PAST YEARS OPHTHALMOLOGY Qs Short form : CP (clinical picture), Mx (management), Rx (treatment) ,DD (diff diagnosis), Dx (diagnosis) 1.

Anatomy of the eye -anatomy upper eye lid*** -draw a labelled section of cornea**** (disclaimer: bukan saya yg lukis. amik kt google je)

so basically cornea has 5 strata (superficial to deep): 1) epithelium 2) Bowmans layer 3) Stroma 4) Descements membrane 5) Endothelium -draw a labelled diagram of eye globe** -labelled diagram of lacrimal apparatus

(disclaimer lagi: bukan saya yg lukis. google je) lacrimal apparatus is divided to 2 parts: secretory and excretory part 1. secretory part 1) Reflex: main lacrimal gland middle aqueous layer 2) Basic: i) accessory lacrimal gland (Wolfring and Krause) middle aqueous layer ii) Meibomian gland and Zeiss gland superficial oily layer

iii) Goblet cells deep mucus gland 2. excretory part: 1) puncti 2) upper and lower canaliculi 3) lacrimal sac 4) nasolacrimal duct -gonioscopic structure of angle of anterior chamber

(tak perlu lukis pun, tapi senang skit nk nampak kalau ada gambar) from behind forwards are: 1. root of the iris. 2. anterior surface of ciliary body 3. scleral spur. 4. trabecular meshwork 5. schwalbles line 6. posterior surface of cornea. 2. -anatomy extra-ocular muscles Visual and pupillary pathways -discuss acute loss of vision crvo (ischemic type) crao - sudden LOV,not acute papillitis vitreous hge -causes of yellow papillary reflex [rasanya ni sama dgn white pupillary reflex/leukocoria] a) retinoblastoma b) endophthalmitis -3 causes dilated fixed pupila

optic neuritis/ optic atrophy (yg ni bukan marcus gunn pupil ke?) > [MG kalau partial, kalau full affection causes permanent dilatation kan] > erm xsure 3rd nerve palsy effector(iris/muscle) affection , eg: atropine traumatic mydriasis (blunt trauma to iris) acute congestive glaucoma (dilated oval)

-components of near reflex

accommodation miosis convergence

-causes of unilateral dilate fixed pupil [ni tak same ke dgn soalan atas] > same je -mydriatic? - 3rd nerve palsy 3. Eye lids -causes & CP entropion

Congenital Spastic Senile (involutional) Cicatricial (both lids may be affected)

CP: due to mechanical irritation and injury to cornea; Irritation, pain, congestion, lacrimation and photophobia -causes & Rx of ectropion** causes: 1.paralytic : facial palsy 2. senile 3. cicatricial : extensive chemical/heat burn on the face/ contraction of skin as in eczema etc 4. mechanical 5. congenital (cong eNtropion >> cong eCtropion) Rx: Rx the cause Rx of cicatricial ectropion 1. if mild: release tension of linear scar 2. if severe: scar revision and excision and its replacement by pedicle flap or free grafting (inner side of arm, behind ear or clavicular area) Ps- care shud be taken on the cornea till cause of ectropion is treated -types, CP,& Rx of blepharitis
Types : ant(seborrheic,ulcerative) . post(MGD) . allergic . parasitic . angular . CP 1. Burning itching eye strain worse in morning 2. Photophobia

3. FB sensation 4. Lid margin ; dry,red,thick,hyperemia,greasy in seborrheic type,ulcerated in staph 5. Scales : brittle,crusting,colarette 6. Lashes : matted (ulcerative type ) Rx 1. Eye lid hygiene n hot foment (Na HCO3 or diluted baby shampoo)(triple dye) * eyelid massage n expression of meibomian glnd 2-4x/d 2. Top or syst Ab (tetraC doxyC erythroM-child n pregnant) 3. Artificial tears for dry eye 4. Topical steroid for ass keratitis 5. Rx ass scalp seborrhea w antidandruff shampoo

-causes & rx of trichiasiscauses of trichiasis: 1. following diseases that cause scarring of the eyelid margin eg. ulcerative blepharitis 2. any condition that causes entropion eg. trachomatous cicatricial entropion and spastic entropion 3. distichiasis

treatment of trichiasis: 1. if few and focal: destroy the follicles by laser, electrolysis, diathermy or cryocoagulation 2. if general: operate(split lid n grey line insert mm graft) ..the so called Van Mellingans operation 3. if due to entropion: operate to reconstruct the lid margin

-complications of ulcerative blepharitis 1. 2. 3. 4. 5. 6. 7. madarosis trichiasis permanent reddening of eye lid recurrent styes eczema----ectropion chronic conjunctivitis keratitis

-define districhiasis The lashes and lid margin are normal but an extra row of lashes arises from tarsal gland orifices behind the grey line -causes of ptosis**

a) Congenital - abnormal development. b) Paralysis - destructive lesion of the occulomotor nerve/nucleus. c) Sympathetic - Mullers muscle affection in Horners syndrome. d) Myogenic - disease of the muscle itself, famous example: myasthenia gravis. e) Aponeurotic - defect in function caused by senile degenerative process or following cataract or retinal surgery 2ry to manipulation. f) Mechanical - increased weight. g) Traumatic - to the muscle or nerve. -CP & Mx of ptosis***
CP Upper eyelid cover cornea more than 2mm in 1ry gaze Bilateral n pupil cover : raised eyebrow , wrinkling skin forehead , throw head backward Unilateral congenital pupil cover : diminish vision CP of the causes (eg : myasthenia muscle weakness, horner anhydrosis,miosis) Mx 1. Rx of the cause (eg: myasthenia anticholinesterase, mechanical Rx cause of heaviness) 2. Surgery (depend on degree of ptosis) mild : fasanella servant operation (tarsomullerctomy) severe : (depend on levator function) good fx : levator resection x fx : frontalis sling operation (hess operation)

-causes & complications of lagophthalmos 1) physiological: during sleep 2) mechanical:-enlargement/protusion eyes (buphthalmos, proptosis, staphyloma) -structural lid loss: coloboma -impair normal mvmt lid (severe ectropion) 3) paralytic: orbicularis oculi(facial palsy) 4) spastic: spasm levator of Mullers muscle(endocrine exophtalmopathy) 5) functional: extreme debility, unconciousness, general anaesthesia. complication: 1) cornea: dry/xerotic and exposure keratopathy (lead to corneal opacity, ulceration, perforation, loss eye) 2) conjunctiva: exposed, dry, xerotic -define: symblepharon cicatrical adhesions between the palpebral conjuctiva and bulbar conjuctiva or cornea. 4. Errors of refraction -discuss hypermetropia** (tak masuk kot soalan camni. blh baca sendiri kot dari definition hinggalah treatment) > eh mana tau xleh kire jugak sbb pernah masuk -CP & types of hypermetropia CP: -symptoms: 1. accomodative asthenopia 2. defective near vision 3. early presbyopia

-signs: 1. small eyeball 2. small cornea 3. relatively shallow anterior chamber 4. fundus shows a greater brightness of light from the retinal surface (watered silk appearance) 5. optic disc: less defined edges with torturous retinal vessels TYPES of HYPERMETROPIA: 1. Total 2. Latent 3. Manifest 4. Facultative 5. Absolute -types of myopia & complications of high myopia** types - simple myopia (most common, puberty till 25-30years, <6diopters, eyeball normal, retinoscopy show myopia) - progressive/high myopia (childhood, progresses with age, 20-25 diopters, large eyeball, large cornea, large pupil, deep AC, fundus ex***) complications of high myopia 1) retinal complications
o o o o o o o

choroido-retinal degenerations retinal tears retinal detachment macular hge Euch spot - black spot on macula(subretinal hge), diminished central vision post staphyloma CONSECUTIVE optic atrophy

2) lens - complicated cataract 3) squint - apparent convergent, true divergent(neglect of accomodation) -treatment/surgical treatment of low & high myopia** 1) glasses of minus/ concave lens 2) contact lenses 3) surgical for low myopia -radial keratotomy(up to 3D) -PRK(up to 6D) -LASIK(up to 10D) 4) surgical for high myopia -LASIK if not more 10D -clear lens extraction and IOL implantation if more 10D

-define: facultative hypermetropia** part of manifest hypermetropia that is corrected by accomodation -define: astigmatism with rule,regular astigmatism Astigmatism- state of refraction of eye in which there is difference in the refraction of the different meridians of the eye, parallel rays of light will not focus in a point, but in a line.

Regular- fulfill 2 criteria:

(a) meridian of maximum and minimum powers are at right angle to each other (b) there is gradual changes of power between meridian maximum to minimum

With rule- verical meridian is more curved (more myopic) than the horizontal

-define: myopia The state of refraction of the eye in which parallel rays of light focus on a point in front of the retina while accommodation is at rest 5. Lacrimal Apparatus -Rx of acute dacryocystitis medical: -antibiotic(local/systemic) -analgesic and hot fermentation -Vasoconstictor nasal drop surgical -abscess-- incision and drainage -lacrimal fistula--fistulectomy & dacryocystectomy -causes of watery eye** 1. Lacrimation
o o

psychic conditions reflex watering (due to foreign body of cornea and conjunctiva)

2. Epiphora
o o o o o

eversion of lower punctum occlusion of puncti occlusion of canaliculi chronic dacryocystitis stricture or obstruction of naso-lacrimal duct

-2 lesions treated by dacryocystectomy

1. Long standing chronic dacryocystitis with destruction of the sac structure and atrophic rhinitis 2. tuberculosis of the lacrimal sac

Other answers: a. Primary neoplasms of the sac b. presence of hypopyon corneal ulcer c. If the patient is going to undergo an intraocular operation in the near future

6.

Squint -Mx concomitant squint in 5y old child

accomodative esotropia - GOOS(Glasses,Occlusion of stronger eye,orthoptic ,Surgery) congenital esotropia -recession of both medial recti sensory esotropia - surgical after rx the cause consecutive eso - surgery b4 4 years old to avoid compllications primary exotropia - correction of refractive error (myopia full corre ,hyperopia under corre)

- orthoptic -eliminate amblopia-anti suppression ecxesrcise ,increased fusional amplitude - base in prism -surgery (bilateral LR / unilateral LR+MR recession)

heterophoria??

-method of detection of heterophoria

alternate cover test maddox rod maddox wing worth 4 dot test synotophore

-2 muscles causing intortion

Sup.oblique sup.rectus

-2 causes of uniocular diplopia

iridodialysis subluxated lens irregular astigmatism early cataract

-CP paralytic squint

limited ocular mov in direction of paralysed muscle binocular diplopia manifest squint 2ry angle>1ry angle of deviation nausea,vomitting,vertigo w unstable gait abn. head posture false projection

7.

Conjunctiva -DD red eyes** 1. Conjunctival injection: conjutvts 2. Ciliary injection -acute angle-closure glaucoma -keratitis -iridocylitis 3. subconjunctival hge (blepharitis,Uveitis,corneal ulcer,allergic) --> (tak pasti yg ni nk letak kt bahagian mana) -clinical stages of trachoma
Stage T1 Immature follicle -greyish,non expressible, no necrotic tissue,non raised 1. Cornea: Trachomatous pannus Sx: - sandy gritty sensation ; mucous discharge

T2

T2a: mature follicle ( yellowish,expressible,raised , necrotic tissue) T2b: Raised projected papillae. Cornea: Marked pannus Sx: -Abundant discharge, heavy upper lid Stage of cicatrisation. Sign of active trachoma ( follicle n papillae )

T3

Scarring on upper tarsal : star shape,radiate,white line ; Artls line PTC n PTD may appear on this stage. T4 Healed trachoma. No active inflammation Only scar tissue are present

-stages of active trachoma , CP, Rx

Stage T1 Immature follicle -greyish,non expressible, no necrotic tissue,non raised Cornea: Trachomatous pannus Sx: - sandy gritty sensation ; mucous discharge RX: MEDICAL a)LOCAL -Terramycin 6w -Sulphacetamide b)SYSTEMIC Child:Erythromycin 2w Adult:Doxycyclin 2w New rx: Azitromycin Keyword:TSEDA Same above T2a: Expression follicle by Graddys forceps T2b: Scraped by sharp spoon after lid eversion. T3: Pick up the PTC n PTD by sharp scalpel blade. RX:SURGICAL

T2

T2a: mature follicle ( yellowish,expressible,raised , necrotic tissue) T2b: Raised projected papillae. Cornea: Marked pannus Sx: -Abundant discharge, heavy upper lid Stage of cicatrisation. Sign of active trachoma ( follicle n papillae ) Scarring on upper tarsal : star shape,radiate,white line ; Artls line PTC n PTD may appear on this stage. Healed trachoma. No active inflammation Only scar tissue are present

T3

Same Above

T4

N/B: THIS IS NOT AN ACTIVE STAGE...U CAN OMIT IT =)

(soalan: T4 ni dah tak kira sebagai active dah kan?) : Exactly...T4 bkn active stage...xpayah tulis xpe.

-complications of trachoma**** a) Lid - trichiasis, entropion (circatricial), ptosis. b) Conjunctiva - xerosis, symblepharon, hyaline degeneration. c) Cornea - corneal scars ----> irregular astigmatism, xerosis. d) Lacrimal - chronic dacryocystitis, chronic dacryoadenitis. -CP vernal keratoconjunctivitis Symptoms:
o

Intense itching, lacrimation, photophobia, and ropy discharge (rich in eosinophils)

Signs:
o

o o

Palpebral type: Affection of upper palpebral conjunctiva; Flat topped, multiple, cobble stone pattern of papillae. They are red in color and larger in size than those of trachoma. Bulbar type: Limbal gelatinous elevation with localised limbal conjunctival injection. White spots called Tranta spots can appear within the limbal lesion. Mixed type: Both palpebral and bulbar manifestations Corneal affection (rare): Punctate epithelial keratitis (keratitis superficialis vernalis) & Epithelial macro-erosions (Shield ulcer) + corneal opacity (pseudo-gerontoxon)

-corneal manifestations & complications of trachoma

corneal ulcer -linear w horizontal linear axis

-lower border of pannus -superficial

pannus (cellular infiltration + superficial vascularization on upper pt of corneal)

-clinical types,CP of purulent conjunctivitis clinical type: epidemic, genital, ophtalmia neonatorum, metastatic gonococcal conjuctivitis CP: (a)incubation period: few hours to 3days (b) infiltration stage: 2-3 days. conjuctiva red,chemotic, lid edema. no discharge. mild fever,preauricular lymph node enlarged and tender.

(c)discharge: 2-3 weeks. lid swolen, conjuctiva red, chemotis. pus- form false membrane. (d) chronic- papillary thickening. -type of allergic conjunctivitis,details about CP of spring catarrh 1) hypersensitivity to EXOgenous allergen -vernal keratoconjunctivitis -atopic keratoconjunctivitis -giant papillary conjunctivitis -hay fever keratoconjunctivitis 2) hypersensitivity to ENDOgenous allergen -phlyctenular keratoconjunctivitis CP spring catarrh symptoms: intense itching, lacrimation, photophobia, ropy discharge signs: 1) palpebral type(upper)- PAPILLAE-flat-topped -multiple -cobble stone appearance -dark red -larger than trachoma -associated hyperemia and chemosis 2) bulbar/limbal type- limbal gelatinous elevation - localized limbal conjuctival injection - tranta spot 3) mixed type 4) rare cornea affection -3 causes of follicular conjunctivitis a) adenoviral conjunctivitis b) acute hemorrhagic conjunctivitis c) acute herpetic conjunctivitis hny 8. Cornea -CP of hypopyon ulcer**** a) Symptoms: Pain, lacrimation, photophobia, blepharospasm and severe diminution of vision. b) Signs: mild to moderate lid oedema, ciliary and conjunctival injection, the ulcer itself (disc like greyish or yellowish area of stromal infiltration, near the center of the cornea), positive fluoroscin stain, corneal oedema, perforation, anterior chamber involvement with hypopyon and pupillary constriction. -classify keratitis, give Rx for hypopyon ulcer Rx -top antibiotic combination to cover g-ve & g+ve (gentamycin &ciprofloxacin) promote re-epi -eye closure,lub,CL,corneal grafting -complications of hypopyon ulcer Cases without perforation

Corneal opacity (usually vascularized) Irregular astigmatism (facet) Keratectasia Descematocele Cases with perforation Depends on site Central lost AC PAS fistula 2ary glaucoma corneal staphyloma Peripheral iris prolapse leukoma adherent Corneal fistula Central perforation with epithelialization of the walls of the ulcer Intraocular infection (endophthalmitis) Intraocular hemorrhage -Rx of ophthalmia neonatorum -Rx & Cp of herpetic ulcer -pathognomonic of herpetic keratitis a. dendritiform ulcer b. history of recurrent ulcerations c. hyposthesia of cornea d. absence of corneal vascularization

- 2 corneal manifestations of phlycten -corneal phlycten -fascicular ulcer -phlyctenular pannus -predisposing factors for corneal ulcer

dryness(xerosis) exposure (lagopthalmus) decrease sensation-neuroparalysis/herpetis keratitis decrease resistant- DM,decrease vit A epithelial corneal edema eyelid malposition contact lens wearer

-3 different signs between superficial & deep corneal vascularisation Superficial Deep

Origin branch Characteristic

traced over the limbus from conjunctiva arborescent fashion bright red, well defined

ends at the limbus run parallel and branch at one angle brush like grayish or bluish red, ill defined

-indications keratoplasty,brief surgical techniques Indications :

optical/visual o central corneal opacities : ulcers, degenerations, trauma, dystrophies, keratoconus o corneal edema : keratoconus with corneal hydrops, pseudophakic bullou keratopathy therapeutic : resistant corneal ulcer, corneal fistula structural : after treatment of pterygium cosmetic : blind eyes w corneal opacities

9.

Lens -discuss congenital cataract** -CP of lamellar cataract

*Most common type ; usually bilateral *involving foetal nucleus *arcuate opacities often straddle the equator of the lamellar catarct. ( so called Riders ) *viewed from front: disc-shaped configuration Causes: - Transient toxic during embyrogenesis - Calcium and Vit D deficiency during pregnancy

-types of developmental cataract & shortly about treatment**

Types: a) Polar * Ant. polar: Less affect Visual * Post polar b) Lamellar c) Complete d) Coronary - Less affect Visual e) Blue dots - Less affect Visual f) Nuclear g) Sutural - Less affect Visual h) Membranous Treatment: a) Non surgical treatment:

- if no visual impairment like blue dot, sutural cataract - Optical treatment : in non dense cataract if can improve the vision to >6/18 b) Surgical treatment: - Anterior capsulorhexxis with irrigation and aspiration, posterior. capsulotomy, and ant. vitrectomy - Lansectomy thru pars plana / pars plicata

-3 causes of complicated cataract

Local: i-PCR Iridocylitis Perforated corneal ulcer - central will lead to ant.polar cataract ( unilateral and central corneal opacity ) Chronic glaucoma Retina and choroid disease ( Retinitis pigmentosa, long standing Retinal detachment, Intraocular tumour ( retinoblastoma, malignant melanoma ) GENERAL DISEASE: Metabolic : DM, GALACTOSEMIA Endocrinal : hypothyroid / hypoparathyroidism Severe anaemia

-complications of cataract extraction** (intra & post-operative)

Intraoperative: a) Vitreous prolapse may occur during intra/extracapsular C.Extraction b) Expulsive haemorrhage ( most serious ) - occur in old age with ATH + High IOP -----> usually loss of the eye. Postoperative: a) Endophtalmitis b) Corneal edema c) Wound distortion d) Glaucoma e) IOL dislocated f) Uveitis g) Retinal detachment h) Cystoid macular edema

-Mx of unilateral aphakia A. unilateral aphakia with good vision of the other eye i. Secondary implantation of IOL -posterior chamber IOL (if there is intact post capsule) -anterior chamber IOL (if no post capsule) -scleral fixation (if no post capsule, and disturbed ant chamber anatomy) ii. Contact lenses B. unilateral aphakia with NO useful vision in the other eye i. corrected with glasses only 10. Glaucoma -CP of buphtalmos (congenital glaucoma) ox eye A. Symptoms a) triad: watering, photophobia, blepharospasm B. Signs a) cornea: i. corneal edema

ii. corneal enlargement (buphthalmos) iii. widening of limbus iv. corneal clouding (tears of Descemet membrane) b) blue sclera c) deep anterior chamber d) subluxated lens (late) e) optic disc; glaucomatous cup f) refractive state of eye: axial myopia dt globe enlargement g)increase IOP -CP of acute stage angle closure glaucoma** Symptoms: a. Severe unilateral headache, nausea, vomiting and abdominal pain (that may give the wrong diagnosis of acute abdomen) b. Unilateral ocular pain radiating along the branches of trigeminal nerve c. Marked diminution of vision down to HM or PL d. Redness, lacrimation and photophobia

Signs: a. Lid and conjunctival oedema b. Ciliary congestion c. Corneal oedema d. Shallow AC e. Loss of iris pattern f. Pupil is dilated, oval with absent reflexes g. Marked rise of IOP h. Difficult fundus examination due to corneal edema i. Gonioscopy shows abnormally closed angle

-Rx of acute congestive glaucoma*** -patient must be hospitalized -Medical treatment: (a) sedatives- lumunal, largactil,morphine (b) dehydrating measures: IV hyperosmolar therapy (manitol,urea), oral glycerin, magnesium sulphate enema (c) pilocarpine drops (d)Carbonic anhydrase inhibitor- acetazolamide (e) topical steroid drop - Not continued medical treatment beyond 24hours. Wait until eye is quiet before operating. -operation: (a) iridectomy (if perip ant synaechiae not extensive) (b) filtration surgery such as trabeculectomy (If extensive) (c)other eye- prophylactic peripheral iridectomy

-causes & Rx neovascular glaucoma A. causes: proliferative diabetic retinopathy, CRVO, carotid artery insufficiency B. Rx i. Medical a)beta-blocker b)carbonic anhydrase inhibitor c)atropine and steroid (comfort) ii. surgica a)laser photocoagulation to -retinal hypoxic area -neovascular fronds in the angle b)filtering surgery c)cyclodestructive -causes of 2ry glaucoma (page 170 buku tebal :) -2ry glaucoma due to corneal disease 1. Corneal fistula 2. Corneal staphylomata

-field changes in chronic simple glaucoma** -lense induce glaucoma 1) intumescence cataract (phacomorphic glaucoma) -take up fluid and swell-pupillary block 2) lens dislocation (ant/post) -pupillary block, damage TM, vitreous plug, 2ry uveitis, angle recession 3) phacolytic glaucoma - lens ptn seep out obstruct angle directly or engulf by macrophage and macrophage obstruct angle 4) phacoanaphylactic glaucoma -desensitization of lens ptn--granulomatous uveitis--edema TM -define: scotoma 11. Uveal diseases -CP acute iridocyclitis**

symptoms pain photophobia lacrimation dimunition of vision

1. 2. 3. 4.

signs ciliary injection keratic percipitate aqueous cell aqueous flare loss of iris pattern(muddy iris) small irregular and sluggishly reacting pupil intraocular pressure change acute cyclitis-lower IOP thick fibrinous exudation-increase IOP

1. 2. 3. 4. 5. 6. 7.

-sequalae of acute iridocyclitis/complications** 1. posterior synechiae 2. seclusio pupillae 3. occlusio papillae 4. total posterior synechiae 5. peripheral anterior synechiae 6. secondary glaucoma 7. complicated cataract 8. corneal degeneration 9. cyclitic membrane and tractional retinal detachment 10. band shaped keratopathy. 11. atrophia bulbi

Easy to recall by remembering: a) SYNECHIAE : Posterior Syn. / Total Posterior Syn. / Anterior synechiae b) PAPILLAE : Occlusio papillae / secclusio papillae.

-DD & main line of Rx of iridocyclitis**

DDx of red eye: o acute iridocyclitis. o acute conjunctivitis o acute closed angle glaucoma o corneal ulcer main Rx: o mydriatic cycloplegics - pain relief and prevention of synechiae. o steroids - mainstay of treatment, local or systemic. o cytotoxic agents - only in special types of severe uveitis. o cyclosporin - only in special types of severe uveitis. o other - hot fomentation, NSAID, treatment of the cause, treatment of the complications.

 - define:iridocyclitis iridocyclitis is inflammation of the iris and anterior part of the ciliary body -3 signs of acute iritis ( Q#....acute iritis ni same ngn acute iridocyclitis ke? Iritis is another name for anterior uveitis which is also known as iridocyclitis, based on maklumat kat tenet la.) 12. Retina -differences between rhegmatogenous & non rheg retinal detachment
Rhegmatogenous Break Configuration Mobility Present Concave Freely Tractional Absent Concave REduce Exudation Absent Convex Fixed

-fundus picture in diabetic retinopathy**

mild-moderate non proliferative DR

1. microaneurysm - showing small dots 12-100um , early detec in DR, 2. intraretinal hge- showing Dots and blot in the compact middle layer
retina,flame shape haemorrhage follow the nerve course 3. hard exudate - it is yellowish waxy appearance have affinity to macula,composed of lipoprotein n distributed in circinate pattern.

severe non proliferative DR

1. 2. 3. 4. 5.

large retinal hge cotton wool exudate venous changes-beading,dilated,saucer shape IRMA(intra retinal microvascular abn) retinal ischaemia

proliferative DR

1. neovascularization

2. pre retinal hge 3. tractional retinal detachment

-short account on treatment diabetic retinopathy

1) Good metabolic control can delay progression of diabetic retinopathy 2.1 Mild non proliferative - refer to ophthalmologist is essential for early detection - Retinopathy = Follow up every 6m - Macular edema = Laser rx can be done - Follow up every 3m - Laser rx should be done in case * PATIENT = Lack compliance, one eyed patient * MEDICAL CONDITION = Pregnant ; Renal failure - Pan retinal photocoagulation - if new vessel is persist another session photocoagulation or peripheral retinal cryotherapy -LASER THERAPY USED in: a) Diabetic macular edema b) Proliferative -VITRECTOMY : a) persistent intravitreous hge b) tractional detachment -INTRAVITREAL INJECTION a) Triamcilon b) Anti VEGF

2.2 Severe non proliferative

2.3 Proliferaive retinopathy

-etiology & CP of CRVO

Incitin factor: Trombus formation and inflammation Predisposing factor: Diabetic, hypertension, Open angle glaucoma. CLINICAL PICTURE: Non ischemic Symptom Sign: Vessel Vision Haemorrhage Rx discover during routin fundus exam. Dilated tortuous vessel 20/20 Scattered all over retina Ischemic Sudden drop n cloudiness of vision after awake Marked dilated tortuous ENgorge retinal vein 20/200 or worse extensively

-ophthalmic manifestation of retinitis pigmentosa**

Fundus examination showing pigmentary black spot.LAter on it will increase and spread. Vessel are attenuated and thread like Optic disc : pale waxy yellowish colour

Later stage,post cortical cataract appear and turn out to complete opacity.

13. Ocular tumours -causes of yellow papillary reflex a) retinoblastoma b) endophthalmitis 14. Ocular trauma -complications of retained intraocular foreign body 1) mechanical- direct injury ocular structures 2) infective: endophthalmitis 3) specific reaction: siderosis(iron), chalosis(copper) 4) immunonlogical: symphathetic ophthalmia -Rx of extraocular foreign body -CP lens changes after blunt trauma

dislocation or subluxation contusion cataract vossious ring

-Effects of blunt trauma on iris

traumatic miosis traumatic mydriasis iridodialysis traumatic iritis iris atrophy traumatic aniridia

-blunt trauma to lens 1. Dislocations/subluxations:

o o

dt. complete/partial disruption of zonules can be compicated by pupillary block glaucoma

2. Traumatic cataract
o o

rosette-shaped cataract (usually in post. cortex, sometimes in ant. or both) may be complicated by lens-induced glaucoma, either: lens-particle glaucoma (dt. liberated lens proteins) phacolytic glaucoma (dt. macrophages that engulf denatured lens proteins)

3. Vossious ring
o

a circular ring of pigmented stippled opacity seen on the ant. lens capsule dt. impression of the pupillary border of iris

-Rx of chemical burn of eye** 15. Optic nerve -3 different signs to differentiate papilledema & papillitis papilloedema symptoms Increase ICP (headache, vomiting, blurred vision) visual acuity N N Papillitis Marked visual deterioration

pupils

sluggish unsustained reaction on affected side.(relative afferent pupillary defect) disc swelling & elevation is less. vitreous dusty opacity central scotoma for red & green.

fundus

disc swelling & elevation is more. no vitreous opacity N in early cases. later it shows enlarged blind spot. latest it shows contraction.

field

16. Orbit -causes,CP,DD of orbital cellulitis causes: staph or strep CP: sudden onset of unilateral chemosis, pain, lid oedema, reduction of ocular movement, proptosis(frequently laterally & downward) DD:tenositis, cavernous sinus thrombosis, orbital periostitis -Rx orbital cellulitis adult: high IV dose of penicillin (200 000 unit) alternating with penicillin resistant antibiotic children <15y: ampicillin 200mg/kg per day in divided dose combined with penicillin resistant antibiotic administered parentally -differentiate orbital cellulitis & panophthalmitis -causes of proptosis

1) congenital: dermoid cyst, meningio-encephalocele, developmental anomalies skull and orbit. 2) traumatic: surgical emphysema, retrobulbar hge, carotid-cavernous fistula(pulsating) 3) inflammatory:-acute: orbital cellulitis, CST, orbital periosteitis, tenonitis -chronic: inflammatory pseudotmor, TB, syphilis 4) endocrinal: thyroid ophthalmopathy 5) neoplastic:-1ry: dermoid, vascular tumor, rhabdomyosarcoma, neuroma - extension from surrounding - metastatic: neuroblasoma(children), breast cancer, lung cancer -enumerate endocrinal causes of exophthalmos -CP & complications of thyroid exophthalmos -Exposure keratopathy? -Optic nerve atrophy? 17. Diseases of the sclera. 18. Ophthalmic lasers.( E.L) -4 treatment modalities using laser

refractive error:PTK,PRK & LASIK acute n open angle glaucoma diabetic macular oedema cataract surgery:post capsulotomy n for cataract extraction subretinal neovascular membrane proliferative diabetic retinopathy early m.choroidal melanoma

-indications of argon laser photocoagulation

argon laser trabeculoplasty laser peripheral iridectomy laser cyclophotocoagulation diabetic macular oedema Rx of early m.choroidal melanoma n retinoblastoma

19. Others -ocular manifestation in patient with Diabetes Mellitus*** a) Eyelid - xanthelasmata. b) Increased liability to conjucntivitis and keratitis. c) Increased liability for iritis and iridis rubeosis. d) Lens - temporary refractive changes, early presbyopia and diabetic cataract. e) diabetic retinopathy. f) intraocular haemorrhages - hyphaemia, vitreous hemorrhage. g) Acute papillitis or retrobulbar neuritis.

h) Extraocular muscles palsy due to ischaemic neuropathy. -ocular manifestation in hypertensive patient -Vit A deficiency eye manifestation & short treatment Early: Loss of corneal lustre with dryness and hyposthesia Late: Rapidly progress to corneal ulceration and melting No inflammatory signs are seen & perforation can occur Treatment: Vitamin supplementation and treatment of protein deficiency malnutrition

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