Medical Ophthalmology

Dr/ M. Abd Ul-ghaffar (MASS)

2009
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Anatomy
Gross Anatomy:
- Site: Ant. 1/6 of outer coat of eye.
- Shape: smoothly Curved
- Transparency: transparent, clear and brilliant (lustre)
- Diameter: Horizontal = 12mm & Vertical = 11mm
- Thickness: Central = 0.5 mm & Peripheral =1mm
- Refractive power = 42 D
Minute Anatomy: 5-layers (from Ant. to Post.)

1- Epithelium: (5-6 layers) ‫أﺳﺮع ﻧﻤﻮ ﻓﻰ اﻟﺠﺴﻢ ﻛﻠﮫ‬

- Stratified squamous non keratinized epithelium.

- Quickly regenerates when cornea is injured.
2- Bowman’s membrane: Elastic, Clear structurless. If destroyed  not regenerate
3- Stroma:
- The thickest layer (about 90%)
- Composed of 100-150 transparent regular lamellae of tiny collagen fibrils,
running parallel to each other, giving cornea its Clarity.
4- Descemet’s membrane:
- Elastic, Resistant (descematocele), Easily regenerates
5- Endothelium:
- Single layer of hexagonal flat cells.
- Important for corneal dehydration
Nutrition: (Cornea is a vascular)
* By diffusion from (Limbal capillaries, Aqueous humour, Tear film)
Nerve Supply:
* 5th n  Ophthalmic n  Nasociliary n  2-Long ciliary ns  nervous plexus (Non-myelinated,
very low threshold)  in: Stroma, Subepithelium, Intraepithelium
* Nerves of the surrounding conjunctiva.
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Definition: Inflammation of cornea, being infective or non infective

Classification:

Keratitis

Superficial Keratitis Interstitial Keratitis

(Inflammation of epithelium + superficial stroma) (Intact epithelium + Inflammation of stroma)

Ulcerative Keratitis (Corneal Ulcer) Non-Ulcerative Keratitis

* loss of epithelium + superficial stroma.
* may be: (bacterial, viral, fungal, protozoal)

(Bacterial CU, Herpes Simplex Keratitis, HZO)

Bacterial Corneal Ulcers

Definition: Loss of epithelium + superficial stroma.

Ocular emergencies: Excellence Ophthalmology :‫ﺗﺠﻤﯿﻌﮫ ﻣﮭﻤﺔ ﺟﺪاً ﻓﻰ ﻣﺬﻛﺮة‬

Etiology:
I- Predisposing factors
- Traumatic abrasion as rubbing lash, … - CL wear - Dry eyes
- Exposure - Loss of sensation
II- Causative Organism ( MO) :
‫ ﺧﺎص‬- Bacteria attacking healthy corneal epithelium:
(N. gonorrhoea, C.diphtheria, Listeria, H. aegypticus)
‫ ﻋﺎم‬- Bacteria needing corneal abrasions: Strept, Staph, Pneumococci, Pseudomonas …
III- Sources of infection:
Chronic Conjunctivitis, Blepharitis, Dacryocystitis
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Clinical Picture:
I) Symptoms(FAHM.HR, 3PLV): Severe Pain, Photophobia, Blepharospasm, Lacrimation, ↓ VA
II) Signs
- Lids: Oedema
- Conjunctiva: Chemosis, Ciliary injection
- Cornea:
-Loss of corneal lustre
-Fluorescein stain 1% ED: green Ulcer/Blue light ‫ﻻﺗﻨﺴﻰ أﺑﺪا‬
-Infiltration in Bed, Edges of epithelial defect
-Acute serpiginous ulcer (Hypopyon ulcer) = ‫ﺻﺎروخ ﺷﻔﻮي‬
.Central ulcer (central edge: advancing, undermined peripheral edge: healing, sloping)
. Hypopyon
.Caused by pneumococci
-AC: aqueous Flare  Plasmoid aqueous  Hypopyon
III) Complications: (unilateral  Squint bilateral  Nystagmus)
- Anterior Uveitis  hypopyon, posterior synechia
- Corneal Opacities (scars) LMN ‫ ﻻزم ﺗﺄﺗﻰ ﺣﺎﻟﺔ ﻣﻨﮭﻢ‬، ‫ﻣﮭﻤﺔ ﺟﺪا ﻓﻰ اﻟﺮاوﻧﺪ و ﺷﻔﻮى اﻻﻛﻠﯿﻨﯿﻜﻰ‬
. d2 fibrosis + vascularization (during healing stage)
. Types: - Nebula : superficial , faint
- Macula : opacity of medium size
- Leucoma : dense opacity
- Descematocele  Actual perforation
IV) Complications of Perforation: ٢٠٠٨/٦ ‫ﺳﺆال‬
- Corneal fistula 
- Epithelialization to back of cornea, angle of AC, anterior surface of iris
- PAS 
- 2nd ry Glaucoma
- LA 
- Anterior Staphyloma: due to bulging of weak cornea! scar + IOP
- IO hge (Introcular haemorrhage), Subluxation, Dislocation of Lens
- Complicated Cataract
- Endophthalmitis: the most serious complication
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Treatment
1- Mydriatic Cycloplegics ( Atropine 1% ED ) ‫ﻻ ﺗﻨﺴﻲ أﺑﺪاااااااااااااااااااااا‬
× Ant. uveitis, ↓Pain, × Post. synechia
2- Topical Antibiotics (Local broad spectrum antibiotics are tried first)
- Fluoroquinolones e.g. Ciprofloxacin 0.3%  almost all MOs
- Aminoglycosides + Cephalosporines  gram +ve + -ve cocci
3- Patching:
↑ Epithelialization, ↓ Pain+ Photophobia
4- Bandage CL:
↑ Epithelialization
5- Surgery (Surgical intervention is indicated in certain specific situations)
- Paracentesis  descemetocele, hypopyon e 2ry glaucoma
- Tissue adhesive glue  small perforations
- Therapeutic Keratoplasty  large perforations
- Tarsorrhaphy and conj Flaps  exposure, loss of cornea ! Sensation
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

I. Herpes Simplex Keratitis

Definition: It is the classical corneal lesion in recurrent HSV Keratitis
Clinical Picture:
1-Epithelial Infiltration:
- SPK  Striate (linear)  Stellate  Dendritic e round knobs / +ve Rose Bengal
 Amoeboid  Geographic

SPK
Dendritic Ulcer Amoeboid Ulcer Geographical Ulcer

2- Sheding of infected epithelium:

- Sheding  dendritic ulcer
- stained by double stain:
.Fluorescein 2%  bed
.Rose Bengal 1%  margin
3- Corneal Hyposthesia: bed of ulcer is insensitive
4- If BM and stroma are not involved  lesion may heal e out opacity
5- The ulcer is characteristically superficial and non-vascularized
Treatment: ‫ﻣﮭﻢ ﺟﺪاااااااااااااااااااااااااا‬

A- ttt of CU ‫ اذﻛﺮه‬+
B- Antiviral drugs ‫ﺣﻔﻆ ﺻﻢ‬  Acyclovir: 3% , EO , 5-times /day
C- Surgery:
- Debridement to remove infected epithelium is one line of simple surgical treatment to be followed by intensive antiviral topical medications
- Cautery by tincture iodine 7.5 %, or absolute Alcohol
- Lamellar Penetrating keratoplasty is done to manage opacified comeas

Topical Steroids (=‫)ﺧﺮُم‬

- absolutely contraindicated in presence of herpetic ulcer
-  amoeboid ulcer or perforation
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

II. HZO
Definition: Unilateral affection of Ophthalmic n. of 5th n. by HZV
Clinical Picture:
A. Prodroma: Severe FAHM, severe neuralgia along distribution of nerves
B. Skin lesions: (frontal, lacrimal, and nasociliary nerves)
Papules  Pustules  crusting Ulcers  punched out Scars
C. Ocular lesions 
- conjunctiva:
Mucopurulent conjunctivitis
- sclera:
Episcleritis and Scleritis
- Cornea:
I. SPK
II. Microdendrites
III. Nummular keratitis
IV. Disciform keratitis
- Iris, CB:
Anterior Uveitis
- Retina:
Acute retinal necrosis
D. Neurological
- Cranial Nerve affection: 2, 3, 4, 5, 6
- Encephalitis
- Post herpetic neuralgia: severe, chronic
Treatment:
A- ttt of CU ‫ اذﻛﺮه‬+
B- Topical Acyclovir and Steroid-antibiotics  Ocular and Skin lesions
C- Systemic Acyclovir (Zovirax): 800mg tablets (5 X 1 X 7)
 Exposure Keratopathy
Causes
- Associated e 7th n. paralysi
OO paralysis + Lagophth
- ↓ Corneal protection from
minor trauma + dryness Æ
necrosis, slough of superfic c lay
Treatment
A- Prophylaxis against CU
‫ﻧﻬﺎر‬: lubricant ED,‫ﻧﻬﺎر‬
dark Glasses, CL
: EO, Eye patching, Adhes tape
‫ﻟﻴﻞ‬
B- If Ulcer forms :- as before
C- ‫ ﻟﻮ اﺗﺨﻨﻘﺖ‬: Lat tarsorrhaphy
Neuropathic Keratopathy Keratomalacia Photophthalmia
Causes Definition Definition:
Æ (Destruction of 5th gang): Acute melting of cornea d2 severe Superficial keratitis by UV rays
-Trauma: fracture of skull base vit A deficiency
Etiology
Etiology
-Inflammation: gummat meningitis, Exposure to UV as welding arcs, skiing
Advanced starvation & marasmus
post HZV, HSV in very young children.
Clinical Picture
-Iatrogenic: ttt of 5th neuralgia *Latent period: 4-5hr
Clinical Picture
Mechanism of Ulceration :- *Sm:-
1) Minimal inflammatory respon:-
*Loss of corneal protection Æ Loss . 3PLV,
-2ry bact infect Æ Panophthalmiti
of (reflex blinking, lacrimation, . Extreme burning Pain
trophic nerve impulses) -Blindness
*Sn:-
2) Bilat melting of cor overnight:-
-Prolapse of ocular contents -EL, Conj: swelling
-Cornea:
Treatment Treatment multiple superficial erosions
A- If recovery of B- If pathology is -Large doses of Vit A /syst,local -Hyperaemia Æ
sensation is likely to be
-Improve general condition -Discharge: watery or mucoid
expected permanent
- ‫إﻟﻰ ﻣﺴﺘﺸﻔﻰ اﻷﻃﻔﺎل‬ Treatment
- Lubricants - Conj flap, or
-Protection: Glasses, Goggles
- Bandage CL
-Cold compresses
- Tarsorrhaphy/T -Tarsorrhaphy/P
-Lubricants: frequent topical
-Bandage 2-eyes/1d
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Keratoconus

(Conical Cornea)
‫اﻟﻘﺮﻧﯿﺔ اﻟﻤﺨﺮوﻃﯿﺔ‬
Definition: Progressive central stromal thinning  ectasia and apical protrusion

Etiology: unknown, but may be:-

- hereditary
- developmental
- endocrinal
- degenerative

Clinical Picture:
Incidence:
- Bilateral in 85% of cases.
- starts around puberty (10-20 yrs)  progresses for few years
- associated e other systemic: Down’s syndrome, Marfan’s syndrome or
ocular diseases: Spring catarrh
Symptoms: *Frequent changing of glasses
Signs:
- Cone shaped deformity/ profile view
- Corneal thinning, scarring and opacities (Vogt striae)/Slit lamp
- Fleischer's ring: iron deposits at the base of the cone
- Munson's sign: angulation of LL on downward gaze

Management: (ttt)
- Spectacles can he used in early cases before astigmatism becomes irregular
- Rigid CL may help in irregular astigmatism
- Penetrating keratoplasty (PKP) ‫اﻟﻠﻰ ﺑﺘﺨﻠﺺ‬
- Thermokeratoplasty ‫ﺣﺮق ﺣﻮل ﻗﺎﻋﺪة اﻟﻘﻮن ﯾﺤﺪث ﻓﺎﯾﺒﺮوزﯾﺰاﻟﺬى ﯾﺸﺪ ﻋﻠﻰ اﻟﻘﻮن وﯾﺴﻄﺤﮫ‬
- Epikeratophakia ‫ﻏﺎﻟﯿﺔ ﻗﻮى‬، ‫اﻣﺎم اﻟﻘﺮﻧﯿﺔ وﺗﺜﺒﯿﺘﮭﺎ ﺑﺨﯿﻂ ﺟﺮاﺣﻰ‬ ‫وﺿﻊ ﻗﺮﻧﯿﺔ اﻧﺴﺎن ﻣﯿﺖ ﺑﻌﺪ ﺿﺒﻄﮭﺎ‬
 Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Some Primary Corneal Ulcers

Typical
Fasicular Ulcer e Dendritic Hypopyon
Trachomatous
Lagophthalmos

Corneal Vascularizaion

Superficial Vascularization Deep Vascularization

1- conjunctival vessels - anterior ciliary vessels
2- crossing limbus - end at limbus
3- bright red, well-defined - dark red, ill-defined
4- branch - parallel
5- irregular corneal surface - smooth surface
6- vessels in superficial stroma - in post 2/3
7- occur in: - occur at:
.Pannus, CU, Trichiasis, .Interstitial keratitis, Deep ulcers
Pterygium, Ariboflavinosis

-: ‫اﻷﺳﺌﻠﺔ اﻟﻤﮭﻤﺔ ﻓﻰ ھﺬا اﻟﻔﺼﻞ‬

- Give an account on Keratomalacia 9 / 2008
- Clinical Picture of Herpetic CU: 6 / 2007
- How to treat Herpeic (dendritic) CU: 2 / 2007
-management of Herpetic CU in 7/2008
- Ocular manifestations of Vit.A deficiency: 6 / 2006
- C/P, Complications, TTT of Hypopyon Ulcer: 80 – 82 – 90 – 92 -93 – 97 - 98 – 7/2002 – 7/2003 – 3/2005 – 7/2005- 7/2007
- Keraoconus: 6 / 2006
- What are Uses of Contact Lens in Ophthalmology: 2 / 2003
- Indications for Keratoplasy: 2 / 2002
- Keratomalacia: 6 / 89
- Diagnosis of Corneal Ulcer: 3 / 83
- Descematocele: 2 / 81
- complications of perforated corneal ulcer: 6/2008
Dr / M. Abd Ulghaffar (MASS) / 016 570 1914 ‫ﺻﻠﻲ ﻋﻠﻲ اﻟﻨﺒﻲ‬

Corneal Opacities
Corneal opacities are the commonest cause of blindness in Egypt.
↓VA by:
1. Dense central leucoma blocks the passage of light rays
2. Leucoma adherent may be associated with 2nd ry glaucoma
3. Nebulae (faint cornea! opacities): scatter the rays in irregular fashion
Management:
1. Nebulae (causing irregular astigmatism)  CL, Lamellar keratoplasty or Excimer laser
2. Central Leucoma  Penetrating Keratoplasty
3. Peripheral scars (according to the astigmatism induced)  Glasses, CL , or Surgically
4. If only cosmetic problem  colored CL

Keratoplasty
‫ﺗﺮﻗﯿﻊ أو زرع ﻗﺮﻧﯿﺔ‬
Definition:
Removal of diseased corneal part, replacing it by clear donor`s graft (cadaveric eye)
, from autogenous graft or allograft
Types:
A) Lamellar
B) Penetrating
Indications:
- Optical: corneal opacities
- Tectonic: keratoconus ‫ھﺪﻓﮫ ﺟﺪاراﻟﻘﺮﻧﯿﺔ ﻟﺤﺠﻤﮫ اﻟﻄﺒﯿﻌﻰ ﺑﻌﺪ اﻟﻨﺤﺎﻓﺔ‬

- Therapeutic: resistant corneal ulcers, perforation, fistula ‫ﻋﻼج ﻣﺮض ﻓﯿﮭﺎ‬

- Cosmotic: leucoma in blind eye ‫ﺗﺤﺴﯿﻦ اﻟﻤﻨﻈﺮ اﻟﺠﻤﺎﻟﻰ ﺑﺎزاﻟﺔ اﻟﺒﯿﺎض وﺟﻌﻠﮫ ﻣﺜﻞ ﻟﻮن اﻟﻌﯿﻦ اﻷﺻﻠﻰ‬

Lamellar Penetrating