Gede Pardianto - MataPedia2014 for Ophthalmologist
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Transcript of Gede Pardianto - MataPedia2014 for Ophthalmologist
2014’2014’sM t P di TMMataPediaTM
for Ophthalmologistfor Ophthalmologist
(Slides Compilation)
Gede PardiantoSumatera Eye CenterM d I d iMedan - Indonesia
The information provided within this book is for educational and scientific purposes only and it should not be construed as
commercial advice.
Author thanks all of our teachers, fellow ophthalmologists, publishers, sponsors, and all manufacturers for their works those
all being cited in this handout book.
FREE COPYFREE COPY
NOT FOR SALE2
• Being an ophthalmologist doesn’t mean you can be the rich person or you can do everything. As a little light, the sincerity you can perform in your meaningful life is giving a humble tribute tomeaningful life is giving a humble tribute to humanity by serving the people against blindness.blindness.
Gede PardiantoMay 20, 2008
3
Gede PardiantoGede Pardianto
• Graduate from– Doctor of Medicine Airlangga University– Ophthalmologist Airlangga University– Doctor of Philosophy Sumatera Utara Universityp y y
• Office– Dr. Komang Makes Hospital – Sumatera Eye Center– Sumatera Utara University, Medical Schooly
• Member of– IOA– InaSCRS– APACRS– ESCRS– ASCRS– EuCornea– AAO– ICO– ICO
4
Here are awarded to the souls of the valiant who gave their lives in the service of theirlives in the service of their country and who sleep in unknown graves…
All Indonesian heroes…
Some there be which have no sepulchre.sepulchre.
But their name liveth for evermore.
Airlangga University - Medical School 1913
Dedicated to 100 Years of the Spirit of Nationality 1908 – 2008and 1 Century of Medical Education in Surabaya 1913 – 2013 y y
5
Basic and LatestSpirit of BaliSpirit of Bali
Only one on earth
Visual functions including :Visual functions including :
• Visual acuityVi l fi ld• Visual field
• Color vision• Dark adaptation• Contrast sensitivityContrast sensitivity• Binocular single vision
7
Examination
Which one goes wrong ?8
Examination : FingerExamination : Finger
• Finger countingC f t ti t t• Confrontation test
• Digital tonometry• Open the eye lid
9
Confrontation Visual Field testingConfrontation Visual Field testing
• TechniqueTechnique– Examiner sated about 1 meter opposite patient– Patient directed to cover one eye and fixate on y
examiner’s opposite or nose– Patient asked whether examiner’s entire face is
visible or specific portions are missingvisible or specific portions are missing– Patient asked to identify a target of 1,2 or 5 presented
at the midpoint of each of four quadrants in a plane p q phalfway between the patient and examiner
American Academy of Ophthalmology10
Confrontation Visual Field testingConfrontation Visual Field testing
– Patient is asked to add total number of fingers gpresented in opposing quadrants (double simultaneous stimulation)A h i ti d t d i t b t d– Aphasic, uncooperative, sedated intubated or very young patient can use finger mimicry, pointing, visual tracking or reflex blink to respond and allow gross appraisal of VF integrity. If a patient saccades to a visual stimulus in a given quadrant, the visual field area can be considered to be relatively intactarea can be considered to be relatively intact
– Check patient’s ability to distinguish color of red object when looking directly at it
American Academy of Ophthalmology 11
Examination : At least• Optotypes charts• Phoropter and/or Trial lens and frame • Torch• Slit lamp• Jaegger’s reading chart
L t• Lensometer • Color test Ischihara’s pseudoisochromatic plates• Tonometer• Fluorescein for Defect and Siedel’s test• Fluorescein for Defect and Siedel s test• Ophthalmoscope• Amsler grid and Red dots• RulerRuler• Placido disc keratoscope• Whatman No. 41 paper by 5x30mm for Schirmer test
12
Examination : PhoropterExamination : Phoropter
• A device containing different lenses usedA device containing different lenses used for refraction of the eye during sight testing
• The instrument used to measure refractiveThe instrument used to measure refractive status of the eyes.
• It contains many lenses which are thenIt contains many lenses which are then changed in front of the eyes while the patient is looking at an eye chart. p g y
• This is when the doctor usually asks, "Which is better, one or two?"
13
Examination : OptotypesExamination : Optotypes
• High contrast visual acuityHigh contrast visual acuity– Snellen chart
Bailey Lovie chart– Bailey-Lovie chart• Low contrast visual acuity
– Reagan chart
14
Examination : Torch• Light perception• Projection of Illumination / Light projectionProjection of Illumination / Light projection• Macula Photostress Recovery Test
– Measure visual acuity firstPlace torch 2 cm from eye– Place torch 2 cm from eye
– 10 seconds illumination– Measure visual acuity again
R d th ti d d f b k t i i l– Record the time needed for recovery back to previous visual acuity
– 55 seconds normalLarger (90 180) macular dysfunction– Larger (90-180) macular dysfunction
• Pupil examination• Crude anatomical screening
Deborah Pavan-Langston 15
Examination : Slit lampExamination : Slit lamp
• How to adjustHow to adjust– Up and down
Horizontal move– Horizontal move– Pupil distance
Light– Light– Angle
Slit d t ti– Slit maneuver and rotation– Color option
16
Slitlamp examination
anterior
Slitlamp examination
anteriorcornea
posteriorpcornea
anteriorlens limbus
anterioriris
17
Examination : OphthalmoscopeExamination : Ophthalmoscope
• How to use :How to use :– Power switch
Size of illumination– Size of illumination– Diopter
Color Red free– Color Red free– Placido disc Crude
18
Dilating dropsDilating drops
• MydriaticMydriatic– Phenylephrine 2.5%, 10% 20 min 3 hours
• Cycloplegics– Tropicamide 0.5%, 1% 20-30 min 3-6 hours– Cyclopentolate 0.5%, 1%, 2% 20-45 min 24 hours– Homatropine 2%, 5% 20-90 min 2-3 days– Scopolamine 0.25% 20-45 min 4-7 days– Atropine 0.5%, 1%, 2% 30-40 min 1-2 week(s)
Will’s Eye Manual, 2004 19
Examination : Amsler gridExamination : Amsler grid
• Boldly cross-hatched paperWill b d t i• Will be mandatory in :– Metamorphopsia– Central scotoma– Discomfort “perfect” vision– Color vision disturbance
20
Amsler gridAmsler grid
21
To use the gridg• Sit in an area with good lighting, and hold the chart at
eye level and at a comfortable distanceeye level and at a comfortable distance • You may find it convenient to attach the grid to a wall at
eye level and stand 12 inches to 14 inches away (comfortable reading distance)(comfortable reading distance)
• If you wear glasses, keep them on. If you wear bifocals, use the bottom or reading portion of the lens
• Cover one eye completely• Stare with your other eye at the central dot on the grid.
While doing this, observe the pattern of vertical andWhile doing this, observe the pattern of vertical and horizontal lines
• Repeat the test with the other eye
22
Schirmer test ISchirmer test I• Whatman No. 41 paper p p• Filter strip 5x30mm, folded 5mm• Dimly light room
Pl l l b l j ti t it l t l 1/3• Place lower palpebral conjunctiva at its lateral 1/3• Eye kept open and look upward• Blinking is permissibleBlinking is permissible• Remove after 5 minutes• 10-30 mm wet normal or basal secretion may be low
but compensated for by reflect secretionbut compensated for by reflect secretion• Less than 5 mm wet repeated hyposecretion of
basic tearing
Deborah Pavan-Langston, 2008 23
Examination : Add 1Examination : Add 1• 76 or 90 D lens• Goldmann’s 3 mirrors lens• Hruby lens
I di t hth l• Indirect ophthalomoscopy• Manual or automatic keratometry• Standard A-Scan biometryStandard A Scan biometry• Retinometer• WFDT• Prisms• Streak retinoscopy• Hertel’s exophthalmometerHertel s exophthalmometer
24
Examination : Goldmann’s 3 MirrorsExamination : Goldmann s 3 Mirrors
• Central : Posterior pole O l G i• Oval : Gonioscopy
• Trapezium : Equator• Square : Periphery
25
Examination : Add 2• Visual field test
– Bjerrum’s tangent screenGoldmann’s perimetry– Goldmann’s perimetry
– SAP, SWAP, FDT, HPRP– For AMD Preferential Hyperacuity Perimeter (PHP)
Foresee PHP (Notal Vision)Foresee PHP (Notal Vision)– For Retina Micro Perimeter MP-1 (Nidek)
• Advanced biometry– Partial Coherence Laser Interferometera t a Co e e ce ase te e o ete– Non-contact Optical Coherence Biometry– Laser Interferometry Technique
• Advanced High Definition AB-Scan USGg– Aviso (Quantel Medical)– VuMax II (Sonomed)
• Standard digital fundus camera with FFAg– VisuCam (Carl Zeiss Meditec AG), AFC-330 (NIDEK)
26
Visual Field Analyzers
Octopus 101
FDT Perimetry
Perimetry
Goldmann Perimetry
Humphrey Perimetry 27
Examination : Add 2
• Advanced anterior examination– Pachy-Autorefrakto-Keratometer
• PARK 1 (OCULUS Optikgeräte GmbH)• Galilei G4 (Ziemer) Placido and Dual ScheimpflugGalilei G4 (Ziemer) Placido and Dual Scheimpflug
– Anterior Optical Coherence Tomography• Visante OCT (Carl Zeiss Meditec AG)• SL OCT (Heidelberg Engineering)• TOMEY SS-1000 (TOMEY GmbH)
– Scheimpflug Camera Pentacam Keratometry CornealScheimpflug Camera Pentacam Keratometry, Corneal topography, Pachimetry, Corneal wavefront, AC and angle analyzer, Lens analyzer, Phakic IOL and Post refractive surgery biometryy
• Pentacam HR (OCULUS Optikgeräte GmbH)28
Examination : Add 2
• Advanced anterior examination– Keratograph Oculus Keratograph (OCULUS
Optikgeräte GmbH)E d th li S l Mi– Endothelium Specular Microscope
– Advanced High Definition Ultrasound Biomicroscopy(UBM)( )
• P60 UltrasoudBioMicroscope (Paradigm)• Aviso (Quantel Medical)• VuMax (Sonomed)• VuMax (Sonomed)
– Very high frequency (VHF) ultrasound eye scanner Artemis (ArcScan, Inc)
– HRT3 with Cornea Module (Heidelberg Engineering)29
Advanced anterior examination
Artemis (ArcScan, Inc)
P60 UltrasoudBioMicroscope (Paradigm)
Pentacam HR (OCULUS Optikgeräte GmbH)Visante OCT (Carl Zeiss Meditec AG) 30
Examination : Add 2• Advanced posterior examination
– Posterior Optical Coherence TomographySt t OCT (C l Z i M dit AG)• Stratus OCT (Carl Zeiss Meditec AG)
• 3D OCT 2000 FA Plus Swept-Source SS OCT and DRI (TopCon)( p )
• 3D OCT-1 Maestro OCT (TopCon)• RS3000 Advance (Nidek)
RTV FD OCT (O t )• RTVue FD OCT (Optovue)• High Definition Cirrus + SmartCube HD OCT (Carl
Zeiss Meditec AG))• SOCT Copernicus (Reichert)• HRA OCT Spectralis (Heidelberg Engineering)
E i P di t i SDOCT (bi ti )• Envisu Pediatric SDOCT (bioptigen)31
Examination : Add 2
• Advanced posterior examination• Advanced posterior examination– Scanning Laser Ophthalmoscopy
• OCT-SLO (Opko Instrumentation)O t Ult Wid fi ld I i S t (O t )• Optos Ultra Widefield Imaging System (Optos)
– Scanning Laser Polarimetry• GDxVVC Glaucoma Diagnosis - Variable g
Corneal Compensation (Carl Zeiss Meditec AG)– Confocal Scanning Laser Tomography
• HRT3 Heidelberg Retinal Tomography 3 e de be g et a o og ap y(Heidelberg Engineering)
32
Stratus OCT (Carl Zeiss Meditec AG)
RTVue FD OCT (Optovue)
HRT3 (Heidelberg Engineering)
HRA-OCT Spectralis (Heidelberg Engineering)
GDxVCC (Carl Zeiss Meditec AG)Cirrus HD OCT
(Carl Zeiss Meditec AG)33
Examination : Add 2• Pediatric visual examination
– Pictures cards Allen card– Letter HOTV– Matching games Lea symbols
• Binocular vision test – Titmus, TNO, Lang, Madox’s Rod, – Bargolini striated test– Hering-Bielschowsky afterimage test
Al f t t t• Also for teatment – Synophtophore– Holme’s stereoscope
H S• Hess Screen• ERG and EOG• Visual Evoked Potential (VEP)
34
Contrast sensitivity tester• Aberrometry• Glare
– Letter Pelli-Robson ChartLetter Pelli Robson Chart– Grating
• Functional Acuity Contrast Test (FACT) Chart • Contrast Sensitivity Tester 1800• Landolt-C based Miller Nadler Glare Tester• Frankfurt-Freiburg Contrast and Acuity Test System (FF-CATS)• Grating-based Charts CSV-1000 (Vector Vision)
– Scotopic testing lower than 0 032 cd/m²– Scotopic testing lower than 0.032 cd/m• Rodenstock Nytometer (Rodenstock)• Mesoptometer (Oculus Optikgeräte GmbH)
• Scatter– Van den Berg Stray Lightmeter
• Haloes– Tomey Glare and Halo Software (Tomey)o ey G a e a d a o So t a e ( o ey)
Kohnen T, Koch DD, 2005 35
Examination equipmentExamination equipment
• Well accepted• Well approvedpp• Well proven• Easy to learn its manual• Easy to use• Easy and comfortable for patient• Easy to make accurate and reliable interpretation • Reproducible
36
EMBRIOLOGY
The Marshall
dr. Norman Tagor Lubis, Sp.M
37
Neuroectoderm-Neuresonsory retina-Retinal pigment epithelium
American Academy of Ophthalmology
et a p g e t ep t e u-Pigmented ciliary epithelium-Nonpidmented ciliary epithelium-Pigmented iris epithelium -Sphincter and dilator muscles of iris-Optic nerve, axons, and glia-Vitreous
Cranial Neural Crest cells-Corneal stroma and endothelium-Trabecular meshworkSheaths and tendons of extraocular muscles
DERIVATIVES OF -Sheaths and tendons of extraocular muscles
-Connective tissues of iris-Ciliary muscles-Choroidal stroma-Melanocytes (uveal and ephitelial)-Meningeal sheaths of the optic nerve
OF EMBRYONIC TISSUES : ECTODERM g p
-Schwann cells of ciliary nervers-Ciliary ganglion-All midline and enferior orbital bones, as well as part of orbital roof and lateral rim-Cartilage-Connective tissues of orbitM l l d ti ti h th f ll l d bit l l
ECTODERM
-Muscular layer and connective tissues sheaths of all ocular and orbital vessels
Surface Ectoderm-Ephitelium, glands, cilia of skin of eyelids and caruncle-Conjuntivital ephiyelium-Lens-Lens-Lacrimal glan-Lacrimal drainage system-Vitreous 38
• Fibers of extra ocular musclesDERIVATIVES
OF• Endothelial lining of all
orbital and ocular blood l
OF EMBRYONIC TISSUES :
vessels• Temporal portion of sclera
Vitreous
MESODERM
• Vitreous
American Academy of Ophthalmology 39
22 days Optic primordium appears in neural folds (1 5-3 0 mm)
American Academy of Ophthalmology
22 days Optic primordium appears in neural folds (1.5-3.0 mm).25 days Optic vesicle evaginates. Neural crest cells migrate to surround vesicle 28 days Vesicle induces lens placode.
Second Invagination of optic and lens vesicles.month Hyaloid artery fills embryonic fissure.
Closure of embryonic fissure begins.Pigment granules appear in retinal pigment epitheliumPigment granules appear in retinal pigment epithelium.Primordial of lateral rectus and superior oblique muscles grow anteriorly Eyelid folds appear.Retinal differentiation begins with nuclear and marginal zones. Mi ti f ti l ll b iMigration of retinal cells begins.Neural crest of corneal endothelium migrate centrally. Corneal stroma follows.Cavity of lens vesicle is obliterated.ySecondary vitreous surrounds hyaloid system.Choroidal vasculature develops.Axons from ganglion cells migrate to optic nerve.Glial lamina cribrosa formsGlial lamina cribrosa forms.Bruch’s membrane appears.
.
40
Third Precursors of rods and cones differentiate.month Anterior rim of optic vesicle grows forward
Ciliary body starts to develop.Sclera condenses.Vortex veins pierce sclera.Eyelid folds meet and fuse.Eyelid folds meet and fuse.
Fourth Retinal vessels grow into nerve fiber layer near optic disc.month Choroidal vessels form layers.
I i t i l i dIris stroma is vascularized.Eyelids begin to separate.
Sixth Ganglion cells thicken in macula.gmonth recurrent arterial branches join the choroidal vessels.
Dilator muscle of iris forms.
SeventhOuter segments of photoreceptors differentiateSeventhOuter segments of photoreceptors differentiate.month Central fovea starts to thin.
Fibrous lamina cribrosa forms.Chorodial melanocytes produce pigment. Circular muscle forms in ciliary body
American Academy of Ophthalmology 41
Oculoplastic
43
Eye lid layery y• Anterior lamellar
– Skin and subcutaneus tissue– Muscles of protraction Ocular orbicular muscle
• Medial lamellarO bit l t– Orbital septum
– Orbital fat– Muscles of retraction
• Palpebral levator muscle• Muller’s muscle
• Posterior lamellar– Tarsus– Conjunctiva
American Academy of Ophthalmology 44
OP : Ptosis1. PSEUDOPTOSIS2. CONGENITAL3. ACUIRED
– MYOGENIC• BLEPHAROPHIMOSIS SYNDROME• MYASTHENIA GRAVIS• PROGRESSIVE EXTERNAL
OPHTHALMOPLEGIA• OPHTHALMOPLEGIA
– NEUROGENIC PTOSIS• HORNER’S SYNDROME• MARCUS GUNN JAW WINKING• THIRD NERVE PALSYTHIRD NERVE PALSY• BOTULISM• CEREBRAL PTOSIS
– APONEUROTIC PTOSIS• INVOLUTIONAL PTOSIS• POST CATARACT SURGERY• POST CATARACT SURGERY• POST EYELID TRAUMA• POST EYELID OEDEMA• POST CONTACT LENS WEAR
– MECHANICAL PTOSIS• EYELID TUMOURS
ORBITAL LESIONS• ORBITAL LESIONS• CICATRIZING CONJUNCTIVAL DISORDERS• ANOPHTHALMOS
45
Diagnostic keysg y• Levator Function • Margin reflex distance (MRD)• Margin limbal distance (MLD)g ( )• Inter palpebral fissure• Lid lagLid lag• Bell’s phenomenon Eye lid closing
failure without moving eye ball upward orfailure without moving eye ball upward or outward at the SAME time
• Ocular motilityOcular motility46
Levator function
• The most practical measure of the strength of the levator muscle
• Excursion of the upper lid from extreme down-gaze to extreme up-gazeto extreme up-gaze
• Normally 15 mm 47
MRD• A simple way to measure
the height of the upper lid.N ll 4 5• Normally 4-5 mm
• MRD 1 = distance of the lid f th lupper lid from the corneal
light• MRD 2 = distance of the• MRD 2 = distance of the
lower eye lid from the corneal light reflexcorneal light reflex
48
Ski h i ht d t thSkin crease height and strength
• The distance from the lid margin to crease– Men 6-8 mm, Asia 5-6 mm– Women 8-10 mm, Asia 7-8 mm
• A weak levator muscle creates less pull on the skin the crease is weakon the skin the crease is weak
• MLD Normal 9-10 mm
49
System for Ptosis surgeryLevator function
System for Ptosis surgery
> 10 mm < 10 mm> 10 mm < 10 mm
Degree of ptosis Levator function
< 2 mm > 2 mm > 2 mm < 4 mm
Aponeurosis surgery
Fasanella servat
Brow suspension
Levator resection
Collin JRO, 1989 50
System for myogenic ptosisSystem for myogenic ptosis
Collin JRO, 1989 51
Collin JRO, 1989 52
Collin JRO, 1989 53
Collin JRO, 1989 54
Fascia lata : How to getFascia lata : How to get
• Mark outside of thigh 1/3 distally Ski i i i 4 5 d ll d i• Skin incision 4-5 mm dull undermine
• Find the white fascia• Take 3 X 1.5 cm of fascia• Suture the edge of fasciaSuture the edge of fascia• Suture sub cutan and skin
55
OP : EntropionOP : Entropion
CLASSIFICATION :
C it l– Congenital• Entropion• Epiblepharon• Epiblepharon
– Acquired :• Involutional• Involutional• Spastic• Cycatricaly
56
Entropion : InvolutionalEntropion : Involutional
• Overriding of lower lid protractor muscleOverriding of lower lid protractor muscle• Horizontal eye lid laxity lateral and
medial canthus ligamentmedial canthus ligament• Disinsertion or weakness of lower lid
t t lretractor muscle• Fat atrophy enophthalmos• Anteriorly prolapse of orbital fat
57
Involutional Entropion : ExaminationInvolutional Entropion : Examination
• Horizontal laxityPi h / Di t ti t t– Pinch / Distraction test
– Snap back test• Medial canthal laxity• Lateral canthal laxityy• Vertical laxity Retractor dehisence
58
Pinch / Distraction testPinch / Distraction test
• Distant between globe and lower lid margin after full lower lid pull outg p
• None 5 mm• Mild 5 7 mm• Mild 5-7 mm• Moderate 10-12 mm• Severe more than 12 mm
59
Snap back testSnap back test
• Dynamic test Pull downward lower lid margin then rapidly releasedmargin then rapidly released
• Normal Lid margin back on its position t ith t bli kispontaneous without blinking
• Laxity Not spontaneous back on position
60
Medial canthal laxityMedial canthal laxity
• Lateral distraction test Position shift ofLateral distraction test Position shift of inferior lacrimal punctum
• Normal The punctum must be stable on• Normal The punctum must be stable on semilunar plica while pulled to lateral
1 2 hift i th– 1-2 mm shift in youth– 3-4 mm shift in elderly
• If any greater position shift Laxity
61
Medial canthal laxityMedial canthal laxity
0 1 2 3 4 5 6
Grade of Lancrimal punctum position shift 62
Cycatrical EntropionCycatrical Entropion
Pathophysiologyp y gy• Cycatric at posterior lamellar Posterior
lamellar shortening lid margin inversionlamellar shortening lid margin inversion to the globe Entropion Trichiasis
63
System for upper lid entropionLid closure possible?
NoYes
Yes
Corneal graft considered?Keratinisation of marginal tarso-conjunctiva?
Posterior Tarsal
NoYesNo
Posteriorlamellar
graft
Tarsal excisionRotation of
terminal tarsusLashes abrading
cornea?
Anterior lamellar reposition
NoYes
Tarsus thickened?
Yes No
Tarsal wedge resection Lamellar division +/- MM graft
Collin JRO, 198964
Collin JRO, 1989 65
Congenital Entropion : Surgery
Congenital epiblepharon• Congenital epiblepharon– Could be disappear by age– If there any punctate keratopathy Tarsal
fixation
66
Involutional Entropion : SurgeryInvolutional Entropion : Surgery
• Without lid laxity – Everting sutureg– Wies procedures
• With lid laxityWies procedures with tarsal strip– Wies procedures with tarsal strip
67
Cycatrical Entropion : Surgery
• Mild to Moderate
Cycatrical Entropion : Surgery
Mild to Moderate– Anterior lamellar reposition (ALR)
Tarsotomy– Tarsotomy
S• Severe – Posterior lamellar graft– Terminal tarsus rotation
68
OP : EctropionOP : Ectropion
CLASSIFICATION :
Congenital– Congenital– Acquired :
• InvolutionalInvolutional• Paralytic• Mechanical• Cycatrical
69
Ectropion : Principal surgeryEctropion : Principal surgery
• LaxityLaxity– Tarsal strip
Pentagonal excision Medial Canthal– Pentagonal excision Medial, Canthal, Lateral
– Medial canthus ligament shortening– Medial canthus ligament shortening• Cycatrix
Ski ft– Skin graft
70
Shortage of skin?System of acquired ectropion
Yes
Cicatricial ectropion
Localized defect?
No
Normal eyelid closure?
No Yes
P l ti t i
p
No Yes
Z - plasty Skin replacement
Paralytic ectropion
Medial canthal tendom laxity?
YN Yes
Yes
No
No
Medial ectropion only?
Medical canthoplasty
Medical canthoplasty + lat canth sling
Medical canthal resection
Lump in lid
Involutional
Yes No
Mechanical t i canthoplasty + lat. canth. slingectropion ectropion
Ectropion mainly medial?
Yes Collin JRO, 1989Yes
Horizontal lid laxity?
No Yes
Excision of diamond of
t j ti
Med.canth. tendom lax?
Exess skin?
Horizontal lid h t i
Horiz .lid short. + bl h l t
No
No
Yes
tarso-conjunctiva
Med.canth. tendom placation or resection
No Yes
Lazy - T
shortening blepharoplasty
71
Collin JRO, 1989 72
OP : TrichiasisOP : Trichiasis
• Cilia emerge from their normal anterior lamellar locationlamellar location
• Associated with cicatrizing processes of the conjunctiva
73
OP : BlepharospasmeOP : Blepharospasme
• Eye lid squeezing disordersL t di i ti ith• Long standing association with :– Eye lid and brow ptosis– Dermatochalasis– Entropion– Canthal tendon abnormalities
74
OP : Blepharophimosis
G li d i f th l b l
OP : Blepharophimosis
- Generalized narrowing of the palpebral fissure
- A CONGENITAL ANOMALY
- EPICANTHUS INVERSUS- MICROBLEPHARIA PTOSIS AND- VERTICAL STRETCHING OF THE BONY ORBIT- VERTICAL STRETCHING OF THE BONY ORBIT
75
COLOBOMA PALPEBRA orCOLOBOMA PALPEBRA orCOLOBOMA PALPEBRA or COLOBOMA PALPEBRA or BLEPHAROSCHIZISBLEPHAROSCHIZIS
• FULL THICKNESS DEFECTS OF THE EYELIDS• FULL THICKNESS DEFECTS OF THE EYELIDS• RARE. UNILATERAL OR BILATERAL• THE CONFIGURATION TRIANGULAR OR
QUADRILATERAL• THE CORNEA EXPOSE CORNEAL OPACITY• THE RISKS ARE GREAT INVOLVES THE CENTER• THE RISKS ARE GREAT INVOLVES THE CENTER
OF THE LID
76
OP : Blepharochalasisp• Thin and wrinkled eyelid skin • Familial variant of angioneurotic edema• Familial variant of angioneurotic edema• Idiopathic episodes of inflammatory edema of
the eyelidthe eyelid• Most frequently in young females • Younger patient than dermatochalasis• Younger patient than dermatochalasis• Different with Dermatochalasis
• Redundancy of eyelid skin• Redundancy of eyelid skin• Often associated with orbital fat protrusion or prolapse• Upper eye lid indistinct or lower than normal eyelid crease
American Academy of Ophthalmology 77
Contracted socketsContracted sockets
• Causes ofCauses of– Radiation
Extrusion of an enucleation implant– Extrusion of an enucleation implant– Severe initial injury
Poor surgical technique– Poor surgical technique– Multiple socket operations
P l d i d f f th i– Prolonged periods of conformer or prothesis removal
American Academy of Ophthalmology 78
Collin JRO, 198979
Collin JRO, 198980
Prof. dr. Mardiono Marsetio, Sp.M(K)andand
Prof. dr. Wisnujono Soewono, Sp.M(K)
Ocular surface85
Tear film : FunctionsTear film : Functions
• Maintains optical clear for corneaMaintains optical clear for cornea• Moistening, lubricating and protecting
surface of conjunctiva and corneasurface of conjunctiva and cornea• Inhibits microorganism growth by
h i d ti i bi lmechanism processes and anti-microbial actions
• Feeding the cornea
Vaughn GD, 2000 86
Tear film : Layersy• Monomolecular lipid layer
– Superficial– Origin from Meibomian glands– Inhibits evaporation– Closed palpebra Water-tight barrier
• Aqueous layerAqueous layer– Origin from major and minor lacrimal glands– Water soluble salts and proteins
• Mucin layer– Secreted principally by conjunctival goblet cells– Glycoprotein coating conjunctiva and cornea– Absorbed by hydrophobic corneal epthelial cells membrane on
microvilio– Normally on 15-45 seconds of Break-up time test– Abnormally on less than 10 seconds of Break-up time test
Vaughn GD, 2000 87
Tear film : FormationsTear film : Formations
• Thickness 7-10 µmThickness 7 10 µm• Volume 7 + 2 µL each eye• pH 7 35 vary from 5 20 8 35• pH 7.35 vary from 5.20-8.35• Isotonic 295-309 m osmol/L
Alb i 60% t t l t i• Albumin 60% total protein• Defence mechanism by Lisozym, Ig A,
I G d I EIg G and Ig E
Vaughn GD, 2000 88
Tear dynamicsTear dynamics
• Tear volume is 10 µ L or lessTear volume is 10 µ L or less• The maximum volume of fluid that can be contained in
the “cul-de sac” without overflow is 30 µL. Th d l i i l 40 L• The eye drop volume is approximately 40 µL
• The excess fluid instilled is rapidly removed by spillage from the conjunctiva sac until the tear fluid returns to jits original volume
• The reflex tearing after the instillation of an irritating drug may produce up to 400 µL excess tearsmay produce up to 400 µL excess tears.
• Dilution of 5–50 fold usually occurs in the first 2 minutes, depending on the irritating power of the substance
Cornea, 2002 89
Ocular surface : Hyperemia
• Conjunctivalj
• Corneal
• Scleral
90
Ocular surface : Red eyeOcular surface : Red eye
• ConjunctivitisConjunctivitis• Uveitis
K titi• Keratitis• Glaucoma
91
Acute Conjunctivitis
Acute Iritis Acute Glaucoma
Acute KeratitisConjunctivitis Glaucoma Keratitis
Incidence ++ + +/- +Secret ++ - - +VA - +/- ++ +Pain + ++ +/++Pain - + ++ +/++Injection Diffuse, to
fornicesCircum cornea Circum cornea Circum cornea
C Cl U ll l Cl d ClCornea Clear Usually clear Cloudy Clearance change
Pupil Normal Small Oval dilated Normal or Small
Light response Normal Decrease None Normal
IOP Normal Normal Increase Normal
Swap Organism + No organism No organism Only in ulcers
92
Sign Bacterial Viral Allergic Toxic Trachoma
Injection Marked Moderate Mild/ Moderate Mild/ Moderate ModerateInjection Marked Moderate Mild/ Moderate Mild/ Moderate Moderate
Hemorrhage + + - - -Chemosis ++ +/- ++ +/- +/-Secret Purulent Scant/
WateryString/ White - Scant
Watery
Pseudo membrane
+/-Streptococcus/
Corynebacterium
+/- - - -
Papillae +/- - + - -Follicles - + - + +
(Medication)Peri auricular node + ++ - - +/-Pannus - - -
(Except Vernal)
- +93
Staining : Gramg• Older technique
– 3 seconds of Carbol Gentian Violet on fixated object glass3 seconds of Carbol Gentian Violet on fixated object glass– ¾ seconds Lugol solution– 1 second 90% Alcohol– Wash by watery– 3 seconds Watery Fuhcin
• New techniqueq– ½ - 1 second(s) Ammonium oxalate crystal violet– Wash by water– 1-2 seconds Lugol solution– Wash by water– 1 second Acetate alcohol– Wash by water
1 d S ff i– 1 second Sofframin
94
Staining : Giemsa and KOHStaining : Giemsa and KOH
• GiemsaGiemsa– Giemsa solution : Aquadest 1 : 10– 2 seconds Methanol on Fixated object glass2 seconds Methanol on Fixated object glass– Waste and add 10-15 seconds Giemsa stain– Wash by water and make it dryy y
• KOH– 1-2 drops 10% KOH on object glassp % j g– Place specimens on object glass– Covered with coverglassg
95
Ocular surface : Conjunctivaj• Follicle
– Focal lymphoid noduley p– With accessory vascularization
• Papilla– Dilated, talengiectatic conjunctival blood vessels, g j– Anchoring septa– Dot like changes to enlarged tufts, surrounded by edema and
inflammatory cells G l• Granuloma– Nodule of chronic inflammatory cells– With fibrovascular proliferation
Phl t l• Phlyctenule– Nodule of chronic inflammatory cells– Often at or near the limbus
American Academy of Ophthalmology 96
Follicle and Papillap
Area to be examined
FolliclesFollicles
Papillae
97
Follicle and Papillap
Papilla
FollicleFollicle
American Academy of Ophthalmology 98
Phlycten and Phlyctenule y yPhlycten Phlyctenule
Etiology Staphylococcus Delayed hypersesitivityEtiology Staphylococcus Delayed hypersesitivity
General condition Good Poor
Conjunctivitis + -
Location LimbusWithout progression
LimbusTo central
Age All ages ChildrenAge g
Cycatrix - +
Recurrence - +
Shape TriangularBase at limbus
TriangularApex at limbus
Therapy Topical antibiotic Steroid based on pyUnderlying disease
99
Ocular surface: Cornea
• Epithelium
Ocular surface: Cornea
Epithelium– 5-6 layer structure
50 100 µm thickness– 50-100 µm thickness– Great sensitivity
Composed– Composed• Basal cells layer• Wing cells layer• Wing cells layer• Surface cells layer
Deborah Pavan-Langston, 2008100
Ocular surface : Cornea
• Bowman’s layer
Ocular surface : Cornea
Bowman s layer– Homogenous condensation of anterior
stromal lamellae• Stroma
– 90% of corneal thickness– Bundles of collagen fibrils of uniform
thickness enmeshed in mucopolysaccharide btsubtance
– Maintain corneal clarity
Deborah Pavan-Langston, 2008 101
Ocular surface : CorneaOcular surface : Cornea
• Dua’s LayerDua s Layer– Discovered by examining the separation that
often occurs along the last row of keratocytesoften occurs along the last row of keratocytes during the big bubble (BB) technique
– Attached to the deep stromaAttached to the deep stroma– is not "residual stroma."– Distinct layer that is 10 15 ± 3 6 microns thickDistinct layer that is 10.15 ± 3.6 microns thick
between stroma and descemet membrane
102EuroTimes, 2013
Ocular surface : Cornea
• Descemet membrane
Ocular surface : Cornea
Descemet membrane– Basement membrane of the endothelial cells
Can be easily stripped– Can be easily stripped– Homogenous glasslike structure
Anterior Composed of stratified layers of– Anterior Composed of stratified layers of very finecollagenousfilamentsPosterior Amorphous layers that increases– Posterior Amorphous layers that increases with age
Deborah Pavan-Langston, 2008 103
Ocular surface : Cornea
• Endothelium
Ocular surface : Cornea
Endothelium– Single layer
5 18 µm size of approximately 500 000– 5-18 µm size of approximately 500,000 polygonal cells
– Maintain corneal deturgescence– Maintain corneal deturgescence– Contributes the formation of Descemet
membranemembrane
Deborah Pavan-Langston, 2008 104
Ocular surface : Cornea• Blood supply
– Predominantly from– Predominantly from • Conjunctival vessel• Episcleral vessel• Scleral vessel
– Arborize about the corneoscleral limbus• Innervation• Innervation
– Sensory mostly ophthalmic division of the trigeminal nerveg
– Is via long ciliary nerves that branch in the outer choroid near ora serrata region
Deborah Pavan-Langston, 2008 105
Ocular surface : KeratititisOcular surface : KeratititisMarginal k titi
Bacterial k titikeratitis keratitis
Location Peripheral Central
Size < 1 mm > 1 mm
Epithelial defect Small or absent Present
Uveitis Absent Present
Kanski JJ, 2007 106
Chemical trauma : Hudge GradeChemical trauma : Hudge Grade
I II III IVPrognosis Good Good Intermediate Poor Prognosis
Broken Epithelial Epithelial Epithelial loss Hazy cornea
Iris/Pupil Visible Visible Blurred Very blurreddetail
Ischemia None <1/3 limbus 1/3 -1/2 limbus
> 1/2 limbuslimbus
107
Corneal endothelial layerCorneal endothelial layer
• Normal 2 000 – 3 000 cells / mm²Normal 2,000 3,000 cells / mm• Stressed 800 -1,500 cells / mm²
D t 500 ll / ²• Decompensate < 500 cells / mm²
108
KeratoplastyKeratoplasty
• Penetrating Keratoplasty (PK)Penetrating Keratoplasty (PK)• Barron’s Keratoplasty• Sterile Cornea Allograft VisionGraft• Sterile Cornea Allograft VisionGraft
(TBI/Tissue Bank International)• Deep Anterior Lamellar Keratoplasty (DALK)• Deep Anterior Lamellar Keratoplasty (DALK)• Femtosecond laser-assisted Anterior Lamellar
Keratoplasty (FALK)Keratoplasty (FALK)• Femtosecond laser-assisted Descemet Stripping
Endothelial Keratoplasty (F-DSEK)dot e a e atop asty ( S )109
Keratoprostheses: Boston K ProKeratoprostheses: Boston K Pro
EuroTimes 2006 110
Keratoprostheses: AlphaCorKeratoprostheses: AlphaCor
EuroTimes 2006 111
Keratoprostheses: PintucciKeratoprostheses: Pintucci
IJO 2011 112
113
114
Refraction
115
Prof. Dr. dr. Admadi Soeroso, Sp.M, MARS
Visual acuityVi l th h ld• Visual threshold– Light discrimination
• Brightness sensitivity (minimum visible)B i ht di i i ti ( i i tibl )• Brightness discrimination (minimum perceptible)
• Brightness contrast• Color discrimination
Spatial discrimination– Spatial discrimination• Minimum separable• Vernier acuity (hyperacuity)
– Separated by little as 3-5 seconds of arcSepa a ed by e as 3 5 seco ds o a c– Considerable less than the diameter of single foveal cone– The basis of Amsler’s grid
• Minimum legible acuitiesDi t di i i ti• Distance discrimination
• Movement discrimination– Temporal discrimination
Flickering light• Flickering light
American Academy of Ophthalmology 116
Some basic acuityType Description Point acuity (1 arc minute) The ability to resolve two distinct point targets. y ( ) y p g
Grating acuity (1-2 arc minutes) The ability to distinguish a pattern of bright and dark bars from a uniform grey patch.
Letter acuity (5 arc minutes) The ability to resolve a letter. The Snellen eye chart is a standard way of measuring this ability. 20/20 vision means that a 5-minute letter target can be seen 90% of the timeseen 90% of the time
Stereo acuity (10 arc seconds) The ability to resolve objects in depth. The acuity ismeasured as the difference between two angles for a just-detectable depth difference.for a just detectable depth difference.
Vernier acuity (10 arc seconds). The ability to see if two line segments are collinear
Healey CG, 2005 117
Visual acuity in different notationFEET METERS MINIMUM ANGLE OF LOGMAR DECIMALFEET METERS MINIMUM ANGLE OF
RESOLUTIONLOGMAR DECIMAL
NOTATION20/10 6/3 0.50 -0.3 2.020/15 6/4 5 0 75 -0 1 1 520/15 6/4.5 0.75 0.1 1.520/20 6/6 1.00 0.0 1.020/25 6/7.5 1.25 0.1 0.820/30 6/9 1 50 0 2 0 720/30 6/9 1.50 0.2 0.720/40 6/12 2.00 0.3 0.520/50 6/15 2.50 0.4 0.420/60 6/18 3 00 0 5 0 320/60 6/18 3.00 0.5 0.320/80 6/24 4.00 0.620/100 6/30 5.00 0.7 0.220/120 6/36 6 00 0 820/120 6/36 6.00 0.820/150 6/45 8.00 0.920/200 6/60 10.00 1.0 0.120/400 6/120 20 00 1 3 0 00520/400 6/120 20.00 1.3 0.005
American Academy of Ophthalmology 118
Visual acuity : Developmenty pAge Visual acuity
2 months 20/400 (6/120)
6 months
1 year
20/200 (6/60)
20/100 (6/30)
2 years 20/60 (6/18)
3 years
4-5 years
20/30 (6/9)
20/20 (6/6)y ( )
Duke Elder119
Visual acuity : Various test in childrenAGE (Years) VISION TEST NORMAL
0-2 VEP 20/300-20-20 2
VEPPreferential lookingFixation behavior
20/3020/30CSM*0-2
2-52 5
Fixation behaviorAllen picturesHOTV
CSM20/40-20/2020/40 20/202-5
2-55
HOTVE-GameS ll h t
20/40-20/2020/40-20/2020/30 20/205+ Snellen chart 20/30-20/20
* CSM Method : Refers to Corneal light reflex, Steadiness of fixation and Maintain alignmentMaintain alignment
American Academy of Ophthalmology 120
Light : BasicLight : Basic
• Wavelength of visible light 380-760nmWavelength of visible light 380 760nm• Velocity of light waves
300 000 k / d– 300.000 km/second or– 86.000 mils /second
• Character of light– Hue– Saturation– Brightness or Luminance
121
Illumination • Radiometry
Measures term of power– Measures term of power– Irradiance = watts per square meter, lamberts
• Sunny day = 10,000 – 30,000 foot lamberts• PhotometryPhotometry
– Measures units based on the response of the eye– 1 candela = 12.6 lumens– Illuminance = lumens per square meterIlluminance lumens per square meter– Luminance of surface is amount of light that reflected or emmited– Apostlib surface perfectly emitting or reflecting 1 lumen per
square meter– Ideally 100 watt lamp bulb provides about minimum
• 600 foot candles 3 feet away• 150 foot candles 6 feet away
American Academy of Ophthalmology 122
Photobiologygy• Scotopic vision is the monochromatic vision of the eye
in low light. Since cone cells are nonfunctional in lowin low light. Since cone cells are nonfunctional in low light, scotopic vision is produced exclusively through rod cells so therefore there is no color perception. Scotopic vision occurs at luminance levels of 10-2 to 10-6 cd/m².vision occurs at luminance levels of 10 to 10 cd/m .
• Mesopic vision occurs in intermediate lighting conditions (luminance level 10-2 to 1 cd/m²) and is effectively a combination of scotopic and photopic visioneffectively a combination of scotopic and photopic vision. This however gives inaccurate visual acuity and color discrimination.Ph t i i i I l li ht (l i l l 1 t• Photopic vision In normal light (luminance level 1 to 106 cd/m²), the vision of cone cells dominates good visual acuity (VA) and color discrimination
Lars Olof Björn, 2002 123
The cone cells
• Sharp photoreceptor• A human eye can see wavelengths in the range of 380 to
760nm. This range is called the visible region • Trichromatic Theory 3 types of cones, each with a y yp ,
different iodopsin (a photosensitive pigment)• Each type of iodopsin can absorb and respond to a
range of wavelengthsrange of wavelengths• Photosensitive pigments
– Erythrolabe maximum absorption at 565nm (red) Chl l b i b ti t 535 ( )– Chlorolabe maximum absorption at 535nm (green)
– Cyanolabe maximum absorption at 440nm (blue)
124
Visible lightVisible light
Hue Wavelength (nm)Indigo 400-450gBlue 450-480Cyan-Blue 480-510Green 510-550Yellow-Green 550-565Yellow 565-590Yellow 565 590Orange 590-630Red 630-700
125
Chromatic aberrationChromatic aberration
• The type of error in an optical system in which the formation of a series of colored images occurs, even though only white light enters the systemthough only white light enters the system.
• Chromatic aberrations are caused by the fact that the refraction law determining the path of light through an optical system contains the refractive index which is aoptical system contains the refractive index, which is a function of wavelength.
• Thus the image position and the magnification of an optical system are not necessarily the same for all wavelengths, nor are the aberrations the same for all wavelengths
126
Chromatic aberrationChromatic aberration
• Short wavelength light focusedShort wavelength light focused more anterior than long
l th li htwavelength light• Violet focused more anterior• Violet focused more anterior
than Red127
Spherical aberrationSpherical aberration
• A blurred image that occurs when light from the margin of a lens or g gmirror with a spherical surface comes to a shorter focus than light from theto a shorter focus than light from the central portion.
• Also called dioptric aberration
128
Spherical aberrationSpherical aberration
• A perfect lens (top) focuses all incoming rays to a point on the optic axisoptic axis
• A real lens with spherical surfaces (bottom) suffers from spherical aberration
• It focuses rays more tightly if they enter it far from the optic axis than if they enter closer to the axisthe axis
• It therefore does not produce a perfect focal point
129
Spherical aberrationSpherical aberration
• Mirror spherical aberrationaberration
• Reflective Caustic d fgenerated from a
circle and parallel rays
130
Accommodation tableAge (years) Rate of Accommodation (Diopters)
8 13.825 9.95 9 935 7.340 5 840 5.845 3.650 1.955 1.3
Vaughan DG 131
Refractive index (Helium D Line)Refractive index (Helium D Line)
• Air 1.000• Water 1.333• Cornea 1.376• Aqueous and vitreous 1 336• Aqueous and vitreous 1.336• Spectacle crown glass 1.523
PMMA 1 492• PMMA 1.492
American Academy of Ophthalmology 132
Refracting power (D)• Corneal system 43.05
– Anterior surface 48.83Anterior surface 48.83– Posterior surface - 5.88
• Lens system– Relaxed 19.11
Maximum accommodation 33 06– Maximum accommodation 33.06
• Complete optical systemComplete optical system– Relaxed 58.64– Maximum accommodation 70.57
American Academy of Ophthalmology 133
DIOPTER CONVERTION - MILIMETERDIOPTER CONVERTION MILIMETER
KK
Radius (mm)
Reading (D)
Radius (mm)
Reading (D)
KK
7.307 34
46.2546 00
7.077 11
47.5747 50
(mm)(D)(mm)(D)
7.347.387 42
46.0045.7545 50
7.117.147 18
47.5047.2547 00 7.42
7.4645.5045.25
7.187.22
47.0046.75
7.5045.007.2646.50134
Pinhole visual acuity measurementPinhole visual acuity measurement
• If visual acuity improves refractive errorIf visual acuity improves refractive error usually present
• Disease of macula• Disease of macula – Unable to adapt to amount of light through the
pinholepinhole– Visual acuity can decrease markedly
M t f l 1 2• Most useful 1.2 mm– Refractive error – 5.00 to + 5.00 D
American Academy of Ophthalmology 135
RefractionRefraction
CommonCommon Disorder Mild Moderate Severe
1 00 t 4 00 4 00 t 6 00 6 00 d bMyopia -1.00 to – 4.00 Diopters
-4.00 to – 6.00 Diopters
-6.00 and above Diopters
Hyperopia +1.00 to +2.00 Diopters
+2.00 to +4.00 Diopters
+4..00 and above Diopters
Astigmatism -1.00 to –2.00 Diopters
-2.00 to -4.00 Diopters
-4.00 and above Diopters
136
RefractionRefraction
• Myopia (Nearsightedness)Myopia (Nearsightedness)– Pathophysiology
• Axial Curvature Increased index of refraction• Axial, Curvature, Increased index of refraction– Severity
• Mild Moderate HighMild, Moderate, High– Clinical
• Simplex/Stationary, Progressive, MalignantSimplex/Stationary, Progressive, Malignant
Deborah Pavan-Langston, 2008 137
Myopiay p• Children born myopic small percentage not become
emmetropic by age 6-8 yearsP i l t i hild h i b i• Previously emmetropic children or hyperopic may become myopic– Hyperopes greater than +1.50 D rarely become myopic and may
become more hyperopic• Prevalence of myopia begins to increase at about age of 6 yearsy p g g y• Juvenile-onset myopia
– 7-16 years of age– Primarily due to growth in globe axial length
L t i i i l t 9 10 d i b t 11 12– Largest increase in girls at age 9-10 years and in boys at age 11-12 years
– Usually stops in middle teen years, 15 for girls and 16 for boys• Myopia starting after 16 is less severe and less commony p g• Adult-onset myopia
– Begins at about 20 years of age– Risk factor extensive near work
American Academy of Ophthalmology 138
Significant myopia in childhoodg y p• Cycloplegic refraction are mandatory• Full refractive error, including cylinder, should be corrected• Young children tolerate cylinder wellYoung children tolerate cylinder well• On theory prolonged accommodation increase development of
myopia– Some undercorrection myopia
S bif l ith ith t At i– Some use bifocal, with or without Atropine• Parents should be educated about
– Progression of myopia– Need for frequent refractionNeed for frequent refraction– Possible prescription changes
• Contact lenses older children avoid problem of image magnification by high minus lensesI t ti l d ti f i t d th• Intentional undercorrection for myopic esotrope decrease the angle of deviation well tolerated
• Intentional overcorrection for myopic error controlling exodeviation (some value)( )
American Academy of Ophthalmology 139
Refraction• Hypermetropia (Farsightedness)
– Structural • Axial, Curvature, Index of refraction
– AccommodativeAccommodative• Latent, manifest, total
– Severity
Uncorrected can causes• Strabismus Esotropia• Ambliopia
Deborah Pavan-Langston, 2008 140
Correcting hyperopia in childhoodCorrecting hyperopia in childhood
• No esodeviation and reduced vision NOT necessary correcting low hyperopia
• Significant astigmatic error must be fully dcorrected
• Hyperopia coexists esotropia full correction of the cycloplegic refractive errorthe cycloplegic refractive error
• In a school age child full correction may cause blurred visioncause b u ed s o– Because inability to relax accommodation fully– A short course of cycloplegia may help
American Academy of Ophthalmology 141
Clinical refractionClinical refraction• Refraction approach ARK• Subjective Trial and error by trial optical• Subjective Trial and error by trial optical
lenses• Objective Streak retinoscopy
– Characteristic of reflex• Speed• Brilliance• Width
– Four characteristic of STREAK reflex• Break• Width• Intensity• Skew
American Academy of Ophthalmology 142
Streak retinoscopyStreak retinoscopy
Neutralization
With
Againstga s143
Finding Neutrality• In against movement, the far point is between the examiner and the
perfect therefore, to bring the far point to the examiner’s pupil, minus, lenses should be placed in front of the patient’s eye.lenses should be placed in front of the patient s eye.
• Similarly, in the case of with movement plus lenses should be placed in front of the patient’s eye.
• Similarly, in the case of with movement, plus lenses should be placed in front of the patient’s eyefront of the patient s eye.
• This leads to the simple clinical rule: if you see with motion, add plus lenses (or subtract minus); if you see against motion, add minus lenses(or subtract plus). Lens power should be added (or subtracted) until neutrality is reached y
• Since it is considered easier to work with the brighter, sharper with image, it is preferable to overminus the eye and obtain a with reflex and then reduce the minus (add plus) until neutrality is reached.
• Be aware that the slow, dull reflex and then reduce the minus ,refractive errors may be confused with the pupil-filling neutrality reflex or with dull reflexes (as seen in patients with hazy media).
• Place high-power plus and minus lens over the eye and look again.
American Academy of Ophthalmology 144
Finding Neutralityg y
145
Finding the cylinder axisg y• Before retinoscope is used to measure the powers in
each of the principal meridians, the axes of the p pmeridians must be determined.
• Characteristics of the streak reflex can aid in determining axis.– Break. A break is seen when the streak is not parallel to one of
the meridians. The are projecting the line is discontinuous, or broken. The break disappears (ie, the line appears continuous) when the streak is rotated on to the correct axis. The correcting gcylinder should be placed at this axis.
– Width. The width of the streak varies as it rotated around the correct axis. It appears narrowest when the streak aligns with the axisthe axis
– Intensity. The intensity of the line is brighter when the streak is on the correct axis. (This is a subtle finding, useful only in small cylinders)
American Academy of Ophthalmology 146
Finding the cylinder axisg y
American Academy of Ophthalmology 147
Finding the cylinder axisg y
148
Finding the cylinder axisg y
American Academy of Ophthalmology 149
Finding the cylinder axisg y
150American Academy of Ophthalmology
Finding the cylinder axisg y
151American Academy of Ophthalmology
Finding the cylinder power• Once the two principal meridians are identified, the axis separately
in turn.• With two spheres• With two spheres.
– Neutralize one spherical lens. If the 90º axis is neutralize with a +1.50 sphere and the 180º axis is neutralized with a +2.25 sphere, the gross retinoscopy would be +1.50 + 0.75 x 180. The examiner’s working distance should be subtracted from the sphere to obtain the refractivedistance should be subtracted from the sphere to obtain the refractive correction.
• With a sphere and cylinder. – Neutralize one axis with spherical lens. To continue working using with
reflexes neutralize the lens plus axis first Then with this spherical lensreflexes, neutralize the lens plus axis first. Then, with this spherical lens in place, neutralize the axis 90º away by adding a plus cylindrical lens directly from the trial lens application. The spherocylindrical gross retinoscope can be read directly from the trial lens application.
• It is also possible to use two cylinders at right angles to each other• It is also possible to use two cylinders at right angles to each other for this gross retinoscopy ; however, this variant does not seem to provide any advantages over the other methods.
American Academy of Ophthalmology 152
Aberrations of the Retinoscopic Reflex
• With irregular astigmatism, almost any type of aberration may appear in the reflex.
• Spherical aberration tend to increase the brightness at the center or periphery of the pupil, depending on whether the aberrations are positive or negative.
• As the point of neutrality is approached one part of the reflex may• As the point of neutrality is approached, one part of the reflex may be myopic while the other is hyperopic relative to the position of the retinoscope. This will produce the scissors reflex.
• Sometimes a marked irregular astigmatism or optical opacity produces confusing distorted shadows that can markedly reduceproduces confusing, distorted shadows that can markedly reduce the precision of the retinoscopic result. In such as subjective refraction should be used.
• All of these aberrant reflexes become more noticeable with larger ill di I h id i h l ipapillary diameters. In these cases, considering the central portion
of the light reflex yields the best approximation.
153American Academy of Ophthalmology
Summary of retinoscopy1. The steps below summarize how to performing streak retinoscopy using
a plus cylinder phoropter. Set the phoropter to 0 D sphere and 0 D cylinder Use cycloplegia if necessary Otherwise fog the eyes or use acylinder. Use cycloplegia if necessary. Otherwise, fog the eyes or use a non accommodative target.
2. Hold the sleeve of the retinoscope in the position that produces a divergent beam of light. (If the examiner can focus the linear filament of the retinoscope on a wall the sleeve is in the wrong position)the retinoscope on a wall, the sleeve is in the wrong position).
3. Sweep the streak of light (the intercept) across the pupil perpendicular to the long axis of the intercept and watch the papillary light reflex. Sweep in several different meridians. Use the right eye to examine the patient’s right eye, and use the left eye to examine the patient’s left eye.right eye, and use the left eye to examine the patient s left eye.
4. Add minus sphere (dial up on a phoropter) until the retinoscopic reflex shows with motion in all meridians. Add a little extra minus sphere if uncertain. If the reflex are dim or indistinct, consider high refractive errors and make large changes in sphere (-3 D, -6 D, -9 D, etc).g g ( )
5. Add plus sphere (dial down on a phoropter) until the retinoscopic reflex neutralizes or shows a small amount of residual with motion in one meridian. If all meridians neutralizes simultaneously, the patient’s refractive error is spherical. Proceed to step 9.
154American Academy of Ophthalmology
Summary of retinoscopy6. Rotate the streak 90º and set the axis of the correcting plus cylinder
parallel to the streak. Sweep this meridian to reveal additional with motion. Add plus cylinder power until the remaining with motion is neutralized Now the retinoscopic reflex should be neutralized in all
y py
neutralized. Now the retinoscopic reflex should be neutralized in all meridiens simultaneously.
7. Refine the correcting cylinder axis by sweeping 45º to either side of it. Move in slightly closer to the patient to pick up with motion. Rotate the axis of the correcting plus cylinder a couple of degrees toward the “guide”axis of the correcting plus cylinder a couple of degrees toward the guide line, the brighter and narrower reflex. Repeat until both reflexes are equal.
8. Refine the cylinder power by moving in closer to the patient to pick up with motion in all directions. Back away slowly, observing how thewith motion in all directions. Back away slowly, observing how the reflexes neutralize. Change sphere or cylinder power as appropriate to make all meridians neutralize simultaneously.
9. Subtract the working distance. If working at 67 cm, subtract 1.5 D. if the examiner’s arms are short or the examiner prefers working closer, the p g ,appropriate dioptric power for the distance chosen should be subtracted.
10. Record the streak retinoscopy findings and, if possible, check the patient’s visual acuity after he or she has had time to wear the prescription and readjust to ambient room light.
155American Academy of Ophthalmology
Retinoscopy: Final correctionRetinoscopy: Final correction
• If we use working lenses Another correcting lenses Final correction
• If for example in 50 cm working distance, we use S +2.00 working lenses, and wewe use S 2.00 working lenses, and we get: Horizontal S -6.00 and Vertical S -3.00, the Final correction:3 00, t e a co ect o
– S -6.00 C +3.00 A 90 or,– S -3 00 C +3 00 A 180S 3.00 C +3.00 A 180
156
LensesLenses
• Meniscus Lens or Curve Lens Lens withMeniscus Lens or Curve Lens Lens with one spherical convex surface and the other spherical concave. Meniscus lenses often have a base of 6 D for the surface of lesser curvature.
• Polarizing Lens A lens that transmits light waves vibrating in one direction only. In the other direction perpendicular to it, the light waves are absorbed In this way reflected glarewaves are absorbed. In this way reflected glare is reduced.
157
The Basic LensesThe Basic Lenses
(A), biconvex; (B), biconcave; (C), planoconvex; (D), plano concave; (E),concavoconvex, periscopic convex, converging meniscus; (F), convexoconcave, periscopic concave, diverging meniscus;(G, H), cylindrical lenses, concave and convex.
158MedDict 2007
Sphere lensesSphere lenses
159
Sphere Lens
Plano Convex Lenses Plano Concave Lenses
g, 2
006
Biconvex Lenses Biconcave Lenses
hun
Jixi
ang
Cha
ngch
CaF2 Lenses Meniscus Sphere Lenses
160
Spheric correctionSpheric correction
• Least minus for myopiaLeast minus for myopia– More minus forces contraction of cilliary
muscles for unnecessary accommodationmuscles for unnecessary accommodation Fatigue
• Most plus for hyperopesMost plus for hyperopes– Less plus retains accommodation
161
Spherical aberrationsSpherical aberrations
• More peripheral rays focused anteriorlyMore peripheral rays focused anteriorly• Exacerbates myopia in low light (night
myopia) about – 0.50 Dmyopia) about 0.50 D• Increase as fourth power of pupil diameter
– Small pupil can cause better visionSmall pupil can cause better vision• Can also occurs following refractive
surgerysurgery– Aspheric cornea becomes more spherical
American Academy of Ophthalmology 162
Achromatic lensesAchromatic lenses• Achromatic Lenses consist of two or more elements, usually of
crown and flint glass that have been corrected for chromaticcrown and flint glass that have been corrected for chromatic aberration with respect to two selected wavelengths.
• Most company provides achromatic lenses consisting of two elements.
• These lenses have considerably reduced not only chromatic aberration bust also spherical aberration and coma aberration.
• These are designed with respect to three wavelength 480nm, 546 1nm and 643 8nm546.1nm and 643.8nm.
• They are best used in replacing singlet where improved performance is required. – Positive Achromatic Lenses– Negative Achromatic Lens
Changchun Jixiang, 2006 163
Achromatic lensesAchromatic lenses
Positive Achromatic Lenses Negative Achromatic Lenses
Changchun Jixiang, 2006 164
Astigmatismg• Classified as
Sh– Shape • Regular astigmatism
– With the ruleWith the rule» Common in children» Vertical meridians is steepest
A i 90º» Axis near 90º– Against the rule opposite
» Older adult
• Irregular astigmatism– Rigid contact lenses may be useful
American Academy of Ophthalmology 165
Circle of least confusion
Conoid of Sturm 166
Cylinder lensesy
167
Cylinder lenses
Plano Convex Cylindrical Lenses Plano Concave Cylindrical Lenses
Biconvex Cylindrical Lenses Biconcave Cylindrical Lenses
Changchun Jixiang, 2006
Meniscus Cylindrical Lenses
Changchun Jixiang, 2006
168
Cylinder axisCylinder axis
169American Academy of Ophthalmology
Astigmatic dial techniqueAstigmatic dial technique• Obtain best visual acuity using SPHERES onlyy g y• FOG the eye to about 20/50 by adding PLUS
sphere• Note the BLACKEST and SHARPEST line of• Note the BLACKEST and SHARPEST line of
the astigmatic dial• Add MINUS CYLINDER with axis
PERPENDICULAR to the blackest and sharpest line (Rotate minus cylinder if necessary) until all lines APPEAR EQUALes QU
• REDUCE plus sphere or ADD minus until best acuity is obtained with the visual acuity chart
170American Academy of Ophthalmology
Astigmatic correctiong• For children full correction with correct axis• For adult adaptable full correction• For adult adaptable full correction• Reduce distortion
– Use minus cylindery– Minimize vertex distance– Rotate axis toward 180º or 90º – Reduce cylinder power and use spherical equivalentReduce cylinder power and use spherical equivalent
• Spatial distortion is binocular phenomenon occlude one eye to verify
• If fail to reduce distortion use contact lenses or iseikonic corrections
171American Academy of Ophthalmology
Toric lenses
172American Academy of Ophthalmology
Toric lensesToric lenses
• Shaped like a section through a rugby ballP ib d t t ti ti • Prescribed to correct astigmatism contact lenses and IOLs
• Toric lenses can be plus, minus, one principle meridian plus with the other minus
• Referred as Spherocylinder lensesp y173
Prism lensesPrism lenses
174
Prisms aberrationPrisms aberration
• In addition to chromatic aberrationIn addition to chromatic aberration• Producing colored fringes at the edges of
objects viewed through the prismobjects viewed through the prism• Other aberration
– Asymmetrical magnification of fieldAsymmetrical magnification of field– Asymmetrical curvature of field
• Usually insignificant but produceUsually insignificant but produce symptoms even with low-power ophthalmic prisms.p p
175American Academy of Ophthalmology
Prismatic effect of decentred lensPrismatic effect of decentred lens
• Convex lens twoConvex lens two prisms cemented together at their BASEBASEs
• Concave lens two prisms cemented
Decrease convergenceprisms cemented together at their APEXs
• Decentred lens Prism effect Base in or Base outin or Base out
Increase convergence
BifocalsBifocals
• A lens having oneA lens having one section that corrects for distantcorrects for distant vision and another section thatsection that corrects for near visionvision.
177
BifocalsBifocals
The dot indicates the optical centre of the near portion A, executive-type segment; B, flat-top segment; C, round segment; D d
178
D, curved segment
MedDict 2007
TrifocalsTrifocals
• Three prescription powers: a distance power, a mid-range power, and a near power.
• The distance power helps to see things at a distance, the mid-range power helps to see things at intermediate distances and the near powerpower helps to see things at intermediate distances, and the near power corrects vision close up.
• Tri-focal lenses are available in a variety of options, including thin and light lenses, impact resistant lenses and transition lenses (lenses thatlight lenses, impact resistant lenses and transition lenses (lenses that change from light to dark).
179MedDict 2007
Progressive LensProgressive Lens• Characterized by a gradient of
increasing lens power added toincreasing lens power, added to the wearer's correction for the other refractive errors.
• The gradient starts at a minimum, or no addition power, at the top of the lens and reaches a maximum addition power, magnification, at the bottom of the lens.
• The length of the progressive• The length of the progressive power gradient on the lens surface is usually between 15 and 20 mm with a final addition power between 1 00 to 3 00power between 1.00 to 3.00 dioptres.
180MedDict 2007
Transposition
181
S - 6.00 C + 3.00 A 90º- 6.00 0.00
- 6.00- 6.00 +3.00+3.00
- 6.00 0.00
- 6.00
Make the- 3.00- 3.00
Make the transposition of it
- 6.00182
Transposition • New sphere is the ALGEBRAIC SUM of old sphere and
cylinder• New cylinder is same value with old cylinder but with• New cylinder is same value with old cylinder, but with
OPOSITE sign• Change axis of cylinder by 90º
S - 6 00 C + 3 00 A 90ºS 6.00 C 3.00 A 90
S - 3.00 C - 3.00 A 180º
IS IT SAME OR EQUAL ??? 183
S - 3.00 C -3.00 A 180º- 3.00 - 3.00
- 3.00- 3.00 0.000.00
- 3.00 - 3.00
- 6.00
- 3.00- 3.00EQUAL
- 6.00184
Is your correction correct?y• Duke Elder add + 0.25 or – 0.25 D
I i bl d ill l ?– Is it blurred or still clear ?– Smaller, darker, farther away or any such change
• Duochrome test RAM-GAP• Duochrome test RAM-GAP– Red add minus, green add plus
Binocular balance• Fogging• Prism dissociation• Cycloplegics
American Academy of Ophthalmology 185
Refraction : Correction• Spectacle / glass• Contact lenses• Keratorefractive surgery• Keratorefractive surgery
– RK Radial keratotomy– PRK Photo Refractive Keratotomy / Keratectomy– Laser Thermal Keratoplasty– LASIK (Laser-assisted in-situ Keratomileusis), EpiLASIK – SBK Sub-Bowman Keratomileusis– LASEK Laser-assisted Sub-Epithelial Keratomielusis– LaserACE Restoring accommodative abilityLaserACE Restoring accommodative ability– CK Conductive Keratoplasty Radio-frequency-based Collagen
shrinking procedures– Arcuate keratotomy
Intrastromal corneal ring– Intrastromal corneal ring
• IOL– AC Lens, Claw lens (25-6) Artisan (Ophtec), Verisyse (Abbott , ( ) ( p ), y (
Medical Optics), STAAR Visian ICL and Toric ICL– Posterior lens by CLE / RLE (>13) 186
Corneal Collagen Cross-Linkingg g• Corneal thermal remodeling (also) can be induced by
Micro a e Keratoplast treat Keratocon s andMicrowave Keratoplasty treat Keratoconus and Refractive Errors
• UV radiation accelerates corneal stiffening by riboflavinriboflavin
• Cross-linking occurs between collagen helix, aminoglycans and other substances in corneal substrateD li i “C t ll d I lt” t St l C ll Fib• Delivering “Controlled Insult” to Stromal Collagen Fibers bellow epithellium and Bowman’s layer change shape without cutting.Fatten the cornea after Lasik or incisional surgery• Fatten the cornea after Lasik or incisional surgery
• Achieve corneal rigidity equivalent to 600 years of natural ageing
Marshall J, 2010 187
Corneal Collagen Cross-Linkingg g
• Older procedure 30 minutes riboflavin soaks and 30 minutes UV pexposure potential endothelial damage, complication to lens and retina
• Newer procedure 2 minutes riboflavin soaks and 3 minutes UV exposure with mask-covered protection at peripheral and central of the cornea protecting endothel, corneal stem cells, lens and retina Keraflex KCL (A d )(Avedro)
Marshall J, 2010 188
Contact Lenses FittingContact Lenses Fitting
189
Contact lenses : MaterialsContact lenses : Materials
1 HEMA (Hydroxyethyl methacrylate)1. HEMA (Hydroxyethyl methacrylate) 2. Non HEMA Hydrogel lenses Hydrophyllic3. HEMA + PVP (Polyvinylpyrrolidone) ( y y py )
- To increase water holding ability , - PVP Yellowing by age / heat disinfection
4 HEMA MMA (M th l th l t )4. HEMA + MMA (Methylmethacrylate) - To increase stiffness.
Lens more durable- Lens more durable. - The pores are smaller than any known
bacterium or virus
190
Contact Lenses Fitting• Base curve
– Radius of curvature to be cut on the posterior surface of the lens– Minimal apical clearance
Guided by the K measurements along two principal meridians– Guided by the K measurements along two principal meridians– Selected to ensure a comfortable and healthy fit for patients– Range from 8.40 mm (40.25 D) to 7.00 (48.25 D)
• Diameter– Optical zone range between 6.0 – 8.0 mm– Central thickness less than 0.10 mm
• Peripheral curveCurve radii range between 8 40 13 00 mm– Curve radii range between 8.40 – 13.00 mm
– Curve width 0.10 – 0.45 mm• Power• Lens surface designLens surface design
– Spherical lens– Back surface toric lens– Front surface toric lens
Bit i– Bitoric
191American Academy of Ophthalmology
The Contact Lenses
Peripheral curve width
Base curve Peripheral curve radiiOptic zone
Peripheral curve width
Center thickness 192
VERTEX DISTANCE CORRECTIONVERTEX DISTANCE CORRECTIONVertex Distance (mm)
1311 121311 12 10
Plus LensesMinus LensesContact Lens Power
10Spectacle Power (D)
4.254.75
4.124.75
3.754.25
3.874.25
4.254.75
3.874.25
4.124.75
Plus Lenses
3.874.25
4.004.50
Minus Lenses
5.375.876.50
5.255.876.37
4.755.125.50
4.755.125.62
5.255.876.50
4.755.125.62
5.255.756.37
4.755.255.62
5.005.506.00
7.127.758.25
7.007.628.12
6.006.377.25
6.006.506.87
7.007.628.25
6.006.506.87
7.007.508.12
6.126.507.00
6.507.007.50
8.878.757.627.37 8.877.25 8.757.378.00
193
FITTING STEPS
Good fitGood fit1. Sufficient movement
2. Proper centration
3. Stable vision
4 Sharp retinoscopic reflex4. Sharp retinoscopic reflex
5. Clear keratometry mires
194
FITTING STEPSFITTING STEPS
Tight fit
1 Vision fluctuates (clears briefly after blink)1. Vision fluctuates (clears briefly after blink)2. Bubbles trapped under the lens3. Declining comfort over a span of hours as the lens is worn4. A burning sensation following by redness or an indication
appearing around the corneal circumference5. Restricted or no movement of the lens6. Keratometry mires that are distored, but clear on blinking7. A fuzzy retinoscope reflex that clears on blinking
195
FITTING STEPSFITTING STEPSLoose fit
1. Variable vision (briefly clears after blinking)2 Bothersome lens awareness2. Bothersome lens awareness3. Lack of centration4. Too much movement5 L d t d ff l d t t th l5. Lens edge stand off lens decenter onto the sclera7. Bubbles forming under the lens edge8. Keratometry mires that are clear, but blurs on blinking,
and than clear 9. A clear retinoscopic reflex, that blurs after blinking
196
197
Toric contact lensesToric contact lenses
• An astigmatic eye is not perfectly round (like a soccer ball) but more shaped like a rugby ball. O i f l i h l f• One-in-four people with low amounts of astigmatism can get away with wearing normal (spherical) contact lenses(spherical) contact lenses.
• A person with higher amounts of astigmatismneeds to wear special contact lenses called toric lenses
198
What makes a toric contact lens different?at a es a to c co tact e s d e e t
• If you think of the eye as a rugby ball, that ‘rugby ball’ is y y g y , g ypositioned at a certain angle in the eye socket.
• In order for the contact lens to correct astigmatism, it needs to lie at that same angle in front of the eyeneeds to lie at that same angle in front of the eye.
• Usually contact lenses rotate on the eye with each blink. A toric contact lens is designed in such a way, that it won’t rotate on the eyewon t rotate on the eye.
• Most toric lenses are made slightly thicker at the bottom of the lens.
• The thicker part will weigh the lens down at the bottom, preventing it from turning on the eye.
199
Radial Keratotomy
200
Laser Thermal Keratoplasty
201
Laser-assisted in situ KeratomileusisLaser assisted in situ Keratomileusis
202
Laser-assisted Sub-Epithelial Keratomileusis
203
Arcuate Keratotomy
204
Intrastromal Corneal Ring
205
AniseikoniaAniseikonia• Translated from Greek aniseikonia meansTranslated from Greek aniseikonia means
"unequal images".• It is a binocular condition so the image in• It is a binocular condition, so the image in
one eye is perceived as different in size compared to the image in the other eyecompared to the image in the other eye.
• Two different types of aniseikonia can be diff ti t d t ti d d idifferentiated: static and dynamic aniseikonia
206
AniseikoniaAniseikonia• Static aniseikonia or• Static aniseikonia or
aniseikonia in short means that in a static situation where the eyes are gazing in a certaineyes are gazing in a certain direction
• The perceived (peripheral) images are different in sizeimages are different in size
207
Aniseikonia : StaticAniseikonia : Static
208
AniseikoniaAniseikonia• Dynamic aniseikonia or (optically• Dynamic aniseikonia or (optically
induced) anisophoria means that th h t t t diff tthe eyes have to rotate a different amount to gaze (i.e. look with the sharpest vision) at the same point in spacep
• This is especially difficult for eye rotations in the vertical directionrotations in the vertical direction
209
Aniseikonia : DynamicAniseikonia : Dynamic
210
AniseikoniaAniseikonia
Schematic presentation of the different steps to get to a perceivedSchematic presentation of the different steps to get to a perceivedimage size and the visualization of a field angle α
211
AniseikoniaAniseikonia
Features : a) Example of a single aniseikonia test image, b) same aniseikonia test image as on the left, but now with an (exaggerated) vertical fixation g , ( gg )
disparity compensation (click on image to enlarge). 212
AnisophoriaAnisophoria• Is a condition in which the balance of theIs a condition in which the balance of the
vertical muscles of one eye differs from that of the other eye the visual lines dothat of the other eye the visual lines do not lie in the same horizontal plane
• Eye muscle imbalance the horizontal• Eye muscle imbalance the horizontal visual plane of one eye is different from that of the otherthat of the other
213
Amblyopiay pType :
St bi i bl i• Strabismic amblyopia– Frequently in esotropia patients
A i t i (R f ti ) bl i• Anisometropic (Refractive) amblyopia– Difference in refraction greater than 2.50 D
• Isoametropic amblyopia• Isoametropic amblyopia– Bilateral refractive error grater than + 5.00 or – 10.00 D
• Deprivation amblyopia• Deprivation amblyopia– Caused by such as media opacities
Deborah Pavan-Langston, 2008214
CyberSight, 2003
215
216
Strabismus
217
Position of gazeg• Primary position
– Straight ahead• Secondary position
– Straight up, straight down– Right gaze, left gaze
• Tertiary position Four oblique position– Up and right, up and left– Down and right, down and left
• Cardinal position
218American Academy of Ophthalmology
Cardinal position and Yoke musclesCardinal position and Yoke muscles
RSRLIO
LSRRIO
RLRLMR
LLRRMRRight Gaze Left Gaze
RIR LIRRIRLSO RSO
219American Academy of Ophthalmology
Eye movementEye movement• Agonist
– Primary muscle moving the eye in a GIVEN direction• Synergist
– Muscle in the same eye– As the agonist– That can act with agonist– Produce a GIVEN movement
E S i t ith I f i bli l t th– E.g : Superior rectus with Inferior oblique elevate the eye• Antagonist
– Muscle in the same eyeA th i t– As the agonist
– That can act with in the direction opposite – E.g : Medial rectus and lateral rectus
220American Academy of Ophthalmology
Basic • Sherrington’s law for reciprocal innervation
Increased innervation and contraction of GIVEN– Increased innervation and contraction of GIVEN EOM
– Accompanied by reciprocal decrease of innervation f Oand contraction of its antagonist EOM
• Yoke muscleYoke muscle– Two muscle (one in each eye)– Are Prime mover of their respective eyes– In GIVEN position gaze– E.g : right gaze RLR and LMR simultaneously
innervated and contracted to be “yoked” togetherinnervated and contracted to be yoked together
221American Academy of Ophthalmology
Basic
• Hering’s law of motor correspondence
Basic
Hering s law of motor correspondence– The state equal and simultaneous
innervation flow to Yoke muscleinnervation flow to Yoke muscle– Concerned with the desired direction of the
gazegaze
222American Academy of Ophthalmology
EOM : FunctionsMuscle Primary Secondary Lateral rectus Abduction NoneLateral rectus Abduction None
Medial rectus Adduction None
Superior rectus Elevation AdductionIntorsion
Inferior rectus Depression AdductionInferior rectus Depression AdductionExtorsion
Superior oblique Intorsion DepressionAbduction
Inferior oblique Extorsion ElevationAbductionAbduction
Vaughan DG 223
EOM : OriginMuscle Origin Functional
i i
g
originLateral rectus Annulus of Zinn Annulus of Zinn
M di l t A l f Zi A l f ZiMedial rectus Annulus of Zinn Annulus of Zinn
Superior rectus Annulus of Zinn Annulus of Zinn
Inferior rectus Annulus of Zinn Annulus of Zinn
Superior oblique Orbit apex above Trochlea Annulus of Zinn
Inferior oblique Behind lacrimal fossa Behind lacrimal fossa
American Academy of Ophthalmology 224
EOM : Insertion from limbusEOM : Insertion from limbus
• Medial rectus 5 5 mm• Medial rectus 5.5 mm• Lateral rectus 6.9 mm• Superior rectus 7.7 mmSuperior rectus 7.7 mm• Inferior rectus 6.5 mm
225American Academy of Ophthalmology
EOM : Wide and LengthEOM : Wide and Length
• Superior Rectus 5.0 mm and 41.8 mmSuperior Rectus 5.0 mm and 41.8 mm• Inferior Rectus 4.2 mm and 40 mm• Lateral Rectus 6 5 mm and 40 6 mmLateral Rectus 6.5 mm and 40.6 mm• Medial Rectus 4.0 mm and 40.8 mm• Superior Oblique 1 2 mm and• Superior Oblique 1-2 mm and
– Muscle part 40 mm– Tendineus part 20 mmTendineus part 20 mm
• Inferior Oblique 1-2 mm and 37 mm
Kumar SM 2007 226
EOM : GazesUp and right RSR - LIO
Up and left LSR – RIO
Right RLR – LMR
Left LLR - RMRLeft LLR - RMR
Down and right RIR - LSO
Down and left LIR - RSO
Vaughan DG 227
Eye movementEye movement• Versions
– Eyes move in the same direction
• Vergences Disconjugate binocular eye• Vergences Disconjugate binocular eye movement– Convergence 15-20 ∆ distance and 25 ∆ for near– Divergence 6-10 ∆ distance and 12-14 ∆ for near– Incyclovergence 2-3º– Excyclovergence y g– Vertical vergence 2-3 ∆
228American Academy of Ophthalmology
Eye movement : Supranuclear control systemEye movement : Supranuclear control system
• Saccadic systemG t ll f t t fi ti– Generates all fast eye movements or refixation
– Up to 400-500º/sec• Smooth pursuit
– Generates all following or pursuit eye movementsGenerates all following, or pursuit, eye movements– Pursuit latency is shorter than for saccades– Maximum velocity 30-60º/sec
• The vergence system– Controls disconjugate eye movements
• The position maintenance– Maintains a specific gaze position– Allowing an object to interest to remain on the foveaAllowing an object to interest to remain on the fovea
• The non optic reflex– Integrated eye movement with the body movement– Most important system is Labyrinthine system
229American Academy of Ophthalmology
Variation of deviation
With gaze position or fixating eye• Comitant (Concomitant)
– Deviation doesn’t vary in size with direction of gaze or fixating eye
• Incomitant (Noncomitant)– Deviation varies in size with direction of gaze or
fixating eye– Most paralytic or restrictiveMost paralytic or restrictive– In acquired condition may indicate neurologic or
orbital problems or diseases
230American Academy of Ophthalmology
Grades of binocular visionGrades of binocular vision
• 1st Grade1 Grade– Simultaneous perception
2nd Grade• 2nd Grade– Fusion
• 3rd Grade– Stereopsis
Kanski JJ, 2007
231
Fusion• Cortical unification of visual object into a single percept• Made by simultaneous stimulation of corresponding retinal areasMade by simultaneous stimulation of corresponding retinal areas
Sensory fusion– Relationship between retina and visual cortex– Corresponding retinal points project to same cortical locus– Corresponding adjacent retina points have adjacent cortical
representationsrepresentations
Motor fusion– Vergence movement
C i il i l i– Causes similar retinal image– Fall and be maintained on corresponding retinal areas– Disparities can be induced by, E.g : phoria, etc
232American Academy of Ophthalmology
Stereopsis and Depth perception
• Stereopsisp– Binocular sensation – Relative or subjective ordering of visual objects in
depth or 3 dimensionsdepth or 3 dimensions
• Depth perceptionM l l i l d– Monocular clues include
• Object overlap• Relative object size
Highlight and shadow• Highlight and shadow• Motion parallax• Perspective
233American Academy of Ophthalmology
AC/A Ratio• Accommodative Convergence / Accommodation Ratio
– Normal is between 3:1 to 5:1
– AC/A = PD + ∆n – ∆oD
Gradient method– PD = pupil distance (millimeter)
D
– ∆n = near deviations (prism diopter)– ∆o = distance deviations (prism diopter)
sign convention :– Esodeviation +– Exodeviation -Exodeviation
– D = diopter of accommodation – Distance 6 m– Near 0.33 m
234American Academy of Ophthalmology
ESODEVIATIONESODEVIATION
• EsodeviationEsodeviation– Esophoria
• Controlled by fusion under condition of normal ybinocular vision
– Intermittent esotropiaC t ll d b f i d diti f l• Controlled by fusion under condition of normal binocular vision
• Spontaneous becomes manifest• Particularly with fatigue or illness
– Esotropia
235American Academy of Ophthalmology
Esotropia• Pseudoesotropia• Pseudoesotropia• Congenital esotropia
– Classic essential– Nystagmus and esotropiay g p
• Accommodative esotropia– Refractive (Normal AC/A ratio)– Non refractive (High AC/A ratio)
Partially accommodative– Partially accommodative• Non-accommodative acquired esotropia
– Basic– Acute– Cyclic– Sensory depriviation– Divergence insufficiency and divergence paralysis
Spasm of near synkinetic reflex– Spasm of near synkinetic reflex• Incomitant esotropia
– Sixth nerve paresis– Medial rectus restriction Thyroid and traumay– Duane’s syndrome and Möbius syndrome
236American Academy of Ophthalmology
Pseudoesotropia
• Infant often have a wide, flat nasal bridge with prominent medial epicanthal folds and p o e ed a ep ca a o ds a da small interpupillary distance.
• May appear esotropicI f t th i t i ht• In fact their eyes are straight.
• No real deviation exists• Both corneal light reflex and cover testing• Both corneal light reflex and cover testing
results are normal.
237
Congenital Esotropia
• Large constant esotropia (usually > 40 PD)• Onset birth to 6 months of age• Onset birth to 6 months of age• Amblyopia common (50%-60%)• Associated motor phenomenon (usually p ( y
present after 1 year of age) :– Inferior Oblique Over Action (IOOA)– Dissociated Vertical Deviation (DVD)Dissociated Vertical Deviation (DVD)– Latent nystagmus
238
Non-surgical treatmentCongenital esotropia
• Abduction should be full or only slightly limited. Mild (-1) limitation of abduction is common and does not necessarily indicate a lateral rectusabduction is common and does not necessarily indicate a lateral rectus paresis.
• Try the dolls head maneuver or spinning the child (vestibular stimulation) to elicit full abduction in infants
• Check for inferior oblique overaction and V-pattern• Check for inferior oblique overaction and V-pattern• Check fixation preference: strong fixation preference for one eye indicates
amblyopia in the fellow eye.• Cross-fixate fixing with right eye for objects in the left visual field and with
left eye for objects in the right visual fieldleft eye for objects in the right visual field• Cross-fixate indicate no significant amblyopia.• Measure deviation :
– Prisms Alternate Cover Test (PACT) is the BEST.KRIMSKY t t if PACT i bt i bl– KRIMSKY test if PACT is unobtainable
• Cycloplegic refraction– Use cyclopentolate 0.5% in infant < 24 year of age and 1% for older children– If cycloplegic refraction shows > 3 D prescribe full hyperopic correction.– If ET > 10 to 15 PD persist after prescribe full hyperopic correction
SURGERY is required239
Accommodative esotropiaAccommodative esotropia
• CLINICAL FEATURES– Usually acquired around 2 to 4 years of age– Moderate to large esotropia (20 to 50 PD)– Variable angle that is often intermittent– Associated with hyperopia usually +2 to +6 D– Classify as
R f ti (N l AC/A ti )• Refractive (Normal AC/A ratio)• Non refractive (High AC/A ratio)• Partially accommodativePartially accommodative
240
Non surgical treatment• Refractive accommodative esotropia
– Corrective lenses• Full amount of hyperopia as determined under cycloplegia• Full time spectacle wear instill Atropine 1% at bed time to make initial
compliance• Esotropia fully corrected distance and near
– Full hypermetropic correction – ET < 8 to 10 PD– Single vision spectacle (without bifocal)
Surgery is not needed– Surgery is not needed.• Distance corrected, but there is residual esotropia at near (high AC/A ratio)
– Full hypermetropic correction– Distance deviation resulting fusion (i.e, < 10 PD ET)– Residual ET at near that can not be fused (i e > 10 PD ET)Residual ET at near that can not be fused (i.e > 10 PD ET)– Prescribe a flat-top bifocal add. (start : + 2.50 to + 3.00 D)– Prescribe the least amount of near add to obtain fusion while leaving a
small near esophoria (E < 5 PD)• Residual esotropia distance and near (Partially Accommodative esotropia)p ( y p )
– With full hypermetropic correction – Distance esotropia persist can not be fused (usually > 10 PD). SURGERY is INDICATED
– Miotic agent subtitutes for glasses
241American Academy of Ophthalmology
Non surgical treatment• Non-refractive accommodative esotropia
– Bifocals • Flat-top design preferred• +2.50 to +3.00 D• Top of the segment should CROSS the pupil• Vertical height not exceed distance portion of the lens• Progressive lens must be fitted higher of 4 mm than adult fitting
with maximum bifocal power of +3.50 D• Give detail to opticians• Acceptance value
– Fusion at distanceL th 10 ∆ id l t i t– Less than 10 ∆ residual esotropia at near
– Long-lasting cholinesterase inhibitors 0.125% echothiophate iodide both eye one time daily for 6 weeks
242American Academy of Ophthalmology
Bifocal for DeviationsBifocal for Deviations
243
Order for surgery
• Surgery between 6 months and 2 years of age (most referenceyears of age (most reference recommend)
• Surgery between 6 months and 1 year• Surgery between 6 months and 1 year of age (standard approach).
• Early surgery between 3 and 5 months• Early surgery between 3 and 5 months of age (controversial, but may improve sensory outcome)sensory outcome).
244
Surgical ApproachSurgical Approach
• The procedure of choice bilateral medial• The procedure of choice bilateral medial rectus muscle recession
• Near deviation as the target angle.g g• In older patients with irreversible amblyopia recession medial rectus and resection l t l t t bl ilateral rectus to amblyopic eye
• The surgical goal not to operate the patients out of glasses but to achievepatients out of glasses, but to achieve alignment and fusion with full hypermetropic correctioncorrection
245
Non-accommodative esotropia• CLINICAL FEATURES :
Non accommodative esotropiaCLINICAL FEATURES :– Usually emmetropic, may be myopic– Onset after 2 years, even in late adulthood– Full duction– Late onset ET of unknown etiology– Surgery is the treatment of choice– Surgery is the treatment of choice
• Bilateral lateral rectus recession• Often undercorrection increase the amount of recession
Try using prism adaptation to determine the full target angle• Try using prism adaptation to determine the full target angle, especially if there is a disparity between the distance and near deviation.
• Operate for the full prism adapted angleOperate for the full prism adapted angle
246
Sensory Esotropia
• Associated with a monocular blindness or dense amblyopiaor dense amblyopia.
• Treatment : recession lateral rectus and resection medial rectus muscle isand resection medial rectus muscle is performed on the eye with poor vision
• To obtain Cosmetic appearance of• To obtain Cosmetic appearance of straight eyes.
247
EXODEVIATIONEXODEVIATION
• ExodeviationExodeviation– Pseudoexotropia
• An appearance of exodeviation when in fact the ppeyes are properly aligned
• Positive angle kappa• Wide interpupillary distance• Wide interpupillary distance
– Exophoria• Controlled by fusion under condition of normal Co o ed by us o u de co d o o o a
binocular vision– Intermittent exotropia
248American Academy of Ophthalmology
Intermittent exotropiaIntermittent exotropia• Classified by
– Difference distance and near between alternating prism and cover testDifference distance and near between alternating prism and cover test measurement
– Change in near measurement by unilateral occlusion or +3.00 D lenses
Clinical features• Clinical features– Most common form of exotropia– Usually present after 1 year of age– Large exophoria that spontaneusly becomes to a tropiag p p y p– High grade stereopsis when fusing; suppression when tropic– Squint one eye to bright sun light– The exotropia is typically manifest when the patient is fatigued,
daydreaming or illdaydreaming or ill– Symptoms blurred vision, asthenopia, visual fatigue and rarely
diplopia in older children and adults
249American Academy of Ophthalmology
Intermittent exotropiaIntermittent exotropia• Basic type
– Same at near and distance• Divergence excess
– Greater at distance– True divergence excess
• Greater at distance even after a periods of monocular occlusion• High gradient AC/A ratio at near by +3.00 D lenses
Simulated divergence excess– Simulated divergence excess• Greater than distance• Same after one eye is 1 hour occluded to remove the effect of
tenacious proximal fusion• Convergence insufficiency
– Greater at near than distance– Excludes isolated convergence insufficiency
250American Academy of Ophthalmology
Non surgical treatment• Corrective lenses
– Improve retinal image clarity• Additional minus lens power
– Usually 2-4 D beyond refractive error correction– Temporarily stimulate accommodative convergence
• Part time patching– Passive orthoptic treatment– Passive orthoptic treatment– 4-6 hours per day or alternate daily patching– Treatment for small to moderate-sized deviation
• Active orthoptic treatment– Anti suppression therapy / diplopia awareness– Fusional convergence training – Alone or in combination with patching, minus lenses and surgery– Good for deviations of 20∆ or less– Good for deviations of 20∆ or less
• Base in prism– Promote fusion– Not recommended for long term treatment cause a reduction in
f i l lit dfusional vergence amplitudes
251American Academy of Ophthalmology
Surgical treatmentSurgical treatment
• Deviation of 15 ∆ or moreDeviation of 15 ∆ or more• Nearly constant exotropia
Still i t itt t• Still intermittent• Before 7 years of age• Before 5 years of strabismus duration
252American Academy of Ophthalmology
NOTE
• Children under 4 years of age are at i k f d l i t tirisk for developing postoperative
amblyopia and losing binocular vision.• It is probably best to postpone surgery
until 4 years of age unless the patient demonstrates progressive loss of fusion control.
253
Another exodeviationAnother exodeviation
• Constant exodeviationConstant exodeviation– Congenital exotropia
Sensory exotropia– Sensory exotropia– Consecutive exotropia
Exotropia Duane’s retraction syndrome– Exotropia Duane’s retraction syndrome– Neuromuscular abnormalities
Di i t d h i t l d i ti– Dissociated horizontal deviation
254American Academy of Ophthalmology
A V P tt i h i t l t biA-V Patterns in horizontal strabismus
• A PatternEyes closer together in up gaze– Eyes closer together in up gaze
– 10 PD difference compares to down gazeV P tt• V Pattern– Eyes closer together in down gaze– 15 PD difference compares to up gaze
Deborah Pavan-Langston, 2008 255
A Pattern• Etiology
f f SO– Most frequent overaction of SO – With or without underaction of IO– As SO acts abduction in downward gaze
• Esotropia decreases• Esotropia decreases• Exotropia increases
– If no overaction of SO suspect underaction of LR• TreatmentTreatment
– Deviation more than 10 PD– Bilateral weakening Tenotomy with silicone expander– Horizontal surgery g y
• With upward displacement of MR• With downward displacement of LR
– Bilateral SO surgery avoided in patient with foveal bifixator
Deborah Pavan-Langston, 2008 256
V Pattern• Etiology
Most frequent overaction of IO– Most frequent overaction of IO – Primary underaction of SO– As IO acts abduction in upgaze
• Esodeviation decreases• Exodeviation increases
– Overaction of LR V exotropia• Head position
– V esodeviation chin held down close workV esodeviation chin held down close work– V exodeviation chin held up
• Treatment V esotropia– Recession or disincertion of overacting IO– Recession or downward the MR if obliques are normal
• Treatment V esotropia– Recession or disincertion of LR if IO overacts
Deborah Pavan-Langston, 2008 257
Strabismus : Position testStrabismus : Position test
Measurement of deviationMeasurement of deviation• Hiscberg test
C t t• Cover test• Cover uncover test• Krimsky test• Prisms Cover testPrisms Cover test• Prisms Alternate Cover Test (PACT)
258American Academy of Ophthalmology
259
260
261
262
263
Strabismus : Sight testStrabismus : Sight test
• WFDTWFDT• Maddox’s rod
264
265
266
267
268
Approach to Recession surgeryApproach to Recession surgery
Minimal (mm) Average maximum (mm)
Maximum ever (mm)
LR 4 7 adult6 children
8 - 10
MR 2.5 5 - 5.5 6 - 714 for nystagmus
SR 2.5 5 10IR 2.5 5
Eugene M. Helvestone 269
Approach to Resection surgeryApproach to Resection surgery
Minimal (mm) Average maximum (mm)
Maximum ever (mm)
LR 5 8 infant10 children and adult
-
MR 5 8 infant -MR 510 children and adult
SR 2.5 - 3 5 -SR 2.5 3 5IR 2.5 - 3 5 -
Eugene M. Helvestone 270
Prisms-Muscle length conversionPrisms Muscle length conversion
5 ∆ Di t f 1 MR i• 5 ∆ Diopter for 1 mm MR recession• 2.5 ∆ Diopter for 1 mm LR recession• 2.5 ∆ Diopter for 1 mm MR and LR
resection
271
Both eye surgery for Esodeviation :Both eye surgery for Esodeviation :
Angle of esotropia (∆) Recess MR OU (mm) Resect LR OU (mm)OR
10 3.0 4.0
20 3 5 5 020 3.5 5.0
25 4.0 6.0
30 4.5 7.0
35 5.0 8.0
40 5.5 9.0
50 6.0 9.0
American Academy of Ophthalmology 272
Monocular surgery for EsodeviationMonocular surgery for Esodeviation
Angle of esotropia (∆) Recess MR OU (mm) Resect LR OU (mm)AND
10 3.0 4.0
20 3 5 5 020 3.5 5.0
25 4.0 6.0
30 4.5 7.0
35 5.0 8.0
40 5.5 9.0
50 6.0 9.0
American Academy of Ophthalmology 273
Both eye surgery for Exodeviation :Both eye surgery for Exodeviation :
Angle of exotropia (∆) Recess LR OU (mm) Resect MR OU (mm)OR
15 4.0 3.0
20 5 0 4 020 5.0 4.0
25 6.0 5.0
30 7.0 6.0
40 8.0 6.0
American Academy of Ophthalmology 274
Monocular surgery for Exodeviation :Monocular surgery for Exodeviation :
Angle of exotropia (∆) Recess LR OU (mm) Resect MR OU (mm)ANDg p ( ) ( ) ( )
15 4.0 3.0
20 5.0 4.0
25 6.0 5.0
30 7.0 6.0
40 8.0 6.050 9.0 7.060 10 0 8 060 10.0 8.070 10.0 9.080 10.0 10.0
American Academy of Ophthalmology 275
Strabismus : ExerciseStrabismus : Exercise
Synophthophore
Holme’s stereoscope 276
Glaucoma
277
Glaucoma : BasicGlaucoma : Basic
• DefinitionDefinition– Optic neuropathy
Visual field defect– Visual field defect– Rise of IOP as major risk
278
279
Glaucoma : BasicGlaucoma : Basic
• IOP measureIOP measure• Angle examination • Optic nerve head examination• Optic nerve head examination• Vascular change
RNFL i ti• RNFL examination• Visual field examination• Central corneal thickness and rigidity• General eye examination*
280
IOP : BasicIOP : Basic
• Normal IOP 10-20 mmHgNormal IOP 10 20 mmHg• Average 15 mmHg
Fl t ti 2 56 H• Fluctuation 2.56 mmHg• Diurnal Variation 3-6 mmHg• Peak period Morning• Decrease during the nightDecrease during the night• Hypotony < 5-6 mmHg
Gumansalangi MNE, 2003 281
IOP : Determining factorsIOP : Determining factors
F C (P P )F = C (Po – Pe)
• F = rate of aqueous outflow (normal 2 µl/min)• C = facility of aqueous outflow (normal 0.2C facility of aqueous outflow (normal 0.2
µl/min/mmHg• Po = IOP in mmHg• Pe = episcleral venous pressure (normal 10 mmHg)
Kanski JJ, 2007 282
How to measure the IOPHow to measure the IOP• First line
– Applanation tonometer Nowadays Gold standard AT 900D (Haag-Streit International)
– Dynamic contour tonometer E g : PASCAL (Ziemer)Dynamic contour tonometer E.g : PASCAL (Ziemer)
• Second line– Air-puff non-contact tonometer– Corvis ST Air-puff non-contact tonometer with Scheimpflug
Camera Cornea Monitoring (OCULUS)– Tono-Pen, The Pachmate DGH 55, Diaton, Schiotz tonometer– iCare ONE tonometer, SOLX IOP sensor* IOP monitoring
283
IOP : FlowIOP : Flow
• Cilliary bodyCilliary body• Posterior chamber
P il• Pupil • Anterior chamber• Delivery
– Trabecular pathway (85-95%)Trabecular pathway (85 95%)– Uveo-scleral pathway (5-15%)– Iris (Kanski)Iris (Kanski)
284
IOP : FlowIOP : Flow
• Aqueous come in to eye by :Diff i– Diffusion
– UltrafiltrationC– Carbonic Anhydrase II activity
– Active secretion
American Academy of Ophthalmology 285
Glaucoma: Vascular dysregulationy g
• Endhotelial dysfunction– Impaired endothelium-derived nitric oxide
activity – Abnormalities of the endothelin system
altered Endothelin-1 (ET1) vasoreactivity• Defective auto regulation of ocular blood
flow• Instable blood supplies to the tissue
Henry E, 2006; Araie M, 2010286
Glaucoma : AngleGlaucoma : Angle
• TorchTorch • Von Herrick Slit-lamp• Gonioscopy• Gonioscopy• Ultrasound Biomicroscopy (UBM)
A t i OCT• Anterior OCT• Scheimpflug Camera Pentacam• Very high frequency (VHF) ultrasound eye
scanner Artemis (ArcScan, Inc)
287
Angle : ObservationAngle : Observation
288
Angle Examination : TorchAngle Examination : Torch
289
Angle Examination : Van Herick
Von Herrick and Shaffer grades
Grade Ratio of aqueous gap/cornea Clinical interpretation Shaffer angle degrees
4 > ½ / 1 Closure impossible 45-35
3 ½-¼ /1 Closure impossible 35-20
2 ¼ / 1 Closure possible 20
1 < ¼ / 1 Closure likely with full dilation 10 or less
0 Nil Closed 0
290
Angle Examination : GonioscopyAngle Examination : Gonioscopy
291
Identification of Schwalbe’s LineIdentification of Schwalbe s Line
Thomas R, 2006 292
Shaffer’s Intepretation
Classification Angle Width Visible Structure Clinical Intepretation
Grade 0 Closed Schwalbe’s line is not visible Totally closed angle
Grade I 10° Schwalbe’s line visible Considerable risk of closure
Grade II 20° Anterior trabeculum is visible Bear watching
Grade III 30° Scleral spur is visible No risk of angle closure
Grade IV 40° Ciliary body is visible No risk of angle closure
293
PAS look alike
Thomas R, 2006 294
RubeosisRubeosis
Thomas R, 2006 295
Angle Recessiong
Thomas R, 2006 296
Angle Examination : UBMAngle Examination : UBM
297
Angle Examination : UBMAngle Examination : UBM
Normal eye’s angle
Angle : Pupillary block298
Angle Examination : Anterior OCTAngle Examination : Anterior OCT
Visante OCT (Carl Zeiss Meditec AG)
299
Scheimpflug Camera PentacamScheimpflug Camera Pentacam
300
Artemis ( Ultralink)50 MHz ArcScan50 MHz ArcScan
301
The AngleThe Angle
302
Shaffer’s IntepretationCl ifi ti A l Width Vi ibl St t Cli i l I t t ti
Shaffer s IntepretationClassification Angle Width Visible Structure Clinical Intepretation
Grade 0 Closed Schwalbe’s line is not visible Totally closed angley g
Grade I 10° Schwalbe’s line visible Considerable risk of closure
Grade II 20° Anterior trabeculum is visible Bear watching
Grade III 30° Scleral spur is visible No risk of angle closure
Grade IV 40° Ciliary body is visible No risk of angle closure
303
Optic discOptic disc
A. Surface
B. Pre Laminar
C. Laminar
D. Retro Laminar
304
GON : Evaluation
• Indirect ophthalmoscope*
• Direct ophthalmoscope
• Slit lamp : stereoscopic view
H b El B di l• Hruby or El Bayadi lens
• 60, 78, 90 D
• Contact lens
Thomas R, 2006 305
GON : EvaluationGON : Evaluation
• Disc GenerallyDisc Generally• Cup
N R ti l Ri (NRR)• Neuro Retinal Rim (NRR)• Peripapillary hemorrhage• Circum Linear Vessels (CLV)• Para Papillary Atrophy (PPA)Para Papillary Atrophy (PPA)• Retinal Nerve Fiber Layer (RNFL)
306
GON : EvaluationGON : Evaluation
Generalized Focal Less specific
L ti N i ( t hi ) f th i E d l i ibLarge optic cup Narrowing (notching) of the rim Exposed lamina cribosaAsymmetry of the cup Vertical elongation of the cup Nasal displacement of vesselsProgressive enlargement Cupping to the rim margin Baring of circumlinear vesselsof the cup Regional palor Peripapillary crescent
S li t h hSplinter hemorrhageNerve fiber layer loss
(TJ et al 2003)(TJ et al, 2003)
307
Cup and DiscCup and Disc
308
Disc ExcavasionDisc Excavasion
309
Definition of Cup : Disc RatioDefinition of Cup : Disc Ratio
• Disc Diameter
• Cup Diameter
dc
• Cup Diameter
• CDR = c / d
• Horizontal > Vertical
Thomas R, 2006310
Thomas R 2006Thomas R, 2006
311
a. Normal C/D Ratio 0.2 b. Same Disc 1 year later with C/D
R i 0 5Rasio 0.5c. Cup enlarge to Infero Temporal
and Splinter Hemorrhagesd. Cup enlarge to Superior and show
Inferior Bayoneting Signe. Advance Cupping Oval Disc
enlarge to superior and inferiorenlarge to superior and inferiorf. Pale Papil with deep excavasion
312
CDR AsymmetryCDR Asymmetry
Thomas R, 2006 313
Asymmetric cuppingAsymmetric cupping
314
Cup DepthCup Depth
• Not of much importance• In normal : depends on disc area• In normal : depends on disc area • In glaucoma : type & level of IOP• Deepest with high IOPDeepest with high IOP
– Juvenile POAG– Angle recession
Thomas R, 2006 315
Neuro Retinal Rim (NRR): ShapeNeuro Retinal Rim (NRR): Shape
• Sloping rim in small and intermediate discs
• Steep or over hanging with oblique insertion
• Supero nasal tilt in normal
• Nasal tilt in myopes
Thomas R, 2006 316
NRR in Glaucoma
• Loss of physiological shapeLoss of physiological shape
ISNT l i b k• ISNT rule is broken
• Vertical cup enlarges
Thomas R, 2006 317
Jonas ISNT RuleJonas ISNT Rule
• Less marked in large discs
• Rim more evenly distributed
• Punched out well defined
cup in large discs
• Also compare Inferior & p
Superior to temporal rim
• Inferior to Temporal 2 : 1
• Superior to Temporal 1.5 : 1
Thomas R, 2006 318
NRR : I S N TNRR : I S N T
• Partially depends on exit of central retinal lvessels
• Rim furthest away is more affected• May explain unusual configuration of rim
Thomas R, 2006 319
Temporal Portion of RimTemporal Portion of Rim
• Papillo macular bundle
• Preferential cupping temporally with field loss near fixationloss near fixation
• POAG with Myopia and NTG
Thomas R, 2006 320
Glaucoma & Contour of RimGlaucoma & Contour of Rim
• May cause a backward bowing of the rim tissue
• Deep extension of the cup in one meridian• Gentler sloping backward : Saucerization
Thomas R, 2006 321
Rim contour : NormalRim contour : Normal
Thomas R, 2006 322
SaucerizationSaucerization
• Slight backward bowing : like saucer
• Periphery or a tiportion
• Or whole disc• May be first
change
Thomas R, 2006 323
Shelving : No Field Defect ?Shelving : No Field Defect ?
Thomas R, 2006 324
Excavation : Field DefectExcavation : Field Defect
Thomas R, 2006 325
Excavation : Field DefectExcavation : Field Defect
Thomas R, 2006 326
Excavation : Superior and InferiorExcavation : Superior and Inferior
Thomas R, 2006 327
NotchingNotching
Thomas R, 2006 328
Disc HemorrhageDisc Hemorrhage
• Rare in normals (1%)• 4 7 % in glaucoma• 4 -7 % in glaucoma• > In “NTG”• Lasts 10 weeks (10-
35)
Thomas R, 2006 329
Disc HemorrhageDisc Hemorrhage
• Splinter or flame shapedshaped
• Border of disc• Inferior or superiorInferior or superior
temporal region• RNFL defects,RNFL defects,
Notching, Focal perimetric loss
Thomas R, 2006 330
Circum Linear Vessels (CLV)Circum Linear Vessels (CLV)
• Vessel hugging gg gthe NRR
• Exits disc forExits disc for macula
• Normally present• Normally present in 50 % of eyes
Thomas R, 2006 331
Circum Linear Vessels (CLV)Circum Linear Vessels (CLV)
Thomas R, 2006 332
Circum Linear Vessels “Bared” in Glaucoma
N l CLV• Normal CLV• As rim is lost : gap
between vessel andbetween vessel and rim– Implies loss of rim
F i l ifi• Fairly specific• Superficial or deep
CLV normally present in 50 % of eyes Thomas R, 2006 333
Para Papillary Atrophy (PPA)Para Papillary Atrophy (PPA)
• Central beta zone • Peripheral alpha zonePeripheral alpha zone• Rare nasally or
circumferentialcircumferential• Correlate with myopia
and ageand age
Thomas R, 2006 334
Para Papillary Atrophy In NormalsPara Papillary Atrophy In Normals
• Beta zone : 20 %• Beta zone : 20 %
• Alpha zone : 95 + %
Thomas R, 2006 335
PPA : Alpha ZonePPA : Alpha Zone
• Peripheral to beta or disc marginIrregular Hyper and Hypo pigmentation• Irregular Hyper and Hypo pigmentation
• Thinning of RPE• Relative scotoma
Thomas R, 2006 336
PPA : Beta ZonePPA : Beta Zone
• Central to alpha• Peripheral to disc marginPeripheral to disc margin• Marked atrophy of RPE• Visible choroidal vessels & sclera• Absolute scotoma
Thomas R, 2006 337
PPA in GlaucomaPPA in Glaucoma
• Central beta zone more importantmore important
• Peripheral alpha zone
Thomas R, 2006 338
PPA in POAGPPA in POAG
B t l i hi h• Beta larger in high myopic POAG
• Next in age• Next in age related POAG
• Less in SOAG• Less in SOAG• ? NTG and POAG
Thomas R, 2006 339
Disc Hemorrhage and Para Papillary Atrophysc e o age a d a a ap a y t op y
• PPA associated ith h hwith hemorrhages
• PPA marker for old hemorrhages
Thomas R, 2006 340
Axonal distributionAxonal distribution
341
Glaucoma : RNFL DefectGlaucoma : RNFL Defect
342
Normal RNFL : Axons Bundled by Mueller Cell Processes
• Best seen
Bright fine striations
• Best seen Inferior and superior temporal p p(Inferior > Superior)
• Bright Dark Bright• Fans off the disc to
periphery
Thomas R, 2006 343
RNFL VisibilityRNFL Visibility
• Clear media• Without yellowing of lensWithout yellowing of lens• Deeply pigmented RPE
D ith• Decreases with age– Loose 4000 - 5000 per year
Thomas R, 2006 344
RNFL : Normal ?RNFL : Normal ?
• “Obscures” normal vesselsnormal vessels
• Slit like or groove like defectslike defects
• Narrower than retinal vessels
Thomas R, 2006 345
Localized RNFL DefectsLocalized RNFL Defects
• Dark wedge• Larger than vessel • Touching disc• Fan out• Broad at temporal
raphe
Thomas R, 2006 346
Localized RNFL DefectsLocalized RNFL Defects
• Not seen in normal• 20% of Glaucoma eyes
– Less with early glaucomaTouch the disc– Touch the disc
• Other causes of atrophy– Drusen, Toxoplasmosis,
Ischemia, Papiledema, Optic Neuritis
Thomas R, 2006 347
Localized RNFL Defects and Disc Hemorrhageoca ed e ects a d sc e o age
• Disc hemorrhageLocalized defect• Localized defect – 6 - 8 weeks
• Localized type of• Localized type of disc damage : Notch
Thomas R, 2006 348
Diffuse RNFL DefectsDiffuse RNFL Defects
I f i l i ibl• Inferior less visible than Superior
• Bright Dark Bright• Bright, Dark, Bright pattern lost
• Macula as bright gas Superior and Inferior“N k d” l• “Naked” vessels
Thomas R, 2006 349
Frequency of RNFLD in GlaucomaFrequency of RNFLD in Glaucoma
• More with focal NTG
• Less with – Age related POAG– Highly myopic OAG
J il OAG– Juvenile OAG
Thomas R, 2006 350
Importance of Localized RNFL pDefects in Early Diagnosis
E ith l• Eyes with normal IOP and Visual FieldsFields
• Show field loss on follow up
• “Pre perimetric” GlaucomaJ t’ R l # 2• Jost’s Rule # 2
Until proved otherwise, all glaucoma (suspects) have a RNFL defect
Thomas R, 2006 351
S btl R ti l N Fib L D f tSubtle Retinal Nerve Fiber Layer Defect
Thomas R, 2006 352
With Experience :With Experience :
Thomas R, 2006 353
With More Experience :
Thomas R, 2006 354
Re-check !Re check !
Thomas R, 2006 355
Many Optic Disc Changes Have Been Described in GlaucomaBeen Described in Glaucoma
Loss of ISNT pattern Asymmetry in CDR > 2 Loss of ISNT pattern Localized notch in the rim Acquired Pit
y y Cup large for disc size Vertically oval cup Baring of CL vessels
Disc Hemorrhage Wedge / diffuse loss of retinal
nerve fibers
Baring of CL vessels• Over pass phenomenon• Large CDR
Absent rim inferiorly, superiorly, temporally & or nasally
• CDR of > 0.7• Deep cup• Laminar dot sign
Increase in cupping over timeg
• Thinned retinal arterioles
Don’t Just Use The Cup : Disc Ratio !Don t Just Use The Cup : Disc Ratio !Thomas R, 2006 356
Once moreOnce more
357
RNFL ExaminationRNFL Examination
• Ophthalmoscope (Red free light)R d F Ph t h• Red Free Photographs
• HRT, OCT, GDxVCCSlit lamp (Green light)
358
SLP, OCT and CSLO/T• Pre Perimetric Glaucoma Detection• Non Perimetric Glaucoma Progression Analysis• RNFL analysis over Optic disc analysis• RNFL analysis over Optic disc analysis
359
Scanning laser polarimetryGD VCC (C l Z i M dit AG)– GDxVCC (Carl Zeiss Meditec AG)
360
GDxVCC
361
OCTOCT
Normal retina OCT Glaucomatous retina OCT
362
OCT : Symmetric optic discs with C/D ratio of 0.3
Optic Nerve Head Analysis ResultsVert. Integrated Rim Area (Vol.) .321 mm3Horiz. Integrated Rim Width (Area) 1.717 mm2Di k A 2 53 2Disk Area 2.53 mm2Cup Area .938 mm2Rim Area 1.592 mm2Cup/Disk Area Ratio 0.371Cup/Disk Horiz. Ratio 0.647pCup/Disk Vert. Ratio 0.593
Optic Nerve Head Analysis ResultsVert. Integrated Rim Area (Vol.) .313 mm3Horiz. Integrated Rim Width (Area) 1.706 mm2Disk Area 2.217 mm2 Cup Area .764 mm2Rim Area 1.453 mm2Cup/Disk Area Ratio 0 345Cup/Disk Area Ratio 0.345Cup/Disk Horiz. Ratio 0.622Cup/Disk Vert. Ratio 0.586
RNFL analysis demonstrates a typical pattern in the OD and flattening of the RNFL pattern in the OS.y yp p g pThinning of the superior RNFL is consistent with the visual field defect and the diagnosis of glaucoma.This was later confirmed by visual field with infero-nasal defect, OS
363
OCT : OD appears within normal limits with a C/D ratio of 0.5. OS has large cup with C/D ratio of 0.7. Visual fields within normal limits
Optic Nerve Head Analysis ResultsVert. Integrated Rim Area (Vol.) .327 mm3Horiz. Integrated Rim Width (Area) 1.578 mm2Di k A 1 998 2Disk Area 1.998 mm2Cup Area .646 mm2Rim Area 1.352 mm2Cup/Disk Area Ratio 0.323 Cup/Disk Horiz. Ratio 0.538pCup/Disk Vert. Ratio 0.58
Optic Nerve Head Analysis ResultsVert. Integrated Rim Area (Vol.) .188 mm3Horiz. Integrated Rim Width (Area) 1.597 mm2Disk Area 2.973 mm2Cup Area 1.766 mm2Rim Area 1.207 mm2Cup/Disk Area Ratio 0 594Cup/Disk Area Ratio 0.594Cup/Disk Horiz. Ratio 0.775Cup/Disk Vert. Ratio 0.791
Anatomic large nerve head with normal RNFL. Only distinguished with Stratus OCT Cross-g y gsectional imaging is vital in the analysis of RNFL thickness in vivo, particularly in differentiatinghealthy RNFL from glaucomatous RNFL
364
Glaucoma RNFL scanning on Cirrus OCTNEW Optic Disc cube 200 X 200 scan pattern
365
Optic Disc Cube 200 X 200 scan patternOptic Disc Cube 200 X 200 scan pattern
Auto Center™ Center of ONH automatically identified. Measurement of TSNIT graph thickness is automatic. Less operator dependant and crucial f tibilitfor repeatibility
366
Cirrus HD-OCT Normal OU RNFL
i t tprintout
Similar to Stratus OCT RNFL thi k ti f tthickness reporting format
RNFL thickness map
RNFL thickness deviation map (LSO p (fundus)
RNFL thickness valuesRNFL thickness values ISNT and Average
Multi-ethnicity (Including Asian Eye) NDB
367
Cirrus HD-OCT RNFL thickness report
OS RNFL
RNFL thickness report
OS RNFL loss at 6 o’clock
368
Cirrus HD-OCT OU nerve loss RNFL printoutp
369
RTVue 3D SD-OCT with Ganglionwith Ganglion Cells Analyzer
370
Confocal scanning laser topography– HRT3 (Heidelberg Engineering GmbH) provides
objective measurements of the optic nerve head and surrounding RNFLsurrounding RNFL
– High quality stereo photographs of the optic disk
371
HRTHRT
372
The Moorfields Regression Analysis
HRT measurements have been shown to have high diagnostic accuracy for detecting glaucomadetecting glaucoma.The Moorfields Regression Analysis had a sensitivity and specificity of 84% and 96% respectively. An analysis based on the shape of the optic disc and surrounding RNFL resulted in a sensitivity and specificity of 89% and 89%. A sophisticated type of neural network analysis called a Support Vector Machine resulted in a sensitivity and specificity of 91% and 90% 373
VISUAL FIELD (VF)( )
• Isopter /isop·ter/ (i-sop´ter) a curveIsopter /isop ter/ (i sop ter) a curve representing areas of equal visual acuity in the field of vision
• A curve of equal retinal sensitivity in the visual field – Designated by a fraction – The numerator being the diameter of the test
object– The denominator being the testing distance
MedWeb, 2008 374
Indication of Visual field test
• Raised IOP• Suspected GON• Asymmetric C/D Ratio > 0.3
3 H IOP diff b h• 3 mmHg IOP difference on both eyes• Glaucoma on other eye• Previous retinal detachment• Previous retinal detachment• Unexplained low visual acuity• Discomfort “perfect” visionsco o t pe ect s o• Unexplained headache and migraine• Injured eye
Gumansalangi MNE, 2003 375
Visual field : NormalVisual field : Normal
• The field of vision is defined as the area that is perceived simultaneously by a fixating eye.
• The limits of the normal field of vision are 60° into the superior• The limits of the normal field of vision are 60 into the superior field, 75° into the inferior field, 110° temporally, and 60°nasally.
• An island of vision in the sea of darknessAn island of vision in the sea of darkness• The island represents the perceived field of vision, and the
sea of darkness is the surrounding areas that are not seen. • In the light adapted state the island of vision has a steep• In the light-adapted state, the island of vision has a steep
central peak that corresponds to the fovea, the area of greatest retinal sensitivity.
MedWeb, 2008 376
THE NORMAL VISUAL FIELD
377
THE NORMAL VISUAL FIELDTHE NORMAL VISUAL FIELD
• The contour of the island of vision relates to bothThe contour of the island of vision relates to both the anatomy of the visual system and the level of retinal adaptation.
• The highest concentration of cones is in the fovea, and most of these cones project to their own ganglion cell.
• This one-to-one ratio between foveal cone and li ll l i i l l i i hganglion cell results in maximal resolution in the
fovea.
MedWeb, 2008 378
KINETIC PERIMETRYKINETIC PERIMETRY
In kinetic perimetry a stimulus is moved from a nonseeing• In kinetic perimetry, a stimulus is moved from a nonseeing area of the visual field to a seeing area along a set meridian.
• The procedure is repeated with the use of the same stimulus along other meridians usually spaced every 15°along other meridians, usually spaced every 15 .
• In kinetic perimetry, one attempts to find locations in the visual field of equal retinal sensitivity.
• By joining these areas of equal sensitivity, an isopter is y j g q y, pdefined.
• The luminance and the size of the target is changed to plot other isopters.
• In kinetic perimetry, the island of vision is approached horizontally.
• Isopters can be considered the outline of horizontal slices of the island of visionthe island of vision.
MedWeb, 2008 379
STATIC PERIMETRY
• In static perimetry the size and location of the testIn static perimetry, the size and location of the test target remain constant.
• The retinal sensitivity at a specific location is determined by varying the brightness of the test target.
• The shape of the island is defined by repeating theThe shape of the island is defined by repeating the threshold measurement at various locations in the field of vision.
MedWeb, 2008 380
STATIC PERIMETRYSTATIC PERIMETRY
381
MANUAL PERIMETRY: THE GOLDMANN VISUAL FIELDMANUAL PERIMETRY: THE GOLDMANN VISUAL FIELD
• The Goldmann perimeter is the most widely used instrument for manual perimetry.
• It is a calibrated bowl projection instrument with a background intensity of apostilbs (asb), which i ll ithi th h t iis well within the photopic range.
• The size and intensity of targets can be varied to plot different isopters kineticall and determineplot different isopters kinetically and determine local static thresholds.
MedWeb, 2008 382
THE GOLDMANN VISUAL FIELDTHE GOLDMANN VISUAL FIELD
First in 1945 by Hans Goldmann• First in 1945 by Hans Goldmann• Photopic background ( 10 cd/m² )• Moving and static circular targets• The stimuli used to plot an isopter are identified by a
Roman numeral, a number, and a letter. • The Roman numeral represents the size of the object, p j
from 0.05º Goldmann size 0 (1/16 mm2) to 1.7º Goldmann size V (64 mm2) .
• Each size increment equals a twofold increase in di d f f ld i idiameter and a fourfold increase in area
• Visual angle + 90º
MedWeb, 2008 383
GOLDMANN VISUAL FIELDGOLDMANN VISUAL FIELD
MedWeb, 2008 384
GOLDMANN VISUAL FIELDGOLDMANN VISUAL FIELD
• The number and letter represent the• The number and letter represent the intensity of the stimulus.
• A change of one number represents a 5-dbA change of one number represents a 5 db (0.5 log unit) change in intensity, and each letter represents a 1-db (0.1 log unit) h i i t itchange in intensity.
• The dynamic range of the Goldmann perimeter from the smallest/dimmest targetperimeter from the smallest/dimmest target (01a) to the largest/brightest target (V4e) is greater than 4 log units, or a 10,000-fold hchange.
MedWeb, 2008 385
GOLDMANN VISUAL FIELDGOLDMANN VISUAL FIELD• The number and letter represent the intensity of p y
the stimulus. A change of one number represents a 5-db (0.5 log unit) change in intensity and each letter represents a 1 db (0 1intensity, and each letter represents a 1-db (0.1 log unit) change in intensity.
• The dynamic range of the Goldmann perimeterThe dynamic range of the Goldmann perimeter from the smallest/dimmest target (01a) to the largest/brightest target (V4e) is greater than 4 l it 10 000 f ld hlog units, or a 10,000-fold change.
MedWeb, 2008 386
GOLDMANN VISUAL FIELDGOLDMANN VISUAL FIELD• Isopters in which the sum of the Roman numeral (size) and
b (i t it ) l b id d i l tnumber (intensity) are equal can be considered equivalent. For example, the I4e isopter is roughly equivalent to the II3e isopter.
• A change of one number of intensity is roughly equivalent to aA change of one number of intensity is roughly equivalent to a change of one Roman numeral of size.
• The equivalent isopter combination with the smallest target size usually is preferred because detection of isopter edges is y p p gmore accurate with smaller targets.
• One usually starts by plotting small targets with dim intensity (I1e) and then increasing the intensity of the target until it is maximal before increasing the size of the targetmaximal before increasing the size of the target.
• The usual progression then is I1e (ARW1) I2e (ARW1) I3e (ARW1) I4e (ARW1) II4e (ARW1) III4e (ARW1) IV4e (ARW1) V4ee
MedWeb, 2008 387
GOLDMANN VISUAL FIELDGOLDMANN VISUAL FIELD
388
AUTOMATED PERIMETRYAUTOMATED PERIMETRY
• The introduction of computers and automation heralded a new era in perimetric testing. St ti t ti b f d i bj ti• Static testing can be performed in an objective and standardized fashion with minimal perimetrist bias. p
• A quantitative representation of the visual field can be obtained more rapidly than with manual testingtesting.
• The computer allows stimuli to be presented in a pseudorandom, unpredictable fashion.
MedWeb, 2008 389
AUTOMATED PERIMETRY• Patients do not know where the next stimulus will
AUTOMATED PERIMETRYPatients do not know where the next stimulus will appear, so fixation is improved, thereby increasing the reliability of the test.
• Random presentations also increase the speed with which perimetry can be performed by b i th bl f l l ti l d t tibypassing the problem of local retinal adaptation, which requires a 2-second interval between stimuli if adjacent locations are testedif adjacent locations are tested.
MedWeb, 2008 390
Static suprathreshold and threshold testing
• Is processes to determine sensitivity of the retina to light stimulusstimulus
• In addition to plotting isopters kinetically, static suprathreshold and threshold testing can be performed
llmanually. • Once an isopter is plotted, the stimulus used to plot the
isopter is used to statically test within the isopter to look for localized defects.
• In this way, it acts as a suprathreshold stimulus. • Static thresholds also can be determined along set• Static thresholds also can be determined along set
meridians to obtain profile plots of the visual field, but like any multiple thresholding task, it is time consuming.
MedWeb, 2008 391
Visual Fields : Advanced Concepts• The Threshold Strategy
– The threshold strategy defines the threshold as being that level of light intensity that the patient responds to 50% of the timeTh t l i th H h Vi l A l 24 2 th h ld– The most common example is the Humphrey Visual Analyzer 24-2 threshold strategy for glaucoma.
– In this strategy, a grid of 54 points is tested in the central 24 degrees
Swedish Interactive Thresholding Algorithm (SITA)• Swedish Interactive Thresholding Algorithm (SITA)– Designed to reduce testing time while still providing an adequate test of visual
sensitivity.– Reduced test time should increase attentiveness and result in a more reliable
testtest– There are two different SITA programs :
• SITA Standard designed to replace the Full Threshold program (e.g. Full Threshold 30-2 a grid of 76 test points).
• SITA Fast designed to replace Fastpac, which is a simplified Threshold program
• The Suprathreshold or Screening Strategy– Screening strategies use knowledge of the normal threshold values to present
only suprathreshold stimuli that are just above the normal threshold values.If the patient misses a significant number of these stimuli then the program is– If the patient misses a significant number of these stimuli, then the program is considered to have detected a defect that warrants further testing
392
Visual Field Analyzery
• Standard Achromatic Automated Perimetry (SAP)Whit hit i t– White-on-white perimetry
– First established 1972 by Franz Frankhauser et al– Mesopic to Photopic background (1.27 cd/m² or 10 cd/m²)– Static test targets with 0.43º Goldmann size III for Standard test– 1.7º Goldmann size V for low vision testing– Standardized-high availability-wide dynamic range– Feasible visual range usually ± 30º, theoretically up to ± 90º– SAP :
• Humphrey Visual Field Analyzer II (Carl Zeiss Meditec AG), 24 2 f i 3 4 d h SITA iprogram 24-2, software version 3.4.7, and the SITA testing
algorithm • Centerfield 2 Compact Perimetry (Oculus Optikgeräte GmbH)
Survey of Ophthalmology, 2007 393
Automated perimetry : Indicator• Fixation errors: the number of times the patient looks
away from the central target. This is a key indicator of patient cooperation or fatiguepatient cooperation or fatigue.
• False positives: the number of times the patient pushes the button when, in reality, a light source is not illuminated.
• False negatives: the number of times the patient fails toFalse negatives: the number of times the patient fails to push the button when, in reality, there is a light source illuminated. These spots can be repeat tested by the onboard computer at exactly the same spot to best
d d h i ' bili d fi ldunderstand the patient's ability to produce an accurate field test.
• Points tested: indicates the total number of separately illuminated testing points and therefore data pointsilluminated testing points, and therefore data points presented to the patient for testing. Reliable patients can produce a very useful field with a limited number of test points.po ts
MedWeb, 2008 394
Automated perimetry : Indicator• Reliability index : the overall reliability of the patient's
testing for each eye. Poor reliability may indicate patient fatigue insufficient understanding of the test or poorfatigue, insufficient understanding of the test, or poor vision for other reasons such as cataracts. Visual field tests can also be used to ferret out malingerers.
• Standard deviation: the difference in peripheral fieldStandard deviation: the difference in peripheral field acuity when compared to a normative data base, or simply put, a large group of similar normal patients. This tells the doctor whether or not a particular part of the p pperipheral field is normal, depressed, or absent.
• Visual field map: the final basic report indicating the patient's visual field anywhere from the central 10 degrees all the way out to the farthest reaches of the field at 90 degrees. Altered patterns in the field map from reliable patient testing are often extremely useful in the diagnosis of ocular or neurological disordersdiagnosis of ocular or neurological disorders.
MedWeb, 2008 395
ASSESSING RELIABILITY
False-Positive Catch Trials• A sound cue is given before each stimulus is presented in automated
tests. • Periodically, the sound cue is given but no test stimulus is presented.
A f l iti lt if th ti t d t th d• A false-positive result occurs if the patient responds to the sound cue alone.
False-Negative Catch TrialsFalse-Negative Catch Trials• A false-negative catch trial is recorded if a patient does not respond at a
location that had a measurable threshold earlier in the examination. • A high number of false-negative catch trials may indicate patient g g y p
inattentiveness and an unreliable visual field. • The false-negative response rate is higher in eyes with extensive visual
field defects than in those with normal visual fields.
MedWeb, 2008 396
How to Interpret : HFAHow to Interpret : HFASingle Field Analysis (SFA) print out :g y ( ) p• Test parameter• Patient’s data• Reliability indices• dB graph• Gray scale pattern• Total deviation• Localized pattern deviation• Glaucoma Hemifield Test (GHT)• Global indices
397
HFA Interpretation : AcceptabilityHFA Interpretation : Acceptability
• Right test data• Right test data• Correct patient’s data
398
HFA Interpretation : ReliabilityHFA Interpretation : Reliability
Fi ation Loss < 20 %• Fixation Loss < 20 %• False positive < 33 %• False negative < 33 %
399
Normality : dB GraphNormality : dB Graph
• The dB test by HFA range between “0” and “50” dB50 dB
• A typical “normal” reading is around 30reading is around 30 dB
• A value at or above 40 dB is very unusual
400
Normality : Gray scaleNormality : Gray scale
• The actual threshold valueThe actual threshold value on the dB graph converted to a Gray scale
• The value less than or equal 0 dB d b lidto 0 dB represented by solid
black• The value above 40 dB are
represented by total whiterepresented by total white• Commonly we can not
make a diagnosis based on the gray scaleg y
• The gray scale format quite useful when the patients to be explained about their visual field statusvisual field status
401
Total deviation : Numerical plotTotal deviation : Numerical plot
• The numeric plot is the actual decibelThe numeric plot is the actual decibel deviation at each point as compared to normative datanormative data– Zero Threshold
Positive More sensitive– Positive More sensitive– Negative Depressed
402
Total deviation : Probability plot
• The probability plot indicates the statistical
Total deviation : Probability plot
The probability plot indicates the statistical significance and predicts the possibility of such an normality in normal populationsuch an normality in normal population
• Gray scale pattern“ < 5 % “ l th 5 f 100 l– “ < 5 % “ means less than 5 of 100 normal people (control) have this result“ < 0 5 % “ means less than 5 of 1000 normal– “ < 0.5 % “ means less than 5 of 1000 normal people (control) have this result
403
Total deviationTotal deviation• The Total deviation plot p
highlights any overall depression of visual field– Generalized lossGeneralized loss– Localized loss (scotoma)
• The generalized field loss is caused byis caused by– Cataract– Corneal opacities– Media opacities– Miosis– Refractive errorsRefractive errors
404
Pattern deviationPattern deviation• Shows sensitivity y
losses after an adjustment to remove anyremove any generalized depression Primarily• Primarily highlights only significant l li d i llocalized visual field loss
• The most useful analysis
405
Deviation : NormalityDeviation : Normality
Total Deviation Pattern Deviation InterpretationTotal Deviation Pattern Deviation Interpretation
No symbol No symbol Normal
Some symbols Same pattern Pure localized loss
Many symbols No symbols Pure generalized loss
Many symbols Fewer symbols Mixed lossMany symbols Fewer symbols Mixed loss
No or fewer Many symbols Trigger happy
406
Glaucoma Hemifield Test (GHT)Glaucoma Hemifield Test (GHT)
• It compares points on the upper field toIt compares points on the upper field to corresponding points on lower one
• The GHT based on :– The sensitivity of field should be similar on both
hemifieldIn Glaucoma the upper and lower hemifield are often– In Glaucoma the upper and lower hemifield are often significantly different
• Sensitivity difference between the upperSensitivity difference between the upper and lower hemifield are hallmark of glaucomatous field loss
407
GHT : ApproachGHT : Approach
408
GHT : ResultGHT : Result
• Outside normal limits• BorderlineBorderline• General Reduction of sensitivity
Ab ll hi h iti it• Abnormally high sensitivity• Within normal limits
409
Global indicesGlobal indices
• Mean Deviation (MD)Pattern Standard Deviation (PSD)• Pattern Standard Deviation (PSD)
410
Mean Deviation (MD)Mean Deviation (MD)
Th f h h l i• The average measure of how much elevation or depression the patient’s visual field compared to a normal person of the same agea normal person of the same age
• Derived from the Total deviation • Shows how much the whole field departs from• Shows how much the whole field departs from
normal• Very sensitive to generalized loss• Very sensitive to generalized loss• A small defect will not affect MD significantly
411
Pattern Standard Deviation (PSD)Pattern Standard Deviation (PSD)
It i f th d t hi h th• It is a measure of the degree to which the shape of the patient’s field differs from the
l t d f fi ldnormal age-corrected reference field• An index of localized non uniformity of the
f f th hill f i isurface of the hill of vision• Strongly sensitive to the localized defect
I t ff t b l li d d f t• Is not affect by purely generalized defect• Very helpful in diagnosing early glaucoma
412
Global indices : SummaryGlobal indices : Summary
MD PSD InterpretationMD PSD Interpretation
Normal Normal Probably Normaly
Abnormal Normal Generalized loss
Normal Abnormal Small localized defect
Abnormal Abnormal Large defect with significantLocalized component
413
Normality : Definitively AbnormalNormality : Definitively Abnormal
• GHT Outside normal limitsPSD < 5 %• PSD p < 5 %
414
Visual Field Loss : IndicatorVisual Field Loss : Indicator
• Mean Deviation < - 5 dB• Mean Deviation p < 10%• Mean Deviation p < 10%
415
Defect identification
• Type • Pattern• TendencyTendency
416
Defect identification : Type
G li d• Generalized• Localized• Mixed
417
Defect identification : PatternDefect identification : Pattern
• Paracentral scotoma• Nasal stepNasal step• Arcuata
T l d• Temporal wedge• Altitudinal• Hemianopsia• EtcEtc
418
Defect identification : TendencyDefect identification : Tendency
• Glaucoma• Retinal disorders• Neurological problems• Neurological problems• Artifact
419
Anderson’s criteriaAnderson s criteria
It must be Glaucoma• GHT Outside normal limitsGHT Outside normal limits• PD Cluster of 3 or more non-edge
points p < 5% with one of p < 1%points p < 5% with one of p < 1%• PSD p < 5 %
420
GLAUCOMATOUS VISUAL FIELD DEFECTS
• Any clinically or statistically significant deviation from the normal shape of thedeviation from the normal shape of the hill of vision can be considered a visual field defect.field defect.
• In glaucoma, these defects are either diffuse depressions of the visual fielddiffuse depressions of the visual field or localized defects that conform to nerve fiber bundle patterns.p
MedWeb, 2008 421
Glaucomatous VF DefectGlaucomatous VF Defect
Most appearances • Paracentral• Arcuate• Nasal stepNasal step• Temporal wedge• Altitudinal defect• Altitudinal defect
American Academy of Ophthalmology 422
GON and VF Defect ProgressionGON and VF Defect Progression
423Community Eye Heath 2012
PARACENTRAL DEFECTSPARACENTRAL DEFECTS
• Circumscribed paracentral defects are an early sign of localized glaucomatous damage. g g g
• The defects may be absolute when first discovered, or they may have deep nuclei , y y psurrounded by areas of less dense involvement.
• The dense nuclei often are numerous along the course of the nerve fiber bundle
MedWeb, 2008 424
PARACENTRAL DEFECTSPARACENTRAL DEFECTS
MedWeb, 2008 425
ARCUATE SCOTOMAS• More advanced loss of arcuate nerve fibers
leads to a scotoma that starts at or near the blind spot, arches around the point of fixation, and terminates abruptly at the nasal horizontal meridianmeridian .
• An arcuate scotoma may be relative or absolute.
• In the temporal portion of the field, it is narrow because all of the nerve fiber bundles converge onto the optic nerveonto the optic nerve.
• The scotoma spreads out on the nasal side and may be very wide along the horizontal meridian.
MedWeb, 2008 426
ARCUATE SCOTOMASARCUATE SCOTOMAS
• A notch at the inferior pole ofA notch at the inferior pole of the optic disc (A) reflects damage to retinal nerve fibres projecting in an arcuate pattern, (B) resulting in an arcuate field(B) resulting in an arcuate field defect.
• Section through the optic disc (C) illustrates that nerve fibres from peripapillary areas (redfrom peripapillary areas (red arrow) are located centrally in the optic nerve while fibres from peripheral areas (green arrow) are located near the nerveare located near the nerve sheath.
• Damage occurring midway between sclera and cup yields a
t l d f t (bl )paracentral defect (blue arrow).
427
Differential Diagnosis of Arcuate ScotomasDifferential Diagnosis of Arcuate Scotomas
MedWeb, 2008 428
NASAL STEP DEFECTS
• Because of the anatomy of theanatomy of the horizontal raphe, all complete arcuate scotomas end at thescotomas end at the nasal horizontal meridian.
• A steplike defect along the horizontal meridian results from asymmetric loss of nerve fiber bundles innerve fiber bundles in the superior and inferior hemifields.
MedWeb, 2008 429
NASAL STEP DEFECTS
• Nasal step defects may be evident in someNasal step defects may be evident in some isopters but not in others, depending on which nerve fiber bundles are damaged.
f• The width of the nasal step also varies. Nasal steps frequently occur in association with arcuate and paracentral scotomas, but a nasal p ,step also may occur in isolation.
• Approximately 7% of initial visual field defects are peripheral nasal step defectsare peripheral nasal step defects.
MedWeb, 2008 430
TEMPORAL WEDGE-SHAPED DEFECTSTEMPORAL WEDGE SHAPED DEFECTS
• Damage to nerve fibers on the nasal side of theDamage to nerve fibers on the nasal side of the optic disc may result in temporal wedge-shaped defects.
• These defects are much less common than defects in the arcuate distribution.
• Occasionally, they are seen as the sole visual field defect.
• Temporal wedge defects do not respect the horizontal meridian.
MedWeb, 2008 431
TEMPORAL WEDGE-SHAPED DEFECTSTEMPORAL WEDGE SHAPED DEFECTS
Community Eye Heath 2012 432
Altit di l S tAltitudinal Scotoma
• A more extensive arcuate defect• Involving 2 quadrants in either the superior
or inferior field
American Academy of Ophthalmology433
Altitudinal Scotoma: CausesAltitudinal Scotoma: Causes• RETINAL CAUSES
B h R ti l A t O l i– Branch Retinal Artery Occlusion– Branch Retinal Vein Occlusion– Retinal Coloboma
• OPTIC NERVE LESION– Ischemic optic neuropathy (both arteritic and non-arteritic types)– Papil edema– Optic disc coloboma
• LESION IN CEREBRAL CORTEXSuperior or Inferior calcarine cortex lesion– Superior or Inferior calcarine cortex lesion
– Temporal lobe lesion– Parietal lobe lesion– Tumors affecting both occipital lobe may produce bilateral superior or
i f i ltit di l fi ld d f t
434
inferior altitudinal field defect.
GLOBAL INDICESGLOBAL INDICES• The mean deviation (HFA) or mean defect ( )
(Octopus) reflects the overall depression or elevation of the visual field.
• The deviation from the age-matched normalThe deviation from the age-matched normal value is calculated at each location in the visual field. Th d i ti i i l th• The mean deviation is simply the average (Octopus) or the weighted average (HFA) of the deviation values for all locations tested.
• Like the mean sensitivity, the mean deviation is most sensitive to diffuse changes and is less sensitive to small localized scotomassensitive to small localized scotomas.
MedWeb, 2008 435
GLOBAL INDICESGLOBAL INDICES• Pattern standard deviation (HFA). Such ( )
irregularities can be due to a localized visual field defect or to patient variability. Th d l i d• The corrected loss variance or corrected pattern standard deviation provides a measure of the irregularity of the contour of the hill of vision thatirregularity of the contour of the hill of vision that is not accounted for by patient variability (short-term fluctuation).
• It is increased when localized defects are present
MedWeb, 2008 436
INTEREYE COMPARISONSINTEREYE COMPARISONS
• The difference in the mean sensitivity between a patient's two eyes is less than 1 dB 95% of thepatient s two eyes is less than 1 dB 95% of the time and less than 1.4 dB 99% of the time.
• Intereye differences greater than these values• Intereye differences greater than these values are suspicious if they are unexplained by non glaucomatous factors, such as unilateral g ,cataract or miosis.
MedWeb, 2008 437
New opinions in VF analyzingNew opinions in VF analyzing
• Nowadays SAP armed by Visual field i ft Eprogression software, E.g :
PROGRESSOR GPA software package f HFA (C l Z i M dit AG)for HFA (Carl Zeiss Meditec AG)
438
Glaucoma Progression Analysis (GPA)Glaucoma Progression Analysis (GPA)
• Advancing the Science of Progression Analysis with i d GPA d i d t i th t f diimproved GPA design determine the stage of disease and the rate of progression, and assess your patient’s risk of future vision loss all at a glanceN i l G id d P i A l i (GPA)• New single-page Guided Progression Analysis (GPA) report delivers current exam results, trends the entire visual field history and projects future vision loss. New Visual Field Index (VFI) an improved measure of• New Visual Field Index (VFI) an improved measure of a patient’s visual function status and is optimized for glaucoma progression analysis.
• New software reporting offers guidance for severely• New software reporting offers guidance for severely depressed visual fields
• New GPA algorithm allows GPA analysis to be run on more patients right away by allowing a mix of Fullmore patients right away by allowing a mix of Full Threshold and SITA exams.
439
New opinions in VF analyzingNew opinions in VF analyzing
• But still SAP can only detect the visual field defect after about 50% loss of thefield defect after about 50% loss of the ganglion cells
• How to detect earlier ?
440
Weinreb’s Structural/ Functional Relationship in Glaucoma as the Disease Progressesg
VF
s
EarlyAs compared to GCC, RNFL is still most widely used
% L
oss
Moderate
most widely used and accepted by thought leaders and Drs orld ide
Severe
Drs worldwide
Ad t d f P f R b t N W i b
Time
Adapted from Professor Robert N. Weinreb Hamilton Glaucoma Center, University California San Diego 441
442
Latest generation :gGanglion cell VF Analyzer
• Short-Wavelength Automated Perimetry (SWAP)– First 1986 by Pam Sample et al– Photopic background– Static test targets with 1.7º Goldmann size V and 440 nm Blue color– In SWAP, a 440-nm, narrow-band, 1.8° target is presented at 200-
2ms duration on a bright 100 cd/m2 yellow background and selectively tests the short-wavelength–sensitive cones and their connectionsSelecti e test for Koniocell lar path a Bl e sensiti e cones– Selective test for Koniocellular pathway Blue sensitive cones
– Feasible visual range + 30º– Detecting glaucoma 5 years earlier than white on white perimetry
Survey of Ophthalmology, 2007 443
Latest generation :
F D bli T h l P i t
Ganglion cell VF Analyzer• Frequency-Doubling Technology Perimetry
(FDT)First 1966 by Don Kelly et al– First 1966 by Don Kelly et al
– FDT was measured with the frequency-doubling visual field instrument (Carl Zeiss Meditec AG) using Welch-Allyn technology (Skaneateles Falls, NY) and the N-30 program, software version 3.00.1Magnocellular Motion detecting sensitivity– Magnocellular Motion detecting sensitivity
– The targets consist of a 0.25-cyc/deg sinusoidal grating that undergoes a 25-Hz counterphase flickerg g g p
Survey of Ophthalmology, 2007 444
Latest generation :
• Frequency Doubling Technology Perimetry
Ganglion cell VF Analyzer• Frequency-Doubling Technology Perimetry
(FDT)– The test involves a modified binary search staircase y
threshold procedure with stimuli presented for a maximum of 720 ms. FDT measures the contrast needed for detection of the stimulus
– Each grating target is a square subtending approximately 10° in diameter. Targets are presented in one of 18 test areas located– Targets are presented in one of 18 test areas located within the central 20° radius of the visual field temporally and 30° nasally
Survey of Ophthalmology, 2007 445
Latest generation :Ganglion cell VF Analyzer
• High-Pass Resolution Perimetry (HPRP)
Ganglion cell VF Analyzerg y ( )
– First introduced 1987 by Lars Frisen– In HPRP, ring-shaped vanishing optotypes which vary
in size are used to assess resolution ability in the central 30° of the visual fieldThe optotypes used in HPRP are high-spatial-– The optotypes used in HPRP are high-spatial-frequency filtered targets where the inner and outer portions of the rings are darker (15 cd/m2), whereas th t ti f th i i b i ht (25 d/ 2)the center portion of the rings is brighter (25 cd/m2)
– Parvocellular Color, Form, Long wavelength sensitivitysensitivity
446
Latest generation :Ganglion cell VF Analyzer
Hi h P R l ti P i t (HPRP)
Ganglion cell VF Analyzer
• High-Pass Resolution Perimetry (HPRP)– The space-averaged luminance of the entire ring is equal to the
luminance of the photopic background (20 cd/m2)Th f h th d f th i t b l d th– Therefore, when the edges of the ring cannot be resolved, the rings blend into the background, that is, the targets are either resolved (seen) or they are invisible
– The target consists of rings of different sizes presented at 50– The target consists of rings of different sizes, presented at 50 locations within the central 26-30°
– No stimuli are presented within the central 5° of the visual field – The subject responds when the target is large enough to resolveThe subject responds when the target is large enough to resolve– E.g : HPRP is with the Ophthimus High-Pass Resolution
Perimeter, version 2.0, software version 2.51 (HighTech Vision, Malmö, Sweden).
447
Examples of visual field pattern deviation display for SAP, SWAP, FDT, and the small and deep dent display for HPRP in a patient with GON. Each plot shows the location and number of stimulus test locations as designated by either a box or a dot Dot: within normal limits The shading in thetest locations as designated by either a box or a dot. Dot: within normal limits. The shading in the boxes denotes the probability of abnormality relative to the internal normative database of each device. Probabilities are shown in the corresponding key. 448
VF Defect :VF Defect : Charts and Facts
449
Source of error in VF AnalyzingSource of error in VF Analyzing• Miosis• Lens or media opacities• Uncorrected refractive error
S l• Spectacles – Decrease of sensitivity up to about 1.2 dB per Diopter– Boundary scotoma caused by the frameBoundary scotoma caused by the frame
• Ptosis• Inadequate retinal adaptation• Fatigue
Kanski JJ, 2007 450
Another VF AnalyzerAnother VF Analyzer
• MatrixMatrix• PULSAR
Fli k P i t• Flicker Perimetry• Motion Detection Perimetry (MDP)• Motion Automated Perimetry (MAP)• Motion Coherence Perimetry (MCP)Motion Coherence Perimetry (MCP)• Rarebit Perimetry
Survey of Ophthalmology, 2007 451
Endothelial cell losscell loss
Trabecular damage /
PASIris atrophy
Primary angle
PAS
angle closure
IschemicLens damage
Glaucomatus
IschemicOptic
Neuropathy
Lens damage
OpticNeuropathy
Damage to ocular tissue in angle-closure glaucomaDamage to ocular tissue in angle closure glaucoma
Foster PJ 2001 452
CLASSIFICATION OF GLAUCOMA
ANTERIOR CHAMBER ANGLE
(JAPAN GLAUCOMA SOCIETY, GUIDELINES FOR GLAUCOMA)
NORMAL OPEN ANGLE
GON GVFD
NO YES NO YES
NORMAL ELEVATED
IOP IOP IOP
NORMAL NORMALELEVATED ELEVATED
NORMAL
OCULAR HYPERTENSION
NORMAL-TENSION GLAUCOMA (SUSPECT)
NORMAL-TENSION GLAUCOMA
OCULAR HYPERTENSION
PRIMARY OPEN-ANGLE GLAUCOMA (SUSPECT)
PRIMARY OPEN-ANGLE GLAUCOMA 453
Steroid-induced glaucomag
• UncertainUncertain • Steroid excessive deposit of acid
mucopolysaccharide ormucopolysaccharide or glycosaminoglycan (GAG)It t i t b l h k• It present in trabecular meshwork abnormal function
Trans Am Ophthalmol Soc,1977
454
Newest term of POAG and NTGNewest term of POAG and NTG
• Developmental and degenerative ocularDevelopmental and degenerative ocular problems– Degenerative of entire ocular vascular and trabecular
meshwork*– Regression failure of hyaloid artery in third trimester
of gestation facilitating the high IOP to directly hitsof gestation facilitating the high IOP to directly hits the optic nerve head
– Previously “ fragile “ optic nerve head and RNFLy g p
* Does not occur in NTG
455
Gl T t tGlaucoma : Treatment
• Causes Trauma, New vessels etc• Medical• Laser• Surgery• Others*Others
456
Gaucoma : MedicalClass Dosage IOP
decrease Time to peak effect/ washout
1. blockersTimolol Maleat bid 20 30% 2 3 hours/1 monthTimolol Maleat bid 20-30% 2-3 hours/1 monthBetaxolol bid 15-20% 2-3 hours/1 month
2. Alpha 2 adrenergic agonistBrimonidine bid, tid 20-30% 2 hours/7-14 days
3. Carbonic Anhidrase inhibitorD l id bid tid 15 20% 2 3 h /48 hDorzolamid bid, tid 15-20% 2-3 hours/48 hoursBrinzolamide bid, tid 15-20% 2-3 hours/48 hours
4. Prostaglandin analogues & Prostamidesostag a d a a ogues & osta desLatanoprost qd 25-32% 10-14 hours/4-6 weeks
Travoprost qd 25-32% 10-14 hours/4-6 weeksBimatoprost qd 27-33% 10-14 hours/4-6 weeksp qUnoprostoneTafluprost
bid qd
13-18%18-22%
UnknownUnknown 457
Glaucoma : Pathways to IOP reduction
458
Target IOPg
Target IOP may be defined as a pressure, rather a range of intraocular pressure levels within which the progression of glaucoma and visual field loss will be delayed or haltedloss will be delayed or halted
• Advanced POAG 12 mmHg• Early glaucoma 17 mmHgy g g• NTG 11 mmHg
Gumansalangi MNE, 2002 459
AAO GUIDELINES TARGET IOPAAO GUIDELINES: TARGET IOP
• Open angle glaucoma with IOP in the mid to high 20s Target IOP range 14-18 mmHg18 mmHg
• Advanced Glaucoma Target IOP is < 15 mmHg< 15 mmHg
• OHT whose IOP > 30 mmHg with no sign of optic nerve damage Targetsign of optic nerve damage Target IOP < 20 mmHg
Survey of Ophthalmology, 2003 460
Factors to be consideredFactors to be considered• Efficacy: Maximal IOP reduction• Efficacy: Maximal IOP reduction• Minimum required drug• Easy to use and compliance• Easy to use and compliance• Giving flat diurnal curve• Ocular tolerabilityOcular tolerability• Systemic safety• Cost effectiveCost effective• Quality of life
Gumansalangi MNE, 2002 461
Glaucoma : LaserGlaucoma : Laser
• Argon laser trabeculoplasty• Selective laser trabeculoplasty Primary p y y
Glaucoma Therapy?• Laser gonioplasty• Nd:YAG laser iridotomy• Diode laser cycloablationy• Endoscopic cyclo laser photocoagulation
462
Glaucoma : SurgeryGlaucoma : Surgery• Inflow proceduresp• Vitrectomy• Lens extraction
P il t ti• Pupil reconstruction• Iridectomy• TrabeculectomyTrabeculectomy• Tubes and Shunting• Canaloplasty• Viscocanalostomy• Deep sclerotomy• Crosslinked NaHA surgery enhancer*Crosslinked NaHA surgery enhancer
463
Glaucoma: SurgeryGlaucoma: Surgery
464
Glaucoma Devices, Tubes and ShuntingGlaucoma Devices, Tubes and Shunting
• Molteno Implant• Pressure Ridge Molteno Implant• Ahmed Valve• Baerveldt Tube ShuntBaerveldt Tube Shunt• SOLX Gold Shunt• iScience Microcatheter Canaloplasty
GLAUCOLIGHT C l l t D i (DORC)• GLAUCOLIGHT Canaloplasty Device (DORC)• ExPress Mini-Shunt (Alcon Inc)• iStent (Glaukos)• Hydrus (Ivantis)• Stegmann Canal Expander• AqueSys Collagen Tube ImplantAqueSys Collagen Tube Implant
465
Glaucoma : Cilliary body ablationGlaucoma : Cilliary body ablation
• Cyclocryo therapy• Ultrasound• Diode laserDiode laser
466
467
Is there more to glaucoma h l i IOP ?treatment than lowering IOP ?
• Inhibition of activation of Astrocytes• Inhibition of activation of Astrocytes• Inhibition of Nitric-Oxide-Syntase 2 (NOS-2)• Reduces nocturnal overdipping
– Fludrocortisone 0.1 mg 2 times per week• Improvement of vascular regulation and autoregulation• Combat of oxidative stress• Combat of oxidative stress• Inhibition of Metalloproteinase-9 (MMP-9)• Stimulation of Heat Shock Protein (HSP) production• Neuroprotection
– Memantine N-Methyl D-Aspartate (NMDA) receptor antagonistg
Survey of Ophthalmology, 2007 468
L d t tLens and cataract
The PioneerThe Pioneer
Prof. dr. Prof. dr. IstiantoroIstiantoro SukardiSukardi, , Sp.MSp.M(K)(K)
469
Lens fluid dynamicsLens fluid dynamics
470
Lens Opacities Classification System III (LOCS III)(LOCS III)
471
Optical Biometry Based – Cataract ClassificationOpt ca o et y ased Cata act C ass cat o
• No Cataract (NC) • For Refractive Lens Extraction (RLE)
Phacoemulsification PlanOptical Biometry Examinable Cataract (OBEC)• Optical Biometry Examinable Cataract (OBEC) • For Low Energy Phacoemulsification Plan• For learning Phacoemulsification and for transition toFor learning Phacoemulsification and for transition to
MICS and Femtosecond Laser Cataract Surgery• Optical Biometry Un-examinable Cataract (OBUC)
• For High Energy and More Maneuver Phacoemulsification Plan
Pardianto G ESCRS 2010472
Paradigm of lens surgeryParadigm of lens surgery
• Avoid advanced cataract complications t id bl bli dprevents avoidable blindness
• Restores visual function• Nowadays refractive surgery
improves visual functionpPhacoemulsification or more*
Eurotimes, 2009 473
Refractive SurgeryRefractive Surgery
• Optical synergy Sharper visionOptical synergy Sharper vision– Zero spherical aberration
Reduced chromatic aberration– Reduced chromatic aberration– Full visible light transmission
Glistening free– Glistening free – Limited Lens Epithelial Cells (LEC) migration
Eurotimes, 2009 474
Cataract surgery : State of the ArtCataract surgery : State of the Art
• More comfort, faster and reliable ,advanced examination
• Minimal invasion• Minimal manipulation• Minimal complicationMinimal complication• Better result• Better outcome• Better outcome• More improved visual function
475
Intraocular materialsIntraocular materials
• SterileI t• Inert
• Non toxic• Non allergenic• pH BalancedpH Balanced• Long lasting stable
476
Crystalline Lens vs IOLsCrystalline Lens vs IOLs
• 200-250 vs 20 mm3 volume200 250 vs 20 mm volume• 11 vs 12-13 mm overall diameter
4 5 1 thi k• 4.5 vs 1 mm thickness• 10 vs 5-6 mm front surface radii of
curvature• 6 vs 5-6 mm back surface radii of
curvature
Eurotimes, 2010 477
Spherical vs Aspheric LensSpherical vs Aspheric LensSphericSpheric
478
Spherical vs Aspheric LensSpherical vs Aspheric LensAsphericAspheric
479
Spherical vs Aspheric LensSpherical vs Aspheric Lens
Changchun Jixiang, 2006 480
IOL : BiometryIOL : Biometry
• A Scan biometry– Very dense cataract– Use different keratometry analyzer
• 3rd and 4th generation formulated biometry Phakic IOL and post refractive surgery biometry– Partial Coherence Laser Interferometer or Non-contact Optical
C h Bi t L I t f t T h iCoherence Biometry or Laser Interferometry Technique• IOL Master 5.0 (Carl Zeiss Meditec AG), • Lenstar LS 900 (Haag-Streit International)• Pentacam HR (OCULUS Optikgeräte GmbH)( p g )• IOL Station (NIDEK)
– Advanced Immersion A Scan biometry• Aviso (Quantel Medical)
481
Aviso (Quantel Medical)
IOL Master 500 (Carl Zeiss Meditec AG) Lenstar LS 900 (Haag Streit International)IOL Master 500 (Carl Zeiss Meditec AG) Lenstar LS 900 (Haag-Streit International)
482
IOL Calculation FormulasIOL Calculation Formulas
• 1st Generation1 Generation– SRK Sanders, Retzlaf and Kraff
• 2nd Generation2 Generation– Binkhort, Hoffer, SRK II, Holladay
• 3rd Generation3 Generation– SRK/T, Hoffer-Q
• 4th Generation• 4 Generation– Holladay 2, Haigis, Camellin-Calossi– Double K technique Post LASIK– Double K technique Post LASIK
483
IOL calculation formulas
• SRK P = A - (2.5L) - 0.9K– L in millimeter– K in Diopter
• Older guidance (Axial length approach)– > 26 mm SRK-T, Optimized Haigis– 24.4 – 26 mm Holladay
22 24 5 mm Holladay 2 Haigis– 22 – 24.5 mm Holladay 2, Haigis» or Average of SRK/T, Holladay,
Hoffer-Q
– < 22 mm Hoffer-Q, Optimized Haigis484
Reevaluated IOL Calculation :Reevaluated IOL Calculation :
• Less than 22 mm or more than 25 mmLess than 22 mm or more than 25 mm axial length
• Less than 40.00 D or more than 47.00 D ofLess than 40.00 D or more than 47.00 D of K Reading
• Difference in both eyes :Difference in both eyes :– More than 1.00 D K Reading– More than 0.3 mm axial lengtho e t a 0 3 a a e gt– More than 1 D IOL Power in target of
emmetropia
485
The IOLsThe IOLs
• 360º barrier edge360 barrier edge• Corrects spherical aberration to essential zero• Increases contrast sensitivityIncreases contrast sensitivity• Reduces harmful blue lights• Significant improvement of visual functiong p
486
IOL: Spheric vs AsphericIOL: Spheric vs Aspheric
IOL Spherical aberration correction by Spherical IOL vs Aspheric IOL
Alcon, 2010 487
Lens and Cataract : IOLsAberration-counter Aspheric IOLs
Lens and Cataract : IOLsAberration counter Aspheric IOLs• Acrysof IQ Aspheric Natural IOL (Alcon, Inc)
• enVista Glistening-free Aspheric IOL (Bausch & Lomb g p (Incorporated)
• Akreos MI60 Microincision Lens with Aspheric Aberration-Free Optics IOL (Bausch & Lomb Incorporated)Optics IOL (Bausch & Lomb Incorporated)
• TECNIS 1-Piece Aspheric IOL (Abbott Medical Optics)
• C-flex and Superflex Aspheric IOL (Rayner)p p ( y )
• HOYA’S Aspheric ABC Design IOL (HOYA)
• Afinity Collamer Aspheric IOL (Staar)y
488
Multifocal IOL : RefractiveMultifocal IOL : Refractive
• Designed with several optical zones on the i t l lintraocular lens.
• These zones provide various focal points, allowing for an improvement in distance, intermediate, and near vision.
489
Multifocal IOL : DiffractiveMultifocal IOL : Diffractive
• Gradual diffractive steps on the intraocular lens implant that create a smoothlens implant that create a smooth transition between focal points. Th IOL l b d i i li ht t th• The IOL also bends incoming light to the multiple focal points to increase vision in ario s lighting sit ationsvarious lighting situations.
490
ApodizationApodization
• Is the gradual reduction or blending of diffractiveIs the gradual reduction or blending of diffractive step heights.
• Distributes the appropriate amount of light to pp p gnear and distant focal points regardless of the lighting situation.
• The apodized diffractive optics are also designed to improve image quality and minimize i l di b i ifi ivisual disturbances – a significant improvement
over traditional multifocal technologies
Alcon, 2010 491
Multifocal*: AccommodativeMultifocal : Accommodative• An accommodative intraocular lens implant only p y
has one focal point, but it acts as if it is a multifocal lenses. Th IOL d i d i h hi i il h• The IOL was designed with a hinge similar to the mechanics of the eye’s natural lens.
• Using the eye’s muscles the single focal point of• Using the eye s muscles, the single focal point of an accommodative intraocular lens can shift to bring objects at varying distances into focus.– Change in SHAPE of the lens in the eye– Change in POSITION of the lens in the eye
492
Multifocal, Accommodating IOLs, g
493
Multifocal IOLs• AcrySof ReSTOR Diffractive Apodization
Aspheric IOL (Alcon Inc)Aspheric IOL (Alcon, Inc)• ReZoom TECNIS Multifocal IOL (Abbott
Medical Optics)Medical Optics)• TECNIS 1 Diffractive Aspheric 1-piece
Multifocal IOL (Abbott Medical Optics)• Acriva Reviol Multifocal IOL (VSY
Biotechnology)• AT Lisa (Carl Zeiss Meditec AG)• AT Lisa (Carl Zeiss Meditec AG)• MF4 (Ioltech Carl Zeiss Meditec AG)• M-flex (Rayner)( y )• Versario (CROMA)
494
Accommodating IOLsAccommodating IOLs
• Crystalens AT-45 Accommodating IOL (C&C Visions)(C&C Visions)
• KH-3500 (Lenstec)Bi C F ld 43A (M h )• BioComFold 43A (Morcher)
495
Toric IOLsToric IOLs
• AcrySof Toric Natural IOL (Alcon, Inc)• Acri.LISAToric IOL (Acri.Tec Carl Zeiss (
Meditec AG)• AA4203TF (Staar)
MicroSil (H manOptics)• MicroSil (HumanOptics)• T-flex (Rayner)• M-flex-T Toric Multifocal (Rayner)M flex T Toric Multifocal (Rayner)
496
Photochromic IOLsPhotochromic IOLs
• Colorless UV-Blocking at night• Changes to a yellow outdoor during the day• Changes to a yellow outdoor during the day • Does not compromise scotopic vision at night• Provides additional protection from blue light• E.g : MATRIX Acrylic AURIUM (Medennium)
497
MICS IOLMICS IOL
• MI60 (Bausch and Lomb)MI60 (Bausch and Lomb)• AT Lisa (Carl Zeiss Meditec AG)
AT S t 48S (C l Z i M dit AG)• AT Smart 48S (Carl-Zeiss-Meditec AG)• ThinLens UltraChoice 1.0 (Technomed
GmbH) • Lentis L-303 (Oculentis GmbH) ( )• CareFlex (w2o Medizintechnik AG)
498
Hydrophilic vs Hydrophobic IOLHydrophilic vs Hydrophobic IOL• Hydrophilic IOLHydrophilic IOL
– Less Uveitis– Less Anterior Capsule Contraction– Less Glaucoma– Less Capsular Block
• Hydrophobic IOL• Hydrophobic IOL– More adhesiveness to posterior capsule– Less PCO
• New design Anterior surface hydrophilic and posterior surface hydrophobic Bi Flex 1.8 (M di t )(Medicontur)
499
HapticHaptic
• Three-pieceThree piece– Less PCO if square-edged optic IOL
Less space if in posterior chamber / sulcus– Less space if in posterior chamber / sulcus fixation less glaucoma
• One piece• One-piece– Less PCO if design as 360-degree square-
edged IOLedged IOL– Not recommended fixated in the sulcus
500
Hi-end Operating microscope• Excellent in
– Bright illumination– Red reflexRed reflex– Depth perception– Outstanding Beam splitter Assistance, Teaching and Recording– Smooth X-Y-(Z)
G t i d f– Great in zoom and focus maneuver– UV barrier– Blue filter
• Carl-Zeiss OPMI Lumera i and Lumera T• MÖLLER Hi-R 900 and Hi-R 1000• Leica M844 F40• Alcon LuxOR™ Surgical Microscopes with Q-VUE™ 3-D assistant
Do not forget : How to adjust your microscope• Do not forget : How to adjust your microscope.
501
Cataract surgery : Phacotechnique • 1st Generation• 1st Generation
– Kelman tecnique • Can-opener capsulotomy• Anterior chamber
• 2nd Generation– Can-opener capsulotomyp p y– Posterior chamber Phaco– Sculpting
• 3rd Generation• 3rd Generation– Continuous Curvilinear Capsulorrhexis (CCC)– In-situ Phaco Endo-capsular– E.g : Divide and Conquer, Sheperd’s Phaco Fracture
Technique, Fine’s Chip and Flip Technique, Fine and colleagues’ Crack and Flip Technique, Nagahara’s Ph C Pf iff ’ Q i k Ch d K h’ StPhaco Cop, Pfeiffer’s Quick Chop and Koch’s Stop and Chop 502
Cataract surgery : Phacotechnique
• 4th Generation– CCCCCC– Supracapsular – E.g : Fine, Parker and Hoffman’s Choo Choo Chop
and Flip– Revolution in
• Micro incision 1 7 1 8mm• Micro incision 1.7 - 1.8mm• Cooler Phaco• Phaco-tip• IOLs• Improvement in uncorrected post-operative day one visual
acuity
503
Cataract surgery : AnesthesiaCataract surgery : Anesthesia• Nowadays trend Topical, and some add y p ,
by Viscoelastic-borne intra cameral anesthesia• But please do not forget and keep your ability to
fperform– Akinesia the absence (or poverty) of movement– Retrobulbar– Retrobulbar– Peribulbar– Sub-tenon– Sub-conjunctiva
• In special case General anesthesia
504
Cataract surgery : IncisionCataract surgery : Incision• Clear Corneal Incision recomended• Small to Micro• Micro to 1.6 - 1.8 mm incision (MICS)( )• But size is not everything• Factors to be considered
– Shape and contour of incision– Well sealed and water tight
Depend on cataract density and hardness– Depend on cataract density and hardness– Depend on instruments to perform– Depend on surgeon abilityp g y
505
Avoid incision leakAvoid incision leak
• Square incisionSquare incision• Proper size• 2 3 steps direction• 2-3 steps direction• Avoid incision burns
G d t h i h d IOL i ti• Good technique phaco and IOL insertion• Good tip and cartridge• Checking incision at end of surgery• Stromal hydration
506
Limbal relaxing incisionLimbal relaxing incision
• With the rule CCI and superior limbal l i i i irelaxing incision
• Against the rule temporal CCI and limbal relaxing incision
Vajpayee RB 2005Vajpayee RB, 2005
507
Cataract surgery : “Peri-phaco”Cataract surgery : Peri phaco• CCC Continuous Curvilinear
Caps lorrhe isCapsulorrhexis• Tools:
N dl– Needle– Forceps
F t d L – Femtosecond Laser • Alcon LenSx (Alcon LenSx Laser Inc)• LensAR Laser System (LensAR Inc)LensAR Laser System (LensAR Inc)• Catalys Precision Laser System (OptiMedica)• CUSTOMLENS TECHNOLAS (Perfect Vision)
EuroTimes, 2010; EyeWorld, 2010 508
Cataract surgery : “Peri-phaco”Cataract surgery : Peri phaco
• Hydrodissection Injection of a small amount of fluid into the capsule of the lensamount of fluid into the capsule of the lens to separate the nucleus from cortexH d d li ti I j ti f fl id• Hydrodelineation Injection of fluid between the layers of the nucleus of the l i bl t dl G ld Rilens using a blunt needle Golden Ring
509
Hydrodissection : Be carefulHydrodissection : Be careful
• Posterior pole cataract• Traumatic cataract• Traumatic cataract• Hard brown cataract• Post vitrectomy cataract
Rajan M, Mehta C, 2009
510
Phacomachine and instrumentation
• Well contour micro incision
Phacomachine and instrumentation
Well contour micro incision• Surge free anterior chamber maintenance• Cooler phaco tips• Cooler phaco tips• Smoother vacuum and phaco power
E d th li l f i dl• Endothelial friendly• Reduce dropping nucleus• Less edema, less astigmatism• Better outcome
511
Phacomachinesa. Peristaltic Pump
A pump which fluid is forced along by waves of contraction produced mechanically on flexible tubingtubing
512
Phacomachinesb. Venturi Pump
This pump is driven by compressed gas (nitrogen or air) that is directed through chamber B
513
Phacomachinesc. Diaphragm Pump
A flexible diaphragm A is alternately pushed in and pulled out by a rod connected to an electric motor rotating as indicatedrotating as indicated
514
Comparison of pumpsp p p
Peristaltic Venturi
Flow based Vacuum basedFlow based Vacuum based
Vacuum created on occlusion of phaco tip Vacuum created instantly via pump
Flow is constant until occlusion Flow varies with vacuum level
Drains into a soft bag Drains into a rigid cassette
Devgan U, 2008 515
Phaco Pump ComparisonPhaco Pump Comparison
Pump Pro Contra Vacuum Less posterior occlusion surge Need source of compressed gase.g. Venturi Better for vitreous removal
Material comes to tip easily Need rigid cassette
Fl B tt f l ti P t l iFlowe.g. Peristaltic
Better for sculptingNo need for compressed air
Post occlusion surgeNeed occlusion for vacuum to build
Siebel BS, 2008
516
Lens and Cataract : Phacomachines
Newest phacomachines :• WHITESTAR SignatureTM System with FusionTM• WHITESTAR SignatureTM System with FusionTM
Fluidics and ELLIPSTM Transversal Ultrasound (Abbott Medical Optics) Th St ll i MICSTM Vi i E h t S t• The Stellaris MICSTM Vision Enhancement System with EQ FluidicsTM Technology (Bausch & Lomb Incorporated)
S TM• INFINITI Vision System with INTREPIDTM Fluidics Management System and the OZil® IP Intelligent Phaco Torsional Handpiece (Alcon, Inc)
• The CENTURION® Vision System (Alcon, Inc)• Qube Smart System (CROMA)• Faros OS3 and CataRhex3 (Oertli)• Faros OS3 and CataRhex3 (Oertli)
517
Micro Incision Sleeve Development
Support smaller incisions– Reduce shaft diameter
Optimize performance– Maximize chamber
stabilitystability– Wound protection– Minimize wound leakage
Alcon Inc 518
Infusion Sleeve TechnologyTranslucence
Maximize visualization– Maximize visualization
Thin Walls– Maximize Flow– Minimize bulk
Large Holes– Maximize Flow
Smooth Profile– Ease of insertion
MicroSmooth Technology– MicroSmooth Technology
Tight Tolerances– Consistency– Quality
Alcon Inc 519
Older Footswitch PositionsOlder Footswitch Positions
1. Irrigation1. Irrigation
2 Irrigation2. IrrigationAspiration + Vacuum
3. IrrigationAspiration + VacuumAspiration + Vacuum U/S Power
520
Footswitch PositionsFootswitch Positions1 Irrigation can set1. Irrigation can set
always ‘On’
2. IrrigationgAspiration + Vacuum
3. IrrigationAspiration + VacuumAspiration + Vacuum U/S Power
521
Phacodynamics : FundamentalsPhacodynamics : FundamentalsPhacodynamics : FundamentalsPhacodynamics : Fundamentals•• Ultrasound (U/S):Ultrasound (U/S): Repulsive forces Power (percent)
d l Ph ti ( d) A U/Sand also Phaco time (second) Average U/S, Effective U/S and Absolute U/S
•• Aspiration Flow RateAspiration Flow Rate:: (cc/min); is the magnetic action in system to ATTRACT lens material at a specific speed.
•• Vacuum:Vacuum: (mmHg) is negative pressure in system used to HOLD the pieces
•• Bottle height:Bottle height: (cm) Estimate IOP (mmHg) = Bottle height X 0.74 now automated by compressor technologygy
522
Ultrasound: Phaco powerUltrasound: Phaco power
• Absolute phaco time (APT) and EffectiveAbsolute phaco time (APT) and Effective phaco time (EPT)
• Equivalent phaco time at 100% power• Equivalent phaco time at 100% power• APT = total phaco time (seconds)• EPT = phaco time (seconds) X average
phaco power (percents)
523Devgan 2004
Power DeliveryPower Delivery
• Duty cycle: The ratio of working time to total time of U/S usually expressed as atotal time of U/S usually expressed as a percentP l d (PPS) A t f l• Pulse per second (PPS): Amount of pulse those are delivered in one second.
524
Power modulation
525Devgan 2004
AFR and VacuumAFR and VacuumAFR and VacuumAFR and Vacuum
• Aspiration Flow Rate (Attracts)Aspiration Flow Rate (Attracts)• Vacuum (negative holding pressure)
Alcon Inc 526
ASPIRATION FLOW RATE (AFR)ASPIRATION FLOW RATE (AFR)ASPIRATION FLOW RATE (AFR)ASPIRATION FLOW RATE (AFR)
• What does it do?• What does it do?– Attracts material to the tip– Determines how fast material is
drawn to the phaco tip
Alcon Inc 527
ASPIRATION FLOW RATE (AFR)ASPIRATION FLOW RATE (AFR)• Fluid moving through the tubing toward the
ll ti b i f d t A i ti Fl
ASPIRATION FLOW RATE (AFR)ASPIRATION FLOW RATE (AFR)
collection bag is referred to as Aspiration Flow, or Aspiration.
• Aspiration starts when the pump starts .ASPIRATION
FLOW
-Pump rotation pushes fluid out-More fluid moves in
TO DRAIN BAG
-That is Aspiration Flow-Speed of flow is Aspiration Flow Rate-Pump speed controls AFR
PERISTALTIC PUMP Alcon Inc 528
AFR: FOLLOWABILITYAFR: FOLLOWABILITY
• WHAT DOES THIS TERM APPLY TO?WHAT DOES THIS TERM APPLY TO?– The ability to attract material to the tip
• WHAT CONTROLS IT?WHAT CONTROLS IT?– Aspiration Flow Rate
Alcon Inc
529
VACUUMVACUUM
Negative Pressure or
VACUUMVACUUM
–Negative Pressure or Holding Force
–Measured in mmHg –Holds material onto the tip–The higher the vacuum the–The higher the vacuum the
greater the holding force
Alcon Inc 530
Vacuum: OCCLUDEVacuum: OCCLUDEVacuum: OCCLUDEVacuum: OCCLUDE
• Occlusion refers to an obstruction of the• Occlusion refers to an obstruction of the phaco tip
Alcon Inc 531
Vacuum: Purchase
• The grip of the vacuum on the occluding
Vacuum: Purchase
• The grip of the vacuum on the occluding material.
• The higher the vacuum the greater the• The higher the vacuum, the greater the purchase.
Alcon Inc 532
Rise TimeRise TimeRise TimeRise Time• WHAT IS IT?
The measurement of how fastThe measurement of how fast–– The measurement of how fast The measurement of how fast vacuum builds upon occlusionvacuum builds upon occlusion
–– Rise Time is directly related to AFR Rise Time is directly related to AFR –– The faster the AFR the shorter the The faster the AFR the shorter the
Rise TimeRise Time
Alcon Inc 533
COMPLIANCECOMPLIANCE• WHAT IS IT?WHAT IS IT?“The ability of an object
to yield elastically when a force is applied”
• WHAT IMPACT DOES IT HAVE?
The more compliance, the slower the responsiveness andresponsiveness and performance
Alcon Inc 534
NON-COMPLIANCENon-Compliance is “the ability
of an object to maintainof an object to maintain rigidity when a force is applied”.
The more Non-compliant a pfluidic system is, the more responsive it’s performance will be (ie: “True Control”)
Alcon Inc 535
Vacuum: VENTINGVacuum: VENTING
Vacuum Back to neutral
Alcon Inc 536
V REFLUXVacuum: REFLUX
• Push fluid flowR l t i l th t tt h d th• Release material that attached on the phacotip after complete venting process
Alcon Inc 537
Vacuum: SURGEVacuum: SURGE
FLUIDICFLUIDICIMBALANCE
• Outflow • Exceeds • Inflow
Alcon Inc 538
Vacuum: SURGEVacuum: SURGE
539
ULTRASOUND (U/S)ULTRASOUND (U/S)( )( )
•• Refers to frequencies above the range of Refers to frequencies above the range of human audibility, or above 20,000 vibrations human audibility, or above 20,000 vibrations per secondper secondper second. per second.
•• In phacoemulsification, the term “ultrasound” is In phacoemulsification, the term “ultrasound” is used because the phaco needle moves backused because the phaco needle moves backused because the phaco needle moves back used because the phaco needle moves back and forth in excess of 20,000 times per second and forth in excess of 20,000 times per second MICS is in 28,500MICS is in 28,500 times per second times per second ,, pp
•• There are no “sound waves” associated with There are no “sound waves” associated with phacoemusification.phacoemusification.
Alcon Inc 540
U/S: FREQUENCYU/S: FREQUENCY
•How FAST the phaco needle moves back and forthHow FAST the phaco needle moves back and forth
Frequencyq y
WHAT IS THE FREQUENCY RANGE?•The frequency of ultrasonic handpieces is between
2 000 d 60 000 l d27,000 and 60,000 cycles per secondAlcon Inc 541
U/S: STROKEU/S: STROKE• WHAT IS IT?
The tip travels 3.5 mils at maximum power
StrokeHow FAR the phaco tip moves back and forthp p
Alcon Inc 542
U/S POWERU/S POWER• U/S Power is the percent of the maximum
t k l th t l d b th h tistroke length traveled by the phaco tip.• Phaco tip moves in and out in linear fashion.• Some handpieces have a maximum
excursion (Stroke) of 3.2 mils , or 3.2 thousands of an inch (0 001 inch) whichthousands of an inch (0.001 inch), which would represent 100% power.
• Lower power settings are some portion of the• Lower power settings are some portion of the maximum stroke, e.g., 60% would be 1.92 mils of travel.
Alcon Inc 543
PIEZOELECTRIC HANDPIECEPIEZOELECTRIC HANDPIECE
• The forward and back linear (in a straight line) motion of a U/S handpiece isline) motion of a U/S handpiece is generated by piezoelectric crystals. Th t l hi h l t d i th• These crystals, which are located in the handpiece, vibrate at a known frequency
hen electricit r ns thro gh themwhen electricity runs through them.
Alcon Inc 544
PIEZOELECTRIC HANDPIECE• Motion is generated when a tuned, highly refined crystal is deformed
by the electrical energy supplied from the console. Th t l i il t th i t h• These crystals are similar to the ones in a watch.
• The phaco tip is attached to the vibrating crystals.
Alcon Inc 545
CHATTERCHATTERCHATTERCHATTER• WHAT IS IT?
– Fragments rebounding from the tip– Fragments rebounding from the tip
WHAT CAUSES IT?• Chatter occurs when stroke overcomes Vacuum and AFR
Alcon Inc 546
WHAT IS IT?U/S:U/S: LOADLOAD
• WHAT IS IT?• Occurs when the tip encounters nuclear material• WHAT HAPPENS?• Requires more power to maintain stroke• Load is constantly changing
No Load Load
Alcon Inc 547
CAVITATIONCAVITATIONCAVITATIONCAVITATIONWHAT IS IT?WHAT IS IT?• The formation of vacuoles in a liquid by a swiftly moving solid
body (an ultrasonic tip)• The collapse of the vacuoles produces energy which will
erode solid surfaceserode solid surfaces
Alcon Inc
Boat Propeler Example of CavitationBoat Propeler Example of Cavitation 548
CAVITATIONCAVITATION
Kelman tip
I l i f l dImplosion of vacuoles produces:Nine (9) ATA of pressure
l 5000° F destructive energy release
This takes place on a microscopic scale Alcon Inc 549
TUNINGTUNING
• The method used to match up the driving frequency of the console with the operatingfrequency of the console with the operating frequency of the phaco handpiece and tip.
Alcon Inc 550
U/S: Power modulation• Continuous
– Continuous delivery of power– Phaco is on in position three – Usually increasing ultrasound power with
depth into foot position – Used for partial-occlusion sculpting
Chang DF, 2004; Oetting T, 2005 551
U/S: Power modulation• Pulse
Allows surgeon to vary the power with linear control– Allows surgeon to vary the power with linear control with a fixed number of pulse per second (pps)
– Ranges from 1 to 20 pps– With a 50% duty cycle and linear control of power– Phaco pulses with duty cycle on and off
Usually with equal on and off time or 50% duty cycle– Usually with equal on and off time or 50% duty cycle (time on/cycle time)
– Usually the rate (or inverse of duty cycle) is fixed (Hz) – Usually increasing ultrasound power with depth into
foot positi
Chang DF, 2004; Oetting T, 2005 552
U/S: Power modulation• Burst
Allows surgeon to vary the number of burst of power– Allows surgeon to vary the number of burst of power per unit time
– With Constant amount of power– Duration varied widely 5-600 ms– Reduce in thermal and exposure time of energy
Bursts of power come with off time that decreases– Bursts of power come with off time that decreases with depth into foot position
– Usually when floored in position 3 -- ultrasound power b ibecomes continuous
– Ultrasound power is fixed
Chang DF, 2004; Oetting T, 2005 553
U/S: Power modulation• Hyperpulse
– Uses short on time pulses e.g. 25% on; 75% off
– Fixed duty cycle; fixed pulse rate – Usually increasing ultrasound power with
depth into foot position
Oetting T, 2005 554
Advantages & Disadvantages of Various U/S Modes
Mode Advantages Disadvantages Applications
of Various U/S Modes
Continuous Simple - Repels nuclear material
- Hot
Sculpting
Pulse Less hot - Can repel nuclearmaterial
- Choo choo chop- Segment removal
B t L h t Ch iBurst - Less hot- Holds material
well
Chopping
Hyperpulse Followability with SculptingHyperpulse - Followability withlong off cycle
- Cool with long offcycle
- Sculpting- Bimanual small
incision y
Siebel BS, 2008 555
U/S: Amount of Power
• Early phacomachineEarly phacomachine– Available in pedal position 3
Power level was set on the machine panel– Power level was set on the machine panel• Over a decade
S– Surgeon able to vary the power– In LINEAR fashion– By modulating pedal travel in position 3
Chang DF, 2004556
Laws of Phaco PhysicsLaws of Phaco PhysicsLaws of Phaco PhysicsLaws of Phaco Physics
Smaller tips occlude easier The smaller the tip, the more precise p, p
ultrasonic control The smaller the tip, the easier to p
maneuver The larger the tip, the better it holds
Alcon Inc 557
Laser PhacoemulsificationLaser Phacoemulsification• 2940 nm Erbium:YAG Laser
– Erbium:YAG Phacolase (Carl Zeiss Meditec AG)Erbium:YAG Phacolase (Carl Zeiss Meditec AG)• Neodymium:YAG Laser
– Neodymium:YAG Photon Laser PhacoLysis System (Paradigm Medical)Medical)
– Dodick Q-Switched Neodymium:YAG laser (ARC GmbH)• Femtosecond Laser
Vi t (TECHNOLAS P f t Vi i )– Victus (TECHNOLAS Perfect Vision)– Alcon LenSx (Alcon Inc) Rhexis, Incision, Nuclear
fragmentation, Limbal Relaxing Incision (LRI)L AR– LensAR
– Catalys (OptiMedica)– Femto LDV Z Models (Ziemer-S)*
Kohnen T, Koch DD, 2005; Auffarth G, 2010; EyeWorld 2010; Salz JJ, 2010 558
Femtosecond Laser Cataract SurgeryFemtosecond Laser Cataract Surgery
• Data collectionData collection• Docking
OCT S h i fl S• OCT or Scheimpflug Scan• Laser works:
– CCC– Lens softeningg– Clear corneal incision– Limbal relaxing incisiong
559
Docking and OCT guide scanDocking and OCT guide scan
• Diagram of the opticalDiagram of the optical and mechanical interface between the laser system and the yeye.
• The femtosecond laserThe femtosecond laser and OCT beam share the same optical path, providing an exact p gco-registration of the OCT image with the laser segmentation patterns.
560
Femtosecond Laser Cataract SurgeryFemtosecond Laser Cataract Surgery
561
Tips in Zonular weaknessp• Full dilated pupil
M i t i d b BSS d li (1 1 000 0 5• Maintained by BSS-adrenaline (1:1,000 or 0.5 ml in 500 ml)Viscoadaptive ophthalmic viscosurgical devices• Viscoadaptive ophthalmic viscosurgical devices (OVD)
• 2 4 to 2 75 mm incision• 2.4 to 2.75 mm incision• Large capsulorhexis ( 5mm or more)
Cortical cleaving hydrodissection*• Cortical cleaving hydrodissection*• Use a Capsular tension ring (CTR)
Chee SP 2009; Kim WS 2009; Pangputhipong P 2009 562
Tips in Zonular weaknessp• Groove long, wide and deep or triangular groove
B l ti d d• Bevel tip downward• Long horizontal chop• Utilize Triangular cracking technique chop
both distal corner without any nuclear rotation*I i ti l l ibl ( b t 70• Irrigation pole as low as possible (about 70mm –75 mm) reduce any BSS misdirectionImplant Three piece foldable IOL with PMMA• Implant Three-piece foldable IOL with PMMA haptics
Chee SP 2009; Kim WS 2009; Pangputhipong P 2009 563
Small Pupil Management DevicesSmall Pupil Management Devices
• Malyugin’s Ring Pupil Expander• Behler’s Iris Retractor• Iris Hooks
564
Viscoelastic materialsViscoelastic materials
• Maintains spaceMaintains space• Spreads and protects tissues• Coats tissues and instruments• Coats tissues and instruments• Non-toxic
N i fl t• Non-inflammatory• Optically clear but visible• Neutral effect on IOP• Protects the endothelium
American Academy of Ophthalmology 565
Viscoelastic : RheologyViscoelastic : Rheology
• Viscosity• Pseudo plasticity• Elasticity• Cohesion and Dispersion• RigidityRigidity
Kohnen T, Koch DD, 2005 566
Viscoelastic materials
• Sodium Hyaluronate (SH)Healon Healon GV Healon 5 (Abbott Medical– Healon, Healon GV, Healon 5 (Abbott Medical Optics)
– Provisc (Alcon, Inc)( , )– AmVisc Plus (Bausch & Lomb Incorporated)– VisThesia (Ioltech – Carl Zeiss Meditec AG)
Plus 2% Lidocain HCl• Chondroitin sulfate (CS)
Vi (Al I )– Viscoat (Alcon, Inc)– DisCoVisc (Alcon, Inc)
Kohnen T, Koch DD, 2005 567
Viscoelastic materials
• Hydroxypropyl methyl cellulose (HPMC)– Ocuvis (CIMA Technology)– Ocuvis (CIMA Technology)– OcuCoat (Bausch & Lomb Incorporated)
• Colagen IVColagen IV– Removed from market world-wide fear of possible
prior contamination of human-sourced protein• Polyacrylamide
– Formation of microgel clogged the trabecular h k ld b li i d idlmeshwork could not be eliminated rapidly
removed from the market in Europe and USA
Kohnen T, Koch DD, 2005 568
569
Cohesive vs DispersiveC h i Vi d ti Vi• Cohesive Viscoadaptives, Viscous-cohesive viscoelastics– Heavy molecular weightHeavy molecular weight– High concentration– Create and preserve space– Displace and stabilize tissues– Pressurize the anterior chamber– Clear view of posterior capsule– Clear view of posterior capsule– Easy to remove– E.g : 2.3% SH Healon 5 (Abbott Medical Optics (Abbott
Medical Optics) SH 1 6% Amvisc (Bausch and Lomb)Medical Optics), SH 1.6% Amvisc (Bausch and Lomb), 1.4% SH Healon GV (Abbott Medical Optics), SH 1.2% StaarVisc II (Staar Surgical), and SH 1% ProVisc (Alcon, Inc))
Kohnen T, Koch DD, 2005 570
Cohesive vs Dispersive• Dispersive Medium viscosity Very low• Dispersive Medium viscosity, Very-low
viscosity– Coating tissues– Partition spaces– Prolonged retention– E.g : 3.0% SH Viscoat (Alcon, Inc), Healon D (Abbott Medical g ( , ), (
Optics), HPMC 2% Ocucoat (Bausch and Lomb)
• Dual Characters Viscous-DispersiveDual Characters Viscous Dispersive– Cohesive and Dispersive in one– E.g :
• Healon D + GV (Abbott Medical Optics)ea o G ( bbott ed ca Opt cs)• Duovisc (Alcon, Inc)
– The proven protection of Viscoat– The ease to removal of ProVisc
Kohnen T, Koch DD, 2005 571
Rojanapongpun P, 2010 572
Soft shell techniqueSoft shell technique– Protects compromised
corneal endothelium andcorneal endothelium and posterior capsular bag
– Injects dispersive viscoelastic materials
– Followed by cohesive viscoelastic materials injectionP h di i i l ti– Push dispersive viscoelastic materials anteriorly coating the endothelium
– Or also push dispersive i l ti t i lviscoelastic materials
posteriorly coating the posterior capsular bag safer in-the-bag IOL implantationimplantation
573
Vasavada A, 2009 574
Steroid cataract formationSteroid cataract formation
• Glucocorticoids are convalently bound toGlucocorticoids are convalently bound to lens proteins
• Resulting in destabilization of the• Resulting in destabilization of the protein structures All i f th difi ti i id ti• Allowing further modification, ie : oxidation
• Leading to cataract
Experimental Eye Research, 1997
575
Vitreoretina
577
Retinal LayersRetinal Layers
American Academy of Ophthalmology 578
Retinal LayersRetinal Layers
American Academy of Ophthalmology 579
Retina : BasicRetina : Basic• Strongest junctiong j
– Ora serrata– Optic nerve head
• Retinal vessel• Retinal vessel– Inner 2/3 by Central retinal artery– Outer 1/3 by Choriocapillaris also supply
• Fovea• RPE
– Cilioretina artery• In 50% of persons it supplies 30% parts of inner retina• In 15% of persons it contributes to some of macular
circulation
580
Retinal vesselsRetinal vessels
581
Retina : Blood Ocular Barrier
• Blood Retinal Barrier– Retinal Blood Vessel analogous to Cerebral Blood
Vessels maintain Inner Blood-Retina BarrierI Bl d R ti B i f d b– Inner Blood-Retina Barrier performed by
• Single Layer of Non Fenestrated Endothelial Cells Tight-Junction (zonulae occludens)
• Basement Membrane, pericytes (Interupted layer) • Internal Elastic Lamina & Smooth Muscle (Near Optic Head )
– Outer Blood-Retina Barrier performed by RPE in– Outer Blood-Retina Barrier performed by RPE, in which adjacent cells are similarly joined by zonulae occludens
American Academy of Ophthalmology 582
Retina : Blood Ocular BarrierRetina : Blood Ocular Barrier
• Blood Aqueous BarrierI i t d illi ith li– Inner non-pigmented cilliary epithelium
– Tight-junctions between epithelial and endothelial cellsendothelial cells
American Academy of Ophthalmology 583
RPE : FunctionRPE : Function• Vitamin A metabolism• Maintenance of outer blood-retina barrier• Phagocytosis of photoreceptor outer segmentg y p p g• Absorption of light (reduction of scatter)• Heat exchange• Formation of basal lamina• Production of mucopolysaccharide matrix• Active transport of material in and out of the
RPE
American Academy of Ophthalmology 584
Clinical FactsClinical Facts
• The outer Blood retinal barrier the RPEThe outer Blood retinal barrier, the RPE, and the retinal vascular endothelium utilize the same receptor-ligand pairing to controlthe same receptor ligand pairing to control lymphocyte traffic into the retina
• The outer Blood retinal barrier is a• The outer Blood retinal barrier is a common site for inflammatory attack, often resulting in breakdown of barrier functionsresulting in breakdown of barrier functions and choroidal neovascularization
Penfold PL, Provis JM, 2005 585
Blue Light toxicity to RPEBlue Light toxicity to RPE
• Over time RPE accumulates Fluorescent material Lipofuscin
• Lipofuscin absorbs blue light Lipofuscin Fluorophore A2E in presence of Oxygen generate A2E Epoxidesgenerate A2E Epoxides
• A2E Epoxides toxic to RPE and induces Apoptosispoptos s
• RPE can no longer nourish photoreceptor cells adversely affect the vision
586
Fundus : ExaminationFundus : Examination
• Optic nerve head• Retinal appearanceRetinal appearance• Vascular shape
Macula• Macula
587
Fundus : Optic nerve headFundus : Optic nerve head
• MarginMargin• Color• Disc Cup Rim shape• Disc, Cup, Rim shape• Para papil
V l h• Vascular change• Hemorrhage• Myeline• Membrane
588
Fundus : RetinaFundus : Retina• RNFL• Hard exudates
– Intra retinal lipoprotein deposits• Soft exudates Cotton Wool Spot (CWS)p ( )
– Fuzzy or ill-defined edges as retinal ischemia to infarction cotton-wool spot
• Microaneurysm around areas of capillary non perfusion• Hemorrhage
– Pre-retinal– Retinal Flame-shaped– Sub-retinal Fluids level– Roth spot hemorrhages with white center Leukemia
• Degeneration
589
Fundus : VascularFundus : Vascular
• AV ratioAV ratio• AV crossing
– SallusSallus– Gunn– BankingBanking
• Axial reflect– Copper wireCopper wire– Silver wire
• MalformationMalformation590
Fundus : MaculaFundus : Macula• Reflect• Malformation :
– Edema– HoleHole– Drusen deep or dull yellow deposit
• Located in the outer retina of posterior pole• Histologically corresponds to abnormal thickening of the innerHistologically corresponds to abnormal thickening of the inner
aspect of Bruch’s membrane• Basal laminar deposits long-spacing collagen between the
plasma membrane and basement membrane of the RPEB l li d it d it f l t d l d• Basal linear deposits deposits of electron-dense granules and phospolipid vesicles in the inner parts of Bruch’s membrane
– Pigment– Cicatrix– Cicatrix
American Academy of Ophthalmology 591
American Academy of Ophthalmology 592
The 1.5 mm Macula
The central human retina or macula,ith id li d i f it bl d lwith an idealized view of its blood vessels.
The optic disc (OD) is to the left. The macula is subdivided into the central-most foveola, which is surrounded in turn by the , y0.35 mm fovea, parafovea and wider perifovea in 5.5 mm of posterior pole. Each is indicated by concentric circles. Blood vessels form a ring outlining the fovealvessels form a ring outlining the foveal avascular zone, which marks the inner limits of the foveal pit
Penfold PL, Provis JM, 2005593
DrusenDrusen• Drusen
– Hard drusen appear clinically as small yellow punctate– Hard drusen appear clinically as small, yellow, punctate deposits
– Soft drusen paler, larger deposits• Is presence of cellular debris• Located in the outer retina of posterior pole, underneath the RPE• Histologically corresponds to abnormal thickening of the inner
aspect of Bruch’s membrane• Consist of extracellular deposit that aggregate between RPE and• Consist of extracellular deposit that aggregate between RPE and
Bruch’s membrane• Basal laminar deposits long-spacing collagen between the
plasma membrane and basement membrane of the RPE• Basal linear deposits deposits of electron-dense granules and
phospolipid vesicles in the inner parts of Bruch’s membrane
Penfold PL, Provis JM, 2005 ; Eurotimes 2009 594
M l HRA OCT S li (H id lb E i i )Macula : HRA-OCT Spectralis (Heidelberg Engineering)595
Simple test for macular functionSimple test for macular function
• Colour test• Photostress Recovery test• Amsler gridg• Heyne Retinoscopy
596
Distribution of photoreceptor cells and ganglion cells on the g gmacula
Penfold PL, Provis JM, 2005
597
The cone cellsThe cone cells
• Sharp photoreceptor• Sharp photoreceptor• A human eye can see wavelengths in the range of 380 to
760nm. This range is called the visible region • Trichromatic Theory 3 types of cones, each with a
different iodopsin (a photosensitive pigment)• Each type of iodopsin can absorb and respond to aEach type of iodopsin can absorb and respond to a
range of wavelengths• Photosensitive pigments
Erythrolabe maximum absorption at 565nm (red)– Erythrolabe maximum absorption at 565nm (red) – Chlorolabe maximum absorption at 535nm (green) – Cyanolabe max. absorption at 440nm (blue)
598
Color testColor test
• Color naming• Color naming• Yarn test• Lantern test• Plate test
– Hardy-Rand-Rittler plates Red/Green and Bleu/Yellow – Ischihara’s Polychromatic or Pseudoisochromatic platesIschihara s Polychromatic or Pseudoisochromatic plates
Red/Green• Arrangement test Hue discrimination test• Anomaloscopes test• Anomaloscopes test• Panel test Farnsworth Panel D-15 and Farnsworth-
Munsell 100-Hue test
599
Deficient Color Vision
• Dichromacy (Color blindness)Red / Green deficiencies– Red / Green deficiencies• Protanopes
– Confusion at a point at the red end (right end) of the lspectrum locus
– Reds also appear darker to protonopes than to normals• Deuteranopes
– Confusion lines an extraspectral point (off the chart to the lower right, in these coordinates) and their brightness vision is more like that of color-normals
T it i d T it l Y ll / Bl– Tritanopia and Tritanomaly Yellow / Blue deficiencies
– The third class AchromacyThe third class Achromacy
Birch, 2001 600
Ischihara’s Pseudo-isochromatic platesp
• Standard illumination– Daylighty g– 20-60 foot candles
• 75-100 cm reading distance75 100 cm reading distance• 3-5 seconds observation time per plate
N l t t l• No color contact lens wear
Deborah Pavan-Langston, 2008 601
Dark-adaptation testp• The Goldman-Weekers machine• Used to plot the dark-adaptive curve• Used to plot the dark-adaptive curve• In bright light 10 minutes and then all lights are
extinguished• Interval 30 seconds make a measurement of light• Interval 30 seconds make a measurement of light
threshold in one area of visual field• By presenting a gradually increasing light stimulus
U til b l i ibl t th ti t• Until barely visible to the patient• The graph of decreasing retinal threshold against time :
– Initial steep slope cone adaptation– Subsequent gradual slope rod adaptation
• Depression of the dark-adaptation affecting outer retina and RPE, E.g : Retinitis pigmentosa
Deborah Pavan-Langston, 2008 602
Retina : How to draw the retinaRetina : How to draw the retina• Central Macula• Ora Serrata
– Temporal– Nasal Thinner
• Color :R d– Red
– Blue– Red with blue marginRed with blue margin– Brown– Black
603
RD : BasicRD : Basic
• RETINAL DETACHMENT (RD) :A SEPARATION OF THE SENSORIC RETINAA SEPARATION OF THE SENSORIC RETINA FROM THE RETINAL PIGMENT EPITHELIUM
• RETINAL BREAK :A FULL-THICKNESS DEFECT IN THE SENSORY RETINA
604
RD : ClassificationRD : Classification
I. RHEGMATOGENOUS R.D. (RRD)( PRIMARY R D )( PRIMARY R.D. )
II. NON-RHEGMATOGENOUS R.D.( SECONDARY R D )( SECONDARY R.D. )1. TRACTIONAL R.D.2 EXUDATIVE R D2. EXUDATIVE R.D.
605
RD : Classification• MINIMAL
– Vitreous haze– Vitreous pigment clumpsp g p
• MODERATE – Wrinkling of inner retinal surface– Rolled edge of retinal breaks– Rolled edge of retinal breaks– Retinal stiffness– Vessel tortousity
• MARKED full thickness fixed retinal folds• MARKED full thickness fixed retinal folds– C1, C2, C3 (1,2,3 quadrant(s))
• MASSIVE fixed retinal folds in four quadrantq– D1 wide funnel shape– D2 narrow funnel shape– D3 closed funnel invisible optic disc
American Academy of Ophthalmology 606
RD : Rhegmatogenous
Kanski JJ, 2007 607
RRD : Principle of managementRRD : Principle of management
• First : find all breaks• Second : create a chorioretinal irritationSecond : create a chorioretinal irritation
surrounding each breaks• Finally : bring the retina and choroid into contactFinally : bring the retina and choroid into contact
for sufficient time produce chorioretinal adhesion permanently close the breaks
American Academy of Ophthalmology 608
RD : ManagementRD : Management
• Break only : Laser PhotocoagulationBreak only : Laser Photocoagulation• With Detachment
Si l– Simple• Scleral buckle Local and Encircling• Sub retinal fluid drainage• Sub retinal fluid drainage• Pneumoretinopexy• Cryoretinopexy Limited due to PVR formationCryoretinopexy Limited due to PVR formation
– Vitrectomy
609
Buckle vs VitrectomyBuckle vs Vitrectomy
• VitrectomyVitrectomy– More expensive*
More equipments and technology– More equipments and technology– Longer learning curve to perform
Induce more complication– Induce more complication– Need specific positioning
S l diffi lt– Solve more difficult case
610
Buckle vs Vitrectomyy• Buckle
– Cheaper and faster– Less equipments and technology– Longer learning curve to perform– Less complication– Better mobilization– Need more skill to identifying break location
and placing buckle precisely on it– More painful– Myopic shift
611
Vitrectomy is prefer : When?Vitrectomy is prefer : When?
Unclear media• Unclear media• Unsolved traction• Not indented breaks by buckle• Posterior breaks• Need of membrane peeling• PVR • Multiple or spreading breaks• Combined with anterior segment surgeryCombined with anterior segment surgery
612
BuckleBuckle
• Make indentation to close and preventMake indentation to close and prevent breaks
• SiliconeSilicone– Band– TireTire– Sponge
• Sleeve for adjust the tighteningSleeve for adjust the tightening• Suture to sclera with non absorbable
materialmaterial613
Vitrectomy• Machines 1,000 up to 7,500 cuts per minute face to Micro-
incision Vitroretinal Surgery (MIVS)incision Vitroretinal Surgery (MIVS)– Examples :
• CONSTELLATION Vision System (Alcon, Inc)
• Stellaris PC Phacoemulsification and Vitrectomy System (Bausch & Lomb Incorporated)
• Oertli OS3 and Faros Ophthalmic Micro-incision Surgery System (Oertli Instruments)
• The Associate 6000 Ophthalmic Microsurgical System (DORC)g y• eva Ophthalmic Microsurgical System (DORC)
• The VersaVIT and Core Essentials Vitrectomy Machine System and Vitrectomy Packs (Synergetics)
• New Vitreoretinal Endoscopic– Micro endoscopy for vitrectomy and endophotocoagulation– Examples :p
• Endo Optiks• 23 g tapers to 27 g probe and 25 g tapers to 30 g probe IRIDEX EndoProbe
614
VitrectomyVitrectomy
• Microscope enhancement system Retinal wide angle observation tools– Examples :
• RESIGHT Fundus Viewing System (Carl Zeiss)• MERLIN Surgical Viewing System (Volk)• Oculus SDI 4 (OCULUS Optikgeräte GmbH) • Oculus BIOM 5 (OCULUS Optikgeräte GmbH)Oculus BIOM 5 (OCULUS Optikgeräte GmbH)• EIBOS 200 (Platinum Medical) • SUPER VIEW Wide Angle (Insight Instruments)
615
Vitrectomy• Endo Laser
– Example :
yp
• PUREPOINT Laser (Alcon, Inc)
• Instruments Example :– Example :
• 23 and 25+ gauge Micro-Incision Vitrectomy Surgery MIVS (Alcon, Inc) ULTRAVIT® High Speed Vitrectomy Probes with Duty Cycle ControlProbes with Duty Cycle Control
• 25+ and 27+ Probe TotalPLUS Paks (Alcon Inc) 7,500 cpm Ultra-High Speed Cutting
• Hi-speed 23 and 25 gauge NovitreX3000 and p g gOertliKatalyst (Oertli Instruments)
• Intraocular pressure stabilizer Autoseal PMS (Oertli Instruments)
• 27 gauge MIVS system pack (DORCH and Synergetics)• GRIESHABER® Instrumentation (Alcon Grieshaber AG) 616
Vitrectomy : IlluminationVitrectomy : Illumination
• Halogen Yellow Dimmer Light• Xenon Bright White• Xenon Bright White• Metal Halide Bright Natural
Ph t G Y ll• Photon Green Yellow• Light-Emmiting Diode (LED)• 29/30 g Chandelier Fiber Optics
(Synergetics)
617
G d Li idGas and Liquid
Purpose :p1. MECHANIC MANIPULATION OF RETINA2. TEMPORARY INTERNAL TAMPONADE OF RETINAL BREAK3 TO FLATTEN RETINAL DETACHMENT3. TO FLATTEN RETINAL DETACHMENT4. TO MAINTAIN CLEAR VIEW- RETINA5. TO MAINTAIN OCULAR TONE
618
The GasThe Gas
NONEXPANSILE GASES– AIR (NOT PURE GAS) 20% OXYGENE +
80% NITROGENE < 5 DAYS– OXYGENE ( O2 )– CARBON DIOXIDE (CO2 )
EXPANSILE GASES– SULFUR HEXAFLUORIDE (SF6) 2x
10 14 DAYS 10 – 14 DAYS– PERFLUOROPROPANE (C3F8) 4x
55 – 65 DAYS
619
The LiquidqBSS – PLUS
GLUTATHIONE ANTI OXIDANT
SILICONE OILVISCOSITY 1,000 – 5,300 cSt
HEAVY LIQUIDS- PERFLUORODECALIN (C10F18)- SURFACE TENSION 16 – 21.6 dyne/cm- VISCOSITY 2.6 – 8.03 cSt
HEAVY SILICONE OILMIXTURE OF- MIXTURE OF :
- ULTRAPURE POLYDIMETHYLSILOXAN (CH3)3SiO-n-Si(CH3)3 AND
- PERFLUOROHEXYLOCTANE (C6F8)PERFLUOROHEXYLOCTANE (C6F8)
620
Heavy LiquidHeavy Liquid
621
The LaserThe Laser
TO MANAGE THE BREAKS– ARGON GREEN (532 nm)
• PREFFERED– KRIPTON RED (647 nm)
• HAZY MEDIA• DEEP BURNS
LESS CHANCE OF RNFL DAMAGE• LESS CHANCE OF RNFL DAMAGE– DIODE (810 nm)
VITREORETINAL TRACTIONS• VITREORETINAL TRACTIONS622
Precaution• Excessive cryoretinopexy Risk of PVR• Heavy laser burn
– Iatrogenic breakg– Pain and inflammation– Retinal edemaet a ede a
• Long time heavy fluid Toxic to retina• Long time silicone oil More difficult to• Long time silicone oil More difficult to
manage Risk of inferior PVR St id i il fill d N ti ti• Steroid in oil filled eye Necrotic retina
623
PVR : Classification• Grade A
– Vitreous haze– Vitreous pigment clumps– Pigment cluster on inferior retinaPigment cluster on inferior retina
• Grade B– Wrinkling of inner retinal surface
Rolled and irregular edge of retinal breaks– Rolled and irregular edge of retinal breaks– Retinal stiffness– Vessel tortousity– Decreased mobility of vitreous
• Grade CP 1-12– Posterior to equator : focal, diffuse or circumferential full thickness folds– Sub retinal strands
• Grade CA 1-12– Anterior to equator : focal, diffuse or circumferential full thickness folds– Sub retinal strands
A t i di l t– Anterior displacement– Condensed vitreous with strands
American Academy of Ophthalmology624
Diabetic Retinopathy (DR)Diabetic Retinopathy (DR)
Basic of diseaseBasic of disease– Hyperglicemia EPO, IGF PKCβ, VEGF
Basal membrane thickening– Basal membrane thickening– Pericyte death
Mild endothel proliferative (Microaneurysm)– Mild endothel proliferative (Microaneurysm) with plasma leakage
Ong SG, 2009 625
Diabetic Retinopathy (DR)Diabetic Retinopathy (DR)
Basic of diseaseBasic of disease– Lost of intramural pericytes– Compromised blood-retinal barrier by defect in the p y
junction between abnormal vascular endothelial cells– Increased vascular permeability dot and blot
hemorrhages edema and hard exudateshemorrhages, edema and hard exudates– Extensive capillary closure in tripsin-digest flat
preparations of the retinap p– Retinal rendered ischemic by capillary closure
elaborates VEGF stimulates neovascularization
American Academy of Ophthalmology 626
Diabetic Retinopathy (DR)Diabetic Retinopathy (DR)
Muller cellsMuller cells– Uptake glutamate toxic to neurotransmitter – Maintain the synaps release of neurotrophic agentsy p p g– Control extracellular ion concentration– Regulate water transport out of retina Aquaporin 4– Responsive to VEGF Express VEGFR1– Responsive to Glucocorticoids Only one*
Express Glucocorticoid receptorsExpress Glucocorticoid receptors
Ong SG, 2009 627
DR : Basic
Haematologic and biochemical abnormalitiesHaematologic and biochemical abnormalities– Increased platelet adhesiveness
Increased erytrocyte aggregation– Increased erytrocyte aggregation– Abnormal serum lipids
Defective fibrinolysis– Defective fibrinolysis– Abnormal level of growth hormone
Ab l d h l bl d i it– Abnormal serum and whole blood viscosity
American Academy of Ophthalmology 628
DR : HighlightDR : Highlight
1. No Diabetic Retinopathy2 N lif ti Di b ti R ti th2. Non proliferative Diabetic Retinopathy
A. Background Diabetic RetinopathyB. Preproliferative Diabetic Retinopathy
3. Proliferative Diabetic Retinopathy3. Proliferative Diabetic Retinopathy4. Diabetic maculopathy
Deborah Pavan-Langston, 2008 629
DR : Non-proliferativeDR : Non proliferative
• Dilated veinsD t d bl t i t ti l h h• Dot and blot intra retinal hemorrhages
• Microaneurysms• Hard exudates• Edema and CWSEdema and CWS
Deborah Pavan-Langston, 2008 630
Progression from NPDR to PDRProgression from NPDR to PDR
• Diffuse intra retinal hemorrhages and mycroaneurysms in 4 quadrantsy y q
• Venous beading in 2 quadrants• IRMA in 1 quadrantIRMA in 1 quadrant
American Academy of Ophthalmology 631
DR : Pre-proliferativeDR : Pre proliferative
• Intra retinal hemorrhages• MicroaneurysmMicroaneurysm• Intra retinal microvascular abnormalities (IRMA) dilated vessel within the retina dilated vessel within the retina
• Venous beading• Widespread capillary closure• Widespread capillary closure• 10-50% develop to proliferative within a year
Deborah Pavan-Langston, 2008 632
DR : ProliferativeDR : Proliferative
• New vessel on surface the retina and optic nerve head usually attached ofnerve head usually attached of posterior hyaloid of vitreous bodyC t i l t it h h• Cycatrical stage vitreous hemorrhages and traction retinal detachment
Deborah Pavan-Langston, 2008 633
Diabetic maculopathyDiabetic maculopathy
• Result from increased vascular bilitpermeability
• With or without hard exudates• Less commonly result from ischemia
due to closure of foveal capillariesp• May NOT be seen in early background DR
Deborah Pavan-Langston, 2008 634
DME : Type of ThickeningDME : Type of Thickening
• Uniform speckled– Extra cellular fluid Vasogenic mechanismExtra cellular fluid Vasogenic mechanism
• CysticSwollen of Muller’s cells Toxic mechanism– Swollen of Muller’s cells Toxic mechanism
– Not extra cellular fluids
Ong SG, 2009 635
DME : Clinical variationsDME : Clinical variations• Vasogenic
Localized leakage from microaneurism– Localized leakage from microaneurism• Toxic - Non vasogenic
– Leakage from poorly identifiable sitesLeakage from poorly identifiable sites– Massive leakage
• Mechanical– Vitromacular tractions– Epiretinal membrane (ERM)
T id VEGF di t d• Toxid - VEGF mediated– Perpheral ischemia VEGF over expression
Ong SG, 2009 636
DR : CSMEDR : CSME
Clinically Significant Macular EdemaClinically Significant Macular Edema• Thickening of the retina at or within 500 µm of
center of the maculacenter of the macula• Hard exudates at or within 500 µm of center of
the maculathe macula• A zone of retinal thickening one disc area or
larger any part of which is one disc diameter g y pof center of the macula
American Academy of Ophthalmology 637
DR : CSMEDR : CSME
American Academy of Ophthalmology 638
DR : CSMEDR : CSME
American Academy of Ophthalmology 639
DR : CSMEDR : CSME
American Academy of Ophthalmology 640
DR : High risk PDRDR : High risk PDR
• Mild Neovascularization on disc (NVD) with vitreous hemorrhages
• Moderate to severe NVD larger than ¼ to ⅓ disc area with or without vitreous hemorrhagesM d t N l i ti t l h• Moderate Neovascularization at elsewhere (NVE) ½ disc area or more with vitreous hemorrhageshemorrhages
American Academy of Ophthalmology 641
DR : High risk PDRDR : High risk PDR
• At least 3 of :Vitreous or pre retinal hemorrhages– Vitreous or pre retinal hemorrhages
– New vessels (NV)Location of new vessel on or near optic disc– Location of new vessel on or near optic disc
– Moderate or severe extent of new vessels
American Academy of Ophthalmology 642
DR : ApproachDR : Approach
• Reduce blood sugarReduce blood sugar• Monitoring Hba1c
L h t l ti• Laser photocoagulation• Steroids• Anti-VEGF• Rapamycin (Sirolimus)*Rapamycin (Sirolimus)• Surgery
Ong SG 2009; Blumenkranz, 2009; Eurotimes 2009 643
DR & DME: Clinical Trial UpdateDR & DME: Clinical Trial Update
• N-acetylcarnosine Eye DropsN acetylcarnosine Eye Drops• Nepafenac Eye Drops
F fib t O l• Fenofibrate Oral• Dextromethorphan Oral• Danazol Oral• Ranibizumab (Advance Clinical Trial)Ranibizumab (Advance Clinical Trial)• Dexamethasone Implant
644Retinal Physician 2013
DR : Laser rationaleDR : Laser rationale
RetinaRetina• Thinning of retina• Destruction of ischemic retina• Destruction of ischemic retina• Reduction of VEGF release
P lif ti f d th li l ll• Proliferation of endothelial cells• Increase blood flow• Improve auto regulation
Ong SG, 2009 645
DR : Laser rationaleDR : Laser rationale
RPERPE• Destruction of RPE new growth• Increase transmission of metabolism• Increase Oxygen transmissionyg• Improve “pump”
Ong SG, 2009 646
DR : Laser rationaleDR : Laser rationale
Bruch’s membraneBruch s membrane• Altered permeability• Lipid destruction
ChoriocapillaryDestruction of choriocapillary• Destruction of choriocapillary
Ong SG, 2009 647
DR : LaserDR : LaserGrid Laser Photocoagulationg• Macular application 500 µm up to 3000 µm from
foveal center• Excluded area of PMB• Grid Lens / +78 and +90 D Lens• Start at 100mW power increments of 10-20mWStart at 100mW power increments of 10 20mW• 50-100 µm spot size• 0.100 second or less duration• Spots spaced at least one burns apart• Spots spaced at least one burns apart• Supplemental treatment considered at least 3-4 month
after initial coagulation up to 300 µm
648
DR : LaserDR : Laser
F l L Ph t l tiFocal Laser Photocoagulation
• Grid Lens / +78 and +90 D LensGrid Lens / +78 and +90 D Lens• Start at 100mW power increments of 10-
20mW• 50-100 µm spot size• 0.100 second or less duration• Attempt to whiten or darken microaneurysms
649
Laser : PRPPan-Retinal Photocoagulation/ Scatter Laser Photocoagulation/ Scatter Laser Photocoagulation
• NVD or / and NVEPRP L• PRP Lens
• Start at 180mW power increase gradually to achieve the end point
• 500 µm spot size• 0.100 to 0.200 second duration• 1800 total applicationspp• 1 – 1.5 burns width apart• 3 sessions complete 10 days to weeks apart• Usually inferior half of retina coagulated first• Usually, inferior half of retina coagulated first
650
DR : LaserDR : Laser
• Poor visual outcome afterPoor visual outcome after photocoagulation associated with :
Diffuse macular edema with center involved– Diffuse macular edema with center involved– Diffuse fluorescein leakage
Macular ischemia extensive perifoveal– Macular ischemia extensive perifoveal capillary non perfusionHard exudates in the fovea– Hard exudates in the fovea
– Marked Cystoid Macular Edema (CME)
American Academy of Ophthalmology 651
DR : LaserDR : Laser• Side effect and complication
– Paracentral scotomata– Transient increased edema decreased
vision– Choroidal Neovascularization (CNV)– Subretinal fibrosis– Scar expansionp– Inadvertent foveolar burns
American Academy of Ophthalmology 652
Laser in Retina: NowadaysLaser in Retina: Nowadays
• Highly focusedHighly focused• Adjustably patterned • Burn effectively Speed and accuracyBurn effectively Speed and accuracy• Surrounding area safety• OCT guided with high transparency• OCT guided with high transparency• Navigated and tracked• Real time information and comfort for patient• Real time information and comfort for patient• Better result and less side effect
653
DR : IVTA ConsiderationDR : IVTA Consideration
• Edema refractory to Laser photocoagulationEdema refractory to Laser photocoagulation treatment
• Proximity of leakage to the foveaProximity of leakage to the fovea• Difficult to laser or more exacerbate of
edema High risk PDR, Cataract with DMEedema High risk PDR, Cataract with DME• Hard exudates with heavy leak close to
foveafovea• Extreme exudation
Ong SG, 2009 654
DR : IVTA to Muller’s cellsDR : IVTA to Muller s cells
M ll ’ ll t t f St id• Muller’s cells are target of Steroids treatment
• Increase in Adenosin mediated fluid resorption
• Reducing the cystic thickening DME
Ong SG, 2009 655
DR : SteroidsDR : Steroids
• Slow released injectable non-erodibleSlow released injectable non erodible intravitreal steroids• Fluocinolone Acetonide Medidur (Bausch &• Fluocinolone Acetonide Medidur (Bausch &
Lomb) 18 to 36 months• Oral treatment• Oral treatment
– Danazol Optina (Ampio Pharmaceuticals)
Cousins SW, 2009; Retina Today 2012, ; y
656
Vitreous hemorrhagesVitreous hemorrhages
• Major cause– Diabetic retinopathy (39-54%)– Retinal break without detachment (12-17%)– Posterior vitreous detachment (7.5-12%)( )– Rhegmatogenous retinal detachment (7-10%)– Retinal NV following BRVO or CRVO (3.5-10%)Retinal NV following BRVO or CRVO (3.5 10%)
American Academy of Ophthalmology 657
DR: Vitrectomy IndicationsDR: Vitrectomy Indications
American Academy of Ophthalmology 658
Central Serous Chorio-Retinopathy (CSCR)S d t h t f th ti lti f• Sensory detachment of the sensory retina, resulting from– Altered barrier function– Deficient pumping function at level of the RPE and may also involving
the choriocapillarisp• Preferentially in 30-50 years old healthy men• Sudden onset of
– Blurred and dim visionMi i– Micropsia
– Metamorphopsia– Decreased color vision
• FFAFFA– Expansile dot most common
• Focal hyperfluorescent leak from RPE• Appear in early phase• Increase in size and intensity as angiogram processesIncrease in size and intensity as angiogram processes
– Smokestack • Leakage of fluorocein into sub retinal fluid pocket• Produce a pattern of sub retinal pooling of dye
Mushrooms Umbrella– Mushrooms, Umbrella
American Academy of Ophthalmology 659
Infrared CSCR : HRA OCT Spectralis (Heidelberg Engineering)
660
Sub retinal fluid in elderly
CSCR CNV associated with AMDwith AMD
Pin point leak relative to a large area of sub retinal fluid on FFA
Sub retinal fluid corresponds closely to area of leakage on FFA
Multifocal RPE abnormalities- Small serous PED
Large drusen
Absence of blood and significant lipid
Presence of blood and significant lipid
American Academy of Ophthalmology 661
CSCR : Laser indicationCSCR : Laser indication
• Persistent serous detachment 3-4 monthsPersistent serous detachment 3 4 months• Recurrences in eye with visual deficit from
previous episodesprevious episodes• Presence of permanent visual deficit from
previous episodes in fellow eyeprevious episodes in fellow eye• Development of chronic signs
– Cystic changesCystic changes– Widespread RPE abnormalities
• OccupationalOccupational American Academy of Ophthalmology 662
Retina : AMDRetina : AMDInternational Classification (1995)( )
•• AgeAge--related maculopathy (ARM)related maculopathy (ARM)gg p y ( )p y ( )–– DrusenDrusen
•• Small, intermediate, largeSmall, intermediate, large•• Hard soft confluentHard soft confluent•• Hard, soft, confluentHard, soft, confluent
–– Hyper or hypopigmentation of RPEHyper or hypopigmentation of RPE
•• AgeAge--related macular degeneration (AMD)related macular degeneration (AMD)–– ExudativeExudative
NN d tid ti–– NonNon--exudativeexudativeKoh A, 2005 663
AMD : ExudativeAMD : Exudative
•• Choroidal Neovascularisation (CNV)Choroidal Neovascularisation (CNV)Pi t E ith li l D t h t (PED)Pi t E ith li l D t h t (PED)•• Pigment Epithelial Detachment (PED)Pigment Epithelial Detachment (PED)
•• Glial/scar tissue (disciform scar)Glial/scar tissue (disciform scar)
Koh A, 2005 664
AMD : Non-ExudativeAMD : Non Exudative
•• RPE hypopigmentation >175 RPE hypopigmentation >175 m diameterm diameter(G hi t h )(G hi t h )(Geographic atrophy)(Geographic atrophy)
Koh A, 2005 665
AMD : SignsAMD : Signs
•• GreenishGreenish--gray or Yellowgray or Yellow--green lesiongreen lesionGreenishGreenish gray or Yellowgray or Yellow green lesion green lesion •• Pigmented halo around lesionPigmented halo around lesion
S b ti l h hS b ti l h h•• Subretinal hemorrhageSubretinal hemorrhage•• Hard lipid exudatesHard lipid exudates•• Sensory retinal detachmentSensory retinal detachment•• RPE detachmentRPE detachmentRPE detachmentRPE detachment•• Cystoid edemaCystoid edema
Koh A, 2005 666
AMD : SymptomsAMD : Symptoms
•• Monocular vision lossMonocular vision loss•• MetamorphopsiaMetamorphopsiap pp p•• Decreased contrast sensitivityDecreased contrast sensitivity•• ScotomaScotoma•• Decreased color visionDecreased color vision•• MicropsiaMicropsia•• Nowadays level of vision early detection and Nowadays level of vision early detection and
monitoring monitoring ForeseeHome (NOTALVISION)ForeseeHome (NOTALVISION)
Koh A 2005, Retina Today 2013 667
AMD : RF, IF, AF, FA, ICGARed Free AutofluorescenceInfrared
ICG AngiographyFluorescein ICG AngiographyFluorescein Angiography
HRA Spectralis (Heidelberg Engineering) 668
AMD : HRT and OCTAMD : HRT and OCT
HRT3 Heidelberg Engineering
Cirrus HD OCT (Carl Zeiss Meditec AG)
669
CNV : MorphologyCNV : Morphology
• VascularVascular• Hypervascular
Fib l• Fibrovascular
Cousins SW 2009Cousins SW, 2009
670
CNV : Diverse cell typesCNV : Diverse cell types
• EndothelialEndothelial• Smooth muscle cells• Pericytes• Pericytes• Myofibroblasts
RPE ll• RPE cells• CD34 progenitor cells• Macrophages
Cousins SW 2009Cousins SW, 2009
671
CNV : FFACNV : FFA
Classic (Type 1) CNVClassic (Type 1) CNV•• Bright area of fluorescence surrounded Bright area of fluorescence surrounded
by hypofluorescent margin in early phaseby hypofluorescent margin in early phase• Leakage of fluorescein at boundaries of
bright area in late phase
Koh A, 2005672
CNV : FFAOccult (Type 2) CNV• Fibrovascular PED
–– Irregular elevation of the RPEIrregular elevation of the RPEStippled fluorescence within 1 to 2 minutesStippled fluorescence within 1 to 2 minutes–– Stippled fluorescence within 1 to 2 minutesStippled fluorescence within 1 to 2 minutes
– Persistent staining or leakage in late phase frames
• Late Leakage Undetermined Source–– Leakage at level of RPELeakage at level of RPE
A f l k d t d t fA f l k d t d t f–– Areas of leakage do not correspond to an area of Areas of leakage do not correspond to an area of classic CNV or fibrovascular PED in early or mid classic CNV or fibrovascular PED in early or mid phase frames to account for leakagephase frames to account for leakage
Koh A, 2005 673
Occult (Type 2) CNVOccult (Type 2) CNV
H GS 2008Hagerman GS, 2008
674
CNV : ICGCNV : ICG• Componentsp
– Subretinal fibrovascular complex– Intrachoroidal “Feeder Artery”– Intrachoroidal “Draining Vein”
• Patterns• Patterns– Capillary pattern– Arteriolar patternp– Mixed pattern
Cousins SW, 2009 675
Occult CNVOccult CNV
• More than one lesionMore than one lesion• Sub RPE low flow and poor defined
vascularityvascularity• High flow arteriolarized• Atypical polypoidal choroidal vasculopathy• Retinal angiomatous proliferationg p
Cousins SW 2009Cousins SW, 2009
676
AMD : Major Risk FactorAMD : Major Risk Factor
• Molecular Biology :– H Gene (Known as CFH of HFI) Located ( )
on Human Chromosome Iq31– Less of Particular Non-Coding SNP Variant
(Allele A) Found in Intron 6 of the Serping 1 Gene
E ti 2009Eurotime, 2009
677
AMD : Approach• Laser photocoagulation
• Signal Anti VEGF– Macugen® OSI Eyetech (Pegabtanib) Selective g y ( g )
VEGF165 Inhibitor– Lucentis® Genentech (Ranibizumab)
Avastin™ Genentech (Bevacizumab)– Avastin™ Genentech (Bevacizumab)– ALG-1001Allegro Ophthalmic (Anti Integrin Oligo Peptide)
Signaling and Regulating
Cousins SW 2009; Eurotimes 2009, Retina Today 2013 678
AMD : Approach
• Signaling pathway Steroids– Anecortave– Anecortave– Triamcinolone
• Formation PDT– Verteporfin dye (Visudyne)p y ( y )
• Liposome-encapsulated Benzoporphyrin• Maximum absorption light near 689 nm wavelength
Others :– Others :• Tin Ethyl Etiopurpurin (SnET2, Purytin)• Lutetium (Lu-Tex)
Cousins SW 2009; Eurotimes 2009, Retina Today 2013 679
AMD : ApproachAMD : Approach
E10030 A ti PDGF A t • E10030 – Anti PDGF Aptamer (Ophthotech) Synthetic RNA molecules bind protein similar to antibody
• Implantable Miniaturized Telescope (MT)*p p ( )• The Lipshitz Macular Implant (LMI)*• The IOL-VIP System*• Gene Therapy Small interfering (si)RNA*• Membrane Differential Filtration (MDF) Rheopheresis Dry AMD* Dry AMD
Eurotimes, 2009, 2011680
AMD : ApproachAMD : Approach
I t i P tid Th• Integrin Peptide Therapy• ALG-1001
• Topical Therapies*:– ATG3 (coMentis)
OT 551 (Oth Ph )– OT-551 (Othera Pharm)– TG100801 (TargeGen)
Pazopanib (GlaxoSmithKline)– Pazopanib (GlaxoSmithKline)– OC-10X (OcuCure)
Eurotimes, 2010; Retina Today 2012 681
AMD : Approachpp
• Brachytherapy• Source of radiation is placed close to the
surface of targeted therapeutic area• Beta radiation targeted at abnormal or leaking
vessels• Stereostatic Radiotherapy Oraya Therapy
(O I )(Oraya Inc)
Retina Today, 2011, 2012 682
Dry AMD : Approachy pp
• Anti oxidants– Vitamin C, Vitamin E, Beta-Carotene, Zinc and Copper– Lutein and Zeaxanthin– Omega 3 fatty acid
• Visual cycle inhibition• Anti inflammatory agents• Complement inhibitor• Targeting amyloid• Neuroprotector
Retina Today, 2011 683
Response to Anti-VEGFResponse to Anti VEGF
C ill d i t d CNVW ll• Capillary-dominated CNV Well response
• Mixed CNV variable response depends on Ratio of feeder artery caliber and length to capillary area
• Arteriolarized CNV Poor responsep
Cousins SW, 2009 684
Remember
• PDT induces hypoxia in tissueyp• PDT induces formation of oxygen free radical• After 1 day Strong VEGF expressionAfter 1 day Strong VEGF expression• After 1 month PDT increases expression of
– CD 34 ( marker of endothelial cell)CD 34 ( marker of endothelial cell)– CD 105 ( marker of activated endothelial cell)– KI-67 ( marker of proliferation )
Eurotimes, 2009685
PDT : Post procedurePDT : Post procedure• Inflammatory cells observedy
– Monocytes– Macrophages– Platelets– Mast cells– LeukocytesLeukocytes
• Release angiogenic factors VEGF, bFGF• Release cytokines IL-1β, IL-2, TNFαRelease cytokines IL 1β, IL 2, TNFα• Release vasoactive mediators Thromboxane,
TNFα, Histamine
Koh A, 2009 686
RememberRemember•• Fundus fluorescein angiography remains an Fundus fluorescein angiography remains an g g p yg g p y
indispensable tool in diagnosis and indispensable tool in diagnosis and management of AMDmanagement of AMD
•• Indocyanine green angiography is useful inIndocyanine green angiography is useful inIndocyanine green angiography is useful in Indocyanine green angiography is useful in certain situationscertain situations
•• Optical coherence tomography is very popular Optical coherence tomography is very popular b f f d i t t tib f f d i t t tibecause of ease of use and interpretation, because of ease of use and interpretation, particularly useful for followparticularly useful for follow--upup
•• Newer techniques such as SLO angiography Newer techniques such as SLO angiography e e tec ques suc as S O a g og ap ye e tec ques suc as S O a g og ap yand autofluorescence not so essential for clinical and autofluorescence not so essential for clinical practicepractice
Koh A, 2005 687
Wet AMD: Clinical Trial UpdateWet AMD: Clinical Trial Update• Proton Beam Irradiation• Slidenafil• Zeaxanthin Oral (Advance Clinical Trial)• Aflibercept Intravitreal injection• Squalamine Lactate Eye Drops
( C )• Ranibizumab (Advance Clinical Trial)• LFG316 Intravitreal injection• AGN 150998 Intravitreal injection• AGN-150998 Intravitreal injection• ESBA 1008 Microvolume injection• E10030 Intravitreal administrationE10030 Intravitreal administration
688Retinal Physician 2013
Occult CNV AF and OCT : HRA OCT Spectralis (Heidelberg Engineering)
689
Polypoidal Choroidal Vasculopathy (PCV)Polypoidal Choroidal Vasculopathy (PCV)
• Also as "idiopathic polypoidal choroidal vasculopathy")p p yp p y )• A distinct form of choroidal neovascularization (CNV)• Disorder characterized by vessel networks and
polypoidal lesionspolypoidal lesions • Specifically, an inner choroidal vascular abnormality
with two distinct components: – A network of branching vessels predominantly external to the
choriocapillaris, and – Aerminal aneurysmal dilatations
Nakashizuka H, 2008; Cousins SW, 2009690
Polypoidal Choroidal Vasculopathy (PCV)Polypoidal Choroidal Vasculopathy (PCV)
• Sometimes clinically seen as reddish-orange y gspheroidal, or polypoidal, vascular lesions.
• Location Peripapillary, Sub foveal, J f l E f lJuxtafoveal, Extra foveal
• Formation Single, Cluster (more than 2 polyps in a group) or String (more than 3 polypspolyps in a group) or String (more than 3 polyps in a line )
• Size in µmS e µ• Area Single, Multiple
Nakashizuka H, 2008; Cousins SW, 2009 691
Polypoidal Choroidal Vasculopathy (PCV)Polypoidal Choroidal Vasculopathy (PCV)
• (A) Color fundus(A) Color fundus photograph showing a white fibrin-like lesion (arrow) adjacent to
b ti l h hsubretinal hemorrhage (arrowhead) and serous retinal detachment in the macula.macula.
• (B) Fluorescein fundus angiography showing granular hyperfluorescence in the early phase (arrow).
• (C) IGA showing polypoidal lesions resembling grape clustersclusters
Nakashizuka H, 2008 692
Polypoidal Choroidal Vasculopathy (PCV)Polypoidal Choroidal Vasculopathy (PCV)
• (A) Color fundus photograph(A) Color fundus photograph shows orange lesions (arrow) surrounded by a white lesion. These findings are consistent with PCV (i.e., a polypoidal lesion
i d b fib i )accompanied by fibrin). • (B) Fluorescein fundus
angiography showing two small round hyperfluorescent lesions near the fovea (arrow) and anear the fovea (arrow) and a hyperfluorescent lesion indicating pigment epithelial detachment (arrowhead).
• (C) IGA showing polypoidal(C) IGA showing polypoidal lesions corresponding to hyperfluorescent lesions on fluorescein fundus angiography.
Nakashizuka H, 2008 693
PCV : ManagementPCV : Management
• Focal laser photocoagulation• PDT• PDT• Anti VEGF
Cousins SW 2009Cousins SW, 2009
694
Macular hole
• A, Standard StratusOCT image of the normal human macula. Most of the major intraretinal layers can be visualized in the Stratus OCT image and correlated withintraretinal layers can be visualized in the Stratus OCT image and correlated with intraretinal anatomy.
• B, Ultrahigh-resolution optical coherence tomography (Cirrus HD OCT?) image of normal human macula. Ultrahigh-resolution OCT has an improved ability to visualize smaller structures such as the external limiting membrane (ELM) and ganglion cell layer (GCL) INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS =layer (GCL). INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform layer; RPE = retinal pigment epithelium
Fujimoto J, 2006695
Macular hole : Lamellar
• Lamellar hole. A, Fundus photograph depicting the direction of optical , p g p p g pcoherence tomography (OCT) scans. StratusOCT (B) and ultrahigh-resolution OCT (UHR-OCT) (C) images. D, Two-times magnification of the UHR-OCT image in the region of the hole. ELM = external limiting membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer segment junction;plexiform layer; IS/OS = photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform layer; RPE = retinal pigment epithelium.
Fujimoto J, 2006696
Macular hole : Stage 1
• Stage 1 macular hole. A, Fundus photograph depicting the direction of g , p g p p goptical coherence tomography (OCT) scans. Stratus OCT (B) and ultrahigh-resolution OCT (UHR-OCT) (C) images. D, Two-times magnification of the UHR-OCT image in the region of the hole. ELM = external limiting membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer segment junction;plexiform layer; IS/OS = photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform layer; PR OS = photoreceptor outer segment; RPE = retinal pigment epithelium. *Henle’s fibers of the OPL. Fujimoto J, 2006
697
Macular hole : Stage 2• Eccentric stage 2 macular hole.
A, Fundus photograph depicting the hole before surgery and the direction of optical coherence t h (OCT) B Ctomography (OCT) scans. B, C, Stratus OCT (B) and ultrahigh-resolution OCT (UHR-OCT) (C) images of the hole before surgery. D, Two-times magnification of the UHR-OCT gimage in the region of the hole. E, Fundus photograph depicting repair of the hole after surgery. F, G, StratusOCT (F) and UHR-OCT (G) images of the repair of the hole after surgery H Two-the hole after surgery. H, Twotimes magnification of the UHR-OCT image in the region of the hole repair. ELM = external limiting membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = innernuclear layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform l PR OS h t tlayer; PR OS = photoreceptor outer segment; RPE = retinal pigment epithelium.
Fujimoto J, 2006698
Macular hole : Stage 3
• Stage 3 macular hole. A, Fundus photograph depicting the direction of g , p g p p goptical coherence tomography (OCT) scans. B, C, Stratus OCT (B) and ultrahigh-resolution OCT (UHR-OCT) (C) images. D, Two-times magnification of the UHR-OCT image in the region of the hole. ELM = external limiting membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outerlayer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform layer; PR OS = photoreceptor outer segment; RPE = retinal pigment epithelium. Fujimoto J, 2006 699
Macular hole : Stage 4
• Stage 4 macular hole. A, Red-free fundus photograph depicting the direction of optical coherence tomography (OCT) g p y ( )scans. B, C, Stratus OCT (B) and ultrahigh-resolution OCT (UHR-OCT) (C) images of the hole before surgery. D, Two-times magnification of the UHR-OCT image in the region of theOCT image in the region of the hole. E, Fundus photograph depicting repair of the hole after surgery. F, G, StratusOCT (F) and UHR-OCT (G) images of the repair of the hole after surgery. H Two times magnification ofH, Two-times magnification of the UHR-OCT image in the region of the hole repair. ELM = external limiting membrane; GCL = ganglion cell layer; INL = inner nuclear layer; IPL = inner plexiform layer; IS/OS = photoreceptor inner and outer segment junction; NFL = nerve fiber layer; ONL = outer nuclear layer; OPL = outer plexiform layer; PR OS = photoreceptorlayer; PR OS photoreceptor outer segment; RPE = retinal pigment epithelium.
Fujimoto J, 2006 700
Hole Form Factor ‘HFF’Hole Form Factor HFF
Pullifiato, 1999; Ullrich S, 2002 701
Hole Form Factor ‘HFF’Hole Form Factor HFF
• ‘HFF’ > 0,9 80% success rate• ‘HFF’ < 0,5 25% success rate• Higher ‘HFF’ Better visual outcome
Pullifiato, 1999; Ullrich S, 2002 702
Vitreo-Macular Adhesion (VMA)Vitreo Macular Adhesion (VMA)• Symptomatic VMA is which the vitreous gel
dh i b ll t t thadheres in an abnormally strong manner to the retinaVMA can lead to vitreomacular traction (VMT)• VMA can lead to vitreomacular traction (VMT) and subsequent loss or distortion of visual acuity
• Anomalous posterior vitreous detachment (PVD)• Anomalous posterior vitreous detachment (PVD) is linked to several retinal disorders including macular pucker, macular hole, age-relatedmacular pucker, macular hole, age related macular generation (AMD), macular edema, and retinal tears and detachment
Retina Today 2012; Retina Physician 2012 703
Vitreo-Macular Adhesion (VMA)Vitreo Macular Adhesion (VMA)
• Approach Pars Plana Vitrectomy (PPV)Approach Pars Plana Vitrectomy (PPV) is used to surgically induce PVD and release the traction on the retina forrelease the traction on the retina for selected cases
• PPV may result in incomplete separation• PPV may result in incomplete separation, and it may potentially leave a nidus for vasoactive and vasoproliferativevasoactive and vasoproliferative substances, or it may induce development of fibrovascular membranesof fibrovascular membranes
Retina Today 2012; Retina Physician 2012 704
Vitreo-Macular Adhesion (VMA)Vitreo Macular Adhesion (VMA)• Approach pp
– Ocriplasmin 2.5mg/ml, a vitreolysis agent JETREA (TromboGenics)
– ALG-1001 (Allegro)ALG 1001 (Allegro)
• Pharmacologic vitreolysis has the following advantages g y g gover PPV: It induces complete separation, creates a more physiologic state of the vitreomacular interface, prevents the development of fibrovascular membranesprevents the development of fibrovascular membranes, is less traumatic to the vitreous, and is potentially prophylactic
Retina Today 2012; Retina Physician 2012 705
CME• Intraretinal edema contained honeycomb-like
cystoid spaces• Abnormal perfoveal retinal capillary permeability• FFA because of Henle’s fiber layer Flower-
petal patternpetal pattern• Irvine-Gass syndrome
– High as 60% after ICCE– Lower when posterior capsule remains intact– Occurs 6-10 weeks post operatively– Uncomplicated cases 95% spontaneous resolutionUncomplicated cases 95% spontaneous resolution
after 6 months
American Academy of Ophthalmology 706
Hypertensive retinopathyHypertensive retinopathy
• Grade 0 No changes• Grade 1 Barely detectable arterial narrowing• Grade 2 Obvious arterial narrowing with focal
irregularityGrade 3 Grade 2 plus retinal hemorrhages and• Grade 3 Grade 2 plus retinal hemorrhages and
or exudates• Grade 4 Grade 3 plus disc swellingp g
American Academy of Ophthalmology 707
CRAOCRAO• Sudden• Severe• Painless
R ti d t thi k t fib l• Retina opaque, edematous, thickest nerve fiber layer and ganglion cell layer in the posterior pole
• Cerry-red spot orange reflex intact choroidal vasculature beneath the fovea stands out in contrast to surrounding opaque neural retina
• Iris neovascularization 18% in 1-12 weeks afterIris neovascularization 18% in 1 12 weeks after onset with mean time 4-5 weeks
American Academy of Ophthalmology 708
BRVOBRVO
In BRVO, the blockage occurs in one of the smaller b h l th t tbranch vessels that connect
to the central retinal vein.
Allergan 709
BRVO : Cause of poor visionBRVO : Cause of poor vision
• Macular edemaMacular edema• Macular pigmentation
E i ti l b (ERM)• Epi retinal membrane (ERM)• Macular ischemia• Vitreous haemorrhage• Tractional retinal detachmentTractional retinal detachment
Yeo KT, 2009710
CRVO• Non-ischemic
– Milder form• Mild dilatation and tortuosity of central retinal veinsy• Dot and flame hemorrhages• Macular edema decreased visual acuity• Mild optic disc swelling• FFA prolongation of circulation time with breakdown of permeability but minimal
areas of non perfusionareas of non perfusion– Sometimes referred as partial, perfused or venous stasis retinopathy
• Ischemic– 80% CRVO progress to be– 80% CRVO progress to be– Marked venous dilatation at least 10 disc areas– Cotton wool spot– Decrease visual acuity– FFA– FFA
• Retinal capillary non perfusion on posterior pole non perfused, complete or hemorrhagic
• Widespread capillary non perfusion– Iris neovascularization 60% in 3-5 months after onset
American Academy of Ophthalmology 711
CRVO : ApproachCRVO : Approach
Hypoxia Induced Increased Hydrostatic Inflammatory Vascular ypVEGF
yPressure
yLeak
Increased Hydrostatic Pressure
Rheopheresis* Grid Laser
Increased Hydrostatic Pressure
Cousins SW, 2009
712
CRVOCRVO
In CRVO, the blockage occurs in the central retinal
vein, which is the main drainage line for blooddrainage line for blood
leaving the retina
Allergan 713
Allergan 714
Macular EdemaMacular Edema
Allergan 715
CRVO : Anti-VEGF and SteroidsCRVO : Anti VEGF and Steroids
• Anti-VEGF*• Intra Vitreal Injection Preservative-free
Triamcinolone• Slow-released Drug Delivery System
– Fluocinolone Retisert (Bausch & Lomb) ( )30 months
– Dexamethasone • Posurdex (Allergan)• Ozurdex (Allergan)
Cousins SW, 2009; EuroTimes, 2010 716
Retinal Vascular Disease : SurgeryRetinal Vascular Disease : Surgery
• CRAO DecompressionCRAO Decompression• BRVO Arteriovenous Sheatotomy (AVST)
Reduce compression artery-venous p y– Persistent CME– ERM with Vitreous traction– Significant retinal ischemia more than 5 disc-
diameter of capillary non-perfusion with or without NVM l i h i– Macular ischemia
• CRVO Radial Optic Neurotomy (RON) Yeo KT, 2009
717
ROP : Indirect ophthalmoscopyROP : Indirect ophthalmoscopy
• Stage 1: Demarcation lineStage 1: Demarcation line• Stage 2: Ridge : height, width, volume
St 3 N l i t f id• Stage 3: New vessels growing out of ridge• Stage 4: Partial retinal detachment
– 4 a. Extra fovea– 4 b. Involving fovea g
• Stage 5: Total retinal detachment with funnelfunnel
American Academy of Ophthalmology 718
Zone and clock hoursZone and clock hours
719
St 1Stage 1: Demarcation Line
Stage 2 : Ridge
Stage 3: Neo Vascularization
720
ROP : ScreeninggIndirect ophthalmoscopy• All infants with a birth weight of ≤ 1500 g• All infants with a birth weight of ≤ 1500 g• All infants with a gestational age of ≤ 28 weeks
Infants o er 1500g if nstable clinical co rse• Infants over 1500g if unstable clinical course• Timing: 4-6 weeks after birth or 31 to 33 weeks
after conceptionafter conception• Treat < 72 hours after diagnosis of threshold
diseasedisease
N h RetCam Di it l I i (Cl it )New approach RetCam Digital Imaging (Clarity)721
ROP : TreatmentROP : Treatment
• Laser photocoagulationC th• Cryotherapy
• Retinal detachment surgery
American Academy of Ophthalmology 722
Intravitreal Antibiotics ( / 0 1 ml )Intravitreal Antibiotics ( / 0.1 ml )
G t i 0 1• Gentamycin 0.1 mg• Vancomycin 1.0 mg• Amikacin 0.4 mg• Chlorampenicol 1.0 mgChlorampenicol 1.0 mg• Amphotericin B 5.0 µg
Cefta idime 2 0 2 25 mg• Ceftazidime 2.0-2.25 mg
American Academy of Ophthalmology 723
Intravitreal Steroids ( / 0 1 ml )Intravitreal Steroids ( / 0.1 ml )
• Dexamethasone 0.4 mg• Triamcinolone 4 mg
American Academy of Ophthalmology 724
Consideration : AnatomyConsideration : Anatomy
• Limbus identificationLimbus identification• Lens existence
Ph ki 3 5 4– Phakic 3.5 – 4 mm– Aphakic / Pseudophakic 3 mm
• Cilliary body 2.5 mm• Widest Pars plana and Ora Temporo p p
inferior Safest area
725
Retina : VEGF SessionRetina : VEGF Session
• VEGF isVEGF is– Survival factor
Neuro protector– Neuro protector– Fenestration
• New vessels Endothelial tubes
Eurotimes, 2009726
Angiogenesis factorsAngiogenesis factors
• VEGFVEGF• bFGF
A i i ti• Angiopoietin• PGE2• Erythropoietin
Cousins SW 2009Cousins SW, 2009
727
The VEGFThe VEGF
• A sub-family of growth factorsA sub family of growth factors • More specifically of platelet-derived growth
factor family of cystine-knot growth factors.factor family of cystine knot growth factors. • They are important signaling proteins
involved in both ofinvolved in both of– Vasculogenesis (the de novo formation of the
embryonic circulatory system)– Angiogenesis (the growth of blood vessels
from pre-existing vasculature)
728
The VEGF : ProductionThe VEGF : Production• VEGFxxx production can be induced in cells that p
are not receiving enough oxygen. • When a cell is deficient in oxygen it produces
Hypoxia Inducible Factor (HIF) a transcriptionHypoxia Inducible Factor (HIF) a transcription factor.
• HIF stimulates the release of VEGFxxx th f ti (i l di d l ti famong other functions (including modulation of
erythropoeisis). • Circulating VEGFxxx then binds to VEGF C cu at g G t e b ds to G
Receptors on endothelial cells triggering a Tyrosine Kinase Pathway leading to angiogenesisangiogenesis
729
The VEGFType Function
VEGF-A • Angiogenesis • Migration of endothelial cells • Mitosis of endothelial cells • Methane mono oxygenase activity • αvβ3 activity • Creation of blood vessel lumen• Creation of blood vessel lumen • Creates lumen • Creates fenestrations
• Chemo tactic for macrophages and granulocytes • Vasodilatation (indirectly by NO release)
VEGF-B Embryonic angiogenesisVEGF-C Lymph angiogenesisVEGF-D Needed for the development of lymphatic vasculature
surrounding lung bronchiolesPlGF Important for Vasculo genesis, Also needed for
angiogenesis during ischemia, inflammation, wound healing, and cancer.
730
VEGF AVEGF A
• Located on Chromosome 6Located on Chromosome 6• Consist of 8 exons and 7 introns• DiffusibleDiffusible• Tightly bound to intracellular matrix• Isoforms• Isoforms
– A121– A165A165– A185– A206
Eurotimes, 2009731
VEGF 165VEGF 165
• Moderate difusibleModerate difusible• Potent inducer of angiogenesis
N l i ti– Neovascularization– Inflammation– Increase permeability
Eurotimes, 2009732
AMD : Intravitreal injectionsAMD : Intravitreal injections
Drug Structrure DosageDrug Structrure DosageBevacizumab Complete 2.5 mg/0.1 ml(Avastin))
pimmunoglobulin
g
Ranibizumab Antibody 0.3–0.5 mg/0.1 ml(Lucentis fragment
Pegaptanib Aptamer 0.3–1.0 mg/0.1 ml(Macugen) (oligonucleotide)
Williamson TH, 2008
733
Potential MethodsPotential Methods
1. Adult 1. Phakic : 4 mm
2. Aphakic : 3.5 mm
3 Pseudophakic : 3 5 mm3. Pseudophakic : 3.5 mm
2. Infant 1 – 1.5 mm
Krieglstein GK, Weinreb RN, 2005
734
Retinal Artery Occlusion: ApproachRetinal Artery Occlusion: Approach
• Vasodilators: Increase blood oxygenVasodilators: Increase blood oxygen content
Sublingual isosorbide mononitrate– Sublingual isosorbide mononitrate– Systemic pentoxifyline
Carbogen inhalation– Carbogen inhalation– Hyperbaric oxygen
735Retinal Physician 2013
Retinal Artery Occlusion: ApproachRetinal Artery Occlusion: Approach
• Reduction retinal edemaReduction retinal edema– IV methylprednisolone (suspected areteritic
CRAO)CRAO)• IOP reducers
Acetazolamide– Acetazolamide– Mannitol
T i l ti l– Topical anti glaucoma– Paracentesis
736736Retinal Physician 2013
Retinal Artery Occlusion: ApproachRetinal Artery Occlusion: Approach
• Dislodge the emboliDislodge the emboli– Ocular massage
Nd:YAG laser embolectomy– Nd:YAG laser embolectomy
737737Retinal Physician 2013
738
Neuro-ophthalmology
739
The optic nerve• Intra ocular
– 1.0 mm length– 1 5 X 1 75 mm diameter1.5 X 1.75 mm diameter– Supplied by retinal arterioles and branches of posterior ciliary arteries
• Intra orbital25 mm length– 25 mm length
– 3-4 mm diameter– Supplied by intraneural branches of central retinal artery
• Intra canalicular• Intra canalicular– 4-10 mm length– various diameter– Supplied by Ophthalmic artery
• Intra cranial– 10 mm length– 4-7 mm diameter
S li d b b h f i t l ti d hth l i t– Supplied by branches of internal carotic and ophthalmic artery
American Academy of Ophthalmology 740
Optic nerve : Intra ocularOptic nerve : Intra ocular
• Surface• PrelaminarPrelaminar• Laminar
– Scaffold for optic nerve axonsScaffold for optic nerve axons– Point of fixation for central retinal artery and vein– Reinforcement of posterior segment of the globep g g
• Retrolaminar
American Academy of Ophthalmology 741
Optic discOptic disc
A. Surface
B. Pre Laminar
C. Laminar
D. Retro Laminar
742
Vascularization
Surface : branches of central retinal artery
Vascularization
Surface : branches of central retinal arteryPrelaminar and laminar : posterior cilliary arteryRetrolaminar : central retinal artery and yposterior cilliary artery anastomosis
743
Euro-ophthalmic examinationEuro ophthalmic examination
• HistoryHistory• Visual acuity• Color vision• Color vision• Pupil reactions
O l tilit• Ocular motility • Discs• Visual fields• Advanced intracranial examination
Cullen JF, 2007 744
Neurologic and imaging : IndicationNeurologic and imaging : Indication
• Progressive visual loss more than 4 weeksProgressive visual loss more than 4 weeks• No recovery of vision and fields after 10 weeks• Head or periocular pain for more than 4 weeksHead or periocular pain for more than 4 weeks• Patient older than 50 year• Quadrantic or Hemianopic fields defect• Quadrantic or Hemianopic fields defect• Development of field defect in fellow eye• Atypical features• Atypical features• History of paranasal sinus disease
Kumar SM 2007 745
Neuro-imaging : Which?Neuro imaging : Which?
• Brain• Anterior visual pathwayp y• Pituitary area• Orbit + Coronal view ?• Orbit + Coronal view ?• Base of skull
C ll JF 2007Cullen JF, 2007
746
Visual pathway RL RL
NasalRetina
TemporalRetina
TemporalRetina
OpticChiasm
OpticNerve
OpticTract
LGN
OpticRadiations
PrimaryPrimaryVisual Cortex
747
Visual cortexVisual cortex
• The term visual cortex refers to – The primary visual cortex Striate cortex or V1– Extrastriate visual cortex V2, V3, V4, and V5.Extrastriate visual cortex V2, V3, V4, and V5.
• The primary visual cortex is anatomically equivalent to Brodmann Area 17 or BA17equivalent to Brodmann Area 17 or BA17
748
Visual pathway and VF defectsVisual pathway and VF defects
749Miller-Keane 2003
Intracranial hypertension and VF d fdefects
(a)Enlarged blind spot.
(b)Nasal step.
(c)Biarcuate scotoma.
(d)Severe visual field constriction
Kedar, Gathe and Corbett 2011
750
The pupillary light reflex pathwayThe pupillary light reflex pathwayp p y g p yp p y g p y
751
Afferent pupillary pathwayAfferent pupillary pathway• Light stimulates photoreceptorsg p p• Signal conveyed to a special set of ganglion cells
send nerve impulses through the axons in similar topographic distributiontopographic distribution
• Carrying signal to optic nerve• Decussation occurs at the optic chiasm• Afferent fibers NOT enter lateral geniculate bodies• BUT instead exit and pass the brachium of of the
superior colliculus its synapse on the protectal olivarysuperior colliculus its synapse on the protectal olivary nuclei (pontine olivari and sublentiform nuclei)
• This nuclei project bilaterally to Edinger-Westphal nuclei
Kourouyan and Horton, 1997752
Efferent pupillary pathway• Efferent parasympathetic response
Efferent pupillary pathwayp y p p
– The Edinger-Westphal nuclei send fiber to join the cranial nerve IIIFollow that course on dorsomedialsurface of the– Follow that course on dorsomedialsurface of the nerve
– After coursing through the cavernous sinus, fibers emerge to enter orbit with the inferior oblique branch of cranial nerve III
– Fibers synapse at ciliary gangliony p y g g– Enter the eye through short posterior ciliary nerves to
distribute fiber to choroid, ciliary body and iris
Kourouyan and Horton, 1997753
Efferent pupillary pathway• Efferent sympathetic response
– This believed to start in the hypothalamus and project in an uncrossed fashion with synapses in mesencephalon and pons
p p y p y
uncrossed fashion with synapses in mesencephalon and pons– These neurons project to and synapse upon intermediolateral
cell column from C8-T2 in spinal cord– These exit the spinal cord and pass through stellate ganglion to p p g g g
synapse in the superior cervical ganglion– Fibers go with internal carotic artery– Enter the cavernous sinus
G ith i l VI– Go with cranial nerve VI– Enter superior orbital fissure with cranial nerve V– Go with the nasociliary branch of cranial nerve V
Pass through the ciliary ganglion without synapsing– Pass through the ciliary ganglion without synapsing– Pass through the long ciliary nerves– Terminate the dilator muscle– Some fibers diverge in the superior orbital fissure to innervateSome fibers diverge in the superior orbital fissure to innervate
Muller’s muscleKourouyan and Horton, 1997 754
Swinging flashlight testSwinging flashlight testSwinging flashlight testSwinging flashlight test
755
RAPD: Grading Scaleg• Grade 1+:
A k i iti l ill t i ti f ll d b t dil ti– A weak initial pupillary constriction followed by greater redilation– Minimally detectable
• Grade 2+:– An initial pupillary stall followed by greater redilation– Pupil fails to constrict or dilate slightly when the light swings to weaker
eye
• Grade 3+:– An immediate pupillary dilation– Pupils dilate or “escape” readily
• Grade 4+:– No reaction to light – Amaurotic pupil
Non reactive mydriatic pupil– Non reactive mydriatic pupil
Kumar SM 2007; Uhwi 2011 756
RAPDRAPD
D k• Dark room• Bright light torch• 2 eyes2 eyes• Patient fixation is at distance• 2-3 seconds per eye longer may create an p y g y
iatrogenic RAPD• Check by your self do not rely on others
Burton B, Golnik K, 2010
757
Cause of light-near dissociation• Unilateral
– Afferent conduction defectAfferent conduction defect– Adie pupil– HZO– Aberrant degeneration of the cranial nerve III– Aberrant degeneration of the cranial nerve III
• Bilateral – Neurosyphilis
T I di b t– Type I diabetes– Myotonic distrophy– Parinaud dorsal midbrain syndrome– Familial amyloidosis– Encephalitis– Chronic alchoholism
Kanski JJ, 2007 758
AnisocoriaAnisocoria• Good light reaction
– PhysiologicHorner’s Syndrome– Horner s Syndrome
• Sympathetic chain disruption• Miosis, Ptosis, Anhydrosis• Anisocoria worse in the dark• Dilatation Lag
• Poor light reaction– Adie’s tonic
• Post ganglionic parasympathetic usually idiopathic • No ptosis, No ophthalmoplegia• Mydriatic pupil• Mydriatic pupil• Segmental iris contraction• Slow (tonic) redilation• Light – Near dissociation
– 3rd nerve palsy– PharmacologicPharmacologic– Sphincter damage
• Trauma• Surgery• Herpes Zoster
Burton B, Golnik K, 2010 759
Papilledema : Walsh & Hoyt’sE l if t ti• Early manifestations
– Disc hyperemia – Subtle edema of the nerve fiber layer can be identified with careful slit lamp biomicroscopy
and direct ophthalmoscopy. This most often begins in the area of the nasal disc. A key finding occurs as the nerve fiber layer edema begins to obscure the fine peripapillary vesselsvessels.
– Small hemorrhages of the nerve fiber layer are detected most easily with the red-free (green) light.
– Spontaneous venous pulsations that are normally present in 80% of the individuals may be obliterated when the intracranial pressure rises above 200 mm water.
L t if t ti• Late manifestations– As the papilledema continues to worsen, the nerve fiber layer swelling eventually obscures
the normal disc margins and the disc becomes grossly elevated. – Venous congestion develops, and peripapillary hemorrhages become more obvious, along
with exudates and cotton-wool spots. Th i ill ti d l t i i ll di l f ld k– The peripapillary sensory retina may develop concentric or, occasionally, radial folds known as Paton lines. Choroidal folds also may be seen.
• Chronic manifestations– If the papilledema persists for months, the disc hyperemia slowly subsides, giving way to a
gray or pale disc that loses its central cup. – With time, the disc may develop small glistening crystalline deposits (disc pseudodrusen).
• Atrophic manifestations– Blurred-border and pale disc– Atrophic vessels
Giovannini J, 2005 760
761
Papilledema : Lars Frisen’s Scale• Stage 0
– Normal disc with blurring of nasal and temporal disc; no obscuration of the vessel and the cup is maintained. p
• Stage 1– C shaped blurring of the nasal, superior and inferior borders.
Usually the temporal margin is normal • Stage 2• Stage 2
– Elevation of the temporal margin • Stage 3
– Elevation of the entire disc with obscuration of the retinal vessels at the disc margin
• Stage 4– Complete obliteration of the cup and obscuration of the vessels
on the surface of the disc.on the surface of the disc. • Stage 5
– Dome shaped appearance with all vessels being obscured
Lars Frisen, 2004 762
Stage 0Stage 0
Lars Frisen, 2004 763
Stage 1
Lars Frisen, 2004 764
Stage 2Stage 2
Lars Frisen, 2004 765
Stage 3
Lars Frisen, 2004 766
Stage 4
Lars Frisen, 2004 767
Stage 5
Lars Frisen, 2004 768
Differentiating Papilledema from Pseudopapilledema
Papilledema Pseudopapilledema
Physiologic cup usually present Central cup often absent, disc diameter small
Vessels arise normally Vessels from central apex of disc
Arterioles bifurcate Anomalous branching, trifurcation
Hyperemia due to dilation of the disc capillaries Absence of superficial capillary telangectasia
C shaped blurring of RNFL in peripapillary region Disc margins irregular with pigmentary derangement
Diffuse elevation of the disc Irregular elevation, refractile masses which glow
Peripapillary NFL radial hemorrhage Rare 'blot' subretinal hemorrhage
Dilation of the retinal veins No venous dilation
Exudates in chronic situations No exudates or cotton-wool spotsp
Not usually familial Familial
Absence of SVP SVP usually present
Lars Frisen, 2004 769
Optic Neuropathiesp p• Trauma ocular, orbit and skull
Single or multiple nerve defect• Single or multiple nerve defect• Metabolic
• Early diabetic Insufficient in vascular to nourish the optic nerve
• Toxic• Methanol, Ethambutol, Isoniazid
• Neuritis• Primary inflame• Secondary inflameSecondary inflame
• Giant Cell Arteritis• Multiple Sclerosis
t th d l i i fl ti b ti• teeth and paranasal sinus inflammation or nearby tissue inflammation 770
AION : SymptomsAION : Symptoms
• Giant cell arteritisGiant cell arteritis• Sudden, painless, non progessive visual loss• Initially unilateral may rapidly bilateralInitially unilateral, may rapidly bilateral• Older than 60 years, Women greater than Men• Antecedent or simultaneous headache jaw• Antecedent or simultaneous headache, jaw
claudication or chewing pain, scalp or hair combing tenderness, proximal muscle and joint co b g te de ess, p o a usc e a d jo tache, anorexia, weight loss and fever may occur
Will’s Eye Manual 771
AION : Signs• Critical
Aff ill d f
g
– Afferent pupillary defect– Devastating worse visual loss– Pale swollen disc with flame shape hemorrhagesPale, swollen disc with flame shape hemorrhages
atrophy– Erythrocytes Sedimentation Rates, C Reactive
Protein and platelets may be markedly increasedProtein and platelets may be markedly increased• Other
– Visual field defect altitudinal, involving central fieldVisual field defect altitudinal, involving central field– Non pulsatile temporal artery– CRAO an cranial nerve palsy may occur
Will’s Eye Manual 772
NAION : SymptomsNAION : Symptoms
• Sudden, painless, non progressive visual loss of moderate degreeloss of moderate degree
• Initially unilateral, may become bilateral45 65 ears commonl o nger than• 45-65 years, commonly younger than AION
Will’s Eye Manual 773
NAION : EtiologyNAION : Etiology
• IdiopaticIdiopatic– Arteriosclerosis
Diabetes– Diabetes– Hypertension
Hyperhomocystinemia– Hyperhomocystinemia– Anemia
Sl i k f t– Sleep apnea risk factor– Relative nocturnal hypotension
Will’s Eye Manual 774
NAION : Risk factors
• HypertensionH li id i• Hyperlipidemia
• Diabetes mellitus• Smoking• ObesityObesity
Deborah Pavan-Langston, 2008 775
NAION : Signs• Critical
g
– Afferent pupillary defect– Pale, swollen disc involving only a segment of the disc with
flame shape hemorrhage– Normal Erythrocytes Sedimentation Rates – Non-progressive sudden decrease of VA and VF, which
stabilized– Progressive sudden decrease of VA and VF, followed with
another decrease of VA and VF
• Other• Other – Visual field defect altitudinal, involving central field– Reduced color vision proportional to decrease in acuity
Will’s Eye Manual 776
AION PION ONS dd i l l ft S dd i l l ft R id l f i iSymptoms Sudden visual loss, often on awakening
Sudden visual loss, often on awakening
Rapid loss of vision over several days to 1 week
VA Can be good if central field maintained
Can be good if central field maintained
Good to no perception of light
CV Normal in unaffected field Normal in unaffected field Disproportionate loss of color vision
Pupils Relative afferent pupil defect
Relative afferent pupil defect
Relative afferent pupil defectdefect defect
VF Most commonly inferonasal loss, or altitudinal defects, but other patterns possible
More commonly central scotoma seen
Central visual field loss relatively common, nerve fiber bundle defects also possibleother patterns possible possible
Disc -Hyperemic disc swelling in early phase-Pallor developing 3-6
-Disc appear normal at onset-Pallor develops about 6
-Hyperemic disc swelling in early phase-Pallor developing from
weeks after onset-However arteritic AION usually causes chalky white disc infarction from
weeks after onset about 6 weeks after onset
onset
Cullen JF, 2007 777
Acquired optic atrophy in childhoodAcquired optic atrophy in childhood
• CraniopharyngiomaCraniopharyngioma• Optic nerve / Chiasmal glioma
R ti l d ti di• Retinal degenerative disease• Hydrocephalus• Optic neuritis• Post papil edemaPost papil edema• Hereditary
Cullen JF, 2007 778
Optic PitOptic Pit• Often appear as small, hypopigmented, yellow pp yp p g y
or whitish, oval or round excavated defects.• Most often within the inferior temporal portion of
the optic cupthe optic cup. • Approximately 20 to 33 percent are found
centrally, with an average size of 500µm (one-thi d di di t )third disc diameter).
• Typically, optic pits occur unilaterally (85 percent). pe ce t)
• The optic disc in these patients appears larger than normal, and 60 percent of discs with optic pits also have cilioretinal arteriespits also have cilioretinal arteries.
779
Optic PitOptic Pit
780
Optic Disc Drusenp• The classic appearance involves bilaterally elevated
optic discs with irregular or "scalloped" margins, a smalloptic discs with irregular or scalloped margins, a small or nonexistent cup, and unusual vascular branching patterns that arise from a central vessel core.
• Often there are small, refractile hyaline deposits visible , y pon the surface of the disc and/or in the peripapillary area.
• Most often manifests on the nasal disc margin, but can be found within any part of the nerve head. y p
• In younger patients, the disc elevation tends to be more pronounced and the drusen less calcific, making them less visible ophthalmoscopically, and hence offering a more challenging diagnostic dilemma.
• Unlike true disc edema, its very rarely presents with juxtapapillary nerve fiber edema, exudate, or cotton-wool
tspots.781
Optic Drusen : Pathophysiology• There is no histopathological correlation between drusen
of the optic nerve head and retinal drusen; the former t ll l l i t d ti ft ti llrepresent acellular laminated concretions, often partially
calcified, possibly related to accumulation of axoplasmic derivatives of degenerating retinal nerve fibers.
• Optic disc drusen are globules of mucoproteins and• Optic disc drusen are globules of mucoproteins and mucopolysaccharides that progressively calcify in the optic disc.
• They are thought to be the remnants of the axonal• They are thought to be the remnants of the axonal transport system of degenerated retinal ganglion cells.
• Optic disc drusen have also been referred to as congenitally elevated or anomalous discscongenitally elevated or anomalous discs, pseudopapilledema, pseudoneuritis, buried disc drusen, optic nerve head drusen and disc hyaline bodies.
• They may be associated with vision loss of varyingThey may be associated with vision loss of varying degree
782
Optic Disc DrusenOptic Disc Drusen
783
VF Defects in Optic neuropathies• Central scotoma
– Demyelinationy– Toxic and nutritional– Leber disease– Compression
• Enlarged blind spot• Enlarged blind spot– Papil edema– Congenital anomalies– AIBSE (Acute Idiopathic Blind Spot Enlargement) with flashing light ( p p g ) g g
seen, normal retina, normal imaging– AZOOR (Acute Zonal Occult Outer Retinopathy) with flashing light
and other field loss, normal retina, normal imaging• Respecting horizontal meridianp g
– Anterior Ischemic Optic Neuropathy– Glaucoma– Disc drusen
Kanski JJ, 2007; Burton B, 2010 784
Unexplained visual loss• Miss the real diagnosis• MunchausensMunchausens
– Factitious disorder, or mental illness repeatedly acts as has a physical or mental disorder when
– People with factitious disorders act this way because of an inner d t b ill i j d t t hi tneed to be seen as ill or injured, not to achieve a concrete
benefit • Hypochondriac
Health phobia or health anxiety– Health phobia or health anxiety – Excessive preoccupation or worry about having a serious illness
• Hysteria (Conversion disorder)Exacerbation of symptoms during psychological stress– Exacerbation of symptoms during psychological stress
– Relief from tension (primary gain)– Gain of outside support or attention (secondary gains)
• MalingeringMalingering
Burton B, Golnik K, 2010 785
Nystagmus• Clinician’s notes
– Amplitude– Frequency– Direction of gaze that induces nystagmus– Null point Gaze location where nystagmus at least evidentp y g
• Concerns– Congenital or acquired
Specific lesion location– Specific lesion location– True nystagmus or nystagmoid movements (saccadic oscillations)
• CharacteristicsI it j t t i ll ff ti b th– Is it conjugate symmetrically affecting both eyes
– Slow or fast, equal speed or different speed– Movement horizontal, vertical, torsional or mixed
American Academy of Ophthalmology 786
Nystagmus : Type
• Latent nystagmus• Pendular nystagmus• Congenital motor nystagmusCongenital motor nystagmus• Spasmus nutan
Acquired pendular nystagmus• Acquired pendular nystagmus• Acquired jerk nystagmus
– Gaze paretic nystagmus– Vestibular nystagmus
Deborah Pavan-Langston, 2008 787
Nystagmus : Other nystagmus form
• Endgaze (physiologic) nystagmus• Upbeat nystagmus• Upbeat nystagmus• Downbeat motor nystagmus• Rotary nystagmus• Dissociated nystagmusssoc a ed ys ag us• Seesaw nystagmus• Optokinetic nystagmus• Other nystagmoid-like oscillations
– Ocular myoclonus– Ocular bobbling– Ocular flutter One plane of ‘Back to Back Saccades’ without inter
saccadic intervalsaccadic interval– Opsoclonus Multi directional of ‘Back to Back Saccades’ without inter
saccadic interval
Deborah Pavan-Langston, 2008 788
Nystagmus : Medical treatmenty g• Cyclopentolate 1%
– One drop bid Latent nystagmus 60 % reduce the amplitude, p y g pvelocity and frequency
– With occlusion improve visual acuity• Baclofen
– 5 mg po tid starting dose acquired periodic alternating nystagmus– 5 mg po tid starting dose acquired periodic alternating nystagmus– Dosage increased every 3 days 80 mg maximum per day
• Botulinum A– Dampened acquired nystagmus and oscillopsia– 66% improve visual acuity
• Other drugs– Gabapentin/Memantine dampen nystagmus/oscillopsia
Clonazepam downbeat nystagmus– Clonazepam downbeat nystagmus– Carbamazepin SO myokymia– Propanolol Opsoclonus
Deborah Pavan-Langston, 2008 789
Nystagmus : Optical treatment• Glasses or contact lenses
– Decrease nystagmus in bilateral aphakia• Stimulating accommodative convergences
– Overcorrecting with minus lenses dampening nystagmus at distance fixation
– Improve visual acuityp y• Galilean arrangement
– Stabilizing retinal images• Base-out prisms
– Promote covergence and dampen nystagmus in Congenital motor nystagmus
• Fresnel stick-on prisms– Displace image at null point in Congenital motor nystagmusp g p g y g– Vertically correct head position in Vertical nystagmus and Acquired
downbeat nystagmus– Combination prisms help in Oblique head turns
Deborah Pavan-Langston, 2008 790
Nystagmus : Surgical treatment
• Kestenbaum Anderson procedures
Nystagmus : Surgical treatment
Kestenbaum Anderson procedures– Recession of horizontal muscles
The versions are blocked– The versions are blocked
F d ti• Fade operation– Acts like recession by creation of a more
t i tt h tposterior attachment– Reducing the area of contact
Kumar SM 2007 791
Optic AtaxiaOptic Ataxia• Is lack of coordination between visual inputs and hand movements,
resulting in inability to reach and grab objectsresulting in inability to reach and grab objects. • Optic ataxia may be caused by lesions to the posterior parietal
cortex. • The posterior parietal cortex is responsible for combining and p p p g
expressing positional information and relating it to movement. • Outputs of the posterior parietal cortex include the spinal cord, brain
stem motor pathways, pre-motor and pre-frontal cortex, basal ganglia and the cerebellumganglia and the cerebellum.
• Some neurons in the posterior parietal cortex are modulated by intention.
• Optic ataxia is usually part of Balint's syndrome, but can be seen in i l ti ith i j i t th i i t l l b l it tisolation with injuries to the superior parietal lobule, as it represents a disconnection between visual-association cortex and the frontal premotor and motor cortex.
792
Visual AgnosiaVisual Agnosia• Is an inability of the brain to make sense of or make use y
of some part of otherwise normal visual stimulus• Typified by the inability to recognize familiar objects,
people or faces.people or faces. • This is distinct from blindness, which is a lack of sensory
input to the brain due to damage to the eye, optic nerve, or primary visual systems in the brain such as the opticor primary visual systems in the brain such as the optic radiations or primary visual cortex.
• Visual agnosia is often due to damage, such as stroke, i th t i i it l d/ t l l b ( ) i thin the posterior occipital and/or temporal lobe(s) in the brain.
793
Horner SyndromeHorner Syndrome
794
Uvea and Immunology
I bIn remembrance:
dr. Muhammad Anie, Sp.M
799
Choroid : LayersChoroid : Layers
Th h i ill i• The choriocapillaris• Small vessels• Large vessels
800
UveitisUveitis
• How to avoid complicationFi t C l l i t– First Cycloplegic agents
• Complication– Acute Cell– Chronic Synechiae
801
UveitisNon-granulomatous Granulomatous
O A Ch i Hidd
U e t sOnset Acute Chronic – HiddenPain Marked + / -Photophobia Marked MildBlur vision Moderate ObviousCircumcorneal injection Marked MildKeratic precipitate White - smooth Big – grey / Mutton fatPupil Small - irregular Small – irregular (vary)Posterior synechiae + / - + / -Iris nodule + / - + / -Predilection Anterior uvea Anterior and posterior uveaRecurrent Often + / -
Vaughan DG, 2000 802
Flare and CellFlare and Cell
• Flare Resulting of extra protein in theFlare Resulting of extra protein in the aqueous
• CellWhite Blood Cell in the aqueous• Cell White Blood Cell in the aqueous– Hallmark of Iritis
Ob d d Hi h M ifi ti Slit L– Observed under High-Magnification Slit Lamp examination by 1 X 3 mm field of lightIf it l t i l d th li – If its clustering on corneal endothelium Keratic Presipitate
803
Grading anterior chamber cellsgGrade Cells in field
0 0
0 5+ (Trace) 1 50.5+ (Trace) 1-5
1+ 6-15
2+ 16-25
3+ 26 303+ 26-30
4+ > 50
Kanski JJ, 2007 804
Grading anterior chamber flareg
Grade DescriptionGrade Description 0 Nil
(Completely Absent)
1+ Faint(Barely Present)
2 Moderate2+ Moderate(Iris and lens detail clear)
3+ Marked3+ (Iris and lens detail hazy)
4+ Intense(Fibrinous exudates)
Kanski JJ, 2007
(Fibrinous exudates)
805
Type of AllergyType of Allergy
806
Type of AllergyType of Allergy
807
HLA Immunogenic testg• Specific ocular inflammatory :
– Acute anterior uveitis : HLA-B27, HLA-B8– Adamantiades-Behçet disease : HLA B-51
Birdshot retinopathy : HLA A29– Birdshot retinopathy : HLA-A29– Multiple sclerosis, uveitis and optic neuritis : DR2– Ocular pemphigoid :HLA-B12, DQw7Ocular pemphigoid :HLA B12, DQw7– Presumed ocular histoplasmosis : HLA-B7, DR2– Reiter syndrome : HLA-B27– Sympathetic ophthalmia :HLA-A11, DR4, Dw53– VKH disease : DR4, Dw53, DQw3
Deborah Pavan-Langston, 2008 808
Lipid mediatorsLipid mediators
809
Lipid mediators : Basic activitiesLipid mediators : Basic activities
810
Vasoactive amineVasoactive amine
• Containing amino groupsContaining amino groups • Breakdown of amino acids. Many natural
neurotransmitters like epinephrineneurotransmitters like epinephrine, norepinephrine, dopamine, serotonine, histaminehistamine
• Acts on the blood vessels to alter vascular bilit t dil tipermeability or to cause vasodilation.
811
CytokinesCytokines• Small secreted proteins which mediate and regulate p g
immunity, inflammation, and hematopoiesis. • Produced de novo in response to an immune stimulus. • Generally (although not always) act over short distances• Generally (although not always) act over short distances
and short time spans and at very low concentration. • Act by binding to specific membrane receptors, which
th i l th ll i d ftthen signal the cell via second messengers, often tyrosine kinases, to alter its behavior (gene expression).
• Responses to cytokines include increasing or decreasing y g gexpression of membrane proteins (including cytokine receptors), proliferation, and secretion of effector molecules.
812
Selected Immune Cytokines and Their Activities*
Cytokine Producing Cell Target Cell Function**
GM-CSF Th cells progenitor cells growth and differentiation of monocytes and DCmonocytes and DC
IL-1monocytes
macrophages
Th cells co-stimulation
B cells maturation and proliferation
IL-1 B cells DC
NK cells activation
various inflammation, acute phase response, fever
activated T and B cells growth proliferationIL-2 Th1 cells activated T and B cells, NK cells
growth, proliferation, activation
IL-3 Th cellsNK cells
stem cells growth and differentiation
mast cells growth and histamine releasemast cells growth and histamine release
IL-4 Th2 cells
activated B cells proliferation and differentiationIgG1 and IgE synthesis
h MHC Cl IImacrophages MHC Class II
T cells proliferation813
IL-5 Th2 cells activated B cells proliferation and differentiationIgA synthesisIgA synthesis
IL-6
monocytesmacrophages
Th2 cells
activated B cells differentiation into plasma cells
plasma cells antibody secretion
stem cells differentiationstromal cells
stem cells differentiation
various acute phase response
IL-7 marrow stromathymus stroma stem cells differentiation into progenitor B and
T cellsy
IL-8 macrophagesendothelial cells neutrophils chemotaxis
IL 10 Th2 cellsmacrophages cytokine production
IL-10 Th2 cellsB cells activation
IL-12 macrophagesB cells
activated Tc cells differentiation into CTL(with IL-2)
B cellsNK cells activation
IFN- leukocytes various viral replicationMHC I expression
IFN- fibroblasts various viral replicationMHC I expression
814
various Viral replication
IFN- Th1 cells, Tc cells, NK cells
macrophages MHC expression
activated B cells Ig class switch to IgG2a
Th2 cells proliferationTh2 cells proliferation
macrophages pathogen elimination
MIP-1 macrophages monocytes, T cells chemotaxis
MIP-1 lymphocytes monocytes, T cells chemotaxis
monocytes, macrophages chemotaxis
TGF- T cells, monocytesactivated macrophages IL-1 synthesis
activated B cells IgA synthesis
various proliferationvarious proliferation
TNFmacrophages, mast cells, NK
cells
macrophages CAM and cytokine expression
tumor cells cell death
TNF- Th1 and Tc cellsphagocytes phagocytosis, NO production
tumor cells cell death 815
Reactive Oxygen IntermediateReactive Oxygen Intermediate
• Including both radicals and non-radicals.Including both radicals and non radicals. • Constantly formed in the human body and
have been shown to kill bacteria andhave been shown to kill bacteria and inactivate proteins, and have been implicated in a number of diseases. p
• Produced by inflammatory phagocytes to cancer development.p
• Important signals controlling cell growth and cell death
816
Reactive Oxygen IntermediateReactive Oxygen Intermediate
817
Immune SystemsImmune SystemsSystems exhibit fascinating complexity and y g p y
interrelationships that allow them to fine-tune immune reactions to almost any antigen, or molecule that stimulates an immune responsep
• Humoral immunity Deals with infectious agents in the blood and body tissues– Deals with infectious agents in the blood and body tissues
– Managed by B-cells (with help from T-cells)
C ll di t d i it • Cell-mediated immunity – Deals with body cells that have been infected. – Managed by T-cells.
818
Immune Systems : Humoraly• The humoral system of immunity is also called the antibody-mediated
system because of its use of specific immune-system structures called antibodies.
• Activation phase – The first stage in the humoral pathway of immunity is the ingestion
(phagocytosis) of foreign matter by special blood cells called macrophages. (p g y ) g y p p g– The macrophages digest the infectious agent and then display some of its
components on their surfaces. – Cells called helper-T cells recognize this presentation, activate their immune
response, and multiply rapidly
• Effector phase– Involves a communication between helper-T cells and B-cells. – Activated helper-T cells use chemical signals to contact B-cells, which then begin
to multiply rapidly as well B cell descendants become either plasma cells or Bto multiply rapidly as well. B-cell descendants become either plasma cells or B memory cells.
– The plasma cells begin to manufacture huge quantities of antibodies that will bind to the foreign invader (the antigen) and prime it for destruction.
– B memory cells retain a "memory" of the specific antigen that can be used to y y p gmobilize the immune system faster if the body encounters the antigen later in life. These cells generally persist for years.
819
Immune Systems : Cell-Mediated• The cell-mediated immune response involves cytotoxic T-cells, or
killer-T cells. • Body cells that have been infected by foreign matter often present• Body cells that have been infected by foreign matter often present
components of that material on their surfaces. • Killer-T cells recognize these displays and respond by ingesting or
otherwise destroying the infected cell. • Killer-T cells are also important in the body's defenses against
parasites, fungi, protozoans, and other larger cells that might have found their way into the body.
• The killer-T cells recognize these large invaders by their foreignThe killer T cells recognize these large invaders by their foreign proteins and then destroy them.
• Killer-T cells also produce T memory cells which "remember" a specific protein or antigen. Th bi ti f T ll d B ll th b d f• The combination of T-cell and B-cell memory assures the body of familiarity with any antigens or foreign agents that have been present in the body within the last few years.
• A response to an agent against which the body has already formed p g g y ymemory cells is called a secondary response. All other responses are primary responses.
820
Inflammatory cascade: Steroids vs NSAID
Cervantes-Coste G et al 2009 821
Retinal arteritisRetinal arteritis
• CausesCauses– SLE
Polyarteritis nodosa– Polyarteritis nodosa– Churg-Strauss
Microscopic polyangitis– Microscopic polyangitis– Frosted branch angitis
S hili– Syphilis– Herpetic viruses
Retinal Physician 2011 822
Retinal phlebitisRetinal phlebitis
• CausesCauses– Sarcoidosis
Paraviral– Paraviral– Toxoplasmosis
Birdshot– Birdshot– HIV
E l di– Eales disease
Retinal Physician 2011 823
Mixed retinal vasculitisMixed retinal vasculitis
• CausesCauses– Multiple sclerosis
Behçet’s disease– Behçet s disease– Wegener’s granulomatosis
Retinal Physician 2011 824
Non infectious uveitis: ApproachNon infectious uveitis: Approach
• ANTIMETABOLITESANTIMETABOLITES– Methotrexate (MTX)
Azathioprine (AZA)– Azathioprine (AZA)– Mycophentolate Mofetil (MMF)
825Retinal Physician 2013
Non infectious uveitis: Approachpp• BIOLOGIC RESPONSE MODIFIERS
– Adalimunab– Interferon 2a– Anakinra
ALKYLATING AGENTS• ALKYLATING AGENTS– Cyclophosphamide– Clorambucil– Mycophentolate Mofetil (MMF)
826Retinal Physician 2013
dr. Bakri Abdus Syukur, Sp.M
Orbit and Tumor829
The orbitThe orbit
• 7 bones make the bony orbit :7 bones make the bony orbit :– Frontal
Zygomatic– Zygomatic– Maxillary
Ethmoidal– Ethmoidal– Sphenoid
L i l– Lacrimal– Palatine
American Academy of Ophthalmology830
The orbit : Marging
• Superior by frontal bone, interrupted p y , pmedially by Supraorbital notch
• Medial above by frontal boneMedial above by frontal bone• Medial bellow by
P t i l i l t f l i l b– Posterior lacrimal crest of lacrimal bone– Anterior lacrimal crest of maxillary bone
• Inferior by maxillary and zygomatic bone• Laterally by zygomatic and frontal bone
American Academy of Ophthalmology 831
The orbit : RoofThe orbit : Roof
• Orbital plate of frontal boneL i f h id b• Lesser wing of sphenoid bone
American Academy of Ophthalmology 832
The orbit : Medial wallThe orbit : Medial wall
• Frontal process of maxillaL i l b• Lacrimal bone
• Orbital plate of ethmoid• Lesser wing of sphenoid
American Academy of Ophthalmology 833
The orbit : Lateral wall
• Formed by
The orbit : Lateral wall
Formed by– Zygomatic– Greater wing of sphenoidGreater wing of sphenoid
• Lateral orbital tubercle of WhitnallLateral orbital tubercle of Whitnall– Check ligament of the lateral rectus muscle– Suspensory ligament of the eyeballSuspensory ligament of the eyeball– Lateral palpebral ligament– Aponeurosis of the levator muscleAponeurosis of the levator muscle
American Academy of Ophthalmology 834
The orbit : Floor
• Formed by
The orbit : Floor
Formed by– Maxillary
Palatine– Palatine– Orbital plate of zygomatic
• Very fragile to orbital blunt trauma
American Academy of Ophthalmology 835
The Orbit : Superior orbital fissureThe Orbit : Superior orbital fissure• Above the ring
– Lacrimal nerve of V-1– Frontal nerve of V-1– Cranial nerve IV
• Within the ring (Heads of 4 rectuses)– Superior and inferior division of cranial nerve III
N ili b h f i l V 1– Nasociliary branch of cranial nerve V-1– Sympathetic root of ciliary ganglion– Cranial nerve VI
Superior ophthalmic vein– Superior ophthalmic vein
• Bellow the ringInferior ophthalmic vein– Inferior ophthalmic vein
American Academy of Ophthalmology 836
The orbit : Cavernous sinusThe orbit : Cavernous sinus
• Posterior to orbital apexPosterior to orbital apex• Lateral to the sphenoidal air sinus and
pituitary fossapituitary fossa• Structures located within are :
– Internal carotic artery thatInternal carotic artery that,– Surrounded by sympathetic carotid plexus– Cranial nerves III, IV and VICranial nerves III, IV and VI– Ophthalmic and maxillary divisions of cranial
nerve VAmerican Academy of Ophthalmology 837
Orbital surgical spaceOrbital surgical space
• Sub periorbitalE t l• Extra conal
• Intra conal• Episcleral
American Academy of Ophthalmology838
RetinoblastomaRetinoblastoma• Most common primary intraocular malignancy of p y g y
childhood• 30-40% occurs bilaterally
If associated with ectopic intracranial retinoblastoma– If associated with ectopic intracranial retinoblastoma Trilateral retinoblastoma pineal gland and para sellar region
• Most abnormal finding• Most abnormal finding– Leukocoria (50-62%)– Strabismus (20%)
• Esotropia : Exotropia 50:50– Redness, painful, glaucomatous, decreased vision,
etc
American Academy of Ophthalmology 839
Retinoblastoma : Histopathology
840
BasaliomaBasalioma• Basal cell carcinoma• Most common eye lid malignancy 90-95%• Lower eyelid margin 50-60%y g• Near medial canthus 25-30%• Upper eyelid 15%• Lateral canthus 5%• Most common Nodular• Less common Morpheaform of Fibrosing type more aggressive
American Academy of Ophthalmology 841
Basalioma : ManagementsBasalioma : Managements
• Localized to the adnexaLocalized to the adnexa– 3-5mm excision from macroscopic margin frozen
section• Invasion to the orbit
– Exenteration– Radiation therapy
• Only a palliative treatment• Generally be avoided for periorbital lesionsGenerally be avoided for periorbital lesions
• Invasion to intracranial or paranasal sinuses– PalliativePalliative
842
Squamous Cell CaSquamous Cell Ca
• 40 times less common than basalioma40 times less common than basalioma biologically more aggressive
• Metastasize through :• Metastasize through :– Lymphatic transmission
Bl d b t i i– Blood-borne transmission– Direct extension often, along nerves
American Academy of Ophthalmology 843
Squamous Cell Ca : EyelidSquamous Cell Ca : Eyelid• Localized to the adnexa
6 7 i i f i i f ti– 6-7 mm excision from macroscopic margin frozen section
• Invasion to the orbit– Without regional lymphatic nodes involvementWithout regional lymphatic nodes involvement
• Exenteration• Radiation therapy
– With regional lymphatic nodes involvement– With regional lymphatic nodes involvement• Exenteration• Lymphatic nodes disection joint surgery• Radiation therapy
• Invasion to intracranial or paranasal sinuses or far metastasizing – Palliative
844
Squamous Cell Ca : Conjunctiva
• 1-2 mm diameter of tumor
Squamous Cell Ca : Conjunctiva
1 2 mm diameter of tumor– 6-7 mm excision from macroscopic margin
70 degree subzero cryotherapy– 70 degree subzero cryotherapy • 2-5 mm diameter of tumor
f– If excision not available Enucleation or Excenteration
M th 5 di t f t• More than 5 mm diameter of tumor– Excenteration
845
Sebaceous Adeno CaSebaceous Adeno Ca
• Highly malignant and potentially lethal tumor• Tarsal plate meibomian glandsTarsal plate meibomian glands• Eyelash Glands of Zeis• Or sebaceous glands of caruncle eyebrow or• Or, sebaceous glands of caruncle, eyebrow or
facial skins• Patient commonly older than 50 years of age• Patient commonly older than 50 years of age
American Academy of Ophthalmology 846
Sebaceous Adeno Ca : ManagementsSebaceous Adeno Ca : Managements
• Less than 1 mm diameter of tumorid i i f i i f ti– wide excision from macroscopic margin frozen section
• More than 1 mm diameter of tumor– Without regional lymphatic nodes involvementWithout regional lymphatic nodes involvement
• Exenteration
– With regional lymphatic nodes involvement• Exenteration• Exenteration• Lymphatic nodes disection joint surgery• Radiation therapy
• Invasion to intracranial or paranasal sinuses or far metastasizing• Invasion to intracranial or paranasal sinuses or far metastasizing– Exenteration and joint surgery if possible– Lymphatic nodes disection joint surgery– Radiation therapypy– Palliative
847
Malignant melanomaMalignant melanoma
• 5% of cutaneous cancers5% of cutaneous cancers• 1% of eyelid malignancies• Develop de novo or from preexisting• Develop de novo or from preexisting
melanocytic nevi or lentigo maligna• Four clinicopathologic forms• Four clinicopathologic forms
– Lentigo maligna– Nodular– Nodular– Superficial spreading– Acro-lentiginousAcro lentiginous
American Academy of Ophthalmology 848
Malignant melanoma : Managements• Localized
– Incision biopsy– 6-7mm full thickness excision from macroscopic margin frozen
sectionsection
• Invasion to the orbit– Without regional lymphatic nodes involvement
• Exenteration• Radiation therapy• Cytostatic agent and immune therapy
– With regional lymphatic nodes involvement• Exenteration• Lymphatic nodes disection joint surgery• Cytostatic agent and immune therapy
• Invasion to intracranial or paranasal sinuses or far metastasizing – Exenteration and joint surgery if possible– Lymphatic nodes disection joint surgeryy p j g y– Cytostatic agent and immune therapy– Palliative 849
Epithelial tumors of Lacrimal glandEpithelial tumors of Lacrimal gland
• 50% of epithelial tumor malignantp g• Types
– Pleomorphic adenoma (Benign mixed tumor)– Malignant mixed tumorMalignant mixed tumor– Adenoid cystic carcinoma
• Half of the carcinomas• Grow in tubules, solid nest or cribiform Swiss-cheese patternGrow in tubules, solid nest or cribiform Swiss cheese pattern
• Management– Percutaneous biopsy
Permanent section– Permanent section– Radical orbitectomy– High dose radiation with surgical debulking
Palliati e– Palliative
American Academy of Ophthalmology 850
Secondary orbital tumorSecondary orbital tumor
• Lung 40% in maleLung 40% in male• Breast 68 % in female• LeukemiaLeukemia
– Ocular involvement 80%– Choroid is more often affected– Also found in retina, optic disc and vitreous– Retinal hemorrhages and pseudo Roth spots are
common
American Academy of Ophthalmology 851
Thyroid orbitopathy : ClassificationClass Mnemonic Suggestion
0 N No physical signs or symptom
1 O Only signs
2 S Soft tissue involvement
3 P Proptosis of 3 mm or more3 op os s o 3 o o e
4 E Extra ocular muscle involvement
5 C C l i l t5 C Corneal involvement
6 S Sight loss (due to optic nerve)
Werner, 1963 852
Thyroid orbitopathy : ClassificationThyroid orbitopathy : Classification
• Soft tissue involvement0 : Absent– 0 : Absent
– A : Minimal– B : Moderate– C : Marked
Werner, 1963 853
Thyroid orbitopathy : ClassificationThyroid orbitopathy : Classification
• Proptosis of 3 mm or more0 : Absent– 0 : Absent
– A : 3 – 4 mm– B : 5 – 7 mm– C : 8 mm or more
Werner, 1963 854
Thyroid orbitopathy : ClassificationThyroid orbitopathy : Classification
• Extra ocular muscle involvement0 : Absent– 0 : Absent
– A : Limitation of motion at extremes of gaze– B : Evident restriction of motion– C : Fixation of globeg
Werner, 1963 855
Thyroid orbitopathy : ClassificationThyroid orbitopathy : Classification
• Corneal involvement0 : Absent– 0 : Absent
– A : Punctate lesions– B : Ulceration– C : Necrosis or perforationp
Werner, 1963 856
Thyroid orbitopathy : ClassificationThyroid orbitopathy : Classification
• Sight loss (due to optic nerve)0 : Absent– 0 : Absent
– A : 20/20 – 20/60– B : 20/70 – 20/200– C : Worse than 20/200
Werner, 1963 857
Staging of DiseaseStaging of Disease
• Rundle’s Curve – Disease Activity– Active (Dynamic) Stage Proptosis and Lid
retraction– Static (Partial regression) Stage Stable
di ith littl i tdisease with little improvement– Inactive (Burnt out) Stage Spontaneous
l ti i trelative improvement
Sanjeev Y, 2010 858
Disease Activity (EUGOGO)Proptosis Diplopia Neuropathy
Mild 19-20 mm Intermittent Subclinical
Moderate 21-23 mm Inconstant 6/9 -6/12Moderate 21 23 mm Inconstant 6/9 6/12
Marked > 23 mm Constant(P i )
6/12 and worse(Primary) worse
• Severe disease– 1 Marked– 2 Moderate– 1 Moderate + 2 mild
Sanjeev Y, 2010
1 Moderate 2 mild
859
Auto-antibodiesAuto antibodies
• Anti-TSH.RA tit id P id• Antityroid Peroxidase
Sanjeev Y, 2010 860
Blow out fracture : SignsBlow out fracture : Signs
• Major signsMajor signs– Enophthalmos– DiplopiaDiplopia– Hypoesthesia
• Also– Positive forced duction test– Cloudiness and fluid level in the maxillary
sinus
861
Le Fort fractures• Le Fort I• Le Fort I
– Low transverse maxillary fracture above the teeth– No orbital involvement
• Le Fort II• Le Fort II– Pyramidal configuration– Nasal, lacrimal and maxillary bones medial orbital floor
L F t III• Le Fort III– Disjunction of craniofacial bones – Suspended only by soft tissues– Orbital floor, medial and lateral
bit l ll i l dorbital walls are involved
American Academy of Ophthalmology862
Painful ophthalmoplegiaPainful ophthalmoplegia
• Think Life saving first Infection ??Think Life saving first Infection ??– Orbital cellulitis
Tumor• Tumor• Tolosa-Hunt-Syndrome
– High dose steroids usually produce rapid and dramatic resolution
863
Painful blind eyePainful blind eye
• Think Life saving first infection ??Think Life saving first infection ??• Relieving the pain immediately• Cryo-therapy ?Cryo-therapy ?• Enucleation Last choice that strongly to be
avoidedavoided
• Remember :• Remember :– Incisional intra ocular surgery strictly contra indicated
in blind eye and in eye with severe decreased vision.
864
Community Ophthalmology
865
What is blindness?• WHO classification of visual impairment
C r i t e r i a VisionNormal 6/6 to 6/18Normal 6/6 to 6/18Visual impairment (1) <6/18 to 6/60Severe visual impairment (2) <6/60 to 3/60Severe visual impairment (2) <6/60 to 3/60Blind (3) < 3/60
Or Visual Field 5-10ºOr Visual Field 5 10Blind (4) 1/60
Or Visual Field < 5ºTotally blind (5) No light perception
866
Legal BlindnessLegal Blindness
• Best corrected of visual acuity both eyes 20/200 or less (USA)20/200 or less (USA)
• Or, Visual fields in both eyes of less than 10 degree centrally (USA)10 degree centrally (USA)
Deborah Pavan-Langston, 2008 867
Decreased vision percentageDistance vision Decrease (%)
20/20 020/20 020/25 520/40 1520/40 1520/50 2520/80 4020/100 5020/160 7020/200 8020/400 90
Vaughan DG 868
Decreased vision percentage
Near vision Decrease (%)1 02 03 106 507 6011 8514 95
Vaughan DG 869
Trachoma • Initially Chronic follicular conjunctivitis• Marked on upper tarsal plate• Marked on upper tarsal plate• Pannus
– Usually pronounced on upper half of the cornea– Corneal infiltrates– Superficial vascularization
• Art line– Transverse band of scar Fine linear– Occurring on superior tarsal conjunctiva
• Herber pitsHerber pits– Regression of the follicles formation– Locate at the limbus– Sharply defined depression at the base of the pannus– Sharply defined depression at the base of the pannus
American Academy of Ophthalmology870
Trachoma : WHO
SIGN DEFINITIONTF Trachoma Follicullar 5 or more follicles on superior tarsal
conjunctiva
TI Trachoma Intense Pronounced inflammatory thickening of the upper tarsal conjunctiva obscures more than ½ the normal deep tarsal vessels
T h t The presence of scarring in the tarsalTS Trachomatous Scarring
The presence of scarring in the tarsal conjunctiva
TT Trachomatous At least one eyelash rubbing on the TT Trichiasis eyeball
CO Corneal opacity Easily visible corneal opacity over the pupil
American Academy of Ophthalmology 871
Trachoma : MacCallan• Trachoma I
– Immature follicles on upper tarsal plate– Including in central area– Without scarring
• Trachoma II– Mature follicles on upper tarsus necrotic or soft– Obscuring tarsal vessels– Still without scarringStill without scarring
• Trachoma III– Follicle presents on tarsus
Definite scarring of the conjunctiva– Definite scarring of the conjunctiva• Trachoma IV
– No follicles on tarsal plate– Marked scarring of the conjunctiva
872
Vitamin A deficiencyVitamin A deficiencyXerophthalmia (WHO 1996)
• (XN) : Nyctalopia• (X1A) : Conjungtival xerosis(X1A) : Conjungtival xerosis• (X1B) : Conjungtival xerosis + Bitot spot• (X2) : Corneal xerosis
(X3A) : Keratomalacia or corneal ulceration• (X3A) : Keratomalacia or corneal ulceration with < 1/3 corneal involvement
• (X3B) : Keratomalacia or corneal ulceration with > 1/3 corneal involvementwith > 1/3 corneal involvement
• (XS) : Corneal scar• (XF) : Xerophthalmia fundus
American Academy of Ophthalmology 873
Fortified topical antibioticsFortified topical antibiotics
• Fortified Tobramycin (or Gentamycin)Fortified Tobramycin (or Gentamycin)– Inject 2 ml of 40mg/ml Tobramycin
Directly into a 5 ml 0 3% Tobramycin– Directly into a 5 ml – 0.3% Tobramycin ophthalmic solution
– This gives a 7 ml fortified Tobramycin– This gives a 7 ml fortified Tobramycin approximately 15 mg/ml
– RefrigerateRefrigerate– Expires after 14 days
Will’s Eye Manual, 2004 874
Fortified topical antibioticsFortified topical antibiotics
• Fortified VancomycinFortified Vancomycin– Add non preservative sterile water to 500 mg of
Vancomycin dry powder to form 10 ml of solution– This provides a strength of 50 mg/ml solution– To achieve a 25 mg/ml solution take 5 ml of 50
mg/ml solutionmg/ml solution– Add 5 ml sterile water– RefrigerateRefrigerate– Expires after 4 days
Will’s Eye Manual, 2004 875
Fortified topical antibioticsFortified topical antibiotics
• Fortified CefazolinFortified Cefazolin– Add non preservative sterile water to 500 mg
of Cefazolin dry powder to form 10 ml ofof Cefazolin dry powder to form 10 ml of solution
– This provides a strength of 50 mg/ml solutionThis provides a strength of 50 mg/ml solution– Refrigerate– Expires after 7 daysExpires after 7 days
Will’s Eye Manual, 2004 876
Fortified topical antibioticsFortified topical antibiotics
• Fortified BacitracinFortified Bacitracin– Add non preservative sterile water to
50 000 U of Bacitracin dry powder to form50,000 U of Bacitracin dry powder to form 5 ml of solution
– This provides a strength of 10,000 U/mlThis provides a strength of 10,000 U/ml solution
– Refrigerateg– Expires after 7 days
Will’s Eye Manual, 2004 877
Intracameral AntibioticsIntracameral Antibiotics
• GlycopeptideGlycopeptide – Vancomycin Use Millipore powder filter
• CephalosporinsCephalosporins– Cefuroxime– CefazolinCefazolin
• Fluoroquinolones– GatifloxacinGatifloxacin– Moxifloxacin
EyeWorld 2009878
Intravitreal antibiotics ( / 0 1 ml )Intravitreal antibiotics ( / 0.1 ml )
G t i 0 1• Gentamycin 0.1 mg• Vancomycin 1.0 mg• Amikacin 0.4 mg• Chlorampenicol 1.0 mgChlorampenicol 1.0 mg• Amphotericin B 5.0 µg
Cefta idime 2 0 2 25 mg• Ceftazidime 2.0-2.25 mg
American Academy of Ophthalmology879
The Laser
883
LaserLaser
• Light Amplification• By• Stimulating• The Emission of Radiation• The Emission of Radiation
884
Laser : EffectLaser : Effect
• Photochemical• Thermal• Photovaporization• Ionizing effectsIonizing effects
885
Laser : TypeLaser : Type
• GAS ION LASERS- Argon, Krypton
• SOLID STATE LASERSR b C t l Nd YAG- Ruby Crystal, Nd:YAG
• LIQUID LASERSD e- Dye
• DIODE LASERS
886
Laser for EyeLaser for Eye
• Photocoagulation Protein-denaturating processes– Argon Blue Green– Argon Green– Krypton Red– Diode– Tunable Dye– Frequency Doubled Nd:YAG
X A– Xenon Arc887
Laser for EyeLaser for Eye
• Photodisruption Cutting by optical break down 10,000° K– Q-switched Frequency Doubled
Nd:YAG Laser
888
Laser for EyeLaser for Eye
• Photodecomposition Carving C tti th l l b d Cutting the molecular bond
UV short wavelength– UV short wavelength– Excimer (Excited Dimmer) Laser
889
Laser for EyeLaser for Eye
Photoevaporation Infra Red• Photoevaporation Infra Red– CO2 Laser
H l i YAG L– Holmium:YAG Laser– Erbium:YAG Laser
Shorter Long Wavelength LaserLaser
890
MODERN LASERSMODERN LASERS
• Continuous Wave ( CW )accurate selection of power & emission timep
• Efficiency- lower power and energy consumption- lower space consumption- lower cost- long term use
891
The Lasers• integrepro multicolor laser (ellex)
PUREPOINT Laser (Alcon Inc)• PUREPOINT Laser (Alcon Inc)• MicroPulse Fovea-Friendly Laser (IRIDEX)• VISULAS 532s VITE (Carl-Zeiss)VISULAS 532s VITE (Carl Zeiss)• PASCAL (Pattern Scan Laser) Photocoagulator
(OptiMedica, now: TopCon)• Novus Varia multicolor photocoagulator
(Lumenis)• MC-500 Vixi Multi-Colour Laser (NIDEK)MC 500 Vixi Multi Colour Laser (NIDEK)• Vitra Multispot Laser (Quantel Medical)
892
Laser on RetinaLaser on Retina
My teacher, my mentor, my friend:
dr Tjuk Suparjadi Sp M
895
dr. Tjuk Suparjadi, Sp.M
Laser on Retina : PhotocoagulationLaser on Retina : Photocoagulation
L• Lenses– PRP Lens– Goldmann 3 mirror Lens
• 59°, 67°, 73°F l d G id L– Focal and Grid Lens
– +78 and +90 D Lens– PDT Lens
896
897
LASER ON RETINALASER ON RETINA
• GREEN LASER : 532 nmGREEN LASER : 532 nmProduced by :
Gas ( Argon )- Gas ( Argon )- Diode Pumped Solid State (DPSS) F d bl d Nd YAG Frequency doubled Nd:YAG
898
LASER ON RETINA : Argong
• 514 nm and 532 nm wavelength• Clear media safe and proven effective• Indications :
– DRDR– Veins occlusions– CNV– CNV– Retinal breaks
899
LASER ON RETINA : Dye Yellow
• 577 nm wavelength• Better than Argon for microaneurism• Preferred for Coats disease• Not acceptable in hemorrhage
M l b b d b h l bi b b d b• Macula absorbed by haemoglobin, unabsorbed by Xanthophil
900
LASER ON RETINA : Krypton Red
• 647 nm wavelength• Less absorption by blood• Hazy media
D b• Deep burns• Less NFL damage• Not preferable for Coats disease and Retinal angioma• Not preferable for Coats disease and Retinal angioma• Indications :
– DR with vitreous hemorrhage– Veins occlusions with vitreous hemorrhage– Vitreoretinal tractions– CNV General Peripapillary Near PMB with pre-retinalCNV General, Peripapillary, Near PMB, with pre retinal
membrane901
LASER ON RETINA : Diode
• 810 nm wavelength• 810 nm wavelength• Deep burns• Less NFL damageLess NFL damage• Less absorbed by blood• Not preferable for Coats disease and Retinal angioma• Indications :
– DR with vitreous hemorrhageVeins occlusions with vitreous hemorrhage– Veins occlusions with vitreous hemorrhage
– Vitreoretinal tractions– CNV General, Peripapillary, Near PMB, with pre-retinal
bmembrane902
HOW to OPERATEHOW to OPERATE
• TECHNICAL SPECIFICATION1. Laser Specificationp2. Electrical Requirement3. Visualization
- Slit Lamp- Aiming Beam- Laser Safety Eye Wear
MPE = maximum permissible exposure
903
How to select the mode
• Type of Laser : Wavelength• Power : 0 3 1 7 W ( DPSS )• Power : 0.3 - 1.7 W ( DPSS )
0.5 - 4.0 W ( Gas )S t Si 50 2000• Spot Size: 50 - 2000 um
• Exposure time : 0.01 - 4.0 s ( DPSS )0.01 - 1.0 s ( Gas )
• Pulse Interval : 0.1 - 1.0 s
904
Nice to knowNice to know
• Xantophyl, Oxyhaemoglobin and Melanin• Indirectly mechanism• Indirectly mechanism• Exposure time :
< 0 1 h i l ff t< 0.1 sec : mechanical effect> 0.1 sec : thermal effect
• Energy Density inversely proportional to the focal spot size
905
ApplicationsApplications
• Diabetic retinopathy– Non-perfusion– Edema
G id– Neovascularization• Venous occlusion• Retinal breaks
• Grid• Focal• Pan retinal• Retinal breaks
• Retinal degeneration• Retinal vasculitis
Pan retinal
• CSCR• AMD
906
Applications : Grid LPCApplications : Grid LPC• Grid Laser Photocoagulation
• Macular application 500 µm up to 3000 µm from foveal center
• Excluded area of PMB• Grid Lens / +78 and +90 D Lens• Start at 100mW power increments of 10-20mW• Start at 100mW power increments of 10-20mW• 50-100 µm spot size• 0.100 second or less duration
S t d t l t b t• Spots spaced at least one burns apart• Supplemental treatment considered at least 3-4 month
after initial coagulation up to 300 µm
907
Applications : Focal LPCApplications : Focal LPC
Focal Laser Photocoagulation
• Grid Lens / +78 and +90 D LensGrid Lens / +78 and +90 D Lens• Start at 100mW power increments of 10-20mW• 50-100 µm spot size• 0.100 second or less duration• Attempt to whiten or darken microaneurysms
908
Applications : PRPPan-Retinal Photocoagulation/ Scatter Laser Photocoagulation/ Scatter Laser Photocoagulation
• NVD or / and NVE• PRP LensPRP Lens• Start at 180mW power increase gradually to achieve the end
point• 500 µm spot size• 500 µm spot size• 0.100 to 0.200 second duration• 1800 total applications• 1 – 1.5 burns width apart• 3 sessions complete 10 days to weeks apart• Usually, inferior half of retina coagulated firsty, g
909
Applications : OthersApplications : Others
• ROP• Retinoblastoma• Coats disease• Vitreolysis• Retinal cavernosus hemangioma• Choroidal hemangioma• Optic Disc Pit – Maculopathy• Idiopathic Juxtafoveal Retinal talengiectasis
910
Chorioretinal burn intensityChorioretinal burn intensity
• Light– Barely visible retinal blanching
• Mild– Faint white retinal burn
• Moderate– Opaque, dirty white retinal burn
• Heavy– Dense-white retinal burn
911
Laser on Retina : PDTLaser on Retina : PDT
• Systemic administrationSystemic administration• Use photosensitizing drugs
F ll d b li ht li ti• Followed by light application• Particular wavelength to affected tissue• Incite a localized photochemical reaction
912
Laser on Retina : PDTLaser on Retina : PDT
• CW beam 500 - 590 µm of low thermal energyCW beam 500 590 µm of low thermal energy laser
• Extend at least 500 µm beyond lesion marginµ y g• 50 J/cm2 laser energy• 600 mW/cm2 dose rate600 mW/cm dose rate• 15 minutes after start the infusions
913
Laser on Retina : PDTLaser on Retina : PDT
• Liposome-encapsulated Benzoporphyrin Verteporfin dye (Visudyne) Verteporfin dye (Visudyne)– Maximum absorption light near 689 nm
wavelengthwavelength• Others :
– Tin Ethyl Etiopurpurin (SnET2, Purytin)– Lutetium (Lu-Tex)
914
Laser on Retina : PDTLaser on Retina : PDT
• 30 ml Verteporfin via 10 minutes infusion pump30 ml Verteporfin via 10 minutes infusion pump injection, plus
• 5 ml D5W injected simultaneously via Y tube• Filtered by 1.2 um filter to venflon catether into
Cubiti vein
915
Laser on Retina : TTTLaser on Retina : TTT
• Transpupillary ThermotherapyAlt ti th f S bf l CNV– Alternative therapy for Subfoveal CNV
– Rise intralession temperature of 4-9° C• Infra Red Diode laser 810 nm• Infra Red Diode laser 810 nm• Within 72 hours of recent FFA
Diode coated Volk QuadrAspheric Lens• Diode-coated Volk QuadrAspheric Lens• 0.8 mm, 1.2 mm, 2.0 mm, 3.0 mm spot size
200 600 W• 200 – 600 mW power916
Laser for Glaucoma
919
A Tribute toA Tribute to Prof. dr. Ratna Kentjana, Sp.M(K)
P f d MNE G l i S M(K)Prof. dr. MNE. Gumansalangi, Sp.M(K)
920
ALTALT
• Argon Laser Trabeculoplasty
921
ALT : AimsALT : Aims
I tfl• Increase aqueous outflow• By burning the trabecular meshwork• By applying a low energy of laser
922
ALT : MechanismALT : Mechanism
• Absorption of laser by Pigmented TM• Produces thermal energy• Shrinkage of collagen of trabecular lamellae
– Probably opens un intratrabecular space in untreated regionregion
– Trabecular tightening pulling meshwork centrally opens Schlemm’s canal
• Attract phagocytes that clean up debris• Allows aqueous to flow better
923
ALT : PreparationsALT : Preparations
• CW Argon laser : – Bichromatic Blue-Green
Monochromatic Green– Monochromatic Green• Krypton Red • Frequency doubled Nd:YAG laser q y• Diode
– Lesser painLesser PAS– Lesser PAS
– Lesser disruption of Blood Aqueous Barrier• Gonio lens
924
ALT : Protocol1. Pre-Treatment
ALT : Protocol
● Alpha-adrenergic antagonist (Apraclonidine 1%) and topical anesthetic
2. TreatmentG i i● Gonioprisms
● Focus aiming beam to target the entire height of TM● 180° or 360° of TM can be photocoagulated in single or two sessions
● Goniolens rotated clockwise and make 25 burns for each 90°● Goniolens rotated clockwise and make 25 burns for each 90
3. Post-Treatment ● Alpha-adrenergic antagonist ● Topical steroid or NSAID for 3 to 5 days (optional)● 1 hour IOP check after treatment
● Regular follow-up routine
925
ALT : IndicationsALT : Indications
• POAG• Exfoliation syndrome• Pigmentary glaucomaPigmentary glaucoma• Glaucoma in aphakia and pseudophakia
926
ALT : ContraindicationsALT : Contraindications
• Closed or Extremely narrow angle• Corneal haze and diminished aqueous clarityCorneal haze and diminished aqueous clarity• Vitreous in anterior chamber• Neovascular glaucoma• Neovascular glaucoma• Active uveitis• Poor responsiveness glaucoma Congenital• Poor responsiveness glaucoma Congenital
glaucoma and Angle recession glaucoma
927
ALT : ComplicationsALT : Complications
• Elevated IOPP i i l fi ld l• Progressive visual field loss
• Iritis• PAS• HemorrhageHemorrhage• Corneal complications
928
SLTSLT
• Selective Laser TrabeculoplastySelective Laser Trabeculoplasty
929
SLT : MechanismSLT : Mechanism
• Uses specific wavelength • Absorption of laser by Pigmented TM
l ti t t d Nselective targets no damage on Non-pigmented TM
• Produces Photothermolysis Non-thermalProduces Photothermolysis Non thermal• Trabecular tightening• Allows aqueous to flow betterAllows aqueous to flow better
930
SLT : PreparationsSLT : Preparations
• 532nm Wavelength Q-switched frequency doubled Nd:YAG laser(Neodymium: Yytrium-Aluminum-Garnet)63 W l h Di d l• 635nm Wavelength Diode laser
• Goldmann, Thorpe or Latina lens (0° ifi ti )(0° magnification)
931
SLTSLT• Allerex• EllexEllex
932
SLT : Protocol1. Pre-Treatment
SLT : Protocol
● Alpha-adrenergic antagonist and topical anesthetic
2. TreatmentG ld Th L ti l (0° ifi ti )● Goldmann, Thorpe or Latina lens (0° magnification)
● Focus aiming beam to target the entire height of TM● Set laser to 0.8 mJ (average) and then increase in 0.1 mJ steps until
champagne bubbles appear approximately 50%-70% of the time champagne bubbles appear approximately 50% 70% of the time ● Approximately 50 shots are placed onto the TM in the same pattern as ALT
3 P T3. Post-Treatment● Alpha-adrenergic antagonist ● Topical steroid or NSAID for 3 to 5 days (optional)● 1 hour IOP check after treatment● 1 hour IOP check after treatment● Regular follow-up routine
933
SLT is not ALTSLT is not ALT
Spot size comparison:
400µm50µm
SLTALT
ALT SLT
ALT SLT50 micron SPOT SIZE 400 micron
500 – 1,000 mW720 – 1,200 mW
ENERGY OUTPUT 0.8 – 1.5 mJ
10 ms PULSE DURATION 3 ns
60,000 mJ/cm2 FLUENCE 600 mJ/cm2
934
SLT is not ALT
The SLT technique is much less traumatic to the eye than ALT
SLT is not ALT
The SLT technique is much less traumatic to the eye than ALT, and evokes a gentle response of the auto-immune system to begin clearing the TM without the coagulative damage of ALT.
TM tissue after ALT TM tissue after SLT
935
SLT : ProcessesSLT : Processes
SLT is a non-thermal treatment which uses short pulses of relatively low energy 532nmlight to target and irradiate only the melanin-rich cells in the trabecular meshwork (TM);the laser pulses affect only these melanin-containing cells, and the surrounding structureof the TM is unaffected.
During the procedure approximately 50 confluent spots are applied along the meshwork in order to treat a 180° angle.
Animation 936
1. SLT is selectiveSLT selectively targets only the melanin-rich cells of the trabecular meshwork.
2. SLT is non-thermalThe short pulse duration of SLT is below the thermal relaxation time of the TM tissue, thereby eliminating the incidence of thermal damage.
3. SLT is repeatableSLT treatment can be repeated without causing harm or further complications.p
937
SLT : IndicationsSLT : Indications
Open Angle Glaucoma • POAG• OHT
Pigmentary Glaucoma• Pigmentary Glaucoma• Pseudo-exfoliative glaucoma
Poorly compliant to drug therapy
I l i d hIntolerant or unresponsive to drug therapy
Failed ALT (either 180˚ or 360˚)
Inflammatory glaucomaInflammatory glaucoma
Patients currently undergoing drug therapy who wish to use SLT in conjunction with glaucoma medications
938
Compliance issues minimized
SLT represents a whole new approach to managing open-angle glaucoma
Compliance issues minimized
Gentle, non-invasive treatment
SLT does not cause thermal damage of the trabecular meshworktrabecular meshwork
No systemic side effects
SLT can be used in conjunction with medicine to enhance the overall IOP lowering effectto enhance the overall IOP-lowering effect
Non-penetrating glaucoma surgery is not compromised as with ALT
The latest in ‘Primary Glaucoma Therapy’The latest in Primary Glaucoma Therapy
939
ALPIALPI
• Argon Laser Peripheral Iridoplasty
940
ALPI : AimsALPI : Aims
• Laser energy placed near iris rootS t I i f TM• Separate Iris from TM
• For PACG• Reopening of closed angle• Widening of narrow angleWidening of narrow angle
941
ALPI : PreparationsALPI : Preparations
• 532nm Wavelength Q-switched frequency doubled Nd:YAG laser(Neodymium: Yytrium-Aluminum-Garnet)Ab h l 66 D• Abraham contact lens +55 to +66 D
942
ALPI : IndicationsALPI : Indications
• Plateau iris syndrome• Unbreakable attack of angle close• Unbreakable attack of angle close
glaucoma laser iridotomy not possible• Phacomorphic glaucoma• Phacomorphic glaucoma• Adjunct to laser trabeculoplasty
R t ti i h l i i t k• Retracting peripheral iris stuck• Rare case of nanophthalmos
943
ALPI : Contraindications• Advanced corneal edema / opacity• Flat anterior chamberFlat anterior chamber• Extensive PAS• Creeping angle glaucoma not effective
ALPI : ComplicationsALPI : Complications• Iritis• Corneal endothelial burns• Corneal endothelial burns• Hemorrhage• Transient IOP rise
944
Nd:YAG Laser IridotomyNd:YAG Laser Iridotomy
R li th ill bl k• Relieve the pupillary block• 532nm Wavelength Q-switched frequency
doubled Nd:YAG laserdoubled Nd:YAG laser(Neodymium: Yytrium-Aluminum-Garnet)
• Abraham contact lens +55 to +66 D• Abraham contact lens +55 to +66 D
945
Nd:YAG Laser IridotomyNd:YAG Laser Iridotomy
• Indications :• Indications :– PACG :
A t / S b t l l• Acute / Sub acute angle closure• Creeping angle closure
Fellow eye of ACG– Fellow eye of ACG– Non-pupillary block angle closure
• Plateau iris• Plateau iris• Forward lens position
– Narrow or closed angle– Narrow or closed angle946
Nd:YAG Laser Iridotomyy
• Complications :• Complications :– Corneal epithelial / endothelial burns– IritisIritis– Pigment dispersion– Hemorrhagesg– Lens opacities– Retinal burns– Raised IOP– Posterior synechiae
M l di l i– Monocular diplopia947
Laser for Glaucoma and OthersLaser for Glaucoma and Others
Nd YAG L C l• Nd:YAG Laser Capsulotomy• Diode Laser Cyclophotocoagulation• Endoscopic Cyclo Photo Coagulation• Nd:YAG Laser Iridolenticular Synechiolysis• Nd:YAG Laser Iridolenticular Synechiolysis• Cyclophotocoagulation
– Transpupillary CP– Endo CP– Nd:YAG Trans-scleral CP Contact and Non-contact– Diode laser CP (DLCP)
• Excimer Laser Trabeculotomy (ELT)308 X Cl l 35 55 J/ t i 200 d ti 10– 308 nm XeCl laser, power 35-55 mJ/mms spot size 200 um, duration 10 sec, freq 20Hz
• Excimer Laser Assisted Deep Sclerotomy– Argon Fluoride XL 193 nm at 180 mJ x sq cm fluenceg q
948
Laser for Refractive SurgeryLaser for Refractive Surgery
• PRK• LASIK• LASIK• Epi LASIK• SBK • LASEK• LaserACE
949
LASIK : Wood carvingLASIK : Wood carving
W d C• Wood Cornea• Equipment Laser • Carver Ophthalmologist
950
Argon Fluorine (ArF)Argon Fluorine (ArF)
• 193 nmAb th h ld t b k l l b d• Above threshold to break molecular bond
• Ablative photodecomposition• Neighboring tissue <10º C (Cold laser)• Minimal collateral damageMinimal collateral damage• Maximal accuracy & precision
951
Solid State UV 213Solid State UV 213
• 213 nmDPSS Nd YAG P l 21 (C t Vi )• DPSS Nd:YAG Pulzar 21 (CustomVisc)
• Less absorbed by neighboring tissue• Much better penetrating• Less sensitive to environmental factorLess sensitive to environmental factor
952
Solid State UV 210Solid State UV 210
• 210 nmDPSS L S ft (K t T h l i )• DPSS LaserSoft (Katana Technologies)
• Less inflammations• Less pain• Faster visual recoveryFaster visual recovery
953
LasikLasik• Pre Lasik
– General Examination– Mapping Topography and pachymetry, AberrationMapping Topography and pachymetry, Aberration
measurement and collecting data – Making algorithm for laser treatment
• Durante– Flapping Micokeratome or Femtosecond– Eye-tracked Laser treatment– Eye-tracked Laser treatment– Recovery management
Post Lasik• Post Lasik954
Corneal Topography, CornealCorneal Topography, Corneal Pachymetry and Aberrometry System
955
Femto and Excimer Laser SystemFemto and Excimer Laser System
956
Pre LasikPre Lasik
• Topography - KeratometryAb t• Aberrometry
957
Topography
3 types3 types3 types3 types
–– PlacidoPlacido--based systemsbased systems
–– ElevationElevation--based systemsbased systems–– ElevationElevation--based systemsbased systems
–– Interferometric systemInterferometric systemyy
Bausch and Lomb 958
Topography
Provide topography of the cornea, like a map
Bausch and Lomb959
ORBSCAN II zORBSCAN II z
Combination of :Combination of :• Placido based-system• Scanning slit imaging (elevation
based system)based system)
Bausch and Lomb 960
Reflective and Slit-Scan Technologies
• One image, one surface.A l d d t l
• Multiple images, multiple surfaces• Angle-dependent specular
reflection.• Measures slope (as a
f ti f di t )
surfaces• Omni-directional diffuse
backscatterT i l t l tifunction of distance). • Triangulates elevation
The overwhelming advantage Placido reflective systems is that they can measure curvaturethat they can measure curvature.
Bausch and Lomb 961
How corneal shape relates to shape factorHow corneal shape relates to shape factor
962
LASIK Fit the corneaLASIK Fit the cornea
Data surface(cornea)(cornea)
Fit-zone
Reference surface (Best Fit Sphere)( p )
Bausch and Lomb 963
3D Corneal Topography
BFSBFS
BFS : Reference surface (Best Fit Sphere)
Bausch and Lomb 964
Major points• Anterior Elevation• Posterior ElevationPosterior Elevation• Pachymetry Thickness• Keratometry - Surface Curvature• Statistics and Data
• Sim K• Steep and Flat Axis• Steep and Flat Axis• White to White• Pupil diameter• Thinnest point• Anterior Chamber Depth (ACD)• Angle Kappag pp• Kappa Intercept
Bausch and Lomb 965
Anterior Elevation Map Posterior Elevation Map
C M P h MS i i d DCurvature Map Pachymetry MapStatistics and Data
Bausch and Lomb 966
El ti (f f f )
RedMax
Elevation (from a reference surface)
• High• Anterior to the
RedMax
(+)reference surface
f l l
(+)
• Low• Posterior to the
reference surface
reference level(-)
reference surface
BlueMin
Bausch and Lomb 967
Elevation Map Reading
• Warmer colors are above “sea level”
G i “ l l” ( t h ith
• Warmer colors are above sea level
• Green is “sea level” (match with a sphere that best matches the cornea)
• Cooler colors are below “sea level”
• Both Anterior and Posterior are read in the same wayy
Bausch and Lomb 968
Eye #1
Highest Point Lowest Point
Bausch and Lomb 969
Eye #1
Lowest PointHighest Point
Bausch and Lomb 970
Pachymetry MapsPachymetry Maps
• Warmer colors are THINNERCooler colors are THICKER• Cooler colors are THICKER
Pre Op eyes are usually thinnest in thePre-Op eyes are usually thinnest in the temporal and inferior quadrant
Bausch and Lomb 971
Thickness
RedMin
• ThinRedMin
(+)
(+ +)
Thi k
(+ +)
BlueMax• Thick
Bausch and Lomb 972
Pachymetry Thickness
THINNEST Area THICKER Area
Bausch and Lomb 973
Pachymetry mapy y p• Thinnest point obtain from data sheet
Bausch and Lomb 974
Pachymetry map
• Orbscan pachymetry measurements 5% to 8% more compared to ultrasonic5% to 8% more compared to ultrasonic– Orbscan measures from epithelium to
endotheliumendothelium– Ultrasonic pachymetry : Stroma
Bausch and Lomb 975
High and Low is not alwaysHigh and Low is not always directly related to Steep and Flat
High Tissue is usually flatter, but not alwaysg y , y
Low Tissue is usually steeper, but not alwaysLow Tissue is usually steeper, but not always
Color coded in elevation map >< curvature map (keratometric)
Ablation requires Elevation Data because tissue that needs to be removed is high
Bausch and Lomb 976
Color-coded scalesColors :
– Warm (red, orange, yellow) for steeper portions of cornea
– Green denotes intermediate portions
– Cool (blue, dark blue) depict flatter portionsportions
Bausch and Lomb 977
S rface C r at reRedMax
Surface Curvature
• Sharp• Fast bend
RedMax(+ +)
• Fast bend• Short radius
• Flat• Slow bend(+)• Long radius
BlueMin
Bausch and Lomb 978
Bausch and Lomb 979
Orbscan topography prior to refractive surgery
• Ultrasound pachimetry > 475 µm• Residual bed thickness (RBT) > 250 - 300 µmResidual bed thickness (RBT) 250 300 µm• Posterior elevation < 50 µm• Posterior bed fit sphere < 50 D• Anterior/Posterior Radii-Ratio 1.21 – 1.27• Irregularity (3mm) < 1.5 D• Irregularity (5mm) < 2 0 D• Irregularity (5mm) < 2.0 D• Peripheral-Central Pachimetry < 20 µm• SimK (Max) < 47 D• Astigmatism variance between eyes < 1.0 D• Symetric bowtie
EyeWorld 2009; Joo CK 2009 980
ANY CAUTIONSANY CAUTIONS
981
KeratoconusKeratoconus
Refractive surgery makes early diagnosis of corneal abnormalities more important
Bausch and Lomb 982
Close-Fitting Reference SurfacesTopographic maps of terrestrial landscapes are displayed in the form of constant-elevation contours, measured from the “mean sea level” of the earth
Data surface
mean sea-level of the earth.
(cornea)
Reference surface (sphere)
Corneal topography differs from terrestrial topography in that the reference surface is not some fixed “mean sea-level”, but is movable. Bausch and Lomb 983
Close-Fitting Reference SurfacesF th f f (t i ll h ) iFor the cornea, a reference surface (typically, a sphere) is constructed by fitting the reference surface as close as possible to the data surface.
Data surface(cornea)
p
(cornea)
Reference surface (sphere)Fit-zone
A best-fit minimizes the square difference (always a positive number) between the two surfaces, but only within p ) , ya specified region known as the fit-zone.
Bausch and Lomb 984
Elevation Topology: Central HillBausch and Lomb
Sharp center
The normal cornea is prolate meaning that meridional curvature
Flat periphery
The normal cornea is prolate, meaning that meridional curvature decreases from center to periphery.Prolateness of the normal cornea causes it to rise centrally above the
f h Th lt i t l hillreference sphere. The result is a central hill.Immediately surrounding the central hill is an annular seaannular sea where the cornea dips below the reference surface.
In the far periphery, the prolate cornea again rises above the reference surface, producing peripheral highlands. 985
Elevation DistortionB h d L b
Spherical reference surface
Post Lasik profile
Bausch and Lomb
Relative elevation profile
As an example of distortion, consider the corneal surface following
p
p gmyopic lasik correction. It is centrally flattened by the surgery.To see surface features, elevation must be measured with respect to some reference surface.This relative elevation peak is NOT the highest point on the cornea.
This apparent central "concavity" does NOT exist. 986
Normal Post LASIK Anterior Elevation
Bausch and Lomb
Lower in the Center - OD Lower in the Center - OS987
Elevation (sphere) Elevation (sphere)
These are pre-op (left) and post-op (right) elevation maps of a myopic with-the-rule astigmatic eye corrected with LASIK.y p g yThe post-operative central “sea” is not a concavity but a central flattening.The ring of relatively highest terrain is not absolutely higher (more anterior) than the “sea” bottom near the map center. 988
Abnormal Post LASIK Posterior Elevation
Abnormally High but High & De centered Poor Vision
Bausch and Lomb
Abnormally High but Centered -
High & De-centered -Moderately Good Vision
Poor Vision• Diplopia at night
989
Normal Band ScaleNormal Band ScaleBausch and Lomb
Accentuates anomaliesAccentuates anomalies
Filters small irregularities990
N l B d S lNormal Band Scale
• Elevation Maps (Anterior & Posterior)– + 0.25 microns of Best Fit Sphere
• Total Cornea Power– 40 to 48 Diopter
• Pachymetry – 500 to 600 microns
Bausch and Lomb 991
Posterior KeratoconusPosterior Keratoconus
The normal band scale on the left indicates very small changes on the anterior corneal surface and a relatively small area of corneal steepening above 48 D.
These findings are indicative of milder disease than the contra-lateralThese findings are indicative of milder disease than the contra lateral eye but probably represents an earlier forme fruste of keratoconus.
Bausch and Lomb 992
The CRS-MasterH d l t t t ?How do you plan your treatments ?
RefractionWavefront
C l C t
Wavefront
Corneal CurvaturePatient Data
MicrokeratomePachymetry
• Modern refractive excimer surgery is based on a complex data set
I k i l f d b ll• It must take into account not only wavefront data, but allrelevant parameters of each individual patient.
Bausch and Lomb993
AberrometryAberrometry
• Collecting aberration data• Collecting aberration data• Make algorithm for laser treatment• Minimizing aberration post surgery
Bausch and Lomb 994
Aberration : Category• Two categories of aberrations commonly are used to
describe vision errors, including:– Lower-order aberrations consist primarily of nearsightedness
and farsightedness (defocus), as well as astigmatism. They make up about 85 percent of all aberrations in an eye.
– Higher-order aberrations comprise many varieties of aberrations. Some of them have names such as coma, trefoil and spherical aberration, but many more of them are identified p , yonly by mathematical expressions (Zernike polynomials). They make up about 15 percent of the total number of aberrations in an eye.
• Order refers to the complexity of the shape of the wavefront emerging through the pupil — the more complex the shape the higher the order of aberrationcomplex the shape, the higher the order of aberration.
Vessel M, 2008 995
Aberration : What Exactly y• A higher-order aberration is a distortion acquired by a
wavefront of light when it passes through an eye with i l iti f it f ti t (t filirregularities of its refractive components (tear film, cornea, aqueous humor, crystalline lens and vitreous body
• Abnormal curvature of the cornea and crystalline lens• Abnormal curvature of the cornea and crystalline lens may contribute to the distortion acquired by a wavefront of light.
• Serious higher order aberrations also can occur from• Serious higher-order aberrations also can occur from scarring of the cornea from eye surgery, trauma or disease.
• Cataract clouding the eye's natural lens also can cause• Cataract clouding the eye s natural lens also can cause higher-order aberrations. Aberrations also may result when dry eye diminishes your eye's tear film, which helps bend or refract light rays to achieve focusp g y
Vessel M, 2008 996
Aberration : How to diagnose• Higher-order aberrations are identified by the types of distortions
acquired by a wavefront of light as it passes through your eye. Because light travels in bundles of rays a common way ofBecause light travels in bundles of rays, a common way of describing an individual wavefront involves picturing a bundle of light rays. The tip of each light ray in the bundle has its own point. We create the wavefront or wavefront map by drawing lines perpendicular to each pointperpendicular to each point.
• The shape of a wavefront passing through a theoretically perfect eye with no aberrations is a flat plane known, for reference, as piston (see next chart). The measure of difference between the actual wavefront shape and the ideal flat shape represents the amount ofwavefront shape and the ideal flat shape represents the amount of aberration in the wavefront.
• Because no eye is absolutely perfect (emmetropic), a wavefront passing through an eye acquires certain three-dimensional, distorted h S f th 60 diff t h b ti hshapes. So far, more than 60 different shapes, or aberrations, have
been identified.• Significant amounts of aberrations can pose vision problems
because they interfere with the eye's ability to see clear and distinct y y yimages (focus).
Vessel M, 2008 997
Aberration : Visual quality• The impact of higher-order aberrations on vision quality
depends on various factors, including the underlying cause of the aberration.the aberration.
• People with larger pupil sizes generally may have more problems with vision symptoms caused by higher-order aberrations, particularly in low lighting conditions when the
il idpupil opens even wider.• But even people with small or moderate pupils can have
significant vision problems when higher-order aberrations are caused by conditions such as scarring of the eye's surfacecaused by conditions such as scarring of the eye s surface (cornea) or cataracts that cloud the eye's natural lens.
• Also, specific types and orientation of higher-order aberrations have been found in some studies to affect vision quality of q yeyes with smaller pupils.
• Large amounts of certain higher-order aberrations can have a severe, even disabling, impact on vision quality.
Vessel M, 2008 998
Aberration : Symptoms
• An eye usually has several different hi h d b ti i t tihigher-order aberrations interacting together. Th f l ti b t• Therefore, a correlation between a particular higher-order aberration and a specific symptom cannot easily be drawnspecific symptom cannot easily be drawn.
• Nevertheless, higher-order aberrations are generally associated with double visiongenerally associated with double vision, blurriness, ghosts, halos, starbursts, loss of contrast and poor night visionof contrast and poor night vision.
Vessel M, 2008 999
TERMS OF WAVEFRONTS O O
Aberrometry
P id i f i h b d h Provide information, how bad the Aberrations of the rays inside the eye Wavefront technologygy
1000
What is Wavefront?• Wavefront Technology is the latest generation of laser
vision correction. • Light travels in a flat uniform beam. • When there is nothing disturbing it, such as light going
through space, it is perfectly flat without error. • This pattern of a straight beam of light is called a
wavefront. • As light goes through objects, the light beam becomes g g g j , g
distorted or becomes more like a wave. • When light enters the eye, the light rays become
distorted because of the many components of the eyes optical system.
• Some of these components include the cornea, lens and aqueous fluid, although the greatest amount of distortion
h li ht t th h thoccurs when light enters through the cornea. 1001
What is Wavefront?
Perfect beam Imperfect beamp
Wa efront in E eWavefront in Eye
1002
How does Wavefront Work?
• As the light rays touch the retina, the Wavefront Analyzer measures the amount of distortion that hasAnalyzer measures the amount of distortion that has occurred prior to the light entering the eye and after going through the eye.
• As with the diagram the simulation grid would be• As with the diagram, the simulation grid would be considered the ideal or perfect optical grid.
• This grid is projected on to the back of the eye and is measuredis measured.
• The measurement is compared to the original grid producing what is called a wavefront map.
• This wavefront map calculates the specific aberrations of the cornea precisely measuring each section of the cornea to provide the most accurate pand detailed information about our vision.
1003
How does Wavefront Work?• Once the information is collected, it is
How does Wavefront Work?,
transferred to the laser. • The laser then does a customized treatment that
i ifi h i d i b dis specific to the patient and is not based on general guidelines of treatment.
• No two wavefront maps are identical therefore a• No two wavefront maps are identical, therefore a customized treatment is specific to that patient, enhancing the opportunity for superior quality of vision, reduced or eliminated night vision and improved uncorrected visual acuity.
1004
Why wavefront technology ?
Real eye: To reshape corneal surface to t f ti l
rays do not intersectcompensate for optical
aberrations
Ideal eye:
all rays intersect in image plane
retina
Determine actual shape Determine actual shape ppof wavefrontof wavefront
retinaBausch and Lomb1005
Wavefront methodsWavefront methods
• Hartman-Shack• Tscherning• Optical Path Difference (OPD) Scan
Deborah Pavan-Langston, 20081006
Measurements & TerminologyMeasurements & Terminology
• Zernike polynomialsP i t S d F ti (PSF)• Point Spread Function (PSF)
• Root Mean Square (RMS)• Strehl Ratio• DiffractionDiffraction• Convolution
Bausch and Lomb 1007
Zernike polynomialsZernike polynomials
• Prof. Frits ZernikeProf. Frits ZernikeGroningen, HollandAwarded Nobel prize in Physics 1953
• The complex shape of wavefront is approximated by a sum of function to give a special
t i l dgeometrical mode
Bausch and Lomb1008
1009
Zernike polynomialsZernike polynomials
Bausch and Lomb 1010
LowerLower--order aberrationsorder aberrations
2nd
Bausch and Lomb 1011
3 common higher order aberrationsgmost patients suffer from
3rd 3rd
4thBausch and Lomb 1012
Aberrations of the eye
Bausch and Lomb1013
Aberrations of the eye
Bausch and LombBausch and Lomb
1014
Understanding AberrationsSecond Order
CylinderMyopia
Second Order
CylinderSaddle Shape
MyopiaBowl Shape
Third Order Fourth Order
Coma Trifoil Sph Aber QuadrafoilComaBump & Dip
TrifoilNapoleon’s Hat
Sph AberSombrero
QuadrafoilPlant Stand
Bausch and Lomb1015
Understanding Aberrationsg
Coma (3rd order) Spherical Aberration( )(4th order)
Bausch and Lomb 1016
Point Spread Function (PSF)Point Spread Function (PSF)
Normal eyeNormal eye Monocular DiplopiaMonocular Diplopia
Bausch and Lomb 1017
Point Spread Function (PSF)Point Spread Function (PSF)
Bausch and Lomb 1018
Root Mean Square (RMS)Root Mean Square (RMS)
• Single valueSingle value• Measure the magnitude of a set of number• Example :• Example :
– Set of no : -2 +5 -6 +4 -1– Average = 0 not informative– Average = 0 not informative– We want to know the variation, disregard the
signs average = 3.6g g
Bausch and Lomb 1019
Root Mean Square (RMS)Root Mean Square (RMS)
Another way to know the variation :Another way to know the variation :1. Square all values2 Take average of the squares2. Take average of the squares3. Square root of average
Smaller RMS = Less aberrationsGeneral agreement : RMS < 0.38 plano LASIKGeneral agreement : RMS < 0.38 plano LASIK
Bausch and Lomb 1020
Strehl RatioStrehl Ratio
• A metric calculated from :A metric calculated from :
A t l k PSFActual peak PSFDiffraction-limited peak PSF
Results closer to 1 Results closer to 1 less aberrationless aberration
Bausch and Lomb 1021
Strehl ration
eyeHDiffraction limited PSFDiffraction limited PSFAberration freeAberration free
dlHeyeHratioStrehl
H dl
Actual PSF with aberrationsActual PSF with aberrations
H eyeBausch and Lomb
1022
DiffractionDiffraction
• Diffraction causes light to bend perpendicular toDiffraction causes light to bend perpendicular to the direction of the diffracting edge
• Spreading of light waves as they pass through a p g g y p gsmall opening. (Christiaan Huygens, 1678)
• Cause the light imaged not as a single sharp g g g ppoint AIRY DISK
• Smaller apertures generates more diffraction
Bausch and Lomb 1023
ConvolutionConvolution• Method to portray blur, using PSF in every point of p y , g y p
object to stimulate retinal image
Bausch and Lomb 1024
Wavefront AnalyzersWavefront Analyzers
• Zywave (Bausch & Lomb Incorporated)• CRS Master (Carl Zeiss Meditec AG)( )• WaveScan (Abbott Medical Optics)• Allegro Topolyzer Vario (WaveLight, Alcon)g p y ( g )• MAXWELL (Ziemer)
1025
GlareGlare
• Glare can be described as “extreme brightness” from the presence of excessive visible light.
• Glare can be distracting and even dangerous and can occur day or night in a number of ways. Gl t i t lti i• Glare can cause you to squint, resulting in eye strain and eye fatigue. In extreme cases, glare can even result in temporary blindnesscan even result in temporary blindness.
1026
• Distracting glareDistracting glare can be caused by car headlights or streetlights– Distracting glare can be caused by car headlights or streetlights at night.
– It can also be as simple as light being reflected off the front of ff fyour lenses making it difficult for others to see your eyes.
– Similarly, it may be from light reflected off the back – or inside –of your lenses so that you see the distracting reflection of your own eyes of objects behind you in your forward field of vision.
– As a result, this kind of glare may cause eye fatigue, annoyance and distraction.and distraction.
1027
• Discomforting glare– Glare can be caused by everyday, normal sunlight conditions.
D di ’ li ht iti it thi l– Depending upon one’s light sensitivity, this glare can be discomforting regardless of weather or time of day.
– It can be present in any level or intensity of light, or when moving from one lighting condition to another.
– Discomforting glare often causes squinting and eye fatigue
1028
• Disabling glareDisabling glare– Straylight– This type of glare comes from excessive, intense light that can
occur when you face directly into the sun. – Disabling glare can block vision because the intense light can
cause significantly reduced contrast of the retinal image. g y g– The latent effects can last well beyond the time of exposure.– It can occur by light scattering from IOL edge, glistenings or
calcificationscalcifications.
1029
• Blinding or reflected glare– This comes from light reflected off smooth, shiny g , y
surfaces such as water, sand or snow. – It can be strong enough to block vision.
Reflected light is polarized and requires polarized– Reflected light is polarized and requires polarized lenses to reduce it optimally.
1030
All being measured to make anAll being measured to make an…
Eye of the Thief
Eye of the Eagle1031
Another Pre-LASIK examinationAnother Pre LASIK examination• Understand the Cornea Measuring the biomechanical g
properties of the cornea • Is to quantify various corneal conditions by means of a
measurable and repeatable metric.measurable and repeatable metric. • Low Corneal Hysteresis (CH) demonstrates that the
cornea is less capable of absorbing (damping) the energy of the air pulseenergy of the air pulse.
• The differences in CH between normal and compromised corneas are highly evident, and lead some
t t th i th t l hibitiexperts to theorize that normal eyes exhibiting significantly lower than average CH may be at risk of developing corneal disorders in the future.
1032
How does it work?How does it work?
• The Ocular Response Analyzer utilizes a rapid air impulse, and an advanced electro-optical
d l isystem to record two applanation pressure measurements; one while the cornea is moving inward and the other as the cornea returnsinward, and the other as the cornea returns.
• Due to its biomechanical properties, the cornea resists the dynamic air puff causing delays in the inward and outward applanation events, resulting in two different pressure values
1033
How does it work?How does it work?• The average of these two pressure values g p
provides a repeatable, Goldmann-correlated IOP measurement (IOPG). Th diff b h• The difference between these two pressure values is Corneal Hysteresis (CH); a new measurement of corneal tissue properties that ismeasurement of corneal tissue properties that is a result of viscous damping in the corneal tissue.
• The ability to measure this effect is the key to understanding the biomechanical properties of the cornea.
1034
How does it work?How does it work?
Ocular Response Analyzer (Reichert)Analyzer (Reichert)
1035
How does it work?How does it work?
• The CH measurement also provides a basis forThe CH measurement also provides a basis for two additional new parameters: Corneal-Compensated Intraocular Pressure (IOPCC) and Corneal Resistance Factor (CRF). IOPCC is an Intraocular Pressure measurement that is less
ff t d b l ti th thaffected by corneal properties than other methods of tonometry, such as Goldmann (GAT) CRF appears to be an indicator of the(GAT). CRF appears to be an indicator of the overall “resistance” of the cornea
1036
Standard vs Customized LASIKStandard vs Customized LASIK
STANDARD CUSTOMIZED
• No data necessary• Correct defocus only
• Use aberration data• Correct both defocus y
(Sphere & Astigmatism)• Contrast sensitivity (-)
and High order aberrationy ( )
• Contrast sensitivity (++)
1037
Aberrometer ZywaveAberrometer Zywave
Complete Wavefront AnalysisComplete Wavefront AnalysisOrbScanOrbScan IIz IIz
Corneal architectureCorneal architecture
Zylink Zylink Generation of optimized Laser Generation of optimized Laser
TreatmentTreatmentLaser SystemLaser System
1038
Eye registrationThe integrated procedure
• Ease of Use: Fully automated imaging with online data quality check
WASCA WASCA MEL 80WASCAWavefrontAcquisition
WASCAReference
Image
MEL 80SurgicalImage 1039
MicrokeratomesMicrokeratomes
• Hansatome (Bausch & Lomb) • Moria Evolution 3E (Moria)
G b SL (G b M di i )• Gebauer SL (Gebauer Medizin)• Zyopic XP (Bausch & Lomb)• ML7 (Med Logics Inc)• ML7 (Med-Logics, Inc)• Amadeus II (AMO, Inc
Ziemer)
• Make ‘Hinged Flap’• Take 110 – 180 um
corneal thicknesscorneal thickness
1040
MicrokeratomeMicrokeratome
AnimationAnimation
1041
Some kind of older microkeratomes A Hansatome (Ba sch & Lomb)Some kind of older microkeratomes : A. Hansatome (Bausch & Lomb); B. LSK-one (Moria); C. Amadeus (Abbott Medical Optics); D. MK-2000 (Nidek)
1042
Hinged flapHinged flap
Animation 1043
Femtosecond Laser
• A femtosecond is one millionth of a• A femtosecond is one millionth of a nanosecond or 10-15 of a second and is a measurement used in laser technologya measurement used in laser technology
• Procedure of laser corneal flap making– Increased accuracy and predictability for
corneal flap thickness– Faster – Better visual outcomes
1044
Femtosecond Laser• Range of uses
– Flap creation • IntraLase FS (Abbott Medical Optics)IntraLase FS (Abbott Medical Optics)• CUSTOMFLAP TECHNOLAS (Perfect Vision) • FEMTO LDV CrystalLine(Ziemer)• VisuMax (Carl Zeiss Meditec AG)• WaveLight FS200 (Alcon Inc)g ( )
– Presbyopia surgery INTRACOR TECHNOLAS (Perfect Vision) – CUSTOMSHAPE TECHNOLAS (Perfect Vision)
• Astigmatic Keratotomy (AK)• Astigmatic Keratotomy (AK)• Limbal Relaxing Incisions (LRIs)• Penetrating and Lamellar Keratoplasty (PK/LK)• Endothelial Keratoplasty (FL-EK) • Intrastromal segment insertion ring implantation (ICRS)• Intrastromal segment insertion ring implantation (ICRS)• Cross-linking
– Even for glaucoma patient and Cataract surgery
1045
Femtosecond LaserFemtosecond Laser
• Pulse of energy– Low Less than 1 µJ– High 1 µJ and above
• Pulse of frequency– Low Bellow 80 kHzLow Bellow 80 kHz– High Above 100 kHz
1046
Femtosecond LaserFemtosecond Laser
• High pulse energy and Low pulse• High pulse energy and Low pulse frequency
IntraLase FS (Abbott Medical Optics)– IntraLase FS (Abbott Medical Optics)– TECHNOLAS (Perfect Vision)
• Low pulse energy and High pulse frequencyq y– FEMTO LDV CrystalLine(Ziemer)– VisuMax (Carl Zeiss Meditec AG)su a (Ca e ss ed tec G)
1047
Femtosecond : The IntraLase FS The IntraLase laser produces tiny bubbles to be able to lift up the surface of the cornea
The ability to precisely place the bubbles up to the edge of cornea enables an exactcornea enables an exact preparation of the flap
The corneal flap isThe corneal flap is opened up in order to treat the deeper layers fof cornea
EuroEyes, 2008 1048
Another “Flaps”Another Flaps
• Hinged Flap – Lasik– Epi-Lasik Epi-K (Moria)– SBK One Use-Plus SBK (Moria)
• Smaller flap diameter 8 5 mm• Smaller flap diameter 8.5 mm• 100-115 microns flap thickness• 50% fewer fibers being cut than a 150 microns flap
• Epithelial Scrubber PRKAmoils Epithelial Scrubber– Amoils Epithelial Scrubber
1049
Eyetracker
1050
Decentered ablations : Causes
• Saccadic eye movements• Saccadic eye movements• Improper head alignment• Cyclotorsion• Pupil shiftp• Centroid shift• Eye rolling• Eye rolling• Technical misalignment of the laser beam
1051
CyclotorsionCyclotorsion
Diagnostic Treatment
1052
CyclotorsionCyclotorsion
• Eye rotates 3.7° + 2.3°y• Some until 9.1°• 60% counter clockwise• 60% counter-clockwise• 40% clockwise
1053
CyclotorsionCyclotorsion
• Iris Recognition• Iris Registration • Eye-Tracker• Eye-Tracker• Dynamic Rotational Eye-Tracker (DRET)
1054
JUST FOR YOU AND SAFETYJUST FOR YOU AND SAFETY
i fi iIris structure finger print
S f•Safe•Compensate pupil center shift & cyclotorsion 1055
SAFETYSAFETY
• Adapted for medical use from military technology tili d f hi h l l it t lutilized for high level security control
1 out of 3,493..E24 or
1 t f 3 493 000 000 000 000 000 000 0001 out of 3.493.000.000.000.000.000.000.000
There are not more than 10.000.000.000 people or
20 000 000 000 th20.000.000.000 eyes on earth
1056
Eyetracker : Abilityy y• Not all eyetrackers are created equally.
The ne generation e etracker has a sampling rate• The new generation eyetracker has a sampling rate faster than 200 Hertz.
• The reason why this is so important is because your eye can twitch at a rate of 60 Hzcan twitch at a rate of 60 Hz.
• If the eye twitches faster or at the same speed as the eyetracker then the eyetracker may not be able to get the appropriate readings of the movement of the eyethe appropriate readings of the movement of the eye.
• In turn, the laser may not be able to place the right pulse of the laser in the appropriate section of the cornea because of the lack of informationbecause of the lack of information.
• What is also extremely important is the ability of the laser to react to the information being sent to it from the eyetrackereyetracker.
1057
Eyetracker : Ability• What is also extremely important is the ability of the laser
to react to the information being sent to it from the t k
y y
eyetracker. • The response time of the laser must be very fast to
ensure that each laser pulse is placed exactly on the appropriate part of the corneaappropriate part of the cornea.
• Even if the laser can sample the movement of the eye 1000 times but the laser reacts slowly to this information, the result is that the laser may be placing pulses onthe result is that the laser may be placing pulses on areas of the cornea based on old information.
• The best example of the relationship between the eyetracker and the laser is to try and imagine throwing aeyetracker and the laser is to try and imagine throwing a ball at a moving object that is going 200 miles an hour.
• Although we can see the moving object, our reflexes are too slow to adjust to the constant changes of the movingtoo slow to adjust to the constant changes of the moving object.
1058
Eyetracker : Ability• As a result, every time you throw the ball you are
Eyetracker : Ability, y y y
missing the moving object. Slow or older lasers work on the same principle. Al h h h k h• Although the eyetracker can see the eye moving, it is too slow to react and may miss the targeted area of the corneatargeted area of the cornea.
• Eyetracker with the ability to react between 4 to 8 ms optimizes the ability of each pulse being placed on the appropriate spot on the cornea reducing erroneous misplaced pulses of the laser more common on older laser technologylaser more common on older laser technology
1059
Laser ablation
1060
Laser ablationLaser ablation
• Extremely precise ablationse e y p ec se ab a o s• Disrupting molecular bonds• Vaporising material• Vaporising material• Without generating heat
1061
ArF Laser (Photoablation)
• Laser energy ArF = 6.0 eV• Tissue inter-molecular bond = 3.5 eV• Ablation Cut the bond
Laser 6.0 eV
3.5 eV
1062
0.25 um
1063
Energy distributionsEnergy distributions
Heterogen Homogen
1064
Beam Size and ProfileBeam Size and Profile• A small diameter laser beam or also known as spot p
size is very important for both accuracy and smoothness.
• An ideal beam size is approximately 1mm or less• An ideal beam size is approximately 1mm or less. • If the size of the laser beam is larger the result is that
the beam is too large to make fine adjustments throughout the cornea.
• Imagine filling a fishbowl with marbles compared to filling is with sand.filling is with sand.
• The marbles allow gaps while the sand contours and fills the fishbowl exactly.
1065
Beam Size and ProfileBeam Size and Profile
1 mm vs 2 mm
1066
Laser Beam ProfileLaser Beam Profile• Gaussian BeamGaussian Beam• Flat Top
T t d G i B• Truncated Gaussian Beam
1067
Gaussian Beam• Energy not well homogene distributed
Hi h t l• Higher energy on central • Lower energy on peripheral
Energy
Ablation ThresholdHeat sensation
1068
Gaussian Beam• Advantage : Smoother ablation profile• Disadvantage : Heat sensation
Energy
Ablation threshold
Absorbed as heat
1069
1070
Flat Top Beamp• Homogen energy distribution• No heat• Less smooth ablation profile
Energy
Ablation threshold
1071
Truncated Gaussian Beam
• Bausch & Lomb Combine all benefits of Gaussian Beam + Flat Top Beam
• Smooth ablation surface• No heat no residual energy• No heat, no residual energy
Energy
Ablation threshold
1072
Gaussian Beam Flat Top Beam
Truncated Gaussian Beamu c ed G uss e
1073
Laser treatmentLaser treatment• WaveLight EX500 (Alcon Inc) • VISX Star S4 IR Advanced CostumVue (Abbott
Medical Optics)• MEL 80 and MEL 90 (Carl Zeiss Meditec)• MEL 80 and MEL 90 (Carl-Zeiss Meditec)• TECHNOLAS Perfect Vision
– SUPRACOR is a new corneal approach to treating pp gpresbyopia with TECHNOLAS Excimer Workstation 217P
• Z LASIK (Ziemer)( )• Pulzar ZI (CustomVisc)• LaserSoft (Katana Technologies)• Schwind Amaris (Schwind Eye-Tech)
1074
Laser treatmentLaser treatment
Animation
1075
Ri d Fl l iRinse and Flap closing
AnimationAnimation
1076
Special Laser Vision CorrectionSpecial Laser Vision Correction• Reduce aberrations• Improve contras sensitivity
– Scotopic – Intermediate Mesopic– Photopic
• Improve reading speed• Improve the ability to special task force p y p
Astronauts and Fighter-Pilots– NASA, US Navy Aviation and US Air Force– Using :
• iDesign Advanced WaveScan (Abbott Medical Optics) • 5th Generation Femtosecond IntraLase FS
iFS Advanced Femtosecond Laser (Abbott Medical Optics) 10 seconds only
• VISX Advanced CustomVue Technology (Abbott Medical Optics)
1077
Once more : LasikOnce more : Lasik
1078
Flap & Stromal Thickness Analysis
1079
Presby LASIKy
• Monovision LASIK• Monovision LASIK • Pseudo-accommodative cornea
PAC Nidek EC 5000 Excimer Laser (Nidek Co Ltd)PAC Nidek EC 5000 Excimer Laser (Nidek Co Ltd)• Aspheric-multifocal cornea
VISX CustomVue STAR S4 IR Aspheric (AbbottVISX CustomVue STAR S4 IR Aspheric (Abbott Medical Optics)
• Lens Femtosecond laser treatment 100 i thi k th t d t 2 3microns thickness that corresponds to 2-3
Diopters INTRACOR (TECHNOLAS Perfect Vision)INTRACOR (TECHNOLAS Perfect Vision)
1080
Non LASIK Presby LaserNon LASIK Presby Laser
Illuminating LaserACEIlluminating LaserACE• Bladeless microsurgical procedures• Ablate scleral tissue Restoring Eye’s natural• Ablate scleral tissue Restoring Eye s natural
accommodative ability• VisioLite Er:YAG Ophthalmic laser system• VisioLite Er:YAG Ophthalmic laser system
LaserACE (ACE Vision Group, USA)• Laser ablations made in 3 Scleral critical zonesLaser ablations made in 3 Scleral critical zones
EyeWorld, June 2008 1081
Laser : Miscellaneous Application
• Femtosecond laser assisted Descemet stripping
Laser : Miscellaneous Application
• Femtosecond laser assisted Descemet stripping Endothelial keratoplasty (FS-DSEK)
• Laser suturolysisLaser suturolysis• Bleb remodeling• GoniopunctureGo opu ctu e• Laser in DCR• Lids Trichiasis and Punctal occlussionLids, Trichiasis and Punctal occlussion
1082
Laser : Miscellaneous ApplicationLaser : Miscellaneous Application
• Deep sclerotomy• Anterior hyaloidotomyAnterior hyaloidotomy• Persistent pupilary membrane
removalremoval• Lysis of vitreous strand
1083
Laser PhacoemulsificationLaser Phacoemulsification• 2940 nm Erbium:YAG Laser
– Erbium:YAG Phacolase (Carl Zeiss Meditec AG)Erbium:YAG Phacolase (Carl Zeiss Meditec AG)• Neodymium:YAG Laser
– Neodymium:YAG Photon Laser PhacoLysis System (Paradigm Medical)Medical)
– Dodick Q-Switched Neodymium:YAG laser (ARC GmbH)• Femtosecond Laser
Vi t (TECHNOLAS P f t Vi i )– Victus (TECHNOLAS Perfect Vision)– Alcon LenSx (Alcon Inc) Rhexis, Incision, Nuclear
fragmentation, Limbal Relaxing Incision (LRI)L AR– LensAR
– Catalys (OptiMedica)– Femto LDV Z Models (Ziemer-S)*
Kohnen T, Koch DD, 2005; Auffarth G, 2010; EyeWorld 2010; Salz JJ, 20101084
Laser Phacoemulsification
1085
AcknowledgementAcknowledgement• All My Teachers in Department of Ophthalmology,
Airlangga University, Medical School, 1913• All My Friends in Laser and Advanced Eye Care Team of
Sumatera Eye CenterSumatera Eye Center• All My Teachers from IOA/Perdami, InaSCRS, ESCRS,
Euretina, APAO, APACRS, ASCRS, EuCornea, AAO, IIRSI, ICO, AIOS, Cicendo Eye Hospital Bandung, Jakarta Eye Center, SN Feodorov MSC Moscow, Yale Eye Center and Yale School of Medicine, BeijingEye Center and Yale School of Medicine, Beijing Tongren Hospital, Mitsui Hospital Tokyo, and Singapore National Eye Center
1086
And also special thanks to• Alcon, Inc• Bausch & Lomb Incorporated and TECHNOLAS• Abbott Medical Optics• Carl Zeiss Meditec AG
H id lb E i i• Heidelberg Engineering• OCULUS Optikgeräte GmbH• Haag Streit• Haag Streit• Ziemer• Allergang
© May 20, 2008 – 2014See also: gedepardianto blogspot comSee also: gedepardianto.blogspot.comAny suggestions : [email protected]
1087
Main references• American Academy of Ophthalmology, Basic and Clinical
Science Course • Kanski JJ Clinical Ophthalmology• Kanski JJ, Clinical Ophthalmology• Deborah Pavan-Langston, Manual of Ocular Diagnosis and
Therapy• Will’s Eye Manualy• Vaughan DG, General Ophthalmology• Kohnen T, Koch DD, Cataract and Refractive Surgery• Journal of Cataract and Refractive Surgery, Ophthalmology, g y, p gy,
American Journal of Ophthalmology, British Journal of Ophthalmology, Clinical Ophthalmology
• ESCRS, EUROTIMESASCRS E W ld USA• ASCRS, EyeWorld USA
• APACRS, EyeWorld Asia-Pacific• Retina Today• Retina Physician• Retina Physician
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Support TeamSupport Team
• Sight for a Lifetime.TM
B i h t th li ht TM• Bring hope to the light.TM
• ACT-G.TM
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Sail across Pacific Ocean of the 150 years of Gold Rush in California USA 1999
© 2008-2014. 100 tahun Kebangkitan Nasional…
California ,USA, 1999
KRI Dewaruci : Duta antar bangsa dan lambang kejayaan bangsa bahari