Eye Lecture
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| Extra-ocular eye structures | Eyebrows, Eyelids Eyelashes, Conjunctiva
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| Intra-ocular eye structures | Cornea, Iris, Pupil, Anterior chamber, Lens, Retina, Optic nerve. Responsible 4:Transmitting visual images to the brain.Maintaining homeostasis of the inner eye
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| Cataract definition | Waterfall. Cloudiness of the eye's lens that causes vision loss.
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| Eye physiology | Normal Lens: Clear transparent button-like structure that lies behind the Iris and Pupil. Works much like a camera lens: focuses light onto the film where an image is recorded.Focuses light onto the retina at the back of the eye where an image is recorded
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| Eye physiology | Lens also adjusts the eye's focus: can see objects clearly both up close and far away; made of mostly water and protein. Protein is arranged in a precise way that keeps the lens clear for the light to pass through it.
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| Cataract pathophys | some of the protein may clump together and begin to cloud a small area of the lens. Eye lens becomes cloudy = blurred & unclear view. Normal part of aging process. 1 may be worse than the other b/c ea cataract develops & progresses at diff rate
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| Cataract progression | Some ppl won't notice b/c it's not bad; others will lose all vision. Starts at periphery and moves into the center.
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| Cataract risk factors: Aging | Aging: senile cataracts: Changed proteins and fibers in the lens. Degenerated lens from the wear and tear. Eventually lens will loose its clarity. Most start after 65, but some in 40s & 50s.
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| Cataract risk factors | Congential: If woman contracts the German measles early in pregnancy: unborn child may have congenital cataracts. Smoking: potentially damaging lens proteins & fiber cell membrane in the lens. Long-term use of corticosteroids: alter protein metabolism
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| Cataract risk factors | Systemic disease: DM or Hypothyroidism
Exposure to radiation or long hours of bright sunlight
Other eye disorders: inflammation of iris or ciliary body
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| Types of cataracts | Immature:affected only a portion of the lens
Mature: opacity of the entire lens.
Most significant form of cataract
Has the appearance of “frost on a window”
Ripen cataract
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| Clinical Manifestations of cataracts | Starts out small: has little effect. May noticed slight blurred vision: looking through a cloudy piece of glass. Color diminished. Glare from headlights or sun too bright due to light bouncing off opacity. Never happy with new glasses. Double vision.
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| Diagnostic tests for cataracts | Standard eye: acuity & field (card pts)
Ophthalmoscopic examination: aka fundoscopy Examining eye Fundus: Retina, Optic disc, Macula, & Retina vessels
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| Diagnostic tests for cataracts | Slit-lamp: various shapes & colors of light: Admin eye drops to dilate pupils. Exam the front surface of the eye: cornea sclera ant. chamber trabecular meshwork
Glare test: Vision drops considerably in sunlight or when looking at lights
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| Diagnostic tests for cataracts | Contrast Sens.: Crispness of vision: enable to see objects that don't stand out from background.
Good contrast sensitivity is when they see objects even when they are displayed against increasingly low-contrast backgrounds
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| Cataract surgery | Only effective tx: remove lens & replace with plastic. v. effective: 1.5 mil/year, non-emergent, usually done when vision changes are bad
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| Phacoemulsification surgery | Outpt, v. sm incision =a 3 mm or 1/8th ".
breaks up the cloudy with sound waves & removes thru vacuum
back 1/2 of the lens is left. plastic disc, aka intraocular lens is folded and inserted to provide light refraction and restore visual acuity
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| Extracapsular surgery | Advanced cataract: can't break up the clouded lens
Requires larger incision, about 2/10 inch (10 mm)
Remove lens as one piece
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| Complications from surgery | 2-5% of sx, Loss of vitreous humor (gel-like substance in the back of the eye allowing light to the retina), Cornea edema, Increased intra-ocular pressure, Hemorrhage, Inflammation, Retinal detachment, Displacement of implanted lens.
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| Scar tissue in cataracts | 20-35% of pts may have a thin film scar tissue formed behind the newly implanted Lens causing blurred vision.
Feels as cataract has "grown back."
Cloudiness usually develops a year or more after surgery causing same vision problems as a cataract does.
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| YAG Capsulotomy | Uses a laser beam to make a tiny hole in the post capsule to allow the light to pass through to reach the retina.
Painless out-patient surgery takes 5 minutes.
Not require repeated cataract surgery.
Approximately 98% of pts experience vision improveme
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| Glaucoma | Characterized by increased intra-ocular pressure & vision loss.
Increased ocular pressure = Fluid within the eye (aqueous humor) does not drain properly
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| Aqueous humor: structure and function | Thick fluid in the eye.
Occupies both anterior & posterior chambers
Delivers essential nut. to the non-vasc tissues of the ant chamber (cornea, lens, & trabecular meshwork)
Removes metabolites from the eyes to provide the proper environment for the ey
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| Aqueous humor: structure and function | Produced by Ciliary body, flows from the Posterior chamber to the Anterior chamber, and outflow through Trabecular meshwork to Canal of Schlemm
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| Intra-ocular pressure | Normal IOP: 12-20 mm/Hg. Maint pressure by a balance between the production of aqueous humor in the Ciliary body and its outflow through Canal of Schlemm.
Disrupted balance = Increased IOP
Increased intra-ocular pressure = Damage optic nerve
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| Glaucoma pathophys | Deteriorated optic nerve = Develop blind spots & vision change
Affected peripheral vision 1st then front or central vision.
Eventually = blindness without tx
2% of pop 40+ in U.S.
Leading cause of blindness in the U.S.
13% of all blindness worldwid
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| Closed Angle: Acute Glaucoma | less common: med emerg. Anatomical changes of angle between the Pupil & lateral Cornea associated with pupillary dilation.
When pupils are dilated, the iris is displaced toward the cornea which narrows/closes the anterior chamber angle.
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| Closed Angle: Acute Glaucoma | Closed off aqueous humor exit so it accum = incr IOP. May occur when a person is sitting in a darkened room or during the time of stress: dilated pupil.
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| Risk factors for acute angle Glaucoma | Elderly, Farsightedness (have small eyes), Stress
Anything that causes the pupil to dilate (i.e. dim lighting)
Certain medications like anti-histamines (anti-cholinergic effect with pupillary dilation)
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| Clinical manifestations for acute angle glaucoma | May be rapid, no warning, in dim room, pup dilated. It affects one eye: other eye is at risk in the future.
Severe throbbing eye pain and headache
Redness in eye, Blurred vision, Halos around light
Tender and firm eyeball, Fixed and dilated pupil
N-V
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| Open Angle Glaucoma aka Chronic simple glaucoma | most common. Normal anterior chamber angle between the iris and cornea. Relatively obstructed AH flow thru Trabecular meshwork and into the Canal of Schlemm (but idiopathic closure)= slow incr of IOP. both eyes, but not symmetrical. silent thief of night
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| Risk factors for open angle glaucoma | Age over 40 years old, Family history of Glaucoma
Diabetes, Nearsightedness (expanded eye thinning the support structures for the optic nerve?)
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| Clinical manifestations of open angle glaucoma | vague: unhappy with new glasses, blurred vision, Halos around light.
Difficulty with color presentation
Hard time to find the way into the seat at theater.
Eyes may feel hard to the touch
Mild, chronic headache
Peripheral vision loss
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| Diagnostic tests for open angle glaucoma: Non-Contact Tenometry | Non-Contact Tenometry: puff of air measures the air force that flattened the cornea.
Thick cornea: higher IOP requires greater air pressure to flattened the cornea. 40+ y/o done annually. IOP > 26 consist: incr chance by 50%
IOP >30 consist: 100%
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| Diagnostic tests for open angle glaucoma: pupillary reflex and refraction | Pupillary Reflex: Non-reactive pupil in affected eye
Refraction: Myopia: nearsightedness: Distant objects appear blurry
Eye is longer than usual Image falls short of the retina.
Most common vision problem
Hyperopia: farsightedness
Abnormal small eye
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| Refraction test: astigmatism | Cornea curves more severely like a football.
All objects both near and far are distorted.
Images are blurred due to some of the light rays are focused and others are not
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| Refraction test: | Presbyopia: “old eye”
Inability to focus on objects thatare close to self.
Need reading glasses
Lens starts to lose its flexibility.
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| Medical management of open angle glaucoma | Treatment goal: To reduce the intra-ocular pressure.
Depending on the type of glaucoma: achieved by medications or surgery
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| Medications for open angle glaucoma general | Oral, IV, Topical eye drops
Can’t cure glaucoma: Control IOP to preserve vision indefinitely with drug therapy
Can be used alone or in combination
Four major types of drugs
Decrease production of aqueous humor
Increase drainage of aqueous humor.
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| Beta blocker for open angle glaucoma | Affects Ciliary body where the Aquous humor is being produced.
Decrease production of AH by the Ciliary body.
Effective and have low side effects
Usually applied BID
Timoptic: most common drug
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| Adrenergic Agonist for open angle glaucoma | Increases drainage of aqueous humor.
May cause ocular redness
Glaucon (Epinephrine): common drug
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| Cholinergic Agonists for open angle glaucoma | Increase drainage of aqueous humor
Mild miotic effect that constrict pupil
Have a short duration of action
Cause blurred vision.
Pilocarpine: common drug
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| Pilocarpine insert | Ocusert ocular therapeutic system for Pilocarpine
Effect of Pilocarpine lasts for 2-4 hours: conventional method.
Placed in the upper or lower sac of the eye to allow Pilocarpine to slowly diffuse out over 7 days.
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| Carbonic Anhydrase Inhibitors for open angle glaucoma | Decrease the production of aqueous humor.
Systematic drugs that can be given by orally or intravenously.
Usually used as adjunctive therapy.
Given in combination of any of the above topical eye drops.
Diamox: common drug
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| Osmotic Agents for open angle glaucoma | Mannitol: common drug
Hypertonic solution to draw fluid from the eye = Decrease IOP
Used in emergency treatment for acute angle-closed glaucoma
🗑
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| Prostaglandins for open angle glaucoma | Hormone-like substances that help open blood vessels
Increase outflow of aqueous humor
Drugs: xalatan, rescula, travatan, lumigan
🗑
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| Trabeculoplasty | LOOK UP
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| Iridotomy | It is frequently used to treat angle-closure glaucoma.
Make small drainage hole in the iris to allow the aqueous humor to drain more freely
So the iris does not plug up the trabecular meshwork.
🗑
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| Cyclophotocoagulation | Freezing selected areas of the ciliary body to reduce the aqueous humor production.
Used for more advanced or aggressive cases.
🗑
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| Macular Degeneration: definition and general | Referred to age-related macular degeneration (ARMD) or senile macular degeneration (SMD)
Leading cause of blindness 60+y/o in U.S. Considered as aging process.
men & women equally
2 mil new cases are diagnosed annually
< 1% is successfully treated.
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| Macular Degeneration: definition and general | Exact cause is unknown
Suggested that it results from the changes to the macular as the macula deteriorates or becomes scarred
🗑
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| Macular degeneration pathophys | M in center of Retina.
light enters the eyes & is focused by Cornea & Lens ->Retina.
Retina has photo-sensitive cells that line the back of the eye respons 4 color and fine vision.
concentration of photo-sensitive cells are found in Bull-Eye: Macula
🗑
|
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| Closed Angle: Acute Glaucoma | less common: med emerg. Anatomical changes of angle between the Pupil & lateral Cornea associated with pupillary dilation.
When pupils are dilated, the iris is displaced toward the cornea which narrows/closes the anterior chamber angle.
🗑
|
||||
| Closed Angle: Acute Glaucoma | Closed off aqueous humor exit so it accum = incr IOP. May occur when a person is sitting in a darkened room or during the time of stress: dilated pupil.
🗑
|
||||
| Risk factors for acute angle Glaucoma | Elderly, Farsightedness (have small eyes), Stress
Anything that causes the pupil to dilate (i.e. dim lighting)
Certain medications like anti-histamines (anti-cholinergic effect with pupillary dilation)
🗑
|
||||
| Clinical manifestations for acute angle glaucoma | May be rapid, no warning, in dim room, pup dilated. It affects one eye: other eye is at risk in the future.
Severe throbbing eye pain and headache
Redness in eye, Blurred vision, Halos around light
Tender and firm eyeball, Fixed and dilated pupil
N-V
🗑
|
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| Open Angle Glaucoma aka Chronic simple glaucoma | most common. Normal anterior chamber angle between the iris and cornea. Relatively obstructed AH flow thru Trabecular meshwork and into the Canal of Schlemm (but idiopathic closure)= slow incr of IOP. both eyes, but not symmetrical. silent thief of night
🗑
|
||||
| Risk factors for open angle glaucoma | Age over 40 years old, Family history of Glaucoma
Diabetes, Nearsightedness (expanded eye thinning the support structures for the optic nerve?)
🗑
|
||||
| Clinical manifestations of open angle glaucoma | vague: unhappy with new glasses, blurred vision, Halos around light.
Difficulty with color presentation
Hard time to find the way into the seat at theater.
Eyes may feel hard to the touch
Mild, chronic headache
Peripheral vision loss
🗑
|
||||
| Diagnostic tests for open angle glaucoma: Non-Contact Tenometry | Non-Contact Tenometry: puff of air measures the air force that flattened the cornea.
Thick cornea: higher IOP requires greater air pressure to flattened the cornea. 40+ y/o done annually. IOP > 26 consist: incr chance by 50%
IOP >30 consist: 100%
🗑
|
||||
| Diagnostic tests for open angle glaucoma: pupillary reflex and refraction | Pupillary Reflex: Non-reactive pupil in affected eye
Refraction: Myopia: nearsightedness: Distant objects appear blurry
Eye is longer than usual Image falls short of the retina.
Most common vision problem
Hyperopia: farsightedness
Abnormal small eye
🗑
|
||||
| Refraction test: astigmatism | Cornea curves more severely like a football.
All objects both near and far are distorted.
Images are blurred due to some of the light rays are focused and others are not
🗑
|
||||
| Refraction test: | Presbyopia: “old eye”
Inability to focus on objects thatare close to self.
Need reading glasses
Lens starts to lose its flexibility.
🗑
|
||||
| Medical management of open angle glaucoma | Treatment goal: To reduce the intra-ocular pressure.
Depending on the type of glaucoma: achieved by medications or surgery
🗑
|
||||
| Medications for open angle glaucoma general | Oral, IV, Topical eye drops
Can’t cure glaucoma: Control IOP to preserve vision indefinitely with drug therapy
Can be used alone or in combination
Four major types of drugs
Decrease production of aqueous humor
Increase drainage of aqueous humor.
🗑
|
||||
| Beta blocker for open angle glaucoma | Affects Ciliary body where the Aquous humor is being produced.
Decrease production of AH by the Ciliary body.
Effective and have low side effects
Usually applied BID
Timoptic: most common drug
🗑
|
||||
| Adrenergic Agonist for open angle glaucoma | Increases drainage of aqueous humor.
May cause ocular redness
Glaucon (Epinephrine): common drug
🗑
|
||||
| Cholinergic Agonists for open angle glaucoma | Increase drainage of aqueous humor
Mild miotic effect that constrict pupil
Have a short duration of action
Cause blurred vision.
Pilocarpine: common drug
🗑
|
||||
| Pilocarpine insert | Ocusert ocular therapeutic system for Pilocarpine
Effect of Pilocarpine lasts for 2-4 hours: conventional method.
Placed in the upper or lower sac of the eye to allow Pilocarpine to slowly diffuse out over 7 days.
🗑
|
||||
| Carbonic Anhydrase Inhibitors for open angle glaucoma | Decrease the production of aqueous humor.
Systematic drugs that can be given by orally or intravenously.
Usually used as adjunctive therapy.
Given in combination of any of the above topical eye drops.
Diamox: common drug
🗑
|
||||
| Osmotic Agents for open angle glaucoma | Mannitol: common drug
Hypertonic solution to draw fluid from the eye = Decrease IOP
Used in emergency treatment for acute angle-closed glaucoma
🗑
|
||||
| Prostaglandins for open angle glaucoma | Hormone-like substances that help open blood vessels
Increase outflow of aqueous humor
Drugs: xalatan, rescula, travatan, lumigan
🗑
|
||||
| Trabeculoplasty | LOOK UP
🗑
|
||||
| Iridotomy | It is frequently used to treat angle-closure glaucoma.
Make small drainage hole in the iris to allow the aqueous humor to drain more freely
So the iris does not plug up the trabecular meshwork.
🗑
|
||||
| Cyclophotocoagulation | Freezing selected areas of the ciliary body to reduce the aqueous humor production.
Used for more advanced or aggressive cases.
🗑
|
||||
| Macular Degeneration: definition and general | Referred to age-related macular degeneration (ARMD) or senile macular degeneration (SMD)
Leading cause of blindness 60+y/o in U.S. Considered as aging process.
men & women equally
2 mil new cases are diagnosed annually
< 1% is successfully treated.
🗑
|
||||
| Macular Degeneration: definition and general | Exact cause is unknown
Suggested that it results from the changes to the macular as the macula deteriorates or becomes scarred
🗑
|
||||
| Macular degeneration pathophys | M in center of Retina.
light enters the eyes & is focused by Cornea & Lens ->Retina.
Retina has photo-sensitive cells that line the back of the eye respons 4 color and fine vision.
concentration of photo-sensitive cells are found in Bull-Eye: Macula
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| Macular degeneration physiology | macula provides sight in the center of our visual field; is responsible for clear, sharp, straight-ahead vision needed for reading, writing, driving, doing close work.
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| Macular degeneration pathophys | In aging, the cells in the macular zone break down and thin: causes a malfcn or lost fcn. Brain may compensate & fill in the missing part of the picture in early cases with spotty macular cell damage or dysfcn.
disease is fairly advanced when symp occur
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| Risk factors for Macular degeneration | No known cause for AMD
Family history
Smoker
Elderly Caucasians, especially northern European descent: more ultraviolet rays reach the retina in blue-eye individuals because of the lower pigment density in the eye.
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| Types of Macular degeneration | Dry/atrophic and wet/exudate
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| Dry Macular degeneration | AKA Atrophic
Approximately 90% of cases
Caused by aging and thinning of the tissue of the macula.
Generally experience a gradual loss of central vision.
No treatment or cure.
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| Wet Macular degeneration | 10% of ARMD cases
Macula is forming the scar tissue as blood vessels around the macula are leaking
Has more sudden, rapid vision loss
Has permanent vision loss = accounts for 90% of all cases of legal blindness.
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| Clinical manifestations of macular degeneration | Rapid & severe or gradual vision loss.
Only 1 eye loses vision
Dim or Distorted esp when reading.
Gradual loss of color
May still have good side vision, but dark or blank spots appear in the center of vision.
Straight lines look wavy
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| Amsler Grid test for macular degeneration | detect blind spots or distortion of central vision.
Wear reading glasses
chart at arms distance & cover one eye.
stare at the white dot in the center of grid.
Holes, blurry spots, wavy, fuzzy, crooked, distorted, or broken line: ARMD
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| Medical Management for macular degeneration | No specific, definitive treatment or cure for MD.
Treatment goal: assist pt see better & stabilize the condition
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| Angiogenesis Inhibitor for macular degeneration | Pegaptanib (Macugen): first drug to directly slow down the disease process
Impeding vascular endothelial growth factor (VEGF): inhibit new blood vessel formation and its subsequent leakage.
Needs 9 separate injections given 4-6 weeks apart
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| General info about macular degeneration | Lost vision can't be restored. Only lose central. Low vision aids can help pts fcn (telescopic and microscopic lenses, mag glasses, needle threader, large print books, etc).
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| Photocoagulation treatment for macular degeneratio | Laser surgery of the eye to coagulate leaky blood vessels and to destroy the abnormal vessels may be useful in the early stage of the disease.
Effectiveness of this laser photocoagulation treatment is limited to small numbers of patients with wet form.
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| Prognosis and prevention for macular degeneration | Prog: will affect for rest of life
Prev: no known, reg eye exams, avoid anything that blocks blood flow: fat, cholesterol. Sunglasses for UV light. Eat green leafy veggies. No smoking.
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| Diet for macular degeneration | Low fat, cholesterol. Lots green leafy veggies. Anti-oxidant supplements: vit c, e, beta caratene, zinc, decrease fatty deposits on vessels. Can slow, but not reverse process. Good for people over 50 who have not eaten these during life.
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