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OPHTHALMOLOGY
#Layers of Eye Lid: 1) Skin
2) Subcutaneous layer
3) Striated muscle layer
4) Sub muscular layer
5) Non-skeletal muscle layer
6) Tarsal plate
7) Palpebral conjunctiva
#Layers of Cornea: 1) Corneal epithelium
2) Bowman’s layer
3) Corneal stroma
4) Descemet’s membrane
5) Corneal endothelium.
#Structure of Conjunctiva: 1) Epithelium
2) Sub-epithelial layer
3) Fibrous layer.
Transparency of Cornea:
Anatomical factors Physiological factors
-Uniform regular arrangement of the epithelium. -Stromal swelling pressure.
-Absence of blood vessels, lymphatics. -Metabolic pump.
-Packed stromal lamellae of uniform size. -Barrier function.
-Non myelinated fibers. -Evaporation of corneal surface.
-Intra-ocular pressure.

#Causes of Red eye: 1) Conjunctivitis

2) Foreign body -Cornea
-Conjunctiva
3) Corneal -Abrasion
-Ulcer
-Keratitis
-Foreign body
4) Endophthalmitis
5) Panophthalmitis
6) Acute congestive glaucoma
Layers of retina:
From outwards to inwards: 1) Retinal pigment layer
2) Layers of rods & cones
3) External limiting membrane
4) Outer nuclear layer
5) Outer plexiform layer
6) Inner nuclear layer
7) Inner plexiform layer
8) Ganglion cell layer
9) Nerve fiber
10) Internal limiting membrane.
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Blood supply: Inner 2/3 by central retinal artery
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Outer 1/3 by chorio capillaries
Outer plexiform layer dual blood supply by both central retinal artery and chorio capillaries.

#Boundary of bony orbit:

Roof: Orbital plate of frontal bone lesser wing of sphenoid
Floor: Orbital surface of body of Maxilla; Orbital surface of the Zygomatic bone; Orbital process of Palatine bone
Lateral wall: Greater wing of Sphenoid; Frontal plate of Zygomatic bone
Medial wall: Frontal process of Maxilla; Lacrimal bone; Orbital plate of Ethmoid; Body of Sphenoid
[Total 7 bones]

#Content of orbit: 1) Eyeball

2) Fascia- Orbital; Bulbar
3) Muscles- Extra ocular
4) Vessels- Ophthalmic artery & branches
Ophthalmic vein (superior & inferior)
5) Nerves- Optic nerve; Oculomotor; Trochlear; Abducent; Ophthalmic division of trigeminal
nerve [lacrimal, frontal, nasocillary].
6) Lacrimal gland and sac
7) Orbital fat

#Importance of sac patency: 1) Patency of lacrimal passage

2) Site of occlusion detection

#Extra ocular muscle: (Superior rectus; Inferior rectus; Medial rectus)- oculomotor nerve
Lateral rectus- Abducent (LR6)
Superior oblique- Trochlear (SO4)
Inferior oblique- Oculomotor

#Vitreous humor: It is a transparent, colorless, jelly like substance composed of 99% water, collagen fibers, hyaluronic
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acid with other components occupies the post 4/5 of the globe and lies between anteriorly ciliary body, suspensory
ligaments, lens and posteriorly retina. Total volume 4ml.
Function: -Structural support to globe.
-A clear and optically uniform path to retina.
#Functions of Rods and Cones: 1) Rods: Scotopic vision (Dim light)
2) Cones: -Photopic vision (Day light)
-Color vision
-Visual acuity.

#Circulation of aqueous humor:Formation of aqueous humor from ciliary process Posterior chamber Through
pupil Anterior chamber
─Trabecular / conventional outflow (90%): Angle of anterior chamber Trabecular meshwork Canal of schlemn
Aqueous vein Episcleral veins Superior / Inferior ophthalmic vein Cavernous sinus systemic circulation.
─Uveo-scleral / unconventional outflow (10%): Ciliary body Supra-choroidal space Venous circulation of ciliary
body, choroid & sclera.
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Pathway of light reflex: Fall of light on cornea refractive media retina received by rods and cones optic nerve
Optic chiasma optic tract Pretectal nucleus

Direct reflex Consensual reflex

Edinger Westphal nucleus of same side Edinger Westphal nucleus of opposite side
↓ ↓
Oculomotor nerve of same side Oculomotor nerve of opposite side
↓ ↓
Ciliary ganglion Ciliary ganglion
↓ ↓
Short ciliary nerve Short ciliary nerve
↓ ↓
Sphincter pupilae of the eye of same side Sphincter pupilae of the eye of opposite side
↓ ↓
Constriction of pupil of the eye of same side Constriction of pupil of the eye of opposite side

Pathway of accommodation reflex:

Light fall on cornea
↓
Mediated through retina
↓
Optic nerve
↓
Optic chiasma
↓
Optic tract
↓
Lateral geniculate body
↓
Optic radiation
↓
Visual area of occipital cortex (area 17)
↓
Superior longitudinal association tract
↓
Frontal eye field
↓
3rd nerve nucleus
↓
3rd nerve (Oculomotor)

Medial convergence by contraction of medial Contraction of ciliary muscle Ciliary ganglion

rectus muscle ↓ ↓
↓ Relaxation of suspensory ligament Short ciliary nerve
Causes conversion ↓ ↓
Increased anterior curvature Sphincter pupillae muscle
↓ ↓
Slight forward movement of ciliary body Constriction of pupil.
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Orbital Cellulitis
Definition: Inflammation of the soft tissue of the orbit behind orbital septum. (infront- pre septal cellulitis)
#Treatment: 1) Hospital admission
2) Antibiotics: I/V ceftriaxone or ceftazidime until apyrexial for 4 days, then orally for 1-2 weeks
3) Monitoring of the optic nerve function
4) Drainage of orbital abscess
5) Drainage of orbital sinus
6) Lateral cantholysis (if optic nerve damage)
#Complication of orbital cellulitis:
Ocular: ~Exposure keratopathy
~Corneal ulcer
~Endopthalmitis
~Central retinal vein and artery occlusion
Intra cranial: ~Meningitis
~Encephalitis
~Cavernous sinus thrombosis
~Brain abscess
Orbital: ~Sub periosteal abscess

#Proptosis: Abnormal forward protrusion of the eyeball beyond the orbital margin.
Causes: 1) Thyroid opthalmopathy
2) Orbit cellulitis
3) Orbital tumor - Capillary haemangioma
- Retinoblastoma
- Rhabdomyosarcoma
- Glioma
4) Pseudo tumor: Dermoid
#Lens induced Glaucoma: 1) Phacomorphic
2) Phacolytic
#Pathology of phacolytic glaucoma: Mature or hyper mature cataractFragile lens capsuleMicro leakage of cortical
matterPhagocytosis by macrophageCortical laden macrophage
Macrophage obstruct the trabecular meshworkIncreased IOPPhacolytic
glaucoma.
#Ptosis: dropping of the upper eyelid below its normal position is called ptosis.
Classification: 1) Congenital
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2) Acquired: a) Neurogenic: 3 nerve palsy
b) Myogenic: Myasthenia gravis
Myotonic dystrophy
External ophthalmoplegic
3) Aponeurotic: Detect in aponeurosis of levator palpebrae superiosis (old age)
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#Hyphaemia: Hemorrhage in the anterior chamber of eye is called hyphaemia.

Cause: ~Ocular trauma & surgery
~Inflammation (herpetic uveitis)
~Neoplastic (Retinoblastoma)
~Neovasculariztion of Iris (DM)
~Systemic cause (Haemophilia; Purpura)
C/S: ~Trauma
~Bleeding disorder
~Postsurgical
~HTN
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#Feature of 3 nerve palsy: ~Profound ptosis
~Diplopia [Pt. can’t tell due to ptosis]
~Restricted ocular motility: [Limited adduction; Limited elevation; Limited depression;
Normal abduction (LR6 no problem)]
~Dilation of pupil [in case of surgery: aneurysm, trauma]
~Medical cause [in case of DM & HTN pupil is spared]
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#Features of 6 nerve palsy: ~Diplopia
~Adducted eye [problem in LR6]
~False localization sign in Papilloedema (swelling of optic nerve & dilated vein)
~Compensatory face turns towards paralysed muscle
#7 : চ োখের পোতো বন্ধ কখর- Orbicularis oculi
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#3 : চ োখের পোতো চেোখ঱- Levator palpebrae superioris

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Conjunctivitis
Definition: Inflammation of conjunctiva.
Classification:
Infective conjunctivitis Allergic Conjunctivitis of Miscellaneous
conjunctivitis blistering conjunctivitis
mucocutaneous
disease
Bacterial Ophthalmia Adult Viral 1) Acute allergic 1) Mucous 1) Superior limbic
conjunctivitis neonatorum chlamydial conjunctivitis conjunctivitis membrane kerato-
conjunctivitis 2) Seasonal & pemphigoid conjunctivitis
1) Acute catarrhal Caused by Caused by Most Perennial 2) Stevens-johnson 2)Ligneous
or mucopurulent chemicals, Chlamydia commonly by allergic syndrome conjunctivitis
conjunctivitis- [Link], trachomatis. Adenovirus. conjunctivitis 3)Factitious
caused by [Link], Others: HSV, 3) Vernal conjunctivitis
[Link], Herprs simplex Enterovirus, kerato-
[Link], virus, Coxsackie conjunctivitis
[Link] & Staphylococcus, virus, Varicella, 4) Atopic
Moraxella Streptococcus, Measles & kerato-
catarrhalis. [Link]. Mumps virus. conjunctivitis
2) Purulent 5) Giant
conjunctivitis: papillary
i) Gonococcal conjunctivitis
conjunctivitis
ii)Meningococcal
conjunctivitis
3) Membranous
conjunctivitis
4) Pseudo-
membranous
conjunctivitis
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Allergic conjunctivitis
#Definition: Is a type I (immediate) hyper sensitivity reaction, mediated by degranulation of mast cells in response to the
action of IgE, there is an evidence of an element of type IV hyper sensitivity reactions in at least some forms.
Types: Acute allergic conjunctivitis: occurs in children by pollen; self-limiting; Artificial tear.
Seasonal allergic conjunctivitis: In late summer, spring; environmental allergen.
Perennial conjunctivitis: Throughout the year; Household allergen (house mite, animal hair)
Vernal keratoconjunctivitis: Type I & II; spring & summer; 5-15 years; (late teen);
Supra tarsal conjunctiva infection (Dexamethasone, Triamcinolone).
Sign: 1) Giant papillary hypertrophy with the typical cobblestone appearance of the upper tarsal conjunctiva.
2) Tranta’s dots in the superior limbus represent an aggregation of epithelial cells and eosinophils.
3) Corneal shield ulcers (Togby’s ulcers) are mainly located in the upper paracentral cornea.
Atopic keratoconjunctivitis: Late teen to onwards; H/O atopic allergy; genetically determined hypersensitivity.
Symptoms: 1) Redness; 2) Watering; 3) Itching; 4) Associated with severe sneezing & nasal discharge.
Signs: 1) Conjunctival hyperemia
2) Mild papillary reaction
3) Chemosis edema of conjunctiva around the cornea
4) Lid edema.
Investigation: Eosinophilia

Treatment: (is not usually required, conjunctival swelling subside in hours)

1) Artificial tear for mild symptoms.
2) Mast cell stabilizer: Na cromoglycate, Nedocromil Na, Lodoxamide suitable for long term use.
3) Anti histamine: Emedastine (Topical), Epinastine, Bepotastine, Levocabastine.
4) Combined: Anti histamine + vaso-constrictor: Antazoline & Xylometazoline, Tetrazoline.
5) Duel action anti histamine & mast cell stabilizer: Azelastine, Ketotifen, Olopatadine (may be effective
for exacerbation).
6) Topical steroid are effective but rarely necessary.
7) Oral anti histamine may be indicated to severe symptoms.

#Prevention: ~Avoid- food (Allergenic)

Environmental allergens
~Protective glass
Ophthalmia neonatum
#Definition: Conjunctivitis (purulent or non-purulent) which occur during neonatal period (First 28 days of life).
st
#Timing of onset: ~Chemical irritation- 1 few days
st
~Gonococcal- 1 week
st
~Staphylococcal & other bacteria- End of the 1 week
~Chlamydia- 1-3 weeks
#Signs: ~Types of discharge varies according to underlining cause
~Severe eyelid edema- gonococcal infection
~Eyelid & peri-ocular vesicles- HSV infection
~Keratosis in gonococcal or HSV infection
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#Investigation: 1) Conjunctival scraping applied to glass slide for gram & giemsa staining.
--Multinucleated giant cells may be present in case of HSV infection.
2) Conjunctival swabs for c/s in chocolate agar or Thayer Martin for- N. gonorrhoea.
3) Epithelial cells infected & HSV may show eosinophilic intranuclear inclusions & papanicolaou stain.
#Causative factors: ~Chemical- povidone
~Bacteria: Staphylococcus; Streptococcus; N. gonorrhea; H. influenzae
~Virus: Herpes simplex
~Chlamydia trachomatis
#Treatment: 1) Chemical conjunctivitis: Doesn’t require t/m apart from artificial tear.
2) Mild conjunctivitis: Is very common in neonate & may require a broad spectrum topical antibiotic
(Chloramphenicol; Fusidic acid)
3) Moderate to severe causes: Should be investigated-
a) If bacteria in gram stain: A topical broad spectrum antibiotic should
be served unit sensitivities are available.
b) Chlamydial: Erythromycin- Oral (2 weeks); Tetracycline- ointment.
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c) Gonococcal: 3 generation Cephalosporin; (I/V Ceftriaxime).
d) Herpes simplex: I/V high dose acyclovir under paediatric specialist care
~If encephalitis develops- treated immediately. Also
Topical Acyclovir may be considered in addition.
e) H. influenzae: Amoxicillin & Clavulenic acid.
#Prophylaxis: ~A single instillation of povidone 2.5% - effective against common pathogens.
~Tetracycline 1% ointment
~ 1% solution agglutinates gonococcal & still utilized where gonococcal infection is common.

Optic Atrophy
#Definition: Optic atrophy refers to the late stage changes that take place in the optic nerve resulting from degeneration
in the pathway between the retina and the lateral geniculate body manifesting disturbance in visual function and in the
appearance of the optic nerve head.
#Cause:
Primary: 1) Retrobulbar neuritis
2) Compression by the tumors and aneurysms
3) Hereditary optic neuropathies
4) Ophthalmia neonatorum
5) Pituitary tumor
6) Frontal lobe tumor
7) Neurosyphilis
Secondary: 1) Papillitis
2) Chronic papilloedema
3 ) Anterior ischemic optic neuropathy
#Treatment of accidental acid burn:
Why patients get dry eye?
1) Topical steroid (7-10 days)
-Due to goblet cell damage. Goblet cell
2) Artificial tear create mucin layer of tear film that helps
in lubrication and converts hydrophilic to
3) Vitamin C (oral 2gm daily) for healing.
hydrophobic.
4) Anti-collagenase (Tertacycline-topical,oral)
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Dacryocystorhinostomy (DCR)
#Indication: Chronic dacryocystitis.
#Contraindication:
Absolute: 1) Malignancy of sac
2) Malignancy of nose and surrounding area
3) Atrophic rhinitis
4) Multiple fistula of lacrimal sac
5) Fibrosed sac
6) Any growth of sac.
Relative: 1) Grossly deviated nasal septum
2) Nasal polyp
3) HIT (hypertrophic inferior turbinate)
4) Granulomatous inflammation of lacrimal sac and underlying bone.

Pre-operative preparation of DCR surgery:

Investigation: 1) RBS (if DM then FBS & 2hrs after breakfast)
2) ECG (After 40 years)
3) BT CT (Bleeding time may be raised)
4) X-ray of PNS OM view
5) HBsAg (Surgeons safety)
General examination: Blood pressure
#Complication of DCR surgery:
Per operative: 1) Hemorrhage (primary hemorrhage):- ~Angular vein
2) Injury to the nasal mucosa or ~Muscles (extra
ocular) orbicularis
surrounding structure.
oculi
3) Inadequate osteum
~Nasal mucosa
4) Improper position Causes of Failed DCR:
~Perosteal
Post-operative: 1) Reactionary Hemorrhage vessels ~Faulty patient selection
2) Failed DCR ~Faulty surgical technique

3) Scar ~Inadequate size of osteum

~Hemorrhage
4) Keloid
~If bone piece close the opening of
5) Stricture of passage canaliculi
#Indication of DCT: 1) Contraindication of DCR
2) Old age.

Chalazion
#Definition: It is a chronic, sterile, granulomatous, inflammation of meibomian gland.
Location of meibomian gland: Tarsal plate of eyelid.
Number: Upper: 25; Lower: 20.
What type of gland: Modified sebaceous gland.
Infected Hordeolum: ~Infected chalazion
~Red, tender swelling
~Away from eye lid margin.
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#Treatment: ~Small size: Hot compression; Antibiotics.

~Large size: Incision; Curettage.
~If pt. does not want surgery: Intra lesional injection of steroid.
~If recurrent: Systemic tetracycline.
#Procedure of incision and curettage: 1) At first, give topical anesthesia (0.4% Oxybuprocaine; Proparacaine).
2) Fix with calazion clamp.
3) Maintain hemostasis.
4) Blade used- Fenestrated- towards conjunctiva; Solid.
5) Eversion of lid.
6) Incision given: vertical. [horizontally duct কোটো যোখব dry eye because
function of meibomian gland: superficial oily layer (prevent
evaporation; Reduce surface tension; Help in spreading of
tear film)].
7) Curettage with Chalazion scope.
8) 0.5% Chloramphenicol should be given.
9) Bandage given.
#Fates of Calazion: 1) Infected calazion
2) Burst through skin or conjunctiva
3) Spontaneous resolution
4) Increase in size, decrease in size, stationary
5) Malignant change (rarely)

Stye(External Hordeolum)
#Definition: Acute staphylococcal inflammation of gland of Zeis & Moll with their follicle (lash follicle). [Along lid margin]

#Treatment: 1) Epilation
2) Antibiotic
3) Analgesic (systemic)
4) No need of Bandage.
Layers of Tear film:
1) Outer lipid layer: Source: Meibomian, glands of Zeis and Moll.
Function: a) Prevent evaporation of aqueous layer.
b) Act as surfactant (spread the tear).
2) Middle aqueous layer: Source: Lacrimal & accessory lacrimal.
Function: a) Provide atmospheric to the corneal epithelium.
b) Antibacterial function.
c) Wash away debris & noxious stimuli.
3) Inner mucin layer: Source: Goblet cell.
Function: a) Converts the corneal epithelium from a hydrophilic to hydrophobic surface.
b) Lubrication.
#Treatment of Accidental Acid burn: Common acids and alkalis: Acids
Alkali
𝐻 𝑆𝑂4
𝐶𝑎𝐶𝑂 [Alkali is more dangerous
𝐻𝐶𝑙
because penetration is
𝑁𝐻𝑂 more & does saponification.]
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#Management:
Emergency: 1) Profuse irrigation by NS / plain water for 20-30 minutes until removal of any retained chemical.
Litmus paper test.

satisfied? - upper eyelid । So, double eversion ।

Medical treatment: 1) Topical steroid (7-10 days).
2) Artificial tear
3) Vitamin C (Oral, 2gm daily)- for healing.
4) Anti-collagenase (Tetracycline- topical, oral)
5) To prevent symblepharon (adhesion of palpebral conjunctiva of the eyelid to the bulbar
conjunctiva of the eyeball) by rodening.
Surgical treatment: Early: 1) Suturing of tenon’s capsule to restore limbal vasculature.
[Extra] 2) Limbal stem cell transplantation.
Late: 1) Release of bands and adhesions.
2) Keratoplasty.

Epiphora
#Definition: Watering of the eye due to defective lacrimal drainage system.
Cause: 1) Chronic dacryocystitis.
2) Punctal stenosis.
3) Malposition of punctum.
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4) Lacrimal pump failure (7 nerve palsy).
Less: -Agenesis of punctum.
-Stone, Foreign body in lumen.
-Neoplasm of lacrimal sac.

Lacrimation
#Definition: Watering of the eye due to excessive secretion of tear in which lacrimal drainage system is normal.
Cause: -Irritation
-Reflex secretion (sneezing, coughing).
-Conjunctivitis
-Foreign body
-Corneal ulcer
-Endophthalmitis
-Acute congestive glaucoma
-Psychogenic
-Emotion.
Procedure of Fluorescein test: Only 1 drop of fluorescein dye in lower conjunctival fornix  Instruct the patient to
Blink for several times  Wash out dye with distilled water or normal saline  Look for any Green staining.
Interpretation: 1) Green color: Active corneal ulcer or corneal abrasion.
2) No staining: May be keratitis or healed corneal ulcer (Corneal opacity).
Tear Pathway: Lacrimal gland, Accessory lacrimal gland, conjunctival gland  Along the surface of eyeball 
conjunctival sac  Lacrimal puncta (upper & lower)  Superior and inferior canaliculi  Common canaliculi  Lacrimal
sac  Naso lacrimal duct  Inferior meatus of nose.
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Pterygium
#Definition: It is a triangular, fibrovascular, sub epithelial ingrowth of degenerative bulbar conjunctival tissue over the
limbus on to the cornea.
Risk factor: 1) Chronic dryness of eye / chronic ocular surface disease
2) UV ray (field workers are prone)
3) Hot dry climate (middle east).
Types: 1) Type I- Extends <2mm on to the cornea. A deposit of iron (stocker line) may be seen in the corneal epithelium
anterior to the advancing head of the pterygium.
2) Type II- Involves up to 4mm of cornea.
3) Type III- Encroaches up to >4mm of cornea & involves the visual axis.
Clinical type: 1) Progressive (needs surgery).
2) Regressive
Medical treatment
3) Stationary
Parts: 3 parts: 1) A cap,
2) A head (infront of it- Stocker line)
3) A body Cap
Head

Body

#Treatment: 1) Medical treatment: symptomatic patient -Tear substitute

-Topical steroid for inflammation.
2) Surgical (Progressive): a) Simple excision (bare sclera technique) [Disadvantage: Chance of recurrence
In 50% cases].
b) Excision of pterygium with conjunctival autograft (superior para limbal area).
c) Excision of pterygium with amniotic membrane graft.
d) Excision of pterygium with β radiation.
e) Excision of pterygium with cytotoxic drug (Mytomicin-C).
Advice: Dark sunglasses to reduce UV exposure.

Corneal Ulcer
#Definition: Inflammatory or infective condition of cornea involving disruption of its epithelial layer with involvement of
corneal stroma.
#Complication of corneal ulcer:
Before perforation: 1) Anterior uveitis
2) Secondary glaucoma
3) Descemetocele
4) Iridocyclitis
5) Endophthalmitis.
After perforation: 1) Corneal scaring
2) Adherent leukoma
3) Anterior staphyloma
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4) Complicated cataract
5) Panophthalmitis
6) Phthisis bulbi.
#Investigation of Corneal ulcer:
Corneal scraping: How?  -From floor of ulcer, necrotic debris are collected.
` -11 number BP blade.
-11/26 g. niddle
-Placed on glass slide
- (10%): wet film preparation to see fungal hyphae (as Aspergillus is filamentous).

Corneal scraping: 1) Wet film (10% , hyphae)

2) Gram stain [(+ve), (-ve)]
3) Calcofluor-white (Fluorescent stainAcanthamoeba)
AFBZiehl Neelsen (Mycobacteria).
C/S: Blood agar: Most of the bacteria except Neisseria, Haemophilus, Moraxella.
Chocolate agar: Neisseria, Haemophilus, Moraxella.
SDA: Fungi.
L.J media: Mycobacterium, Nocardia.
Conjunctival swab.
Corneal biopsy (C/S antibiotic )
Fluorescein dye test.

Fungal Corneal Ulcer

Fungal ulcer: Margin indistinct; Ulcer is dry in nature; Satellite lesion (beside 1 ° lesion).
#C/F:
Symptoms: 1) Gradual onset of pain.
2) Grittiness
3) Photophobia
4) Blurred vision
5) Watery or mucopurulent discharge.
Signs: 1) Candida keratitis: yellow white densely suppurative infiltrate.
2) Filamentous keratitis: -A gray or yellow white stromal infiltrate with indistinct fluffy margin.
-Progressive infiltration, often surrounded by satellite lesions.
-Feathery branch like extension or a ring shaped infiltrate may develop.
3) An epithelial defect: Is not invariable and is sometimes small when present.
4) Other features: Include anterior uveitis, hypopyon, endothelial plaque, raised IOP, scleritis, sterile or
infective endopthalmitis, upper surface concave.
Investigation: Samples for laboratory examination should be acquired before anti-fungal therapy.
~Corneal scraping: -Wet film preparation: 10%
-Gram & giemsa stain
-Culture: SDA media.
~Corneal biopsy (when anti-fungal don’t respond in 1 week).
~Confocal microscopy: -Histopathology of ulcer tissue.
-Directly we can identify organism in vitro.
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Treatment of fungal corneal ulcer:

#General: 1) Hospital admission
2) Removal of epithelium over the lesion (for better penetration).
3) Dark glass
4) Decontamination of contact lens
#Topical: At least 12 weeks because most anti-fungal are fungistatic.
a) Candida: Natamycin, Econazole, Amphotericin B, Miconazole, Clotrimazole, Fluconazole.
b) Filamentous: Natamycin, Econazole, Amphotericin B, Miconazole, Clotrimazole, Fluconazole.
c) Broad spectrum antibiotic.
d) Cycloplegic: relieves pain.
#Sub-conjunctival Fluconazole: In severe case.
#Systemic antifungal: i) In severe cases.
ii) When resistance to topical.
iii) When lesions are near the limbus.
iv) Scleral involvement.
v) Suspected endophthalmitis.
=>Options: Voriconazole; Itraconazole; Fluconazole
#Surgery: i) Superficial Keratectomy
ii) Therapeutic Keratoplasty (when medical therapy is ineffective or following perforation).

Bacterial Corneal Ulcer

C/F:
Symptoms: 1) Pain
2) Photophobia
3) Blurred vision
4) Purulent discharge (N. gonorrhea, N. meningitides) & Mucopurulent (other bacteria).
Signs: 1) Ciliary congestion.
2) An epithelial defect associated with a layer of infiltrate.
3) Enlargement of the infiltrate and epithelial defect.
4) Stromal edema / folds in descemet’s membrane and anterior uveitis.
5) Descemetocele formation and perforation.
6) Chemosis and eyelid swelling in severe case.
Investigation:
Corneal scraping: 1) Wet film (10% , hyphae)
2) Gram stain [(+ve), (-ve)]
3) Calcofluor-white (Fluorescent stainAcanthamoeba)
AFBZiehl Neelsen (Mycobacteria).
C/S: Blood agar: Most of the bacteria except Neisseria, Haemophilus, Moraxella.
Chocolate agar: Neisseria, Haemophilus, Moraxella.
SDA: Fungi.
L.J media: Mycobacterium, Nocardia.
Conjunctival swab.

Treatment:
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General consideration:
1) Hospital admission
2) Discontinuation of contact lens (Mandatory)
3) Broad spectrum antibiotics (before microscopic result are available).
4) Local therapy: a) Antibiotic mono-therapy: Fluroquinolones Ciprofloxacin, Ofloxacin, Moxifloxacin, Gatifloxacin
Gemifloxacin.
b) Antibiotic duo- therapy: Fortified aminoglycoside + Cephalosporin (Cefuroxime, Ceftazidime
Problems: Fortified antibiotics include high cost, limited availability, Cefoxitin).
contamination risk, short shelf life and need refrigeration.

c) Sub-conjunctival antibiotic: Gentamicin

d) Mydriatics: Cyclopentolate 1%, Homatropine 2%, Atropine 1%- to prevent formation of posterior
synechia, to reduce pain.
5) Systemic antibiotics: N. meningitidis -I/MBenzyl penicillin, Ceftriaxone or Cefotaxime /
-Oral Ciprofloxacin.
rd
N. gonorrhoea e -3 generation Cephalosporin such as Ceftriaxone.
H. influenzae -Oral Amoxicillin & Clavulanic acid
Fortified Antibiotics Preparation:
Antibiotics Method Concentration Shelf life
Cephalosporin 500mg parenteral antibiotic 50mg/ml (5%) 24 hours at room
Ceftaroline is diluted with 2.5ml sterile temperature, at least 4 days
Cefuroxime water and added to 7.5ml of if refrigerated.
Ceftazidime preservative free artificial
tear.
Gentamicin 2ml parenteral antibiotics 15mg/ml (1.5%) Upto 14 days if refrigerated.
(40mg/ml) is added to 5ml
commercially available
gentamicin ophthalmic
solution (0.3%)

LASIK
st
Laser assisted in situ keratomileusis (Lasik): By this procedure, the superficial corneal flap is lifted 1 then central
corneal stromal bed is ablated by excimer laser.
Condition: -Age of patient >21 years.
-Refractive error stable for 6 months / (1 year- anis sir)
Indication: Correction of refractive errors: -Hypermetropia  upto 4D/6D
-Astigmatism  upto 5D
-Myopia  upto 12D
Eye signs of Xerophthalmia / Ocular manifestation of vitamin A deficiency: WHO classification-
XN Night blindness
X1AConjunctival xerosis
X1BBitot’s spot
X2 Corneal xerosis
rd
X3ACorneal ulceration / Keratomalacia < 1/3 of corneal surface.
rd
X3BCorneal ulceration / Keratomalacia > 1/3 of corneal surface.
XS Corneal scar
XF Xerophthalmic fundus.
 15

Bitot’s Spot: Foamy; Triangular area near the limbus; occurs due to metaplasia & keratinization of conjunctival epithelium
Sources of vitamin A:
Plant source Animal source
-Green leafy vegetables -Small fish
-Papaya -Egg
-Tomato -Liver
-Carrot -Cod liver
Soya bean oil

Treatment of Xerophthalmia: 1) Vitamin A >6 month of age 50,000 I/U 0,1,14 days [orally].
6 months1 year 1,00,000 I/U 0,1, 14 days [orally].
More than 1 year 2,00,000 I/U 0,1, 14 days [orally]
2) Treatment of risk factor: Diarrhoea, Measles, Malabsorption.
3) Balanced diet, vitamin A rich diet.

Keratoplasty
Definition: Keratoplasty is an operation in which abnormal corneal host tissue is replaced by healthy donor cornea.
Types: 1) Lamellar Keratoplasty (Partial thickness)
2) Penetrating Keratoplasty (Full thickness)
Indications:
~General:
Optical Tectonic Therapeutic Cosmetic
-Corneal scarring Is carried out to restore or -Removal of infected To improve the appearance
-Keratoconus preserve corneal integrity in corneal tissue of the eye.
-Dystrophy eyes with severe structural unresponsiveness to
-Keratopathy changes [such as severe antimicrobial therapy.
-Pseudophakic bullous thinning with -Perforated corneal ulcer
keratopathy descemetocele].
-Degenaration

~Penetrating Keratoplasty: 1) Disease involving all layers of the cornea.

2) Specific common indications are corneal scar, Keratoconus, pseudophakic bullous
Keratopathy, corneal dystrophy.
~Lamellar Keratoplasty:
Superficial lamellar keratoplasty Deep anterior lamellar keratoplasty Descemet Stripping Endothelial
Keratoplasty (DESK)
rd
-Opacification of the superficial 1/3 of -Disease involving the anterior 95% of -Endothelial disease such as
the corneal stroma. the corneal thickness with normal pseudophakic bullous keratopathy.
-Marginal corneal thinning in recurrent endothelium & absence of breaks or
pterygium, Terrien marginal scars in Descemet membrane (e.g.
degeneration & limbal dermoids. Keratoconus)
-Localized thinning or descemetocele -Chronic inflammatory disease such as
formation. atopic keratoconjunctivitis that carries
an increased risk of graft rejection.

#Treatment of superficial corneal foreign body:

1) Sterilization of eyelid by spirit.
2) Surface anesthesia by 0.4% oxybuprocaine.
3) Application of universal eye speculum to retract the eyelid. [If foreign body not found: evert the eyelidsee tarsal
plate]
 16

4) Wash with normal saline.

5) Sweeping of foreign body by sterile swab stick.
6) If failed Impacted foreign body is removed by hypodermic needle. (26g)
If failed also then operation.
7) Application of 0.5% chloramphenicol eye ointment and pad bandage for 24 hours.
8) Follow up after 24 hours.

Hypopyon
Definition: Sterile inflammatory exudate in the anterior chamber is called hypopyon.
Cause: 1) Staphylococcal corneal ulcer (mainly)
2) Fungal corneal ulcer.
Treatment: According to the cause.

Aphakia
Definition: Absence of crystalline lens from its normal anatomical region (pupillary region).
Type: 1) Congenital: Failure to develop.
2) Acquired: i) Post-operative: After cataract surgery.
ii) Post-traumatic: Blunt or penetrating injury.
iii) Untreated hyper-mature cataract: (Dislocation, Subluxation)Ectopia lentis.
Signs: 1) Iridodonesis (Fine movement of iris along with movement of eyeball).
2) Scar mark at the level of superior limbus.
3) Jet black pupil.
4) Deep anterior chamber.
Treatment: 1) Spectacle correction: +10D spherical, +1.5 cylindrical at 180°.
2) Contact lens
3) Secondary Intraocular lens implantation: Fixed with sclera by suture material in ant./posterior chamber.

Myopia
Definition: It is a refractive error where parallel rays of light coming from infinity after refraction focus infront of retina
when accommodation is at rest.
Types:
Etiological: 1) Axial (length ↑)
2) Curvature (↑)
3) Index (R. index ↑)
Clinical: 1) Physiological / simple
2) Pathological
Another: 1) Forward displacement of lens.
Physiological/Simple myopia: 1) Commonest type myopia.
2) Doesn’t progress after 18-20 years.
3) It usually remains below -6D.
4) No degenerative changes in retina / fundus.
Pathological myopia: 1) Common in female.
2) Progress even after 18-20 of age.
 17

3) Strongly hereditary.
4) High myopia.
5) Typical degenerative changes in fundus.
6) Not fully correctable by spectacle.
7) Dioptic power of eye is >6D.

Treatment:
Non-surgical: 1) Spectacle correction by concave lens.
2) Contact lens.
Surgical: 1) LASIK ─ Myopia upto 12D
Hypermetropia upto 4D
Astigmatism 5D
2) Clear lens extraction.
3) Radial Keratotomy.
4) Intra-corneal ring.
5) Phakic IOL.

Hypermetropia
Definition: It is a refractive error of eye in which parallel rays of light coming from infinity after refraction is focused
posterior to the light sensitive layer of retina when accommodation at rest.
Cause: 1) Axial Axial length of eyeball is <24mm.
2) CurvatureLess curvature of cornea / lens.
3) Index ↓ Refractive index of lens.
=>Fluid ↑  ↓RI
=>RI increases in myopia In DM.
=>In hypermetropia: Cortex of lens ↑RI; ↓ RI of nucleus.
=>In old age (>40 years): ↑ RI of nucleus second site of vision (Nuclear sclerosis ↓ distance vision).
Management of hypermetropia: 1) Spectacles (Corrected by spherical convex lens).
2) Contact lens.
3) LASIK [After 21 years; At least 6 months refractive error should be stabled].
#Pseudophakia: It is a condition in which human lens is replaced by artificial lens.
#Presbyopia: Physiological aging process in which near point gradually recedes beyond the normal reading or working
distance due to gradual decrease in amplitude of accommodation [Due to loss of lens protein (Crystalline)].
Treatment: Spherical convex lens- 40y +1.0D 55y +2.5D
45y +1.5D 60y +3.0D
50y +2.0D >60y +(3.0-3.5)D
 18

Cataract
Definition: Any opacification of the lens &/or its capsule is known as cataract.
Classification: a) Congenital: ~Hereditary: Down syndrome (Trisomy 21), Edward syndrome (Trisomy 18).
~Maternal infection (TORCH).
~Metabolic disorder: Galactosemia, Galactokinase deficiency.
~Enzyme deficiency:(Galactosemia Galactose 1 phosphate uridyl transferase).
b) Acquired:
Age related Cataract according Cataract in systemic Secondary / Traumatic Cataract Drug induced
cataract to maturity disease Complicated cataract
cataract
-Sub capsular -Immature: grayish -DM: classical -Chronic anterior -Penetrating -Corticosteroid
cataract white snowflake uveitis -Blunt trauma -Phenothiazines
-Cortical cataract -Mature: pearly appearance. -Acute congestive -Electric shock -Miotics
-Nuclear cataract white -Myotonic dystrophy glaucoma -Ionized radiation -Amiodarone
-Christmas tree -Hyper mature: -Atopic dermatitis -High myopia -Chemical injury. -Tamoxifen
cataract milky white -Neurofibromatosis -Hereditary fundus -Statin
-Morgagnian Type 2 dystrophy
cataract: Nucleus -Galactosaemia -Retinitis
will settle down in pigmentosa
periphery. -Stickler syndrome
-Leber congenital
amaurosis.

#What do you mean by hyper mature Morgagnian cataract?

st
=>1 cataract become hyper mature then liquefies cortex Nucleus settle down.
Common types of cataract in ward: -Age related
-Traumatic
-Cataract due to drug
-Cataract due to systemic disease
Fates of untreated cataract:
Lens induced glaucoma: ImmaturePhacomorphic glaucoma
Mature/Hyper-maturePhacolytic glaucoma
Dislocation/Sublaxion: Dislocation Posterior dislocation
Anterior dislocation (Anterior dislocation anterior chamber touches the
endothelium endothelial lossendothelial
decompensation).
Methods of cataract surgery: 1) Phacoemulsification
2) Small incision cataract surgery (SICS).
Investigation before surgery: 1) Blood sugar (if ↑ Endophthalmitis)
2) ECG, after 40 years (prevent anesthetic hazards).
3) HBsAg (serum safety)
G/E: Blood pressure.
Ocular Examination: 1) Visual Acuity: Unaided, aided or pinhole using a snellen chart.
2) Pupillary light reaction: Direct / Consensual RAPD (Rapid afferent pupillary defect).
3) Ocular adnexa: Dacryocystitis, Blepharitis, Chronic conjunctivitis, Ectropion, Entropion etc.
4) Cornea: Endothelial cell count; Specular microscopy.
5) Anterior chamber: Will be shallow.
 19

6) Pupil: Size, shape, reaction.

Pupil constricted- Uveitis constricted, irregular posterior synechiaeadhesion of
pupil with lens.
Pupil dilated- Optic atrophy, acute congestive angle-closure glaucoma mid dilated,
vertically oval, non-reactive to light.
7) Lens: Color, Iris shadow, maturity (Immature/mature/hyper-mature/subluxation).
8) Fundus examination: By ophthalmoscope to exclude any retinal pathology
(maturefundus absent)
9) Biometry: Lens power by SRK-T formula. [Corneal powerKeratometry]
10) Sac patency test: for obstruction if H/O of watering.
11) IOP by Tonometry.
Complication of cataract surgery:
Per-operative: 1) Endothelial injury
2) Iris injury
3) Posterior capsule tear lens drop; nucleus drop
4) Vitreous prolapse
5) Button hole of scleral tunnel
6) Premature entry
7) Hemorrhage.
Post-operative:
Immediate: 1) Acute post-operative endophthalmitis
2) Secondary glaucoma
3) Anterior uveitis
4) Wound leak
5) Shallow anterior chamber
6) Striate keratopathy.
Delayed: 1) Delayed post-operative endophthalmitis
2) Post capsular opacification
3) Retinal detachment
4) Ptosis
Treatment option of cataract: 1) Extra-capsular cataract extraction (ECCE) with PC IOL implantation:
-Conventional method
-Small incision cataract surgery (SICS) (5-6mm incision)
- Phaco-emulsification (2.2-2.8mm incision).
2) Intra-capsular cataract surgery (ICCE) with AC IOL implantation.
Anesthesia in Cataract: 1) 2% Lignocaine
2) 0.5% Bupivacaine (long acting)
3) Hyaluronidase
4) Oxybuprocaine
5) Xylocaine
Types: 1) Sub-tenon block
2) Peri-bulbar block [lignocaine & bupivacaine]
3) Topical
 20

Ocular Adnexa: -Eyelash

-Eyelid
-Conjunctiva
-Lacrimal drainage system

Ocular Anesthesia
1) Ocular Anesthesia
2) Local anesthesia: i) Retro-bulbar
ii) Topical
iii) Sub-tenon
iv) Peri-bulbar (2% lignocaine, 0.5% Bupivacaine)
3) Mixture of anesthesia: 1) 50% Lignocaine (rapid onset)
2) 50% Bupivacaine (prolonged action)
3) Hyaluronidase (spreading)

Tonometry
Definition: Objective measurement of the intra-ocular pressure.
Types: a) Digital tonometry
b) Instrumental tonometry:
i) Indentation tonometry: Schiotz tonometry
ii)Application tonometry: -Goldmann applanation tonometry
-Perkins applanation tonometry
-Air-puff tonometry
-Pneumatic tonometry
-Tonopen (child)
Miotics: Drugs which cause pupillary constriction.
Topical: -Pilocarpine
-Carbachol
-Ecothiophate
Systemic: Above + Neostigmine
Use: Glaucoma, Amblyopia
Mydriatics: Drugs which causes dilation of pupil.
Types: Long acting: Atropine: -Acute anterior uveitis
-Corneal ulcer.
Short acting: Tropicamide: -Dilation of pupil for the examination of posterior segment.
-After cataract surgery to keep pupil mobile.
Intermediate acting: Homatropine.
Panophthalmitis: Inflammation of all three layers of the eyeball including tenon’s capsule.
Endophthalmitis: It is a severe form of intra-ocular inflammation involving the ocular cavities and inner coat (choroid +
retina) of the eye without involving the sclera and tenon capsule.
 21

Treatment of Endophthalmitis:
~Antibiotics: 1) Intravitreal antibiotics: -Ceftazidime
-Vancomycin
-Amikacin (if allergic reaction to penicillin or cephalosporin).
2) Topical antibiotics: -Gentamycin
3) Systemic antibiotic: -Fluoroquinolones: Moxifloxacin or Ciprofloxacin.
~Steroids: 1) Topical: Dexamethasone
2) Systemic: Prednisolone
3) Intravitreal: Dexamethasone
~Atropine (Mydriatic & cycloplegic).
~Finally, Pars plana vitrectomy (If drug doesn’t work).

Acute Anterior Uveitis

Symptoms: 1) Pain
2) Redness
3) Photophobia
4) Watering
Sign: 1) Visual acuity mildly reduced.
2) Conjunctiva Ciliary congestion
3) Cornea Inflammatory cell (Epitheliod, macrophage, lymphocyte, rarely neutrophil). Cell count: 3000; child:5000
Cell is counted by specular microscope).
Keratic precipitant [origin- inflammation of Iris (blood vessel of iris)].
4) Anterior chamber: -Cells (presence of inflammatory cells in anterior chamber).
-Flare (presence of excess protein in aqueous humor).
5) Iris: Muddy color.
6) Pupil: Constricted, irregular, sluggish, reacting to eye.
7) Synechia
Treatment: 1) Topical steroid: -Betamethasone
-Dexamethasone (6 hourly)
-Prednisolone (1%)
2) Systemic steroid: If not controlled by topical prednisolone  oral Prednisolone / oral Dexamethasone.
3) Regional steroid: (sub tenon) -Methylprednisolone
-Triamcinolone
4) Atropine: Mydriatic (pupil dilation) & Cycloplegic (paralysis of ciliary muscle ↓ ciliary spasm ↓ pain).
5) Immuno-modulator: -Methotrexate
-Cyclosporine
# 2 Drugs for Acute anterior uveitis: Topical steroid & Atropine.
Anti-cholinergic drugs: -Atropine
-Homatropine
-Tropicamide
-Adrenaline
-Phenylephrine
 22

Role of Anti-cholinergic dugs in AAU: 1) To relieve pain by preventing spasm of ciliary muscle and sphincter pupillae.
2) To prevent formation of posterior synechia.
3) To break down recently formed synechia by pulling the iris towards periphery.

Glaucoma
IOP: It is the lateral pressure excreted by intra ocular contents on the wall of eyeball.
Normal IOP: 11-21 mmHg; Average: 16 mmHg.
Determinants: 1) Rate of aqueous production.
2) Rate of outflow.
3) Episcleral venous pressure.
Glaucoma: It is a chronic progressive optic neuropathy with damage of the optic nerve and visual field defect in which
raised IOP is the key modifiable factor.
Types: 1) Congenital: a) Primary
b) Secondary -Open angle
-Closed angle
2) Acquired: a) Primary: -Primary open angle glaucoma
-Primary angle closure glaucoma
b) Acquired: -Open angle glaucoma
-Angle closure glaucoma
Complication of Glaucoma: 1) Cataract
2) Corneal edema corneal decompression.
3) Ciliary body shut down (Phthisis bulbi).
4) Painful blind eye.
5) Anterior staphyloma (bulging of uvea).
6) Optic nerve damage.
Q: When there is visual impairment in glaucoma?
 Primary open angle glaucoma optic atrophy central vision loss.
Primary open angle glaucoma
Symptoms: 1) Maybe asymptomatic.
2) Sometimes headache, eye ache.
3) Frequent spectacle change.
4) Painless progressive loss of vision.
Sign: 1) 3 cardinal sign: -Raised IOP (>21 mmHg).
-Visual field loss
-Optic disc cupping (asymmetrical). >0.2 is significant; 0.3 is normal.
2) IOP raised in diurnal variation. Morning ↑; Late evening ↓.
3) Gonioscopy Angle: Open.
Disc: -Nasal shifting of blood vessel.
-Focal defect in the disc.
-Notching of optic disc.
-Splinter shape hemorrhage along the optic disc margin.
4) Focal / wedge shape defect.
5) Bayoneting sign: Double angulation of blood vessels of optic disc.
 23

Treatment:
Anti-glaucoma drug: 1) β blocker: Non selective Timolol.
Selective Betaxolol, Carteolol, Levobunolol.
2) Carbonic anhydrase inhibitor: Acetazolamide, Dorzolamide, Brinzolamide.
3) agonist: Brimonidine Tartrate.
4) Prostaglandin analogue: Bimatoprost, Latanoprost, Travoprost.
5) Osmotic agent: Mannitol 20% I/V, Glycerol (oral).
Surgery: If patient non complaint, not responding to drug. So, to avoid multi-pharmacy: -LASER Trabeculoplasty.
-If failed- Trabeculectomy.
Primary angle closure glaucoma
Symptoms: 1) Sudden severe pain
2) Severe headache
3) Nausea, vomiting
4) Photophobia & lacrimation
5) Redness
6) Blurring of vision
7) Rainbow halo around light.
Signs: 1) Conjunctiva: Ciliary congestion.
2) Cornea: Hazy (due to edema).
3) Anterior chamber: Shallow
4) Pupil: Mild dilated, vertically oval, non-reactive to light.
5) IOP: Very high, 50-100 mmHg >30 mmHg, >5-7 days optic nerve damage.
6) Visual acuity: Markedly diminished. >50 mmHg, >2 days optic nerve damage.

7) Folded descemet membrane.

Treatment:
Anti-glaucoma drug: 1) Pilocarpine: Cholinergic Pupil contraction Pull the eyelash from the trabecular mashwork
 Angle open increased outflow of aqueous humor.
2) β blocker: Non selective Timolol. PG analogues are avoided due to
increased chance of acute inflammation.
Selective Betaxolol
3) Carbonic anhydrase inhibitor: Acetazolamide, Dorzolamide, Brinzolamide.
4) Osmotic agent: Mannitol 20% I/V
5) Topical steroid to subside inflammation.
Surgery: To prevent recurrence. If IOP becomes normal then LASER peripheral iridotomy in both eye. But more
Specific Trabeculectomy.

Retinoblastoma
Definition: Most common primary intra-ocular malignant tumor of children arising from primitive retinal cell (Retinoblast).
Common presentation: White pupillary reflex (Leukocoria).
D/D of white pupillary reflex: 1) Retinoblastoma 7) Persistent hyperplastic primary vitreous.
2) Retinopathy of prematurity
3) Retinal dysplasia
4) Congenital cataract
5) Coats’ Disease
6) Toxocara endophthalmitis
 24

Symptoms: Presentation within 3 years-

1) Leukocoria (white pupillary reflex) or cat’s eye reflex
2) Strabismus- Squinting of the eyes.
3) Painful red eye with secondary angle closure glaucoma
4) Uveitis- maybe associated with pseudohypopyon.
5) Pre-septal or orbital cellulitis
6) Proptosis
7) Metastatic disease to regional lymph node & brain
8) ↑ IOP due to trilateral retinoblastoma.
Signs: 1) An intra-retinal tumor (homogenous, dome shaped, white lesion).
2) An endophytic tumor (projects towards vitreous body as a white mass, may seed into the gel).
3) An exophytic tumor forms multi-lobular sub-retinal white masses; causing retinal detachment.
Treatment: 1) Chemotherapy- Carboplatin Etoposide, Vincristine.
2) Trans-pupillary thermotherapy.
3) Cryo-therapy
4) Brachytherapy (radioactive plaque utilized for an anterior tumor).
5) External beam radiotherapy (Avoided if possible)
6) Enucleation & Extraction.

─ Prepared by- Haroon (42nd Batch) ─