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Opthalmology for Naturopathy Fall 2006


Dr Peter Shaw O.D.

Scarborough Low Vision Centre
3030 Lawrence Avenue , suite 206, Scarborough
416 438 3525
5915 Leslie Street, suite 205, Willowdale
416 4394 3050

• My notes are in blue.
• The order of the lecturer’s notes was rearranged slightly to reflect the order of
• The sections without any additional notes were not discussed in class. I’m assuming we
are still responsible for them…

Review of Eye Physiology

Knowing anatomy of eye helps differentiate pathologies.
Eye = Digital video camera.
Blur/fog is a problem with light transduction. Blind spot may be a neural problem.
Lens/Cornea = Lens system.
Retina = CCD/Film + Image compression sofware!
Retina is part of brain: functions as cortical tissue. Sends multiplexed signal to brain.
Optic nerve and tract = USB Cable
Visual Cortex = Image decoding software and Magic!
Brain receives decoded picture. Visual cortex: perception of vision.

Always be thinking laterally with eye disorders: What else is wrong? Look for associated
disease. The eye is not separate from the rest of the body.

Infective organism
Age related
• Most children are born slightly far-sighted. Uncorrected farsightedness in children:
accommodation, associated convergence, child’s eyes turn in. “Lazy eye” can occur.
Children should be examined before age 3.
• People from tropical countries tend to need reading glasses 4-5 years earlier. May be due to
the amount of sunlight they are exposed to.
• Flicker of old-school computer screens is not good for the eye/brain. The eye likes stable,
high contrast (books). New computer screens are better: light doesn’t flicker. This is the


only time when not wearing glasses causes harm. Flickering can trigger epileptic episode in
susceptible people.
Secondary to other disease
Iatrogenic (treatment, medication side effects)
Combination of any/all

Blurred Vision
Diplopia (double vision)

Refractive Errors

Can see close, can’t see far. Nearsighted. Optical focus of eye isn’t correct. Disorder of growth.
More common in larger eyes.
Light rays focus in front of retina, patient can see well at near but distance blurred
Corrected with concave spectacle lenses or contact lenses
Usual age of onset 8 – 20
usually stable after age 20
Causative factors: genetic, environmental? diet (if severe malnourishment)

More common in smaller eyes: point of focus is behind retina.
Light rays focus behind retina when accommodation relaxed (cilliary muscle = accommodation.
As we age, we can no longer accommodate: lens becomes more dense.)
Age of onset birth after 40
Accommodation can compensate in younger patient
Far Sightedness (Near vision poorer than distance)
Eyeglasses contact lenses
If left uncorrected amblyopia and strabismus may be a result
All children should be screened for this, a chief cause of reading/learning dysfunction

Refracting surface is not spherical, but egg-shaped. Pointless vision.
Very common
Cornea has a cylindrical profile (like the side of an egg)
Changes through-out life
Spectacles /contact lenses
Age of onset: 0-all


Affect reading and distance vision (blur at all distances)
Symptoms include headaches, poor reading skills, squinting

This happens with every person: inability of eye to focus with age.
Normal physiological changes in crystalline lens preventing accommodation
Lens proteins coagulate = higher density --- decreased elasticity
Cannot adjust to focus at near or adjust for hyperopia
Corrected with reading glasses (convex) or multi-focal lenses
Age of onset 40-50 stable at 60
Accelerated by UV exposure (earlier onset in those from tropical climates

Binocular vision anomalies

Can cause eye strain/problems.
Strabismus= Manifest (visible) deviation The eyes don’t line up to look at the same thing at the
same time. Can be corrected at a young age: neural pathways are plastic until age 4. If 1 eye is
turning in different direction, the brain turns the eye “off” to avoid confusion.
Esodiviation: 1 eye is turned in. Find out if this is the result of hyperopia.
Phorias=: Latent (hidden) deviation. Latent strabismus. Patient compensates by using muscles,
but this creates strain in muscles. If a child isn’t doing well in school, check their eyes and other
senses. If they can’t see properly, they can’t take in the information, and can’t concentrate.
They get distracted, don’t focus, don’t do well.
Periodic either Near or Far only
Correction with exercises
Correction with surgery
Amelioration with prism
In = eso tropia / phoria
Out = exo tropia / phoria,
Up = hyper tropia / phoria
Typically a lower deviation than a strabismus
Able to compensate
Binocular vision therapy may be applicable
Exophoria is most treatable
Symptoms are subtle but may cause blur and diplopia
Esophoria treated with bifocals in juveniles

Primary cause of distraction with children

Esotropia: first rule out accommodative esotropia
All children should be assessed by age of 3 years preferably at 6 months by an optometrist or
If untreated will most likely lead to amblyopia



Can be caused by hyperopia, ,strabismus. “Lazy Eye”: the RESULT of strabismus. Result of
brain turning off the eye.
Typically due to one eye not receiving a clear image prior to age 4
Visual cortex actively supresses a blurred eye or one causing double vision
Screen < age 4 for anisometropia (unequal refractive error), hyperopia and strabismus
Treatment consists of correcting the underlying disorder and possible patching/exercises
Treatment to be initiated as early as possible
Efficacy rapidly decreases after age 4
Lay term= Lazy Eye,

Common Disorders of the Eyelids

• Can grow inwards and scratch the cornea. Scratch leads to abrasion, can cause corneal ulcer.
Potential entry point for bacteria.
• Haziness from ulcer prevents clear vision. The cornea is avascular: we have trouble clearing
• Cornea is very sensitive, so patient will likely seek help for discomfort caused by scratching
• Primary treatment for all eyelash disorders: HYGIENE!
• Diet also an important factor. Epidermis of the eye is affected by the same conditions that
affect the rest of the skin. Good to help patients manage their diets.
• #1 pathogen of eyelids is staph. Opportunistic bacteria. It is everywhere, but will be
problematic if immune system is compromised.
Trichiasis: Misdirection of the eyelashes often resulting in corneal trauma and abrasion potential
causing a corneal ulcer
Phthiriasis palbebrarum: Lice of the eyelashes
Madarosis: Missing lashes, Alopacia, prosiasis, chronis margin disease

Allergic Disorders
Atopic Dermatitis:(Excema of the eyelids), associated with asthma and hay fever
Acute allergic edema,: unilateral or bilateral puffy lids without pain
Contact dermatitis:localised erythema and crusting

Chronic marginal Blepharitis:

• Can be treated by lid cleansing (there are products on market for cleaning lids, maintaining
good hygiene.)
Staphyloccocal infection and Seborrhhea play a major role
Due to the positionexpect secondary corneal pathology
Treatment through lid hygiene (lid cleansing) and artificial tears
Antibiotics may be useful as a kick start but not chronically. Antibiotics may not be necessary:
can lead to more serious reactions. Steroids are often prescribed too: may also be unnecessary!
Steroids may be used to treat associated complications Watch for symptoms of staph exotoxins
(injected conjunctiva, mild keratitis)
Tear film instability


• Glands in eyelids secrete mucin, water, oil to protect cornea. Eyelids maintain the integrity
of the cornea.
Lid Nodules and Cysts
• Determine if condition is acute or chronic
Chalazion: meibomian gland cyst, chronic lipo-granulomatous inflammatory lesion caused by a
blocked meibomian gland.
• A gland that becomes hard. Gets plugged
• Benign condition, but can be cut out if the patient desires.
• Lacrimal glands (above eye) flush stuff away, produce “crying” tears. Different from mucin
produced by meibomian glands in eyelids. Tears wash away mucin, leave the eye feeling dry
after crying. Mucin (water, oil) keeps eyes “wet”
• B6 may be good for encouraging the production of mucin (we will learn more about this in
other classes). There may be other systemic supplements that can help with this.
Internal Hordeolum: small abscess caused by acute staph. infection of meibomian gland. A
STYE. Can turn into chalazion if infection (staph) is chronic. Gradual transition from
hordeolum to chalazion.
External Hordeolum: acute abscess of lash follicle or
Xanthelasma: common in aged, yellow subcutaneous plaques of cholesterol and lipid
Lid Tumours: Non healing , pigmented, localised unilateral,

Mechanical Disorders of the lids

Ptosis: unilateral upper lid droop
Neurogenic: Third nerve palsy, oculo-sympathetic palsy
Horner’s syndrome, Mercus-Gunn jaw winking syndrome
Myogenic: Levator muscle Congenital, myasthenia gravis

Ectropian: Lower lid away from cornea, tissue dries dry eye Surgery, lubricant gels

Lower lid turn in, lashes abrade cornea,Treat with surgery/ soft contact lens
Potential for corneal ulcer (a bad thing)
• Caveat with laser surgery: patient must have no lid disorders! Need good mucin, especially in
immediate post-operative stage. Cornea has to be kept clean and moist for proper healing.

• When using contact lenses, FOLLOW THE RULES! Dispose of solution and lenses when
you are supposed to.
• #1 cause of conjunctivitis is allergy.
• Also called “red eye” (not “pink eye”)
Allergic - Viral – Bacterial –Toxic – Trauma
• If allergic: clear stuff will come out of the eye. Could indicate presence of toxin, foreign
• If discharge is stringy, mucous-y, or possibly clear, this is viral.
• If discharge is yellow-green: this is a bacterial infection. Patients may be given antibiotics,
but this may not help at all. (not sure why…)


Injected vessels
Palpebral – Inner lid
Bulbar – on the eyeball
• No yellow-green discharge, no pain? No problem.
• Eg. “Pink Eye”: common in daycares (epidemic). Contagious, but not treatable. Spreads
through rubbing eyes, through shared towels. No cure for pink eye: treat with hygiene.

Sub Conjunctival Hemorrhage

Solid red appearance to eye. Bleeding under conjunctiva. Burst blood vessel that leaks into
space between conjuctiva and sclera. Can’t see dilated blood vessels as you wood in
Causes? Hypertension, also look for systemic bleeding disorders.
Usually benign
Check Blood pressure
Resolves in two weeks
Possible blood dyscrazia

Giant Papillary Conjunctivitis

Papillae under the upper lid
Soiled soft contact lenses the primary cause
Disposable lenses advocated
Treatment = change contacts or discontinue
Tears and secretions
An even tear film = clear vision
Watery eyes = blur
2nd Most common cause of blurred vision after refractive errors
Causes: marginal blepharitis,lid disorders, dry eye, allergic conjunctivitis, viral conjunctivitis.
Cause changes in the tear film
Age, Envirionment, Allergies, Other diseases

Corneal Ulcer
• Some benign pathologies in other parts of body limit function in the eye: more serious
consequences in the eye. Ulcer on lip? Ok. Ulcer on eye? Painful, red eyes, excessive
tearing, blurring.
• Could be due to herpes simplex infection. Have to refer for antibiotic treatment.
Corneal ulcer or abrasion characterised by a white spot on the cornea
Herpes simplex, pseudomonas, opportunistic pathogens
Eye red, excessive tearing, blurred,
Refer immediately for treatment
Often associated with soft contact lens wear or injury abrasion
• The problem isn’t the virus, but the inflammation that the body creates as a response to the
• Associated with unhygienic soft contact use.



Mild inflammation of pinguecula
• “snow blindness”. Due to UV burn on eye.
Treat with sunglasses
May be due to excess uv exposure
Lubricants can be used to treat if it causes irritation.
• Pinguecula is a small pterygium

Red Eye: Pterygium

• Response to UV exposure. Seen especially in rural areas, farmers, fisherman. Can start in
corner of eye. Has to be removed as it grows over pupil.
fibrovascular tissue
• Fibrous: can’t see through it as it grows. Pulls on cornea and deforms it.
Common near the equator
Surgical excision when large

• Light is bent by cornea and lens.
Lens is made of proteins
Homogenous in clear lens
Random sizes in cataract
UV energy may cause proteins to “clump together”
• With age, proteins start to change and become opaque. Non-homogenous proteins in lens.
Like an egg white as it cooks: goes white and opaque.
Typical onset >65
Rarely <50
More common in sunny countries and outdoor lifestyle (UV component)
Congenital with rubella
Treat with surgical removal
Cataract surgery: Indicated when patients vision is less than they desire and cataract is the cause.
Surgery only needed when it bothers the patient.
“Ripe” is an antiquated term
No stitches (small incision through cornea) Lens is replaced with a plastic one.
20 minutes, local anaesthesia, out patient
• Possible correlation with free-radicals.
• Cornea doesn’t change with age.

Anterior Chamber Haze: Uveitis:

Inflammation of anterior structures releasing inflammatory cells into AC
Associated with other inflammatory conditions Arthritis, Cholitis etc
Be aware, your patients may be pre-disposed. (lupus, IBS, Chron’s, etc)