(Practical section ( 1 Vision : The refractive system of the human eye is composed of .Cornea .Aqueous humor .

Crystalline lens .Vitreous humor :In normal emmetropic eyes :A) Focusing for distant objects Parallel light rays from objects 6meters or more away are focused on the retina. In such case: the ciliary muscle is relaxed ,the suepensory ligaments are tense and the .lens is flat (B) Focusing for near objects:( at distance less than 6 meters In this case light rays are divergent. If ciliary muscle relaxation is maintained, light rays from near objects are focused behind the retina and the object appear blurred. This problem is solved by increasing the curvature of the lens to increase its ;refractive power. This process is called accommodation. In such case .Ciliary muscle contracts: .Suspensory ligaments relaxThe lens becomes more convex. This provides the shorter focal length needed to .focus close objects on the retina The power of accommodation is limited : the nearest distance of the eye at which an object can be seen clearly is called near point of vision. At this point visual .accommodation is at its maximum

Emmetropia
Fovea Light rays

.Fig (1) Emmetropic eye Common defects of image forming mechnism Theoritically, visual problems related to refraction could result from a hyporefractive ( underconverging ) or hyperrefractive ( overconverging ) lens or from structural abnormalities of the eyeball. In practice 99% of refractive problems .are related to eyeball shape- either too long or too short

Myopia ( short vision) occurs when distant objects are focused not on, but in front of the retina fig (2). Myopic people see close objects without problems because they can focus them on the retina , but distant objects are blurred. The common name for myopia is near sightedness {Notice that the terminology names the aspect of the vision that is unimpaired}. Myopia typically results from an eyeball that is too long. Correction has traditionally involved use of concave lenses that diverge light rays .before they enter the eye

Uncorrected, light focuses in front of fovea

Corrected by divergent lens, light focuses on fovea

. Fig( 2 ) Myopia Hyperopia (far vision) or far sightedness , occurs when parallel light rays from distant objects are focused behind the retina fig(3).Hyperopic individuals can see distant objects perfectly well because their ciliary muscles contract almost continuously to increase the light bending power of the lens , which moves the focal point forward onto the retina. However, diverging light rays from nearby objects are focused so far behind the retina that the lens cannot bring the focal point onto the retina even at its full refractory power. Thus, close obects appear blurred , and convex corrective lenses are needed to converge the light more strongly for close .vision. Hyperopia usually results from an eyeball that is too short

Uncorrected, light focuses behind fovea

Corrected by convergent lens, light focuses on fovea

Fig (3) hyperopia

Astigmatism usually occurs when the shape of the cornea is oblong. Because of this shape, the curvature of the cornea in one plane is less than the curvature in the other plane. Accordingly, the light rays coming from an object are bent to a different extent in these two different planes, preventing the light rays from coming to a .single focal point Presbyopia is the physiologic recession of the near point of vision with age. The condition is due principally to increasing hardness of the lens with a resulting loss of accommodation. By the time a normal individual reaches age 40-45 years, the loss of accommodation is usually sufficient to make close work difficult. The condition .is corrected by convex lenses Control of papillary diameter The size of the pupil is neurally controlled by sphincter and dilator pupillae muscles of the iris. - The sphincter pupillae (constrictor pupillae) encircles the pupil and its contraction results in pupillary constriction (miosis). The diameter of the pupil may thus be reduced from a maximum of 8 mm to about 1.5 mm. The sphincter pupillae muscle is innervated by motor parasympathetic fibers. The preganglionic fibers start in the occulomotor nucleus in the midbrain (Edinger Westphal nucleus), then relay in the ciliary ganglion, from which the short ciliary nerves arise as post ganglionic fibers. - The dilator pupillae muscle spreads radially from the outer border of the sphincter to the root of the iris, its contraction dilates the pupil (mydriasis). The dilator muscle receives motor sympathetic supply. A higher papillary dilator center is present in the hypothalamus. The preganglionic fibers arise from the last cervical and first thoracic segments. They relay in superior cervical sympathetic ganglia. .(I- Conditions that cause constriction of the pupil (miosis .Light reflex .1 2) Accommodation reflex 3) Injury of the sympathetic supply to the eye: Horner's syndrome i.e injury of cervical sympathetic chain so the parasympathetic constrictor pupillae will act unopposed. 4) Sleep During sleep there is predominance of the parasympathetic functions. Also there is release of the subcortical centers from cortical inhibition. 5) General anaesthesia The diameter of the pupil changes according to the depth of anaesthesia. In the rd 3 stage of anaesthesia the pupils constrict. 6) Drugs One) Parasympathomimitics (acetyl choline, pilocarpine).

Two) Antichohine esterases (eserine, prostigmine). Three) Morphine poisoning. The pupils are constricted due to release of the constrictor center from cortical inhibition II.Conditions that cause dilatation of the pupil (mydriasis) 1) Dark adaptation . 2) Far vision ( when accommodation is relaxed). 3) Emotions and all conditions that result in generalized sympathetic stimulation. 4) Paralysis or injury to the occulomtor nerve. 5) During the 2nd and 4th stage of anaesthesia. 6) Drugs: One) Sympathomimitics (adrenaline, ephidrine). Two) Parasympatholytics (atropine, homatropine). : Effect of anesthesia on the size of the pupil :Anesthesia pass in 4 stages during which the size of the pupil varies as follows In the first stage (first induction stage), the pupils have a normal size or they are .slightly dilated In the second stage (second induction stage), the pupils are widely dilated due to .(increased sympathetic activity (as a result of emotional excitement In the third stage (surgical stage), the pupils are constricted due to release of the Edinger Westphal nucleus from the normal cortical inhibition (because the cortex .itself is depressed). This stage is the proper stage to start surgical procedures In the fourth stage (postsurgical), the pupils are dilated due to paralysis of the Edinger Westphal nucleus .It is an indication to stop anathesia , because administration of more anesthesia would depress the lower nerve centers in the medulla oblongata, which is more dangerous or may be fatal due to depression of .respiratory centers N.B During anesthesia, pupil dilatation occurs in both the induction as well as the postsurgical stage, and it is essential to differentiate between these stages because anesthesia is indicated in the induction stage, but is dangerous in the postsurgical stage.Such differentiation is achived by examining a) the corneal reflex,b) the papillary light reflex,c) the movement of the eyes. These are intact in the induction .stage but lost in the postsurgical stage :How to test for the eye reflexes a ) Corneal reflex Prcedure Touch the lateral edge of the cornea at its conjunctival margin while the subject .is gazing at a distance or lightly blw a puff of air on each cornea Results .In both conditions the subject blink Questions

?What is the nervous pathway of corneal reflex .1 .Mention the importance of the corneal reflex .2 b) Light reflex Sudden illumination of thr eye by a bright light causes the pupil to contract reflexly in direct proportion to the light intensity. This is a protective mechanism to .prevent damage to the delicate photoreceptors Procedure .The subject sits in a dark room for few minutes. Ask him to look at distant object .1 .Shine the torch into right eye. Quickly observe the pupil of that eye .2 Wait for some time until the pupil dilates and shine the light into the right eye .3 .while watching the pupil of the left eye Results .(There will be constriction of the right pupil ( direct light reflex .1 .(There will be constriction of the left pupil ( indirect light reflex .2 Questions ?.What is the cause of the indirect light reflex .1 ?.What is the importance of light reflex examination .2 ?What is meant by Argyl Robertson's pupil .3 C) Accommodation convergence reflex .It is concerned with the formation of sharp image on the retina Procedure The subject looks to distant object. Watch his pupil and the condition of the.1 .eyeballs Tell him to look at your finger about 15cm in front of his head in the midline .2 .above the eye level .Notice what happens to the pupils and to the position of the eyeballs .3 ;Results .The pupils constrict and the axes of the eyeballs converge Questions .Mention the components of the near response .1 .Mention the nervous control of the accommodation convergence reflex .2 .Define presbyopia .3

Practical section 2 :The basis of visual acuity examination

VISUAL ACUITY
Visual acuity is the degree to which the details and contours of objects are perceived and is usually defined in terms of the minimum separable i.e the shortest distance by which two lines can be separated and still be perceived as 2 lines. In the fovea centralis cones are thin (1.5 micrometer in diameter) and condensed. It was found that two lines or points cannot be appreciated as two if their images fall on the same cone. So a person can distinguish two separate points or lines if their centers lie at least 2 micrometers apart on the retina, which is slightly greater than the width of a single foveal cone .In this condition, the light rays from the 2 points form a visual angle at the nodal point of the lens that equals one minute (1/60 of a degree). If the visual angle is less than the minimal value the two lines will be seen as one line. Fig 4 N.B.: 1. The nodal point is the optic center of the lens, it coincides with the junction of the middle and posterior 1/3 of the lens. Any beams of light traversing this point passes straight without refraction. 2. The minimal visual angle was calculated in some normal sharp sighted persons to be only 28 seconds i.e. less than half a minute.

Fig. (4): The principle of visual acuity testing. Visual acuity is a complex phenomenon and is influenced by a large variety of factors .These include optical factors such as the state of image forming mechanism of the eye, retinal factors such as the state of cones and stimulus factors including illumination and brightness of the stimulus and the contrast between the stimulus and background. ?How to test for the visual acuity .Equipment: Snellen's chart and landolt's chart

.Fig (5) Landlot's and Snellen's chart for visual acuity This is based on having a series of rows of alphabetical letters (Snellen's chart) or incomplete circles ( Landolt's Chart). The circles are arranged in 7 rows with the openings of the circles in different directions. The chart is placed at a distance of 6 meters from the tested person ( to relax the ciliary muscle). Opposite to each row is written the distance in meters at which the edge of the openings make visual angle of one minute at the nodal point of the lens. The opening of the biggest circle makes a visual angle of one minute at a distance of 60 meters. The openings in the lower rows of circles makes the same angle at distance of 36 m, 24 m , 18m , 12m ,9 and 6 .m respectively A person with normal vision is able to see accurately the directions of the openings in the 7 rows. The results are expressed as a fraction: the numerator of the fraction is 20feet or 6 meters which is the distance at which the subject read the chart. The denominator is the greatest distance from the chart at which a normal individual can read the smallest line the subject can read. For example, if a person can see only the first row, his visual acuity is 6/60 .This is because he can see at 6 m .what a normal individual see at 60 m :Procedure .The subject to be tested stands at 6 meters from the chart .1 .Cover one eye .2 Ask the person to read the letters or to tell the direction of the circles beginning .3 from the top row .Note the last row he can read accurately .4 .Repeat with the other eye .5 Results Record the visual acuity as 6 over the distance in meters written beside the last line read correctly by the subject. The normal visual acuity is 6/6 or 20/20 if distance is

.expressed in feet :Questions ?What are the criteria for acute vision ?.What do we mean by a person visual acuity 6/18 or 6/24 ?What are the factors that affect the visual acuity

This figure illustrate the procedure of visual acuity test.

COLOR VISION
Color vision is the sense of discrimination of the different wave lengths that constitute the visible spectrum. The sensations aroused are described as red, orange, yellow, green, blue, indigo and violet arranged in the order of magnitude of their wave lengths. This is the function of cones only, and so they are most developed at the fovea. Retinae that contain only rods appreciate all the chromatic series as shades of gray. The limits of visible spectrum are between 400-730 mu. Characteristics of color 1- Colors have three attributes: hue, intensity and saturation (degree of freedom from dilution with white). 2- For any color, there is a complementary color that, when properly mixed with it, produces a sensation of white. Black is the sensation produced by the absence of light .It is probably a positive sensation because the blind eye does not see black, it sees nothing. 3- The sensation of white, any spectral color, and even the extraspectral color e.g purple can be produced by mixing various proportions of red light, green light and blue light. Red , green and blue are therefore called primary colors Fig (6).

Fig. (6): Absorption spectra of the three cone pigments of the retina.

Trichromatic mechanism of color vision by the retina

(Young-Helmholtz trichromatic theory ) -The retina has 3 kinds of cones, each containing a different photopigment that are maximally sensitive to one of the three primary colors. One pigment (the blue sensitive or short wave length) absorbs light maximally in the blue-violet portion of the spectrum at 420 mu. Another (the green sensitive or the middle wave pigment) absorbs maximally in the green portion at wave length at 530 mu. The third (the red sensitive or long wave pigment) absorbs maximally in the yellow portion of the spectrum at 560mu, but its spectrum extend far more enough into the long wave lengths to sense red Fig (6). - Each of the three photochemical pigments is affected mostly by its specific wave length, but is also affected to a varying extent by other wave lengths of the chromatic series. - If the three types of cones are equally stimulated, the sensation of white is perceived. If the three types of cones are not equally stimulated, any of the chromatic series of colors may be perceived depending on the relative frequency of impulses from each of these cone systems. - Color processing takes place in ganglion cells of the retina and the lateral geniculate nucleus produce impulses that pass along neural pathways to the visual cortex. Color blindness Some color blind individuals are unable to distinguish certain colors, whereas others have only color weakness. 1- Red- green color blindness This occurs when either the red or green cones are lacking. 2- Blue weakness. Inheritance of color blindness:

Abnormal color vision is present as an inherited abnormality in Caucasian populations in about 8% males and 0.4% females. Defects of the blue cones are rare and show no sexual selectivity. However, abnormalities of the red or green cones are inherited as recessive and X-linked characteristics i.e they are due to abnormal gene on X- chromosome. ?How to test for color vision (Test A ( coloured tufts of wool :Procedure The person is given many tufts of wool whose colours cover the whole visual .1 .spectrum .He is asked to group tufts of similar colours together .2 Results .State your findings (Test B( the hidden figure test or Ishihara's test : Principle The test uses a series of Ishihara charts made up of sets of dots that differ in size and in depth of colours ( some being paler and some more intense). Some of these spots are arranged to represent certain figures or numbers. People with good color .discrimination associate together the dots of the same colour and can see the figures : Procedure Look at various colour charts in bright light or sunlight at a distance of about 75 cm .from the eye for few seconds

.Ishihara chart

. Fig (7) Examples of Ishihara charts

.Practical section 3 Hearing tests

Types of sound transmission (bone and air conduction) 1-Air conduction When sound vibrations are elicited in the air, it is conducted to the cochlea by: a. Ossicular route: transmission through the middle ear ossicles is the main pathway for normal hearing ( the most efficient route ). b. Some sound waves in the air elicit vibrations of the secondary tympanic membrane that closes the round window. This process is unimportant in normal hearing because direct transmission from air to perilymph is associated with great loss of sound energy. 2-Bone conduction Is transmission of vibrations of the bones of the skull to the fluid of the inner ear . Considerable bone conduction occurs when tuning forks or other vibrating bodies are applied directly to the skull. This route also plays a role in transmission of extremely loud sounds.

Deafness: Deafness is loss of hearing. It may be partial or complete. Types and causes:
1. Conduction deafness:
It is due to impaired sound transmission in the external or middle ear. It may result from: a) Obstruction of the external auditory meatus with wax or foreign bodies.

b) Closure of the Eustachian tube resulting in negative pressure in the middle ear. c) Damage of the tympanic membrane i.e. by perforation. d) Destruction of the auditory ossicles. In conductive deafness the cochlea and the nerves are intact so sound waves can be conducted into the cochlea by means of bone conduction. * Bone conduction is normal while air conduction is impaired or lost.
2.

Nerve deafness (Sensorineural deafness) :

It is due to impaired sound transmission in the cochlea or damage to the auditory pathway. It may result from: a) Damage of the fibres of the basilar membrane by high intensity sounds e.g. industrial noise. b) Degeneration of the hair cells in the organ of corti e.g. prolonged use of antibiotics as kanamycin, neomycin, gentamycin. c) Damage to the cochlcar nerve by tumour. d) Damage of the hearing pathway beyond the cochlear nerve. e) Damage of auditory cortex on both sides. In nerve deafness the person is completely deaf if either the cochlae or the nervous pathway on both sides is completely destroyed or there is bilateral destruction of cortical auditory centers, so both air and bone conduction are impaired or lost on both sides. On the other hand, unilateral lesion of the cochlea, cochlear nerve or cochlear nuclei elicit deafness in the ipsilateral ear.

Hearing tests:

I- Tuning fork tests

a) Rinne' test: The base of a vibrating tuning fork is placed on the mastoid process until the subject no longer hears it, then put it in the air next to the ear. - Normally, the subject hears vibrations in air after bone conduction is over (Rinne' +ve). - In conductive deafness the subject does not hear vibrations in air after bone conduction is over ( Rinne' ve). -In nerve deafness ( partial defect in one ear) , the subject hears vibrations in air after bone conduction is over although hearing is reduced in both ( reduced Rinne' +ve). Fig (8) b) Weber test The base of a vibrating tuning fork is placed against the center of the person's forehead. - Normally, it is heard equally on both sides. - In conductive deafness in one ear, sound is heard better on the diseased side than on the healthy side ( because the masking effect of environmental noise is absent on the diseased side ).

- In nerve deafness (one side) , sound is louder in the healthy side.Fig (8)

Fig (8) tuning fork tests. .

1. The audiogram in nerve deafness The person has decreased or total loss of ability to hear sounds as tested by both air and bone conduction. Fig (9a) 2. The audiogram of middle ear conductive deafness In this case bone conduction is normal but air conduction through the ossicular system is greatly depressed. Fig (9 b)

an audiometer