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


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


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


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


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


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


Follicle and Papillap

Area to be examined

FolliclesFollicles

Papillae

97

Follicle and Papillap

Papilla

FollicleFollicle


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


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


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


• Descemet membrane


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



• Endothelium


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


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


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

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


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


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


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


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


• 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


• 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


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


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


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


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


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)( )


Refraction• Hypermetropia (Farsightedness)

– Structural • Axial, Curvature, Index of refraction

– AccommodativeAccommodative• Latent, manifest, total

– Severity

Uncorrected can causes• Strabismus Esotropia• Ambliopia


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


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


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.


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)


Finding the cylinder axisg y



148


150American 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.


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.


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.


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.


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


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


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


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


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


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


Toric lenses


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


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


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


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

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


CyberSight, 2003

215

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


Cardinal position and Yoke musclesCardinal position and Yoke muscles

RSRLIO

LSRRIO

RLRLMR

LLRRMRRight Gaze Left Gaze

RIR LIRRIRLSO RSO


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


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


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


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


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


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 ∆


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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)


Strabismus : Sight testStrabismus : Sight test

• WFDTWFDT• Maddox’s rod

264

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


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


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


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


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

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


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


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


• 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


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


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


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

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


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


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


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


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


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


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


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

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


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


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


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


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


Viscoelastic : RheologyViscoelastic : Rheology

• Viscosity• Pseudo plasticity• Elasticity• Cohesion and Dispersion• RigidityRigidity


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)


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


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))


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


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


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


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


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


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


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


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


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


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


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


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


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



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


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


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


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


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


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


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


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


DR : CSMEDR : CSME


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


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


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


RPERPE• Destruction of RPE new growth• Increase transmission of metabolism• Increase Oxygen transmissionyg• Improve “pump”

Ong SG, 2009 646


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)


DR : LaserDR : Laser• Side effect and complication

– Paracentral scotomata– Transient increased edema decreased

vision– Choroidal Neovascularization (CNV)– Subretinal fibrosis– Scar expansionp– Inadvertent foveolar burns


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%)


DR: Vitrectomy IndicationsDR: Vitrectomy Indications


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


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


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


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


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


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


• 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


• (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


• (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


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


• 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


• 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


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


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


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


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


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


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


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


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


Intravitreal Steroids ( / 0 1 ml )Intravitreal Steroids ( / 0.1 ml )

• Dexamethasone 0.4 mg• Triamcinolone 4 mg


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


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



• 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



• Dislodge the emboliDislodge the emboli– Ocular massage

Nd:YAG laser embolectomy– Nd:YAG laser embolectomy


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


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


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

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


Stage 1


Stage 2Stage 2


Stage 3


Stage 4


Stage 5


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


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


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


NAION : EtiologyNAION : Etiology

• IdiopaticIdiopatic– Arteriosclerosis

Diabetes– Diabetes– Hypertension

Hyperhomocystinemia– Hyperhomocystinemia– Anemia

Sl i k f t– Sleep apnea risk factor– Relative nocturnal hypotension


NAION : Risk factors

• HypertensionH li id i• Hyperlipidemia

• Diabetes mellitus• Smoking• ObesityObesity


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


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


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


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


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


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


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


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


Mixed retinal vasculitisMixed retinal vasculitis

• CausesCauses– Multiple sclerosis

Behçet’s disease– Behçet s disease– Wegener’s granulomatosis


Non infectious uveitis: ApproachNon infectious uveitis: Approach

• ANTIMETABOLITESANTIMETABOLITES– Methotrexate (MTX)

Azathioprine (AZA)– Azathioprine (AZA)– Mycophentolate Mofetil (MMF)


Non infectious uveitis: Approachpp• BIOLOGIC RESPONSE MODIFIERS

– Adalimunab– Interferon 2a– Anakinra

ALKYLATING AGENTS• ALKYLATING AGENTS– Cyclophosphamide– Clorambucil– Mycophentolate Mofetil (MMF)


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


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


The orbit : RoofThe orbit : Roof

• Orbital plate of frontal boneL i f h id b• Lesser wing of sphenoid bone


The orbit : Medial wallThe orbit : Medial wall

• Frontal process of maxillaL i l b• Lacrimal bone

• Orbital plate of ethmoid• Lesser wing of sphenoid


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


The orbit : Floor

• Formed by

The orbit : Floor

Formed by– Maxillary

Palatine– Palatine– Orbital plate of zygomatic

• Very fragile to orbital blunt trauma


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


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


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


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


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


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


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


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


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


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


• 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


• 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


• Corneal involvement0 : Absent– 0 : Absent

– A : Punctate lesions– B : Ulceration– C : Necrosis or perforationp

Werner, 1963 856


• 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


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)


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


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


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


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



• 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



• 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



• 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


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


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


• Photodisruption Cutting by optical break down 10,000° K– Q-switched Frequency Doubled

Nd:YAG Laser

888


• Photodecomposition Carving C tti th l l b d Cutting the molecular bond

UV short wavelength– UV short wavelength– Excimer (Excited Dimmer) Laser

889


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

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


• 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


• 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


• 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


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

Zernike polynomialsZernike polynomials


LowerLower--order aberrationsorder aberrations

2nd


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)


Point Spread Function (PSF)Point Spread Function (PSF)

Normal eyeNormal eye Monocular DiplopiaMonocular Diplopia


Point Spread Function (PSF)Point Spread Function (PSF)


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


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


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


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


ConvolutionConvolution• Method to portray blur, using PSF in every point of p y , g y p

object to stimulate retinal image


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


Ocular Response Analyzer (Reichert)Analyzer (Reichert)

1035


• 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


• Eye rotates 3.7° + 2.3°y• Some until 9.1°• 60% counter clockwise• 60% counter-clockwise• 40% clockwise

1053


• 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

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

1088

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

1089

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