1

continuing
education
course
Approved by the American Board of Opticianry
and The National Contact Lens Examiners





























Anatomy and
Physiology
of the Eye
National Academy of Opticianry
8401 Corporate Drive #605
Landover, MD 20785
800-229-4828 ph
301-577-3880 fax
www.nao.org

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National Academy of Opticianry
8401 Corporate Drive #605
Landover, MD 20785
800-229-4828 ph
301-577-3880 fax
www.nao.org

3
Anatomy & Physiology of the Eye

PREFACE
This continuing education course for opticians was prepared under the auspices of the National
Academy of Opticianry and is designed to be convenient, cost effective and practical for the
optician.

The skills and knowledge required to practice the profession of opticianry will continue to
change significantly in the future, as advances in technology are applied to this eyecare specialty.
Higher rates of obsolescence will result in an increased tempo of change and opticians at all
levels will have to devote more time to acquire the necessary skills and knowledge to meet these
changes. The National Academy of Opticianry recognizes the need to provide a Continuing
Education Program for all opticians to be taken by home study. This course has been developed
as a part of the overall program to enable opticians to develop and improve their technical
knowledge and skills in their chosen profession,

The National Academy of Opticianry

INSTRUCTIONS
Read and study the material presented in the following pages. After you feel that you understand
the material thoroughly, take the test following the instructions given at the beginning of the test.
Upon completion of the test, mail the answer sheet to the National Academy of Opticianry, 8401
Corporate Drive #605, Landover, MD 20785

CREDIT
The American Board of Opticianry (ABO) and the National Contact Lens Examiners (NCLE)
have approved this course for Continuing Education Credit toward certification renewal. The
number of credit hours for this course are 3 (three) hours. These courses may be eligible for
credit to meet the Continuing Education Requirements of various states. To earn this ABO
and/or NCLE credit you must achieve a grade of 80 percent or higher on the test. The Academy
will notify all test takers of their score and issue certificates of credit to those who pass. The test
passer must then forward the certificate of credit to the ABO or the NCLE.

AUTHOR
David D. Michaels, M.D., is a Clinical Professor of Ophthalmology at the University of
California School of Medicine, Los Angeles, California. He is also Chairman of the Department
of Ophthalmology of San Pedro and Peninsula Hospital, San Pedro, California. Dr. Michaels is a
noted lecturer and the author of Visual Optics and Refraction, A Clinical Approach and has been
honored by being elected Professor Emeritus at two Universities.

INTENDED AUDIENCE
Anatomy & Physiology of the Eye is designed for the basic individual

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COURSE DESCRIPTION
Lectures, models, demonstrations and slides covering basic gross and microscopic anatomy of
the eye and orbit. Functional correlations emphasize mechanisms of acuity, refractive error,
corneal oxygenation, adaptation, binocular vision and intraocular pressure.


INSTRUCTIONAL OBJECTIVES
Upon successfully completing this course, the participant should be able to:
o Describe the anatomic organization of the eye and orbit
o Explain the structure-function relationship in refractive error, strabismus, glaucoma,
presbyopia, and contact lens wear.
o Define anatomic terms frequently used in an ophthalmic practice




















5
Anatomy & Physiology of the Eye

By David D. Michaels, M.D
INTRODUCTION



The fibrous tunic consists of sclera and cornea. The sclera is the white of the eye. It is composed
of tough inelastic fibers, tightly laced together. It thus resists the intraocular pressure without
losing shape, and provides an anchor for the attachment of extraocular muscles. The cornea fits
into the scleral shell like a watchglass into its case. Unlike the sclera, the fiber bundles making
up the cornea are all parallel. This makes it transparent without losing stability. So as not to
interfere with transparency, the cornea contains no blood vessels, but receives its nutrition by
diffusion from the surrounding area, aqueous humor; and the choroid which is composed almost
entirely of blood vessels interspersed with dark pigment.

The neural tunic consists of the retina. The retina is a complex tissue containing photoreceptor
cells (rods and cones), intermediate nerve cells (bipolars), and terminal nerve cells (ganglions)
whose extensions make up the optic nerve. There are about 120 million rods and 6 million cones
in each retina. All the nerve fibers traverse the retinal surface to exit through the same opening--
the optic disc. Unlike the film in a camera which is equally sensitive throughout, the human
retina has one area about the size of a pinhead which is exquisitely designed to distinguish
details--the fovea. When we turn our eyes to look at an object, the region we look with is the
fovea.

UVEAL TRACT FIG. 5-2

The vascular tunic (also called uveal tract) (fig.
5-2) consists of three parts; the iris which acts
as a diaphragm to regulate the amount of light
entering the eye; the ciliary body which
provides the musculature to focus on near
objects (accommodation) and secrete Situated
behind the pupil is the crystalline lens. About
the size of a large pea, it is a transparent
structure capable of changing its shape when
acted on by the ciliary muscle.
FIG. 5-1

The eye is like a living camera. It has an
outer protective coat (fibrous tunic); a
middle coat to insulate it from stray light
and nourish it (vascular tunic); and an
inner photosensitive coat which acts like
a photographic film (neural tunic). (fig.
5-1 )

6
This change in curvature is called accommodation. The lens is held in place by fine inelastic
fibers; the suspensory ligaments. The ciliary muscle pulls or releases tension on these ligaments,
which in turn flatten or increase the curvature of the crystalline lens.

FIG. 5-3


In order to rotate the eyeball, six extra-ocular muscles (fig. 5-4) are firmly attached to the sclera.
Four are recti (meaning straight) and two are obliques. Some branches of their blood vessels
supply the front of the eyeball (anterior ciliaries). The back half of the globe receives branches
(posterior ciliaries) from the ophthalmic artery which is in turn a division of the carotid---the
major artery to the brain. The blood drainage of the eyeball is by four vortex veins which empty
into the ophthalmic veins.

The nerve supply to the eyeball consists of a sensory optic nerve which relays the light-induced
messages from the retina to the back part of the brain; autonomic nerves (both sympathetic and
parasympathetic) which control pupil size, ciliary muscle action, lacrimal secretion, and blood
vessel diameter; and branches of the trigeminal (V cranial) nerve which provide for pain, touch,
and temperature sensation. In addition, there are motor nerves to the extra-ocular and lid
muscles.

The eyeball, together with its blood and nerve supply, is surrounded by a tough covering called
Tenon's capsule. The capsule acts somewhat like a ball and socket joint to allow free movement
of the globe. Surrounding the muscles and Tenon's capsule is the orbital fat which, in life, is
more like thick oil to minimize friction.


It will be evident that the interior of the eyeball
(fig. 5-3) can be divided into three spaces; the
space between the back of the cornea and the
iris (anterior chamber); the space between the
iris and the lens and suspensory ligaments
(posterior chamber); and the largest or vitreous
space between lens and retina. The anterior
and posterior chambers are filled with a watery
fluid which is constantly produced and
drained; the aqueous humor. The vitreous
chamber is filled with gel-like fluid that
remains unchanged throughout life; the
vitreous humor.

EXTRA-OCULAR MUSCLES FIG. 5-4

The eyeball and its adjacent tissues lies
in a bony cavity of the skull called the
orbit. (fig. 5-5) The bones making up the
orbit are partly those of the face, partly
those of the cranial cavity, and partly
those of the sinuses.
7
Above and behind the orbit is the brain; below is the maxillary sinus; on the inner side is the
ethmoid sinus and nasal cavity; on the outer side is the zygomatic arch and temple.

[C:\AnaPhyDoc\AnaP0011.TIF]

The conjunctiva thus consists of three parts; the portion lining the lids (palpebral), the backward
curving portion (fornix), and the portion adherent to the eyeball (bulbar).

The conjunctiva is a mucous membrane because it contains cells that produce mucus (goblet
cells). Their function is to lubricate the movements of the lids as they blink 10 to 16 times a
minute. To further minimize friction, the lacrimal gland secretes tears which are distributed over
the cornea by the blink reflex. The tears accumulate in the inner cornea of the eye, from where
they are drained by a system of canals into the nose.

The following important average dimensions should be committed to memory: the globe is 25
mm in diameter; the cornea is 12 mm in diameter and 0.5 mm thick in the center; the separation
between eyes can range from 55 to 75 mm; the pupil diameter under average light is 3.5 mm; the
anterior chamber depth is about 3.5 mm; the diameter of the optic disc is 1.5 mm.

Having outlined the general anatomic plan, let us now return and look at each part in more detail.

Cornea
If the eye is the window of the soul, the cornea is the window to the eye. Although the tissue
looks crystal clear, it is actually made up of five distinct layers: epithelium, Bowman's
membrane, stroma, Descemet's membrane, and endothelium. (fig. 5-6) Each can be seen easily
with the slit lamp biomicroscope (available in most offices). The epithelium is a stratified layer
of cells which is continuously renewed; Bowman's and Descemet's membranes are structureless;
the stroma makes up 90% of the corneal thickness and is composed of band-like fibers of
uniform size and arrangement. Between the fibers are the actual corneal corpuscles (keratocytes)
squeezed almost fiat. The innermost endothelium is a single layer of cells which also serves as a
lining for the anterior chamber.
THE BONY ORBIT FIG. 5-5

We see that the eye has bony protection on all
sides except the front. The forward protection
is provided by the lids. The upper and lower
lids consist of a fibrous skeleton (tarsal
plates), muscles which open them (levator)
and muscles which close them, (orbicularis
oculi). On the surface, the skin of the lids is
continuous with the skin of the face. On the
inner side, the lids are covered by a mucous
membrane---the conjunctiva. The conjunctiva
is reflected backwards to cover the exposed
parts of the sclera.
8



The cornea is the most powerful refractive component of the eye. Of the total 60 D. power of the
eye, the cornea contributes 43 D. and the crystalline lens 17 D. This is not because the corneal
radius of a curvature is so small, but because the refractive index difference between air and
cornea is so large (1.00 and 1.37). You should be able to calculate from these figures that the
average corneal radius is about 8.6 mm.

The cornea is bathed on each side by watery fluids. On the front is the tear film which smoothes
out any epithelial irregularities; on the back is the aqueous humor. To keep it from absorbing
water and swelling, endothelial cells act like tiny bilge pumps (deturgescence). This metabolic
work requires a source of energy and oxygen. The cornea gets its energy by way of glucose from
the aqueous and its oxygen directly from the air. When the oxygen supply is cut off by an
improperly fitted contact lens, or if the endothelial cells are injured by intraocular surgery or lost
from old age, the cornea swells (edema). As the water percolates into and between the surface
epithelial cells, they break up to produce painful erosions (bullous keratopathy). Since surface
irregularity is compromised, vision is also impaired.

The cornea is not only a barrier to injury and infection, but also to drugs. When ointments or
drops are instilled into the conjunctival sac, they must negotiate the corneal layers to gain access
into the interior (e.g., to dilate or constrict the pupil or produce cycloplegia). Because it is
exquisitely sensitive, a topical anesthetic is usually necessary to measure intraocular pressure.

CORNEA IN CROSS
SECTION FIG. 5-6

The cornea is about 1/2mm
thick at its center and is
slightly thinner at the center
when compared to the
periphery.

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Sclera


Corneal incisions in cataract or other intraocular surgeries are generally made at the limbus. It is
also a point of reference in measuring the insertions of the extraocular muscles. Umbal blood
vessels are the source of diffusional nutrients to the cornea. In chronic inflammation or anoxia,
limbal vessels may actually invade the cornea. While this attempt to restore metabolic balance is
admirable it also interferes with vision. Moreover, it destroys the immunologic isolation which
makes corneal transplants successful.


Tear film
An understanding of the tear film is important because of its role in debilitating dry eye
syndromes on the one hand, and happy contact lens wearers on the other.

Two types of tearing are recognized; tearing as a reflex response to pain, emotion, freshly cut
onions, etc., and basic secretion which goes on at a steady rate the rest of the time. The lacrimal
gland supplies tears via small canals into the upper fornix for reflex tearing. Basic tear secretion
is carried out by scattered small tear glands in the conjunctiva (accessory lacrimal glands).
The tear film covering the cornea is composed of three distinct layers. (fig. 5-9)

CORNEAL GEOMETRY FIG. 5-7


FIG. 5-8

The sclera is a dense, collagenous connective tissue
about 1 mm thick. It is pierced by various vessels and
nerves which enter or leave the globe. The optic nerve
fibers cross a sieve-like membrane at the optic disc
(lamina cribrosa). Because of its close resemblance to
connective tissue, scleritis may be a complication of
diseases like rheumatoid arthritis.

The 1 mm transition zone between cornea and sclera is
the limbus--an important surgical landmark. (fig. 5-8)


10

The corneas of patients wearing hard contact lenses get their oxygen from the tear pool
underneath the lens. This pool must be constantly renewed by proper blinking and adequate tear
production. Soft contact lenses transmit oxygen directly and thus require little movement. But
enough tears must be available to keep them hydrated.


Anterior chamber



FIG. 5-9

An outer oily layer supplied by glands of
the lids; a middle watery layer which makes
up the bulk thickness and is supplied by the
tear glands; and an inner mucin layer,
supplied by conjunctival goblet cells. The
mucin has somewhat the same function as
"wetting" solution used on hard contact
lenses. Dry eyes can therefore be caused by
insufficient oil gland secretion (e.g., lid
disease), insufficient aqueous tears (not
infrequent in old age), or inadequate mucin
production (conjunctival disease). Dry eye
manifestations are chiefly corneal; dry
spots, erosions, filaments, and even
ulceration.



FIG. 5-10

The depth of the anterior chamber varies with age, the
size of the eye, whether a cataract has been removed,
or an intraocular implant inserted. (fig. 5-10) Gradual
shallowing of the chamber with advancing age is one
factor which increases the susceptibility of the elderly
to glaucoma. The most important part of the anterior
chamber is the angle where iris and cornea meet
circumferentially. The angle is filled with a meshwork
of connective tissue (trabeculae) (fig. 5-11) through
which aqueous is filtered on its way to Schlemm's
canal.
11





Iris
The iris (fig. 5-12) is a thin vascular membrane whose color varies according to the amount of
pigment it contains (blue irises simply have less pigment--not blue pigment). Its central aperture
the pupil, is controlled by fine muscles. The muscles regulate the size of the pupil according to
the prevailing light. Drugs which dilate the pupil are called mydriatics; drugs which constrict the
pupil are called miotics. These drugs act by their effects on the autonomic nerve fibers. When the
iris is inflamed (iritis), there is an outpouring of protein and cells into the anterior chamber. This
can be seen as a "flare" with the fine beam of the biomicroscope, analogous to the visibility of a
beam of light in a dusty room.

The response of the pupils to light provides an important clinical sign of the integrity of the
retina and the function of the nerve fibers to the iris. Three reflexes are generally elicited; direct
pupil constriction to light; the simultaneous constriction of the pupil of the opposite eye even
though it is not illuminated (consensual reflex); and the bilateral pupil constriction when looking
at a near target (not illuminated). If the eye is blind, for example, the direct and consensual
reflexes will be absent, but the near reflex will be present.


FIG. 5-11

From Schlemm's canal, collector channels
carry the aqueous into a venous plexus in the
sclera and thus into the general circulation.
On the basis of the anatomic configuration,
glaucoma is classified into open angle and
closed angle. Open angle glaucoma is by far
the most common (about 98%) and is a
slowly progressive disease which seldom
produces pain or other symptoms. It is
caused by an as yet undetermined block in
the trabeculae. Closed angle glaucoma, on
the other hand, is due to adhesion between
iris and cornea, usually from pupil dilation,
which prevents aqueous from gaining access
to the trabeculae. In closed angle glaucoma,
there is a sudden large rise in intraocular
pressure, causing severe pain and rapid
visual loss.



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Ciliary body

FIG. 5-12

In cross-section, the ciliary body (fig. 5-12) has a triangular shape, with finger-like extensions
toward the crystalline lens (ciliary processes). The ciliary processes are extremely vascular and it
is from these vessels the aqueous humor is elaborated by the ciliary epithelium. The exact
mechanism of production is not known, but is believed to be a process of secretion by the cells in
which they transfer fluid from the blood into the posterior chamber. The aqueous then circulates
through the pupil into the anterior chamber, and is drained through the trabeculae. In
inflammations where the pupillary margin becomes adherent to the crystalline lens, the aqueous
is blocked and pressure builds up in the posterior chamber (pupillary block glaucoma). To
prevent such adhesions, the pupil is dilated in patients with active iritis.

Fine non-elastic fibrils (suspensory ligament or zonule of Zinn) extend from the valleys between
ciliary processes to the crystalline lens capsule. The tension of these fibrils is regulated by the
ciliary muscle. When the muscle contracts it reduces in size, causing it to move forward and
inward. This decreases the tension on the fibrils and allows the lens to become more convex,
providing more plus power to bring near objects into focus (accommodation). As we get older,
this focusing ability begins to fail (presbyopia). But not because the ciliary muscle gets weaker--
rather because the lens becomes less elastic.





13

Choroid



CHOROID FIG. 5-13 FIG. 5-14

The choroid is the largest portion of the uveal tract. (fig. 5-13) It is a thin membrane made up
almost entirely of blood vessels. The vessels get progressively smaller from the scleral to the
retinal side. Next to the retina, they have the diameter of capillaries (choriocapillaries). A thin
but important membrane separates the choriocapillaries from the rods and cones of the retina
(Bruch's membrane). In some older people, this membrane cracks and degenerates, perhaps
because of partial obstruction of the capillaries. The vessels can now leak blood into
the retina. This is the main mechanism of senile macular degeneration.

The junction of the choroid with the ciliary body forms a dentate border (ora serrata). Note that
the ora serrata (fig. 5-14) is considerably forward of the equator. It can only be visualized
clinically by the indirect ophthalmoscope and scleral depression. Such visualization is important
because many holes which lead to retinal detachment begin here.





14




Fig. 5-15
CATARACT FIG. 5-16



Crystalline lens
The lens is a biconvex, semisolid, transparent
body consisting of an elastic capsule
surrounding the lens substance. (fig. 5-15) On
the front side (only) is a single layer of
epithelial cells which continuously gives rise
to new lens fibers. The fibers are laid down
like the layers of an onion, a process that goes
on throughout life. This means the lens gets
larger as we get older, and this is the reason the
anterior chamber becomes shallower.

At birth, the lens consists only of a few fibers
(nucleus). With growth, the nucleus is covered
by new fibers, like the rings on a tree. One can
therefore time a small injury by its depth
within the lens.

The lens fibers actually are not long enough to
grow entirely around the nucleus. Fibers from
each direction meet about the middle, and
where they do give rise to "suture lines." Since
there are more fibers in later life, the suture
lines get progressively more complex. All
layers of the lens, epithelium, capsule, and
suture lines are readily seen with the
biomicroscope.

15
Opacities of the crystalline lens obstruct and scatter light, and hence interfere with vision. Any
opacity is technically a cataract, but it takes many opacities before vision is seriously
compromised. (fig. 5-16) The time to operate for cataract depends, not on the lens, but on a
particular patient's visual disability. That cataracts can only be removed when they are "ripe" is a
common, but untrue myth.

Cataracts are usually senescent changes caused by complex biochemical alterations in the lens
substance. These are probably universal if we live long enough. Some people, such as diabetics,
may develop opacities at an earlier age. But the onset and rate of progression is not predictable.
In early stages of cataract, the lens may swell rather than become opaque. This induces an
artificial myopia, and the patient may find himself able to read without glasses ("second sight").
Not all cataracts are senescent, however. Lens changes may also be congenital, or caused by
injuries, drugs, radiations, or intraocular disease (complicated cataract).


Vitreous
The vitreous body is a gel-like fluid which vegetates in splendid isolation from birth to death. It
neither circulates nor carries out any work except to hold the retina against the choroid. With
advancing age, however, it tends to shrink and collapse. Small aggregates form and cast shadows
on the retina, especially in bright light. These shadows are the annoying floaters most of us
acquire with age. The collapsed vitreous may also bounce against the retina, causing flashing and
scintillations. Or residual adhesions actually tug on the retina and may cause it to detach. Only
careful (and prompt) examination can distinguish between inocuous flashes and those which
precede more ominous detachments. When the retina does detach, the patient may note a veil or
curtain in his field of vision. Every vitreous hemorrhage should be suspected of hiding a retinal
detachment in older people. More rarely, detachment and hemorrhage are caused by an
intraocular tumor. Vitreous bleeding without detachment is usually due to diabetic retinopathy.

Retina
The retina is embryologically an outgrowth of the brain. Like brain and spinal cord nerve fibers,
once damaged it cannot regenerate. The optic nerve, in fact, is not a true nerve, but a "tract"
connecting one part of the brain to another. It too will not regenerate, and any damage it sustains
is permanent.

The entire eyeball is designed around the retina. The optics of the cornea and lens bring the
image of an object into focus on the retina; the sclera protects it; the choroid nourishes it and
keeps out extraneous light; and the intraocular pressure maintains its stability. It would not do to
have a camera which collapses at unpredictable moments. The retina, therefore, is the film for
our living camera.


16


Optic nerve
The optic nerve is made up of the axons of retinal ganglion cells. Since there are only one
million optic nerve fibers and 126 million photoreceptors, it must mean that many rods and cones
hook up (by way of bipolars) to a single ganglion. This accounts for our ability to detect very
small amounts of light. Only in the fovea is each cone connected to a single optic nerve fiber;
this is the anatomic basis for its resolving power.


Lids
Fig. 5-17




The lids are folds of tissue (fig. 5-17)
whose function is protection, tear
distribution, and supplying oxygen to the
cornea (via its conjunctival capillaries)
during sleep. When the lids are open, the
space is termed the palpebral aperture.
Note that it is not always symmetric or
equidistant from the nose. Drooping of the
lid (ptosis) will make it smaller and might
occur in III nerve palsy, myasthenia, or lid
tumor. A large palpebral aperture is
usually caused by lid retraction, and is
often seen in Grave's disease. It is
characterized by the fact that sclera shows
above the eye, whereas normally the upper
lids cover about 1/4 of the cornea.

The lids contain oily glands, of which the
most prominent are the Meibomian glands.
(fig. 5-18) These secretions lubricate the
cornea and make up the outer layer of the
tear film. The blink reflex distributes the
tears over the cornea and activates the
lacrimal drainage pump.
FIG. 5-18
17

Lacrimal apparatus

FIG. 5-19 THE LACRIMAL APPARATUS FIG. 5-20

The lacrimal glands consist of the lacrimal gland proper and accessory glands (Wolfring and
Krause glands) scattered throughout the lid. (fig. 5-19) The main gland provides reflex tear
secretion, while the accessory glands take care of basic secretion (steady state). The aqueous
tears are covered on the outside by the oily secretions of the lids, and on the inside by the mucin
secreted by conjunctival goblet cells. The precorneal tear film thus consists of three layers, each
of which may be selectively involved in disease. Abnormal lashes, lid-cornea incongruities,
pterygia, contact lenses, drugs or infections may all affect the tear film. Tear quantity can be
measured by a strip of filter paper (Schirmer test) or by observing the thickness of the tear
meniscus resting on the lower lid with the biomicroscope. Tear film quality can be evaluated by
tear film break-up time as you hold the lids apart.

Drainage of the tears proceeds through the punctum, (fig. 5-20) into canaliculi, lacrimal sac, and
from there via the lacrimal duct into the nose. Sulfa instilled into the eye may sometimes cause a
bitter taste because of this communication. In some infants, the lacrimal drainage system may
fail to canalize. The baby tears on one side and may show a chronic unilateral conjunctivitis.
This plumbing problem can usually be solved by simple probing.

Normal tears contain a variety of antibacterial (lysozymes) and immune substances that help to
prevent infection of the anterior ocular surface. These substances are depressed in tear deficiency
diseases. Thus patients with keratitis sicca also frequently suffer from blepharitis.


Conjunctiva
The conjunctiva lines the inside of the lids and the front of the eye up to the limbus. (fig. 5-21)
The upper and lower reflections make up the fornices, and the entire space is called the
conjunctival sac. This sac receives ocular medications and prevents contact lenses from getting
into the orbit proper (a frequent concern expressed by patients). On the other hand, the fornices
also hide foreign bodies--even contact lenses have been "lost" into the space because the lids
were not carefully everted to look for them.

18

CONJUNCTIVA FIG. 5-21

Non-infectious causes of red eyes are toxins, drugs, allergies, environmental irritants, orbital
tumors, keratitis, uveitis, and glaucoma. The pattern of hyperemia is fairly typical in
conjunctival, uveal, and acute glaucomatous disease (make yourself a table of differentiating
features). A patient with conjunctivitis complaining of photophobia, pain, and impaired vision
probably has secondary corneal involvement.




Extra-ocular muscles



EXTRA-OCULAR MUSCLES FIG. 5-22

Orbit
The orbit is the pyramidal space in the skull designed to hold the eyeball and its contents. (fig. 5-
23 It is arbitrarily divided into a roof, floor, lateral and medial wall. Various openings and
The conjunctiva is a mucous membrane by virtue
of its goblet cells. Mucin aids in the adhesion of
the tear film to the cornea. A reflection at the inner
canthus called the plica semilunaris is the vestigal
remnant of a third eyelid in lower animals. The
fleshy protuberance (caruncle) is a normal
anatomic feature but may frighten a patient into
believing he has a tumor when it becomes swollen.

Infection of the conjunctiva by bacteria or viruses
is the most common cause of a red eye. This is
usually accompanied by a discharge, tearing,
itching or burning, swelling, foreign body
sensation, and a velvety appearance to the
conjunctival surface.
The six extra-ocular muscles (fig. 5-22) rotate
each globe in all possible directions, but their
mechanism of action is somewhat complex. The
best way to learn them is to draw the insertions
on a rubber ball, and attach a string to each with
a pin. Such a model will serve to demonstrate
how the superior oblique turns the eye down
and the inferior oblique turns the eye up.

19
depressions constitute landmarks. For example, the roof has a depression for the lacrimal gland,
the medial wall for the lacrimal sac, the floor for the infraorbital nerve, and the lateral wall for
the zygomatic nerve. (fig. 5-24)


THE BONY ORBIT FIG. 5-24

Visual acuity
The traditional criterion of retinal image clarity is resolving power. Thus if an eye resolves 100
lines/mm it is said to have better acuity than one which resolves only 50 lines/mm. Resolution is
highly dependent on measurement conditions; design, size, shape, color, illumination, contrast,
as well as patient cooperation.

The standard of clinical acuity is the Snellen chaff. The equation for recording the Snellen
fraction is V=d/D where d is the distance at which a given letter can just be discriminated, and D
the distance at which the same letter subtends one minute of arc. For example, 20/40 means the
minimum angle of resolution is two minutes. Care should be taken not to misinterpret 20/40 as
50% visual loss.


EYE POSITION--UPPERVIEW FIG. 5-23

20
Ametropia and presbyopia





MYOPIA Fig. 5-25 HYPEROPIA Fig. 5-26

An eye is considered emmetropic, if parallel rays focus on the retina with accommodation
relaxed. The definition says nothing about biologic health--an eye may be emmetropically blind.
If the focal point of a distant target is in front of the retina, the eye is said to be myopic; (fig. 5-
25) if behind the retina, hyperopic. (fig. 5-26) Of course there is an image on the retina in all
cases, but the image is clear or blurred. The hyperope with sufficient accommodation can bring
the image into focus; the myope cannot. The myope can, however, squeeze his lids together to
create a smaller opening and the increased depth of focus helps improve vision.
Instead of defining refractive error in terms of retinal focus by parallel rays, we can turn the thing
around and ask where a target must be placed to produce a sharp retinal image in any eye,
whatever its ametropia. This position is termed the far point. The far point for an emmetropic eye
is at infinity. It is somewhere between the eye and 6 meters for a myope. It is behind the eye in
hyperopia. How can a target be behind an eye? What is meant, optically, is that the light rays
must already be convergent when they enter the hyperopic eye to form a focus. Such convergent
rays would produce a picture somewhere behind the eye. Of course, they never get there; they
enter the eye and focus on the retina instead. To distinguish between a far point in front or
behind the eye, we give it an algebraic sign. Since rays from any far point in front of the eye
must be divergent, we give it a minus sign. Similarly, convergent rays are given a plus sign.
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Thus the sign of the far point coincides with that of the correcting spectacle lens; plus in
hyperopia, minus in myopia.

To be more specific, we can actually measure the location of the far point. This measurement
constitutes clinical refraction. It may be objective, as in retinoscopy, or subjective as in the test
with trial lenses.

Where would the far point of a 2D myope be? The answer is 50 cm in front of the eye (-50 cm).
Stated differently, we are saying that if an object is placed 50 cm in front of the eye, the image
will be in sharp focus with accommodation relaxed. Or we might say that this myope must
approach to within 50 cm of an object in order to see it clearly. What about the hyperope? He
cannot see clearly at any distance unless he accommodates. And if he is over 55 years old, he
cannot even do that. How much must a 2D hyperope accommodate to see clearly at 20 feet?
Obviously 2D. How much to see clearly at 50 cm ? Another 2D, for a total of 4D. Note that the
uncorrected hyperope has to accommodate more than an emmetrope to read. You can work out
the reading requirements of a myope for yourself.

What about the far point in an astigmatic eye? Obviously such an eye has two far points/just as it
has two foci), corresponding to each of the principal meridians. If an eye is 2D myopic in the
vertical meridian and 2D hyperopic in the horizontal meridian, the vertical far point is at -50
cm. and the horizontal far point in at +50 cm. You should draw this and similar examples on
paper until this somewhat confusing subject falls into place.









ACCOMMODATION FIG. 5-27

The closest point an eye can see exerting its maximum available accommodation is called the
"near point." (fig. 5-27) An emmetropic eye with a 10D amplitude of accommodation would
have a near point of 10 cm. The near point of a 20D uncorrected myopic eye with the same
amplitude would be 5 cm. Where would the near point of a 10D uncorrected hyperope with the
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same amplitude be? (Answer is infinity). Why might a 60 year old person who is 3D myopic
object to wearing bifocals?

Presbyopia technically means the vision of old age. Actually it signifies that stage of life when
accommodation has so diminished that the patient can no longer read the size of print at the
distance he wants to. The diagnosis (and treatment) therefore depends not on accommodative
amplitude but on the person's needs. The amplitude of accommodation, as is well known,
decreases progressively from birth to old age. It is about 15 diopters in a child and zero at age
55-60.

Binocular vision and strabismus
Binocular vision refers to the cerebral unification of two images, one from each eye, to produce a
single three-dimensional percept. The eyes are brought into alignment upon a fixation target by a
complex series of reflexes involving muscular tonus, accommodation, and vergence. This
process is called "fusion."


Intraocular pressure and glaucoma
We have already seen that aqueous is continuously produced and drained. Together with the
unchanging vitreous, this maintains a constant pressure within the globe. This is resisted by the
counter pressure of the ocular coats and the intraocular circulation. The purpose of maintaining
constant ocular pressure is to keep the refracting surfaces in precise alignment since even minor
collapse would greatly distort the optical image on the retina.

It is not possible to measure the intraocular pressure directly without sticking a needle into the
eye and balancing the pressure against a column of mercury. Instead it is measured indirectly
(hence called intraocular tension). The units, however, are still the same so many mm of Hg. The
two common ways of estimating pressure are with the Schiotz tonometer which indents the
cornea, or the applanation tonometer which flattens the cornea. The latter is generally more
precise, and can be done while the patient is sitting at the slit lamp.

Normal intraocular pressure, like normal blood pressure, varies from one individual to another,
and from time to time. The average range is from 15 mm Hg to 21 mm Hg approximately. The
person with a tension of 25 mm Hg may or may not have glaucoma, however, depending on
whether that pressure reading is excessive for that eye. How can one tell? By looking at the optic
disc and measuring the visual field. If these show abnormalities, it means that nerve fibers are
being damaged and the pressure must be reduced to a safer level.

Pressure reduction in glaucoma means life long treatment, for like diabetes, it can be controlled
but not cured. The conventional drugs used in open angle glaucoma are those which increase
drainage (outflow) such as pilocarpine, timolol, and epinephrine; those which reduce aqueous
production (diamox); or those which alter the osmotic balance with the blood (glycerol and
mannitol). Some drugs have more than one mechanism of action. Surgery is used only for those
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situations where glaucoma cannot be controlled by drugs or the patient cannot be relied on to
take medication regularly. In contrast, closed angle glaucoma is an ophthalmic emergency
because the extremely high pressure (60 + mm Hg) can lead to blindness within 24 hours. The
patient is usually hospitalized, and once the pressure is brought down, scheduled for prompt
surgery (iridectomy). If done in time, they may cure the patient so that further medication is
unnecessary. If treatment is delayed, however, the outflow is permanently compromised and the
patient now has chronic glaucoma superimposed on the closed angle mechanism. In addition to
anatomically narrow angles, aqueous outflow may also be compromised by injury (bleeding into
the chamber), inflammation (keratitis, uveitis), or tumors. These are termed secondary
glaucomas, and may be unilateral. Occasionally, a hypermature cataract may swell and block the
angle. More commonly, one sees certain people whose tension rises when they use topical or
systemic steroids for more than two weeks. These induced glaucomas can be cured by
eliminating use of the drug.


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Bibliography

Bausch and Lomb Optical Company, The Human Eye in Anatomical Transparencies, The
Bausch and Lomb Press, Rochester, N.Y., 1943

Borish, Irvin M., Clinical Refraction, Third Edition, The Professional Press, Chicago Illinois,
1970

Davidorf, Frederick H. and Hill, Donald A., Atlas of Eye Surgery and Related Anatomy,
Ophthalmology Illustrated, Keller Publishing Co., Columbus, Ohio, 1978

Hogan, Michael J., AIvarado, Jorge A. and Weddell, Joan E., Histology of the Human Eye, W.B.
Saunders Company, Philadelphia, PA. 1971

Michaels, David D., Visual Optics and Refraction, Second Edition, C.V. Mosby Company, St.
Louis, Mo., 1980

Moses, Robert A., Adler's Physiology of the Eye, Seventh Edition, C.V. Mosby Company, St.
Louis, Mo., 1981

Scheie, Harold G. and Albert, Daniel M., Textbook of Ophthalmology, Ninth Edition, W.B.
Saunders Company, Philadelphia, Pa., 1977

Stimson, Russell L., Ophthalmic Dispensing, Charles C. Thomas, Publishers, Springfield Illinois,
1979
Tisdale, Ralph, Review Outline, Anatomy and Physiology, N.Y.C. Community College,
Brooklyn N.Y., 1971

Vaughan, Daniel and Ashbury, Taylor, General Ophthalmology, Lange Medical Publications,
Los Altos Ca., 1980

Warwick, Roger, Wolff's Anatomy of the Eye and Orbit, W.B. Saunders Company, Philadelphia,
Pa., 1976








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