n . The
Structure o f a virus. There are diverse groups of characteristic change is the release of mature virus
viruses of different shapes and sizes. The viral particles, i.e. elementary bodies from the infected
particles contain genomes or nucleocapsids, which cell. They now involve further cells. Large
may be helical (tubular) or icosahedral (isometric). aggregations o f elementary bodies are called
Helical nucleocapsids contain structural units inclusion bodies. The are either intracytoplasmic
called capsomeres bound to helical form o f nucleic or intranuclear, basophilic or acidophilic.
acid. Many viruses contain a protein or lipid (d) Assembly of the virus particles.
envelope. (e) Release o f infective virus particles then
occurs and the cycle is repeated.
Characteristics o f viruses Viruses are strict
parasites. They contain a single nucleic acid RNA Synthesis.2 The synthesis of the viral components
or DNA, and a protein coat. The majority o f them and ingredients can be divided into three stages.
are ultramicroscopic. Because of their size 10 to (I) Synthesis o f messenger RNA on viral DNA
15 millicrons in diameter, they are filter-passing. as a template. Viruses provide DNA, while the
cells provide purine and pyrim idine bases, Rubella virus, a member o f togavirus, causes
phosphate, energy and enzymes, which lead to German measles producing developmental cataract
synthesis of messenger.RNA. and other congenital defects.
(2) Synthesis o f viral protein on the code of Cytomegalovirus (CMV) may cause retinitis.
viral messenger RNA. The ribosomes are the
centres for synthesis o f protein within the cell. Laboratory diagnosis. These include:
Viral messenger RNA is synthesized in the infected Rapid antigen detection. The tests include
cell, while the host cell provides amino acids, immunofluorescence (IF) and enzyme immuno
phosphate and energy. The amino acids are assay (EIA).
transported by transfer RNA to the ribosomes and Serologic analysis. The tests include
there is synthesis o f viral protein on the code of neutralization, complement fixation (CF), immuno
messenger RNA. adherence h aem o ag g lu tin atio n (IH A ),
(3) Synthesis o f DNA. This occurs due to virus- haemoagglutination inhibition (HI), fluorescent
specific enzymes. antibody to m em brane antigen (FAM A)
Structural characteristics o f different viruses and enzym e-linked im m unosorbent assay
are described under Table 29.2. (ELISA).

Table 29.2
Structural C haracteristics o f D ifferent V iruses4

Virus Envelope Genome form Capsid shape Size (nm)


Papovavirus No ssDNA, circular Icos 45
Adenovirus No dsDNA, linear Icos 70-90
Herpes virus Yes dsDNA, linear Icos 150-200
Pox virus Yes dsDNA, linear Brick 300-450 x 170 -260
Orthomyxovirus Yes ssRNA, segmented Helical 90-100
Picornavirus No ssRNA Icos 25-30
Toga virus Yes ssRNA Icos 60-70
Retrovirus Yes ssRNA Icos and helical 80-130

Icos ■ icosahedral, ss = single stranded, ds = double stranded.

Ocular lesions. They are summarized below. Nucleic acid hybridization. This is a highly
M olluscum contagiosum produces eyelid specific technique of viral identification. Viral DNA
lesions. from the specimen is spotted onto a nitrocellulose
Papovavirus causes warts on the lid margin. filter. The DNA is denatured with alkali and
Herpes simplex virus (HSV). Ocular HSV exposed to radioactive recombinant viral DNA
infection is caused primarily by type I (oral) and fragment probes.
occasionally by type II (genital).
For ocular lesions, see Table 38.5, p. 220.
Adenovirus. There are 47 serotypes. Three Chlamydial Infection1
m ajor ocular affectio n s are epidem ic
keratoconjunctivitis, pharyngoconjunctival fever Chlamydia (C) or Bedsonia was included under
and nonspecific follicular conjunctivitis. psittacosis-lym phogranulom a-trachom a (PLT)
Enterovirus 70, a member o f picornavirus virus. Recently, they are described as a separate
causes cpidemic haemorrhagic conjunctivitis. group occupying a taxonomic position midway
between bacteria and viruses. They show the dextran enhances susceptibility o f the cells to
following characteristics: infection.

1. They contain both DNA and RNA


F u r th e r R ea d in g
2. They replicate by binary fission
1. Heggie, A.D. and Lass, I.H., Chlamydial
3. They possess a cell wall disease. In P rin cip les and P ractice o f
4. Their replication is inhibited by some Ophthalmology: Basic Sciences, Albert, D.M.
antibiotics. and Jacobiec, F.A. (Eds.), W.B. Saunders,
Morphology and life cycle o f C. trachomatis. The Philadelphia, 1994, p. 840.
elementary body is the infectious particle o f 2. Jones, B.R., Prospects in treating viral diseases
chlamydia. The diameter o f the elementary body o f the eye, Tr. Ophthalmol. Soc., UK, 87, 537.
is about 300 nm. The life cycle starts with 1967.
attach m en t o f the elem entary body to the
3. Kelly, L.D. and Dunkel, E.C., Ocular virology.
susceptible host cells, followed by its entrance into
In Principles and Practice o f Ophthalmology:
the cell. About 8 hours after its entrance, the Basic Sciences, Albert, D.M. and Jacobiec,
elementary body reorganizes into a reticulate body. F.A. (Eds.), W.B. Saunders, Philadelphia, 1994,
This process leads to flexible and permeable cell p. 891.
wall. About 48 hours after attachment, the cell
and one or more intracytoplasmic inclusions 4. K ichington, P .R ., V iral k eratitis and
rupture releasing newly-formed elementary bodies, conjunctivitis: virology. In the Cornea:
the latter affecting other cells or new host. Scientific Foundations and Clinical Practice
(3rd ed.), Smolin, G. and Thoft, R.A. (Eds.),
Laboratory diagnosis (Table 29.3). There are 15 Little, Brown and Co., Boston, 1994, p. 169.

Table 29.3
M ethods o f Laboratory D iagnosis o f
C. Trachomatis1 30. MYCOTIC AND
PARASITIC INFECTIONS
Cytologic examination
Y olk sac o f em bryonated eggs
M cC oy cells
Mycotic Infections1,3,4
H e L a cells Certain terms used in relation to mycotic (fungal)
Antigen detection infection are described below.
Fluorecein staining Mycology is the science that deals with fungi,
C onjugated m onoclonal antibody either moulds or yeasts.
Enzym e im m uno assay Molds are multicellular, filamentous organisms.
Nucleic acid hybridization Yeasts are usually single celled and capable of
Serologic tests reproducing by budding process.
C om plem ent fixation Hyphae are multicellular, long, cellulose-like
M icro im m unofluorescence testing tubes produced by moulds.
E nzym e-linked im m uno assay Pseudohyphae are elongated buds o f some
yeasts.
serotypes (serovars) of C. trachomatis. Only three M ycelium is the netw ork com posed o f
serotypes L,, L2, L 3 readily infect the cell culture. hyphae.
The pretreatment o f He La cells and uncentrifused C onidiophore is a special hyphal branch
McCoy cells with diethyl aminoethyl (DEAE)- connecting the spores (conidia).
There are about 200,000 species o f fungi and
of these about 175 can cause ocular infection. The
cell-mediated immune system offers protection
against a fungal infection. Debilitating diseases,
breach of anatomic continuity, prolonged use of
antibiotic, steroid or both predispose to fungal
infection. Table 30.1 lists the fungi responsible
for ocular lesions.

Table 30.1
Fungi C ausing O cular Lesions

Candida albicans
F ig . 30.1Photomicrograph of the sporangia of
Penicillium
Aspergillus (A) fumigatus, A. flavus, A. niger rhinosporodiosis (Dr. E. Ahmed and Dr. S.N. Roy).
Fusarium (F) solani, F. oxyporium
Sporothrix schenckii
Rhinosporidium seeberi
Cephalosporium
Actinomyces bovis
Histoplasma capsulatum

Rhinosporidiosis
Rhinosporidiosis is a chronic disease of the nasal
and conjunctival mucosa due to Rhinosporidium
seeberi. The lesion is polypoid in appearance. The
disease is present in the Asian subcontinent and
South America. F ir. Aspergillus sp. colony showing
3 0 .2
conidiophores (x320) (Dr. A. Roychowdhury).
O cular lesions
Ocular lesions, (a) The comea is the principal site
(a) In the conjunctiva the presence of reddish, in the eye. Following injury and contamination,
polypoid, single or m ultiple papillom a-like
the fungus causes a superficial localized ulcer with
elevations with characteristic white dots are noticed. soap-lather appearance and a dry surface. It is
The lesion bleeds easily, (b) In the lacrimal sac it
surrounded by a yellowish demarcation line which
presents a picture of nonspecific dacryocystitis, (c) gradually deepens to form a furrow. The ulcer has
The eyelids may show some tumour-like masses. a slow progress. It is usually accompanied by
Diagnosis is confirm ed by histopathological hypopyon, (b) From the comea the fungus spreads
examination of the mass and nasal polyps which to the conjunctiva. It is usually treated by
shows characteristic sporangia of rhinosporidium amphotericin B.
(Fig. 30.1).
It is best treated by excision of the polypoid
Sporotrichosis
lesion followed by cauterization.
Sporotrichosis is mostly caused by Sporotrichum
Aspergillosis schenckii. It may involve the skin, lungs and
Aspergillosis is caused by Aspergillus fumigatus central nervous system. In the eye, the lesions are
(Fig. 30.2) • in the eyelids—presenting multiple bead-like
nodules, with a tendency to ulcerate involving the Streptothrix
eyelids or eyelid margins, conjunctiva—presenting
This word is occasionally used as a synonym for
erythematous or granulomatous lesions; and very
both aerobic and an aero b ic actinom yces.
rarely, other structures.
Streptothrix is studied in material collected from
Moniliasis or Candidosis the concretions of canaliculitis. The characteristic
manifestation is that o f mycotic canaliculitis. It
Moniliasis or Candidosis is usually caused by usually occurs in fem ales and is unilateral
Candida albicans. The infection is usually from involving chiefly the low er canaliculi. It is
the mouth, rectum and vagina. The predisposing evidenced by mild inflammation with copious
factors include diabetes, pregnancy and the use of yellowish material within the canaliculus.
antibiotics or steroids. It may occur in subjects Among the fungi that cause occasional eye
otherwise immuno compromised. lesions are trichophytum which causes ringworm,
H istoplasm a ca p su la tu m —h isto p lasm o sis,
Ocular lesions M ucoraceas—m u co rm y co sis, N ocardia
(a) Obstruction o f the nasolacrimal duct may be a stero id es— n o card io sis, C ephalosporium —
caused by the fungi, (b) Comeal lesions caused cephalosporiosis and Fusarium oxyporium and
by Candida albicans follow injury and are deep solani— fusariosis.
ulcers with undermined edges and dry surfaces. Laboratory diagnosis is difficult. This can be
They are frequently, accompanied by hypopyon described as under:
and iritis, (c) The conjunctiva and other structures (i) For superficial infection
may be rarely affected. • Scraping o f surface lesions and identification
either by direct staining o f smear or culture.
Actinomycosis (ii) For deep keratitis or intraocular infection
• Biopsy o f deep comeal lesion and use of
Actinomycosis is usually caused by Actinomyces special stains
bovis. The species are similar to anaerobic bacteria.
• Culture o f the aspirate.
The infection spreads from the mouth to the soft
tissues o f the face forming small abscesses with Examination o f direct smear is done by potassium
fistulae. Because of the presence o f granules on hydroxide (KOH) or calcofluor white. Fifteen per
their surface the infecting agents present a star- cent KOH is instilled on gently teased tissue and
shaped appearance from w hich the nam e examined under a microscope to demonstrate
‘actinomyces’ is derived. hyphae. Staining is done with Gram stain, Giemsa
or PAS (Periodic acid-Schiff). Culture is done with
O cular lesions Saboraud’s media, blood agar or brain-heart
infusion broth medium.
(a) The eyelid is involved next after the face and
it shows similar lesions, (b) In the conjunctiva Parasitic Infections1"4
there may be inflammation, pseudomembrane A parasite is a living organism which receives
formation and nodular lesions, (c) The comea may nourishment and shelter from another organism
show ulcer with hypopyon, (d) In the lacrimal where it lives.
canaliculi, the lower canaliculus is commonly The terms related to parasitology are briefly
affected. The canaliculus is filled up with soft described.
yellowish cheese-like material, which later on Symbiosis denotes close association between the
becomes hard with presence o f concretions, (e) dissimilar organisms. In case of parasitism this
Other structures in the eye and orbit are rarely association is advantageous to the parasite but
affected. detrimental to the host.
Horizontal transmission denotes all types of Toxoplasmosis
transfer of infection between the individuals except
transfer that occurs from the parents. Toxoplasmosis is caused by Toxoplasma (T.) (Gk.
Vertical transmission. This mode refers to toxon, arc) gondii. T. gondii is an intracellular
congenital transfer from a parent to progeny via protozoan with a crescent shape measuring 3 x 6
transplacental route. millimicron having a well-defined round nucleus.
Vectors are carriers that transfer parasite from This has two phases: proliferative (tachyzoites)
one host to another. and cystic (bradyzoites). Cats are known definitive
Zoonosis is a disease of the animals that can be hosts. The intermediate hosts include rodents, birds
transmitted to humans. and humans. The life cycle is divided into intestinal
Definitive host is one in which a parasite passes (sexual) and tissue (asexual) phases. Cats are
its adult and sexual existence. infected by ingestion of bradyzoites —» rapidly
Intermediate host is one in which a parasite transform into tachyzoites, the latter enter the cat’s
passes its larval or nonsexual existence. intestinal mucosa, undergo sexual proliferation and
Protozoa is a unicellular structure which develop into oocysts. The oocysts detach from the
performs all the functions and is composed of intestinal epithelium and are voided with the
cytoplasm and nucleus. faeces. These oocysts enter the human system
H elm inths are m u ltic e llu la r, b ilaterally through contam inated food —> b rad y zo ites
sym m etrical show ing three germ layers and transform into tachyzoites —» reach intestinal
grouped into tw o phyla: nem atodes and lymphatics -> disseminate to the cerebrum, liver,
platyhelminths. lungs, muscles and eyes. Host immunity is initiated
and the organisms encyst.
Parasites causing Ocular Affections
Ocular manifestations. Refer to Table 48.7, pp. 407-8.
Parasites causing ocular affections belong to four
phyla of animal kingdom: protozoa, platyhelminths, Laboratory diagnosis. The tests are as follows.
nemathelminths, and arthropods. (Table 30.2). Sabin-Feldman dye test. A suspension of live
T a b le 30.2 toxoplasma is added to the patient’s serum to
which saturated alcoholic solution of alkaline
Parasitic InfecUons Causing Ocular Manifestations
methylene blue is mixed. If there is no staining of
Protozoal the cytoplasm it indicates the presence of antibody
Toxoplasmosis against toxoplasmosis in the patient’s serum. But
Acanthamocbiasis
Malaria if there is staining it indicates the absence of
Leishmaniasis antibodies and there is no toxoplasmosis. This test
Giardiasis is positive as early as the fourth day and it persists
Amoebiasis
Platyhelminths longer. False-positive reaction may be seen in other
Cysticercosis parasitic infections. However, if this test is positive
Taeniasis with a titre of 1:128 it is suggestive of an active
Echinococcosis (hydatid cyst) toxoplasmosis.
Schistosomiasis (bilharziasis)
Nemathelminths Complement fixation test is positive 3 to 4
Onchocerciasis
Ancylostomiasis (hookworm) weeks after an infection. This test utilizes a soluble
Ascariasis (roundworm) parasitic antigen derived from chick embryo
Dracontiasis (guineaworm) cultures. A titre less than 1:8 is not indicative of
Gnathostomiasis
active toxoplasmosis infection.
Arthropods
Ophthalmia nodosa Haemo agglutination test. The lysed organisms
Phthiriasis
are coated onto the RBCs indicating a positive
Ophthalmomyiasis
result.
Indirect immunofluorescent assay. The killed Malaria
parasites are added to the patient’s serum and
Malaria is caused by Plasmodium. Occasionally
antihuman globulin labelled with fluorescein. Now
they are examined under a fluorescent microscope. the following complications may be encountered:
This test has now largely replaced the dye test dendritic keratitis, unilateral IK, conjunctival
used for detection o f antitoxoplasma IgM or IgG pigmentation and retinal haemorrhages.
antibodies. Both false-positive and false-negative
may be present. Leishmaniasis
E n zym e-lin ked im m u n o so rb en t a ssa y In India, visceral leishmaniasis or kala-azar caused
(ELISA) is a specific and sensitive test for by L. donovani is not rare. Other two forms are:
detection o f toxoplasmosis. The patient’s serum is cutaneous and mucocutaneous leishmaniasis. Gross
incubated with parasitic antigen followed by anaem ia in k ala-azar resu lts in retin al
incubation with enzyme-linked second antibody. haemorrhages.
Measurement o f enzyme activity indicates specific
antibody co n cen tratio n . In recu rren t cases Giardiasis
measurement o f Ig and IgM points toward an active Giardiasis is due to Entamoeba histolytica. It is
infection. not certain whether uveitis associated with this
affection is caused by am oebiasis or is a
Acanthamoebiasis coincidence.
Ocular acanthamoebiasis is presumably due to
direct ocular invasion by free living soil amoeba, Taeniasis and Cysticercosis
Acanthamoeba. The portal o f entry is the nose or
Taeniasis is caused by T. solium and T. saginata.
the cornea. T his p arasite has tw o stages:
Cysticercosis is caused by larva o f the tapeworm
trophozoite and cyst. The use of steroids, injury,
T. solium called Cysticercus cellulosae. Terminal
herpetic infection, contaminated water, vegetable
gravid segments of this worm containing 50,000
matter, etc. may predispose to this infection.
to 100,000 eggs are voided in the faeces. The eggs
are ingested by intermediate hosts like cattle, pig
O c u la r lesions
or human, and hatching o f the eggs occurs
Ocular infection is unusual, keratitis cases being producing larvae.
reported. This keratitis is characterized by
remissions and exacerbations, pain, insidious lesion O c u la r lesions (see p. 409)
and features resembling those of herpetic or fungal
keratitis. Echinococcosis (Hydatid Cyst)
L a b o ra to ry d ia g n o sis. C lin ically involved Echinococcosis is due to Echinococcus, usually E.
epithelium and stroma are scraped vigorously with granulosus. Definitive hosts, dogs or cats, pick up
a sharpened Kimura or Bard Parker No. 15 blade. infection by eating sheep's or pig’s viscera. Humans
If the initial cultures are negative or if there is are contaminated by ingesting eggs shed in dog's
deep stromal involvement with intact epithelium, faeces.
a corneal biopsy may be necessary to obtain the
infected tissue. Smears are examined for cysts. Toxocariasis
The trophozoites stained with calcofluor white are Toxocariasis is caused by Toxocara canis or catis.
viewed with ultraviolet light under a fluorescent It is transmitted to humans by ingestion of eggs
microscope. Cultures are plated on 1.5 per cent from the soil contaminated with dog’s or cat’s
non-nutrient agar with an E. coli overlay for an faeces. The larvae reach the eye via choroidal
optimal growth. circulation.
appearance. Nits or lice eggs cases are cemented to
the hair shafts of the eyelashes.
Onchocerciasis Myiasis is caused by maggots (larvae) of Diptera
flies. There are three types: ocular surface,
Also called river blindness, it is caused by intraocular and orbital. Ophthalmia nodosa (see
Onchocerca volvulus. The affection is common in p. 195) is caused by caterpillar hairs.
Africa, central and north America. The vector is
the black fly, Simulium. When a black fly bites an F urther Reading
infected individual the microfilariae enter the fly.
The pathologic changes are the direct or indirect 1. Chatterjee, K.D., Parasitology (12th ed.),
result of local death of microfilariae. Chatterjee Medical, Calcutta, 1980.
2. De Freitas, D. and Dunkel, E.C., Parasitic and
Ocular lesions (see p. 410) rickettsial infections. In Principles and Practice
o f Ophthalmology: Basic Science, Albert, D.M.
Rare Helminthic Infections (Table 30.3) and Jacobiec, F.A. (Eds.), W.B. Saunders,
Philadelphia, 1994, p. 865.
Arthropods 3. R odger, F .C ., Eye D iseases in Tropics,
The notable arthropod infections are briefly Churchill Livingstone, Edinburgh, 1981.
described. Phthiriasis (refer to p. 166) is caused 4. Tabbara, K.F. and Hyndiuk, R.A. (Eds.),
by Phthirus pubis, a lice infestation. P. pubis is Infections o f the Eye, Little, Brown and Co.,
1.5 to 2 m illim icron long with a crab-like Boston, 1986.

Table 303
Rare Helminthic Infections Causing Ocular Lesions

Helminths Disease Ocular lesions


Ascaris lumbricoides Roundworm Hypersensitivity, uveitis
Ancylostoma dudenale/americans Hookworm Evidence of anaemia, xerosis
Dracunculus medinensis Guineaworm Worms detected in lid, conjunctiva, orbit
Gnathostoma spinigerum Gnathostomiasis Larva in anterior chamber, uveitis
Schistosoma haematobium Bilharziasis Oedema of lid, conjunctival nodule
Thelazia callipoeda Thelaziasis Chemosis, comeal haze, worm in AC, etc.
Fig. 28c. 1 Staphylococci from conjunctival sm ear Fig. 28c.2 Pneum ococci from conjunctival sm ear
(M ay). (M ay).

Fig. 28c.3 Streptococci from conjunctival secretion F ig . 2 8 c .4 C o rn y b a c te riu m d ip h th e ria e


(M ay). conjunctival scraping (M ay).

Fig. 28c.5 Corny bacterium xerosis from conjunctival Fig. 28c.6 Neisseria gonorrhoeae (M ay),
scraping (May).

Fig. 28c.7 Pseudomonas aeruginosa (M ay).


Part Four
Ocular Therapeutics, Optical Defects
and Ocular Examinations

H P h ree important subjects have been grouped under this section.


X In ocular therapeutics emphasis has been laid only on those
aspects o f pharmacology and therapeutics which are related to ocular
disorders.
The physiological optics include correction o f refractive errors with
lenses, optical defects o f the normal eye and accommodation. The
determination of the refractive state is one o f the procedures followed
in ophthalm ology, and is perhaps more an art than a science.
Accommodation is a true physiologic process and has already been
dealt with.
Lastly in examining a case, it is essential to elicit the history, perform
routine clinical exam ination, and if necessary conduct special
investigations.
31. OCULAR THERAPEUTICS paraffin; (iii) emollient or softening agent, e.g.
liquid paraffin and glycerine; (iv) irritants, e.g.
The basic study in ocular therapeutics 2 considered dionin; (v) astringents, e.g. zinc, boric and acetic
includes the following: acid; (vi) corrosives; (vii) caustic agents, e.g.
carbolic acid, trichloracetic acid and iodine. The
O phthalm ic solutions salts of a few heavy metals such as mercury, zinc,
The problems involved are: (i) tonicity—the eye silver and copper are used as astringents, irritants
tolerates solutions with sodium chloride equivalent and corrosives; and (viii) antiseptics act in one of
to 0.7 to 2 per cent; (ii) pH o f 6.6 to 7.8 is well the three following ways: (a) by coagulation of
tolerated; (iii) stability; (iv) sterility—is the most protein, (b) by disruption o f cell membrane, and
important attribute; and (v) preservatives, e.g. (c) act as strong oxidizing agents. Antiseptics used
in the eyes include mercurochrome, protargol,
benzalkonium chloride.
argyrol and zinc sulphate.
O phthalm ic ointm ents
Autonomic Drugs
The base is a bland, non-irritating one. It may be:
(i) simple—either oils or mucilages, and (ii) Autonomic drugs may be cholinergic or adrenergic.
compound—either oil-in-water type or water-in- Tables 31.1 and 31.2 give a list o f these drugs.
oil type. The compound base is more useful. The
mixture containing 10 per cent liquid paraffin, 10 Table 31.1
per cent wool-fat and 80 per cent soft yellow Cholinergic Agents
paraffin is the most convenient base.
Cholinergic-stimulating (agonists) or
C h ief m ethods o f adm inistration parasympathomimetics
Direct-acting
(i) Solutions; (ii) ointments; (iii) subconjunctival Acetylcholine
in jectio n s; (iv) retro b u lb ar in jectio n s; and Pilocarpine nitrate or hydrochloride
(v) systemic therapy. Methacholine chloride
Carbachol (Glaucostat)
Cholinesterase-inhibiting or anticholinesterases
Agents needed for special effects Physostigmine (Eserine) salicylate
Demccarium bromide (Humorsol)
(i) H ypertonic substances, e.g. glycerine for Edrophonium chloride (Tensilon)
p u rp o se o f red u cin g corneal oedem a; Ecothiophate iodide (Phospholine)
(ii) lubricants, e.g. methyl cellulose, 1 or 2 per Neostigmine bromide (Prostigmine)
cent; (iii) staining agents, e.g. fluorescein and rose Di isopropyl fluorophosphate (DFP)
Bengal; (iv) epitheliolytes, e.g. iodine and alcohol; Cholinergic-blocking (antagonists) or
parasympatholytics
(v) chelating agents, e.g. ethylene diamine tetra­
Muscarinic antagonists
acetate (ED TA ) sodium to rem ove calcium Atropine sulphate
d ep o sits as in band-shaped k erato p ath y ; Homatropine hydrobromide or hydrochloride
(vi) tattooing, e.g. gold and platinum; (vii) irritants, Scopolamine sulphate (Hyoscine)
e.g. ethylmorphine hydrochloride or dionin. The Cyclopentolate hydrochloride
Tropicamide
value of using irritant is doubtful. Ganglion stimulators
Hexamethonium chloride
Surface effectors Pentolinium
They may be grouped as (i) mechanical cleansers,
e.g. normal saline lotion and sodabicarb lotion; Cholinergic agents. Acetylcholine is the effector
(ii) dem ulcent or soothing agent, e.g. liquid substance or the chem ical m ediator in the
Table 31.2 Sites of actions of drugs on parasympathetic system
Adrenergic Agents CNS
Stimulators (agonists) or sympathomimetics
Direct-acting
Epinephrine (adrenaline) hydrochloride, borate Preganglionic neuron
or biborate
Phenylephrine
Dipyvalyl epinephrine
©■ i
Ciliary- ganglion
<D
Apraclonidine
Indirect-acting Postganglionic neuron
Cocaine hydrochloride
Hydroxyamphetamine (Paredrine)
Brimonidine (4) Neurocellular junction
Blockers (antagonists) or sympatholytics
Direct-acting Effector cell
Alpha-antagonists
Thymoxamine Fig. 31.1 Sites of actions of the drugs on the
Dapiprazole parasympathetic system. 1, ganglion stimulation by the
Beta-antagonists drugs like acetylcholine and tetramethylammonium; 2,
Timolol ganglion stimulation by the agents like hexamethonium
Betaxolol and pentolinium; 3, direct peripheral stimulation by the
Laevobunolol drugs like pilocarpine, methacholine and acetylcholine,
Metipranolol 4, indirect peripheral stimulation by the drugs like
Carteolol physostigmine, ecothiophate, edrophonium and
Atenolol isofluorophate and 5, cholinergic peripheral block by such
Pindolol drugs like atropine, homatropine, eucatropine,
Indirect-acting scopolamine and cyclopentolatc.
Guanethidine enzym es— catechol-o-m ethyl transferase and
monoamineoxidase (MAO).
cholinergic system. Acetylcholine is formed from The different sites o f adrenergic system
choline and acetylcoenzyme A in the presence of stimulation and blockade have been shown in
the enzyme cholineacetylase. It is released at Fig. 31.2.
cholinergic nerve endings where it is rapidly In the eye there are two types o f receptors:
hydrolyzed and inactivated by the enzym e alpha (postsynaptic, type 1 and presynaptic, type
acetylcholinesterase, present on the neuron and 2) and beta (type 1 and type 2).
membrane o f the receptor cell, into acetic acid Alpha-receptors are present in the arterioles,
and choline. Traditionally, acetylcholine has a outflow channels, dilatator pupillae and Miiller’s
muscarinic effect on the smooth muscle, cardiac muscle. Hence, their stimulation causes enhanced
muscle and glands and a nicotinic effect on the aqueous outflow, mydriasis and lid retraction.
skeletal muscle and ganglia. Beta-receptor type / is present in the cardiac
The different sites o f stimulation and blockade muscle.
o f cholinergic system have been show n in Beta-receptor type 2 is present in bronchial
Fig. 31.1. Parasympathomimetics are essentially muscles, blood vessels o f the anterior ocular
used as m iotics and parasym patholytics as segment, outflow channels and ciliary body.
mydriatics-cycloplegics. Stim ulation o f beta-receptor type 1 causes
Adrenergic agents In the adrenergic system there tach y card ia and enhanced cardiac output.
are two chief effector substances, norepinephrine Stim ulation o f beta-receptor type 2 causes
and epinephrine and both are catecholamines. bronchial dilatation and increased aqueous
These two substances are inactivated by two secretion.
S i t e s o f a c t i o n s o f d r u g s on s y m p a t h e t i c s y s t e m the ciliary ganglion causes the pupil unresponsive
CNS, C ,- T 2 to eserine.
For details about miotics (see Table 44.5,
p. 299).
Preganglionic neuron
Mydriatics
д>-— -F — - g>
[Superior cervical g a n g lio n ] Mydriatics are agents needed to dilate the pupil,
while cycloplegics cause paralysis of the ciliary
Postganglionic neuron muscle and accommodation. Some mydriatics are
© -— ___ I __—- - © also cycloplegics, e.g. atropine and homatropine.
~ ^ N e r v e e n d i n g ----------
A tro p in e . T his is the lo n g e st-actin g
I ______ . © parasympatholytic drug. A 1 per cent drop or
ointment causes mydriasis within 15 minutes which
© —
peaks in about 30 minutes and lasts for 12 days or
Fig. 31.2 Sites o f actions o f the drugs on the sym pa­
more. Cycloplegia starts around 25 minutes, begins
thetic system. I, ganglion stim ulation by the cholinergic
drugs; 2, ganglion block by th e cholinergic drugs; 3,
to decline in 3 to 5 days but lasts for 2 to 3 weeks.
ad ren erg ic p erip h eral stim u latio n by the d ru g s like Evidence of acute poisoning includes dryness of
hydroxyam phetam ine; 4, adrenergic peripheral block by the mouth and skin, flushing of the face, fever,
the drugs like reserpine, guanethidine and m ethyldopa; 5, and tachycardia.
direct cell stim ulation by the drugs like phenylephrine and
ephedrine; 6, stim ulation o f the effector cell by the agent Homatropine. A 1 or 2 per cent solution induces
like epinephrine; and 7, blocking o f the effector cell by a mydriasis within 15 minutes, and reaches its
the drugs like tolazolinc and dibenzylene. peak within 1 hour. It lasts for about 24 hours.
Scopolamine (Hyoscine), 0.25 per cent or 0.5 per
Adrenergic agents. See p. 299.
cent drops cause mydriasis within 1/2 hours and
m axim um cycloplegia in less than 1 hour.
Miotics Mydriatic-cycloplegic action lasts for 3 to 7 days.
Miotics are drugs which constrict the pupil.
Cyclopentolate. This is used as a 0.5 or 1 per
Pilocarpine. This is the drug of choice used in cent solution. Mydriasis develops in 45 minutes
glaucoma. It may be used as a 1 per cent drop if and cycloplegia in 60 minutes. The action lasts
the tension is below 30 mm Hg Schifltz, as a 2 per for 12 to 24 hours.
cent drop if the tension is well above 30 mm Hg Tropicamide. This is used as a 0.5 or 1 per cent
SchiOtz and a 4 per cent drop in very high tension. solution. Full cycloplegia occurs in 20 minutes.
The 2 per cent drop is the most effective strength.
The action lasts for about 6 hours.
It is used as nitrate or hydrochloride. It acts within
15 minutes of instillation and lasts for about six Phenylephrine. This is an alpha-receptor stimulant
hours and sometimes longer. Maximum drop of but with little beta activity. A 10 per cent drop
IOP occurs within one hour. is often sufficient for effective mydriasis within
30 minutes. The action lasts for 3 to 4 hours. It
Eserine (Physostigmine). It is used as salicylate, should never be used in the presence of angle
usually as 0.25 per cent or 0.5 per cent drops. It closure.
is a stro n g er m iotic than p ilo carp in e and
accom m odative spasm is com m oner than in
Anaesthesia in Ophthalmology
pilocarpine. The action starts within 5 minutes and
miosis disappears within 2 to 3 days. Blocking of The essential prerequisite for a successful surgical
procedure is an effective anaesthesia. Local (C N S) e ffe c ts— stim u la tio n or depression;
anaesthesia is sufficient for the vast majority of (ii) peripheral nervous system effects; and
cases. General anaesthesia is resorted to nervous (iii) cardiorespiratory effects, and (b) abnormal
and apprehensive patients, children and evidently resp o n ses, e.g. a lle rg ic responses such as
in prolonged surgical procedures. idiosyncrasy.
L ocal an aesth etics in clu d e: (a ) surface
Sedatives and analgesics. They are often used as
anaesthetics and (b) infiltration and regional
pre- or postanaesthetic drugs: (a) to allay or prevent
anaesthetics.
nausea and vomiting; and (b) to avoid side effects
The common surface anaesthetics used are:
of anaesthetics.
(i) Amethocaine or tetracaine hydrochloride
(1/2%), a novocaine substitute, readily soluble in Chemotherapeutic Agents and
water, effective within minutes and produces Antibiotics
burning sensation and slight hyperaemia.
These are primarily classified as:
(ii) Lignocaine hydrochloride or Xylocaine (4%).
(a) Bacteriostatic—sulphonamides, tetracyclines,
(iii) Cocaine hydrochloride (1 to 4%) is chloramphenicol, erythromycin in low dose, para
e ffe c tiv e w ithin 2 m in u tes. It causes aminosalicylic (PAS) acid etc.
vasoconstriction, m ydriasis, desquam ation of (b) Bactericidal— penicillins, cephalosporins,
co rn eal epithelium , and o ccasio n ally toxic aminoglycosides, e.g. streptomycin, neomycin and
reactions. kanamycin as well as cotrimoxazole, erythromycin
Toxic reactions may be local, determined by: in high concentration and isoniazid.
(i) nature o f the drug; (ii) so lu b ility ; and
(iii) concentration. They can also be arranged according to
mechanism o f action:
Infiltration and regional anaesthetic (a) Inhibition o f biosynthesis o f the cell The
peptidoglycan component o f the cell wall of the
M ixtures o f lignocaine and bupivacaine have bacterium is essential for the integrity. The growth
become popular because the former has rapid onset o f bacteria causes lysis o f the wall, e.g. by
but short duration o f action, while the latter penicillins and cephalosporins.
has slow onset but long duration o f action (b) Inhibition o f protein synthesis. Tetracyclines,
(Table 31.3). streptomycin, chloramphenicol and erythromycin
General manifestations are varied and include: interfere with the production of the peptide chains
(a) in normal subjects: (i) central nervous system on ribosomes.
Table 31.3 (c) Alteration o f the permeability o f the cell
wall. Agents like colistin and amphotericin cause
D rugs Used for Infiltration and R egional A naesthesia
such alteration.
Drug Concentration Maximum Onset Duration (d) In te rfe re n c e w ith the in term ed ia ry
(%) dose (mg) of of metabolism. PAS, sulphonamides, trimethoprim
action action
and iso n iazid in te rfe re w ith b acterial
(minutes) (hours)
metabolism.
Lignocaine
(Xylocaine) 2 500
(e) Interference with nucleic acid metabolism.
4 -6 1/2-1
Procaine RNA and DNA metabolism may be affected by
(N ovocaine) 1-4 500 6 -8 1/2 -3 /4 nalidixic acid, rifampicin and actinomycin.
M epivacaine
(Carbocaine) 1-2 500 3 -5 1-1/2-2 The different chemotherapeutic agents used in
Bupivacaine
(M arcaine) 0.25-0.75 175 3 -5
ocular infections include sulphones, PAS acid,
4 -1 2
isoniazid and cotrimoxazole.
Sulphonamides Antibiotics therapy may not respond because
o f these factors: (a) wrong diagnosis; (b) wrong
Sulphonamides act by competitive action. They selec tio n o f the drug; (c) w rong dosage;
chemically almost resemble para-aminobenzoic (d) development of drug resistance; (e) presence
acid (PABA), the latter being a precursor o f folic o f pus; and (f) infection with multiple organisms.
acid. Folic acid is needed for the growth of many
bacteria. When sulphonamides are administered Use o f antibiotics in ocular disorders. The external
they com pete w ith PA BA , but their slight infections o f the eye respond favourably to
difference in chemical structure does not allow antibiotic therapy. The control o f intraocular
the bacteria to synthesize folic acid. infection by antibiotics appears to be a problem
because of relative impermeability of the blood-
Ocular uses. They are used topically as sodium aqueous barrier. The lipoid-soluble substances such
sulphacetamide (Albucid) 10%, 20% and 30% as chloramphenicol are more perm eable than
drops or 6% ointm ent, and occasionally as water-soluble substances such as penicillin and
sulphisoxazole drop with a wetting agent. streptomycin. In inflammations the blood-aqueous
Being lipoid-soluble they are at times suitable barrier is more permeable.
for co n tro llin g in tra o c u la r in fectio n s, but
hypersensitivity and toxic reactions m ust be Topical uses. The usual methods o f local therapy
considered. Slowly-excreted sulphonamides, e.g. include instillation o f drops and suspensions,
sulphamethoxypyridazine (Lederkyn or Midikel), ap p lic a tio n o f o in tm en ts or ap p licap and
sulphaphenazole (O risul), sulphadim ethoxine occasionally subconjunctival or retrobulbar
(M adribon) are preferred in conditions like injections.
trachoma.
Antim icrobial spectrum o f antibiotics
Cotrimoxazole. (Scptran or Bactrim ) is a
ch em o th erap eu tic agent w hich com prises It shown in Table 31.4.
sulphamethoxazole and trimethoprim. A tablet
Topical preparations. Table 31.5 lists the major
contains 400 mg o f sulpham ethoxazole and
topical antibiotics.
80 mg o f trim ethoprim . It is reported that
D oses o f su b co n ju n ctiv al in je c tio n s o f
the concentration in the aqueous is higher than
antibiotics are indicated in Table 31.6.
any other sulphonamide.

Antiviral Agents1,4,6
Antibiotics24
There are two groups:
Local route o f administration is preferable to
(a) Nonselective
systemic administration, provided the antibiotic is
Idoxuridine (IDU)
able to reach the site o f infection. Newly developed
Trifluorothymidine (F3T)
antibiotics should only be used in infections by
Vidarabine (Ara-A)
organisms resistant to older antibiotics.
Cytarabine (Ara-C)
As the use o f antibiotics is essential the
Methisazone
following factors should be considered: (a) the
Amantadine, rimantadine, tromantadine
predisposition o f the patient; (b) the disease;
(b) Selective
(c) the responsible pathogen; and (d) the antibiotic.
Acyclovir (ACV)
Patients with apparently similar infections react
Ganciclovir (GCV)
differently. The dose and the type of antibiotic
Bromovinyl deoxyuridine (BVDU)
may have to be modified if the liver or kidney is
Foscamet trisodium
involved. Full bacteriological assessment is the
Azidothymidine (Zidovudine)
basis of definitive therapy.
Table 31.4
Antibiotics with General Antimicrobial Spectrum

Antibiotics Effective predominantly against


Penicillins
Benzyl (Penicillin G) Staphylococci
Penicillinase-resistant Staph, and Strepto. haemolyticus
Methicillin
Cloxacillin
Nafcillin
Oxacillin
Broad spectrum Gram-positives
Ampicillin
Amoxycillin
Carbenicillin
Cephalosporins Both Gram-positives and negatives
Cephazolin
Cephalothin
Cephalexin
Cephotaxime
Aminoglycosides
Streptomycin Myco. tuberculosis
Framycetin Gram-positive cocci and Gram-negative
(Soframycin) bacilli
Amikacin Both Gram-positives and -negatives
Tobramycin As above
Sisomicin sulphate As above
Spectinomycin N. gonorrhoeae
Gentamicin Both Gram-positives and -negatives
Neomycin Gram-negatives
Chloramphenicol Gram-positive cocci and Gram-negative cocci
Tetracyclines Gram-positives and -negatives,
Lincomycin Chlamydia, Rickettsiae
Macrolides Gram-positives
Erythromycin As that of penicillin
Spiramycin Toxoplasma gondii
Azithromycin Chlamydia trachomatis and
Roxithromycin Toxoplasma gondii
Polymyxins Chlamydial infections
Polymyxin B+ Pseudomonas pyocyanea
Gramicidin + Neomycin
(Neosporin)
Polymyxin В + Polymyxin E
(Colistin)
Fluoroquinolones Staphylococci, Pseudomonas pyocyanea
Ciprofloxacin Kforaxella, Haemophilus and N. gonorrhoeae
Norfloxacin
Ofloxacin
Clindamycin As that of lincomycin
Rifampin Myco. tuberculosis and leprae
Fusidic acid (Fucidin) Staphylococcal infection
Vidarabine (Vira-A) or adenine arabinoside
Topical Antibiotic Preparations Used in the Eye (Ara-A) is a purine derivative, while IDU and F3T
are pyrimidine derivatives. It is phosphorylated
Antibiotic Preparations without the help o f thymidine kinase. It is said to
Penicillin G Sol 100,000 units ml be more effective than IDU but less effective than
Chloramphenicol Sol 0.5%, oint 1% F3T. It is used as 3 per cent ointment 5 times daily
Tetracycline Sol or oint 1% up to 10 days. The use should be reserved for
Chlortetracycline Oint 1%
cases allergic or resistant to IDU or F3T.
Oxytetracycline (Terramycin) Oint 1%
Framycetin (Soframycin) Sol or oint 1% Cytarabine or cytosine arabinoside inhibits
Ofloxacin Sol 0.3%
synthesis o f nucleic acid. It is used against herpes
Norfloxacin Sol 0.3%
Ciprofloxacin Sol 0.3% simplex and vaccinia. It is used as 0.5 or I per
Gentamicin Sol 0.3% cent drops and 1 per cent ointment.
Tobramycin Sol or oint 0.3%
Sisomicin Sol 3 mg/ml Acyclovir (АСУ), acycloguanosine or Zovirax
activates only in virus infected cells. At first
there is co n v ersio n o f ACV to ACV
Table 31.6 monophosphate. Then it enters preferentially into
Doses of Antibiotics Given by Subconjunctival in fec ted cells. The activ ated A CV , ACV
Injections triphosphate has a 30 times greater affinity for
Antibiotic Subconjunctival dose viral DNA polymerase and causes a 3000 times
greater effect o f ACV on HSV replication. It is
Benzyl penicillin 300 mg/ml
Carbenicillin 100 mg/0.5 ml used as 3 per cent ointment 5 times daily for 2
Cephazolin 100 mg/0.5 ml weeks. In HZO 500 mg 5 times daily for 2 or
Gentamicin 40 mg/ml more weeks may be advocated.
Tobramycin 40 mg/ml
Vancomycin 25 mg/0.5 ml Ganciclovir (GCV) or dihydroxy propoxymethyl
Streptomycin 250 mg/0.5 ml g u a n in e (D H PG ) is stru ctu ra lly and
pharmacologically related to ACV.

5-iodo-2 deoxyuridine or idoxouridine (/DU). Brom ovinyl deoxyuridine (BVDU) is most


IDU molecule closely resembles thymidine and is potent antiviral agent against HSV type 1 and
incorporated into viral and host DNA instead of HZO. Its action resembles that of ACV. It may be
thymidine causing production of altered messenger used as 0.1 to 0.2 per cent drops 5 to 8 times
RNA. This antimetabolite is used in treating daily.
epithelial HSV keratitis. The drug is poorly soluble. Foscarnet trisodium inhibits replication o f all
It is used as 0.1 per cent drops to be used every human herpes and retroviruses including HIV and
2 hours during waking and 0.5 per cent ointment may be used in ACV-resistant cases. It is given as
4 to 5 times daily. The treatment should not exceed IV injection, 2.4 mg in 0.1 ml, once a week.
3 weeks.
Azidothymidine (AZT) or zidovudine prevents
Trifluorothymidine, trijluridine (F 3T) or viroptic the production o f viral DNA chains by inhibiting
blocks DNA synthesis by inhibiting cellular the reverse transcriptase o f HSV type 1. It is
thymidylate synthetase and is incorporated into recommended in treatment o f AIDS and CMV
viral DNA. It is soluble in water and fat and hence retinitis. It is given 100 to 200 mg orally 5 to 6
is more effective in controlling HSV keratitis,
times daily for 4 to 6 weeks.
particularly epithelial lesions. It is used as 1 per
cent solution, 5 to 9 times daily for 2 to 3 weeks. Toxicity o f antiviral agents, see Table 31.17.
Antifungal Agents1-4 disadvantages. These are: (a) the activity is less
intense than that o f steroids: (b) there is metabolic
Table 31.7 gives an account o f various antifungal upset; and (c) 25 units every 8 hourly can be given
drugs, their mode of administration and spectrum. by IM or IV injection but not orally.
Table 31.7
Antifungal Agents, Their Mode of Administration and EfTectivity

Antifungal agent Mode of administration Effective against


Polyenes
Amphotericin В Topical, SC, IV, intravit, Keratomycosis and mycotic endophthalmitis
Natamycin Topical Filamentous fungi and
(Pimaricin) C. albicans
Nystatin Topical Candida
Imidazoles
Clotrimazole Topical, oral, SC Acanthamoeba
Miconazole Topical, intravit, SC, IV Y easts and filam entous fungi
Econazole Topical, IV, oral Aspergillus
Ketoconazole Topical, oral Candida, Fusarium, Penicillium
Triazole
Fluconazole Topical, oral Aspergillus, Candida
Pyrimidines
Flucytosine Topical, oral Candida
Others
Silver sulphadiazine Topical Fusarium

SC = Subconjunctival; IV = Intravenous; Intravit = intravitrcal.


Preparations and doses o f topical antifungals Deoxycorticosterone (DOCA) was the first
are listed in Table 31.8. sy n th etic adrenal com pound. In 1950
hydrocortisone was discovered. Later more potent
Table 31.8 and synthetic preparations were introduced. While
Preparations and Doses of Topical Antifungals d ecid in g about the use o f stero id s in
ophthalmology the local hazards as well as general
Antifungal Preparations Daily dose contraindications are to be considered.
There is a daily 10 to 15 mg secretion of
Amphotericin В Drop, 50,000 U/ml 5 times
Clotrimazole Suspension, 1% 2 hourly hydrocortisone in the normal person and any
Econazole Suspension/oint, 1% 8 hourly increase in the secretion by the administration of
Fluconazole Drop. 0.2% 5 times steroids can cause a pharmacological effect.
Flucytosine Drop, 1% 2 hourly Steroids are divided into three groups: (a)
Miconazole Suspension, 1% 2 hourly
mineralocorticoids, e.g. deoxycorticosterone and
Natamycin Suspension, 5% 5 times
Nystatin Ointment. 10000 U/g 2 hourly fludrocortisone; (b) glucocorticoids—(i) natural,
Silver sulphadiazine Drop, 1% 5 times e.g. h y d ro c o rtiso n e ; (ii) sy n th e tic , e.g.
prednisolone, methyl prednisolone, triamcinolone,
Steroids1-3 betam ethasone and dexam ethasone; and (c)
androgens.
Corticosteroids and adrenocorticotrophic hormone Glucocorticoids fill a great need because o f its
(ACTH) have rem arkable anti-inflam m atory valuable antiinflammatory action.
effects. ACTH causes stimulation of the adrenal The antiinflammatory action of steroid is due
cortex to produce steroids. ACTH has certain to the following mechanisms .1
1. Inhibition of vascular permeability Table 31.10
2. Stabilization of lysosomal membranes Routes of Administration of Steroids
3. In h ib itio n o f in tra c e llu la r lysosom al Systemic Oral
membranes Parenteral
4. Inhibition or release of damaging enzymes Topical Solution
5. Inhibition o f PMN (Polym orphonuclear Suspension
Ointment
neutrophil) cell degranulation and macrophage
Subconjunctival
activity Repository
6 . M obilization o f PM Ns from the bone
marrow causing increased neutrophilic leucocytosis In addition to topical drops or ointments in
and preventing their adherence to the vascular severe form s o f irid o cy clitis and scleritis,
endothelium. su b co n ju n ctiv al in jectio n and/or system ic
7. Suppression of lymphocyte proliferation administration are necessary. In inflammatory
8 . Suppression of fibroplasia diseases of the posterior segment of the globe,
optic nerve and the orbit, systemic administration
9. D ecom pression o f bacterial activity of
of glucocorticoids or ACTH injection is valuable.
monocytes and macrophages
Retrobulbar injection of repository corticoids
10. Prevention of formation of prostaglandins is effective in selected cases of posterior segment
and leucotriens through inhibition of phospholipase affection, the advantages of such therapy being
A 2 and release of arachidonic acid, affecting high local concentration of the drug and avoidance
both cy clo o x y g en ase and lip o o x y g en ase of systemic side effects.
pathways.
Dosage o f systemic steroids. In severe cases daily
Therapeutic indications. See Table 31.9. dose of 40 to 80 mg of prednisolone or its
equivalent is used. The reduction of the dose is
Table 31.9 done gradually over a period of days or weeks.
Indications of Steroids in Ophthalmology The doses o f com m only used topical
preparations of steroids are shown in Table 31.11.
Allergic blepharitis
Allergic conjunctivitis Table 31.11
Contact dermatitis Showing Usual Strength of Topical Steroids
Episcleritis
Scleritis Topical steroids Percentage
Interstitial keratitis
Scleritis Hydrocortisone solution 0.2
Uveitis Hydrocortisone ointment 0.5
Optic neuritis Hydrocortisone acetate suspension 2.5
Retinal vasculitis Prednisolone ointment 0.25
Postsurgery Dexamethasone phosphate solution (Decadron) 0.1
Temporal arteritis Betamethasone solution (Betnesol) 0.1
Pseudotumours of orbit Triamcinolone acetonide ointment (Kenalog) 0.1
Mucocutaneous conjunctival affections Mcdrysone suspension 1.0
Chemical bums
Sympathetic ophthalmitis The side effects include aggravation of herpetic
infection, predisposition for fungal overgrowth,
Steroids can be administered orally, parenterally retardation of healing, glaucoma—in those subjects
and topically (Table 31.10). genetically predisposed to glaucoma, and cataract.
Enzymes in Ophthalmology3 Withdrawal of oral therapy is made in about
6 weeks.
These enzymes are proteolytic or fibrinolytic. Antagonist to coumarin drugs. IV injection of
A lphachy mo trypsin. This is a proteolytic vitamin Kj reduces the prothrombin time to almost
enzyme prepared from mammalian pancreas. It is normal in 3 to 5 hours.
used for ease o f intracapsular extraction o f the
lens. Carbonic Anhydrase Inhibitors (CAIs)2,3
The normal dosage is 750 units with 5 ml
The enzyme carbonic anhydrase is present in the
diluent yielding a 1:5000 solution. For irrigation
ciliary epithelium, comeal endothelium, lens and
o f the posterior chamber, 1 to 3 ml for about 3
retina. CAIs inhibit this enzyme which catalyzes
minutes is used. 0.5 ml or less of 1:10,000 solution
the reaction between carbon dioxide and water to
may be quite effective. The possible side effects
form carbonic acid. This decreases the rate of
are keratopathy, delayed wound healing, transient
aqueous humour secretion by 40 to 50 per cent.
rise o f in tra o c u la r p ressu re and v itreo u s
The pressure-lowering effect lasts for 3 to 5 days
degeneration.
following cessation of therapy.
H yaluronidase. It is an enzym e w hich
depolymerizes the polysaccharide, hyaluronic acid Doses. The doses of CAIs are follows:
found in the tissues. It is available in 150 unit Acetazolamide (Diamox, Actamid)— 250 mg
ampoules. The usual dosage is 6 units per ml of thrice daily in children 10 mg/kg body weight;
anaesthetic solution. Addition to an anaesthetic 500 mg IV and 500 mg slow release capsule.
solution for injection ensures increased tissue Methazolamide (Neptazane)— 50 mg tablet twice
permeability, rapid spread and quicker absorption. daily.
Urokinase. It is a fibrinolytic enzyme used for Dichlorphenamide (Daranid)— 50 mg tablet
washing out the AC. It is indicated in hyphaema. twice or thrice daily.
E thoxzolam ide (C ardase)— 125 mg tablet
Anticoagulant Therapy3 4 times daily.

Principally, there are two drugs, the heparin and T o p ic a l C A Is. T hese include sezo lam id e,
the coumarin group o f drugs. acetazo lam id e and do rzo lam id e. O f these,
Heparin should be given in the dosage o f 7,500 dorzolamide 2 per cent was introduced in 1995; it
to 10,000 units by IV injection since it causes a is given thrice daily or twice daily as adjunctive
rather rapid effect. Coumarin drugs are started instillation.
simultaneously as their action does not start before Systemic side effects are common and depend
12 to 96 hours. Heparin is withdrawn after 24 to upon the agent administered and total dose given.
48 hours and coum arin drugs are given as Minor effects include paraesthesia o f the fingers
maintenance therapy. Prothrombin time should and toes, and area around the mouth. Major effects
always be checked. Important drugs for oral therapy include drug allergy, gastrointestinal disorders,
are’ dicoum arol, phenindione (Dindevan) and metabolic acidosis, potassium depletion and renal
biscoumacetate (Tromexan). calculi. Potassium supplementation is essential to
The dosage o f dicoumarol is on the first day counteract these effects.
300 mg; on second day 200 mg; and thereafter 50
to 75 mg daily. Prothrombin time should be
Hyperosmotic Agents
maintained between 20 and 25 per cent o f normal
levels. They lower intraocular pressure prim arily by
Contraindications include bleeding tendencies reducing the ocular volume.
and hepatic disorder. Indications of the use o f osmotic agents are:
angle-closure glaucoma, malignant glaucoma, Table 31.13
secondary glaucoma, hyphaema with seconddary Various Immunosuppressive Agents
glaucoma likely to produce blood staining of
comea, and orbital exploration. Alkylating agents
Contraindications are severe renal, cardiac or Busulphan or myeleran
Chlorambucil
hepatic damage. Cyclophosphamide or endoxan
Doses and methods of administration of osmotic Thiotepa
agents are shown in Table 31.12. Antimetabolites
Methotrexate
Table 31.12 Mercaptopurine
Dosage and Mode of Administration of Osmotic Agents Azathioprine
5-fluorouracil (5-FU)
Dosage Vincristine
Osmotic Route of
Cyclosporine
agents administration
Antimicrobial
Glycerol 1.5 gm/kg, 50% glycerol Oral Mitomycin С (MMC)
dissolved in 0.9% saline Alkaloid
Urea . 0.5-1 gm/kg as a 30% IV Bromocriptine
solution, dissolved Pulsed steroid therapy: high dose of IV steroid.
in 10% inert sugar
Mannitol 2 g/kg as a 20% IV Table 31.14 enumerates the possible indications
water solution of different immunosuppressive agents.
Ascorbate 0.5-1 gm/kg in 20% IV
solution Table 31.14
Isosorbide 1.5 gm/kg of 50% Oral
solution Indications of Immunosuppressive Agents

Agents used Clinical condition


Side effects may be headache, nausea, vomiting
and other hazards at the site o f injection. Oral 5-fluorouracil Filtering operation
Mitomycin С Filtering operation,
agents have their onset of action within 1/2 hour pterygium operation
of administration, maximum effect within 2 hours Cyclosporine A Behcet’s syndrome, Vogt-
and duration of action for 4 to 5 hours. Koyanagi-Harada syndrome
Methotrexate Uveitis, necrotizing scleritis,
Intravenous hyperosmotic agents have more sympathetic ophthalmitis, scleritis
rapid onset o f action, 10 to 20 minutes after IV Chlorambucil Sympathetic ophthalmitis
injection, and greater hypotonic effect, 5 to 6 Azathioprine Uveitis, Wegener’s granulomatosis,
hours, than oral agents. The drugs should be cicatricial pemphigoid
Cyclophosphamide Uveitis, Mooren’s ulcer,
used with caution in elderly subjects and in necrotizing scleritis.
patients suffering from cardiac, renal and hepatic
disorders. These drugs are toxic and may cause bone marrow
Side effects. The common side effects are suppression, hepatotoxicity and nephrotoxicity.
headaches, backache, nausea and vomiting. The 5-fluorouracil is used after filtering surgery, it
severe effects seen after IV injection are chest pain, is administered by subconjunctival injection, 5 mg
pulmonary oedema, congestive cardiac failure, twice daily for one week and then once daily for
agitation, disorientation and urinary retention. another week.
Mitomycin С is given as 0.02 to 0.05 per cent
Immunosuppressive Agents drops post pterygium surgery for one week. During
filtering surgery it is instilled as 0.02 to 0.05 per
These agents are listed in Table 31.13. cent drops on the scleral surface.
Nonsteroidal Antiinflammatory Drugs 3. Pseudoplasticity, i.e. ability to pass through
(NSAIDs) small channel

Mechanism o f action. Arachidonic acid is the 4. Noninflammatory


primary precursor of prostaglandins, leucotriens and 5. Nonpyogenic
related compounds. Cyclooxygenase is responsible 6 . Nontoxic
for conversion o f arachidonic acid to
endoperoxidase. Nonsteroidal antiinflammatory 8 . Nonantigenic.
drugs exert inhibitory effects on cyclooxygenase M ode o f action. These agents act by coating the
and thereby block prostaglandin biosynthesis. surfaces thus protecting them, maintain or increase
Table 31.15 lists the important NSAIDs. tissue spaces within the eye, separate tissue planes,
form temporary blockade and prevent capillary
Table 31.15 oozing.
Nonsteroidal Antiinflammatory Drugs
Preparations. Healon appears to be safest and
For systemic use easiest to handle because of its smooth transition
Aspirin from viscous to elastic nature. Others are shown in
Mefenamic acid Table 31.16. -
Indomethacin
Phenylbutazone Table 31.16
Ibuprofen Viscoelastic Agents and Their Composition
Naproxen
Diclofenac sodium Viscoelastic Composition Concentration
Piroxam Agent (Percentage)
For ophthalmic use
Indomethacin 1% Healon Sodium hyaluronate 1
Armvisc Sodium hyaluronate 1.2
Flurbiprofen sodium 0.03%
Armvisc plus Sodium hyaluronate 1.6
Sodium cromoglycate 2% Visilon or
Diclofenac sodium 0.1% Viscomet Hydroxypropyl methyl
Ketorolac tromethamine 0.5% cellulose 2
Suprofen 1% Viscoat Sodium hyaluronate 3
4i .
Indomethacin and diclofenac sodium drops are Chondroitin sulphate 4
used in episcleritis or scleritis.
Sodium cromoglycate drops are used in vernal Indications. These agents are used during cataract
conjunctivitis. surgery, keratoplasy, trabeculectomy and other
Flurbiprofen acts on the receptors of arachidonic filtering operations, retinal surgery, after vitreous
acid and controls prostaglandin formation. This loss and during repairing injury.
drug is used in inflammatory affections and for
Side effects are rare if the viscoelastic is
maintaining intraoperative miosis.
m eticulously washed off after com pletion o f
surgery. Otherwise there is chance of secondary
Viscoelastic Agents1
rise o f IOP and postoperative inflammation.
Viscoelastic agents have been increasingly used
during past few years. An ideal agent should be: Toxic Effects of Ocular Drugs5,7
1. Solution o f high viscosity
The toxic effects o f com m only-used topical
2. Elastic quality enabling it to rebound
following mechanical stress and compression preparations have been indicated in Table 31.17.
Table 31.17
Toxic Effects of Common Topical Drugs

Drug Systemic effects Ocular effects


Antibiotics Allergic reaction, gastrointestinal Allergic dermatoconjunctivitis, folliculosis, etc.
upsets, etc.
Antivirals Hypersensitivity Superficial punctate keratitis, canalicular block,
thickening of lid margin, etc.
Atropine Dry mouth and skin, flushing Allergic dermatoconjunctivitis, folliculosis, etc.
of face, fever, delirum. etc.
Miotics Perspiration, diarrhoea, increased Accommodative spasm, myopia, retinal
salivation, nausea, vomiting, etc. detachment, etc.
Beta-blockers Cardiac or/and respiratory trouble, Superficial punctate keratitis, decreased tear
confusion, impotence, etc. secretion, etc.
Steroids Possible systemic absorption Secondary glaucoma, cataract, reactivation of herpetic
and fungal infection, comeal thinning, etc.

Toxic effects of Systemic Drugs5 7 2. Lipotropic agents include atromid S.

These have been indicated in Table 31.18. A tro m id -S (C lofibrate). It reduces elevated
triglyceride and cholesterol level. It is used as an
Other Therapeutic Measures adjunct in the treatment of exudative form of
diabetic retinopathy. The recommended dosage is
1. Artificial tear, e.g. methylcellulose, isoptotear,
500 mg 4 times daily.
tearisol, etc.
Table 31.18
Toxic Effects of Commonly-used Systemic Drugs
Drugs Effects Drugs Effects

A spirin Rare. Excessive dosage causes acidosis C hloroquine Corneal deposits and m acular oedem a
and chance o f decrease o f IOP
C hloram phenicol O ptic neuritis
A nti-parkinsonian M ydriasis, paralysis o f accom m odation
D igitalis B oating spots and yellow , blue or
drugs a n d p r e c ip ita tio n o f a n g le - c lo s u re
green vision
glaucom a
Insulin O verdosage leads to hypoglycacm ia
A tropine and related M ydriasis, paralysis o f accom m odation
and m ay cause diplopia
drugs like and precipitation o f angle-closure
probanthinc glaucom a, and visual hallucinations Penicillin H ypersensitivity reactions
A cetazolam ide Paresthesia, num bness and tingling o f Salicylates Rctinat haem orrhages
(D iam ox) extrem ities, potassium depletion and Cataract, glaucom a, activation o f
Steroids
exfoliative derm atitis fungal and herpetic keratitis
A ntihypertensives S udden lo w e rin g o f B P m ay induce Streptom ycin O ptic neuritis
retinal ischaemia
Sulphonam ides Transient im pairm ent o f
A ntihistam ines Impairment o f accom m odation accom m odation, erythem a m ultiform e.
Alcohol A m blyopia, optic atrophy, visual field etc.
defects, etc Etham butol O ptic neuropathy and loss o f visual
Barbiturates Impaired ocular m otility, m iosis or acuity
m ydriasis, xanthopsia, transient loss o f T ranquillizers Pigm ent disturbances in the retina and
vision, etc. uveal tract
3. Physiotherapy includes application of heat
and cold, diathermy, electrolysis, ionization, [5-rays,
X-rays and radium therapy.
4. Protein shock therapy is the injection of non­
specific protein, e.g. milk which induces production
o f antibodies within the body.
5. T issue-therapy is the use o f biogenic
stimulator, e.g. injection o f placenta extract. It was
originally advocated in 1933 by Filatov. They are
used in various degenerations and dystrophies. This
therapy is doubtful.
6 . Vasodilators include tolazoline hydrochloride
(Priscol) and aminophyllin.

F u rth er R eading The angle of reflection is equal to the angle of


incidence.
1. A lbert, D.M. and Jacobiec, F.A. (Eds.),
Principles and Practice o f Opthalmology: Basic Rotation o f a plane mirror (Fig 32.2). If the mirror
Sciences, W.B. Saunders, Philadelphia, 1994. is rotated in the plane of the incidence o f light, the
2. Duke-Elder, S., System o f Ophthalmology, angle of reflection is twice that through which there
Vol. VII: The Foundations in Ophthalmology, is rotation of the mirror.
Kimpton, London, 1962.
3. Ellis, P.P. and Smith, D.L., Handbook o f
Ocular Therapeutics and Pharmacology,
(3rd ed.), C.V. Mosby, St. Louis, 1969.
4. Fechner, P.U. and Teichmann, K.D., Ocular
Therapeutics, Slack (1st Indian Ed.), Jaypee
Bros, New Delhi, 1998.
5. Grant, W.M., Drug intoxication and chemical
injuries, In M odem Ophthalmology (2nd ed.),
Sorsby, A. (Ed.), Vol. II, Butterw orths,
London, 1972, p. 661.
6. Jones, B.R., Prospects in treating viral diseases
7r. Ophthalmol. Soc., UK, 87: 537, 1967.
Fig. 32.2 Rotation of a plane mirror M: IN, the
7. M artin-D oyle, J.L .C ., A Synopsis o f
normal; the incident ray: R, the reflected ray; and Ml,
Ophthalmology (3rd ed.), John Wright and the minor tilted.
Sons, Bristol, 1967.
8. Newell, F.W., Ophthalmology—Principles and Reflection at Uniformly Curved
Concepts, ( 8th ed.), C.V. Mosby, S t Louis, 1997.
Surfaces: Spherical Mirrors6
The centre of curv ature is the centre of the sphere
32. OPTICS AND REFRACTION o f which the mirror is part.
The pole or vertex is the central point of the
Geometrical Optics8,9
reflecting surface.
Laws o f reflection (Fig. 32.1). The incident ray, The radius of curvature is the radius of the
the normal and the reflected ray lie in one plane. sphere.
The axis is any line passing through the centre
o f curvature.
The principal axis is the axis passing through
the pole (Fig. 32.3).

axis

Fig. 32.4 Principal focus in a concavc lens (F)


Principal
axis

Fig. 32.3 Principal and secondary axes.

The subsidiary axis is any other axis other than


the primary.
The sign conventions are all distances measured
Fig. 32.5 Principal focus in a convex lens (F).
from the pole, those in the direction of incident
ray are called positive and those against the incident Focal planes are the planes passing through the
ray negative. focal points.
The principal focus is the point where parallel Conjugate foci are the positions of the object
rays are focused after refraction (Figs 32.4 and and image bearing a constant relation to each other.
32.5). There are two principal foci. Any ray passing Magnification is equal to the size o f the image
through the first or anterior focus will emerge divided by the size of the object.
parallel to the principal axis. The second or
posterior focus is the point on the principal axis at Position o f images
which parallel rays entering the lens reach a focus.
In the convex lens the image is smaller, inverted
The focal length is the distance o f the principal
and real, if the object is situated just beyond the
focus from the lens and is equal to half the radius
principal focus (Fig. 32.6).
of curvature.

Fig. 32.6 Image formed by a convex lens when the object is at O.


In the concave lens the image is smaller than index o f refraction o f the medium in
the object, erect and virtual (Fig. 32.7). which the refracted ray travels
angle o f incidence
angle o f refraction
The critical angle is the angle between the
incident ray and the normal. The light is so
refracted that the emerging ray becomes paralel to
the surface separating the two media.
The internal reflection o f light is caused by light
incident at a greater angle to the critical angle.

Spherical Lens (Fig. 32.8)


Fig. 32.7 Image formed by a concave lens when
the object is outside the principal focus. The spherical lens is divided into two types:
(A) Convex (converging)
The image that can be seen on a screen is called (a) Biconvex
a real image, and the one that cannot be seen is (b) Planoconvex
known as a virtual image. (c) Concavoconvex meniscus
(B) Concave (diverging)
R efraction8 (a) Biconcave
When light rays pass from one transparent medium (b) Planoconcave
to another o f d ifferen t d en sity bend, the (c) Convexoconcave meniscus.
phenomenon o f bending o f light rays is called A biconvex lens is formed by two prisms placed
refraction. base to base, while a biconcave lens is formed by
The refractive index is the measurement of the two prisms arranged apex to apex (Fig. 32.9).
optical density by comparing the velocity of light All the rays passing through the optical centre
in air, and that o f a medium. It is inversely of the lens remain undeviated (Fig. 32.10).
proportional to the wavelength of the refracted light. The geometric centre o f the lens is the point in
Law o f refraction (Snell’s law) states that the middle o f the lens.

n sine i - n ' sine r


Astigmatic Lens
where
These are o f two types.
n index of refraction of the initial optical
medium Cylindrical (Fig. 32.11). One surface is curved

Fig. 32.8 Different types of spherical lenses: 1, biconvex; 2, planoconvex; 3, biconcave; 4, planoconcave;
5, convexoconcave; 6, concavoconvex.
Tone (Fig. 32.12). A toric lens is a combination
of a sphere and a cylinder. Both meridians are
curved, but to a different degree. The numerically
smaller power of the toric surface is called the
base curve.

Fig. 32.9 Formation of (a) biconvex and


(b) biconcave lenses.

Fig. 32.12 Toric curve.

Meniscus Lens
The cylindrical curve is ground on the spherical
surface on one side. Meniscus lens produces least
aberration.

Thick lens4 5 (Fig. 32.13)


A thick lens is one with a finite thickness. The
cardinal points of these lenses are: (a) focal points
(Fi and F2); (b) nodal points (N, and N2); (c)
principal points (Pi and P2); and (d) principal
planes.
There are two principal foci or focal points:
first or anterior and second or posterior. There are
two nodal points and these correspond to the optical
centre of a simple lens. The principal points are
while the other is plane. The cylindrical lens is a those where two principal planes strike the principal
segment of a cylinder and axis of cylinder is axis. The principal or unit planes are conjugate
parallel to that o f the cylinder. planes where magnification is unity which means
T .. r +1.00 Dsph
Transposition o f -------------- -—
-2 .0 0 Dcyl 90°

- 1.00 Dsph
“ +2.00 Dcyl 180°
Toric transposition. The toric formula is written
as a fraction, the numerator o f which is a sphere,
and the denominator consists of the base curve
plus the necessary cylinder.
+1.00 Dsph
-2 .0 0 Dcyl 90°
By simple transposition it becomes
Fig. 32.13 Thick lens showing the cardinal points,
-1.00 Dsph
F,F2; the nodal points, N,N2 and the anterior focal
length, F,N,. + 2.00 Dcyl 180°
Let us suppose that we are dealing with a lens
an object located at one plane will produce an with a base curve o f - 6 D. For toric transposition,
image of the same size in the second plane. subtract - 6 D. Hence, the power of the spherical
The equivalent pow er o f a thick lens is surface would be -1.00 Dsph - ( - 6 Dsph) =
dependent on the thickness o f the glass, its +5 Dsph while the cylindrical power is added to
refractive index and the refracting powers o f the the base curve, i.e. +2.00 Dcyl 180° + (-6.00 Dcyl
surfaces. 180°) = -4 .0 0 Dcyl 180° and power sign o f the
Between the first focal point and the principal cylinder is altered from 180° to 90°.
plane is the first or anterior focal length and the Therefore, the toric transposition would be:
latter is equal to the second or posterior focal
length. + 5.00 Dsph
-6 .0 0 Dcyl 90° with -4 .0 0 Dcyl 180°
Thin lens
Vertex (accurate) transposition. It is especially
In a thin lens, the equivalent power is simply the indicated in thick lenses and meniscus lenses. The
addition of the front and back surface powers, the steps are: (i) simple transposition for the front
others are neglected, i.e. one principal plane instead surface, (ii) obtain the focal length in mm by taking
o f two and is situated at the centre of the lens, the reciprocal o f (i) xlOOO, (iii) divide the thickness
anterior and posterior focal lengths are identical, in mm by the refractive index, (iv) ascertain the
and one nodal point instead o f two. focal length o f the front surface by adding (ii) and
(iii), and finally (v) obtain the power of the
Transposition of Spherocylindrical
front surface in D by taking the reciprocal of
Lenses1,610 (iv) xlOOO.
Transposition means alteration o f the power of
lenses from one form to another equivalent form. Prism8
There are three types o f transposition.
A prism (Fig. 32.14) is a portion o f a refractive
Simple. The steps are: (i) addition of numerical medium bounded by two plane refractive surfaces
power o f the cylinder to that o f the sphere; at an angle to each other. This angle is termed the
(ii) change of the axis by 90°; and (iii) alteration angle of the prism, and the opposite the base of
verging power of the spherical lens. Dioptre (D) is
defined as the reciprocal of the distance in metres
from the reference light source. It is the unit of
measurement o f the refractive power of the lens
and indicates the verging power of a lens with a
focal length of 1 metre. An object situated 1 metre
away will produce a divergence of - I D , while
4 metres away will produce -1/4 D, and so forth.
A convex or converging lens induces convergence,
while a concave or diverging lens causes divergence
(Figs 32.15 and 32.16).
Fig. 32.14 Prism. ABC, the prism; ВАС, the base
of the prism; I, the incident ray and R, the refracted
ray.
the prism. A line from the apex to the base forms
the axis of the prism. The light is deviated towards
the base. Prism dioptre (A) is the strength of the
prism which produces a linear deviation of 1 cm
o f an object situated one metre away from the
prism.
The uses of prisms are: (a) diagnostic, e.g. use
o f Maddox rod; (b) for treatment, e.g. to improve
fusional reserve; and (c) incorporation in Front and Back Vertex Powers4,6
instruments, e.g. ophthalmoscope, applanation
tonometer and keratometer. The vertices or poles are the centres of the first
and the last refractive surfaces o f the optical system.
Vergence and Dioptre4,6 The distance o f the vertices from the focal points
are called the anterior and posterior vertex focal
The term vergence m eans w hether light is lengths and their reciprocal is expressed in dioptres
convergent, parallel or divergent. The unit of as the front and back vertex powers. The usual
vergence is the dioptre. The reciprocal of the second procedure of neutralizing the front vertex power
focal length (1/F2) o f the spherical lens is the of a thin lens is by using lenses from a trial case

Fig. 32.16 Effect o f biconcave lens on the parallel rays.


o f lenses. In case o f thick bent-form lens distorition results. Pincushion distortion occurs if
neutralization in this manner is not possible. To the axial parts o f an o b ject show lesser
determine the back vertex power a refractometer magnification than the peripheral pans.
is used.
Prismatic Effects of the Lenses4
Aberrations in Lenses5,9
These may arise from the following causes:
The main aberrations in lenses are: spherical
aberration, coma, oblique astigmatism and image 1. The spherical component o f the distance
distortion. lenses may be different.
Lens aberrations are natural and they may be 2. The spherical component may be identical,
due to: actual lens form, lens curvature, lens but the power of the cylinder may differ.
thickness and the angle of the plane o f the lens 3. The spherical and cylindrical powers may be
relative to the incident light and plane o f the eye. similar, but the axes o f the cylinder may be
Spherical aberration (Fig. 32.17). It can be different.
eliminated by grinding the optical lens so that its 4. The axes of the cylinder are parallel but
curvature decreases slightly at the periphery. These oblique, e.g. right eye +2.00 Dcyl 75°; left eye
lenses are called aplanatic. +2.00 Dcyl 75°.

Coma. This is the spreading out of an image in a Decentration of the Lenses


plane about 90° to the optic axis and following
Decentration of the lens can be done by one of
unequal magnification of different zones of the
the two ways: displacem ent of the frame by
lens. This can be corrected by aplanatic lens.
lengthening or shortening o f the nose-piece and
Oblique astigmatism. This results from the plane displacement of the lens in its rim.
o f the lens being oblique to the incident rays. It Decentration causes prismatic effect. Decentration
can be avoided by using meniscus or best-form
o f a convex lens inwards causes the effect of a
lens. base-in prism. That of the same outwards causes
Image distortion. Different portions of the lens the effect of a base-out prism. Decentration of a
may show various magnification effects causing cylindrical lens in the direction perpendicular to
barrel distortion and pincushion distortion. If the the axis has the same effect as in the case of a
p erip h eral parts o f an object show lesser sphere.
magnification than the axial parts then a barrel Indications of decentration are: (a) to adapt a
pair of glasses to an asymmetrical face; (b) for
close work; (c) in correction of heterophoria; and
(d) for overcom ing deficiency or excess of
convergence.

Refraction by lens combinations. The effect of


such combinations is additive, especially when the
lenses are thin.

Homocentric or Coaxial Lens System


The component lenses when centred on a common
optic axis form the coaxial or homocentric lens
system. In the compound system such as the eye
itself, there are three pairs of cardinal points as
described by Gauss and Listing: (a) two principal
foci; (b) two principal points; and (c) two nodal
points.

Fig. 32.18 Reduced eye. The lower figure represents


Refraction in the Normal Eye the reduced eye. The upper figure represents the normal
Light rays reach the retina after traversing the eye which shows two focal points, Fj and F2; two
following structures: (a) the anterior surface of the principal points. Pi and P2 and two nodal points. Nj
and N2.
cornea; (b) the substance of the comea; (c) the
posterior surface of the cornea; (d) the aqueous (d) posterior focal distance is 22.78 mm or 24.13
humour; (e) the anterior surface of the lens; (0 the mm behind the plane of the comea.
substance of the lens; (g) the posterior surface of
the lens; and (h) the vitreous humour. Optical Aberrations of the Eye5
In the cornea and lens, the substance of the
comea and lens may be neglected and their two The eye is not a perfect optical instrument, and
surfaces are parallel. Thus, they may be considered the optical aberrations are classified as:
as one. Physiological. Aberrations depending upon the
Refractive indices of the aqueous and vitreous
nature of light: (a) diffraction; and (b) chromatic.
are 1.33, those of the cornea and crystalline lens
A berrations depending upon the optical
are 1.33 and 1.43 respectively.
instrument: {a) spherical; (b) decentring; and
So, there are two chief elements: the cornea
(c) peripheral.
and the lens, both acting as convex lenses.
Pathological. Refractive errors.
Reduced Eye or Schematic Eye5 Diffraction o f light. Deviation of the sides of
the light wave occurs while travelling in space.
The concept of reduced eye (Fig. 32.18) introduced
The narrow wave produces more pronounced
by Donders has these particular features. It is an
effect.
ideal spherical surface having: (a) radius of
curvature which is 5.73 mm; (b) nodal point
is 7.08 mm behind the anterior comeal surface; Chromatic aberration (Fig. 32.19)
(c) anterior focal distance is 17.05 mm or 15.7 During refraction of white light the short blue
mm in front of the plane of the cornea; and wavelengths are refracted most and they reach a
focus in front of longer red rays. This process is pure axial nature when corrected by a lens placed
enhanced when the pupil is dilated. An achromatic at the anterior focal plane, the absolute size of
lens reduces this aberration. the retinal image is identical to the image produced
in em m etropia w ith com parable dioptric
Spherical aberration (see Fig. 32.17) components.
As there is higher refracting power in the periphery
o f the lens than in the central part, the pripheral
rays are brought to a focus more quickly than the
central ones. This process is also enhanced when
the pupil is dilated. The aberration can be reduced
by making the anterior surface of the lens more
curved than the posterior one.

Peripheral aberrations Nodal point and anterior


focal point o f eye
These include coma, oblique astigmatism and image
distortion. Fig. 32.20 K napp’s rule.

Catoptric Images (Purkinje-Sanson Badal's principle (Fig. 32.21). The retinal angular
size subtended by an object situated at any position,
Images)
О,, 0 2, Оз along the optic axis does not vary when
If a strong light such as a lighted candle falls on a biconvex lens is placed in front of the eye so that
the eye, there are four images formed from: (a) the the posterior focal point of the corresponding lens
anterior surface of the comea; (b) the posterior coincides with the nodal point of the eye.
surface o f the comea; (c) the anterior surface of
the lens, and (d) the posterior surface of the lens.
The first three o f these images move in the
same direction, while the fourth moves in the
opposite direction, since the first three o f the
surfaces are convex and the fourth surface is
concave.
Knapp’s rule (Fig. 32.20). In refractive error of Fig. 32.21 B adal's principle.
Em m etropia HEM
Em m etropia is a perfectly normal condition
in which parallel rays of light are brought to
a focus on the retina under physiological
condition.

Refractive errors
Ametropia is relatively more common. The three
subtypes are: hyperm etropia, m yopia and
astigmatism. Fig. 32.22 In hypermetropia (H) the parallel rays
meet behind the retina. In emmetropia (E) they arc
focused on the retina and in myopia (M) they are
Hypermetropia or Hyperopia5 focused in front of the retina.
The parallel rays o f light are brought to a focus
(d) To get a clearer and distinct image, the
behind the retina, when the eye is at rest.
converging power of the optical system is increased
Aetiology. There are three types of hypermetropia. and this is achieved in two ways: by increasing
the curvature of the crystalline lens (Fig. 32.23).
Axial. This is the most common form, the
and by placing a convex lens in front o f the eye
eyeball being too short. 1 mm shortening represents
(Fig. 32.24).
+3 D of refractive change.
Curvature. This is caused by the flattening of
the cornea. An increase o f 1 mm radius of
curvature of comea causes an error of + 6 D.
Index. It is present in diabetic cataract.
M ost norm al infants are born with
hypermetropia of about +4 D because the eyeball
is shorter, the comeal curvature flatter and the Fig. 32.23 Increased converging power in
lens placed nearer the com ea. As the child hypermetropia during accommodation. The dotted line
grows hypermetropia tends to disappear or lessen. indicates the normal lens and the solid line indicates
I f it p ersists it is considered as delayed the lens during accommodation.
development.
Aphakia is a classical example of acquired high
hypermetropia.
Optical condition (Fig. 32.22). (a) At rest, the
parallel rays are brought to a focus behind the
retina, causing a distorted image.
(b) Because the axis of the eye is shorter and
the retina is nearer the nodal point, the image is
smaller than in emmetropia. Fig. 32.24 Provision of biconvex lens in
(c) The rays from the near object will be hypermetropia.
increasingly divergent as they reach the eye
and will be brought to a focus further behind the Accom m odation in hypermetropia
eye. Total hypermetropia is the entire amount detected
after accom m odation is fully paralysed by Correction of presbyopia by provision of near
cycloplegia and is made up of: addition is recommended.
(a) Latent hypermetropia which is overcome by Occasionally contact lens is recommended
a normal tone of the ciliary muscle. and in selected cases keratam ileusis may be
(b) Manifest hypermetropia which is detected advocated.
without paralysing accommodation. It is measured
by the strongest convex glass with which the Myopia5
maximum visual acuity is obtained. This may be:
(i) Facultative. When it can be overcome by The parallel rays of light come to a focus in front
the effort of accommodation. It can be measured of the retina, when the eye is at rest. The clinical
types are: (a) congenital; (b) simple, usually starts
by the fogging method or dynamic retinoscopy,
which determ ines the difference between the between 4 and 7 years; (c) degenerative or
strongest and weakest convex lens with which progressive, i.e. myopia which steadily increases
maximal visual acuity is achieved. and exceeds - 6 dioptres; and (d) acquired, e.g. in
diabetes.
(ii) Absolute. When it cannot be overcome by
the effort of accommodation. It is measured by the Aetiology. There are three aetiological types of
weakest convex lens with which maximum visual myopia:
acuity is obtained. A xial. T his is due to increase in the
Accommodation in hypermetropia is always in anteroposterior diameter of the eye in the majority
excess of convergence. o f cases. Two types are known: sim ple and
pathological or progressive.
Clinical features. Patients are asymptomatic, when
Curvature. There may be increased curvature
the degree of hypermetropia is less, the patients
of the comea.
young and when the defect is overcome by the
Index. Increased refractive index of the nucleus
accommodative effort. In higher degrees, symptoms
or decreased index of the cortex of the lens may
include indistinctness, obscurations of vision caused
be present.
by temporary failure of the ciliary muscle, and
symptoms of eye strain caused by accommodative Pseudom yopia. Pseudomyopia occurs due to
asthenopia. spasm of the ciliary muscle and of accommodation
Ophthalmoscopically. In higher degrees of in uncorrected hypermetropia and early presbyopia.
hyperm etropia there may be: (a) w ater-silk
Optical condition, (a) The parallel rays of light
appearance of the retina; (b) pseudoneuritis; and
(c) frequently an inferior crescent. are brought to a focus in front o f the retina
(Fig. 32.25) and hence the image on the retina is
Pathology. The eyeball is typically small in all by the diverging beam.
directions, the comea is small, and the anterior (b) Because the axis of the eye is longer and
chamber is shallow. the retina is further away from the nodal point, the
Treatment Treatment is unnecessary when: (a) the image is larger than in emmetropia (Fig. 32.23).
(c) If the rays are to be brought to a focus at the
error is small; (b) visual acuity is normal; (c) there
are no symptoms; and (d) there is no muscular retina the parallel rays coming from a distance are
rendered divergent by provision of a diverging or
imbalance.
Between 6-16 years o f age. If any of the above concave lens (Fig. 32.26).
conditions are violated, convex glasses are C linical features. Most commonly simple or
prescribed. school myopia starts manifesting between 7 and
In older people. Glasses are only necessary if 10 years, and is bilateral. Primarily there is
the degree of hypermetropia is high and it produces defective distant vision, the greater the degree of
symptoms. myopia, the greater the defect. In small degrees of
(e) V itreous opacities due to prem ature
liquefaction and degeneration may be seen.
oo
(f) M acular changes include atrophy,
pigmentation or haemorrhage. Fuchs’ spot, the dark
pigmented macular lesion, results from combined
effects of retinal pigment epithelial hyperplasia and
oo
pigments derived from haemorrhage.
(g) Rarely, posterior staphyloma may be present
due to increased length o f the anteroposterior
diameter o f the eyeball.
Fig. 32.25Parcllel rays meeting in front of the
retina in myopia. Complications. The following are present in
progressive myopia:
(a) Retina and choroid—atrophy, haemorrhage,
break, detachment of retina and macular degeneration.
(b) Vitreous— liquefaction, opacities and
detachment.
(c) Lens—cataract.
(d) Intraocular pressure—high m yopia is
som etim es asso ciated w ith chronic sim ple
glaucoma.
Treatment Optical correction consists of
error, symptoms o f eye strain are present. In (a) Provision o f appropriate concave lenses.
progressive myopia, visual impairment may be Glasses which give best vision with maximum
serious. Myopia progress is till late adolescence. comfort are prescribed. Full correction is advised
In p ro g ressiv e m yopia there m ay be in young patients with low degrees of myopia, up
pseudoproptosis with large pupil. to - 6 D. In adults, undercorrection is advised
O phthalm oscopically, the m ajor findings especially for reading because the ciliary muscle
especially in a progressive myopia are (Fig. 32c.l) becomes unusually weak and cannot tolerate normal
(a) Temporal crescent is present. The failure of accommodative effort offered by the correcting
the retinal pigment epithelium to extend to the lenses. In high myopia a full correction can be
temporal border of the disc leads to exposure of rarely tolerated.
choroidal pigment and thus causes a choroidal (b) Contact lens. In very high degree of myopia
crescent. where diminution in size o f image and optical
(b) Supertraction crescent: on the nasal side the aberrations o f the correcting glasses render it
retina extends over the disc margin causing a difficult for the full correction to be prescribed,
blurring at this region. contact lens is of real help. This eliminates prismatic
(c) Tigroid fundus in which there is loss of effects and provides a greater field than the glasses.
pigment from pigment epithelium of the retina and (c) Telescopic glasses. This may be helpful in
as a result the choroidal vessels are well seen. cases associated with macular degeneration.
(d) There are patches of choroidal atrophy (d) In progressive myopia, shortening o f the
especially in the posterior region. Myopic choroidal axial length o f the eye, i.e. scleral shortening
atrophy is present in high degree of myopia, but operation is o f some prophylactic value. Radial
its severity is not necessarily parallel to that of keratotom y is som etim es resorted to. Other
myopia. It is genetically determined and is usually measures include keratomileusis and excimer
rccessive. photorefractive keratectomy.
(e) Ocular hygiene includes good and adequate
illumination, easy and natural posture, large and
clear print, etc. Improvement of general health
appears to be justified especially in growing
children.

Astigmatism5,12
Astigmatism (GK. stigma, point) is a form of
ametropia where the formation o f a point focus of Fig. 32.27 Diagram of a spherocylindrical lens
light on the retina due to unequal refraction of showing the more curved vertical meridian (VV) and
light in the different meridians is absent. the less curved horizontal meridian (HH) as well as
the Sturm’s conoid and the circle of least diffusion
Aetiology. An error which may be caused in the: (D). А, В, C, D, E. F and G are the sections of the
(a) Curvature. Chiefly in the comea and also in conoid, while В to F represents the focal interval.
the lens due to slight obliquity in placement. The
most common is the error in which the vertical a circle of least diffusion, where the processes at
curve o f the comea is greater than the horizontal. В and С are equal and opposite. At E, the long
This has been accepted as physiological. This type axis o f the ellipse is vertical because o f the
in which the astigm atism is corrected by a preponderance of the divergent vertical rays. At F,
+ cylinder near 90° is known as astigmatism-with- there is a vertical straight line—this indicates that
the rule. The opposite co n d itio n is called the horizontal rays have come to a focus. At G,
astigmatism-against-the rule. beyond the point F where both sets are always
(b) Centring. The defect may be slightly in diverging, there will be a gradual increasing o f the
oblique position of the lens or subluxation o f the vertical oval.
crystalline lens.
(c) Index. Because of uneven refraction of the Types o f astigm atism
lens. Regular (Fig. 32.28). When two meridians are at
Optical condition, (a) Those rays, which pass right angles, one shows the maximum and the other
through the meridian o f greater curvature, come to the minimum refraction. These are called the
a focus sooner than those which pass through the principal meridians.
meridian of lesser curvature. Simple. Where one o f the foci falls upon the
(b) The focal lines are formed instead o f a simple retina and the other either in front or behind the
focal point. These two lines are separated by a retina. Hence, one meridian is emmetropic and the
focal interval (Sturm). other is either myopic or hypermetropic. These are
(c) The length o f the focal interval is the degree respectively called simple myopic and simple
o f astigmatism. hypermetropic astigmatism.
(d) Fig. 32.27 shows refraction by an astigmatic Compound. When neither o f the foci is situated
lens (Sturm's conoid). This is further described on the retina but in front or behind it. They are
below. At A, there is a horizontal oval ellipse. The respectively known as compound myopic and
vertical rays converge more rapidly than the compound hypermetropic astigmatism.
horizontal ones. At B, there is a horizontal straight Mixed. When one axis is myopic and the other
line. This indicates that only the vertical rays have hyper metropic.
come to a focus. At C, there is a horizontal oval Oblique. When the two principal meridians are
ellipse. The vertical rays diverge, while the usually either symmetrical, e.g. both at 45° or
horizontal rays are still converging. At D, there is complementary, e.g. at 45° and 135° respectively.
70° 900
(g) (h) (i)
Fig. 32.28 D iagram s to show different types o f regular astigm atism , a, sim ple hyperm etropic; b, sim ple m yopic;
c, com pound hyperm etropic; d, com pound m yopic; e, m ixed; f, oblique; g, com pound hyperm etropic; h, com pound
m yopic and i, mixed. E=the em m etropic m eridian; M =the m yopic m eridian; H=the hyperm etropic m eridian; M M =the
m ore m yopic m eridian; HH=the m ore hyperm etropic m eridian, a, b, c, d and e represent astigm atism -w ith-thc rule,
w hile g, h and i indicate astigm atism -against-the rule.

They may be crossed obliquely, i.e. bioblique Diagnosis. There are two methods:
astigmatism.
Objective method. Most accurate diagnosis is
Irregular. This is due to irregularities in the by retinoscopy. If corneal cause is suspected,
curvature of the meridians. keratometry may be needed.
Clinical features. The symptoms are diminution Subjective methods. They include:
o f acuity o f vision, both distant and near, (a) P ersistent confusion o f verticals and
proportional to the degree and type of astigmatism horizontals or obliques o f the letters HMN
and those of asthenopia. and T.
(b) Astigmatic fan or dial (Fig. 32.29). The
line corresponding to the ametropic meridian is
seen most distinctly while the one corresponding
to the emmetropic meridian is seen least distinctly
in simple astigmatism. These indicate the axes of
the two principal meridians.

R&G

Fig. 32.29 Astimatic fan (top) and Worth’s four- Fig. 32.30 Cross cylinder.
dot test (down). R= red; G=green; R and G=rcd and
green. side o f the axis of the trial cylinder. If the visual
acuity improves, the correcting cylinder is moved
(c) Stenopaeic slit. The slit can be rotated in
slightly in the direction o f axis o f the cylinder of
front o f the eye and subjective testing o f refraction
the same denomination in the cross cylinder. This
done.
checking is repeated till rotatipn o f the cross
(d) Cross cylinder (Fig. 32.30). A mixed cylinder
cylinder does not cause alteration in distinctness in
in w hich h a lf the pow er o f the sphere is
either position.
diametrically to the other half o f the cylinder with
(e) Keratometer (Fig. 32.31). Two illuminated
the axes at right angles, e.g. combination o f a
‘mires’ which are used as an object, are placed on
-0 .2 5 D sphere with a +0.25 D cylinder.
a rotatable circular arc. The curvature o f any
Cross cylinder is used to check the strength of
diameter o f the comea is measured by viewing
the cylinder and the axis of the cylinder. After the
through a telescope. It measures the astigmatism
best possible spherical correction, the cross cylinder
o f the front surface of the comea at two points
is placed in the trial frame with the axis of the plus
about 1.25 mm on either side of its centre.
cylinder at 90° and the axis o f the minus cylinder
at 180°. This is then rotated through 90°. If the T rea tm en t. T reatm ent is essential w hen
visual acuity remains good, the cylinder in the trial astigmatism causes asthenopic symptoms. Constant
frame is correct. If the visual acuity improves, use o f proper cylindrical lens is advocated. Contact
corresponding correction is usually advised. lens is needed especially for irregular astigmatism.
The cross cylinder is then placed in such a Irregular astigmatism due to comeal opacity may
fashion that each axis is alternately 45° to either have to be treated by penetrating heratoplasty.
(c) If one eye is myopic, the other hypermetropic
and they do not cause any discomfort, the condition
may be better left alone. Otherwise undercorrection
o f more ametropic and overcorrection o f less
ametropic eye have been advocated.

Aniseikonia5
Aniseikonia is a condition in which the two images
presented to the visual cortex from the two eyes
differ in size and shape.
Types. Aniseikonia is classified under two types:
(a) Physiological or retinal disparity. It is of
very small degree, responsible for stereopsis.
(b) Abnormal
(i) Optical. Developmental and acquired, the
latter is caused by lenses.
(ii) Anatomical. This is possibly determined by
the density of the retinal mosaic.
Clinical features. A difference of size up to 5 per
Fig. 32.31 K erato m eter ( C ourtesy: A ppasam y
Associates, Chennai).
cent is tolerated, while higher difference is usually
accompanied by symptoms. Usually asthenopic
sym ptom s are p resen t. D iagnosis is by
Anisometropia5 eikonometer, with complicated units but it is of
Anisometropia (Gk. anisos, unequal) is the unequal no clinical value.
refraction in both the eyes. Treatment. Specific iseikonic lenses are prescribed
Types. Anisometropia can be classified under these in certain cases.
types.
(a) Simple—one eye is emmetropic, the other is Aphakia5
ametropic, i.e. hypermetropic or myopic. The absence of the crystalline lens causes the eye
(b) Compound— both eyes are ametropic, i.e. to become strongly hypermetropic. Parallel rays of
hypermetropic or myopic. light reach a focus about 31 mm behind the comea.
(c) Mixed—O ut eye is myopic, and the other is The average anteroposterior diameter o f the eye is
hypermetropic. 23 to 24 mm.
Anisometropia may be congenital or acquired, The optics o f the eye is essentially that of the
e.g. uniocular cataract extraction. corneal system, i.e. the refractive system is reduced
to the refractive pow er o f the cornea alone
Treatment, (a) The provision of spectacle lenses
(+43.05 D). The total refractive power of the eye
to correct anisometropia is limited. A lens power
is +58.64 D.
difference of over 4 D can result in a difference
Optical considerations are as follows.
in retinal image size o f 7 per cent or more. But in
(a) Astigmatism against the rule is usually
case of myopic anisometropia a higher difference
present, because of a section in the upper half of
is often tolerated by a young individual.
the cornea. +8 or +10 D is needed in the first 8 to
(b) Contact lens is beneficial in high degrees of 10 days after an operation. +2 or +3 D cyl is needed
astigmatism. 6 weeks after the operation.
Thus, it is safe to order an aphakic correction Contact Lens1”3,10
6 weeks after an operation.
The use o f contact lens is getting more popular
(b) The size o f the image is an important than ever and am ong its other benefits, the
consideration. At the usual spectacle distance the following factors are important: (a) cosmetic
retinal image is about 25 per cent larger than in co n sid eratio n ; (b) elim in atio n o f corneal
the phakic eye. irregularities in such conditions as keratoconus and
(c) A vision o f 6/9 in a corrected aphakic eye high astigmatism; (c) elimination of peripheral
corresponds to 6/12 in a normal phakic eye. aberrations inherent in spectacle lenses; (d) a good
(d) Accommodation is absent. substitute for heavy spectacles in the higher degree
o f refractive error; (e) allowance for a wide visual
(e) There is distortion if the patient does not
field; and (f) formation of the part o f the optical
look through the central portion o f the aphakic
system moving in conjunction with the eye.
lens.
(f) Visual field is limited and shows disturbing
O ptical principles
scotomata.
(a) The refractive power of the comea itself is
It must be emphasied that adaptation to the use greatly reduced, if not altogether eliminated.
of aphakic lens comes with time. (b) The front surface of the contact lens becomes
C linical fea tu res. Postcataract surgery signs the new comeal surface.
include: (c) The refractive power of the anterior surface
(a) a linear scar corresponding to the section o f the contact lens consists of normal power of
made in the proximity of the upper segment of the the comea plus the correction for the refractive error.
limbus; (b) the iris shows peripheral buttonhole Indications
iridectom y, or two iridectom ies or complete
iridectomy; (c) the anterior chamber is deep from They are listed in Table 32.1.
lack o f support o f the iris by the lens; (d) there is
Table 32.1
often an iridodonesis for the same reason as the
deep anterior chamber; (e) the pupil is jet black; Indications for Contact Lens
(f) Purkinje third and fourth images are absent;
Optical
and (g) there is gross dimness of vision because of (i) Irregular astigmatism
acquired high hyperm etropia follow ing lens (ii) High myopia
removal. (iii) Uniocular aphakia
Optical correction o f aphakia. There are 5 (iv) Anisometropia
available methods: spectacle correction, contact (v) Aniseikonia
Therapeutic- Principally for the
lens, in trao cu lar lens, epikeratophakia and protection of an exposed
keratophakia. or insensitive comea
Protective, e.g. (i) Albinism
(ii) Aniridia
Transient Changes in Refraction Occupational
Changes in refraction are caused by local conditions Diagnostic, e.g. (i) Gonioscopy
(ii) Slit-lamp examination
such as orbital inflammation and lid tumour and of posterior segment of
general conditions like diabetes mellitus and drug the eye
toxicity. In diabetes the change may sometimes be (iii) Fundus photography
sudden and b ilateral, m yopia is found in
hyperglycaem ia and hyperm etropia in (d) In ease o f substitution of spectacle lens by
hypoglycaemia. co n tact lens, decreased and increased
magnifications occur in hypermetropia and myopia •♦Total diameter

respectively only because of slight displacement Peripheral —«


curve width
o f the cardinal points of the combined optical Intermediate
system caused by the use of contact lens. curve width
Optical zone
(e) In aphakia, the conventional lenses increase diameter
the size of the image by 33 per cent. Contact lenses
increase it by 11.4 per cent. This tends to retain
binocular vision in uniocular aphakia.

Types o f contact lens (Fig. 32.32)


Contact lenses may by blown or ground. They are
Fig. 32.33 Different measurements of hard contact lens.
made of glass and synthetics.
1.49, and with a low toxicity. These are popoular
because they are: (a) highter, (b) thin, (c) flexible,
(d) unbreakable, (e) easier to wear and ( 0 easier
to make.
Possible modifications in a contact lens. They
are chiefly: (a) shape o f the edge o f the lens,
(b) thickness (as thin as 0.3 mm), (c) diameter
(average 8 - 1 0 mm), (d) dioptric power, (e) radii
of peripheral curves, and (f) base curve o f the
central zone which is either parallel to or slightly
Fig. 32.32 Contact lens. shorter in radius than curvature o f the comea.
Fitting o f a contact lens. Apart from knowledge
Blown and ground contact lenses have been
o f the patient’s refraction this involves the
discontinued. In ground lenses there were two
following procedures.
curvatures, corneal and scleral or haptic.
(a) The measurement of the flattest meridian of
Moulded lenses first made of dentacoll, an
the anterior surface of the comea referred to as К
impression material made to fit the individual globe,
is done by a keratometer. The central posterior
were next in veogue. These have been further
curve (CPC) o f the contact lens is determined in
replaced by synthetics. Tuohy introduced the all
relation to K, steeper or flatter than K.
plastic corneal contact lenses in 1948. Recently
(b) A standard lens from a trial set o f contact
microlenses have been introduced. A microlens is
lenses of varying diameters and radii is fitted.
a single curve lens with a diameter below 8.5 mm.
(c) The convenient method o f determining
The latest to be introduced are the soft hydrophilic
the smooth and accurate comeal fit is by instillation
contact lenses, some of which are semipermeable
of a drop o f 2 per qent solution of fluorescein
and can be worn continuously for a month, and
and the eye is examined by a cobalt blue light.
gas-permeable lenses.
A reas o f contact are seen as blanched in
contrast to brilliant fluorescence in the areas of
Hard (conventional) contact lens
separation.
(Fig. 32.33) (d) The patient is taught how to insert a contact
Hard (conventional) contect lenses are made or lens cleaned in wetting solution containing methyl
polymethyl methacrylate (PMMA). They have cellulose or polyvinyl alcohol and rinse it and to
excellent light transmission, its refractive index is remove it.
no spectacle blur. The lens can be w orn
intermittently. It provides a good protection for
Symptoms o f contact lens postwearing may be the comea. It has property for minimal comeal
grouped as those w hich do not necessarily damage and minimal dislodging.
indicate specific m odification, e.g. excessive
lacrimation or blinking, photophobia, foreign body Indications fo r its use. It is indicated in the
sen satio n , sen satio n o f blurred vision and follow ing: aphakia, k erato co n u s, b u llo u s
discomfort on upward gaze, and these disappear keratopathy, ‘dry eye’ syndromes, lens use with
between 2 and 4 weeks; and which indicate specific supplementary drugs, alkali bum o f the comea
modifications, e.g. persistent sense of scratching, and as ‘bandage lens’ for protection o f the comea.
blurred vision, glare and sensation o f looseness of
the lens. Rigid gas-perm eable lens
Tolerance o f contact lens. Improvement is possible The m aterials used include cellulose acetate
by reducing the diameter o f the lens, the thickness butyrate (CAB), siloxanyl methacrylate, silicone,
o f the lens and the addition o f intermediate curves fluorocarbon and styrene. A gas-permeable lens
between the peripheral curves. has a large optical zone, capacity o f better
centration and enhanced facility o f oxygen
Corneal changes in contact lens wear.'1 In the transmission.
epithelium the sequence of events are: oedema—
necrosis—scarring—ulceration—vascularization. In C om plications. C om plications are listed in
the stroma—oedema. In Descemet’s membrane— Table 32.2.
folds.
Table 32.2
Soft contact lens Possible Complications following Contact Lens Wear
Hydrophilic plastic, introduced in 1960, is a In the conjunctiva
tridim ensional co-polym er o f ethylene glycol Giant papillary conjunctivitis
monomethacrylate with the addition o f a little Infective conjunctivitis
triethylene dimethacrylate collect ethylene glycol In the comea
dimethyl aerylaxe (EDMA). The basic plastic that Superficial punctate keratitis
is polymerized in the soft lens is hydroxyethy Epithelial microcysts
methacrylate (HEMA). The hydrocurve lens is Oedema
Ulcer
m ade up o f a polym er co n sistin g o f
polyvinylpyrrolidone (PVP) and HEMA. In the contact lens
Mechanical damage
P h ysicoch em ical p ro p erties. The thickness Lens deposits
determines the permeability of the lens, and the ‘Tight syndrome’
latter is dependent on the water-content of the and
these are o f three types: with more than 70 per Other types o f contact lens
cent water, with 45 -7 0 per cent water and with 45
Extended wear lens like ‘Permalens’ as well as
per cent water.
disposable lens like ‘Acuvue’ are available.
Diameter o f the lens. This is determined by
making a choice of diameter which is 2 mm larger Visual Aids1,2,7
than the corneal diameter.
There are three groups of patients who need visual
Advantages o f soft lens. The advantages are the aids: (a) those who have affections causing
comfort and ease o f fit which are of special subnormal vision, e.g. comeal opacity, comeal
importance. Rapid adaptation is possible. There is dystrophy and keratoconus; (b) those suffering from
dense opacities in the media or central retinal lengths. The anterior focus of the convex lens
lesions, which need an enlarged retinal image; and coincides with the posterior focus o f the concave
(c) the patients who need a non-magnified, but lens. These spectacles are especially helpful in high
sharper and more definite image. myopia with macular degeneration, and are used
primarily for near vision.
Classification. Table 32?3. shows classification of
optical aids. Hand-held magnifiers are available in varying
sizes and power between +4 and +20 D. Low
Table 32.3 power magnification lenses are preferable than
Classification of Optical Aids7 high power magnification lenses since the latter
cause disturbing optical aberrations like oblique
For distance: I. Spectacles- astigmatism. The use o f magnifier has a limited
(i) Conventional
(ii) Telescopic value because of its difficulty to maintain constant
(iii) Pin hole focus, and there is decreased magnification with
2. Spectacle modifications, e.g. clip-on increased lens diameter. The introduction of press-
monocular telescopic spectacle on F resnel lens, w hich is light w eight and
3. C ontact lens membrane-like has overcome the problem of hand­
4. Non-spectacle aids
held magnifier.
For near: 1. Spectacles
(i) Strong convex High plus reading lens offers larger field of
(ii) Bcst-form +16.00, +20.00 and
+24.00 D view and greater depth o f focus. Such lenses can
(iii) Telescopic be single vision or bifocal. The power varies
(iv) Specially designed between +4 and +20 D.
2. Spectacle modifications, e.g.
(i) Monocular telescopic clip-on Pin hole spectacles are indicated with opacities
(ii) Binocular head-bomc loupe o f the media in the presence o f good macular
3. Non-spectacle magnifier - function.
(i) Hand-held
(ii) Stand with fixed object-to-lens
distance Special Lenses12
(iii) Focusable stand Special lenses include the following:
4. Projection magnifiers
Lenses—bifocals, trifocals and multifocals.
F ram es—drop-on or ‘K lip p -o n ’ fram es,
M agnifying lens. It consists of a convex lens reversible and frames for very young and school
placed at a distance within the anterior focal length children.
from the object, so that there is formation of a Bifocals (Fig. 32.34)— In the bifocal there are
virtual erect image. two segments: the upper for distant focus and the
lower for near. Straight-split bifocal was originally
Telescopic lens. This comprises a negative lens of
used. This was followed by cemented bifocal. Then
short focal length and a positive lens separated by
invisible bifocals—either solid or fused—were
a distance equal to the difference in their focal
introduced.
lengths.
The main difficulty in using bifocals is the
Telescopic spectacles. The galiiean system as sudden jump of the image while changing the gaze
applied to the telescopic spectacles consists of a from distance to near or the difficulty in going
strong minus lens close to the eye or the eye­ downstairs. This can be averted by: (i) making the
piece and a strong plus lens in front of it or the lens unicentric or monocentric, i.e. coinciding the
objective glass, these two lenses being separated optical centres o f the distance and reading
by a distance equal to the sum of their focal segments; (ii) providing a twincentric bifocal,
Fig. 323 4 Different types of bifocal lens. A; a, geometry of a bifocal lens showing the centre of the distance
portion (D) and the centre of the near segment (N) which is 8 mm downward and 2 mm inward to D; b, round top;
c, flat top; d, univis B; e, bifocal with a supplementary wafer; f, fused; g, executive and h, upcurve

where the centres o f distance and reading— Half-eye glases (Pantoscopic glasses). The subject
segments are on the same horizontal line, the centre sees through the lower half while reading or doing
o f the reading portion being nearer the nose. The close work, while it is easy to look over them for
latter allows convergence. distant vision.
Each case o f reading addition is judged
Trifocals. These are useful particularly for
according to its own merit. In case o f smaller
presbyopic hypermetropes, the correction being
reading portion there will be larger field for
almost similar in both eyes. There are three
distance. If the reading portion o f the bifocal is not
portions: (a) the distance segm ent; (b) the
up to the bottom o f the spactacle frame, but there
intermediate addition—for easier transition from
is a space o f about 3 mm, the latter portion with
reading to distance; and (c) the reading segment.
distant correction aids in avoiding certain difficulty,
e.g. going down the staircase. Multifocals. The reading portion of the lens has a
Certain special varieties need a little description. continuously variable curve which graydually
Upcurve bifocals help the subject to do desk work increases the power from the periphery to the
with ease and while looking up can see people centre. The system appears to be complex.
clearly. Raised lower segment (or strip bifocal)
consists o f an outer rim o f distance correction Tinted Glasses
around the supplementary segment, the outer rim
helps to see low down objects beyond the reading T inted glasses may be used for providing
range. ‘Rising front’ bifocal provides a device protection against glares, comfort, for cosmetic
lifting the frame higher on the nasal bridge for reason.
near work, and helps in avoiding the difficulty Sunglasses. They are commonly used to protect
w hile looking obliquely dow nw ards during the eyes from ultraviolet, infrared rays as well as
tiresome close work. to absorb 60 to 80 per cent o f the incident rays of
the spectrum. The green or grey tint is normally Ptosis crutches. These are provided with metal
used. Glass is more effective than plastic in extension arising from the inner part o f the rim
avoiding infrared rays. which supports the drooped upper lid.
Photochromic glasses. An ordinary glass absorbs
co n sid erab le am ount o f u ltra v io le t, w hile Verification of Spectacle Lenses
photochromic can alter the capacity of ultraviolet
V erifica tio n o f sp ectacle len ses involves
absorption. They are not effective in shades.
determination of: (a) type o f the lens; (b) power
Photogrey lenses. It is not effective as a sunglass. of the lens; and (c) optical centre o f the lens.
Its absorption varies between 15 and 45 per cent.
Types o f lenses. There are several types of lenses:
Photosun lenses. Its minimum absorption is 35 spherical, cy lin d rical, sp h ero -cy lin d rical,
per cent and maximum is 80 per cent. They should planoprismatic or prism combined. Their uses are
not be used in night driving. determined by utilizing their prismatic power.
In case of the spherical lens, the object focused
Tinted glasses fo r industrial concern. These glasses
at a distance seems to move in opposite direction
are meant for welders, glass blowers, steel industry,
and appears enlarged as in the case of the convex
etc. and they cut down harmful infrared and
lens or seems to move in the same direction and
ultraviolet rays.
appears smaller as in the case o f the concave lens.
In case of the weak lens, the object appears to
Frames12
move slowly, while in case o f the stronger lens it
Frames may be metal, plastic, combination of metal appears to move rapidly.
and plastic, rimless and special frames. The object seen through the cylindrical lens
Metal frames may be made up of gold-filled, becomes elongated in one meridian. This indicates
nickel, and aluminium. the axis of astigmatism.
Plastic frames may be of two types— injection- In case of incorporation of the prism, the object
molded and higher quality plastic (cellulose nitrate, seen through it appears to be shifted to one side,
cellulose acetate and lucite). i.e. towards its apex.
Combination frames are made up o f metal
Power o f the lens, (a) The most common method
chassis with plastic or both plastic and metal, along
of determination of the power o f the lens is of
with two adjustable pads.
neutralization. Lenses of opposite power are placed
Rimless frames may be made up of metal or
against the lens being tested and both lenses are
plastic.
moved in front o f the observer’s eyes. The lens
Special frames include:
which which stops all apparent movements of the
Frames fo r infants. Because of almost lack of subject is the neutralizing lens.
bridge to the nose, the ordinary frames are not
(b) Geneva lens measure. This quickly indicates
adjustable. So, a special nose-constmction in the
the type and power of the lens.
frame is incorporated.
(c) Refractionometer or focimeter or lensometer
Hemianopic glasses (right or left). In hemianopia
(p. 127).
o f homonymous type one-half o f the visual field
is affected. Such glasses provide a semitransparent
mirror hinged at the nose-bridge, which helps in Optical Centre of the Lens (Fig. 32.35)
averting difficulty. Optical centre of the lens is the place in the lens
Side shields. These are necessary to cover the eye which does not show any prismatic action. The
between the frame and the eye. optical centre does not necessarily correspond with
Sliding sleeve
governing width
of streak

Rotating sleeve
Fig. 32 .35 a, The optical centre, vortex or pole (c) controlling angle
located at the centre of the frame; b, the optical centre of streak
decentred downward and inward (cl) for reading. A Fig. 32.36 Purvis streak retinoscope, with variable
right spectacle is represented in both cases. direction of the rays (Hamblin). О = observer;
M = mirjor; P = patient.
the centre o f the spectacle frame, and this is the Diagram of head of the retinoscope. This is
geometric centre illuminated by battery in handle, or from mains with a
To determine the optical centre, two lines resistance. The lamp has an exactly straight filament.
crossing each other at right angles are seen through By sliding the projector-lcns the direction of the rays
reflected by the mirror is altered. When lens is at top
the lens held a few inches above them, and the
(dotted outline), rays are convergent, as from powerful
lens is m oved in these two m ajor opposite concave mirror; when in intermediate position (broken
directions. The point of no prismatic deviation of lines), the rays are focused on the eye and there is no
the image and the axes are found out which is the moving light in the pupil; when slid further down
pole or vertex, or the optical centre o f the lens. (continuous line), the reflected rays arc parallel, as from
a plane mirror. Clinically, when working at 1 metre, the
streak is first accurately focused on the patient’s forehead,
Instruments Used in Refraction Work and then the projecting lens is slid further down to get
the plane mirror effect (Whittington).
Retinoscope. This is the most important instrument
in determining the refractive error o f the eye. streak can be rotated and it disappears at the
Retinoscopy is the accurate objective method of neutralization point The streak effect is variable
assessment o f the total refractive error and is done by slid in g the p ro je c to r lens upw ards or
by either o f the follow ing instruments: downwards. Its special use is in the determination
o f the axis of astigmatism (Fig. 32.37).
Retinoscopy mirror- ' *>*ane
Concave
• Streak retinoscope
Plane retinoscopy mirror. By tilting the mirror,
the mirror image is situated as far behind the mirror
as the light in front o f it.
Concave retinoscopy mirror. The mirror image of (А) (В) (C)
the light source placed behind the patient's head is Fig. 32.37 Streak retinoscopy. A shows the reflex
situated in front o f the mirror in between the at the point of neutralization; В the reflex and streak in
observer and the patient. a ‘with movement in hypermetropia’ plane mirror;
The mirror, concave or plane, has a central С the reflex and streak in an ‘against movement in
myopia’ plane mirror (Parsons).
aperture (4 mm) approximating the size of the
observer’s pupil. Trial fra m e and trial set o f lenses (Fig. 32.38). A
S trea k retinoscope (Fig. 32.36). It is either trial frame is needed during retinoscopy and during
illuminated by battery in the handle, or by electric subjective method of estimation o f visual acuity
currents from mains with a resistance. The linear by test types and trial lenses. The trial set of lenses
The image o f the target is seen through a
telescope and focused by a standard lens.
For measurement o f the dioptric power of an
unknown lens, it is placed into a special rack in
between the standard lens and the telescope.
The instrument must be set to ‘O ’ before use.
The target is then moved until the light rays
reaching the telescope are parallel and the image
is therefore in focus. The change in position of
the target indicates the dioptric power o f the
unknown glass.
Fig. 32.38 Trial set of lenses with trial frame.
Placido’s disc (or keratoscope). It is a centrally
is a box containing + and - spherical and perforated disc, 25 cm in diam eter, having
cylindrical lenses arranged in pairs usually from alternating concentric black and white rings painted
0.12 to 20.00 D, along with a set o f prisms. The on its surface. The patient sits with his or her
other contents are the occluder, the pinhole, the back towards light. The disc is held close to the
stenopeic slit, the Maddox rod, red and green glass, eye and the observer looking through the hole
plane glass and also a trial spectacle frame. will see the reflection o f the concentric lines of
the disc over the comea. The patient is asked to
Pinhole. A pinhole allows only the central rays
rotate the eye and the reflections are noted. The
through it and if the vision improves with it, the
rings visible may be circular, i.e. normal, elliptical
vision will improve with lenses.
as in reg u lar astig m atism , d isto rted as in
Cross cylinder. This has already been discussed keratoconus or irregular astigmatism, or interrupted
on p. 118, Fig. 32.30. as in comeal foreign body.
Lensometer or refraclionometer. This is useful for Stenopeic slit It is used either as an aid to refraction
determining the optical centre and axes o f the or at times to determine the clear part o f the comea
cylinder, measuring the dioptre o f the lens, and affected by opacity before performing an optical
also direction of the prism. (Fig. 32.39) iridectomy. It is a black disc which can be put in
a trial frame and is provided with a slit, 1 mm
wide and 6 mm long.

F u rth er R eading

1. Agarwal, L.P., Principles o f Optics and Refrac­


tion, M edical P u b licatio n , New D elhi,
1962.
2. Arora, R. and Gupta, A.K., Contact lens
update. In Current Topics in Ophthalmology>.
Vol. I, Gupta, A.K. (Ed.), B.I. Churchill
Livingstone, New Delhi, 1993, p. 132.
3. Buckley, R. and M orris, J., Contact lens
practice. In R ecent A dvances in
Ophthalmology, Vol. VlII, Davison, S.J. and
Fig. 32.39 Lensometer (Courtesy: Appasamy Jay, B. (E ds.), C hurchill L ivingstone,
Associates, Chennai). Edinburgh, 1992, p. 19.
4. Davey, J.B., Ophthalmic optics. In Modem stenopaic slit, Maddox rod, red-green glasses,
Ophthalmology (2nd ed.), Vol. I, Sorsby, A. prism s and cross cylinder, ophthalm oscope,
(Ed.), Butterworths, London, 1972, p. 383. retinoscopy m irro r and streak retinoscope,
5. Duke-Elder, S., The Practice o f Refraction (9th tonometer, colour vision charts and a set of
ed.), R evised by Abram s, D., C hurchill com m only used drugs, e.g. hom atropine,
Livingstone, Edinburgh, 1978. pilocarpine, phenylephrine and lignocaine.
Other instruments for an ophthalmic clinic
6. Duke-Elder, S., System o f Ophthalmology, include a perimeter, Bjermm’s screen, a slit-lamp
Vol. V: Ophthalmic Optics and Refraction, biomicroscope with accessories, a binocular indirect
D uke-E lder, S. and A bram s, D. (Eds.), ophthalmoscope, synoptophore, H ess’ screen,
С. V. Mosby, St. Louis, 1970. Maddox wing, transilluminator and keratometer.
7. Fonda, G., Management o f the Patient with The examination of the eyes and their disorders
Subnormal Vision, C.V. Mosby, St. Louis, may be considered under the following broad
1970. headings:
8. May, C. and Worth, C., Manual o f the Diseases (1) History of the case
o f the Eye (13th ed.), Keith Lyle, Т., Cross, (2) Ocular examinations
A.G. and Cook, C.A.G. (Eds.), Bailltere, (a) Objective
Tindall and Cashell, London, 1968. (i) External
9. Mittelman, D., Geometric optics. In Principles (ii) Examination in the dark room
and Practice o f Ophthalmology, Peyman, G.A., (iii) Special examinations, if or when
Sanders, D.R. and Goldberg, M.F. (Eds.), W.B. necessary
Saunders, Philadelphia, 1980, p. 174. (b) Subjective (functional) and whenever
needed
10. Ruben, М., Optics. In M ay and W orth’s (3) Systemic examinations
Manual o f the Diseases o f the Eye (13th ed.), (4) Laboratory investigations.
Keith Lyle, Т., Cross, A.G. and Cook, C.A.G. B ut in routine clin ical p ractice, an
(Eds.), Bailliere, Tindall and Cashell, London, ophthalmologist prefers to follow his or her own
1968. personal order to avoid omissions.
11. Ruben, М., Comeal chenges in contact lens
wear. Tr. Ophthalmol. Soc., UK, 87: 27, 1967. History of the Case6 10
12. W hittington, Т .Н ., The A rt o f C linical (1) The age o f the patient is given due
Refraction, Oxford University Press, London, consideration chiefly because of some of these
1958. factors: (a) certain disorders relate to certain age-
groups; (b) progress of refractive error, e.g. myopia;
(c) treatm ent o f am blyopia in children; and
33. THE EXAMINATION OF (d) onset o f presbyopia.
(2) Correction of refractive error in relation to
THE EYES occupational hazards are important.
(3) Onset, duration and course,
Basic Equipments
(4) Hereditary factors,
The basic equipm ents needed for ocular (5) Presenting symptoms such as
examinations include a good source of illumination, (a) Asthenopia
a monocular loupe or binocular loupe, adequately (b) Headache. If present, enquiry comprises:
illuminated distant vision Snellen’s charts, standard (i) characteristics of onset; (ii) duration; (iii)
set of near vision charts, a trial set of lenses of severity; (iv) location; (v) quality; and (vi) relief
good qualities with accessories such as pinhole, with drugs or not.
(c) Pain. E nquiries are m ade regarding:
(i) location; (ii) type—dull, throbbing, paroxysmal;
(iii) duration; (iv) periodicity; and (v) aggravating
and relieving factors.
(d) Visual deterioration/or loss: (i) onset;
(ii) duration; (iii) progress
(e) Redness
(0 Conjunctival discharge
(g) Photophobia
(h) Haloes
(i) Spots before the eyes
(j) Diplopia Fig. 33.1 Aids to produce magnification. 1, the 10
xloupe used to examine the anterior segment of the
(k) Night blindness eye; 2, inexpensive operating glasses (2x); 3, a simple
(1) Physical signs described by the patient as: magnifier with a head band; 4, the more sophisticated
(i) red eye; (ii) new growth; (iii) abnormal position (and expensive) Keeler operating glasses 2x)
of the eyes or eyelids; (iv) protrusion of the globe; (Galbraith).
(v) widening or narrowing of the palpebral fissure; The orbit. See p. 149.
and (vi) pupillary abnormalities.
The eyeball The normal position of the eyeball
External Examinations11 can be assessed as follows. A vertical line passing
through the midpoints of the upper and the lower
Careful and methodical examination o f the eyes is
orbital margin is tangential to the comea. There is
o f great significance.
neither protrusion nor retraction. The ocular
Inspection in good diffuse light and oblique
movements are tested uniocularly and binocularly.
illumination—focal or lateral—by a condensing
Cover test is important to diagnose a case of squint.
lens or a corneal loupe are simple but valuable
Any involuntary oscillatory movement is noted.
clinical methods o f examination.
The eyelids and palpebral fissures. In primary
Focal illumination. A comeal loupe and sometimes
position of the eyes the upper lid margin covers
a +13 D condensing lens for further magnification
about 2 mm of the comea. On voluntary closure,
of the illurtiinated area are used about two feet
there is no exposure o f the sclera. Note whether
away from the patient’s eye laterally and slightly
there is any elevation or depression of each lid.
in front. The light is held on a level with the eye.
The lid skin may show ecchymosis, pigmentation,
The comeal loupe is held in one hand and the
oedema, emption, scar, cyst and tumour. Observe
light in the other hand. If both comeal loupe and
whether there is any drooping, lagging, spasm,
condensing lens are used one hand holds the lOx
twitching and infrequent blinking. Both lids should
loupe and the other the condensing lens, while the
elevate and drop nicely with upward and downward
source of illumination is a lit electric bulb.
gaze respectively. Note the position of the lid
The various aids to produce magnification are
margins and they remain in contact with the globe
shown in Fig. 33.1.
normally. The lid margin is also examined for any
O cular exam inations may be done in the
hyperaemia, scale, ulcer, crust, localized abscess
following order:
around an eyelash, misdirected or missed cilia and
The face. The face is inspected for abnormalities abnormal Meibomian secretion.
like: (a) any bony abnormality; (b) asymmetry of The palpebral fissure in an adult is 28 to 30
the face such as in facial palsy; (c) head-tilt; mm in length, and 14 to 15 mm in height. These
(d) naevus, vesicles and scars; and (e) missing of measurements are slightly lesser in children and
the eyelashes and lashes of the eyebrows. old people.
The lacrimal gland. Look at the superotemporal needs to be differentiated from ciliary congestion
part o f the orbit for any evidence o f swelling. The (Table 37.1).
palpebral part is not visible on eversion of the
The sclera. Examination may reveal congestion,
upper lid under normal condition. It becomes
nodule, pigmentation, bulging and thinning.
visible only when swollen. Schiimer’s test, a useful
clinical examination, is described under ‘Diseases T he cornea. T his is exam ined by diffuse
o f the Lacrimal Gland’. illumination, focal illum ination and slit-lamp
biomicroscopy. Simple instrument like comeal
The lacrim al passages. Normally both puncta
loupe may be used to get a magnified view.
remain in close contact with the eyeball. Note any
Staining is at times essential.
swelling, redness, occlusion or its absence. The
Note whether the com ea is round or oval.
sac region is examined for presence o f swelling,
Curvature may be abnormal. Look for disturbance
tenderness or any fistula. Note whether digital
o f tran sp aren cy , u lcer, v a sc u la riz a tio n ,
pressure over this region causes regurgitation of
pigmentation and deposit. For testing its sensation
mucopus or pus through the puncta into the
the lids are held apart and lightly touch various
conjunctival sac. Syringing has been described
parts o f the comea with a wisp o f cotton drawn
in detail on p. 452. The other m ethods o f
out into fine threads. Normally blinking is present
investigations are described under ‘Epiphora’
for details seep.
(p. 186).
The anterior chamber. Depth and content are the
The conjunctiva. All parts of the conjunctiva are
important factors. Normal depth in the axial region
inspected. Place the base o f the thumb near the
is 3 mm. Normal content is colourless aqueous
lower lid margin, evert the lower lid to inspect the
humour. A light is focused from the temporal side
lower palpebral conjunctiva and fornix. Ask the
perpendicular to the limbus. Note the distance
patient to look upward, downward, outwards and
between the back surface of the comea and the
inwards to exam ine the whole o f the bulbar
front surface of the iris. The AC may be shallow
conjunctiva. Eversion o f the upper lid is done in
or deep. If the depth is sufficient there will be
the following manner. Request the patient to look
uniform illumination, and if shallow the half of
downward, gently grasp the. lashes o f the upper lid
the AC near the light will be illuminated and thus
between the index finger and thumb o f the left
the remaining half is in shadow. This is called the
hand and pull the lid slightly downward and
eclipse test. Abnormal contents include pus, blood,
forward away from the globe. Then place the edge
precipitates, lens matter, foreign bodies and
o f the nail o f the little finger o f the right hand on
parasites. The examination is facilitated by the use
the skin surface above the superior border o f the
o f a slit-lamp biomicroscope.
upper tarsus and exert pressure backward and
downward. Eversion is achieved if these two The iris. Observe its colour, texture and pattern.
manoeuvres are carried out simultaneously. There may be evidence o f synechia, nodule,
Examination o f the upper fomix is rather a coloboma, tear, atrophy and neovascularization.
difficult procedure. There are two methods. The
The p u p il The pupil is single and is slightly
first and better method is turning up o f the everted
inferonasal to the centre of the iris, measuring 2
upper lid by means of a lid retractor. The other
to 4 mm. They are equal in both eyes. Three
method is the eversion o f the upper lid with the
reactions are tested—direct, indirect and near.
left hand and exerting gentle pressure downward
Abnormalities may involve number, position,
and backward on the skin surface above the tarsus
shape, size, equality and reaction.
with an applicator.
L ook for any evidence o f co n ju n ctiv al The swinging flash light test is performed with
congestion and discharge. Conjunctival congestion a bright flash light in a dim room. The pupils are
about 8 mm in diameter in darkness. The patient Patient Observer
is asked to fi* a d istan t targ et to avoid
accommodation and convergence. Now the light is
shown from below the eyes and is alternated from
one eye to another every 2 to 4 seconds. Normally,
the responses consist of constriction followed by
redilatation till the pupils become 5 mm after a
few oscillations. Patient s far-
Myopic patient point plane Observer
In the presence of afferent pupillary defect both
pupils become larger with stimulation o f the
defective side, but they become smaller with the
stimulation o f the sound eye.
The lens. Mydriasis is desirable in examination Fig. 33.3 Principle of retinoscopy: A, With motion
o f the lens in detail. It is subjected to focal if the far point is behind the observed eye or the
observer; B, against motion is seen when the far point
illumination with or without a magnifier, slit-lamp
is situated between the observed eye and the observer.
b io m icro sco p e, retin o sc o p e and an (Peyman, Sanders and Goldberg).
ophthalm oscope. Note w hether there is any
opacity, dislocation, absence and deposit over its D ilatation o f the pupils is essential for
anterior surface. satisfactory examination of the interior of the eyes.
When a beam of light is reflected on to the
The ocular tension. A rough method to assess
pupil by a plane mirror (Fig. 33.4) held at a
tension is digitally. For precision, a tonometer is
distance o f 1 metre from the eye, lateral and
used. The two index fingers of the examiner are
placed on the upper lid close to one another while
the patient looks downwards (Fig 33.2). A slight
pressure is applied downwards by one index fmger
while the other index fmger feels ocular tension.
Tonometry is described in detail on p. 282.

Fig. 33.2 Digital tonometry

Examination in Dark Room


Retinoscopy (Syn.: Skiascopy or shadow
test) (Fig. 33.3)
Principle. An objective method is to find out
the point of reversal or the myopic far point. Fig. 33.4 Plane retinoscopy mirror
v e rtic a l m ovem ent o f the m irro r elicits Date: 03 OCT 1998
corresponding movement of the shadow. If it is in Name: M. Khatun
the opposite direction, the refractive error is a SPH CYL AXIS
myopia o f more than -1.00D ; if in the same -0.75 -2.75 1 11
-0.75 -2.75 1 11
direction— it may be hypermetropia, emmetropia
-0.75 -2.75 1 11
or myopia o f less than -1.00D. If there is no -0.75 -2.75 1 11
movement the subject has myopia of -1.00D . -0.75 -2.75 117
Neutralization of the movement of shadow is done -0.75 -2.75 1 11
by putting trial lenses in a trial fram e. A +0.25 -1.00 73
postmydriatic test (PMT) is advised after the drug +0.50 -1.25 75
action com pletely disappears. Since there is +0.50 -1.25 75
residual impairment o f accommodation for two or +0.50 -1.25 75
+0.50 -1.25 75
three days a period of four days is allowed in case
+0.50 -1.25 75 PD 60
o f homatropine. Following retinoscopy under
atropine ointment a three-week gap is allowed. Fig. 33.6

Dynamic retinoscopy. The method just described D irect ophthalm oscopy


applies to measurement of static refraction for Though the first ophthalmoscope was described
distance. For measurement of refraction o f the eye by Charles Babbage in 1847, the science o f
focused for close work, retinoscopy is done with ophthalmology owes its inception in 1851 to von
a self-luminous retinoscope on which a target is Helmholtz.
set. The patient looks and accommodates for the Examination with ophthalmoscope (Fig. 33.7)
target. This method of retinoscopy for near vision at a little distance reveals anv haziness in the media.
is called dynamic retinoscopy.
A utom ated refraction. In recent years an
autorefractometer has been introduced. This is a
com bination o f electronic m icrocircuitry and
computer technology. Certain preconditions for
accuracy are good relaxation o f accommodation
and clear ocular media. However, accuracy is
guarded (Fig. 33.5). Figure 33.6 shows a print out
from a case.

Fig. 33.7 Direct ophthalmoscope (Courtesy: C,


Fig. 33.5 Autorefractomcter. Davis Keeler Ltd).

Вah an
The ophthalmoscope is held as close as possible
in front of the eye. If the observer is ametropic,
he or she must either wear correcting glasses or
rotate a correcting lens into the aperture of the
ophthalmoscope. W hen the patient is grossly
ametropic, a suitable lens must similarly be rotated
to place in the apperture. Magnification is about
15 times.
O ptical p rin cip le o f direct ophthalm oscopy
(Fig. 33.8).9 The convergent light beam is reflected
from the ophthalmoscopic mirror and the incident
ray reaches the retina causing it to be illuminated.
The emergent rays from the fundus then reach the
retina of the observer through the hole in the mirror.
Fig. 33.9 Emergent rays from the observed eye,
0 | in emmetropia (E), hypermetropia (H) and myopia
(M) forming the retinal image on the observer’s retina,
0 2 in direct ophthalmoscopy. In-E, the emergent rays
are parallel and are brought to a focus on the retina of
0 2 under physiologic condition of rest. In H, the
emergent divergent rays reach the observer’s retina with
the help of accommodation or biconvex lens placed
Fig. 33.8 Illumination of the ocular fundus and before the patient’s eye. In M, the emergent rays which
the area of the field of illumination in direct are convegent reach 0 3 by means of biconcave lens
ophthalmoscopy. O, the observed eye; 0 2. the placed before his or her eye.
observer’s eye; M, mirror and L. light source.

If both observer and patient are emmetropic,


the emergent rays become parallel and reach a focus
on the retina of the observer.
If the patient is either hypermetropic or myopic,
the em ergent ray s, d iv erg en t in case of
hypermetropia, are made parallel by appropriate
lenses so that they reach a focus on the retina of
the observer (Fig. 33.9). The distinguishing
features of direct and indirect ophthalmoscopy
have been listed in Table 45.2.
Indirect ophthalm oscopy9
In the indirect method of examination by the
ophthalmoscope a strong convex lens of +13 D is Fig. 33.10 Binocular indirect ophthalmoscope
placed betweeen the patient and the observer. The
observer uses a concave mirror. In the binocular binocularity and stereopsis; (c) both hands are free
method (Fig. 33.10) the convex lens used are of so that a scleral depressor may be used to observe
+30 D. +20 D or +14 D. The advantages of the the extreme retinal periphery; and (d) total retinal
binocular method over the ordinary indirect method area and pars plana can be examined with scleral
are: (a) stronger illu m in atio n ; (b) superb depression.
The indirect ophthalmoscope, either hand-held In emmetropia, parallel emergent rays reach a
or spectacle-m ounted type, has two systems focus by the strong lens at its principal focus.
illumination and viewing. In hypermetropia, the divergent rays reach a
focus beyond the principal focus of the lens.
Schepens indirect ophthalmoscope8 consists of:
In myopia, the convergent rays reach a focus
1. Indirect ophthalmoscope nearer to the lens and eye (Fig. 33.12).
2. Scleral depressor
3. Filters
4. Teaching mirror
5. Drawing board
6 . Drawing chart
7. Colour pencils.
The usual condensing lens is +20 D lens with Fig. 33.12 Position of the image depending on
50 mm diameter (Volk or Nikon). Other lenses are whether it is emmetropic (E), myopic (M) or
+ 14 D, +33 D or panfundus lens, all being aspheric hypermetropic (H) in indirect ophthalmoscopy. The lens
lenses. is placed at its focal distance. In E, the emergent parallel
rays cross at the principal focus by the lens. In M, the
The examiner stands on the right side of the
emergent convergent rays and in H, the emergent
patient for observing the right fundus, the patient divergent rays cross nearer to and cross further away
lying supine. The drawing chart is placed inverted from the principal focus respectively.
over the patient’s chest. The examiner now looks
through the widely dilated pupil and the condensing T ransillum ina tion11
lens having the surface with higher curvature facing Transillumination is classified under these types:
the examiner gradually shifted away from the (a) Of the anterior ocular segment:
patient's eye till the clear fundus details are seen. (i) Transpalpebroscleral
The indirect ophthalm oscope provides an (ii) Transscleal
inverted image which is magnified about 5 times. (iii) Transpupillary
Optical principle o f indirect ophthalmoscopy.9 (b) Of the posterior ocular segment:
The convergent light beam is cast, say by a (i) Transpalpebroscleral
perforated concave mirror, and the patient’s eye is (ii) Transscleral
made myopic by placing a +13 D convex lens (iii) Oral
between the observer and the patient. A real, (iv) T ran sclero ophthalm oscopic
inverted image of the fundus is formed between exam ination (tran sillu m in atio n +
the lens and the observer (Fig. 33.11). ophthalmoscopy)
(v) Retrobuloar.
MEH The two methods of transillumination are:
(a) Direct. An intense beam of light is thrown
through the conjunctiva and sclera. Normally the
pupil appears red. If it appears black it suggests
the presence of an obstruction in the path of light.
(b) Indirect. An intense beam of light is placed
in the mouth and the eyes are illuminated from
behind. This method is less reliable.
F ig. 33.11 Illum ination o f the fundus and the area Indications. The following are the indications:
o f the field o f illum ination in indirect ophthalm oscopy. (a) detection of a solid mass; (b) differentiation
between a cyst and tumour; and (c) presence of patient to read the chart from a distance of 6 metres,
opaque foreign body in a cataractous lens. each eye being tested separately.
If the patient cannot read the topmost line of
Visual Acuity the chart, his or her distant vision is less than
6/60; and accordingly his or her vision may be
The plan of assessment is as follows: 11
3/60, 2/60, etc. The visual acuity may be still less,
1. Vision for distance: e.g. hand movements (HM) or perception of light
(a) Vision without correction (PL) and projection o f rays (PR).
(b) Pinhole vision without correction
(c) Vision with correction Principle. The whole letter subtends an angle
(d) Pinhole vision with correction o f 5 minutes while the breadth o f the letter
2. N ear vision and near point o f subtends an angle o f 1 minute at the nodal point
accommodation. The following four should of the eye.
be checked: (b) Near vision is tested by a near vision chart,
e.g. Jaeger’s chart. Near vision charts standardized
(a) Near vision test with a near vision chart
by the Faculty of Ophthalmologists numbered from
(b) Punctum proximum
N 5 to N 48 are commonly used (Fig. 33.14). N 5
(c) Punctum optimum
means numbers corresponding to the finest print
(d) Punctum remotum.
which can be read. Each eye is to be tested
separately.
Functional Examinations (c) Field of vision. See pp. 139-40.
(a) Distant central vision is tested by distant test (d) Colour vision testing. See pp. 71-72.
charts. In Snellen ’s test types (Fig.33.13) the letter (e) Light sense is the faculty to perceive light in
at the top of the chart is of a magnification visible all its gradations o f intensity. It is tested by
at 60 metres, the letters of the second row at determining the light minimum by means of an
36 metres, and so on down the chart at 24, 18, 12, adaptometer or photometer. Light minimum is the
9 and 6 metres respectively. The illumination lowest limit of illumination with which an object
should be adequate. The test is done by asking the can still be seen.
A daptom eter. The prerequisite is full dark
• г • «щ adaptation by keeping in a dark room minimum
for 20 minutes. Dark adaptation is tested with a
м Ш
a1

Goldmann-Weeker adaptometer. The patient looks


at the test light within the dome of the adaptometer.
D L - Т Е A series o f light flashes are presented. The
3 Ш j recording drum continuously keeps record of the
T С E - ■L Е Н • patient’s responses. The chief indication is its use
X с V г - D О С V
Е III Э 1 in retinitis pigmentosa.
t
Z А ОT H • 2 Г АТ Р е з ш m
г TСVLС - • г И1 * г о Special Examinations
1ИЭЕПП
Ск*9 *?1с • г 1 • ?• 4. в
• аа ц Slit-lam p biom icroscope (Fig. 33.15)
• • * In tro d u ced by G ullstrand, a slit-lam p
biomicroscopy is especially called for when minute
Fig. 33.13 Snellen’s distant test types (reduced). examination is needed.
The letters subtend a visual angle of 5 minutes at above It provides a strong beam o f light which,
distances. traversing the parts to be examined, shows them in
N6
W h m I w v tco y e n o U . my father had • tcnaJI esuae near Ram u used to drive his cattle to graze aod bring them
S a u ra « h o c b e uaed to lafce u s d w n f th e holidays It w m back to shelter at the end o f day. He was lean aod o f
o tu a u d Ю fo u fb end uDOjtarMed o o u * y o d e w « w ild m tm ais a short build aad w as ta rtly fifteen H e used to be my
w t crfler i t e c Once w e heard feat there » * a petfh er n the oompenjcQ whenever I m et him winding his way home.
к г т о д й а р w h o w a a to lh a j t o c a rte and tf ia d u Q f t ie v ii U f in
One afternoon, ju st about five’o clock early in the
Pather hed »jn v ed m e noc to * a n d e r far from hom e in (he
e v m m f. I had mode fnend* w ith a young villager c a lk d R a irn m o n th o f M a rc h c h a n c e b ro u g h t u s to g e th e r

th ro w i s u p re m e ta b le p o r te r w o rth y sy m b o l
fra il c id e r p re a c h fo rw a rd ta b le t sy stem

N8 N 10
The cattle were slowly making their way home There was a msh of a wild animal from the
in front of us. The dog which helped Ramu ran
bushes. It was a tiger, and I saw with terror
barking at the hooves of the cows, who
sometimes made a playful rush at the dog. that it sprang on the back of a white cow
Crows and mynas in flocks were passing home that had strayed behind the rest of the heard.
over our heads. We wer passing a thick patch
swich heaven party mirror carrier prank
vision receive noble elusive chief hinder preface

N 14
N12
The cow was knocked over and I saw I felt cold with fear but Ramu
the tiger sitting over its white body. did not hesitate. Naked and with
The cow kicked and struggled and the nothing but a lathi in his hand he
tiger found it difficult to get a grip. rushed up to the struggling animals
th e ft h e a te r ab id e d efe c t e n d ear Bottle measure assist clumsy

N 18 N 24

Ramu struck the tiger on My eyes closed for


the head with his stick.
a moment with fear
decade employ flare
cart poet noble
N36

I expected him to be tom apart


N 48

but it was the tiger that fled


Fig. 33.14 N ear vision chart. N um bers N5 to N 48 correspond to the m odern tim e Rom an types in various sizes
from 5 pt. to 48 pt. (Courtesy: N icholas, Indian Schering; reproduced w ith perm ission)
Technique o f examination. (1) The setting of a
biomicroscope includes the following:

9 (a) The illumination device must be checked


10 and properly centred.
11
(b) A djustm ent o f the slit image and the
13 binocular microscope is done so that there is a
12
common axis o f the illumination arm and the
microscope arm.
14
(c) Checking o f the dioptric adjustment of the
eyepieces especially in relation to an ametropic
observer.
2 (d) Height adjustment o f the chin rest and head
rest is checked.
(2) Examination o f the anterior ocular segment:
(a) Examination with a clear optical section.
The brilliant slit-beam is utilized for focusing
directly upon an object such as a foreign body.
For direct illumination, the optimal magnification
is perhaps 10 times and 16 times. The short
Fig. 33.15 T h e H a a g -S trc it s lit-la m p 9 0 0 :1 ,
sections o f the media are examined systematically.
accessory box; 2, joy-stick lever for horizontal coarse
and fine adjustm ents; 3, roll for setting the angle Large slits provide information about the size and
between m icroscope and illumination unit; 4, guide plate shape of abnormalities o f the comea and lens,
for preset lenses and applanation tonom eter; 5, chin cloudiness o f the aqueous, while narrow slits
support; 6, lever for changing objectives; 7, inter­ display abnormality in the layers, e.g. a corneal
changeable cyc-pieces; 8, lamp casing; 9, lever for four opacity.
d iffe re n t lig h t filte rs; 10, le v e r fo r six d iffe re n t
diaphragm s; 11, ball-handle for tu rn in g slit-im age; (b) Retroillumination. The slit-beam is focused
12, interchangeable illum ination m irror; 13, fixation on reflecting surface behind the part under
lam p w ith annular fixation m arker; 14, centring screw; ex am in atio n , the p art being exam ined by
15, level adjustm ent control for chin support; 16, height transmitted light, e.g. for detection of KP.
adjustm ent control o f slit-lam p; 17, transform er with
sw itch (Parsons). (c) Indirect illumination. It is the examination
of an area next to a focally illuminated area in its
optical section, the area is then examined with a stray light, and is called for examination of an
binocular microscope. opaque structure, e.g. a blood vessel.
Principal methods o f illumination employed in (d) Zone o f specular reflection. Here the angle
biomicroscopy are as follows1: of the slit-beam and the line of the gaze of the
(a) Direct illumination patient are angled to the microscope axis. This
(i) with the broad beam method is employed to observe oedema of the
(ii) with the narrow beam epithelium and endothelium of the comea, anterior
(iii) with the conical beam and posterior surfaces o f the lens.
(b) Indirect illumination (e) Sclerotic scatter. This is particularly indicated
(c) Retroillumination to detect epithelial oedema due to contact lens wear.
(d) Oscillation The narrow beam is directed at the outer part of
(e) Examination in the zone of specular reflection the limbus and the observer sets the microscope
(f) Sclerotic scatter on the centre of the comea.
Cornea. C ornea ap p ears p arallelep ip ed .
P relim inary survey is best done by direct
illumination with the broad beam. By narrowing
the beam, an optical section providing a third
dimension, which displays the depth, is obtained
which shows: (i) a reduplicated anterior line which
represents the comeal epithelium and Bowman’s
m em brane; (ii) hom ogeneous interval, i.e.,
substantia propria; and (iii) a posterior line
indicates Descemet’s membrane.
Aqueous humour. Normally it appears clear.
When floaters are present as in iridocyclitis, the
aqueous becomes cloudy with the particles settling
and the slit-beam reveals the so-called aqueous
flare (Tyndall phenomenon).
Iris. Direct illumination displays the pupillary Fig. 33.16 S c h e m a tic r e p r e s e n ta tio n o f th e
reflex, pupillary margin, crypts and collarettes, and biom icroscopic picture o f the hum an lens: A, em bryonic
hosts of pathological changes and developmental nucleus; B, anterior Y o f the foetal nucleus; C, posterior
Y o f the foetal nucleus; D, foetal nucleus; E, infanitle
defects.
nucleus; F, adult nucleus; G. cortex and H , anterior
C rystalline lens. For exam ination o f the capsule.
anteroposterior plane, the narrow beam is used,
periphery. Its chief drawback lies in its inability
and for that o f coronal plane the broad beam is
to be used in a recently operated patient. Cloquet’s
used; both beams provide a two-dimensional
canal is seen as an empty space situated posterior
picture. The examination reveals: (a) anterior and
to the crystalline lens. At birth its course is straight
posterior lens capsule; (b) beneath the capsule lies
and with age it becomes sinusoidal. In the eyes o f
the cortex; clefts and globules may indicate early
young people, the vitreous sheets inserting into
lental opacity; and (c) the innermost part is the
Cloquet’s canal apear as ‘bands’. The process of
nucleus comprising three outer layers indicating
fibrous destruction progresses into cavity formation
the adult, infantile and foetal nuclei within which
and is a normal ageing process. It also occurs
there is a central dark interval, i.e. the embryonic
p rem atu rely in high m yopia. O ccasio n ally
nucleus (Fig. 33.16).
vitreoretinal adhesions are found especially at old
Vitreous humour. The anterior part o f the choroiditic foci and in areas of cystic degeneration.
vitreous can be examined without any accessories.
For achieving this use the brightest beam and the Angle o f the AC. This is visualized by a slit-
narrow slit. The illumination is directed from the lamp with the aid o f a gonioscopic lens. Refer to
greatest angle possible. gonioscopy for detail (see pp. 285-86).
It is difficult to examine the vitreous because Biomicroscopy o f the fundus oculi. This can be
o f its low refractive index. Examination of the done by using
posterior segment requires the help of pre-set or (a) Hruby lens. It is a planoconcave lens having
contact lens, while that o f the anterior does not. a refractive power o f -58.6 D attached with a
The use of contact lens has certain advantages: special device to the slit-lamp. This neutralizes the
(a) good magnification; (b) appreciation of depth; total refractive power of the eye, + 60 D. The
and (c) ease o f exam ination o f the retinal comeal microscope is converted into a telescope.
(b) Goldmann s three-mirror contact lens. The Methods fo r charting visual field. The central
three-mirror leas is made of organic glass. Through visual field has a radius of 30°• around the fixation
the centre of the contact lens the axial portion of point, while the peripheral field is beyond 30°.
the vitreous and the posterior pole of the fundus The central field can be examined by confrontation
is seen. Inside the contact lens three mirror surfaces tests, Amsler’s grid. Bjemim’s screen, Goldmann’s
of different inclinations 59°, 67° and 73° are perimeter and automated perrimeter. The peripheral
provided; these m irrors help in the detailed field can be exam ined by either manual or
examinations of the entire retina. This lens replaces automated perimetry.
the refractive surface of the comea with an afocal Confrontation tests. A confrontation test is a
flat surface. simple, quick, rough, but useful qualitative test for
(c) El Bayadi lens. This is a +60 D lens used detecting gross peripheral field defect. It is
for indirect ophthalmoscopy with a slit-lamp. The invaluable in bed-ridden patients. It is beyond 30°
real, inverted image of the retina is about 17 mm isoptre around the fixation point. After explaining
in front of this lens. the nature of the test to the patient, the examiner
(d) Volk lens (see p. 311). and the patient face one another about 2 feet apart.
The patient has his or her back to the light source.
G o n io sco p y (see pp. 285-86) The patient is asked to look straight into the
F undus photography. Fundus photography is examiner’s uncovered eye which serves as the
essential for: (a) permanent record; (b) minute fixation point for the patient’s eye. For examination
lesions not seen by ophthalmoscopy; (c) assessment of the patient's right visual field, the examiner
of treatment; (d) course of the disease; (e) review covers his or her right eye with the right palm,
of the condition at intervals; and (0 fluorescein while the patient covers his or her left eye with the
angiography. left palm. Now the examiner moves his or her
A fundus photography can be taken commonly index finger in a plane halfway between themselves,
by: (a) fundus camera; (b) hand-held camera; and the movements being from the periphery towards
(c) slit-lamp camera. the centre.
Other special examinations indicated by history The movements are repeated in at least four
and c lin ic a l ex am in atio n include: (a) quadrants of the visual field.
ex o p h th alm o m etry ; (b) keratoscopy and Both eyes may be tested together in which the
keratometry; (c) tonography; (d) tear quantity and index finger of each hand is moved at the same
quality tests; (e) ultrasonography; (f) fluorescein time, and the patient consistently fixes on only
angiography; and (g) radiologic studies. one point. A homonymous hemianopia may be
detected in this manner.
Abnormalities of the visual field are chiefly:
Visual Field2 4
(a) contraction; (b) depression; and (c) scotoma.
According to Traquair, the visual field is considered Perimetry may be static or kinetic, qualitative
to be an island of vision in a sea of blindness. or quantitative, threshold or suprathreshold.
Fovea centralis is imagined to be the mountain The static perimetry uses stimuli of varying
peak near the centre of the island, where the visual luminance in the same position to produce vertical
acuity is the highest, and the coastline is determined boundary of the visual field. This method is
by perimetry. preferred in quantitative perimetry. The kinetic
Isoptres. They represent the limits of the field of perim etry uses m oving stim ulus o f know n
vision with each target. If a 3 mm white test object luminance or intensity from a non-seeing area to a
is selected with a perimeter having a radius of 330 mm, seeing area until the patient is able to perceive the
the isoptre is recorded as the field for 3/330 white. stimulus.
The qualitative perimetry detects a visual field or her attention to the central white dot of the arc
defect and is utilized in the screening phase of having' a radius of 330 mm from the eye. The arc,
glaucoma suspects. calibrated in degrees, can be rotated in a plane
The quantitative perimetry detects the severity through its mid point. The test object is a disc
of the visual field loss. usually 3 mm, which is movable along the arc and
The threshold perimetry offers a quantitative it is moved in from the periphery. The patient is
information and is the most accurate method of asked to say when the test object is first seen by
follow-up o f glaucomatous field defects. It involves him or her while fixing his or her gaze towards the
the presentation o f threshold luminance value of central dot. This is repeated using 16 positions of
the patient in different areas of the visual field and the arc. The least is eight positions. The test is
compares the results with age-matched normal then repeated with colour discs of the same size.
values. Readings are recorded on a perimeter chart by
The suprathreshold perimetry is a qualitative perforations with a sharp point (Fig. 33.18).
test and is used in screening glaucoma suspects.
The stimuli at luminance levels above normal Right eye
threshold values are presented in the different areas ^ White
of the visual field. Then the patient sees the targets. 330
The detection indicates normal visual function, but
missing o f targets indicates areas o f decreased
visual sensitivity.
M anual perimetry. The patient sits with the chin
resting on the chin-rest o f the perimeter (Fig. 33.17)
and one eye occluded. He or she is asked to fix his

Fig. 33.18 A norm al peripheral visual field. R ight eye.

The main causes of peripheral field contraction


are: (a) glaucoma; (b) optic atrophy; (c) papillitis;
(d) peripheral retinochoroiditis; (e) retinitis
pigmentosa; and (f) quinine or salicylate poisoning.
Scotom etry by Bjerrum screen (Fig. 33.19).
Bjerrum screen is a black square screen— 2 x 2
metres marked with a central white spot and circles
at 5°, 10°, 20° and 30° around the central point.
The patient sits at 2 metres from the screen, with
one eye occluded and fixing his or her gaze towards
Fig. 33.17 Sim plified perimeter. the central spot. At first the blind spot is charted
fixation point. It is elliptical in shape simulating
tem poral nerve fibre bundles and usually
crosses the vertical midline and producing a 'nasal
step’.
Causes can be subdivided into three groups:
(a) lesions at the optic disc are those of enlargement
of the blind spot; (b) lesions in the anterior optic
nerve, e.g. ischaemia and atrophy; and (c) lesions
in the posterior optic nerve and optic chiasma, e.g.
meningioma at the optic foramen or dorsum sella
and pituitary adenoma.

Field defects
Reed7 considered field defects under four headings
and their characteristics:
(a) R etinal lesion corresponding to the
course of nerve fibres or blood vessels of the
retina and crossing of the midline through the
fovea.
(b) Retrobulbar lesions giving rise to central
Fig. 33.19 Bjerrum screen
scotoma.
(c) Chiasmal lesions giving rise to bi,temporal
between 14° and 19° out along the horizontal
defects which is seldom symmetrical and is more
equator and extends about 4° above and below it
advanced in one eye than the other.
using a standard test object. Blind spot o f Mariotte
(d) Lesions behind the chiasma producing
in the visual field corresponds with the optic
homonymous hemianopia.
disc.
If the lesion is beyond the lateral geniculate
A 5 mm white test object is used which is moved
body, two features are superadded, congruous
in from the periphery of the screen until seen by
homonymous hemianopia and macular sparing.
the patient. The position is indicated by placing a
When hemianopia is identical in both eyes it is
pin. The test is repeated till the charting is complete
called congruous.
in all aspects.
If 5 mm object is not seen, a larger one is used. Goldmann projection perim eter consists of
In scotometry, several factors are important: a hemispherical bowl with a radius o f 33 cm and
(a) size of the test object; (b) distance from eye to a chin rest. It has a test object (circle o f
screen; (c) illumination; and (d) background. illumination) whose size, luminance and colour
Causes of enlargement of the blind spot include: can be changed. The patient fixates the preset spot
(a) papilloedema; (b) glaucoma; (c) progressive o f light onto the bowl, while the observer monitors
myopia with a temporal crescent; (d) juxtapapillary the patient’s fixation through the central viewing
choroiditis; (e) medullated nerve fibres; and aperture.
( 0 drusen of the optic nerve-head. etc.
Tubinger perimeter. Facilitates the plotting of
visual response along any meridian of the visual
B je rru m scotom a
field. It can plot both central and peripheral fields,
Bjerrum scotoma affects the so-called Bjerrum area and can be used for static and kinetic perimetry,
of the visual field which is 10 ° and 20 ° from the specifically for static.
M ultiple pattern m ethod for visual field Defect

О
examination (Fig. 33.20) Blindness Right optic
right eye nerve
Multiple pattern method is not a substitute for
standard perimetry but a simple screening device
for the majority o f field defects. There are 20 cards,
10 for each eye. Each card contains abstract patterns Bitemporal Optic chiasma
hemianopia
o f dots and crosses on which the eye should
concentrate. The central dot is black and the others
are white fluorescent sulphide painted. The card is
illuminated by ultraviolet radiation of quarter Left Right optic tract
homonymous or optic radiation
second duration when the pattern is distinctly
visible against the white card. If there is any defect
hemianopia C O or visual cortex

in any part o f the visual field the stimulus of the


pattern is not seen and so the patient describes it Left upper J Anterior loop
erroneously.
quadrantanopia J
о right optic
radiation

Left lower Upper part of


quadrantanopia right optic
radiation

Left homonymous f
hemianopic
central scotoma
( %J
J
0 5 Posterior part
right visual
cortex

Fig. 33.21 Schem atic edxam ples o f visual field


defects (Parr).

Table 33.1
C lassification o f Types o f H em ianopia

Unilateral Temporal
Nasal
Superior altitudinal
Inferior altitudinal

Bilateral H om onym ous


H eteronym ous Bitemporal
Binasal

Fig. 33.20 Assessment of visual field by multiple


pattern method. Quadrantanopia
Quadrantanopia is the sector-shaped defect limited
Hemianopia (Fig. 33.21) by vertical and horizontal radii. A crossed
Hemianopia is the blindness of one-half o f the quadrantanopia is one which involves one upper
visual field in one or both eyes. The classification in one side and one lower in the other side. For
has been shown in Table 33.1. clsssification, see Table 33.2.
Table 33.2 Table 33.3
Classification o f Q uadrantanopia T ypes o f Scotom ata

Unilateral Central- at the fixation point


Bilateral Bitemporal Paracentral- adjacent to the fixation point
Homonymous Binasal Pericentral- surrounding the fixation point
Upper Pericaecal- surrounding the blind spot
Lower Paracaecal- in the proximity of the blind spot
Crossed Centrocaecal- between the fixation point and blind
spot
Arcuate
Scotomata (Figs. 33.22-33.24) Annular or ring
Peripheral
Scotoma is an area o f depressed vision within Hemianopic
the visual field. The different types are shown in Quadrantanopic
Table 33.3. Positive
Negative
Relative

Positive scotoma is complained of by the patient.


Negative scotoma is detected by the observer.
Relative scotoma is the defective appreciation of
colour. Altitudinal hemianopia means defect o f the
superior or inferior half-field bounded by the
horizontal m eridians. Junction scotom a is a
temporal hemianopia involving the nasal fibres at
Fig. 33.22 Central scotoma.
the point where the optic nerve joins the optic
chiasma.

Visual Field Changes in Different


Ocular Disorders2'4
The visual field changes in some groups o f ocular
conditions are now described.

Choroidal diseases
Choroiditis. Different morphological types of
choroiditis may cause the following types o f field
changes: (a) scotomas—central, arcuate, sector, or
multiple; (b) enlargement of the blind spot; and
(c) general depression o f all the isoptres of the
field.
Central choroidal atrophy. It is due to myopic
ch o rio retin al d eg en eratio n or o b literativ e
vasosclerosis. It may cause a central scotoma.
Central areolar choroidal dystrophy causes an
absolute central scotoma.
Coloboma o f the choroid and retina. There is Streptomycin. The field changes are secondary to
scotoma which corresponds with the coloboma neuritis and include arcuate scotoma.
more or less.
Iso n ia zid . This may cause bilateral central
scotoma.
Retinal diseases
The field changes are seen in vascular lesions, Optic Nerve Affections
inflam m ations, degenerations o f the retina,
retinopathies, injuries, tumours or detachment of Papilloedema. The early visual field change is a
the retina. gradually developing concentric enlargement of the
Occlusion o f the central retinal artery. If blind spot. A relative central scotoma in which
complete, there is total blindness; with the presence there is blue blindness predominant may occur if
of the cilioretinal artery, there is retention of central the oedema involves the macular area.
island of vision. In occlusion o f the superior branch When atrophy sets in there is also peripheral
o f the central retinal artery, there is loss o f lower field contraction.
field. There may be additional field defects as a result
Occlusion o f the cilioretinal artery shows o f effect o f an intracranial lesion on the visual
centrocaecal scotoma and a normal peripheral field. pathways and centres.
In central retinal vein thrombosis, central Retrobulbar neuritis. The visual field changes are
scotoma o f varying density and size may be substantially the same in both acute and chronic
detected. cases. The changes are: (a) central scotoma is
In central serous retinopathy and commotio typically present; (b) centrocaecal scotoma and
retinae, central scotoma is found. peripheral field contraction are also commonly
Solar retinitis also produces central scotoma. present; and (c) rarely sector-shaped defects are
In toxoplasmic retinochoroiditis bilateral, central seen.
and paracentral scotomas are detected which
correspond to the lesions visualized
Chiasmal Affections
ophthalmoscopically.
In pigmentary dystrophy o f the retina there is The visual field changes are perhaps the result of
ring scotoma occupying the midperiphery of the ischaemia following constriction of the blood
visual field. The outer edge of the scotoma expands vessels supplying the region, evidenced by clear-
towards the periphery and the inner edge contracts cut margins o f the defective field and rapid
towards the fixation point. recovery o f the defect on relief of pressure.
In senile macular degeneration central scotoma The important chiasmal lesions include vascular,
of varying density is detected. i.e. intracranial aneurysm, arteriosclerosis and
Disciform degeneration causes irregular and arterial compression, inflammatory lesions such as
dense central scotoma. basal meningitis and neuritis, and tumours o f the
chiasma.
Toxic Effects on the Retina and Optic While considering chiasmal field defects one
Nerves must consider the relation of optic chiasma with
the neighbouring blood vessels and its varying
Tobacco. Typically centrocaecal scotoma is seen relation with the sella turcica. It is absolutely
in tobacco amblyopia. essential to know the precise pattern o f the
D ig ita lis. S cotom as m ay be seco n d ary to arrangement of the fibres in the optic chiasma.
retrobulbar neuritis or toxic effects on the retinal There are six types o f chiasmal field defects
receptors. (Table 33.4).
(a) The most important tumours attacking the
Types o f Pressure on the Optic Chiasma and Visual Field anterosuperior aspect are meningiomas o f the
Defects2
olfactory groove, tuberculum sellae, or lesser wing
1. Median pressure: Bitemporal hemianopia of the sphenoid bone.
2. Lateral pressure: (a) Ipsilateral nasal Olfactory groove meningioma is a midline
hemianopia + diagonally tumour and spreads into the anterior chiasmal angle
quadrantic temporal defects
(b) Then, ipsilateral and causes symmetric bitemporal hemianopia. It
blindness and can grow in an eccentric manner to involve one
contralateral temporal optic nerve or the other before reaching the
hemianopia
3. Anterolateral pressure: (a) Ipsilateral nasal chiasma.
hemianopia + Meningioma from tuberculum sellae produces
contralateral superotemporal similar change in the visual field as in olfactory
quadrantanopia
(b) Ipsilateral blindness + groove meningioma.
contralateral superior Meningioma o f the lesser wing o f sphenoid bone
temporal quadrantanopia shows irregular and asymmetric field changes
4. Anteromedial pressure: (a) Ipsilateral temporal
hemianopia + caused by chiasmal compression.
contralateral superior (b) C hiasm al com pression from the
temporal quadrantanopia p o stero su p erio r aspect is caused by
(b) Then, ipsilateral
blindness with craniopharyngioma and dilatation o f the third
contralateral superior ventricle. Craniopharyngioma produces bitemporal
quadrantanopia hemianopia, though it can cause variable changes
5. Posterolateral pressure: (a) Ipsilateral nasal
hemianopia like central, irregular and asymmetric bitemporal
(b) Followed by scotomas.
contralateral hemianopia
6. Posteromedial pressure: (a) Contralateral temporal
hemianopia Vascular Lesions
(b) Followed by ipsilateral
hemianopia The relation o f the circle of Willis with the optic
chiasma is an important consideration. The most
common vascular lesion in this area is aneurysm
Infrachiasmatic Lesions
of the internal carotid artery. The important field
A typical example is the pituitary adenoma, which defects following an aneurysm are:
presses the chiasma from below in the midline. (a) Ipsilateral nasal defect with a scotoma
Here it is stressed that the chiasma may be prefixed, (b) Contralateral temporal defect
in the middle position, or postfixed. Hence, the (c) Inferior bitemporal hemianopia
field defects may vary. (d) Unilateral nasal hemianopia
The classical field defect is a symmetric (e) Homonymous hemianopia.
bitemporal hemianopia. As the chiasma is pushed
superiorly, its anterior part along with two optic Retrochiasmal Lesions
nerves may be compressed in between the tumour
and two anterior cerebral arteries, consequently, O ptic tra ct lesio n s produce hom onym ous
the field changes appear in complex forms. hemianopia. The defect is incongruous. Such
lesions may be caused by aneurysm of the internal
Suprachiasmatic Lesions carotid artery or the posterior communicating
artery, craniopharyngioma, pituitary adenoma and
Broadly there are two groups of lesions—those demyelinating disease.
involving the chiasma from the anterosuperior
direction, and those from the posterosuperior. Temporoparietal lesions include vascular.
neoplastic or demyelinating diseases. Temporal Textbook and Atlas o f Clinical Perimetry,
lobe lesion at first affects the superior visual fields, 3rd ed., C.V. Mosby, St. Louis, 1971.
while parietal lesions causes inferior field defects 5. Hruby, K., Slit Lamp Examination o f Vitreous
in the beginning. and Retina (English translation), Posner, A.,
Occipital lesions beyond the lateral geniculate Williams and Wilkins, Baltimore, 1967.
body also produce homonymous hemianopia, but 6 . Newell, F.W., Ophthalmology: Principles and
two features are characteristic— congruity and Concepts, 8th ed., C.V. Mosby, St. Louis,
sparing. The lesions in this region include vascular 1997.
affections, tumours, demyelinating diseases and
7. Reed, H., The Essentials o f Perimetry, Oxford
injury.
University Press, London, 1960.

F u rth er R eadin g 8 . Schepens, C., Retinal Detachment and Allied


Diseases, W.B. Saunders, Philadelphia, 1985.
1. Doggart, J.H., O cular Signs in Slit-lamp
9. Trevor-Roper, P.D. and Curran, P.V., The Eye
Microscopy, Kimpton, London, 1949.
a n d Its D isorders, 2nd ed., B lackw ell
2. Duke-Elder, S., System o f Ophthalmology, Scientific, Oxford, 1984.
Vol VII: The Foundations in Ophthalmology,
10. Vaughan, D., Asbury, T. and Tabbara, K.F.
Kimpton, London, 1962.
(Eds.), General Ophtholmology (12th ed.),
3. G oldm ann, H.; The diagnostic value o f Appleton and Lange, Connecticut, 1989.
biomicroscopy o f the posterior parts o f the
11. Zuckerman, J., Diagnostic Examination o f the
eye, Br. J. Ophthalmol., 45: 449, 1961.
Eye, 2nd ed., J.B. Lippincott, Philadelphia,
4. H arrington, D .O., The Visual Fields: A 1964.
Part Five
Ocular Diseases and Ocular Affections
in Systemic Diseases

here are several diseases that affect the eyes and ocular involvement
T in many systemic disorders is present. These will be discussed
now.
34. DISEASES OF THE ORBIT Proptosis or Exophthalmos1,6,9,20

The relations and contents of the bony orbit are Though these two terms are used synonymously,
extremely important since the affections of the orbit they connote different meanings. Proptosis is the
follow those of the structures around or involve passive or mechanical protrusion of the eyeball,
any o f the contents. The fissures and foramina bear while exophthalmos is the active protrusion of the
important relationship, e.g. there is intracranial eyeball forw ard. A classic exam ple o f
communication through the optic foramen and exophthalmos is a dysthyroid exophthalmos.
sphenoid fissure. The affections may spread from A true p ro p to sis (F ig. 34.1) should be
the paranasal sinuses to involve the orbit or may differentiated from a pseudo- or apparent proptosis.
spread far afield from the orbit through the venous
channels, sometimes rapidly. Tenon’s capsule,
th ro u g h w hich the ex trin sic m uscles are
invaginated, forming a fibrous wall may be
involved. Because of the unyielding bony walls
any swelling causes a protrusion o f the globe, i.e.
proptosis.
Investigations in orbital disorders have been
summarized in Table 34.1.

Table 34.1
Investigations of Orbital Disorders5

History Fig. 34.1 Proptosis.


of proptosis, pain, vision changes
of head injury, injury to the orbit, fever A p seu d o p ro p to sis occurs eith er due to
of associated systcmic affections, thyroid disorder in enlargement of the eyeball or retraction o f the
family
ey elid s; the causes include high m yopia,
Proptosis or exophthalmos
Visual acuity asymmetry of the orbit, lid retraction, buphthalmos,
Visual fields shallow orbit, external ophthalm oplegia and
Pupillary reactions contralateral enophthalmos. It is essential to note
General inspection of the orbits whether in primary position the upper lid margin
Palpation around the eyeball and the orbital rim rests at or above the limbus, i.e. lid retraction, or
Evidence of congestion and inflammation both upper and lower lids are equally withdrawn
Examination of the lids from the cornea as in exophthalm os, or the
Ocular movements
exposure of the sclera is asymmetrical, the distance
Examination of the ocular fundi
of the upper lid margin from the limbus is greater
Imaging studies
X-rays than that of the lower as in simultaneous presence
Ultrasonography of exophthalmos and lid retraction.
Computerized tomography (CT)
Aetiology. A etiology can be enum erated as
Magnetic resonance imaging (MRI)
follows:
Examination of tissue specimens obtained by
Open biopsy Unilateral. Inflammatory, vascular, tumours,
Tumour excision cysts and trauma.
Fine-needle aspiration biopsy
Bilateral. Dysthyroid exophthalmos, cavernous

С
sinus throm bosis, congenital anom alies (e.g. anything which presses upon the optic nerve or
oxycephaly), osteopathies, occasionally some causes defective blood supply to this nerve causes
tumours like multiple myeloma, and systemic loss o f vision.
affections like Wegener’s granulomatosis.
Ophthalmoscopy. This is done for evidence of
Acute. H aem orrhage w ithin the orbit and
venous en g o rg em en t, haem orrhage and
emphysema from the paranasal sinuses.
papilloedema.
P ulsating. (a) T rue: ty p ically in
caroticocavemous fistula and aneurysm o f the Estimation o f the degree o f proptosis, (a) The
internal carotid artery. observer stands behind the patient who is sitting,
(b) Pseudo: e.g. frontal mucocele, angioma and raises both upper lids while asking him or her to
neurofibroma. look downwards. Normally the comea disappears
Intermittent. Typical in orbital varix. from the view.
(b) In exophthalmometry, an exophthalmometer
Investigations takes the measurement of the distance of the comeal
apex which protrudes in front o f the lateral orbital
H istory includes age o f the patient, onset, rim. Normally, this distance does not exceed 16
fluctuation, duration, chronology o f symptoms, mm. A transparent plastic ruler with scale engraved
local symptoms, history related to the thyroid gland, on both sides and with a groove which can fit into
general symptoms, etc. the lateral margin o f the bony orbit is commonly
employed as an exophthalmometer.
Clinical eye examinations O ther exam inations. These include
orbitonometry, visual field charting, tonometry, slit-
Inspection. The following plan o f examinations
lam p biom icroscopy, tran sillu m in atio n and
may be followed:
ausculation.
(a) Unilateral or bilateral—more often proptosis
is unilateral.
G eneral exam ination
(b) True or pseudoproptosis.
(c) Presence of lid lag— if present a tumour can G eneral exam ination includes check-up for
be ruled out. dysthyroid state, otorhinolaryngological conditions,
(d) Direction of proptosis—axial or eccentric. blood picture, stool, urine and search for any
(e) Restriction o f ocular movements. primary neoplasm.
(f) Presence o f any swelling or fulness.
(g) Comparison o f the level of the two eyes, Plane X-ray of the o rb it 12,16
(h) Presence of inflammatory signs in the lid
and conjunctiva. X-ray o f the eye and orbit is indicated in injury,
(i) Presence o f pulsation. foreign body and tumour. X-ray can be taken from
(j) Colour of the lid skin. different angles.
(k) Pupillary reactions. Caldwell view. This is a posteroanterior view,
(1) Inspection o f the neighbouring area, e.g. with the patient lying prone with his or her
shape o f the skull, and fulness o f the maxillary forehead and nose touching the X-ray table. It is
fossa. needed to visualize the orbital rim and roof, the
O rb ita l p a lp a tio n . T his in v o lv es digital greater and lesser wings o f the sphenoid, and the
compression o f the eyeballs backwards, palpation superior orbital fissure.
o f the orbital rim, presence o f any mass, bony Waters view. Here in addition to Caldwell’s the
defect and thrill. head is extended with the chin lying about 4 cm
V isual acuity. It may be em phasised that above the table. The areas seen are the inferior
orbital rim, the lateral orbital wall and the paranasal
sinuses.
Oblique view. This is for better demonstration of
the outer rim of the orbit.
Rhese position. This is needed to visualise the optic
canal. The patient lies prone with the zygoma, nose,
and chin resting on the table.
Lateral view. This is required in localizing foreign
bodies.

Possible changes seen in plane X-rays


These include:
(a) Alteration of general radiographic density
of the orbit
(b) Increased bone density
(c) Symmetrical enlargement with a tumour
within the muscle cone or asymmetrical with a
tumour involving the orbital wall
(d) Change in the shape of the orbit
(e) Dehiscence in the bony wall
(0 Change in the diameter of the sphenoidal
fissure or optic canal. Fig. 34.2 Ophthalmic artery. Diagrams of the three
(g) Presence of calcification. orthogonal views: 1 , ophthalmic artery; 2 , lacrimal artery;
3, supraorbital artery; 5, diary arteries; 6, inferior
Special Radiological Techniques16 maxillary; 8, ethmoidal arteries. [By courtesy of Dr G
Salamon, from Salamon and Associates: Ann Radiol
Carotid angiography (Fig. 34.2). This helps to (Paris) 8 : 557, 1965; Lombardi]
demonstrate an orbital lesion in two ways: (a) the
displacement o f the ophthalmic artery and its are o b literatio n o f the fascial space and
branches; and (b) the demonstration of an abnormal displacement o f normal topography o f structures.
vascular pattern. The common carotid artery is This is also referred to as pneumoorbitography.
injected with an iodine-containing dye. An orbitography may cause discomfort and even
visual impairment.
Orbitography. An orbitography can be done with
either positive contrast or negative contrast, i.e. Orbital venography. Injection o f a contrast
air. With positive contrast, 5 ml o f a 20 per cent medium is given through the frontal or supraorbital
contrast medium is slowly injected retrobulbarly vein. In a frontal venography to prevent reflux of
after a ciliary block and check-up of the needle by the contrast medium over the forehead a rubber
X-ray followed by withdrawing the needle and band is placed around the hair-line and to prevent
application o f a tight pressure bandage. The pictures influx in the facial veins finger pressure is applied.
are then taken. For localization o f an intraorbital lesion the
With negative contrast, the injectcd air is seen following appearances should be noted—the
on X-ray as dark area, while the normal intraorbital displacement of the veins and the demonstration
structures are seen as areas of negative contrast. o f abnormal veins.
Abnormal appearances suggesting an orbital lesion Orbital tomography. This is a method in which
the superimposed structure in the neighbourhood Aetiology. Most commonly there is a spread of
are blurred for clear visibility o f a given spot at a infection from the paranasal sinuses— ethmoid,
given depth. Two types— linear or laminography frontal or maxillary. In children, ethmoiditis is very
and hypocycloidal or polytomography are indicated common. Infection reaches the orbit by two ways—
in detection o f orbital tumours and linear fractures. through thrombophlebitis o f the communicating
veins, and rarely by bony dehiscences.
Ultrasonography4 This noninvasive technique
Infection may spread to the orbit from the teeth,
confirm s the diagnosis thus m aking X -ray
the lacrimal apparatus or the skin.
unnecessary in some cases. А -scan provides
A penetrating injury with retained foreign body
information about the swollen optic nerve and
in the orbit may sometimes provoke inflammation.
extrinsic muscles. В-scan indicates the shape of
the lesion and proximity o f the lesion to the normal P athology. The characteristics are those of
structures. inflammation, absence o f lymphatics, digestive
action o f orbital fat and limitation o f inflammation
C om puterized tom ography.4 The bony and
by fascial membranes.
calcium-containing lesions are preferably evaluated
by computerized tomography (CT). Hence, this is Clinical features. In mild cases, there is slow
a preferred method of investigation in optic nerve development of insignificant constitutional signs,
sheath meningioma, orbital fractures and foreign while in severe cases, the constitutional signs are
bodies in the orbit. marked.
Symptoms and signs in an advanced case are
Magnetic resonance imaging (MRI)4 appears to
severe ocular pain, marked swelling of the lids
be the best mode o f evaluation for various orbital
and conjunctiva, axial and irreducible proptosis,
and ocular diseases because o f its high tissue
restriction of all ocular movements and marked
contrast ability. All parts of the optic nerve can be
constitutional symptoms such as fever, headache,
clearly visualized. Certain lesions around the apex
nausea and prostration. Vision may be reduced due
of the orbit, superior orbital fissure and optic canal
to associated optic neuritis.
can be better evaluated by MRI than by CT.
Therapeutic Trial with Steroids and Antibiotics. Complications. Complications are quite common
Retrogresion indicates that certain inflammatory and include exposure keratitis, papilloedema, optic
lesion is the cause of proptosis. neuritis leading to optic atrophy, septic uveitis,
Surgical Exploration. Surgical exploration may panophthalmitis, cavernous sinus thrombosis,
be called for to determine the nature o f the lesion. rarely septicaemia and pyaemia.
Occasionally biopsy is resorted to and depending Differential diagnosis. The condition should be
on the report such treatment is suggested. differentiated from stye, suppurative chalazion,
tenonitis, panophthalmitis and cavernous sinus
Enophthalmos thrombosis.
Enophthalmos is the retraction o f the globe into Treatm ent. The principles o f treatm ent are
the orbit. It is caused by blow-out fracture o f the adequate systemic antibiotics, local heat and
orbit, postsurgical shortening or postinflammatory treatment of the primary focus, e.g. drainage of
scarring o f the extrinsic m uscles, m axillary pus from an infected paranasal sinus. An incision
hypoplasia, microphthalmos, etc. is sometimes done to drain the peripheral surgical
space.
Acute Orbital Cellulitis (Postseptal
Cellulitis) Preseptal (Periorbital) Cellulitis
Acute orbital cellulitis is a purulent inflammation Preseptal or periorbital cellulitis is an inflammation
o f the cellular tissues of the orbit. of the subcutaneous tissue of the eyelid in front of
the septum orbitale. The distinguishing features are Clinical features. There are eccentric proptosis,
depicted in Table 34.2. focal tenderness plus other localizing signs.
In anterior periostitis, the sequences are oedema
T a b le 34.2 and tenderness—»abscess-»fistula-»cicatrization.
D istinguishing Features o f O rbital and Periorbital Posterior periostitis is characterized by a triad
C ellulitis o f signs: (a) absolute immobility of the globe since
the III, IV and VI cranial nerves are involved;
Features Orbital Periorbital (b) am aurosis w here the II cranial nerve is
cellulitis cellulitis
involved; and (c) anaesthesia where the trigeminal
A ge at presentation Over 5 years Y ounger than 5 nerve is involved.
years
O edem a o f lid Yes Yes ++ Treatment. Most often it resolves with antibiotic
Proptosis Yes A bsent or therapy. But if there is suppuration, it should be
m inim um drained. Occasionally in deep-seated inflammation,
C hem osis Marked A bsent or mild surgical exploration is called for.
O phthalm oplegia Present Absent
V isual acuity May be Normal Cavernous Sinus Thrombosis
reduced

The anatom y o f the venous channels which


Chronic Orbital Cellulitis18 communicate with the cavernous sinuses is of great
importance in this connection. The cavernous
Chronic orbital cellulitis may present clinically as sinuses (Fig. 34.3) lie on either side o f the body of
pseudotumours of the orbit. It may be a sequel of the sphenoid, between the two layers of the dura
tuberculous affection of the malar bone, syphilitic mater, extending from the superior orbital fissure
affection o f the upper orbital m argin or a backward for about 2 cm. They are formed by the
nonspecific granuloma. superior ophthalmic, a tributary from the inferior

Tenonitis

Tenonitis may be serous, chiefly rheumatic and


purulent. It is characterized by a sudden onset, pain,
slight proptosis, lid oedema, chemosis, limitation
o f ocular movements and annular swelling around
the muscle insertions. Treatment consists of local
and systemic antibiotic therapy.

Osteoperiostitis

There are two types: Fig. 34.3 Lateral view o f the tributaries o f the
cavernous sinus. I, cavernous sinus; 2, frontal vein; 3,
(a) Anterior—involving the orbital margin. angular vein; 4, facial vein; 5, supraorbital vein; 6, nasal
(b) Posterior—involving the apex of the orbit. vein; 7, superior ophthalm ic vein; 8, inferior ophthalmic
vein; 9, communicating vein; 10, middle meningeal veins;
Aetiology. Tenonitis is caused by: (a) trauma; 11, pterygoid venous plexus; 12, superior petrosal sinus;
(b) extension from the neighbouring inflammation; 13, inferior petrosal sinus; 14, lab y rin th in e veins;
and (c) specific granuloma, e.g. tuberculosis, 15, ju g u lar vein; 16, lateral sin u s and 17, m astoid
syphilis, etc. em issory vein.
ophthalmic, central retinal veins, sphenopalatine sinuses causing mucocele and pyaemia, or the
sinus along with various emissary veins. Each sinus posteriorly-placed sinuses causing optic neuritis and
drains backwards through the superior and inferior myositis.
petrosal sinuses into the sigmoid sinus and finally
into the internal jugular vein. The cavernous sinuses Pseudotumours of the Orbit2,17
also intercommunicate.
Contents (Fig. 34.4) are the internal carotid
Birch-Hirschfeld (1930) coined the term. An
artery with accompanying sympathetic nerves orbital pseudotum our may be defined as a
within the sinus and in its lateral wall are the III, nonspecific, idiopathic and benign inflammatory
IV, VI and the first and second divisions of V process.
cranial nerves.
Internal carotid A. Pathology. In the acute form there is hypocellular
Infundibulum
polym orphous infiltrate made up o f mature
Hypophysis
O culom otor N.
lymphocytes, plasma cells, polymorphonuclear
T rochlcar N.
neutrophils (PMNs), macrophages and eosinophils.
O phthalm ic N.
In subacute and chronic forms, there are increasing
M axillary N. A bducent N.
amounts o f fibrovascular stroma as well as
Internal carotid A
replacement of normal muscle, fat and glandular
Sphenoidal sinus
elements by fibrous tissue.
M andibular N. Pterygoid lam inae

C hoana nose C linical fe a tu r e s . The affection is usually


Vomer
unilateral. Onset may be acute, subacute or chronic.
Fig. 34.4 Coronal section through the sella turcica There is no sex predilection. The inflammation may
and cavernous sinus (Cunningham ). be localized or diffuse; the localized form may
involve either the anterior orbit or the posterior
Aetiology. Carvemous sinus thrombosis is caused orbit, extraocular muscles or lacrimal gland. In
by septic thrombophlebitis o f the sinus from acute case there are pain, swelling of the eyelid
pyogenic foci in the face, mastoid region and and redness. In chronic type there are progressive
sometimes from pyaemia. visual loss, diplopia and proptosis. Involvement of
the a n terio r o rb it causes the p attern o f
Clinical features. Cavernous sinus thrombosis is
inflam m ation w hich is called p eriscleritis,
characterized by a violent onset, bilaterality, rapid
sclerotenonitis or anterior inflammatory pseudo-
evolution o f proptosis, marked constitutional upset,
tumour (see p. 242).
paralysis of the motor cranial nerves, a swelling
The posterior pattern o f acute pseudotumour
of the skin over the mastoid process due to back
presents primarily with features of orbital apex
pressure of the mastoid emissary vein, plus all the
syndrome (see p. 159).
features of an acute orbital cellulitis. Simultaneous
throm bosis o f both cavernous sinuses with Differential diagnosis (Table 34.3). The condi­
proptosis and papillitis occurs in diseases o f the tion needs differentiation from other orbital
sphenoid sinuses .15 conditions.
Treatment. The principle are: (a) intense systemic Investigations. Investigations include contrast-
an tib io tic therapy; and (b) intravenous enhanced CT (C E C T ) scan o f the orbit,
anticoagulants to control the extension of the clot. ultrasonography (USG), fine-needle aspiration
biopsy (FNAB), magnetic resonance imaging
Nasal Sinusitis
(MRI), occasionally electromyography (EMG) and
Nasal sinusitis may affect the anteriorly-placed forced duction test.
Table 34.3 Exophthalmos-producing substance (EPS). It is
D ifferential D iagnosis o f Pseudotum our o f O rbit possibly a gamma globulin present in the serum
and probably secreted by the anterior pituitary.
D ysthyroid ophthalm opathy
Infections
Long-acting thyroid stimulator (LATS). This is
G ranulom atous disease like sarcoidosis found to be present in about 80 per cent of patients
Vasculitis with Graves’ disease. It is a 7S globulin produced
Foreign body reaction by lymphocytes in such patients. It acts as an
R uptured derm oid cyst antithyroid antibody. Thyroid microsome may act
N eoplasia as an antigen.
V ascular disorders
Systemic manifestations o f hyperthyroid state.
They may be briefly grouped under two headings:
Treatment Treatment is not definite, but various
(a) Epinephrine-like, e.g. tremor, tachycardia and
measures are: (a) systemic antibiotics; (b) steroids;
excessive sweating.
(c) surgery; and (d) radiotherapy.
(b) Hypermetabolic, e.g. increased appetite and
Antibiotics and steroids are used before and after
increased basal metabolic rate (BMR).
an operation. Bilateral, diffuse infiltrative and those
with severe inflammation should be treated with Tests o f thyroid fu n c tio n 16,19. Tests of thyroid
these agents. Surgery is particularly indicated in function are indicated to detect whether the patient
smaller and more circumscribed and accessible is hyperthyroid, euthyroid or hypothyroid.
tumours located in the anterior part of the orbit. (a) Total serum thyroxine or T4 has now become
Radiotherapy including radioactive cobalt shows a routine thyroid function test, replacing protein-
satisfacto ry resolution in benign lym phoid bound iodine (PBI) test. High T 4 values are
hyperplasia. indicative of hyperthyroidism.
(b) Total serum Triiodothyronine or T 3 is
Dysthyroid Exophthalmos affected but in a lesser degree than T4.
(c) T 3 resin uptake.
Thyroid disorders in ophthalm ology may be (d) Radioiodine uptake. The uptake is high in
broadly grouped under two headings :13 hyperthyroidism.
(i) Hyperthyroidism, (a) with exophthalmos and (e) Serum thyroid-stimulating hormone. It is
(b) without exophthalmos. high in hyperthyroidism
(ii) Hypothyroidism, (a) in adults—myxoedema (f) Thyrotropin-releasing hormone test. It is
and (b) in infants—cretinism. particularly useful in cases where T 4 and T 3 levels
Synthesis o f thyroid hormones. Synthesis o f the are equivocal.
thyroid hormones are as follows: (g) Thyroid antibodies. Autoantibodies directed
(a) The trapping of iodide by the thyroid cell against thyroglobulin and complement fixing
and its oxidation into iodine. directed against the microsomal fraction o f the
(b) Iodine + tyrosine — M onoiodotyrosine thyroid cell.
(MIT). (h) T hyroid scan. T hyroid scan using
(c) MIT + iodine —Diiodotyrosine (DIT). technetium (Wm Tc) is a useful test to differentiate
(d) MIT + DIT-Triiodothyronine (T3). betw een G ra v e s’ disease and secondary
(e) DIT + DIT-Thyroxine (T4). hyperthyroidism.
Relation with the pituitary gland. A low serum Dysthyroid ophthalmopathy. Pathogenesis 14 is
level of thyroxine induces an increased thyroid- obscure. Two views are prevalent.
stim ulating horm one (TSH) which leads to H um oral im m unity to thyroglobulin.
enhanced thyroxine secretion and vice-versa. Thyroglobulin and the allied products perhaps reach
the orbit passing through the cervical lymphatic
vessels. It is thought that an autoimmune reaction Eponym s o f M ajor Clinical Signs in O phthalm ic
is provoked by thyroglobulin-antithyroglobulin G raves’ Disease
complexes on the sarcolemma o f the extrinsic
Clinical signs Eponyms
ocular muscles.
Delayed hypersensitivity to thyroglobulin. The U pper lid retraction Dalrym ple sign
presence o f thyroglobulin in the orbital tissues U pper lid lag on dow ngaze von Graefe sign
triggers an autoimmune reaction in which the Extrinsic m uscle palsies Ballet sign
W eakness o f convergence M obius sign
sensitized thymus-dependent (T) cells interact with
Absence o f norm al forehead creases Joffoy sign
th y ro g lo b u lin , causing a delayed type o f
Infrequent blinking reflex Stellwag sign
hypersensitivity. Lower lid lag on upgaze Griffith sign
The anatom ical p a th o lo g y o ccu rrin g in Increased pigm entation o f skin Jellinek sign
dysthyroid exophthalmos is as follows: T rem or o f closed eyelids Rosenbach sign
(a) Slight elevation of the upper eyelid causing O edem a o f low er lid Enroth sign
widening of the palpebral fissure is perhaps due to Spasm odic upper lid retraction K ocher sign
overaction of epinephrine on Muller’s muscle and during fixation
tethering of the inferior rectus to the inferior oblique N ystagm oid jerk s during W ilder sign
on causing overaction o f the levator palpebrae abduction to adduction
suberioris.
Eye changes in Graves’ disease can be grouped
(b) There is oedema involving fats, fascia,
into seven classes :21
extrinsic muscles due to accumulation of material
Class 0— no ocular signs or symptoms
rich in mucopolysaccharides and diffuse round cell
Class 1—upper lid retraction, with or without
infiltration.
lid-lag and proptosis
(c) Limitation of ocular movements (restrictive
myopathy) is due to fibrosis and inelasticity of the Class 2—soft tissue involvement
opposite muscle. Class 3—proptosis
(d) Involvement of the optic nerve is probably Class 4— extrinsic ocular muscle involvement
due to pressure by swollen muscles, infiltration Class 5—corneal involvement
and/or defective blood supply. Class 6 —loss o f sight (optic nerve involvement).
Two types o f exophthalmos (Fig. 34.5)—mild
C lin ic a l fe a tu r e s . Two form s m ay be
and severe can be distinguished (Table 34.5).
distinguished:
(a) Mild (benign, thyrotoxic or dry)
(b) Severe (malignant, thyrotropic or wet)

Thyrotoxic Exophthalmos (Graves’


Disease)

Thyrotoxic exophthalmos is common in females of


30 to 40 years of age. There is a strong hereditary
pattern.
Exophthalmos is noticed in about 25 per cent
cases and in about 90 per cent cases of ophthalmic
Graves’ disease. Apart from this other signs are
Fig. 34.5 T h y r o tro p ic e x o p h th a lm o s ( T re v o r-R o p e r
listed in Table 34.4.
and Curran).
Table 34.5 (a) Systemic iodide and antithyroid drugs like
D istinguishing Features o f T w o T ypes o f E xophthalm os thiouracil— in mild type
(b) Systemic steroids help to reduce the oedema
Points M ild Severe and infiltration
A ge U sually adults U sually elderly (c) Lid retraction may respond to guanethidine
Sex Predom inant in Equal o r m ore in or Ismelin drops (10% or 5%)
w om en m ales (d) Protection of the comea—if required, by
Thyroid state H ypcrthyroid A ny: hyper-, hypo-
o r euthyroid tarsorrhaphy
Evidence o f Y es and prom inent M inim al (e) O rbital d eco m p ressio n — in rapidly
thyrotoxicosis progressing, irreducible proptosis with threatening
Exophthalm os M ild and reducible Severe and often
irreducible involvement o f the optic nerve.
U pper lid V ariable in early Slight
retraction stage
Orbital Tumours6 810 "
O phthalm oplegia W eak convergence M ore prom inent and
m ay precede
exophthalm os Classification. (a) Primary tumours o f the orbital
O edem a Slight in eyelids M arked in eyelids
tissues
and conjunctiva
C om plications U ncom m on C om m on and often (b) Secondary tum ours from the adjacent
severe structures
(c) Metastasis from the distant organs
D ifferential diagnosis . 3 The condition must be (d) Manifestations in general diseases.
differentiated from a space-occupying lesion of the
orbit (Table 34.6). C linical fea tu res. All slow-growing tumours
are asym ptom atic except perhaps for vague
Table 34.6 discomfort or diplopia in their early stages, because
the orbital contents adapt themselves well to the
D ifferentiation betw een D ysthyroid Exophthalm os
tumours.
and Space-occupying Lesion
A rapidly-growing tumour produces marked
Points Dysthyroid Proptosis d ue to a symptoms and signs owing to vascular disturbance
exophthalm os space-occupying and oedema.
lesion Proptosis may be axial or eccentric. Apart from
U nilaterality Rare Usual clinical assessment, exophthalmometry helps in
Evidence o f estimating the progress of proptosis.
thyrotoxicosis Yes No Oedema is a characteristic feature in rapidly-
O nset and Insidious onset R apidly progressive
and slow progress
growing tumour. Immobility is caused earlier in a
progress
Involvem ent o f U nlikely All m uscles supplied malignant tumour. Visual disturbance depends on
m uscles supplied by the nerve arc the involvement o f the optic nerve, the vascular
by oculom otor likely to be affected supply and the eyeball itself.
nerve together
Pupillary No Yes
Investigations are as those described under
abnorm ality ‘P roptosis’. It is m andatory to exam ine the
Ptosis Rare C om m on neighbouring structures to determine whether the
O ptic disc Rare C om m on orbital invasion is primary or secondary.
changes
X-ray — M ay be o f value
FNAB is an important diagnostic aid . 17
Thyroid function R evealing U nrevealing
tests Primary Tumours
T rea tm en t. S everal m easures have been Benign. These tumours can be classified as follows
suggested: (Table 34.7).
Table 34.7 R habdom yosarcom a is the m ost com m on
C lassification o f Prim ary Benign O rbital Tum ours primary malignant tumour of the orbit in children.
The tumour starts from the extrinsic muscles of
Vascular: h aem an g io m a, h a e m a n g io e n d o th e lio m a , the eye or the lid muscles. Lid swelling may be the
h a e m a n g io p e ric y to m a , v a s c u la r m a lfo rm a tio n s , first sign but rapid proptosis is the common
lym phangiom a presenting sign.
Neural: neurofibrom a
Lymphosarcoma and allied blood cell tumours
Mesenchymal: fibroma, lipom a, m yxom a, chondrom a,
osteoma
occur usually in elderly persons. The types include:
Myomatous: rhabdom yom a, leiom yom a (a) lymphocytic cell sarcoma; (b) reticulum cell
Epithelial: typically from the lacrimal gland lymphosarcoma; (c) giant follicle lymphosarcoma;
Pigmented: melanom a (d) Hodgkin’s disease; and (e) lymphoma and
chloroma.
Haemangioma is usually o f cavernous type. It Carcinoma of the lacrimal gland may present as
produces variable proptosis. It is compressible and adenocarcinoma, carcinoma or mixed tumour.
increases in size with certain physical acts such as Apart from the conditions described above, the
crying, straining or stooping. It may produce prim ary tum ours o f the orbit also include:
pseudopulsation and cause visual loss by prolonged (a) dermoid cyst; (b) phakomatoses; (c) epithelial
pressure on the optic nerve. tumours of the lacrimal gland; (d) pseudotumours;
Neurofibroma affects the lids, orbit, face, scalp and (e) tumours from the fatty and fibrous tissues,
and skin in general. Its association with drusen of m uscle, nerve, cartilag e, bone and
the optic nerve head or glioma has been recorded. reticuloendothelial system.
Pressure-erosion o f the bone wall caused by this
tumour very rarely produces pseudopulsation. Tumours of the Optic Nerve Sheaths
The incidence of benign mesenchymal tumours
Tumours of the optic nerve sheath include glioma,
is rare.
meningioma—arising from the arachnoid sheath,
Table 34.8 lists the important distinguishing
and fibroma—arising from the dura.
features of benign and malignant tumours o f the
T hese tum ours may be in trao rb ital or
orbit.
intracranial.
Table 34.8 The intraorbital neoplasms are characterized by:
(a) slowly progressive, axial and irreducible
D istinguishing C linical Features o f O rbital Tum ours
proptosis; (b) early and rapid visual loss; (c)
Features Benign M alignant usually there is evidence of vascular obstruction;
Proptosis Mild Gross (d) impairment o f ocular mobility is late in onset;
Restricted ocular and (e) there is radiographic evidence of bone
m ovem ents Insignificant Present involvement, e.g. in glioma.
Visual impairment No Yes
Pain No Yes Glioma. Glioma is a benign astrocytic tumour
Duration W eeks M onths arising from the intraorbital portion of the optic
Im aging studies Intact bone Bone erosion, nerve near the optic foramen and spreading
circum scribed infiltrative posteriorly. Histologically, there are irregular
mass mass disposition o f glial cells with areas of mucoid
degeneration. There is associated proliferation of
M a lig n a n t. Sarcom a m ay arise from any the connective tissue. This tumour is unilateral
mesodermal constituent o f the orbit. The affection and occurs typically in the first decade o f life.
is common in children or young adults and is Early visual loss accompanied by gradual, painless,
terminal. axial proptosis are characteristic features. Optic
atrophy is more common. X-ray shows an enlarged Meningioma of the Sphenoid Ridge
optic foram en w ith a polished border. CT
especially helps in finding out any intracranial Meningioma of the sphenoid ridge, e.g. extension
extension. from a retinoblastoma, nasopharyngeal carcinoma,
is a secondary tumour. It may involve the inner
Meningioma. This arises from the arachnoid
third, middle third or lateral third o f the ridge.
sheath of the optic nerve and invades the orbit and
More laterally placed neoplasms are frequently
nasal fossae, spreading both anteriorly and
asymptomatic in their early stage.
p o sterio rly . The pia is rarely penetrated.
However, an advanced case is characterized by:
Histologically, there are irregular lobules containing
(a) unilateral proptosis; (b) oculomotor palsies;
large syncytial cells. Psammoma bodies are
(c) optic atrophy; (d) anaesthesia in the distribution
characteristic. These are the hyaline masses formed
of the trigeminal nerve; and (e) X-ray shows two
by the collagenous material between the lobules
types of changes—osteolytic and hyperostotic, the
(Fig. 34.6). Because o f the late involvement of the
latter being m ore com m on, involving the
nerve itself in the course o f the disease, visual
sphenoidal wings. The sphenoidal fissure may be
failure is characteristically late in its onset. Visual
enlarged.
loss is associated with papilloedema or optic
atrophy, and slowly progressive proptosis. The
tum our can be evaluated by X -rays, Metastatic Tumours
ultrasonography and CT scan.
Metastatic tumours may arise from neuroblastoma
of the adrenal medulla or sympatheticoblastoma,
leukaemia, lung carcinoma and carcinoma o f the
breast. M etastatic sym patheticoblastom a or
neuroblastoma usually metastasizes to both orbits;
it may present as proptosis associated with a mass
in the cheek or temple area.

Manifestations in General Diseases

Lipodystrophies and osteopathies are among the


manifestations in general diseases.
L ipodystrophies include typically
Hand-Schuller-Christian disease, also known as
Fig. 34.6 Meningioma of the optic nerve sheath ‘diabetic exophthalm ic d y so sto sis’. It is
(Dr. I.S. Roy, and Dr. E. Ahmed). characterized by association o f diabetes insipidus
with xanthomatous deposits in the skull bones
and the orbit in a physically and m entally
Superior Orbital (Sphenoid) Fissure
handicapped child.
Syndrome
Osteopathies include bony hyperplasias, rickets
and hydrocephalus.
Superior orbital fissure or orbital орех syndrome
is characterized by presence of unilateral paresis Treatment o f orbital tumours. The principles are:
of III, IV and VI cranial nerves as well as that of
Benign—surgical excision
the ophthalmic division of V cranial. There is lack
Malignant
of venous congestion, a feature which differentiates
it from cavernous sinus syndrome. (a) Surgical excision
(b) Radiotherapy Dermoid Cyst (Fig. 34.7)
(i) Conventional
(ii) Teleradiation—cobalt-60 Dermoid cyst contains sebaceous material and hair
(iii) Intercavitary irradiation follicles and is lined by the epithelium. It is most
(c) Combinations. commonly found at the upper and outer angle of
the orbit and less commonly at the other angles of
Dermoid cyst and some other benign tumours
the orbit. It presents as smooth, fluctuant and
can be removed without injuring the eyeball. If
painless mass. It is free from the skin but is attached
radical treatm ent is contem plated, surgical
exploration and removal of a portion of the tumour to the periosteum. It occasionally causes pressure—
for microscopic examination is essential.
Many o f the malignant tumours tend not to
metastasize, and thus they are treated by more
conservative methods than are usual in other parts
of the body. The majority o f these tumours are
treated by complete excision following orbitotomy.
Occasionally for the sake of complete removal of
the malignant tumour, even the eye may have to
be excised. If the malignant tumour extends to the
periorbita an exenteration operation is needed.
Reticular tumours are especially responsive to
radiation therapy.
Routes of surgical approach are the following:
Fig. 34.7 Peribulbar derm oid.
(a) Anterior orbitotomy. Incision at the anterior
orbital margin and access to the anterior half of absorption o f the part of the wall. It rarely extends
the orbit. backwards to cause proptosis. The anteriorly-placed
(b) Lateral orbitotomy (Kronlein). Incision orbital cyst can be fully excised without much
outside the lateral canthus and access to the deeper difficulty. A deeply-placed cyst can be removed
parts of the orbit. with extreme difficulty.
(c) Transfrontal or Naffziger’s operation. This
is for access to the apex o f the orbit. Vascular Disturbances18
(d) Lateral orbitocranial decompression.
Haem orrhage
(e) Transconjunctival orbitotomy.
Aetiology. Haemorrhage may be caused by a blunt
The additional space provided by the opening
injury in the orbital region. Sometimes there may
allows the orbital contents to expand reducing the
be spontaneous haemorrhage as in arteriosclerosis
risk of proptosis.
and blood dyscrasias.
Orbital Cyst Clinicalfeatures. Haemorrhage is characterized by
variable degree o f proptosis, subconjunctival
Orbital cysts are relatively rare and divided into haemorrhages, restriction of ocular movements
eight groups: ( 1 ) congenital e.g. dermoid cyst; which is dependent on the site of haemorrhage. If
(2) im plantation; (3) haem atic; (4) parasitic; within the muscle cone all movements will be
(5) serous; ( 6) mucous cysts from paranasal sinuses; restricted and evidence of haematoma is present.
(7) dentigerous; and ( 8 ) cysts o f intraorbital The extravasated blood slowly disappears within a
structures, e.g. lacrimal gland. few weeks.
Caroticocavernous Fistula Clinical features. Orbital varix causing intermittent
proptosis (Figs. 34.8 and 34.9) is characterized by
Aetiology, (a) It is often traumatic. There is fracture the following features:
o f the base of the skull especially when the arteries
are sclerotic.
(b) Occasionally there is spontaneous rupture
o f the carotid artery into the cavernous sinus which
presents as ‘pulsating exophthalmos*.
(c) There is rarely leaking aneurysm o f the
ophthalmic artery.
C linical fea tu res. Caroticocavernous fistulae
include sudden and marked proptosis, palpable and
audible systolic pulsations caused by transmission
o f higher arterial pressure into low-pressure venous
system, distended conjunctival vessel, chemosis
and swelling of the lids, engorgement of the retinal
veins, accompanied by pain and impairment of
vision. Visual prognosis is guarded.
D iagnosis. D iagnosis is aided by pneum o-
tonometry, angiography, ultrasonography, MRI and
colour Doppler imaging.
Colour Doppler imaging is a noninvasive
technique that provides a tw o-dim ensional
structural imaging and Doppler evaluation o f the
blood flow.
Treatm ent. Treatment is conservative. If the Fig. 34.8 Orbital varix. Undisturbed eye.
application of continuous pressure on the carotid
stops pulsation, a cure may be affected by ligation (a) Unilaterality—it is common on the left side.
o f the carotid. The opposite carotid may also be (b) Transient proptosis induced by bending the
tied at the expiry of some weeks after the first head forwards and pressure on the jugular veins.
operation. This procedure may also fail. In this (c) Occasionally it pulsates and/or murmurs.
case intracranial ligation proximally and distally (d) X-ray may show evidence of calcification
to the aneurysm is resorted to. Other methods due to phlebolith.
include carotid embolization with muscle fragments (e) Diagnosis is confirm ed by an orbital
and transcavemous electrocoagulation. venography.
(0 Colour Doppler imaging is a noninvasive
method of evaluation.
Orbital Varix
Treatment. Many of the varices may eventually
Orbital varix may be primary or secondary. A resorb or recanalize resulting in improvement of
primary varix may be congenital and follow trauma symptoms, and hence conservative treatment is
or occur in association with a haemangioma. suggested. Associated secondary glaucoma due to
S econdary varices are due to e ith e r increased episcleral venous pressure should be
caroticocavernous fistula or an arteriovenous medically treated. But surgery is indicated when
malformation (intraorbital). there are intractatable pain, gross degree of
Oxycephaly is caused by premature ossification
o f all the sutures. It is characterized by proptosis,
divergent squint, restriction of ocular movements,
primary optic atrophy and sometimes evidence
of raised intracranial pressure, i.e. papilloedema,
X -ray shows thinning and digitation o f the
bones.
It may be associated with syndactyly, A pert’s
disease.
Brachycephaly is short skull due to premature
closure o f the coronal suture.
Dolichocephaly is the increased anteroposterior
diam eter o f the skull causing a long narrow
head.
Scaphocephaly is the lop sided skull due to
asynchronous fusion o f the cranial bones.
Crouzon’s disease. It is a craniofacial deformity
characterized by brachycephaly or wide skull,
shallow orbits, divergent squint, proptosis, greater
breadth o f the bridge o f the nose, atrophy o f the
upper jaw, etc.

Fig. 34.9 A ppearance o f proptosis after bending Facial Dystrophies6


the head forward.
The orbit is developed by the meeting and growth
proptosis, compressive optic neuropathy or venous o f the two mesodermal masses— the paraxial
thrombosis. Carbon dioxide and yttrium-aluminium mesoderm o f the head-fold and the maxillary
garnet (YAG) lasers may help in removal of process o f the first visceral arch, between the 12
superficial and subcutaneous varices. and 16 mm stage. Inhibition of the development
of the first visceral arch leads to a deformity known
Developmental Anomalies of the as ‘mandibulofacial dysostosis’.
Orbit
M andibulofacial dysostosis (Franceschetti). A
Anomalies of the head and face include chiefly: fully developed case is b ilateral and it is
(a) dysostoses o f the skull; and (b) facial characterized chiefly by:
dystrophies. (a) Antimongoloid obliquity of the palpebral
A nom alies o f the orbit include chiefly: fissure with a coloboma usually in the outer part
(a) meningocele and cephalocole; (b) cysts— of the lower lid.
typically dermoids; and (c) tumours. (b) Hypoplasia of the facial bones.
(c) M alformation o f the ears, blind fistula
Dysostoses of the Skull between the angles of the mouth and the ears.
D ysostoses o f the skull are perhaps due to (d) Various other (facial and skeletal) anomalies.
premature closure o f one or more sutures. Normally Other anomalies include oculoauriculovertebral
synostosis coincides with completion o f growth of dysplasia (Goldenhar’s syndrome), mandibulo-
the brain. oculofacial dyscephaly, etc.
Orbital Meningocele and Cephalocele Orbital and Para-orbital Diseases, Duke-
Elder, S. and MacFaul, P. (Eds.), Kimpton,
There is protrusion of the portion of the contents London, 1974.
o f the skull into the orbit. They are encephalocele, 7. Duke-Elder, S., System o f Ophthalmology, Vol
hydroencephalocele and meningocele (rare). III: Normal and Abnormal De\>elopment, Part
The most common site is the inner angle of the 2: Congenital Deformities, Kimpton, London,
orbit or at the root of the nose and corresponds to 1963.
the suture-lines between the bones.
8 . H enderson, J., O rbital Tumours, W.B.
A typical anterior orbital cephalocele is
Saunders, Philadelphia, 1973, p. 139.
characterized by a fluctuating cyst, reducible under
pressure, and producing impulse on coughing. It is 9. Jain, I.S., Diagnosis and investigations in
transparent and there is evidence o f bone defect proptosis. Proc. All India Ophthalmol Soc.,
seen radiologically. Undue pressure may induce 31:21, 1970.
cerebral symptoms. 10. K anski, J.J., C linical O phthalm ology
Treatment entails reposition o f the hernia and (3rd ed.), Butterworth-Heinemann, London,
repair of the bony defect, if necessary by dural 1994.
substitute.
11. Levine, R.A., Orbital tumours. In Principles
and Practice o f Ophthalmology, Peyman,
F u rther R eading Sanders and Goldberg (Eds.), W.B. Saunders,
Philadelphia, 1980.
1. Ashworth, B., Clinical Neuro-Ophthalmology, 12. Llyod, G.A.S., The radiological investigation
Blackwell Scientific, Oxford, 1973. o f u n ilateral p ro p to sis. In M edical
2. Blodi, F.C. and Gass, G.D.M., Inflammatory Ophthalmology, Rose, F.C. (Ed.), Chapman
pseudo-tumour of the orbit, Br. J. Ophthalmol., Hall, London, 1976, p. 56.
52:79, 1968. 13. M eadows, S.P., Endocrine D isorders. In
3. Brain, R. and Walton, J., Diseases o f the Modern Ophthalmology (2nd Ed.), Sorsby,
Nervous System, 7th ed., Oxford University A. (Ed.), Vol. 2, Butterworths, London, 1972,
Press, London and ELBS, 1969. p. 301.

4. C houdhury, V. and G u lati, P., 14. Mulin, B.R., Dysthyroid exophthalmos. In


U ltrasonography, com puted tom ography Pathobiology o f Ocular Disease, Gamer, A.
and magnetic resonance imaging: efficiency and Klintworth, G.K. (Eds.). Marcel Dekker
and pitfalls in ophthalmology. In Current Inc., New York, 1982, p. 1077.
Topics in Ophthalmology’, I, Gupta, A.K. (Ed.), 15. Parsons, J.H., Diseases o f the Eye (18th Ed.),
B.I. Churchill Livingstone, New Delhi, 1993, Miller, S.J.H. (Ed.), Churchill Livingstone,
p. 35. Edinburgh and ELBS, 1990.
5. Dallow, R.J. and Pratt, S.G., Approach to orbit 16. Pavan-Langstone, D. (Ed.). Manual o f Ocular
disorders and frequency of disease occurrence. Diagnosis and Therapy (4th ed.) Little, Brown
In Principles and Practice o f Ophthalmology: and Co., Boston, 1996.
Clinical Practice, Albert, D.M. and Jacobiec, 17. Snebold, N .G ., N oninfectious orbital
F.A. (Eds.), W.B. Saunders, Philadelphia, inflammations and vasculitis. In Principles and
1994, p. 1881. Practice o f Ophthalmology: Clinical Practice,
6 . Duke-Elder, S., System o f Ophthalwology Vol. Albert, D.M. and Jacobiec, F.A. (Ed.), W.B.
XIII: The Ocular Adnexa, Part 2: Lacrimal, Saunders, Philadelphia, 1994, 1923.
18. Trevor-Roper, P.D. and Curran, P.V., The Eye In infective type: (a) bacterial, e.g. erysipelas;
and Its D isorders (2nd ed.), B lackw ell (b) viral, e.g. typically in herpes zoster; (c) fungal
Scientific, Oxford, 1984. like pityrosporon causing seborrhoeic and tinea
19. Trevor-Roper, P.D. (Ed.), Recent Advances in causing ringworm dermatitis; and (d) parasitic, e.g.
Ophthalmology, No. 5, Churchill Livingstone, lice, are the main causes.
Edinburgh, 1975. Treatment o f irritant dermatitis consists of the
removal o f the cause and application of a steroid
20. Vaughan, D., Asbury, T. and Tabbara, K.F. ointment. In infective type, treatment must be
(Eds.), General Ophthalmology (12th ed.), directed against the cause.
Appleton and Lange, Connecticut, 1989.
21. Werner, S.C., Classification o f the eye changes O phthalm oderm atozoosis1
o f Graves’ disease, J. Clin. Endocrin. Metabo,
29: 982, 1969. Dermatozoosis may involve any part of the exposed
skin and is caused by the irritant secretion, possibly
from the hindgut o f the beetle of genus Paederus
(P. fusipes).
Following insect hit, the insect is unintentionally
35. DISEASES OF EYELIDS squashed near the medial canthus liberating the
irritant secretion. This is characterized by dermal
Apart from inflammations, motor and sensory lesions which involve the eyelids usually near the
disorders and tumours, the eyelids may be affected medial canthus and periocular region (Fig. 35c. 1).
in circulatory, secretory, metabolic and congenital The chain o f events are: oedema —> erythematous
disorders. Diseases o f the eyelashes and anomalies papules vesicles —> pustules -» desquamation
o f the palpebral fissure are also considered. —» cicatrization, often pigmented. The lesions
persist for about one week.
Diseases of the Skin of Eyelids4,9,12 Ocular lesions include conjunctivitis and comeal
abrasions.
The thinness and rich vascularity o f the lid skin Treatment consists o f local and systemic
causes unusual d isten sio n , co n g estio n and antibiotics for about a w eek. O ccasionally
secondary infection involving the conjunctiva and antihistamines are o f help.
other structures. All precautions must be taken in order that the
In an inflammatory lesion, the sequence of lesions are not further aggravated.
events are:

✓ Infection (Pustule)
Vesicular lid inflam m ations4,10
Erythem a-Papule-V esicle ^ - B u r s t i n g (W eeping eczem a)
\ D rying (Scaly eczem a) Lid inflammations are occasionally present and the
causes include: (a) acute viral inflammations, e.g.
herpes simplex and herpes zoster; (b) Stevens-
D erm atitis
Johnson syndrome, (c) benign mucous membrane
Dermatitis may be: (a) irritant which is either pemphigoid; (d) pemphigus vulgaris, and (e) drug-
contact or eczematous; and (b) infective. The induced bullae.
contact and eczematous types are chiefly allergic In both primary and recurrent herpetic infection,
in origin, where an exogenous allergy is mainly crops of vesicles of pin-head size appear on the
due to spectacle frames, by cosmetics, alkaloids, lid, particularly the lower. The lesions are typically
chemotherapeutic agents and antibiotics. unilateral.
The vesicles in herpes zoster make their
appearance typically unilaterally. They rapidly Differences between Squamous and Ulcerative
become turbid and yellow. The latter burst within Blepharitis
a short time.
Features Squamous Ulcerative
The skin lesion of Stevens-Johnson syndrome
is as follow s. In the lids sharply defined Scales W hite, fine, Y ellow ish, coarse
erythem atous patches are found w hich are pow dery and dry and wet
Ulceration No Yes
symmetrically distributed. In a severe case they
Bleeding No Yes
are turned into vesicular lesions.
A lopecia o f the Tem porary and Perm anent and
In benign mucous membrane pemphigoid the lashes localized to few alm ost all eyelashes
bullae are subepidermal and the lids may be eyelashes are involved
involved. Course Mild Progressive
Pemphigus vulgaris affects older people, its C om plications Occasional Usual and serious
incidence being rare. Crops of bullae appear on
the apparently normal skin. There is no preceding exacerbations; (c) frequent association with other
erythema. staphylococcic lesions, e.g. sycosis vulgaris;
(d) hyperaemia of the lid margins; (e) eczematous
Blepharitis4 changes of the skin of the lids at the angles of the
lids; (f) onset with acute conjunctivitis; and (g) in
Blepharitis (Gk. blepharon, eyelid) is a chronic severe exacerbations, presence of punctate epithelial
inflammation o f the lid margin and is a very keratitis.
common condition. They are o f two types— Seborrhoeic blepharitis is characterized by:
squamous and ulcerative. (a) persistent inflammation o f the lid margins;
Aetiology. Aetiology is often varied, involving (b) associated seborrhoeic dermatitis of the scalp
both local and general factors. In the local and eyebrows; (c) presence o f soft, oily flakes;
fa c to r, m a lfu n ctio n in g o f the M eibom ian and (d) fluctuations in severity.
glands, staphylococcal infection and parasitic Blepharitis may exist without conjunctivitis.
infection, typically Phthirus pubis are noticed. In Complications and sequelae. If the treatment is
general, seborrhoeic dermatitis of the scalp and inadequate, there is accom panying chronic
eyebrows and lowering o f systemic resistance are blepharoconjunctivitis. In the ulcerative form the
noticed. sequelae are serious. When the ulceration is deeper
the eyelashes fall out which are either not replaced
P a th o lo g y. Squam ous b lep h aritis shows
or replaced by a few small and scattered lashes,
hyperaemia. oedema, desquamation, acanthosis, i.e.
and the condition is called madarosis. These lashes
increased thickness of the prickle layer of the
are distorted and may be drawn out of place giving
epiderm is, p arak erato sis, i.e. incom plete
them a false direction. The m isdirected and
keratinization and infiltration.
distorted cilia rub the comea and this condition is
Ulcerative blepharitis displays hyperaemia,
termed trichiasis. A vicious cycle is formed when
oedema, infiltration and perifollicular abscesses.
the lower lid tends to lose its contact with the
Clinical fe a tu res (Fig. 35c.2). There may be eyeball causing ectropion which is the eversion of
soreness, grittiness and discomfort along the lid the lid margin. This leads to epiphora, which in
margins. Two types—squamous and ulcerative can turn worsens into an eczema. Two occasional
be distinguished (Table 35.1). sequelae are tylosis, i.e. hypertrophy o f the lid
Staphylococcic blepharitis is characterized by: margin and milphosis, i.e. permanent reddening of
(a) chronic course; (b) periodic acute or subacute the lid margin.
Treatment Treatment must aim at the symptomatic D iffe r e n tia l d ia g n o sis. A stye should be
relief and eradication o f the cause. As medication differentiated from: (a) chalazion; (b) acute
is retained in the organisms occupying the crypts d acry o cy stitis: (c) o rb ital cellu litis; and
o f the folliculoglandular structures, the course of (d) erysipelas.
treatment is often prolonged. C halazion is asym ptom atic unless it is
Local treatment consists o f an antibiotic-steroid suppurative. In a stye, history and presence o f an
ointm ent since it com bats in fectio n plus eyelash d ifferen tiate it from a suppurative
inflammation. This is perhaps more effective than chalazion.
other measures such as soaking and removal o f the In acute dacryocystitis, epiphora and signs
scales and application o f an antiseptic ointment limited to the lacrimal sac region are present.
such as yellow oxide of mercury. In orbital cellulitis, proptosis, chemosis, ocular
General treatment consists o f eradication of immobility and marked constitutional upsets are
associated scalp infection and enhancement of present.
body resistance. E rysipelas is a d iffu se strep to co ccal
inflammation along the cuticular lymphatics.
Phthiriasis palpebrarum infection is caused by
Rapidly spreading erythema with irregular edges,
numerous nits of pediculosis and crab-lice, which
and m arked c o n stitu tio n a l sym ptom s are
cling to the eyelashes. Treatment is frustrating and
characteristics.
includes the removal o f parasites by forceps,
application o f yellow oxide o f m ercury or Treatment. Treatment consists o f localization in
application of eserine under direct observation and the early stage of the stye. This is achieved by
pyrethrum ointment. fomentation accompanied with a short course of
sulphonamides or antibiotics. A small incision may
Stye or hordeolum externum sometimes be needed to relieve the pus.
An antibiotic ointment is necessary after the stye
Stye (Gk. steigan, to rise) is a suppurative discharges to prevent further infection of the other
inflammation o f one or more of Zeis’s glands and roots o f the eyelashes.
only occasionally o f Moll’s glands. In recurrent styes, correction o f refractive error,
treatment of debility, check-up for diabetes and
Aetiology. Styes are commoner in young adults enhancem ent o f general body resistance are
and children, and there is often lowering o f important measures.
systemic resistance to Staphylococcus aureus.
Recurrences are common.
Chalazion or M eibom ian cyst
Clinical features. The affection starts with pain
Chalazion (Gk. chalza, hailstone) is a chronic
and occasional fever in children. It is characterized
inflammatory granuloma of a meibomian gland.
by tenderness, oedema and finally suppuration
localized around an eyelash (Fig.35c.3). It, at times, A etiology. There is retention o f m eibom ian
involves the entire lid margin when it occurs near secretion due to obstruction or vicarious activity,
the canthi impairing the venous and lymphatic flow. with associated low-grade infection of the glands.
In severe inflammation, preauricular lymphadeno-
Pathology. Retention of the sebaceous secretion
pathy and constitutional upsets are not uncommon.
causes chemical irritation and subsequent reaction.
Within three to six days, pus is discharged from
The infiltration includes epithelioid, plasma,
the stye.
lymphoid and giant cells along with fibroblastic
Treatment sometimes aborts it.
activity. A pseudocapsule forms around this
Com plications though rare now-a-days are
granulom a whose central portion ultim ately
spreading cellulitis and rarer still cavernous sinus
becomes gelatinous.
thrombosis.
Clinical features (Fig. 35.1). Single or multiple and kept apart postoperatively. Covering with an
chalazion often appears as a nodule of varying epithelial graft is necessary when adhesion extends
sizes, free from the skin but better seen as a pallid to the angle o f the lids.
area of the conjunctiva when the lid is everted.
Chalazion may progress towards the conjunctiva, Symblepharon
the lid margin or the lid skin.
Adherence of the eyelid to the eyeball is called
symblepharon (Gk. sym.t with).
Aetiology. Caustics and mucocutaneous affections
involving the conjunctiva are the causative factors.
Apposition of two raw surfaces—palpebral and
bulbar conjunctivae—causes adherence.
There are three types: (a) anterior—when the
lid margin adheres to the bulbar conjunctiva;
(b) posterior—when there is obliteration o f the
fomix; and (c) total—when the entire lid is fixed
against the globe.
Treatment If the case is inflammatory, treatment
Fig. 35.1 Chalazion. consists o f topical and systemic medications, with
this treatm en t it may resolve. But if the
Course and complications. Chalazion may remain inflammation does not resolve with maximum
stationary, be infected and suppurated known as therapy and the cicatrization is large, treatment is
hordeolum internum . T hey at tim es abort. frustrating. In a stable and small cicatrization, glass
Recurrence is not uncommon. Malignancy is rare. rod separation may be helpful. In recurrent affection
T reatm ent. T reatm ent includes an incision Z-plasty or mucous membrane graft is advocated.
and evacuation of its content. Marginal chalazion Following a mucous membrane graft either a
w ith sprouting granulation tissue may need silicone sleeve in moderately extensive surgical area
diathermy application, 20 to 30 milliamperes for a or a scleral shell in extensive surgical area may be
second. advised.

Sudorific and sebaceous cysts Disorders of Eyebrows and Eyelashes


Disorders of the eyebrows and eyelashes may be
They are tiny cysts at the lid margin or scattered overgrowth o f the lashes, hypertrichosis; or lack
over the lid skin. Tiny sebaceous cysts are called or absence o f the lashes, hypotrichosis; or
milia. anomalies of pigmentation such as poliosis.

Ankyloblepharon Trichiasis
Ankyloblepharon (Gk. angkylos, crooked) is the Trichiasis (Gk. thricks, hair) is the intuming of
adhesion o f the margins of both eyelids. It may be the eyelashes which rub against the comea. The
congenital or acquired often associated with lashes are seldom normal as they are stiff and
symblepharon, partial or complete. distorted.
Treatment, is dependent on the amount of It may or may not be associated with an
symblepharon. Operation is contraindicated in entropion.
extensive cases. In other cases the lids are separated Aetiology. Trichiasis may be due to: (a) trachoma;
(b) ulcerative blepharitis; and (c) deformity o f the and rarely congenital. A cquired entropion is
lid margin owing to inflammation, ulcer, trauma classified under:
and burn. (a) Acute spastic. This is caused by ocular
Clinical features. Symptoms like irritation and inflammation or prolonged bandaging. It involves
persistent foreign body sensations are present. mostly the lower lid and is usually a temporary
condition.
Complications and sequelae. Complications and (b) Mechanical. This is due to loss of support
sequelae are recurrent comeal erosions, nebula and furnished to the lids by the globe— seen in
comeal vascularization. anophthalmos and microphthalmos.
Treatment Treatment consists of epilation of the (c) Cicatricial. This may affect either the upper
misdirected offending cilia, repetitions every few or lower lid. Trachoma is the most common cause;
weeks are necessary and destruction of the cilia by other causes include physical and chemical bums,
electrolysis, diathermy or cryoapplication. and cicatrizing diseases o f the conjunctiva.
In electrolysis, the positive pole is wrapped (d) Senile, involutional or atonic. This is the
round the arm, and the negative pole, whose most common variety. It is unilateral or bilateral
terminals dipped into saline release hydrogen and involves either the lower or the upper eyelid.
bubbles, is introduced into the hair follicle. A The contributory factors for its development are:
current o f 2 milliamperes is applied for 5 to 10 (a) horizontal lid laxity, (b) laxity of lower lid
seconds. Thus, a slight foam is produced, and the retractors, (c) preseptal part of the orbicularis oculi
lash can be pulled out with ease. overriding a portion o f postseptal part, and
In diathermy a current o f 30 milliamperes is (d) thinning and atrophy of the tarsus.
applied for 10 seconds. If associated with entropion,
Treatment Treatment o f acute spastic entropion,
operative procedures for entropion are called for.
caused by prolonged bandaging in an elderly
In cryoapplication the temperature falls to
patient, is to simply remove the bandage.
-20°C.
In mechanical entropion good prosthesis and
measures to correct senile entropion are needed.
Entropion3,5 (Fig. 35.2)
The surgical procedures adopted for correction
o f cicatricial entropion are indicated in
Entropion (GK. en, inward; trepein, turn) is an
Table 35.2.
inversion of the lid margin. It may be slight or When entropion is due to cicatricial contraction
severe, thus, the symptoms will vary from mild of the palpebral conjunctiva from bums, treatment
discomfort to severe keratitis. It is mostly acquired consists o f complete dissection o f the scarred
conjunctiva and subconjunctival fibrous tissue,
followed by free conjunctival graft or very thin
free mucous membrane graft.
In the lower lid excision of the skin and muscle
may be effective.
In slight degree of senile entropion treatment
consists o f temporary measures which include
application of adhesive plaster from the lower
eyelid to the cheek and 5 to 6 cautery punctures at
3 mm intervals after a skin incision 3 mm below
and parallel to the lash line, and full-thickness
transverse sutures or everting sutures.

Fig. 35.2 Entropion. P erm anent procedures. In the absence of


Surgical Procedures in Different Types of Cicatricial
Entropion3

Upper lid
Mild Anterior lamellar reposition
Moderate
Thick tarsus Tarsal wedge resection
Thin tarsus Lamellar division with or
without mucous membrane
graft
Keratinization of Rotation of terminal tarsus
tarsoconjunctiva
Moderate lid
contraction Posterior lamellar Fig. 35J Ectropion of the lower lid.
advancement
Severe Posterior lamellar graft or (iii) elongation; (iv) drooping of the lid; and
tarsal excision (v) conjunctival hypertrophy and keratinization.
Lower lid (d) Paralytic. Only the lower lid is affected, the
Mild/moderate Wies’ procedure upper lid being held in contact with the eyeball by
Severe Posterior lamellar grafting
its weight. It is due to paralysis of the orbicularis
oculi.
extensive lid laxity transverse lid split and everting (e) Cicatricial. This is due to scarring of the
sutures are advocated. In recurrent cases, plication skin of the lid.
o f lid retractors is indicated. (f) Congenital.
O f the many operations indicated in senile type,
Treatment. The treatment recommended in each
skin-muscle is the simplest although result is
case is as suggested.
unsatisfactory. There is chance o f recurrence. So,
In acute spastic, no treatment is needed except
operation of resection of the tarsus, skin and muscle
perhaps patching o f the eye.
has been designed to brace the atrophic tarsus and
In mechanical, the offending factor needs attention.
atonic orbicularis muscle.
In senile, the procedures are: (a) in early punctal
For details of entropion surgery refer to the
eversion, localized cautery punctures are advocated;
chapter on ‘Surgery’, p. 447.
(b) in advanced punctal eversion, resection of a
horizontal strip o f the conjunctiva and the
Ectropion 3.5 subconjunctival tissue below the punctum is done;
(c) in still more advanced cases, cautery punctures
Eversion (Gk. ek, out of; trepein) (Fig. 35.3) of the along the whole length o f the lid margin are
lid margin is called ectropion. It is classified required; (d) in slight degree, a V-Y operation has
as: been advocated; and (e) in a fully established case,
(a) Acute spastic. In young children or in elderly the principles are to counteract eversion and
patients it occurs with proptosis. The condition is elongation and counteract laxity and sagging of
transient. tissues; hencc, a combination of ‘shortening’ and
(b) Mechanical. This is caused by conjunctival ‘raising’ by a procedure known as the Kuhnt-
hypertrophy. Szymanowski operation is indicated.
(c) Senile. This is the most common form and In p araly tic, a lateral tarsorrhaphy or
affects the lower lid. There are five stages in its canthoplasty is a lesser surgical procedure. In severe
development: (i) loss of muscle tonus; (ii) eversion; cases, fascia lata sling has been advocated.
In mild case of cicatricial, a V-Y operation Table 35.3
is indicated. Two other procedures are lazy Classification of Ptosis
T-procedure in medial without medial canthal
tendon laxity, and medial canthal tendon plication Congenital
in severe medial ectropion. Myogenic (dystrophic)
Aponeurotic (nondystrophic)
Lagophthalm os Acquired
Apparent
Mechanical
An incomplete closure o f the palpebral fissure Myogenic
when an attempt is made to shut the eyes is called Paralytic
lagophthalmos (Gk. lagos, hare; ophthalmos, eye). Pseudoparalytic
Atonic (senile)
Aetiology. The causes are: (a) physiological—
Hypertonic
during sleep; (b) paralytic— in facial paralysis; Sympathetic
(c) mechanical—due to proptosis; (d) ectropion— Traumatic
especially cicatricial; and (e) absence of reflex
blinking— in an extremely ill patient.
bilateral. Heredity is an important factor. It is due
Complications and sequelae. Epiphora, exposure mostly to either a weak levator or a weak levator
keratitis and xerosis o f the comea are the usual plus superior rectus.
complications. It may be em phasised that a child with
Treatment. Treatment comprises essentially o f the congenital ptosis tries to overcome the difficulty
protection of the comea. Temporary measure is an by raising the eyebrow, wrinkling the forehead
application o f suture anchored to the medial and tilting the head backwards when the eyeballs
palpebral ligament, threaded round both the upper roll downwards.
and lower lid margins and fixed to the lateral Complicated congenital ptosis. A ptosis may occur
canthus. In severe degree, the use of fascia lata along w ith ophthalm oplegia. T here may be
sling is advised. congenital aplasia of the oculomotor nerves. A
ptosis may be associated with an epicanthus.
Ptosis258 Marcus Gunn jaw-winking phenomenon (Figs.
35.4 and 35.5) are characterized by unilateral ptosis,
Ptosis (Gk, ptosis, fall) is the drooping of the upper the drooped lid rising above when the patient opens
lid. The majority o f cases are congenital. It may be his or her mouth or moves the jaw to the other
unilateral or b ilateral, partial or com plete. side. It is most likely due to abnormal nervous
Table 35.3 gives a classification o f ptosis. communication from the trigeminal to the levator
muscle.
Congenital ptosis
Apparent or pseudoptosis
Majority of such cases follow dystrophy of the
levator palpebrae superioris (dystrophic), while the Apparent or pseudoptosis is due to lack o f support
remaining cases are due to aponeurotic defects and of the upper lid as occurs in microphthalmos,
nerve palsies (nondystrophic). A congenital ptosis phthisis bulbi, empty socket, etc.
may be simple, complicated or synkinetic.
M echanical ptosis
Sim ple congenital ptosis
Mechanical ptosis follows a heavy upper lid due
It occurs in 75 to 80% of all cases and is often to inflammation, tumour, oedema or haemorrhage.
M yogenic ptosis

Myogenic ptosis due to myasthenia. Myasthenia


gravis is characterized by its chronic course and
tendency to relapse. It occurs usually in adults,
and involves the extraocular and other muscles such
as the bulbar, neck and shoulder muscles causing
abnorm al exhaustion especially detected by
electromyography (EMG). Though it is generally
known that the condition is due to a curare-like
block at the myoneural junction, recent findings
denote the condition may be due to the production
of an antibody by the thymus against muscle end-
plate protein. Persistent thymus is present in about
one-third of the cases.
It is clinically characterized by ptosis (Figs.
35.6 and 35.7) increasing with fatigue, often
asymmetrical and bizarre paresis o f the extrinsic

Fig. 35.4 Marcus Gunn syndrome. Left ptosis


(Dr. A.K. Mitra).

Fig. 35.6 Ptosis in myasthenia gravis.

Fig. 35.7 Improvement of ptosis after prostigmine


injection.

muscles, weakness of the orbicularis oculi and


Fig. 35.5 Note the improvement of ptosis and occasionally weakness of the muscles of the palate,
apparent shooting up of the paretic upper lid on opening p h ary n x , tongue and larynx. In jec tio n o f
mouth (Dr. A.K. Mitra). prostigmine intramuscularly or injection o f a
quickly acting edrophonium hydrochloride causes may be aneurysm o f the carotid, cervical
(Tensilon) intravenously is o f great diagnostic cord injury or tumour, enlarged cervical lymph
importance. glands and mediastinal tumours.
Sympathetic ptosis is almost always a unilateral
M yogenic ptosis due to m yotonic dystrophy.
condition with the following features present on
Myotonic dystrophy is characterized by myotonia,
the affected side:
i.e. excessive contractility but with poor tendency
to relax and distal muscular dystrophy along with (a) Slight ptosis due to paralysis of Muller’s
ptosis, myopathic facies, cataract, baldness, among muscle
others diagnosis is aided by EMG. (b) Smaller pupil
(c) Pupil dilates less well with cocaine drops
Paralytic ptosis
(d) Reduced sweating indicating preganglionic
A palsy o f the levator palpebrae superioris may be lesion
due to a lesion o f the oculomotor nerve in any part (e) Elevation of the lower lid due to paralysis
o f its course— su p ran u clear, nuclear and o f smooth muscle attached to inferior rectus
infranuclear.
(f) Lighter colour o f the iris in congenital cases.
The levator is the only extrinsic muscle having
a separate representation in the parietal lobe o f the L ocalization is possible w ith 1 per cent
cortex. So, an isolated ptosis can occur in a cortical hydroxyamphetamine (Paredrine) instillation. After
lesion. instillation in both eyes either both pupils dilate
A unilateral ptosis with dilated pupil is seen in indicating central or preganglionic lesion, or the
a temporal lobe tumour. affected pupil does not dilate pointing towards a
A midbrain lesion produces usually bilateral postganglionic lesion.
ptosis, with constricted pupil and often impaired
elevation o f the eyes. Parinaud’s syndrome. Traum atic ptosis
A supranuclear lesion causes ptosis but with
parallelism of the eyes. Traumatic ptosis may be due to the direct injury
A nuclear lesion produces ptosis often with other o f the muscle or its nerve supply.
muscle palsies.
A peripheral oculomotor lesion produces total In v e s tig a tio n s o f p to sis. The follow ing
and unilateral ptosis. investigations are needed:
1. History. Time o f onset, progress, fluctuation,
any birth trauma and hereditary factors.
Pseudoparalytic ptosis
2. Amount o f ptosis in primary position. This is
roughly judged by measuring the width o f the
This may be: (a) atonic as atony of the levator in
palpebral fissure in the primary position of the eyes.
senility; and (b) hypertonic as in hysteria and
However, a better assessm ent is possible by
parkinsonism.
measuring the distance from comeal light reflex to
the upper eyelid in the primary position. This
Sym pathetic ptosis (H orner’s distance is called margin reflex distance which is
syndrome) 5 mm. In ptosis this distance is reduced.
3. Amount o f levator function. The presence of
Sympathetic ptosis or Homer’s syndrome is due folds in the upper lid is indicative o f levator
to total or partial interruption of the sympathetic function. In order to assess the function, first press
chain anywhere along its course between the the patient’s brow to eliminate the action of the
hypothalamus and the eye. Among others the frontalis muscle, and the patient is asked to look
downward and then upward. The am ount o f Treatment Treatment varies according to the cause
excursion is measured while holding the brow by and degree of ptosis.
the other hand. The function is graded as follows: The most common variety is simple congenital
0.15 mm — normal ptosis and the optimum time is decided by the
0.8 mm — good droop of the upper lid Operation is desirable at four
0.5-7 mm — fair or five years and even earlier in a bilateral ptosis
0.4 mm or less — poor covering the pupillary area by the drooped lids.
These operations perhaps occasionally achieve
Levator function may be assessed by measuring ideal results—strengthening of the levator, through
the margin limbal distance which is the distance the conjunctival surface or through the skin surface.
from the 6° clock limbus to the central upper eyelid This is indicated when levator function is present.
margin while the patient looks in extreme upgaze. A plan for levator resection has been given in
Normally it is 8 mm. In ptosis it is reduced. Table 35.4.
4. Visual acuity. Table 35.4
5. E xam ination o f the eyes for ocular Type of Levator Resection Depending on Levator
m ovem ents, presence o f lid lag and B e ll’s Function5
phenomenon. Amount of levator Type of operation
6 . Pupillary reactions. function indicated
7. Check-up for normal tearing and normal 10 mm or more Fasanella-Servat
comeal sensibility. Less than 10 mm with Aponeurotic
more than 2 mm ptosis
8 . Any jaw-winking phenomenon. 6 mm or more Posterior approach lev. res.
4 mm or more Anterior approach lev. res.
Figure 35.8 presents the flow chart of diagnosis
Less than 4 mm Brow suspension
of ptosis.

Drooping of upper lid


Г ----------- 1
Ptosis Pseudoptosis

Congenital Acquired

Simple Complicated
1
Examination of pupils

Г ------------ 1-------------
Normal pupils Smaller pupil Dilated pupil

History No history Homer syndrome Neurogenic


of injury of injury evaluation
+
Traumatic Myogenic Computerized
tomography
Cl. features+
Tensilon
Intracranial tumour
Aneurysm
Myasthenia gravis Myotonic dystrophy

Fig. 35.8 Ptosis in myasthenia gravis'.

b
M otais’ operation is the utilization o f the The cystic benign tumours are adenoma of
superior rectus to elevate the lid, if the levator is sebaceous glands, adenoma of sweat glands and
paralysed but the superior rectus is active. milia.
H ess' operation is the suspension o f the upper
lid from the frontalis muscle, when both the levator Papilloma
and superior rectus are paralysed.
In minimal degree o f ptosis, the Fasanella- Papilloma is the most common benign tumour
Servat operation is indicated in which the upper 4 o f the eyelid. The number may be single or
to 5 mm of the upper tarsus with the palpebral multiple. It may be sessile or pedunculated. It is
conjunctiva, Miiller’s muscle and the levator are usually found at the lid margin near the medial
engaged in the jaws of artery forceps and excised. can th u s. Its co lo u r resem bles that o f the
neighbouring skin.
Tumours of Eyelids4,11
H istology. There are papillae with vascularized
Tumours of the eyelids are classified as depicted connective tissue covered by acanthodc epithelium.
in Table 35.5. Treatment consists o f excision. Recently, carbon
dioxide laser ablation has been found to be
Table 35.5 effe c tiv e in co n tro llin g the incision and
Classification of the Tumours of the Eyelids haemostasis.

1. Epithelial Seborrhoeic keratosis


Cutaneous Benign: Papilloma, seborrhoeic
keratosis, molluscum contagiosum, Seborrhoeic keratosis is also called basal cell
senile keratosis, trichoepithelioma, papilloma. Microscopically it is differentiated from
cornu cutaneum, keratoacanthoma a basal cell carcinoma by the deposition o f keratin
and xanthelasma in crypts.
Malignant: Carcinoma, xerodermal
pigmentosum
Glandular Benign: Adenoma of sebaceous M olluscum contagiosum
glands or of sweat glands
Malignant: Adenocarcinoma Molluscum contagiosum is characterized by the
2. Mesenchymal Benign: Fibroma, lipoma, myoma, presence of small, globular, umbilicated epithelial
myxoma and chondroma tumours of the skin.
Malignnant: Rhabdomyosarcoma,
fibrosarcoma, myxosarcoma, Xanthelasma
liposarcoma, fibromyxosarcoma and
leiomyosarcoma X anthelasm a or xanthom a occurs in elderly
3. Vascular Haemangioma, lymphangioma w om en and som etim es associated w ith
4. Melanotic Benign: Naevus, melanoma h y p erch o lestero laem ia and diabetes. It is
Malignant: Malignant melanoma
characterized by the presence of slightly raised,
5. Nerve tissue Neurofibroma and neurilemmoma
6 . Reticuloses Lymphoma, rcticulumcell sarcoma yellowish skin plaques on the inner parts o f the
and lymphosarcoma upper and those of the lower lids (Fig. 35.9). They
7. Developmental I Dermoids, teratoma and choristoma grow very slowly. Histologically there are lots of
histiocytes distended with fat-forming foam cells.
Benign epithelial tumours Treatment is needed when it causes disfigurement.
The measures include full-thickness excision,
Benign epithelial tumours may arise from the skin sometimes advancement flaps, grafts or carbon
or glands, or they may be noncystic or cystic. dioxide laser application.
Table 35.6
Proders' Gradation of Malignant Tumours

Differentiation De-differentiation
(percentage) (percentage)
Grade I 100-75 0-25
Grade II 75-50 25-50
Grade III 50-25 50-75
Grade IV 25-0 75-100

The usual locations are: (a) lower eyelid— 54%


(b) inner canthus— 28%; (c) upper eyelid— 13%;
Fig. 35.9 Xanthelasma.
and (d) outer canthus— 5%.
Three types are common: (a) basal cell—85%;
(b) squamous cell— 10 %; and (c) adenoidal basal—
Senile keratosis
5%.
It is common between 50 and 55 year and is
Also called solar keratosis is characterized by dry,
predominantly in males.
wrinkled, hyperpigmented skin patches on exposed
Carcinomas arise in an otherwise normal skin
areas.
without any apparent cause. Only at times chronic
irritation is a precipitating factor.
Trichoepitheliom a
Pathology. Basal cell carcinomas are locally
Trichoepithelioma is a rare lesion. It starts as wart- malignant, and tend to form adnexal structures
like growths in the regions o f face, lids and w hile squam ous cell carcinom as are highly
eyebrows. It is basically a tumour o f the hair malignant with a tendency to metastasize and they
follicle. tend to cause anaplasia.
There is epidermal invasion with downgrowth
of columns o f epithelial cells, the downgrowth
Keratoacanthom a
showing secondary budding processes laterally and
terminally (Table 35.7).
Also called molluscum sebaceum keratoacanthoma
is particularly characterized by its rapid growth,
Table 35.7
maximally within 6 to 8 weeks. Keratin material is
C ellu lar A rrangem ent o f Squam ous C ell C arcin o m as
found within crater-like lesion.
Peripheral C ylindrical cells
Cornu cutaneum Interm ediate Prickle cells
C entre Squam ous cells
Cornu cutaneum is a clinical term to describe a
hyperkeratotic condition superadded on conditions ‘Cell nests’ are compressed squamous cells
like papilloma, senile or seborrhoeic keratosis and staining strongly with acid dyes, e.g. eosin. In basal
Bowen’s disease. cell carcinoma, the cells are basal cells o f the
epidermis taking basophilic stain, and do not show
Carcinoma of the Lid8 ‘cell nests’.
Clinical features (Fig. 35.10). Carcinoma o f the
B ro d ers’ classificatio n is as depicted in lid has a slow, insidious and painless onset. It
Table 35.6. occurs at or near the lid margin. At first there is
Xeroderm a pigm entosum

Aetiology. Xeroderma pigmentosum is presumably


an actinodermatosis of alarming nature. Recessive
trait is well documented, especially with a history
of consanguinous marriage. It starts within the first
decade of life.
Clinical features. The eyelids are frequently
and primarily affected. The stages o f affection are
Fig. 35.10 Malignant tumour of left upper lid. (a) acute erythema following exposure to sunlight;
(b) diffuse pigmentation; (c) atrophy o f the lid
an indurated, elevated and sharply demarcated especially the lower with sequelae like entropion
nodule w ith an irregular surface. T here is or ectropion; (d) exposure keratitis followed by
infiltration into the skin. It is freely mobile over ulcer; and (e) involvement o f the orbit. The
the underlying tissue unless strictly at the lid affection is fatal.
margin. The next stage is characterized by a thin
and more glossy skin with development of an M esenchym al tum ours
abnormal vascular pattern. Finally, it develops into
a typical carcinomatous ulcer. Mesenchymal tumours are rather rare and they
include myoma, rhabdomyoma of the orbicularis,
Diagnosis. The diagnosis is made from the clinical leiomyoma, fibroma and lipoma.
features and histological study using excisional
biopsy in small tumours, incisional biopsy in large Haemangiom a
ones and fine-needle aspiration biopsy (FNAB).
Complications and sequelae. These include: Haemangiomata are common tumours. O f the four
(a) Occlusion of meibomian ducts types described below, the first two are rather
(b) Erosion of the entire lid margin common.
(c) Fungation C apillary angiom a or telan giectasia. It is
(d) Involvement of the orbital tissues. histologically characterised by endotheliallined
Treatment The principles of treatment include dilated capillaries with little connective tissue
the following measures: stroma. It is clinically exhibited as portwine spots
Surgery. Most small basal cell carcinomas can involving small or large portions of the eyelid and
be excised along with clinically normal tissue the face, often following first and second divisions
margin. The large lesions are dealt with wide o f the trigeminal nerve.
ex cisio n follow ed by lid reco n stru ctio n . Naevus flammeus. the characteristic capillary
Exenteration is resorted to when there is orbital angioma, forms one of the features of Sturge-Weber
involvement. syndrome.
Radiotherapy is indicated in cases which are Cavernous haemangioma. It is histologically
unsuitable for operation and small basal cell characterized by encapsulated masses of endothelial
carcinoma not affecting the medial canthus. spaces in the subcutaneous tissue. Clinically it
Cryotherapy is only tried in superficial, small appears as a reddish elevated tumour, soft and
basal cell carcinoma. compressible and increasing in size by venous
Chemotherapy helps in reducing the large size congestion (by crying or bending the head). The
o f basal cell carcinoma and is indicated when the tumour may spread to involve the cheek or even
patient refuses exenteration to be done. orbit.
Plexiform angioma. It occurs very rarely in infants may be secondarily involved causing proptosis and
and presents as nodular tumour with bleeding pulsation.
tendency. Operative treatment may be advocated but it is
Angioendothelioma. It is also very rare. There is always unsatisfactory.
proliferation of endothelial cells causing reduction
of the blood space. M elanotic tumours

Treatment. If small, they may be treated by Normally the basal cells of the epidermis contain
electrolysis or excision. Injection o f sclerosing fluid melanin derived from melanocytes.
such as 5 per cent sodium morrhuate may be given
in large ones tumours. Naevus or mole
They may be left untreated since some of them
Naevi occur at the lid margin, sometimes presenting
usually disappear.
Cryoapplication may be effective in destroying as hairy mole (hairs arise from its surface) and
small superficial lesions. sometimes as divided naevus, i.e. partly on the
upper lid and partly on the lower, both together
Systemic steroids give sometimes dramatically
form ing a com plete one. T hey p resen t as
successful results in o rb ital and adnexal
birthmarks, but develop actively at two stages of
haemangiomata. They perhaps exert an inhibitory
action on immature vascular tissue or act as life— infancy and puberty.
Naevus is composed of naevus cells. These cells
nonspecific antiinflammatory agents.
are small with deeply staining nucleus and scanty
Carbon dioxide laser may be tried.
cytoplasm, arranged in nests, sheets or strands.
They are divided into four groups: (1) junctional;
Lym phangiom a
(2) compound; (3) intradermal; and (4) blue, the
former three from the epidermis and the remaining
Its incidence in the lid is rare. It is slowly
from the dermis.
progressive. It may be simple capillary or cavernous
Treatment is cosmetic.
type. Treatment is same as that o f haemangioma.

Malignant Melanoma of the Eyelid


Neurofibromata or von
Recklinghausen’s Disease Malignant melanoma of the eyelid is rare before
puberty. The majority often appear to develop in
Neurofibromatosis causes lesions in the peripheral a preexisting naevus which has remained quiescent.
sympathetic nerves and the central nervous system, However, it is signalled by the increase in size
with cafe-au-lait pigmentation and hypertrophy of and pigmentation, consistency becoming harder
skin and subcutaneous tissues. and the fixity.
Three classical types of lid lesions are seen:
Pathology. Malignant melanoma of the eyelid
(a) Plexiform neuroma which affects usually the shows all the features of malignancy: cellular
upper lid causing it to be thickened and pendulous pleomorphism, hyperchromatic nuclei, mitosis and
in the advanced state; usually areas o f necrosis.
(b) Diffuse neurofibromatosis which causes The changes that occur are: (a) the migration
involvement of both lids and face; and o f epiderm al pigm ent into the derm is and
(c) Molluscum fibrosum which may appear as subsequent phagocytosis; (b) the increased
soft subcutaneous multiple tumours. number of clear cells in the basal layer of the
Association with buphthalmos and medullated epidermis; (c) the mild infiltration with chronic
nerve fibres has been noted. Orbits and skull bones inflammatory cells in the superficial dermis;
(d) irregular deposits o f clumped intradermal the facial nerve and resection of a band, about 8
melanocytes and subsequent pleomorphism; and mm o f the orbicularis.
finally (e) the invasion of the dermis by malignant
Blepharoclonus. This is the involuntary rhythmic
cells.
contraction of the orbicularis fibres. It may involve
The cellular types are: (a) the epithelioid
the whole o f the orbicularis oculi or some o f its
cells—more common types; (b) the naevoid cells;
fibre bundles. When fibrillar twitching occurs in
(c) the spindle cells; and (d) the bizarre cells.
some fibre bundles especially near the outer
Prognosis depends on the cellular content. Those
canthus, this condition is termed myokymia. These
with spindle cells is good while it is bad with
involuntary contractions occur in fatigue and
epithelioid cells.
irritability.
Treatment Treatment of choice is wide surgical
excision. Lid retraction. Normally in an adult the upper lid
margin cuts the limbus 1 to 3 mm below its highest
Abnormal Lid Movements9 point, but if in the primary position o f the eyes
the upper lid margin so rests that a rim of the
sclera is visible, lid retraction is said to be present
The rate o f blinking is on an average 3 to 7 times
(Fig. 35.11).
per minute.
The causes o f abnormal lid movements are:
(a) blinking; (b) squint; (c) tic; (d) blepharospasm;
(e) blepharoclonus; (f) lid retraction; (g) lid lag;
and (h) Bell’s phenomenon.
Blinking. Blinking may be reflex, spontaneous,
voluntary and spasmodic. Reflex blinking may be
sensory reflex and optical blink reflex.
Spontaneous blinking occurs in weaking hours.
V oluntary blinking or winking is usually
uniocular. It is assisted by the orbicularis muscle. Fig. 35.11 Bilateral lid retraction and protosis.
In creased b lin k reflexes are due to any
inflam m ation, fatigue, strenuous close work, Aetiology. The main causes are listed in Table 35.8.
psychopathic tic and blepharospasm. Decreased
Table 35.8
blanking occurs in dysthyroid ophthalmopathy and
progressive supranuclear palsy. M ain Causes o f R etraction o f U pper Eyelid

Tic. This involves clonic contractures of isolated Physiologic: in the new born
orbicularis fibres. Dysthyroid
Cicatricial
Blepharospasm. This is involuntary, persistent and Posttraum atic
strong orbicularis spasm causing firm closure of Postsurgical
the eyelids lasting from few moments to few days. Mechanical
Trachom atous upper lid
The causes include: (a) the most common is the Proptosis
reflex sensory irritation through the trigeminal; (b) High myopia
stim ulation o f the facial nerve or its central Buphthalmos
connections; and among others (c) hysteria. Facial nerve palsy
Treatment is always difficult and may need M arcus Gunn syndrome
Drug induced
canthotomy or canthoplasty, injection of alcohol
Phenylephrine, apraclonidine. etc.
into the orbicularis, neurectomy of branches of
Lid lag. When the upper lid lags behind during the of the lid-folds. Treatment is essential when there
downward movement o f the eyeball, the condition is corneal exposure due to a large defect. It consists
is described as a lid lag. It is a characteristic feature of plastic repair and occasionally an end-to-end
of dysthyroid ophthalmopathy. anastomosis.
B ell's phenom enon. Physiologically there is Ankyloblepharon. It is the fusion of the upper and
synergistic up and out deviation of the eyeballs on lower lid margins particularly at the lateral side. It
lid closure, and this nociceptive reflex is called should be separated surgically if it is disfiguring.
Bell’s phenomenon. It occurs in sleep and coma, Ptosis. Most ptosis cases are congenital and are
and also on attempted closure in facial paralysis. It caused by a lack of peripheral differentiation or
may be absent in normal patients or in congenital aplasia o f the levator palpebrae superioris. The
supranuclear oculom otor paralysis. When the condition has been described with other types of
eyeballs deviate downwards it is called an inverse ptosis.
B e ll’s phenom enon or a perverse B e ll’s
phenomenon. Congenital entropion. This abnormality is a rare
condition affecting the lower lid. It may be
confused with an epiblepharon, the latter being
Abnormalities of the Palpebral
characterized by redundant horizontal skin fold
Aperture
adjacent to the lower lid margin.
The antagonistic muscles—the orbicularis oculi and Congenital ectropion. This abnormality is also rare
levator palpebrae superioris— assisted by Muller’s and may be associated with blepharophimosis.
muscle determine the width o f the palpebral
Blepharophimosis syndrome. It exhibits bilateral
aperture.
ptosis, blepharophimosis, telecanthus, lower lid
Widening of the fissure results from facial nerve
ectropion and epicanthus inversus.
palsy, exophthalm os, high m yopia and
buphthalmos. Epicanthus. This is a semilunar skin-fold situated
Narrowing of the fissure occurs from ptosis, above and at times across the inner canthus. It is
Homer’s syndrome and enophthalmos. usually bilateral. It produces an apparent convergent
squint. It is a racial characteristic of mongolism.
Developmental Abnormalities of Telecanthus. It means increased width between the
Eyelids and Palpebral Fissure medial canthi. Unless it disappears with age
operation such as Spaeth’s Z-transposition or
Colobomas. A coloboma is a notch primarily Mustarde’s operation of producing a horizontal scar
affecting the lid margin. One or all four lids may across the medial canthus is called for.
be involved. The degree of defect is variable. It Epiblepharon. This is a prominent skin-fold in front
may be a slight indentation o f the lid margin to of the lower tarsus usually at its medial margin. It
nearly complete absence o f the lids (ablepharon). usually resolves spontaneously.
Abnorm ally small lids may be present, this
co n d itio n is called m icro b lep h a ro n . W hen Cryptophthalmos. This condition is rare. It is
coloboma develops in the lower lid it usually affects caused by the complete failure of the development
the lateral side. of the lid folds. The skin passes continuously from
More commonly the medial part of the upper the eyebrow over the hidden eye to the cheek.
lid is affected. It may be associated with craniofacial Blepharochalasis. It is characterized by redundant
dysostosis, Treacher-Collins syndrome. skin of both upper lids hanging down over the
The condition occurs due to injury from the eyes. It is often hereditary. Treatment is by surgical
amniotic bands or localized failure of the adhesion correction.
B lep h a ro p h im o sis. This is the generalized 5. Fox, S.A. Ophthalmic Plastic Surgery (4th ed.),
narrowing o f the palpebral fissure. It can be Grune and Stratton, New York, 1970.
surgically dealt with. 6 . Harley R.D. (Ed.), Pediatric Ophthalmology,
Euryblepharoru This is the generalized enlargement W.B. Samelers, Philadelphia, 1975.
o f the palpebral fissure. Treatment is by lateral 7. van Heuven, W.A.G. and Swann, J.T. (Eds.),
tarsorrhaphy. Decision Making in Ophthalmology, Mosby
Distichiasis. In this condition there are double rows Year Book, St. Louis, 1992.
of eyelashes, extra row situated in the line of the 8 . Kanski, J.J., Clinical Ophthalmology (3rd ed.),
openings o f the Meibomian glands. The extra lashes Butterworth-Heinemann, London, 1994.
should be removed, otherwise they will irritate the
com ea. Treatm ent consists o f destruction o f 9. Newell, F.W ., Ophthalmology: Principles
eyelashes by electrolysis or cryoapplication. and Concepts ( 8th ed), C.V. Mosby, St. Louis,
1997.
Dermochalasis. It occurs in senile eyes wherein
there is redundancy of the lid skin associated with 10. Pau, H ., D ifferen tia l D iagnosis o f Eye
herniation through the orbital septum. Often there Diseases, trans. Cibis, G.W., W.B. Saunders,
is a family history. Treatment is by blepharoplasty. Philadelphia, 1978.
11. Reese, A.B., Tumours o f the Eye (2nd ed.),
Oedema of the Lids Hoeber Division, Harper and Row, New York,
1963.
O edem a o f the lids m ay be c lassified as: 12. Trevor-Roper, P.D. and Curran, P.V., The Eye
inflammatory—due to inflammations of the lids, and Its D isorders (2nd ed.), Blackw ell
conjunctiva, lacrimal sac, orbit and nasal sinuses; Scientific, Oxford, 1984.
and passive—due to circulatory obstruction, e.g.
renal diseases and cardiac failure.
Oedema o f the eyelids is a common condition.
The eye may be covered by profound oedema of 36. DISEASES OF THE
the lids. LACRIMAL APPARATUS
A n g io n eu ro tic oedem a, perhaps due to
vasomotor instability, is a condition where there is
an intermittent acute oedema of the eyelids. Diseases of the Lacrimal Gland

F u rth er R eading The various disorders may be enumerated as


follows:
1. A hm ed, E. and Roy, S.N ., O phthalm o- (a) Disorders o f Hypersecretion
dermatozoosis: a study o f fifty cases, J. All secretion Paradoxic lacrimation
India Ophthalmol Soc., 17: 145, 1969. Hyposecretion
2. Beard, C., Ptosis, C.V. Mosby, St. Louis, 1969. (b) Inflam m ation - acute and chronic
3. Collin, J.R.O., A Manual o f Systematic Eyelid dacryoadenitis
Surgery (2nd ed.), Churchill Livingstone, (c) Tumours
Edinburgh, 1989. (d) Congenital anomalies
4. Duke-Elder, S., System o f Ophthalmology, Vol. (e) Atrophy
XIII, Part I: Diseases o f the Eyelids, Duke-
(0 Involvement in systemic diseases
Elder, S. and MacFaul, P. (Eds.), Kimpton,
London, 1974. (g) Trauma
Hypersecretion of Tears1,11 release of hydroxypropyl methyl cellulose over
12 hours.
Excessive tears may be due to stimulation of the (c) Soft contact lens
basic secretors or reflex secretors as in: (a) exposure (d) Temporary punctal occlusion. It can be done
to wind, cold or bright light; (b) inflammations of temporarily by agent like Teflon.
the conjunctiva, lids, orbit, comea, uvea, and nasal (e) Other measures include instillation of 10 to
sinuses; (c) lid lesions; and (d) parasympathetic 20 per cent acetylcysteine 6 hourly, parotid duct
stimulation. transplantation which is often unsatisfactory, fitting
Oversecretion of tears can be allayed by alcohol of artificial tear tank, and 0.01 per cent topical
injection into the gland, by excision or irradiation. vitamin A (Tretinoin) thrice daily.

Paradoxic Lacrimation Acute Dacryoadenitis1


Incidence o f acute dacryoadenitis is rare. Three
Also known as ‘crocodile tears’ it occurs as a sequel types are known: (a) palpebral; (b) orbital; and
to facial nerve palsy. There is an aberrant (c) orbitopalpebral.
regeneration of the nerve fibres. It is evidenced by
Aetiology. Acute dacryoadenitis may be primary
hypersecretion of tears while eating. The affection
or secondary. In the first instance the cause is not
is mostly unilateral and very rare.
obvious. It occurs especially in children and
adolescents, it is unilateral, mild and it affects the
Dry Eye7,10,11 palpebral lobe. In the second instance the causes
are local as in trauma and erysipelas, and metastatic,
Aetiology. The causes include: characteristically as in mumps which is the most
(a) Xerosis caused by cicatricial degeneration common cause.
of the conjunctiva and other mucous tissues as in Pathology. The features include: (a) swelling and
Sj 6gren’s syndrome, Stevens-Johnson disease, proliferation of the epithelium of the glandular
trachoma and alkali bum ducts; (b) degeneration and casting off o f the cells
(b) Sensory lesions of the V cranial nerve into the lumen; (c) surrounding of the remaining
(c) Keratoconjunctivitis sicca—typically in part by the infiltrative cells (lymphocytes, plasma
Sjogren’s syndrome cells, polymorphs, etc.); (d) vascular lesions which
(d) Systemic diseases such as pemphigus and include thrombosis, necrosis, obliterative arteritis
benign mucous membrane pemphigoid. and phlebitis; (e) infiltration o f the connective
Clinically the patients complain of dry and gritty tissue between the alveoli, around the vessels and
sensations. Investigations are described under nerves; and (f) finally sclerosis, fibrosis and
Sjogren’s syndrome. thickening.
Treatment. Several measures are advocated but C linical fe a tu res. C linical features include:
none is particularly effective. (a) oedema o f the lids spreading towards the temple
(a) Artificial tears. There are tears and lubricants and cheek and causing mechanical ptosis with a
available with methyl—or ethyl cellulose base, e.g. S -shaped curve o f the upper lid m argin;
isoptotears, tearisol, etc.; hypoosm otic base; (b) localised chemosis in the upper and outer
polyvinyl alcohol base; polyvinylpyiToline polymer quadrant; (c) conjunctival congestion; along with
or other polymers. palpable and tender preauricular gland; and
(b) For prolonged action one 5 mg insert (d) constitutional upsets such as pain, fever and
(lacrisert) is inserted every morning into the malaise. The orbital type produces less chemosis,
lower fomix and the insert swells up 10 times its more pain because of constriction o f the orbital
original size by imbibition of fluid resulting in slow part by the fascia, and slight down and in proptosis.
Complications and sequelae. Acute dacryoadenitis d acry o ad en itis, tu b ercu lo u s and m alignant
usually resolves w ithin one to two w eeks. conditions.
Suppuration may ensue in some cases leading to
abscess and then fistula. Subacute dacryoadenitis Dislocation of the Lacrimal Gland1
may follow in other cases which resolves in one
to three months. Sequelae include fistula, atrophy, D islo catio n o f the lacrim al gland m ay be
cyst formation and hyposecretion. spontaneous of traumatic. The probable cause is a
Treatment Treatment consists of heat, antibiotics weakness o f the orbitopalpebral fascia.
and measures to allay the symptoms.
TUmours of the Lacrimal Gland1,2,4,11
Chronic Dacryoadenitis1 Lacrimal gland tumours are relatively rare. They
may be benign or malignant, epithelial or non-
Aetiology. The various causes may be: (a) a sequel epithelial. The important ones are pleomorphic or
to acute d a cry o ad e n itis; (b) trachom a; benign m ixed tum ours, adenocarcinom a and
(c) tuberculosis; (d) leprosy; (e) syphilis; and reticuloses. Epithelial tumours and lymphosarcoma
(f) sarcoidosis. comprise 50 per cent o f the cases.
Trachomatous dacryoadenitis. This may arise
Clinical features. Clinical features include ptosis,
in two ways, by sclerosis of the gland secondary
raisin g o f the eyebrow , palpable grow th,
to trachomatous cicatrization o f the subconjunctival
displacement of the eyeball down and in, diplopia
tissues leading to obliteration of the ductules and
and occasional proptosis due to posterior extension
by direct invasion o f the gland by trachoma.
o f the tum our. In m alignant tum ours, other
Tuberculous dacryoadenitis. This may be
additional features may include enlargement o f the
acute miliary and localized. A localized type may
neighbouring glands, swelling of the lids due to
be either in the sclerotic form, forming a granuloma
oedema or infiltration, and pain due to tumour
or in the caseous form.
involvement o f the nerves.
Mikulicz syndrome is characterized by bilateral,
X-ray shows an enlarged lacrimal gland fossa.
chronic symmetrical enlargement o f both lacrimal
In benign variety, the surrounding bones may show
and parotid glands due to obscure aetiology but
no evidence o f involvement for a long time. In
usually with lymphoid tissue hyperplasia.
malignant tumours, early bone involvement, often
Differential diagnosis. An acute dacryoadenitis hyperostosis and rarely erosion, is a characteristic
should be differentiated from: (a) lid abscess; feature.
(b) stye; (c) a suppurative chalazion; (d) an acute Biopsy (by direct/or lateral approach) is an
purulent conjunctivitis; (e) a