CURSO PREPARACIÓN

EXAMEN EBO
AMIR-ALCON
Dra. Silvia Pérez Trigo, M.D. Ph.D. FEBO.
Madrid, febrero 2018
 LOGISTICS FOR EXAMINATION
• Fly the morning before the exam
• Accommodation close to the Congress
Palace
• Arrive early to take the accreditation
the first day
• Carry a ruler and a pencil for the
answer sheet
 STRUCTURE OF THE EXAM
WRITTEN PART (40%)
• MCQ-paper
Contains 52 questions
• T (True)
• F (False)
• D (Don’t know)
+1 (only) the correct answer is marked
0 (only) the option D (Don’t know) is marked
–0,5 (only) the incorrect answer is marked OR multiple options have been marked (T and F) (T and D) (F and D) (T, F and D)
 STRUCTURE OF THE EXAM
ORAL PART (60%)
• Four separate vivas of 15 min:
The viva voce panels are:
• Optics, Refraction, Strabismus, Pediatric ophthalmology and Neuro-ophthalmology
• Cornea, External Diseases, Orbit and Ocular Adnexa
• Glaucoma, Cataract and Refractive Surgery
• Posterior Segment, Ocular Inflammation and Uveitis
 BIBLIOGRAPHY

Webs:
http://emedicine.medscape.com/
http://eyewiki.aao.org/Main_Page
Neuro-ophthalmology
 OPTIC NERVE
• ANATOMY:
• 1.2 million nerve fibers
• Diameter: 1.5 mm 3.5 mm
• Length: 45-50 mm
Intraocular: 1 mm
Intraorbital: 25-30 mm
Intracanicular: 9 mm
Intracranial 10-15 mm
• Blood supply: Zinn Haller ring
• Surface fiber layer: central retinal artery
• Prelaminar región short post ciliary arteries
• Lamina cribosa region
• Retrolaminar: both
 OPTIC NERVE
PAPILEDEMA IDIOPATHIC INTRACRANEAL HYPERTENSION
Pseudotumor cerebri
• ♀ 33 y
• Intracraneal pressure • Papilledema findings + headache, nausea, vomiting
• Loss spontaneous venous pulsations • Tinnitus (pulsatile intracraneal noises)
• Visual obscurations (postural changes) • Retrobulbar pain
• Blind spot • VF defect (blind spot, constriction, arcuate)
• Diplopia CN 6 palsy • Associations: obesity, endocrine disorders, tetracycline,
steroids, female hormones…
• Acute normal: vision, colors, pupils • Diagnosis:
• Diagnosis: • MRI (+ contrast) + Magnetic resonance venography
• CSF pressure + normal composition
• Blood pressure
• Serial Visual fields
• Brain CT/MRI
• Treatment:
• Lumbar puncture
• Weight loss, Acetazolamide, serial lumbar punctures,
lumbar-peritoneal shunt
 OPTIC NERVE
OPTIC NEURITIS:
• Most common optic neuropathy < 45y • Differential diagnosis:
Idiopathic
• Most frequent in ♀ Multiple Sclerosis
• VF defects: 50% diffuse, 20% CENTRAL Sarcoidosis
Lyme Disease
• Unilateral vision loss + RAPD + Pain Devic’s síndrome
movements + vision color/contrast sensibility (bilateral optic neuritis + transverse mielitis)
• Pulfrich phenomenon: motion of pendulum appears
elliptical • Treatment in Multiple Sclerosis:
• NOT INITIAL oral steroids
• Uhthoff’s sympton: worsening of symtomps with • IV steroids
heat/exercise
• Interferon beta 1 alpha
• Phosphenes • Fingolimod (macular edema)
• Auditory clicks
 OPTIC NERVE
ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)
• Infarction just posterior lamina cribosa (posterior ciliary
arteries)
• Altitudinal/arcuate VF defects
• Optic disc edema (ANT)
• Contralateral disc crowded
• Pesudo Foster-Kennedy syndrome:
edema+ contralateral atrophy

ARTERITIC (AAION)
NONARTERITIC (NAION)
• Inflamatory vasculopathy, Associated symtoms
• >55 y ♀ (amaurosis fugax/diplopia) • No associated symtoms

• Elevated ERS (♂ > age/2 ♀ > 10+age/2) • 50-75 y

• CRP >2.45 • Microvascular disease (DM, HT)

• Low hematocrit, increased platelets • Vascular disorders
• FA: patchy choroidal filling • Normal ERS
• Temporal artery biopsy • Sheath fenestration not effective
• Treatment: Steroids IV: 1g for 3 days.
 OPTIC NERVE
POSTERIOR ISCHEMIC OPTIC NEUROPATHY
• Bilateral
• Severe anemia/ hypotension/ medication
(head-neck surgery, blood loss from surgery)

TOXIC/NUTRITIONAL OPTIC NEUROPATHY

• Bilateral
• Painless progressive vision loss (centrocecal)
• Etiology:
• Ethanol, metanol
• Ethambutol, Isoniazid, rifampin (TBC)
• Chloramphenicol
• Thiamine, B12 deficiency
 OPTIC NERVE

• LEBER’S HEREDITARY OPTIC NEUROPATHY:

• Maternal mitocondrial DNA (DNA analysis)

• Transmission to all offspring (affected ♂ 50%, ♀ 15%)

• 15-30 y
• Tobacco or alcohol can trigger
• Rapid vision loss (days ≤ 20/200) + disc edema+
peripapillary telangiectatic vessels (FA not leak)
• Cardiac conduction abnormalities
• No treatment
 OPTIC NERVE TUMORS
ON MENINGIOMA
NEURILEMMOMA
ON GLIOMA
• Children: Low grade astrocytoma
(SCHWANNOMA)
• No malignant
Hamartoma
• ♀ • NF 1
NF 1
• NF 1 • Compression, perineural spread
CT/MRI: fusiform mass
• Vision loss • Superior orbit
Treatment: observation/excision
• Optociliary shunt vessels • Pathology: Antoni A /Antoni B cells
• Adults: malignant ON glioma
• Optic nerve atrophy • CT scan: fusiform mass
(glioblastoma multiforme)
• Pathology: Psammoma bodies • Treatment: excision
calcification
• CT/MRI: Railroad track sign
 CHIASM
• 55% cross (nasal fibers)
• Macular fibers: posterior
• Knee of Von Villebrand: junctional scotoma
(Inferonasal retina fibers, Meningioma)
• Bloody supply: ICA, anterior cerebral artery
• Heteronymous VF (BITEMPORAL) defects

Pituitary Tumors Sheehan’s Syndrome

• Superior bitemporal VF defect • Acute hemorraghe pregnancy
• Most common: chromophobe
• X Ray: Double floor sign Craniopharyngioma
• Dopamine agonist
• Inferior bitemporal VF defect
Pituitary Apoplexy • MRI: calcification
• Acute hemorraghe tumor
• Vision loss progress NLP
 RETROCHIASMAL DISORDERS
• Homonymous VF defects
• Vision NOT reduced by UNILATERAL POSTCHIASM lesion
OPTIC TRACT
• Lower fibers lie laterally (90° rotation)
• CONTRALATERAL RAPD (55% fibers cross)
• Before Lateral geniculate body:
Hypothalamus fibers
Pupilary fibers
Brachium of superior colliculus
• Incongrous homonymous hemianopia
• Bilateral optic atrophy: Bow-tie appearance
 RETROCHIASMAL DISORDERS
LATERAL GENICULATE BODY
• NORMAL PUPILS
• Incongrous homonymous hemianopia
• Part of thalamus
• Lower fibers run laterally
• Cross fibers: 1,4,6 • Uncross fibers: 2,3,5
• Magnocellular neurons:
Motion detection
Stereoacuty
Contrast sensitivity
• Parvocellular neurons:
Spatial resolution
Color vision
 RETROCHIASMAL DISORDERS
OPTIC RADIATIONS

Temporal lobe Parietal lobe

• Meyer’s Loop: Pie in the sky defect • Contralateral homonymous inferior
(no macular defect) quadrantananopia
• Contralateral homonymous superior quadrantananopia • Asymetric OKN
• Formed hallucinations • Gerstman’s syndrome: acalculia, agraphia,
agnosia…
• Mass/vascular • Mass/Vascular
 RETROCHIASMAL DISORDERS
PRIMARY VISUAL CORTEX
(V1, Brodmann’s area: 17)
OCCIPITAL LOBE
• Unformed hallucinations
• Symetric OKN
• Vascular 90%

Post: macular fibers

unilateral if vascular (double blood supply)
bilateral if trauma
Intermediate: peripherial defect
Anterior: Temporal crescent
(contralateral monocular defect)
• Riddoch phenomenon: not perceive stationary objects
• Anton’s syndrome: deny blindness
 EYE MOVEMENT DISORDERS
HORIZONTAL GAZE PALSIES

INTERNUCLEAR OPHTHALMOPLEGIA ONE AND A HALF SYNDROME

• Medial longitudinal fasciculus (MLF) • Fisher’s síndrome
• Inability ADDuction Ipsilateral • Paramedian pontine reticular
formation (PRRF)-Abducens
• Nystagmus contralateral
nucleus (VI cranial nerve)
• Ischemia/Desmyelination
+ MLF
• Only movement: ABDUCTION
CONTRALATERAL
• Stroke
 EYE MOVEMENT DISORDERS
VERTICAL GAZE ABNORMALITIES
PARINAUD’S SYNDROME (Dorsal midbrain síndrome)

• Supranuclear UPgaze palsy + nuclear CN 3 palsy

• Pineal tumor 90%
• Doll’s head intact
• Convergence-retraction nystamus
• Light-near dissociation
• Mid-dilated pupils
• Skew desviation
• Lid retraction
• Treatment: Radiation therapy
 CRANIAL NERVE PALSIES
OCULOMOTOR NERVE (CN 3) PALSY

• May cause PAIN (compression)

• Nuclear palsy:
-Elevator subnucleus: both elevator muscles (Bilateral ptosis/no ptosis)
-Superior rectus subnucleus: contralateral superior rectus
-IR, MR, IO subnucleus: ipsilateral muscles
• Pupil-sparing: ischemic
• Aberration regeneration: NEVER AFTER VASCULOPATHIC INJURY
Inferior rectus lid retracts
Medial rectus pupillary constriction

• Miasthenia gravis may mimic CN3 palsy (no pupil)

• CT scan/ MRI/ MRI angiogrophy
 CRANIAL NERVE PALSIES
TROCHLEAR NERVE (CN 4) PALSY
• Dorsally from brain stem
• Longest intracranial course
• Most common CN following head injury
• Nuclear palsy: contralateral CN 4 palsy
• Isolated CN 4 palsy:
Congenital:
large vertical fusion amplitudes (10-15∆)
facial asymmetry
• Bilateral:
Alternate hypertropia
V-pattern esotropia
Chin-down head postere
>10° of exciclotorsion
 CRANIAL NERVE PALSIES
ABDUCENS NERVE (CN 6) PALSY
• Vascular/ head injury
• Subarachnoid space: Increased intracranial pressure
• Gradenigo’s syndrome: abscess petrous apex (mastoiditis)
• Greater risk of being damaged cavernous sinus

Cavernous sinus syndrome

• Trauma, vascular, inflamation….
• CN 3, 4, V1, Horner’s, chiasm and hypophysis
• NOT CN2!!
 CRANIAL NERVE PALSIES
FACIAL NERVE (CN 7) PALSY
• Supranuclear palsy
Contralateral lower face TRIGEMINAL NERVE (CN 5) PALSY
• Brain stem lesion
Ipsilateral superior + lower face
• Trigeminal neuralgia:
• Peripheral CN7 lesion Compression CN5 root
Ipsilateral superior + lower face PAIN
Bell’s palsy
Ramsay-Hunt syndrome

Aberrant facial inervation

Marcus-Gunn jaw winking
Crocodile tears by chewing

Möebius syndrome
CN6 and CN7 palsies
Esotropia with ABDuction
limitation
 PUPILS

LIGHT-NEAR DISSOCIATION RELATIVE AFFERENT PUPILLARY

DEFECT
• Not light reaction (RAPD, MARCUS-GUNN PUPIL)
• Near response intact • Etiology: retinal, visual path disease
• Etiology: • Optic tract: contralateral RAPD
• Argyll-Robertson • No RAPD lesions posterior to LGB
• Adie’s pupil
• Parinaud’s syndrome
• Myotonic dystrophy
 PUPILS
HORNER’S SYNDROME
• Sympathetic pupillomotor damage
• Ptosis + miosis + anhidrosis
• Congenital: iris heterochromia
• Preganglionic:
-First order neuron:
Hypothalamus to ciliospinal center of Budge (C8-T2)
-Second order neuron:
Ciliospinal center of Budge to superior cervical ganglion
Neuroblastoma/ Pancoast’s
• Postganglionic:
-Third order neuron:
Superior cervical ganglion to iris dilator
 PUPILS
HORNER’S SYNDROME
• Preganglionic: Diagnosis:
-First order neuron: -Horner’s?:
Hypothalamus to Cocaine test: (blocks reuptake NE)
ciliospinal center of Budge (C8-T2) Horner NOT dilatation
-Second order neuron: Aproclonidine test: (alpha agonist)
Ciliospinal center of Budge to Horner DILATATION (Hypersensitivity)
superior cervical ganglion

-Horner’s Level:
• Postganglionic:
Hydroxyamphetamine test:
-Third order neuron:
(releases NE from nerve terminal, 3rd neuron)
Superior cervical ganglion to iris dilator
- Pupil DILATES
- Pupil NOT dilates
 PUPILS
ADIE’S TONIC PUPIL
• Postganglionic parasympathetic pupillomotor damage
• ♀ 20-40 y
• Unilateral
• Midriasis vermiform movements miosis
• Light-near dissociation
• Diagnosis: Pilocarpine 0,125% test

ARGYLL-ROBERTSON PUPIL
• Bilateral miosis
• Terciary syphilis
• Light-near dissociation
 Pupils
OCULAR MUSCLE DISORDERS not altered

CHRONIC PROGRESSIVE EXTERNAL

OPHTHALMOPLEGIA (CPEO)
• Bilateral ptosis + bilateral ophthalmoplegia + slowly progressive
• Sporadic/maternal inheritance (mitochondrial DNA)
• Associations:
- Kearns-Sayre syndrome:
Retinal pigmentary + cadiomyopathy
- Abetalipoproteinemia
- Refsum’s disease: RP-like
- Oculopharyngeal dystrophy:
AD, French-Canadian ancestry
 OCULAR MUSCLE DISORDERS
MYOTONIC DYSTROPHY
Steinert disease
• AD
• Christmas tree cataract
• Mild pigmentary retinopathy
• Ptosis, lid lag
• Light-near dissociation
• Miotic pupils
• Baldness
• Strong handshake
 OCULAR MUSCLE DISORDERS
MYASTHEMIA GRAVIS
• Antibodies block Ach receptors
• FATIGABILITY
• 90% eye symptoms:
asymmetric/seesaw ptosis, Cogan’s lid twitch, weakness
• ♀>♂
• NO affected pupils
• Associations: thymic hyperplasia, thyroid disease
• Jaw weakness, dysphagia, dysarthria, dyspnea….
• Diagnosis:
- Tensilon test (edrophonium/ neostigmine): AChE inhibitor (antidote: atropine)
- ACh receptor antibody: 50% eye MG, 80% general MG
- EMG: IS THE BEST
- Rest test/ Ice test
• Treatment: pyridostigmine (AChE inhibitor)
Pediatrics
 EMBRYOLOGY

Embryonic plate > Optic sulci > Optic pit (23d) >Optic vesicle (25d) > Optic cup
• Embryonic fissure: 33rd day pressurization (6th week) - Choroid (stroma, vessels)
• Coloboma INFERONASAL (≠ eyelid coloboma not related) - Cornea (stroma, endothelium)
- Trabeculum
Neural crest - Stroma iris
- Ciliary body (stroma, muscles)
- Retina (sensory, RPE) - Sclera
- Iris (sphincter, dilator) - Cartilage/ bone orbit
Ectoderm Neural ectoderm - Ciliary body (epithelium) - Connective tissue extraocular muscles
- Optic nerve
- Sympathetic ganglion
- Lateral geniculate body
- Lens
- Extraocular muscles Surface ectoderm - Epithelium cornea/conjunctiva
Mesoderm - Sclera (small area temporal) - Lacrimal gland
- Vascular endothelium - Nasolacrimal system
- Schlemm’s canal
 ORBITAL LESIONS
BENIGN LESIONS
• DERMOID CYST:
• Choristoma (dermal elements) tissue not normally found that site
• Most common orbital mass in childhood
• SUPEROTEMPORAL
• No malignant potential
• CAPILLARY HEMANGIOMA:
• Most common benign tumor in orbit in children
• First weeks of life, enlarge first 6-12 months, spontaneous resolution
• SUPERONASAL, ♀ > ♂
• Kasabach-Merrit syndrome: coagulopathy, platelet trapping
• Treatment: β-blockers IV
• LYMPHANGIOMA:
• SUPERONASAL
• Increasing with upper respiratory infection
• May hemorrhage (chocolate cyst)
• VARIX:
• SUPERONASAL
• Valsalva, crying,…
• Phlebolith
 ORBITAL LESIONS Metastasis in children: ORBIT
( ≠ Adults: uvea)
MALIGNANT NEOPLASMS

RHABDOMYOSARCOMA NEUROBLASTOMA EWING’S SARCOMA

• Most common primary • Most common metastatic • Second most common
orbital malignancy in children orbital tumor in children metastatic orbital tumor in
• SUPERONASAL • Adrenal gland, sympthic children
•♂ chain, mediatinum/neck • Treatment:
• Rapidly progressive proptosis • Raccon eyes • Chemotherapy
• Types: • Sudden proptosis
• Embryonal: most common (botryoid) • Horner’s Sd
• Pleomorphic: least common, best • Opsoclonus
prognosis
• Alveolar: poorest prognosis • Bony destruction
• Treatment: • Treatment:
• Radiation • Radiation
• Debulking • Chemotherapy
 CRANIOFACIAL SYNDROMES
TREACHER-COLLINS SD. GOLDENHAR’S SD.
• 1 st-2nd brachial arches • 1 st-2nd brachial arches
• Hypoplasia midface: • Limbal dermoids
• Lateral lid defects (coloboma) • Dermolipomas
• Ectropion
• Dental/ear abnormalities
• Lower lid coloboma
• Micrognatia • Duane’s Sd.
• Pretargal appendages
 CRANIOFACIAL SYNDROMES
CROUZON’S SD. BLEPHAROPHIMOSIS
• Craniosynostoses • AD inheritance if syndrome
• Proptosis
• V-pattern exotropia
• Trisomy 18
• Hypertelorism • Ptosis
• Apert’s Sd: Crouzon’s + • Telecanthus
syndactyly
• Epicanthus inversus
 ANTERIOR SEGMENT DYSGENESIS
• Alteration of neural crest migration (6th week)
• Association: GLAUCOMA
• BILATERAL, congenital (RIEG1,2 / FOXC1/ PAX6)
P
O
S
• Axenfeld’s anomaly:
T • Posterior embryotoxon
E
R
I
O
R
• Alagille’s syndrome:
• Axenfel’s + pigmentary retinopathy
E
M
B
R
Y
• Rieger’s anomaly:
O
T
• Axenfel’s + iris hypoplasia
O (syndrome: systemic abnormalities)
X
O
N

• Peter’s anomaly:
• Corneal leukoma + iris adhesions + cataract
 ANIRIDIA
Neural Ectoderm disturbance
• Bilateral
• Sporadic/ hereditary: gen PAX6
• Types:
• AN1: 85%, AD, eye
• AN2: sporadic, WILMS’S TUMOR (nephroblastoma) Abdominal ECO
• AN3: AR
• Hipoplasia foveal/optic nerve
• Nystagmus
• Cataracts, glaucoma, pannus, alteration of meibomian glands
 CONGENITAL CATARACTS
UNILATERAL BILATERAL
• Not metabolic/genetic • AD
• Metabolic workup
• Testing is not needed: • TORCH
trauma/TORCH (Toxo, others, Rubeolla, CMV, HSV) • GALACTOSEMIA:
• PHPV •
•
AR, galactose-1-P-uridil transferase
Galactisol
• Lenticonus: •
•
Dx: urine reducting substances
Oil-droplet cataract (resersible)
Anterior: Alport’s Sd. • FABRY’S DISEASE:
Nephritis • α galactosidase A deficiency
• Cornea verticillata
Deafness • Spoke-like cataract
• Tumors… • Cardiovascular (infarction), skin pain, renal, etc
• LOWE’S SD:
• X-linked
Congenital cataract + glaucoma • Defect of amino acids metabolism
are very rare • Glaucoma
• Dx: urinalysis amino acids
• ALPORT’S SD
 CHILDHOOD GLAUCOMA
PRIMARY CONGENITAL GLAUCOMA

• 75-85% association gen mutation: CYP1B1

(neural crest origin: facial bones, teeth,…)
• Bilateral, ♂
• Buphthalmos
• Haab’s striae (Horizontal)
• Dx:
Diameter: >11mm (<1y), >13mm (>1y), >14mm (advanced)
IOP under anesthesia: lower IOP (except: ketamine/succinylcholine)
Gonioscopy direct lens Koeppe (Barkan’s membrane)
• Treatment:
• Medication: Brimonidine contraindicated
• Surgery:
• Goniotomy (requires clear cornea)
• Trabeculotomy (ab externo)
• Trabeculectomy
 UVEITIS
Juvenile Rheumatoid Arthritis (JRA) Toxocariasis
• Most common cause of uveitis in children • Toxocara canis (roundworms)
• Pauciarticular: (< 5 joints, large joints) • Clinical presentations:
• ANA + FR – • Endophalmitis (most frequent)
• ♀ • Granuloma
• Ophthalmologic examination every 2 months • Peripherial granuloma
• Cataracts • Temporal traction of the macula (Kappa
• Band keratopathy positive)
• No calcifications
• DX: ELISA (No ova/parasites in stool)
Toxoplasmosis
• Most common cause of retinochoroiditis in humans
• Toxoplasma gondii (protozoan)
• Congenital/acquired
• Tachyzoite: inflammation
 RETINAL DISORDERS
PERSISTENT HYPERPLASTIC VITREOUS (PHPV)
• Unilateral
• Microphthalmia
• Remnants of hyaloid vasculature system
• Mittendor’s dot
• INFERONASAL
• Small opacity posterior lens
• Bergmeister’s papillae
• Glial sheath
• Persistent pupillary membrane

COAT’S DISEASE
• Non heredirary
• Unilateral, ♂ (5-10 y, Young adulthood)
• Leukocoria
• Strabismus
• Telangiectatic blood vessels leak lipids/ yellow subretinal lesions
• No calcifications ( ≠ retinoblastoma)
• Treatment: cryo/laser
 RETINOPATHY OF PREMATURY
International Classification of ROP
• Risk factors/screening (4-8 weeks of life) • Zones (centered on optic disc)
≤ 1500 kg • Stages
< 32 gestation weeks • 1. demarcation line
Oxygen > 72h • 2. Ridge
Premature unstable clinical course • 3. Ridge with tufts (fibrovasc prolif)
• 80-90% spontaneosly regress, not treatment • 4. Subtotal retinal detachment
(A extrafoveal/ B foveal)
• 5. Total RD
 RETINOPATHY OF PREMATURY
• PLUS disease (tendency to progression)
Engorged tortuous vessels + vitreous haze + iris vascular congestion
• Threshold disease Treatment < 48 h
Zone 1 + PLUS
Zone 1 + Stage 3 (fibrovasc)
Zone 2 + Stage 2-3 + PLUS
• Prethreshold disease Review 1-2 weeks
• Zone 1 + Stage 2/3
• Zone 2 + Stage 3
• Treatment:
• Diode laser (better than green)
• Surgery: stages 4/5
• Bevacizumab (zone 1 + stage 3 + PLUS)
 RETINAL DYSTROPHIES
FUNDUS FLAVIMACULATUS STARGARDT’S DISEASE BEST’S DISEASE
AD
AR
Second most common hereditary
Most common hereditary macular dystrophy
macular dystrophy
Adults 10-20 y 10 y
Firstly: Peripherial retina Bull’s eye maculopathy Macular RPE affected
Stages:
(central vision preserved) Decreased vision, nyctalopia Previtelliform
Vitelliform
Pisciform flecks Scrambled egg
Lipofuscin deposits in RPE Cyst stage
FA: Dark choroid, HiperF, Window defects Pseudohypopyon
Atrophy
ERG/EOG normal o subnormal
FA: blockage by egg yolk lesion
ERG normal /EOG abnormal
Good prognosis Bad prognosis Good vision
(except CNV)
 RETINITIS PIGMENTOSA (RP)
• Progressive dystrophies
RP type 1 (rod-cone)
• sporadic > AR > AD > X-linked recessive (most severe)
• Vitreous cells
• Cataract
• CME not leak
• VF inferotemporal escotoma first
• ERG precede retinal changes
RP type 2 (cone-rod)
• Less pigment deposition (sine pigmento)
Variants: Gyrate atrophy
• LEBER’s congenital amaurosis (AR) • AR
• Nystagmus + oculodigital sign • Deficiency ornithine aminotransferase
• Usher’s syndrome (ornithine elevated, low lysine)
• Most common
• Progressive retinal degeneration
• Deafness
• Refsum’s disease • Starts peripherially
• Deficiency phytanic acid oxidase (acid accumulates in RPE)
• Abetalipoproteinemia (Bassen-Kornzweig Sd)
• Deficiency fat-solubles vitamins
• Chronic progressive external ophthalmoplegia
 VITREORETINAL DISORDERS
Juvenile Retinoschisis Jansen Sd
• X-linked recessive • AD
• ♂ • Wagner Sd + retinal detachment
• Cleavage NFL (≠ senile) Stickler’s Sd
• Foveal/INFEROTEMPORAL • AD, myopia
• Appears like CME (not leak) • Progressive arthro-ophthalmopathy
• Hyperopia • Optically empty vitreous
• Rhegmatogenous retinal detachment + Vitreous • Lattice/ retinal detachment
hemorrhage
• ERG reduced b-wave + Normal EOG • Pierre Robin/marfanoid
Goldmann-Favre disease Albinism
• AR • AR (AD)
• Retinitis pigmentosa like + juvenile renitoschisis • Foveal hypoplasia + nystagmus
• Optically empty vitreous • Oculocutaneous
• Tyrosinase – no pigmentation (Chr 11)
Wagner Sd • Tyrosinase + some pigmentation (less severe) (Chr 15)
• AD, myopia • Potentially Lethal variants (AR)
• Optically empty vitreous • Chédiak-Higashi Sd (reticuloendothelial
dysfunction)
• NO retinal detachment • Hermansky-Pudlak Sd (abnormal platelets, Puerto
Rico)
• Lattice
• Cataract • Ocular
 RETINOBLASTOMA (RB)
• Most common intraocular malignancy in children
• Chromosome 13q14 // gen RB1 (tumor suppressor protein)
• < 5 y (♀ = ♂)
• 60% sporadic (2 spontaneous mutations) Unilateral
• 40% Hereditary or with germinal mutation (<1 y, bilateral)
• Leukocoria > Strabismus > decreased vision
• Endophytic / exophytic
• Calcifications
• Neovascular glaucoma
• Trilateral retinoblastoma: bilateral RB + pinealoblastoma/parasellar neuroblastoma
• Pathology: ROSETTES
Homer-Wright (no lumen) • Treatment:
Flexner-Wintersteiner (lumen, early retinal differentiation)
• Chemotherapy + Brachytherapy
Fleurettes (highest differentiation)
• Very radiosensitive (≠ melanoma)
• Dx:
• Ophthalmoscopy • Small: cryo/laser/thermotherapy
• ECO: calcium • Enucleation: blind painfull eyes/ unilat
• MRI (Pineal gland / cerebral extension) • Bilateral: Systemic chemotherapy + Intraarterial/vitreous
• Metastatic workup
PHAKOMATOSES (neurocutaneous syndromes) The majority with AD inheritance

Von Recklinghausen’s Sd/ Neurofibromatosis type 1

• Lisch nodules + café au lait spot + plexiform neurofibroma (congenital GLAUCOMA)
• Optic nerve GLIOMA + MENINGIOMA+ Schwannoma
NF type 2
• No Lisch nodules
Sturge-Weber Sd/ Encephalotrigeminal angiomatosis (No hereditary)
• Port wine stain + GLAUCOMA (if upper lid) + cavernous choroidal hemangioma
• Pheochromocytoma
Von Hippel-Lindau disease/ Angiomatosis retinae
• Retina angioma with serous RD
• Pheochromocytoma // renal cell carcinoma
Bourneville’s disease/ Tuberosis sclerosis
• Astrocytic hamartoma of retina + adenoma sebaceum (angiofibromas)
• Seizures + mental retardation
Louis-Bar Sd/ Ataxia-telangiectasia (AR)
• Conjunctival/skin telangiectasias + thymic hipoplasia
Wyburn-Mason Sd/ Racemose hemangiomatosis
• Racemose hemangioma retina
Strabismus
 ANATOMY
EXTRAOCULAR MUSCLES
Inervation Tendon Arc of Insertion from Origin Actions Diagnostic
length contact limbus positions
Spiral of Tillaux
CN3 Medial rectus 4.5 mm 5.5 mm ADD

CN6 Lateral rectus 6.9 mm ABD

Annulus of
CN3 Superior 7.7 mm Zinn ADD 23° ABD
Inciclo Pure elevator
rectus
CN3 Inferior rectus 6.5 mm ADD 23° ABD
Exciclo Pure depressor

CN4 Superior The longest Passes Apex, above ABD 51° ADD
(26 mm) inferior to RS annulus of Inciclo Pure depressor
oblique Zinn Depress

CN3 Inferior The 15 mm Behind ABD 51° ADD

shortest Passes lagrimal sac Exciclo Pure elevator
oblique (1 mm) inferior to IR Elevates
 NISTAGMUS
CONGENITAL LATENT SENSORY SPASMUS NUTANS
• Benign • Cover 1 eye • Pendular • Benign
• Horizontal • Asocciated: • Vision Loss • 3-18 months
• No oscillopsia Congenital ESOT Aniridia • Rapid (small amplitude)
• Fixation DVD Albinism • Asymmetric
• Convergence • Jerk (sacudida) Cataract….
• Head nodding/bobbing
• OKN reversal • Null with ADD • Torticollis
• Slow phase • Normal vision • Spontaneous resolution
• No spleeping • OKN normal
• Treatment: • Neurological disease
• Kestenbaum
• Slow phase Neuroimaging
• Base out prism
 OCULAR DESVIATIONS
• Incomitant: desviation varies in different positions
(paralytic/restrictive)
• Angle Kappa: (visual axis and anatomic axis)
• Positive: pseudoEXOtropia (ROP, toxocariasis, PHPV)
• Negative: pseudoESOtropia
• Sensory tropia:
< 6 y: ESOtropia
> 6y/adults: EXOtropia
• ESOdesviations: most common strabismus (50-75%)
• Minus lenses: measures mores strabismus (EXO/ESO)
 HORIZONTAL ESTRABISMUS
CONGENITAL ESOTROPIA CONGENITAL EXOTROPIA
• 6 months • Rare, most resolver age 6 months
• ≥ 30 ∆ • > 35 ∆
• Small refractive error • Small refractive error
• Amblyopia uncommon • Amblyopia uncommon
• Associations:
• Associations:
• DVD
• Overaction Inferior Oblique • DVD
• Nistagmus • Overaction Inferior Oblique
• Cross fixation (Doll’s head maneuver)
• Rule out congenital CN 6 palsy
• Treatment: bilateral rectus reccesion
 HORIZONTAL ESTRABISMUS
MONOFIXATION SYNDROME
MICROTROPIA
• Small angle strabismus <8 ∆: most frequent ESOTROPIA
• Central scotoma (suppression)
• Peripherial fusion (abnormal retinal correspondence)
• Amblyopia
• Anisometropia associated
• Stereoacuity reduced
• 4 ∆ base out prism test: no refixation normal eye, no initial turn affected eye.
• Treatment:
• Glasses
• Occlusion
 HORIZONTAL ESTRABISMUS
ACCOMODATIVE ESOTROPIA Onset varies (4 y)

REFRACTIVE accommodative NONREFRACTIVE

esotropia accommodative esotropia

• NORMAL AC/A ratio • HIGH AC/A ratio

• Same esotropia near/distance • Esotropia GREATER
• HIGH hipertropia AT NEAR>>DISTANCE
• Treatment: • LOWER hipertropia
• Full cycloplegic refraction • Treatment:
• Bifocal lens (executive type)
 HORIZONTAL ESTRABISMUS
NONACCOMODATIVE ESOTROPIA/ACQUIRED ET

CYCLIC ESOTROPIA DIVERGENCE INSUFFICIENCY CILIARY SPASM

• Intermittent • ET greater at distance • Sustained convergence
• 48 h cyclic constant • Neurological disease • Acommodative spasm
• Illnes, trauma, … • Mimic bilateral CN6 palsy • Miosis
• V-pattern • Treatment: • Pseudomyopia
• Treatment: Base-out prism/surgery • Treatment:
Glasses/Surgery cycloplegia
 HORIZONTAL ESTRABISMUS
INTERMITTENT EXOTROPIA

• Most common form of XT

• Onset varies
• Reflex closure 1 eye bright light.
• Facultative suppression
• Amblyopia uncommon
• XT at distance XT more constant XT at distance and near
• Good stereovision
• Treatment:
• Alternate occlusion
• Induce convergence: overminus spectacle, base-out prisms.
• Base-in prism
• Surgery: bilateral lateral rectus recession
 HORIZONTAL ESTRABISMUS

CONVERGENCE INSUFFICIENCY
• EXOPHORIA greater at NEAR
• Reduced near point of convergence
• Students: Excessive visual demand DIVERGENCE INSUFFICIENCY
• Asthenopia, diplopia… • ESOTROPIA greater at DISTANCE
• Treatment: • Neurological disease
Orthoptic exercises
Base-out prism (convergence training) • Mimic bilateral CN6 palsy
• Treatment:
Base-out prism/surgery
 VERTICAL ESTRABISMUS
DISSOCIATED VERTICAL DEVIATION
(DVD)
• Cover eye: upward + excyclotorsion/abduction
• Uncover eye: no refixation after uncover fellow eye
• Bilateral, asymmetric
• DOES NOT OBEY HERING’S LAW
• Occurs with eye occlusion/intattention
• Latent/manifest
• Associations:
• Nystagmus
• Congenital ET
• Inferior oblique overaction
• Treatment: (bilateral surgery)
• SR recession
• IR resection
• IO weakening/anterior transposition
 VERTICAL ESTRABISMUS
INFERIOR OBLIQUE
OVERACTION (IOOA) PALSY
• Association: congenital ET • Eye hypotropic
• Bilateral, asymmetric • A-pattern
• Adducting eye elevated
• V-pattern
• Treatment:
• IO weakening
Recession
Myectomy
Anteriorization
 VERTICAL ESTRABISMUS
SUPERIOR OBLIQUE
CN 4 palsy

OVERACTION PALSY
• Less common than IOOA • CONGENITAL:
Large fusional amplitudes
• A-pattern
Facial asymmetry
• Adducting eye depressed Torticollis
• Treatment: Mimic double superior rectus palsy
SO weakening • ACQUIRED:
Treatment:
Trauma - Knapp classification:
Diplopia Strengthen palsied: SO
• BILATERAL: Weaken antagonist ipsilat: IO
Weaken yoke: IR
10° excyclotorsion - Torsional symtpms:
V-pattern endotropia Harada-Ito procedure: lateral
Alternate hypertropia transposition of anterior SO
 VERTICAL ESTRABISMUS
BROWN’S SYNDROME

• Restrictive vertical strabismus most common

• Inhability to elevate in ADDuction
• Mechanical problem superior oblique muscle/tendon is unable to lengthen
• Congenital/acquired
• V-pattern
• NO/minimal superior oblique overaction (≠ Inferior Oblique palsy)
• Clicking
• Treatment: observation/surgery
 VERTICAL ESTRABISMUS
ALPHABETICAL PATTERNS

A PATTERN V PATTERN
• Superior oblique overaction • Inferior oblique overaction:
Bilateral CN IV palsy
Congenital esotropia
• Cyclic esotropia
• Brown’s síndrome
• Craniosynostoses
 SPECIAL FORMS OF ESTRABISMUS
DUANE’S RETRACTION SYNDROME
• Restrictive horizontal strabismus most common
• Abnormal inervation lateral rectus by CN3 (Abducens nucleus)
• DOES NOT OBEY SHERRINGTON’S LAW
• Narrowing of palpebral globe
(cocontraction medial/lateral rectus)
• UP/DOWN shoots
• Types:
• 1: ABDuction limitation, appears esotropic
• 2: ADDuction limitation, appears exotropic
• 3: ABD/ADDuction limitation
• Associations: deafness, Goldenhar’s Sd.
• Treatment:
• Avoid muscle resection
• Faden procedure for up/downshoot: splitting lateral rectus
Oculoplastic
 ANATOMY
• No lymphatic vessels in orbit
• 45 mm deep, volume 30cc
Orbital apertures
• Superior fissure (greater-lesser sphenoid wings)
CN 3, 4, V1, 6 + superior ophthalmic vein + sympathetics
Annulus of Zinn : out CN4, lacrimal/frontal nerves
• Optic canal (lesser sphenoid wing)
Optic nerve + ophthalmic artery + sympathetics nerves

Orbital walls
Roof: frontal, sphenoid
Lateral: Zygomatic, sphenoid
Floor: Zygomatic, maxillar, palatine
Weakest
Medial: Maxillar, ethoid, lacrimal, sphenoid
 ORBITAL INFLAMMATION
CELLULITIS (S. aureus)
(Adults: Polymicrobial // Children: Unimicrobial (ethmoid))
• Preseptal
• Orbital
THYROID-RELATED OPHTHALMOPATY
IDIOPATHIC ORBITAL TUMOR • Most common cause of uni/bi-lateral proptosis
• Pain and diplopia in adults
• Unilateral (bilateral 33% in children) • ♀ (8-10 x) > ♂
• Enlargement muscles + tendons • Smoke (7x)
• Dx: CT scan, ECO, Biopsy,… • Enlargement muscles, sparing tendons (IMSLO)
• Treatment: steroids • Associated with Myasthemia gravis
Tolosa-Hunt Sd: • Eye lid retraction (most frequent finding)
Granulomatous inflammation - Pain
• CAS (Clinical Activity Score) - Redness
Cavernous sinus/Superior orbital fissure/Optic canal - Swelling
• Treatment: steroids - Impared function
• Surgery: Descompression > strabismus > eyelid
 ARTERIOVENOUS FISTULA
• Communication carotid artery-cavernous sinus
DIRECT:
• Carotid-cavernous sinus
• Head trauma (skull fracture) /spontaneous rupture aneurysm
• Pulsatile proptosis + chemosis (corkscrew vessels) + bruit + IOP elevated
• CN6 palsy / blood Schlemm’s canal
• Dx: CT scan > MRI > Selective arteriography
DURAL-SINUS:
• Meningeal branches of carotid artery-dural walls of cavernous sinus
• Low flow
• Asymptomatic (proptosis)
 ORBITAL TUMORS
CAVERNOUS HEMANGIOMA NEURILEMMOMA (Schwannoma)
• Most common benign orbital tumor adults MENINGIOMA
(≠ children: capillary)
• ♀ (growth accelerated pregnancy)
• Apex LYMPHOID TUMORS
• 90% non Hodgkins B-cells tumors (MALT)
• Slowly progression
• NO pain proptosis
• Encapsulated
• SUPERIOR/ Lacrimal gland
• High internal reflectivity (ultrasound) • TC scan: putty-like molding
• Systemic involvement: Eyelid> orbit > conjunctiva

HEMANGIOPERICYTOMA
• Obnormal pericytes surronding blood vessels
• Rare, ♀
METASTASIC TUMORS
• Superior
• ♀: Breast carcinoma (enophthalmos)
• ♂: lung carcinoma
 LACRIMAL GLAND TUMORS
NON EPITHELIAL
• Lymphoma
Most common tumor in lacrimal gland
Around globe
EPITHELIAL
• 50% Benign
PLEOMORPHIC ADENOMA
Most common epithelial tumor
♂
Slow growth
Painless mass, proptosis
NO BIOPSY: complete excision
• 50% Malignant
Painfull (perineural invasion), rapidly progressive, bony destruction
ADENOID CYSTIC CARCINOMA
Most common malignant tumor
Pathology: cribiform pattern (Swiss-cheese)
Exenteration
PLEOMORPHIC ADENOCARCINOMA
 MALIGNANT EYELID TUMORS
• EPITHELIAL
Actinic keratosis: most common precancerous lesion
BASAL CELL CARCINOMA
Most common malignancy of the eyelid
Lower lid > medial canthus (lacrimal invasion) > upper lid > outer canthus
Nodular, ulcus rodens, morpheaform
SQUAMOUS CELL CARCINOMA
Lower lid
More agressive
Direct extension/ metastasize
KERATOACANTOMA:
Keratin-filled crater, rapid onset
Muir-Torre Sd:
keratoacantoma + sebaceous adenocarcinoma + visceral tumors
SEBACEOUS ADENOCARCINOMA
Second most common malignancy of the eyelid
Upper lid
Lethal tumor (metastasis)
Pagetoid invasion
• MELANOMA
<1% all eyelid cancers
Nodular: most common type in eyelid
 NASOLACRIMAL SYSTEM DISORDERS
• Obstruction
Congenital:
Valve of Hasner
Massage/Probing
Acquired:
Dacryocystitis: DCR surgery (middle turbinate)
• Canaliculitis
Actinomyces israelii
Curetttage
• Tumor lacrimal sac
Squamous papilloma: most common primary lacrimal sac tumor
Squamous cell carcinoma: most common primary malignant lacrimal sac tumor
Lymphoma: second most common primary malignant lacrimal sac tumor
GLAUCOMA
 TESTING GLAUCOMA
TONOMETRY
Higher IOP: lying down, mornings
Lower IOP: exercise, pregnancy, summer
• INDENTATION
Schiotz: affected by scleral rigidity (falsely low in elastic eyes)
• APPLANATION
Imber-Fick principle
GOLDMANN-PERKINS
- Not affected by scleral rigidity. AFFECTED by corneal thickness - Rings too narrow
- Astigmatism: >1.5 D (axis of MINUS cylinder align with red mark) Understimated - Thin cornea
• REBOUND - With the rule astigmatism
- AFFECTED by corneal thickness
- No need anesthesia
• PASCAL DYNAMIC CONTOUR TONOMETER
- The most independent corneal thickness
- Overestimates compared to Goldmann tonometer
• OCULAR RESPONSE ANALYZER
- Column of air of increasing intensity as the applanating force
- Corneal hysteresis
• APPLANATION + INDENTATION
TONOPEN
PNEUMOTONOMETER
• GONIOSCOPY
TESTING GLAUCOMA
• INDIRECT LENS
• Big size: GOLDMANN (scleral indentation)

• Small size: corneal indentation (angle closure)

ZEISS, SUSSMAN, POSNER
• DIRECT LENS: KOEPPE

• VISUAL FIELD
Affected by pupil < 3 mm
Vision < 20/80 scotoma appears larger and deeper
Fixation loss: Best method to know reliability GENETICS:
False-positive: nervous or happy trigger
False-negative: loss attention/fatigue - Congenital: CYP1B1
- Juvenile: GLC1A = GLC1A /MYOC
• OPTIC NERVE HEAD ANALYZERS - Normal tension: OPTN
Confocal scanning laser ophthalmoscopy (HRT) - PXG: LOXL1
Indirect measure NFL thickness, digital ·D picture - Aniridia: PAX6
Optical coherence tomography - Anterior segment dysgenesis:
Low frequency inferometry FOXC1/PAX6/CYPX2
Scanning laser polarimetry (GDx)
Birefringent properties of NFL
NFI index: >30 glaucoma suspect, >50 abnormal
 PRIMARY OPEN-ANGLE GLAUCOMA
• Most common cause of glaucoma
• Risk factors:
African race (3-4x)
Thinner central corneal thickness (<550 µm)
DM
Retinal disease: central retinal vein occlusion, retinitis pigmentosa, rhegmatogenous retinal
detachment
• Peripapillary atrophy is not a sign of glaucoma damage
• Damage in yellow-blue color axis occurs first
• Splinter hemorrhage:
- Inferotemporal
- Normal tension glaucoma
- Precede the scotoma in the visual field
 SECONDARY OPEN-ANGLE GLAUCOMA
• Cells clogging of trabecular meshwork
Hyphema
Sickle cell (treatment: B-blockers, contraindicated: CAIs/hyperosmotics)
Tumor cells
• PIGMENTARY GLAUCOMA PSEUDOEXFOLIATION GLAUCOMA
• AD
• Young myopic ♂ (Lattice) • ♀, LOXL1, amyloid-like substance deposits
• Concave iris • Scandinavians
• Krukenberg spindle • Sampaolesi’s line
• Angle: pigment distribution HOMOGENEOUS • Angle: pigment distribution HETEROGENEOUS
• Transillumination: RADIAL midperipherial • Transillumination: MARGIN pupil
• Treatment: laser trabeculoplasty/iridotomy
• Weak zonules
• Decreased enothelial cells
• Schwartz’s syndrome • Trearment:
Rhegmatogenous RD (photoreceptor outer segments, pigment RPE) More difficult to control
laser trabeculoplasty
• Elevated episcleral venous pressure
Blood in Schlemm’s canal
AV fistula, NF, Sturge Weber, thyroid-related ophthalmopathy
 PRIMARY OPEN-CLOSURE GLAUCOMA
ACUTE ANGLE CLOSURE PLATEAU IRIS
• Eskimos > Asians (Chronic Africans) • Configuration
• 55-65 y, ♀ Deep central AC / shallow peripheral AC
• Optic nerve swelling/ hiperemia Flat iris
• Glaukomflecken (sequele of ischemia) • Syndrome
• Compression gonioscopy Angle closure, in spite of a patent iridotomy
Not pupillary block
• Shallow AC 40-50 y
• Convex iris Indentation gonioscopy: double hump sign
• Closed angle Treatment: laser iridoplasty
• Pupillary block
 SECONDARY OPEN-CLOSURE GLAUCOMA
NANOPHTHALMOS
• Small eye with normal features
• > 10 D hyperopia, <20 mm axial length, cornea 10.5 mm, shallow AC, narrow angle
Pupillary block
Uveal effusion: thick sclera // anterior rotation of CB
Treatment:
Cycloplegics, laser iridoplasty, surgery

MALIGNANT GLAUCOMA (aqueous misdirection syndrome)

• Ciliary processes rotate against lens (anterior displacement of lens-iris diaphragm)
• Risk factor: shallow AC, elderly ♀, hyperopia, following surgery
Entire shalow AC (≠ acute angle closure)
Treatment:
Cycloplegics, aqueous suppressants
Miotics are contraindicated
Photocoagulation CB, YAG in anterior hyaloid, vitrectomy

NEOVASCULAR GLAUCOMA
• Iris rubeosis > fibrovascular membrane (open angle glaucoma) > membrane contraction (closure angle glaucoma)
• Retinoblastoma: 50% develop
 TREATMENT
OCULAR HYPONTENSIVE MEDICATIONS
• Β-BLOCKERS Adverse effects
Reduce aqueous production
Less effective over time - May mask hipoglucemia
Maximum effect 2h, duration 12 h - Impotence
Many contraindications - Increase stherogenic profile
Cardioselective: β-1 betaxolol - Decreases exercise tolerance
Pregnancy
• α- AGONISTS - Allergy
Reduce production // Increase uveoescleral outflow - CNS penetration
Contraindicated in children and with antidepressant drugs
• MIOTICS
Parasymphathetics agonist: pilocarpine - Myopia
Increase trabeculum outflow // decrease uveoescleral outflow - Breakdown blood-aqueous barrier
• CARBONIC ANHYDRASE INHIBITORS (CAIs) - Orals: Metabolic acidosis
Decrease bicarbonato formation - Corneal endotelial decompensation
• PROSTAGLANDIN ANALOGUES
Increase uveoescleral outflow - CME
Bimatoprost: Increase trabeculum/ uveoescleral outflow - Reactivation of herpes
• HYPEROSMOTIC AGENTS - Congestive heart failure
Increase serum osmolality - Headache
 TREATMENT
LASER TRABECULOPLASTY (Contraindicated: large PAS/ uveitic glaucoma)
PXG and pigmentary glaucoma, old people: best results
• ARGON (ALT)
Twice in life Same effectiveness
• SELECTIVE (SLT)
Less energy, less tissue destruction
It is repeatable (twice/year)
SURGERY
• TRABECULECTOMY
Most common cause of failure: epiescleral fibrosis
Do not use antimetabolites in young myopic patients

• DRAINAGE IMPLANTS
• Valve: Ahmed
• Nonvalve: Molteno, Baerveldt
 Complications
ENCAPSULATED BLEB

ELEVATED IOP?
EXCESSIVE FILTRATION
FAULT OF THE BLEB
BLEB? SUPRACHOROIDAL HEMORRHAGE
PUPILLARY BLOCK
MALIGNANT GLAUCOMA
FLAT IOP?
BLEB LEAK
CHOROIDAL DETACHMENT
GOOD LUCK!!!