retinal detachment + tears 📷 📷

Floaters look like small specks, dots, circles, lines or cobwebs in your field of vision. While they seem to be in front of your eye, they are floating inside. Floaters are tiny clumps of gel or cells inside the vitreous that fills your eye. What you see are the shadows these clumps cast on your retina. Flashes can look like flashing lights or lightning streaks in your field of vision. Some people compare them to seeing “stars” after being hit on the head.

young: migraine vessel spasm

elderly: micro-emboli

📷 ⇒ ischemic event or retinal detachment

• always?
• worsen when reading/watching TV? → dry eyes, blink less
• glare problem at night? → cataract

• DM present? → poor control

• hows the pain? → scratchy, aching, only with bright light
• discharge? → infection

• allergies
• blepharitis (eyelid infection)

temporal (giant cell) arteritis

→ also jaw cladication, polymylagias, weight loss, night sweats

DD: migraine

• DM
• HT
• Coronary artery disease
• thyroid diseases
• asthma → in case of beta-blocker prescription, might trigger bronchospasm

Past occular history

• cataract surgery? 📷
• eye trauma?
• glaucoma? 📷

→ checking eyedrops might reveals these infos

FH (family history): glaucoma or blindness?

Allergies: esp. sulfadrugs (ingredient in a lot of pressure releasing drops)

Medication - eyedrops? anticoagulants? oral betablocker?

• Vision
• Pupil
• Tonometry (Pressure)

BEFORE DILATING PATIENTS EYE! → the drops will mess up these parameters

Snellen chart 📷

refractive error

pinhole 📷

filter misaligned rays → central ray on retina

think about cataracts or other media opacities

• opacification - caterac, corneal edema, vitrous hemorrhage, etc)
• optical n. + retinal illness: retinal detachment, diabetic retinop, ischemia, toxic, ...
• Amblyopia → without organic cause (strabismus)

near-card or small print in newspaper

>40y → Presbyopia (Alterssichtigkeit)

constriction → also the non-illuminated one (equal and synchronous)

constriction

= Marcus Gunn Pupil → one eye cant sense light as good as the other one

⇒ Swinging light test 📷: abnormal: dilation of both eye when flashing in the direction of pathological eye and constriction when going back in the direction of the good eye

how much force is necessary to flatten an predetermined area of corneal surface

• Goldman Applanation Tonometer 📷
• Tono-Pen (not really accurate) 📷

visual field (periph. vision)

"tunnel vision" due to neurological diseases or glaucoma

📷

• pat. cover one eye and look at your nose
• you cover your own eye (cover left eye, when pat. covers right eye)
• flash your fingers in different quadrant in the periphery and let them say how many fingers you showing
• if you can see them they should see them too

or perimetry 📷

• you might see decr. mobility
• or you see nothing but pat. complains about double vision

mono - or biocular diplopia

→ cover one eye? → still double vision → monoocular → refractive error: astigmatism, cateract, corneal surface wrinkling

→ if double vision is solved after cover one eye → biocular diplopia → neuromuscular paralysis or posttraumatic muscle entrapment → determine what muscle group/ nerve is involved

(dont be confused it will be covered later again)

📷

1. External (EXT)

→ Ptosis (drooping up. eyelid 📷) or Proptosis(=Exopthalmus 📷)

→ Conjunctivits? → swelling pre-auricular nodes (in front of the ear) and sub-mandibular/mental nodes?

2. Lids and lacrimation (L/L)

→ Blepharitis? (infection lid margins) 📷

→ follicles or papillary bumps on the lid inside? 📷→ infection / irritation

3. Conjunctiva + Sclera (C / S)

→ white, icteric?

→ injected conjunctival blood vessel (red + inflammed) 📷

4. Cornea (K)

→ Corneal erosions + abrasion? 📷 → trauma → consider Fluorescein dye 📷

→ Clear stroma?

→ folds or gutatta bumps at endothelial surface? 📷

5. Anterior Chamber (AC)

→ individual cells (PMN) or protein flare? 📷 📷→ inflammation (uveitis, iritis, postsurgery)

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💬


→ shallow ant. chamber 📷→ setup for angle-occlusion glaucoma!

6. Iris (I)

→ flat? , pupil round?

→ if diabetes or old retinal vascular occlusion → neovascularization?

7. Lens (L)

→ clear or hazy with cateract? 📷

→ phakic, pseuophakic, aphakic?

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💬


8. Vitreous (V)

→ floating cells? → retinal hemorrhage or detachment

MVP-D

• Macula + Fovea → flat + good reflex?
• Vessels → arterial nicking from HT, attenuation or neovascularization?
• Periphery → atrophy, tears, detachments
• Optic-Disk → pink, cup-to-disc ratio 📷 → large in glaucoma 📷

direct 📷 and indirect 📷 opthalmoscopy

inbalance in aqueous humor production + drainage into the canal of Schlemm 📷 → incr. occular p → optic nerve death (ganglion nerve atrophy)

open angle:

• angle betw. iris + cornea normal
• decr. drainage due to:
• clogging + degeneration of trabecular mashwork - unknown cause
• unknown dysfunction in general

• chronic elevation in pressure → gradual vision loss (years)

‣

💬

closed angle:

• abrupt closure of iris + cornea angle
• rapid incr. of intraoccular p. → "acute glaucoma" → alert! 🚑

open angle → 80%

screening

because of the sneaky bastard character

• High intraocular pressure (obviously)
• Age
• Family history
• Race (African American and Hispanics)
• Suspicious optic nerve appearance (large vertical cupping)
• Thin central corneal thickness (** remember this one!)

PDP

• elevated intraocc. pressure >22mmHg (normal 10-22)
• optic disk changes (indicate ganglion atrophy) 📷

→ cup-to-disk-ration >0,5, or assymetry betw. eyes

→ abnormal ISNT-rule

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💬

• peripheral vision defect

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💬

corneal thickness

→ thick → incr. pressure

→ thin → decr. pressure

⇒ check with ultrasonic pachymeter

goal: decr. intraoccular pressure

1. Medical
• beta blockers → decr. production humor
‣
💬

1. alpha-agonist
2. PGs → incr. humor outflow
• topical CAIs
‣
💬

2. Surgical
• trabeculectomy 📷
• plastic tube-shunt 📷
‣
💬

• Argon laser trabeculoplasty (ALT) 📷
‣
💬

pupillary block:

lens plasters against back of iris → block aqueous flow through pupil → pressure gradient forces iris ant. →closure irido-corneal angle → blockage trabecular meshwork

• dark
• stressful situation
• drugs: antihistamined + cold meds

→ pupil dilation

• nausea + vomiting
• pupil slaggish (träge) + mid-dilated

• high intraocc pressure (often >60mmHg)

‣

💬

• Halos around light, due to corneal edema

‣

💬

• shallow angle test:
• iris shadow when during penlight exam 📷
‣
💬

• gonioscopy 📷
‣
💬

acute:

• topical beta blocker (Timolol)
• CAIs (Diamox)
• i.v. osmotic agent (mannitol, glycerin) → draw fluid
• miotic agent (pilocarpine) → constrict pupil
• topical glycerin

to prevent recurrance:

• laser iridotomy 📷

‣

💬

• neovascular glaucoma
• pigment dispersion syndrome
• pseudoexfoliation syndrome

retinal vein occulusion → VEGF (vascular endothelial growth fact) production → float through pupil → neovascularization iris → fibrous membrane in i-c angle → open-angle glaucoma → later: new vessel pull iris forward → closed angle glaucoma (irreversible)

• Laser peripheral retina → dec. VEGF production
• tube shunt

rubbing of pigmented surface of iris against zonules → shedding of some pigments → into aqu. humor → into trabcular meshwork +clogging

• high p after exercise
• pigments on gonioscopy
• trans-illumination defects on slitlamp

• Krukenberg spindle 📷

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💬

BM-like material throughout the body + ant lens capsule → rough surface → iris rubbs off pigments through daily activity → clogging trabceular meshwork

glycosylation of vessel wall → over time: denaturation collagen → capillary thickening → breakdown

• signs of renal dmg: proteinuria, BUN+crea incr.
• duration of diabetes: after 10y →50%, 15y→90%

• good bloodsugar control
• avoid: smoking, HT, pregnancy

• NPDR: nonproliferative diabetic retinopathy

‣

💬

• PDR: Proliferative diabetic retinopathy

• microaneurysm on fundus exam
• if burst: dot-and-blot hemorrhages 📷

→DD: Flame hemorrhage 📷 in ganglionic layer caused by HT, spreads horizontally, can also occur in diabetic retinopathy a little bit later due to HT

• cotton-wool spots 📷

i.e. in diabetic retinopathy

later might progress to beading of larger retinal veins 📷

📷

complete retinal vessel ischemia → VEGF → neovascularization → bypass the clogged artery → BUT arteries are abnormal in appearance + function (friable + leak) → also sprout into vitreos fluid → attach to vitreous proteins → when vitreos movement/contraction → pull on retina → retinal detachment + dmg to the friable arteries → intraoccular hemorrhage → vision loss → vessel scar down → massive traction on retina

→ can also lead to NVI (neovasc. of iris) → cover trabecular meshwork → neovascular glaucoma

retinal macular edema

due to capillary+microaneurysm leakage

cloudy + elevated macula

yellow hard exudates (past edema) 📷

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💬

📷

separation sensory retina + underlying RPE (retinal pigment. epithelium) + chroroid plexus

→no further blood supply of the photoR → ischemia

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💬

macula

• myopic (near sighted) patients

‣

💬

• post surgery (catarct)
• traumatic sport injuries (boxing, football, and bungee-jumping)

📷 ←

1. rhegmatogenous (most common) → full thickness break (trauma, preexisting holes) →vitreous fluid into subretinal space → retina tear away + peel of underlying RPE + choroid → might spread along entire retina
2. Traction: vitreous pulling or neovascular membrane contraction in diabetic retinopathy
3. Exudative / Hemorrhagic: ocular tumor, inflammatory diseases, congenital abnormalities → breakdown of RPE+choroid plexus (blood-retina barrier) → pushing retina upwards

Retinal tear secondary to posterior vitreous detachment (PVD) 📷

‣

💬

• flashing lights (photopsias 📷) - like camera flash

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💬

• floaters 📷 - look like swarm of flies (blood cells or pigments in vitreous fluid)
• "dark curtain" 📷 - peripheral vision - most detachment involve periph. retina

REMEMBER: The combination of flashing lights and floaters should be considered a retinal detachment until proven otherwise.

• indirect opthlmoscope 📷
• Scharfer's signs ("tobacco dust") in ant. vitreous (suspended pigment particles) 📷- pathognomionic for retinal tear
• US - might look like letter V 📷

• primary: surgery - esp. quick when macula is still attached
• laser therapy of sourrunding unattached retina
• cryo(probe) → also scarrs down retina by freezing from outside
• scleral buckling → silicon band as a belt → pushes RPE on retina
• pneumatic retinopexy → bubble of gas or silicon oil into eyeball → pushes retina back in place
• vitrectomy → retina manually floated back + also removal of scar tissue + neovascular membranes

📷

"drusen" (extracellular breakdown deposits) in Bruch's membrane which is betw. RPE/REtina + choroid → no nutrition + no removal of photoR waste products → retinal atrophy + pigmentary changes in macula → central poor vision

but slow progression (years)

= neovascular ARMD

📷

bruchs membrane break → vessel grow from chorid into retina → bleeding, edema, vision destruction

• PDT (photodynamic therapy) i.v. chemical that reacts to specific light wavelenght → focus light when in retinal blood vessel → coagulation
‣
💬

• Anti-VEGF drugs injection into eye → Avastin or Lucentis

Amsler grid 📷

→ check for metamorphosia (distorted lines indicate macular edema) 📷

viral, bacterial, allergic

• after upper resp infection by adenovirus
• red eye, watery tearing, NO discharge (little)
• uni or bilateral
• enlarged follicular bumps 📷
• swollen preauricular nodes
• enlarged follucular bumps inside of eyelid

symptomatic

• pus (mucupurulent discharge)
• sticky eyelashes (due to creamy discharge) 📷
• papillary conjunctiva reaction
• unilateral

Etiologies:

• staph + strep,
• hemophilus influenza (in children)
• chlamydia + gonococcus (see below) → severe + sudden discharge

erythromycin

• red, watery eyes
• itching + swelling
• allergic shiners (swelling around eyes)
• history of seasonal allergies
• concommitant allergic symtpoms: stuffy nose + cough
• bilateral

• antihistamines
• mast-cell stabilizers
• steroids

stinging, tearing + "gritty" sensation (sand im auge)

ant + post blepharitis

ant 📷→ debris (scurf) at base of eyelashes → bacteria inside of that scurf shed irritant into tear film → ulcerations + eyelash loss

post 📷→ meibomian gland orifices clog up

• wash eyelashes with baby shampoo
• warm compresses
• topical ABs + steroids
• oral doxycycline → not AB-effect but changing fatty acid oil composition of meobomian glands

chalazion: noninfectious inflammatory granuloma rection

firm, mobile, nodular, nontender, nonpainful

• warm compresses, massage + lid scrubs
• incision + drainage

• chronic conjunctivitis >3weeks
• injection (redness) of conjunctival vessel 📷
• purulent discharge 📷
• follicular "cobblestoning" 📷

• newborns (during delivery)
• horny teens with concurrent genital infection

• hand-eye
• shared cosmetics
• hottubs with not enough chlor

• immunofluorescence
• conjunctival culture → Giemsa → inclusion bodies 📷

• AB eyedrops + systemic azithromycin

• newborns → erythromycin

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💬

• undeveloped countries with poor sanitation

→ leading cause of blindness in these countries

scarring eyelids

→ closure lacrimal galnd pores → chronic dry eyes

→ entropion (inward rotation eyelid) 📷

→trichiasis (direction of eyelash growth changes 📷) → rubbing cornea → corneal scarring → blindness

very serious!

can penetrate cornea within 24-48h → endopthalmitis 📷 + loss of eye

• red
• severe + a lot of discharge

gram-negative diplococci

• ceftriaxone systemic!
• +topical AB

give prophylacticic erythromycin or silver nitrate(but gives "chemical conjunctivitis) after birth

superficial epithelial defect

caused by trauma, infection, exposure

• severe pain
• intense photophobia
• "something is in the eye"

📷 flurosceine uptake → glow green under blue light

• aggressive lubrication → healing in 1-2days!
• empiric erythromycin

abrasion + associated bacterial infiltrate

aggressive AB aufn Nacken!

small → fluros (ciproflox)

large/central/not healing → culture → specific sensitive AB

pseudomonas → ciproflox

caused by ext. foreign body → give more aggressive ABs

(e.g. tree branch, fingernal, soil)

signs of inflammation → swollen eyelid, erythema, warmth, fever

from tarsal plate to orbital rim 📷

post septal! = orbital cellulitis

superficial/preseptal looks bad but resolve without problem 📷

pics for orbital cellulitis later!

children → sinus disease

can also occur in patients with:

• tooth abscess
• fungal infection (immuno-compr)

• proptosis (exopthalmus)
• chemosis (swelling of conjunctiva) 📷
• decr. + painful eye motility (intraoc. muscle inflammation)
• decr. vision + RAPD(=marcus gunn pupil) (optic nerve dmg)

CT 📷

IV AB + surgical abscess drainage

HSV type-1

mainly during childhood → latent: dormant in trigeminal ganglion → trigger (fever, trauma, psychological stress, UV sunlight)

• red injected eye
• pain
• periorbital classic vesicular "herpes" rash 📷
• mainly unilateral
• Slitlamp: dentritic ulcer + stain with fluorescein ⇒ 📷

initially only superficial cornea → heals + reactivate → deeper and deeper → corneal stroma scarring → sensory nerve death (decr. corneal sensitivity)

‣

💬

• Debridement (with cotton-tipped swab 📷)
• topical antiviral drops (Viroptic)

• Acyclovir orally

‣

💬

• corneal transplant (in severe corneal scarring)
• NSAID + mydriatic drops to prevent synnechia betw. lens + iris

📷

• cotton-wool (infarction of ganglion layer)
• microaneurysm
• hemorrhages

diabetes + HT

opportunistic infection with CMV (with CD4+ count <50)

→ necrotizing retinitis! 📷 → peripheral retinal necrosis (+ assoc. hemorrhages)

• antivirals: gancylclovir, foscarnet

but only virostatic → maintained treatment with gancyclovir or implant 📷

infection inside the eyeball

• post surgery (even years)
• trauma
• endogenous infection spreads

often not the retina lel

filled with hazy inflammatory cells 📷

hypopyon 📷

pat. can see hand-motion or better → "tap and inject" = needle draw out sample culture + inject back broad-spectrum AB

if only light-perception or worse → vitrectomy (clean out the shit)

monooccular: refractive problem → most common astigmatism

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💬

⇒ cover one eye → still double vision? → monoocular diplopia

DOWN + OUT DEVIATION 📷

still functioning abducens → lateral rectus → pull lateral

still functioning trochlear → sup. oblique → depresses

PTOSIS → levatpr palpebrae dysfunction

"BLOWN PUPIL" (dilation) → parasympathic pupil constriction fibers travel within CN3

See also Neuromuscular anatomy

ischemic events due to DM or HT

compressive aneurysm pushing on nerve 📷

→ at junction of post. communicating artery + internal carotid artery

⇒BLOWN PUPIL

compressive lesion tend to involve pupil, vascular lesions spare it

MRI + angiography → rule out compressive cause (aneurysm or tumor)

blood pressure + gluc 🍨

• upward deviation
• " cyclotorsion" twisting of the eye → tilt head away from lesion

normal action: 📷

• trauma
• congenital → check old pictures for head tilt → indicate an old/congenital palsy that has recently decompensated
• ischemic (diabetic, ht)
• tumor

lateral rectus doesnt work → cross-eyed 📷

→ turn head to compensate

• CN3: The eyes are “down and out” with a droopy eyelid. Think of an aneurym if the pupil is blown.
• CN4: Patient tilts their head away from the lesion. Think of trauma or a congenital head-tilt that has decompensated with age. •
• CN6: The patient looks “cross-eyed.” Consider increased intracranial pressure.

auto-antibodies against nictonic Acetylcholine receptors of striated muscles → block + destroy R

diploplia + ptosis

systemic:

• mastication problems
• drinking + swallowing problems
• talking problems
• pulmonary problems

when 30% of the R are destroyed

only striated

NOT smooth+cardiac

aspiration pneumonia + respiratory failure (inability to clear secretion)

inflammation optic nerve → demyelination

associated with MS!

‣

💬

• decr. color vision
• pain with eye movement
• MRI enhancement of optic n.
• RAPD - marcus gunn pupil
• young patients

IV steroids

‣

💬

if brain involvement: enhancing lesions on MRI → interferons (avonex)

medium - small sized

around head - esp. temporal

• 60-80y
• sudden painless vision loss unilateral
• pathognomonic:
• scal tenderness + headache
• jaw claudication
• polymyalgias arm + shoulder
• B-symptomatic: fever, night sweat, weight loss

give high dose steroids asap!!

• ESP + CRP
• temporal artery biopsy → disruption internal elastic lamina giant cells

non-arteritic ischemic optic neuropathy → localized ischemia where nerve enters eyeball due to Arteriosclerosis

ESR + CRP normal

sympathetic pathway which innervates the iris muscles gets knocked out

📷

• ptosis
• meiosis (constriction) → can dilate at all
• scalp anhydrosis

Cocaine test → cocaina into eye → no dilation? → no sympathetic tone → horner sy.

• carotid dissection
• pancoast tumor

⇒ imaging!

carotid dissection! 🚑

• opposite of horner sy
• dilated eye → doesnt constrict to light (but to near vision) 📷
• parasympathic plexus damage after viral infection

red reflex to figure out myopia/hyperopia (but not really accurate)

direct scope from distance

→ hows red reflex? 📷

myopia (inf. crescent)

hyperopia (sup. crescent)

hyperopia - small eyes + still growing

retinoscopy

flashing beam of light into eye → holding different power lenses in front → what focuses light properly + neutralizes red reflex

patch on good eye (without/with less refractory error or stabismus)

→ gives bad eye competitive advante to regrow afferent nerve fibers

DO IT ASAP! regrowth only possible until 7-10years

📷

• Esotropia - inward
• Exotropia - outward
• Esophoria - inward, only sometimes (stress, illness, fatique)
• Exophoria - outward, only sometimes (stress, illness, fatique)

actually a lot of children have some tropia which goes away in few month

illusion of crossed eye due to nasal epicanthal skin folds → less sclera on nasal side

→ normal corneal-pupil light reflex 📷

• non-surgical causes: correct refractive error + treat amblyopia → many cases will be resolved
• surgery: recessing medial or lateral rectus → reattach more post. → weakens the actions of this muscles and lets eye return in normal position

shaken baby syndrome

impressive retinal bleeding similar to that seen in Shaken Baby Syndrome (SBS) is only observed in cases of major trauma such as high-speed car accidents or falls from a significant height.

1. Congenital cataract (idiopathic, genetic, metabolic(galactosemia), TORCH)
2. Retinoblastoma (tumor of retinal photoreceptors → cream-colored mass filles eye with white creamy mass + cause reinal detachment)
3. Retinopathy of prematurity 📷 (periph. retinal hasnt developed bloodvessel yet due to premature birth → ischemia → VEGF → neovascularization → bleeding + traction → retinal detachment ⇒compare diabetic retinopathy

see corneal abrasion

Corneal laceration

!Perforation

Seidel test

wipe with fluorescin paper of wound → does it flow down the corneal surface? → seidel positive! ⇒ leaking aquaous fluid from the orbit washes it down

⇒ surgery

1. vision (esp. color) → optic n.
2. extraocular movement → entrapment?
3. Proptosis (exophtalmus) or enopthalmus → use hertel exophtalmometer
4. Palpation orbital rim
5. Sensation of V1+V2 → forehead+cheek

• Keflex (cephalexin)
• Augmentin (Amoxi-Clavu)
• Afrin nasal spray (oxymetazolin) → decr. swelling of nasal mucosa

→ also no "nose blowing"!

how close is the laceration to the canicular (tear drainage) system?

→ put silicon tubes into nose to keep canaliculus patent before treating laceration 📷

• corneal abrasion → rust ring on cornea within a day

!if history metal-striking-metal → possibility of intraocular foreign body which entered the eye at highspeed and usually dont show really signs of injury → toxic to retina! → order CT and not MRI!

how quickly washed out

bases

Acids are less harmful than bases because acids have a tendency to cause precipitation of denatured proteins, which limits tissue damage. Bases, on the other hand, continue to cause damage without stopping, requiring continuous irrigation and pH monitoring until normalization.

photophobia (inflammation → spasm of iris + ciliary bodies )

• topical steroids
• cycloplegic drugs (anti-muscarinic) → paralysis iris+ciliary muscles + dilation→ iris moves ant. + cant stick to lens and form synechia + helps photophobia (second. to spasm)

blood in anterior chamber (compare hypopyon)

often caused by blunt eye trauma

• steroids → encounter inflammatory response
• cyclopledic dilation drops → photophobia + prevent iris-lens-synechia

• glaucoma → blood clot clog trabecular meshwork

(+synechia betw. iris + lens)

📷

• nearsighted
• big + long eye
• light focus in front of retina
• give concave (minus lens) to weaken refractory power

📷

• farsighted
• small + short eye
• light focus behind eye
• convex (plus) lens to add refractory power
• minor to medium hyperopia are usually corrected by rounding of the lens (accomodation) and dont need any correction

📷

• age related less flexible lens (becomes dense + cant round out to accomodate)

‣

💬

• after 40
• corrected with bifocals

has part to correct nearsighted-ness + farsightedness

sphere

• in children
• difference of 2.00 diopters of both eyes →!might lead to amblyopia (one eye wont develop as good as the other) → plaster on the "better" eye needed

device to determine glas prescription

has a big box full of different lenses that can be put in front of the eye

→ figure out spherical error, the extra cylinder to correct + angle of cylinder correction

📷

📷

lens is "footballshaped" in astigmatism and not "spherical" 📷

→ different refraction power at different points of the lens

cyclinder → how much cylindrical correction is needed to correct the refractory aberration along the axis? → add cylindrical lens

angle of cylinder 📷→ in what angle has the cylinder be placed to correct the "football" - if football is at 180° you need an angle of a cylinder of 90° (like in children)

📷

positive or negative cylinder lens

but they have to have a 90° difference

foveal red-reflex

phakic - natural lens

pseudophakic - cataract replaces with artifical lens

aphakik - cataract removed but not replaced

⇒ 📷

attached via zonular fibers to ciliary muscle

• controls lens focusing (accomodation-rounding by contraction)
• produce aqueous fluid

nuclear sclerotic cataracts

over time lens (esp. nucleus) become larger and brunescent 📷(yellow or brown)

→ visual obstruction and problems with glare (blendung)

→ angle closure glaucoma (pushes iris forward)

→ "Morgagnian cataract" 📷 : far advanced state → cortex liquefies+becomes milky and nucleus hardens+fall to the bottom of capsule

lens becomes round due to enlargement → correct coexisting presbyopia

post. subcapsular cataract 📷→ forms on post. capsule bag (looks like breadcrumbs or sand)

→ vision difficulty

• steroids use
• diabetes
• history of ocular inflammation

post → affects more the refractive power

• Posterior cataracts have a greater impact on visual complaints compared to anterior cataracts due to the optics of the eye.
• The eye has a refractive power of approximately 60 diopters, with 40 diopters from the cornea and 20 diopters from the lens.
• The nodal point of this system, located near the back of the lens, is crucial.
• Light rays are more affected the closer they are to this nodal point.
• Small posterior subcapsular (PSC) cataracts have more significance than larger anterior cataracts.

amblyopia 📷

other causes for leukocoria (📷 white pupillary reflex):

• TORCH infection

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💬

• retinoblastoma
• galactosemia

⇒ deadly!!

remove quickly within first 2 month → no implant because eye still grows → aphakic glasses/contacts → old enough: implant

trauma → capsule break → swells with water + turn white

CAVE! concommitant zonular tear

lens has no blood supply → nutrition due to glycolysis → high blood sugar → phosphorylation pathway (normal pathway) saturated → sorbitol pathway → sorbitol buildup in the lens → osmotic swelling → episodic blurred vision

‣

💬

appears after cataract surgery

residual lens epithelial left behind after surgery → migate along back of the implant → opcaify

YAG laser capsulotomy → little hole post. capsule→light can pass through

• trauma to zonules
• diseases affecting zonular strenghts:
• marfans → upward lens dislocation
• homocystinurea (zonules are composed of cysteine, without become fragile+break) → downward lens dislocation

• visual acuity (20/50=classic cutoff; but depends on pat. need)
• degress of glare
• underlying retinal diseases (DM); cataract interfere with fundus exam/laser treatment

1. corneal curvature - the more powerful refraction of cornea, the less powerful lens - use keratometer to determine
2. lenght of the eye - the short the more powerful lens - use A-scan mode ultrasound 📷

mnemoic: ASS EATING COCK PHAC (fuck) COCK INSERTION COCK POUNDING

1. Anesthesia - topical tetracaine or retrobulbar block 📷
2. Enter the eye - cutting cornea(fast) or tunneling sclera(slow but extendable if complication) 📷
3. Capsulorhexis - hole into ant. lens 📷
4. Phacoemulsification - phaco handpiece: oscillates - groove ridges into lens - broke into piece and eat up nucleus 📷
5. Cortical removal - through suction (remove as much as possible→ see post. capsule opacification) → maintain post. capsule! 📷
6. Insertion of the lens - foldable lens in remaining capsule (alternative if support is questionable: on capusle bag, on top of iris in ant. chamber, sutured to back of iris) 📷
7. Close up - small incision=self-sealing; some require suturing
8. Post-OP care: immediately antbiotic drops + shield over eye 📷; next day: AB drops + steroid drops

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