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MEDICAL UNIVERSITY - PLOVDIV DEPARTMENT OF OPHTHALMOLOGY PRACTICAL GUIDE IN OPHTHALMOLOGY FOR DENTAL MEDICINE STUDENTS Edited by Prof. Dr. NELLY SIVKOVA, MD, PhD, FEBO Plovdiv, 2015 Autors: Atanassov M. Baliyan A. Cenova M. Gerdzhikov A. Kermedchieva R. Koleva-Georgieva D. Konareva-Kostianeva M. Kostianeva Sn. Marinov V. Mitkova - Hristova V. Sivkova N. Stoyanova N. Teodossieva – Krashkova A. Editor: Prof. Dr. Nelly Sivkova, MD, PhD, FEBO Reviewer: Prof. Dr. Blaga Chilova-Atanassova, MD, DSc Publisher: Medical University – Plovdiv 4002 Plovdiv, V.Aprilov 15A www.meduniversity-plovdiv.bg ISBN 978-619-7085-43-3 CONTENT EXERCISE № 1 ANATOMY OF THE VISUAL SYSTEM. SYSTEMATIC APPROACH OF OPHTHALMIC EXAMINATION. FOCAL ILLUMINATION, BIOMICROSCOPY. DISEASES OF CONJUNCTIVA AND LACRIMAL SYSTEM D. Koleva-Georgieva, N. Stoyanova ……….………………………….. EXERCISE № 2 5 CENTRAL VISION, VISUAL ACUITY. VISUAL FIELD, PERIMETRY. EXAMINATION OF COLOUR VISION. PATHOLOGY OF COLOUR VISION AND LIGHT SENSITIVITY V. Marinov, A. Gerdzhikov………………………………………………. EXERCISE № 3 TRANSILLUMINATION. CORNEA AND LENS OPHTHALMOSCOPY. DISEASES 19 OF A. Teodossieva , V. Marinov, M. Cenova……………………………... EXERCISE № 4 28 METHODS FOR MESURMENT OF THE INTRAOCULAR PRESSURE (IOP). GLAUCOMA: DIAGNOSIS AND TREATMENT. ACUTE GLAUCOMA ATTACK: HOW TO ACT М. Кonareva-Kostianeva, М. Аtanassov, Sn. Kostianeva…………… EXERCISE № 5 41 DISEASES OF THE EYELIDS AND ORBIT N. Stoyanova, V. Mitkova-Hristova…………………………. 53 EXERCISE № 6 INTRAOCULAR INFLAMMATION (UVEITIS) – ANTERIOR AND POSTERIOR UVEITIS. RETINAL VASCULAR OCCLUSIVE DISORDERS: RETINAL ARTERIAL/ VEIN OCCLUSION. CONNECTION BETWEEN OPHTHALMIC AND DENTAL DISEASES N. Sivkova, V. Mitkova-Hristova, D. Koleva-Georgieva…... 66 EXERCISE № 7 OCULAR TRAUMA – BLUNT TRAUMA (CONTUSIONS), INJURIES, BURNS A. Gerdzhikov, A. Baliyan, R. Kermedchieva……………….. 83 SUMMARY TESTS D. Koleva-Georgieva, N. Sivkova…………………………….. 95 EXERCISE № 1 ANATOMY OF THE VISUAL SYSTEM. SYSTEMATIC APPROACH OF OPHTHALMIC EXAMINATION. FOCAL ILLUMINATION, BIOMICROSCOPY. DISEASES OF CONJUNCTIVA AND LACRIMAL SYSTEM D. Koleva-Georgieva, N. Stoyanova Anatomy of the visual system The visual system comprises of peripheral part (eyes), visual pathway and central part (occipital visual cortex). The eye ball has wall, comprised of three layers with different structure and function, and ophthalmic contents. According to their clinico-anatomical characteristics, the eye structures are divided into two segments – anterior eye segment and posterior eye segment. The layers of the eye wall are: - external (fibrous) – cornea and sclera - middle (vascular, uvea) – iris, ciliary body, and choroid - internal (retina) Ophthalmic contents: - intraocular fluid (anterior chamber and posterior chamber fluid) - lens - vitreous body Indicate all arrowed structures on the schematic drawing: List down the parts of the anterior eye segment: ............................................................................................................... ............................................................................................................... List down the parts of the posterior eye segment: ............................................................................................................... ............................................................................................................... List down the so called organa oculi accessoria (ocular adnexa): ............................................................................................................... ............................................................................................................... ............................................................................................................... Systematic approach of the eye examination. Focal illumination and biomicroscopy The performance of systematic ophthalmic examination suggests collection of information about the whole visual system, and this is a prerequisite for setting the correct diagnosis. Systematic approach of the eye examination – has anatomical principle, i.e. examines anatomical structures from anterior to posterior. The division of ophthalmic structures into anterior and posterior eye segment is determined by the specificity of the diseases of the two segments, and also by the differences in their methods of examination. Focal illumination – method of examining the anterior eye segment. It is based on the principle of the contrast. There are two types of focal illumination – simple and combined. During the combined focal illumination the examiner is observing the anterior eye segment under magnification. List down the appliances, needed for performing focal illumination: ............................................................................................................... ............................................................................................................... ............................................................................................................... 6 Biomicroscopy (slit-lamp examination) – routine method for examining the anterior and posterior eye segment (for example biomicroscopy), based on the combined focal illumination. Biomicroscope (slit-lamp) Optical slice through the Anterior eye segment Ophthalmoscopy – method for examination of the posterior eye segment (vitreous body and retina). Direct ophthalmoscopy Indirect ophthalmoscopy 7 List down the structures of the eye fundus on the photography: Do you know specialized imaging modalities for examination of the posterior eye segment? Write down the methods, represented on the photographies: ....................................... ............................................ .................................. ………………………….............................................................................. 8 REMEMBER! The visual system comprises of peripheral part, visual pathway and central part (visual cortex). The good knowledge of the anatomical structures is a prerequisite for the understanding and learning the specific pathological changes of ophthalmic deseases. The strict performance of the systemic ophthalmic examination with routine imaging and functional methods, as well as with highly specialized methods, when needed, gives opportunity for gathering information about the overall state of the visual system of the examined patient. Lacrimal apparatus Anatomy of the lacrimal system The lacrimal apparatus consists of: - lacrimal gland- situated in.................................................................. - accessory lacrimal glands- glands of ................................................ - lacrimal canaliculi (ducts): ................................................................. Lacrimal secretion can be: - main- normally existing tear film on the conjunctiva and cornea - reflectory- watery tear secreted by the lacrimal gland during local stimulation of the conjunctiva and cornea, as well as during emotional excitement 9 The tear film is comprised of three layers: 1. Lower – mucous (in contact with epithelium cells):............................ 2. Middle – watery: ................................................................................ 3. Upper – lipid: ..................................................................................... (List down the glands producing each layer!) Tear functions: - keeps the cornea moist, maintains its optical qualities and takes part in its nutrition - protective function for washing away any foreign bodies - bacteriostatic and bactericidal components Lacrimal secretion and lacrimal duct examination: What are the names of the tests shown in the pictures? ............................................. ........................................... The ''dry eye'' syndrome is caused by reduced lacrimal secretion, both in terms of quality and quantity, and/or accelerated tear evaporation. Civilization disease! List the reasons leading to occurrence of dry eye ............................................................................................................... ............................................................................................................... For examining lacrimal duct passability, we use: 1. Color tests with administration of 3% collargol solution or 2% fluorescein solution in the conjunctival sac: - Duct test- positive if ......................................................................... - Nasal test- positive if ....................................................................... 10 2. Test of Anel 3. Squeezing of the lacrimal sac Acute inflammatory disorders of the lacrimal gland are called ……………………………………………………………………............... - painful edema of the upper eyelid with S-shape curve and dropping of its temporal end - lacrimal gland enlargement- visible on turning up the upper eyelid - difficult movement of the eyeball in upward-temporal direction - frequently- high temperature - enlarged preauricular lymph nodes. Chronic inflammation of lacrimal glands is observed in: - Miculicz disease - Sjogren's syndrome This is two-way process! Lacrimal duct disorders REMEMBER! A major symptom of lacrimal duct disorders is epiphora (eye tearing). The inflammation of the lacrimal sac is called ...................................... It is more frequent in women due to their narrower lacrimal ducts. 11 REMEMBER! Chronic dacryocystitis hides potential risk of corneal damage. Bacteria, nested in the lacrimal sac may cause the development of crawling eye corneal ulcer with epithelium damage (Ulcus serpens corneae). Chronic dacryocystitis exacerbation leads to development of ............................. dacryocystitis- the process infiltrates adjacent tissues. - Thick painful swelling and hyperemia in the area of the lacrimal sac and the back of the nose - epiphora - preauricular lymphadenopathy - high temperature - infiltration- fluctuation- fistulization The most pronounced fluctuation is under the medial eyelid junction! Therapy: - heating pad, incision and drainage, general application of antibiotics (during the acute stage) - dacryocystorhinostomy (after overcoming the acute inflammation) - lacrimal sac extirpation Dacryocystitis in newborns (see infant disorders) 12 DISEASES OF THE CONJUNCTIVA Anatomy of the conjunciva: The conjunciva is a transparent mucous tissue that has three parts: 1. ..................... - covers the inner surface of the eyelids; 2. ..................... - covers the front of the sclera; 3. ..................... - a transition between the other two that is folded and provides movement of the eyeball. REMEMBER! The bulbar conjunctiva covers the eyeball, over the anterior sclera, reaches the limbus and does not go on the cornea! Conjunctival exposure requires inspection of all three parts of the conjunctiva with sequential withdrawal of the lower eyelid and turning of the upper eyelid. List down the main functions of the conjunctiva: 1.................................................................................................................. 2.................................................................................................................. 3.................................................................................................................. List down the methods for examination of the conjunctiva ..................................…………………………………………………………... ..................................…………………………………………………………... ..................................…………………………………………………………... 13 The inflammatory diseases of the conjunctiva are called conjunctivitis. Conjunctivitis is the most frequent pathology in the ophthalmic ambulatory (40%). In most cases it affects both eyes consistently, and has good prognosis. Classification of conjunctivitis: 1. Infectious - bacterial, viral, chlamydial, fungal, parasitic. 2. Non-infectious – due to refractive errors, due to mechanical, physical and chemical affects, allergies, in dry eye syndrome; in skin and autoimmune diseases. REMEMBER! The visual acuity in patients with conjunctivitis is not reduced! Objective symptoms of conjunctivitis are hyperemia, chemosis, hemorrhage, follicles, papillae, phlyctena, scarring, discharge, edema and hyperemia of the eyelids, blepharospasm, lacrimation. REMEMBER! Main symptoms of acute conjunctivitis are redness and conjunctival secretion! 14 Differential diagnosis between ciliary and conjunctival injections (fill in table) Features Conjunctival Ciliary Placement Color Characteristics of vessels Upon pressure Upon instillation of epinephrine Secretion In which disease occurs Connect each type of discharge with possible causes: Purulent discharge Viral conjunctivitis Mucous discharge Bacterial conjunctivitis Mucopurulent discharge Conjunctivitis in dry eye Serous discharge Chlamydia conjunctivitis Pseudomembranous conjunctivitis Diphtherial conjunctivitis Membranous discharge conjunctivitis Some bacterial/viral List down the differences pseudomembranes: 1................................................ 2................................................ 3................................................ between true membranes and Membranous conjunctivitis is caused by .............................................. 15 Hyperacute conjunctivitis is caused by gonococci (Neisseria gonorrhoae) and is called ......................... conjunctivitis. It has a short incubation period (several hours) and is severe, with abundant purulent secretion and hidden danger of melting of the cornea with subsequent loss of vision. REMEMBER! Gonoccocal conjunctivitis requires prophylaxis in all infants with 1% solution of ........................, or repeatedly dropping of a .........................! In case of conjunctivitis in newborn differential diagnosis must be made between: 1. Gonoccocial conjunctivitis – incubation period-days ………...., .......................... secretions, follicles – yes / no 2. Bacterial conjunctivitis – incubation period – days .……......., .......................... secretions, follicles – yes / no 3. Chlamydial conjunctivitis – incubation period – days ……......., .......................... secretions, follicles – yes / no What treatment and prevention of acute bacterial conjunctivitis would you suggest? ............................................................................................................... List down ophthalmic drops and antibiotic ointments: ............................................................................................................... Viral conjunctivitis is caused by: 1. .................................... 3. .................................... 2. .................................... 4. .................................... It is characterized by the presence of ………..................... on the eyelid conjunctiva, serous discharge, recurrent course, chronification. 16 REMEMBER! Conjunctivitis is predominantly infectious in nature and therefore personal and collective hygiene is very important - regular hand washing, use of individual towels, avoiding close contact and regular disinfection of objects, instruments and apparatus, that are used in outpatient practice. List down the types of allergic conjunctivitis: 1. .................................... 4. .................................... 2. .................................... 5. .................................... 3. .................................... 6. .................................... Which type of immune-allergic response is characteristic for acute allergic conjunctivitis and which immunoglobulins are involved? ...................................……………………………………………………… ………………………………………………………………………………. Allergic conjunctivitis is characterized by the following subjective and objective symptoms: ...................................……………………………………………………… ……………………………………………………………………………….. Phlyctenulosis is frequently associated with S. aureus in developed countries and classically associated with Mycobacterium tuberculosis in malnourished children in areas around the world with endemic tuberculosis. Continous symptoms with persistent discrepancy between subjective compaints and objective findings are characteristic for ............................. conjunctivitis. Chronic refraction. blepharoconjunctivitis occurs 17 in ................................... Which chronic conjunctivitis occurs in four stages with the formation of follicles, scarring in the conjunctiva and corneal pannus? Specify the agent? ................................………………………………………………………… What are the stages? Stage 1 ………………………... Stage 3 ………………………... Stage 2 …………………………. Stage 4 ………………………... Blindness occurs because of ……........................................................ Which skin or autoimmune diseases can affect the conjunctiva? ............................................................................................................... Degenerative diseases of the conjunctiva are: .......................... .......................... .......................... A pterygium has two parts : 1..........................; 2........................... It causes irregular astigmatism. Treatment is ..................................... . Often recurs. 18 EXERCISE № 2 CENTRAL VISION, VISUAL ACUITY. VISUAL FIELD, PERIMETRY. EXAMINATION OF COLOUR VISION. PATHOLOGY OF COLOUR VISION AND LIGHT SENSITIVITY V. Marinov, A. Gerdzhikov BASIC FUNCTIONS OF VISUAL ANALYSER: LIGHT SENSITIVITY COLOUR SENSITIVITY VISUAL ACUITY - Central - Peripheral BINOCULAR VISION CENTRAL VISION, VISUAL ACUITY: Central vision is photopic vision, including testing of visual acuity for near and distance. It is the possibility of human eye to discriminate two separate points as two different points from maximal distance. It is known also as Visual acuity (VA). The numbers that represent visual acuity are called VISUS. VA is tested subjectively by visual acuity tables, based on the principle of Snellen.Visual acuity of each eye can be calculated via the Donders‟ formula: Each ophthalmological examinaton starts with VA testing! (Exception – chemical burns! IMMEDIATE AND MASSIVE IRRIGATION!). 19 Which part of the retina is responsible for central vision: ……………………................................................................................ List down the morphological substrate of central vision: ……………………................................................................................ Define the following terms: 1. Visual angle ……………………................................................................................ 2. Minimal visual angle ………………………….......................................................................... 3. Minimal angle of resolution ………………………….......................................................................... What does the Donders‟ formula show? V = d/D …………………………........................................................................... Visual acuity of a patient, counting fingers from 3 meters is …………………………........................................................................... Visual acuity of a patient, who detects hand movement in front of his/her eye is …………………………………………….............................. Visual acuity (VA) can exceed 1.0 …........................... Yes/No Visual acuity (VA) must be tested for each eye separately ............................. Yes/No 20 Reasons for decreased visual acuity (VA) can be organic and refractive ................... Yes/No We can discriminate organic from refractive cause for decreased visual acuity (VA) with a standard set of trial lenses and visual acuity table ................... Yes/No What does Vis oc deх = PPLC mean? ……………………................................................................................ What do we call the symbols (numbers, letters, pictures), we use for visual acuity (VA) testing? ……………………................................................................................ ……………………................................................................................ Is it possible to have immediate visual loss on dentist‟s chair? ................... Yes/No 21 VISUAL FIELD, PERIMETRY Peripheral vision – vision, performed by the retina outside macular region. Peripheral vision is colourless, “gray scale” vision. It plays major role in space orientation! List down the morphological substrate of peripheral vision: ……………………................................................................................ Visual field – part of the space, perceived by the eye (central and peripheral vision), when fixating a single point with a head and a sight straight ahead. Visual field is monocular and binocular. List down the borders of monocular visual field for white in a healthy person: ……………………................................................................................ ……………………................................................................................ ……………………................................................................................ Irregular borders of monocular visual field are due to facial characteristics (anatomy). Do you think that if we remove surgically the “obstacles” (nose, superior orbital margin), this will lead to change/enlargement of visual field borders? Why? ……………………................................................................................ ……………………................................................................................ ……………………................................................................................ 22 What is the clinical significance of the overlapping of bigger parts of the visual fields of both eyes according to early diagnostics of diseases, affecting peripheral vision? ……………………................................................................................ ……………………................................................................................ ……………………................................................................................ Visual field testing: Control (confrontation) method of Donders – rough, orientating method, showing gross visual field losses. Campimetry – for central and paracentral visual field testing. Perimetry: can be kinetic, in which the target is moved along different meridians of visual field, and static, in which target objects are still, but their intensity is changing. In contemporary ophthalmology automated computer perimetry is mostly used and is considered a “gold standard” in visual field testing. 23 Pathological changes in visual field: Scotomata – localized, “island like” defects in visual field; according to their localization we discriminate central, paracentral and peripheral scotomata. We have positive and negative scotomata, according to patient‟s awareness of them. Concentric narrowing of visual field. Sectoral defects Hemianopic defects – can be homonimous (leftsided or rightsided) or heteronimous (binasal or bitemporal) Quadrantopic defectas The “shape” of visual field defects gives the ophthalmologist valuable information not only for the amount, but also for the place of the pathological process (topical diagnostics). EXAMINATION OF COLOUR VISION Colour vision is the ability of human eye to discriminate irritations by separate wave lengths. This leads to subjective perception of different colours. Sir Isaak Newton in 1666 was the first who resolved the white light into 7 spectral colours via prism (Newton‟s wheel), thus giving the basis of different theories for colour perception. 24 According to Newton, mixing the seven spectral colors in different amounts leads to perception of all other colors. Except for the 7 spectral colors, perceived by Newton, colors can also be: Basic: Red (R), Green (G) and Blue (B). Mixing the 3 basic colours in equal parts leads to perception of White (W) colour. Compound: all other colours, except the basic. Additional: couple of colours, which mixture gives white colour. Intermediate: couple of colours, which mixture gives third, “intermediate” colour. Basic characteristics of colours: Colour tone: depends on the reflected wave length. Intensity: depends of the amount of white to the basic tone. Brightness: depends on object‟s illuminance. 25 Trichromatic (three component) theory of colour perception of Lomonossov – Young – Helmholz: three types of cones in human retina: R, G, B. List down the morphological substrate of colour vision: …………………………........................................................................... Colour vision testing: Pseudoisochromatic methods. Ishihara‟s tables, Rabkin‟s tables, 15 Hue test. Spectral methods – anomaloscopy. 26 PATHOLOGY OF COLOUR VISION AND LIGHT SENSITIVITY Disturbances of color vision How do we call the “normal” color sensitivity? …………………………........................................................................... …………………………........................................................................... What are the basic color vision disturbances? …………………………........................................................................... …………………………........................................................................... Disturbances of light sensitivity Define the therm NICTALOPY …………………………........................................................................... ……..………………................................................................................ Define the therm HEMERALOPY: …………………………........................................................................... …………………………........................................................................... Differential Diagnosis (DD) between congenital and acquired colour disturbances: SIGN CONGENITAL ACQUIRED AFFECTION Binocular Different COLOUR One of the basic colors (R G B) Can not define START From birth After an assault DYNAMICS Stationary Dynamic HEREDITY YES, x-linked (recessive) NO REMEMBER! Visual acuity (VA) is a basic function of visual analyzer! Only in cases of complete lack of light sensation we talk about COMPLETE BLINDNESS! Pathological changes in visual field in preserved visual acuity occur unnoticeably and painless, leading to late diagnostics and treatment! Color vision disturbances are congenital and acquired, both leading to serious limitations of human‟s career! 27 EXERCISE № 3 TRANSILLUMINATION. OPHTHALMOSCOPY. DISEASES OF CORNEA AND LENS A. Teodossieva, V. Marinov, M. Cenova TRANSILLUMINATION: method for examination of transparent eye structures. List down the transparent structures of the healthy human eye: …………………………........................................................................... …………………………........................................................................... Necessary conditions for performing transillumination – marc the unnecessary: Dark room Narrow pupil Wide pupil Light source Condensing lens Electrical ophthalmoscope In which diseases the method of transillumination has a practical role: …………………………........................................................................... …………………………........................................................................... Define the term „red reflex“: …………………………........................................................................... …………………………........................................................................... 28 OPHTHALMOSCOPY: Basic method for examination of the posterior eye segment! List down the structures of the POSTERIOR eye segment: …………………………........................................................................... …………………………........................................................................... …………………………........................................................................... Write down the differences between direct and indirect ophthalmoscopy: Sign Direct Indirect Source used Image characteristics Distance between the examiner and the eye of the patient Image magnification Dependence on refraction Dependence on transparency of the eye structures 29 List down the basic marks in ocular fundus of a healthy human: …………………………........................................................................... …………………………........................................................................... …………………………........................................................................... DISEASES OF THE CORNEA The cornea is taking the anterior 1/6th of the superficial (outer) fibrous layer of the eyeball. It is a transparent, avascular, complex structure. Corneal diseases cause compromise of transparency and decrease in visual acuity. Anatomy of the cornea: Histological layers Corneal functions: Together with the sclera comprises the …………................................. sheath of the globe. 30 It takes part in the dioptric apparatus of the eye with refractive power of …………………. Dpt (diopters). List down the methods of examination of the cornea: 1. ........................................................................................................... 2. ........................................................................................................... 3. ........................................................................................................... 4. ........................................................................................................... 5. ........................................................................................................... 6. ........................................................................................................... Pathologic changes of cornea include (underline the correct): edema, hemorrhage, erosion, ulceration, infiltrate, scar, vascularization, discharge. Fill in the table: Infiltrate Scarring Hyperemia (type of hyperemia) Pain, tearing, photophobia Color Surface Borders Treatment required Diseases of the cornea include: superficial non-infectious diseases – traumatic erosion, keratoconjunctivitis caused by UV light exposure; inflammation – bacterial, viral, mycotic, acanthamoeba keratitis, stromal (deep) keratitis; degenerations; dystrophies, etc. 31 Traumatic corneal erosion is: ……………………................................................................................ REMEMBER! Foreign bodies like particles of different dental materials can hit the patient‟s eye and cause a traumatic erosion of the cornea. The keratoconjunctivitis caused by UV light exposure is characterized by …………………………........................................................................... …………………………........................................................................... REMEMBER! Warn your patients to stay with closed eyes during procedures with UV light exposure! Changes in corneal dimensions and shape 1. Megalocornea – corneal diameter over .................. mm. 2. Microcornea – corneal diameter under ................... mm. 3. Keratoconus – a progressive disorder in which the cornea assumes conical shape because of central or paracentral stromal thinning. Presentation is during .............................................., more often. ............................................................... (sex). There is a myopic refraction accompanied by astigmatism, which with progression of the disease becomes…..…………………………………….. In cases of severe keratoconus the symptom of Munson is found.......................................................... 32 Treatment is depending on the severity of the disease: optical correction with glasses, soft or rigid contact lenses; collagen crosslinking; surgery – keratoplasty. 4. Keratoglobus – ................................. protrusion and thinning of the cornea in the center and ...................................... Corneal inflammations The corneal inflammations are called keratitis. They are infectious – bacterial, viral, mycotic or non-infectious – autoimmune disorders. Superficial suppurative keratitis 1.Bacterial keratitis - Ulcus serpens corneae It is more often in people exposed to ….…...……… patients wearing soft contact lenses. Predisposing factor for bacterial infection is compromised corneal……………………. 33 Underline the right answer/s: Clinical signs of bacterial keratitis are: Ciliary injection of the conjunctiva Punctate erosions Conjunctival injection Yellow-whitish infiltrate with ulceration in the center Vascularization Hypopion Topical therapy of bacterial keratitis: а)...................................... b)…………........................ с)……………………..…..... REMEMBER! Do not administer steroids! 1. Acanthamoeba keratitis – it is caused by..................…………………… More often in patients …………………………………….......................... 2. Mycotic ulceration (Keratomycosis) – it is caused by ………………………………………………............................................... Clinical signs of mycotic ulceration are: Ciliary injection ………….... yes/no Stromal infiltrate with an amoebic shape ………….. yes/no Dried, crumbly, grayish-white infiltrate over the corneal surface .............................................. yes/no Corneal erosions ………….... yes/no Hypopyon …………………… yes/no Satellite foci …………………. yes/no Opacities……………………… yes/no 34 REMEMBER! Differential diagnosis – bacterial keratitis: isolating the causative agent; the mycotic ulceration has more prolonged course of the disease. Viral keratitis 1. Herpes simplex keratitis List down the epithelial forms of herpes simplex keratitis …………………………………...…………………………………………… Subjective symptoms of herpes simplex keratitis: Pain ……………………………... yes/no Photophobia …………………… yes/no Foreign body sensation ………. yes/no Decreased visual acuity …….… yes/no Tearing …………………………. yes/no Itching …………………………... yes/no Typical for Herpes simplex keratitis are …………………………………...…………………………………………… The deep stromal-endothelial form of herpes simplex keratitis is called ………………………………. There is a ……………………………… infiltrate with endothelial …….………………. and folds of the Descemet‟s membrane. Treatment of herpetic keratitis: Epithelial debridement Antiviral therapy topical and orally Lubricating ointments 35 REMEMBER! Do not treat epithelial forms of herpetic keratitis with steroids! 2. Herpes zoster ophthalmicus The virus causing the disease is the same as....................................... n ………........................ is affected, a branch of n ...................... and the innervated area. It is more often among …………………………. people. When skin lesions involve the tip of the nose, this is the symptom of………………………. and suggests involvement of……….……………… REMEMBER! Herpes zoster ophthalmicus in contrast with herpes simplex keratitis is not a relapsing disease! Treatment of herpes zoster keratitis is with: 1 1. ........................................................................................................... 2. ........................................................................................................... 3. ........................................................................................................... 4. ........................................................................................................... 36 DISEASES OF THE LENS The human lens is an intraocular biconvex transparent structure, with a refractive power without accommodation of +16D. The lens is a part of the structures that participate in accommodation. List down these structures and mark them on the picture: The lens itself does not have inflammations because ……….………………………..…………………………………………… The most frequent diseases of the lens are: changes in its transparency (cataract) and changes in its position (luxation and subluxation) The methods of examination of the pathology of the lens are …………………………………..…………………………………………… …………………………………..…………………………………………… …………………………………..…………………………………………… 37 CATARACT The cataract can be congenital and acquired. The most frequent acquired cataract is the age related cataract. List down the other types of acquired cataract …………………………………..…………………………………………… List down the type of cataract that is on the picture: …………………………………..…………………………………………… When should a congenital cataract be operated and why? …………………………………..…………………………………………… …………………………………..…………………………………………… …………………………………..…………………………………………… The age related cataract can be nuclear and cortical. List down the stages of the cortical cataract: 1. ........................................................................................................... 2. ........................................................................................................... 3. ........................................................................................................... 4. ........................................................................................................... 5. ........................................................................................................... Describe the objective findings in the picture: 38 What visual acuity of the left eye is expected in that patient? …………………………………..…………………………………………… What is a “symptomatic myopization” and in which type of age related cataract is found …………………………………..…………………………………………… …………………………………..…………………………………………… Diabetes mellitus damages the lens causing …………………………………..…………………………………………… and the retina causing …………………………………..…………………………………………… The differential diagnosis between cataract, glaucoma and age related macular degeneration is very important! The treatment of cataract is surgical – the nontransparent human lens is removed and the refractive power of the eye is restored with an artificial intraocular lens. The contemporary phacoemulsification. surgical technique of cataract is The energy used in this method is …………………………………….………………………………………… Define the terms: - pseudophakia ……………………………………………………………. - aphakia ……..………..…………………………………………………… - secondary cataract ……………………………………………………… 39 LUXATION AND SUBLUXATION OF THE LENS Describe the objective findings on the picture below: The most frequent reasons for changes in the position of the lens are …………………………………….………………………………………… …………………………………….………………………………………… The lens might luxate either in the anterior chamber or in the vitreous body and its most common complication is elevation of the intraocular pressure. The treatment of the luxation of the lens is …………………………………….………………………………………… …………………………………….………………………………………… REMEMBER! Transillumination is a basic method for examination of the transparent ocular structures. Ophthalmoscopy (direct and indirect) is a basic method for visualization of ocular fundus. In order to keep the cornea transparent and optically clear structure proper medical and/or surgical treatment of corneal diseases is needed. The age related cataract is the most common reason for reversible blindness. Differential diagnosis must be made with glaucoma and age related macular degeneration. The treatment of cataract is surgical. The restoration of the refractive power of the eye after the cataract extraction is made by an artificial intraocular lens. 40 EXERCISE № 4 METHODS FOR MESURMENT OF THE INTRAOCULAR PRESSURE (IOP). GLAUCOMA: DIAGNOSIS AND TREATMENT. ACUTE ANGLE CLOSURE GLAUCOMA: HOW TO ACT М. Кonareva-Kostianeva, М. Аtanassov, Sn. Kostianeva І. Methods for IOP measurement Іntraocular pressure, Tonometry Іntraocular fluids dynamics - production - outflow Тonometry types : 1.1. Direct tonometry - clinically irrelevant 1.2. Palpation tonometry 1.3. Indentation tonometry Schiotz tonometer – Indirectly measures the tonometric intraocular pressure (Pt) (real IOP (Po) + IOP, induced by the tonometer`s weight) 41 1.4. Applanation tonometry 1.4.1. Maklakoff tonometry (Pt) (measures the diameter of corneal fixed tonometer weight) 42 applanation by a 2.4.2. Goldmann tonometry (Po) (fixed area of applanation, variable pressure) 43 1.5. Other methods 1.5.1. Non-contact tonometry (the applanation is achieved by an airflow and a sensor measures the time necessary for cornea to regain its normal shape) What is the "normal" intraocular pressure?........................................... It is statistically determined that in 95 % of the ppopulation, intraocular pressure varies between 10 and 21 mm Hg. The graphic shows that the distribution curve is skewed slightly to the left. This means that a relatively large group of people have intraocular pressure higher than 21 mmHg. Ocular hypertension is the main risk factor for the development of visual field defect. This does not necessarily mean the patient has glaucoma. 44 Visual field defects may occur in people who have intraocular pressure less than 21 (the so called “normal tension glaucoma“). Intraocular pressure has diurnal fluctuations. A single measurement of the IOP has no real clinical value. What are the advantages and disadvantages of the different methods of tonometry? What are the main sources of errors in measuring IOP? II Glaucoma – diagnosis, treatment Glaucoma is one of the leading causes for irreversible binocular blindness in the world. 45 Before 1980s the glaucoma was identified with elevated intraocular pressure (IOP). From the 80s of the twentieth century to the mid 90s glaucoma was regarded as a disease in which there is an increased IOP and visual field changes. After the mid-90s it is established that glaucoma is a neurodegenerative disease of the optic nerve. From a sign of the disease, the IOP has become a major risk factor. According to data from the literature 4% -7% of individuals in USA have elevated IOP (ocular hypertension), but they never develop glaucoma. On the other hand, patients with normal, even lower IOP, may have glaucoma, developing atrophy with excavation of the optic nerve and the corresponding changes in the peripheral vision. What is the definition of ocular hypertension? Structural and functional changes in glaucoma What is the course of the primary open-angle glaucoma? 1. Asymptomatic 3. Very severe pain 4. With a strong eye redness 5. With a sudden decrease in vision To establish glaucoma the following tests must be carried out except for: 1. Tonometry 2. Perimetry 3. Ultrasound 4. Gonioscopy 46 Case: Kinetic perimetry - temporal "island" of vision Computed automatatic perimetry performed with Humphrey analyzer defect in the upper-nasal quadrant The basic method for assessment the glaucoma stage is: …………………………………….………………………………………… The basic method for assessment the glaucoma type is: …………………………………….………………………………………… 47 Glaucoma excavation (cupping) The basic method for detecting glaucomatous changes in optic nerve head (and retinal nerve fiber layer) is: …………………………………….………………………………………… Retinal nerve fiber layer contains the axons of ganglion cells that form the optic nerve. Where is the end of the ganglion cell axons? …………………………………….………………………………………… What are the diseases that lead to a strong decrease of visual functions? We make differential diagnosis of open-angle glaucoma with: (list them)............................................ ............................................ ............................................ ............................................ Vision of "colored circles" is characteristic for: 1. Primary open angle glaucoma 2. Primary angle closure glaucoma 3. Congenital glaucoma 4. Cortisone-induced glaucoma The measurement of the corneal thickness is called pachymetry. Why is it necessary to establish central corneal thickness in suspect glaucoma? 48 In thin cornea IOP measured by the Goldman method actually is: higher/lower (underline the correct answer) In thick cornea IOP measured by the Goldman method actually is: higher/lower (underline the correct answer) Treatment of glaucoma includes: 1. drugs 2. laser 3. surgery List down some of the most commonly used anti-glaucoma drops. …………………………………….………………………………………… ……………………………………….……………………………………… Laser surgery for open-angle glaucoma is called ..................... The name of classical antiglaucoma operation is ..................... Buphthalmus is a condition in which the eyeball size (unilateral or bilateral) is greatly increased. Buphthalmus is manifestation of which type of glaucoma? ……………………………………….……………………………………… REMEMBER! Glaucoma is a neuropathy – it is optic nerve disease! Patients lose visual functions not because of high intraocular pressure, but because of atrophy with excavation of the optic nerve! 49 III. Acute Angle-Closure Glaucoma Definition: Acute episodic increase in the intraocular pressure (IOP) to values from 35mmHg to 60mmHg due to sudden blockage of the drainage of the aqueous humor on level irido-corneal angle (ICA). The anatomic factor is of great importance for the occurrence of acute angle-closure glaucoma attack. Acute angle-closure glaucoma can be the first manifestation of: А) Primary open-angle glaucoma B) Primary angle-close glaucoma C) Pigment glaucoma D) Juvenile glaucoma Mechanism of angle closure in primary angle-closure glaucoma: 50 Which of the following factors can provoke acute angle-closure glaucoma? 1. Stress 2. Mydriatic agents 3. Myotic agents 4. Antibiotic collyrs 5. Alcohol 6. Smoking 7. Trauma 8. Intraocular tumor Subjectively the patient complains of pain in the eye and in the same side of the head – which nerve is responsible? n. …………………………. The patient reports nausea and vomiting – which nerve is irritated? n. ……………………………………… Acute angle-closure glaucoma. Picture of the anterior eye segment Following the systemic course of examination of the anterior segment of the eye, underline the signs of acute angle-closure glaucoma: Visual acuity – 1,0/ 0,001 to PPLC Conjuctiva – without injection/ conjuctival injection/ ciliary injection/ mixed injection Cornea – transparent / edematous with normal sensitivity / with decreased sensitivity Anterior chamber – normal/ shallow 51 Pupil – reacts normally to light / is fixed in myosis / mydriasis What condition is included in the differential diagnosis and why the DD is so important? ……………………………………………………………………………… ……………………………………………………………………………… REMEMBER! Acute angle-closure glaucoma is an emergency and the patient requires immediate treatment by an ophthalmologist! The treatment includes: Conservative therapy - Mannitol 10% i.v. Acetazolamide 250mg – 500mg Pilocarpine 1% collyr Analgetics Surgical management – “shunt” between the anterior and posterior chamber - Nd: YAG laser iridotomia - Basal iridectomy - Trabeculectomy - Phacoemulsification Do we make prophylaxis of the other eye so that it will not undertake acute angle-closure glaucomas? ……………………………………………………………………………… ……………………………………………………………………………… Clinical case: Fourty nine years old female during preparation for tooth extraction after instillation of local anesthetic reports sharp pain in the left eye and the temple, blurred vision and suddenly appeared colored halo around light. What do we think about in this case and what provokes it? ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… 52 EXERCISE №5 DISEASES OF THE EYELIDS AND ORBIT N. Stoyanova, V. Mitkova-Hristova Diseases of the Eyelids The eyelids are ocular adnexa and the eyeball is completely covered when the eyelids are closed. Strong mechanical, optical, and acoustic stimuli (such as a foreign body, blinding light, or sudden loud noise) “automatically” elicit an eye closing reflex. In this way the eye is protected from injuries and excessive light. Regular blinking (20–30 times a minute) helps to distribute tears over the conjunctiva and cornea, keeping them from drying out. List down the layers of the eyelid from anterior to posterior: 1………………….…………………. 4………………….…………………. 2………………….…………………. 5………………….…………………. 3………………….…………………. The eyelids are examined by direct inspection under a bright light. Inspection of the eyelids includes the following aspects: 1. Eyelid position: normally the margins of the eyelids are in contact with the eyeball. 53 2. Width of the palpebral fissure (6-10 mm): the upper lid should cover the cornea by about 1 mm. Possible causes of abnormal width of the palpebral fissure Increased palpebral fissure Decreased palpebral fissure Peripheral facial paresis lagophthalmos Congenital and acquired ptosis Grave‟s disease Progressive ophthalmoplegia Buphthalmos Microphthalmos High-grade myopia Enophthalmos Retrobulbar tumor Shrinkage of the orbital fat 3. Skin of the eyelid: it is thin with only a slight amount of subcutaneous fatty tissue. Allergic reaction and inflammation of eyelids, inflammation of sinuses and upper jaw cause rapid extensive edema and swelling. A slit lamp may be used to examine the details of both surfaces of the lids. What does the grey line mean? ……………………………………………………………………………… It is an important surgical landmark and separates the eyelids of two parts: - Anterior lamella – skin and orbicularis - Posterior lamella – tarsal plate and conjunctiva The chronic inflammation of the lid margins is called ……………….…………………………………………………………… 54 Patients usually complain of …..…….. (Underline the right answers) - Mild discomfort - Epiphora - Itching - Discomfort and foreign body sensation - Pain - Rapidly decreased of vision List down the most common etiological factors, which are leading to blepharitis ………………………………..…………………………………… ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… According to anatomical classification blepharitis is: 1. Anterior: - Ulcerative blepharitis - Seborrhoic blepharitis Differential diagnosis between seborrhoeic and ulcerative blepharitis Seborrheic blepharitis Ulcerative blepharitis Occurs in people with seborrheic dermatitis and oily skin. Results from staphylococcal infection Soft and oily scales found everywhere along the lid margin and the lashes Hard scales located only at the base of the lashes Sticking together of the lashes Hyperemia and telangiectasias observed on the front surface of the lid margin Removal of the scales discloses a hyperemic and thinned skin (no bleeding) Removal of scales discloses an ulcerated bleeding surface 55 List down the complications of blepharitis: ............................................................................................................................ ........................................... .................................................. Treatment of ulcerative blepharitis: lid hygiene, antibiotic ointment, weak topical steroid, topical NSAID, tear substitutes. Treatment of seborrheic blepharitis: lid hygiene, topical tetracyclines, weak topical steroid, topical NSAID, tear substitutes. 2. Posterior: - Meibomian seborrhea – by excessive meibomian gland secretions. The amount of oil in the tear film is increased. - Primary meibomianitis – seen more commonly in persons with acne rosacea and seborrheic dermatitis. Meibomian gland secretion appeares as toothpaste-like plaques. - Meibomianitis with secondary blepharitis. Systemic tetracyclines are the mainstay of treatment of posterior blepharitis. 56 Inflammatory diseases of the palpebral skin: 1. Bacterial: - Contagious impetigo – it is caused by ................................, more frequently found in ........................ age. - Erysipelas – it is caused by......................................... Characteristics:............................................................................... - Anthrax – it affects people who have been in contact with affected animals, the eyelids being a rare location. 2. Viral: - Herpes simplex; - Herpes zoster ophthalmicus. Fill in the table: Characteristics Herpes simplex Age Skin involvement Pain Post-treatment neuralgia Bilateral involvement Recurrence Scarring following treatment 57 Herpes zoster ophthalmicus 3. Mycotic – become more frequent because of the indiscriminate administration of antibiotics. 4. List down the chronic infections of the eyelid skin: …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… Hordeolum is: ………………………………………………………………… According to anatomical localization: 1. Internal hordeolum – acute, purulent inflammation of the ……………………………………………………………........... REMEMBER! A stye localized in the internal palpebral angle must be differentiated from acute dacryocystitis, a condition in which the lacrimal drainage is obstructed. 2. External hordeolum (external stye) – acute, purulent inflammation of the …………………. ……………………………….. A characteristic triade is ............................, ........................ and ...................... in the area of the lid margin. Differential diagnosis with the internal stye, in which the infiltrate is at some distance from the lid margin. 58 Treatment of hordeolum (underline the right answers): 1. Hot fomentation 2. Squeezing the abscess 3. Topical antibiotic eyedrops 4. Therapeutic contact lens Chalazion – a chronic inflammation of the …………………………………………………………………………………… According to its localization, it can be: ...................................................... and ...................................................... Treatment – surgical. REMEMBER! In cases of frequent occurrence of chalazia, refractive error and diabetes should be considered! Differential diagnosis with carcinoma of the meibomian glands, the latter being of a denser consistency and recurring following operative treatment. Abscess is ………………………………………………………………………, this is an emergency and requires immediate treatment. REMEMBER! Never squeeze out an abscess localized in the area of the lids! Explain why.................................................................................................. 59 Treatment includes ..................... and a ...................... compress, and after softening of the tissues because of localization of the pus collection, ........................ and drainage should follow. Describe how a warm compress is made …………………………………………………………………………………… …………………………………………………………………………………… Static disturbances in the position of the lids are: 1. Ectropion is ............................................................ The chief symptom is lacrimation because of eversion of the inferior punctum. 2. Entropion is ............................................................ In entropion, there is a risk of traumatic keratoconjunctivitis! Differential diagnosis with trichiasis, in which there is a posterior misdirection of lashes arising from normal site of origin! Dynamic disturbances in the position of the lids are: 1. Ptosis is …………………………………………… 2. Lagophthalmos is ………………………………… 3. Blepharospasm is ………………………………… 60 REMEMBER! Eyelids and anterior eye surface are in close anatomic and physiologic relationship. The process of blinking protects and maintains the optical features of the cornea. Disorders of the eyelids, lead to distortion of corneal integrity and carry the risk of decreased visual acuity. Orbital disorders The orbit is a four sided bony pyramid with solid walls and specific content. It has anatomical connection with the anterior and middle cranial fossa, the paranasal sinuses, the nose and the maxillary sinus. I. Anatomy of the orbit: List down the bones forming the orbit: 1. ............................................ 2. ............................................ 3. ............................................ 4. ............................................ 5. ............................................ 6. ............................................ 7. ............................................ These are the bones forming the orbit walls: superior, inferior, medial and lateral. The thinnest is .............................; the strongest is............................... Orbital content includes: eyeball, optic nerve, extraocular muscles, m. levator palp. sup., Orbital muscle of Muller, Tenon's capsule, lacrimal gland, ciliary ganglion, peripheral nerves, v.ophthalmica, a.ophthalmica, orbital fat body. 61 Important orbital communications are: - optic canal - communication between orbit and the middle cranial fossa; structures passing through it: n.opticus and a.ophthalmica; - superior orbital fissure - communication between orbit and the middle cranial fossa; structures passing through it: III, IV, VI cranial nerves, n.ophthalmicus, v.ophthalmica, a.meningea recurens, sympathetic fibers, parasympathetic fibers to n.oculomotorius. - inferior orbital fissure - communication between orbit and the fossa pterygopalatina; In case of pathological processes in the superior orbital fissure area, the superior orbital fissure syndrome develops. Considering the anatomical elements going through superior orbital fissure, describe the symptoms: .................................................................................................. REMEMBER! The visual acuity is not affected! When the optic canal (canalis n.optici) is engaged in the process, the visual acuity is affected. Why? II. Orbital disorders. 1. Symptoms: - Changes in eyeball position: A major symptom of orbital disorders is exophthalmos - a protrusion of eyeball. It is caused by the increased volume of the orbital content. The measurement of the exophthalmos is made with a common ruler or the Hertel exophthalmometer. 62 Types of exophthalmos: - unilateral / bilateral - permanent / temporary - central / eccentric - reductible / non-reductible - quickly / slowly growing - pulsating - intermittent Exorbitismus – enyire orbital contents, along with the globe are outside and infront of orbit fissure. Enophthalmos is ..............................................and it is caused by ................................................................................................ - Other symptoms of orbital disorder: restriction in eye mobility, diplopia, increased intraocular pressure, eyeball deformation, visual acuity deterioration, changes in periferal vision, corneal damage, and edema of the eyelids. 2. Imaging methods for examination of the orbit are: …………………………………………………………………………………… 63 Inflammatory orbital disorders: Through which ways can an infection enter the orbit? - .............................................................................................................. - .............................................................................................................. - .............................................................................................................. Inflammation of the soft orbital tissue can be: - cellulitis - inflammation of ................................................................... - thrombophlebitis - inflammation of ..................................................... - phlegmon - acute purulent inflammation without definitive borders .............................................................................................. - panophthalmitis - inflammation of....................................................... - tenonitis - inflammation of................................................................... - periostitis - inflammation of................................................................. Why can inflammatory orbital disorders be life threatening? …………………………………………………………………………………… Therapy must be immediately administered with: - a combination of broad-spectrum antibiotics with general application (intravenous, intramuscular) - antipyretics - heating pad - anticoagulants - in case of sinus cavernosus thrombosis - incision and drainage (in case of fluctuation) REMEMBER! The incision is performed in the inferior temporal quadrant of the orbit, near the orbital edge! Which is the most common reason for cellulitis in children? …………………………………………………………………………………… 64 What are the complications of granulomatous tooth of the maxilla? …………………………………………………………………………………… Why you should not squeeze upper lip, nose and eyelids abscessus? …………………………………………………………………………………… Parasitic orbital disorders: Fill in the table: Parasitosis: Echinococosis Cysticercosis Trichinellosis Filariasis Loaosis Caused by: Endocrine disorders whit orbital manifestations: - Eye symptoms in thyreotoxicosis - Endocrine ohthalmopathy - Malignant exophthalmos For determining an accurate diagnosis in case of exophthalmos, the levels of T3,T4, TSH, thyroglobulin antibodies must be tested too, as well as specific thickening of the eye muscle bodies (using CT scan, eye sonography), which is typical for endocrine-related ophthalmopathy. Orbital tumors: - primary - metastatic - adjacent - benign - malignant REMEMBER! There are connections between the vessels of the orbit, the face and the brain (facial vein-angular vein-superior ophthalmic vein-cavernous sinus)! The most common inflammatory and tumor processes in the orbit originate from the paranasal sinuses. An inflammatory process in the orbit can be transmitted through the venous circulation to the cranial cavity and lead to death. 65 EXERCISE № 6 INTRAOCULAR INFLAMMATION (UVEITIS) – ANTERIOR AND POSTERIOR UVEITIS. RETINAL VASCULAR OCCLUSIVE DISORDERS: RETINAL ARTERIAL/ VEIN OCCLUSION. CONNECTION BETWEEN OPHTHALMIC AND DENTAL DISEASES N. Sivkova, V. Mitkova-Hristova, D. Koleva-Georgieva INTRAOCULAR INFLAMMATION (UVEITIS) – ANTERIOR AND POSTERIOR UVEITIS Uveitis includes a heterogeneous group of inflammatory diseases, related to the medial coat (uvea) of the eyeball. Not only they recur very often, but also damage both eyes. Mainly people between the age of 20 and 50, who work actively, suffer from this disease. Teenagers suffer 7 times less, but the disease is more serious. This age range defines uveitis as a disease with socio-economic importance. The middle part of the uvea includes: 1. ……………………………. 2. ……………………………. 3. ……………………………. The anatomical classification of uveitis is the most convenient in clinical practice and divides inflammatory diseases of the uvea into: 1. ………………………... – the inflammation engages the iris and anterior part of the ciliary body. 2. ………………………... – the inflammation engages the posterior part of the ciliary body, the peripheral retina and adjacent vitreous. 66 3. ……………………....... – the inflammation engages choroid and more often the adjacent retina. That is why they are also called ……………………….. 4. ……………………….. – the inflammation engages all three parts of the uvea. REMEMBER! The iris and the ciliary body usually suffer together because of the mutual blood supply from …………………….. and ……………………. As for the choroid, it is damaged on its own. It is supplied with blood from ……………………………………………………………………………………. The anatomical classification describes the location of uveitis, but it does not give any information related to the etiological cause and the concomitant systemic association. Clinical classification of the uveitis, based on the etiologic criteria, divides the diseases as follows: І. Infectious: 1. Bacterial 2. Viral 3. Fungal 4. Parasitic and etc. ІІ. Noninfectious: 1. With known systemic associations 2. With unknown systemic associations 3. ІІІ. Masquerade syndromes: 1. Neoplastic 2. Nonneoplastic 67 Anterior uveitis is the most common inflammatory disease of the uvea. It is very difficult to determine the nature of disease due to the fact that eyes react similarly in the majority of systemic diseases and infections. The complaints in anterior uveitis are (underline the right answers): - Discomfort and foreign body sensation - Pain - Discharge - Lacrimation - Photophobia - Blepharospasm - Metamorphopsia (distortion of straight lines of the objects) REMEMBER! The pain in anterior uveitis is due to the fact that there is an affluent sense perception of the iris and the ciliary body from nn. ……………….……, whereas there is no sense perception in the choroid and posterior uveitis is not painful. Describe the objective symptoms in anterior uveitis (iridocyclitis): ………………………………………. ………………………………………. 68 ………………………………………. ………………………………………. ………………………………………. ………………………………………. ………………………………………. ………………………………………. The most common secondary complications of anterior uveitis are: ………………………………………. ………………………………………. 69 ………………………………………. ………………………………………. It is important to do the differential diagnosis between acute anterior uveitis and other causes of “acute red eye” – acute angle-closure glaucoma and acute conjunctivitis. The acute conjunctivitis is treated in outpatients‟ department practices, whereas the acute anterior uveitis and acute angle-closure glaucoma require treatment in an eye hospital. The last two mentioned conceal the risk of permanent damage and visual acuity loss. Complete the table: Differential diagnosis between acute conjunctivitis, acute anterior uveitis and acute angle-closure glaucoma: Acute Acute Acute Feature anterior Angle-closure Conjunctivitis Uveitis glaucoma Onset Pain Visual acuity Discharge Congestion Cornea Anterior chamber depth Anterior chamber transparency Iris Pupil Intraocular pressure 70 REMEMBER! Secondary glaucoma may occur in anterior uveitis after pupillary block (secclusio pupillae)! Treatment of uveitis: 1. Symptomatic: А) Topical (list down the groups of medications used) ..…………………………………………………………………………….… ..…………………………………………………………………………….… ..…………………………………………………………………………….… REMEMBER! It is a great mistake when mydriatic drops are used for the treatment of patients with acute angle-closure glaucoma. Whereas it is necessary to use them in cases with acute anterior uveitis in order to release the existing posterior synechiae! B) Systemic (list down the groups of medications for systemic treatment) ..…………………………………………………………………………….… ..…………………………………………………………………………….… ..…………………………………………………………………………….… 2. Specific – when etiology is known. List the most common rheumatology diseases (HLA B-27+) related to anterior uveitis: ..…………………………………………………………………………….… ..…………………………………………………………………………….… ..…………………………………………………………………………….… Intermediate uveitis occurs rarely. The etiology is very often inknown. In 80% of the cases both eyes are involved. Mainly young people suffer from this disease. 71 List down the most common infectious and non-infectious diseases, related to the intermediate uveitis: ..…………………………………………………………………………….… ..…………………………………………………………………………….… ..…………………………………………………………………………….… Posterior uveitis - very often without pain and red eyes, the socalled “white eye”. The involved eye elements in the inflammatory process are the adjacent choroid, the retina, the sclera and sometimes the optic nerve. Toxoplasmosis is the most common cause for posterior uveitis. The most common complaints of patients with posterior uveitis are (underline the right answers): - Black spots floating in front of the eye - Follicles - Photopsia - Macropsia - Hyphema - Micropsia - Hypopyon - Positive scotoma - Metamorphopsia Describe the objective symptoms in posterior uveitis (chorioretinitis): ..…………………………………………………………………………….… ..…………………………………………………………………………….… 72 Complete the table: Differential diagnosis between an active lesion and an atrophic scar of the choroid: Feature Active lesion of the choroid Atrophic scar of the choroid Color Edges Elevation compared to the surrounding retina Pigmentations Cellular infiltration of the vitreous Mark in the pictures which is an active choroidal lesion and which is an atrophic scar: ……………………………. ……………………………. In which case these changes are going to cause a decrease of the visual acuity and why? ..…………………………………………………………………………….… ..…………………………………………………………………………….… 73 Which of the following objective methods should be used to diagnose posterior uveitis (underline the correct answers): - Focal illumination - Biomicroscopy - Direct ophthalmoscopy - Indirect ophthalmoscopy - Shiermer‟s test - Perimetry - Fundus biomicroscopy List down the most common clinical forms of posterior uveitis and panuveit: ………………………………………………………………………… Sympathetic Ophthalmia is: ..…………………………………………………………………………….… ..…………………………………………………………………………….… Why after penetrating ocular trauma systemic steroids should be used? ..…………………………………………………………………………….… ..…………………………………………………………………………….… Uveitis in children is rare, but lead to heavy visual damage. Clinical examination in children is difficult. In many cases diagnose comes too late. Treatment modalities in children are limited and there is a risk of amblyopia. REMEMBER! In most cases patients with uveitis suffer from systemic diseases. In order to clarify the etiological factors, it is necessary to have a lot of experts‟ opinions from other medical specialities. That is why these diseases require multidisciplinary approach for diagnosis and treatment. 74 RETINAL VASCULAR OCCLUSIVE DISORDERS 1. CENTRAL RETINAL ARTERY OCCLUSION (CRAO) CRAO is caused by: - Atherosclerosis-related thrombosis (cardiovascular diseases); - Embolization; Different types of embolus – cholesterol, fibro-platelet, calcific: - Spasm; - Dissecting aneurysm within the central retinal artery; - Giant cell arteriitis. Typical clinical symptom: sudden, complete, and painless loss of vision. Which method for examination of the fundus should be used? ……………………………………………………………………………… 75 Would you describe the early clinical findings on the image? Why is the fovea red (cherry red spot)? ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… Would you describe the fundus in the late period of CRAO? ……………………………………………………………………………… ……………………………………………………………………………… CRAO with the presence of cilioretinal artery: Fluorescein angiography (FA) – preservation of the papillomacular area, good perfused in the angiogram Fundoscopic view 76 Branch retinal arterial occlusion (BRAO) The superotemporal branch of CRA is affected: a) Fundoscopic view – the retina becomes opaque and edematous in the superotemporal area and in the superior part of the posterior pole, where the nerve fiber and ganglion cell layers are thickest. Management of CRAO and BRAO: - Reduction of IOP by ocular massage; - Inhalation therapy with 95% oxygen and 5% carbon; - Trental (4 x 100 mg) i.v.; - Aspirin per os; - Heparin s.c. REMEMBER! The therapy should be undertaken without delay! Studies have suggested that irreversible damage to the sensory retina occurs only 90 minutes after complete CRAO! CENTRAL RETINAL VEIN OCCLUSION (CRVO) AND BRANCH RETINAL VEIN OCCLUSION (BRVO) CRVO and BRVO occure most commonly at an arteriovenous crossing. 77 Risk factors: - History of systemic arterial hypertension; - Cardiovascular diseases; - History of open-angle glaucoma; - Diabetes mellitus; - Coagulation disorders; - Oral contraceptives use/pregnancy; - Obesitas. Whould you describe what you see? a) Fundus of CRVO ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… b) FA ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… c) Fundus of BRVO ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… The most common complaints of patients with CRVO/BRVO are (underline the right answers): - Sudden decrease of vision - Poor vision within a week - Secretion - Metamorphopsia - Pain - Red eye 78 REMEMBER! In patients with CRVO the visual acuity is poor due to the chronic macular edema. a) CRVO - fundus c) OCT – macular edema b) FA Treatment: - Trental (4 x 100 mg) i.v.; - Aspirin per os; - Heparin s.c. - Laser treatment of the ischemic areas. Prophylaxis of iris neovascularization and secondary glaucoma!! - VEGF- inhibitors or corticosteroids intravitreally management of macular edema. REMEMBER! CRAO/BRAO and CRVO/BRVO can occur during surgical dental procedure. Why? You should be prepared to recognize and to treat them. CONNECTION BETWEEN OPHTHALMIC AND DENTAL DISEASES The near collocation between the eye balls (with ocular adnexa) and the dental apparatus, as well as the presence of anatomical and neuroreflectoral connections between them, determines the appearance of ophthalmic diseases with dental origin, and the presence of ophthalmic (dental) symptoms in cases of dental (ophthalmic) diseases. Emphasis: Anatomical connections – bony, vascular, sensory Neuro-reflectory connections. Sensorial disturbances Focal infection with dental origin 79 Anatomical connections Bony connections – the maxilla constructs the orbital floor and the bony passage of the naso-lacrimal duct. The maxillary sinus may lead to communication between the orbit and the teeth. In children the maxillary sinus hides the alveolus of two premolars and the first molar teeth, and in adults – 3, 4, 5, 6, 7 and 8. In children a vasculo-neuronal cannel exists from the alveolar process to the orbital floor (a way for transmission of infection). A passage of infection may be also the nasolacrimal duct (maxillary sinus nasal cavity nasolacrimal duct orbit). Vascular connections – arterial anastomoses: the communication between internal carotid artery (vascular supply to the orbit and the eye) and external carotid artery (vascular supply of the face and maxilla) is accomplished by dorsal nasal artery (branch of ophthalmic artery) and angular artery (branch of facial artery); venous anastomoses: ample anastomoses between superior ophthalmic vein and facial vein. The orbital veins are without valves. This eases the way of infection. The infection may reach the cavernous sinus by this way: facial vein angular vein superior ophthalmic vein cavernous sinus. 80 List down which dental and ophthalmic diseases may lead to infectious thrombosis of the cavernous sinus: ……………………………………………………………………………… ……………………………………………………………………………… ……………………………………………………………………………… Sensory connections – the sensory innervations of the orbit, eye and maxilla is carried out by the trigeminal nerve, the sympathetic innervations is carried out by carotid plexus. Neuro-reflectory connections. Sensorial disturbances Possible neuro-reflectory manifestations in the eye with dental origin: neuralgic pain, epiphora (excessive tearing), and light sencitivity. Possible neuro-reflectory manifestations (pain sensation) in teeth with ophthalmic origin: acute iridocyclitis, acute angle closure glaucoma, excessive accommodation. Transient (or permanent) loss of visual acuity is possible during tooth extraction. This is because of reflectory stimulation of the sympathetic periarterial plexus and spasm of central retinal artery. 81 Focal infection with dental origin Inflammatory diseases of dental cavity may lead to a number of ophthalmic inflammatory diseases – iridocyclitis, chorioretinitis, orbital cellulitis, orbital phlegmona, orbital supperiostal abscess, and the lifethreatening thrombosis of cavernous sinus. The way of infection is by bony and vascular communications or haematogenous dissemination. List down which patients are at risk for eventual permanent visual loss during tooth extraction: 1. Young patients with status of trombophily. 2. Elderly patients on anticoagulant and antiagregant treatment. 3. Elderly patients, not on anticoagulant or antiagregant treatment. REMEMBER! Good knowledge of the anatomical, vascular, and neuro-reflective connections between the visual system and the teeth is a prerequisite for the correct interpretation of symptoms and diagnosis of the interconnected diseases. 82 EXERCISE № 7 OCULAR TRAUMA – BLUNT TRAUMA (CONTUSIONS), INJURIES, BURNS A. Gerdzhikov, A. Baliyan, R. Kermedchieva Ocular trauma is one of the leading causes for monocular blindness. Even slight injuries can lead to significant reduction of the visual functions. Ocular trauma Closed globe Chemical and thermal injuries Contusion Open globe Lamellar laceration Rupture Laceration Penetrating Perforating A. CONTUSIONS OF THE EYEBALL AND OCULAR ADNEXA Contusions of the eyeball and its surrounding tissues are commonly produced by a direct blow of a blunt object. I. Contusions of the eyeball The primary effect of blunt force on the globe may be local injury at the sight of impact or contrecoup injury to the posterior portion of the eye from energy suddenly being dispersed through a closed system. Several types of ocular injuries are associated with blunt trauma: 83 Injury of: the cornea – traumatic abrasion. What test do we use to visualize traumatic abrasion of the cornea? ............................................................................................................ ............................................................................................................ Subjective complaints include: pain, photophobia, tearing, red eye, blurred vision. What treatment do we apply: a) topical antibiotics b) topical steroids c) systemic antibiotics and steroids the anterior chamber (AC) – hyphema (bleeding into the AC from a ruptured iris vessel). Hyphema Iridodialysis Hyphemas may be small or large. Rebleeding occurs 2-5 days after the initial injury in 20-25 % of traumatic hyphemas. Most traumatic hyphemas clear spontaneously. What is the risk of massive hyphemas? a) secondary glaucoma: b) hematocornea (blood staining of the cornea) yes/no yes/no the iris: - rupture of the iris sphincter – traumatic mydriasis - rupture of the root of the iris – Iridodialysis 84 What is the main symptom of Iridodialysis? ............................................................................................................ ............................................................................................................ the ciliary body: - iridocorneal angle recession (separation of the circular muscle fibres of the ciliary body from the longitudinal ones) - cyclodialysis (the longitudinal muscle are torn from the scleral spur) the lens: - traumatic cataract: a) due to small lesions of the lens capsule b) due to rupture of the lens capsule The treatment of traumatic cataract is: a) topical antibiotics b) oral analgetics c) surgical - dislocation of the lens due to rupture of the lens zonules: partial (subluxation) or complete (luxation) Complete rupture of the zonules lead to luxation of the lens into: 1 ...................... 2 ...................... Traumatic cataract Lens subluxation 85 the sclera Ocult rupture of the sclera may be caused close to site of injury or it can indirectly be caused from an increase in the intraocular pressure causing the wall of eye to tear at one of the weaker points. Common sites of indirect ruptures are parallel at the corneal limbus or at the the insertion of rectus muscle on the opposite site of the impact. Patient with blunt trauma presents on examinations with: palpebral hematoma,large conjunctival hemorrhage, hyphaema and marked ocular hypotony. What should we think of? a) traumatic cataract b) lens dislocation c) scleral rupture the vitreous: - hemophtalmus (vitreous hemorrhage) - acute posterior vitreous detachment retinal ruptures retinal detachment the choroid - hemorrhage - ruptures the retina (contusion and commotion of the retina due to a countercoup effect) – retinal edema is often associated with hemorrhage leading to retinal atrophy and hole formation. What is the visual acuity of a patient with traumatic macular hole? а) 0.01 – 0.1 б) 0.2 – 0.5 в) 0.5 – 1.0 Secondary glaucoma may result from contusion of the eyeball. Numerous mechanisms are involved such as: severe AC hemorrhage, extensive synechia closing the angle, severe angle recession, traumatic cyclodialysis or lens injury. 86 II. Contusions of the ocular adnexa Contusions of: the orbit - orbital hemorrhages - expanding orbital hemorrhage may cause visual dysfunction due to compression of the optic nerve or central retinal artery occlusion. - Fractures of the orbital walls - they may be caused by direct blow or by extension of a fracture line from adjacent bones. Blunt traumas of the orbit may give rise to a sudden increase of the intraorbital pressure that is directed towards the walls, causing a blow-out fracture of one or more walls (usually the floor and or the medial wall). Blow-out fracture of the orbit Patient with orbital trauma presents on examination with enophthalmos and inability to rotate the eye upwards. Which one of the orbital muscles is captured in the rupture? a) lateral rectus muscle b) inferior rectus muscle c) inferior oblique muscle d) medial rectus muscle the extraocular muscles Injuries to the extraocular muscles or the superior eyelid levator muscle may cause diplopia, limitation of the eye movements and ptosis. the eyelids and conjunctiva - eyelid hematoma - conjunctival hemorrhage 87 Eyelid hematoma Conjunctival hemorrhage B. INJURES OF THE EYEBALL AND OCULAR ADNEXA 1. Globe lacerations 1.1. With closed globe Lamellar lacerations of cornea and sclera belong here. They can be with or without foreign body in wound‟s lips. Clinical case: While working with a patient „something‟ flies off and hits dentist‟s eye. Tearing and ocular pain start, vision is not disturbed. What is the possible diagnose? ............................................................................................................... ............................................................................................................... ............................................................................................................... What kind of test is performed to rule-out corneal penetrating injury? How is it performed? ............................................................................................................... ............................................................................................................. What is the management in cases with superficial corneal foreign body? ............................................................................................................... ............................................................................................................... Positive Seidel test Corneal foreign body 88 In cases with lamellar corneal lacerations sometimes suturing is necessary. What are the possible reasons for reduced visual acuity after the period of recovery in such kind of trauma? ............................................................................................................... ............................................................................................................... ............................................................................................................... 1.2. With open globe Penetrating globe injuries In this type of injures penetration through the cornea and/or sclera in full thickness is present. Clinical case: While working with a patient the latter performs abrupt movement and hits dentist‟s arm, holding a sharp instrument. As a result patient‟s eye is injured and he reports for acute ocular pain and decreased vision. Examination of the injured eye shows deformation of the pupil and presence of „darkly-colored formation‟ at the peripheral sector of the cornea. What is the possible diagnosis? What is the reason for the described findings? ............................................................................................................... ............................................................................................................... ............................................................................................................... ............................................................................................................... What is the primary management in cases which are suspicious for open globe trauma? ............................................................................................................... ............................................................................................................... ............................................................................................................... Like the cases of superficial injury foreign body may or may not be present. What kind of examination is performed for confirming intraocular foreign body presence and its localization? MRI CT scan B-scan (ultrasound) X-ray 89 What is the appearance of the anterior chamber in cases of penetrating corneal injury? ............................................................................................................... ............................................................................................................... ............................................................................................................... What can be visualized in wound‟s lips in cases of scleral penetrating injury? ............................................................................................................... ............................................................................................................... ............................................................................................................... Globe penetration Intraocular foreign body (CT scan) Corneal laceration suture What kind of complications can be expected for the injured eye after a penetrating trauma? How should they be prevented? ............................................................................................................... ............................................................................................................... 90 And for the other uninjured eye? How should they be prevented? ............................................................................................................... ............................................................................................................... What happens with the lens when its capsule is damaged by the traumatic agent? ............................................................................................................... ............................................................................................................... What complications can develop after such kind of trauma in the injured and in the uninjured eye? ............................................................................................................... ............................................................................................................... Penetrating injuries to the globe can be caused by little particles moving with high velocity. In these cases the traumatic agent may remain in some of the intraocular structures or pass through the globe and lodge in the orbit, sinuses etc (perforating injury). The prognosis after such injuries depends on: foreign body‟s dimensions; the structures it has passed through; its velocity; bringing in infection; foreign body‟s material. What kind of complication can we expect in cases with ironcontaining intraocular foreign bodies? ............................................................................................................... ............................................................................................................... ............................................................................................................... What kind of complication can we expect in cases with coppercontaining intraocular foreign bodies? ............................................................................................................... ............................................................................................................... Some kinds of foreign bodies, as such made of glass, some kinds of plastics, etc. are well tolerated by the ocular tissues. In such cases restraining from extraction is sometimes possible. 91 2. Injures of the ocular adnexa Eyelids lacerations Superficial lacerations of the eyelid skin can be sutures with 6-0 silk. When parallel to the lid margin without gaping they can be repaired with medical cyanoacrylate glue after disinfection. An application of TT is made. Deeper eyelid wounds need repair in two layers and sometimes drainage. Full thickness eyelid laceration requires repair of the tarso-muscular layer first, followed by suturing the skin. Special attention should be paid on the repair of the eyelid margin Why should not be sutured the eyelid conjunctiva? ............................................................................................................... ............................................................................................................... Full thickness eyelid laceration repair When laceration is situated nasally to the lacrimal punctum laceration of the canalicular system should be ruled out. If there is one, canalicular intubation is performed, followed by suture of the laceration. This silicone stent remains 3 to 6 months in order to prevent canalicular obturation resulting from cicatrisation. 92 Lacerations of the conjuctiva Conjunctival lacerations smaller than 3-4 mm usually do not need suturing. Antibiotical eyedrops are instillated. Larger lacerations are sutured with 8-0 Biosorb. What condition should be ruled out when revising bulbar conjunctiva lacerations? ............................................................................................................... Primary care in cases of ocular injuries: cleansing instillation of antiseptic eye-drops and sterile patch placing TT or SAT systemic antibiotic therapy transportation to an eye clinic C. OCULAR BURNS Types: thermal, chemical, radiation. In cases with history of chemical injury IMMEDIATE profuse irrigation for at least 30 min. of the eye and conjunctival fornices with eyelids everted with saline, distillated water, and if sterile solutions are not available – with tap water is performed! What are the late complications in cases of ocular burns? ............................................................................................................... ............................................................................................................... What is the type of tissue necrosis in cases of acid and alkali burns and which type has more „favorable‟ prognosis? ............................................................................................................... ............................................................................................................... Why no patching is made in cases of chemical burn? ............................................................................................................... ............................................................................................................... 93 Suggest a therapy for a case of ocular chemical burn: ............................................................................................................... ............................................................................................................... Which ocular structures are damaged in cases of prolonged exposure to UV radiation?? ............................................................................................................... ............................................................................................................... Alkali burn Damage of the eye after UV exposure What kind of precautions are necessary when using photopolymeric and teeth whitening lamps? ............................................................................................................... REMEMBER! The results of blunt injuries are variable and may not be obvious on superficial examination! A trauma to the facial region may damage the orbital bones and adjacent soft tissues. Many of these injuries are accompanied by simultaneous cranial injuries also requiring treatment! While performing initial management of ocular trauma restraining from penetrating foreign bodies removal is recommended as it may lead to extra damaging of the iris, ciliary body or choroid tamponing the wound! Timely made irrigation considerably decreases the time of contact of the chemical agent with the ocular tissues thus improving the prognosis for the injury outcome! No patching is made in cases of chemical injury! 94 SUMMARY TESTS D. Koleva-Georgieva, N. Sivkova TEST 1 1. Biomicroscopy (slit-lamp examination) is method for examining: а) iris, lens and retina b) nasolacrimal duct, vitreous body and retina c) cornea, anterior chamber and lens d) ciliary body, vitreous body and optic nerve 2. Which of the listed structures is not part of the uvea: а) iris b) choroid c) vitreous body d) ciliary body 3. Decreased corneal sensitivity is typical for: а) conjunctivitis b) herpetic keratitis c) “dry eye” syndrome d) hypopion keratitis 4. Which from the listed eye drops should not be used in acute angle closure glaucoma: а) beta-blockers b) carboanhidrase inhibitors c) atropine d) pilocarpine 5. The adhesions between the iris and anterior lens capsule are called: а) anterior synechiae b) posterior synechiae c) goniosynechiae d) precipitates 95 6. The inflammatory disease of the cornea is called: а) keratitis b) iridocyclitis c) retinitis d) conjunctivitis 7. Which from the ophthalmoscopy: а) optic nerve disc b) macula c) ciliary body d) vitreous body listed structures cannot be visualized by 8. Characteristic perimetry finding in open angle glaucoma is: а) quadrantopsia b) hemianopsia c) ring scotoma d) arcuate paracentral scotoma 9. Which is the contemporary method for surgical treatment of cataract, that uses ultrasound for removal of the opaque lens nucleous: а) phacoemulsification б) intracapsular cataract extraction в) phacofragmentation г) extracapsular cataract extraction 10. Patient complaints of severe pain in his/her eye and the corresponding half of the head and extremely decreased vision. The eye examination reveals vessel congestion in conjunctiva, corneal edema, shallow anterior chamber with transparent contents, paretic pupil and intraocular pressure of 45 mmHg. The possible diagnosis is: а) acute iridocyclitis б) acute angle closure glaucoma в) acute conjunctivitis г) endophthalmitis 96 TEST 2 1. Objective methods for examination of refraction are: а) biomicroscopy and ophthalmoscopy b) biomicroscopy and kampimetry c) sciacsopy and refractometry d) perimetry and tonometry 2. In cases of acute angle closure glaucoma the intraocular pressure (IOP) is: а) decreased b) increased c) normal d) IOP has no relation to angle closure glaucoma 3. Choroiretinitis is: а) inflammatory disease of the posterior uvea b) inflammatory disease of the anterior uvea c) inflammatory disease of the lachrymal system d) inflammatory disease of the ciliary body 4. In myopia the focus of the optical system of the eye is: а) in front of the retina b) on the retina c) behind the retina d) has no attitude to determine the clinical refraction of the eye 5. The adhesion between the bulbar and palpebral conjunctiva is called: а) synechia b) synchisis c) symblepharon d) pinguecula 97 6. In cases of central retinal artery occlusion the patient complains of: а) severe ischaemic pain in the eye and no visual disturbances b) sudden vision loss, no ocular pain c) gradual vision loss, eye redness and tearing d) sudden vision loss, with eye pain and redness 7. During phacoemulsification the lens nucleous is emulsified by means of: а) ultrasound b) laser c) air d) watter 8. Which form the listed is not correct in the treatment of chemical burns: а) lavage of the ocular surface with solution of NaCl for 30 minutes b) anesthetic drops (Alcaine) c) ocular bandage d) antibiotic drops 9. Presbiopy is corrected with: а) concave lenses b) convex lenses c) surgically with lens extraction d) cannot be corrected 10. During prophylactic examination of a patient with no ocular complaints and normal vision, the ophthalmologist detects the presence of binocular swelling of the optic disc. Which may be the possible reason: а) intracranial hypertension b) bilateral anterior ischaemic opticoneuropathy c) bilateral occlusion of central retinal artery d) bilateral thrombosis of central retinal vein 98 TEST 3 1. Which from the listed structures is not part of the anterior eye segment: а) cornea b) anterior chamber c) lens d) vitreous body 2. What is the visual acuity, if the patient counts correctly the fingers from a distance of 2 m: а) 0.4 b) 0.04 c) 0.02 d) 0.2 3. Which from the listed is not characteristic for the ciliary hyperemia: а) purple colour b) does not vanish after instillation of adrenalin c) is a sign of acute conjunctivitis d) the hyperemia is most prominent in the limbal zone 4. What is the type of the cataract that develops after iridocyclitis: а) pathologic b) complicated c) senile d) iatrogenic 5. Buphthalmos is characteristic for: а) congenital glaucoma b) congenital cataract c) endocrine associated ophthalmopathy d) orbital tumor 99 6. The presence of puss in anterior chamber is called: а) hyphaema b) hypopion c) hemosis d) hemophthalmus 7. In cases of stress and pain (i.e. on the dental chair) there is a probability of: а) acute angle closure glaucoma b) acute conjunctivitis c) acute occlusion of central retinal artery d) а and c 8. Which from the listed operations is performed in glaucoma: а) phacoemulsification b) trabeculectomy c) dacryocystorhinostomy d) vitrectomy 9. Which is not characteristic for diabetic retinopathy: а) microaneusismae b) haemorrhagiae c) hard exudates d) opacitates 10. Patient complains of sudden vision loss of one eye 30 minutes before. No pain, no redness of the eye. What is the possible diagnosis and what first aid would you give to the patient: а) acute angle closure glaucoma; Mannitol 10% i.v., Pilokarpin collyr b) occlusion of central retinal artery; vasodilators, Aspirin p.o., Clexan s.c. c) acute iridocyclitis; NSAID, steroids and mydriatics d) the described eye condition is not curable 100 TEST 4 1. The combined focal illumination is method for examination of: а) anterior eye segment b) posterior eye segment c) intraocular pressure d) refraction 2. Which from the listed structures is not part of the uvea: а) iris b) ciliary body c) choroid d) sclera 3. Intraocular fluid is produced from: а) vitreous body b) retina c) sclera d) ciliary body 4. Macula implements: а) visual acuity and color vision b) peripheral vision c) accommodation d) produces intraocular fluid 5. The retinal photoreceptors are: а) bipolar cells b) ganglion cells c) rods and cones d) Mueller cells 101 6. In traumatic erosion of the cornea the use of which of the following is contraindicated: а) Alcaine collyr 4х1 drops/daily b) antibiotic eye drops c) steroid drops d) а) and c) 7. Which of the following simptoms is not characteristic for the acute conjunctivitis: а) conjunctival discharge b) decreased vision c) conjunctival injection (hyperemia) d) eye itching 8. Which from the listed keratites may be epidemic: а) herpes zoster keratitis b) mycotic keratitis c) adenoviral keratitis d) hypopion keratitis 9. In senile cataract the reduction of vision most often occurs: а) suddenly without pain b) suddenly with pain c) gradually without pain d) gradually with pain 10. In cases of chemical burn with quicklime, the first aid should be: а) immediate placement of sterile eye bandage b) immediate lavage with 30 minutes duration c) immediate neutralization with solution of soda (saleratus) d) immediate instillation of steroid drops 102 TEST 5 1. What is the visual acuity if the patient counts correctly the fingers from 4 m: а) 0.8 b) 0.08 c) 0.02 d) 0.2 2. Which lenses are used to correct myopia (nearsightedness): а) convex lenses b) concave lenses c) prismatic lenses d) cylindrical lenses 3. The island obsolescence in the visual field is named: а) scotoma b) isopter c) hemianopsia d) metamorphopsia 4. Which disease is not inflammatory disease of the orbit: а) cellulitis b) phlegmona c) pseudotumor orbitae d) dacryocystitis 5. In cases of acute occlusion of central retinal artery there is: а) sudden vision loss b) ciliary hyperemia (injection) c) acute ischeamic eye pain d) increased intraocular tension 103 6. Blood in anterior chamber is named: а) hypopion b) hyphaema c) hemosis d) haemophthalmus 7. Hypopion is present in: а) ulcus serpens corneae b) iridocyclitis c) endophthalmitis d) all of the above 8. Leucoma corneae is: а) cloudiness of the cornea after inflammation or trauma b) acute inflammation of the stroma c) malignant tumor d) benign tumor 9. In cases of acute angle closure glaucoma which from the listed is not characteristic: а) decreased corneal transparency b) tiny dot-like pupil c) eye congestion hyperemia d) eye pain 10. In cases of ulcus serpens corneae is contraindicated: а) cortisone eye drops b) antibiotic eye drops c) mydriatic eye drops d) epitelizing eye ointments 104
