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8 Common Eye Diseases and their Management
Ciliary body
Conjunctiva
Upper punctum
Sclera
Caruncle Choroid
Retina
Lower punctum
Openings of tarsal glands Figure 2.2. Layers of the globe.
Semilunar folds
In the region of the limbus, the epithelium on of the triangle (mainly ciliary muscles) lies
the outer surface of the cornea becomes con- against the sclera. The inner side is divided into
tinuous with that of the conjunctiva, a thin, two zones: (1) the pars plicata forms the ant-
loose transparent nonkeratinising mucous erior 2 mm and is covered by ciliary processes
membrane that covers the anterior part of the and (2) the pars plana constitutes the posterior
sclera, from which it is separated by loose con- 4.5-mm attened portion of the ciliary body.
nective tissue. Above and below, the conjunctiva The pars plana is continuous with the choroid
is reected onto the inner surface of the upper and retina.
and lower lids. This mucous membrane, there- The choroid consists of the following:
fore, lines the posterior surface of the eyelids
Bruchs membrane membrane on the
and there is a mucocutaneous junction on the
external surface of the retinal pigment
lid margin. Although the conjunctiva is con-
epithelium (RPE). It consists of the base-
tinuous,it can be divided descriptively into three
ment membrane of RPE cells and chorio-
parts: palpebral (tarsal), bulbar and fornix.
capillaris. Between the two layers of
The sclera consists of irregular lamellae of
basement membrane are the elastic and
collagen bres. Posteriorly, the external two-
collagenous layers. Small localised thick-
thirds of the sclera become continuous with the
enings of Bruchs membrane (which
dural sheath of the optic nerve, while the inner
increase with age) are called drusen.
one-third becomes the lamina cribrosa the
fenestrated layer of dense collagen bres The choriocapillaris a network of capil-
through which the nerve bres pass from the laries supplying the RPE and outer retina.
retina to the optic nerve. The sclera is thickest Layer of larger choroidal blood vessels
posteriorly and thinnest beneath the insertions external to the choriocapillaris.
of the recti muscles. There is a layer of loose Pigmented cells scattered in the choroid
connective tissue deep to the conjunctiva, over- external to the choriocapillaris.
lying the sclera, called the episclera.
Inner Layer
Middle Layer
The inner layer of the eye, which lines the vas-
The middle layer is highly vascular. If one were cular uvea, is the neurosensory layer. This layer
to peel the sclera away from this layer (not an forms the retina posteriorly; but, anteriorly it
easy task), the remaining structure would comes to line the inner surface of the ciliary
resemble a grape, as this middle layer, which is body and iris as a two-layered pigment epithe-
called the uvea, is heavily pigmented as well as lium. These same layers can be traced into the
being vascular. The anterior part of the uvea retina, which is composed of an outer pigment
forms the bulk of the iris body and hence epithelium and an inner sensory part, which
inammation of the iris is called either anterior contains the rods and cones, bipolar cells and
uveitis or iritis. The posterior part of the uvea is ganglion cells (Figure 2.4). The junction of the
called the choroid. retina and the pars plana forms a scalloped
The iris is the most anterior part of the uvea. border known as the ora serrata.
It is a thin circular disc perforated centrally It is important to note that the photoreceptor
by the pupil. Contraction of the iris sphincter cells are on the external side of the sensory
muscle constricts the pupil, while contraction of retina. The relationship of the retinal elements
the dilator pupillae muscle dilates the pupil. can be understood most readily by following the
The ciliary body is part of the uveal tissue and formation of the optic cup. As the single-cell
is attached anteriorly to the iris and the scleral layer optic vesicle invaginates to form the two-
spur; posteriorly it is continuous with the cell layered optic cup, the initially supercial
choroid and retina. The ciliary body is also cells become the inner layer of the cup. The RPE
referred to as the intermediate uvea. develops from the outer layer of the cup, facing
The ciliary body is triangular in cross- the photoreceptors across the now obliterated
section. The anterior side of the ciliary body is cavity of the optic vesicle. The neurons of the
the shortest and borders the anterior chamber sensory retina differentiate from the inner layer
angle; it gives origin to the iris. The outer side of the optic cup.
10 Common Eye Diseases and their Management
Ganglion cells
Bipolar cells
Lacrimal gland
Lacrimal artery
Optic nerve
Pigment epithelium
Ophthalmic artery
Optic Nerve
The optic nerve meets the posterior part of the
Blood Supply globe slightly nasal to the posterior pole and
slightly above the horizontal meridian. Inside
The blood supply of the globe is derived from the eye this point is seen as the optic disc. There
three sources: the central retinal artery, the are no light-sensitive cells on the optic disc
anterior ciliary arteries and the posterior ciliary and hence the blind spot that anyone can nd in
arteries. All these are derived from the ophthal- their eld of vision. The optic nerve contains
mic artery, which is a branch of the internal about one million nerve bres, each of which
carotid. The central retinal artery runs in the has a cell body in the ganglion cell layer of
optic nerve to reach the interior of the eye and the retina (Figure 2.6). Nerve bres sweep
its branches spread out over the inner surface of across the innermost part of the retina to reach
the retina supplying its inner half. The anterior
ciliary arteries emerge from the insertion of the
recti muscles and perforate the globe near the Optic disc Macula
iris root to join an arterial circle in the ciliary
body. The posterior ciliary arteries are the ne
branches of the ophthalmic artery, which pene-
trate the posterior pole of the eye. Some of these
supply the choroid and two or more larger
vessels run anteriorly to reach the arterial circle
in the ciliary body. The larger vessels are known
as the long posterior ciliary arteries, and those
supplying the choroid are known as the short
posterior ciliary arteries. The branches of the
central retinal artery are accompanied by an
equivalent vein, but the choroid, ciliary body
and iris are drained by approximately four
vortex veins. These leave the posterior four
quadrants of the globe and are familiar land-
marks for the retina surgeon (Figure 2.5). Figure 2.6. The optic fundus.
Basic Anatomy and Physiology of the Eye 11
the optic disc. They can be seen with the and pain is also sometimes experienced during
ophthalmoscope by carefully observing the way laser coagulation treatment of the chorioretina
light is reected off the inner surface of the this would seem to prove the existence of
retina (Figure 2.7). The retinal vessels are also sensory bres in the iris and choroid. The
embedded on the inner surface of the retina. cornea is extremely sensitive, but again, the only
There is therefore a gap, which is the thickness sensory endings are those for pain.
of the transparent retina, between the retinal The visual pathways include the following:
vessels and the stippled pigment epithelium.
1. The retina:
Apart from the optic nerve, the posterior pole of
the globe is also perforated by several long and rods and cones
short ciliary nerves. These contain parasympa- bipolar cells
thetic, sympathetic and sensory bres, which ganglion cells.
mainly supply muscles of the iris (dilator and 2. Axons of the ganglion cells visual and
sphincter) and ciliary body (ciliary muscles). pupillary reex pathways:
Patients can experience pain when the iris is nerve bre layer of retina
handled under inadequate local anaesthesia,
optic nerve
optic chiasm
optic tract.
3. Subcortical centres and relays:
superior colliculus reex control of
eye movements
pretectal nuclei pupillary reexes
lateral geniculate body cortical relay.
4. Cortical connections:
optic radiations
visual cortex (area 17) vision and
reex eye movements
association areas (areas 18 and 19)
frontal eye eld voluntary eye
movements.
a
If the rods and cones are considered analo-
gous to the sensory organs for touch, pressure,
temperature, etc. then the bipolar cells may be
compared to the rst-order sensory neurons
of the dorsal root ganglia. By the same token,
the retinal ganglion cells can be compared to
the second-order sensory neurons, whose cell
bodies lie within the spinal cord or medulla.
The Eyelids
The eyelids may be divided into anterior and
posterior parts by the mucocutaneous junction
the grey line (Figure 2.8). The eyelashes arise
b from hair follicles anterior to the grey line, while
Figure 2.7. The normal fundus of a a Caucasian and b an the ducts of the meibomian glands (modied
African. The background is darker in the African owing to sebaceous glands) open behind the grey line.
increased pigment in the retinal pigment epithelium (RPE).The The meibomian glands are long and slender,
nerve fibre layer is noticeable, especially along the superior and and run parallel to each other, perpendicular to
inferior temporal arcades. the eyelid margin, and are located in the tarsal
12 Common Eye Diseases and their Management
The aqueous normally contains a low con- 2. Circular bres form the inner part and
centration of proteins, but a higher concentra- run circumferentially. Contraction moves
tion of ascorbic acid compared with plasma. the ciliary processing inwards towards the
Inammation of the anterior uvea leads to center of the pupil leading to relaxation of
leakage of proteins from the iris circulation into the zonules.
the aqueous (= plasmoid aqueous).
Accommodation
The Vitreous Body Accommodation is the process whereby relax-
ation of zonular bres allows the lens to become
The vitreous consists of a three-dimensional more globular, thereby increasing its refractive
network of collagen bres with the interspaces power. When the ciliary muscles relax, the
lled with polymerised hyaluronic acid mole- zonular bres become taut and atten the lens,
cules, which are capable of holding large quan- reducing its refractive power. This is associated
tities of water. The vitreous does not normally with constriction of the pupil and increased
ow but is percolated slowly by small amounts depth of focus.
of aqueous. There is liquefaction of the jelly with Accommodation is a reex initiated by visual
age, with bits breaking off to form oaters. This blurring and/or awareness of proximity of
degeneration occurs at an earlier age in myopes. the object of interest. The maximum amount
of accommodation (amplitude of accommo-
dation) is dependent on the rigidity of the lens
The Lens and contractility of the ciliary muscle. As the
lens becomes more rigid with age (and contrac-
The lens, like the cornea, is transparent. It is tions of the ciliary body reduce), accommo-
avascular and depends on the aqueous for nour- dation decreases. Reading and other close
ishment. It has a thick elastic capsule, which work become impossible without optical
prevents molecules (e.g., proteins) moving into correction presbyopia.
or out of it.
The lens continues to grow throughout life,new
lens bres being produced from the outside and The Retina
moving inwards towards the nucleus with age.
The lens is comprised of 65% water and 35% This is the photographic lm of the eye that
protein. The water content of the lens decreases converts light into electrical energy (transduc-
with age and the lens becomes less pliable. tion) for transmission to the brain. It consists of
The lens is suspended from the ciliary body two main parts:
by the zonule, which arises from the ciliary body 1. The neuroretina all layers of the retina
and inserts into the lens capsule near the equator. that are derived from the inner layer of the
embryological optic cup.
2. The RPE derived from the outer layer of
The Ciliary Body the optic cup. It is comprised of a single
layer of cells, which are xed to Bruchs
The ciliary muscle (within the ciliary body) is a membrane. Bruchs membrane separates
mass of smooth muscle, which runs circumfer- the outer retina from the choroid.
entially inside the globe and is attached to the
scleral spur anteriorly. It consists of two main The retinal photoreceptors are located on the
parts: outer aspect of the neuroretina, an arrangement
that arose from inversion of the optic cup and
1. Longitudinal (meridional) bres form allows close proximity between the photosens-
the outer layers and arise from the scleral itive portion of the receptor cells and the
spur and insert into the choroid. Contrac- opaque RPE cells, which reduce light scattering.
tion of this part of the muscle exerts trac- The RPE also plays an important role in
tion on the trabecular meshwork and also regeneration/recycling of photopigments of the
the choroid and retina. eye and during lightdark adaptation.
Basic Anatomy and Physiology of the Eye 15
In order for the light to reach the photo- vision in poor (dim) light and for the wide eld
receptors to form sharp images, all layers of the of vision.
retina inner to the photoreceptors must be The retinal capillary network (derived from
transparent. This transparency is contributed to the central retinal artery) extends no deeper
by the absence of myelin bres from the retinal than the inner nuclear layer and nourishes the
neurons. The axons of the retina ganglion cells neuroretina from inside up to part of the outer
normally become myelinated only as they pass plexiform layer. It is an end-arterial system. The
through the optic disc to enter the optic nerve. choroid serves to nourish the RPE and the
There are two main types of photoreceptors photoreceptors (by diffusion of nutrients).
in the retina the rods and the cones. In the There are no blood vessels in the outer retina.
fovea centralis the only photoreceptors are The central fovea is completely avascular and
cones, which are responsible for acute vision depends on diffusion from the choroidal circ-
(visual details) and colour vision. Outside the ulation for its nourishment. Thus, normal func-
fovea, rods become more abundant towards the tioning of the retina requires normal retinal and
retinal periphery. The rods are responsible for choroidal circulation.