The Atlas of Ophthalmology

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Eyelid Anatomy - Entropion / Ectropion

Eyelid Anatomy - Entropion / Ectropion
Elizabeth J. Rosen, MD
Karen H. Calhoun, MD

Entropion is a medical condition in which the eyelids fold inward. Ectropion is a medical condition in which the lower eyelid turns outwards

Eyelid Anatomy
* Tarsal plates
o Length 25mm
o Thickness 1mm
o Height
+ Upper 10mm
+ Lower 4mm
* Orbicularis Oculi
o Orbital
o Palpebral
+ Preseptal
+ Pretarsal
* Medial canthal tendon
o Anterior reflection
o Posterior reflection
o Vertical fascial support
* Lateral canthal tendon
* Lateral retinaculum
* Orbital septum
o Origin
+ Arcus marginalis
o Insertion
+ Medial: posterior lacrimal crest
+ Lateral: orbital tubercle
+ Superior: levator aponeurosis
+ Inferior: inferior tarsal border
* Upper lid levators
o Levator palpebrae superioris
o Whitnall’s ligament
o Muller’s muscle
* Lower lid retractors
o Capsulopalpebral fascia
o Lockwood’s ligament
o Inferior palpebral muscle
* Lacrimal apparatus
o Gland
o Punctum
o Canaliculus
o Sac
o Duct

Entropion
* Congenital
* Involutional (senile)
* Cicatricial
* Congenital Entropion
* Epiblepharon
* Correction of congenital entropion or epiblepharon
* Correction of involutional entropion
* Correction of cicatricial entropion
* Correction of cicatricial entropion
Ectropion
* Congenital
* Paralytic
* Cicatricial
* Involutional

Ectropion
* Paralytic ectropion
* Correction of paralytic ectropion
* Correction of cicatricial ectropion
* Correction of involutional ectropion

Entropion / Ectropion.ppt

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Retinopathy of Prematurity

Retinopathy of Prematurity
Medical and Surgical Update
Presentation by: Tim Stout MD PhD
Casey Eye Institute
Oregon Health Sciences University

Retinopathy of Prematurity - What is it?

An uncontrolled neovascular process in which retinal endothelial cells stop developing and die, then later, proliferate, migrate, organize, scar and cause a detachment of the retina

ROP - What is it ?

* Found in premature infants with immature retinal vasculature who have received supplemental oxygen.
* It is the most common cause of permanent blindness in children
o it lasts a lifetime
o it shares common pathophysiologic features with a variety of common diseases


Normal Human Eye
Normal Human Retina
ROP – Geography (Zones)
TEMPORAL
NASAL
SUPERIOR
INFERIOR, RIGHT EYE
ROP Classification

* Stage 1 : Line separates vascular and avascular retina
* Stage 2 : Ridge (intra-retinal neovascularization)
* Stage 3 : Extra-retinal neovascularization
* Stage 4 : Subtotal retinal detachment
* Stage 5 : Total retinal detachment

PLUS Disease - dilated and tortuous retinal vessels
ROP Classification
THRESHOLD DISEASE
ROP Progression
ROP Incidence - Gestational Age
ROP Incidence - Birth Weight
ROP Screening - When
ROP - Current Treatment
Surgical Treatment
ROP - Laser Technique
Laser Treatment for ROP
ROP - Scleral Buckle
ROP - Late Sequelae
ROP - Retinal Dragging

ROP is a BIOLOGIC process which we currently treat MECHANICALLY

Retinopathy of Prematurity.ppt

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Vision Therapy

Vision Therapy
Presentation by:Cathy Chang
UC Sandiego

What is Vision Therapy?

* Vision therapy (visual training, vision training) is an individualized supervised treatment program designed to correct visual-motor and/or perceptual-cognitive deficiencies

Why Vision Therapy?

* Behavioral Optometrists believe that vision is a learned skill; Vision plays the largest role in learning.
“There's more to vision than just having 20/20 eyesight. A strong visual system is needed for reading, using a computer, and playing sports.”

Vision Related Learning Problems

* Physical Symptoms
• Jerky eye movements, one eye turning in or out
• Squinting, eye rubbing, or excessive blinking
• Blurred or double vision
• Headaches, dizziness, or nausea after reading
• Head tilting, closing or blocking one eye when
reading
* Secondary Symptoms
• Smart in everything but school
• Low self-esteem, poor self image
• Temper flare ups, aggressiveness
• Frequent crying
• Short attention span
• Fatigue, frustration, stress
• Irritability
• Day dreaming

* Performance Clues

• Avoidance of near work
• Frequent loss of place
• Omits, inserts, or rereads letters/words
• Confuses similar looking words
• Failure to recognize the same word in the next sentence
• Poor reading comprehension
• Difficulty copying from the chalkboard
• Book held too close to the eyes
• Inconsistent or poor sports performance
* Social Labels

• Lazy
• Dyslexic
• Attention Deficit Disorder
• Slow learner
• Behavioral problems
• Working below potential

Amblyopia (lazy eye)

* A condition in which one eye has reduced vision; There’s a difference in visual acuity between the two eyes


Normal Vision Lazy Eye Vision
Causes
Clinical Symptoms
Early Diagnosis
Treatment Options
Strabismus (crossed eyes)
Causes
Symptoms
Treatment
VT Approach & Techniques
Demonstrations
Research Studies

Vision Therapy.ppt

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Oculomotor Lecture

Oculomotor Lecture
Presentation lecture from:Mary Warren, Uni. of Alabama at Birmingham

Evaluation Purpose

* Determine if an oculomotor impairment exists and interferes with occupational performance
o Not to diagnose the impairment
* Evaluation should be a simple screening using a “look and listen” approach
o Look at the deviations in oculomotor control
o Listen to patient complaints regarding occupational performance

Begin Evaluation by Listening

* Obtain visual history
o Congenital childhood strabismus
+ Did pt have eye surgery, patching as a child?
+ Did anyone ever tell the patient h/she had a lazy eye?
o If patient had a head injury
+ Was there any trauma to the eye or orbit?

* What are the patient’s functional complaints?
o Print blurs when reading
o Unable to keep objects in focus
o Balance difficulty
o Past pointing/reaching
o Eye fatigue/eye pain/headache with sustained focus
o Difficulty maintaining concentration on activities requiring sustained focus
+ Reading or computer work
o Nausea/blurring vision with head movement
o Blurring of vision when changing focal distances

Assessment of Diplopia

* Subjective complaints of diplopia
o Lateral or vertical splitting of images
o Present at near distances or far distances
o Present intermittently or constantly
o Direction of affected gaze
+ Primary gaze
+ Right or left gaze
+ All gaze directions
o Minimize or exacerbated by head position
o Accompanied by blurring vision when head movement

* Objective observations
o Disappears when one eye is closed
+ Indicates oculomotor impairment
o Remains with closing of one eye
+ Indicates some other cause such as retinal injury
o Area of fusion
+ All persons have some area where they can see a single image known as the fusion zone
+ Distance from face
+ Ability to maintain fusion within the zone
o Neck range of motion
+ Horizontal and vertical

General Appearance of Eyes and Head

* Have pt focus on a distant, visible target and compare appearance of the eyes
o Symmetry of pupil size
o Symmetry and function of eyelids
o Presence of nystagmus
* Does patient assume a deviated head position?
* Observe symmetry of corneal reflections in primary gaze

Corneal Reflections

* Spot of light reflected off the cornea of the eyes.
* Observation of corneal reflections is one of the simplest ways to assess ocular alignment.

* When eyes are aligned the reflections should match in location (note: some persons have slightly unequal reflections due to corneal imperfections).
* Known as Hirschberg test

Corneal Reflections Test

* Test materials
o Recording form
o Penlight
o Distant interesting target large enough to be seen easily at 6 plus feet
* Environment
o Well lighted room; ensure light source is not shining directly into the patient’s eyes. Room illumination can be decreased if corneal reflections are difficult to see.

* Procedure:
o Patient should have glasses on if worn
o Instruct the patient to focus on the target held at eye level
o Hold the penlight centered in front of the patient’s face approximately 12 inches from the tip of the nose; hold the penlight vertically so the light is directed upward and not shining into the patient’s eyes

Observe the cornea reflection in each eye
as the patient fixates

Examples of Corneal Reflections
Esotropia: reflection is on the outer rim of the cornea

Corneal Reflections Test
Assessment of Eye Movements
Smooth Pursuits
Recording
Example
Convergence
Recording
Eye Movements
Diplopia Testing
Cover Uncover Test
Outward movement: esotropia
Inward movement: exotropia
Downward movement: hypertropia
Upward movement: hypotropia
Alternate Cover Test
Diplopia Tests
Evaluating the Low Functioning Patient
Treatment
Performance Areas Affected by Oculomotor Dysfunction
Considerations in Treatment
OT Treatment Approach
Management Techniques
Occlusion
Prisms
Occlusion
Complete Occlusion
Partial Occlusion
Both Types of Occlusion
Prism
Restoration Techniques
Eye exercises
Surgical intervention

Oculomotor Lecture.ppt

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Surgical Outcomes in Intermittent Exotropia

Surgical Outcomes in Intermittent Exotropia
Presentation lecture by:
Jeffrey D. Colburn, M.D., PGY-3
Preceptor: David Morrison, M.D.
Vanderbilt Eye Institute

Intermittent Exotropia

* Intermittent exotropia x(t) is a latent tendency (phoria) for the eyes to turn out, which is intermittently controlled by fusional convergence.
* Characteristics
o Typically good bifoveal fusion and stereoacuity when aligned.
o Amblyopia is rare in x(t).
o X(t) Tends to remain stable or progress.
o Progression might result in dense suppression.

Intermittent Exotropia

* X(t) Sub-types
1. Basic
+ Angle is equal at near & distance

2. Pseudo-divergence excess (PDE)
+ Angle is equal at near & distance but appears larger in distance because of masking

3. True divergence excess (TDE)
+ Angle is larger in distance

4. Convergence insufficiency (CI)
+ Angle is larger at near

Surgical Treatment

* Goals
o Improve alignment & control
o Improve binocular vision
* Basic concepts
o Recession (weakening procedure)
o Resection (strengthening procedure)
* Two primary approaches
o Bilateral lateral rectus recession (BLRc)
o Unilateral recess & resect (R&R)

Predictors of Outcomes

age
pre-op deviation
pre-op control
sub-type
procedure type
asymmetric accommodation
pre-op deviation
central fusion or stereopsis
Observations

* Effect of pre-operative angle size on surgical outcomes in x(t) patients.
* Disparate opinions on the more successful procedure for x(t).
Hypotheses
* Larger angle x(t) patients have more successful surgical outcomes than smaller angle x(t) patients.
* R&R procedures have more successful surgical outcomes than BLRc in the management of x(t).
Methods

* Retrospective chart review
o Inclusion criteria
+ X(t) surgical cases
+ January, 2003 through January, 2008
+ Age ≤ 18 years
Methods

* Exclusion criteria
o Developmental delay
o Vertical deviation
o Pattern deviation
o Prior surgery
o Partially or untreated amblyopia
o Monocular exotropia
o Constant exotropia
o Secondary exotropia
o Nystagmus

Data collection

* Variables considered
o Gender
o Age at time of surgery
o X(t) sub-type
o Pre-op deviation
o Stereo-acuity
o Presence of fusion
o Presence of suppression
o Procedure type
o Deviation post-op visit #1
o Deviation post-op visit #2

Outcome Measures

* Surgical success:
o Intermittent exotropia ≤ 8 PD
o No esotropia
* Surgical failure:
o Not meeting above success criteria
o Repeat surgery for poor control
* Time to surgical failure
* Over-correction or under-correction

Demographics
History of amblyopia
Average pre-op deviation (PD)
Mean age at surgery (mos)
Characteristic Results

* Overall outcomes
o 61 BLRc, 19 R&R, 2 unilateral LRc
o 42 (51.2%) patients failed
o Mean time to failure was 6.9 months (1-34)
o 35 patients (43%) were under corrected
o 6 patients (7.3%) were over corrected

Other variables
Multivariate logistic regression
Surgical procedure (blrc vs. r&r)
Presence of suppression
Presence of fusion
Stereo acuity
Pre-operative deviation
Chi-square
Multivariate survival analysis
Cox proportional hazards model
Surgical procedure
Stereo Acuity
Presence of Suppression
Comment
Summary

Surgical Outcomes in Intermittent Exotropia.ppt

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Carotid Cavernous Fistula

Carotid Cavernous Fistula
Presentation by: Laura S Gilmore, MD
Department of Ophthalmology, TTUHSC

Discussant: Kenn Freedman, MD

Case Presentation

* 26yo AAM s/p MVA
* CHI, L zygoma fracture
* Consulted for proptotic, red OS
* CT: proptosis OS. No basilar skull fracture. no retrobulbar hematoma, no superior ophthalmic vein enlargement, no ocular muscle enlargement

Differential Diagnosis

Cavernous Sinus Thrombosis
* Retrobulbar Hematoma
* Unrecognized intra-orbital FB, with possible cellulitis
* Carotid Cavernous Sinus Fistula
* Tumor

Physical Exam

* General: sedated, intubated
* Lids: edematous, margins intact
* Pupils: 2.5mm->2mm, 7->NR
* Conj: chemosis, OS>OD; SCH OS
* IOP: 16, 28
* Cornea 2+ edema OS, clear OD
* + gross proptosis OS
* + bruit OS on auscultation, no neck bruit
* DFE: discs flat with sharp edges, vessels normal, retina flat OU

MRI of CC Fistula
Carotid Cavernous Fistula

* Abnormal communication between previously normal carotid artery and cavernous sinus
* Characterized as:

-Direct vs. Indirect
-High vs. Low Flow
-Traumatic vs. Spontaneous

Types of CC Fistula
Mechanisms of CCSF

* Trauma
* Spontaneous causes:
o rupture of intracavernous aneurysms
o neurofibromatosis
o atherosclerotic disease
o collagen vascular disease
* Iatrogenic

Direct Carotid Cavernous Fistula

* Arterial blood passes directly through a defect in the wall of intracavernous portion of ICA
* Blood in vein becomes arterialized
* Venous pressure increases
* Arterial pressure and perfusion decreases

Signs of Direct CCSF

* Ptosis
* Very red, chemotic conj
* Increased IOP from increased episcleral venous pressure
* Anterior segment ischemia in 20%
o Corneal edema, cell/flare, iris atrophy, rubeosis, cataract
* Proptosis is pulsatile
* Bruit and thrill
* Muscle palsies
* Visual loss

Etiologies of Direct CCSF

* From trauma in 75% of all cases
o Basal skull fracture tears ICA within cavernous sinus
o Traumatic fistulae-high flow rates, sudden and dramatic onset of symptoms
* Spontaneous rupture of aneurysm or atherosclerotic artery in 25%
o Post-menopausal, hypertensive females
o Lower flow rates, less severe symptoms


Mechanisms of Traumatic CCSF

* direct injury from basilar skull fracture
* injury from torsion or stretching of the carotid siphon upon impact
* impingement of the vessel on bony prominences

Indirect Carotid Cavernous Fistula

* Fistulous connection is within the wall of the cavernous sinus
* Tend to be low-flow
* Small meningeal arteries supplying dural wall of cavernous sinus can rupture spontaneously, while ICA itself remains intact
* Insidious onset, mild orbital congestion, proptosis, low or no bruit
* Lesions may fluctuate, and may resolve spontaneously

Clinical Presentation of CCSF

* Ophthalmic consequences of CCSF are caused by compression and ischemia related to increased venous pressure and reduced arterial pressure
o flow reversal leads to engorged ophthalmic veins causing proptosis, conjunctival injection, chemosis.
o Patients complain of retro-orbital headache, or a bruit. Facial pain with V1 and V2 involvement
* Other manifestations:
o congestion of the opposite orbit
o diplopia
o ptosis, mydriasis
o corneal ulceration
o loss of visual acuity
o transient neurological deficits
o subarachnoid hemorrhage

Radiological Evaluation of CCSF

* Angiography is the definitive diagnostic examination
* CT and MRI may show
o Enlarged superior ophthalmic vein
o Enlarged muscles
o Enlarged cavernous sinus with a convex shape to the lateral wall

Treatment of CCSF

* Most are not life-threatening
o Only involved eye is at risk typically
* Main indicators for treatment
o Glaucoma
o Diplopia
o Intolerable bruit or HA
o Severe proptosis causing exposure keratopathy
o Spontaneous closure from thrombosis of cavernous sinus is unlikely (as in trauma, high-flow)

Treatment of CCS Fistulas

* 99% of treatment is done by interventional neuroradiologists
o Intravascular approach-placement of thrombogenic materials, eg coils
* Other therapies include:
o carotid artery ligation
o surgical exposure with clipping of the fistula

Summary

* Direct CCSF usually results from trauma
* Patients typically present with proptosis, conjunctival injection, and a bruit
* Angiography when pt stable
* Transarterial embolization

Carotid Cavernous Fistula.ppt

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Sudden Loss of Vision

Sudden Loss of Vision
Presentation by: L Perera
Specialist Registrar, Manchester Royal Eye Hospital


Causes
Examination
Causes - Anatomical
Causes – Urgent / Emergency
Anterior Ischaemic Optic Neuropathy (AION)
AION – key features
AION - Management
Optic Neuritis
Optic Neuritis - Treatment
Central Retinal Artery Occlusion
Central retinal vein occlusion
Retinal Detachment
Macular Haemorrhage – key features
Vitreous haemorrhage - features
Vitreous haemorrhage - causes
Vitreous haemorrhage -management
Unilateral transient visual loss

Sudden Loss of Vision.ppt

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Visual Loss of Neuro-ophthalmic Interest

Visual Loss of Neuro-ophthalmic Interest.
Presentation by:Prof. Dr. P. Sudhakar.
Professor And Head Of Department.
Strabismus And Neuro-ophthalmology Clinic.
RIOGOH Chennai, India


Visual Loss – Form And Function
Profound Loss Of Vision.
Segmental Loss Of Vision.
Loss Of Central Vision
Transient Loss Of Vision
Macular Vs Optic Nerve Causes.
Decreased Vision With Macular Changes.
Decreased Vision With Normal Disc.
Decreased Vision With Disc Edema.
Decreased Vision With Normal Disc.
Decreased Vision With Abnormal Disc Appearance.

Optic neuritis.ppt

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