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OPHTHALMOLOGY MADE EASY DR VINEET SEHGAL MBBS MD (AIIMS) FELLOWSHIP IN GLAUCOMA INCHARGE GLAUCOMA SUBSPECIALITY SHARP SIGHT CENTRE EX CONSULTANT- MEDANTA MEDCITY ASSISTANT EDITOR- DJO NTSE SCHOLAR

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Embryology  Development starts from 3 weeks  Choroidal fissure is formed due to differential growth of optic vesicle.  If this choroidal fissure does not fuse it becomes typical colobomas

 Mesoderm forms the hyaline system of vessels  INFERONASAL COLOBOMA

NEURAL ECTODERM

NEURAL CREST

MESODERM

•RETINA •RPE •SPHINCTER & DILATOR PUPILLAE •POSTERIOR IRIS EPITHELIUM •CILIARY BODY EPITHELIUM •OPTIC NERVE

•CORNEAL ENDOTHELIUM •TRABECULAR MESHWORK •STROMA OF CORNEA, IRIS & CILIARY BODY •CHOROID AND SCLERA •CONNECTIVE TISSUE •SMOOTH MUSCLE CELLS •SECONDARY VITREOUS •ZONULES

•Muscle & vascular endothelium •EOM •CILLIARY MUSCLES

SURFACE ECTODERM •CORNEAL & LACRIMAL EPITHELIUM •LENS •LACRIMAL GLAND •EYELID STRUCTURES

KERATOCONUS SIGNS IN KERATOCONUS • Munson Sign • Enlarged corneal nerves • Oil droplet reflex (DDO) • Rizutti Sign • Fleischer ring (Epithelium) • Scissor reflex on retinoscopy • On keratometry - Steep cornea - Bow tie pattern - Paracentral thinning of cornea Rizutti sign seen in keratoconus

Acquired condition- VKC has high association.

SURGERIES - Collagen cross linking - Corneal transplant - ALTK or DALK

LENSES - Rigid Gas Permeable - Rose K lenses - Soper lenses

INTACS Intracorneal ring segments used to reduce corneal steepening, made of PMMA. • Used in Pellucid Marginal Degeneration, post LASIK ectasia and keratoconus.

ANTERIOR SEGMENT DYSGENESIS SYNDROME

Peters anomaly •Histopathologically, Endothelium & Descement”s is absent. •There is central or paracentral corneal opacity. • Peter 1 is without corneolenticular touch. Peter 2 has corneolenticular touch. • Peter 2 having more systemic associations than Peter 1. •Peter plus syndrome has many systemic malformations with it like, short stature, hearing defect, CVS malformations etc. PAX 6 gene associated with it

Pterygium is a type of connective tissue degeneration. (Q) • Probe test done to distinguish between pterygium & pseudopterygium, • In pseudopterygium it can , but not in pterygium. (AIIMS) • Stockers line is an evidence of iron deposition in pterygium. •KP ‘s are seen on endothelium.

Crescent-shaped ulceration with an overhanging central edge & vascularized base is seen temporally. It by definition should NOT BE ASSOCIATED WITH ANY SYSTEMIC DISEASE and scleritis. PERIPHERAL ULCERATIVE KERATITIS.....

Granular Dystrophy

•B/L Small, discrete, sharply demarcated, grayish-white opacities, •DROP, CRUMB, RING shaped. •Initially stroma is clear between lesion with periphery remain free.

Macular Dystrophy

• Initially by central ground glass haze superficially & small, multiple,gray-white, pleomorphic opacities. In later stages stroma is diffusely involved, gray appearance of DESCEMET’s with rominent surface irregularities. • Full thickness •involves corneal periphery

Lattice Dystrophy Apple green birefringence is seen in the lattice dystrophy due to amyloid deposition.

Cogan Map Print epithelial basement membrane dystrophy

Recurrent epithelial corneal erosions are the characteristic. Most common corneal dystrophy.

AdenoVIRUS may be a bit slow in presentation. Normally it affects cornea also, have tiny white spots

WILSON DISEASE – - KF ring is formed due to copper deposition in Descemet's membrane - It is reversible ring. On treatment, it can disappear - Sunflower Cataract

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ASPERGILLUS COLONIES

SPHEROIDAL DEGENERATION

SUBCONJUNCTIVAL HEMORRHAGE

SPECULAR MICROSCOPY • Endothelial cell count done by specular microscopy. • Based on the principle of specular reflection of light where angle of reflection is equal to angle of incidence. •Endothelium is usually made up of hexagonal, regular cells which are uniform in shape.

ANKYLOBLEPHARON / SYMBLEPHARON •Fusion of palpebral & bulbar conjunctiva symblepharon. •Fusion of upper and lower palpbral conjunctiva ankyloblepharon.

VERNAL KERATOCONJUNCTIVITIS Antibiotics does not have any prominent role. Steroids- Fluorometholone & loteprednolol topical. - DOC-Antihistaminics with Dual action (Antihistaminics+Mast) cell stabilizersOlopatadine

Other Drugs - Sodium Cromoglycate, Ketotifen & Epinastine. - Refractory VKC-Cyclosporine (Topical), Tacrolimus d. acetyl cysteine 0.5% - SIGNS- Maxwell-Lyon sign, Horner Trantas Spots

LASIK • Principle: Flatten or steepen the Curvature of cornea & Change refractive power Types -Myopic -Hyperopic both. • Indication age > 18 yr, no viral keratitis, stability of power of spectacles for at least six months, no lattice with hole, adequate thickness of cornea, CCT > 490 for I LASIK & 530 micrometer for conventional LASIK. (PGI TYPE) • LASIK can't be done safely for > 10 D. • Severe dryness, schirmer < 5 mm is also a contraindication. Pregancy & lactation relative contraindications • Corneal ectatic condition like keratoconus, pellucid marginal degeneration are contraindications of doing LASIK. There is no upper limit of age. •corneal transplant is not an absolute contraindication for LASIK. Note PRK is photorefractive keratectomy. That's not typical LASIK. That is superficial ablation done, followed by laser application of laser

• SMILE- is small incision lenticular extraction, I lasik is bladeless lasik.

(Both I LASIK and SMILE use femtolaser) • Pentacam: Now the investigative modality of choice to do any corneal topography, it may be keratoconus, ectasia, LASIK.

• Conventional LASIK is microkeratome based that uses blade and excimer (193 micrometer) laser

•ARLTS LINE IN TRACHOMA

HERPES ZOSTER OPHTHALMICUS, Single dermatome involvement is there , so always unilateral

HERBERT’S PITS

Can u see the opacified encirclation ring near limbus. Close differential is arcus senilis that has clear space between limbus and cornea

Band shaped keratopathy Calcium deposition in band shaped pattern. Most common cause of BSK is post vitrectomized eye with Silicon oil in situ

PANNUS

Can you see angry vessels on the cornea. It can be seen IN pterygium also but the fleshy component would be much more than the vascular component

OPTICAL COHERENCE TOMOGRAPHY MEASURES Retinal Nerve Fibre Layer Contour, Both macula and optic nerve head can be evaluated

LID TARSORRAPHY

HORNER TRANTAS SPOTS

DENDRITIC ULCER: Seen in Herpes Simplex Virus, Pseudodendrites can be seen in the other modules like HZV and acanthamoeba too

RING OF WESSLEY - Acanthamoeba Keratitis - Fungal corneal Ulcer

RETINA – ANATOMY & PHYSIOLOGY Area of Macula - 5.5 mm Fovea - 1.5 mm Foveola 0.35 mm. (Thinnest part of retina. No ganglion cells, only cones) Signal transduction process is same in rods & cones though there number, color & intensity at which it excites differ. (AIIMS Q) Rods function – main fx in vision in dim light. Cones main fxn is color vision- blue, green & Red Peak absorption at 500 nm, 120 million rods in retina, contrast to only 6.5 million cones (may be imp in NEET & DNB) Contains Rhodopsin pigment – OPSIN + RETINAL (Chromophore of VIT A Retinaldehyde) No rods at foveola, max 20 deg of foveola, in contrast to cones that has highest concentration at foveola

Cotton wool spots are present in nerve fibre layer.  It is seen more commonly in hypertensive retinopathy  Soft exudates or Cotton wool spots are small yellowish type,

irregular margins, due to axonal debris.  Its due to axonal transport blockage. •

Retinal Detachment (RD) •RD is separation of neurosensory retina from retinal pigment epithelium •RPE is the 1st layer of retina that contains single layer of cells attached to bruch’s memberane of choroid. (imp in wet ARMD) •On retinoscopy there is Grey Reflex •Curtain falling over eyes & Flashes are typical presentations of RD. Floaters can appear in both RD, pars planitis, CRVO & Vitreous Hemorrhage. (VH) •In Chronic RD, important signs are - Watershed lines(q) - Proliferative vitreo-retinopathy - Retinal Cyst

PNEUMATIC RETINOPEXY JIPMER •Air is also used for tamponade in pneumatic retinopexy. •Basically these gases provide tamponade for retinal detachment surgery. •Air is shortest acting, SF 6 is long acting and C3F8 is longest acting.

•Exudative retinal detachment occurs in toxemia of pregnancy.

• MC cause of Exudative RD- Malignant Melanoma • Pilocarpine drug is associated with RD. So should be used with caution in high myopics with glaucoma. • Lattices (q), Retinal tears, High myopics(q), trauma are known risk factors • Shaffer sign - Pigments floating in anterior vitreous, sign of retinal tear, that can lead to RD. • Know the difference between tear and a hole: With tear

there is a traction that is not there in a hole.

RETINOPATHY OF PREMATURITY: (ROP)

ROP GUIDELINES: @ WHICH BABIES TO BE SCREENED GUIDELINES: - Less than 1500gm - Less than 32 weeks -Pediatrician feels the necessity looking at the baby’s condition ,like mechanical ventilation, sepsis, prolonged oxygen therapy & hemodynamic instability

When to screen: its four week after birth or at thirty one weeks whichever is later •If the patient is LASERED ROP, then we have to follow him long. •If patient has ROP, but its initial stage, then we can follow up till 40 weeks or when there is no

progression or change in three successive visits. •If there is no ROP till 36 weeks, u can be safe.

ROP REQUIRING TREATMENT

•Zone I, any stage ROP with plus disease or •Zone I, stage 3, with or without plus disease •Zone II, stage 2 or 3 ROP, with plus disease NOT TO TREAT · Zone I, stage 1 or 2 with no plus disease or · Zone II, stage 3 with no plus disease

NON PROLIFERATIVE DIABETIC RETINOPATHY WITH CLINICALLY SIGNIFICANT MACULAR EDEMA DIABETIC RETINOPATHY INVOLVES WHOLE OF FUNDUS. CAN U SEE EXUDATES ALL OVER THE FUNDUS , ALSO SMALL HEMORRHAGES AND MICROANEURYSMS, ALSO ONE IMPORTANT THING TO NOTICE IS SOME YELLOWISH DOTS NEAR MACULA , SO OUR DIAGNOSIS IS CSME

Central Serous Retinopathy (CSR) A type of choroidoretinopathy, due to excessive leakage from choriocapillaries CLINICAL SCENARIO (AIIMS/USMLE): Young anxious male coming to OPD with chief complaints of central scotoma/blurred vision acute onset and says this happens quite often to him but resolves itself in few months.

Ink blot appearance (more common) & Honeycomb appearance is seen in CSR on FA. Also note CSR have •Central scotoma @ •Type A personalities, males, it is more common •Ask e of Steroids from patient • Hyperopic shift Mx - Wait and observe - LASER the leaky areas - PDT experimentally used

MICROBIOLOGY OF RETINA • SYPHILLIS- salt and pepper retinopathy with extensive chorioretinal scarring. • Leprosy affects cooler parts of the body. It affects all parts of eye. Retina is very rarely involved and that two few here and there nodules.

• In tuberculosis, there are creamy coin shaped nodules in fundus. • Toxoplasma has excavated scar in fundus, macula is its favorite site for toxoplasma. Also headlight in fog appearance • CMV Retinitis- Pizza Pie appearance

HEADLIGHT IN FOG APPEARANCE

TOXOPLASMA SCARHealed Toxoplasma

FROSTED BRANCH ANGITIS CMV Retinitis The florid translucent perivascular exudate is called 'frosted branch angiitis'

Fundus Photo of Sarcoidosis • Candle wax drippings- see exudates in fundus, & near blood vessels, note these are just yellow lesions & these are not hard exudates as those are more distinct margines. These are characteristic findings of sarcoidosis

Placoid disc lesions in TB. Diffferentiate it from sarcoidosis lesions where it is more exudates around the vessels

BERLINS EDEMA WITH CHERRY RED SPOT- Red spot in midst of a pale retina ( c.f Bull’s eye retinopathy, where the red glow of fundus is maintained)

CLINICAL SCENARIOS: Iritis with t pain – Ankylosing spondylitis. other Associations: Reiter & Psoariasis Most common cause of arthritis involved with anterior uveitis- Ankylosing Spondylitis

Heterochromic uveitis involve anterior part of uveitis. Fuchs heterochromic iridocyclitis (FHI) is a chronic, unilateral iridocyclitis characterized by iris heterochromia. Don’t have posterior synechia.

• Koeppe nodules are small nodules in inner margin of iris. • Busaca nodules are seen in mid periphery • Lisch Nodules of NF • Brushfield spots in Downs Syndrome

Koeppe’s Nodules- On the

LISCH NODULES

margin of iris

BUSACA NODULE

Traumatic macular hole looks like Cherry Red spot. But its not red. More of hyperpigmentation than redness.

Stem cells trial has been done for macular hole closure

GYRATE ATROPHY

Arginine free diet is given.  It's deficiency of ornithine aminotransferase in gyrate atrophy.

Vit B 6 is also given.

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•Neovascular glaucoma occurs when there is abnormal proliferation as in DM, CRVO or OIS, in open angle glaucoma there is no abnormal proliferation normally.

•CRVO induced glaucoma called 90 day glaucoma.

BRANCH RETINAL VEIN OCCLUSION, CAN U SEE ONLY INFERIOR PART IS AFFECTED

INDOCYANIN GREEN ANGIOGRAPHY(ICG) @ Agiography technique to diagnose choroidopathies

NEW ADVANCEMENT: Argus 2 retinal implants RP

like occult ARMD, CSR, polypoidal choroidopathy. In ICG- the optic nerve head is shown hypofluorescent. It is hyperfluorescent on FA.

Imdocyanin Green

Fluorescein Angiography

Roths spot•Seen in bacterial endocarditis. Roth's spots are retinal hemorrhages with white or pale centers. •They can be composed of coagulated fibrin including platelets, focal ischemia, inflammatory infiltrate, infectious organisms, or neoplastic cells. • Caused by immune complex mediated vasculitis often resulting from bacterial endocarditis. •Roth's spots may be observed in leukemia, diabetes, subacute bacterial endocarditis, pernicious anemia, ischemic events, hypertensive retinopathy and rarely in HIV retinopathy.

•Usually they don’t contain BACTERIAS

COATS DISEASE

Can u see variety of exudates, some yellow, some whitish, some confluent. These are characterastic of ongoing leakage. Its not diabetic retinopathy as you cant see hemorrhages. Compare it with the photo of diabetes I have given, this is COATS DISEASE fundus photo. Features are -1st decade of life - Telengiectasia - Characterisitic exudates all along vessels - Leukocoria

BEST VITELLIFORM DYSTROPHY •Vitelliform dystrophy, or Best disease, is hereditary retinal dystrophy involving RPE and leads yellow egg yolk appearance of the macula. It present itself in childhood or early adulthood.

•EOG is characteristically decreased

CILIARY STAPHYLOMA • • • •

MYOPIA TRAUMA SURGERY UVEITIS

RETINITIS PIGMENTOSA  Centrocecal scotoma diagnostic of RP.  X linked most severe.  Bigenic inheritance pattern  Most common inheritance pattern Autosomal

Recessive.  Abetalipoproteinemia, or Bassen-Kornzweig syndrome, AR rdisorder that interferes with the normal absorption of fat and fat-soluble vitamins.  NARP – neuropathy, Ataxia and RP, ( Abetalipoproteinemia, refsum disease are known associations.)  Bardet–Biedl syndrome (It is characterized by obesity, polydactyly, RP, hypogonadism, and renal failure in some cases.

 High Dose VITAMIN A & ARGUS RETINAL IMPLANTS

•PHPV associated with microphthalmos.

Post operative endophthalmitis •Delayed: MC cause- Propionobacterium acnes •MC in total- Coagulase neg Staphylococci •MC-Post traumatic- Bacillus Cereus •MC fungal infection in eye in HIV - Candida

INVERSE HYPOPYON- SILICON OIL IN AC

• Tamoxifen & Travoprost is implicated in causation of macular edema. • FA PICTURE OF CYSTOID MACULAR EDEMA

How to solve Fundus Based Questions Now when u see a fundus, see the Optic nerve head and Macula first. See any lesion or change in these two areas, and collaborate with options given these three Colors:

• Yellow • Black • Red See the fundus and identify these three colours in disc and macula first, then in other areas in the retina. Collaborate with the options given. Mostly the answer correspond to the most prominent of these colors

Bull’s Eye Maculopathy Foveal area is hyperpigmented, followed by the hypopigmented macular area. Like an eye, this is called Bull’s eye maculopathy. Please don’t confuse it with the Cherry Red Spot of the CRAO. That has pale fundus surrounding it

HOLLENHORST PLAQUE CAN U SEE WHITE PLAQUE IN SUPERIOR VESSEL). This question was asked recently

MORNING GLORY SYNDROME Blood vessels radiating like spikes from the optic nerve head. This is not a glaucomatous disc. Glaucomatous disc have more of cupping and yellowish pale disc, with nasalization of vessels

Dark Adaptation Curve of Both Rods & Cones

ANGIOID STREAKS These can be precursor of Choroidal Neovascular Membrane in some cases.

DISC EDEMA NOTE: PAPPILEDEMA IS BILATERAL, MAY BE ASSYMETRICAL, OPTIC NEURITIS CAN BE UNILATERAL. ITS SUDDEN PAINLESS LOSS OF VISION

SEA FAN NEOVASCULARIZATION

SEEN IN SICKLE CELL ANEMIA, less commonly seen in Diabetic Retinopathy, CRVO, Ocular Ischemic Syndrome

DRY ARMD

WET ARMD

Can u see yellowish drusens near the macular area. These are typical of ARMD. A wet armd would have red areas. A diabetic retinopathy would have yellowish exudates, red spots all over. In ARMD our lesions are basically in macular areas

GLAUCOMA MADE EASY Definition: • Chronic optic neuropathy • High IOP as one of the most preventable risk factor • Characteristic visual field defect.

   

• 1-1.2 MILLION NEURONS • Average dimensions of 1.76mm horizontally by 1.92mm vertically • DEVELOPS FROM THE OPTIC STALK

TM outflow is 90-95%,Uveoscleral 10 % AQUEOUS OUTFLOW 2.7 MICROLITRE/MINUTE AH produced by non pigmented ciliary epithelium Trabecular meshwork outflow is pressure dependent , Uveoscleral outflow is pressure independent.  High concentration of pyruvate, lactate & ascorbate & low concentration of protein, urea, & glucose in aqueous humor 🔸 Protein in aqueous humor is less than blood.

Goldmann Applanation Tonometry Gold Standard and the Ix of choice to measure IOP.

Tonopen- based on Mackay marg principle, used for determining iop in scarred cornea

REBOUND TONOMETER

• Mackay marg tonometer is suited for irregular corneasIt is better suited for scarred and irregular corneas • Malkalov tonometer - Principle of fixed force and variable area. Same is case of Halberg tonometer. • Drager & Perkins are type of Goldman that can be used without slit lamp.

GLAUCOMA PROCEDURES • All glaucoma procedures are done in dark room • Peripheral iridectomy, trabeculoplasty, trabeculectomy is done in

GONIOSCOPE- VISAULIZATION OF ANGLE 

DIRECT GONIOSCOPE: Koeppe



INDIRECT GONIOSCOPE: Zeiss, Goldman, Sussman.

constricted pupil

RING SOCTOMA

AION: ALTITUDNAL FIELD DEFECTS

SEEN IN RETINITIS PIGMENTOSA •Earliest field defect in glaucoma is isopter contraction followed by baring of blind spot

Glaucoma drainage implants that have been used extensively, include •Non-restrictive/valved glaucoma drainage devices •Molteno implant •Baerveldt implant •Schocket tube shunt •Valved, restrictive drainage devices •Krupin Denver Valve •Ahmed Glaucoma Valve – Silicone polymer

EXPRESS SHUNT

Indications - Failed Pk - NVG - Uveitic Glaucoma - Aphakic Glaucoma AHMAD GLAUCOMA VALVE

PSEUDOEXFOLIATION SYNDROME • Non dilating pupil • Exfoliative material on pupil

• Bulls eye sign on lens • Open angle that progress to closed angles • Weakened zonules

• LOX L1 GENE ASSOCIATED PEX syndrome: May be associated with amyloidosis or CVS ABN

• Bulls eye sign on lens

Pigmentory glaucoma

- Krukenbergs spindles - Transillumination defects in iris - Deep AC - Myopia - Inc in IOP post exercise - SLT RxOC

PRIMARY OPTIC ATROPHY

GLAUCOMATOUS OPTIC ATROPHY

Embryology - SURFACE ECTODERM

C LOOP IOL

ACIOL

MULTIFOCAL IOL

CRYSTALENS

FLEXER WINTERSTEINER LESIONS

CALCIFICATION IS THE DIAGNOSTIC FEATURE. IxOC is MRI HEAD & ORBIT WITH GALDOLINIUM CONTRAST

CHALAZION o lipogranulomatous inflammation. o Incision and curettage is done from conjunctival side o Horizontal incisions are avoided to minimize damage to meibomian ducts.

o Recurrent chalazion and blepharoconjunctivitis o Adenocarcinoma and seb cell carcinoma

MC cause of u/l proptosis in children: Orbital cellulitis MC cause of b/l proptosis in children: neuroblastoma MC cause of u/l proptosis in adults: thyroid

ophthalmopathy MC cause of b/l proptosis in children: thyroid HERTELS EXOPHTHALMOMETER

ophthalmopathy  Ethmoidal sinuses are most commonly involved in orbital cellulitis

Entropion

Goldenhar Syndrome with Limbal Dermoid

Sebaceous cell Carcinoma

Acute Dacryocystitis

Mitomycin-C has many uses in Ophthalmology- In trabeculectomy - In recurrent pterygium - in Ocular surface squamous neoplasia - In Refreactive surgeries

GLC3B on 1p36 and GLC3C on 14q24.3 are genes implicated in Congenital glaucoma

THYROID OPHTHALMOPATHY

LATTICE DEGENERATION POTENTIAL AREA OF WEAKNESS IN RETINA MOLLUSCUM CONTAGIOSUM: ITS NOT HERPES, LOOK THERE IS NO INFLAMMATION

Pin cushion effect seen in high power convex glasses.

Optical Coherence tomography- OCT Showing macula. It is called optical biopsy. Shows the layers of retina.

Kerrison bone punch Used to make osteotomies in DCR Surgery

SCHIRMER TEST Evaluation of Dryness - Less than 5 mm in 5 minutes indicate severe dryness

PSEUDOPHAKIC BULLOUS KERATOPATHY Its not viral keratitis, look at the scleral part, there is no inflammation at all. The PBK occurs post intraocular surgery, due to loss of endothelial cells. The treatment is DSAEK, that is descemnets stripping automated endothelial keratoplasty

OCULAR SURFACE SQUAMOUS NEOPLASIA

CAN U SEE VESSELS GROWING OVER THE MASS. THIS IS NOT PTERYGIUM. PTERYGIUM FIRST OF ALL DOES NOT HAVE THIS TYPE OF ELEVATED LESION, SECONDARILY THE VESSELS ARE NOT LIKE THIS ARBORIZING TYPE OF PATTERN

CAPPILARY HEMANGIOMA Port Wine Stain in Sturge weber syndrome Propanolol is the new modality that is being used for this lesion

ACUTE DACRYOCYSTITIS MANAGEMENTIS ANTIBIOTICS, DON’T DO SYRINGING AND PROBING IN THIS CHILD

MUNSON SIGN Bulging of lower lid in Keratoconus Don’t confuse it with the Mobius sign that is in thyroid ophthalmopathy that is loss of convergence

INCLUSION CYST

Most Common cyst of Conjunctiva

PLACIDO DISC KERATOSCOPE USED FOR MEASURING CURVATURE OF CORNEA

GONIOSCOPY IMAGE

Gonioscopy is the Investigative modality of choice to diagnose angle closure glaucoma

PANDA EYES/ RACOON EYES

BIOMEDICAL WASTE HAZARD

NON IONIZING RADIATTION

IONIZING RADIATION

IRIDODIALYSIS This is not coloboma, this is post-traumatic iridoialysis, iris is detached from its root

PERIPHERAL IRIDOTOMY Peripheral Iridotomy or Yag iridotomy is the procedure of choice in primary angle closure

SYNAPTOPHORE

V Important instrument, used in squint work up, diplopia charting, measuring interpupillary distance.

MADDOX ROD

It’s a misnomer. Its basically a lens that has been named as rod. Its principle is that it disassociates two eyes and manifests the squint

Essential Infantile Esotropia

HESS CHART- Showing the action of Extra-ocular Muscles

S SHAPED PTOSIS : PLEXIFORM NEUROFIBROMATOSIS

Marcus Gunn Jaw Winking Phenomenon Look that on opening the jaw the ptosis has improved, this is typically marcus jaw winking phenomenon due to misinnervation of nerve. Rx: Sling surgery has better results than LPS resection or Muller’s resection

BITOTS SPOTS

POLIOSIS- Greying of Eyelashes

Ultrasound B Scan Can you see this black and white image. It is Ultrasound of eye B – Brightness . Showing posterior segment of eye

CT Head & Orbit Showing blow out fracture