Pathology: Eye

Eye Overview (I & II)

Orbit
Pear shaped, 7 bones: shock absorber
(Ethmoid, Lacrimal, Maxillary, Sphenoid, Palatine, Zygomatic, Frontal )

Orbital fat cushions eye

Force from trauma transmitted to bones break Orbital contents prolapse into sinuses; preserved Pic: L. orbital floor blowout fracture Includes all orbital contents Orbital rim = palpable opening

Openings for blood vessels & nerves

Superior orbital fissure (CN 3/4/6, V1, symps, sup. orbital v.) Inferior orbital fissure (V2, infraorbital n, inf. orbital vein) Foramina for vessels / nerves Nasolacrimal canal (not really part of orbit)

Rectus muscles attach to orbital apex form cone Classification of pathology: extraconal / intraconal Remember the six muscles (4xRectus, 2xOblique) & nerves (CN3/4/6) Clinical approach: the six Ps Pain Proptosis Progression Palpation Pulsation Periorbital changes

Thyroid Eye Disease

MOST COMMON CAUSE of unilateral PROPTOSIS in ADULTS
Proptosis = eye sticking out

Can cause: Exposure keratopathy, diplopia, compressive optic neuropathy Inferior, then medial rectus most often affected o CT: thickened muscles with normal tendons

Clinically: see whites of eyes above irides conjunctiva protruding from lids Later: thyroid stare Pathophysiology: largely unknown Autoimmune (thyroid-stimulating IGs mimic TSH, other stuff?) Histology: Mononuclear cells in muscle 1

Orbital Septum

Key anatomic landmark in surgery / trauma Separates true orbit from stuff outside (eyelids, etc)
Arises from periosteum (over superior / inferior orbital rims)

Preseptal Cellulitis
Infection of structures anterior to orbital septum Orbital contents are uninvolved Etiology: Staph, strep mostly Dx: CT / MRI can help Rx: Oral/topical/IV antibiotics, drain abscesses, fix blepharitis

Orbital cellulitis
From spread of infection into orbit through septum (anterior), orbital walls (posterior / medial), or hematogenous Presentation: Proptosis Chemosis (swelling/edema of conjunctiva) Pain with eye movement Frozen globe: mobility restriction (pics) muscles involved! Fever Complications: can track into other areas
Orbital apex syndrome (compressive optic neuropathy, othalmoplegia, blindness) Cavernous sinus thrombosis (cranial nerve palsies brain abscess, death) o WORK UP aggressively if suspected (including LP)

Dx: Rx:

CT or MRI; look for abscesses, foreign bodies, sinusitis

Pic: ethmoid sinusitis (superior/medial) causing proptoic & down/out eye)

IV abx, drain abscesses / sinuses

Eyelids
Skin, subcutaneous tissue Muscles:
Opening (retraction) Levator muscle and aponeurosis Mullers muscles orbicularis oculi Lower lid retractors Rich blood supply to eyelids with multiple anastamoses Lots of blood if eyelids cut Closure (protraction) (CN III) (sympathetics)

Chalazia & Styes

Chalazion Lipogranuloma of Meibomian gland Non-infectious Painless / subacute Meibomian gland (just subtarsal) Usually larger Stye (hordeolum) Bacterial infection of hair follicle Yes Staph / Strep spp Painful (acute) Hair follicle Usually small

Infectious? Painful? Involves Size

Gross / Histology Note lipogranuloma Lots of PMNs

Basal Cell Carcinoma of Lid

Most common eyelid tumor Notched, ulcerated crater Usually on lower lid / medial canthus PALASAIDING of tumor cells Surgical excision > radiation, cryoablation very curable

Histology: Treatment: Prognosis:

Herpes Zoster
Usually affects V1, V2, or V3 Hutchinsons sign: affects V1 down to tip of nose o V2/3 & opposite side spared

Lacrimal gland & Nasolacrimal Drainage System

Lacrimal gland: Responsible for reflexive tearing E.g. crying, NOT basal tearing Drainage: Tears wash across eye Drain into punctae Canaliculi Nasolacrimal sac Nose

Pathology Dacryoadenitis

Nasolacrimal duct occlusion

Dacryocystitis

Infectious, swollen lacrimal gland (esp. in kids)

Nasolacrimal duct closure (e.g. congenital) mucopurlent tears (sac becomes infected)

Infection of nasolacrimal sac Rx with Abx surgery to drain abcess, make new opening 3

Conjunctiva
Filmy, transparent structure Covers whole surface of eye except cornea Bulbar, forniceal, palpebral sections Histology Pseudostratified columnar epithelium o non-keratinized Goblet cells secrete mucin (basal tearing) Stroma (substantia propia) is fibrovascular tissue
o Has lymphocytes, plasma cells, lymphoid aggregates

Conjunctivitis
a.k.a. pinkeye Etiology: Can be bacterial, viral, allergic, toxic (can culture to help determine) Allergic Signs / Sx
Itching Tearing Mild redness Antihistamines Mast cell stabilizers

Toxic
Aminoglycosides Preservatives Anesthetic abuse

Infectious Bacterial
Mucopurulent discharge ( if gonococcal) Papillae, crusting Topical antibiotic (FQ/ TMP). Avoid gentamycin

Viral
Tearing, redness vision Preauricular adenopathy Follicles

Treatment

Cornea
Normally completely transparent (if dry) Made of several layers of stromal & epithelial cells which lay in a clear, compact array Endothelium, epithelium keep stroma dry Creates refractive index (major focus device of eye)

Keratitis
Inflammation of the cornea Can be infectious, immunologic, dry-eye related, toxic, or traumatic Pseudomonas keratitis Herpes simplex keratitis

Infectious keratitis

Dendritic pattern of scarring Complete involvement of stroma Treatable if you get it early; otherwise can resolve into a stromal scar (cloudy) Risk factors for infectious keratitis: dry, cant protect it, or cant feel it Exposure keratopathy (drugs, Bells palsy) dry eye Corneal hypesthesia / anesthesia (previous HSV keratitis, topical anesthetic abuse) Topical corticosteroids From contact lens overwear 4

Other Corneal Pathologies

Central keratolysis (severe dry eye): Central cornea melting

Complete corneal melt (RA)

Keratoplasty to fix (note sutures)

LASIK
Use one laser to create a corneal flap Use another laser to reshape corneal stroma Can use similar idea to treat stromal scarring, etc.

Uveal Tract
Uvea = pigmented portion of eye Iris / ciliary body in front Choroid in back

Iris
Anterior border layer, stroma Sphincter muscle (parasymps: CN 3) Dilator muscle (sympathetics) Pigmented epithelium

Ciliary body
Right next to iris Inner non-pigmented epithelium continuous with retina o Makes aqueous humor Outer pigmented epithelium o continuous with retinal pigment epithelium Zonular fibers (dotted lines) attached to ciliary bodies o Hold lens in place o Ciliary mm pull on lens (accommodation)

Iritis (Anterior Uveitis)

Iris infection can spill WBC into aqueous humor Posterior synechiae can form (adhesions from constant inflammation

Picture: A, B: WBC in aqueous humor C: fibrin filling up chamber D: deposits on lens surface

CMV Retinitis
Can be treated by ganciclovir intraocular drug delivery drug-releasing implant 5

The Angle
Formed by confluence of cornea, iris, ciliary body Functions: filtration, maintenance of intraocular pressure Where aqueous fluid drains Drainage: o From ciliary processes o Exchanges with vitreous o Through angle (lens / iris) into ant. Chamber o Out canal of Schlemm o Through episcleral venous plexus

Glaucoma
Characteristic loss of visual field (nasal, central-sparing, etc.) with specific changes in optic nerve appearance Often (but not always) associated with eye pressure Angle can be open or closed Major cause of vision loss in AAs

Pathophysiology: not totally understood IOP (function of rate of aqueous production, outflow, episcleral venous pressure)
Aqueous production has diurnal fluctuation Outflow affected by blood, inflammatory cells, tumor cells, blockage of meshwork Episcleral venous pressure affected by A-V shunts, body position, head/neck diseases

Screening: measure eye pressure in pretty much everybody

Use applanation tonometry (painless, precise)

Opthalmoscopic findings:
See progressive optic disc cupping in glaucoma C/D ratio with time (notch cup entire nerve affected)

Visual acuity findings: lose nasal vision, central often spared esp. at first Management of glaucoma: Pharmacologic
Aqueous suppressants (-blockers, CAIs) uveoscleral outflow (prostaglandin analogues) -2 agonists

Laser
Argon laser trabeculoplasty Selective laser trabeculoplasty

Surgery
Trabeculectomy Tube shunts

Angle Closure Glaucoma Associated with shape of eye, trauma, big cataracts, scarring Very treatable (laser iridotomy put a hole in it)

Lens
Anatomy: Histology: Function: Embryology: Crystalline lens with capsule, should be transparent, zonular fibers attach to ciliary processes Surrounded by true basement membrane (capsule) Refraction: ciliary body contracts relaxes zonular fibers lens AP Lens vesicle invaginates from surface ectoderm

Accommodation Ciliary body relaxed Zonular fibers tight Lens A-P diameter See far away things

Ciliary body contracted Zonular fibers loose Lens A-P diameter See close things

Cataracts
#1 cause of vision loss worldwide Gross appearance Lens with blobs in it (focal opacities) Yellowing = normal aging change Risk Factors
Age UV light Steroids Trauma Diabetes FHx Radiation Uveitis poor nutrition smoking

Symptoms:

Blurred vision, glare, difficulty driving / reading

Treatment New glasses may be helpful Surgery: extract!

o o Probe uses U/S to break up cataracts into smaller bits, then sucked out with vacuum Need to put intraocular lens implant after surgery (removing old one)

Vitreous Humor
Gel-like substance (97% H2O, a little hyaluronic acid) Function: not well understood Adherent to retina at specific spots o (ora, over blood vessels, around optic nerve)

Vitreous Detachment
Vitreous detaches from retina Little floaters (spots of light) result pulling on retina from inside Retinal breaks can result (if retina stays adherent) 7

Sclera
Collagen of variable diameter arranged in coarse bundles Extraocular muscles attach to sclera Traversed by nerves, blood vessels, o/w avascular o Nourished by episclera, uveal tract Continuous with dura around optic nerve

Sclera is what the cornea would look like if it werent dry

Scleritis
Inflammation of the sclera

Can be so thin that you see blue choroid (uvea) underneath

Associated with RA / inflammatory conditions Can be thickened in idiopathic scleritis Inflammatory infiltrate on histology

Retina
Anatomy: Lots of Layers Inner retina Outer retina
Inner limiting layer Nerve fiber layer Ganglion cell layer Inner plexiform layer Inner nuclear layer Outer plexiform layer Outer nuclear layer External limiting membrane Photoreceptors (rods and cones) Retinal pigment epithelium

Blood supply
Note that branches of arterioles dont cross each other (horizontal raphe)

Light passes through lots of layers before hitting the rods & cones Fovea: area of mostly cones (and rods), inner retina pushed away Small area of best sight (central vision)

Pathology of the Retina

Infectious Retinitis Embolic disease

CMV retinitis in AIDS: mixed hemorrhage & necrosis with optic nerve infiltrations; edema too

HIV retinopathy: see cotton wool spots (L)

Histology: edema of nerve fiber layer; normal underlying architecture

Retinal artery occlusion

AMD: Age-related Macular Degeneration

Diabetic Retinopathy

Non-neovascular (dry) AMD

Drusen (L) ; atrophy is hallmark (R)

Neovascular (wet) AMD:

hemorrhage, lipid exudates under retina; severe central vision loss

This is non-proliferative: blood vessels leak, deposit in retina (hard exudate blood cells, plasma)

Choroid (Posterior Uvea)

Outer pigmented layer Outer layer of larger vessels, middle layer of smaller vessels Choriocapillaris: o fenestrated endothelium o Cubic arrangement with central feeder vessels o Lobular blood supply

Choroidial Tumors
Choroid is really vascular tumors can seed here a lot Examples o Lump sticking into vitreous metastatic breast cancer (L) o Choroidal melanoma (R)

Choroiditis
Often goes with vasculitis Example: pseudomonas infection in AIDS (pic)

Coloboma
Optic cup (becomes sclera) from prosencephalon Forms from flat sheet invaginates has to close fissure If the choroidal fissure doesnt close, get a coloboma can look like a notch in iris, or be posterior imperfection in choroid

Optic Nerve
about 3-4mm (15 nasal to fovea), usually 1.7mm vertical, 1.5mm horizontal No photoreceptors overlying disc (blind spot) Central cup is free of nerve fibers Nerve fibers: 1.4 M in all, about as long as a nerve could be inside the head!
Visual lateral geniculate (LGN thalamus) optic radiations occipital ctx Pupillomotor edinger-westphal nucleus

Blood supply: rich Outside supply from short posterior ciliary aa Inner supply from central retinal artery (what you see with opthalmoscope)

Optic nerve Pathology

Optic nerve compression Optic disc edema = papilledema

Here in Wegners granulomatosis (orbit filled with fluid) Also proptosis in this case

Papilledema: ICP disc edema Compressed nerve: swollen disc, congested Cant see vasculature, optic disc has lack of definition 9

Optic nerve Histology

Extension of brain Myelination begins posterior to lamina cribosa (nerve thickens) Interstitial cells: o oligodendrocytes (myelin) o astrocytes (nutrition) o microglia (phagocytes) Fibrovascular pia mater septa around myelinated nerve bundles

Visual Fields
Good functional test of optical nerve

Normal (L eye) note blind spot Remember this chart:

Suprotemporal deficits in both eyes (like pt is looking at you)

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