Ministry of Education and Science of Ukraine Sumy State University S. E. Lekishvili PRACTICAL OPHTHALMOLOGY Study guide Recommended by the Academic Council of Sumy State University Sumy Sumy State University 2019 УДК 617.7(075.8) L51 Reviewers: O. V. Olkhova – Candidate of Medical Sciences, Head of the Department of Clinical Disciplines of the Ivan Franko National University of Lviv, M. D. Board certified in Ophthalmology; L. V. Hrytsay – Candidate of Medical Sciences, Head of the Department of Eye Microsurgery of the Sumy Regional Clinical Hospital, chief ophthalmologist of the Sumy region, M. D. Board certified in Ophthalmology Recommended for publication by the Academic Council of Sumy State University as a study guide (minutes № 5 of 10.11.2016) Lekishvili S. E. L51 Practical Ophthalmology : study guide / S. E. Lekishvili. – Sumy : Sumy State University, 2019. – 392 p. ISBN 978-966-657-763-7 The study guide is intended to train students of higher medical educational institutions of the fourth level of accreditation on the specialty “Medicine”, interns, residents and masters. The guide is a new progressive step in teaching the discipline “Ophthalmology”. УДК 617.7(075.8) © Lekishvili S. E., 2019 ISBN 978-966-657-763-7 © Sumy State University, 2019 2 CONTENTS P. LIST OF ABBREVIATIONS ………………………………… 4 TOPIC 1. OCULAR ANATOMY AND PHYSIOLOGY ……. 7 TOPIC 2. EYE EXAMINATION …………………………….. 45 TOPIC 3. REFRACTION AND ACCOMMODATION ……... 56 TOPIC 4. DISEASES OF EYELIDS AND ORBIT ………….. 78 TOPIC 5. DISEASES OF LACRIMAL SYSTEM …………... 106 TOPIC 6. STRABISMUS AND NYSTAGMUS …………….. 118 TOPIC 7. DISEASES OF THE CONJUNCTIVA ……………. 130 TOPIC 8. DISEASES OF THE CORNEA AND SCLERA ….. 164 TOPIC 9. DISEASES OF THE UVEAL TRACT ……………. 205 TOPIC 10. GLAUCOMA …………………………………….. 253 TOPIC 11. DISEASES OF THE LENS ………………………. 268 TOPIC 12. DISEASES OF THE OPTIC NERVE ……………. 278 TOPIC 13. DISEASES OF THE RETINA ………………….... 301 TOPIC 14. OCULAR MANIFESTATIONS OF SYSTEMIC DISEASES ……………………………………………………. 346 TOPIC 15. INJURY OF THE VISUAL ORGANS …………... 355 TOPIC 16. OPHTHALMIA ONCOLOGY …………………... 378 TOPIC 17. FIRST AID IN OPHTHALMOLOGY …………… 384 REFERENCES ………………………………………………... 390 3 LIST OF ABBREVIATIONS ADED – advanced diabetic eye disease AIDS – acquired immune deficiency syndrome AION – anterior ischaemic optic neuropathy AK – allergic conjunctivitis AMPPE – acute multifocal placoid pigment epitheliopathy ARMD – age-related macular degeneration ARN – acute retinal necrosis bid – bis in die BRVO – branch retinal vein occlusion BRVO – branch retinal vein occlusion BUT – tear film break-up (break-up time) CFF – critical fusion frequency flashing CLV – corrected loss variance – reducing variability in light sensitivity magnitudes CME – cystoid macular edema CME – cystoid macular edema CMV – cytomegalovirus COD – congestive optic disc CRVO – central retinal vein occlusion CRVO – occlusion of the central retinal vein and its branches CSME – clinically significant macular edema CSR – central serous retinopathy D – Dioptre DES – dry eye syndrome DR – diabetic retinopathy DR – diabetic retinopathy ELISA – enzyme immunoassay EOG – electro-oculogram ERG – electroretinogram ERG – electro-retinogram GC – glucocorticoids ICE – iridocorneal endothelial syndrome 4 ICSOLs – intracranial space-occupying lesions IF – intraocular fluid IIH – idiopathic intracranial hypertension IOFB – intraocular foreign bodies IOL – intraocular lens IOP – intraocular pressure IOP – intraocular pressure IRMA – intraretinal microvascular abnormalities KCS – keratoconjunctivitis sicca LASEK – laser assisted sub-epithelium keratomileusis LF – lacrimal film LGN – lateral geniculate nucleus LP – lumbar puncture LTK – laser thermal keratoplasty LV – loss variance (reducing variability index sensitivity) LVA – low vision aids MD – mean defect (the average depth of the defect) MFA – fluorescent antibody method MRI – magnetic resonance imaging scan MS – mean sensitivity (mean retinal sensitivity) NLD – nasolacrimal duct NPDR – non-proliferative diabetic retinopathy NSAIDs – nonsteroid anti-inflammatory drugs NVG – neovascular glaucoma NVM – neovascular membrane OA – ophthalmic artery OCRA – occlusion of the central retinal artery OCT – optical coherence tomography OD – right eye OKT – optical coherence tomography OS – left eye PCG – primary congenital glaucoma PCR – polymerase chain reaction PDR – proliferative diabetic retinopathy 5 PDT – photodynamic therapy PKC – protein kinase C PORN – progressive outer retinal necrosis PRK – photorefractive keratectomy PRP – panretinal photocoagulation qid – quater in die RAPD – relative afferent pupillary defect RF – reliability factor (considers the degree of probability study) ROP – retinopathy of prematurity RPE – retinal pigment epithelium stat – immediately STM – superior tarsal muscle TIOP – tolerant intraocular pressure TTT – transpupillary thermotherapy UBM – ultrasound biomicroscopy VECP – visually evoked cortical potential VECP – visually evoked cortical potential VEGF – vascular endothelial growth factors VEP – visually evoked potential VER – visually evoked response VER – visually evoked response Visus – visual acuity 6 TOPIC 1. OCULAR ANATOMY AND PHYSIOLOGY The ability to see is dependent on the actions of several structures in and around the eyeball. The graphic below lists many of the essential components of the eye‟s optical system. Figure 1 – Essential components of the eye‟s optical system [12] When you look at an object, light rays are reflected from the object to the cornea, which is where the miracle begins. The light rays are bent, refracted and focused by the cornea, lens, and vitreous. The lens‟ job is to make sure the rays come to a sharp focus on the retina. The resulting image on the retina is upside-down. Here at the retina, the light rays are converted to electrical impulses which are then transmitted through the optic nerve, to the brain, where the image is translated and perceived in an upright position. 7 The eye (Lat. – oculus; Greek – ophthalmos) is the organ that allows us to see. It is situated in the eye socket. An eye socket, or an orbit, is a bony cup in the skull that contains the eyeball with its auxiliary apparatus (vessels, nerves, muscles, fat, fascia, tear glands, connective membrane and lacrimal passages). The eyeball itself is a sphere spanning approximately 24 mm in diameter. The depth of the orbit in adults is 4 cm, width of the entrance to the orbit – 4 cm, height – 3.5 cm. The walls of the orbit are as follows: superior wall (a roof); inferior wall (a floor); medial wall; lateral wall. How each of them is formed? 1. The superior wall is formed by the frontal part of the orbital bone, and the lesser wing of the sphenoid bone. 2. The inferior orbital wall is formed by a part of the orbital surface of the maxilla, zygomatic bone, orbital process of palatine bone. 3. The medial wall is formed by the frontal offshoot of the upper jaw, lacrimal bone, orbital plate lattice bones, body sphenoid bone and frontal part of the orbital bone. 4. The lateral orbital surface is formed by the greater wings of the sphenoid bone, zygomatic bone. The orbit borders with the outer wall of the nasal cavity, namely the ethmoid labyrinth; at the top – the orbital part of the anterior cranial fossa, which houses the frontal lobes of the brain, as well as the frontal sinus of the frontal bone. Outside – the borders of the temporal fossa, at the bottom – from the top wall of the maxillary sinus of the upper jaw. An eyeball consists of three layers and an internal optic core. There are three covers: external (fibrous membrane); 8 middle (choroid); internal (retina). The outer layer is placed around the outside of the eye, plays a mechanical role, which is protective and is the mainstay of the eye. There are two parts of the outer layer: anterior (cornea); posterior (sclera). The eyes move symmetrically (in the same direction at the same time). These symmetrical movements are made possible through the coordination of the extraocular muscles (muscles outside the eye). Around the eyes there are three pairs of eye muscles. One pair of eyes turns left and right, the second – up and down, and the third pair rotates it relative to the optical axis. Since the eyes are paired structures, the brain receives two slightly different images that overlap with one another. Interpretation of the different images is possible via coordinated eye movements achieved by complex neural mechanisms. Humans are also able to perceive three- dimensional images because they possess binocular vision, which enables the perception of depth and distance. Conjunctiva is a mucous membrane covering the under surface of the lids and anterior part of the eyeball up to the cornea. Parts of conjunctiva: palpebral (covering the lids – firmly adherent); forniceal (covering the fornices – loose – thrown into folds); bulbar (covering the eyeball – loosely attached except at limbus); marginal and limbal parts, and plica semilunaris. 9 Nerve supply Sensory innervation: bulbar conjunctiva – long ciliary nerves – nasociliary n. – an ophthalmic division of the trigeminal n.; superior palpebral and forniceal conjunctiva – frontal and lacrimal branches of Ophthalmic division of the trigeminal n.; inferior palpebral and forniceal conjunctiva – laterally from lacrimal branches of the ophthalmic division of the trigeminal n. and medially to the infraorbital n. – maxillary n.; a division of the trigeminal n. Sympathetic innervation: superior cervical sympathetic to