Unit One

Ophthalmology

By Dr.Nhial
Anatomy
Of The Eye
 Surface Anatomy
• Eyelids – the eyes are covered externally
with these movable folds that protect the
eye from injury & excessive light
• They swab the eyes and spread a film of
tears over the cornea, preventing
evaporation from the surface of the eye
• The upper lid extends to the eyebrow
which separates it from the forehead
• The lower lid passes without any line of
demarcation into the skin of the cheek
• The upper lid is more mobile of the two
• When it is open, it covers 1mm of the
cornea
• Levator palpebrae superioris – is the
muscle that elevates the lid
• It is always active, contracting to keep
the eye lid open
• During sleep the eyelid closes by
relaxation of this muscle
• The lower lid lies at the lower border of the
cornea when the eye is open, & it rises
slightly when it shuts
• Canthi – The triangular space visible on
either side of the cornea
• Formed by the junction of the upper & lower
lids
• Are denoted by the terms, medial (closer to
the nasal bridge) & lateral
• Palpebral fissure – the size of this
determines the portion of the eyeball visible
on external examination
• The shape of the fissure also determines the
appearance
• Medial fissure – There are two fleshy
mounds : the deeper one is called the plica
semilunaris
: the superficial one is called the
caruncle
• Caruncle – Is modified skin that contains oil &
sweat glands, occasionally it contains fine cilia
or hairs
• When the eyes are open, the palpebral fissures
measure about 30mm in width & 15mm in
height
• The largest oil-secreting glands are the
meibomian glands, which are embedded in
the posterior connective tissue substance of
the lids called the tarsus
• The lacrimal gland is located above and
lateral to the globe. Tears are produced here
& travel through fine channels referred to as
ducts, to empty onto the conjunctival surface
• Papllia is where the lashes cease, on the
medial aspect of the lower lid
• At the apex of this papilla is a tiny
opening called the punctum. By a small
canal, this leads to the lacrimal sac
which eventually drains into the nose
• Tears are carried to the punctum by the
pumping action of the lids
• The muscle underlying the eyelid skin is
the orbicularis oculi, which is roughly
circular.When contracted, it closes
• The portions of the eye that are normally visible
in the palpebral fissures are the cornea & sclera
• Because the cornea is transparent, on looking at
the cornea is the underlying iris & the black
opening in the centre of the iris called the pupil
• The sclera forms the white of the eye & is
covered by a mucous membrane called the
conjunctiva
• Bulbar conjunctiva – covers the eye
itself
• Palebral portion – is the portion that
lines the inner surface of the upper &
lower lids
• The junctional bay created when the 2
portions of conjunctiva meet is the
fornix
• The role is to defend & repair the cornea (in
the event of scratches, infections etc)
• The conjunctiva has almost invisible blood
vessels
• Those present dilate & leak nutrients,
antibodies & leucocytes into tears that wash
over the avascular corneal surface
• Also secretes oil & mucous to keep the
cornea moist & clean, & to reduce friction
when the eyelids blink
• Helps resurface the cornea with
epithelial cells ( if the entire surface has
been scraped or burned)
• Tenon’s capsule – is under the layer
under the conjunctiva & a fibrous layer
that overlies the sclera & the recti
muscles
• It is a common surgical landmark
 Tear Film
• Composed of 3 layers ;
- Outer lipid layer
- Aqueous layer
- Mucous layer
• The outermost layer is a lipid & fatty
layer
• It is extremely thin & acts to prevent
evaporation of the underlying aqueous
layer
• The central layer is chiefly aqueous
• Includes some dissolved salts, glucose, urea,
proteins & lysozyme
• The third layer is a very thin mucous layer lying
over the surface of the conjunctiva & cornea
• The layer is secreted by specific cells of the
conjunctiva called goblet cells
• This mucous layer is important in the stability
of the tear film
• The precorneal tear film layer serves 3
main functions :
1. It forms a smooth refractive surface on
the epithelium
2. It maintains a moist environment for
the epithelium
3. It carries oxygen to the eye
 Cornea
• The cornea is a clear , transparent
structure with a brilliant, shiny surface
• It has a convex surface that acts as a
powerful lens
• Most of the refraction of the eye takes
place not through the crystalline lens of
the eye but through the cornea
• The cornea is relatively large at birth &
almost adult size during the 1st - 2nd years,
fully developed at 2 years
• It is thicker at it’s periphery (1mm) than
it’s centre (0.5mm)
• Divided into 5 distinct portions :
1. Epithelium
2. Bowman’s layer
3. Stroma
4. Descemet’s membrane
5. Endothelium
• Epithelium – usually injured by
superficial abrasions or small foreign
bodies
• Functions as a barrier & as an important
refractive optical surface
• Regenerates rapidly without leaving a
scar
• Injury to the deeper structures usually
results in formation of an opacity in the
cornea
• Bowman’s membrane – consists of
randomly orientated collagen fibrils
• An acellular layer
• Has no regenerative capabilities
• It’s function is unclear
• Stroma – Accounts for 90% of the
corneal thickness
• Composed of 78% water
• Consists of 200-250 evenly spaced type
1 collagen lamellae, at right angles to
other adjacent lamellae
• Descemet’s membrane – composed of type
III collagen
• Very elastic layer that retracts if cut
• It forms the basement membrane of the
epithelial cells
• Endothelium – No known mechanism of
attachment with Descemet’s membrane.
• Maintains corneal deturgescence
• Increases proportionately with the amount
of contact lens wear
• No regeneration of this layer known in
humans
• Limbus – is the junction of the cornea & sclera
that is demarcated by a gray, semitransparent
area
• This is a transitional zone only 1mm wide &
marks the point of insertion of the conjunctiva
• The cornea is completely nourished by 3
sources: (as it contains no blood vessels)
1. A plexus of fine capillaries at the limbus
2. The tear film
3. The Aqueous humor
 Sclera
• The opaque sclera forms the posterior
5/6ths of the protective coat of the eye
• Anterior portion is visible & constitutes
the white part of the eye
• In children – appears bluish, as the
sclera is thin & underlying pigmented
structures are visible through it
• In adults – may become yellowish, due
to deposition of fat
• Attached are all the extraocular muscles
• Nerves & blood vessels that penetrate the
interior of the eye pass through the sclera
• Optic nerve – is attached at the most
posterior portion
• The sclera becomes thin & sievelike and
is called lamina cribrosa
• It is through this sieve that the retinal
fibers leave the to form the optic nerve
• Episclera – is a loose connective & elastic
tissue that covers the sclera & unites it
with the conjunctiva above
• Unlike the sclera, episcleral tissue is highly
vascular
 Uvea
• The uveal tract
consists of 3
structures :

1. Iris
2. Ciliary body
3. Choroid
• 1. Iris – most anterior structure of the
uveal tract
• It is perforated at it’s centre by a circular
aperture called the pupil
• The surface has many ridges & furrows on
it’s anterior surface
• Contraction of the iris occurs in response
to bright light
• Sphincter pupillae – is the muscle at the
pupillary opening that facilitates the
dilation of the pupil
 Iris

• composed of connective
tissue and smooth muscle
• pupil is hole in iris
• dim light stimulates
radial muscles and pupil
dilates
• bright light stimulates
circular muscles and
pupil constricts

33
• Aqueous humor – is the clear fluid
between the iris & the cornea
• Anterior chamber – is the space where the
aqueous humor occupies
• 2. Ciliary body – is in direct continuity
with the iris
• Is adherent to the underlying sclera
• Directly posterior to the iris, the ciliary
body is plump & thrown into numerous
folds referred to as the ciliary processes
• Is responsible for the major production
of aqueous fluid
• The equator of the lens is only 0.5mm
from the ciliary processes & is suspended
by fine, ligamentous fibers known as the
zonular fibers of the lens
• Most of the zonular fibers of the lens
originate from the ciliary body
• In general is triangular
• The iris takes root from it’s middle
portion
• Ciliary muscle – lies against the sclera
on the outer side of the triangle
• Contraction of the ciliary muscle releases
the tension of the zonular fibers,
controlling the size & shape of the lens
Lens accomodation
Emmetropia
Hyperopia
Astigmatism
• After the age of 40 years , the lens loses its
ability to change its shape gradually , &its
power becomes progressively weaker
• So focusing at near point or
accommodating becomes difficult
• This condition is called presbyopia
3. Choroid - is in direct continuity with the
iris & ciliary body
• Lies between the retina & sclera
• Primarily a vascular structure
• Function is to provide nourishment for the
outer layers of the retina
 Angle Structures

• The angle structures are formed by the

tissues posterior to the cornea &
anterior to the iris
• The aqueous humor intervening
• Included in the angle structures :

1. The root of the iris

2.A portion of the anterior surface of the ciliary
body
3.A spur from the sclera
4.The canal Schlemm
5.The corneoscleral trabeculum
• Aqueous humor leaves the eye by
filtering through the crevices of the
trabecular meshwork
• Consists of tiny pores through which
aqueous humor travels until it reaches
Schlemm’s canal
• From here the aqueous humor leaves
the eye through the aqueous veins that
penetrate the sclera
• Obstruction within the trabecular
meshwork or the angle structures, by iris
or scar tissue, results in raised intraocular
pressure & glaucoma
 Lens
• The lens of the eye is a transparent
biconvex structure situated between the
iris & the vitreous
• Only that portion of the lens not
covered by iris tissue is visible
• Anterior pole – is the centre of the
anterior surface of the lens
• Is only about 3mm from the back
surface of the cornea
• The diameter of the lens is about 9-
10mm
• Equator – peripheral margin lies about
0.5mm from the ciliary processes
• The lens is surrounded by a capsule
• A transparent, highly elastic envelope
• The lens material is a soft & puttylike in
infants
• With age it tends to grow harder,
especially towards the centre of the lens
• The harder central portion of the lens
found in adults 30 years or older is called
the nucleus of the lens
• The outer lens fibers form the lens cortex
• The harder nucleus is a product of
normal developmental growth of the lens
• As new lens fibers are produced, the
older fibers are pushed toward the centre
& are compressed in a concentric fashion
 Vitreous
• Is a jellylike structure, thick & viscous
• Occupies the vitreous chamber in the
posterior concavity of the globe
• It fills the largest cavity of the eye,
occupying 2/3rds of its volume
• Surrounded mainly by retina
• Normally the vitreous is quite transparent
• Within the body of vitreous , fine
collagen fibers crisscross in a
scaffolding manner
• The resulting matrix is filled with a
viscous mucopolysaccharide &
hyaluronic acid (this is a great shock
absorber & can compress & rebound
slowly – important in injuries to the
eye)
• Vitreous is almost 99% water
• The envelope that surrounds the
vitreous & is anchored to the more
forward part of the retina, the ora
serrata at the head of the optic nerve
along the major blood vessels
• If the vitreous shrinks, the resulting
tension on its anchors can produce a
tear in the retina
• This may permit the adjacent vitreous
to enter between the choroid & retina to
produce a retinal detachment
• With age some of the collagen fibers of
the vitreous often break away from the
main structure
• May condense into strands & float freely
• Patients may sometimes see floating
specks or webs that move as their eyes
move
• Usually harmless
• Often disappear in time
 Retina
• Contains all the
sensory receptors for
the transmission of
light, is really part of
the brain
• Retinal receptors
divided into 2 main
populations :
1. Rods
2. Cones
1. Rods
• Function best in dim light
• 125 million rods
• Vision with rods is relatively poor
• Rods are distributed in the periphery
of the retina (not the macula)
• Damage to these structures results in
night blindness but, with the retention
of good visual acuity for straight-
ahead objects
2. Cones
• Function best under daylight conditions
• 6 million cones
• Enable us to see small visual angles with
great visual acuity
• Colour vision is totally dependant on
the integrity of the cones
• Form a concentrated area in the retina
known as the fovea, which lies in the
centre of the macula lutea
• Damage to this area can severely reduce
the ability to see directly ahead
• In the extreme periphery of the retina
there are no cones & only a few rods
• Ora serrata – the junction of the
periphery of the retina & the ciliary
body
• The retina is firmly attached to the
choroid at the ora serrata
• This is the reason why that retinal
detachments never extend beyond the
ora serrata
• The other site of firm attachment of the
retina is at the circumference of the
optic nerve
• Pigment epithelium – the posterior
layer of the retina, is firmly secured to
the choroid
• Retinal detachment occurs as a result of
cleavage between its anterior layers &
the posterior pigment layer
 Optic Nerve
• Located at the posterior portion of the
globe & transmits visual impulses from
the retina to the brain itself
• Optic disc – head of the optic nerve
• Only seen by ophthalmoscopic
examination
• Optic nerve contains no sensory
receptors itself
• Therefore, its position corresponds to
the normal blind spot of the eye
• Retinal arterioles & veins – branch out
from the surface of the optic disc
• Divide soon after leaving the optic disc
& extend out on the surface of the retina
to supply the inner 1/3rd with nutrients
• As the optic disc enters the globe, it goes
through a fibrous, sievelike structure
(visible with ophthalmoscope) called the
lamina cribrosa
• When the lamina cribrosa is prominent,
it forms the base of a depression in the
disc called the physiologic cup
• Consists of 1 million axons arising from
the ganglion cells of the retina
• The nerve emerges from the back of the
eye through a small circular opening
• It extends for 25-30mm & travels within
the muscle cone to enter the bony optic
foramen
• From there it travels another 4-9mm to
pass into the intracranial cavity & joins
its fellow optic nerve to form the optic
chiasm
 Visual Pathway
• As the retinal fibers leave the optic
nerves ½ of them cross to the opposite
side
• The fibers that cross are derived from
the retinal receptors nasal to the macula
• Optic Chiasm – structure formed by the
mutual crossing of nasal fibers by both
optic nerves
• Optic tract – a band formed from the
optic chiasm where the nasal fibers
emanating from the nasal half of the
retina of 1 eye intermingle with the
fibers derived from the temporal sector
of the retina of the opposite eye
• Fibers in the optic tract continue toward
a cell station in the brain called the
lateral geniculate body
• This is a relay station
• Here the fibers spread out in a fan-
shaped manner & extend to the parietal
& temporal lobe of the brain
• They continue to their final destination,
the posterior portion of the brain called
the occipital lobe in an area denoted as
the visual striate area
• Conscious recognition of visual
impulses takes place in this part of the
brain
• In conclusion :
• ½ of the visual field from each eye is
projected to 1 side of the brain.Thus,
visual impulses from the right visual
field of each eye will be transmitted to
the left occipital lobe
Visual Nerve Pathway

78
 Ocular Muscles
• Six ocular muscles
move the globe :
1.Medial rectus
2.Lateral rectus
3.Superior rectus
4.Inferior rectus
5.Superior oblique
6.Inferior oblique
• Medial • Lateral
rectus rectus

- Moves the eye - Moves the eye

toward the nose, horizontally to
or adducts the eye the outer side, or
abducts the eye
 Superior & Inferior rectus

• Superior rectus - elevates the eye

primarily
• Inferior rectus – depresses the eye
• The 4 rectus muscles are inserted very
close to the limbus
• Medial approx 5.5mm & lateral 7mm
from the limbus
• Not normally visible as they are covered
with conjunctiva & subconjunctival
tissue
• Lie on the surface of the globe
• Therefore, readily accessible for muscle
surgery
• Superior • Inferior
oblique oblique
- Functions - Acts to extort
primarily as an the eye & also
intorter by serves to
rotating the elevate the eye
vertical &
horizontal axis of Oblique muscle
the eye toward are inserted
the nose behind the
equator of the
globe
• In the lid the levator palpebrae
superioris muscle serves to elevate the
lid
• The orbicularis oculi muscle closes the
eye during winking, blinking or forced
lid closure
• If the levator muscle is weak or absent
the lid droops & ptosis results
The end