To Ali and Harry

© BMJ Books 1999

BMJ Books is an imprint of the BMJ Publishing Group

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechalnical, photocopying, recording and/or
otherwise, without the prior written permission of the publishers

First published in 1994 under the title: MCQs in Basic Science Opthalmology
by the BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR

First edition 1994

Second edition 1999
Second impression 2002
Third impression 2005

British Library Cataloguing in Publication Data

A catalogue record for this book is available

from the British Library

ISBN-10: 0-7279-1377-8
ISBN-13:978-07279-1377-7

Typeset by Latimer Trend & Company Ltd, Plymouth

Printed and bound by Replika Press Pvt. Ltd, India

1
Contents

Foreword ix
Preface xi
Acknowledgments xiii

1. Ocular anatomy 1
1.1 The orbit and paranasal sinuses 1
1.2 The lacrimal system 6
1.3 The eyelids 11
1.4 The conjunctiva 15
1.5 The cornea 17
1.6 The ciliary body 23
1.7 The iris 25
1.8 The lens 30
1.9 The choroid and sclera 33
1.10 The retina 36
1.11 The visual pathways 43
1.12 The extraocular muscles 50
1.13 The cranial nerves 54
1.14 Orbital vasculature and the cavernous sinus 60
Answers 66

2. Neuroanatomy and head and neck anatomy 67

2.1 Neuroanatomy 67
2.2 Autonomic nervous system of the head and neck 88
2.3 Skull osteology 93
2.4 Head and neck anatomy 97
Answers 106

3. Genetics 108
3.1 Gene expression and cell division 108
3.2 Mutations and patterns of inheritance 113
3.3 Molecular biological techniques 124
Answers 128

2
Microbiology 129
4.1 General bacteriology 129
4.2 Cocci 135
4.3 Bacilli 138
4.4 Chlamydiae and spirochaetes 144
4.5 General virology 148
4.6 Herpes viruses 152
4.7 Airborne and enteric viruses 157
4.8 Retroviruses 161
4.9 Hepatitis B virus, human papilloma viruses and
molluscum contagiosum 166
4.10 Fungi 170,
4.11 Parasites 174
4.12 Antimicrobial agents 180
Answers 190
. Pathology 191
5.1 Inflammation and wound healing 191
5.2 General immunology 208
5.3 Ocular immunology 226
5.4 Hypersensitivity reactions 231
5.5 Transplantation immunology 235
5.6 Thrombosis and atherosclerosis 238
5.7 Cell growth, cellular interaction, and cell death 246
5.8 Neoplasia 258
Answers 267
>. Pharmacology 269
6.1 Pharmacokinetics 269
6.2 Cholinergic agonists 272
6.3 The adrenergic system 276
6.4 Ocular hypotensive drugs 280
6.5 Corticosteroids and non-steroidal
anti-inflammatory drugs (NSAIDs) 283
6.6 Ocular anaesthetics 287
Answers 288

1. Ocular physiology 289

7.1 The lacrimal apparatus 289
7.2 The eyelids 294

3
4. The cornea 297
5. The aqueous and intraocularpressure 305
6. The lens 317
7. Accommodation 324
8. The vitreous 328
9. The pupil 332
10. The extraocular muscles and eye movements 342
11. The retina 351
12. Electrodiagnostic tests 375
13. The visual pathway 387
14. Visual acuity and adaptation 392
15. Colour vision 408
16. Binocular vision and stereopsis 412
Answers 418
1.2.1 General physiology 420
1.2.1 Cardiovascular physiology 420
1.2.1 Respiratory physiology 427
1.2.1 Endocrinology 431
1.2.1 Renal physiology 440
1.2.1 Muscle physiology 448
1.2.1 The central nervous system 454
Answers 457
1.2.2 Statistics and epidemiology 458
Answers 465
Index 467

4
Foreword

Multiple choice examinations remain a favorite method of testing knowledge of the basic sciences
allied to ophthalmology. Although questions and viva voce examinations are often components of
examinations on a worldwide basis, it is often the multiple choice examination in basic sciences
that will stretch the knowledge of candidates. The advantages of this method of examination is
that there can be a wide coverage in a short period of time, the marking is objective, feedback can
be precise and computers can be employed in marking. There are also disadvantages; for example,
it can be difficult to set questions where the science is not yet fully described. Students will
sometimes complain that in such situations there may be a lack of clarity which adds to the
difficulty in
answering positively or negatively.
In spite of the objectivity of such methods it is known that skill and strategy are an important
component in determining success or failure. Hence the need for a manual that illustrates the kind
of questions that may appear. For those in particular who have not
been exposed to the manual, it has expanded since the first edition into neuroanatomy, genetics
and statistics in epidemiology. The series of probing questions are informative and practical in
understanding and practising techniques that are involved in the
construction of multiple choice questions and answers.
The text will serve to refresh memories and to perhaps identify areas of individual weakness.
John Ferris has collected an impressive array of questions that will be a useful revision in the
basic sciences particularly in view of the lucid descriptions of the ideal answers to the questions,
which have been added. It cannot be regarded as a short cut to the process of learning from text,
lectures and practical experience but it will almost certainly indicate to the candidates themselves
whether the time is appropriate for them to
sit their examinations.

David Easty
Professor of Ophthalmology,
University of Bristol

5
Preface

Since the publication of MCQs in Basic Science Ophthalmology in 1994 there

have been many advances in the basic sciences related to ophthalmology. This
edition aims to touch upon all of the basic sciences related to ophthalmology and to
highlight developments
in the rapidly changing fields of immunology, genetics, wound healing and ocular
biochemistry.
As with the first edition the answers to the questions, along with additional
information, have been incorporated into summary questions and together they
form a concise synopsis of the topic covered in each chapter. Simple diagrams
have also been used extensively to complement the text.
Although this book will primarily be of interest to ophthalmologists in training
who are preparing for basic science examinations, I hope it will also have
something to offer those
who have completed their training. With the current emphasis on continuing
medical education and the introduction of specialist reaccreditation, there is a need
for ophthalmologists to be familiar with advances in the basic sciences as they
relate to ophthalmology. These changes are not remote from clinical
ophthalmology; in fact many have had, and will continue to have, a direct
influence on our clinical practice. This book will I hope provide an enjoyable
means by which ophthalmologists may refresh their knowledge of established
concepts and familiarise themselves with the more recent developments in the
ocular basic sciences.
John Ferris

6
Acknowledgments
My special thanks go to:

Keith Martin for rewriting the sections on Visual acuity and adaptation,
and Colour vision (original written by Professor G.
(Arden);

Richard Sheard for writing the Statistics and epidemiology chapter;

Alison Currie who along with Keith Martin and Richard Sheard
proofread the manuscript;

Finally, I would like to thank all of those ophthalmologists who cook the
trouble to write to me with their comments, criticisms and corrections
many of which I have tried to incorporate into this edition.

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 1. Ocular anatomy
1.1 The orbit and paranasal sinuses
1.1.1 Orbit

a. The lateral wall is formed by the frontal and zygomatic bones.

b. The palatine bone lies in the medial wall.
c. The superior orbital fissure is in the lesser wing of the sphenoid bone.
d. Whitenall‘s tubercle is found on the zygomatic bone.
e. The roof is made solely from the frontal bone.

The bony orbit is a pear-shaped cavity that is made from constituents of seven
individual bones. The thin orbital floor is formed primarily by the orbital plate of
the maxilla with contributions from the zygomatic and palatine bones. The lateral
wall is formed by the zygomatic bone (on which lies Whitnall‘s tubercle) and the
greater wing of the sphenoid posteriorly. The orbital roof is formed predominantly
by the orbital plate of the frontal bone with contributions from the lesser wing of
the sphenoid bone. The maxilla, lacrimal, ethmoid and body of the sphenoid all
contribute to the thin medial wall of the orbit. The superior orbital fissure at the
orbital apex lies between the greater and lesser wings of the sphenoid bone.

1.1.2 Relations and connections of the orbit

The orbit:
a. Is separated from the ethmoidal air cells by the lamina papyrecia.
b. Is connected to the pterygopalatine fossa by the inferior orbital foramen.
c. Is in communication with the middle cranial fossa via the superior orbital
fissure.
d. Lies superior to the maxillary sinus.
e. Is connected to the middle meatus via the nasolacrimal duct.

8
The orbit has a number of important relations with the paranasal sinuses. It is separated from the
ethmoidal air cells by the lamina papyrecia, and ethmoidal mucoceles may break through this
thin barrier causing proptosis of the globe. Fractures of the orbital floor may result in herniation
of orbital contents into the maxillary sinus, e.g. blowout fractures. The orbit is connected to the
pterygopalatine fossa via the inferior orbital fissure and to the middle cranial fossa via the
superior orbital fissure. The nasolacrimal duct connects the orbit to the inferior meatus of the
nose.

1.1.3 Contents of the orbital fissures and canals

a. The optic nerve, ophthalmic artery and vein ere all found in the optic canal.
b. The lacrimal nerve passes through the superior orbital fissure outside the tendinous ring.
c. The abducent nerve passes through the superior orbital fissure outside the tendinous ring.
d. The inferior orbital fissure transmits branches of the maxillary nerve.
e. The oculomotor nerve divides after passing through the superior orbital fissure.

9
The optic canal contains die optic nerve (with its meningeal coverings)
and the ophthalmic artery, the ophthalmic vein being found in the superior orbital fissure. The
lacrimal, frontal and trochlear nerves pass through the superior orbital fissure above the
tendinous ring, whereas the nasociliary, abducent and both divisions of the oculomotor nerve
pass through the superior orbital fissure inside the tendinous ring. The inferior orbital fissure is
continuous with the infraorbital canal and transmits branches of the maxillary nerve, plus an
emissary vein connecting the ophthalmic vein to the pterygoid plexus.

1.1.4 Paranasal sinuses

a. All air sinuses, except the ethmoidal sinuses, are normally present at birth.
b. Sinuses are lined by a stratified squamous epithelium.
c. The maxillary sinus drains via the hiatus semilunaris.
d. The sphenoidal sinus drains into the superior meatus of the nose.
e. Ethmoidal sinuses drain into the middle and superior meatuses of the nose.

10
All paranasal sinuses are normally present at birth (apart from the frontal sinus which is
rudimentary until 2 years of age). All sinuses are lined by a pseudostratifieci columnar ciliated
epithelium, which aids the passage of mucus into the nasal cavity. The maxillary sinus drains via
the hiatus semilunaris into the middle meatus of the nose. The anterior and middle ethmoidal air
cells, along with the frontal air cells, also drain into the middle meatus of the nose. The posterior
ethmoidal air cells drain into the superior meatus whereas the sphenoidal air cells drain into the
sphenoethmoidal recess.

11
1.1.5 Innervation and lymphatic drainage of the paranasal sinuses
a. The ophthalmic division of the trigeminal nerve innervates the frontal sinuses.
b. Branches of the nasociliary nerve provide the majority of the innervations to the ethmoidal
sinuses.
c. The maxillary sinus is innervated by the infraobital, anterior, middle and posterior superior
alveolar nerves.
d. Lymph from the maxillary sinus drains to retropharyngeal nodes.
e. Lymph from the frontal sinus drains to submandibular nodes

A knowledge of the paranasal sinuses‘ innervation explains the distribution of referred pain from
sinus infection. The frontal sinus is innervated by the supraorbital nerve (a branch of the
ophthalmic division of the trigeminal), which also supplies the skin of the forehead and scalp, so
explaining the distribution of referred pain in patients with frontal sinusitis. Likewise, maxillary
sinusitis may cause referred pain in the upper teeth and the skin of the cheek because of their
innervation by the infraorbital, anterior, middle, and posterior superior alveolar nerves. The
ethmoidal sinuses are supplied by the anterior and posterior ethmoidal nerves, and by branches
of the pterygopalatine ganglion. All lymph drainage from the paranasal sinuses is to the
submandibular nodes, except the sphenoidal sinuses and posterior ethmoidal sinuses which drain
into the retropharyngeal group of nodes.

12
1.2: The lacrimal system
1.2.1 Lacrimal gland structure

a. The lacrimal gland consists of two equally sized lobes.

b. The lacrimal gland lies within a definitive capsule.
c. The lacrimal ducts open into the superior fornix via the palpebral lobe.
d. The gland lies wholly behind the orbital septum.
e. The two lobes of the gland are separated by the levator muscle.

The lacrimal gland is a bilobed gland, possessing no definitive capsule, which lies
superotemporally in the orbit behind the orbital septum. The orbital lobe is the larger of die two
and is continuous with the smaller palpebral lobe around the lateral border of the levator
palpebrae aponeurosis. The palpebral lobe lies below the aponeurosis and extends into the upper
eyelid. Lacrimal ducts arising in .the orbital lobe pass through the palpebral lobe and into the
superior fornix of the conjunctiva, along with additional ducts that arise from the palpebral part
of the gland.

1.2.2 Parasympathetic innervations of the lacrimal gland

a. Preganglionic secretomotor fibres arise in the superior salivatory nucleus.
b. Preganglionic fibres travel in the nervus intermedius.
c. Preganglionic fibres approach the pterygoid canal in the lesser petrosal
nerve.
d. Preganglionic fibres synapse in the ciliary ganglion.
e. Preganglionic fibres ―hitchhike‖ to the gland on branches of the maxillary
. and ophthalmic nerves

The parasympathetic supply to the lacrimal gland arises in the superior salivatory nucleus, one of
the parasympathetic brain stem nuclei. Fibres travelling in the nervus intermedius leave the
middle ear as the greater petrosal nerve, which enters the

13
middle cranial fossa. The greater petrosal and deep petrosal nerves combine in the pterygoid
canal, which opens into the pterygopalatine fossa. The preganglionic fibres synapse in the
pterygopalatine ganglion, and postganglionic fibres ―hitchhike‖ along the infraorbital,
zygomaticotemporal and lacrimal nerves to the lacrimal gland.

1.2.3 Lacrimal gland histology

a. The lacrimal gland is a lobulated tubuloacinar structure.

b. Acinar cells have an apically located nucleus.
c. Acinar cells are rich in rough endoplasmic reticulum, golgi apparatus and
mitochondria.
d. Large ducts are surrounded by myoepithelial cells.
e. Large ducts have a single layered epithelium.

The lacrimal gland is a tabulated tubuloacinar gland. Acinar cells, which have a predominantly
serous secretion, are characterised by their basally located nuclei and are rich in rough
endoplasmic reticulum, golgi apparatus, and mitochondria. A

14
basement membrane separates these cells from the surrounding myoepithelial cells. The larger
intralobular ducts have a two layered epithelial lining whereas smaller ducts are lined only by a
single layer of cuboidal cells. Both are ringed by myoepithelial cells, which have contractile
properties.

1.2.4 Lacrimal drainage

a. Lacrimal canaliculi run horizontally throughout their length and measure 10 mm.
b. The common canaliculus pierces the lacrimal sac 2.5 mm below its apex.
c. The common canaliculus lies in front of the medial palpebral ligament.
d. The lacrimal canaliculi may enter the sac separately.
e. The lacrimal canaliculi are surrounded by fibres of the orbicularis oculi.

A knowledge of lacrimal canaliculus anatomy is important when conducting lacrimal probing.

The canaliculi are L shaped structures with a short (2 mm) vertical portion and a longer (10 mm)
horizontal portion. They normally unite to form a common canaliculus, which lies behind the
medial palpebral ligament and pierces the lacrimal sac 2.5 mm below its apex. On occasions the
canaliculi may enter the sac separately. The lacrimal canaliculi are surrounded by fibres
continuous with1 the palpebral component of the orbicularis oculi, which by its contraction aids
the pumping action of tears from the lacrimal canaliculi into the lacrimal sac.

15
1.2.5 Lacrimal sac and nasolacrimal duct
a. The lacrimal sac lies in a fossa bound solely by the lacrimal bone.
b. The sac is surrounded by a fascial sheath.
c. The sac is lined by columnar cells.
d. The nasolacrimal duct is membranous.
e. The nasolac5imal duct passes downwards, backwards and medially.

The lacrimal sac lies in the lacrimal fossa formed by the lacrimal bone, the frontal process of
maxilla, and the lacrimal fascia. The sac is covered by a fascial sheath only between the anterior
and posterior lacrimal crests and is separated from the sac by a venous plexus. The lacrimal sac
is lined by columnar cells

16
and is continuous with the nasolacrimal duct. The duct is a membranous structure that passes
downwards, backwards and laterally in an osseous canal to enter the inferior meatus of the nose.

1.2.6 Relations of the lacrimal sac and nasolacrimal duct

a. The medial canthal tendon liesanterior to the lacrimal sac.
b. The lacrimal sac lies lateral to the ethmoidal air cells.
c. The angular vein lies anterior to the lacrimal sac.
d. The nasolacrimal duct is formed by the maxilla and the lacrimal bone.
e. The nasolacrimal duct opens into the inferior meatus.

The lacrimal sac has a number of important relations, which must be considered in procedures
such as a dacryocystorhinostomy. The medial canthal tendon (also known as the medial
palpebral ligament) lying anterior to the sac may be divided in this procedure but care should be
taken to avoid another important anterior relation—the angular vein, which lies 8 mm medial to
the medial canthus. The ethmoidal air cells lying medial to the lacrimal sac may be entered
inadvertently if the lamina papyracea is breached during surgery. The osseous canal for the
nasolacrimal duct is formed by the maxilla, the lacrimal bone, and the inferior nasal concha; it
opens into the inferior meatus of the nose.

17
1.3: The eyelids

1.3.1 Orbital septum and tarsal plates

a. The orbital septum is continuous with the periosteum at the orbital margins.
b. The orbital septum lies anterior to the medial but posterior to the lateral palpebral
ligaments.
c. The upper tarsal plate measures 5 mm centrally.
d. the medial palpebral ligament connects the tarsi to the anterior lacrimal crest.
e. The lateral palpebral raphe connects the tarsi to the marginal tubercle.

The orbital septum is continuous with the periosteum at the orbital margins and is ―buttonholed‖
centrally to form the palpebral fissure. Above and below the palpebral fissure the septum is
thickened, forming upper and lower tarsal plates. The upper tarsal plate measures 10 mm
centrally and the lower tarsal piate 5 mm. Both are connected to the anterior lacrimal crest by the
medial palpebral ligament and to the marginal tubercle by the lateral palpebral ligament. Xhe
lateral palpebral raphe lies anterior to the ligament and consists of interlacing fibres from the
palpebral part of orbicularis oculi.

1.3.2 Eyelid structure

a. The orbital septum is continuous with the periosteum at the orbital margins.
b. The orbital septum lies anterior to the medial but posterior to the lateral palpebral
ligaments.
c. The upper tarsal plate measures 5 mm centrally.
d. the medial palpebral ligament connects the tarsi to the anterior lacrimal crest.
e. The lateral palpebral raphe connects the tarsi to the marginal tubercle.

In cross section the eyelids are seen to be made up of a number of layers (running from
superficial to deep): skin, subcutaneous tissue, striated muscle fibres of the orbicularis oculi,
neuro-

18
vascular bundle, the orbital septum tarsal plates, and the conjunctiva. The Meibomian glands are
embedded in thin tarsal plates and number approximately 35 in the upper lid and 25 in the lower
lid. These glands (which produce a sebaceous secretion) open behind the lash follicles, whereas
the sebaceous glands of Zeis open into each follicle. The glands of Moll are modified sweat
glands. The conjunctiva becomes continuous with the keratiniSed skin epithelium along the
posterior margins of the tarsal gland openings and not at the grey line, which lies anterior to
these openings. The grey line marks the tissue plane along which the eyelid may be split into an
anterior lamella consisting of skin, subcutaneous tissue and orbicularis, and a posterior lamella
consisting of the tarsal plate and conjunctiva.

19
1.3.3 Levator function

a. The aponeurosis inserts only into the tarsal plates.

b. Muller‘s muscle arises from the superior aspect of the levator muscle.
c. The levator in an adult can raise the lid by approximately 15 mm.
d. The levator palpebrae superioris is innervated by a branch of the oculomotor nerve
which has passed through the superior rectus.
e. Muller‘s muscle is innervated by sympathetic fibres from the superior cervical
ganglion

The levator palpebrae superioris originates above the tendinous ring and passes forward above
the superior rectus before fanning out into a broad aponeurosis. The bulk of the aponeurosis
descends into the upper lid behind the orbital septum, which it pierces before attaching to the
superior tarsal plate. Some additional fibres pass forward between the fibres of orbicularis oculi
and attach to the skin to form the primary lid crease. The muscle is innervated by a branch of the
oculomotor nerve, which innervates and then passes through the superior rectus en route to the
levator. In the normal adult the levator is able to raise the upper lid by approximately 15 mm.
The levator is assisted by Muller‘s muscle, which arises from the inferior aspect of the
aponeurosis. This smooth muscle is inserted into the upper edge of the superior tarsal plate and is
innervated by sympathetic fibres arising from the superior cervical ganglion.

1.3.4 Orbicularis oculi

a. Is a second branchial arch structure.

b. The orbital portion is responsible for reflex blinking.
c. The palpebral part extends from the medial palpebral ligament to the lateral
palpebral ligament.
d. The palpebral part lies in front of the orbital septum.
e. The orbital part is involved in the lacrimal pump.

20
Orbicularis oculi is a muscle of facial expression that is derived from the second branchial arch
and is therefore supplied by a branch of the facial nerve. The palpebral part of the muscle that
lies on either side of the palpebral fissure extends from the medial palpebral ligament to the
lateral palpebral raphe. It lies in front of the orbital septum and, because of its intimate
involvement with the lacrimal canaliculi, is involved in the pumping action of tears from the
conjunctiva to the lacrimal sac. The palpebral portion of the muscle is also responsible for reflex
blinking (as opposed to the orbital portion, which ―screws‖ the eyelids tightly together).

1.3.5 Blood supply, lymphatic drainage and innervation

a. The upper eyelids are supplied by branches of the ophthalmic artery.
b. Anastomoses between the internal and external carotid systems exist in the eyelids.
c. Venous drainage medially is via ophthalmic and angular veins.
d. Lymph from the lateral two-thirds of the upper and lower lids passes to the
submandibular nodes.
e. Nerves from the ophthalmic and maxillary divisions of the trigeminal innervate the
lower lid.

The lateral palpebral arteries (derived from the lacrimal artery) and the medial palpebral arteries
(arising from the ophthalmic artery) are the main arterial supplies to the eyelids. M.ost of the
venous drainage passes medially to the ophthalmic and angular veins, the lateral aspects draining
into the superficial temporal vein. Anastomoses between the facial artery (derived from the
external carotid) and the palpebral arteries (derived from the internal carotid) are present at the
lateral aspect of the eyelids. Lymph from the lateral two-thirds of the upper and lower lids drains
to the superficial parotid nodes; more medial lymphatic drainage is to the submandibular nodes.
The lower lid receives most of its innervation from the infraorbital division of the

21
maxillary nerve but its medial aspect is supplied by the infratrochlear nerve, a branch of the
ophthalmic division of the trigeminal nerve.

1.4 The conjunctiva

1.4.1 Structure

a. The palpebral coniunctiva adheres firmly to 5the tarsal plates.

b. The fornical coniunctiva is attached to the fascial expansions of the extraocular muscle
sheaths.
c. The bulbar coniuctiva is closely attached to the sclera.
d. The lateral fornix extends posteriorly to the equator.
e. The conjunctival limbus lies 1 mm posterior to the scleroco

The conjunctiva may be divided in anatomical terms into palpebral and bulbar components,
which are continuous at the fornices. ―The palpebral conjunctiva is firmly adherent to the tarsal
plates. The fomical conjunctiva is attached to the fascial expansions of the extraocular muscle
sheaths, allowing tine conjunctiva to be drawn upwards or downwards as the recti contract. The
superior fornix is situated 10 mm from the limbus and the inferior 8 mm from the limbus. The
lateral fornix extends

22
14 mm from the limbus, passing posteriorly to the equator of the globe. The bulbar conjunctiva
lies loosely over the sclera and joins with the comeal epithelium 1 mm anterior to the
sclerocomeal limbus.

1.4.2 Blood supply and innervation

a. The tarsal conjunctiva is mostly supplied by t5he medial and lateral palpebral arteries.
b. The limbal conjunctiva is supplied by branches of the anterior ciliary arteries.
c. Conjunctival vessels cannot be constricted by topical adrenaline.
d. Conjunctival veins may drain directly into the superior or inferior ophthalmic veins.
e. The bulbar conjunctiva is innervated by the long ciliary nerves.

The medial and lateral palpebral arteries divide to form marginal and peripheral arcades in both
lids and are the main blood supply to the palpebral conjunctiva. The peripheral bulbar
conjunctiva is supplied by branches from the peripheral arcade but the limbal conjunctiva is
supplied mainly by branches from the anterior ciliary arteries. As these vessels lie superficially
they will, unlike the episcleral vessels, be constricted by topical adrenaline. Conjunctival veins
may drain directly into the superior or inferior ophthalmic veins; this explains their gross dilation
in conditions such as cavernous sinus thrombosis. The bulbar conjunctiva is innervated by the
long ciliary nerves, which are branches of the nasociliary division of the ophthalmic nerve.

1.4.3 Histology

a. The conjunctiva is a mucous membrane.

b. The bulbar epithelium is suanned sqnamous.
c. The lamina propria forms papillae at the limbus.
d. Goblet cells are most common on the rarsal conjunctiva.
e. Accessory lacrimal tissue is found in the bulbar conjunctiva.

23
The conjunctiva is a mucous membrane consisting of an epithelium and underlying lamina
propria. The stratified squamous epithelium of the palpebral conjunctiva becomes a stratified
columnar layer in the bulbar region before again becoming stratified squamous in continuation
with the corneal epithelium. Another change found at the limbus is that papillae are formed by
the lamina propria. The goblet cells responsible for the inner layer of the tear film are most
commonly found in the inferonasal bulbar conjunctiva. Accessory lacrimal tissue is found
throughout the bulbar conjunctiva.

l.5: The cornea

1.5.1 Corneal embryology
a. Development of the cornea precedes separation of the lens cup from surface
ectoderm.
b. The corneal stroma is derived from the surface ectoderm.
C The epithelium and endothelium are derived from the surface ectoderm.
d. The corneal diameter is determined by the optic cupdiameter.
e. The fetal cornea is transparent.

Corneal development begins at day 33 of gestation, after the lens cup has separated from the
surface ectoderm. The corneal epithelium is derived from surface ectoderm, whereas the
endothelium and fibroblasts that produce the comeal stroma are derived from neural crest cells.
The final diameter of the cornea is determined by the diameter of the optic cup. The fetal cornea
is very hydrated compared to the adult form and is therefore translucent rather than transparent.

24
1.5.2 Milestones in corneal development

a. The stroma is the first layerto develop.

b. The endotheliumis initially a bilayered structure.
c. Descemet‘s membrane is presentat 3 months‘ gestation.
d. Corneal nerves are present at 5 months.
e. The adult form of the cornea is present at 5 months.

The initial step in comeal development is the production of a bilayered epithelium and basement
membrane separate from a bilayer (or occasionally a trilayer) of endothelial cells and associated
basement membrane- At approximately 7 weeks* gestation a primitive stroma is formed., which
is infiltrated by fibroblasts producing; collagen fibrils. By the third month the stroma is a
structure of 25—30 layers3 a thin Descemet‘s membrane is present and the endothelium is now a
single layer. By 5 months the corneal nerves are present and at 7 months the cornea has reached
its adult form.

1.5.3 Gross structure

a. The vertical diameter of the cornea is greater than its horizontal diameter.
b. The antcrior radius of curvature is greater than the posterior radius of curvature.
c. The cornea is more curved in the vertical meridian.
d. The central region of the cornea is 1 mm thick.
e. The cornea‘s refractive index is 1.30.

The cornea does not form a perfect sphere^ as its average horizontal diameter (11.7 mm) is
greater than its average vertical diameter (10.6 mm). The radius of curvature of the anterior
surface of the cornea is approximately 7.8 mm whereas that of the posterior surface is 6.5 mm.
As a rule the vertical meridian is more curved than the horizontal. The cornea measures 1.1 mm
at the limbus and thins to 0.5 mm centrally. The refractive index of the cornea is 1.36 (as
opposed to the aqueous humour, which has a refractive index of 1.33).

25
1.5.4 Fine structure

a. The cornea is a five-layered structure.

b. The corneal epithelium is approximately 10 cells thick at the limbus.
c. Bowman‘s layer is the basement membrane of the epithelium.
d. Gorneal stroma accounts for approximately 60% of total corneal thickness.
e. Descemet‘ smembrane is the basement membrane of the endothelium.

The cornea is a five-layered structure consisting of an epithelium. Bowman‘s membrane, the

stroma (or substantia propria), Descemet‘s membrane and an endothelium. The epithelium is a
stratified structure whose superficial cells are flat and become more columnar in the deeper
layers. Centrally the epithelium consists of five layers of cells, but this may increase to ten at the
limbus. Bowman‘s layer is an acellular layer consisting of interwoven collagen fibres but it is not
the basement membrane of the epithelium. Corneal stroma, made up of collagen fibres arranged
in a regular lattice, account for 90% of the total corneal I. thickness. Descemet‘s membrane,
which is made of collagen fibres arranged in a hexagonal pattern, is the basement membrane of
the cornea.

26
1.5.5 Epithelium and endothelium
a. Both layers have macrovilli.
b. Basal cells of the epithelial and endothelial layers are columnar.
c. Adiacent cells are linked by hemidesmosomes.
d. Epithelial and endothelial cells are capable of regeneration.
c. Both layers are continuous with the conjunctiva.

The corneal epithelium is a multilayered structure but the endothelium is composed of a single
layer of cells. The basal epithelial cells of the epithelium are columnar; the endothelial cells are
cuboidal. Both surface epithelial and endothelial cells possess microvilli. Adjacent cells in both
layers are linked by desmosomes; hemidesmosomes connect the cells to their respective
basement membranes. Only the corneal epithelium is capable of regeneration, which occurs at
the limbus with migration of epidielial cells to cover any defect. The corneal epithelium is
continuous with that of the conjunctiva and the endothelium continues as a lining to the
passageways of the trabecular meshwork.

27
1.5.6 Coneal innervation

a. Innervation is via the long ciliary nerves.

b. the annular plexus consists of myelinated fibers.
c. Fibres travel in the stroma before piercing Bowman‘s layer.
d. Intraepithelial nerves are unmyelinated.
e. The cornea is sensitive to pain, heat and cold.

The cornea is predominantly innervated by the long ciliary nerves, which are branches of the
ophthalmic division of the trigeminal nerve. They initially form an annular plexus of myelinated
fibres at the corneal limbus with radial branches extending from this plexus in the corneal stroma
to form a subepithelial plexus. Divisions from this plexus pierce Bowman‘s layer to form an
intraepithelial plexus of unmyelinated nerves. Cold and pain are the only stimuli of the corneal
epithelium.

1.5.7 Corneal limbus

a. The cornea becomes continuous with the sclera at the corneal limbus.
b. The surgical limbus lies slightly anterior to the anatomical limbus.
c. the corneal limbus lies 1 mm posterior to the conjunctival limbus.
d. The endothelium forms the palisades of Vogt at the limbus.
e. The groove on the inner surface of the corneal limbus contains the trabecular
meshwork.

The limbus or corneoscleral junction measures 1.5—2 mm in width and is the point at which the
cornea becomes continuous with the sclera (this is 1 mm posterior to the conjunctival limbus).
The anatomical limbus is defined by Schwalbe‘s line and lies slightly posterior to the surgical
limbus. The outer surface is marked by a similar groove (the internal scleral sulcus) that contains
the trabecular meshwork and the canal of Schlemm.

28
The palisades of Vogt are formed by epithelial cells, which are thrown into folds by the
subepithelial connective tissue at the limbus.

1.5.8 Angle anatomy

a. Schwalbe‘s line marks the end of Descemet‘s membrane.
b. The endothelium is continuous with cells lining the trabecular meshwork.
c. Schlemm‘s canal lies within the internal sclera sulcus.
d. Schlemm‘s canal is directly connected to trabecular meshwork passages.
e. The sclera spur lies posterior to Schlemm‘s canal.

Schwalbe‘s line marks the end of Descemet‘s membrane and the trabecular meshwork begins
just posterior to this. The trabecular meshwork is attached to the scleral spur, which also contains
the canal of Schlemm. The passageways of the trabecular meshwork are lined with endothelium
but they are not in direct communication with the canal of Schlemm and aqueous is thought to
pass between the two in giant vacuoles found in the cytoplasm of the endothelial cells.

29
1.6: The ciliary body
1.6.1 Embryology
a. The ciliary epithelium is derived from neuroectoderm.
b. Epithelial differentiation occurs at 4-6 months of gestation.
c. Ciliary processes are formed at 3 months.
d. The primitive ciliary muscle is visible at 2 months.
e. the sclera spur is fully developed at term.

The ciliary body is derived from neuroectoderm and mesenchyme. The ciliary epithelium is
formed from the anterior edge of the optic cup but does not differentiate like the rest of the
retina. At approximately 3 months‘ gestation this epithelium is thrown into folds, forming the
ciliary processes, and from the fourth to sixth month differentiation occurs to produce tight
junctions and interdigitations. The ciliary stroma is formed from mesenchyme lying between the
optic cup and the cornea, with primitive muscle becoming visible at 3 months. During the fourth
month a primitive scleral spur appears which is not fully formed until after the first year of life.

30
1.6.2 Ciliary body structure

a. The cilliary body consists of the ciliary stroma, epithelium, and muscle.
b. It is continuous with the choroid posteriorly at the pars plicata.
c. The ciliary body is continuous anteriorly with the peripheral iris.
d. Ciliary processes aris from the pars plana.
e. the lens zonule attaches to the ciliary processes.

The ciliary body is a circular structure composed of the ciliary stroma, a bilayered epithelium
and the ciliary muscle. It is continuous with the choroid posteriorly at the pars plana and with the
peripheral iris anteriorly. The ciliary processes found at the pars plicata are regions of epithelium
that have been thrown into folds and form lie attachments for the zonular fibres of the lens.

1.6.3 Ciliary epithelium

a. The ciliary epithelium is a bilayered cubcidal epithelium.

b. The inner layer is pigmented
c. The outer layer cells are rich in golgi apparatus and rough endoplasmic reticulum.]
d. The two cell layers lie apex to apex.
e. The basement membrane of the inner layer is continuous with the basement
membrane of the retinal pigment epithelium.

The ciliary epithelium is a bilayered cuboidal epithelium that forms an integral part of the blood
aqueous barrier. The two cell layers lie apex to apex, the inner layer being rich in golgi apparatus
and rough endoplasmic reticulum while the outer layer contains numerous melanocytes. There
are numerous tight junctions between the cells of the inner layer but not between cells of the two
layers. The basement membrane of the inner layer is continuous with the internal limiting
membrane of the

31
retina, whereas the basement membrane of the outer layer is continuous with that of the retinal
pigment epithelium.

1.6.4 Ciliary muscle

a. this is a striated muscle.
b. Longitudinal fibres run posteriorly into the choroidal stroma.
c. Oblique fibres radiate our from the sclera spur.
De. The circular fibres are the most external.
e. Contraction increase the refractive power of the lens.

The ciliary muscle makes up the bulk of the ciliary body. It is a smooth muscle which can be
divided into longitudinal, oblique and circular fibres. The longitudinal fibres run posteriorly and
are attached to the choroidal stroma which therefore moves anteriorly when the eye
accommodates. The oblique fibres radiating from the scleral spur increase the facilitation of
aqueous outflow when they contract. The circularly arranged fibres are the most internal and
their contraction slackens the tension in the zonular fibres, increasing the refractive power of the
lens.

1.7: The iris

1.7.1 Embryology

a. Normal development is dependent on embryonic fissure closure.

b. The tunica vasculosa lentis contributes to the iris epithelium.
c. The posterior and anterior ciliary arteries invade the stroma at 3-4 months‘
gestation.
d. The iris musculature is derived from mesenchyme.
e. The central papillary membrane absorption occurs at 6 months.

Normal iris development is dependent on the closure of the embryonic fissure which occurs on
days 33—35; abnormal closure

32
results in iris coloboma and/or hypoplasia. By the sixth week of development the anterior
chamber boundaries have been formed by the cornea and the tunica vasculosa lentis. Widi the
pupillary membrane the tunica vasculosa lentis will form the primitive iris stroma that is
infiltrated in the third and fourth months by the long posterior and anterior ciliary arteries.
During the fifth month the pupillary membrane remodels itself and at the sixth month the central
portion is absorbed, forming the pupil. The sphincter and dilator muscles, and the bilayered iris
epithelium, are derived from neuroectoderm.

1.7.2 Muscle and epithelial development

a. the sphincter muscle arises from the anterior epithelial layer.
b. The dilator muscle develops before the sphincter muscle.
c. The dilator muscle develops from anterior epithelium peripheral to Von Michel‘s
spur.
d. The dilator muscle develops from the basal processes of epithelial cells.
The posterior epithelium is originally pigmented.

Both the iris muscle and its bilayered epithelium are derived from neuroectoderm. The sphincter
and dilator muscles arise from the anterior epithelial layer. The dilator muscle develops later and
is first seen as outgrowths from the basal processes of epithelial cells that lie peripheral to Von
Michel‘s spur. The posterior epithelium does not give rise to any muscular processes and is
originally unpigmented, but during the fourth month of gestation pigmentation begins at the
pupil margin and spreads peripherally.

33
1.7.3 Grosss structure

a. the sphincter muscle arises from the anterior epithelial layer.

b. The dilator muscle develops before the sphincter muscle.
c. The dilator muscle develops from anterior epithelium peripheral to Von Michel‘s
spur.
d. The dilator muscle develops from the basal processes of epithelial cells.
The posterior epithelium is originally pigmented.

The iris is a pigmented diaphragm that consists of a posterior bilayered epithelium and an
anterior stroma rich in melanocytes and fibroblasts (the colour of the iris is determined by the
amount of pigment produced by the melanocytes). The collarette;, which lies approximately 2
mm from the pupil margin, is the thickest region of the iris and divides it into a pupillary and
ciliary zone. The sphincter pupillae is located in the pupillary zone and is a concentrically
arranged muscle, whereas the dilator pupillae is arranged radially and lies in the more peripheral
ciliary zone.

1.7.4 Epithelium

a. The iris epithelium is bilayered, with cells lying base to base.

b. The anterior layer of iris epithelium is continuous with the outer pigmented
layer of the ciliary epithelium.
c. The anterior layer is rich in melanocytes.
d. The posterior layer is closely related to the muscular processes of the dilator
muscle.
e. The iris epithelium does not extend on to the anterior iris surface.

The iris epithelium is a bilayered cuboidal epithelium which, like that of the ciliary body, is
arranged with cells lying apex to apex. The anterior layer (which is continuous with the outer
pigmented layer of the ciliary epithelium) is lacking in melanocytes, unlike the posterior layer
which is heavily pigmented. The basal processes of the anterior epithelial cells give rise to the
myoepithelial cells of the dilator muscle. The

34
pigmented posterior epithelium will extend anteriorly a short distance to the ruff but any furdier
excursion is classified as ectropion uveae.

1.7.5 Blood supply of iris and ciliary body

a. The major arterial arcade is formed solely by the long posterior ciliary arteries.
b. The major arterial arcade lies in the ciliary stroma.
c. The minor arcade is formed at the ruff.
d. All vessels are non-fenestrated with endothelial tight junctions.
e. Venous drainage is via the vortex veins.

The major arterial arcade, which is formed by the long posterior ciliary arteries with
communication from the anterior ciliary arteries, is the major blood supply to the iris and ciliary
body. This arcade lies in the ciliary stroma and its radial branches form a further minor arcade at
the collarette of the iris. Iridiai vessels are non-fenestrated, with endothelial tight junctions but
those vessels located in the ciliary body have numerous fenestrations and no tight junctions, the
blood-aqueous barrier in this region being maintained by the tight junctions of the ciliary
epithelium. The veins follow the arteries and form a minor venous circle that drains directly into
the vortex veins, not into a corresponding major circle.

35
1.7.6 Innervation of ciliary and iris muscle

a. Parasympathetic nerves supply the ciliary muscle and sphincter papillae.

b. Parasympathetic fibres arise from the Edinger-Westphal nucleus.
c. Preganglionic parasympathetic fibres travel in the short ciliary nerves.
d. Long ciliary nerves carry sensory branches from the nasociliary branch of the
ophthalmic division of the trigeminal nerve.
e. Sympathetic fibres in the long ciliary nerves supply the dilator papillae.

Parasympathetic nerves supply the ciliary muscle and the sphincter pupillae. They arise from the
Edinger-Westphal nucleus in the mid brain and travel with the oculomotor nerve to the orbit,
where they synapse in the ciliary ganglion. Postganglionic fibres travel in the short ciliary nerves
to supply the ciliary and sphincter muscles. The long ciliary nerves are mixed nerves containing
sensory fibres from the nasociliary nerve and sympathetics from the internal carotid plexus that
supply the dilator muscle.

36
1.8 The lens

a. A lens placode is formed from the surface ectoderm.

b. The lens vesicle is formed at two months of gestation.
c. Primary lens fibres arise from the anterior lens vesicle.
d. Secondary lens fibres arise from anterior epithelial cells.
e. The anteroposterior diameter of the fetal lens is initially greater than the equatorial
diameter.

37
The lens is formed from a disc shaped thickening of the surface ectoderm overlying the optic
vesicle on day 27 of development. This is known as the lens placode. Substances from the optic
vesicle are thought to induce placode cells to elongate so forming the lens vesicle on day 33.
Cells from the posterior part of the vesicle lengthen, to form primary lens fibres that fill the
vesicle lumen. The secondary lens fibres arise from the anterior epithelial cells, and migrate and
taper to form the characteristic Y shaped (anterior) and inverted Y shaped (posterior) sutures.
Initially the anteroposterior diameter of the fetal lens is greater than the equatorial diameter, but
this situation slowly reverses.

1.8.2 Gross structure

a. The lens has a uniform capsule.

b. The lens is surrounded by a cuboidal epithelium.
c. The fetal nucleus is the innermost nucleus.
d. The lens continues to grow throughout life.
e. Zonular fibres run from the ciliary processes to the lens equator.

The lens is a transparent biconvex structure that in the adult measures approximately 10 mm in
diameter and 4 mm thick. It is surrounded by an elastic capsule, which is relatively thickened in
the periequatorial regions and thinned at the anterior and posterior poles. The lenticular
epithelium, which lies below the capsule, is found only on the anterior surface of the lens and is
cuboidal in nature, becoming columnar as the cells approach the equator. The embryonic nucleus
is the innermost nucleus of the lens and is surrounded by the fetal and adult nuclei. The epithelial
cells have increased mitotic activity at the lens equator, the elongating cells becoming lens fibres
and running from the posterior to the anterior lens surface. This process continues throughout
life, increasing the size of the lens. Acellular fibres: known as zonules connect the lens equator to
the ciliary processes.

38
1.8.3 Histology

a. Lens fibres are derived from epithelial cells.

b. Mitotic activity is maximal at the anterior pole.
c. The lens bow is formed by anterior anigration of lens fibre nuclei.
d. The anterior suture is an inverted Y shape.
e. The lens cortex contains newly formed fibres.

The lens fibres are formed by the mitotic activity of the epithelial cells, which is greatest at the
lens equator. The maturing fibres stretch from the posterior to the anterior surface of the lens,
and the migration of their nuclei anteriorly forms a characteristic lens bow. In the fetal nucleus
the opposing lens fibres in the same layer produce patterns known as sutures, the anterior suture
being Y shaped and the posterior suture an inverted Y. The lens cortex refers to the region
surrounding the adult nucleus and contains the recently formed nucleated fibres.

39
1.9: The choroid and sclera
1.9.1 Embryology

a. The choroid and sclera are of mesenchymal origin.

b. Choroidal development is dependent on a vascular framework.
c. Choroidal melanoblasts are derived from the neural crest.
d. Scleral development proceeds in a posterior to anterior direction.
e. The sclera spur is fully formed at 3 months‘ gestation.

The choroid and sclera are formed by differentiation of mesenchyme surrounding the optic cup.
Choroidal development is dependent on the vascular framework that develops around the long
and short posterior ciliary arteries, Melanoblasts from the neural crest invade the choroidal
mesenchyme during the seventh month, mature and form melanocytes. Scleral development
proceeds in a posterior direction and is characterised by the laying down of collagen and elastic
fibres by fibroblasts. By 3 months‘ gestation the optic nerve is reached and by 5 months‘ the
scleral spur is fully formed.

1.9.2 Choroid
a. The choroid and sclera are of mesenchymal origin.
b. Choroidal development is dependent on a vascular framework.
c. Choroidal melanoblasts are derived from the neural crest.
d. Scleral development proceeds in a posterior to anterior direction.
e. The sclera spur is fully formed at 3 months‘ gestation.

The uveal tract is a vascular pigmented layer that consists of the choroid, ciliary body and the
iris. Anatomically the choroid can be divided into the vessel layer, capillary layer and Bruch‘s
membrane. It is firmly attached to the sclera at the optic nerve and at the exit of the vortex veins.
The blood vessels and the nerves supplying the choroid lie in the potential space between

40
the choroid and the sclera, known as the suprachoroidal space. The two long posterior ciliary
arteries and the short posterior ciliary arteries are the main supply to the choroid but the anterior
ciliary vessels also contribute. The choroidal capillaries are lined by a continuous layer of
fenestrated endothelial cells and are found to be most dense at the macula (in a central retinal
artery occlusion the blood flow in these vessels enables them to be seen as the characteristic
foveal cherry red spot). The choroid is innervated by the long and short ciliary nerves.

1.9.3 Bruch‘s membrane

a. Measures 2-4 um thick.

b. Has the basement membrane of retinal pigment epithelial cells forming its inner layer.
c. Has a bilayer of collagen.
d. Lies adjacent to the vessel layer of the choroid.
e. Forms part of the blood-retinal barrier.

Bruch‘s membrane is the innermost layer of the choroid and is approximately 2—4 |um in
thickness. It is a five-layered structure consisting of the basement membrane of the capillary
endothelium, a meshwork of elastic fibres sandwiched between a bilayer of collagen and the
inner basement membrane of the retinal pigment epithelial cells. The membrane lies adjacent to
the capillary layer of the choroid and does not contribute to the blood—retinal barrier, which at
this point is represented by tight junctions between the retinal pigment epithelial cells.

1.9.4 The sclera.

a. Is thickest posteriorly and thinnest at the equator.

b. Is fused with the dural sheaths of the optic nerve.
c. Forms the lamina cribrosa.
d. Is pierced by the vortex veins 4 mm anterior to the equator.
e. Is directly continuous with the cornea anteriorly.

41
The sclera forms the tough relatively avascular ―outer coating‖ of the eye, which fuses
posteriorly with the dural sheaths of the optic nerve and is directly continuous with cornea
anteriorly. It is thickest (1 mm) at its posterior pole, thins to 0.6 mm at the equator and is thinnest
(0.3 mm) immediately posterior to the tendinous insertions of the recti. The sclera is perforated 3
mm medial and 1 mm above the posterior pole by the optic nerve: here it has a sievelike
appearance and is known as the lamina cribrosa. The sclera is pierced by three other groups of
structures: the anterior ciliary arteries, the long and short ciliary nerves and vessels, and the
vortex veins 4 mm posterior to the equator.

1.9.5 Histology
a. The episclera is connected to Tenon‘s capsule.
b. The episclera is relatively avascular.
c. The stromal collagen is organized in a regular lattice.
d. The lamina fusca contains melanocytes.
e. The laminal fusca is completely separate from the choroid.

The sclera consists of three layers—the episclera, the scleral stroma and the lamina fusca. The
episclera consists of loose connective tissue and has a rich blood supply from the anterior ciliary
arteries that lie deep to the conjunctival vessels and are

42
not constricted by topical adrenaline. The episclera is also connected to Tenon‘s capsule (the
fascial sheath of the eyeball). The stromal collagen is not organised in a regular lattice and is
therefore not transparent. The innermost layer (the lamina fusca) contains a number of
melanocytes and has some collagen connections with the overlying choroid.

1.10: The retina

1.10.1 Formation of the optic ‘vesicle and optic cup

a. The optic vesicle is an outgrowth from the mesencephalon.

b. the optic vesicle is usually formed by day 25 of gestation.
c. Involution of optic cup and stalk occurs at around 5 weeks.
d. Optic fissure closure proceeds from the cup to the forebrain.
e. The hyaloids artery is enclosed in the optic fissure during weeks 5-7.

The optic vesicle is formed by a lateral out-pouching from the diencephalon and is usually fully
formed by day 25 of gestation. The proximal portion of the optic vesicle becomes constricted to
form the optic stalk, and the dilated distal segment forms the optic cup; both become involuted
during the fifth week producing a groove on their inferior aspects (known as the optic or
choroidal fissure). The hyaloid artery and surrounding vascular mesenchyme are enclosed in the
optic fissure. The optic cup closes in the fifth week, followed by closure of the optic stalk that
proceeds from the forebrain towards the cup in week six.

43
1.10.2 Optic vesicle
a. The outer layer contains piginented pseudostratified columnar cells.
b. The inner layer has an outer nuclear and inner marginal zone.
c. Mitosis in the outer layer finishes bythe fifteenth week of gestation.
d. Cell differentiation is initiated in the marginal zone.
e. The cilia of the optic vesicle disappear by week seven of gestation.

The optic vesicle consists of an outer and inner layer. The outer layer is composed of
pseudostratified columnar cells with pigment granules being present as early as the third week of
gestation; this layer will form the retinal pigment epithelium. The inner layer (which will form
the neural retina) consists of an outer nuclear and inner marginal zone. Mitosis is maximal in the
outer zone of the inner layer and is completed by 15 weeks, whereas the cells of the future retinal
pigment epithelium continue to divide late into fetal life. As mitosis finishes differentiation
begins: this is initiated in the marginal zone. The cilia found in the outer nuclear zone of the
inner layer disappear by the seventh week.

1.10.3 Retinal differentiation

a. The neural epithelium normally forms an inner and outer neuroblastic layer by week
seven of gestation.
b. Inner neuroblastic layers give rise to amacrine and ganglion cells.
c. Lamination is complete by 2 ½ months of gestation.
d. The photoreceptors develop from the inner marginal zone.
e. the ora serrata is fully developed at 6 months‘ gestational.

44
By the seventh week of gestation the neural epithelium has separated into inner and outer
neurobiastic layers. The inner layer will produce ganglion and amacrine cells whereas the outer
layer gives rise to horizontal and bipolar elements. Lamination is essentially complete by 4|
months and the ora serrata by 6 months. Photoreceptors are thought to be derived from cilia
found in the outer nuclear zone.

1.10.4 Neural retina

a. the photoreceptor nuclei are found in the outer nuclear layer.
b. The outer plexiform layer contains amacrine cells and bipolar cells.
c. The inner nuclear layer contains ganglion cell nuclei.
d. The inner plexiform layer contains synapses between ganglion and bipolar cells.
e. The nerve fibre layer consists of myelinated ganglion cells

The neural retina may be divided into nine layers based on the findings of light microscopy. The
rods and cones form the outermost layer and are separated from the outer nuclear layer (in which
are found the photoreceptor nuclei) by the external limiting membrane. The outer plexiform layer
comprises photoreceptor and bipolar axons, and the processes of the horizontal cells. The
bipolar, horizontal, and amacrine cell bodies are found in the inner nuclear layer, along with the
cell bodies of the Muller cells. Processes of the bipolar, amacrine, and ganglion cells are found in
the inner plexiform layer. This layer is followed by a layer of ganglion cells whose unmyelinated
dendrites form the penultimate nerve fibre layer. The inner limiting membrane (made from the
intraconnecting foot processes of the Muller cells) is the innermost layer.

45
1.10.5 Photoreceptors

a. There are approximately 120 million rods in the eye.

b. There are approximately 20 million cones in the eye.
c. Rods are absent at the fovea.
d. The ratio of photoreceptors to ganglion cells is approximately 10:1.
e. Cone density decrease gradually from the fovea to the periphery.

The retina contains approximately 120 million rods. They are absent from the fovea but have a
maximum density of approximately 160 000/mm2 in the perifoveal region3 decreasing gradually
to 30 000/mm2 at the retinal periphery. There are approximately 6.3—6.8 million cones in the
retina. They are most numerous in the rod-free fovea (160 000 mm2) and their density falls
rapidly to 5000/mm2 farther than 10° from fixation. Photoreceptors have a ratio with ganglion
cells of 100:1.

46
1.10.6 Retinal membranes and glial cells

a. Muller cells are derived from neuroectoderm.

b. The inner limiting membrane is composed of Muller cell processes and their
basement membranes.
c. The inner limiting membrane forms part of the blood retinal barrier.
d. The outer limiting membrane is formed by connections between Muller cells and
retinal pigment epithelial cells.
e. The outer limiting membrane forms a part of the blood retinal barrier.

Muller cells are neuroglial cells and hence are derived from neuroectoderm. They are arranged
radially in the retina and extend through the whole thickness of the neural retina. Their
processes, in combination with their basement membranes, form the inner limiting membrane. At
the outer surface of the neural retina tight junctions between photoreceptor cells and the radial
processes of the MtUler cells form the outer limiting membrane. Neither of these membranes
contribute to the blood retinal barrier.

47
1.10.7 Macular embryology

a. The macula is characterized by an increased thickness of the ganglion cell layer

during the fifth month of gestation.
b. Peripheral displacement of ganglion cells occurs during the seventh month.
c. Cones increase in length and width during the seventh month.
d. Cones are not fully developed at term.
e. Ganglion cells are absent from the fovea by term.

Mascular development is characterised by a localised superimposition of ganglion cell nuclei at

the posterior pole during the fifth month of development- By the sixth month of gestation there
are eight or nine layers of nuclei but peripheral displacement of ganglion cells caused by axonal
elongation commences by the seventh month. The foveal cones increase in length but decrease in
width, so increasing their density, but because they are not fully developed until several months
after birth the newborn infant has imperfect central fixation. At term a single layer of ganglion
cells is present as an internal nuclear layer overlying the macular cones; these are displaced by
the fourth month of life, leaving the central cones ―uncovered‖.

1.10.8 Macula
a. The macula measures three disc diameters.
b. The macula lies medial to the optic disc.
c. The foveal floor cone concentration is approximately 100 000/mm2.
d. The foveola consists solely of photoreceptors and bipolar cells.
e. The foveal avascular zone has diameter of 300 um.

The macula lutea is a yellowish oval area 4.5 mm (three disc diameters) long lying
approximately 3 mm lateral to the optic disc. The central area of the macula is depressed and is
known as the fovea centralis; it measures 1.5 mm in diameter. The cone

48
destiny is maximal at this point (approximately 150 000/mm²). The floor of the fovea is known
as the foveola and consists purely of photoreceptor cells, with bipolar cells being displace
peripherally. The normal foveal avascular zone measures 300 um in diameter. It defines the
anatomical fovea and laser treatment
for conditions such as diabetic retinopathy should not encroach on this region.

1.10.9 Retinal blood supply

a. The outer two-thirds of the retina receives nutrients from the choroidal circulation.
b. the central retinal artery is an end artery.
c. Retinal arteries run in the nerve fibre layer.
d. Retinal capillaries are absent from the fovea centralis.
e. Cilioretinal arteries exist in approximately 50% of people.

The outer plexiform layer is the watershed region of the retina: structures that lie peripheral to
this layer (rods and cones in the outer nuclear layer) receive their nutrients by fiffusion from the
choroidal circulation, whereas the inner two-thirds of the retina receive nutrients directly from
the central retina artery and its tributaries. The retinal arteries run in the nerve fibre layer and are
functional end arteries with four branches supplying each quadrant of the retina. The arterioles
running through the different layers of the neural retinal as far as the internal nuclear layer are
also devoid of anastomoses and give rise to a diffuse capillary network whose walls are lined
with non-fenestrated endothelial cells. These retinal capillaries are concentrated in the macula
but are absent from the fovea centralis. The cilioretinal artery (arising from a posterior ciliary
artery) exists in approximately 20% of people and explains why macular function may be
preserved in occlusions of central retinal artery.

49
1.11 The visual pathways
1.11.1 Optic nerve embryology

a. The optic stalk and cup close simultaneously.

b. All inner optic stalk cells develop vacuoles.
c. Myelination is complete by 7 weeks of gestation.
d. Meningeal sheaths are formed from neural crest mesoderm.
e. Optic nerve colobomas are usually inferotemporal.

The optic nerve is formed from the primitive optic stalk. Optic stalk closure follows that of the
optic cup and is dependent on breakdown of basal lamina, inversion of the outer layers of the
stalk, and regeneration of the basal lamina. Cells from the inner stalk will either vacuolate to
make way for ganglion cell neurones or differentiate to form glial cells. By the seventh week of
development the optic stalk is full of nerve fibres, but myelination does not commence until the
seventh month. Meningeal sheaths derived from neural crest mesoderm appear in the fifth month
and invest the nerve m pia, subarachnoid and dura mater. Owing

50
to the positioning of the optic fissure., defects in its closure result in inferotemporal colobomas.

1.11.2 Optic nerve

a. The optic disc measures approximately 2mm in diameter.

b. The intraobital portion of the optic nerve is approximately 25 mm long.
c. A sheath of dura, arachnoid and pia mater surrounds the optic nerve.
d. Ganglion cells become myelinated only posterior to the chiasma.
e. The optic canal lies wholly within the sphenoid bone.

The optic nerve is part of the central nervous system and as such has a meningeal sheath of dura,
arachnoid and pia mater. For descriptive purposes it may be divided into four parts: the
intraocular, intraorbital, intracanalicular and intracranial portions. The intraocular portion is
represented by the optic disc, which measures 1.5 mm in diameter and is the point at which the
optic nerve pierces the sclera. The intraorbital portion is approximately 25 mm long—here the
central retinal artery enters and the central retinal vein exits the dural sheath. The nerve chiefly
comprises ganglion cell neurones, which become myelinated only posterior to the lamina
cnbrosa. However, it also contains a number of neuroglial cell such as astrocytes. The optic canal
(which lies wholly within the lesser wing of the sphenoid bone) measures approximately mm
long and transmits the optic nerve and ophthalmic artery. The intracranial portion of the optic
nerve travels upwards, backwards and medially to reach the optic chiasma.

51
1.11.3 Relations of the optic nerve

a. The ciliary ganglion lies medial to the optic nerve.

b. The nasociliary nerve and ophthalmic artery cross the optic nerve superiorly.
c. The central retinal artery pierces the inferomedial aspect 12 mm behind the globe.
d. The optic nerve lies within the muscular cone at the orbital apex.
e. It lies with the ophthalmic artery and vein in the optic canal.

The optic nerve has a number of important relations in the orbit. It runs superomedial to the
ophthalmic artery in the optic canal and enters the orbital apex within the muscular cone. The
ophthalmic artery and nasociliary nerve pass above it from lateral to medial, the ophthalmic
artery having already given off the central retinal artery. The central retinal artery passes inferior
to the optic nerve and pierces the inferomedial aspect of the dural sheath 12 mm behind the
globe. The ciliary ganglion lies lateral to the nerve, between it and the lateral rectus muscle.

1.11.4 Optic chiasma

The optic chiasma lies:
a. Inferior to the lamina terminalis.
b. Superior to the infundibulum.
c. Lateral to the internal carotid.
d. Superior to the diaphragm sellae.
e. Inferior to the cavernous sinus.

The optic chiasma is the point at which fibres from the respective nasal retinas decussate. It lies
inferior to the floor of the third ventricle, just below the lamina terminalis, and has a number of
important anatomical relations. The chiasma lies superior to the diaphragma sellae (which
transmits the pituitary stalk or infundibulum). Anteriorly it is related to the anterior cerebral

52
arteries, superiorly to the anterior communicating artery, and laterally to the internal carotid
artery and the cavernous sinus.

1.11.5 Blood supply to the anterior visual pathway

a. The central retinal artery supplies the intraocular optic nerve.
b. Short posterior ciliary arteries anastomose with the central retinal artery at the optic
nerve head.
c. The orbital optic nerve is primarily supplied by pial plexus vessels.
d. The intracranial optic nerve is supplied by the superior hypophyseal and
ophthalmic ateries.
e. The optic nerve blood supply is compromised by raised intracranial pressure

The intracranial optic nerve is supplied by the superior hypophyseal and ophthalmic arteries.
Despite the fact that the central retinal artery pierces the dural sheaths of the orbital optic nerve,
its primary blood supply is from a pial plexus of vessels and not from the central retinal artery.
The intraocular portion of the optic nerve is supplied by the short posterior ciliary arteries that
form the circle of Zinn; this forms no

53
significant anastomoses with branches of the central retinal artery. The central retinal artery and
vein run within the optic nerve‘s dural sheath, and a rise in intracranial pressure may
compromise blood flow in these vessels (for example, the venous engorgement seen in
papilloedema).

1.11.6 Lesions in the visual pathway

a. Inferior and anterior chiasmal lesions produce superotemporal defects.
b. Distal optic nerve lesions may produce bilateral field loss.
c. All post chiasmal lesions produce a bilateral field defect.
d. Lesions of the lateral geniculate nucleus are associated with profound ipsilateral
sensory loss.
e. Temporal lobe lesions tend to cause superior quadrantic field defects.

A knowledge of the anatomy of the afferent visual pathway is essential when interpreting field
loss secondary to lesions in the afferent visual system. The optic chiasma is the site at which
fibres from the nasal retinas decussate. Fibres from the inferonasal quadrants decussate in the
inferior and anterior region of the chiasma, and so lesions here will produce superotemporal field
defects. These decussating fibres may pass anteriorly into the contralateral optic nerve before
passing to the optic tracts and so lesions in the distal optic nerve may produce bilateral field loss.
In general, post chiasmal lesions will result in an homonymous hemianopia which will become
more congruous (symmetrical) the more posterior the site of the lesion. An exception to this rule
is a lesion found at the anterior aspect of the calcarine sulcus, which receives fibres only from the
contralateral nasal retina: lesions here will produce a contralateral temporal crescentic defect.
Lesions of the lateral geniculate nucleus characteristically produce contralateral hemianopias that
are associated with profound contralateral sensory loss. Optic tract fibres found in the temporal
lobe tend to arise from the inferior nasal and temporal quadrants, producing superior quadrantic
field defects.

54
1.11.7 Primary -visual cortex

a. The primary visual crtex is Brodmann‘s area 18.

b. Lesions above the calcarine sulcus produce contralateral and inferior field defects.
c. the macula is represented in the posterior aspect of the visual cortex.
d. Superotemporal retinal fibres connect with ipsilateral cells lying above the sulcus.
e. Cortical blindness is characterized by absent papillary reflexes.

The primary visual cortex is situated in the walls of the calcarine sulcus found in the medial
aspect of the cerebral hemisphere. It extends from the junction of the calcarine and parieto-
occipital sulci to the occipital pole posteriorly and is Brodmann‘s area

55
17. The area above die calcarine sulcus receives information from the contralateral and inferior
visual field via ipsilateral superotemporal fibres and contralateral superonasal fibres. The
macula, which has a relatively large representation in the visual cortex, is located at the posterior
aspect of the calcarine sulcus and extends to the posterior lateral aspect of the occipital lobe.
Cortical blindness, which results from infarction of the primarjr visual cortex, is often denied by
the patient and is characterised by normal pupillary reflexes.

1.11.8 Blood supply to the optic tracts and cortex

a. The anterior choroidal and posterior communicating arteries supply the optic tracts.
b. The lateral geniculate nucleus is supplied by the anterior communicating artery.
c. The posterior optic radiations are supplied solely by the posterior cerebral artery.
d. The visual cortex is supplied primarily by the posterior cerebral artery.
e. Middle and posterior cerebral anastomoses exit near the posterior pole.

The optic tracts are supplied by pial arteries derived from the anterior choroidal and posterior
communicating arteries, with the occasional branch from the middle cerebral artery. The lateral
geniculate nucleus is supplied by the middle cerebral artery which, along with the posterior
cerebral artery, supplies the posterior aspects of the optic radiations. The visual cortex derives
most of its blood supply from the posterior cerebral artery but some communicadon with the
middle cerebral artery may exist over the occipital pole and indeed may explain the phenomena
of ―macular sparing‖ seen in some occipital lobe strokes.

56
1.12: The extraocular muscles
1 12.1The rectus muscles

a. All rectus muscles rise from the annulus of Zinn.

b. Vertical recti run at approximately 25° to the optical axis.
c. The lateral rectus inserts on average 7.7 mm from the limbus.
d. The medial rectus inserts on average 5.5 mm from the limbus.
e. The lateral rectus has the longest tendon.

All rectus muscles arise from a common tendinous origin, the annulus of Zinn, which is situated
at the orbital apex. All foui muscles run anteriorly, the superior and inferior recti passing
forwards at approximately 25° to the optical axis of the globe. The recti insert at varying
distances from the corneal limbus; the medial rectus inserts 5.5 mm from the limbus; the inferioi
6.5 mm; the lateral 6.9 mm; and the superior 7.7 mm (these are average, not absolute
measurements). These insertions form i spiral—the spiral of Tilau. The medial rectus has the
shortes‘ tendon (3.7 mm); that of the lateral rectus is the longest at 8.8 mm. The above
measurements are of primary importance ii recessions and resections of these muscles ^re to be
considered in surgery for strabismus.

57
1.12.2 The oblique muscles

a. The superior oblique arises from the annulus of Zinn.

b. The interior oblique arises from within the orbital rim.
c. The superior and inferior oblique muscles insert behind the equator of the globe.
d. The obliques pull at equal angles to the optical axis of the globe.
e. Both the oblique muscles pass below their corresponding rectus muscle.

The superior oblique muscle arises from the body of the sphenoid bone outside the tendinous
ring and gives rise to a rounded tendon that passes through the trochlea at the superonasal aspect
of the orbit. The inferior oblique arises from within the floor of the orbital rim. The superior
oblique pulls forward at an angle of approximately 55° to the nasal side of the globe‘s visual axis

58
with the eye in the primary position; the inferior oblique pulls at an angle of approximately 50°.
Both oblique muscles pass inferiorly to their corresponding rectus muscle before inserting
posterior to the equator of the globe.

1.12.3 Innervation

a. The medial rectus is supplied by the inferior division of the oculomotor nerve.
b. The superior rectus is the only muscle supplied by the superior division of the
oculomotor nerve.
c. The superior oblique is supplied by the trochlear nerve.
d. The nerve to the lateral rectus enters the orbit outside the tendinous ring.
e. The inferior oblique is supplied by the inferior division of the oculomotor nerve.

The third cranial (or oculomotor) nerve supplies the majority of the extraocular muscles. It
divides into superior and inferior divisions just before entering the orbit via the superio orbital
fissure. The inferior division supplies the medial rectus, inferior rectus, and inferior oblique; the
superior division supplies the superior rectus, and the levator palpebrae superioris. The

59
superior oblique muscle is supplied by the fourth cranial nerve, the trochlear nerve. The sixth
cranial (abducent) nerve, which enters the orbit through the inferior aspect of the superior orbital
fissure (but within the tendinous ring), supplies the lateral rectus.

1.12.4 Relations of the extraocular muscles

a. The frontal nerve lies between the levator and superior rectus.
b. The lacrimal artery and nerve lie medial to the lateral rectus.
c. The abducent nerve lies lateral to the lateral rectus.
d. The nasociliary nerve lies superior to the medial rectus.
e. The oculomotor nerve lies superior to the inferior rectus.

The only three nerves to enter the orbit outside the common tendinous ring are the lacrimal
nerve the frontal component of the ophthalmic nerve, and the trochlear nerve. The frontal nerve -
is found above the levator muscle and the lacrimal nerve (plus accompanying artery) is found
superior to the lateral rectus. The nasociliary nerve, a direct continuation of the ophthalmic
division of the trigeminal, passes along the superior border of the medial rectus before dividing
into the anterior ethmoidal and infratrochlear nerves. The inferior division of the oculomotor
nerve runs superior to the inferior rectus and medial to the abducent nerve, which lies on the
medial aspect of the lateral rectus.

60
1.13: The cranial nerves

1.13.1 Oculomotor nerve

a. The nucleus of the oculomotor nerve lies adjacent to the inferior colliculus.
b. The oculomotor nerve lies between the posterior cerebral and superior cerebellar
arteries.
c. It lies in the medial wall of the avernous sinus.
d. The branch to the inferior oblique carries parasympatic fibres to the ciliary
ganglion.
e. The superior rectus is supplied by the contralateral oculomotor nucleus.

The oculomotor nerve is the third cranial nerve and its group of nuclei are found adjacent to the
superior coiliculus in the mid brain. It runs anteriorly, passing the red nucleus, and emerges on
the ventral surface of the mid brain to lie between the posterior cerebral and superior cerebellar
arteries. Aneurysms of the posterior communicating artery, which lies parallel to the nerve, may
compress it, resulting in paresis. It runs anteriorly in the lateral wall of the cavernous sinus and
enters the orbit (after dividing into superior and inferior branches) via the superior orbital fissure.
The oculomotr nerve supplies all the extraocular muscles except the lateral rectus and superior
oblique; its inferior branch carries parasympathetic fibres to the ciliary ganglion. The superior
rectus is the only muscle supplied by the contralateral oculomotor nucleus.

61
1.13.2 Trochlear nerve

a. The trochlear nerve is the only cranial nerve to exit the brain stem on its dorsal
aspect.
b. On leaving the cavernous sinus the trochlear nerve lies above and lateral to the
oculomotor nerve.
c. The trochlear nerve enters the orbit through the tendinous ring.
d. The trochleaar nucleus supplies the ipsilateral superior oblique.
e. Damage to the trochlear nerve may result in a contralateral head tilt.

The trochlear nerve is the fourth cranial nerve. Its nucleus is situated by the inferior colliculus
and its fibres decussate before emerging from the dorsal aspect of the brain stem. The nerve then
runs forward, travelling in the subarachnoid space around the cerebral peduncle, to enter the
lateral wall of the cavernous sinus. It initially lies inferior to the oculomotor nerve but moves to
lie superior and lateral to the oculomotor nerve on leaving the sinus. It enters the orbit through
the superior orbital fissure outside the tendinous ring, and as the fibres decussate before leaving
the brain stem it innervates the contralateral superior

62
oblique. Damage to the trochlear nerve results in superior oblique paralysis and a ,contralateral
head tilt.

1.13.3 Abducent nerve

a. The nucleus of this nerve underlies the facial colliculus.

b. The abducent nerve emerges from the brain stem in the cerebellopontine angle.
c. Infection of the temporal bone may damage the abducent nerve.
d. This is usually the first nerve to be ??naged in cavernous sinus thrombosis.
e. The abducent nerve enters the orbit by passing outside the tendinous ring.

The abducent nerve is the sixth cranial nerve. Its nucleus lies in the floor of the fourth ventricle,
where the seventh cranial nerve passes over it (so forming the facial colliculus). It emerges from
the brain stem in the cerebellopontine angle, where it may be damaged by tumours such as
acoustic neuromas. It passes up the clivus in the subarachnoid space and passes over the apex of
the petrous temporal bone (middle ear infection may cause abducent nerve paresis—such as
Gradenigo‘s syndrome). The abducent nerve is the only nerve to lie wholly within the cavernous
sinus and therefore is often the first to be damaged

63
in cavernous sinus thrombosis. It enters the orbit through the superior orbital fissure inside the
common tendinous ring and pierces the lateral rectus muscle (which it supplies).

1.13.4 Ophthalmic division of the trigeminal nerve

a. The ophthalmic division of the trigeminal divides in the orbit to form the lacrimal,
frontal and nasociliary nerves.
b. The lacrimal nerve carries parasympathetic fibres from the oculomotor nerve.
c. Branches supply the frontal sinus.
d. The nasociliary nerve receives sensory fibres from the ciliary ganglion.
e. The skin at the tip of the nose is supplied by the nasociliary nerve.

The ophthalmic division of the trigeminal nerve is a purely sensory nerve that lies in the lateral
wall of the cavernous sinus and divides into lacrimal, frontal, and nasociliary branches before
entering the orbit. The lacrimal and frontal nerves enter the orbit outside the tendinous ring; the
former then receives parasympathetic fibres (bound for the lacrimal gland) from the
zygomaticotemporal branch of the maxillary nerve. The frontal nerve supplies the frontal sinuses
via its supraorbital and supratrochlear divisions. The nasociliary nerve is the largest

64
branch and enters the orbit through the tendinous ring. It is also the major sensory nerve to the
globe, because it receives fibres from the long ciliary nerves, and from the short ciliary nerves
timt travel via the ciliary ganglion, Xhe anterior ethmoidal nerve is a terminal branch of the
nasociliary nerve; it supplies the lateral wall of the nose and parts of the nasal septum, and
terminates on the tip of the nose as the external nasal nerve. Herpes zoster lesions affecting the
tip of the nose may signal ocular involvement via the nasociliary nerves (Hutchinson‘s sign).

1.13.5 Maxillary division of the trigeminal nerve

a. This is a purely sensory nerve.

b. It lies in the lateral wall of thecavernous sinus.
c. this division of the trigeminal nerve enters the infratemporal fossa via the foramen
rotundum.
d. It supplies sensation to the maxillary sinus.
e. Blowout fractures often cause cheek paraesthesia.

The maxillary division of the trigeminal nerve is a purely sensory nerve, which, after leaving the
trigeminal ganglion, lies in the lateral wall of the cavernous sinus. It then passes through the
foramen rotundum and hence into the pterygopalatine fossa. It is the sensory supply to the
pterygopalatine ganglion (which is

65
suspended from the nerve) and exits the fossa as the infraorbital nerve. The infraorbital nerve,
which lies in the infraorbital canal in the floor of the orbit, is responsible for the innervation of
the maxillary sinuses, the upper incisor, canine, and premolar teeth, and the skin of the cheek,
lower eyelid and the upper lip. ―Blowout‖ fractures of the orbital floor often damage the nerve,
causing paraesthesia in these areas.

66
1.14 Orbital vasculature and tlie cavernous sinus

1.14.4 Ophthalmic artery

a. This is the first branch of the internal carotid after it exits the cavernous sinus.
b. The ophthalmic arterylies within the dural sheath of the optic nerve in the optic canal.
c. In the orbit the ophthalmic artery passes inferior to the optic nerve in 85% of people.
d. It gives rise to the nasociliary artery.
e. the ethmoidal and frontal sinuses are supplied by the ophthalmic artery.

The ophthalmic artery is the first branch of the internal carotid as it emerges from the cavernous
sinus. It lies inferolateral to the optic nerve in the optic canal and is enclosed in its dural sheath.
On entering the orbit the ophthalmic artery passes above the optic nerve in 85% of cases bvt
before doing this it gives off the central retinal artery, which passes below the nerve. Other
important branches of the ophthalmic artery include the long and short posterior ciliary arteries,
anterior and posterior ethmoidal arteries (which supply the ethmoidal sinuses), and the
supraorbital artery (which normally supplies the frontal sinus). Its terminal branches are the
supratrochlear and the dorsal nasal arteries.

1.14.2 Central retinal artery

The central retinal artery:

a. Arises from the ophthalmic artery.
b. Passes superior to the optic nerve.
c. Pierces the dural sheath 12 mm behind the globe.
d. Supplies the pial sheath of the optic nerve.
e. Is functionally an end artery.

The central retinal artery arises from the ophthalmic artery where it lies inferolateral to the optic
nerve. It then passes

67
inferior to the optic nerve and pierces the dural sheath approximately 12 mm behind the globe. It
travels obliquely through the subarachnoid space (accompanied by the central retinal vein) and
gives off a number of small meningeal branches that supply the pial sheath of the optic nerve.
Although some minute anastomoses exist between these pial branches and the short posterior
ciliary arteries, the central retinal artery should be considered as an end artery.

1.14.3 Ciliary arteries

a. The long posterior ciliary arteries supply the choroid posterior to the equator.
b. The long posterior ciliary arteries contribute to the major arterial circle.
c. Two anterior ciliary arteries accompany each rectus muscle.
d. Short posterior ciliaries supply the optic nerve head.
e. Anastomoses exist between the short and the long posterior ciliary arteries.

The long posterior, short posterior, and anterior ciliary arteries constitute the major blood supply
to the globe. The paired long posterior ciliary arteries pierce the sclera outside the circle of Zinn
and travel forward in the suprachoroidal space to the ciliary body, where they contribute to the
major arterial arcade. Recurrent branches supplying the choroid anterior to the equator
anastomose with the short posterior ciliaries. The short posterior ciliaries (which divide into 10—
20 branches) pierce the sclera around the optic nerve; this anastomotic circle of Zinn supplies the
optic nerve head, with the more anterior branches supplying the choroid as far as the equator.
The anterior ciliary arteries ' arise from the muscular branches of the ophthalmic artery; two
arteries accompany each rectus muscle (except the lateral rectus, which has only one associated
artery). They supply the sclera and conjunctiva as well as contributing to the major arterial circle
of the iris.

68
1.14.4 Venous drainage of the globe

a. Thesuperior ophthalmic vein is formed by branches of the supraorbital and facial

veins.
b. The vortex veins enter the superior ophthalmic vein only.
c. The central retinal vein joins the superior ophthalmic vein.
d. The inferior ophthalmic vein communicates with the pterygoid venous plexus.
e. The inferior and superior ophthalmic veins may enter the cavernous sinus
separately.

The superior ophthalmic vein (usually the larger of the two ophthalmic veins) is formed by the
supraorbital and facial veins. It travels posteriorly in the orbit and receives contributions from the
superior vortex veins, and the central retinal vein. The inferior ophthalmic vein receives the
inferior vortex veins and usually drains into the superior ophthalmic vein; it may, however, enter
the cavernous sinus separately. The inferior ophthalmic vein also communicates with the
pterygoid venous plexus and (as the orbital veins have no valves) spread of infection from this
plexus may eventually reach the cavernous sinus, causing a cavernous sinus thrombosis.

69
1.14.5 Connections of the cavernous sinus

The cavernous sinus:

a. Receives blood from the sphenoparietal sinus.
b. Receives the superior ophthalmic vein via the superior orbital fissure.
c. Communicates with the contralateral cavernous sinus.
d. Receives blood from the superior and inferior petrosal sinuses.
e. Communicates with the pterygoid venous plexus via the foramen spinosum.

The cavernous sinuses (which lie between the inner meningeal and outer endosteal layers of dura
mater) are situated on either side of the body of the sphenoid bone. Tributaries that contribute to
the cavernous sinus include the superior ophthalmic vein, part or all of the inferior ophthalmic
vein, the sphenoparietal sinus (that accompanies the middle meningeal artery) 3 and the inferior
and superficial middle cerebral vein (not shown in Figure 1.28). Numerous interconnections exist
between adjacent sinuses and drainage is predominantly via the superior and inferior petrosal
sinuses and hence into the sigmoid sinus and internal jugular vein respectively. Communications
also exist via emissary veins that pass through the foramen ovale or foramen of Vesalius to the
pterygoid venous plexus.

70
1.14.6 Contents and relations of the cavernous sinus

a. The pituitary fossa lies medially.

b. The greater wing of the sphenoid lies inferiorly.
c. The internal carotid artery lies superiorly.
d. The internal carotid artery alone lies within the cavernous sinus.
e. The oculomotor, trochlear and ophthalmic division of the trigeminal are the only
nerves found in its lateral wall.

The cavernous sinuses have a number of important contents and relations. The cavernous sinus
extends from the superior orbital fissure anteriorly to the apex of the petrous part of the temporal
bone posteriorly, with its floor formed by the dural coverings of the greater wing of the sphenoid
bone. Lying lateral to the body of the sphenoid bone, the pituitary fossa is an important medial
relation. The internal carotid artery leaves the foramen lacerum and enters the posterior part of
the sinus before arching upwards and forwards, grooving the medial wall of the sinus; it
eventually pierces the roof of the sinus before passing

71
backwards towards the anterior perforate substance of the brain. The abducent nerve also travels
within the cavernous sinus and is often the first structure damaged in cavernous sinus
thrombosis- It should, however, be noted that both the internal carotid artery and the abducent
nerve lie outside the endothelial lining of the sinus. The lateral wall of the cavernous sinus
encloses the oculomotor nerve, trochlear nerve, and the first two divisions of the trigeminal
nerve.

72
Answers

1.1.1 d 1.5.8 a, b, c, e 1.10.7 a, b, d

1.1.2 a, c, d 1.10.8 a, e
1.1.3 1.6.1 a, b, c 1.10.9 b, c, d
1.1.4 b, d 1.6.2 a, c, e
1.1.5 c, e 1.6.3 a, d 1.11.1 d, e
1.6.4 b, c, e 1.11.2 b c, w
1.11.3 b, c, e
1.2.3 C, d 1.7.1 a, c, e 1.11.4 a, b, d
1.2.4 a, b 1.7.2 a, c, d 1.11.5 c, d, e
1.2.5 a, c, d 1.7.3 a, b, c, e 1.11.6 a, b, e
1.2.6 b, d, e 1.7.4 b 1.11.7 b, c, d
1.2.7 b, d, e 1.7.5 b, e 1.11.8 a, d, e
1.2.8 c, d 1.7.6 a, b, d, e
1.12.1 a, b, d, e
1.3.1 a, b, d 1.8.1 a, d, e 1.12.2 b, c, e
1.3.2 a, b, c 1.8.2 d, e 1.12.3 a, c, e
1.3.3 c, d, e 1.8.3 a, c, e 1.12.4 d, e
1.3.4 a, d, e
1.3.5 a, b, c, e 1.13.1 b, d, e
1.9.1 a, b, c 1.13.2 a, b, e
1.4.1 a, b, d 1.9.2 a, b, d, e 1.13.3 a, b, c, d
1.4.2 a, b, d, e 1.9.3 a, b, c 1.13.4 c, d, e
1.4.3 a, c, e 1.9.4 b, c, e 1.13.5 a, b, d, e
1.9.5 a, d
1.5.1 d 1.14.1 a, b, e
1.5.2 b, c, d 1.10.1 b, c, e 1.14.2 a, c, d, e
1.5.3 b, c, e 1.10.2 a, b, d, e 1.14.3 b, d, e
1.5.4 a, b, e 1.10.3 a, b, e 1.14.4 a, c, d, e
1.5.5 a 1.10.4 a, d 1.14.5 a, b, c
1.5.6 a, b, c, d 1.10.5 a, c 1.14.6 a, b, c
1.5.7 a, b, c, e 1.10.6 a, b

73
2. Neuroanatomy and head and neck anatomy

2.1: Neuroanatomy

2.1.1 Venous sinuses of the dura mater

a. All the venous sinuses lie between the inner fibrous dura and the outer endosteum.
b. The superior sagittal sinus drains all of the upper surfaces of both hemispheres.
c. The superior sagittal sinus becomes the inferior sagittal sinus at the internal occipital
protruberance.
d. The straight sinus receives the inferior sagittal sinus, the basal cerebral veins and the
single great cerebral vein of Galen.
e. The transverse sinus becomes the sigmoid sinus at the jugular foramen.

All the venous sinuses except the straight sinus and the inferior sagittal sinus lie
between the inner dura mater and the outer endosteum. The superior sagittal sinus
begins just above the foramen caecum and runs between the two layers of the falx
cerebri to the internal occipital protruberance. Here it becomes the transverse sinus
(usually the right). The superior sagittal sinus drains all of the upper surface of the
cerebral hemispheres, both lateral and medial, except the frontal pole. The inferior
sagittal sinus lies between the free folds of the falx cerebri and drains the lower
parts of the medial surface of each hemisphere before entering the straight sinus.
The straight sinus also receives at its origin the right and left basal cerebral veins
and the great cerebral vein of Galen. It runs posteriorly to drain into die transverse
sinus (usually the left) at the internal occipital protruberance. The transverse
sinuses pass forward to drain into

74
the sigmoid sinuses at the mastoid bone. They receive tributaries from the surfaces of the
adjacent cerebral and cerebellar hemispheres. The sigmoid sinus expands as it reaches the
posterior aspect of the jugular foramen to form the jugular bulb before becoming the internal
jugular vein as it exits this foramen (Figure 2.1).

2.1.2 Connections of the cerebral ventricles

a. The lateral ventricles communicate with the third ventricle via the interventricular
foramina of Munro.
b. The foramen of Magendie connects the fourth ventricle with the pontine cistern.
c. The third and fourth ventricles are connected via the aqueduct.
d. The foramina of Luschka connect the fourth ventricle with the cerebellomedullary
cistern.
e. The choroidal plexus is a combination of capillaries, pia mater and ependyma

The central nervous system develops from the neural tube, and this cavity persists in the form of
the ventricular system. The ventricles are lined by a single epithelial-like layer of cells, the
ependyma, which in combination with pia mater and

75
invaginating capillaries constitutes the choroidal plexus. The choroidal plexus is responsible for
70% of cerebrospinal fluid production, the remaining 30% coming from other brain capillaries.
The lateral ventricles, which are found in each cerebral hemisphere, are the largest chambers of
the ventricular system. They communicate with the third ventricle via the interventricular
foramina of Alunro. The third ventricle, situated in the diencephalon, communicates with the
fourth ventricle (in the pons and upper medulla) via the aqueduct. Cerebrospinal fluid from the
fourth ventricle can pass into the cerebellomedullary cistern via the foramen of Magendie in the
roof of the ventricle, and into the pontine cistern via the lateral foramina of Luschka.

2.1.3 Relations of the ventricles

a. The caudate nucleus lies in the C shaped concavity of the lateral ventricle.
b. The thalamus borders the lateral wall of the third ventricle, and the floor of the
lateral ventricle‘s inferior horn.
c. The hypothalamic groove is found along the wall of the third ventricle.
d. The abducent nucleus forms the facial colliculus in the floor of the fourth
ventricle.
e. The hypoglossal triangle lies lateral to the vagal triangle in the floor of the fourth
ventricle.

The lateral ventricle is a C shaped structure consisting of anterior, posterior and inferior horns
and a body. The caudate nucleus lies in the concavity of the lateral ventricle, extending from its
bulbous head, next to the anterior horn, to a thin tail lying along the roof of the inferior horn. The
thalamus lies medial and inferior to the caudate nucleus and is related to the lateral wall of the
third ventricle, and the floor and roof of the lateral ventricle‘s body and inferior horn
respectively. The floor of the slit-like third ventricle is formed by the hypothalamus. Just above
the floor the hypothalamic groove forms a lateral prominence that runs from the interventricular
foramen towards the aqueduct. The floor of the fourth ventricle has several features

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related to cranial nerve nuclei; in the pontine part, fibres of the facial nerve pass over the
abducent nucleus to produce the facial colliculus, and at the inferior apex the floor is divided into
the medial hypoglossal triangle and the lateral vagal triangle.

2.1.4 Blood supply of the cerebrum

a. The posterior communicating arteries are a direct communication between the

basilar artery and the internal carotid arteries.
b. The anterior communicating artery unites the anterior cerebral arteries in the cistern
chiasmatica.
c. The middle cerebral artery supplies the sensory and motor cortex for all of the
contralateral half of the body.
d. The anterior cerebral arteries supply the medial surface of the hemispheres above
the corpus callosum and back to the patieto-occipital sulcus.
e. The internal capsule is supplied by branches from the posterior cerebral artery.

The cerebral hemispheres and the walls of the diencephalon are supplied by a network of vessels
derived from the internal carotid and vertebral systems. These arteries are end arteries, that is
they have no precapillary anastomoses with fellow vessels. The two systems meet in the circle of
Willis; the posterior communicating arteries arise from the posterior cerebral arteries (terminal
branches of the basilar artery) and run forward to join the internal carotid artery at the anterior
perforated substance. The circle is completed by the anterior communicating artery, which links
the anterior cerebral arteries in the cistema chiasmatica. The middle cerebral artery is the largest
and most direct branch of the internal carotid. It supplies the cortex responsible for the motor and
sensory areas of the contralateral half of the body excluding the leg and perineum, which are
supplied by the anterior cerebral arteries. The anterior cerebral arteries not only supply the
medial surface of the hemispheres above the corpus callosum as far posterior as the parieto-
occipital junction, but also the superior frontal gyrus and an equal area on the surface of the
adjacent parietal lobe. The internal capsule

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is supplied by striate branches from the anterior cerebral, middle cerebral and anterior choroidal
arteries; these vessels also supply the thalamus and basal nuclei. Branches from the posterior
cerebral artery penetrate the posterior part of the internal capsule before entering the posterior
perforated substance, which supplies the thalamus and caudate nucleus.

2.1.5 Cortical areas

a. The area MsI receives afferents predominantly from the cerebellum and thalamus.
b. The body and face are represented upside down in the precentral gyrus of MsI.
c. SmI includes most of the postcentral gyrus and is involved with the appreciation of
touch, kinaesthetic and vibration sense.
d. The frontal eye field is involved with voluntary eye movements and is in the centre
of the middle frontal gyrus.
e. The motor speech area (of Broca) is in the posterior parts of the superior and middle
temporal gyri.

The sensorimotor cortex can be subdivided into four areas designated by the letters Ms and Sm,
where capital M denotes a predominantly motor function, and capital S a predominantly sensory
function (Figure 2.2).

 M.sl includes what were previously called the motor and premotor regions of the
precentral gyri and other gyri of the frontal lobe. It is involved with the initiation of
movement, and receives inputs mainly from the cerebellum and the thalamus. In the
precentral gyrus the body is represented upside down although the face, which lies
lowest, is represented the right way up. The hand, which has a disproportionately large
representation, lies above the face followed by the arm, trunk and leg. The leg and
perineum overlap the superior border and extend into the paracentral lobule.
 MsII (the supplementary motor area) is located on the medial surface of the frontal lobe
and is thought to be involved with postural mechanisms.

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  Sml includes most of the post central gyrus and its extension to the medial surface of the
parietal lobe. It is involved with the appreciation of touch and kinaesthetic and vibration
sense, and has a similar topographical representation to Msl.
 Smll is associated with the localisation of pain and temperature sensation, and is located
in the inferior part of the post central gyrus.

The frontal eye field is involved in voluntary eye movement and the accommodation pathway; it
is located in the centre of the middle frontal gyrus. The motor (anterior) speech area of Broca

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is situated in tlie inferior frontal gyrus, usually on the left in right-handed and most left-handed
people. The posterior speech area of Wernicke is in the posterior parts of the superior and middle
temporal gyri, extending into the lower part of the parietal lobe.

2.1.6 The internal capsule

a. The anterior limb lies between the head of the caudate nucleus and the lentiform nucleus.
b. The posterior limb lies between the thalamus and the lentiform nucleus.
c. Inferiorly the internal capsule is continuous with crus cerebri of the midbrain.
d. The somatosensory radiation lies laterally in the posterior limb of the internal capsule.
e. Fibres of the optic radiation run in the most posterior region of the internal capsule.

The internal capsule in horizontal section occupies a <-shaped region; the anterior limb is
bordered by the head of the caudate nucleus and the lentiform nucleus, and the posterior limb by
the thalamus and the lentiform nucleus. Inferiorly the internal capsule tapers into the crus cerebri
of the mid brain, and superiorly it fans out as the corona radiata. It contains most of the afferent
and efferent projections to and from the cerebral cortex. The descending fibres of the internal
capsule include the corticothalamic, corticostriatal, corticopontine, corticonuclear and
corticospinal fibres. Almost all subcortical afferents to the cortex arise from the thalamus. One of
the largest afferent systems is the somatosensory radiation, which lies medially in the posterior
limb. The most posterior fibres of the internal capsule run almost horizontally, posterior to the
lentiform nucleus. They include the fibres of the optic radiation.

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2.1.7 The basal nuclei and their connections

a. The lentiform nucleus consists of the putamen medially and the globus pallidus
laterally;
b. The caudate nucleus and the putamen are histologically similar, together they
comprise the striatum;
c. The nigrostriatal dopamine fibres arise from the neurons of the pars reticulate of the
substantia nigra.
d. The putamen receives afferents from bilateral MsI and ipsilateral SmI areas.
e. The subthalamic nucleus has reciprocal GABAergic connections with the globus
pallidus.

The basal nuclei (or ganglia) are areas of grey matter in the interior of the cerebral hemisphere.
They include the following structures:
 the lentiform nucleus, which consists of the medially placed globus pallidus and the
putamen laterally;
 the comma-shaped caudate nucleus; this is histologically similar to the putamen and
together they constitute the striatum;

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  the claustrum, which is the most laterally placed of the basal nuclei;
 the amygdala, which functionally belongs to the olfactory and limbic systems.
The connections of the basal nuclei are illustrated in Figure 2.4.

The striatum receives afferents from the whole of the cerebral cortex. These connections are
predominantly ipsilateral, although the putamen receives excitatory afferents from bilateral Msl
and ipsilateral SmI areas. The nigrostriatal dopamine fibres arise in the pars compacta of the
substantia nigra and pass through the subthalamus and internal capsule to the striatum. The
striatum also has efferent connections with the ipsilateral pars reticulata of the substantia nigra.
The globus pallidus modulates the activity in descending motor pathways by way of inhibitory
fibres, which terminate in thalamic nuclei that project to Msl; it also receives inhibitory fibres
from the ipsilateral striatum and subthalamic nucleus.

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2.1.8 Afferent connections of the cerebellum:

a. Climbing fibres originate from the ipsilateral inferior olivary nucleus and synapse on
Purkinje cells in the cerebellar cortex.
b. Mossy fibres from the pontine nuclei synapse in the granular layer of the contralateral
cerebellar cortex.
c. Fibres from the dorsal spinocerebellar tract decussate before entering the cerebellum.
d. Most fibres in the ventral spinocerebellar tract decussate twice along their course before
entering the ipsilateral superior cerebellar peduncle.
e. The floculonodular lobe receives afferents from the vestibular nuclei via the superior
cerebellar peduncle.

Afferents to the cerebellum are of two main types: climbing fibres and mossy fibres. Almost all
climbing fibres originate from the contralateral inferior olivary nucleus, enter the cerebellum via
the inferior peduncle, and make excitatory synaptic connections with Purlcinje cells in the
cortex. The inferior olivary nuclear complex receives cortical, spinal, vestibular and reticular
fibres as well as afferents from the red nucleus, the superior colliculus and the interstitial nucleus
of Cajal. By far the largest source of cerebellar afferents are the pontine nuclei. These mossy
fibres enter via the middle peduncle and terminate in the granular layer of the contralateral
cortex. The bulk of the input to the pontine nuclei comes from the motor and somatosensory
regions of the cerebral cortex and parts of the visual association cortex.
Proprioceptive information is transmitted to the cerebellum via two main pathways, the
dorsal and ventral spinocerebellar tracts. The dorsal spinocerebellar tract arises mainly from the
nucleus dorsalis in the thoracic and lumbar regions of the spinal cord. Unlike the connections
mentioned above, these fibres run ipsilaterally in the cord and medulla to enter the ipsilateral
cerebellum via the inferior peduncle. This tract carries proprioceptive information from the lower
limb and caudal trunk. The cuneocerebellar tract is the equivalent pathway for the upper limb,
upper trunk and neck.
The ventral spinocerebellar tract arises from cells at or below

83
the mid thoracic spinal level. Most fibres decussate immediately and then once more at the level
of the superior peduncle via which they enter the cerebellum- This tract conveys information -
about the internal state of the spinal cord and the activity of afferents involved in the withdrawal
reflexes. As in the dorsal tracts, this information is from the lower half of the body. The
equivalent for the upper half of the body is the rostral spinocerebellar tract. The floculonodular
lobe is the phylogenetically oldest part of the cerebellum; it is involved with balance and eye
movements, and receives afferents from the vestibular nuclei via the inferior peduncle.

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2.1.9 Efferent connections of the cerebellum
a. The fastigial nucleus receives axons from the Purkinje cells of the lateral cerebellar
cortex.
b. The fastigial nucleus sends axons bilaterally via the inferior peduncles to the vestibular
nuclei and the reticular formation.
c. The globose and emboliform nuclei send connections to the contralateral red nucleus via
the superior peduncle.
d. The dentare nucleus makes indirect connections with the premoror cortex via the nucleus
ventralis lateralis of the thalamus.
e. Fibres from the cerebellum project directly to the spinal cord and to the cranial nerve
nuclei.

Cerebellar efferents are primarily involved with balance3 posture and the fine control of
voluntary movements. Fhey can be divided into three broad categories (Figure 2.6):

85
  The vermal and fioculonodular efferent system—the axons from Purkinje cells in these
medial cerebellar regions pass to the fastigial nuclei. Efferent fibres from each nucleus
then pass bilaterally to the reticular formation and vestibular nuclei via the inferior
peduncles. This system is involved with
coordination, the unconscious maintenance of posture, balance, and control of vestibular eye
movements.
 Paravermal efferents—cells of the paravermal cortex synapse in the globose and
emboliform nuclei. They in turn send connections to the contralateral red nucleus via the
superior peduncle. This efferent system is thought to be involved with the correction of
on-going movements and primarily affects flexor muscle groups.
 The lateral zone of the cerebellar cortex sends efferents to the largest of the cerebellar
nuclei, the dentate nucleus. Fibres from the dentate nucleus pass to the red nucleus and
thalamus (dentatorubrothalamic tract) via the superior peduncle. Most of the thalamic
fibres terminate in the nucleus ventralis lateralis, which projects to the premotor cortex.
This system plays a part in the planning of skilled and/or rapid voluntary movements.

None of the cerebellar nuclei has any direct connections witii the spinal cord or cranial
nerve motor nuclei; instead, they exert their influence on the smooth coordination of movement
via a complex series of feedback and feed-forward influences.

2.1.10 The somatosensory system: the dorsal columnlmedial lemniscal pathway

a. The dorsal column pathway is responsible for fine touch and proprioception.
b. Cell bodies of the primary neurons are found in the dorsal root ganglia of the spinal
nerves.
c. The primary neurons from the lumber region synapse in the cuneate nucleus.
d. Secondary neurons from the gracile and cuneate nu8clei travel in the medial lemniscus
to the ipsilaterala thalamus.
e. The somatosensory radiation passes through the anterior limb of the internal capsule
before reaching the post central gyrus (SmI).

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The dorsal column/medial lemniscal pathway (Figure 2.7a) transmits information from receptors
in the skin (tactile corpuscles) and muscles (muscle spindles) involved wirii fine discriminatory
touch and proprioception. The cell bodies of the myelinated afferent fibres are found in the
dorsal root ganglia of the spinal cord. These primary neurones then travel in the ipsilateral dorsal
columns to the gracile and cuneate nuclei in the medulla. Primary neurones from the region
caudal to T6 lie medially in the dorsal columns and terminate in the gracile nucleus. Neurones
arising above this level are situated more laterally and terminate in the cuneate nucleus.
Secondary neurones from these nuclei decussate to form the contralateral medial lemniscus,
which terminates in the nucleus ventralis posterior lateralis of the thalamus. The somatosensory
radiation then passes to the post central gyrus via the posterior limb of the internal capsule.

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2.1.11 The somatosensory system: the anterolateral (spinothalamic) system
a. This system conveys tactile, pressure, temperature and nociceptive information.
b. Myelinated primary neurons terminate in the dorsal root ganglia.
c. Most secondary neurons decussate to ascend in the contralateral anterolateral
tract.
d. In the anterolateral tract cervical fibres lie superficial to sacral fibres.
e. All secondary neurons terminate in the thalamic nuclei.

The primary neurones in the anterolateral (spinothalamic) system (Figure 2.7b) are
predominantly unmyelinated or poorly myelinated fibres that convey tactile, pressure,
temperature and nociceptive information from free nerve endings. These fibres lie laterally in the
dorsal roots of the spinal nerves and terminate mainly in the ipsilateral dorsal horn. The
secondary neurones in this system decussate to ascend in the contralateral anterolateral tract.
These fibres are arranged so that those of sacral origin lie superficial to those from the cervical
region. Although most secondary neurones terminate in the thalamic nuclei they also connect
with the periaqueductal grey, reticular formation, and superior colliculus. Tertiary neurones from
the thalamus project to SmI and Smll (mainly tactile signals) and to the posterior part of the
frontoparietal operculum (nociceptive signals).

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2.1.12 Sensory trigeminal nuclei

a. Proprioceptive information from the muscles of mastication and the extraocular

muscles passes to the principal sensory nucleus of the trigeminal nerve.
b. Tactile information from the ipsilateral face is conveyed to the mesencephalic
nucleus of the trigeminal nerve.
c. The nucleus of the spinal tract of the trigeminal extends from the pons to the second
cervical segment of the spinal cord.
d. The spinal tract receives afferents from cranial nerves V, VII, IX and X.
e. Nociceptive information is conveyed to the caudal segments of the spinal tract.

There are three principal sensory nuclei of the trigeminal nerve. The mesencephalic nucleus is
the most rostral, located at the level of the superior colliculus. It receives proprioceptive afferents
from the ipsilateral muscles of mastication, extraocular muscles and from other muscles of the
head and neck. The principal sensory nucleus receives discriminatory tactile information from
the ipsilateral face and top of the head. The efferent fibres from these nuclei travel in
contralateral or ipsilateral tracts to the thalamus and then on to the somatosensory cortex. The
spinal tract of the trigeminal receives afferents conveying tactile, thermal, nociceptive and
proprioceptive information, not only from the trigeminal but also from the facial (VII),
glossopharyngeal (IX), and vagus (X) nerves. The nucleus of the tract extends from the pons to
the second cervical segment of the spinal cord. It is subdivided into the pars oralis, which has
similar afferents to the principal sensory nucleus; the pars interpolaris, which receives cutaneous
and proprioceptive information; and the pars caudalis, which is concerned primarily with
nociceptive signals.

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2.1.13 The corticospinal (pyramidal) and corticonuclear tracts

a. Descending fibres in these tracts originate fromboth the motorsensory (MsI) and
sensorimotor (SmI) areas.
b. Corticospinal and corticonuclear fibres are located in the anterior limb of the internal
capsule.
c. All cranial nerve nuclei, except part of the facial motor nucleus, receive bilateral
innervattion from corticonuclear fibres.
d. All the corticospinal fibres decussate at the junction of the medulla and spinal cord to
form the lateral corticospinal tract.
e. Corticospinal fibres tend to be stimulatory to motor neurons supplying extensor muscles
and inhibitory to those supplying flexor muscles.

The corticospinal and corticonuclear tracts (Figure 2.8) are involved with the control of fine,
discrete movements of the distal limb, head, and neck muscles. Aflferents arising from areas Msl
and SmI descend in the posterior limb and genu of the internal capsule to the crus cerebri. In the
brain stem corticonuclear fibres leave the pathway and are distributed to > the cranial nerve
nuclei, either directly or via reticular neurones. Most nuclei receive a bilateral innervation except
for the following, which receive only contralateral fibres:

 the part of the facial motor nucleus responsible for the lower facial muscles, hence the
sparing of the frontalis muscle in . upper motor neurone palsies;
 the spinal accessory nucleus supplying trapezius;
 most of the hypoglossal nucleus.

The spinal accessory nucleus innervating sternocleidomastoid - is supplied from the ipsilateral
cortex.
At the junction of the medulla and spinal cord most pyramidal fibres (75-90%) decussate to
form the lateral corticospinal tract. Those fibres that do not cross over initially run anteriorly in
the ventral corticospinal tract, which extends as far as the upper thoracic segments. Fibres from
the lateral corticospinal tract terminate mainly on intemeurones and motor neurones of the

90
upper and lower limbs. They tend to be stimulatory to motor neurones supplying flexor muscles
and inhibitory to those supplying extensor muscles.

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2.1.14 Supranuclear gaze pathways

a. Fast eye movements (saccades) originate from area 8 of the frontal lobe and from the
superior colliculus.
b. Nystagmus quick phases arise from the pontine paramedian reticular formation (PPRF).
c. Frontomesencephalic pathways terminate in the ipsilateral PPRF.
d. Gortical control of slow eye movements (pursuit) originates in the region of the parieto-
occipital-temporal junction.
e. Vestibular nuclei connect with the ipsilateral PPRF.

Fast eye movements (saccades) originate from the frontal eye fields in area 8 of the frontal lobes
and from the superior colliculus. Frontomesencephalic fibres pass through the anterior limb of
the internal capsule, pass through the thalamus and decussate in the lower mid brain before
terminating in the contralateral PPRF. The quick phase in nystagmus is a phylogenetically older
system that originates in the PPRF. The slow eye movement (pursuit) pathways are less well
defined; they originate in the region of the parieto-occipital—temporal junction and terminate in
the ipsilateral PPRF. Vestibular nuclei connect with the contralateral PPRF, so information from
the ampulla of the right horizontal canal is transmitted to the left PPRF, resulting in slow eye
movements to the left. These pathways are illustrated in Figure 2.9.

92
93
2.1.15 The pontine paramedian reticular formation (PPRF) and the medial
longitudinal fasciculus (MLF)

a. The PPRF is the starting point for the final common pathway for all conjugate horizontal
eye movements.
b. The left PPRF sends fibres to the right abducens nucleus.
c. The abducens nucleus sends fibres via the MLF to the medial rectus subdivision of t5he
ipsilateral oculomotor nucleus.
d. The rostral interstitial nucleus of the MLF initiates vertical saccades.
e. The rostral interstitial nucleus of the MLF receives inputs from the PPRF, the frontal eye
fields and the vestibular nuclei.

The pontine paramedian reticular formation, also known as the horizontal gaze centre, lies
ventral to the MLF and extends from |the trochlear to the abducent nucleus. It is the starting point
for; the final common pathway for all conjugate horizontal eye movements. The PPRF connects
with the ipsilateral abducent % nucleus, which contains two types of neurones; one type
innervates the ipsilateral lateral rectus and the other travels in the MLF to the medial rectus
subdivision of the contralateral oculomotor nucleus. The PPRF and MLF facilitate simultaneous
contraction of a lateral rectus and the contralateral medial rectus resulting in conjugate horizontal
eye movements (Figure 2.9). No vertical gaze centre has yet been identified, although the rostral
interstitial nucleus of the MLF, which receives inputs from the PPRF, the frontal eye fields and
vestibular nuclei, is involved in generating vertical saccades. Commands for upward saccades
pass through the posterior commissure to the third nerve nuclei, and those for downward
saccades travel caudally to the third and fourth cranial nerve nuclei.

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2.2: Autonomic nervous system of the head and neck

2.2.1 Sympathetic supply to the head and neck

a. Most of the preganglionic fibres to the head and neck exit the spinal cord at T1.
b. The sympathetic chain lies by the neck of the first rib.
c. The sympathetic chain lies lateral to the carotid sheath.
d. Head and neck fiberes synapse in the superior cervical ganglion.
c. Postganglionic fibres ―hitchhike‖ on the internal carotid.

Most of the preganglionic sympathetic fibres bound for the head and neck exit the spinal cord in
the XI nerve root before forming white rami communicantes to the sympathetic chain. The
sympathetic chain lies by the neck of the first rib (in close proximity to the apex of the lung) and
passes superiorly, lying just posteromedial to the carotid sneath. All fibres bound for the head
and neck will synapse in the superior cervical ganglion, with most postganglionic fibres
―hitchhiking‖ along the internal carotid to their destinations. Postganglionic fibres also travel on
the external carotid arteries and on the third to sixth* ninth, tentii, and twelfth cranial nerves.

2.2.2 Parasympathetic nuclei

a. The Edinger-Westphal nucleus supplies fibres to the sphincter papillae.

b. The superior salivatory nucleus supplies fibres to the lacrimal gland.
c. The inferior salivatory nucleus supplies fibres to the submandibular and sublingual
glands.
d. The superior salivatory nucleus supplies fibres to the parotid gland.
e. The dorsal motor nucleus supplies fibres to the gastrointestinal tract.

95
The parasympathetic nuclei are midline nuclei that give rise to preganglionic myelinated fibres
emerging from the brain stem with cranial nerves. The Edinger-Westphal nucleus supplies fibres
that ―hitchhike‖ with the oculomotor nerve to the ciliary ganglion and hence to the sphincter
pupillae and ciliary muscles. The superior salivatory nucleus produces fibres that travel in the
nervus intermedius of the seventh cranial nerve and will eventually reach the lacrimal,
submandibular, sublingual, nasal and palatal glands. The inferior salivatory nucleus is associated
with the glossopharyngeal nerve and supplies fibres to the parotid gland via the otic ganglion.
The dorsal motor nucleus is the secretomotor nucleus of the vagus nerve and supplies fibres to
the gastrointestinal tract.

2.2.3 Ciliary ganglion

a. The ciliary ganglion lies lateral to the optic nerve.
b. It contains parasympathetic fibres from the superior division of the oculomotor
nerve, which synapse in the ganglion.
c. Sympathetic fibres from the internal carotid synapse in the ganglion.
d. Short ciliary nerves contain parasympathetic, sympathetic, and sensory fibres.
e. Ganglion lesions may cause a tonic pupil.

The ciliary ganglion is the primary autonomic ganglion of the orbit. It lies near the apex of the
orbit and lateral to the optic nerve. It receives parasympathetic fibres from the inferior division of
the oculomotor nerve; these are the only fibres to synapse in the ganglion. The sympathetic input
is from postganglionic fibres travelling on the internal carotid artery. Short ciliary nerves contain
parasympathetic, sympathetic, and sensory fibres. An Adie‘s pupil is characterised by a tonic
near response and is thought to be caused by a ciliary ganglion lesion of unknown aetiology.

96
97
2.2.4 Pterygopalatine ganglion

a. Parasympathetic fibres travel in the g4reater petrosal nerve to the pterygoid canal.
b. The vidian nerve is a purely parasympathetic nerve.
c. The ganglion receives sensory fibres from the maxillary nerve.
d. Its branches innervate the pharynx, palate, lateral nasal walls and nasal septum.
e. Postganglionic fibres ―hitchhike‖ on the zygomatico-temporal nerve, which leads
them into the lacrimal gland.

The pterygopalatine ganglion, like all head and neck parasympathetic ganglia, receives
parasympathetic, sympathetic, and sensory fibres. .The parasympathetic fibres originate from the
nervus intermedius and travel in the greater petrosal nerve to the pterygoid canal where they join
sympathetic fibres from the deep petrosal nerve to form the vidian nerve. Sensory fibres from the
maxillary division of the trigeminal nerve pass through the ganglion and innervate the palate,
nasopharynx, the lateral aspect of the nose, and parts of the nasal septum. Postganglionic
parasympathetic fibres will ―hitchhike‖ on the zygomaticotemporal branch of the maxillary
nerve and then on the lacrimal nerve, before entering the lacrimal gland.

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2.2.5 Pupillary pathways

a. Postgeniculate fibres synapse in the pretectal nuclei.

b. The pretectal nucleus receives, fibres only from the ipsilateral eye.
c. Decussating fibres from pretectal nuclei pass ventral to the aqueduct.
d. the Edinger-Westphal nucleus receives inputs from both eyes.
e. Parasympathetic fibres ―hitchhike‖ on the oculomotor nerve to the ciliary ganglion.

The pupillary pathway may be divided into afferent and efferent limbs. Fibres from the optic
tracts (Ptegeniculate fibres) synapse in the pretectal nuclei. Each pretectal nucleus will receive
only an ipsilateral input, but fibres from each nucleus will connect with both the ipsilateral and
contralateral Edinger- Westphal nuclei. Decussating fibres from pretectal nuclei pass dorsal to
the aqueduct. The efferent limb of pupillary reflex consists of the preganglionic parasympathetic
fibres

99
(arising from the Edinger-Westphal nucleus) that ―hitchhike‖ along the oculomotor nerve to the
ciliarv ganglion, where they synapse and continue in the short ciliary nerves to the constrictor
pupillae.

2.3: Skull osteology

2.3.1 Sutures

a. The coronal suture separates the frontal and parietal bones.

b. The sagittal suture separates the parietal bones.
c. Parietal and occipital bones meet at the bregma.
d. The lambda is the remains of the anterior fontanelle.
e. The pterion comprises the frontal, parietal, sphenoid, and temporal bones.

The coronal suture extends from pterion to pterion between the frontal and the two parietal
bones. The sagittal suture, which separates the parietal bones, runs from the bregma (the remains
of the anterior fontanelle) anteriorly to the lambda posteriorly (the junction of the parietal bones
and occipital bone). The pterion (situated approximately 3 cm above the zygomatic arch) is the
meeting place of the frontal, parietal, sphenoid, and temporal bones, which usually form an H-
shaped junction. This site is of topographical importance in that fractures here may rupture the
middle meningeal artery (which passes through a bony canal at this point), producing an
extradural haematoma.

2.3.2 Sphenoid bone

a. This bone consists solely of greater and lesser wings plus a body.
b. The sphenoid bone articulates with the basiocciput.
c. The superior orbital fissure lies between the greater and lesser wings.
d. The foramen rotundum lies within the lesser wing of the sphenoid.
e. The pterygoid canal lies medial to the foramen rotundum.

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The sphenoid bone is one of the most complicated skull bones and is divided into greater and
lesser wings, a body, and two pterygoid processes. The body of the sphenoid articulates with the
basiocciput at a synchondrosis that fuses at the age of about 25, and is an important constituent
of the skull base. The lesser wing of the sphenoid contains the optic canal and forms the
boundary of the superior orbital fissure with the greater wing. The base of the pterygoid process
is perforated by the foramen rotundum, which lies lateral to the smaller pterygoid canal.

2.3.3 Temporal bone

a. The temporal bone forms part of the zygomatic arch.

b. The petrous part of the temporal bone houses the middle ear.
c. It transmits the stylomastoid foramen.
d. It transmits the jugular canal.
e. Mastoid air cells are present at birth.

The temporal bone, like the sphenoid bone, can be divided into a number of parts for descriptive
purposes. The squamous part articulates with the greater wing of the sphenoid and the parietal
bone; its zygomatic process forms part of the zygomatic arch. The petrous part houses the middle
ear and labyrinth, and is perforated by the carotid canal. Posteriorly the mastoid part articulates
with the parietal and occipital bones and contains air cells that develop only after birth. This part
of the temporal

101
bone also houses the stylomastoid foramen, which lies posterior to the styloid process and
transmits the facial nerve. The fourth part of the temporal bone (the tympanic part) forms part of
the wall of the external auditory meatus.

2.3.4 Maxilla
a. The maxilla is wholly a membranous bone.
b. It articulates superiorly with the zygomatic and frontal bones.
c. The roof of the maxillary sinus forms the orbital floor.
d. The maxilla forms part of the nasolacrimal canal.
e. It contains the greater palatine canal.

The maxilla is wholly a membranous bone and plays an important part of the formation of the
orbital floor, the lateral wall of the nose and the hard palate. It articulates superiorly with the
lacrimal, nasal, zygomatic, and frontal bones. The pyramidal maxillary sinus dominates the bone,
extending from its apex in the zygomatic process to its floor in the alveolar process. The sinus is
an important inferior relation of the orbit, and its roof is grooved by the infraorbital canal. The
sinus drains into the middle meatus via the hiatus semilunaris in its nasal wall. Lying just
posterior to this hiatus is the greater palatine groove, which (by virtue of its. articulation with the
palatine bone) forms the greater palatine canal. The walls of the nasolacrimal duct are formed
from the v maxilla, lacrimal bone, and the inferior nasal concha.

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2.3.5 Relations of the middle cranial fossa foramina

a. The foramen spinosum connects the middle cranial and infratemporal fossae.
b. The foramen ovale transmits the mandibular division of the trigeminal nerve.
c. The foramen ovale transmits the middle meningeal artery.
d. The internal carotid artery passes through the foramen lacerum.
e. The deep petrosal nerve jeaves the fossa via the pterygoid canal.

Numerous foramina connect the middle cranial fossa with a number of extracranial sites. The
foramen ovale and the smaller foramen spinosum connect the middle cranial fossa with the
infratemporal fossa. The middle meningeal artery (a terminal branch of the maxillary artery)
passes through the foramen spinosum, whereas the foramen ovale transmits the mandibular
division of the trigeminal nerve (v), the accessory meningeal artery, the /esser petrosal nerve and
an emissary vein (OVALE). The foramen lacerum, which lies in the medial aspect of the middle
cranial fossa, does not transmit any structures but the

103
internal carotid artery passes across it. The deep petrosal nerve, containing sympathetic fibres
bound for the pterygopalatine ganglion, leaves the fossa in conjunction with the greater petrosal
nerve via the pterygoid canal.

2.3.6 Foramina and fissures

a. The jugular foramen transmits the ninth, tenth, and eleventh cranial nerves.
b. The foramen magnum transmits the cranial part of the accessory nerve.
c. The stylomastoid foramen transmits the facial nerve.
d. The squamotympanic fissure transmits the chorda tympani.
e. The hypoglossal canal passes through the bases of the occipital condyles.

The jugular foramen (situated in the posterior cranial fossa) transmits the ninth, tenth, and
eleventh cranial nerves, and the internal jugular vein. The accessory nerve consists of two parts:
cranial, and spinal (which enters the skull via the foramen magnum). The stylomastoid foramen
in the temporal bone transmits the facial nerve but the chorda tympani (a branch of the nervus
intermedius that accompanies the facial nerve in the middle ear) does not exit via this foramen—
it enters the infratemporal fossa via the petrotympanic fissure. The hypoglossal canal, which
transmits the twelfth cranial nerve, transects the bases of the occipital condyles.

2.4: Head and neck anatomy

2.4.1 Cervical vertebrae

A typical cervical vertebra is characterized by:

a. A foramen transversarium.
b. A circular shaped vertebral canal.
c. A bifid spinal process.
d. Large transverse processes.
e. Kidney shaped body.

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There are seven cervical vertebrae: the atlas and axis (Cl and C2) are atypical and C7 has certain
peculiar characteristics, so there are only four typical vertebrae (C3-C6). Tlie foramen
transversarium is found in the transverse processes c*f all cervical vertebrae. Features
characteristic of C3—C6 include a triangular shaped vertebral canal, bifid spinal processes,
kiciney shaped body, and small transverse processes. Occasionally tfcie transverse process of C7
may be enlarged to form a cervical rib.

2.4.2 Cervical plexus

a. The sensory roots emerge at the anterior borcler of the sternocleidomastoid.

b. There is no C1 dermatome.
c. The greater auricular nerve supplies the skin over the parotid gland.
d. The ansa cervicalis is the motor supply to the strap muscles.
e. The phrenic nerve root value is C3, 4.

The cervical plexus is formed by the anterior rami of the upper four cervical nerves after each
has received a grey; ramus from the superior cervical ganglion. It is covered by preverrtebral
fascia and its sensory roots pierce this before emerging at ithe posterior border of the
sternocleidomastoid. There is no C1 dermatome but a loop from C1 passes to the hypoglossal
nerve, from which fibres are transmitted to the superior root of the ansa cervicalis.

105
The ansa cervicalis is the motor supply to the strap muscles and comprises the superior root (as
described above) and an inferior root formed by the union of branches from C2 and C3. The
greater auricu1ar nerve (whose root value is C2,3) supplies the skin over the parotid gland, the
angle of the mandible, and both sides of the ear lobe. The phrenic nerve is formed mainly from
C4 fibres but also has contributions from C3 and C5. It is the sole motor supply to the diaphragm
and its sensory fibres innervate the central dome of the diaphragm, the fibrous pericardium, part
of the parietal pleura, and the diaphragmatic peritoneum.

2.4.3 Carotid arteries

a. The right common carotid arises from the aortic arch.
b. The common carotid bifurcates at the level of the superior border of the thyroid
cartilatge.
c. The internal carotid has no branches in the neck.
d. The facial and lingual arteries are anterior branches of the external carotid.
e. The external carotid divides into superficial temporal and maxillary branches before
entering the parotid gland.

The left common carotid artery is the third branch arising from the aortic arch; the right common
carotid artery arises in the root of the neck from the brachiocephalic artery. The common carotid
arteries bifurcate at the level of the superior border of the thyroid cartilage (C3), this bifurcation
being marked by a distension of the artery known as the carotid sinus. The internal carotid artery
has no branches in the neck. The branches of the external carotid artery can be described
according to their origins: the ascending pharyngeal branch is the only one to arise: from the
medial aspect of the artery; superior thyroid, facial, and lingual arteries arise from the anterior
aspect; the posterior auricular and occipital branches arise from the posterior aspect. The external
carotid enters the parotid gland before dividing into its two terminal branches—the superficial
temporal and maxillary arteries.

106
2.4.4 Relations of the carotid sheath

a. The internal jugular vein lies medial to the carotid artery.

b. The vagus nerve lies medial to the common carotid artery.
c. The ansa cervicalis is embedded in the anterior wall of the sheath.
d. The hypoglossal nerve lies superficial to the sheath.
e. The sympathetic chain lies deep to the carotid sheath.

The carotid sheath is made of a dense ―feltwork‖ of areolar tissue surrounding the carotid arteries
(both common and internal), the internal jugular vein, and the vagus nerve. The internal jugular
vein has a lateral position in the sheath, whose wall is thinned over the vein to allow for dilation
during increased blood flow. The vagus nerve is sandwiched between the common carotid
medially and die internal jugular vein laterally. Other important neuronal relations of the sheath
include the ansa cervicalis (which is embedded in the anterior wall), the sympathetic chain
(which lies deep to the sheath), and the hypoglossal nerve (which passes anteriorly, lying
superficial to the sheath).

107
2.4.5 Structure and relations of the thyroid gland

a. The gland may be connected t6o the tongue.

b. The isthmus of the thyroid lies level with the second to fourth tracheal rings.
c. The recurrent laryngeal nerve lies beside the superior thyroid artery.
d. The external laryngeal nerve lies beside the inferior thyroid.
e. The thyroid gland is enclosed by pretracheal fascia.

The thyroid gland consists of two symmetrical lobes that are united in front of the second, third,
and fourth tracheal rings by an istihmus of gland tissue. The thyroid gland develops in the floor
of the primitive pharynx and descends to its adult position. The thyroglossal duct is a simple
downgrowth that originates from the foramen caecum of the tongue. It passes ventrally between
the first and second pharyngeal arches then caudally in front of the remaining arches to the
commencement of the trachea. Remnants of the thyroglossal duct may produce cysts amrwhere
along the course of the duct. During thyroid surgery the two important relations that should be
remembered are that of the recurrent laryngeal nerve (which is intimately related to the inferior
thyroid artery), and the external laryngeal nerve (which runs with the superior thyroid artery).
The entire thyroid gland is enclosed by pretracheal fascia.

2.4.6 Blood supply, venous and lymphatic drainage of the

thyroid glared
a. The superior thyroid artery arises from the external carotid artery.
b. The inferior thyroid artery arises directly from the subclavian artery.
c. The thyroid gland is drained by veins corresponding to the its arteries.
d. The inferior thyroid vein drains into the internal jugular vein.
e. the thyyroidea ima artery is present in 3% of individuals.

108
The arterial supply to the thyroid gland is via the superior thyroid artery, arising from the
anterior aspect of the external carotid and from the inferior thyroid artery (a branch of the
thyrocervical trunk that arises from the first part of the subclavian artery). The thyroidea ima
artery, which arises from the brachiocephalic trunk or directly from the arch of the aorta, enters
the lower part of the isthmus in 3% of individuals. Drainage is via three veins: the superior
thyroid (entering either the internal jugular or the facial vein); the middle thyroid (that passes
directly into the internal jugular); the inferior thyroid veins (which form a plexus that drains the
isthmus and lower poles into the left brachiocephalic vein).

2.4.7 Structure and relations of the submandibular gland

a. The submandibular gland is a mixed mucous and serous gland.
b. It lies mainly deep to the mylohyoid.
c. It is crossed by the lingual artery.
d. This gland receives parasympathetic fibers from the chorda tympani.
e. The submandibular duct passes between the mylohyoid and the hyoglossus.

The submandibular gland is a mixed mucous and serous gland consisting of a large superficial
and a smaller deeper part that
are continuous around the posterior border of the mylohyoid. The submandibular duct emerges
from the superficial part of the gland and runs forward between the mylohyoid and the
hyoglossus. It opens into the floor of the mouth beside the frenulum. An important anterior
relation of the submandibular gland is the facial artery, which often grooves its surface.
Parasympathetic secretomotor fibres originate in the chorda tympani, join the lingual nerve and
synapse in the submandibular ganglion. Postganglionic fibres connect directly with the gland.

109
2.4.8 Relations of the parotid gland
a. The parotid is predominantly a mucous gland.
b. The facial nerve divides in the superficial gland.
c. The retromandibular vein is the deepest structure of the parotid gland.
d. The parotid duct opens opposite the neck of the second upper molar tooth.
e. Parasympathetic fibres from the otic ganglion travel in the auriculot emporal nerve to the
parotid gland.

The parotid gland is predominantly a serous salivary gland surrounded by a tough capsule
derived from the investing layer of deep cervical fascia. It is situated in the gap between the
mastoid process and the stemomastoid, the ramus of the mandible and the styloid process. The
parotid has a number of important relations. These are (from superficial to deep): the facial nerve
(which divides into its terminal branches within the gland); the retromandibular vein (formed by
the maxillary and superficial temporal veins and lies just deep to the facial nerve—by following
its tributaries the surgeon is often able to identify the terminal branches of the facial nerve); the
external carotid artery and its terminal branches (the superficial temporal ahd maxillary arteries)
are the deepest structures in the gland (along with the auriculotemporal nerve, which carries
•postganglionic parasympathetic fibres from the otic ganglion) . The parotid duct emerges from
the anterior surface of the gland and pierces the buccinator before opening opposite the neck of
the second upper molar tooth.

110
2.4.9 Nervus intermedius

a. The nervus intermedius enters the internal acoustic meatus with the facial nerve.
b. Parasympathetic fibres synapse in its geniculate ganglion.
c. The nervus intermedius provides secretomotor fibres to both the submandibular and
the sublingual glands.
d. The lesser petrosal nerve is derived from the nervus intermedius.
e. The chorda tympani supplies taste to the anterior third of the tongue.

The nervus intermedius contains secretomotor fibres arising from the superior salivatory nucleus,
and sensory fibres that terminate in the nucleus of the solitary tract. It leaves the brain stem in
conjunction with the facial nerve and enters the internal acoustic meatus. The geniculate
ganglion, which marks a right angle bend in the nerve as it passes through the middle ear, is a
sensory, not a parasympathetic, ganglion (similar to the dorsal root ganglions of the spinal cord).
The chorda tympani, which arises from the nervus intermedius in the middle ear, carries
secretomotor fibres that synapse in the submandibular ganglion before supplying die sublingual
and submandibular glands. It

111
also contains special sensory fibres that supply taste to the anterior two thirds of the tongue. The
nervus intermedius gives off the greater petrosal nerve at the level of the geniculate ganglion.
This nerve contains parasympathetic fibres that will synapse in the pterygopalatine ganglion
before supplying the lacrimal gland.

2.4.10 Facial muscles and their innervation

a. Frontalis is supplied by the temporal branch of the seventh cranial nerve.
b. Temporalis is supplied by the mandibular branch fo the fifth cranial nerve.
c. The anterior belly of digastrics is supplied by the seventh cranial nerve.
d. Buccinator is supplied by the buccal branch of the fifth cranial nerve.
e. Platysma is supplied by the cervical branch of the seventh cranial nerve.

A simple knowledge of embryology is useful when considering the innervation of the facial
muscles. Those muscles derived from the first pharyngeal arch are the muscles of mastication
and are supplied by branches of the mandibular division of the trigeminal nerve. Those derived
from the second pharyngeal arch are used for facial expression, and are supplied by branches of
the facial nerve. Temporalis, masseter and pterygoid are therefore all supplied by the trigeminal
nerve, whereas frontalis, orbicularis oculi and oris, and platysma are supplied by the facial nerve.
Buccinator is the exception, for while it plays a role in mastication by preventing food from
accumulating in the cheek, it is derived from the second pharyngeal arch and is therefore
supplied by the facial nerve. The digastric is derived from both the first and second arches; thus
its anterior belly is supplied by the trigeminal nerve and its posterior belly by the facial nerve.

112
2.4.11 Infratemporal fossa
a. The medial boundary of the infratemporal fossa is the medial pterygoid plate.
b. The mandibular nerve enters via the foramen ovale.
c. The maxillary artery exits via the pterygomaxillary fissure.
d. The middle meningeal artery exits via the foramen spinosum.
e. The chorda tympani supplies secretomotor fibres to the otic ganglion in the fossa.

The infratemporal fossa is a box like fossa situated behind the maxilla, below and behind the
zygomatic arch. Its roof is formed by the greater wing of the sphenoid bone and by part of the
squamous part of the temporal bone. The medial wall of the fossa is formed by the lateral
pterygoid plate, the anterior wall by the maxilla, the posterior wall by the styloid apparatus, and
the lateral wall by the mandibular ramus. The major vessel in the fossa is the maxillary artery
and its largest tributary, the middle meningeal artery, exits via the foramen spinosum. The
maxillary artery itself leaves the fossa through the pterygomaxillary fissure and so enters the
pterygopalatine fossa. The mandibular division of the trigeminal nerve enters the fossa via the
foramen ovale; this is the only branch of the trigeminal nerve that contains motor fibres. The otic
ganglion, which is situated in the infratemporal fossa, receives preganglionic parasympathetic
fibres from the lesser petrosal nerve.

Answers
2.1.1 D 2.1.10 a, b 2.2.3 a, d, e
2.1.2 a, c* e 2.1.11 a, c 2.2.4 a, c, d
2.1.3 a, c, d 2.1.12 c, d, e 2.2.5 b, d, e
2.1.4 b, d 2.1.13 a
2.1.5 a, c, d 2.1.14 a, b, d 2.3.1 a, b, e
2.1.6 a, b, c, e 2.1.15 a, d, e 2.3.2 b, c, e
2.1.7 b, d, e 2.3.3 a, b, c
2.1.8 b, c, d 2.2.1 a, b, d, e 2.3.4 a, b, c, d
2.1.9 b, c, d 2.2.2 a, b, e 2.3.5 a, b, e

113
2.3.6 a, c, e 2.4.4 c, d, e 2.4.9 a, c

2.4.5 a, b, e 2.4.10 a, b, e

2.4.1 a, c, e 2.4.6 a, e 2.4.11 b, c, d

2.4.2 b, c, d 2.4.7 a, d, e

2.4.3 b, c, d 2.4.8 b, d, e

114
 3. Genetics

3.1: Gene expression and cell division

3.1.1 The structure of chromosomes

a. In a polynucleotide chain adjacent nucleotides are linked byhydrogen bonds.

b. Histones are the only proteins involved in the formation of chromatin.
c. A solenoid is a helical structure composed of compacted nucleosomes.
d. 30% of the DNA in the genome actually encodes genes.
e. Single copy DNA accounts for approximately 75% of the genome.

DNA is a polymeric nucleic acid macromolecule made up of units consisting of a five-carbon

sugar, deoxyribose; a nitrogen- containing base—adenine, guanine (purines) thymine or cytosine
(pyrimidines); and a phosphate group. Adjacent nucleotides in a polynucleotide chain are linked
by 3'-5' phosphodiester bonds; two such chains running in opposite directions are joined by
hydrogen bonds between pairs of bases (adenine—thymidine or cytosine—guanine) to form a
right-handed double helix. Histones are proteins that, with acidic non-histone proteins, form a
complex with DNA to produce chromatin. Segments of the DNA double helix wrap around
histone octamers. These histone cores are linked by ―spacer‖ segments of DNA to form'
nucleosomes, the basic structural unit of chromatin. Long strings of nucleosomes are compacted
into a helical structure known as a solenoid, each turn of the solenoid containing about six
nucleosomes. The solenoids themselves are arranged into loops attached at intervals to a non-
histone protein

115
scaffold. Figure 3.1 illustrates the levels of chromatin packaging in a human chromosome.

Less than 10% of the DNA in the genome encodes for genes. There are three classes of DNA in
the human genome: (1) singlecopy DNA;, in which the nucleotide sequence is represented only
once per haploid genome—such DNA accounts for 75% of the genomej (2) dispersed repetitive
DNA families, repetitive sequences that are dispersed throughout the genome and account for
15% of human DNA—there are two major families in this group, the Alu and LI families; (3)
satellite DNA—these repeat sequences tend to be arranged in tandem, in a head to tail fashion,
and are often found in specific sites such as centromeres or telomeres.

116
3.1.2 Gene expression

a. The primary RNA transcript contains introns and exons.

b. RNA processing and splicing occurs in the cytoplasm.
c. Each tRNA is specific for a single amino acid.
d. Each amino acid is specified by a single codon.
e. The codon for methionine establishes the reading frame of the mRNA.

Gene expression can be broken down into several stages.

 Transcription—RNA polymerase initiates transcription from the ―non-coding‖ or
―antisense‖ strand of the DNA. Synthesis of the primary RNA transcript, which includes
introns, proceeds in a 5'-3' direction beyond the position on the chromosome that
corresponds to the 3' end of the mature RNA. A ―CAP‖ structure is then added to the 5'
end of the RNA and a polyA tail is added after cleavage of the 3' end downstream of the
coding information.
 RNA processing and splicing—removal of the introns from the RNA transcript takes
place in the nucleus. The mature mRNA is then transported to the cytoplasm.

117
  Translation—tRNA molecules (each specific for an amino acid) transport
amino acids from the cytoplasm to the mRNA template located on ribosomes, so adding
to the polypeptide chain. Each set of three bases in the mRNA constitutes a codon. There
are 64 (43) possible triplet combinations and as there are only 20 amino acids most amino
acids are specified by more than one codon. Translation is always initiated at a codon
specifying methionine, so establishing a reading frame for the mRNA. The ribosome then
moves along the mRNA three base pairs at a time until a stop codon is reached. The
completed polypetide is then released.
 Post-translational processing—the polypeptide chain may undergo considerable
modification as it is bonded and folded into a specific three-dimensional product.

3.1.3 The cell cycle and mitosis

a. G1, S phase and G2 constitute the interphase.
b. After mitosis all cells enter G1 and eventually S phase.
c. In prophase the nuclear membrane breaks up, allowing dispersal of the chromosomes
within the cell.
d. Chromosomes separate at the centromere during anaphase.
e. Cytokinesis coincides with telophase.

When a mitotic cell division is complete the cell enters interphase, which consists of G1 (Gap 1),
S phase and G2 (Gap 2). G1 is of variable duration, depending on cell type. In some cell lines G1
may be only a few hours; other cells, such as neurones and red blood cells, do not divide once
they are fully differentiated and are permanently stopped in a gap phase known as G0. S phase is
the stage of DNA synthesis during which each chromosome replicates to form two daughter
chromatids. G2, the stage during which the cell undergoes further enlargement, is ended by
mitosis. The stages of the cell cycle are illustrated in Figure 3.3.
Mitosis is the process by which a cell divides into two daughter cells, each of which receives
a complete set of genetic information. Although mitosis is described as occurring in several
stages, it is a continuous process. During prophase the

118
chromosomes condense, the nucleolus disappears and the mitotic spindle begins to form. When
the nuclear membrane breaks up, with subsequent dispersal of the chromosomes within the cell,
mitosis has entered prometaphase. Kinetochores located at the centromeres facilitate attachment
of the chromosomes to the micro tubules of the mitotic spindle. During metaphase the
chromosomes are maximally condensed and arranged in the equatorial plane of the cell.
JMetaphase is followed by anaphase, when the chromosomes separate at the centromere and the
two chromatids move to opposite poles of the cell. Telophase consists of reformation of the
nuclear membranes and decondensation of the chromosomes, accompanied by cytokinesis
(division of the cytoplasm).

3.1.4 Mieosis
a. Meiosis I results in the production of two daughter cells, each with a haploid number
of chromosomes.
b. Grossing over refers to the exchange of homologous segments between non-sister
chromatids of homologous chromosomes.
c. Crossing over occurs in the pachytene phase of prophase I.
d. Segregation of alleles does not occur in meiosis II.
e. The most error prone phase of meiosis is anaphase I

Meiosis can be defined as the process by which a primary spermatocyte or oocyte divides to
form two cells (gametes), each with a haploid number of chromosomes.
MLeiosis I is a reductive division and has several similarities with mitosis. The prophase is
considerably more involved than that of mitosis. Having undergone an S phase the chromosomes
become visible (leptotene). This is followed by the pairing of homologous chromosomes along
their entire length (zygotene), a process of synapsis that precisely aligns corresponding DNA
sequences. The homologous chromosomes now appear as bivalents (pachytene) and exchange of
homologous segments between non-sister chromatids (crossing over) takes place. The
homologous chromosomes then begin to repel one another (diplotene), although they remain
attached at points known as chiasmata. These chiasmata are thought to mark the sites of cross
over.
Metaphase I is followed by anaphase I, which is the most error prone phase in meiosis. During
anaphase I the bivalents separate independently of each other, so the paternal and maternal set of
chromosomes are sorted into a random combination.
Meiosis II is not preceded by an S phase and is similar to mitotic cell division. Further
segregation of paternal and maternal alleles may occur during meiosis II, depending on whether
they have been involved in a cross over during meiosis I.

3.2: Mutations and. patterns of inheritance

3.2.1 Gene mutations

a. Gene mutations are the most common form of mutation in the human genome.
b. Nonsense mutations involve an amino acid substitution.
c. The number of bases involved in a frameshift mutation is a multiple of three.
d. DNA repair enzymes correct 90% of DNA replication errors.
e. The frequency of replication errors is 1—10 per base pair per cell division.
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A mutation can be defined as any permanent change in the DNA. The change may be a genome,
chromosome or gene mutation. Genome mutations are the most common, with a frequency of
10-2 per cell division. .They are the result of chromosomal missegregation. Chromosome
mutations are the result of chromosomal rearrangements, and have a frequency of 6 x 10 −4 per
cell division. Gene mutations are the least common form of mutation in the human genome, with
a frequency of 10-10 per base pair per cell division. Although the DNA polymerase introduces
one incorrect nucleotide every 107 base pairs, DNA repair enzymes recognise and repair 99.9%
of all replication errors.

Gene mutations caused by replication errors occur by several different mechanisms.

Nucleotide substitutions can take the form of: (1) missense mutations—point mutations leading
to amino acid substitutions that alter the ―sense‖ of the coding strand of the gene, as in the
haemoglobinopathies; (2) nonsense mutations, which involve the inclusion of a premature stop
codon—a nonsense mutation in the neurofibromatosis type 1 gene, for example, results in
premature termination of translation; (3) RNA splicing mutations, which alter the sites; involved
with the recognition of intron/exon (acceptor sites) or exon/intron (donor sites) boundaries, so
leading to faulty RNA splicing. Deletions and insertions can take the form of: (1) frameshift
mutations, in which the reading frame of translation will be altered by a deletion or an insertion
when the number of bases involved is not a multiple of three; (2) codon insertions or deletions,
where The bases involved are a multiple of three; (3) gene deletions and duplications, mutations
that tend to occur in identical or near identical DNA sequences. Misalignment and pairing out of
register may occur in both meiosis and mitosis. Recombination between mispaired chromosomes
or sister chromatids can then lead to gene deletion or duplication. This unequal crossing over is
responsible for the variation in the number and structure of red and green visual pigment genes
between normal individuals and males with defective red or green colour vision.

DNA can also be damaged by extrinsic influences such as ultraviolet or ionising radiation,
and chemical processes such as deamination or depurination.

120
3-2.2 Chromosomal abnormalities

a. Aneuploidy is the most common chromosomal abnormality.

b. Nondisjunction in meiosis II is the most common cause of aneuploidy.
c. Interstitial deletions are unbalanced rearrangements.
d. Pericentric inversions are balanced rearrangements.
e. Robertsonian translocations are balanced rearrangements that result in an abnormal
chromosome number.

Chromosomal abnormalities may be secondary to an abnormal chromosome number

(aneuploidy) or an abnormal structure. The former is the most common chromosomal
abnormality, occuring in 3—4% of all clinically recognised pregnancies. Aneuploidy is usually
the result of meiotic nondisjunction in meiosis I, resulting in a gamete with 24 chromosomes
containing both the maternal and paternal members of the pair. Nondisjunction may occasionally
occur in meiosis II, when die gamete will have both copies of either the paternal or maternal
chromosome.
Structural change in a chromosome arises as a result of a breakage in the chromosome followed
by an abnormal recombination (Figure 3.4). This change is said to be balanced if the
recombination produces a chromosome with a normal amount of genetic information, or
unbalanced if there is additional or missing information.
Unbalanced rearrangements tend to result in an abnormal phenotype. They include: (1) deletions,
which may be terminal or interstitial—the clinical effect depends on the size of the deleted
segment and the number and function of the genes it coded for, (2) duplications, which tend to be
less harmful than deletions; (3) ring chromosomes which can form when a chromosome
undergoes two breaks and the broken ends unite; and (4) isochromosomes, which are
chromosomes that have one arm missing and the other duplicated.
Balanced rearrangements, although they tend not to result in an abnormal phenotype, can pose a
threat to subsequent generations because carriers are more likely to produce

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unbalanced gametes. The two main classes of balanced rearrangement are inversions and
translocations. Inversions occur when a chromosome sustains two breaks and the segment inverts
before rejoining the chromosome. If the inverted segment includes the centromere, the inversion
is pericentric; if both breaks occur in the same arm of a chromosome, the inversion is
paracentric. Translocations involve the exchange of chromosome segments between non-
homologous chromosomes. When there is reciprocal exchange of the broken-off segments—a
reciprocal translocation—the total number of chromosomes is unchanged. A Robertsonian
translocation is a rearrangement that involves two acrocentric chromosomes that fuse near the
centromere, with subsequent loss of the short arms. Although the balanced karyotype has only 45
chromosomes (including the translocation chromosome), the phenotype is invariably unaffected
as the short arms of all five pairs of acrocentric chromosomes have multiple copies of genes for
ribosomal RNA. Therefore deletion of two short arms is not deleterious to the carrier.

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3.2.3 Which of the following are true of an autosomal dominant trait with 100%
penetrance and expressivity?
a. The phenotype appears in every generation, each affected person having an affected
parent.
b. Any child of an affected parent has a 50% risk of inheriting the trait.
c. Male to male transmission is less likely than female to female transmission.
d. Affected males can have unaffected daughters.
e. The phenotypes of all autosomal dominant traits are more severe in homozygotes than
in heterozygotes.

Autosomal dominant traits account for more than 50% of all mendelian phenotypes. As the
prevalence of the abnormal gene is low compared with that of normal alleles, affected children
usually have one unaffected parent and one who is heterozygous for the mutation. Any child with
such parents will have a 50% chance of inheriting the trait. IVlales and females are equally likely
to transmit the phenotype, male to male transmission is as common as female to female or male
to female transmission, and males can have unaffected daughters. The phenotype appears in all
generations of a kindred, each affected person having an affected parent (Figure 3.5). Apparent
exceptions to this rule may arise because of a fresh mutation in the gamete of a phenotypically
normal parent, or because the disorder is not expressed (nonpenetrant) or is expressed very
mildly. Although homozygotes are more severely affected than heterozygotes in most autosomal
dominant disorders, a notable exception is Huntington‘s disease.

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3.2.4 Which of the following are true of an autosomal recessive trait?
a. For most autosomal recessive traits males and females are equally likely to be
affected.
b. If both parents are carriers the recurrence risk for each sibling of the proband is 1
in 4.
c. An autosomal recessive phenotype typically is seen only in the sibship of the
proband and not in its parents or offspring.
d. consanguinity is not associated with autosomal recessive traits.
e. In a mating of an affected homozygote with a heterozygote, 50% of the children
will be affected.

Autosomal recessive disorders are expressed only in homozygotes and account for
approximately one-third of the recognised mendelian phenotypes. The mating of two parents
each of whom carries at least one recessive allele can produce homozygous affected offspring.
The most common scenario is the mating of two carriers.

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 Box 3.1 Inheritance of recessive disorders
Parents Risk too offspring
Genotype Phenotype
Carrier x carrier: R/r x R/r ¼ R/R, ½ R/r, ¼ r/r ¾ Unaffected, ¼ affected
Carrier x affected: R/r x r/r ½ R/r, ½ r/r ½ Unaffected, ½ affected*
Affected x affected: r/r x r/r All r/r all affected
* The mating of a carrier and an affected homozygote leads to a quasidominant
inheritance pattern, with 50% of the siblings being affected. This pattern can be
distinguished from a true autosomal dominant pedigree as it rarely persists over more
than two generations.

An autosomal recessive phenotype is often isolated; if it appears in more than one member of a
kindred, typically it is seen only in the sibship of the pro'band and not in the parents, offspring,
or other relatives (Figure 3.6). Consanguinity between parents of an affected person is more
likely if the gene responsible for the condition is rare in the general population. It should be
noted that consanguinity in previous generations is usually irrelevant. For the majority of
autosomal recessive disorders males and females are equally affected. A typical autosomal
recessive pedigree is illustrated in Figure 3.6.

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3.2.5 Regarding X inactivation, which of the following are true?

a. Inactivation occurs approximately 1 month after fertilization.

b. In any one somatic cell the inactive X maya be the paternal or the maternal X.
c. All of the X chromosome is inactivated.
d. Females are mosaics with respect to their X-linked genes.
e. Unfavourable Lyonisation accounts for manifesting heterozygotes.

The principle of X inactivation was first put forward by Mary Lyon in 1961—2. The Lyon
hypothesis has three main points. (1) Only one X chromosome is active in somatic cells of
female mammals; the second is inactive and appears in interphase cells as a Barr body. The exact
mechanism of this inactivation is unknown. (2) Inactivation occurs from 3 days (16—64 cell
stage) after fertilisation and is normally complete by the end of the first week. (3) In any somatic
cell inactivation is purely random—the inactive X may be the paternal or maternal X; however,
all the clonal descendants of that cell will have the same inactive X. X inactivation explains the
concept of ―dosage compensation‖, whereby the quantity of a product produced by a single allele
in a male is equivalent to that produced by a pair of alleles in a female- However, not all of the
condensed X chromosome is inactive; some segments, such as the distal region of the short arm,
remain active.
Females are mosaics with respect to their X-linked genes, that is, they have two cell
populations in which one or the other X chromosome is the active one. In carrier females, the
proportion of cells in which a particular allele is active is variable. This leads to considerable
phenotypic variability in X-linked disorders, ranging from a normal individual to a full
manifestation of the defect, that is, a manifesting heterozygote.

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3.2.6 Which of the following are true of an X-linked recessive trait?

a. The trait is manifest only in males.

b. The gene responsible for the condition is transmitted from an affected man through
all his daughters.
c. The gene is never transmitted directly from father to son.
d. A carrier female will transmit the condition to 25% of her sons.
e. X-linked traits are always recessive.

The gene responsible for X-linked recessive traits is transmitted from an affected man through all
his daughters. The gene is never transmitted directly from father to son. Any son of a carrier
female will have a 50% chance of inheriting the trait. An X-linked recessive pedigree is
illustrated in Figure 3.7. Although X-linked recessive traits are much more common in males,
females may be affected in the following situations: (1) homozygous females, for example the
daughter of an affected father and a carrier mother; (2) manifesting heterozygotes.

The genes responsible for X-linked recessive disorders are exposed to selection that may be
complete or partial, depending on the fitness of the genotype, and therefore tend to be lost. In
cases where the mutation is genetically lethal (e.g. Duchenne muscular dystrophy), selection will
mitigate against the

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persistence of the trait and new mutations rather than inheritance from a carrier mother account
for a significant proportion of casts. Some X-linked disorders are regularly expressed in
heterozygotes and are described as dominant, for example hypophosphataemic rickets. In an X-
linked-dominant pedigree all the daughters but none of the sons of an affected male will be
affected. The pattern of inheritance through females is no different from that of autosomal
dominant traits.

3.2.7 Regarding mitochondrial inheritance "which of the following are true?

a. Mitochondrial DNA contains no introns.
b. All mitochondrial DNa is maternally inherited.
c. Carrier females will pass on the defect to all their children.
d. Heteroplasmy is a feature of mitochondrial DNA.
e. the mutation rate in mitochondrial DNa is similar to that in the nuclear genome.

Mitochondrial DNA (mtDNA) is devoid of introns. It has been completely sequenced and is
known to code for two types of ribosomal RNA, for 22 transfer RNAs, and for 13 polypeptides
that are subunits of enzymes involved in oxidative phosphorylation. All our mitochondrial DNA
is maternally inherited, because the mitochondria of the sperm are lost after fusion with the egg.
Therefore in mitochondrial inheritance an affected mother passes the defect to all her children,
but only her daughters will transmit the trait to subsequent generations (Figure 3.8). Each
mitochondrion contains 2—10 DNA molecules, and there are multiple mitochondria in each cell,
allowing both normal and mutant DNA to coexist. This condition is known as heteroplasmy. The
proportion of normal to mutant DNA will fluctuate through the process of replicative
segregation. The proportion of mutant mitochondrial DNA required to produce a disease
phenotype is known as the threshold effect, and varies from organ to organ and person to person.
In pedigrees of families with mitochondrial diseases there is often a variable mixture of
mutant/normal mitochondrial DNA in the offspring, the severity of the disease being related

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to the proportion of mutant to healthy DNA. This explains why, although carrier females will
pass on the defect to all their children, not all of them will be manifestly affected.

There are several reasons why mtDNA has a mutation rate 10—17 times higher than that of the
nuclear genome: (1) DNA polymerase misincorporation—the beta and gamma DNA
polymerases are highly inaccurate, and a substitution rate of 1 in 3—8000 base pairs causes
random misincorporations; (2) Oxidative stress is the term used to describe DNA damage caused
by superoxide radicals, hydrogen peroxide and hydroxyl radicals. Mitochondria use 90% of
cellular oxygen and in addition mtDNA is not bound to histones, and is therefore more
susceptible to damage by these oxidised species; (3) Alkylating agents—some of these agents
have been shown to modify the mtDNA five times more efficiently than nuclear DNA in vitroi
(4) The ―DNA repair repertoire‖ of mtDNA is underdeveloped in comparison with that of
nuclear DNA. A rudimentary excision repair mechanism is able to prevent mutations, but the
mitochondrial polymerase cannot proofread and remove certain modified bases; (5) The mtDNA
is devoid of introns, so a random mutation is more likely to strike a coding DNA sequence.

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3.3: Molecular biological techniques
3.3.1 Molecular cloning

a. Restriction endonucleases catalyse the production of DNA from an RNA template.

b. Plasmids are circular, double stranded DNA molecules that replicate extra-
chromosomally in bacteria or yeast.
c. Reverse transcriptase enzymes cleave double-stranded DNA at recognized cleavage
sites.
d. Complementary DNA (cDNA) is devoid of introns.
c. Hybridisation involves the production of a double-stranded DNA molecule from two
complementary single-stranded nucleic acid molecules.

Restriction endonucleases are enzymes that recognise specific double-stranded DNA sequences
and cleave the DNA at or near these recognition sites. These sites tend to be palindromes, that is
they read the same 5' to 3' on both strands. Their discovery has been instrumental in the
development of molecular cloning, as they enabled DNA to be broken up into a characteristic
and reproducible collection of fragments. These fragments will all have identical single stranded
sticky ends; any two DNA fragments produced by a particular restriction endonuclease digest
can therefore be joined together. DNA ligase catalyses the formation of phosphodiester bonds on
each strand, so creating a ―recombinant‖ DNA molecule.
A vector is a DNA molecule into which the gene or DNA fragment of interest is cloned. They
are capable of replicating autonomously in a host such as bacterial or yeast cells. Commonly
used vectors include plasmids, bacteriophages and cosmids. (1) Plasmids are circular, double-
stranded DNA molecules that replicate extra-chromosomally in bacteria or yeast. Cloning into
plasmids is a standard technique for the analysis of short DNA molecules. (2) Bacteriophage
lambda is a bacterial virus that replicates during growth in Escherichia coli and produces large
numbers of infectious double-stranded DNA viruses. These eventually kill the host cell, which
ruptures and releases the bacteriophages. As about one-third of the

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bacteriophage genome is non-essential it can be replaced by other DNA sequences, making it
ideal for cloning pieces of human DNA up to 20 kb (3) Cosmids are essentially plasmids that use
infectious bacteriophage lambda particles to process and introduce large DNA fragments (up to
50 kb) into bacterial cells.
Complementary DNA (cDNA) is a synthetic single-strand DNA that is copied directly from
RNA by reverse transcriptase. cDNA as several advantages over genomic DNA; first, it contains
no introns or other non-coding sequences; second, mRNA isolated from specific tissues will be a
good source of clonse expressed preferentially in that tissue. Single-stranded cDNA can be
converted to a double-stranded molecule, which can then be ligated into a vector to create a
cDNA library
encompassing all the mRNA transcripts from that cell type or tissue.
Probes are cloned DNA or RNA molecules that can be used to detecthomolgous sequences in
nucleic acids. They are often labelled with a radioactive tracer to facilitate detection and analysis
(see next question). Nucleic acid hybridisation is a technique used to find and analyse specific
DNA or RNA fragments; single-stranded nucleic acids are mixed with a specific probe in
conditions that promote the formation of double- stranded nucleic acid. The probe only
hybridises to its complementary strand sequence in the DNA or RNA sample, which is now
marked by a radioactive tag.

3.3.2 Molecular analysis of human mutations

a. Southern blotting can detect single base mutations.

b. In a Southern blot, DNa fragments are generated by restriction enzymes and
separated by agarose gel electrophoresis.
c. Southern and Northern blotting use radioactively labeled probes.
d. Northern blotting is used to analyse RNa.
e. Allele-specific oligonucleotide (ASO) probes are isolated from cloned genes of
cDNA.

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Southern blotting is a technique that uses a cloned gene probe to detect whether a gene is present,
and whether it is grossly normal in structure. It is not able to detect single base mutations. The
technique can be summarised as follows: (1) Genomic DNA (usually from lymphocytes in
peripheral venous blood) undergoes restriction enzyme digestion; (2) The fragments of DNA
generated are separated on the basis of size by agarose gel electrophoresis; (3) The DNA is then
denatured with a strong base to form complementary single-strand nucleic acid strands. These
single strands are transferred to a nitrocellulose or nylon filter paper by blotting or capillarity; (4)
A radiolabelled probe (single-stranded DNA) and the filter paper are incubated together,
allowing the probe to hybridise with matching fragments on the filter; (5) Unbound probe is
washed off and the filter is exposed to x-ray film, to reveal the positions to which the probe
hybridised.

Northern blotting is the RNA equivalent of Southern blotting. It is the standard technique for
analysing the size and abundance of mRNA from a specific gene in a sample of RNA. The only
significant difference between the two techniques is that RNA cannot be cleaved by restriction
enzymes; cellular DNA or purified mRNA is therefore separated by agarose gel electrophoresis.

Single base mutations can be detected using allele-specific oligonucleotides (ASOs). These
probes are synthesised from individual nucleotides and correspond to a known segment of a
particular gene; they are usually around 10—20 base pairs in length. These short probes can be
manufactured to correspond with either the normal or an imperfect DNA sequence, hence their
ability to detect such small mutations. However, if false negative results are to be avoided, the
outcome of ASO analysis should be interpreted with caution, as not all mutant genes at a given
locus have exacriy the same mutation.

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3.3.3 The polymerase chain reaction (PCR)

a. The PCR requires less than 1% of the amount of genomic DNA needed for a
Southern blot.
b. The PCR can amplify a single molecule of DNA over a millionfold in 20 cycles.
c. The PCR uses primers that hybridise to opposite strands of the nucleic acid target
sequences.
d. Primers initiate the synthesis of complementary DNA sequences by DNA ligase.
e. The PCR can be used to analyse RNA.

The PCR has revolutionised the analysis of DNA and RNA; it can amplify a single molecule of
DNA 1 06 fold in 20 cycles, thus enabling the detection and analysis of specific gene sequences
without cloning, and widiout the need for Southern or Northern blotting. It is also faster, less
expensive, more sensitive, and less technically demanding than Southern or Northern blotting.
An additional benefit is that it requires only a fraction of the genomic DNA or RNA needed for
these methods.

The fundamental principles of the PCR are as follows: (1) Target DNA, two oligonucleotide
primers and heat stable DNA polymerase are placed in a tube. The mixture is heated to just
below 100°C and the DNA is denatured to form single-strand nucleic acids; (2) The primers have
sequences that match two sequences of DNA flanking the region of interest. As the solution
cools, the primers hybridise to opposite strands of this target sequence and initiate synthesis of
the complementary DNA sequence by DNA polymerase. The two new strands of DNA are exact
replicas of the original target DNA; (3) This cycle of denaturation, hybridisation of the primers
and enzymatic DNA synthesis is repeated, resulting in the exponential amplification of the target
sequence. Each round of amplification takes about 10 minutes.

RNA samples can also be amplified. cDNA is produced using a reverse transcriptase enzyme.
PCR primers are then added with DNA polymerase, and one of these oligonucleotides primes the
synthesis of the second cDNA strand. The double-stranded DNA can then be amplified as above.

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134
4. Microbiology

4.1: General bacteriology

4.1.1 General characteristics of bacteria

a. Bacteria re prokaryotic cells.

b. The cells contain DNA and RNA.
c. The nuclear DNA is enclosed in a membrane.
d. Bacteria possess intracellular organelles.
e. They reproduce by binary fission.

Bacteria are prokaryotic cells that contain DNA and RNA. The nuclear DNA is not enclosed in a
membrane but lies free in the cytoplasm, which is devoid of intracellular organelles.
Reproduction is by binary fission.

4.1.2 Bacterial structure

a. Porous cell walls make up to 20% of dry weight.

b. Cell membranes provide an osmotic barrier.
c. Plasmids contain RNA fragments.
d. Mesosomes are found in the cytoplasm.
e. Flagella and pili are responsible for motility.

Most bacteria (except L.-forms and mycoplasmas) have a cell wall that makes up approximately
10—20% of the dry weight. All walls contain a mucocomplex containing muramic acid and are
porous to all but very large molecules- The cell membrane, unlike the inert cell wall, is an
important osmotic barrier and the site of a number of important enzymes. Mesosomes are
cytoplasmic sacs with intense enzymic activity associated with division septa. Plasmids contain
DNA fragments and may be responsible for conferring antibiotic resistance. Flagella (made

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of long fibrillary proteins) are responsible for motility; pili are associated with conjugation.

4.1.3 Metabolism and growth

a. Heterotrophs are able to synthesise all their organic requirements.

b. All bacteria need CO2 to initiate growth.
c. Respiration and fermentation are two forms of oxidation.
d. Aerobic bacteria may use fermentation.
e. Strict anaerobes rely entirely on respiration for energy.

Autotrophs are able to utilise simple inorganic compounds but heterotrophs cannot synthesise all
their organic requirements. All bacteria need C02 to initiate growth; usually a trace is enough but
a few species need 3—5% in the atmosphere. Energy comes mainly from oxidation, the two
forms of which are: (1) respiration (usually dependent upon cytochrome with COz and H20 as
end products); and (2) fermentation (hydrogen is transferred to an organic compound with
pyruvic or lactic end products). Aerobic bacteria obtain energy mainly by respiration, though
most also use fermentation (these are termed facultative anaerobes). Strict anaerobes rely entirely
on fermentation for energy production.

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4.1.4 Culture of bacteria

a. Nutrient broth should be sterilized by heat and have a pH of 7.3.

b. Blood agar consists of nutrient agar and defibrinated horse blood.
c. Reducing agents support the growth of aerobes.
d. Desoxycholate-citrate agar is a ―selective medium‖.
e. MacConkey agar distinguishes between lactose and non-lactose fermenting
microorganisms.

M.ost bacteria will grow in an artificial medium resembling their normal habitat. Nutrient broth
is a watery extract of meat, containing partly digested protein, carbohydrate, and electrolytes. It
is sterilised by heat and has a pH of 7.3. Blood agar consists of nutrient agar with added
defibrinated horse blood and is a good medium for fastidious and delicate bacteria. Strict
anaerobes require reducing agents (such as sodium thiogly coll ate, minced cooked meat or
metallic iron) to support their growth. Selective media contain chemicals that inhibit the growth
of some bacteria only (for example desoxycholate-citrate agar, which permits the growth of
salmonellae but inhibits Escherichia coli). MacConkey agar (which contains lactose) is a
differential medium that distinguishes between lactose and nonlactose fermenting
microorganisms.

4.1.5 Gram staining

The gram stain involves:
a. Application of gentian violet.
b. Application of Lugol‘s iodine.
c. application of strong carbol fuchsin.
d. Treatment with acetone.
e. counterstaining with methylene blue.

The sequential application of gentian violet and L/ugol‘s iodine results in the deposition of a
black-purple complex in the bacteria. After treatment with acetone some types of bacteria

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retain the complex and remain darkly stained (Gram positive), while others lose the complex and
become colourless (Gram negative). The latter are usually stained pink for contrast using dilute
carbol fuchsin. Methylene blue is the counterstain used when producing a Ziehl—Neelsen stain
for acid-fast bacilli.

4.1.6 Aficrobacterial pathogenicity

Invasiveness is enhanced by:
a. Adherence of microorganisms.
b. Local tissue damage.
c. Hyaluronidase.
d. Coagulase.
e. Haemolysins.

The virulence of a pathogen depends on its invasiveness (its ability to enter the host, multiply,
and spread) and its toxigenicity; these are largely independent characteristics. Invasiveness will
be enhanced by the ability of the microorganism to adhere to target cells and by local tissue
damage. Spread of the microorganism will be aided by hyaluronidase (which dissolves collagen);
coagulases will precipitate fibrin clots, so walling off the bacteria from host defences;
haemolysins will aid invasiveness by killing host phagocytes.

4.1.7 Bacterial strategies against host defences

a. The surface M-factor of streptococci accepts factor H, which facilitates C3b

breakdown.
b. The capsules of meningococci and pneumococci are resistant to phagocytosis.
c. Esherichia coli can divert complement activation to insensitive sites.
d. Mycobacterial lipids obstruct priming and activation of macrophages.
e. Pseudomonas releases an elastase that inactivates C3a and C5a.

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Bacteria use many different strategies to avoid destruction by the immune system.

 Interference with complement activation or fixation or both:

- streptococci possess a surface M-factor, an acceptor for factor H, which facilitates C3b
breakdown. It also binds fibrinogen, which covers sites that may act as complement
activators;
- some Gram negative organisms., for example Escherichia coli and salmonella, are able to
divert complement activation away from sensitive sites, such as the outer lipid bilayer,
towards insensitive oligosaccaride side chains;
- Pseudomonas releases an elastase that inactivates C3a and C5a;
- Neisseria gonorrhoea binds complement proteins and prevents their insertion in the outer
membranes.
 Several bacteria, including meningococci, pneumococci, Haemophilus influenzae and
Bacillus anthrax, have antiphagocytic capsules.
 Intracellular bacteria such as tubercle and leprosy bacilli, listeria and brucella escape the
immune defences by living within macrophages. They resist intracellular destruction in
several ways:
- mycobacterial lipids obstruct priming and activation of the macrophage, and scavenge
harmful oxygen intermediates;
- Mycobacterium tuberculosis inhibits fusion of lysosomes with the phagocytic vacuole;
- Listeria monocytogenes produces a lysin that enables it to escape from phagosomes and
lie freely within the cytoplasm.

4-1.8 Toxins

a. Exotoxins are proteins.

b. Endotoxins are present in all Gram negative bacteria.
c. Both endotoxins and exotoxins are heat stable.
d. Endotoxins have a specific pharmacological action.
e. Exotoxins have greater potency than endotoxins.

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Traditionally toxins are divided into two categories (exotoxins and endotoxins) although the
distinction is not absolutely clear. Exotoxins are proteins (mostly enzymes), endotoxins are made
from the lipopolysaccharide components of the bacterial cell wall. All Gram negative bacteria
(such as salmonella, coliforms, and neisseria) contain similar endotoxins whether they are
pathogens or not. Exotoxins are heat labile, strongly antigenic and are generally much more
potent than endotoxins. They also have a specific pharmacological action, unlike endotoxins
which have a non-specific acute inflammatory action.

4.1.9 Physical methods of sterilisation and disinfection

a. Ultraviolet radiation causes disinfection.
b. Gamma radiation is used to sterilize syringes.
c. Pasteurisation kills all vegetative organisms.
d. Sterilisation is achieved by dry heat at 100°C for 1 hour.
e. Sterilisation is achieved by steam at 100°C for 1 hour at a pressure of 30 psi.

Sterilisation means the destruction or removal of all microorganisms and is an absolute term
whereas disinfection means the destruction or removal of most microorganisms. Ultraviolet
radiation is strongly absorbed by proteins and nucleic acids, so producing genetic mutations,
enzyme inactivation, and death. It is a commonly used disinfectant in laboratory cabinets.
Gamma radiation (for example, using 60Co) is frequently used in industry for sterilising
prepacked plastic syringes, et cetera. Pasteurisation involves temperatures of 80°C for 10
minutes at half an atmosphere of pressure. Steam generated at this pressure and temperature by
this procedure will kill vegetative organisms but will not kill spores; pasteurisation is therefore a
method of disinfection. Sterilisation by dry heat requires temperatures of 160°C for 1 hour.
Using an autoclave to generate moist heat under pressure (134°C for 3 min at 30 psi) will kill all
organisms, including resistant spores.

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4.1.10 Normal flora of the eye
a. Staphylococcus epidermidis is the most common organism inhabiting the eye.
b. Staphylococcus aureus is a constituent of the normal flora.
c. Propinibacterian granulosum is the most common anaerobe.
d. Demodex follicularum is a yeast found on the eye lashes.
e. There are no viruses existing as normal eye flora.

The commensal organisms present on the body surface are known as the normal flora. These are
mostly saprophytes that live harmlessly on the skin and mucous membranes without invading or
causing disease except in exceptional circumstances or when outside their normal habitat. The
eye is sterile in utero but acquires normal flora during birth. Staphylococcus epidermidis is found
on approximately 40—45% of eyes, and Staphylococcus aureus on 25%. The second most
common bacterial flora are the diphtheroids, which are present on 25—40% of eyes.
Streptococcus viridans and Streptococcus pneumoniae are present on 2—3% of eyes. The most
common anaerobe is Propionibacterium acnes, which has been implicated in some forms of
chronic endophthalmitis and blepharitis. Protozoan commensals include Demodex follicularum
(found on the eye lashes in almost everyone over 70 years of age). Up to 100 fungi (including
Pityrosporon orbicularis a yeast found on the lashes and lid margins) have been found to
normally inhabit the eye. There are no viral commensals of the eye.

4.2: Cocci

4.2.1 General properties of staphylococci

a. Staphylococci are Gram positive bacteria.
b. They are aerobic and feacultatively anaerobic.
c. Staphylococci are catalase negative.
d. Staphylococcus epidermidis is coagulase positive.
e. These organisms grow on simple media.

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Staphylococci are Gram positive cocci that grow in clusters like bunches of grapes on simple
media. They are aerobic, facultatively anaerobic and are distinguished from streptococci in that
they produce catalase. The pathogenic Staphylococcus aureus is distinguished from the usually
non-pathogenic Staphylococcus epidermidis by its coagulase activity.

4.2.2 Staphylococcus aureus

This organism:
a. Contains lysozyme.
b. Has poor adherence.
c. Produces entero and epidermolytic toxins.
d. Has an opsonisation resistant capsule.
e. Contains protein A.

Staphylococcus aureus is carried on the skin of many normal people (especially in the anterior
nares) and infection may often be endogenous. Strains may spread from carriers (such as those
with septic lesions) via the air, by direct, and (most importantly) by indirect contact. The
pathogenicity of Staphylococcus aureus is enhanced by a number of factors that include
lysozymes, coagulase and hyaluronidase. It also adheres well to cell surfaces, has an
opsonisation resistant capsule, and produces a protein A that is thought to decrease phagocytosis
and inhibit complement acdvation. Toxins produced by this organism include an epidermolytic
toxin (responsible for the ―scalded skin‖ syndrome), and an enterotoxin that causes food
poisoning.

4.2.3 Alethicillin resistant Staphylococcus aureus (AIRSA.)

a. Is more virulent than methicillin sensitive Staph aureus.

b. Is more resistant to sterilization than methicillin sensitive Staph, aureus.
c. May be a normal commensal of the anterior nares in healthy individuals.
d. Is a coagulase-negative staphylococcus.
e. All MRSA strains are sensitive to vancomycin.

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MRSA is a coagulase-positive staphylococcus that is no more virulent nor resistant to
sterilisation than methicillin sensitive Staph, aureus. The reasorl that MRSA can cause such
devastating nosocomial infections is its resistance to conventional antibiotic ‗ therapy, which has
been compounded by the emergence of vancomycin resistant strains. MRSA is often found in the
anterior nares of asymptomatic carriers.

4.2.4 Streptococci
a. Streptococci are common ocular pathogens.
b. They are Gram positive and catalase positive.
c. Streptococcus pyogenes is a β haemolytic streptococcus Lancefield group A.
d. Streptococcus pneumonia is an α haemolytic diplococcus.
e. Streptococcus pyogenes produces an erythrogenic toxin.

Streptococci are Gram positive cocci that are catalase negative and are uncommon ocular
pathogens. Streptococcus pyogenes (which causes over 90% of streptococcal infections in
humans) is a P haemolytic streptococcus Lancefield group A. It produces an erythrogenic toxin
and is responsible for the generalised erythematous rash seen in scarlet fever. Streptococcus
pneumoniae is an a haemolytic diplococcus, which may occasionally cause meningitis as well as
pneumonia.

4.2.5 Neisseriae
a. These are aerobic Gram positive cocci.
b. They grow on simple media.
c. The gonococcus contains IgA proteases.
d. The meningococcus is a normal flora of the nasopharynx.
e. Silver nitrate inhibits growth of the gonococcus.

The genus Neisseria comprises two important pathogens, Neisseria meningitidis

(meningococcus) and Neisseria gonorrhoea (gonococcus). They are aerobic Gram negative cocci
that require special media such as heated blood agar with an increased

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carbon dioxide concentration to grow. Both have endotoxin type activity and possess IgA
proteases that cleave immunoglobulins. The meningococcus is a strict parasite that colonises the
human nasopharynx, and dies rapidly outside the body. The gonococcus is responsible for
ophthalmia neonatorum—in 1881 Crede reduced the incidence of this condition from 10% to
0.3% by applying silver nitrate to the eyes of neonates.

4.3: Bacilli
4.3.1 General properties of mycobacteria

a. These are aerobic non-sporing rods.

b. They stain with a Ziehl-Neelsen stain.
c. Mycobacteria grow on simple media.
d. theyhave a generation time of 12-24 hours.
e. All species are pathogenic to humans.

Mycobacteria are aerobic non-sporing rods with waxy cell walls which prevent them taking up
Gram stain. However, they stain with hot strong carbol fuchsin (Ziehl-NTeelsen stain), which is
retained despite attempts to remove it with mineral acids and alcohol (that is, they are acid and
alcohol fast bacilli). They will grow only on enriched media such as Lowenstein-Jensen medium
(which contains egg). They also have a very slow generation time of 12—24 hours, which means
that cultures may take up to 8 weeks to grow. Mycobacteria are widely distributed in nature but
only a few species are pathogenic to humans.

4.3.2 Mycobacterium tuberculosis

a. Man is the primary host of mycobacterium tuberculosis.

b. It produces an endotoxin.
c. It is resistant to intracellular enzymes.
d. Mycobocterium tuberculosis produces a non-caseating granuloma.
e. Prophylaxis is by a live attenuated vaccine.

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Mycobacterium tuberculosis is never a commensal organism: man is the primary host. It does not
produce a toxin nor does it inhibit phagocytosis (its pathogenicity depends on its ability to resist
destruction by intracellular enzymes). The characteristic lesion caused by this organism is a
caseating granuloma made up of macrophages and macrophage derived cells. Prophylaxis is
attained using the live attenuated bovine strain known as the bacille Calmette-Guerin (BCG).

4.3.3 Sporing bacteria

a. Spores consist of a cortex wi5th concentric protective layers.
b. Most of these organisms are Gram positive bacilli.
c. Spores are a means of reproduction.
d. Spores are metabolically active.
e. Spores are resistant to heat, radiation and chemicals.

Characteristically spores consist of a central cortex surrounded by a layered outer coat made
from laminated keratin, that is in turn surrounded by a loose endospore. Nearly all are produced
by Gram positive bacilli that are predominantly saprophytes but include some potent human
padiogens. Spores are not a means of reproduction, nor are they metabolically active—they are a
resting and defensive form of existence. Sporulation allows the organism to survive for long
periods as spores are extraordinarily resistant to heat, radiation, desiccation, and chemicals.

4.3.4 Bacilli
a. Spores are visible as refractile bodies.
b. Bacillus anthracis is non-motile and non-haemolytic.
c. Bacillus anthracis is encapsulated.
d. Bacillus cereus produces a lethal toxin.
e. Some bacilli produce antibiotics.

Members of the genus Bacillus are aerobic Gram positive rods whose spores are visible as
colourless refractile bodies. Bacillus anthracis causes anthrax and is an encapsulated organism
capable

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of producing exotoxins. Bacillus cereus produces a lethal toxin and causes food poisoning in
humans. Bacillus brevis can produce bacitracin—a potent antibiotic.

4.3.5 General properties of clostridia

These organisms:
a. Are facultative anerobes.
b. Live in soil water and decaying vegetation.
c. Swarm on solid media.
d. Produce potent endotoxins.
e. May have a saprophytic relationship with humans.

Clostridia are large Gram positive rods and, being obligate anaerobes, will grow only in
anaerobic jars or in the presence of a reducing agent. The clostridia comprise many saprophytes
living in soil water and decaying vegetation and are found in the gut of humans and other
animals. Some produce powerful exotoxins, and they act as potent pathogens if introduced into
human tissues.

4.3.6 Clostridium tetani and Clostridium perfringens

a. Clostridium tetani has drumstick spores.

b. Both cause local damage to tissues.
c. Produce neurotoxins and enterotoxins respectively.
d. The Nagler reaction distinguishes between the two in culture.
e. Are both sensitive to penicillin.

Clostridium tetani is the causative organism of tetanus and produces large spherical terminal
spores which have a drumstick appearance. Clostridium perfringens is the most common cause
of gas gangrene and forms large haemolytic colonies on blood agar. Each disease will develop
only if the organism is implanted into the tissues by deep penetrating injuries, but only C.
perfringens will bring about local damage to the tissues by its powerful exotoxins. Tetanus toxin
is a specific exotoxin that

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affects the presynaptic terminals of inhibitory interneurones, causing the characteristic tonic
spasm of the voluntary muscles. Some strains of C. perfringens will produce an enterotoxin that
causes food poisoning. The Nagler reaction is an identification technique used to distinguish
different types of C. perfringens. Both organisms are sensitive to penicillin.

4.3.7 Haemophilus influenzae

a. Is a Gram positive bacillus.
b. Is a normal commensal of the mouth and pharynx.
c. Can be cultured on plain nutrient agar.
d. Is the most common cause of preseptal and orbital cellulites in children between 2 months
and 3 years of age.
e. Is sensitive to chloramphenicol.

Haemophilus influenzae is a small Gram negative bacillus that is a normal commensal of the
mouth and upper respiratory tract. It has specific growth requirements for haemarin (or related
compounds) and nicotinamide adenine dinucleotide, which is synthesised by many bacteria. This
explains why H. influenzae needs to be cultured on blood agar (preferably with a low COz
concentration) and why it exhibits ―satellitism‖ around colonies of staphylococci on blood agar.
The composition of the capsule is the major determinant of virulence for II. influenzae. Of the
six antigenically distinct capsular types, type b is present in more than 95% of strains isolated
from invasive infections. Children between the ages of 2 months and 3 years of age are at
particularly high risk because they have neither passively nor actively acquired antibodies to
these capsular antigens. H. influenzae is the most commonly isolated organism in cases of
preseptal/orbitai cellulitis in this age group, it is also a frequent cause of meningitis and
epiglottitis. Most strains are sensitive to third generation cephalosporins such as cefotaxime, and
to chloramphenicol.

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4.3.8 Enterobacteriaceae

a. All are oxidase negative and produce endotoxins.

b. Escherichia coli are lactose fermenting and non-motile organisms.
c. Klebsiella are urease negative and lactose fermenting.
d. Salmonellae are enteric commensals.
e. Proteus is urease positive.

The enterobacteriaceae are intestinal Gram negative bacilli, most of which are commensals in the
gastrointestinal tract that may become pathogenic in other sites such as the urinary tract and
wounds. All are oxidase negative and produce endotoxins. Escherichia coli are lactose
fermenting urease negative organisms and are usually motile; all are commensals apart from the
occasional enteropathogenic strain. Klebsiella are also urease negative and lactose fermenting
gut commensals. Salmonella and proteus are both lactose-fermenting motile organisms: proteus
is a urease positive gut commensal and salmonellae are urease negative enteric pathogens.

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4.3.9 Gram negative bacilli

These include:
a. Moraxella lacunata.
b. Koch-Weeks bacillus.
c. Brucella abornis.
d. Pasteurella mudiocida.
e. Franscisella tularensis.

Moraxella lacunata was first discovered by an ophthalmologist and is known to cause central
corneal ulcers and blepharitis, although the non~Iiquefaciens form is now more common. The
Koch—Weeks bacillus (previously known as Haemophilus aegypzius) causes a form of
conjunctivitis endemic in North Africa and the Gulf States of the USA. Brucella abortus is a
highly pathogenic organism which may cause a nummular keratitis and uveitis. Pasteurella
muhocida is found in the saliva of dogs and - ‘ humans and may cause virulent wound infections
following > bites. Francisella rularensis is another rare but highly pathogenic Gram negative rod.

4.3.10 Pseudomonas aeruginosa

a. This organism is facultatively anacrobic.

b. Iron is essential for its growth.
c. Pseudomonas is able to penetrate healthy corneal epithelium.
d. It produces numerous proteases.
e. It produces a ―toxin A‖.

Pseudomonas aeruginosa is an oxidase positive, Gram negative, atrictly aerobic bacterium. It is a

virulent ocular pathogen. It appears to be dependent on iron for growth and changes in iron
metabolism are thought to affect its virulence with respect to corneal infection. It does not
penetrate healthy cornea) epithelium well but the action of numerous proteases enables it
epithelium pass quickly through, traumatised epithelium. It also produces a ―toxin A‖ with a
mechanism similar to that of diphtheria

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toxin, which breaks protein glycol matrices. Predisposing factors to pseudomonal infection
include corneal trauma, thermal bums, vitamin A deficiency, and immune suppression.

4.3.11 Anaerobic ocular pathogens

These include.
a. pmpior bacterium acnes.
b. Bacteroides fragilis.
c. Clostridium perfringens.
d. Esherichia coli.
e. Nocardia asteroids.

Although Propionibacterium acnes is a normal commensal of the eye, it has been implicated in
some cases of chronic endophthalmitis and some forms of blepharitis. Bacteroides are strictly
anaerobic Gram negative rods that are gut commensals and account for approximately 12% of
anaerobic ocular infections. Clostridium perfringens may cause a conjunctivitis or necrotising
keratitis that can on occasion progress to panophthalmitis widi retinal necrosis. Escherichia coli
is an aerobic organism. Nocardia asteroides is a facultative intracellular aerobic organism that is
a rare cause of microbial keratitis.

4.4: Chlamydiae and spirochaetes

4.4.1 Chlamydia trachomatis

a. These are obligate intracellular bacteria.

b. All serotypes are glyeogen positive.
c. Serotypes D-K cause classic endemic trachoma.
d. Lymphogianuloma venereum is caused by serotypes L1, 2 and 3.
e. This organism causes psittacosis.

Chlamydiae have no cell wall and they are obligate intracellular bacteria, that is they can grow
only within eukaryotic host cells. , Chlamydiae have been described as ―£energy parasites‖ as
they

150
are unable to produce net energy and require host-derived ATP. The genus includes Chlamydia
trachomatis, Chlamydia psittaci and Chlamydia pneumoniae. C. trachomatis may be further
divided into a number of serotypes by micro immune fluorescence tests: all are glycogen positive
and have humans as their only host. Serotypes A, B and C cause classic endemic trachoma and
serotypes D to K cause aduit inclusion conjunctivitis (which is sexually transmitted). Subtypes
LI, 2 and 3 cause lymphogranuloma venereum.

4.4.2 Life cycle of Chlamydia trachomatis

a. An elemental body attaches to and penetrates the cell wall.
b. The elemental body is non-infections.
c. The reticulate body is the replicative form.
d. Replication lasts for approximately 1 week.
e. Different strains have different amino acid needs.

Chlamydia trachomatis exists in two forms: the elemental body (the infectious form that attaches
to a host ceil); and the reticulate body (the replicative form). Once the elemental body penetrates
the cell it is enclosed in a cytoplasmic vesicle that is spared lysosomal degradation and after 6—
8 hours becomes organised into a reticulate body. The metabolically active form divides for
approximately 24 hours before regressing to the elemental form. Different strains have been
found to have different amino acid needs: serotypes A, B and C require tryptophan whereas LI, 2
and 3 need methionine.

4.4.3 Laboratory diagnostic aids

These include:
a. Giemsa staining of smears.
b. Gram staining.
c. ELISA.
d. Antibody detection in serum and tears.
e. Electron microscopy.

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The main laboratory aids to chlamydial identification are Giemsa staining of* smears to identify
inclusions, enzyrne linked immunosorbent assay (ELISA) techniques, and detection ol antibody
to chlamydia in the serum and tears.

4.4.4 Chlamydia trachomatis is sensitive to which of the following antibiotics

a. Tetracycline.
b. Erythromycin.
c. Sulphonamides.
d. Rifampicin.
e. Azithromycin.

Chlamydia trachomatis is sensitive to all of these antibiotics and all are effective in treating
active trachoma. Topical tetracyclines are recommended for large-scale treatment of trachoma.
Current trachoma control programmes are based on the mass application of topical antibiotics to
reduce the ocular reservoir of chlamydia.
This is followed by intermittent, family-based topical treatment to reduce eye-to-eye
transmission. Systemic treatment is recommended for moderate to severe trachoma, usually in
the form of oral doxycycline or erythromycin. A single dose of azithromycin, a long-acting
azalide, has been shown to be as effective as 30 doses of topical tetracycline.

4.4.5 Borrelia burgdorferi

a. Borrelia burgdorferi is the causative agent of Lyme disease.
b. Humans are intermediate hosts for B. burgdorferi.
c. Deer are the primary host.
d. Spread from rodent to humans is via the Ixodes tick.
e. B. burgdorferi is sensitive to amoxicillin.

The spirochaete Borrelia burgdoferi is the causative organism of Lyme disease. The primary
reservoir of B. burgodrferi is the bloodstream of small rodets. Humans are only incidental hosts
for the spirochaete and do not contribute to its maintenance in

152
nature. Spread from rodent to rodent, or from rodent to humans, is through the Ixodes tick. The
tick has three stages in its life cycle: the larva, nymph and adult stages. At each of these stages
the tick will take one obligate blood meal, at which time it may acquire the spirochaete or pass it
on to the host. Deer serve primarily as mating grounds for the adult ticks and provide the blood
meal needed for egg production. The life cycle of the tick is illustrated in Figure 4.3. Humans
acquire the spirochaete following a bite by an infected nymph. Nymphs feed in late spring and
early summer, which explains the seasonal incidence of Lyme disease. B. burgdorferi is sensitive
to amoxycillin, doxycycline and third generation cephalosporins.

4.4.6 Treponema pallidum

a. Is temperature sensitive.
b. Is a facultatively aerobic helical bacteria.
c. Is non-motile.
d. Grows easily on conventional artificial media.
e. Is the causative organism of yaws.

The spirochaete Treponema pallidum is a temperature sensitive, niicroaerophilic helical

bacterium. Treponemes are enclosed by a cytoplasmic membrane, a peptidoglycan cell wall, and
an outer

153
envelope. They are motile organisms that do not survive long outside the body and will not grow
on artificial media. T. pallidum is the causative agent of syphilis, and Treponema pertenue is th_
causative agent of yaws.

4.5: General virology

4.5.1 General properties of viruses

a. Virus particles are acellular.

b. The capsid encloses the nucleic acid.
c. All capsids are icosahedral in shape.
d. The viral genome may contain both DNA and RNA.
e. Viruses replicate by binary fission.

Unlike fungi and bacteria, virus particles are acellular and therefore in order to replicate a virion
must enter a cell to ―borrow‖ its metabolism. The virion consists of the viral genome (either
DNA or RNA) enclosed in a protein shell. This is composed of identical subunits (capsids),
which are in turn composed of identical subunits (capsomers). Capsids may be icosahedral or
helical in shape and are often surrounded by a lipoprotein envelope.

4.5.2 Viral replication

a. Adsorption is the first step.
b. Penetration is solely by viropexis.
c. The capsid is removed by host cell enzymes.
d. Nucleic acid replication is the same for both DNA and RNA viruses.
e. New virus particles are released by cell lysis.

Viral replication has a number of stages. The first of these is adsorption—the virus particle
becomes attached to a cell by random collision, by electrostatic attachment, or by specific host
cell receptors. This is followed by penetration (by viropexis or by fusion of the viral envelope
and cell membrane). The capsid

154
is removed by host cell enzymes and nucleic acid replication (which differs for DNA and RNA
viruses) takes place. Assembly of the new nucleic acid and protein capsid is followed by a period
of maturation before the new virus particles are released by cell lysis or by budding through the
cell membrane.

4.5.3 Replication of nucleic acids

a. All DNA viruses replicate in the nucleus of the host cell.

b. Most DNA viruses use host cell polymerases.
c. RNA viruses replicate in the host‘s cytoplasm.
d. RNA viruses copy RNA from the host‘s RNA using host enzymes.
e. Reverse transcriptase makes DNA from an RNA template.

Nucleic acid replication differs between viruses. JVLost DNA viruses (except the poxviruses)
replicate in the nucleus using host cell enzymes to make messenger RNA and to replicate DNA.
Nucleic acid replication in RNA viruses occurs in the cytoplasm and may proceed in a number of
ways. Unlike the DNA viruses, RNA viruses are unable to borrow host cell enzymes because
none exist for copying RNA from RNA. One way that these organisms overcome this problem is
to use a reverse transcriptase enzyme that can make DNA from an RNA template.

4.5.4 Virus transmission

a. Cytomegalovirus and rubella are spread transplacentally.

b. Herpes simplex virus can be transmitted vertically.
c. Paramyxoviruses are transmitted by airborne routes.
d. Enteroviruses are acid and bile stable.
e. Herpes simplex virus may be transmitted horizontally.

Transmission of viruses may be divided into two main categories: (1) vertical transmission, when
a virus is passed from the mother to the offspring; (2) horizontal transmission, when a virus is
passed from one individual to another after birth.

155
Cytomegalovirus and rubella may be transmitted vertically via a transplacental route and so
cause developmental abnormalities. The herpes simplex virus may be transmitted vertically
(during birth) and horizontally by direct contact. Other forms of horizontal transmission include
the faecal-oral route utilised by the enteroviruses (which tend to be acid and bile stable) and the
airborne-respiratory route by the paramyxoviruses. Parenteral (through the skin) routes are
important in hepatitis B and rabies.

4.5.5 Results of virus infection

a. Formation of multinucleate cells.
b. Cell death.
c. Persistence, with virus in a non-replicative state.
d. Latency, which implies intergration of viral DNA into the host DNA.
e. Malignant and teratogenic change.

The cytopathic effect (CPE) is the visible effect of virus infection cm the cell (for example, cell
shrinking, cell rounding, and production of inclusions) in the formation of giant multinucleate
cells. This may be followed by cell death, caused by cytolysis or inhibition of cell metabolism.
Chronic infection may be in one of two forms: (1) persistence, in which the virus replicates at a
low rate; (2) latency, where the virus does not replicate and the viral genome is integrated into
the host DNA. The other sequela of virus infection is transformation—the virus confers on the
cell new properties of growth and morphology (malignant and teratogenic change).

4.5.6 Viral strategies against host defences include:

a. Changes in antigenicity by point mutations in the viral genome.
b. Changes in antigenicity by swapping of genetic material with reservoirs of different
viruses.
c. Subversion of the complement cascade.
d. Use of complement receptors to gain entry into cells.
e. Antiphagocytic coats

One of the strategies adopted by viruses to avoid detection by host defences is to change
antigens. Minor changes in antigenicity occur by point mutations in the viral genome—a
phenomenon known as antigenic drift. Major changes in genetic material known as antigen shift
occur when the virus swaps whole segments of the genome with reservoirs of different viruses.
Like bacteria, viruses can subvert the complement cascade. Herpes simplex type 1 produces a
C3b-binding molecule that facilitates decay of the alternative pathway C3bBb convertase. Other
viruses such as the Epstein—Barr virus gain entry into cells by binding to complement receptors.
Viruses, unlike bacteria, do not have antiphagocytic coats.

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4.5.7 Virus serology and rapid diagnostic tests

a. The complement fixation test measures the reaction between viral antigen and a
specific antibody.
b. In the complement fixation test indicator erythrocytest are lysed in a positive test.
c. Electron microscopy can identify viruses in tears.
d. Reverse passive haemagglutination is used in detection of hepatitis B surface
antigens.
e. ELISA uses antibodies conjugated to radioisotopes.

Virus isolation has been superseded by virus serology, and other rapid diagnostic methods in the
management of viral infections. Complement fixation (reaction between viral antigen and a
specific antibody, measured by the consumption of added complement) is the test most widely
used. In a positive test the indicator erythrocytes are not lysed by the complement as it has
already been consumed by the antigen/antibody reaction. Electron microscopy has been used to
demonstrate viruses in faeces, vesicle fluids and tears but needs an electron dense stain to
provide contrast. Reverse passive haemagglutination may be used to detect hepatitis B surface
antigen. Enzyme linked immunosorbent assay (ELISA) and RIA (radioimmunoassay) are also
useful diagnostic aids.

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4.6: Herpes viruses

4.6.1 Herpes viruses

a. Are single stranded DNA viruses.

b. Have a helical capsid.
c. Exhibit latency.
d. Include varicella zoster virus.
e. Include the Epstein-Barr virus

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The herpes viruses are double-stranded DNA viruses that possess an icosahedral capsid. They
include herpes simplex, varicella zoster, cytomegalovirus and the Epstein—Barr virus. After the
primary infection some herpes viruses become latent in neuronal sites within the body and under
certain conditions may reactivate causing renewed disease—latency of herpes simplex and
varicella zoster viruses.

4.6.2 Herpes simplex virus

a. HSV-1 may cause acute gingivostomatitis.
b. HSV-2 causes herpes gladiatorum.
c. HSV-1 may become latent in the trigeminal ganglion.
d. HSV-2 produces genital infections.
e. Serology may be used to detect secondary infections.

Herpes simplex viruses may be divided into two subtypes by clinical, biological and serological
criteria. HSV-1 is associated mainly with oral infection and, although the primary infection in
young children is often subclinical, it causes an acute gingivostomatitis in app» oximately 10%
of cases. A rarer primary form of HSV-1 infection is herpes gladiatorum (scrumpox). HSV-1
may become latent in the trigeminal ganglion and may cause recurrent disease in response to a
number of stimuli. HSV-2 is primarily an infection of young adults, in whom it causes a genital
infection that may be accompanied by a mild meningitis. Diagnostic techniques such as ELISA
and DNA probes are of use only in primary infections.

4.6.3 Pathogenicity of HSV-1

a. The vital envelope is highly immunogenic.
b. The HSV genome can code for 10-15 proteins.
c. The genome is the prime determinant of virulence.
d. Stromal keratitis is caused by replicating virus.
e. The immune response determines the frequency of recurrence.

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The pathogenicity of the herpes simplex virus is increased in the immunosuppressed, in
malignancy and by the application of topical steroids. The HSV genome can code for
approximately 50-75 proteins and because of these different combinations each strain will
produce a dendritic ulcer with a characteristic length, pattern and depth. The arrangement of the
viral genome is thought to be the prime determinant of virulence in the non-immunosuppressed
patient. The viral envelope is highly immunogenic and stromal disease is thought to be caused by
a hypersensitivity reaction to viral antigen—not by replicating viruses. The genome is also the
prime factor governing the frequency of recurrent disease.

4.6.4 HSV-1 life cycle

a. Spread to the axonal terminae of sensory neurons is followed by anterograde intra-
axonal transport to neuronal cell bodies in sensory and autonomic ganglia.
b. The peripheral nervous system neurone is the only cell that can support HSV-1 in both
lytic and laten modes.
c. Lytic gene expression is enhanced by the viral structural protein-VP16.
d. During latency the viral genome is transcriptionally inactive.
e. Reactivation leads to the production of infectious virus in the ganglion.

There are four stages that characterise an HSV-1 infection (Figure 4.5): (1) entry into the host
and replication at this peripheral site (e.g. eyes, skin or mucosae); (2) spread to the axonal
terminae of sensory neurones, which is followed by retrograde intra-axonal transport to neuronal
cell bodies in sensory and autonomic ganglia; (3) establishment of latency in the ganglia; (4)
reactivation, with the production in the ganglia of infectious virus that is transported
anterogradely to the periphery. This is followed by further replication at or near the site of
primary infection.
Viral genes can be divided into three temporal classes: immediate-early (regulatory genes),
early (viral DNA replication

160
functions), and late (structural proteins of the virus). Initiation of this transcriptional cascade is
enhanced by the viral structural protein VP 16 that is brought into the nucleus by the viral
genome. The lytic pathway culminates with lysis of the host cell and release of virus particles.
The peripheral nervous system neurone is the only cell that can support HSV-1 in lytic or latent
modes. During latency the viral gene is almost completely repressed, but the viral genome
remains transcriptionally active. Transcription from one end of the viral genome results in a
family of RJSTA molecules known as latency associated transcripts (LATs). Four LATs have
been demonstrated for HSV-1 and although their precise function remains unclear they have
been implicated in the establishment of latency and in reactivation.
Ultraviolet radiation, fever, stress, menstruation and trauma are all known to cause reactivation
of latent HSV-1. Although there is no unifying hypothesis to explain how such diverse

161
stimuli bring about reactivation, cyclic AM.P analogues have been shown to accelerate
reactivation. Some of the above stimuli are likely to cause raised cAMP levels in neurones either
directly, or indirectly by prostaglandin release.

4.6.5 Vdricella zoster virus

a. Varicella zoster is the causative agent of chickenpox.
b. It is spread by the respiratory route.
c. Humoral immunity is essential in maintaining the virus in the latent state.
d. Exposure to X rays can reactivate the virus.
e. Shingles is most common in the thoracic region.

Varicella zoster virus (VZV) is the causative agent of chickenpox (characterised by successive
crops of intraepidermal vesicles on the trunk, face and in the mouth). Chickenpox is highly
infectious and is spread by the respiratory route. The virus may become. ?atent in a number of
ganglia, the irost common sites being the trigeminal followed by the thoracic lumbar and cervical
nerve ganglia. Cell mediated immunity is essential in maintaining the virus in the latent state.
Reactivation, leading to shingles, may be caused by immunosuppression or X ray therapy.

4.6.6 Cytomegalovirus
a. Childhood infection is usually symptomatic.
b. The virus may be spread vertically or horizontally.
c. The virus is shed by 1% of all neonates.
d. Cytomegalovirus may be shed from genital and urinary tracts.
e. It becomes latent in lymphocytes.

Cytomegalovirus infection is very common, but it is subclinical in 80% of cases. The virus may
be shed from the genital and urinary tracts and becomes latent in lymphocytes. The virus may be
reactivated during pregnancy, and results in asymptomatic infection of the fetus; however,
primary infection during

162
pregnancy (especially in the first trimester) may cause fetal abnormalities. The virus is shed at
birth by 1 % of infants., with 10% of these having minor abnormalities such as hearing deficits
and 2—3% exhibiting cytomegalic inclusion disease.

4.6.7 Problems caused by cytomegalovirus

a. Microphthalmia.
b. Post transfusion mononucleosis.
c. Childhood hepatitis.
d. Retinitis in the immunocompetent patient.
e. Transplant rejection.

Congenital infection with cytomegalovirus may cause cytomegalic inclusion disease, which can
produce strabismus, chorioretinitis and microphthalmia. It causes a number of problems for the
immunosuppressed individual including CMV retinitis (in AIDS patients), transplant rejection,
and CMV pneumonia. Post transfusion mononucleosis and childhood hepatitis are rare
complications of infection with this organism.

4.7: Airborne and enteric viruses

4.7.1 Adenoviruses

a. The adenoviduses are DNA viruses.

b. Transmission in ocular infection is solely by airborne routes.
c. Adenoviruses are enveloped viruses.
d. Types 8, 19 and 37 cause epidemic keratoconjunctivitis.
e. Types 3 and 7 cause pharyngocojunctival fever.

The adenoviruses are a diverse group of non-enveloped DNA viruses that are typed into 47
serotypes. Transmission of ocular infection is primarily by direct contact with virus in ocular
secretions, or on shared fomites (towels, linens, soaps). Contact with contaminated instruments,
eye drops, or the fingers of health professionals are other common routes of infection.

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Serotypes 8, 19 and 35 have been associated with outbreaks of epidemic keratoconjunctivitis,
and types 3 and 7 cause pharyngoconjunctival fever.

4.7.2 Cellular features of adenoviral infection

a. Adenoviral infection of a single cell can produce 10000 virions from a single infectious
cycle.
b. All poroteins required for viral replication are made immediately after the entry of virus
into the cell.
c. Adenoviral proteins interact with the retinoblastoma and p53 gene products.
d. Viral-specific proteins interfere with the processing and glycosylation of class I MHC
proteins.
e. Some viral proteins suppress transcription of the cellular genes encoding components of the
class I MHC.

An adenovirus-infected cell is a prolific replicating machine; a single cell infected by a Group C

adenovirus can produce 10 000 virions per infectious cycle of 30—36 hours. Like many complex
viruses, adenoviruses do not make all the proteins required for viral replication immediately after
entry into the cell, but rather particular proteins are made at specific stages of the infectious
cycle. This is known as a transcriptional cascade. Certain adenoviral proteins have been shown to
interact with both the retinoblastoma and p53 gene products, and this explains why certain
strains cause tumours in animal models. Adenoviruses can avoid immune defences in several
ways, allowing the virus to persist in the host. (1) They disrupt class I MJHC presentation by
infected cells; viral specific proteins interfere with the processing and glycosylation of class I
A4HC proteins, which are then trapped within the cell and do not reach the cell surface.
(2) Viral proteins of some serotypes suppress transcription of the cellular genes encoding
components of the class I MHC.
(3) There may be inhibition of cell lysis by tumour necrosis factor.

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4.7.3 Measles
a. Measles is caused by a paramyxovirus.
b. Infection is often subclinical.
c. Conjunctivitis is often a prodromal finding.
d. The incidence of encephalitis is approximately 1 in 10000.
e. SSPE may be associated with chorioretinitis and maculopathy

Measles is caused by a paramyxovirus, infection being characterised by pyrexia, prodromal

cough, coryza, and conjunctivitis. Subclinical infections do not occur. The most common
complication is a secondary bacterial respiratory infection but encephalitis occurs in 1 in 1000
cases. Subacute sclerosing panencephalitis (SSPE) is a rare, slowly progressive and fatal
encephalitis caused by slow viral infection—it has been associated with chorioretinitis and
maculopathy.

4.7.4 Rubella
a. Rubella belongs to the togavirus family.
b. Infection is subclinical in 80% of children.
c. Vertical transmission is most dangerous in the second trimester.
d. Recent infection is detected by a raised IgG titre.
e. Immunisation is by a live attenuated vaccine.

The rubella virus is spread by droplet infection. The disease is subclinical in 80% of small
children and 10% of adults. Its .importance lies in the increased probability of congenital
abnormalities in children born to mothers infected during the first trimester of pregnancy. Recent
infection is characterised by a raised IgM titre that will remain high for approximately 2 months
after the initial infection (a raised IgG titre is an vindication only of previous infection). A live
attenuated vaccine is given to all children under the age of 12 years.

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4.7.5 Congenital abnormalities caused by rubella

a. Cataracts.
b. A patent ductus arteriosus.
c. Microphthalmia.
d. Conductive deafness.
e. Glaucoma.

If a woman is infected with rubella during pregnancy the virus spreads to the placenta and hence
to the fetus. Miscarriages or stillbirths are common sequelae to infection as are congenital
defects such as cataracts, microphthalmia, glaucoma, nerve deafness, and congenital heart
problems such as a patent ductus arteriosus.

4.7.6 Mumps
a. This disease is caused by a paramyxovirus.
b. Rising antibody titres to V antigen indicates recent infection.
c. Mumps may cause a dacryoadenitis.
d. It may cause meningoencephalitis.
e. Mumps may cause extraocular muscle palsies.

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Mumps is caused by a paramyxovirus that produces a fever and parotitis. Recent infection is
characterised by a rise in antibody titre to the S antigen (antibody to the V antigen appears later
but persists for many years). Sequelae of infection include orchitis, pancreatitis and
meningoencephalitis. Ocular complications include dacryoadenitis and extraocular muscle
palsies.

4.7.7 Enteroviruses
a. The enteroviruses are double-stranded RNa viruses.
b. They include the polioviruses.
c. The main mode of spread in ocular infection is the faecal oral route.
d. Acute haemorrhagic conjunctivitis is caused by Entero 70 virus.
e. Acute haemorrhage conjunctivitis is caused by Coxsackie B24.

The enteroviruses are a family of single-stranded RNA viruses that possess an icosahedral
capsid. They are acid and bile stable and include the polio viruses (serotypes 1—3), Coxsackie
(Al—A24, and Bl—B6), and die echoviruses. The main route of transmission is faecal—oral, but
direct contact and droplet spread are the more important modes in ocular infection. Acute
haemorrhagic conjunctivitis (associated with overcrowding and poor hygiene in tropical and
subtropical regions) is associated with the Coxsackie A24 and Entero 70 viruses.

4.8 Retroviruses

4.8.1 HIV
a. HIV is an oncogenic retrovirus.
b. HIV is a single-stranded RNA virus.
c. HIV viruses are homogeneous.
d. HIV infection is completely exogenous.
e. HIV is killed by a pH below 1.0 or above 13.

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The human immusiodeficiency virus (HIV) is a non-oncogenic cytocidal retrovirus- It contains a
single strand of RNA and possesses the reverse transcriptase enzyme. AIDS viruses are not a
homogeneous group: HIV-1 and HIV-2 differ in the make up of their glycoprotein envelopes.
HIV infection is completely exogenous (unlike transforming retroviruses); these viruses do not
contain any conserved cellular genes—nor do they cause infection by activating silent sequences
in cellular DNA. HIV is not a particularly robust virus and is killed by strong acid and alkali (pH
<1.0 and ^ 13), and by exposure to 10% bleach or 50% ethanol.

4.8.2 Pathogenesis of HIV infection

a. HIV is trophhic for CD8 receptors.
b. HIV will cause T helper cells to form multinucleate giant cells.
c. HIV has a profound cytopathic effect on monocytes and macrophages.
d. HIV has no effect on humoral immunity.
e. HIV may become latent in monocytes.

HTV is trophic for T helper lymphocytes, whose CD4 receptors act as receptors for the virus.
Viral infection of T helper cells will produce a profound cytopathic effect, forming multinucleate
cells and eventually causing cell death. Monocytes and macrophages also possess CI>4-like
receptors but viral infection rarely results in a profound cytopathic effect or cell death. By
destroying T helper cells the virus cripples the cell-mediated immune response, predisposing to
viral, protozoan, and some neoplastic conditions. HIV can also affect the humoral immune
response and is known to cause polyclonal antibody production, hypergammagiobulinaemia, and
the production of autoantibodies (it will also cause a decrease in the production of T cell
dependent immunoglobulins). HIV may become latent in monocytes and macrophages and be
transported to sites such as the lungs and central nervous system. The body‘s immune response
against HIV is hampered because the latent vims is ‗‗invisible‖ to immune defences, and its
frequent mutations

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produce different glycoprotein ersvelopes- constantly changing antigenic stimuli.

4.8.3 Serology of HIV

a. Antibodies to envelope glycoproreins are present in ARC and AIDS.

b. Antibodies to the core protein are present in ARC and AIDS.
c. AN increased CD4/CD8 ratio is seen in AIDS.
d. HIV may be grown in culture and isolated from lymphocytes from the peripheral
blood.
e. ELISA is the most common diagnostic set for HIV.

The profile of antibody response to HIV infection will vary between the AIDS related complex
(ARC) and ―fully blown‖ AIDS. Antibodies against envelope glycoproteins such as gp41, gpl20,
and gpl60 are present in both the AIDS related complex and AIDS. Transition from the complex
to AIDS is signalled by a decrease in antibody to core proteins such as p24, and a decrease in the
CD4/CD8 ratio. HIV can be grown in culture with CD4 target cells and can be isolated from
lymphocytes from

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170
the peripheral blood. ELISA is the most common diagnostic test currently in use.

4.8.4 Human T-lymphotropic virus type I (HTLV-I)

a. Is a human retrovirus.
b. The cellular genome of HTLV-I contains oncongene sequences.
c. HTLV-I will immortalize normal human peripheral blood T cells in viiro.
d. HTLV-I tropism is confined to lymphocytes.
e. Transmission of HTLV-I may be both vertical and horizontal.

HTLV-I is a human retrovirus that is known to be the causative agent of adult T cell leukaemia
and T cell lymphoma, progressive myelopathy and some forms of uveitis. Although it is an
oncogenic and transforming virus it does not harbour oncogene sequences derived from the
cellular genome. It also differs from other human retroviruses in that its replication is regulated
by two unique genes known as tax and rex. HTLJV-I will immortalise normal human peripheral
blood T cells (predominantly GD4 phenotype) in •vitro. The tax gene is thought to mediate this
change by transactivating genes for IL-2 and IL-2 receptors, so rendering these T cells
independent of the IL-2 autocrine mechanism. Tropism of HTLV-I is not confined to T cells,
although they are the main target cells. Fibroblasts, epithelial cells and endothelial cells have also
been infected in vitro. HTLV- I transmission may be vertical, from mother to child (this is the
most important route), horizontal through sexual contact, or parenteral via blood transfusion.

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4.9: Hepatitis B virus, human papilloma viruses and molluscum contagiosum
4.9.1 Properties of the hepatitis B virus

a. It is a DNA virus.
b. The Australia antigen is associated with the inner core.
c. The HB ―e‖ antigen is associated with the outer coat.
d. Hepatitis B is transmitted vertically and horizontally.
e. 5% of acute cases become long term carriers.

Hepatitis B is a DNA virus that possesses an inner core and an outer protein coat. An excess of
this protein coat produced by the liver cells is called the hepatitis B surface antigen or Australia
antigen. The HB ―e‖ antigen is associated with the inner core. Transmission of hepatitis B is
predominantly horizontal (by parental inoculation or by sexual routes) but vertical transmission
will occur from mothers to babies if the mother is <£e‖ antigen positive. The virus has an
incubation period of between 6 weeks and 6 months, and approximately 5% of acute cases
become long term carriers.

4.9.2 Serology of hepatitis B

a. The HB surface antigen level is raised in the acute illness and in carriers.
b. The HB surface antibody indicates past or present disease.
c. Presence of the HB ―e‖ antigen indicates acute infection or supercarriers.
d. The HB core antibody is present in the blood of vaccinated people.
e. Carriers of the HB ―e‖ antibody should be classified as ―high risk‖.

A knowledge of the serology of hepatitis B is important when assessing the hepatitis state (past
or present) of a patient. The level of HB surface antigen is raised in the acute illness, and if it
remains raised for 6 months or longer the patient is by

172
definition a carrier. Presence of the HB surface antibody may indicate that the patient has had the
disease and is now immune or that they have been given the hepatitis B vaccine. The HB ―e‖
antigen indicates acute infection or supercarrier status: such patients should be classified as high
risk. Carriers of this antibody, although they should not be blood donors, pose no risk from
needlestick injuries. The presence of the HB core antibody indicates that the patient has had the
disease naturally and is not present in vaccinated people.

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4.9.3 Human papillomaviruses (HPV)

a. Human papillomaviruses are members of the papovavirus family.

b. Most hpVs incorporate their geomes into the host cell DNA.
c. Some HPVs promote neoplastic change by producing proteins that intervene in the
ability of p53 to control cell growth.
d. There is a high prevalence of HPV type 16 and 18 in conjunctival papillomas.
e. HPV types 6 and 11 are associated with conjunctival dysplasia and carcinoma.

Human papillomaviruses are members of the papovavirus family; more than 60 HPV types have
been identified. The genetic material of papillomaviruses is a circular, double-stranded DNA
molecule. The genome is organised into open reading frames (ORFs) and these are divided into
early (E) and late (L) regions. The E regions encode for proteins that are associated with viral
replication. HPVs target epithelial cells but only a minority (those types associated with
dysplastic lesions) insert their genome into the host cell DNA. Malignant change is brought
about by the insertion into the host DNA of a particular type of HPV DNA that itself contains a
disrupted DNA genome. The E2 gene is an important regulator of HPV proliferation. Disruption
of this gene has been found in all tumours that have HPV DNA integration. Disruption of E2
leads to overproduction of E6 and E7. The E6 protein of HPV 16 and HPV 18 forms complexes
with the p53 protein and targets it for early degradation. The E7 protein of HPV 16 is thought to
contribute to the development of neoplasia by inactivating the gene product of the retinoblastoma
tumour suppressor gene. HPV 16 and HPV 18 are classed as high-risk HPVs and are associated
with conjunctival dysplasia and carcinoma. Low-risk HPVs include HPV 6 and HPV 11, which
are associated with conjunctival papillomata.

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4.9.4 Aiolluscum contagiosum virus
a. Molluscum conragiosum is a human poxvirus.
b. Molluscum contagiosum virus relies on host polymerase enzymes for DNA replication and
protein synthesis.
c. Molluscum contagiosum DNA encodes a protein that is related to the conserved domain of
epidermal growth factor.
d. Molluscum contagiosum virions are not visible by light microscopy.
e. Molluscum contagiosum is spread only by direct contact with lesions.

The molluscum contagiosum virus is a brick-shaped human poxvirus and is the most common
poxvirus to cause ocular infection. Poxviruses grow in the cytoplasm with almost no nuclear
involvement. This is possible because they possess a DNA-dependent RNA polymerase, a
transcript poly-A polymerase, a capping enzyme and methylating enzymes, which allow them to
replicate independently of the host cell. Molluscum contagiosum is an infection of the skin that
causes pearly white or flesh coloured lesions, predominantly on the face, extremities, and trunk.
Transmission in children is by direct contact with lesions or through contact with fomites or
contaminated water. Most adult cases are sexually transmitted. The epidermal hyperplasia is
thought to be secondary to production by the virus of a protein related to the conserved domain
of epidermal growth factor. Molluscum contagiosum virions range in size from 130 to 300
kilobase pairs and are just visible with light microscopy.

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4.10 Fungi

4.10.1 Candida albicans

a. Is a normal commensal of the gastrointestinal and genitourinary tracts.

b. Grows as dome shaped creamy white colonies on both Sabouraud‘s glucose media and
blood agar.
c. Exists solely in a budding yeast form.
d. Is a common contaminant of indwelling venous catheter tips.
e. Often causes an endogenous endophthalmitis in patients with systemic candidiasis.

Candida albicans is a yeast that is a normal commensal of the mucocutaneous surfaces of die
gastrointestinal tract, genitourinary tract and respiratory systems. Candida species can be
cultured on Sabouraud‘s glucose media or blood agar, forming dome-shaped creamy white
colonies after 24—48 hours. C. albicans exists in a budding yeast form on Sabouraud‘s glucose
medium, but when aeration is poor or in clinical specimens, mycelium and pseudomycelium may
be visible. Candidaemia is a common sequela of complicated gastrointestinal surgery, especially
if the patient is receiving intravenous hyperalimentation and prolonged antibiotic therapy, and
has indwelling intravascular catheters. Diabetes mellitus, malignancy, intravenous drug abuse,
liver disease and alcoholism are other factors that predispose to candidaemia.
About one-third of pa dents with candidaemia will develop candidiasis, and autopsy studies have
shown that up to 80% of patients with candidiasis have evidence of candidal chorioretinitis.
IJkewise, cases of endogenous candidal endophthalmitis are associated with a 78—88%
incidence of disseminated candidiasis. Contaminated indwelling venous catheter tips are the
most common source of infection in these patients.

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4.10.2 General properties of fungi
a. Fungi are heterotrophic.
b. Fungi function only as saprophytes.
c. Yeasts are unicellular fungi.
d. Moulds are characterized by mycelium.
e. Mycelia bear reproductive spores.

Fungi are heterotrophic eukaryotic microorganisms; that is, they are dependent upon exogenous
sources of organic food and must therefore function as saprophytes or parasites. Broadly
speaking* fungi can be divided into two groups—the yeasts (which are unicellular), and the
moulds (characterised by branching filaments known as mycelium). These mycelia absorb
nutrients from the substrate and bear reproductive spores (which . /are characteristic for each
species).

4.10.3 Cryptococcus neoformans

This organism:
a. Is a true pathogen.
b. Is a mould.
c. Is found in pigeon droppings.
d. Primarily causes lung infections.
e. May cause a chronic meningoencephalitis.

Cryptococcus neoformans is a yeast whose normal habitat is the droppings of pigeons. It is a true
pathogen and primarily causes lung infections (the droppings become dried and the yeast is
inhaled). The organism may spread in the bloodstream to die meninges, where it gives rise to a
chronic meningoencephalitis ithat is fatal if untreated.

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4.10.4 Aspergillus fumigatus
a. This is a true pathogen.
b. Spores germinate in the bronchi, producing mycelium.
c. Mycelial antigens cause Type I and type II hypersensitivity reactions.
d. Aspergillomas have an increased incidence in sarcoidosis.
e. Neutropenia predisposes to deep infections.

Aspergilli are common saprophytic fungi often found decomposing plant debris, and their spores
cause a number of different forms of aspergillosis if inhaled. Aspergillus fumigatu, (the strain
most commonly found in humans) is an opportunistic pathogen. The inhaled spores germinate in
the lumen of the bronchi to form abundant myceiia., which may spark an IgE mediated allergic
response (Type I hypersensitivity)3 and/or the production of IgG antibodies leading to
complement activation and infiltration by polymoiphs (Type IX hypersensitivity reaction). An
aspergilloma consists of a compact mass of myceiia and is found in lung cavities remaining after
healed tuberculosis, bronchiectasis or sarcoidosis. Invasive aspergillosis is a devastating
infection often seen in immunocompromised patients, especially those who are neutropenic.

4.10.5 Actinomyces israelii

a. Is a Gram negative acid fast filamentous bacteria.
b. Is anaerobic or microaerophilic.
c. Forms white to yellow colonies (―sulphur granules‖) in tissue.
d. Is resistant to penicillin.
e. Is best stained with PAS.

Actinomyces israelii is a member of the Actinomycetaceae family of filamentous bacteria. It is a

Gram positive non-acid fast hyphal organism that tends to fragment into bacillary and coccoid
forms. Actinomyces species are anaerobic or microaerophilic and are best cultured under such
conditions in a liquid medium

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such as brain-heart infusion agar. In tissue, white to yellow colonies are formed known as
―sulphur granules‖. In the case of Actinomyces canaliculitis these granules may be visible in
curettings from the infected canaliculus. Actinomyces organisms are invariably sensitive to
penicillins and cephalosporins. PAS does not differentially stain the filaments and it is best to use
the Brown and Brenn Gram staining technique.

4.10.6 Histoplasma cqpsulatum

a. Is a soil fungus.
b. May exist in both mycelia and yeast phases.
c. Transmission is primarily by ingestion of infected material.
d. Is endemic in the Mississippi and Ohio River valleys.
e. Is resistant to amphotericin B.

Histoplasma capsulatum is a soil fungus, and exhibits dimorphism that is temperature and media
dependent. At 26°C it exists in a mycelial (saprophytic) phase, and at 37°C in a yeast (parasitic)
phase. Demonstration of the characteristic tuberculate macroaleuriospores, and conversion to the
yeast phase at 37°C on brain—heart infusion agar, are necessary criteria for the identification of
H. capsulatum. Transmission is primarily by inhalation of infective mycelial fragments and/or
spores with dust particles. Up to 70% of people living in endemic areas such as the .Mississippi
and Ohio River valleys have positive histoplasmin skin test reactivity, indicating previous
infection. H. capsulatum has rarely been associated with productive infection of ocular tissue
(i.e., where the organism has been isolated from the eye) but more commonly the presumed
ocular histoplasmosis syndrome (POHS). The latter is thought to be immunologically mediated
in individuals previously exposed to the fungus. H. capsulatum is sensitive to amphotericin B
and ketoconazole.

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4.10.7 Mucoraceae

a.Mucoracea are ubiquitous sparophytes, and abundant in the soil, air and the nasopharynx.
b. Metabolic acidosis predisposes to infection.
c. Iron is an important growth factor for Mucoraceae.
d. Mucoraceae typically have narrow septate hyphae.
e. Mucoraceae stain with haematoxylin and eosin.

The highly aggressive orbital fungal infection mucormycosis is most commonly caused by three
genera from the fungal class Zygomycetes, order Mucorales and family Mucoraceae, namely
Rhizopus, Mucor, and Absidia. Mucoraceae are ubiquitous saprophytic fungi that are abundant
in the soil, air, ventilation systems and most body orifices including the nose and pharynx.
Inhaled spores are usually destroyed by macrophages before they can germinate; however, in an
acidotic environment (as in diabetes mellitus or uraemia) phagocytosis is compromised and there
is decreased migration of neutrophils. In these conditions germination takes place and infection
is established by hyphae. Iron is an important growth factor for the Mucorales. Desferrioxamine
has been demonstrated to promote Mucor sp. pathogenicity in vitro and in vivo. Typically
Mucoraceae have broad, irregular non-septate hyphae that branch at right angles. Mucorales stain
best with Gomori methenamine-silver, haeinatoxylin and eosin, and periodic acid-Schiff
preparations.

4.11: Parasites
4.11.1 Aietazoa (helminths)

a. Nematodes are flatworms.

b. Filarias are all transmitted by biting insects.
c. Trematodes all have fresh water snails as intermediate hosts.
d. Cestodes are tapeworms living in the lumen of the gastrointestinal tract.
e. Toxoplasma ganidii is a helminth.

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Parasites are classified into two subkingdoms—metazoa (helminths) which are multicellular
organisms with organ systems, and protozoa, which are unicellular organisms. Metazoa can be
divided into two broad groups: platyhelminths (or flatworms); and nematodes (roundworms).
The nematodes can be further divided into filariasis (which are all transmitted by biting insects),
such as Onchocerca volvulusi and intestinal roundworms (such as Ascaris lumbricoides). The
platyhelminths can be further divided into cestodes or tapeworms (including Echinococcus
granulosus, which causes hydatid disease) and the trematodes or flukes (which all have fresh
water snails as their intermediate hosts). The trematodes include Schistosomes. Toxoplasma
gondii is a protozoan parasite.

4.11.2 Onchocerciasis
a. Humans are the only definitive hosts.
b. The disease is spread by mosquitoes.
c. Infective larvae mature over 1 year in the skin.
d. Systemic spread via the blood is the main route of ocular infection.
e. the Mazzottie skin test detects infection.

Onchocerciasis (commonly known as river blindness) is caused by Onchocerca volvulus and

affects 30 million people worldwide. This condition is spread by the blackfiy, and the only
definitive hosts are humans. The blackfiy picks up microfilariae from the skin which
metamorphose to infective larvae in its thoracic walls. Infective larvae (which are transferred to
humans who are bitten by the blackfiy) mature in the skin for approximately 1 year, there being
between 50 and 200 million microfilariae in the skin of a heavily infected individual. Systemic
spread by the blood is unusual and the main route of ocular infection is from the nearby skin
directly to the conjunctiva and cornea. The Adazzotti skin test (which involves injection of
diethylcarbamazine) is used to detect infection.

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4.11.3 Toxocara canis
a. Adult dogs and humans become infected by ingestion of infective eggs in the soil, or
through ingestion of larval infected tissue.
b. After migration from the canine gut, most larvae mature to fully developed worms.
c. Encysted larvae become activated in pregnant bitches.
d. The primary source of infective ova are adult dogs.
e. Ova can withstand temperatures from - 25°C to 35°C.

Toxocara canis is a ubiquitous canine parasite that is endemic in all dog populations, regardless
of socioeconomic conditions. Both adult dogs and humans are infected by ingestion of infective
ova from soil, or by ingesting larval infected tissue (for example, in uncooked meats). Once
ingested, the first- and second-stage larvae remain within the eggshell. Third-stage larvae are
released into the intestine when the eggshell ruptures. These then migrate via the lymphatics and
die bloodstream to seed in end organs including the liver, lungs, brain and eye. After migration
the larvae become encysted. Most remain in this dormant state and do not mature into adult
worms; hence adult dogs are rarely a source of infection. However, in pregnant bitches the
encysted larvae become activated and migrate transplacentally to infect puppies in utero. Before
birth of an infected puppy, third-stage larvae migrate to its trachea, moult again and develop into
the adult worm. Puppies and lactating bitches are the primary source of infective ova. The
bitches shed the ova in their faeces from the fourth week postpartum. The ova are initially
embryonated and require a specific range of temperature and humidity to develop fully. The ova
may remain infective for several months and are able to survive temperatures ranging from —
25°C to 35°C.

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4.11.4 Cestode infections
a. Cysticerosis is caused by Taenia saginata.
b. Cysticerosis caused chronic retinal inflammation and fibrosis.
c. Echinococcus granulosus causes hydatid disease.
d. Echinococcus granudosus has humans as primary host.
e. Schistosomiasis is a form of cestode infection.

Cysticerosis is caused by the cestode Taenia solium., which is found in pork. The ingested larvae
mature in the gut before multiplying and crossing the mucosa to enter the bloodstream and hence
the retina. Retinal involvement is characterised by chronic inflammation and fibrosis and is often
complicated by retinal detachments. Echinococcus granulosus is the causative organism of
hydatid disease; its prevalence is higher in sheep farming communities. Humans (the primary
host) are infected by swallowing ova from dog faeces. The larvae then pass to extraintestinal
sites such as the liver to form hydatid cysts. Ocular involvement is often characterised by
proptosis. Schistosomiasis is a trematode infection which rarely involves the eye, although a case
of central retinal artery occlusion by Schistosomiasis mansoni has been reported.

4.11.5 Properties of Toxoplasma gondii

a. This is an obligate intracellular parasite.
b. The human is the definitive host.
c. Transmission may occur via uncooked meats.
d. Congenital toxoplasma accounts for all ocular disease.
e. Only antibody negative mothers are at risk of vertical transmission.

Toxoplasma gondii is an obligate intracellular protozoan parasite whose definitive host is the cat.
Transmission may occur by a number of routes including ingestion of uncooked meats (as almost
all livestock, for example sheep, pigs and to a lesser extent cows can be infected), or by
inhalation. Vertical transmission is

183
also possible if an antibody negative mother is infected during pregnancy. The chance of
congenital toxoplasmosis is increased if the maternal infection is in the third trimester, but the
severity of the illness is greatest if the infection occurs in the first trimester. It was originally
thought that all ocular disease was congenital in origin. However, recent studies from Brazil have
shown that a significant proportion of patients with ocular toxoplasmosis did not have congenital
infection (as shown by negative toxoplasma IgM titres in umbilical cord blood).

4.11.6 Life cycle of Toxoplasma gondii

a. Asexual merozoites are converted to gametocyres in the cat gut epithelium.
b. Fully infective sporozoites are excreted in cat faeces.
c. Bradyzoites rapidly divide in the intermediate host‘s gastrointestinal epithelium.
d. Extraintestinal cyst sites include skeletal muscle, heart, brain, and the eye.
e. Extraintestinal spread is often via white blood cells.

As the cat is the definitive host of Toxoplasma gondii the conversion of the asexually produced
merozoites to gametocytes can occur only in its intestinal epithelium. These microgametes will
produce oocysts that are excreted in the faeces and spoie in the soil after 1—5 days. The eggs
will become fully infective only after sporulation and ingestion by an intermediate host, such as
humans. The ingested sporozoites assume a rapidly dividing form (tachyzoite) before travelling
to the lymph nodes, often protected inside white blood cells. ExtraintestinaI spread to skeletal
muscle, the heart, brain, and the eye is common and cysts at these sites enclose the slowly
dividing bradyzoites.

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4.11.7 Pathogenicity of Toxoplasma gondii
a. The conoid a primitive mouthpiece.
b. Parasitophorous vacuoles are formed on entering the cell.
c. Vacuoles are susceptible to lysozymal destruction.
d. Cysts are destroyed by ―naïve‖ macrophages.
e. The retina is a more common site of infection than the choroid.

The first stage of infection is cell penetration, which is accomplished by the primitive
mouthpiece or conoid (which contains a number of lytic enzymes). Once in the cell a
parasitophorous vacuole resistant to lysozymal destruction is formed. The retina is infected in
preference to the choroid because it possesses lower immunoglobulin levels. Cell mediated
immunity utilising activated macrophages is the prime defence against toxoplasma infection.

4.11.8 A.canthamoeba
a. Acanthamoeba species have been isolated from swimming pools and bottled mineral
water.
b. Acanthamoeba exist as active trophozoites or dormant cysts.
c. Acanthamoeba castellanii produce collagenases.
d. Acanthamoeba will grow on nutrient agar.
e. Neomycin is effective against both trophozoites and cysts.

Acanthamoeba species are ubiquitous protozoa that have been isolated from public water
supplies, swimming pools, hot tubs, fresh water ponds and lakes, bottled mineral water, and soil.
They are the causative organism of a severe keratitis that is predominantly associated with the
wearing of soft contact lenses. Acanthamoeba species exist in two forms, the active trophozoite
form and a dormant encysted form. The first stage in corneal infection is the attachment of the
amoeba to the epithelial surface, although it is not known whether an epithelial defect is required
for adherence and invasion. The stromal changes seen

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in Acanthamoeba keratitis have been attributed in part to the activity of collagenases produced
by some Acanthamoeba species such as A. castellanii. Acanthamoeba cannot be grown on
nutrient agars; they require non-nutrient agar covered with a lawn of killed Escherichia coli,
which serve as a food source. Treatment of Acanthamoeba infection is often prolonged and no
single regimen is universally effective. Agents that are used include aminoglycosides
(neomycin), diamidines (brolene), imidazoles (ketoconazole, fluconazole), and antiseptic
biocides (polyhexamethylene biguanide). Although most of these agents are effective against the
active trophozoites, only polyhexamethylene biguanide is cysticidal.

4.12: Antimicrobial agents

4.12.1 Properties of penicillins

a. penicillins inhibit cross linking of glycan strands in bacterial cell walls.

b. They are bacteriostatic.
c. These drugs are effective against Gram positive bacilli.
d. Ampicillin is effective against most Gram negative bacilli.
e. Flucloxacillin is susceptible to β lactamase.

The penicillins are a large group of effective, bactericidal and generally non-toxic antibiotics that
are produced from fungi and by molecular modifications. Penicillins achieve their action by
interfering with the cross linking of glycan strands, which is the final stage in the production of
the bacterial cell wall. They are most effective against streptococci and Gram positive bacilli
such as the clostridia. Staphylococcus aureus infections are commonly resistant, because their (3
lactamases destroy penicillin. The antibacterial spectrum of ampicillin has been extended to
include Gram negative bacilli such as Escherichia coli and Haemophilus influenzae. The side
chain of flucloxacillin prevents the action of staphylococcal P lactamase.

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4.12.2 Properties of cephalosporins

a. Cephalosporins inhibit folic acid production.

b. They are bactericidal.
c. Cefuroxime is a third generation cephalosporin.
d. These drugs are effective against Gram negative bacilli.
e. They are effective against β lactamase producing staphylococci.

The cephalosporin family of antibiotics falls into the (3 lactamase category, exerting bactericidal
effects by inhibiting cell wall synthesis. ZVLost cephalosporins have a wider range of activity
than penicillins encompassing (3 lactamase producing staphylococci and Gram negative bacilli.
Cefuroxime is a second generation cephalosporin effective against many Gram negative bacilli
that are resistant to broad spectrum penicillins such as ampicillin. The Gram negative spectrum
has been extended in third generation cephalosporins such as ceftazidime to include
Pseudomonas and Ha.cteroid.es.

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4.12.3 Properties of gentamicin

a. This drug prevents the first ribosome joining with messenger RNA.
b. It is bacteriostatic.
c. Gentamicin is effective against streptococci and anaerobes.
d. It has little effect on Gram negative bacilli.
e. Ototoxicity is more common than renal toxicity.

Gentamicin is from the aminoglycoside group of bactericidal antibiotics. It exerts its actions at
the site of the ribosome by preventing the first ribosome from joining with messenger R3STA; it
may also cause the messenger RNA code to be misread so that the wrong amino acid is
incorporated into the protein. A/lost aminoglycosides are effective against staphylococci and
aerobic Gram negative bacilli, including Pseudomonas and resistant Proteus strains. They are felt
to be ineffective against streptococci and anaerobic bacteria. If administered parenterally
gentamicin is known to cause vestibular, cochlear, and renal side effects (in decreasing order of
frequency). Topical gentamicin has been widely \*sed in the treatment of microbial keratitis,
although prolonged use often results in comeal epithelial toxicity. Intravitreal gentamicin should
no. longer be used to treat endophthalmitis as retinal toxicity has been reported with this route of
administration.

4.12.4 Properties of the tetracyclines

Tetracycline:
a. Disrupts cell wall synthesis.
b. Is bacteriostatic.
c. Is effective against Chlamydia.
d. is effective against Brucella abortus.
e. Is contraindicated in pregnancy.

Tetracyclines interrupt the cycle of attachment of amino acids to the first binding site during
protein synthesis. They are bacteriostatic agents with a wide spectrum that includes Gram 182

188
positive cocci, aerobic Gram negative bacilli and bacteroides. They are also the treatment of
choice in chlamydial infections such as trachoma and the more unusual infections such as
brucellosis and Q fever. Tetracyclines have a number of common side effects such as disturbance
of the gut, and% are contraindicated in pregnancy.

4.12.5 Properties of chloramphenicol

Chloramphenicol:
a. Inhibits protein synthesis.
b. Is bactericidal.
c. Has a broad spectrum, including staphylococci.
d. May cause aplastic anaemia.
e. Causes the ―grey baby‖ syndrome.

Chloramphenicol is a potent, potentially toxic, broad spectrum antibiotic. Its bacteriostatic action
is achieved by preventing the transfer of the growing peptide chain to other amino acids, thus
inhibiting protein synthesis. It is commonly used topically for bacterial conjunctivitis because of
its potency against staphylococci. Its systemic use, however, should be limited to the treatment
of life threatening conditions such as Haemophilus influenzae meningitis or typhoid fever
because of its potentially fatal side effect of aplastic anaemia. It may also cause the ―grey baby‖
syndrome in neonates and is therefore contraindicated in pregnancy and when breast feeding.

4.12.6 Properties of metronidazole

a. This drug affects DNA synthesis.
b. It is effective against anaerobes.
c. it is effective against giardia.
d. Resistance is a problem.
e. use of metronidazole may disrupt liver function tests.

Metronidazole exerts its antimicrobial effect by disrupting DNTA synthesis. It is effective

against many anaerobic bacteria such as

189
bacteroides and is often used as a prophylaxis for gastrointestinal surgery. It is also effective
against protozoan parasites such as giardia, trichomonas and entamoeba. Resistance is not a
problem as yet and side effects are uncommon, aldiough disrupted liver function tests and low
platelet counts have been reported.

4.12.7 Properties of ofloxacin

a. Ofloxacin is a fluoroquinolone.
b. Ofloxacin inhibits bacterial DNA polymerase.
c. The antimicrobial spectrum includes Pseudomonas and chlamydiae.
d. Photosensitivity rashes are a potential side effect of systemic therapy.
e. Intravitreal levels are higher with intravenous therapy than with oral treatment.

Ofloxacin is a fluoroquinolone that inhibits the action of bacterial DNA gyrase, the enzyme
involved with the folding and unfolding of DNA during synthesis. It has a broad spectrum of
antimicrobial activity including Pseudomonas, chlamydiae, Enterobacteriaceae, mycoplasmas
and rickettsia. However, it is slightly less active against Gram positive bacteria and has little
effect against anaerobes. In topical form it penetrates the cornea and enters the anterior chamber
readily and is becoming the topical agent of choice for first-line treatment in most cases of
microbial keratitis. The topical form has few local side effects compared with topical gentamicin.
However, systemic side effects such as gastrointestinal upset and photosensitivity rashes have
been reported following oral treatment. Ofloxacin is generally well absorbed from the gut and
penetrates into most body tissues and fluids. The intravitreal concentration of ofloxacin is just as
high following oral treatment as after intravenous therapy; oral ofloxacin (or ciprofloxacin)
should now be part of most endophthalmitis treatment protocols.

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4.12.8 Vancomycin
a. interferes with nucleio acid synthesis.
b. Is bactericidal against Gram negative bacteria.
c. Is bactericidal against staphylococci.
d. Is well absorbed from the gut.
e. Is retinotoxic if administered intravitreally.

Vancomycin is a glycopeptide antibiotic that interferes with peptidoglycan assembly by binding

to the pentapeptide chain. This prevents incorporation of new r.ubunits into the cell wall and
results in cell lysis and death of the organism. It is bactericidal against most Gram posiuve
organisms^ including staphylococci but is ineffective against Gram negative bacteria.
Vancomycin is poorly absorbed from the gut and must be administered intravenously in the
treatment of systemic infection. In view of its efficacy against staphylococci and lack of retinal
toxicity it is widely used as an intravitreal agent (often in combination with amikacin) in the
treatment of endophthalmitis.

4.12.9 Properties of amphotericin

a. This drug binds to sterols in cell membranes.
b. It may be administered orally.
c. Amphotericin has a narrow fungal spectrum.
d. Renal toxicity is common.
e. Anaemia is a known side effect.

Amphotericin is still the standard antimicrobial agent and until recently was the only drug used
for the treatment of deep mycoses. This polyene is not absorbed from the gut—therefore it must
be administered intravenously. The drug binds to sterols in cell membranes, and its selective
activity is due to its very high affinity for ergosterol (the major sterol in fungal membranes). Its
antimicrobial spectrum includes most fungi that invade humans. . Common side effects include
anaemia and nephrotoxicity, - although the advent of liposomal preparations has reduced the
incidence of these side effects.

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4.12.10 Azoles and flucytosine

a. Azoles cause abnormal protein synthesis and inhibition of DNA synthesis in fungal
cells.
b. Itraconazole is active against Candida species, Cryptococcus neoformans and
Histoplasma capsulatunl.
c. Fluconazole is active against Aspergillus and Mucor species.
d. Flucytosine is hepatotoxic.
e. Fungal resistance to flucytosine is rare.

Azoles alter fungal cell membranes by blocking the biosynthesis of ergosterol, resulting in
leakage of cell contents. Flucytosine is converted in fungal cells to 5-fluorouracil, which is then
incorporated instead of uracil into fungal RNA. This leads to abnormal protein synthesis and
inhibition of DNA synthesis. Fluconazole and itraconazole are active against most Candida
species, Cryptococcus neoformans> and Histoplasma capsulatum. Fluconazole is ineffective in
Aspergillus or Aiucor infections, although itraconazole is active against Aspergillus species.
Flucytosine is effective in candidal and cryptococcal infection. It may be administered orally or
intravenously and has excellent penetration of tissue and cerebrospinal fluid. Unlike azoles,
which may cause transient abnormalities of liver function (and rarely severe hepatotoxicity in the
case of ketoconazole), flucytosine has no hepatotoxic side effects, although it may cause marrow
aplasia. Fungal resistance to flucytosine is common and this can be minimised by using the drug
with amphotericin B.

4.12.11 Resistance to antibiotics

a. Gene mutation induces resistance to antitubercullous drugs.

b. Transduction involves passage of genetic material in plasmids.
c. Conjugation uses bacteriophages.
d. Aminoglycosides are destroyed by acetylation.
e. Resistance may be achieved by modifying the target of antibody attack.

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Resistance to antimicrobial agents may arise in a number of ways. Gene mutation is a
mechanism that is important only in the antituberculous drugs such as rifampicin and antifungals
such as flucytosine. Adore important mechanisms involve gene transfer from one bacterium to
another—by transduction (genetic material is incorporated into a bacteriophage and later into the
genome of another cell), or by conjugation (the direct passage of genetic material using a
plasmid from one cell to another). Exposure to some of the new cephalosporins has been shown
to activate previously dormant or weak resistance mechanisms in certain organisms. The genetic
changes may convey resistance by:
 destroying or inactivating the drug (e.g. acetylation of aminoglycosides),
 excluding the antibiotic;
 modifying the target site (e.g. failure of ribosomes to bind erythromycin) s
 using alternative enzymic pathways that are resistant to the drug (e.g. enzymes resistant
to sulphonamide and trimethoprim).

4.12.12 Properties of acyclovir

a. This drug is a guanosine analogue.

b. Unaltered, it inhibits viral DNA polymerase.
c. Acyclovir is effective against herpes simplex and varicella zoster viruses.
d. Its use may cause renal insufficiency.
e. Resistance arises by viral mutation.

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Acyclovir, which is an acyclic analogue of guanosine, is an extremely safe and effective antiviral
agent, and is the drug of choice for most forms of herpes simplex and varicella zoster virus
(VZV) infections. Acyclovir itself is inactive and inhibits viral DNA polymerase only after
phosphorylation by viral thymidine kinase. Because it is so selective it has affinity only for
viral thymidine kinase—it is effective in infected cells. It may be administered orally,
pairenterally or topically. Common side effects include a mild renal insufficiency,
gastrointestinal upset and headache. The most common cause of resistance to acyclovir is a
mutation resulting in the loss of viral thymidine kinase synthesis, but acyclovir resistant HSV
and VZV mutants are uncommon in immunocompetent patients.

4.12.13 Properties of ganciclovir

a. Ganciclovir is a nucleotide analogue.

b. Is active against cytomegalovirus.
c. Is as effective against herpes simplex as acyclovir.
d. Is viricidal.
e. Neutropenia and thrombocytopenia are rare side effects.

Ganciclovir is an acyclic nucleotide analogue, differing from acyclovir in that it has a terminal
hydroxymethyl group. Its triphosphate form appears to function both as an inhibitor of and as a
faulty substrate for cytomegalovirus DNA polymerase (host cell polymerase is much less
sensitive to it). It is 10—25 times more active than acyclovir against cytomegalovirus and at least
as active against herpes simplex and VZV. Treatment of CMV retinitis requires an induction
course followed by maintenance therapy, because ganciclovir as only a virostatic action. The
reported adverse effects of the drug have been mainly haematological, primarily neutropenia (in
40% of patients) and thrombocytopenia (20% of patients).

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14 Properties of foscamet
a. Foscarnet is a nucleotide analogue.
b. It reversibly inhibits the viral DNA polymerase and reverse transcriptase.
c. It has an intrinsic anti HIV effect.
d. It is active against cytomegalovirus.
e. This drug causes renal insufficiency and neutropenia

Foscarnet is paraphosphate analogue of phosphonoacetic acid it selectively and reversibly

inhibits viral specific DNA lymerases and reverse transcriptases. Foscarnet appears to be about
as effective as ganciclovir for the initial 2—3 week induction; therapy of CMV retinitis and,
because of its mode of action, is effective in treating acyclovir resistant herpes simplex
infections, is of particular use in the AIDS patient because it is thought have an intrinsic anti HIV
activity and may be used in conjunction with zidovudine without the risk of catastrophic
neutropenia. Common side effects include renal insufficiency d proteinuria.

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196
5.Pathology
5.1 Inflammation and wound healing

5.1.1 General characteristics of acute inflammation

Acute inflammation:
a. Is a specific response.
b. Exhibits memory.
c. Comprises a cellular followed by a vascular phase.
d. May be caused by chemical injury.
e. May be present for 1-2 weeks.

Acute inflammation maybe defined as the non-adaptive response of viable vascular tissue to
subfatal injury. Unlike the immune response, which is adaptive, acute inflammation is non-
specific and does not exhibit memory (the acute inflammatory response will not be quicker and
more pronounced on the second exposure to a stimulus). The causes of acute inflammation
include infection, trauma, ultraviolet light, X ray radiation and chemical injury. By definition,
acute inflammation lasts only 1—2 days and comprises a vascular phase followed by a cellular
phase.

5.1.2 Vascular phase of acue inflammation

a. Vasodilatation is initiated by histamine.

b. Kinins will vasodilate capillaries and venules.
c. Prostaglandin E constricts arterioles.
d. There is a decreased vascular permeability.
e. Margination is a feature of the vascular phase.

The vascular phase is initiated by a number of chemical mediators. Histamine, which is released
from degranulated mast cells, produces an increase in vascular permeability and will vasodilate
venules—peak effect is reached after 5 minutes. The

197
effect of histamine is only transient (approximately 15 minutes} but kinins will also cause
capillaries and venules to dilate and their release along with prostaglandins such as prostaglandin
E2 (PGE;,) (which dilates arterioles) produces a delayed and persistent vascular response. Such a
response has a peak effect at approximately 4—24 hours. As a result of vasodilatation, blood
flow becomes slower and cells move to the sides of the vessels—an effect known as
rnargination.

5.1.3 Cellular phase of acute inflammation

a. Neutrophil rolling describes the firm binding of neutrophils to endothelial cells.

b. Histamine and leukotrienes induce expression of selectins on endothelial cells.
c. Platelet activating factor stimulates expression of β integrins on enutophils.
d. Intercellular adhesion molecules (ICAM) are expressed on activated endothelial cells.
e. Migration of neutrophils is stimulated by interleukin-8.

The constituents of the cellular phase vary according to the cause of the acute inflammatory
reaction. In bacterial infections neutrophils predominate, in parasitic infections eosinophils are
the most common cell type, and in viral infections monocytes are prominent. The recruitment of
neutrophils to the site of inflammation is influenced by the expression of a series of cell adhesion
molecules on the surfaces of activated endothelial cells and neutrophils. (1) When neutrophils
have been brought in contact with endothelial cells by margination, a weak bond is established
between the two types of cell. This is mediated by selectins, oligosaccharides that are expressed
by nonactivated neutrophils. This process is known as neutrophil rolling. (2) Histamine,
thrombin, and leukotrienes induce expression of further selectins on endothelial cells, so
stabilising these bonds. (3) Increased adhesion develops between endothelial cells and
neutrophils. Activated endothelial cells produce molecules that enhance neutrophil/endothelial
binding. Platelet-activating factor activates neutrophils and induces expression of β integrins

198
on their cell membranes. Beta integrins and I CAM 1 and 2 (produced by activated endothelial
cells) are instrumental in promoting the firm adhesion between neutrophils and endothelial cells.
(4) Transmigration of neutrophils occurs between endothelial cells. IL-8 produced by activated
endothelial cells is a powerful chemoattractant that enhances transmigration.

5.1.4 Chemotaxis
a. Chemotaxis is the directional and purposive movement of phagocytic cells.
b. It occurs along a concentration gradient.
c. Polymorphs have specific chemotactic binding sites.
d. C3b is a chemotactic factor.
e. Increase of intracellular cyclic AMP stimulates chemotaxis.

Chemotaxis is the directional and purposive movement of phagocytic cells towards areas of
tissue injury or bacterial invasion. Chemotaxis may be divided into two phases: reception of
chemotactic signals; and the cellular response to these signals, known as transduction. Many
substances are known to be

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chemotactic for neutrophils, and may be classified into three groups: (X) low molecular
weight compounds such as
prostaglandin E; (2) intermediate molecular weight compounds (such as C5a and C5 derived
peptides); (3) high molecular weight compounds (e.g. lymphokines and partly denatured
proteins).
Chemotaxis follows a concentration gradient of such factors, which have specific binding sites
on the polymorph. Binding of these factors will cause an influx of calcium by stimulating
phospholipase A2. This in turn stimulates arachidonic acid metabolism with the subsequent
activation of guanosyl cyclase and an increase in levels of cyclic GMP, which will increase
microtubule assembly and so aid polymorph migration. A rise in cyclic AMP will inhibit tubule
assembly and chemotaxis.

5.1.5 Phagocytosis
a. C3b aids recognition.
b. Bacteria are engulfed in a phagosome.
c. A ―respiratory burst‖ is essential for killing cells.
d. Myeloperoxidase increases the bactericidal capacity of hydrogen peroxide.
e. Lactoferin is employed in killing cells.

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The initial stage of phagocytosis (recognition) is aided by the process of opsonisation. Two of
the most important opsonins are IgG and complement C3b. Polymorphs have specific receptor
sites for these molecules, which attach themselves to invading microorganisms. The bacterium or
foreign object is then engulfed by a phagosome. The phagosome fuses with a lysosome; this is
associated with a burst of metabolic activity (the respiratory burst), which results in the
production of hydrogen peroxide. The killing action of hydrogen peroxide is increased 50-fold
by the action of myeloperoxidase which is found in lysosomes. Other methods of cell killing
include lowering the pH, lysosomal hydrolysis and production of lactoferrin (which inhibits the
growth of some microorganisms).

5.1.6 Properties of macrophages

Macrophages.
a. Are derived from monocytes.
b. Are incapable of division.
c. Are activated by complement C3b.
d. Fuse to form epithelioid cells.
e. Are important in antigen presentation.

Macrophages are derived from monocytes within the tissues by a process that involves
enlargement of the cell, and increase in lysosome numbers, and development of a more promine
Golgi apparatus and endoplasmic reticulum. One of the factors involved in macrophage
activation is C3b. Macrophages are capable of cell division and in the face of persistent foreign
material may fuse to form multinucleated giant cells with increased phagocytotic activity.
Epithelioid cells (usually found in granulomas) evolve from a single macrophage and have
increased secretory capacities.

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5.1.7 Properties of activated macrophages
Activated macrophages may:
a. Have greater capacity to kill tumour cells.
b. Produce endogenous pyrogen and interferon.
c. Inhibit proliferation of fibroblasts and polymorphs.
d. Secrete lymphokines.
e. Have increased phagocytic capacity.

Activation of macrophages has a number of consequences: the phagocytotic capacity of the

macrophage is increased, hydrolytic enzymes are produced; activated macrophages are capable
of producing endogenous pyrogen and interferon (which blocks translation of viral messenger
RNA). Macrophage activation also has a number of effects on other inflammatory and immune
cells—for example, it stimulates the proliferation of fibroblasts and its colony stimulating factor
increases polymorph production. Macrophages secrete a lymphocyte activating factor
(interleukin-1), which will stimulate T helper cells. Lymphokines (such as macrophage
chemotactic factor and migration— inhibition factor) are secreted by T helper cells to aid
recruitment of macrophages to the sites of infection.

5.1.8 The complement system

a. C3a and C5a are anaphlatoxins.

b. C3a has greater activity than C5a.
c. C567 is chemotactic to polymorphs.
d. Plasmin stimulates the classical and alternative pathways.
e. C5b6789 causes cell lysis.

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The complement system is involved in acute inflammation, phagocytosis, clotting, immune, and
hypersensitivity ‘reactions. It may be initiated by the classical or alternative pathways, both of
which are stimulated by plasmin. C3a and G5a will increase vascular permeability and are
chemotactic for polymorphs—they are known as the anaphylatoxins. C5a is approximately 1000
times more active than C3a. C567 is also chemotactic to polymorphs but only the killing
complex of C5b6789 is capable of cell lysis-

5.1.9 Kinin, clotting and fibrinolytic systems

a. Active Hageman factor stimulates the kinin cascade.

b. Active Hageman factor inhibits plasminogen.
c. The kinin cascade produces potent vasoconstrictors.
d. Fibrinopeptides stimulate vascular leakage.
e. Plasmin activates Hageman factor.

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Inflammatory mediators derived from the plasma include the kinin system, the clotting system
and the fibrinolytic system. Activated Hageman factor will stimulate all three cascades by its
stimulatory action on factor XI, prekallikrein, and plasminogen- The kinin cascade will produce
a number of potent vasodilators, including bradykinin. Fibrinopeptides produced by the clotting
cascade are chemotactic for neutrophils and will stimulate vascular leakage. Positive
amplification loops exist within all three systems: activated factor XI, kallikrein, and plasmin all
feed back positively to activate Hageman factor.

5.1.10 Natural history of inflammation

a. Resolution may occur after tissue destruction.
b. Organisation produces normal structure.
c. Regeneration produces normal structure.
d. Regeneration is dependent on cell type.
e. In all organs lost tissue is replaced by vascularised connective tissue.

The natural history of an acute inflammatory lesion depends upon a number of factors. If the
inflammatory response does not result in tissue destruction, and exudate is fully removed by
polymorphs, the result is resolution. If the exudate persists it will become organised to produce
scarring. If the inflammatory condition causes tissue destruction, regeneration (return to the
original state) can occur only if the cells lost had been labile cells (which divide and proliferate
throughout postnatal life), or stable cells (which, although normally quiescent, may be stimulated
to divide). If tissue derived from permanent cells (which proliferate only during fetal life) is
destroyed it cannot be replaced, and a scar comprising vascularised connective tissue is formed.

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5.1-11 Properties of chronic inflammation
Chronic inflammation:

a. Has vascular and cellular phases.

b. Is always infectious in origin.
c. Is characterized by granuloma formation.
d. Polymorphs predominate.
e. Always arises from areas of prolonged acute inflammation.

Chronic inflammation is caused by the presence of a persistent and particulate irritant. It is

characterised by a cellular response, during which cellular proliferation and destruction (mostly
of macrophages and macrophage derived cells) occur simultaneously. These cells are often
organised in a special

205
type of chronic inflammation known as a granuloma. Although infections such as tuberculosis
and leprosy are common causes of chronic inflammation, the origin is not aivvays infective (for
example, sutures, silica, and wood granulomas). Non-specific chronic inflammatory conditions
may arise from acute inflammatory lesions, but the specific granulomatous response seen in
tuberculosis has a very transient acute phase.

5.1.12 Properties of tuberculous granuloma

Tuberculous granuloma:
a. Has an inner core of lymphocytes and microorganisms.
b. Contains epithelioid cells with an increased phagocytic capacity.
c. Contains multinucleate giant cells.
d. Is a caseating granuloma.
e. Has an outer layer of fibroblasts.

A granuloma may be defined as a lesion arising from a special type of chronic inflammation,
mostly of macrophage and macrophage derived cells. The tuberculous granuloma consists of an
inner core of microorganisms and epithelioid cells with increased secretory capacity (secondary
to prominent Golgi apparatus and rough endoplasmic reticulum). This core is surrounded by a
layer of activated macrophages (which have ingested the bacilli) and a layer of T lymphocytes.
The outer layer consists of fibroblasts and multinucieate giant cells, although in ―young
granulomas‖ the giant cells may be found in the central core. Caseation is a typical feature of
tuberculous granulomas.

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5.1.13 Regarding healing of full thickness skin incisions

a. Proliferation of epithelial cells is stimulated by chalones.

b. Fibronectin stimulates epithelial migration.
c. New vessels appear within 24 hours.
d. Fibroblasts produce collagen and glycosaminoglycans.
e. Myofibroblasts cause wound contraction.

Wound healing involves both epidermal and dermal events. In the epidermis epithelialisation
occurs in three stages: (1) cell migration, which is stimulated by fibronectin; (2) cell
proliferation, normally inhibited by chalones; and (3) differentiation. Dermal events involve the
invasion of the fibrin clot by solid buds of endodielial cells, which grow from intact capillaries at
the wound edges and form npw vessels within the first week.

Macrophages and fibroblasts then migrate into the wound; macrophages aid clot removal
while fibroblasts produce collagen and glycosaminoglycans. Myofibroblasts will appear at the
wound edges in the first week and are thought to be responsible for wound contraction.

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5.1.14 Regarding healing of full thickness, central corneal lacerations

a. Initially a fibrin plug is formed by aqueous fibrinogen.

b. Mononuclear cells predominate in the leukocytic phase.
c. Full thickness epithelial ingrowth is inhibited by a healthy endothelium.
d. Collagen and mucopolysaccharides are produced by fibroblasts derived from
keratocytes.
e. Bowman‘s membrane regenerates over several weeks.

The healing of full thickness central comeal lacerations occurs

in several phases:

 Immediate phase: this comprises retraction of Descemet‘s membrane and stromal

collagen, causing anterior and posterior gaping of the wound; fibrin plug formation from
aqueous fibrinogen; and stromal oedema.
 Leukocytic phase: after 30 minutes or so, polymorphonuclear leukocytes from the
conjunctival vessels (via the tear film) and from the aqueous invade the wound. In the
case of limbal wounds there are an increased number of mononuclear cells which come
from the limbal vessels. These may be transformed to fibroblasts after 12—24 hours.
 Epithelial phase: epithelial ingrowth occurs after 1 hour, full thickness ingrowth being
inhibited by a healthy endothelium. Compromise of this contact inhibition, by the
presence of an abnormal endothelium, residual lens remnants or vitreous in the wound,
may lead to an epithelial downgrowth syndrome.
 Fibroblastic stage: in the case of central corneal wounds fibroblasts are derived from
keratocytes; they produce collagen fibrils and mucopolysaccharides, which are laid down
in a matrix. This matrix is similar to granulation tissue, except that it is avascular. As the
matrix is laid down, the epithelium slowly retreats anteriorly.
 Endothelial phase: this occurs after 24 hours; there is endothelial sliding, and mitotic and
amitotic multiplication of endothelial cells to cover the posterior aspect of the wound.
After a few weeks this is followed by regeneration of Descemet‘s membrane.

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* Late phase: after 1 week the cellular infiltrate begins to diminish and the collagen fibres
become arranged more uniformly. The stroma and Bowman‘s membrane are incapable of
regeneration and are replaced by this scar tissiue.

5.1.15 Wound healing in other ocular tissues

a. Epithelial healing is indentical in conjunctival and corneal wounds.
b. In full thickness sclera wounds the sclera takes an active part In the production of
granulation tissue.
c. The iris is incapable of wound healing unless the edges of the wound are in direct
apposition.
d. Choroidal wounds heal by the formation of granulation tissue.
e. Avascular inujuries to the retina and optic nerve heal by fibrosis.

Healing of conjunctival wounds differs from that of corneal wounds because of the
presence of a vasculature, a lymphatic system, and a reticuloendothelial system, all of
which facilitate the formation of granulation tissue. However, epithelial healing by cell
sliding and proliferation is identical in both the conjunctiva and the cornea. Although the
sclera is a vascular structure it does not play an active role in wound healing. In the event
of a full thickness scleral injury, tongues of granulation tissue from the overlying
episclera and underlying uvea invade and meet in the wound. The iris is capable of
wound healing only if the edges of the wound are in direct apposition, unless there is
coexistent haemorrhage or infection, which may allow granulation tissue to bridge this
gap. If the wound edges remain in apposition granulation tissue will form in the anterior
stromal part of the wound, and pigment epithelial cells will migrate over the posterior
part of the wound to cover the gap as a single, rather than the normal double, layer. The
ciliary body and choroid heal in the ―classic‖ way with the formation of granulation
tissue that is ultimately replaced by scar tissue. Fibroblasts are not native cells of the
normal retina or optic nerve; healing of these tissues is therefore by gliosis initiated by

209
astrocytes and not by collagen production and fibrosis. However, if the injury is complicated by
haemorrhage or infection, mesodermal elements may produce granulation tissue and a
collagenous scar.

5.1.16 5-fLuorouracil (5FXJ)

a. 5FU is converted intracellularly to its active form 5-fluoro- 2 –deoxyuridine 5 –

monophosphate (FdUMP).
b. FdUMP competitively inhibits thymidylate synthetase in S phase cells.
c. 5FU does not interfere with RNA synthesis and function.
d. 5FU causes corneal epithelial toxicity.
e. Application of 5FU at the time of glaucoma filtration surgery permanently prevents
fibroblast replication.

5-fluorouracil is a fluorinated pyrimidine tiiat is converted intracellularly to its active form 5-

fluoro-2,-deoxyuridine 5'- monophosphate (FdUMP). The antiproliferative effect is primarily
achieved by competitive inhibition of thymidylate synthetase in S phase cells, so impeding DNA
synthesis. Additional antiproliferative effects are induced by conversion of FdUMP to a
triphosphate by intracellular kinases; this is then incorporated into DNA instead of thymine
rendering it unstable. Incorporation of 5FTJ derivatives into D1STA will also interfere with
RNA processing and function. 5FU may also be incorporated directly into RNA disrupting
protein synthesis. Corneal epithelial toxicity is one of the major ocular side effects of 5FU and is
a consequence of its effect on rapidly dividing cells. The doses of 5FU administered at the time
of glaucoma filtration surgery inhibit fibroblast proliferation for approximately 4—6 weeks.

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5.1.17 Mitomycin C
a. Is a naturally occurring alkylating agent derived from Streptomyces caespitosus.
b. Only affects cells in the S phase or G2 phase of the cell cycle.
c. Inhibits fibroblast migration.
d. Commonly causes epithelial toxicity.
e. Permanently inhibits fibroblast proliferation.

Mitomycin C is a naturally occurring alkylating agent with antibiotic and antineoplastic

properties that is derived from Streptomyces caespitosus. It is cell cycle non-specific, that is, it
has an antiproliferative effect on cells irrespective of their stage in the cell cycle, although it has
a maximal effect on cells in the G and S phases. Despite the permanent antiproliferative effect of
mitomycin C on fibroblasts (it is 100 times more potent than 5-fluorouracil) it does not inhibit
their migration or attachment. Epithelial toxicity is not usually associated with the use of
mitomycin C in glaucoma filtration surgery.

5.1.18 Which of the following are consequences of a severe

alkaline injury?

a. Swelling and desquamation of the corneal epithelium.

b. Coagulation necrosis and precipitation of protein at the level of the epithelium.
c. Coagulation of conjunctival blood vessels.
d. Release of collagenase enzymes by the corneal epithelium, and keratocytes.
e. Destruction of lens epithelial cells.

Alkaline injuries carry a worse prognosis than acidic injuries for several reasons. First, the
corneal epithelium is not an effective 1 barrier against penetration of alkali, as it swells and
desquamates on contact with alkali. Acid causes an instantaneous coagulation necrosis and
precipitation of protein, which helps to neutralise the acid and limits further penetration. Second,
alkali coagulates

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conjunctival blood vessels, giving the eye a porcelain white appearance; this leads to widespread
limbal ischaemia and destruction of limbal stem cells. Third, in the first few weeks after an alkali
injury there is a release of collagenases derived from the corneal epithelium and, to a lesser
extent, from keratocytes. These enzymes contribute significantly to comeal and conjunctival
necrosis. Alkali passes easily through the comeal stroma and into the aqueous, where it kills lens
epithelial cells and causes a severe non-granulomatous iridocyclitis.

5.1.19 Which of the following are features of inflammatory comeal angiogenesis?

a. Increased vascular permeability and oedema precede inflammatory corneal

angiogenesis.
b. Endothelial cell activation with retraction and decreased cell junctions.
c. Degradation of endothelial cell basal lamina.
d. Vascular sprouting from precapillary arterioles.
e. Linkage of blind vascular channels to form a capillary network.

Comeal angiogenesis in response to an inflammatory stimulus develops in several overlapping

phases, from a latent period to vascular maturation.
 Latent period between the insult and onset of angiogenesis—this is characterised by
vasodilatation and an increase in the permeability of neighbouring vessels, which enable
inflammatory cells to migrate into the cornea. The resultant stromal oedema facilitates
angiogenesis by separating the closely packed collagen lamellae.
 Endothelial cell activation with retraction and decreased cell junctions—enlargement of
endothelial cell nucleoli is the first sign of this phase, and occurs within 24 hours. o
Degradation of endothelial cell basal lamina—migrating and dividing endothelial cells
must penetrate their basal lamina, and this is aided by proteases derived from a host of
sources including the endothelium itself, PMNs, macrophages and mast cells.

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  Vascular sprouting—endothelial cell migration and replication results in sprouts from
post capillary venules and preexisting capillaries. This is followed by lumen formation
and anastomosis of the blind channels to form a new capillary network.
 Vascular maturation—the endothelium of the newly formed vessels lacks a basal lamina.
Maturation is characterised by the deposition of extracellular matrix and laminin,
followed by basal lamina formation and the development of a pericyte layer.

5.1.20 Factors contributing to inflammatory angiogenesis

a. Plasminogen activator is involved with degradation of endothelial basal lamina.

b. Fibrin and fibrin degradation products inhibit angiogenesis.
c. Macrophages promote angiogenesis.
d. Platelet factor 4 stimulates angiogenesis.
e. Interferon α and β inhibit the migration of vascular endothelial cells.

Many cell types and mediators have been implicated in angiogenesis, but the exact role of each
factor has yet to be clearly defined. Plasminogen activator is a protease known to break down the
endothelial basal lamina. It is produced by fibroblasts, macrophages and comeal endothelium and
epithelium. Other proteases, many of which are released by PMNs, may stimulate angiogenesis
by converting progrowth factors to active mediators. These mediators may stimulate
transmembrane signalling that leads directly to mitosis, or they may induce the secretion of other
proteases in a cascade-like fashion. Fibrin and fibrin degradation products are known to promote
angiogenesis, and the invasion of tissue by blood vessels is enhanced by antifibrinolysins.
Although activated macrophages are known to promote angiogenesis in immunological acute
inflammation, by the release of cytokines such as II-1 and TNFot and p, and by protease release,
they are not thought to be essential for new vessel growth in non- immunological acute
inflammation. Platelet degranulation results in the release of a multitude of factors, most of
which have

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been implicated in some way with angiogenesis. Mediators diat inhibit angiogenesis include
platelet factor 4, and interferon α and β which inhibit the migration of vascular endothelial cells.

5.2: General immunology

5.2.1 B and T lymphocytes
a. Plasma cells are derived from B lymphocytes.
b. T lymphocytes cannot produce antibodies.
c. B cells produce chemotactice factors for macrophages.
d. B cells are found in the paracortical zones of lymph nodes.
e. T cells have surface receptors for Fc and C3b.

Both B and T lymphocytes are derived from bone marrow stem cells. B lymphocytes will mature
into plasma cells that are capable of antibody production, and are the mainstay of the humoral
immune response. T cells are incapable of antibody production but are able to synthesise and
secrete a number of active components known as lymphokines. These activate macrophages,
which (along with T cells) form the basis of the cell mediated immune response. These two
classes of lymphocytes have a different distribution within the secondary lymphoid tissue, B
cells being found in the cortical follicles of lymph nodes and T cells in the paracortical zones.
There are no morphological differences between the two but the cells possess a number of
different surface markers—the Fc and C3b receptors are found only on B cells.

5.2.2 Basic structure of immunoglobulins

a. Immunoglobulins have two heavy and four light chains.

b. Heavy chains determine the type of immunoglobulin.
c. The Fc fragment binds antigen.
d. The chains are held together with disulphide bonds.
e. Heavy and light chains consist solely of ―variable‖, ―constant‖ and ―joining‖
regions.

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Antibodies (or immunoglobulins) when in the monomeric form all have the same basic Y shaped
structure consisting of four polypeptide chains held together by disulphide bonds. Each monomer
has a pair of identical heavy chains and a pair of identical light chains. All heavy and light chains
have a variable (V), joining CO and constant (C) region. In addition, heavy chains also have a
diversity (D) region. The immunoglobulin type is determined by the constant region of the heavy
chains, there being five classes: y, a, p., 8, and e. There are two classes of light chain: k and A..
Bach immunoglobulin monomer has two fragment antigen binding (Fab) sites, located at the
variable regions of the light and heavy chains. The third fragment of the monomer has no power
to bind antigen and is known as the fragment crystallisable (Fc) site; however, it is capable of
complement activation and immune adherence to neutrophils and macrophages.

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5.2.3 Immunoglobulin gene rearrangements
a. κ and λ light chain segments are found on chromosome 2.
b. Heavy chain gene segments are found on chromosome 14.
c. During B cell maturation rearrangement occurs at the immunoglobulin loci.
d. Transcription is initiacted by the approximation of promoter regions from the V
segment to the immunoglobulin enhancer region.
e. The RNA transcripts containing a VDJ and a C domain are the final mature RNA
encoding for a heavy chain.

The k light chain gene segments are located on chromosome 2 and the k locus consists of 100-
300 V segments, five J segments, and one C segment. The X light chain gene is located on
chromosome 22 and consists of several V segments, six J and six C segments. The heavy chain
locus on chromosome 14 consists of 100 V, 30 D, six J and 11 C segments. In immature 3 cells
these segments are arranged in a linear sequence at the above immunoglobulin loci. During
maturation rearrangement of the segments occurs at these loci as illustrated in Figure 5.8. During
the rearrangement of the V, D and J loci intervening DNA, which separated these segments in
the genomic DNA and contained other D and J segments, is usually looped out and lost. This
rearrangement also leads to the approximation of promoter regions from the V segment and the
immunoglobulin enhancer region (which lies between the J and C segments), so initiating
transcription of the rearranged heavy chain gene. This RNA transcript is not the mature RNA
product, as further splicing is required to remove RNA derived from intervening sequences. The
same process occurs concurrently at one of the light chain loci, so each B cell synthesises only
one type of heavy chain and one type of light chain.

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5.2.4 Antibody diversity is generated by

a. Different V, D and J segment combinations.

b. Random insertion of nucleotides into the DNA at the segment joining points.
c. The ability of any light chain to combine with any heavy chain.
d. Imprecise joining of the same germline VDJ sequences.
e. The ability of antibodies produced by mature B cells to accumulate mutations after
they have encountered antigen.

Generation of antibody diversity is essential if an effective humoral response is to be mounted

against a huge number of different antigens. There are several ways in which this antibody
diversity is achieved:

 Germline encoded diversity, which can occur at two levels. First, there are various
combinations of V, D, and J segments; in heavy chains this accounts for 18 000 (100 x 30
x 6) possible VjDJ sequences. Second, D-J and V-DJ joining does not always occur at the
same place within each segment; this results in D segments of different lengths
 Insertion of nucleotides into the DNA at the segment joining points, by the enzyme
terminal deoxyribonucleotidyl transferase; this multiplies the number of possible VDJ
combinations by a factor of 10, approximately
 Different pairing of light chains and heavy chains ® Somatic mutation: antibodies
produced by mature B cells can accumulate mutations in their V regions after
encountering an antigen- This process generates a pool of antibody with different
affinities for the same antigen.
 5.2.5 Immunoglobulin types
a. IgG accounts for 70-80% of plasma immunoglobulins.
b. IgM crosses the placental barrier easily.
c. IgM is a strong complement activator.
d. IgA is a dimer found in seromucus secretions.
e. IgE binds via its Fab portion to mast cells.
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There are five classes of immunoglobulin: IgA; IgE; IgE; IgG; IgM. IgG counts for 70—80% of
plasma immunoglobulins, is a monomeric structure, and functions as an important opsonin and
complement activator. IgM is the largest immunoglobulin and is a pentameric structure with ten
potential antigen binding sites (however, only five of these are usually involved at any one time).
Because of its size IgM does not cross the placental barrier but its pentameric structure renders it
a strong complement activator. IgA appears selectively in seromucus secretions of the
gastrointestinal and respiratory tracts as well as in tears, sweat, bile, and breast milk. It has a
dimeric structure with linkage being achieved by a J chain. The Fc portion of IgE binds to
receptors on mast cells and cross linkage of Fab portions by antigen will result in mast cell
degranulation. IgD (found on the surface of 50% of B lymphocytes) is the least common
immunoglobulin.

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5.2.6 Function of the immunoglobulins

Immunoglobulins are involved in:

a. Neutralisation of bacterial toxins.
b. Prevention of bacterial and viral cell entry.
c. Opsonisation.
d. Complement activation via the alternative pathway.
e. Stimulation of natural killer cells

Immunoglobulins can function in a number of ways:

* Neutralisation of bacterial toxins. This is important in infections such as tetanus, diphtheria and
cholera e
* Opsonisation. Here the Fab fragment binds to the bacterial cell wall and phagocytosis is
mediated via the Fc receptors on the surface of neutrophils
* Complement activation. Immunoglobulins (especially IgG and IgM.) activate complement by
the classical pathway and so cause cell lysis.
* Antibody dependent cell mediated cytotoxicity—the activation of lymphocytes known as
natural killer cells by immunoglobulins
* Prevention of foreign antigen penetration across mucosal surfaces. IgA molecules bind to
bacteria and viruses, preventing them from adhering to mucosal surfaces of the gastrointestinal
and respiratory tracts and from entering these tissues.

5.2.7 Antibody interaction with antigen

a. Antibodies bind to contact areas on antigens known as paratopes.

b. The attractive forces between antibodies and antigens become larger as the distance
between them decreases.
c. Antigen and antibody interact by covalent bonding.
d. Antigen antibody bonds are readily reversible.
e. An antibody displays absolute specificity for a single antigen.

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The contact area of an antigen is known as an epitope and the corresponding region on an
antibody is the paratope. Epitopes are usually arranged in a discontinuous fashion along the
length of the antigen. Several clusters of dominant epitopes called determinants (which often
differ structurally) are present on the surface of each antigen. Antigens and antibody interact by
spatial complementarity and not by covalent bonding. The forces of interaction include
electrostatic, hydrogen-bonding, hydrophilic and Van der Waals. These forces increase in
strength widi increasing proximity of antigen and antibody, but the bonds are readily reversible.
Antigens can exhibit cross-reactivity; this is possible because a given antibody will display
relative rather than absolute specificity towards an antigen.

5.2.8 The major histocompatibility complex (JSAHC)

a. MGC class I molecules are found in all cells.

b. MHC class II molecules are only found on antigen presenting cells such as
macrophages.
c. MHC class I molecules are encoded for by HLA D gene sequences.
d. The distal MHC class I and II molecules are composed of two α-helices above a
floor consisting of a β-pleated sheet.
e. Genes in the MHC code for tumour necrosis factor α and β

The major histocompatibility complex (A4HC) is a set of genes located on the short arm of
chromosome 6. These genes code for cell surface glycoproteins, which are of great importance in
―self‖ recognition. The A1HC contains three classes of genes that code for molecules that differ
in structure, function and distribution.

Class I molecules are coded for by HLA A, B, and C gent sequences, and are found in almost
all cells except erythrocytes. The molecule consists of a heavy peptide chain noncovalendy
linked to a p2 microglobulin. The heavy chain is organised into three domains, a.x, a2 and ot3.
The a, and oe2 domains, which are distal to the cell membrane, are composed of two extended

220
a-helices above a floor consisting of a P-pleated sheet; the overall ippearance is one of a distinct
groove (Figure 5.9).

Class II molecules, consisting of a and (3 polypeptide chains, re coded for by HLA D sequences.
The ai and pt domains limic the a, and a2 domains of the class I molecules in forming groove.
They are found predominantly on macrophages and ther antigen presenting cells such as
Langerhans‘ cells and sndritic cells. However, class II molecules can be induced on ipillary
endothelial and epithelial cells by interferon-y.
Other genes found in the MHC are grouped under the heading ass III molecules. This
heterogeneous group includes tumour xerosis factor a and p, heat shock proteins and
complement )mponents linked to the production of C3 convertase.

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5.2.9 Introduction between antigen, MHC complexes, and T cell receptors (TCR)

a. Peptides from endogenous antigen combine with newly formed class I MHC heavy
chains in the endoplasmic reticulum.
b. Vesicles carrying class II MHC molecules combine with lysosomes containing
exogenous protein ingested by phagocytosis.
c. Specific anschor positions on the antigen bind to allele-specific sites in the MHC
groove.
d. The class II MHC peptide complex is recognized by cytotoxic T cells.
e. The region of the TCR with greatest variability binds to the α-helices of the MHC
molecule.

The processing of antigen differs considerably for class I and

class II MHC.
 Class I MHC: endogenous andgens such as viral proteins are cleaved by proteosomes
and the peptides transported to die endoplasmic reticulum, where they are combined with
newly synthesised class I MHC heavy chains. These class I peptides lie in the MHC
groove and are fixed at two key, relatively invariant, anchor residues to allele-specific
pockets in the MHC. This stable complex is then transported to the cell surface for
presentadon to cytotoxic T cells.
 Class II MHC: exogenous antigen is ingested by phagocytosis or endocytosis. The
resulting lysosomes or endosomes then combine with vesicles containing class II MHC,
which have passed across the Golgi apparatus. The proteins are degraded to peptides by
cathepsins, which then bind to the MHC at three anchor residues. Finally the class II—
peptide complex is transported to the cell surface for presentation to T helper cells. The
TCR, MHC and peptide form a ternary complex. The first and second hypervariable
regions of the TCR (CDR1 and CDR2) bind with the a-helices of the MHC while the
region with the greatest variability (CDR3) interacts with the antigenic peptide (Figure
5.10).

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5.2.10 Generating the antibody response to thymus-dependent antigen

a. Interleukin 1 produced by antigen presenting cells stimulates clonal expansion of the T

helper cells bound to antigen.
b. B cells specific to an antigen internalize it and re-express it in association with class I
MHC molecules on their surface.
c. T cells bound to antigen secrete interleukin 2, which causes a generalized proliferation
of T helper cells.
d. Binding of activated T cells to B cells stimulates B cell proliferation.
e. Interleukins 4 and 5 promote differentiation of B cells into plasma cells and memory
cells.

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Figure 5.11 illustrates the various stages in generating an antibody response to thymus-dependent
antigen. (1) Antigen presenting cells, such as macrophages, ingest antigen. This is degraded
within lysosomes, and fragments of the antigen are then bound to the groove at the surface of the
MHC protein, which is circulated to the cell surface- (2) X cells recognise the antigen in
association with the class II MHC complex, and bind to this complex; this stimulates the
production of interleukin 1 by the antigen presenting cell, which in turn promotes X cell
proliferation and differentiation. Interleukin 1 also stimulates secretion of interleukin 2 by the
bound T cell; this binds to the T helper cells that are specific for the original antigen, causing
them to proliferate. (3) Antigen is also internalised by B cells, which re-express it in conjunction
with class II MHC proteins on their cell surface. Activated X helper cells bind to this complex,
thus stimulating B cell proliferation. Xhese X helper cells also produce interleukin 4 and 5,
which induce differentiation of B cells into plasma cells and memory cells. (4) Xhe short lived
plasma cells produce large amounts of the specific antibody (IgM initially) directed against the
original antigen. Plasma cell maturation is driven by cytokines, which influence the class of
immunoglobulin produced. Memory cells and long lived. X helper cells are ―antigen primed‖
and are capable of mounting a rapid and intense humoral response on subsequent exposure to
that antigen.

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5.2.11 T cell receptor (TCR) structure and signaling
a. Most peripheral T cells express the γδ T cell receptors (TCR1).
b. The β gene locus of the T cell receptor is analogous to the light chain
immunoglobulins.
c. Individual T cell receptors have a high affinity for their specific MHC antigen peptide
complex.
d. CD3 subunits transducer the T cell receptor signal to the nucleus after antigen binding.
e. Inhibition of protein tyrosine kinase blocks interleukin 2 production by T cells.

225
T cell receptors are transmembrane dimers, each chain consisting of two Ig-like domains (Figure
5.12). Adore than 80% of T cells in the peripheral blood have receptors that consist of an a and a
β chain (TCR2). The β chain locus on chromosome 7 is analogous to the heavy chain locus and
consists of V, D, J and C segments. The α chain locus on chromosome 14 is analagous to the
light chain genes and has V, J, and C segments. Other T cells found predominantiy in epithelia
express a receptor with y and 5 heterodimers (TCR1). Although the α and β or γ and 5 chains are
similar to the Fab fragment of immunoglobulins, individual TCRs have a relatively low affinity
for their specific MHC—antigen complex. Stable binding of TCRs to the M.HC— antigen
complex is dependent on pairs of accessory molecules, such as lymphocyte function associated
molecule-1 and intercellular adhesion molecule-1 (LFA-1/ICAA1-1). The CD3 complex, which
consists of five peptides, is an integral part of the TCR and is involved with transduction of
signals from the TCR to the nucleus. Although TCRs do not have an intrinsic protein tyrosine
kinase (PTK) they are linked with other PTKs, and inhibition of these enzymes has been shown
to block proximal TCR-mediated signalling events such as interleukin 2 production. The
phosphatidyl-inositol pathway also plays a part in TCR signalling.

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5.2.12 Cytokines

a. A cytokine has a specific effect on a single cell type.

b. Tumour necrosis factors are produced by Thi cells and macrophages.
c. γ-interferon activates macrophages and inhibits proliferation of Th2 clones.
d. Interleukin 2 and 12 activate natural killer cells.
e. Granulocyte and macrophage colony stimulating factor (GM-CSF) is produced only
by T cells.

Cytokines are secreted proteins of low molecular weight that act as short range intercellular
messengers, mediating cell growth, inflammation, immunity, differentiation and repair. They are
pleiotropic (that is, they have multiple effects on a variety of cell types) and there is also
considerable overlap in function between different cytokines. Figure 5.13 illustrates which
cytokines take part in, and are produced as a consequence of, T cell activation.

Tumour necrosis factors are produced by macrophages (TNF- α) and T cells (TNF-α and β).
They have multiple effects, including induction of acute phase proteins, activation of polymorphs
and monocytes, and induction of 7-interferon, IL- 1, IL-6 and GjML-CSF. γ-interferon is
produced solely by T cells and participates in macrophage activation and inhibition of Th2 clone
proliferation. It acts synergistically with TNF-p in killing virally infected cells and also has a role
in the expression of MHC class I and II on macrophages and other cells, a-interferon produced
by leukocytes and macrophages activates natural killer cells. GM-CSF is produced by a variety
of cells including T cells, macrophages, fibroblasts, mast cells and endothelium.

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5-2.13 Cytotoxic T cells

a. Cytotoxic T cells recognize antigen in conjunction with class I MHC.

b. Activation of cytotoxic T cells is aided by binding of T helper cells to antigen
presented in conjunction with class II MHC on their surface.
c. IL-2 and IL-6 produced by T helper cells stimulate differentiation and proliferation of
cytotoxic T cells.
d. Following cytotoxc T cell activation perforin, TNF and lytic enzymes are released
directly in the target cell.
e. cytotoxic T cells kill target cells by apoptosis.

228
Most cytotoxic T cells are of the CD8 subset and have receptors that recognise antigen presented
with class I MHC. The activation of cytotoxic T cells precursors is aided by T helper cells (Th1).
This activation is not analagous to the activation of B cells, in that cytotoxic T cells cannot ingest
antigen and represent it in conjunction with MHC. What is thought to happen is that
macrophages present antigen in association with class I and class II MHC, and that this is then
bound by cytotoxic and helper T cells respectively. The Th1 then release interleukin 2 and 6 near
to the cytotoxic T cell precursors, stimulating them to proliferate and differentiate into cytotoxic
T cells. Immediately after activation cytoplasmic granules containing perforin, TNF and serine
protease—termed granzymes—become localised between the nucleus and the target cell. The
contents of these granules are released into the extracellular space between the cytotoxic T cell
and the target cell. Perforin activated by granzymes then inserts itself into the membrane of die
target cell and polymerises to form a membrane pore, through which the cytotoxic agents enter
the cell. The target cell is killed by apoptosis effected by a calcium-dependent endonuclease that
causes rapid nuclear fragmentation.

5.2.14 Immunity to viruses

a. Natural killer cells can recognize and kill virally infected cells before replication
occurs.
b. Cytotoxic T cells are strain and haplotype specific.
c. Interferons cause a reduction in mRNA translation in virally infected and
neighbouring cells.
d. Budding viruses can be destroyed by antibody-dependent cell-mediated cytotoxicity
(ADCC).
e. Antibody and complement neutralize and destroy free virus particles.

Although protection against viral infection is predominantly T cell mediated, other defence
mechanisms are also important. Activation of T cells will result in the activation of the following
defence mechanisms (Figure 5.14):

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 Cytotoxic X cell mediated killing: differentiation and proliferation of cytotoxic T cells by
interleukins 2 and 6 renders them direcdy cytotoxic to cells infected with virus. Cytotoxic
T cells are not strain specific, that is* they will cross react with a broad range of viral
antigen. However, they are haplotype specific, that is, they will not attack virally infected
cells unless those cells express the same class I MHC antigens
 Natural killer cells: these innate cells can recognise and kill virally infected cells before
replication occurs. They can do this because of their ability to recognise structures on
high molecular weight glycoproteins that appear only on the surface of virally infected
cells. The natural killer cells have no receptors for viral antigen; however, they recognise
the Fc fragments of antibody coating budding viruses and destroy them by antibody-
dependent cell-mediated cytotoxicity (ADCC)
 Antibody and complement: antibody and complement neutralise and destroy free virus
particles, so blocking the spread of virus released when infected cells are lysed
 Interferon production: cells infected by a virus secrete interferon, which binds to
receptors on neighbouring cells. This leads to a series of enzyme dependent reactions that
result in reduced mRNA translation and degradation of both

230
viral and host mRNA, which renders the contiguous cells nonpermissive for viral replication.
Interferons also activate natuxai kilter cells.

5.2.15 Important factors in immunity to helminths

a. Killing of helminthes by cytotoxic T cells.
b. Stimulation of eosinophils by T cells.
c. Eosinophil mediated anti-body-dependent cell-mediated cytotoxicity.
d. Production of histaminases by eosinophils.
e. T cell mediated increase in gastrointestinal mucus secretions.

Cytotoxic T cells play a relatively small part in immunity against helminth infection—
eosinophils are especially prominent in the immune response against worms. Worm antigen will
stimulate T cells to produce eosinophil stimulation promoter and this, along with eosinophil
chemotactic factors produced by the worms (and by degranulating mast cells), draws activated
eosinophils to the site of infection. There the eosinophils have a twofold effect, which includes
antibody-dependent cell- mediated cytotoxicity and control of the inflammatory process by
production of histaminase. Expulsion of nematodes from the gut is accomplished by an increase
in mucus gastrointestinal secretions (caused by non-specific T cell factors) that stick to and
debilitate the worms, which are then expelled.

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5.3: Ocular immunology
5.3.1 Aiucosa associated lymphoid tissues (JVLAL.T)

a. The conjunctiva and lacrimal glands are MALT.

b. The predominant immunoglobulin associated with MALT is IgG.
c. Exposure to an antigen via the oral route will lead to secretion of antigen-specific
antibodies in the tear film.
d. High titres of antigen-specific IgG are found in the blood after exposure of a mucosal
surface to antigen.
e. T cells mediating antigen-specific delayed hypersensitivity are found in the spleen
after mucosal contact with the antigen.

MALT include the linings of the gastrointestinal, respiratory and urethrogenital tracts, and the
conjunctiva and glands of the ocular adenexa. IgA is the predominant immunoglobulin in
MALT. Exposure to an antigen at one mucosal site leads to the production of antigen-specific
IgA not only at that site but also in the external secretions of other unrelated mucosal surfaces.
This effect is achieved by unique populations of recirculating

232
IgA-producing B and X cells that express homing receptors for addressins displayed on the
endothelial cells of the microvasculature serving mucosal surfaces. The opposite effect is true for
systemic immunity after exposure of mucosal surfaces to antigen; in Jvat there are low IgG titres
to the antigen in the blood (although IgA titres may be elevated) and T cells mediating antigen-
specific delayed hypersensitivity are not found in the spleen and other lymphoid organs.

5.3.2 Antigen-presenting cells and the eye

a. Dendritic cells are commonly found in the central cornea.
b. Dendritic cells are present between the layers of the ciliary epithelium.
c. Dendritic cells are present in the neural retina.
d. Macrophages and dendritic cells are not found choroid.
e. Ocular antigen presenting cells are potent activators of T helper cells.

Antigen presenting cells (APC) in the ocular tissues are broadly speaking of two types: bone
marrow-derived dendritic cells expressing MHC class II molecules, and tissue macrophages. The
central cornea is virtually devoid of APCs, although dendritic cells and macrophages are found at
the Iimbus. APCs have been found between the epithelial layers of the ciliary epithelium and
under the single layer of iris epithelium. They are also present in the ciliary muscle, ciliary
processes and trabecular meshwork.
In the posterior segment typical dendritic cells have been found in the neural retina near the ora
serrata and in connective tissue surrounding the choriocapiliaris. These ocular APCs differ
functionally from those found in other tissues in that they are unable to activate T cells and
therefore do not function as conventional APCs. The antigen-bearing APCs are therefore unable
to activate delayed hypersensitivity T cells or alloreactive T cells.

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5.3.3 Immunosuppressive role of aqueous humour
a. Normal aqueous inhibits T cell proliferation.
b. Aqueous inhibits the ability of cytotoxic T cells to lyse target cells.
c. Any antigen presenting cell exposed to aqueous in unable to activeate a delayed
hypersensitivity response.
d. Aqueous acts directly on macrophages to suppress nitric oxide production.
e. Transforming growth factor beta (TGF-β) is an immunosuppressive cytokine found in
aqueous.

Aqueous humour has profound immunosuppressive properties affecting several aspects of the
immune system. Normal aqueous inhibits T cell proliferation and lymphokine production,
although it does not inhibit the ability of cytotoxic T cells to lyse target cells. If activated T
helper cells are mixed in aqueous and then injected subcutaneously they do not produce the
expected inflammatory response. Exposure of APCs (from any tissue) to aqueous prevents these
cells from stimulating a delayed hypersensitivity response. Aqueous also acts directly on
macrophages by suppressing their ability to produce nitric oxide. Transforming growth factor
beta (TGF-(3) is an immunosuppressive cytokine found in the aqueous; it is a profound
suppressor of X cell proliferation and of y-interferon production. Many of the inhibitory effects
of aqueous described above have been ascribed to TGF-P, although other neuropeptides and
cytokines such as vasoactive intestinal peptide and alpha-melanocyte stimulating hormone may
also be contributing factors.

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5.3.4 Introduction of antigen into the anterior chamber results in which of the
following?

a. Antigen presenting cells process the antigen and preferentially direct antigen-specific
responses to a suppressed state.
b. T cells involved with antigen-specific delayed hyper-sensitivity are downregulated.
c. Serum antibody response to the antigen is suppressed.
d. Activation of suppressor T cells in the spleen.
e. Activation of systemic cytotoxic T cells.

Introduction of antigen into the anterior chamber results in an immunological response known as
anterior chamber associated immune deviation (ACAID). Some of the features of ocular APCs
and of aqueous humour mentioned above are fundamental to the concept of ACAID. A
simplified version of the series of events leading to ACAID is illustrated in Figure 5.16.

The characteristic features of ACAID are as follows. (1) Processing of antigen by APCs,
which preferentially direct antigen-specific responses to a suppressed state. (2) Development of
suppressor T cells that inhibit the induction and expression of Thi cells taking part in delayed
hypersensitivity responses. This is thought to occur by preferential activation of Th2 cells over
Hrhj cells. In the case of soluble antigen, APCs are thought to migrate to the spleen, where they
stimulate production of X suppressor cells. Particulate antigens elicit a T cell reaction in the
anterior chamber that produces a soluble, serum-borne molecule, which induces T suppressor
cells in the spleen. The subtypes of these CD4 and CD8 T suppressor effector cells differ for the
two ACAID pathways (this is not illustrated in Figure 5.16). (3) Normal cytotoxic T cell
responses to the antigen. (4) Normal systemic antibody production to the antigen.

Removal of the spleen before or within 5—7 days of anterior chamber priming will prevent
ACAID and leads to normal delayed hypersensitivity responses to intraocular antigens.
Likewise, removal of die eye shortly after the introduction of antigen aborts ACAID, suggesting
that the antigen must persist

235
in the eye for a finite period if signalling is to reach the spleen.
ACAID can be induced by numerous antigens including herpes simplex virus, melanoma
associated antigens and retinal S antigen. However, many antigens will not induce ACAID and
result in a strong delayed hypersensitivity response, for example purified protein derivative of
Mycobacterium tuberculosis antigens. It is not yet clear why certain antigens induce ACAID and
others do not.

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5.4: Hypersensitivity reactions
5.4.1 Type I hypersensitivity

a. This follows contact with an allergen.

b. Cross linkage of IgE Fab fragments causes mast cell degranulation.
c. C3a and C5a cause degranulation.
d. Mast cells contain histamine, 5 HT and heparin.
e. Histamine stimulates mast cell degranulation.

A hypersensitivity reaction may be defined as an adaptive immune response that has occurred in
an exaggerated or inappropriate form. Type I hypersensitivity is an ―allergic‖ reaction that
immediately follows contact with an antigen which would normally not cause a marked immune
response (an allergen). The basic mechanism of type I hypersensitivity is mast cell
degranulation, caused by cross linkage of IgE molecules on mast cell surfaces via dieir Fab
fragments, by C3a and C5a complement fragments, or by certain drugs such as codeine and
morphine. Mast cell degranulation results in release of histamine, 5 HT, heparin, eosinophil
chemotactic factors, and platelet activating factors. Histamine exerts negative feedback on this
reaction to inhibit mast cell degranulation.

5.4.2 Type II hypersensitivity

a. This is caused by circulating immune complexes.

b. Tissue damage is induced by pbagocytes.
c. It is characterized by the Arthus reaction.
d. Rhesus incompatibility is an example of type II hypersensitivity.
e. Hypeacute graft rejection is an example of type II hypersensitivity.

Type II hypersensitivity is caused by antibody directed against cell surface or tissue antigens
which interact with complement and other inflammatory systems. Tissue damage is caused by

237
―frustrated‖ phagocytes, which are unable to ingest the whole tissue and so release their
lysosomal contents. Rxamples of type II hypersensitivity include rhesus incompatibility of the
newborn, in which IgO against rhesus D antigen is produced by rhesus negative mothers and
crosses the placenta to attack the red cells of the rhesus positive fetus. ABO incompatibility
(mismatched transfusion) is also an example, as is ―hyperacute‖ graft rejection. The Arthus
reaction is characteristic of type III hypersensitivity reactions.

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5.4.3 Type III hypersensitivity

a. This is caused by antibody directed against cell surface antigens.

b. It stimulates an acute inflammatory reaction in the tissues.
c. Turbulence of blood flow may determine site of disease.
d. Type III hypersensitivity is uncommon in autoimmune disease.
e. It may be caused by chronic infection.

Type III hypersensitivity reactions are caused by the deposition of immune complexes in tissues
which then stimulate complement activation, so producing an acute inflammatory reaction.
Common causes of type HI hypersensitivity reactions include persistent infections (e.g. viral
hepatitis), and autoimmune disease (e.g. rheumatoid arthritis). Type III hypersensitivity is
dependent on the persistence of these immune complexes^ but' the more important factor is their
deposition which is governed by:

 haemodynamics—increased turbulence of blood flow (as seen in the glomerulus, choroid

plexus and ciliary body) stimulates deposition;
 increased vascular permeability secondary to histamine;

239
  specific antigen tissue binding, where the antigen-antibody complex is specific to a single
organ.

The Arthus reaction is seen after antigen is intradermally injected into individuals whose
circulating antibody levels are high because of previous immunisation- The antigen-antibody
complex is then deposited, resulting in an acute inflammatory reaction that peaks at 4—10 hours.

5.4.4 Type IV hypersensitivity

a. This may develop within 12 hours of exposure to allergen.
b. It is transferable in serum.
c. It includes contact dermatitis.
d. Type IV hypersensitivity may be produced by subdermal injection of tuberculin.
e. The granulmoatous type peaks at 48 hours.

Type IV hypersensitivity (also known as cell mediated hypersensitivity) is of four types, all
involving T cells and

240
therefore not transferable in serum. They include all those hypersensitivity reactions that take
more than 12 hours to develop.

 The Jones-Mote type is produced by stimulation of basophils and peaks at 24 hours.

 Contact dermatitis is characterised by an epidermal reaction consisting of mononuclear
cells (but no polymorphs) and peaks at 48 hours.
 Tuberculin type hypersensitivity is caused by subdermal injection of tuberculin producing
a reaction in the dermis that peaks at 48—72 hours (the Heaf test)
 Cell mediated hypersensitivity results in a granulomatous reaction, and is usually caused
by persistent antigen in macrophages (e.g. tuberculosis). Tliis reaction peaks at
approximately 4 weeks.

5.5: Transplantation immunology

5.5.1 Tolerance

a. Clonal ―abortion‖ of B cells causes tolerance.

b. B cell ―exhaustion‖ produced by persistent antigenic stimulation is a cause of
tolerance.
c. Fuctional deletion of T helper cells causes tolerance.
d. Development of T cell tolerance is less rapid than B cell tolerance.
e. T cell tolerance is more persistent than B cell tolerance.

Medewar‘s experiments on mice were instrumental in defining the concept of tolerance, which
may be defined as the development of non-reactivity towards a particular antigen. There is now
thought to be a spectrum of tolerance, ranging from antigen induced responsiveness (partial or
low zone tolerance) to antigen induced unresponsiveness (complete or high zone tolerance).
Experimental studies have shown that T cell tolerance is induced more rapidly than B cell
tolerance (1 day versus 7 days) and by lower antigen concentration. T cell tolerance persists for
up to 6 months, whereas B cell tolerance lasts less

241
than 2 months. Exposure of immature B cells to monomeric antigen inhibits the development of
cells with that antigenic specificity—this is known as clonal ―abortion‖. A similar mechanism is
thought to occur with immature T cells, and both result in high zone tolerance. Low zone
tolerance (involving the deletion of only some aspects of the immune system) may be achieved
by a number of means: high concentrations of antigen may reduce the responsiveness of T and B
cells (clonal ―anergy‖); T cells may undergo functional deletion or be suppressed by T
suppressor cells; T helper cell deletion/ suppression may produce a degree of B cell tolerance by
disrupting the production of T cell dependent antibodies.

5.5.2 Types of transplantation

a. Autografts are taken from the patient.

b. Grafts between all twins are isografts.
c. Allografts are not genetically identical.
d. The species of donor and recipient differ in xenografts.
e. The most common allografts are kidneys.

Transplantation may be defined simply as the transfer of a graft from a donor to a recipient.
There are several types of transplantation, including autografts (which are taken from the patient
him- or herself), isografts (which occur between identical twins), allografts (the donor and
recipient are of the same species but are not genetically identical), and xenografts (where the
donor and recipient are not of the same species). The most common allografts are blood
transfusions.

5.5.3 Tissue typing in organ transplantation

a. Typing is carried out for all HLA subtypes.

b. Matching for MHC calls II antigen is more important than for MHC type I antigen.
c. ―Sensitivity‖ is greater in women than in men.
d. ―Sensitivity‖ is decreased by recurrent blood transfusions.
e. HLA mismatch accounts for late onset rejection.

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The major histocompatibility complex antigens HLA class I (A, B and C) and class II (D
subtypes) are those recognised by the body‘s immune surveillance system and are therefore
important *n transplant rejection- Tissue typing is carried out only for HLA subtypes A, B, and
DR loci- It is of primary importance to accurately match the DR locus, as even a single mismatch
significantly increases the incidence of graft rejection. Well matched transplants have a 15%
greater survival at 1 year than transplants that are not well matched. However, after this initial
phase transplants are lost from both groups at the same rate and so HLA mismatching may not
account for late onset rejection. The phenomenon of ―sensitivity‖ is seen more commonly in
women than men (because of pregnancy) and in those who have received multiple blood
transfusions or previous transplants. Highly sensitised patients will benefit from meticulous HLA
matching.

5.5.4 Types of rejection

a. Hyperacute rejection occurs in minutes.

b. Accelerated rejection is predominantly cell mediated.
c. Acute rejection occurs within 7 days.
d. Acute rejection is antibody mediated.
e. Acute on chronic rejection is found only in immunosuppressed patients.

Rejection may be defined as a series of changes that result in the destruction of the graft as a
functioning entity. The terminology used to describe types of graft rejection is often confusing,
but a simple knowledge of the body‘s response to foreign antigens will clarify matters. If
circulating antibodies are present to antigens found on the graft hyperacute rejection
(characterised by complement activation, polymorph infiltration, and thrombus formation) will
occur within minutes. If the recipient has been sensitised to donor antigen memory cells will be
stimulated (T and B cells), which leads to graft destruction (predominantly by cell mediated
mechanisms). This accelerated rejection occurs within 2—5 days. Acute graft rejection is
predominantly cell mediated and occurs at 7—21 days—it is an

243
allogenic reaction to donor antigen. Rejection occurring after 3 months is termed as chronic and
occurs as a result of disturbing post graft tolerance. Antibodies and complement are the main
mediators in pure chronic rejection: X cells are the main instigators of acute on chronic rejection
(which is found only if the recipient‘s immune system has been altered—in
immunosuppression).

5.6: Thrombosis and atherosclerosis

5.6.1 Platelet structure

a. The peripheral zone is rich in glycoproteins.

b. The sol-gel zone contains platelet factor 3.
c. α granules contain factor VIII related antigen.
d. α granules contain ADP.
e. The dense tubular system is found in the membrane zone.

Platelets may be divided into four zones: peripheral, sol-gel, organelle, and membrane zones.
The peripheral zone is rich in glycoproteins essential for the platelet adhesion and aggregation
reactions. This layer also contains platelet factor 3, which 238

244
accelerates the clotting process during platelet aggregation. The sol-gel zone contains
microtubules and microfilaments, which help maintain the discoid shape of the platelet. The
organelle zone contains a granules (whose constituents include factor VIII related antigen, factor
V, fibrinogen, fibronectin, platelet-derived growth factor, and chemotactic factors), and other
granules known as dense bodies (containing ADP, calcium and 5HT). The inner, membrane,
zone is connected to the surface by an open canalicular system and contains the dense tubular
system responsible for platelet contractile functions and prostaglandin synthesis.

5.6.2 Thrombus formation

a. Platelet adhesion is stimulated by exposure to basement membrane collagen.
b. Calcium released from dense tubules stimulates granule release.
c. The granule release reaction is stimulated by prostaglandins E, and I2.
d. Platelet aggregation is stimulated by ADP and thrombin.
e. Platelet aggregation is stimulated by prostaglandin I2.

The initial stage of thrombus formation, stimulated by exposure to endothelial collagen and to
fibrin, is adhesion of platelets to vessel endothelium. Adhesion causes calcium release from the
dense tubular system, which in turn leads to a change in the shape of the platelets and the release
of granules. When the platelets are quiescent calcium is maintained at low levels by the operation
of a cyclic AMP calcium pump. Antiaggregatory prostaglandins E1, D2, and I2 act by stimulating
adenylate cyclase (so increasing cyclic AMP). Aggregation follows platelet adhesion and is
stimulated by ADP and thrombin. During aggregation platelets stick to one another to form a
clump. Aggregation is stimulated by the vasoconstrictive agent thromboxane A2 and is inhibited
by prostaglandin I2.

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5.6.3 Rishfactorsforthrombosis

These include:
a. Venous stasis.
b. Arrhythmias.
c. Atheroscleosis.
d. Type II hyperlipidaemia.
e. Thrombocytopenia.

Virchow described a triad of conditions that predispose to thrombus formation: (1) a change in
the nature of blood flow, such as venous stasis, cardiac arrhythmias, or valve disease; (2) a
change in the vessel wall caused by atherosclerosis, trauma, inflammation, or neoplastic change;
(3) a change in the

246
constituents of the blood—an increase in the number of platelets or altered platelet function such
as that seen in type II hyperlipidaemia (platelets are more sensitive to ADP and thrombin in this
condition).

5.6.4 Factors that inhibit thrombosis

a. Protein C is a vitamin K dependent serine protease.
b. Protein C inhibits factors Va and VIIa.
c. The factor V Leiden mutation leads to activated protein C resistance.
d. Protein S is a cofactor for antithrombin III.
e. Antithrombin III inhibits thrombin, factor IXa and Xa.

Inhibitory factors act at several points in the coagulation pathway to regulate thrombus
formation, and deficiencies of these factors will lead to a thrombophilic state. Protein C is a
vitamin Independent serine protease that is a potent inhibitor of coagulation factors Va and Villa.
Protein C deficiency is inherited as an autosomal dominant trait and clinically affected
individuals are heterozygous with a protein C concentration of about 50% normal. The
prevalence of protein C deficiency in young patients with venous thrombosis is reported as 6—
8%. The factor V Leiden mutation leads to a relative resistance of coagulation factor V to
breakdown by activated protein C. Estimates of the prevalence of this mutation vary, but
approximately 5% of the white population are thought to be carriers. Activated protein G
resistance has been found in 12% of patients with central retinal vein occlusions. Protein S and
phospholipid are cofactors in the inactivation of factors Va and Villa by activated protein C.
Protein S is active only in its free form (40%); the remainder is bound to C4b-binding protein. As
in protein C deficiency inheritance is autosomal dominant, and the prevalence in young patients
with thrombotic episodes is 5-8%. Antithrombin III is die major inhibitor of activated
coagulation factors including thrombin, factor IXa and X.a. Glycosaminoglycans produced by
endothelial cells act as high affinity binding sites for antithrombin III and deficiencies in either
of these can induce a thrombotic state. The prevalence

247
of antithrombin III deficiency in young patients with venous thrombosis is 2—5%.

5.6.5 Natural history of thrombi

a. Thrombi may become deteached from the vessel wall.

b. They may be lysed by plasmin.
c. Recanalisation occurs in mural thrombi.
d. Thrombi may become covered with smooth muscle cells.
e. Mural thrombi are infiltrated by blood vessels from the vasa vasorum.

Thrombi have a varied natural history. They may become detached from the vessel wall, forming
an embolus, or may be lysed by plasmin. If a thrombus persists it will become organised—this
process will vary according to the site of thrombus formation. Occlusive thrombi in vessels may
be replaced by a solid plug of collagenous tissue, or flow may be re-established by
recanalisation. Alural thrombi are eventually covered by a proliferative layer of smooth muscle
cells (which has been stimulated by the release of platelet derived growth factor) and this mass
becomes vascularised by blood vessels derived from the main lumen of the vessel (not from the
vasa vasorum).

5.6.6 Forms of emboli

Emboli come in several forms:
a. Thrombotic.
b. Fluid.
c. Nitrogen.
d. Atherosclerotic.
e. Fat.

An embolus may be defined as an abnormal mass of material, transported in the bloodstream

from one part of the circulation to another, which finally impacts in the lumen of a vessel
through which it cannot pass. Emboli may be solid, fluid, and gaseous.

248
The most common emboli are solid (for example, those caused by dislodged thrombus,
atherosclerotic, tumour, and fat emboli). Amniotic fluid embolus is a rare" obstetric
complication. Gaseous emboli occur when air is introduced into the systemic circulation (such as
by inadvertent opening of a large vein in head and neck surgery). Nitrogen emboli occur in
decompression sickness (the ―bends‖).

5 6.7 Formation of atherosclerotic plaque

a. Endothelial cell trauma is a primary step in formation of plaque.
b. Accumulation of intracellular lipid increases.
c. Accumulation of extracellular lipid is increased.
d. Platelets inhibit intimal proliferation.
e. Plaques have the same topographical distribution as fatty streaks

The initial protagonists in the debate over the aetiology of atherosclerotic plaques were Virchow
and Rokitanslcy, who proposed the ―infiltrative‖ and ―thrombotic‖ theories respectively.
Endothelial damage is now believed to be the primary step in plaque formation. Platelets adhere
to the injured endothelium and stimulate intimal smooth muscle proliferation by releasing
platelet derived growth factor. Endothelial cell barrier function is now lost and accumulation of
intracellular and extracellular lipid increases. Whether fibrolipid plaques are derived from fatty
streaks (which may be seen from the age of 10—11 months) is uncertain—evidence against this
association includes their different topographical distributions, and the triglycerideicholesterol
ratios of these two lesions.

249
5.5.8 Characteristics of fibrolipid plaques
a. Thickening of the intima.
b. Lipid laden macrophages.
c. A smooth muscle layer underlying the lipid pool.
d. Thickening of the adventitia media.
e. Basal necrosis.

The fibrolipid plaque is an elevated lesion that exhibits intimai thickening caused by
proliferation of smooth muscle cells. This smooth muscle layer underlies a pool of lipid rich
tissue debris (atheroma), which contains many lipid laden macrophages. Necrosis and softening
at the plaque base is a common sequela, as is aneurysm formation caused by thinning of the
adventitia media.

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5.6.9 Natural history and complications of atherosclerosis

Sequelae of atherosclerotic plaques include:

a. Platelet microthrombi.
b. Plaque fissures.
c. Intraplauqe haemorrhage.
d. naeurysm.
e. Regression.

The sequelae of atherosclerotic plaques may be uncomplicated or complicated. Included in the

first group are simple plaque growth leading to a decrease in lumen size, and aneurysm
formation caused by media thinning. Complicated plaques may arise by formation of plaque
fissures caused by softening of the plaque base, or by intraplaque haemorrhage. In the first case
small fissures will result in platelet microthrombi, and larger fissures in ―dumb-bell‖ thrombi
which may be occlusive or embolise. Atherosclerotic plaques are not thought to regress, but
some studies have reported that vigorous dietary control has improved the angiographic pictures
of peripheral vascular disease.

251
5.6.10 Risk factors for atherosclerosis

These include:
a. Smoking.
b. Age.
c. Diabetes.
d. Hypertension.
e. Raised levels of high density lipoprotein.

Risk factors for atherosclerosis may be divided into two groups: reversible and non-reversible.
Irreversible factors include age, male sex (but the increased incidence in men diminishes with
age), and race. The most important reversible risk factors are cigarette smoking (risk of dying
from a myocardial infarction is trebled if 15 cigarettes are smoked per day; this decreases in
those who give up smoking), hypertension, diabetes mellitus, and hyperlipidaemia. Levels of
high density lipoprotein are inversely related to the risk of coronary heart disease because it takes
up free cholesterol from extrahepatic tissues.

5.7: Cell growth, cellular interaction, and cell death

5.7.1 Stem cells

a. A finite number of stem cells Is laid down during embryogenesis and this population
decreases slowly with age.
b. All stem cells are multipotent.
c. Stem cells are restricted to specific sites in a tissue.
d. Both cells produced by stem cell division may retain the ability to self renew.
e. The corneal epithelium is derived form limbal stem cells.

Numbers of mature cells are maintained by the proliferation and development of more primitive
cells known as stem cells. It was originally thought that a finite number of stem cells was laid
down during embryogenesis, and that this population

252
decreased slowly with age as the stem cells progressively lost their ability to produce more stem
cells. This is not the case; although a finite number of stem cells arise during embryonic
development, these cells are able to undergo self renewal to produce daughter cells that retain the
same proliferative and developmental capabilities as the parent cells. Some stem cells, such as
marrow stem cells, are multipotent and may give rise to many different cell types, whereas
others, such as limbal stem cells, give rise solely to one cell type, for example comeal epithelial
cells. Stem cells are found in specific sites within a tissue, for example intestinal stem cells,
which are found in the crypts of Lieberkuhn at the base of intestinal villi. These ―niches‖ act to
limit the size of the stem cell pool; after cell division, only one daughter cell can remain in this
niche, where it retains ability to survive and self renew. The other daughter cell will differentiate
or undergo apoptosis. As the daughter cell becomes progressively more differentiated and mature
it loses the ability to self renew (see Figure 5.24). The activity of each stem cell population may
be influenced by a multitude of both systemic or local factors which act by a series of feedback
mechanisms.

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5.7.2 Growth factors and corneal epithelial and stromal interactions

a. Epidermal growth factor (EGF) stimulates corneal epithelial migration and proliferation.
b. Epidermal growth factor (EGF) increases fibronectin synthesis and fibronectine receptor
activity.
c. Transforming growth factor β (TGF-β) stimulates proliferation and motility of stromal
fibroblasts.
d. Transforming growth factor β (TGF-β) stimulates matrix degradation by collagenases.
e. Platelet-derived growth factor (PDGF) stimulates both limbal and corneal epithelial
proliferation.

Growth factors are potent peptide regulators that coordinate cellular migration, proliferation and
differentiation, and control the synthesis and remodelling of extracellular matrix by a variety of
autocrine and paracrine mechanisms. The following growth factors are intimately involved in
controlling short term epithelial and stromal wound healing and long term remodelling (Figure
5.25).

 Epidermal growth factor (EGF): is one of the growth factors active in the autocrine
control of corneal epithelial turnover; it is also produced by stomal fibroblasts. It is a
potent stimulator of corneal epithelial migration and of epithelial and fibroblast
proliferation. It achieves its effects on migration by increasing fibronectin production and
by increasing fibronectin receptor activity. Autocrine production of transforming growth
factor-a (a member of the EGF family) is thought to control normal corneal epithelial
turnover.
 Transforming growth factor β (TGF-p) exists in three isoforms that have overlapping
biological functions. TGF-β causes a dose-related inhibition of epithelial cell
proliferation and inhibits the stimulatory effects of EGF. TGF-β2 has been localised to
the superficial limbal epithelial cells, where it is thought to influence the
transdifferentiation of conjunctival to corneal epithelium. TGF-β stimulates proliferation
and

254
motility of stromal fibroblasts and increases collagen and fibronectin synthesis; it also inhibits
the breakdown of matrix by collagenases.
 Platelet-derived growth factor (PDGF) stimulates limbal stem cell proliferation.
 Fibroblast growth factor (FGF) stimulates epithelial cell and fibroblast proliferation, and
the production of extracellular matrix by fibroblasts.

255
5.7.3 Fibronectin and laminin

a. Fibronectin consists of three polypeptide chains linked by disulphide bonds.

b. Fibronectin stimulates cell proliferation.
c. Fibronectin mediates cell adhesion via interaction with integrins.
d. Laminins promote cell adhesion, growth, migration and differentiation.
e. Laminins are found in the lamina lucida of the basal lamina.

The extracellular matrix consists of fibrous proteins (collagen, laminin and fibronectin) and
polysaccharide glycosamino- glycans. Fibronectin consists of two polypeptide chains linked by
disulphide bonds. Each of the polypeptide chains has six domains with specific binding sites for
integrins, proteoglycans and collagen. In the intact cornea it is found at the level of the stromal
side of Descemet‘s memb-ane, although it may also be present in the subepithelial basement
membrane. The primary role of fibronectin is to promote adhesion between cells and the
extracellular matrix via the integrin a5pl, which is expressed in the wounded cornea and in
cultured fibroblasts. EGF and TGF- P stimulate fibronectin production. Within moments of
epithelial injury fibronectin is deposited over the bare stromal surface, where it provides a
temporary scaffold for epithelial migration and adhesion. Fibronectin does not influence cellular
proliferation. Laminins are large multidomain glycoproteins composed of three polypeptide
chains located in the lamina lucida of the basal lamina. As well as being essential structural
components of basement membranes, laminins are intimately involved in cell growth, migration,
differentiation and proliferation. Laminin-5 is important in comeal wound healing. It is
resynthesised under the migrating cells within 48 hours of corneal trauma, and becomes
continuous after wound closure.

256
5.7.4 Integrins

a. Intergrins are cell surface gylcoproteins.

b. Integrins can transducer signals from the extracellular matrix to the cell interior.
c. Integrins bind to collagen and fibronectin.
d. hemidesmosomes between epithelial cells and the basal lamina contain an integrin.
e. Integrin extracellular matrix interactions are important in early morphogenesis of the
eye.

Integrins are transmembrane glycoproteins consisting of α and β subunits, which are present on
almost all cells. They mediate e attachment of cells to the extracellular matrix and cell—cell
adhesion events; they are also able to transduce biochemical signals from the extracellular matrix
to the interior of the cell via phosphorylation cascades. Integrins serve as receptors for laminin,
collagen, fibronectin, vitronectin, ICAM1 and ICAA42. The corneal epithelium has various
distinct integrin subunits at sites of cell—cell and cell—substrate contact, and the α6β4 integrin
an integral part of hemidesmosomes. Integrin—extracellular matrix interactions are important in
early morphogenesis of the eye and disruption of these interactions prevents normal eye
development.

257
5.7.5 Transmembrane signalling and cell surface receptors

a. The ratio of transmembrane receptors to intracellular signaling mechanisms is

approximately 10:1.
b. β1 and β2 receptors activate adenyl cyclase via a G protein.
c. Muscarinic acetylcholine receptors are ion channel receptors than spn the cell
membrane.
d. Platelet derived growth factor and epidermal growth factor receptors have intrinsic
tyrosin kinase activity.
e. Phosphatidylinositol 4,5-biphosphonate is an important secondary messenger

Cells respond to many different extracellular signals; signals may be from remote organs (e.g.
hormones) or neighbouring cells (e.g. acetylcholine at the neuromus junction). Figure 5.26
illustrates how these extracellular stimuli ultimately influence cell function; note that, although
there be thousands of cell membrane receptors, these transmit sig to 10—20 signalling
mechanisms. H he following are example the most common cell membrane receptors.

 G protein coupled receptors are systems that consist of a receptor, a coupling protein that
depends on guanine nucleotide (G protein), and an effector protein. The effector

258
protein may be an enzyme or an ion channel. There are G protein coupled receptors that
(1) activate adenylate cyclase:
- adrenergic (β1, and β2 receptors);
- TSH, ACTH, glucagon;
- histamine H2 receptor
(2) inhibit adenylate cyclase:
- adrenergic (α2 receptors);
- acetylcholine (muscarinic)
(3) activate phosphoinositidase C (PIC), which then hydrolyses phosphatidylinositol 4,5-
biphosphonate (Ptdlns (4,5) P2) leading to intracellular accumulation of 1,2-
diacylglycerol (1,2-DAG), inositol 1,4,5-triphosphonate and calcium:
- adrenergic (α1 receptor)
- histamine (H1 receptor)
- endothelins
- platelet activating factor
(4) activate a cyclic nucleotide phosphodiesterase:
- rhodopsin
(5) open a hyperpolarising K+ channel.

 Ligand-gated ion channels are multisubunit proteins incorporating transmembrane ion

channels that open transiently when the receptors bind an agonist. They are dependent on
the ionic gradient that exists across cell membranes and is maintained by ATP driven
membrane pumps. The nicotinic acetylcholine receptor is an example of such a receptor.
 Receptors with intrinsic protein kinase activity include PDGF and EGF receptors, the
first known members of this family. These receptors incorporate an extracellular ligand
binding site and a kinase domain on the cytoplasmic surface of the plasma membrane.
Stimulation of the receptor leads to a chain of phosphorylation reactions but it is not yet
clear exactly how expression of tyrosine kinase activity controls cellular functions such
as nuclear gene expression. Receptor

259
tyrosine kinases, such as those for stem cell factor and macrophage colony stimulating factor, are
coded for by protooncogenes; others, which are stimulated by growth factors, are known to
interact with a series of key proteins implicated in growth control.

5.7.6 Cell to cell, and cell to matrix adhesion

a. Cadherins are calcium-dependent cell adhesion molecules involved in the zonula

adherens and desmosome connections between epithelial cells.
b. Members of the immunoglobulin family of cell adhesion molecules are involved with T
cell antigen recognition.
c. Intercellular adhesion molecules ICAM-1 and ICAM-2 are expressed on epithelial but
not endothelial cells.
d. Intergrins are involved with cell to cell, and cell to matrix adhesion.
e. Selectins induce cell to cell adhesion via heterophilic protein to protein binding.

The structure and organisation of tissues depend on contact being maintained between adjacent
cells, and between cells and the extracellular matrix. Most cell adhesion molecules belong to one
of four families: cadherins, the immunoglobulin family, integrins or selectins.

Cadherins, simple transmembrane glycoproteins, are calcium- dependent cell adhesion

molecules. Epithelial cadherins have a role in the zonula adherens and desmosome connections
between epithelial cells; binding is homophilic, with a cadherin molecule on one cell binding to a
cadherin molecule of the same type on an adjacent cell. Not all cadherins are epithelial; neural
cadherin facilitates neuronal migration during development. Among cell adhesion molecules of
the immunoglobulin family, the extracellular component is characterised by the presence of at
least one immunoglobulin-like domain. Examples of such adhesion molecules include:

 CD3, CD4 and CD8 receptors, all of which play a part in the recognition of antigen in
conjunction with the major histocompatibility complex on other cells;

260
  intercellular adhesion molecules ICAM-1 and ICAM-2, which participate in the
inflammatory response and are widely expressed on epithelial and endothelial cells.

integrins are a diverse family of cell adhesion molecules that contribute to both cell to cell, and
cell to matrix adhesion. Each integrin is a heterodimer consisting of an α chain and a β chain; 14
α chains and 8 β chains have been identified. These first three types of adhesion molecule are
characterised by homophilic or heterophilic protein to protein binding; selectins, however, bind
to carbohydrate. Many selectins have a role in the inflammatory response.

5.7.7 Apoptotic cell death

a. The first phase involves induction of a gene within the cell that is responsible for
apoptosis.
b. The cytoplasmic and nuclear volumes are decreased.
c. Nuclear DNa is degraded by Ca2+ and Mg 2+ -dependent endonucleases to form
apoptotic bodies.
d. Apoptotic bodiesare phagocytosed and degrded by lysosomal enzymes from
enightbouring cells.
e. Phagocytosis of apoptotic bodies precipitates an immune response.

Apoptosis or programmed cell death was first described in hepatocytes in 1972. It constitutes a
genetically coded ―suicide‖ programme that is activated when cells are no longer needed or have
been seriously damaged. Apoptotic cell death has four phases. (1) Precondensation: once the
stimulus for apoptosis has been received, a gene within the cell responsible for apoptosis is
induced. (2) Condensation: the cytoplasmic and nuclear volume decrease, chromatin condenses
and the interactions between the apoptotic cell and its neighbours are lost. Other changes include
solubilisation of nuclear matrix proteins (which are responsible for the morphological
configuration of the nucleus), redox changes in actin and other cytoskeletal proteins, and
development of blebs in the plasma membrane. (3) Fragmentation: non-lysosomal Ca²+ and Mg²+
-dependent endonucleases break down the DNA into smaller

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oligonucleosome-length apoptotic bodies. These apoptotic bodies increase in number until the
nucleus becomes pyknotic. (4) Final phase: the apoptotic bodies are phagocytosed and degraded
by lysosomal enzymes from neighbouring cells, without precipitating an immune reaction.

5.7.8 Which of the following factors activate apoptosis?

a. Extracellular matrix.
b. Growth factor withdrawal.
c. Transforming growth factor β.
d. Tumour suppressors such as p53.
e. Radiation.

The apoptotic cascade can be precipitated by a variety of factors. Physiological factors include
growth factor withdrawal; neurotransmitters (e.g. glutamate and dopamine); tumour necrosis
factors and transforming growth factor β; calcium and glucocorticoids. Cell damage may be
induced by viral infections, free radicals and oxidants or oncogenes and tumour suppressor genes
(e.g. p53). Iatrogenic factors include radiation therapy and chemotherapy, and apoptosis may be
triggered by toxins such as ethanol and p amyloid protein. Apoptosis may be inhibited by
physiological factors (such as growth factors, extracellular matrix, and zinc), by certain viruses,
and by cysteine pro tease inhibitors.

5.7.9 Apoptosis genes

a. There is nucleotide sequence homology between apoptosis genes in nematodes and

humans.
b. Bcl-2 induces apoptosis.
c. Bax represses apoptosis.
d. ICE (interleukin-1β-converting enzyme)-related proteases participate in nuclear
disassembly during apoptosis.
e. Baculovirus p35 inhibis ICE-related proteases

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Much of our understanding of the gene expression of apoptosis comes from studying the
nematode Caenorhabditus elegans. C. elegans consists of 1090 cells, 131 of which are destined
to die by means of apoptosis. In C. elegans apoptosis occurs in three stages—execution,
engulfment and degradation. Execution is promoted by ced-3 and ced-4, and inhibited by ced-9.
Mutations in ced-3 and ced-4 lead to differentiation of cells that would normally die; mutations
in ced-9 prevent cell deaths that occur in normal development. Engulfment requires two sets of
genes—ced-1,6, 7 and 8 plus ced-2,5 and 10. Degradation requires the nuc-1 gene.

There is sequence homology between ced-9 and a mammalian gene known as bcl-2 that is
expressed in high levels in follicular B cell lymphoma. A translocation t(14; 18) produces a
fusion between the bcl-2 gene and the heavy chain gene. Over expression of bcl-2 protein results
in enhanced B cell survival and tumorigenesis. The bcl-2 gene product is a 26-kDa protein with
an amino acid sequence different from that of other gene products. Bcl-2 enhances the survival
of neurones that are deprived of neurotrophic factors and protects neurones from damage by, for
example, glutamate and free radicals. The apoptosis repressor effects of bcl-2 are countered by
another member of the bcl family known as bay.which induces apoptosis. Both bcl-2 and bax
form homodimers and heterodimers; the ratio of the homodimers will determine whether
apoptosis is suppressed or initiated.

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Ced-3 encodes a protein that has 29% amino acid homology with in terleukin-1 (3-converting
enzyme (ICE), a cysteine protease. Ten ICE-related proteases (IRPs) have been identified. They
appear to act downstream in the apoptotic cascade, and are thought to influence all of the
enzymic pathways involved in apoptosis, for example the cleaving of laminins that provide
support for inner nuclear membranes, so aiding nuclear disassembly. The baculovirus apoptosis
repressor gene p35 inhibits ICE-related proteases.

5.8: Neoplasia
5.8.1 Characteristics of neoplasia

a. Uncoordinated cell growth.

b. Hyperplasia.
c. A disturbance in cellular differentiation.
d. Hypertrophy.
e. Disturbance in the relationship between cells and surrounding stroma.

The definition of a neoplasm (as suggested by Willis) is ―an abnormal mass of tissue, the growth
of which exceeds and is uncoordinated with that of the normal tissues, and which persists in the
same excessive manner after cessation of the stimulus which has evoked the change.‖
Characteristically neoplasms display a disturbance in cell proliferation, cell differentiation, and
in the relationship between cells and their surrounding stroma. Both hyperplasia (an increase in
the number of cells) and hypertrophy (an increase in the size of the cells) are adaptive
conditions—that is, the excess growth will stop after the stimulus that evoked the change has
ceased. They cannot therefore be classed as neoplastic conditions.

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5.8.2 Characteristics of dysplasia and metaplasia
a. Metaplastic cells are poorly differentiated.
b. Dysplastic cells are poorly differentiated.
c. Chronic irritation is a stimulus for metaplasia.
d. Invasion through the basement membrane is seen in dysplasia.
e. Dysplasia is common in squamous epithelia.

Metaplasia may be defined as a complete change in the differentiation of a cell from one fully
differentiated form to another. It often arises as a response to chronic irritation and the transition
is usually from a cuboidal or columnar epithelium to a squamous epithelium. Tumour metaplasia
(such as adenocarcinomas of the lung changing to squamous carcinomas) has also been noted.
Dysplastic conditions will display undifferentiated cells and abnormal mitoses but they are not
invasive and do not pass through the basement membrane. Dysplasia often arises in a squamous
epithelium—if the full thickness of the epithelial covering shows dysplastic change this is known
as carcinoma in situ.

5.8.3 ChRcteristics of a malignant neoplasm

These include:
a. Loss of differentiation.
b. An increased number of abnormal mitoses.
c. Nuclear pleomorphism.
c. Nuclear pleomorphism.
d. Non-invasiveness.
e. A tendency to metastasise.

Malignant neoplasms tend to be poorly differentiated, the cells being larger than their normal
counterparts with a greater degree of heterogeneity in size and shape. The size of the nucleus is
also variable and it tends to occupy a greater proportion of the total cell volume, increasing the
nuclear:cytoplasmic ratio. The overall number of mitoses increases and the frequency of
abnormal mitoses with tripolar, quadripolar or annular spindles

265
is higher. Malignant neoplasms will display invasiveness, in which cells separate and grow in an
irregular pattern into the surrounding tissue. However, some ―benign‖ lesions such as
meningiomas and pleomorphic adenomas may be invasive. Cells entering the blood or lymphatic
vessels and spreading to distant sites is known as metastasis.

5.8.4 Mechanisms of neoplasia formation

a. Loss of contact inhibition.

b. Increased chalone production.
c. Increased platelet derived growth factor production.
d. Increased growth factor receptors.
e. increased beta transforming growth factor.

Normal cell division ceases once contact is made with a neighbouring cell (contact inhibition).
Contact inhibition is thought to occur by a negative feedback between cells, possibly via
molecules known as chalones. One hypothesis for neoplastic growth is that chalone production is
decreased, leading to excess cell division; another hypothesis is that surface membrane
glycoproteins (which have been implicated in the control of contact inhibition) are changed in
some way. Autocrine growth factors such as platelet derived growth factor and epidermal growth
factor may cause neoplastic change if there is an increase in growth factor production, an
increase in the number of growth factor receptors, or an exaggerated response to receptor
stimulation. The beta transforming growth factor is an autocrine peptide that has a negative
effect on cell growth and is thought to have a role in regulating cell population and size.

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5.8.5 Proto-oncogenes
a. Proto-oncogenes are normal genes involved in the control of cell growth and
differentiation.
b. Epidermal growth factor receptors are the product of a proto-oncogene.
c. The ras gene family encode for G proteins on the inner surface of the cell
membrane.
d. The product of myc proto-oncogenes are located in the cell nucleus.
e. All human proto-oncogenes are related to viral oncogenes found in RNA tumour
viruses.

Proto-oncogenes are normal genes whose gene products influence cell growth and
differentiation. They can exert this influence at any part of the cell proliferation signal pathway,
as illustrated in Figure 5.28. Many but not all human protooncogenes are related to specific
RJSIA tumour viruses; these retroviruses transcribe RNA to DNA that can then be incorporated
into the host chromosomal DNA.

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5.8.6 Proto-oncogene activation

a. Oncogenes have a dominant effect at the cellular level.

b. A single point mutation can convert a proto-oncogene to an oncogene.
c. Activation of proto-oncogenes always requires a structural change.
d. Overexpression of a agene product may be secondary to gene ampilifaction.
e. Activation of a single oncogene can transform a cell to full tumourgenicity.

Oncogenes are proto-oncogenes that have been altered or overexpressed, resulting in

uncontrolled growth of the cell. This activation of proto-oncogenes can occur through structural
change, chromosomal translocations or gene amplification.

 Structural change—point mutations can critically alter the amino acid sequence of a
protein product. The ras protein action is switched off by the hydrolysis of GTP to GDP.
A single point mutation in the ras protein reduces its ability to hydrolyse GTP, so the
signalling activity of the protein is continually turned on. Up to 15% of human cancers
may have this ras gene mutation. Deletions of part of the coding sequence may remove
regions responsible for negative control of the signalling function, so leading to
malignant transformation. A single mutant allele is sufficient to change the phenotype of
a cell from normal to malignant, that is, the oncogene has a dominant effect at a cellular
level.
 Chromosomal translocations—translocation of a protooncogene can lead to fusion of that
sequence to other domains, which may alter the levels and timing of gene expression. In
Burkitt‘s lymphoma the myc proto-oncogene is translocated from chromosome 8 to
chromosome 24, where it is linked to a chromosomal region that permits its permanent
expression. The translocation of the abl proto-oncogene from chromosome 9 to
chromosome 22 in chronic myeloid leukaemia is another well described translocation.

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  Gene amplification—overexpression of DNA segments, which may include proto-
oncogenes, is a feature of some malignant cells. These amplified regions result in one of
two cytogenetic changes—double minutes (small accessory chromosomes) or
homogeneously staining regions (HSRs). The myb oncogene encodes for a nuclear
transcription factor and is amplified in some colorectal and gastric carcinomas.

In general, fully transformed cells must express at least two activated oncogenes; these are
usually of different classes, for example, one will encode for a membrane receptor and the other
for a nuclear protein. Although expression of one class of oncogene may lead to cellular
immortalisation it will not convey full tumourgenicity, that is the ability of that cell to form
tumours when implanted into animals.

5.8.7 Tumor suppressor genes

a. Mutations in tumour suppressor genes ar dominant at a cellular
level.
b. The retinoblastoma protein is a product of a tumour suppressor
gene.
c. In the hereditary form of retinoblastoma the first mutation is carried
in the germ line.
d. The tumour suppressor gene of neurofibromatosis type 1 is located
on chromosome 13.
e. Mutation of the p53 gene is the most common mutation in human
cancers.

Tumour suppressor genes encode for proteins that have a negative effect on cell proliferation, so
blocking abnormal growth and malignant transformation. Tumour suppressor genes are recessive
at a cellular level, that is, both alleles must be lost if a tumour is to develop. The ―two-hit‖
hypothesis was popularised by Knuds on. He proposed that conditions such as retinoblastoma,
which occur in both a sporadic and familial form, could be explained on this basis. In the familial
form a first "hit‖ was inherited in the germline and a second ―hit‖ then occurred in the remaining
intact allele, so making the mutation homozygous. In the sporadic cases both ―hits‖ occurred in
somatic cells.

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 The gene in neurofibromatosis type 1 is located on the long arm of chromosome 17 and acts
as a tumour suppressor gene. A major active portion of the NF1 protein is a GAP-like protein
that may act as a growth regulator interacting with the ras oncogene. The p53 gene is also located
on the short arm of chromosome 17. Its gene product is a negative cell cycle regulator acting at
the G, phase of the cell cycle. The p53 gene is also implicated in inherited tumourigenic
conditions, but more significantly, acquired mutations in this gene are the most frequent genetic
change detected in spontaneous human cancers.

5.8.8 Retinoblastoma protein (pRB) and control of the cell cycle

a. E2F cactivates transcription of genes involved with DNA synthesis.
b. pRB binds to E2F preventing the cell entering S phase.
c. pRB is inactivated by phosphorylation.
d. Phosphorylation of pRB is mediated by cyclin and cyclin dependent kinase (cdk)
complexes.
e. P16 inhibits the phosphorylation of pRB.

The control of the cell cycle is regulated by the retinoblastoma protein and its interaction with
E2F proteins (Figure 5.29). E2F activates transcription of genes involved with DNA synthesis
and production of cell cycle regulators. pRB binds to E2F and inhibits the activation of
transcription by E2F. The pRJB/E2F complex also binds to E2F promotors and prevents
unbound E2F initiating transcription. pRB may be inactivated by phosphorylation, mutation or
by viral oncogene binding. Enzyme complexes consisting of cyclin D1 and cdk4 mediate the
phosphorylation of pRB. There are many cyclin complexes, the activity of which waxes and
wanes at different stages in the cell cycle. The cyclin Dl/cdk4 complex is most active in the G1
phase of the cycle causing progressive phosphorylation of pRB and subsequent release of E2F.
This triggers the transition from Gl to S phase, p16 is a cyclin dependent kinase inhibitor that
indirectly prevents phosphorylation of pRB. The frequency with

270
which components of this pathway are altered in tumours suggests that dysregulation of the
pathway may be a prerequisite for human carcinogenesis.

5.8.9 Mechanism of invasion

a. Loss of adhesiveness.
b. increased fibronectin production.
c. Loss of anchorage dependence.
d. Collagenase trauma to basement membranes.
e. Increased fibrin production.

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For metastasis to occur tumour cells must be shed from the original tumour mass (this may occur
as a result of decreased adhesiveness between cells).- Cell adhesiveness may decrease because of
a deficiency of desmosomes, an increased net negative charge of some tumour cells, or the
decreased production of fibronectin (which normally acts as an adhesive protein in cell to cell
binding). Most cell growth requires a firm surface (anchorage dependent growth). This is not a
feature of tumour cells, which may grow in suspension or in semisolid media. Invasion requires
that neoplastic cells penetrate the interstitial stroma and basement membranes (this is aided by
collagenases, which are present in a number of neoplastic cells such as breast carcinoma). Direct
spread is also aided by plasminogen activator, which conveys an antifibrinolytic action to
neoplastic cells.

5.8.10 Metastasis

a. Metastases are continuous with the primary growth.

b. Metastasis occurs by ymphatic and blood borne spread only.
c. Fibrin protects tumour emboli.
d. Only 1% of emboli survive more than 24 hours.
e. Site of metastasis is determined primarily by anatomical factors.

A metastasis is a growing colony of malignant cells that becomes established at a point distant
from the original or primary lesion, with which it has no continuity. The first step of formation is
liberation of neoplastic cells, which then invade blood vessels or lymphatics (transcoelomic
spread is also possible). These tumour emboli spread to distant sites but only 1% survive the
initial 24 hours. Certain primary tumours preferentially metastasise to certain sites (Ewing and
Paget suggested that different tumour cells would thrive in certain ―biological soils‖ but not in
others). Recent experiments using mouse melanoma cells have shown that cells destined to form
secondary deposits in a particular organ can detach from their initial impaction site and ―home
in‖ on the favoured tissue. This homing property is thought to be related to the nature of the
surface membrane of the malignant cells.

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5.8.11 Chemical carcinogens
The following are chemical carcinogens:
a. 3, 4 benzpyrene.
b. 2-naphthylamine (which is an ―ultimate‖ carcinogen).
c. Nitrosamines, which are ―remote‖ carcinogens.
d- Cyclophosphamide.
e. Arsenic

A carcinogen may be defined as any factor that will increase an individual‘s chance of
developing a malignant neoplasm. All chemical carcinogens are mutagens, that is they induce a
permanent change in cell phenotype. Polycyclic hydrocarbons make up a large group of chemical
carcinogens. Included in this group is 3, 4 benzpyrene, which is metabolised to a diol epoxide
that covalently binds DNA and is highly mutagenic. Aromatic amines used in the textile and
aniline dye industries (such as 2- naphthylamine) are ―remote‖ carcinogens that become
carcinogenic only after hydroxylation in the liver. Nitrosamines (also ―remote‖ carcinogens)
have been implicated in gastric carcinoma. Direct alkylating agents (such as cyclophosphamide),
naturally occurring agents (such as aflatoxin), and occupational chemicals (such as arsenic) are
all chemical carcinogens.

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274
6. Pharmacology
6.1 Pharmacokinetics
6.1.1 Rate and extent of ocular absorption

a. Tear volume will influence ocular absorption.

b. Tear turnover rate will influence ocular absorption.
c. Blink rate will influence ocular absorption.
d. Ratio of conjunctival: corneal surface area will influence ocular absorption.
e. Ocular absorption for topical medications is about 20-40% of the instilled dose.

Many factors have a profound effect on the rate and extent of ocular absorption. The most
important of these are the precorneal factors, such as the tear volume (7—30 pi), tear turnover
time (0.5—2.2 j-ul/min), and the spontaneous blink rate (15 times per min), all of which combine
to limit the time the remains in the conjunctival sac to 3—5 minutes on average. This time will
be reduced further if the medication is irritative, causing increased tear production and blinking.
The corneal thickness and the ratio of conjunctival:corneal surface area (17:1 in humans) will
also influence ocular absorption. The absorption of a medication can be calculated if the total
amount of the drug that has entered the eye is divided by the instilled dose, and the range is 1—
7% for ocular medications.

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6.1.2 Corneal barriers

a. The corneal epithelium is the greatest barrier to ocular drug penetration.

b. Lipophilic drugs penetrate the epithelium via a paracellular route.
c. The stroma has a diffusional rate approximately onequarter that of an aqueous
system.
d. The corneal endothelium is a significant barrier to the penetration of drugs.
e. Transconjunctival and trans-scleral routes contribute to passage of drugs into the
aqueous.

The corneal epithelium is a lipophilic (hydrophobic) layer that is the greatest barrier to ocular
drug penetration. Passage through the epithelium is via an intracellular route in the case of
lipophilic drugs, or via the paracellular route in the case of hydrophilic drugs. The intracellular
route accounts for the most drug transport. The stroma provides relatively little resistance to drug
transport—about one-quarter that of an aqueous system. The single-layered endothelium
provides no significant resistance to the penetration of ophthalmic drugs and is considered to be
in the same pharmacokinetic compartment as the aqueous. Recent studies have demonstrated that
the outer sclera is much less of a barrier to hydrophilic drugs than the corneal epithelium and that
the transconjunctival and trans-scleral routes contribute significantly to ocular penetration of
such drugs. The vascular nature of the episclera and conjunctiva also facilitates the transport of
drugs to deeper ocular tissues.

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6.1.3 Distribution and elimination of ocular medications

a. Binding to melanin can significantly affect the distribution of a drug.

b. Non steroidal anti-inflammatory drugs (NSAIDs) can accumulate in the cornea.
c. Topically applied antibiotics achieve minimal inhibitory concentrations In the vitreous.
d. Eluorescein readily penetrates blood ocular barriers.
e. If the ocular half life of a drug is shorter than the aqueous turnover time, strong tissue
binding of that drug is likely.

The availability of drugs to ocular tissues will be influenced by several factors. Binding of a drug
to melanin in the iris and ciliary body causes a slow release of the drug from this ―reservoir‖,
resulting in a prolonged but reduced effect-—for example atropine in dark irides. Drugs may also
bind to proteins in the aqueous. Rapid turnover of aqueous humour will reduce the availability of
a drug to the intraocular tissues. Drugs tend not to accumulate in ocular tissues such as the iris,
ciliary body and the lens. However NSAIDs and pilocarpine accumulate in the cornea.
Penetration of topical medications into the vitreous is poor, as they must diffuse against an
aqueous humour gradient and diffusion of drugs through the vitreous is slow. This explains why
topical antibiotics do not achieve minimal inhibitory concentrations in the vitreous. The
availability of systemic medications and the elimination of drugs from the eye will be influenced
by the blood ocular barriers. As fluorescein does not cross the intact blood—retinal barrier it can
be used to assess the integrity of the retinal circulation and the retinal pigment epithelium. Once
drugs are absorbed into the anterior chamber they are mostly eliminated by aqueous humour
turnover. The turnover time of the aqueous is about 1.5% per minute of the anterior chamber
volume, which equates to an aqueous half life of 46 minutes. A drug half life of less than 46 min
suggests that metabolism of die drug and uptake by blood vessels is contributing to its ocular
elimination. Conversely, a drug half life of more than 46 min, that is, greater than the aqueous
turnover time, implies there is significant tissue binding of the drug, reducing its elimination
from the eye.

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6.2: Cholinergic agonists
6.2.1 The ocular cholinergic system
a. Cholineacetyl transferase is found in the corneal epithelium and retina.
b. Acetylcholine is found in the corneal sroma and endothelium.
c. Cholinesterase is found in the iris and ciliary body.
d. Cholinesterase is found in the retinal vessels.
e. Muscarinic receptors are found in the epithelium.

Gholineacetyl transferase (the enzyme responsible for acetylcholine production) is found in the
corneal epithelium, the iris, ciliary body, and inner plexiform layer of the retina. Acetylcholine
and cholinesterase are also found in these sites: the latter in particularly high concentrations in
the iris and ciliary body sphincter muscles. However, cholinesterase is not found in the primary
aqueous, the vitreous, or the retinal vessels. Although muscarinic receptors are present in the iris,
ciliary body, and the retina they have not been isolated from the corneal epithelium.

6.2.2 Properties of muscarinic agonists

a. Pilocarpine is a direct muscarinic agonist.
b. Carbachol is both a direct and an indirect muscarinic agonist.
c. These agonists cause miosis and accommodation.
d. They decrease intraocular pressure by decreasing production of aqueous.
e. Muscarinic agonists decrease intraocular pressure by increasing uveoscleral outflow.

Muscarinic agonists may be direct acting (such as pilocarpine) or both direct and indirect acting
(for example, carbachol, which inhibits cholinesterase). They cause the triad of miosis (by
stimulating the iris sphincter muscle), accommodation (by

278
stimulating the ciliary muscle), and decreased intraocular pressure. The mechanism of the last
effect is unknown, but the most widely accepted theory is that these agents produce a passive
increase in outflow facility (the scleral spur traction model). Fluorophotometric studies have
shown that pilocarpine reduces the intraocular pressure, despite increasing aqueous production
and decreasing uveoscleral flow.

6.2.3 Uses and side effects of cholinergic agonists

a. Open angle glaucoma.

b. Esotropias.
c. Reversal of an atropine mydriasis.
d. Diagnosis of Adie‘s puplies.
e. These agents commonly cause head and brow ache.

The main clinical use of cholinergic agonists is in treatment of open angle glaucoma and
prophylaxis of closed angle glaucoma, in which treatment halves the incidence of angle closure
in the second eye. By decreasing the accommodative effort, cholinergic agonists have been used
in the treatment of accommodative squints. Pilocarpine, although it will reverse a phenylephrine
mydriasis, will not constrict an atropine mydriasis. Adie‘s pupils : very sensitive to cholinergic
agonists and a solution of Dcarpine of 0.125% will cause a miosis. The most common e effect of
these agents is head or brow aches but these rmally resolve after 2—3 days.

6.2.4 Indirect acting muscarinic agonists

a. Physostigmine acts by phosphorylating cholinesterase.

b. Echothiophate acts by carbamylating cholinesterase.
c. These drugs increase miosis hen used in conjunction with pilocarpine.
d. They cause an initial increase in intraocular pressure.
e. Indirect acting agonists reverse an atropine mydriasis

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Indirect acting muscarinic agonists (IAMAs) inhibit cholinesterase either by phosphorylation (for
example echothiopate), or by carbamylation (for example, physostigmine). Acetylcholine is a
more potent miotic than pilocarpine; therefore caaing pilocarpine to an IAJMA will decrease the
miosis. IAMAs produce an initial rise in intraocular pressure, and the eventual hypotensive effect
is variable. Some IAMAs will reverse an atropine mydriasis.

6.2.5 Uses and side effects of IAMAs

a. These drugs lower intraocular pressure.
b. They are used in the treatment of esotropias.
c. IAMAs are useful to treat lice blepharitis.
d. One of the side effects is cataract.
e. Their use causes iris nodules.

IAMAs such as physostigmine may be used in open angle glaucoma and occasionally as
prophylaxis against angle closure glaucoma. However, they are more likely to cause pupil block
in the second condition than pilocarpine. They cause less accommodative spasm in esotropias
than direct acting agents. Physostigmine will kill Phthirus pubis and Demodex folliculorum. The
risk of cataract with echothiopate is related to dose and duration of treatment and is five times
greater than that of pilocarpine. Hyperplasia of the iris pigment epithelium produced by some
IAMAs can be prevented by concomitant treatment with phenylephrine.

6.2.6 Properties of muscarinic antagonists

a. These drugs compete with acetylcholine for receptor sites.

b. The order of mydriatic potency in vivo is atropine > cyclopentolate > homatropine >
tropicamide.
c. They are susceptible to pigment binding.
d. Muscarinic antagonists may ave a direct χ agonist effect.
e. Their use decreases the convexity and axial width of the lens.

280
Muscarinic antagonists, naturally occurring or synthetic, act by competing with acetylcholine for
receptor sites on the post- naptic membrane. Their mydriatic effect, which is produced by
inhibiting the iris sphincter muscle, is also dependent on drug availability. This explains why
tropicamide, which readily penetrates the comeal epithelium, is more effective in vivo than
homatropine. Binding of these drugs by pigment accounts for their decreased efficacy and
latency of action in pigmented eyes. Atropine may supplement its antimuscarinic action by
stimula
ting oc receptors on the dilator muscle. All of these agents will produce cycloplegia by inhibiting
the ciliary muscle. This causes thinning and decreased convexity of the lens, reducing the risk of
posterior synechiae.

6.2.7 Side effects of muscarinic antagonists

These include:
a. Fever.
b. Increase in intraocular pressure.
c. Gatrointestinal disturbances.
d. Ataxic dysarthria.
e. Bradycardia.

Minor side effects associated with muscarinic antagonists are mild fever and skin flushing, which
resolve in 24 hours. The intraocular pressure can be raised in several ways, the most obvious of
which is precipitation of angle closure; however, these drugs may also decrease aqueous outflow.
Pre-testing of patients with open angle glaucoma using 1 % cyclopentolate may predict those
who will be susceptible to a rise in intraocular pressure when taking systemic muscarinic
antagonists (such as antidepressants and some ulcer medications). Gastrointestinal effects
include increased distension and risk of necrotising enterocolitis in neonates. Side effects on the
central nervous system include ataxic dysarthria, cerebellar signs, and an increased risk of
seizures. Cardiovascular side effects, if present, tend to be tachyarrhythmias.

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6.3: The adrenergic system.

6.3.1 Catecholamine receptors in the eye

a. α1 receptors are found in the dilator muscle.

b. α1 receptors are found in the ciliary muscle.
c. β2 receoptors are found in the central epithelium.
d. β2 receptors are found in ciliary processes and trabecular meshwork.
e. Dopamine receptors are found in the retina.

receptors are postjunctional ones and are found on the dilator muscle, ciliary muscle, and the
sphincter muscle (where they have an inhibitory action). There are no βl receptors in the eye but
β2 receptors are found in the ciliary processes and trabecular meshwork. Dopamine has been
isolated from the inner plexiform layer of the retina, where it is thought to be the transmitter in
horizontal cells.

6.3.2 Properties of catecholamines

These drugs:
a. Decrease aqueous production via α2 and β2 receptors.
b. Increase outflow facility.
c. Decrease uveoscleral flow.
d. Inhibit the iris sphincter muscle.
e. produce uveal vasoconstriction.

The influence of catecholamines on intraocular pressure is controversial. Two possible

mechanisms are: (1) a decrease in aqueous production via α2 and β2 receptors is thought to occur
by an effect on the non-pigmented ciliary epithelium or by decreasing ciliary blood flow; (2) an
increase in outflow facility has been postulated, by direct effects on the trabecular meshwork.
XJveoscleral flow is increased indirectly by a decrease in episcleral resistance. Mydriasis occurs
by active stimulation of the dilator muscle and active inhibition of the sphincter via

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α receptors. The vascular tissue of the eye is devoid of β receptors but stimulation of α receptors
will cause vasoconstriction.

6.3.3 Pharmacology of timolol

Timolol:
a. Is a relatively selective β1 antagonist.
b. Has a duration of action of 6-8 hours.
c. Has a greater effect on intraocular pressure than pilocarpine.
d. Causes accommodation.
e. Is metabolized in the eye.

Timolol is a relatively selective β1antagonist, despite the fact that most receptors in the eye are
β2 receptors. This problem is overcome by the aqueous concentrations of timolol, which are
1000 times those required for β2 stimulation. The main effect of the drug is to lower intraocular
pressure (which it does more effectively than pilocarpine). Its duration of action of 12—24 hours
allows for twice daily administration. Timolol has no effect on the pupillary or ciliary muscles
and is metabolised in the liver.

6.3.4 Side effects of ocular p blockers

a. Depression.
b. Bradycardia.
c. Wheeze.
d. Impotence.
e. Decrease in the plasma high density lipoprotein (HDL) cholesterol.

Ocular β blockers, when absorbed into the circulation, can produce a number of ―predictable‖
side effects. They should be used with caution in patients with heart block and heart failure
because of their ability to induce bradyarrhythmias and their negatively inotropic effect. β
blockers will also exacerbate bronchospasm in asthmatics or patients with chronic obstructive

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airways disease. Timolol has been shown to decrease the plasma HDL cholesterol levels by 8%
and to elevate the ratio of total cholesterol:HDL cholesterol by 10%. Lowering of plasma HDL
cholesterol increases the risk of myocardial infarction. Impotence and depression have also been
reported with topical p blockers.

6.3.5 Topical β blockers

a. Levobunolol is relatively β1 selective.

b. Betaxolol is relatively β1 selective.
c. Carteolol has intrinsic sympathomimetic activity.
d. Betaxolol is more efficacious than timolol in lowering the intraocular pressure.
e. Long term drift is a problem associated with topical β blockers.

Betaxolol is the only topical β blocker that is relatively β1 selective (cardioselective). It should in
theory reduce the risk of β2-inhibition, but although it is better tolerated in those patients with
reversible airways disease, it can still induce bronchospasm. Betaxolol is also the least effective
topical β blocker with regard to lowering of the intraocular pressure. Carteolol has intrinsic
sympathomimetic activity (ISA), that is it causes an early transient agonist response. This partial
agonist activity could in theory lower the incidence of systemic side effects such as bradycardia
and bronchospasm; however, this beneficial effect is not evident when carteolol is administered
topically. The ISA of carteolol seems to be effective in minimising the decrease in high density
lipoproteins (HDL) associated with other topical β blockers. Tachyphylaxis is a phenomenon
whereby down- regulation of receptors results in a loss of responsiveness to agonist action; the
β2 adrenergic receptor is prone to such desensitisation. Conversely, prolonged antagonist action
may result in upregulation of β2 adrenergic receptors in the iris and ciliary body, resulting in
reduced ocular hypotensive efficacy of topical β blockers.

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5.3.6 Topical α-agonists
a. Apraclonidine is predominantly an α1-agonist.
b. Apraclonidine reduces intraocular pressure primarily by suppressing aqueous
production.
c. Apraclonidine and brimonidine primarily enter the eye via the cornea.
d. Brimonidine lowers intraocular pressure primarily by increasing uveoscleral outflow.
e. Systemic hypotension is a side effect of brimonidine.

Apraclonidine hydrochloride is a relatively selective α2-agonist. In contrast to clonidine and

brimonidine, it is a highly ionised molecule that penetrates the cornea slowly. The primary route
of delivery to the ciliary body is therefore through the conjunctive and sclera. Apraclonidine
lowers intraocular pressure by suppressing aqueous production without altering tonographic
outflow facility. At peak effect apraclonidine 1% lowers intraocular pressure by 30—40%
compared with the baseline. It is primarily used to prevent spikes in intraocular pressure after
anterior segment laser procedures. Brimonidine is a highly selective α2-agonist that lowers the
intraocular pressure by reducing aqueous production. Although brimonidine 0.2% will produce
an initial 20% reduction in the intraocular pressure, this effect appears to be short lived (less than
6 hours), and the long term efficacy of therapy is doubtful. Topical α-agonists frequently cause
an allergic follicular conjunctivitis, dry mouth and conjunctival blanching. Systemic hypotension
is a well recognised dose-related side effect of topical brimonidine.

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6.4: Ocular hypotensive drugs
6.4.1 Mannitol

This agent:
a. Crosses the blood aqueous barrier.
b. Causes loss of fluid from the eye by diffusion.
c. Should be administered intravenously.
d. Is excreted 90% unchanged by the kidneys.
e. May have an additional effect on intraocular pressure via optic nerve efferents.

Mannitol, like all hyperosmolar agents, does not cross the blood aqueous barrier. It should be
given intravenously over a 20—40 minute period and removes water from the eye by osmosis,
not diffusion. It is excreted 90% unchanged by the kidneys and therefore should be used with
caution in those with compromised renal function because of side effects such as fluid retention
and pulmonary oedema. Experimentally small concentrations of mannitol which do not produce
a measurable rise in plasma osmolarity have been found to decrease intraocular pressure. This
action is thought to be secondary to hypothalamic efferents travelling in the optic nerve.

6.4.2 Glycerol
a. Glycerol is rapidly absorbed from the gastrointestinal tract.
b. It penetrates the inflamed eye better than the non-inflamed eye.
c. HYperosmotic coma is a side effect.
d. Ketoacidosis is a side effect.
e. Hypoglycaemic coma is a side effect.

Glycerol is administered orally and is rapidly absorbed from the gastrointestinal tract. Unlike
mannitol, glycerol penetrates more rapidly into the inflamed eye. The average dose of glycerol
has a calorific load of 330 calories, which in the diabetic may cause hyperglycaemia,
hyperosmotic coma and diabetic ketoacidosis.

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6.4.3 Carbonic anhydrase
a. Carbonic anhydiase catalyses the irrecversible reaction
H+ + HCO3 H2CO3
b. it is found in cells of the proximal renal tubules.
c. Carbonic anhydrase is found in red blood cells.
d. it is found in the pigmented ciliary epithelium.
e. The action of this enzyme lowers intraocular pressure.

Carbonic anhydrase catalyses the reversible reaction H + + HCO3- H2COj. Its bicarbonated
form is the body‘s main buffering agent, playing a vital role in acid-base regulation, and is found
in proximal tubule cells (which produce bicarbonate to buffer pH changes in the urine). Carbonic
anhydrase in red blood cells will catalyse the reaction C02 + H2O H2C03. The bicarbonate
produced dissociates to give H+ ions (buffered by haemoglobin) and HC03- ions (which diffuse
into the plasma). In the non-pigmentary ciliary epithelium, this enzyme stimulates aqueous
production, either by increasing bicarbonate availability for co-transport with sodium, or by
increasing H+ concentrations at the inner membrane for sodium transport.

6.4.4 Uses and side effects of acetazolamide

Acetazolamide:
a. Decreases intraocular pressure.
b. May be administered topically.
C. Causes prasthesiae.
d. Causes depression.
e. Causes gastrointestinal upset

Acetazolamide is a carbonic anhydrase inhibitor. It may be administered orally or intravenously.

It can produce a marked and rapid decrease in the intraocular pressure but has a number of well
documented side effects such as parasthesiae, depression, and gastrointestinal upset. Use of
acetazolamide is contraindicated in patients with severe renal impairment.

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6.1.5 Dorzolamide
a. Is an acetazolamide derivative.
b. Is lipophilic at pH7 and hydrophilic at pH 5.
c. Reduces aqueous formation by inhibiting the carbonic anhydrase isoenzyme II.
d. has an additive IOP lowering effect when used with a β blockier.
e. Does not cause the systemic side effects associated with acetazolamide.

Dorzolamide is a topical carbonic anhydrase inhibitor (CAI). Unfortunately topical

acetazolamide, being very hydrophilic, does not readily penetrate the cornea, and this has led to
the development of thienothiopyran-2-sulphonamides such as dorzolamide hydrochloride. All
thienothiopyran-2-sulphon- amides have an ampholytic character, that is they are relatively water
soluble at pH 5 and pH 9, but are lipid soluble at pH 7. This enables them to pass through the
lipophilic cornea and to reach the ciliary epithelium, where they inhibit carbonic anhydrase
isoenzyme II. Dorzolamide lowers the intraocular pressure by about 20—25% and has an
additive effect when used with a topical β blocker. Despite the small doses absorbed
systemically, side effects such as electrolyte imbalance, renal stones and general malaise have
been reported with dorzolamide.

6.4.6. Latanoprost

a. Is a PGF 2 analogue.
b. Is activated by enzymic hydrolysis in the cornea.
c. Significantly increases trabecular outflow.
d. Decreases aqueous production.
e. May increase melanogenesis in iris stroma melanocytes.

Latanoprost is a PGF2a derivative that has been modified by addition of an isopropyl ester and a
phenyl substitution. It is a lipophilic prodrug that undergoes enzymic hydrolysis in the cornea to
the biologically active acid of latanoprost. Ocular

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responses are mediated via prostanoid receptors, particularly the FP-receptor. Latanoprost lowers
the intraocular pressure by increasing uveoscieral outflow. It has no effect on aqueous
production, and only minimally increases trabecular outflow. Latanoprost has a short plasma half
life of 17 min and is completely converted to inactive metabolites by the liver, 88% of which are
excreted in the urine. In contrast, the elimination half life in the eye is about .3 hours, as there is
no significant metabolism of latanoprost in the eye. Latanoprost is well tolerated, with no
systemic side effects. The most common ocular side effect is an increase in the brown
pigmentation of lie iris in mixed colour eyes, which is secondary to increased melanogenesis by
iris stromal melanocytes.

6.5 Corticosteroids and non-steroidal anti- fiammatory drugs (NSAIDs)

6.5.1 Glucocorticoid receptors

a. Glucocrticoid receptors are present in all cells.

b. Glucocorticoid receptors are present on cell membranes.
c. Therre is only a single class of glucocorticoid receptor.
d. HSP-90 (heat shock protein) prevents inactive receptors from migrating to the
nucleus.
e. Activated glucocorticoid receptors bind to DNA at promoter regions of steroid –
responsive target genes.

Glucocorticoid receptors are cytosolic receptors that are found to a greater or lesser degree in all
cells. There is only a single class of glucocorticoid receptor, although there are several steroid-
binding domains that are located towards the C-terminal of the molecule. HSP-90 is associated
with the receptor; it acts as a molecular chaperone, preventing the unbound receptor migrating to
the nucleus, and it helps maintain the optimum configuration for corticosteroid binding. Once
corticosteroid binds to the receptor, HSP-90 detaches from the receptor, which then migrates to
the nucleus. There it binds to DNA at promotor regions of steroid-responsive target genes, and
transcription of these genes is then induced or repressed. The Tau 1 sequences

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at the N-terminal of the receptor aid in the transcriptional transactivation of these genes. It is
estimated that the number of steroid-responsive genes per cell is 10—100, which goes some way
to explain the myriad of effects produced by steroids.

6.5.2 Anti-inflammatory effects of steroids

a. Dexamethasone increases synthesis of lipocortin, which inhibits phospholipase A2.

b. Steroids inhibit brandykinin breakdown.
c. Steroids inhibit the transcription of interleukin 1 and interleukin 2.
d. Steroids block the action of cytokines.
e. Steroids inhibit the induction of nitric oxide gene expression by cytokines.

Steroids influence acute and chronic inflammatory processes in a variety of ways.

Dexamethasone increases the synthesis of lipocortin, which inhibits phospholipase A2 and the
subsequent release of arachidonic acid, a substrate for both the prostaglandin and leukotriene
pathways. Steroids may also have an inhibitory effect on other enzymes necessary for eicosanoid
synthesis. Bradykinin is a vasoactive inflammatory mediator that is degraded by angiotensin-
converting enzyme and neural endopeptidases, both of which can be induced by steroids.
Steroids exert an effect on cytokines by inhibiting their transcription, for example that of 11-1, 2,
3, 4, 5, 6 and 8, TNFα and GM-CSF, and by blocking their action, for example that of TNFα.
Nitric oxide is a potent inflammatory mediator and steroids have been shown to inhibit induction
of nitric oxide gene expression by endotoxin and cytokines.

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6.5-3 Effects of corticosteroids on hypersensitivity, humoral and cell mediated
immunity
a. The effect on T cells is greater than that on B cells.
b. B cells are most sensitive to steroids immediately after antigen presentation.
c. Steroids modify type II and III hypersensitivity reactions.
d. Steroids inhibit histidine decarboxylase and multiplication of eosinophils.
e. Steroids decrease graft versus host reactions.

Glucocorticoids modify both humoral and cell mediated immunity by inhibiting B and T
lymphocytes respectively. The B cells are most sensitive to corticosteroids immediately after
their antigen presentation phase, and type II and type III hypersensitivity reactions can be
dampened by decreased antibody production. Type I hypersensitivity reactions are lessened
because corticosteroids reduce histamine production (by inhibiting histidine decarboxylase) and
eosinophil multiplication. Graft versus host reactions are also decreased by administration of
steroids because these drugs inhibit T cell mediated macrophages.

6.5.4 Absorption and metabolism of topical steroids

a. Prednisolone phosphate rapidly penetrates the cornea.
b. Dexamethasone 0.5% (maxidex) is a more potent anti-inflammatory agent than
prednisolone acetate 1% (pred forte).
c. Dexamethasone is excreted unchangted after topical or systemic administration.
d. Fluoromethalone is metabolized in the cornea.
e. The activity of corneal enzymes may enhance the activity of topical corticosteroids

The corneal penetrance of topical steroids depends on the lipophilicity of the formulation and the
integrity of the corneal epithelium. Prednisolone acetate and dexamethasone acetate.

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are lipophilic preparations. They effectively penetrate the cornea and are therefore potent
intraocular anti-inflammatory agents. The anti-inflammatory activity of dexamethasone 0.5%
(maxidex) is approximately 80% that of prednisolone acetate 1% (pred forte). The penetration of
water soluble agents such as dexamethasone phosphate and prednisolone phosphate is increased
threefold when the epithelium is absent. Dexamethasone is not metabolised in the eye or
elsewhere (which explains its relatively long half life) and is excreted unchanged.
Fluoromethalone is metabolised in the cornea and is therefore less likely to cause unwanted
ocular side effects, such as cataract and glaucoma. Topical steroids may be modified by corneal
enzymes—examples of this include the conversion of cortisone and prednisolone to their active
11-hydroxyl components by comeal hydroxylase, and the conversion of phosphate corticosteroid
derivatives to more active alcohol forms by corneal phosphatases.

6.5.5 Actions of NSAIDs

a. Inhibition of lipoxygenase.
b. Inhibition of cyclo-oxygenase.
c. Scavenging free radicals.
d. Analgesic agents.
e. Antipyretic agents.

The specific action of non-steroidal anti-inflammatory drugs is the inhibition of cyclo-

oxygenase, so preventing prostaglandin synthesis. NSAIDs, with the possible exception of
diclofenac,' have no effect on lipoxygenase activity and therefore do not inhibit leukotriene
synthesis. NSAIDs have anti-inflammatory, analgesic and antipyretic properties, not all of which
are initiated solely by the inhibition of cyclo-oxygenase. NSAIDs also have free radical
scavenging activity, and because of their antichemotactic activity they can modulate humoral and
cellular events during inflammatory reactions.

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6-5.6 Ocular effects of prostaglandins
a. Inducing miosis.
b. Breakdown of blood ocular barriers.
c. Changes in intraocular pressure.
d. Coinjunctival hyperaemia.
e. Inflammation.

Prostaglandins have a diverse spectrum of activity on the eye which includes all of the above
effects. The principle indications for topical NSAIDs are the prevention of intraoperative miosis,
the treatment of postsurgical inflammation, adjunctive use with topical steroids in uveitis, and
the treatment of cystoid macular oedema. The most commonly used topical NSAIDs are
flurbiprofen 0.03% and ketorolac 0.5% (phenylalkanoic acid derivatives), diclofenac 0.1% (a
water soluble phenylacetic acid derivative), and indomethacin 0.5—1%. Other classes of NSAID
such as salicylates or fenamates are too unstable in solution or too toxic for ocular applications.

6.6: Ocular anaesthetics

6.6.1 Local anaesthetic agents

a. These are weak acids.

b. They are biphasic.
c. Block changes in the sodium permeability of axonal membranes.
d. The action is more rapid in myelinated nerves.
e. Local anaesthetics are metabolized in the plasma and liver.

Local anaesthetics consist of three major parts: a lipophilic aromatic residue is linked to an
intermediate aliphatic chain by an ester or amide bond, which is joined to a secondary or tertiary
amine. They are weak bases—the charged form binds to the receptor site to prevent sodium
influx across axonal membranes. Local anaesthetics can enter myelinated nerves only at the
nodes of Ranvier so their rate of action here is considerably slower than

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in unmyelinated nerves. Most of these drugs are metabolised in the liver or in the plasma-

6.6.2 Uses and side effects of topical agents

Topical anaesthetics:
a. Produce analgesia for approximately 10-30 minutes.
b. May have antimicrobial effects.
c. Are suitable for systemic use.
d. Inhibit epithelial mitoses and migration.
e. Cause epithelial loosening and erosions.

Commonly used topical anaesthetics include benoxinate, proparicaine, tetracaine and cocaine; all
take effect in seconds and produce analgesia lasting for 10—30 minutes. Tetracaine and
benoxinate have been shown to inhibit growth of some staphylococci, pseudomonas and Candida
species incubated in 24 hour cultures. Topical anaesthetics are extremely toxic and should never
be administered systemically. Side effects are more common with cocaine, and include toxic
effects on the metabolism and ultrastructure of epithelial cells (causing erosions), and inhibition
of mitoses and migration.

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7. Ocular physiology
7.1: The lacrimal apparatus
7.1.1 Lacrimal gland

This gland
a. is a tubuloacinar gland.
b. has ducts lined with a squamous epithelium.
c. Receives postaganlionic secretomotor fibres from the ciliary ganglion.
d. Develops from neuroectoderm.
e. Contains predominantly serous secretory cells.

The lacrimal gland is a tubuloacinar gland derived from surface ectoderm with ducts lined by a
low columnar or cuboidal epithelium (often bilayered). The secretory cells in the acini have a
predominance of dense granules3 suggesting that most are of a serous nature. However, some
cells are mucus producing. The postganglionic secretomotor fibres (which arise from the
pterygopalatine ganglion) ―hitch-hike‖ on the zygomaticotemporal and lacrimal nerves to the
gland.

7.1.2 Tear production

a. Secretions from acdessory lactimal tissue are identical to those of the lacrimal gland.
b. ―Basal‖ tear production is the result of light or temperature stimulation or both.
c. Lesions of the superior salivatory nucleus willo reduce reflex tearing.
d. Sympathei5tic nerves influence tear production.
e. Psychogenic tearing is always bilateral.

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The accessory lacrimal tissue found at various sites in the conjunctiva is histologically identical
to the main lacrimal gland, as are the secretions it produces. The eponymous naming of these
―glands‖ (after Krause and Wolfring) in light of these histological findings is no longer
appropriate. The concept of ―basal‖ tear production is also a redundant one, as even minimal tear
production in the undisturbed eye is thought to be secondary to light or temperature stimulation
or both (proprioceptors in the lids may also play a part). Reflex tearing is mediated via
parasympathetic nerves that stimulate the myoepithelial cells lining lacrimal acini, causing them
to contract. These fibres originate in the superior salivatory nucleus and lesions in this region
will reduce reflex tearing. Sympathetic nerves may influence tear production by altering the
blood flow to the lacrimal gland. The underlying mechanism of psychogenic tearing is not
clearly understood, but it is always bilateral.

7.1.3 The tear film

a. The tear film is composed of three layers.
b. The main function of the lipid layer is to reduce evaporation of the aqueous layer.
c. The mucin layer is 30 μm thick and is hydrophobic.
d. The goblet cells have their greatest concerntration inferonasally.
e. Tear film break-up time is normally approximately 5-10 seconds.

The original model of the precorneal tear film described a trilayered film composed of a lipid
layer, an aqueous layer and an inner hydrophilic mucin layer produced by the goblet cells. Until
recendy the mucin layer was thought to be 0.002—0.05 um thick; however, confocal microscopy
studies have shown that this layer is considerably thicker (30 um), and that the precorneal tear
film is a mucin dominated gel hydrated by aqueous fluid (Figure 7.1). Mucin secreting cells are
found throughout the conjunctiva with a maximal concentration inferonasally. The stability of
the tear film is dependent on the epithelial glycocalyx, the amievaporative effects of the lipid
layer, and the viscous

296
properties of the tears imparted by the mucin layer. The tear kreak-up time is a crude measure of
tear film stability, and is of the order of 10-30 seconds in normal eyes.
Lipid layer (0.1 Jim).

7.1.4 Tear dynamic

a. The maximum volume of the conjunctival sac is 30 μl.

b. The average tear film volume is 15 μl.
c. Tear film turnover time is approximately 18% per minute.
d. The volume of a ―drop‖ of topical medication is approximately 50 μl.
e. A normal Schirmer‘s test is approximately 15-25 mm of ―wetting‖ over 5 minutes.

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The maximum volume of the conjunctival sac is 20 ul but the normal tear volume is
approximately 6—7 ul because of the effeci of bunking. This explains why only 20% of an
average drop of medication (approximately 50 ul) is retained in the conjunctival sac, the rest
being lost to overflow. A tear turnover rate of 18% per minute compounds poor retention of
medication, which means that after 5 minutes only 40% of the medication is present in the
conjunctival sac. A normal Schirmer's test would produce 15-25 mm of ―wetting‖ over a period
of 5 minutes.

7.1.5 Tear biochemistry

a. The osmolarity of the aqueous layer is approximately that of normal saline.

b. The pH of tears is 7.0.
c. The potassium content of tears is 3-5 times that of plasma.
d. The chloride content of tears is less than that of plasma.
e. The glucose concentration of tears is greater than that of the plasma.

The primary secretion from the acinar region of the lacrimal gland is essentially an ultrafiltrate of
plasma; it is later modified by ductal secretion of potassium chloride. This explains the elevated
potassium (15-30 mmol/1) and chloride (135 mmol/1) concentrations, with respect to plasma.
Passive diffusion of electrolytes through the intercellular spaces of conjunctival or corneal
surface epithelial cells is prevented by tight junctions. The osmolarity of the aqueous layer is
approximately that of normal saline and the pH is 7.4. The precorneal tear film and the limbal
vessels supply the corneal epithelium with glucose; the glucose concentration in the aqueous
layer is therefore lower than that of plasma.

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7.1.6 The protein components of unstimuiated tears

a. lactoferrin and lysosyme are produced by the acinar cells.

b. Secretory IgA levels of unstimulated tears do not fluctuate throughout the day.
c. Lactoferrin and lysosyme concentrations decrease with age.
d. The concentration of IgG and secretory IgA are approximately equal.
e. Tear lipocalin and cystatin inhibit cysteine proteinase

The protein content unstimuiated tears is variable but is usually 7-10 mg/ml; this falls to 3.9
mg/ml with high flow rates. The major protein constituents of the precorneal tear film comprise
those produced by the acinar cells and those derived from other sources. Production of the acinar
derived proteins lysosyme and lactoferrin rises with increasing stimulation, and therefore their
concentration in the tear film remains relatively constant. Lysosyme and lactoferrin are
antibacterial agents; the former breaks down bacterial cell walls and the latter inhibits the growth
of iron-dependent bacteria and also scavenges free radicals. The concentrations of both
lactoferrin and lysosyme decrease with age. The production of secretory IgA by plasma cells
within the lacrimal gland and conjunctiva is constant and not subject to neuronal stimulation; this
explains why the concentration of secretory IgA decreases with increased tear production.
Conversely, the levels of secretory IgA rise markedly at night, as aqueous tear production by the
acinar cells declines. IgG concentrations are very low (0.004 g/1) in the normal tear film
compared with those of secretory IgA levels (1.9 g/l), although IgG levels are elevated in
inflammatory conditions as a result of leakage from conjunctival vessels. Tear lipocalin
(formerly known as tear specific prealbumin) accounts for 20% of tear film protein. It has
significant homology with members of the lipocalin family of proteins, which bind small
hydrophobic molecules. Tear lipocalin was thought to have a protective effect on the epithelium
and has been shown to inhibit cysteine proteinase. Cystatin is another tear film protein that
differs structurally from tear lipocalin but has a similar inhibitory effect on cysteine proteinase.

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7.1.7 Lipid content of the precorneal tear film
a. Tear film lipid is an apocrine secretion.
b. Most tear film lipid is in the form of wax and sterol esters.
c. Fatty acids account for 205 of rear film lipid.
d. Production of tear film lipid is under neuronal control.
e. The composition of lipid on the lid margins is indentical to that produced by the
meibomain glands.

The tear film lipids are derived from the meibomian glands, these holocrine glands excrete a
clear oil on to the lid margins in reponse to each blink. Most tear film lipid is in the form of wax
esters (32%) and sterol esters (27%), free fatty acids accounting for only 2% of tear film lipids-
Other lipid components of the tear film include diesters, triacyl triglycerides and polar lipids. The
profile of free fatty acids and the proportion of lipid classes varies considerably between
individuals, and may be a factor that predisposes to the development of chronic blepharitis. The
composition of lipid after release is altered by the actions of lipolytic lid margin bacteria and is
invariably different from that of the lipid originally produced by the meibomian glands.

7.2: The eyelids

7.2.1 Reflex blinking

Reflex blinking:
a. May be caused by optical stimulation.
b. May be caused by auditory stimulation.
c. A corneal reflex is dependent on the fifth and seventh cranial nerves.
d. Cortical function is needed for a corneal reflex.
e. Is initiated bye the pretarsal fibres of orbicularis oculi.

Reflex blinking may be caused by optical, auditory or tactile stimuli. Tactile stimulation of the
cornea triggers a brain stem reflex via the fifth and seventh cranial nerves and therefore does

300
not require a cortical input. Tumours of the cerebellopontine angle often cause a loss of the
corneal reflex before other branches of the fifth nerve are affected. The pretarsal (as opposed to
the orbital) fibres of orbicularis oculi initiate the action of reflex blinking.

2.2 Spontaneous blinking

a. Spontaneous blinking is absent until the third month of life.

b. Blind people blink spontaneously.
c. Frequency is approximately 15 per minute.
d. Spontaneous blinking is preceded by relaxation of levator palpebrae superioris.
e. Duration is approximately 1-15 seconds.

Spontaneous blinking is absent until the third month of life and, as it does not require retinal
stimulation, is present in blind people. The blink lasts 0.3—0.4 seconds and is preceded by
relaxation of levator palpebrae superioris. It is responsible for spreading the tear film over the
cornea and conjunctiva and occurs about 15 times each minute.

7.2.3 Associated eye movements

a. Upward movement of the globe associated with eye closure is known as the pseudo
Graefe phenomenon.
b. Bell‘s phenomenon is absent in 10% of normal people.
c. Voluntary upward gaze is associated with lid retraction.
d. Fibrillary twitching of the eylids amy be due to refractive error.
e. The marcu sGunn syndrome (jaw winking) is caused by pterygoid linkage with the
levator palpebrae superioris.

Bell‘s phenomenon is the upward movement of the globe associated with eye closure and is
absent in 10% of normal people. The Marcus Gunn syndrome (or jaw winking) is caused by
levator palpebrae superioris and pterygoid muscle linkage (it

301
is not known whether this is at a cortical or peripheral nerve level). Fibrillary twitching may be
caused by refractive errors.

7.2.4 Effect of drugs on eyelids

a. Guanethidine can be used to decrease width of the palpebral fissure.
b. Botulinum toxin inhibits release of acetylcholine from presynaptic terminals.
c. Botulinum toxin is used in the treatment of blephaospasm.
d. Edrophonium acts as an indirect nicotinic agonist in the Tensilon test.
e. The partial ptosis of Horner‘s syndrome is reversed by topical cocaine.

Guanethidine acts by inhibiting release of noradrenaline from nerve terminals (chemical

sympathectomy) and will therefore inhibit the action of Aluller‘s muscle, so decreasing palpebral
fissure width. The therapeutic action of botulinum toxin in blepharospasm is achieved by
inhibiting presynaptic acetylcholine release and decreasing neuromuscular transmission. A
Tensilon test (used in the diagnosis of myasthenia gravis) uses the anticholinergic action of
edrophonium at neuromuscular junctions, increasing the concentration of acetylcholine at these
junctions. Cocaine prevents reuptake of noradrenaline but will enhance sympathetic activity only
if there is an intact sympathetic chain to initiate release of the noradrenaline. It will therefore not
affect the partial ptosis seen in Homer‘s syndrome.

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7.3: The cornea

7.3.1 Physical properties of the cornea

a. The refractive power of the anterior corneal surface is 48.8 dioptres.

b. The cornea represents 50% of the eye‘s refractive power.
c. The anterior corneal surface is hyperboloid in shape.
d. The vertical meridian usually has a shorter radius of curvature than the horizontal
meridian.
e. The refractive index of the cornea is 1.376.

The anterior corneal surface has a refractive power of 48.8 dioptres and the posterior surface —
5.8 dioptres: 43 dioptres in total. This accounts for 70% of the eye's refractive power. The
anterior surface is steepest centrally and flattened peripherally, giving it a hyperboloidal shape.
The vertical meridian has the shorter radius of curvature and hence an increased refractive power
in 95% of eyes. The refractive index of the cornea is 1.376.

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7.3.2 Corneal structure
a. The cornea consists of five layers.
b. Bowman‘s membrane is capable of regeneration.
c. Descemet‘s membrane is capable of regeneration.
d. Bowman‘s membrane is more resistant to solvent flow than Descemet‘s membrane.
e. Endothelial cells are joined by zonula adherens and zonula occludens.

The cornea is made up of five layers. The epithelium (the most superficial layer) is separated
from the stroma by Bowman‘s membrane. Both Bowman‘s and Descemet‘s membranes
(adjacent to Bowman‘s membrane) are 10|im thick, but Descemet‘s membrane is able to
regenerate and is more resistant to the flow of solvent. The deepest layer is the endothelium:

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tight junctions between adjacent endothelial cells are essential for controlling comeal hydration.

7 3.3 Carbohydrate metabolism of the cornea

a. Oxygen requirements of the cornea are met by the aqueous.
b. The endothelium is more metabolically active than the epithelium.
c. The epithelium cataboilises glucose via the citric acid (Kreb‘s) cycle, glycolysis, and
the hexose monophosphare shunt.
d. Keratocytes can metabolise glucose via the hexose monophosphate shunt.
e. Lactic acid is actively pumped into the aqueous by the endothelium.

When the eye is open, the oxygen requirements of the cornea are primarily met by diffusion from
the tear film. When it is closed, oxygen diffuses from the lid vasculature and from the aqueous.
All three forms of carbohydrate catabolism are found in the epithelium and the endothelium; the
latter is particularly rich in mitochondria and has an oxidative activity five to six times that of the
epithelium. Keratocytes lack the enzyme 6- phosphogluconate dehydrogenase and are therefore
unable to utilise glucose via the hexose monophosphate shunt. Under anaerobic conditions any
lactic acid produced in the cornea diffuses slowly from the stroma and endothelium into the
aqueous. If the lactic acid is allowed to accumulate it may lead to the development of comeal
oedema.

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7.3.4 Electrolyte and glucose content of corneal layers
a. The epithelial potassium concentration is approximately 140 mmol/l.
b. The epithelial sodium concentration is approximately 70 mmol/l.
c. The glucose needs of the epithelium are supplied by the aqueous.
d. the stromal potassium concentration is half that of the epithelium.
e. Stromal electroneutrality is maintained by anionic glycosaminoglycans.

A sodium—potassium ATPase pump in the corneal epithelium ensures that potassium

concentrations are kept high and sodium concentrations relatively low. The glucose needs of the
epithelium are supplied by the tear film and the limbal blood vessels. The aqueous supplies the
needs of the endothelium. Stromal potassium is approximately 20 mmol/1 (seven times greater
than that of the epithelium) and its low chloride concentration (110 mmol/1) is compensated for
by anionic glycosaminoglycans which maintain electroneutrality.

7.3.5 Corneal dehydration

a. The endothelium is relatively impermeable to water.
b. Epithelial trauma causes marked and persistent corneal swelling.
c. Ouabain causes corneal swelling.
d. Intraocular pressure may influence corneal hydration.
e. Tear film tonicity may influence corneal hydration

The cornea is 75—80% water and has the highest water content of any connective tissue in the
body. The corneal epithelium constitutes a relatively impermeable. membrane, whereas the
endothelium is leaky. If the cornea is to maintain normal hydration, an intact epithelium and a
metabolically active endothelium are essential. Epithelial trauma will result in mild

306
and transient corneal oedema. The exact mechanism by which the endothelium transports solute
as a means of transporting water from the stroma remains unclear. One element is thought to be
the collective action of sodium and bicarbonate ion pumps leading to the passive secondary
movement of water. Ouabain is a sodium/potassium ATPase inhibitor that will disrupt corneal
dehydration- Intraocular pressure, if above 50 mmHg, will cause corneal oedema. Application of
glycerin to the tear film increases its osmolarity and causes water to be drawn from the cornea,
so decreasing oedema.

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7.3.6 Corneal collagen
a. Collagen constitutes 70% of the dry weight of the cornea.
b. Type II collagen is the predominant type in the human corneal stroma.
c. Collagen fibril diameter and the spacing between collagen fibrils are constant in
corneal collagen.
d. Endothelial cells produce type VIII and type IV collagens.
e. The tensile strength of corneal collagen is provided by hydroxylysineorleucine cross-
linkages.

Collagen constitutes approximately 70% of the dry weight of the human cornea. Type I collagen
is the predominant type, although collagens type V (10-20%), VI (15%), XII and XIV have also
been found in normal adult corneas. The diameter of corneal collagen fibrils (35 nm) and the
spacing between these fibrils (55 nm) is remarkably constant. There appears to be an inverse
correlation between the number of carbohydrate units and the fibril diameter of collagen. The
thin diameter corneal collagens are relatively rich in hydroxylysine-linlced carbohydrate
residues. Comeal endothelial cells in culture synthesise type VIII and type IV collagens. After
injury and polymorphonuclear infiltration, endothelial cells may be transformed into fibroblast
type cells that produce mainly type I collagen. The tensile strength of all collagens is provided by
intermolecular crosslinks; in the case of comeal collagen, hydroxylysineorleucirie is the major
reducible cross-link.

7.3.7 Corneal proteoglycans

a. Proteoglycans constitute 10% of the dry weight of the cornea.
b. dermatan sulphate proteoglycans are the most common corneal proteoglycans.
c. Corneal proteoglycans bind to collagen fibrils.
d. Corneal proteoglycans are uniformly distributed throughout the stroma.
e. Corneal proteoglycans play a part in regulating the spacing between collagen fibrils.

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Proteoglycans constitute 10% of the dry weight of the cornea. They are a family of glycosylated
proteins that contain at least one glycosaminoglycan chain covalently bound to a protein core.
Glycosaminoglycans are made up of repeating disaccharides, the most common comeal
proteoglycans are keratan sulphate proteoglycans (60%) and dermatan sulphate proteoglycans
(40%). The latter are hybrids that consist of dermatan and chondroitin sulphate disaccharides
bound to a protein core. Corneal dermatan sulphate proteoglycan is present as decorin, so named
because it binds to (decorates) collagen fibrils. Corneal proteoglycans are not uniformly
distributed throughout the stromal At birth, keratan sulphate proteoglycans are concentrated in
the anterior stroma and dermatan sulphate proteoglycans in the posterior stroma; this distribution
is reversed in the adult stroma. One hypothesis to explain this redistribution is that under low
oxygen tension synthesis of keratan sulphate proteoglycans is favoured, whereas dermatan
sulphate proteoglycans are preferentially synthesised in conditions of high oxygen tension. Both
keratan sulphate and dermatan sulphate proteoglycans bind to specific (but different) binding
sites on collagen fibrils, and this interaction is thought to play a part in regulating the spacing of
the collagen fibrils.

7.3.8 Theories of comeal transparency

a. The refractive index of collagen fibrils and stromal ground substance is the same.
b. Maurice stated that a regular arrangement of collagen fibrils causes destructive
interference of the light scattered by individual collagen fibrils.
c. Small and uniform diameter collagen fibrils are required for transparency.
d. Collagen fibrils in corneal scars have larger diameters than those of the normal
cornea.
e. The ratio of keratin sulphate: dermatan sulphate increases in corneal scars.

The refractive index of corneal collagen fibrils is 1.55, whereas that of stromal ground matrix is
1.35. This discrepancy in

309
refractive index will cause light to scatter as it passes through the cornea. Maurice hypothesised
in 1957 that regulai arrangement of collagen fibrils causes destructive interference of the light
scattered by individual collagen fibrils, and this leads to comeal transparency. In 1984 he
modified this hypothesis., saying that although a regular arrangement was required for
transparency, this arrangement need not be perfectly regular. Other researchers have argued that
light is not scattered by the stroma, as the fibril diameter of collagen (30 nm) is much smaller
than die wavelength of light (500 nm). Irrespective of the mechanism, there is agreement that
corneal fibrils of small and uniform diameter are essential for comeal transparency. The collagen
and proteoglycan content of corneal scars differs from that of the normal cornea. There is a wider
range of collagen fibre and fibril diameters in corneal scars, and a higher proportion of wide
fibrils with fewer glycoside residues. With time, the width of collagen fibrils decreases and the
number of glycoside residues increases, corresponding widi a reduction in the degree of opacity.
The ratio of keratan sulphaterdermatan sulphate decreases in corneal scars. The loss of keratan
sulphate is accompanied by a distortion of die regular arrangement of corneal fibrils, and this
contributes to the loss of corneal transparency.

7.3.9 Matrix metalloproteinases (MMPs)

a. MMPs are secreted by cells are active enzymes.
b. MMPs are only produced by cells resident in that tissue.
c. MMPs are required for corneal remodeling following injury.
d. MMP-2 is the only MMP found in the normal cornea.
e. MMP-1 has collagenase like activity.

Matrix metalloproteinases are a family of enzymes that break down components of the
extracellular matrix. In the cornea they help maintain the normal framework and have a crucial
role in remodelling after injury. MMPs are secreted as proenzymes by infiltrating inflammatory
cells or by cells resident in the tissue. They are then activated by cleavage of a peptide from their
N-

310
terminal end. All MMPs require a metal cofactor. The MMPs of the cornea have different
substrates:

 MMP-1 (collagenase-I) is active against collagen types I, II,

and III;
 MMP-2 (gelatinase A) and MMP-9 (gelatinase B) are active against collagen types IV, V,
and VII, as well as gelatins and fibronectin;
 MMP-3 (stromelysin-1) breaks down proteoglycans and fibronectin.

Only MMP-2 has been detected in the normal cornea; the other MMPs mentioned above are
found in the cornea only after injury. MMPs 1,2 and 3 are products of stromal cells, whereas
MMP-9 is produced by the corneal epithelium.

7.4: The aqueous and. intraocular pressure

7.4.1 Ciliary epithelium

a. The ciliary epithelium has two layers derived from neuroectoderm.

b. The outer layer is continuous with retinal pigment epithelium.
c. the inner layer is rich in mitochondria, rough endoplasmic reticulum and Golgi
apparatus.
d. The cells of the bilayered epithelium lie base to base.
c. The inner and outer layers are joined by tight junctions.

The ciliary epithelium is a bilayered structure derived from die neuroectoderm of the optic
vesicle. The inner layer is rich in mitochondria, rough endoplasmic reticulum and Golgi
apparatus. It is a continuation of the neural layer of the retina. The outer pigmented layer is a
continuation of the retinal pigment epithelial layer. Tight junctions exist between adjacent cells
in the inner layer, but not between the cells of the different

311
layers or between cells of the outer layer. The outer layer cell are connected by gap junctions.

7.4.2 Components of the blood aqueous barrier

a. Non-fenestrated ciliary capillaries.
b. Tight junctions between non-pigmented ciliary epithelial cells.
c. Non-fenestrated iris vessels.
d. Tight junctions between pigmented ciliary epithelial cells.
e. Tight junctions between endothelial cells of iris vessels.

The blood aqueous barrier in the posterior chamber is maintained because the tight junctions
between the inner non- pigmcnted epithelial cells prevent exudate from the fenestrated ciliary
capillaries reaching the aqueous. There are no tight

junctions between the cells of the pigmented ciliary epithelium. However, there are numerous
gap junctions between the pigmented and non-pigmented epithelial cells. The iris has no
protective epithelial barrier and relies on non-fenestrated vessels to maintain the blood aqueous
banner. However, the endothelial cells of these vessels are not joined by tight junctions and in
inflammatory conditions they become ―leaky‖, causing an aqueous flare.

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7.4.3 Formation of aqueous humour
a. Active secretion accounts for 20% of aqueous production.
b. Ultrafiltration is the major factor in aqueous production.
e. Only the non-pigmented ciliary epithelium is involved with active aqueous production.
d. The rate of aqueous flow in the normal human eye is approximately 2.75 ml/min.
e. Osmosis plays no role in aqueous production.

The major factor in aqueous production (approximately 70%) is active secretion; ultrafiltration
accounts for 20% and osmosis 10%. Until recendy, active aqueous secretion was thought to be
carried out solely by the mitochondrion-rich non-pigmented epidielium. We now know that the
pigmented epithelium plays a significant part in aqueous production. The average rate of aqueous
flow in the normal human eye is about 2.75 ul/min.

313
7.4.4 Active aqueous production

a. The non-pigmented epithelium has greater Na+ -K+- ATPase activity than the
pigmented epithelium.
b. Na+ -dependent cotransporters and exchangers are present in the basolateral
membranes of the pigmentary epithelial cells.
c. Carbonic anhydrase is found in pigmented and non-pigmented epithelial cells.
d. The sodium concentration in pigmented and non-pigmented epithelial cells is
maintained at a relatively high level with respect to that of the aqueous.
e. The basolateral membrane of the non-pigmented epithelium contains chloride, sodium,
bicarbonate and ascorbate channels.

The non-pigmented epithelium exhibits more intense Na+-K+- ATPase activity, contains more
mitochondria and has higher adenyl cyclase activity than the pigmented epithelium. It is also
capable of maintaining aqueous production after selective destruction of the pigmented
epithelium. For these reasons it was thought that active secretion of aqueous was carried out
solely by the non-pigmented epithelium. However, recent studies have shown that the pigmented
epithelium also plays an active role in aqueous production. The basolateral membranes of the
pigmented epithelial cells contain numerous Na+-dependent cotransporters and exchangers
(Figure 7.5), and carbonic anhydrase activity is also present in these cells. The net effect of these
ion transport systems is a low level of Na+ in both epithelial layers (facilitated by the numerous
gap junctions between the pigmented and non-pigmented cells), a high level of ascorbate and
K+, and control of the intracellular pH. The basolateral membranes of the non-pigmented
epithelium contain Cl~, Na + , HC03 and ascorbate channels. Transport of these species into the
posterior chamber induces the movement of water for die formation of aqueous humour. Despite
these advances in our understanding of aqueous production, the picture is far from complete. The
exact nature of the interactions between pigmented and non-pigmented epithelial cells is yet to
308

314
be determined, as is the relationship between the ion transport systems and neural inputs.

7.4.5 Functions of the aqueous

a. The aqueous supplies amino acids to the lens.

b. It supplies glucose to the corneal epithelium.
c. The aqueous maintains intraocular pressure.
d. The aqueous is a transparent conducting medium.
e. It is responsible for focusing light on the retina.

The main functions of the aqueous are: (1) to supply nutrition to the lens, corneal endothelium,
and stroma—but not to the

315
epithelium which relies on tears for its nutrition; (2) to maintain intraocular pressure; (3) to
remain transparent.

7.4.6 Composition of the aqueous

a. The sodium content is similar to that of the corneal epithelium.

b. The potassium content is approximately 4 mmol/l.
c. The glucose content is approximately 80% that of plasma.
d. The lactate concentration is greater than that of the plasma.
e. Aqueous has relatively low ascorbic acid content.

The electrolyte composition of aqueous is similar to that of th< plasma. The concentration of
sodium (140 mmol/1) is twice that of the comeal epithelium; the potassium concentration is
approximately 4 mmol/1. Owing to its nutritional function, aqueous glucose concentration is
80% of that of plasma. Lactate produced by the cornea and lens is excreted into the aqueous,
increasing the lactate level to twice that of plasma. The ascorbic acid concentration of the
aqueous is almost 50 times that of plasma. Several roles for ascorbic acid have been postulated,
including absorption of ultraviolet light and an action as an antioxidant.

7.4.7 Protein content of the aqueous

a. The protein content of the aqueous is half that of plasma.
b. There is a high albumin globulin ratio.
c. All immunoglobulins are usually detectable.
d. Plasminogen is present.
e. Increase with disruption of the blood aqueous barrier.

The protein content of human aqueous is 1/500 that of plasma protein levels, because of the
blood—aqueous barrier; any disruption of this barrier will increase protein influx. The
albumenrglobulin ratio is high, and IgG and IgA4 are the only immunoglobulins detectable in the
aqueous of normal eyes. Plasminogen and its proactivator are present, but none of their

316
inhibitors or other clotting factors are detectable in the aqueous. Numerous growth factors
including FGF, TGF-β and insulin- like growth factor-I have also been demonstrated in the
aqueous.

7.4.8 Aqueous dynamics

a. Outflow is usually described by two pathways.

b. Uveoscleral flow is approximately 0.3 μl per minute.
c. Trabecular outflow is dependent on the intraocular and episcleral pressures.
d. Uveoscleral flow is not affected by the intraocular pressure.
e. Aqueous inflow is constant over a wide range of intraocular pressure.

Aqueous outflow is usually described by two separate pathways. Most of the flow is through the
trabecular meshwork and canal of Schlemm, dependent on the intraocular and episcleral venous
pressures. Uveoscleral outflow is approximately 0.3 ul/min and is surprisingly independent of
intraocular pressure changes. Aqueous production will remain constant until intraocular
pressures are raised to 50 mmHg and over.

7.4.9 Outflow mechanics

a. The flow in a vessel is proportional to the fourth power of the radius of that vessel.
b. Aqueous flow is proportional to resistance in the ―vessel‖ over the pressure
difference along it.
c. The conductance and rssistance are inversely related.
d. The trabecular outflow resistance changes with increasing intraocular pressure.
e. Brubaker‘s correction is related to aqueous outflow.

The Poiseuille Hagen Formula states that the resistance to blood flow in a vessel is inversely
proportional to the fourth power of its radius, and hence flow in that vessel is directly
proportional to the fourth power of the radius.

R = 8r\Unr4

317
where: R = resistance; n = viscosity; L = length of vessel; r =
radius of vessel.

The flow of aqueous through the trabecular meshwork (I) will depend on the pressure
difference between the intraocula pressure and the episcleral venous pressure (V) divided by the
resistance of the trabecular meshwork (R)—a simple adaptation of Ohm‘s law (V=IR; I— V/K).
The conductance is the inverse of the resistance (I= VC) and the trabecular meshwork
conductance is seen to decrease as intraocular pressure rises Brubaker‘s correction allows for this
when calculating aqueous outflow.

7.4.10 Composition of the trabecular meshwork

a. Hyaluronic acid is an endogenous glycosaminoglycan of the trabecular network.
b. Fibronectin is found in the trabecular meshwork.
c. Collagen and elastin are integral constituents of the trbecular meshwork.
d. Smooth muscle myosin-containing cells are found in the trabecular meshwork.
e. The glycoprotein and glycosaminoglycan composition of the trabecular meshwork is
constant throughout life.

The trabecular meshwork is a complex connective tissue, the components of which direcdy or
indirectly affect aqueous outflow. Hyaluronic acid is an endogenous glycosaminoglycan (GAG)
of the trabecular meshwork. Degradation of hyaluronic acid by hyaluronidase in experimental
models enables increased aqueous outflow. Other GAGs, including chondroitin, heparan,
dermatan and keratan sulphates, are constituents of the trabecular meshwork and they too may
influence aqueous outflow. Fibronectin, elastin, laminin, collagen (types I, III, IV, V and VI),
and smooth muscle myosin-containing cells are other integral components of the trabecular
meshwork. Fibronectin secretion by cultured trabecular meshwork cells doubles after treatment
with dexamethasone. The significance of this finding with respect to ―steroid responsiveness‖
has yet to be determined. The glycoprotein and GAG composition of the trabecular

318
meshwork is not constant throughout life; changes in this composition with advancing age have
been implicated in the pathogenesis of primary open angle glaucoma.

7.4.11 Trabecular meshwork cells

a. Have phagocytic properties.
b. Synthesise glycosaminoglycans.
c. Have contractile properties.
d. Possess adrenergic teceptors.
e. Possess cholinergic receptors.

Trabecular meshwork cells line the aqueous channels and their activities promote aqueous
outflow. They create a non- thrombogenic surface that prevents adhesion of collapsed aqueous
channels, and they secrete GAGs that coat the luminal surface, reducing friction. Trabecular
meshwork cells have well developed phagocytic properties. With the aid of enzymes, including
tissue plasminogen activator and hyaluronidase, they are able to ingest and degrade solid
material such as cells, bacteria, necrotic tissue or foreign particles that might otherwise
accumulate in the meshwork. Recently, electrophysiological studies of cultured trabecular
meshwork cells have revealed intrinsic contractile properties. Smooth muscle myosin and a-
smooth-muscle actin have been demonstrated in a subset of trabecular meshwork cells,
especially in those inserting into the scleral spur. Aluscarinic agonists, endothelin and α1-
adrenergic agonists have been shown to stimulate contraction of these cultured cells. Numerous
receptors have been detected on trabecular meshwork cells, including those for catecholamines,
acetylcholine, histamine, prostaglandins, glucocorticoids, neuropeptides and some growth
factors.

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7.4.12 Trabecular meshwork and Schlemm‘s canal endothelial cells
a. Tight junctions exist between the trabecular meshwork endothelial cells.
b. Tight junctions exist between the endothelial cells of Schlemm‘s canal.
c. Aqueous crosses the endothelial cells via transcellular and paracellular routes.
d. Aqueous is transported through endothelial cells in large vacuoles.
e. The trabecular meshwork endothelial cells provide resistance to the outflow of
aqueous.

The exact nature of the junctions between the endothelial cells of the trabecular meshwork and
those of Schlemm‘s canal in human eyes has been studied using freeze-fracture techniques.
Numerous gap junctions have been demonstrated between the endothelial cells of the trabecsilar
meshwork, as have a discontinuous form of tight junction, but no definite zonulae occludentes
were evident. The nature of these intercellular junctions is thought to explain why these cells do
not provide resistance to the passage of aqueous. Numerous zonulae occludentes arranged in
branching and anastomosing patterns are present between the endothelial cells of Schlemm‘s
canal, suggesting a lower paracellular permeability. Although most aqueous passes through these
endothelial cells in large vacuoles (transcellular route), paracellular transport occurs via slit pores
or lacunae, the size of which appears to vary with different conditions of flow and pressure.

7.4.13 Intraocular pressure

a. Intraocular pressure always exhibits a diurnal rhythm.
b. It has a seasonal variation.
c. intraocular pressure is generally higher in males.
d. The diurnal variation is less in glaucomatous eyes.
e. Intraocular pressure increases with advancing age.

320
In most people intraocular pressure exhibits a diurnal rhythm, the peaks and troughs of which
vary between individuals. This iriation is exaggerated in glaucomatous eyes. The usual peak
occurs late in the morning (12.00—13.00), and the trough early in the morning (03.00-04.00).
Statistically, intraocular pressure higher in the winter and lower in the summer. There is little
difference between males and females until the age of 40, when the intraocular pressure becomes
generally higher in women. Intraocular pressure tends to increase with advancing age; the
reasons for this are multifactorial.

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7.4.14 Short term fluctuations in intraocular pressure
a. Intraocular pressure may increase in the extremes of gaze.
b. Intraocular pressure decreases during sleep.
c. Intraocular pressure decreases with the Valsalva manoeuvre.
d. Intraocular pressure may rise during i9nduction of anaesthesia.
e. Intraocular pressure decreases following strenuous exercise

The intraocular pressure exhibits a normal distribution in the population and has a mean value of
about 15—16 mmHg. Aside from the normal diurnal variation, short term fluctuations in
intraocular pressure are common. Sleep and general anaesthesia produce a prompt decrease in
intraocular pressure, because of a reduction in extraocular muscle tone. However, agents such as
suxamethonium can produce a transient but marked rise in intraocular pressure, which is
especially undesirable in patients with penetrating eye injuries. An> thing that raises the central
venous pressure, be it the Valsalva manoeuvre or a change in posture, will increase episcleral
venous pressure and hence the intraocular pressure. The intraocular pressure may be increased in
extremes of gaze, and such an elevation is a feature of restrictive myopathies such as thyroid eye
disease. Strenuous exercise can result in a transient reduction of the intraocular pressure
secondary to the metabolic acidosis of exercise, and/or as a result of changes in extracellular
fluid volume and osmolarity.

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7.5: The lens
7.5.1 Functions

The lens is responsible for:

a. Accommodation.
b. Maintence of transparency.
c. Eiltering infrated light.
d. The main refractive power of the eye.
e. Forming part of the blood aqueous barrier.

The lens accounts for approximately 30% of the refractive power of the eye and is capable of
changing shape so that images of objects at varying distances from the eye may be focused on
the retina—this is known as accommodation. Xo carry out these functions, the lens must remain
transparent. The lens will absorb light at the blue end of the visual spectrum but does not form
part of the blood aqueous barrier.

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7.5.2 Lens epithelium
a. The anterior lens epithelium continues to divide throughout life.
b. Lens epithelial and lens fibre cells contain α-crystallin.
c. Differentiation of lens epithelial cells s stimulated by fibroblast growth factor
(EGF).
d. Factors from the vitreous influence the differentiation of lens epithelial to lens fibre
cells.
e. Differentiation results in the loss of cell organelles and the nucleus.

The anterior lens epithelial cells continue to divide throughout life. Cell division is followed by
differentiation into lens fibre cells. Differentiation is stimulated by several factors, including
FGF derived from the ciliary body or retina, and by factors from the vitreous. Differentiation is
characterised by the loss of ceU organelles and the nucleus, and by the switch from a- crystallin
production to that of the βγ_crystallins.

7.5.3 Metabolism of the lens

a. 50% of lens glucose is metabolized via the glycolytic pathway.
b. The hexosemonophosphate shunt (pentose phosphate pathway) utilizes 10% of lenticular
glucose.
c. The citric acid cycle is a feature of lens fibre cell metabolism.
d. Lactate and ATP production are controlled by feedback inhibition of hexokinase.
e. Sorbitol accumulation in the diabetic lens is the major factor in diabetic
cataractogenesis.

Approximately 90% of lenticular glucose is metabolised via the glycolytic pathway. As the lens
fibre cells have no mitochondria, only epithelial cells are able to use oxidative phosphorylation
for further ATP production. Under physiological conditions most glucose is metabolised via
glycolysis to lactate, with the remaining

324
10% entering the pentose phosphate pathway for the synthesis of pentoses and NADPH. Lactate
and ATP production is regulated by feedback inhibition of phosphofructoldnase. This in turn
leads to an accumulation of glucose-6-phosphate and subsequent inhibition of hexokinase.
Sorbitol has been shown to accumulate in diabetic rat lenses, and this reaction was thought to be
secondary to the activity of aldose reductase. In fact, although the enzyme exists in the lens, it
does not bind glucose and has not been shown to produce sorbitol. Cataract formation in diabetes
is primarily caused by giycosylation of lens proteins, with the subsequent disruption of the
Na+/K+ ATPase pump, and not by sorbitol accumulation.

7.5.4 Biochemistry
a. Sodium 8is actively transported into the lens.
b. chloride passively diffuses into the lens.
c. The potassium content of the lens is five times that of the aqueous.
d. The glucose content is approximately one-sixth of that of the aqueous.
e. Amino acids are actively transported into the lens.

The sodium—postassium ATPase pump in the lens epithelium maintains a sodium concentration
of approximately 20 mmol/1 and a potassium concentration of 125 mmol/1 (25 times that of the
aqueous). Chloride ions follow an electrochemical gradient and passively diffuse into the lens.
Glucose is derived from the aqueous, as are amino acids which are actively transported across
the epithelium.

7.5.5 Glutathione

a. Glutathione is a five amino acid polypeptide.

b. Approximately 90% of glutathione is in the oxidized form.
c. Glutathione is involved in detoxification of free radiacals.
d. Glutathione helps maintain the integrity of lens proteins by preventing protein cross-
linkage formation.
e. A reduction of lens glutathione is a consistent finding in senile cataracts.

325
Glutathione (a three amino acid polypeptide) is found in high concentrations in the lens. Mostly
(93%) it is found in its reduced form (GSH), and is maintained thus by the NADPH produced by
the hexosemonophosphate shunt. Glutathione is vital for the maintenance of lens transparency in
maintaining the integrity of lens proteins of the sodium—potassium ATPase pump (by
preventing protein cross-linkages and maintaining essential thiols). A reduction of lens GSH is a
consistent finding in senile and all tested experimental cataracts. Glutathione peroxidase is
involved in the detoxification of hydrogen peroxide., some of which is formed from 02_ radicals.

7.5.6 Proteins and protein breakdown in the lens

a. Protein accounts for 33% of the lens weight.
b. Crystallins account for 90% of lens proteins.
c. Crystallins are found only in the lens.
d. Active proteolysis occurs throughout the lens.
e. Calpain II degrades α-and β-crystallins.

The protein content of the lens (33% of the lens weight) is higher than that of any other tissue in
the body. The crystallins are soluble proteins that account for 90% of the total protein content.
Crystallins were thought to be unique to the lens, but over the past decade they have been
identified in many other tissues, including the heart, skin, brain, retina, muscle, kidney and lung.
Protein synthesis occurs only in peripheral lens cells. Proteins in fibre cells must therefore
survive many decades if enzymic functions and the integrity of gap junctions are to be preserved.
Therefore active proteolysis is not a feature of lens fibre cells, although it occurs in peripheral
cells. Calpains are calcium-activated cytosomial cysteine proteinases, and calpain II is the
predominant form in the lens. It degrades a- and J$- crystallins, actin and some membrane
proteins. Ubiquitin is another protein involved in lenticular proteolysis. It binds damaged
proteins and these complexes are then digested by ATP-dependent proteases.

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7.5.7 α-crystallins

a. α-crystallin is the largest lenticular protein.

b. the αA and αB subunits of α-crystallin undergo post-translational modification.
c. α-crystallins protect glutathione reductase from inactivation.
d. α-crystallins inhibit the heat induced aggregation of β-crystallins.
e. The αA- and αB-genes are located on chromosome 21 in humans.

Human lenticular crystallins are classified as α-crystallins r βγ-crystallins. Α-crystallins are the
largest lenticular proteins and consist of 30-40 subunits, which are of two types, αA and αB.
These subunits undergo extensive enzymic and non-enzymic post-translational modification, the
complexity of the changes increasing with age. As in all crystallins the basic structure is a β-
sheet; the tertiary and quaternary structure is a matter for debate. As these large molecules will
scatter light, the transparency of the lens is achieved by configuring the crystallins in an
arrangement with short-range order. Crystallins were until recently regarded as purely structural
proteins, but the discovery that α-crystallin acts as a ―molecular chaperone‖ has aroused
considerable interest in thses proteins. Molecular cgaperones

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are proteins that exert a protective influence over other proteins when they are in a vulnerable
state. Examples of this protective effect include the prevention of heat induced aggregation of
numerous proteins, including β-crystallins, and the prevention of glycatioh induced inactivation
of enzymes such as giutathione reductase. This chaperone activity may help to explain how
proteins can survive for such long periods in the lens. The αA and αB genes in humans are found
on chromosomes 21 and 11 respectively.

7.5.8 βγ-crystallins and other crysiallins

a. The secondary structure of β-and γ-crystallins is a β-sheet.
b. β-and γ-crystallins have a similar tertiary structure.
c. β-crystallins exist in acidic (A) and basic (B) forms.
d. All human β-crystallin genes are located on chromosome 22.
e. e-crystallin is closely related to lactate dehydrogenase.

Although β- and γ-crystallins are related to each other and considered as one group, the
homology between them is weak and they can be easily distinguished on the basis of size. β-
crystallins are aggregates of polypeptides (23—35 kDa) whereas γ-crystallins are monomers of
20 kDa. Both form β-sheets but the tertiary structures of β- and γ-crystallins are quite different.
There are acidic (A) and basic (B) β-crystallins. The genes for βBl3 βB2, βB3, and βA4 are
clustered on chromosome 22, the βA1/A3, gene is located on chromosome 17, and the βA2 and
yγ- crystallin genes are found on chromosome 2. Other crystallins found in the lenses of birds
and reptiles appear to be related to enzymes, ε-crystallin (present in birds) is identical to an
active lactate dehydrogenase isoenzyme, and δ-crystalIin (rodents and camels) is related to the
alcohol dehydrogenases but is in fact an active NADPH: quinone oxidoreductase. It appears that
in the course of evolution these proteins, which were once enzymes, have been converted to
structural proteins in the lens.

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7. 5. 9 Lens membranes and intercellular junctions
a. 4, 5-dihydrosphingomyelin is the major component of lenticular plasma membranes.
b. There is no turnover of the plasma membrane in mature lens fibre cells.
c. Lens fibre and epithelial cells are rich in gap junctions.
d. Gap junctions consist of 12 connexins.
e. Major intrinsic protein (MIP) is a constituent of water channels in epithelial and fibre
cells.

Lipids account for 5% of the dry weight of the lens. Lenticular membrane lipid is mostly
sphingolipid and cholesterol, the major component being 4,5-dihydrosphingomyelin, and not
sphingomyelin as was once thought. Membrane lipids are produced only by peripheral cells, and
there is no turnover of lipid in the membranes of mature fibre cells. Lens fibre and epithelial cells
are rich in gap junctions. These intercellular communications are highly specialised organelles
which, unlike other channels, span the plasma membrane of the adjacent cells. Connexins are
protein molecules that make up gap junctions and each cell contributes six connexin molecules
forming half the channel, known as a connexon. The numerous gap junctions facilitate electrical
coupling between cells. Recent studies have questioned the assumption that metabolites such as
glucose and amino acids pass freely between cells via the gap junctions, and it may be that
specific transporters and endocytosis are responsible for intercellular transport of these
molecules. Major intrinsic protein (MIP) is the principle protein constituent (50%) of fibre cell
membranes, but it is absent from epithelial cells. MIP forms water channels that are closed by
calcium and calmodulin. This ability to close reduces with age, resulting in open water channels
from cell to cell in the lens nucleus.

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7.6: Accommodation
7.6.1 Optics of the lens

a. The anterior radius of curvature is 6 mm.

b. The posterior radius of 8c4ruvature is 10 mm.
c. The refractive index of the nucleus is greater than that of the cortex.
d. The accommodative power is approximately 14 dioptres in a 10 year old.
e. Lens size increases throughout life.

The anterior curvature of the lens is 10 mm and that of the posterior surface 6 mm. However,
these values will change with age because the cells of the equatorial lens epithelium continue to
divide throughout life, increasing the size of the lens. The refractive index of the lens nucleus is
approximately 1.41, great than that of the lens cortex, which is 1.39. The accommodate power of
the lens of a 10 year old is approximately 14 dioptres—this decreases to 10 dioptres by the age of
20.

7.6.2 Lenticular changes in accommodation

a. The anterior pole of the lens moves forward.

b. Axial width of the lens increases.
c. There is no change in tension of the lens capsule.
d. The lens always moves inferiorly.
e. There is a physiological lentoconus.

In accommodating for near vision the circular ciliary muscle contracts, decreasing the tension in
the zonular fibres, an. allowing the lens capsule to contract and change the shape c the lens. The
anterior pole moves anteriorly, the axial width increases and the equatorial diameter of the lens
decreases. The lens will move in the direction of gravity as the zonule slackens this will only be
inferiorly if the person is upright. The anterio curvature was considered to increase to a greater
extent than the posterior curvature, causing a physiological lentoconus, but

330
although this appears to be true when using the slitlamp it is probably an artefact of
corneal refraction.

7.6.3 The near triad

a. Pupillary dilatation, accommodation and convergence make up the triad.
b. The near triad is a ture reflex.
c. Accommodation occurs first.
d. The papillary response is slower than the response to light.
e. Blur is the main stimulus to a ccommodation.

The near triad consists of convergence, accommodation and pupillary constriction (not
dilatation). It is not a true reflex but is a synkinesis—no component of the triad depends on the
other two for its appearance^ so that if accommodation is prevented (using a convex lens) and
the eye converges to the near point the pupil will still constrict. Accommodation is the slowest
reaction of the triads taking between 0.56 s (near to far) and 0.64 s (far to near). The main
stimulus for accommodation is image blur. The pupillary response is approximately 0.26—0.2 s;
this is slower than the reaction to light.

7.6.4 Lens capsule

a. The capsule is of uniform thickness.
b. Capsular changes are active.
c. Intralenticular pressure is greatest in the unaccommodated state.
d. The lens capsule is more fragile in the diabetic.
e. Capsular antigens are similar to those found in glomerular basement membranes.

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The lens capsule is not uniformly thick, the capsule over the anterior and posterior poles being
slightly thinner than the equatorial capsule. The capsule is inherently elastic and changes in its
shape (which are passive) occur because of increased pressure within the lens in the
unaccommodated state. The capsule is more fragile in the diabetic lens. Capsular antigens are
similar to those found in glomerular basement membranes.

7.6.5 Properties of zonular fibres

a. Zonular fibres connect the ciliary process to the lens.
b. Zonular fibres are uncrossed.
c. Zonular fibres connect the pars plana to the vitreous.
d. Zonular fibres are acellular and have no metabolism.
e. Cystine makes up approximately 7% of fibre weight

Zonular fibres arise from the ciliary body and may be divided into two groups: those that pass
from the ciliary processes to the lens, most of which attach to the anterior or posterior lens
capsule rather than the equator and do not seem to cross each other; and zonular fibres that either
form a meshwork across the ciliary body, or extend from the pars plana to the vitreous body to
form part of the vitreous base. Both types are acellular and have a cystine concentration of
approximately 7%. This explains why lens dislocation is a common feature of homocystinuria.

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7.1.6 Properties of the ciliary muscle
a. This is a striated muscle.
b. The ciliary muscle is stimulated by muscarinic antagonists.
c. Contraction of the ciliary muscle causes accommodation.
d. The ciliary muscle is attached to the sclera spur.
e. This muscle is composed solely of longitudinal fibres

The ciliary muscle is a smooth muscle consisting predominantly of longitudinal fibres that bend
anteriorly to form a circle. Other ongitudinal fibres pass to the anterior choroid and oblique fibres
pass to the scleral spur. When stimulated by muscarinic agonists the ciliary muscle produces
accommodation, and pulls the choroid anteriorly—the increased traction on the trabecular ibres
via the scleral spur aids aqueous outflow.

7.6.7 Changes in accommodative power

a. Accommodation is well developed by 2 months.
b. The accommodative power for a 20 year old is approximately 10 dioptres.
c. The accommodative power of a 2 year old is approximately 20 dioptres.
d. Accommodation is absent by the age of 60.
e. Accommodative loss is seen in Adie‘s syndrome.

Accommodation begins to develop at the age of 2 months and s well developed by the eighth
month of life. The accommodative power of a 2 year old lens is approximately 20 dioptres. By
the age of 20 years this has decreased to 10 dioptres, and at 60 years of age accommodation is no
longer possible. In Adie‘s syndrome damage to the ciliary ganglion causes loss of
accommodation and explains the initial symptom, which is blurring of vision.

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7.7: The vitreous
7.7.1 Physical properties
a. The vitreous weighs approximately 3.9g.
b. The volume of the vitreous in an emmetropic eye is approximately 7 ml.
c. The refractive index of vitreous is 1.5.
d. The vitreous is 80% water.
e. The vitreous does not transmit light below 300 nm.

The vitreous is a hydro sol—gel structure weighing approximately

3.9 and in emmetropic eyes has a volume of approximately 3.9ml (this may be significantly
greater in myopic eyes). The refractive index is similar to that of aqueous (1.335). Vitreous is
98—99% water, and this water has a turn over time of 10—15 minutes. Most (90%) of visible
light passes through the vitreous, but transmission is zero for wavelengths less than 300 nm.

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7.7.2 Properties of collagen

a. Collagen is the most common proteinin the animal world.

b. Collagen is produced by fibroblasts.
c. Type IV collagen is found predominantly in connective tissues.
d. types I-III collagen are found in basement membranes.
e. A collagen molecule is made of two separate polypeptide chains wrapped in a
helix.

Collagen, produced by fibroblasts, is the most common protein in the animal world and provides
the extracellular framework for all multicellular organisms. A basic collagen unit (known as
tropocollagen) is made of three polypeptide chains arranged in a left-handed helix. Type I—III
collagens are known as interstitial or fibrillar collagen; type I accounts for 80% of collagen in
skin and 90% in bone. Types IV—XI do not form fibrils but appear as amorphous material in
interstitial tissue or basement membranes.

7.7.3 Collagen synthesis

a. The initial stage is transcription and translation of the α chains.
b. Each α chain has a triple repetitive amino acid sequence.
c. Hydroxylation of proline occurs in the rough endoplasmic reticulum and is vitamin
G dependent.
d. The true fibrils are formed in the Golgi apparatus.
e. Lysine oxidation results in cross linkages between α chains.

Collagen synthesis is initiated by DNA transcription, followed by the processing of mRNA

precursors and translation of the α chains (which have a triple repetitive amino acid sequence) in
the ribosomes. The α chains move off the ribosomes into the cisternae of the rough endoplasmic
reticulum, where modifications (such as the vitamin C dependent hydroxylation of proline and
glycosylation) occur. The triple helix is formed in the rough endoplasmic reticulum and passes
unchanged

335
through the Golgi apparatus. The terminal peptide chains are cleaved shortly after excretion from
the cell. The critical extracellular modifications of collagen are lysine oxidation and formation of
cross-links—these are the main contributors to its tensile strength.

7.7.4 Vitreous collagen

a. Type II collagen accounts for 90% of vitreous collagen.
b. Type IX collagen is found in the vitreous.
c. Type V/XI collagen is found in the vitreous.
d. Type IV collagen is found in the vitreous cortex.
e. Vitreous collagen abnormalities are a feature of Stickler‘s syndrome

336
Type II collagen is the predominant (90%) collagen in the vitreous; the type II molecules are
arranged in a staggered array with lysine-derived cross-links between molecules. Type IX
collagen accounts for about 10% of vitreous collagen; crosslinks also exist between type IX and
type II collagens. Type V and type XI collagens were thought to be separate collagen types but
are now placed in the same family. Type V/XI collagen is found in small amounts in the
vitreous. Type IV collagen is a basement membrane collagen and is therefore not found in the
vitreous. Immunohistochemical and ultrastructural studies of the posterior hyaloid membrane,
from patients noted to have had a premortem posterior vitreous detachment (PVD), have shown
that this structure is a distinct membrane that stains for type IV and that the arrangement of
collagen fibrils is markedly different from that of the posterior vitreous cortex. These studies
suggest that the posterior hyaloid membrane is wholly, or part of, the internal limiting membrane
of the retina, and is not, as traditionally thought, condensed vitreous cortex. Stickler syndrome is
a multisystem autosomal dominant disorder of type II collagen. Patients have characteristic
vitreous abnormalities and have a high risk of developing giant retinal tears and retinal
detachment.

7.7.5 Biochemistry of the vitreous

a. Hyaluronan is the major glycosaminoglycan in the vitreous.
b. The glycoprotein content is higher than that of the aqueous.
c. Na f and K+ concentrations are approximately the same as those of the aqueous.
d. The ascorbic acid concentration is similar to that of plasma.
e. There are no lipids in the vitreous.

Hyaluronan is the major glycosaminoglycan in the vitreous. The exact relationship between
hyaluronan and the vitreous collagen remains unclear, although there is some evidence that
hyaluronan interacts via chondroitin sulphate chains on type IX collagen, which coats the larger
type II collagen fibrils. Glycoproteins constitute 20% of the non-collagenous protein content of
the vitreous and are derived from plasma or synthesised by the

337
ciliary epithelium. The glycoprotein content of the vitreous is five times that of the aqueous.
Exchange of electrolytes occurs between the lens, retina, vitreous and the aqueous. The Na+ and
K+ concentrations in the vitreous and aqueous are approximately equal. The ascorbic acid
concentration in the vitreous is almost 10 times that of plasma, because of active transport by the
ciliary epithelium. Saturated and unsaturated fatty acids are present in the vitreous.

7.8: The pupil

7.8.1 The normal pupil

a. The diameter of the adult pupil can change from 2 to 9 mm.
b. Simple anisocoria (≤ 0.4 mm) is found in 10% of the population.
c. Simple anisocoria maychange sides from day to day.
d. The pupil is normally positioned slightly superonasally.
e. Hippus refers to a physiological tremor.

The pupil is capable of changing its diameter from 2 to 9 mm (an 87% change). Simple
anisocoria is found in approximately 25% of the population and may change sides from day to
day. The pupil is normally situated slightly inferonasally and has a physiological tremor, known
as hippus.

7.8.2 Pupillary reaction to light

a. Latency, amplitude and duration of contraction all increase with increasing stimulus
strength.
b. Speed and size of contraction reach a plateau at 7-9 log units above the scotopic
threshold.
c. The latent period varies from 0.2 to 0.5 s (depending on the light source).
d. The pupil can respond o light frequencies up to 10 Hz.
e. The papillary reaction to light is quicker than that to accommodation.

338
With light intensity up to 9 log units above threshold the strength and duration of pupillary
contraction increases and the latency period decreases. At intensities above 9 log units, the
pupillary response plateaus off. The latent period is 0.2—0.5 s; less than that for constriction
induced by accommodation. The pupil is not capable of responding to stimuli with a frequency
greater than 5 Hz.

7.8.3 Effects of increasing pupil size

a. A decreased depth of field.
b. An increased depth of focus.
c. An increased Stiles-Crawford effect.
d. Decreased diffraction of light.
e. Increased chromatic aberration.

Pupillary dilation will decrease the depth of focus and depth of field, the converse being true for
pupillary constriction. Light entering the eye at the edge of the pupil is less effective at
stimulating photoreceptors than light entering at the centre. This is because of the shape of the
receptors and the fact that light hits them obliquely, not axially. This effect (the Stiles—
Crawford effect) is increased with mydriasis. As pupillary size increases diffraction of light
decreases and chromatic aberration increases.

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7.8.4 Light reflexes
a. The integrity of both anterior visual pathwayscan be tested with only one functioning
pupil.
b. There will be a normal indirect (consensual) light reflex in an eye ipsilateral to a
unilateral optic nerve lesion.
c. An impaired indirect papillary reaction alone is of no clinical significance.
e. The papillary light reflexes will be abnormal in occipital cortex lesions.

The integrity of the anterior visual pathways can be adequately tested with only one functioning
pupil, by assessing both direct and indirect (consensual) pupillary light reflexes. An optic nerve
lesion will not affect the efferent pupillary pathway, therefore the indirect light reflex will be
normal in an eye ipsilateral to a unilateral optic nerve lesion. An impaired indirect pupillary
reaction alone is usually of no clinical significance. The most useful clinical sign when assessing
the integrity of the anterior visual pathways is a relative afferent pupillary defect. This describes
the ―paradoxical‖ dilation seen when a light is ―swung‖ from a healthy eye to one ipsilateral to
an anterior visual pathway lesion, and is best demonstrated with the swinging light test. Cataracts
do not cause relative afferent pupillary defects. If an afferent defect exists in the presence of a
cataract there will invariably be coexisting retinal or optic nerve pathology. Pupillary reflexes are
brain stem reflexes and are therefore unaffected by cortical lesions.

7.8.5 Which of the following may cause an efferent pupillary defect?

a. Mid brain lesion at the level of the inferior colliculus.

b. Compressive lesion of the third cranial nerve.
c. Uncal herniation.
d. Inadvertant exposure to a mydriatic.
e. Lesion of the ciliary ganglion.

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Efferent pupillary defects are characterised by a fixed dilated pupil. The causes of an efferent
defect may be classified as allows. (1) Brain stem lesions at the level of the superior colliculus
and red nucleus. Lesions here are often accompianied by long tract signs. (2) Fascicular third
nerve lesions. Compressive third nerve lesions classically have pupillary involvement, although
an efferent defect is not pathognomonic of a compressive lesion as 20% of microvascuiar palsies
will affect the pupillary fibres. An efferent pupillary defect may be i false localising sign when
raised intracranial pressure causes uncal herniation and compression of the third nerve. (3)
Lesions of the ciliary ganglion or short ciliary nerves. (4) Iris damage secondary to previous
surgery or grossly elevated intraocular pressure. (5) Drugs: inadvertent exposure to a mydriatic
agent such as atropine is a common cause of fixed dilated pupil. Pilocarpine 1% will constrict a
dilated pupil secondary to a neurological lesion; it will have no effect on a dilated pupil caused
by a mydriatic agent.

7.8.6 Mydriasis

a. Mydriasis is caused by cholinergic agonists.

b. Mydriasis is caused by sympathomimetics.
c. Phenylephrine produces mydriasis evne in bright light.
d. Phenylephrine produces a rebound miosis.
e. Synthetic anticholinergics are more effective than belladonna alkaloids.

Mydriasis is produced by contraction of the dilator pupillae, which is stimulated by

noradrenergic sympathetic nerves that pass through the ciliary ganglion: sympathomimetic
agents will therefore cause dilation. Cholinergic agents will constrict the pupil by stimulating the
sphincter muscle. Phenylephrine (unlike atropine) is incapable of producing mydriasis in bright
light and will produce a rebound miosis. Cocaine exerts its mydriatic effect by preventing
noradrenaline reuptake. Synthetic anticholinergics such as homatropine and cyclopentolate are
less effective mydriatics than belladonna alkaloids such as atropine.

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7.8.7 Mydriatic agents
a. Heroin produces mydriasis.
b. Nicotine produces mydriasis.
c. Amphetamine produces mydriasis.
d. Alcohol produces mydriasis.
e. Cocaine causes mydriasis by increasing noradrenaline release from nerve
terminals.

Heroin will cause miosis (pinpoint pupils) by reducing the cortical inhibition of the Edinger—
Westphal nucleus. Nicotine will produce mydriasis, as will alcohol. Amphetamine produces
mydriasis by increasing noradrenaline release from nerve terminals: cocaine has a similar
effect by preventing
noradrenaline reuptake into the nerve terminals.

7.8.8 Causes of miosis

Miosis is caused by:
a. Parasympathomimetics.
b. Catbachol inhibiting acetylcholine release.
c. Physostigmine.
d. Thymoxamine.
e. Hydroxyamphetamine.

Stimulation of the sphincter pupillae via cholinergic postganglionic parasympathetic neurones

from the ciliary ganglion causes miosis. Carbachol causes miosis by increasing acetylcholine
release, whereas physostigmine has its effect by inhibiting acetylcholinesterases. Thymoxamine,
an α adrenergic blocker, produces miosis by paralysing the dilator muscle. Hydroxyamphetamine
increases noradrenaline release from nerve terminals and so causes mydriasis.

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343
344
7.8. 9 Homer‘s syndrome

a. Facial anhyydrosis is not a feature of postganglionic Horner‘s syndrome.

b. There is an increased anisocoria in dim light.
c. Preganglionic lesions are usually more sinister than postganglionic lesions.
d. Coaine will dilate a Horner‘s pupil.
e. Hydroxyamphetamine (1%) and adrenaline (1:1000) will both dramatically dilate
the pupil in postganglionic lesions.

Homer‘s syndrome is caused by an interruption of the sympathetic chain in the head and neck
and may be secondary to central (brain stem) lesions, preganglionic and postganglionic lesions.
Anisocoria is increased in dim light because the normal pupil will dilate, whereas the Horner‘s
pupil will not. The postganglionic sympathetic fibres that control facial sweating ―travel‖ on the
external (not the internal) carotid artery and are therefore not affected by a postganglionic
Horner‘s syndrome. Preganglionic lesions are usually more sinister, being caused by lesions such
as a Pancoast lung tumour. Pharmacological testing may be helpful, firstly in making the
diagnosis of Homer‘s syndrome, and secondly in localising the lesion. Cocaine, which prevents
the reuptake of noradrenaline at the adrenergic synapse, will not dilate a Horner‘s pupil but will
cause dilation in the normal eye. Hydroxyamphetamine will dilate a preganglionic or central
Homer‘s pupil if the postganglionic pathway is intact. However, it will have no effect on a
postganglionic Homer‘s pupil. There is no pharmacological test that can differentiate between a
central and a preganglionic Homer‘s pupil. Postganglionic lesions exhibit denervation
hypersensitivity and will therefore dilate with 1:1000 adrenaline.

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7.8.10 Light near dissociation

a. This is present only if the near response is greater than the response to bright light.
b. light near dissociation may be due to a normal light response and hyperactive near
response.
c. It is a feature of Horner‘s syndrome.
d. Light near dissociation may be caused by a pretectal lesion.
e. Light near dissociation may be seen in third nerve lesions.

Light near dissociation is present only if the near response is greater than the response to bright
light, and is always due to a diminished light response (not a hyperactive near response).
Pretectal lesions, such as that seen in the Sylvian aqueduct syndrome, produce light near
dissociation. Third nerve lesions can (surprisingly) cause a light near dissociation, not by sparing

346
of ―near‖ fibres but rather by aberrant reinnervation of the sphincter muscle by . neurones
normally supplying the medial rectos. .Lesions causing light near dissociation are illustrated in
Figure 7.16.

7.8.11 Features of Argyll Robertson pupils

a. Argyll Robertson pupils are small.
b. Argyll Robertson pupils may be confused with peripheral neuropathies.
c. Phasostigmine causes increased constriction.
d. Atropine causes dilation.
e. The lesion is situated in the ciliary ganglion.

The Argyll Robertson pupil was originally described in 1869 in a series of patients with tabes
dorsalis. These patients had light sensitive retinas, a good pupillary near response but did not
respond to light. The pupils were small, did not width atropine and constricted further with
physostigmine. The exact site of the lesion is not known but is thought to be in the vicinity of the
pretectal nuclei.

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7.8.12 Features of Adie‘s pupils
a. Adie‘s pupils exhibit light near dissociation.
b. Adie‘s pupils are supersensitive to cholinergics.
c. Blurred vision is often a presenting symptom.
d. Involvement of ht second eye is often unnoticed by the patient.
e. The lesion is thought to involve the Edinger-Westphal nucleus.

The light reaction of Adie‘s pupils is sluggish and the response is usually strong and tonic. The
supersensitivit cholinergics is a post denervation phenomenon, as this condition is produced by a
ciliary, ganglion lesion. The first symptom usually blurred vision caused by accommodative
paresis. If second eye becomes involved the patient (often in her late 40s) might not notice this
loss of accommodation.

7.9: The extraocular muscles and eye movements

7.9.1 Frames of reference and gaze positions

a. The fixed point of the centre of rotation is 13.5 mm posterior to the corneal apex.
b. The fixed point of the centre of rotation is 1.6 mm to the temporal side of the
geometric centre.
c. Movement to the secondary position involves rotation about X or Z axes.
d. The tertiary position is achieved by movement around the X and Z axes
simultaneously.
e. Tertiary gaze positions are associated with true torsion.

The fixed point of the centre of rotation is 13.5 mm posterior to the corneal apex and 1.6 mm to
the nasal side of the geometric centre. Fick‘s axes include a horizontal X axis, a horizontal Y

348
axis (90° to the X, which passes through the pupil) and a vertical X axis. The secondary gaze
positions are achieved by rotation around the X or Z axes, whereas tertiary gaze or oblique
positions are achieved by simultaneous rotation about- the X and Z axes. The torsional
movements associated with tertiary gaze positions are false.

7.9.2 Muscle action in the isolated agonist model

a. The primary action of the medial rectus is adduction.
b. The primary action of superior oblique is depression.
c. The primary action of superior rectus is elevation.
d. The primary action of inferior oblique is excyclotorsion.
e. The primary action of inferior rectus is depression.

The primary action of the muscle in the isolated agonist model is that movement which occurs
when the muscle contracts with the eye in the primary position. The medial rectus is an adductor
and has no secondary actions. The superior oblique is primarily an incyclotortor, but when
adducted to 54° its prime action is depression. The inferior oblique‘s primary action is excyclo-

349
torsion and it is an elevator in adduction. The superior and inferior recti muscles are primarily
elevators and depressors respectively.

7.9.3 The following are yoked muscles

a. Right lateral rectus, left medial rectus.
b. Right superior rectus, left inferior oblique.
c. Right superior oblique, left inferior oblique.
d. Right inferior rectus, left superior oblique.
e. Right inferior oblique, left superior rectus.

Yoked muscles contract to move both eyes in the same direction, that is, the right lateral rectus
and left medial rectus both move the eyes to the right. The superior oblique on the right and
inferior rectus on the left moves the eyes down and to the left. The right inferior rectus and the
left superior oblique move the eyes down and to the right.

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7.9.4 Torsional movements

a. The torsional action of the superior is maximal in abduction.

b. The torsional action of the inferior rectus is maximal in adduction.
c. The superior rectus causes incyclotorsion.
d. The inferior rectus causes incyclotorsion.
e. The amount of false rorsion associated with any tertiary position of gaze is constant
regardless of how the eye achieved that position.

The superior rectus causes elevation (which is maximal if the eye is aducted 24°), and
incyclotorsion (which is maximal on adduction or medial gaze). The inferior rectus causes
depression (which is maximal in 24° of abduction) and excyclotorsion (which is maximal in
adduction). Donder‘s law states that the amount of false torsion associated with any tertiary
position gaze is constant, regardless of how the eye achieved that position.

7.9.5 Control of extraocular movement

a. The semicircular canals detect rotational movements.
b. The semicircular canals connect with the inferior and medial vestibular nuclei.
c. The utricle and the saccule detect head tilting movements.
d. The floculonodular lobe is intimately involved with the vestibular input to the
extraocular muscles.
e. The vestibulospinal inputs are of prime importance in the regulation of the
extraocular muscle position.

The semicircular canals detect rotatory movements of the head and connect with the superior and
medial vestibular nuclei. The utricle and saccule detect head tilting (gravitational effects) and
connect with the inferior and medial nuclei. The floculonodular lobe of the cerebellum mediates
vestibular inputs to the oculomotor system, whereas the vermis is involved with initiation eye
movements. Although vestibular spinal inputs from

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cervical proprioceptors play an important role in controlling eye movements in certain mammals,
they are of minimal importance in humans.

7.9.6 Influences on extraocular muscle control

a. The superior colliculus is retinotopically mapped.
b. The superior colliculus responds to auditory stimulation.
c. The vermis is involved with initiation of eye movements.
d. Frontal eye fields mediate contralateral saccadic eye movements.
e. The inferior colliculus is connected to the extraocular muscle nuclei.

The superior colliculus is retinotopically mapped and connected to the extraocular muscle nuclei,
unlike the inferior colliculus which is involved in auditory pathways. The cerebellar vermis is
involved with initiation of eye movements, and frontal eye fields mediate contralateral saccadic
eye movements.

7.9.7 Version and mergence

a. Hering‘s law applies to vergence movements.
b. Version movements are quicker than vergence movements.
c. Retinal disparity is a stimulus for version movements.
d. Section of the corpus callosum inhibits vergence.
e. Version movements form part of the near triad.

In versional movements the eyes move in die same direcdon—the visual axes of the eyes remain
parallel. Hering‘s law states that in all voluntary conjugate movements equal and simultaneous
innervation flows from ocular motor centres to the muscle: establishing the direction of gaze.
Vergence movements arc slower than versional movements, are stimulated by retinal disparity
(as opposed to blur), and are inhibited by section of the corpus callosum. They also form part of
the near triad.

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7.9.8 Smooth pursuit movements
a. The function of smooth pursuit movement is to keep an object of interest on the
fovca.
b. The maximum velocity of these movements is 20° per second.
c. Occipitoparietal lesions may lead to loss of smooth pursuit to the ipsilateral side.
d. Frontal lobe lesions may lead to loss of smooth pursuit of the contralateral side.
e. Smooth pursuit movements have a latency of 50 ms.

Smooth pursuit movements are designed to keep an object of interest on the fovea. They have a
velocity of up to 100° per second, a latency of 125 ms and they constitute the slow component of
optokinetic nystagmus. Smooth pursuit movements emanate from an area in the occipitoparietal
region. Destructive lesions (as opposed to vascular lesions) in this area may disrupt smooth
pursuit to the ipsilateral side, leading to asymmetrical optokinetic nystagmus (Cogan‘s law). The
frontal lobe is involved with saccadic movements but not smooth pursuit movements.

7.9.9 Saccadic movements

a. The usual stimulus is an object of interest in the peripheral visual field.
b. Saccadic movements have a maximum velocity of 400° per second.
c. Saccadic movements are produced by ―burst-tonic‖ neurons.
d. Saccadic movements are initiated by the frontal cortex.
e. Visual threshold increases during saccades.

Saccadic movements are designed to place an object of interest in the peripheral visual field on
to the fovea. They are the fastest of all eye movements, with a velocity of up to 400° per second
and are controlled by the frontal cortex. The neurones involved are

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―burst-tonic‖ neurones, which produce a biphasic movement. The initial ―pulse‖ phase and the
following ―step‖ phase are matched by the floculus to produce a smooth movement. During the
saccade there is an increase in the visual threshold.

7.9.10 Fixation movements

a. Drifts are binocular.
b. Microsaccades are monocular.
c. Tremors may have a frequency of up to 80 Hz.
d. Drifts have a maximum amplitude of 30.
e. The amplitude of tremors is approximately 10-30 of arc.

Fixation movements are designed to move the retinal image by very small distances at regular
intervals and prevent the image fading due to persistent bleaching of photoreceptor pigments
(Troxler‘s phenomenon). Drifts are monocular and have a maximum amplitude of 6'.
Microsaccades are binocular. Tremors can have a frequency of up to 80 Hz and have an
amplitude of 10—30' of arc.

7.9.11 Optokinetic nystagmus

a. Optokinetic nystagmus is a mixture of saccadic and slow movements.

b. Optokinetic nystagmus may be elicited by a striped drum revolving at speeds of 30-
200° per second.
c. Optokinetic nystagmus is an accurate test of visual acuity.
d. Direction of initial eye movement varies according to the attentiveness of the subject.
e. A central scotoma decrease the maximum speed at which optokinetic nystagmus may
be elicited.

Optokinetic nystagmus is a biphasic movement that can be elicited by a striped drum revolving
at 30—100° per second. The smooth pursuit component is a compensatory movement and is
followed by a quicker saccadic movement. To elicit optokinetic nystagmus the patient must be
attentive: if he or she pays

354
particular attention to the drum, the initial movement is saccadic (predictive in the direction to
which the stripe entered the peripheral field); if not, the initial movement is compensatory le
direction of the revolving drum. Optokinetic drums may be used as a crude measure of visual
acuity, and may be useful in case of ―hysterical‖ visual loss. The presence of a central scotoma
will increase the frequency at which optokinetic nystagmus can be elicited.

7.9.12 Vestibulo-ocular reflexes and caloric testing

a. Stimulation of a semicircular canal leads to nystagmus in the plane of that canal.

b. The slow phase is always in the same direction as the movement causing the
nystagmus.
c. Hot water in the right ear causes nystagmus with a quick phase to the right.
d. Cold water in the left ear causes nystagmus with a slow phase to the left.
e. Bilateral stimulation causes vertical nystagmus.

Floren‘s law states that stimulation of a semicircular canal leads nystagmus in the plane of that
canal, the slow phase of which always in a direction opposite to that causing the nystagmus, le
direction of the nystagmus always refers to the fast saccadic component. With a patient‘s head
held backwards at 60° the horizontal canal predominates and caloric testing may be carried it.
Warm water causes the endolymph to rise in the horizontal canal, stimulating the end organ. This
is equivalent to an ipsilateral head turn and causes a smooth eye movement to the contralateral
side, which is followed by a corrective fast saccadic movement to the ipsilateral side. The
opposite is true if cold water is used (cold opposite warm same: COWS). Vertical /nystagmus
will be elicited by bilateral stimulation.

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7.9.13 The follozuing reduce the response to caloric testing

a. Fixation on an object.
b. Darkness.
c. Optokinetic stimuli.
d. High plus lenses.
e. Decreased visual acuity.

The response to caloric testing is reduced by fixating intently on an object and by an optokinetic
stimulus. Scotopic conditions and high plus lenses will stimulate the response but decreased
visual acuity has no effect.

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7.10: The retina

7.10.1 Properties of retinal neurotransmitters and neuromodulators

a. Retinal neurotransmitters are synthesized and stored in the oresynaptic cell.
b. Retinal neurotransmitters interact with postsynaptic receptors producing an action
potential.
c. Retinal neurotransmitters are all rapidly degraded in the postsynaptic cleft.
d. Neuromodulators elicit a more distant and long lasting response than
neurotransmitters.
e. Feedback effects in the retina are generated by excitatory neurotransmitters.

Neurotransmirters and neuromodulators are responsible for ntracellular communication in the

retina. Retinal neuro- transmitters are described as putative transmitters because they io not
always fit the exact criteria of a neurotransmitter. For example: (1) retinal neurotransmitters are
synthesised and stored in a presynaptic cell; (2) release occurs when the presynaptic neurone is
stimulated; (3) retinal neurotransmitters produce regional hyperpolarisation or depolarisation in
the postsynaptic neurone, rather than action potentials, the exception to this being the ganglion
cell; (4) retinal neurotransmitters are removed from the synaptic cleft or postsynaptic membrane
by degradation., or by reuptake into the presynaptic neurone.

Feedback pathways in the retina generally involve inhibitory rather than excitatory
neurotransmitters. Neuromodulators are also released from nerve processes; they exert a more
distant effect and have a longer acting response than neurotransmitters.

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7.10.2 Glutamate
a. Always acts as an excitatory neurotransmitter in the retina.
b. Receptors are found on all second and third order retinal neurons.
c. Is converted to aspartate by transmination.
d. Receptors are all ionotropic receptors (i.e. regulate Na*/ K+ permeability).
e. Is broken down by enzymes in the postsynaptic cleft.

Glutamate is the major excitatory neurotransmitter in the ―through retina‖ vertical pathway,
although it acts in an inhibitory fashion at the cone photoreceptor—ON bipolai synapse.
Glutamate has been localised to rods and cones, ON and OFF cone bipolar cells, rod bipolar cells
and ganglion cells, and is thought to be the photoreceptor neurotransmitter. Glutamate receptors
may be ionotropic receptors, that is channels that regulate Na+/K+ or Ca2+ permeability, or
metabotropic receptors. The latter are part of the G-protein coupled receptor family. Receptors
have been found on all secondary and tertiary retinal neurones including horizontal cells, bipolar
cells, amacrine cells, ganglion cells and Muller cells. Interconversion of glutamate and aspartate
is catalysed by a transaminase. Glutamate may also be converted to GABA by glutamate
decarboxylase. Glutamate is not broken down by enzymes in the postsynaptic cleft; instead, it
diffuses away to glutamate transporters in the presynaptic cell membranes where it is recycled.

7.10.3 GABA. (γ-aminobutyrate) and glycine

a. Glutamic acid decarboxylase is found in mammalian ganglion and bipolar cells.
b. GABA is found in Muller cells.
c. In the developing mammalian retina, horizontal cells have GABAergic properties.
d. The number of GABAergic cells increases with increasing retinal maturity.
e. Glycine has been isolated from retinal amacrine cells.

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GABA (γ-aminobutyrate) is synthesised from glutamic acid by the enzyme glutamic acid
decarboxylase. This enzyme has been isolated only from amacrine cells in mammals. GABA has
been 3und in mammalian Muller cells, although the exact nature of his association remains
unclear. One hypothesis is that Muller cells may provide an uptake system that regulates the
levels of GABA in the retina. There is a high concentration of GABAergic rells in the
developing mammalian retina. Horizontal cells are the first to mature and they initially exhibit
GABAergic properties, rlowever, when rod synaptogenesis is complete these GABAergic
properties diminish and the total number of GABAergic cells continues to decline as the retina
matures. It may be that GABA acts as a trophic agent during retinal maturation. Glycine has been
isolated from amacrine cells in the mammalian retina, but the nature of its function as a retinal
neurotransmitter is unknown. Figure 7.20 illustrates the relationships between GABA, glutamate,
aspartate and glycine in the neural and glial compartments of the retina.

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7.10.4 Acetylcholine, dopamine and catecholamines in the retina
a. In vertebrates acetylcholine is found in amacrine cells subserving movement detection.
b. Tyrosine hydroxylase is found only in amacrine cells.
c. dopamine functions both as a neurotransmitter and a neuromodulator.
d. Dopamine has a role in the shift from dark to light adaptation.
e. Retinal catecholamines stimulate retinal pigment epithelial receptors in a paracrine fashion.

In vertebrates, acetylcholine is the neurotransmitter used by a subgroup of amacrine cells that are
involved with motion detection, and supply input to ON—OFF ganglion cells. Acetylcholine has
not been detected in other second order retinal neurones. Dopamine is synthesised by tyrosine
hydroxylase and this enzyme is found in amacrine cells and some interplexiform cells. Release
of dopamine from these cells is calcium dependent and occurs during membrane depolarisation
under photopic conditions. Dopamine may act postsynaptically, or it may diffuse over greater
distances before stimulating D, or D2 receptors. It acts predominantly on horizontal cells,
decreasing horizontal cell-horizontal cell interactions as light intensity increases. Dopamine is
thought to play a major part in the shift from light to dark adaptation. Neural retinal
catecholamines act in a paracrine fashion to stimulate ax-adrenergic receptors in the retinal
pigment epithelium, resulting in conductance and voltage changes in these cell membranes.
Catecholamines may also be involved in the regulation of extracellular ions by Muller cells.

360
5 Melatonin (M-acetyl-5-methoxytryptamine)
a. Melationin is released in a circadian fashion by horizontal cells.
b. N-acetyl-transferase is denatured under scotopic conditions.
c. Dopaminergic amacrine cells regulate melatonin synthesis.
d. Melatonin inhibits acetylcholine release by starbust amacrine cells.
e. Melationin is involved with regulation of photoreceptor disk membrane turnover.

Melatonin is produced exclusively by photoreceptors in a circadian fashion. The controlling

enzyme in the conversion of serotonin to melatonin is 2V-acetyl-transferase. This enzyme is
denatured by light, so in photopic conditions serotonin increases and in scotopic conditions
melatonin increases. The tissue half life of melatonin in light conditions is 15 minutes. The role
of dopaminergic amacrine cells in the regulation of melatonin production is illustrated in Figure
7.21. Melatonin targets higher order retinal cells and will inhibit acetylcholine release from
starburst amacrine cells triggered by GABA, glutamate, or hashing light. Melatonin also plays a
part in the regulation of photoreceptor disk shedding.

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7.10.6 Retinal metabolism
a. The respiratory rate of the retina is twice that of the brain.
b. Glucose stores are adequate for 1 hour.
c. Lactate will accumulate even if adequate oxygen is present.
d. Müller cells have glucose-6-phosphatase activity.
e. Myoid regions of the photoreceptors are rich in mitochondria.

The respiratory rate of the retina is twice that of the brain. Half of the respiratory rate is
accounted for by the ellipsoid regions of the photoreceptors, which are rich in mitochondria.
Unlike the brain, the retina does not require insulin for glucose to

362
enter into the cells. Muller cells possess glucose-6-phosphatase activity, which enables them to
release glucose from their ―stores‘5 into the neuroretina. Glycolysis occurs even if there is a
sufficient supply of oxygen (unlike other tissues): this causes an accumulation of lactate.

7.10.7 Glycolysis
a. Glycolysis produces a net gain of two ATPs.
b. Phosphofructokinase is the rate determining enzyme in glycolysis.
c. Glycolysis in the retina does not occur in the presence of oxygen.
d. Glycolysis occurs in mitochondria.
e. Glucose-6-phosphatase and hexokinase catalyse the same reaction in opposite
directions.

Glycolysis is the process by which glucose is converted to pyruvate and lactate. It produces a net
gain of two ATPs and in most tissues occurs only if there is no oxygen present, the retina being
an exception to this ―rule‖. Phosphofructokinase catalyses the conversion of fructose-6-
phosphate to fructose 1, 6p-biphosphate3 which is the rate determining step in glycolysis. This
reaction is indirectly influenced by hormones such as glucagon. Hexokinase catalyses the
conversion of glucose to glucose-6-phosphate; the opposite reaction is catalysed by glucose-6-
phosphatase. All these reactions occur in the cytoplasm.

363
364
7.10.8 The Krebs' citric acid cycle

a. This cycle requires oxygen.

b. The Krebs‘ cycle produces an ATP yield that is 18 ??? greater than that of glycolysis.
c. This cycle involves the coupling of oxaloacetate and acetyl coenzyme A to produce
citrate.
d. for every two hydrogen ions liberated three ATP are produced via oxidative
phosphorylation.
e. Oxidative phosphorylation occurs in the outer mitochondrial membrane.

The Krebs‘ citric acid cycle is the process by which citric acid (a six carbon sugar formed by the
coupling of oxaloacetate and acetyl coenzyme A) is converted to a four carbon sugar, releasing
hydrogen ions and ATP. This occurs on the inner mitochondrial membrane. For every two
hydrogen ions released three ATPs are produced by oxidative phosphorylation. The cycle
requires oxygen3 and for every glucose molecule fed into the system in glycolysis there is a net
production of 36 ATPs.

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7.10.9 Gluconeogenesis
a. Gluconeogenesis is glycolysis in reverse.
b. Gluconeogenesis is strongly influenced by glucagon.
c. Transamination is the first step in the conversion of amino acids to glucose.
d. Glycerol is converted to glucose via dihydroxyacetone phosphate.
e. Gluconeogenesis occurs predominantly in the liver.

Gluconeogenesis is the production of glucose from noncarbohydrate sources. It is not just the
reverse of glycolysis, as several reactions are catalysed by enzymes different from those involved
in glycolysis. These gluconeogenic enzymes are influenced by‗the action of glucagon. Proteins
can be converted to glucose, the first step being transamination of amino acids;

366
glycerol may also be converted to glucose via dihydroxyacetone phosphate. Gluconeogenesis
occurs predominantly in the liver.

367
7.10.10 The pentose phosphate pathway
a. This pathway is essential for RNA and DNA production.
b. the pentose phosphate pathway is reversibly linked with the glycolytic pathway.
c. NADPH is generated by the pentose phosphate pathway.
d. The pentose phosphate pathway does not occur in the retina.
e. The pentose phosphate pathway encompasses the Cori cycle.

The pentose phosphate pathway is the alternative route for metabolism of glucose and is
important in the production of intermediates for RNA and DNA. It is reversibly linked at a
number of stages to the glycolytic pathway and is important in generating NfADPH. The pentose
phosphate pathway is an integral part of retinal metabolism, in combination with glycolysis and
the Krebs‘ citric acid cycle. The Cori cycle is involved in recycling lactate to glucose by the liver
and is independent of the pentose phosphate shunt.

368
7.10.11 Metabolism of melanin
a. The conversion of tyrosint ot dopa is the rate determining step.
b. Conversion of dop ato dopaquinone is non-enzymaric.
c. Polymerisation of 5, 6-dihydroxyindole produces melanim.
d. Melanin is not found in tissues derived from the neuroretina.
e. Melanin has stable free radicals which can accept electrons.

The production of melanin is an ‗‗offshoot‖ of tyrosine metabolism, the rate determining step
being the conversion of tyrosine to dopa by tyrosine hydroxylase. The conversion of dopa to
dopaquinone is non-enzymatic. The final step in the pathway involves the polymerisation of 5,6-
dihydroxyindole to produce melanin. Melanin is found in the posterior pigmented iris epithelium,
which is derived from the neuroretina. .Melanin has stable free radicals that undergo dipolar
reactions with water to produce characteristic magnetic resonance images.

369
7.10.12 Rhodopsin
a. The opsin molecule crosses the disk membrane seven times.
b. Two plamitate residues are linked to the extracellular C- terminal of opsin.
c. Oligosaccharides are located at the N-terminal of opsin.
d. The amino acid sequence for human blue, green and red cone based opsins is almost
identical.
e. Retinol is the light absorbing form of vitamin A.

Rhodopsin consists of the protein opsin and a molecule of vitamin A. Human opsin is a 348
amino acid protein that crosses the disk membrane seven times (Figure 7.27). Two palmitate
molecules are linked with cysteines via thioester linkages at the intracellular C-terminal. These
fatty acids are anchored into the lipid bilayer forming a fourth intracellular loop. Oligosaccharide
residues are located on the extracellular iV-terminal; there is some evidence that these may help
maintain the structural integrity of the disk. The amino acid sequences for all human cone opsins
is almost identical, the difference in spectral absorbance being determined by a few different
amino acids. The light absorbing form of vitamin A is retinal, which binds to opsin at a SchifF
base linkage site to form rhodopsin.

7.10.13 The visual cycle

a. The conversion of rhodopsin to bathorhodopsin is the only photoreaction in the visual

cycle.
b. The conversion of metarhodopsin I to metarhodopsin II is reversible.
c. The isomerisation of 11-cis-retinal to all-trans-retinal is complete by the lumirhodopsin
step in the visual cycle.
d. All-trans-retinal is released from opsin at the metarhodopsin I step.
e. Metarhodopsin I undergoes a conformational change during its conversion to
metarhodopsin II to facilitate transducin binding.

370
The first step in the visual cycle is the absorption of photon energy by 11 -cis-retinal, inducing it
to convert to the more stable all-trans form. This photoreaction (the only one in the visual cycle)
activates rhodopsin3 which is converted to bathorhodopsin and then to lumirhodopsin. By this
stage the isomerisation of 1 l-cis-retinal to all-rraws-retinal is complete—this is known as
bleaching. .Metarhodopsin I is converted to metarhodopsin II. This is the only reversible reaction
in the visual cycle. Decay of metarhodopsin II to metarhodopsin III releases all-rram-retinal after
cleavage at the Schiff base linkage site. The conversion of metarhodopsin I to metarhodopsin II
requires a conformational change of the cytoplasmic loops that facilitates the binding of
transducin. The steps of the visual cycle are outlined in Figure 7.28.

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7.10.14 Vitamin A. metabolism and the visual cycle

a. Reisomerisation of all-trans-retinal to 11-cis-retinal occurs in the neural retina for cone

and rod based pigments.
b. All-trans-retinal is transported to the retinal pigment epithelium by interphotoreceptor
binding protein.
c. All-trans-retinol is esterified to all-trans-retinyl ester in the retinal pigment opithelium.
d. 11-cis-retinol is transported back across the interphoto-receptor matrix to the
photoreceptors.
e. 11-cis-retinal recombines with opsin to form rhodopsin.

After release from opsin the fate of all-rrans~retinal differs for rods and cones. In the case of
cone based pigments, reisomerisation can occur in the neural retina, regenerating 11-

372
cis-retinal that recombines with the bleached rhodopsin. This does not occur with rod based
pigments. All-rraras-retinal is converted to all-rrczm-retinol by retinol dehydrogenase in the
neural retina, and is then transported by interphotoreceptor retinoid binding protein (IRBP) to the
retinal pigment epithelium. Once in the retinal pigment epithelium, all-trans- retinol is esterified
to form all-rraw5-retinyl ester, reisomerisation to 11-czj-retinol occurs while &\\-trans-ie.x\no\ is
still esterified to a palmitic acid molecule. After reisomerisation the fatty acid molecule is
released and 11 -c/s-retinol is then stored in the RPE as a stable 1 1-cis-retinyl palmitate, or
converted back to ll-cis- retinal and transported across the interphotoreceptor matrix to the rod
outer segments. Figure 7.29 illustrates the pathways of vitamin A metabolism during the visual
cycle.

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7.10.15 Transduction
a. Transducin binds to the extracellular loops of meta-rhodopsin I.
b. After GTP binding transducin separates into an α subunit and a βγ complex.
c. Phosphodiesterase is activated by removal of its two γ subunits.
d. Activated phosphodiesterase stimulates the hydrolysis of cGMP.
e. cDMP keeps ion channels closed in themembrane of the rod outer segment.

Transducin is a G protein that consists of αβγ subunits. It binds to opsin after a conformational
change at the metarhodopsin II stage exposes binding sites on the cytoplasmic loops of opsin.
GDP is bound to die Ta subunit and during transduction it is displaced by GTP, causing the
transducin molecule to separate into a Ta subunit and a py complex that remains linked to the
disk membrane. There is considerable amplification at this point as hundreds of Ta-GTP subunits
are produced for every rhodopsin—photon reaction. The enzyme phosphodiesterase consists of
αβ2γ subunits. It is activated by removal of the two γ subunits, which then form a complex with
two Tα-GTP molecules. Activated phosphodiesterase (PDHap) catalyses the hydrolysis of cGMP
to 5'-GJMLP. cGJMP keeps the ion channels in the rod outer segment membrane open, and when
it is depleted by conversion to 5'-GMP these channels close3 resulting in hyperpolarisation. The
steps in phototransduction are illustrated in Figure 7.28.

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7.10.16 Inhibition of the photocascade

a. Arrestin binds to the phosphorylation sites of rhodopsin, preventing further interaction

with transducin.
b. Transducin is inactivated by hydrolysis of Tα-GTP to Tα- GDP.
c. Phosphorylation of activated rhodopsin switches off the photoexcited molecule.
d. A decrease in intracellular calcium triggers the production of recoverin.
e. Recoverin stimulates guanylat ecyclase.

Inhibition of the photocasca can occure at several stages (Figure 7.28). Activated rhodopsin may
be switched off by phosphorylation phorylation or by the binding of arrestin to its
phosphorylation sites. Activated phosphodiesterase will continue to hydrolyse cGMP until it
recombines with the PDEγ subunits. Tα-GTP is then inactivated by hydrolysis to Tα-GDP,
which recombines with the Tβγ complex. During light stimulation, Ca2+ influx through cGMP
controlled channels is inhibited. This stimulates the activity of recoverin, which in turn activates
guanylate cyclase. This enzyme increases cGMP production, leading to the reopening of ion
channels and membrance deplorisation.

7.10.17 The interphotoreceptor matrix (IPM) and interphotoreceptor retinoid

binding protein (IRBP)

a. IPM is mainly synthesized by the neural retina.

b. IPM plays an integral role in retinal attachment and in molecular trafficking.
c. IRBP accounts for 70% of the soluble protein in the interphotoreceptor matrix.
d. IRBP is mainly produced by the retinal pigment epithelium.
e. IRBP binds only all-trans-retinol and 11-cis-retinal.

The IPM occupies the space between the photoreceptor outer segments and the retinal pigment
epithelium. It is a complex structure consisting of proteins, glycoproteins, GAGs and

375
proteoglycans such as chondroitin sulphate. The IPM has diverse range of functions, including
retinal attachment ar adhesion, molecular trafficking, facilitation of phagocytosis ar, probably
photoreceptor outer segment alignment. IRB accounts for 70% of soluble proteins in the IPM. In
humans is produced by photoreceptors (mainly cones) and can bind all-trarzs-retinol, 11-cis-
retinal, α-tocopherol, retinoic acid and cholesterol. Although the primary function of IRBP is the
efficient transport of retinoids between the photoreceptors and the retinal pigment epithelium, it
may also serve to minimise fluctuations in retinoid availability, and to protect the plasm;
membranes from the damaging effects of high retinoic concentrations. IRBP is not the only
binding protein found in the retina. Cellular retinoid binding proteins are a subgroup o the fatty
acid binding proteins that orchestrate reisomerisatior in the retinal pigment epithelium and may
also have a role in early retinal development. Cellular fatty acid binding proteins (cellFABP) are
also found in the retina. They protect retinal processes from the toxic effects of fatty acids and
take part in cell growth and differentiation.

7.10.18 Properties of photoreceptors

a. Photoreceptors are derived from ciliated ependymal cells.

b. The myoid region is predominantly involved in synthesis.
c. All cones are conical in shape.
d. Most cone disc laminae are continuous with the extracellular space.
e. There are approximately 1000 rod outer segment lamellae.

Photoreceptors are derived from clinical ependymal cells of the neuroectoderm. The myoid
region is involved in synthesis, the elipsoid region with energy production. Characteristically
cones were described as being conical in shape but this is not true of all cones. Most cone
lamellae (unlike rod outer segment lamellae) are in continuity with the extracellular space.
Approximately 1000 lamellae are present at any one time in the rod outer segment

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7.10.19 Disk morphogenesis
a. Disks originate as cytoplasm-filled plates.
b. Rod and cone disks become detached from the outer segment plasma membrane and
are internalized.
c. Opsin is added to the disk membrances only after they have been internalized.
d. Peripherin/rds is an enzymic disk membrane protein.
e. Linkages occur between rhodopsin molecules of upper and lower disk lamellae.

Disk morphogenesis has been studied mainly in rod-dominated retinas. This highly specialized
process takes place in several stages.

 Plate formation—cytoplasm-filled plates are formed by the accumulation of lipid and

protein within a budding of the outer segment membrane. Opsins are present in the
membrane of these plates from the onset of disk morphogenesis.
 Expansion—the plates expand to reach the width of die rod or cone outer segments. As
each plate enlarges, a further plate develops proximally, so that a stack of expanding
plates is formed.
 Rim proteins are added at the cilium and loop outwards into the plasma membrane. The
transmembrane proteins peripherin/rds and rom-1 have been localised to the margins of
photoreceptor disks. They have no enzymic properties and are thought to act as structural
proteins.
 Zipping up of upper and lower membranes is seen only in rods, and is followed by the
internalisation of the newly formed disks.
 Maturation and stabilisation of the disks—interactive homodimers between
peripherin/rds molecules, and between rom-1 molecules at the hairpin/disk lamellae
junction are thought to stabilise this region of the disk (Figure 7.29). Linkage of
rhodopsin molecules in adjacent lamellae also contributes to disk stability.

377
7.10.20 Shedding and phagocytosis of photoreceptor outer segments
a. Shedding in cones is maximal 1 hour after exposure to light.
b. Mammalian rod outer segment disk shedding follows a circadian rhythm.
c. The signal to initiate shedding originates within the retin.
d. Specific receptors for rod outer segments are present at the apex of retinal pigment
epithelial cells.
e. Retinal pigment epithelial cells contain lysosomal acid hydrolases.

Shedding describes the sloughing of the apical sections of photoreceptor outer segments. In rods
it is maximal 1 hour after light exposure, and in cones shedding is maximal 2—3 hours after the
onset of darkness. Mammalian rod outer segment disk shedding follows a light entrained, free
running circadian rhythm. The signal to shed is not disrupted by optic nerve transection, so it is
thought to originate within the retina and

378
not within the central nervous system. The exact nature of the signal has yet to be determined. It
could be transmitted via a neural pathway or be a paracrine effect of a diffusable substance. The
leukotriene LTC4, and a GABA induced reduction in melatonin production are thought to
participate in these effector pathways. The retinal pigment epithelial cells have specific receptors
for rod outer segments at their apices, and the oligosaccharides on the N-terminal of rhodopsin
may function as specific ligands for recognition at these sites. The retinal pigment epithelium is
able to phagocytose many different materials at different rates, suggesting that there are several
phagocytic mechanisms in these cells. The ingestion of rod outer segments is thought to involve
secondary messengers (possibly cAMP). This is followed by digestion, which is aided by the
numerous lysosomal acid hydrolases found in the retinal pigment epithelium.

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7.1l: Electrodiagnostic tests

7.11.1 The electroretinogram

a. The electroretinogram is an electrical mass response of the retina.
b. The a wave is produced by the photoreceptor cells.
c. The b wave is produced by the retinal pigment epithelial cells.
d. The b wave implicit time is the time between onset of the stimulus and peak of the b
wave.
e. The b wave implicit time is the difference between the peak of the a wave and peak of the
b wave.

The electroretinogram was first described in the 19th century by Holmgren. A clinical recording
technique was developed by Riggs (1941) and Karpe (1945) using comeal electrodes mounted in
haptic contact lenses. Its major components in response to a single bright white flash are the a
and b waves, which vary in amplitude and timing according to the adaptive state of the eye and
the type of stimulus. The a wave is a cornea negative deflection that is thought to be generated in
the photoreceptor cells. This is followed by the larger cornea positive b wave which is generated
in the Aluller cells, which act as a ―sink‖ for potassium ions released by depolarising bipolar
cells. For most clinical purposes these are the main components that are considered.
Superimposed upon the b wave is a series of fast wavelets known as the oscillatory potentials
which have limited clinical value. The slower c wave (a positive component generated in the
pigment epithelium), and the d wave (an off- response following the cessation of constant
illumination) are rarely used in routine clinical practice. The ganglion cells make no contribution
to the flash electroretinogram. Measurement comprises the implicit time or latency of the
components, from the onset of the stimulus to the peak (or trough) of the component concerned,
and the amplitude of the a and b waves. The a wave amplitude is measured from onset, the b
wave amplitude from the peak (or trough—the electroretinogram is usually displayed with
positivity upwards) of the a wave.

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7.11.2 Photopic, scotopic and flicker electroretinograms
a. With a bright white flash stimulus the amplitude of the a wave is maximal in scotopic
conditions.
b. With a bright white flash stimulus the amplitude of the b wave is maximal in photopic
conditions.
c. A very dim blue or white stimulus in scotopic condition will give a pure rod
electroretinogram.
d. Con edystrophies have an abnormal flicker electro-retinogram.
e. Retinitis pigmentosa will have a normal scotopic electro-retinogram.

With the standard bright white flash a mixed rod—cone electroretinogram is recorded, both a
and b wave amplitudes being maximal in the dark adapted eye. When a very dim white or blue
flash is used in scotopic conditions the response is generated purely by the rods. In contrast, a
cone response can be recorded with a bright white light superimposed upon a rod-saturating
background, or with a 30 Hz flicker stimulus. The rods have poor temporal resolution and are
unable to respond to a stimulus presented at this rate. Retinitis pigmentosa is primarily a disease
of the rods, and will affect the scotopic electroretinogram. Congenital night blindness produces a
characteristic ―negative‖

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electroretinograph, which is caused by abolition of the rod b wave, probably due' to a selective
block at the rod bipolar synapse. This abnormality is also seen in retinoschisis, and is a classic
sign. The rods apparendy function normally. In early cone abnormalities the increase of the
implicit time is often unaccompanied by any reduction in amplitude.

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7.11.3 Pattern electroretinograms
Pattern electroretinograms are:
a. Produced by bipolar cells.
b. Produced by ganglion cells.
c. Produced by optic nerve activity.
d. Generated by the macula.
e. In glaucoma the pattern electroretinogram is normal.

The pattern electroretinogram consists of two main components, P50 and A/95- The letter refers
to the positive or negative polarity of the response, and the subscript to the timing (ms) of the
peak of the response. P5Q is produced by damage to the inner retina and ganglion cells and N95
is selectively affected by optic nerve damage. The amplitude/unit area of the pattern electro-
retinogram varies with the cell density and therefore is less dominated by the fovea than the
visual evoked potential. It is abnormal in a variety of local macular conditions and early retinal
degenerations.

7.11.4 Uses of the electroretinogram

a. Distinction between localized and diffuse retinal disease.
b. Distinction between retinal and optic nerve disease.
c. Distinction between macular and optic nerve disease.
d. Distinction between disease affecting the choroidal circulation and the central retinal artery
circulation.
e. Esitmation of visual acuity

As the flash electroretinogram is an electrical mass response of le retina, it is

unaffected by a small localised lesion and will be normal in disease confined to the macula. The
ganglion cells make no contribution to the (flash) electroretinogram, which may be used to
distinguish between generalised retinal disease and optic nerve disease but not between macular
and optic neuropathy. The lotoreceptors are supplied via the choroidal circulation whereas e
bipolar cells are supplied via the central retinal artery: both a and b waves are affected in
choroidal disease but the a wave is

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spared in, for example, central retinal artery occlusion. The electroretinogram cannot be used to
determine visual acuity.

7.11.5 The electro-oculogram

a. The electro-oculogram uses fixed excursion lateral eye movements to measure the
corneoretinal standing potential.
b. The electro-oculogram is measured with a skin and scleral contact lens electrode.
c. The electro-oculogram is measured in light adaptation followed by dark adaptation.
d. The electro-oculogram reflects retinal pigment epithelial activity.
e. The critical value is the absolute peak voltage seen following light adaptation.

The electro-oculogram measures the corneoretinal standing potential by using fixed excursion
lateral eye movements in conditions of varying luminance Measurements between pairs of
electrodes at the outer and inner canthi are taken during dark adaptation (approximately 20 min)
followed by adaptation to a bright light for a slightly shorter period. The amplitude of the signal
reaches a minimum in dark (the dark trough) and should increase markedly during light
adaptation to a maximum value (the light peak). The critical value is the ratio between the light
peak and dark trough (the Arden ratio), normally expressed as a percentage, and is usually
greater than 180% in normal eyes.

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7.11.6 Uses of the electro-oculogram
The electro-oculogram:
a. Can distinguish between localized and diffuse retinal disease.
b. Establishes retinal integrity in the presence of opaque media.
c. Can distinguish between rod and cone dysfunction.
d. Can distinguish between macular and optic nerve disease.
e. Always parallels the electroretinogram.

In general the results of the electro-oculogram will parallel those of the electroretinogram, a
notable exception being the case of vitelliform macular dystrophy, where the electroretinogram
is normal and the electro-oculogram light rise is remarkably reduced. It is, therefore, useful in
distinguishing between localised and diffuse retinal disease and for establishing retinal integrity
in the presence of opaque media. However, as it is a function of retinal pigment epithelial
activity, the electrooculogram cannot distinguish between rod and cone dysfunction or between
macular and optic nerve disease.

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7.11.7 The pattern electroretinogram
a. The pattern electroretinogram is generated in the outer retinal layers.
b. The pattern electroretinogram reflects retinal ganglion cell activity.
c. The pattern electroretinogram can distinguish between macular and optic nerve disease.
d. The pattern electroretinogram will always be abnormal in optic nerve disease.
e. The pattern electroretinogram is useful in the management of ocular hypertension.

The first report that small retinal potentials are evoked when a pattern is reversed in contrast was
made by Riggs in 1964. The main components of the transient pattern electroretinogram in
response to a reversing checkerboard stimulus (2—6 reversals per second) are a positive
component (P5o)j at approximately 50 ms, and a larger negative component (N95) at
approximately 95 ms. The disappearance in the cat of the pattern electroretinogram following
optic nerve section, in association with the development of retinal ganglion cell degeneration,
implicated the ganglion cells in the origins of the pattern electroretinogram, but recent work in
humans shows that the P50 and N95 components are different. It seems likely that N95 and some
of P50 are ganglion cell derived, but that there may be a significant contribution to the P50
component from more distal retina. The pattern electroretinogram is derived from central retina
and the P50 component is almost invariably abnormal in macular dysfunction. In contrast, optic
nerve diseas will affect the pattern electroretinogram only if there has bee significant retrograde
degeneration to the retinal ganglion cells—and then the abnormality may occur only in the N0
component. An abnormal pattern electroretinogram in a patien with ocular hypertension suggests
that the patient may b developing glaucoma.

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7.11.8 Visual evoked potentials

a. The visual evoked potential is a measure of the occipital cortices electrical response to
visual stimulation.]
b. Pupillary dilation must be performed to measure the visual evoked potential.
c. The stimulus is usually a bright-white flash.
d. When recording the visual evoked potential, refractive error must always be corrected.
e. the visual evoked potential can be used to assess the function of the optic nerves and
optic chiasm.

"The visual evoked potential is a measure of the response of the occipital cortex to visual
stimulation. It is extracted, using scalp electrodes, from the background electroencephalographic
activity by the computerised averaging of the responses to repeated stimuli. The usual stimuli are
a reversing checkerboard

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pattern or, perhaps less routinely, a diffuse flash. Pupillary dilation is contraindicated for pattern
visual evoked potentials^ due to the resulting loss of accommodation. Correction of refractive
error is necessary for recording the pattern visual evoked potential., but the flash visual evoked
potential is unaffected by defocusing, and does not require the cooperation of the patient to the
extent demanded for successful pattern visual evoked potential recording. The flash visual
evoked potential can be used in uncooperative patients such as infants or preverbal infants or
patients who are unconscious or in coma. Provided that multiple recording channels are used in
conjunction with appropriate stimuli (often hemifield pattern stimuli) assessment of both optic
nerve and chiasmal function is possible.

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7.11.9 The visual evoked potential waveform

a. The amplitude of the pattern evoked major positive component is the most frequently
used measurement parameter.
b. The latency of the pattern evoked major positive component is usually in the region of
100 ms in normal adults.
c. Optic nerve demyelination will give an increased amplitude, reduced latency pattern
evoked major positive component.
d. An amblyopic eye will usually have a normal flash visual evoked potential but an
abnormal pattern visual evoked potential.
e. Diseases of the eye do not produce an increase in pattern evoked major positive
component latency.

The pattern visual evoked potential to a reversing checkerboard contains a prominent positive
component at approximately 100 ms (usually known as the P1QO component). This is preceded
and followed by negative components at approximately 70 and 135 ms respectively, known as
N70 and N!35. The latency of the Pjoo component is the most frequently used measure, although
amplitude can also be relevant. Optic nerve demyelination characteristically produces a delay in
Pjoos often associated with an amplitude reduction, the magnitude of the amplitude reduction
being loosely correlated with the visual acuity. An amblyopic eye will give a normal flash visual
evoked potential but an abnormal pattern visual evoked potential. Eye disease will often cause
both an increase in latency and a reduction in amplitude of the P10o component. Nomenclature
in the flash visual evoked potential is less uniformly accepted, but PI is often used to describe the
early positive component at approximately 70 ms and P2 for the major positive component at
approximately 110 ms.

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7.1 1.10 Uses of the visual evoked potential

a. Visual evoked potentials are useful in cases of functional visual loss.

b. The pattern electroretinogram alone can distinguish between retinal and optic nerve
disease.
c. The pattern visual evoked potential may be used to give an approximate measure of visual
acuity.
d. A delayed pattern visual evoked potential is specific for optic nerve demyelination.
e. Pattern visual evoked potentials in patients with chiasmal compression show no
interhemispheric asymmetry with monocular stimulation.

Normal flash and pattern visual evoked potentials in the presence of symptoms which strongly
suggest otherwise are consistent with functional visual loss, but it should be remembered that
normal electrophysiological findings do not preclude the existence of some underlying organic
dysfunction. Combined use of the electroretinogram and the pattern electroretinogram are also
necessary to exclude peripheral retinal dysfunction, and central retinal dysfunction. A rough
estimate of visual acuity can be obtained using pattern stimuli with progressively smaller
elements; a pattern onset stimulus, where the pattern appears from a uniform background with
the same overall luminance, is most appropriate for this application. Even with pattern reversal
stimulation it is unlikely that a normal pattern visual evoked potential would be obtained from an
eye with a visual acuity of 6/36 or less. The patten electroretinogram helps to interpret an
abnormal pattern visual evoked potential. Macular disease will often give a delayed pattern
visual evoked potential, but will almost invariably also give a very abnormal P50 component; the
pattern electroretinogram is often normal in optic nerve disease. Latency delays frequently occur
in diseases of the optic nerve other than demyelination. This is particularly true for compression
but can also occur in ischaemic optic neuropathy and other optic nerve diseases. Due to the
effects on the decussating fibres in the optic chiasm, monocular pattern visual evoked potentials
will usually be markedly asymmetrical

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7.12: The visual pathway
In the following section questions referring to the ultrastructure of the lateral geniculate nucleus
are based on research carried out on higher primates such as the Rhesus monkey, as there is
rhought to be a close correlation between the geniculate v.lrrastructure in these primates and that
in humans.

7.12.1 Lateral geniculate nuclei

a. The lateral geniculate nuclei are paired thalamic nuclei.
b. Each nucleus has six ventral layers and four dorsal layers.
c. Their medial aspect receives information from the inferior visual field.
d. Layers 2, 3 and 5 receive contralateral retinal fibres.
e. The lateral geniculate nuclei receive fibres from the visual cortex.

The lateral geniculate nuclei are paired thalamic nuclei in which the retinal ganglion cells
synapse. They are retinotopically mapped with information from the superior retina and the
inferior visual field relaying to the medial aspect of the nucleus. Layers 1 and 2 are
magnocellular and layers 3—6 are parvocellular (layers 4 and 6 plus 3 and 5 fuse anteriorly,
forming four ventral layers). Layers 23 3 and 5 receive input from the ipsilateral eye. However,
input is not restricted to ganglion cells and corticofugal fibres from the visual cortex synapse on
geniculocortical cells and intemeurones in the synaptic ―glomeruli‖.

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7.12.2 Physiology of the lateral geniculate nucleus

a. Receptive fields of lateral geniculate nucleus cells have ―centre surround‖ organization.
b. Y cells respond optimally to temporally modulated stimuli.
c. Colour coded cells are Y like cells.
d. Colour coded cells are predominantly parvocellular.
e. Cells terminate in layer III of the visual cortex.

The receptive fields of die lateral geniculate nuclei cells have a centre surround organisation with
―on/off‖ centres (demonstrated in monkey and cat lateral geniculate nuclei). The major cell types
are X and Y cells, the response properties of which are similar to the ganglion cells tiiey connect
with. Y cells respond optimally to temporally modulated stimuli and are therefore suited for
temporal resolution. X cells respond maximally to static and colour coded stimuli (parvocellular
type) and are suited for spatial resolution. Both types synapse in the fourth layer of the visual
cortex.

7.12.3 The striate cortex

a. The striate cortex is Brodman‘s area 17.
b. The striate cortex is composed of five layers.
c. Layer IV is the thickest layer.
d. Pyramidal cells are predominantly found in layer IV.
e. Stellate cells are predominantly found in layer VI.

Gennari described the striate cortex in 1782 while still a medical student. It is found in the
occipital cortex, Brodman‘s area 17. It has a six layered structure (as does all the cerebral
cortex), but a feature unique to the visual cortex is a macroscopic stripe visible in layer IV, the
stripe of Gennari. Layer IV is the thickest layer; it receives efferents from the lateral geniculate
nucleus and contains predominantly stellate cells. The sixth layer sends efferents to the lateral
geniculate nucleus and contains predominantly pyramidal cells.

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7. 12.4 Physiology of the cortical cells
a. concentric cells have centre surround receptive fields.
b. Simple cells are found mainly in layer IV.
c. Complex cells respond best to a stimulus of a specific orientation moving in a specific
direction.
d. Complex cells receive binocular input and are rarely found in layer IV.
e. Hypercomplex cells require the line stimulus to be of a specific length as well as a
specific orientation and direction.

The cortical cells and receptive field structure was established by Hubei and Wiesel, and from
this they inferred a receptive field hierarchy. According to this model there are four types of
visual cortical cells.
 Concentric cells, which have a centre surround receptive field. ® Simple cells: these are
found mainly in layer IV and have receptive fields in simple parallel bands.
 Complex cells have a binocular input and are found on either side of layer IV (layers III
and V). They respond to a stimulus of a specific orientation moving in a specific
direction.
 Hypercomplex cells are more advanced in that the stimulus should also be of a specific
length, so called ―end inhibition‖.

However, this ―model‖ has undergone some modifications in the light of recent research—for
example, the phenomenon of ―end inhibition‖, originally thought to be exclusive to hyper-
complex cells, has been found in some simple cells.

7.12.5 Synaptic connections

a. Cortical geniculate cells synapse with retinogeniculate cells and interneurones.

b. Layer V cells connect to the superior colliculus.
c. The pulvinar and the extrastriate cortex are connected.
d. Intercortical connections exist via the corpus callosum.
e. Connections exist between the visual cortex and cerebellum.

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Cortical geniculate cells originate from layer VI of the visual cortex and synapse with ganglion
cells and intemeurones in the synaptic ―glomeruli‖ of the lateral geniculate nucleus. Layer V
cells relay to the superior colliculus whose connections with the medial longitudinal fasciculus
enable ocular movements to be coordinated with ―flashes‖ of light. The pulvinar is mainly
connected to the extrastriate cortex but visual cortical connections do exist. Cells in layer II
synapse with the contralateral visual cortex via the corpus callosum. This connection is not
essential for binocular and stereoscopic vision as stereopsis is manifest at a cellular level in each
hemisphere.

7.12.6 Representation of the visual field on the visual cortex

a. The superior half of the visual field is represented below the calcarine sulcus.
b. The inferior half of the retina corresponds to the are above the clacarine sulcus.
c. No cortical lesion can produce a monocular defect.
d. The macula Is represented at the anterior aspect of the calcrine sulcus.
e. Macular sparing is suggestive of a cortical lesion.

The superior half of the visual field (and therefore the inferior half of the retina) corresponds to
the area below the calcarine sulcus. At the most anterior end of the sulcus is an area of cortex
that corresponds solely to the most peripheral nasal retina: a lesion here will produce a defect in
the ―temporal crescent‖ of the contralateral eye only. The posterior end of the sulcus lies at the
watershed region between the middle and posterior cerebral arteries, and the area of the cortex
devoted to the macxila is relatively large; these factors may account for the macular sparing seen
in some cortical lesions.

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7.12.7 Visual deprivation in the perinatal period
a. Binocular stimulus deprivation hinders the development of neurons with an oriented
receptive field.
b. Binocular stimulus deprivation inhibits the development of a binocular input to cortical
cells.
c. Monocular stimulus deprivation causes loss of binocular input to cortical cells.
d. Monocular stimulus deprivation causes a change in cortical and lateral geniculate
nucleus morphology.
e. Mnonocular stimulus deprivation predominantly affects Y type cells.

Most of the research on the development and maturation of the visual pathways has been carried
out on kittens, and young primates. In this work stimulus deprivation was achieved by a number
of methods, including suturing of the eyelids and dark rearing. Binocular stimulus deprivation
will prevent neurones developing oriented receptor fields, but binocularity will exist. Normal
binocular development will, however, be disrupted by uniocular stimulus deprivation in the
perinatal period, as this results in ―competition‖ between the cortical afferents. Uniocular
stimulus deprivation will produce a decrease in the size of lateral geniculate nucleus cells
receiving input from that eye (mostly Y cells), and a change in the morphology of cortical layer
IV which receives geniculate efferents

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7.13: Visual acuity and adaptation

7.13.1 Assessment of visual acuity

In the assessment of visual acuity:

a. The normal threshold of visual detection is 1 sec of arc or less.
b. At threshold for visual detection, more than 75% of identical stimulus presentations are
detected.
c. Snellen acuity is an example of a ―minimal discriminable‖ task.
d. Visual resolution requires the appreciation of brightness differences between several
adjacent small areas.
e. Vernier acuity is usually equal to Snellen acuity under optimal conditions.

All objects in the visual field subtend an angle (the visual angle) at the retina. Visual acuity is a
measure of the spatial limits of vision- Measurement requires the determination of a visual
threshold and the result obtained depends on the visual task required of the observer. Detection
of the minimal visible object (―is an object present or not?‖) can be achieved at visual angles of 1
sec of arc or less. At threshold, 50% of identical stimulus presentations will be detected. The
minimum resolvable task requires the identification of small objects (―is that a C or an E on the
Snellen chart?‖) and has a threshold of about 30—60 sec of arc. The minimum discriminable
angle (vernier acuity or hyperacuity) requires the determination of the relative location of objects
and is limited to about 3 sec of arc, as is stereoacuity.

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7.13.2 Subjective measurement of visual acuity
a. Indivdual Snellen letters subtend an angle of 1 min of arc at the eye.
b. The Bailey-Lovie (Log MAR) chart overcomes the problem of crowding by presenting
the same number of letters on each line with constant line spacing.
c. A visual acuity of 6/60 corresponds to a minimum angle of resolution (MAR) of 10
min of arc.
d. The Bailey-Lovie (Log MAR) chart is read from 6 m.
e. Snellen charts include only letters that are equally resolvable.

(Optotype acuity tests are all based on the principle of the I-andholt C test. The gap in the C
subtends an angle of 1 min of arc at the observer‘s eye. The same principle applies to Snellen
letters and the illiterate E test; the complete letters subtend an angle of 5 min of arc. However,
not all letters are equally resolvable; an L is easier to read than an A. The Snellen fraction = •
1/minimum angle of resolution and therefore an acuity of 6/60 corresponds to a M AR of 10 min
of arc: The Bailey—Lovie (Log MAR) chart has five letters on each line, and the line spacing is
proportional to the size of the letters; this helps to overcome the crowding phenomenon. The
chart is read from 4 m.

7.13.3 Objective measurement of visual acuity

a. Visual evoked potential (Vep) techniques using presentations of progressively smaller

Snellen letters can be used to assess visual acuity.
b. VEP estimation of acuity is particularly useful in uncooperative subjects.
c. Flash VEP testing is most appropriate in the assessment of visual acuity in infants.
d. The target in most preferential looking tests in infants is a sinusoidal grating.
e. Preferential looking tests assume integrity of the oculomotor system.

399
Objective assessments of visual acuity include the measurement of visual evoked potentials
(VEP) and oculomotor responses. Pattern VEP testing usually involves alternating checkerboard
patterns of the same average luminance; the size of the squares can be varied and synchronous
cortical activity is recorded when the pattern is resol-ed. The target in most preferential looking
tests for infants is a sinusoidal grating. Both techniques require subject cooperation, and
preferential looking tests in particular require integrity of the oculomotor system.

7.13.4 Optical factors affecting visual acuity

a. Optical aberrations decrease with decreasing pupil size.

b. Diffraction at the pupil is inversely proportionalto pupil size.
c. Diffraction by the pupil increases retinal contrast.
d. The optimal pupil aperture is about 5 mm.
e. Refractive errors improve as the pupil dilates.

Diffraction of light at an aperture causes ―spread‖ of light from a point source, even in a
perfectly focused system. This causes a characteristic diffraction pattern with a central, bright
―Airy‘s disk‖ and surrounding light and dark concentric rings. In the eye, the spread of light
caused by diffraction is proportional to X/a where X is the wavelength of the light and a is the
aperture of the pupil. Optical aberrations also degrade the image formed by the eye. In contrast to
diffraction, aberration increases with increasing pupil size. The optimum pupillary aperture
(abou. 2.8 mm) is a compromise ben the reduction in retinal
illumination as the pupil constricts, the decrease in refractive error with a small pupil, and the
increase in diffraction that causes loss of contrast. Scatter and absorption (especially of short
wavelengths) can also affect visual acuity.

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7.13.5 Physiological factors affecting visual acuity
Which of the following factors may influence visual acuity?
a. Motivation.
b. Orientation of the stimulus.
c. Crowding, especially when caused by objects placed 20-50 min of arc from the target.
d. Duration of exposure to the stimulus.
e. Resolution of blue targets on a blue background.

There are many physiological factors that can influence visual acuity. Crowding phenomena are
maximal with separations of 2-5 min of arc. The resolution of tilted gratings is consistently
poorer than those that are orientated horizontally or vertically. Acuity falls with reductions in
stimulus duration, although at low light intensities this effect can be offset by increases in
stimulus brightness. Colour of the target relative to the background, motivation, certain drugs
and familiarity with particular tests can all affect measured acuity.

7.13.6 Anatomical factors affecting visual acuity

Visual acuity decreases from the fovea to the periphery. Which of the following statements
concerning the mechanism of this change are true?
a. The most important factor determining the acuity at a given retinal eccentricity is the
spacing of the cone photoreceptors.
b. Increasing size of the ganglion cell receptive field is a contributing factor.
c. The cortical magnification factor is greatest for the mid peripheral visual field.
d. Cone photoreceptors at the fovea are about 3 sec of arc apart, thus explaining the limit
of vernier acuity.
e. High spatial frequency information is conveyed to the visual cortex mainly via the
magnocellular pathway.

401
The decrease in visual acuity from the fovea to the periphery of the retina is a function not only
of the spacing of cone photoreceptors, but also of the connections of photoreceptors to ganglion
cells and, in particular, the cortical representation of these ganglion cells. Cone density is
greatest at the fovea and declines towards the periphery, where the cones are separated by
increasing numbers of rods. In addition, there is greater convergence of cone connections in the
periphery^ foveal midget ganglion cells contact a single cone via a single midget bipolar cell,
whereas peripheral ganglion cells may contact three or more cones. However, the human visual
system can achieve vernier acuity of 1 sec of arc despite a minimum cone separation at the fovea
of 1 min of arc. Such hyperacuity requires cortical processing of information that is obtained
from the spatial relationship between an array of stimulated photoreceptors. This information is
transmitted via the parvocellular pathway to the cortex, and the number of cortical cells per unit
visual angle (the cortical magnification factor) is probably the prime determinant of final visual
acuity.

7.13.7 Contrast sensitivity

a. Contrast in a sinusoidal grating is defined as Lmax/(Lmax + Lmin) where L is the

luminance of the grating.
b. The minimal detectable contrast for the human visual system is about 4%.
c. Minimum contrast sensitivity occurs for spatial frequencies of about 1-10 cycles per
degree.
d. Large Snellen letters correspond well with low spatial frequency gratings.
e. The detection of high spatial frequency gratings requires high contrst.

The eye detects an object by responding to contrast, that is to changes in luminance at the edges
of the object. Measuring contrast sensitivity allows a more physiological assessment of visual
function than using an acuity chart, as such charts measure only visual timction at one point in
the high contrast range.

402
Contrast sensitivity measurement requires the patient to recognise light and dark stripes or
gratings for which the spatial frequency (the number of cycles per degree of visual field) and
contrast [defined as (Lmax — Ijmin)/(Lmax 4- JLmin) where L is the luminance of the grating]
can be varied. The contrast sensitivity function (Figure 7.37) demonstrates how the human visual
system performs best at spatial frequencies of 1—10 cycles per degree. At peak sensitivity
differences in contrast of less than 1% can be detected. Contrast sensitivity falls off at higher and
lower spatial frequencies. The measurement of low sp an I l-requencies using large letters gives
ambiguous results, because sharp edges introduce high spatial frequencies.

403
7.13.8 Visual acuity in infancy
a. The acuity of newborn babies is usually equivalent to about 6/36.
b. The acuity of infants as estimated by visual evoked potentials (VEP) is usually better
than that measured by preferential looking techniques.
c. The maximum resolution in neonates is about 1 cycle per degree.
d. The neural pathway from the retina to the visual cortex are usually fully developed by
the age of 4 years.
e. In infants, vernier acuity is often worse than acuity measured by other methods.

The acuity of infants can be estimated using VEP and preferential looking techniques—the latter
usually suggest lower thresholds. The approximate maximum resolution in neonates is about 1
cycle per degree, suggesting an acuity of <6/60. In infancy, measures of ―hyperacuity‖ can be
poorer than other measures of visual acuity, but this reverses as development proceeds.
Development of connections to the visual cortex continues at least until the age of 8 years.

7.13.9 Assessment of potential visual acuity

a. The potential acuity meter gives an objective assessment of visual acuity.
b. Laser interfeometry can be used to assess potential visual acuity before cataract
surgery.
c. The potential acuity meter requires the subject to detect a grating formed on the retina
by diffraction.
d. The presence of a relative afferent papillary defect is of no significance in the
assessment of potential acuity.
e. Laser interferometry avoids the normal focusing mechanisms of the eye.

The potential acuity meter projects a Snellen type chart on to the fovea. Laser interferometry
forms a diffraction grating on

404
the retina; this grating is detected by the subject. Both tests are subjective and require
cooperative subjects. Neither works well in »he presence of dense lens opacities. A relative
afferent pupillary defect is an important sign of poor visual potential.

7.13.10 Spectral sensitivity

Photopic spectral sensitivity at the fovea:

a. Is greatest in the blue region of the spectrum.
b. Is reduced in the green region of the spectrum by macular pigment.
c. Is affected by the almost complete absence of red cones at the fovea.
d. Is greater than scotopic spectral sensitivity.
e. Is similar for all parts of the visible spectrum.

The fovea has no blue cones and absorption by yellow macular pigment further reduces the
sensitivity of the fovea to blue light. Blue cones reach a maximum density at a retinal
eccentricity of 7—10 degrees from the fovea. The absence of rods from the fovea accounts for
the low scotopic spectral sensitivity. With regard to individual photoreceptors, rods are more
sensitive than cones across the entire visual spectrum, although this difference diminishes in the
long wavelength portion of the spectrum, and with deep red stimuli cone function may be
isolated.

7.13.11 Temporal properties of the visual system

a. At high light levels the visual system uses temporal summation to aid object identification.
b. Saccadic eye movements contribute to temporal summation.
c. Absorption of light energy by photopigments is the main rate limiting step in visual
processing.
d. Complete dissociation of rhodopsin in to all-trans-retinal and opsin requires minutes of
continuous light exposure.
e. Temporal summation is most important at low light levels.

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A finite amount of time is required for the visual system to collect and process information, so its
temporal responsiveness is limited. The visual system must filter out from the environment
biologically useful information; in essence, it must detect the borders of objects and how their
position varies over time. Absorption of light energy by photopigments occurs in a matter of
microseconds and is therefore not a rate limiting step in visual processing. The priorities for
vision are different at different light levels. At low light levels, the priority is detection, which is
facilitated by temporal summation. At higher light levels the challenges are differentiation and
identification. Saccadic refixation movements take 10—80 milliseconds, depending on the
angular distance they cover, and occur three to five times per second. The storage and
comparison of these images aids die assimilation of detailed visual information.

7.13.12 Temporal summation: Bloch's law of vision

a. The completely dark adapted visual system can perceive a single quantum of light.
b. Two Sidentical stimuli of luminance L presented to the retina 0.05 s apart will have the
same effect as a single stimulus of luminance L.
c. The critical period for temporal summation is greater for blue light than red light of
equal luminance.
d. The critical period for temporal summation varies with target size.
e. Bloch‘s law applies only within the critical period for temporal summation.

The completely dark adapted retina needs to absorb several quanta of light within a restricted
time and area before a sensation can be elicited. The critical period of temporal summation is
about 0.1 seconds. During this period, a given amount of luminous energy will have the same
effect, regardless of its distribution in time. This is Bloch‘s law, which can be expressed as Bt =
k, where B is the luminance, t the duration of the stimulus, and k a constant. Beyond the critical
duration, temporal summation does not occur and the effect of a test light

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becomes dependent on its luminance alone. The critical period varies with stimulus size,
background luminance, the type of task (about 0.1s for detection, 0.4 s for discrimination) and
wavelength (about 0.25 s for blue targets, 0.1 s for red).

7.13.13 The Broca—Sulzer and Troxler effects

a. The apparent brightness of a light of constant luminance is independent of its duration.

b. The Troxler effect describes the apparent disappearance of images held stationary on the
retina.
c. The Troxler effect can be explained by a photochemical mechanism.
d. When a constant light is swiched on, variation in its apparent brightness with time is in
part the result of temporal summation.
e. Neural mechanisms are important in the Troxler effect.

When a light is turned on, there is a critical period during which its apparent brightness
undergoes temporal summation; the apparent brightness falls to a plateau once the critical period
has expired. This is why a short flash (shorter than the critical period, so that no plateau is
reached) can appear brighter than a longer flash of the same luminance. This is the Broca—
Sulzer effect. The Troxler effect occurs when a spot of light is projected on to the retina and held
completely stationary. The light appears to fade away and disappear, and because this can occur
without the bleaching of an appreciable fraction of retinal photopigment, a neural rather than
photochemical mechanism is likely.

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7.13.14 Control of fixation and osciliopsia
a. Visual thresholds fall dramatically during saccadic eye movements.
b. It is possible to measure the effect of saccadic eye movements on visual thresholds.
c. Congenital nystagmus is usually associated with oscillopsia.
d. Oscillopsia is usually an incidental finding of which subjects are unaware.
e. Saccadic suppression tends not to occur when nystagmus is caused by vestibular
dysfunction.

Visual thresholds are dramatically elevated during saccadic eye movements. This effect can be
measured experimentally using test flashes synchronised with the movements of the eye. Such
―saccadic suppression‖ allows vision effectively to be switched off during rapid eye movements,
presumably to avoid visual confusion caused by rapid movement of the visual field across the
retina. It was thought that proprioceptors in the extraocular muscles initiated this suppression..,
but it is now known that suppression precedes the saccadic movement. It has been postulated that
saccadic suppression may even initiate the saccadic eye movement. Visual suppression may not
occur when eye movements are caused by non-saccadic mechanisms. Diseases of the vestibular
system that cause nystagmus can therefore produce troublesome illusory movements of the
visual field known as osciliopsia. Osciliopsia is not a feature of congenital nystagmus.

7.13.15 Flickering stimuli

If the period of a flickering stimulus decreases from 5 s to 0.1 s (i.e., the frequency
increases from 0.2 Hz to 10 Hz), the light will change in the following ways:
a. Flicker will seem to increase.
b. The light will appear brighter.
c. The new stimulus frequency will be optimal for detection by the visual system.
d. The light will appear pink.
e. The light will appear constant rather than flickering.

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The temporal properties of the visual system can be measured with sinusoidally flickering lights
in much the same way as the spatial properties of vision are assessed by means of sinusoidally
striped gratings. For every temporal frequency, there is a threshold contrast required for its
detection. The optimal temporal frequency for the perception of flicker (the frequency at which
the lowest contrast is required) is 10 Hz. Slowly varying stimuli are less visible because they
tend to cause adaptation to the new level of illumination; at higher frequencies the persistent
excitation of photoreceptors becomes important, thus limiting die detection of the flickering
stimulus. Light flickering at the optimal frequency appears brighter, probably, at least in part,
because of retinal and cortical processing mechanisms.

7.13.16 Critical flicker frequency and Talbot‘s law

Critical flicker frequency:

a. Is the highest temporal frequency at which flicker is always perceived.
b. Varies with the luminance of the test field.
c. Varies with retinal eccentricity.
d. Above the critical frequency, the ―plateau brightness‖ of a rapidly flickering light is
always less than that of a constant light of the same average luminance per unite time.
e. Is a measure of the temporal resolving power of the visual system?

The critical flicker frequency is a simple measure of the temporal resolving power of the visual
system; above this frequency a flickering light appears constant. Strictly, there is a transitional
range and the threshold is therefore measured as the frequency when flicker is perceived 50% of
the time. The critical flicker frequency increases in direct linear proportion to the luminance of
the intermittent stimulus (Ferry-Porter law), although this relationship breaks down at very high
luminances. The critical flicker frequency will also vary with the spectral composition of the
stimulus- However, if stimuli of different spectral compositions are of equal luminance the
critical flicker frequency

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for these stimuli will be identical. The critical flicker frequency decreases with increasing retinal
eccentricity. Talbot‘s law states that the ―plateau brightness‖ of a rapidly flickering light is
indistinguishable from a constant light of the same average luminance per unit time.

7.13.17 Light adaptation

Concerning light adaptation:

a. The intensity increment required for detection, AI, is proportional to the background
intensity (I) at all light levels.
b. The pupil makes only a small contribution to the process of light adaptation.
c. The Weber fraction is constant over the entire photopic range of background intensities.
d. Buffering of calcium ions inside photoreceptors abolishes light adaptation.
e. The light adapted eye is maximally sensitive at about 490 nm.

The visual system must detect contrast over a huge range of light intensities—at least 12 log
units. The area of the pupil can vary only 16 fold (1.3 log units) and therefore its role in visual
adaptation is limited. Light adaptation is a form of ―automatic gain control‖. Over a range of at
least 3 log units of cone function, the intensity increment required for detection, AI, is
proportional to the background intensity (I). This relation, where AI/I is a constant, is known as
the Weber—Fechner relation, and the constant is called the Weber fraction (Figure 7.38). The
relationship breaks down at higher light levels, when saturation occurs. Light adaptation works
very quickly, gets faster as background intensity increases and is dependent on calcium ion flux;
it is abolished when calcium is buffered inside photoreceptors. The light adapted eye is
maximally sensitive at about 555 nm.

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7.13.18 Dark adaptation

Concerning dark adaptation:

a. 30-50% of rhodopsin is bleched at normal room light intensities.
b. The threshold of vision in the totally dark adapted eye corresponds to the absorption of a
single quantum.
c. Stimuli too dim to be perceived under any circumstances may have an effect on the
absolute retinal threshold.
d. The dark adaptation curve in rod monochromats is monophasic rather than biphasic.
e. There is an approximate relationship between the proportion of rhodopsin bleached and
retinal sensitivity.

Dark adaptation is a much slower process than light adaptation, and the sensitivity of the eye to
dim stimuli gradually increases over many minutes in the dark. The change in sensitivity with
time in the dark is known as the dark adaptation curve (Figure 7.39); it is biphasic, with an early
rapid increase in cone sensitivity and a delayed slower increase i*i rod sensitivity. At absolute
threshold, 4—10 quanta absorbed/degree/100 ms can be perceived. Dimmer lights that cannot be
perceived can reduce the retinal sensitivity to further dim stimuli. It appears that rod adaptation
involves changes at or after the first rod synapse. There is an approximate relationship between
the amount of rhodopsin bleached and the state of dark adaptation: elevation of threshold is
roughly related to 1020B where B is the fraction of rhodopsin bleached. Only about 5% of
rhodopsin is bleached at normal room light intensity. The dark adapted eye is maximally
sensitive at about 505 nm.

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7.13.19 Rod sensitivity

You can ensure that vision is mediated by rods alone by:

a. Using a stimulus flickering at less than 15 Hz.
b. Placing the subject in darkness for 30 min.
c. Stimulating the peripheral retina only.
d. Placing a red filter before the eye.
e. Bleaching the cones with a bright flash of light first.

7.13.20 Cone sensitivity

You can ensure that vision is mediated by cones alone by:
a. Using a stimulus flickering at over 30 Hz.
b. Using very small, bright images focused on the fovea in a fully dark adapted subject.
c. Superimposing the stimulus on a constant bright light.
d. Using bright, deep red stimuli (wavelength >680 nm)
e. Using stimuli that move rapidly across the retina.

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Various techniques can help to separate rod and cone responses, aldiough the distinctions may
not be absolute. As rods and cones have different spectral sensitivity functions, rod responses can
be isolated by stimulating fully dark adapted subjects widi relatively dim short wavelength (blue)
light; similarly, the response to brighter deep red stimuli is mainly cone driven. Rod responses
have a greater average latency and duration than those of cones. Rods can follow flickering
stimuli of up to about 30 Hz, but at higher frequencies the flickering sensation is purely cone
driven. Although the central 30 min arc of the visual field is rod free, focusing a small target on
this area in the dark adapted eye is not a pure cone stimulus because scattered light will be
detected by adjacent highly sensitive dark adapted rods. At photopic levels of retinal adaptation,
only cone initiated signals are transmitted to the optic nerve. Thib is not solely because of
saturation of the rod system; rapid cone responses seem to render ganglion cells refractory to
more sluggish rod signals, and thus the temporal properties of the retinal circuitry contribute to
the functional independence of die rod and cone systems.

7.14: Colour vision

7.14.1 Colour constancy

The perceived colour of an object is influenced by:

a. The wavelength of the reflected light from the object.
b. The colour of other nearby objects within the visual field.
c. The spectral composition of the illuminating light.
d. The state of light adaptation of the eye.
e. The physical properties of the object alone.

Colour is a perceptual phenomenon, not just a physical property of an object. Many factors
determine the colour perceived: the spectral composition of light from the object is important,
but the spectral composition of light from the visual surroundings and die state of light
adaptation of die eye also contribute. Colour constancy is the phenomenon whereby the
perceivcd colour of an object can remain die same even when die spectral

414
composition and intensity of the illuminating light vary. It seems that colours acquire their
appearance more by comparison with their surroundings than by their absolute wavelength.

7.14.2 Theories of colour vision

a. Most wavelengths of light within the visual spectrum stimulate more than one class of cone.
b. Medium wavelength sensitive (MWS or green) cones have peak sensitivity at 570-590 nm)
c. Wavelengths over 650 nm stimulate long wavelength sensitive (LWS or red) cones almost
exclusively.
d. The colour opponency theory and the trichromatic theory of colour vision are mutually
exclusive.
e. Rod photoreceptors make a significant contribution to the perception of colour at low light
levels.

Many theories have attempted to explain the properties of human colour vision, but two have
been particularly influential. The trichromatic theory (of Young, Helmholz and Maxwell)
postulated three types of ―particle‖, each with a tuned ―resonance‖, which together could
represent any colour. In more recent times, microspectrophotometric studies on individual cone
cells have confirmed three classes of cones in the primate retina: long wavelength sensitive
(LWS or red cones) with peak sensitivity 570—590 nm, medium wavelength sensitive (MWS or
green cones) with a peak of 535—550 nm and short wavelength sensitive (SWS or blue cones)
with a peak of 440—450 nm. The opponent colour theory (of Hering) points out that some
colours appear to be ―mutually exclusive‖. There is no such colour as ―reddish-green‖, and such
phenomena can be difficult to explain on the basis of a trichromatic theory alone. In fact, it
seems that both theories are useful: colour vision is trichromatic at the level of the photoreceptor,
but colour opponency is explained by subsequent neural processing.

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7.14.3 Meural encoding of colour

a. Neural processing of colour begins at the level of the ganglion cell.

b. Red-blue colour opponent ganglion cells detect red/blue contrast.
c. Colour information is conveyed to the visual cortex mainly via the parvocellular
pathway.
d. The main ―colour centre‖ in the visual cortex is area V5.
e. Are V4 of the visual cortex contains cells with finely tuned spectral sensitivity.

Neural processing of colour probably begins at the level of the ganglion cell, although horizontal
and amacrine cells may modulate the properties of ganglion cell receptive fields. There are two
main types of colour opponent ganglion cells: red—green opponent colour cells use signals from
red and green cones to detect red/green contrast within their receptive field; blue—yellow colour
opponent cells work in a similar way but obtain a ―yellow‖ signal from the summed output of red
and green cones3 which is contrasted with the output from blue cones within the receptive field.
Colour information follows the parvocellular pathway to areas VI and V2 of the visual cortex
and subsequently to area V4, the main ―colour area‖ of the cortex. V4 contains cells with very
fine spectral tuning and complex ―centre-surround‖ receptive fields, which may help to mediate
the phenomenon of colour constancy.

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7 14.4 Assessment of colour vision

a. The Ishihara plate are a pseudoisochromatic test that allows rapid but crude assessment
of colour vision.
b. Pseudoisochromatic tests should be carried out under standard white light conditions.
c. Ishihara plates are particularly useful in the assessment of optic nerve lesions where
blue/yellow defects are an early but important sign.
d. Acquired macular diseases tend to have a greater effect on red/green function.
e. Ishihara plates are useful in screening for red/green colour blindness.

The Ishihara pseudoisochromatic test plates have a matrix of dots arranged to show a number in
the centre of each plate. The test is designed so that the numbers cannot be perceived by contrast
differences alone and are therefore not visible to subjects with red/green colour deficits. More
comprehensive testing can be conducted with the Farnsworth Munsell ―100‖ hue test, in which a
series of 84 coloured tiles must be graded according to their perceived colour. Optic nerve
diseases tend to produce early red/green colour defects, whereas acquired macular diseases tend
to have a greater effect on blue/yellow function.

7.14.5 Deficiencies of colour vision

a. The gene for the medium (green) wavelength sensitive photopigment is carried on the X
chromosome.
b. Deuteranopes completely lack blue cones.
c. Tritanomaly is more common than protanomaly.
d. Blue pigment defects are inherited in an X linked recessive fashion.
e. Protanomalous subjects may have completely normal colour matching in some parts of
the spectrum.

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There are three main groups of colour anomalies: protan deficiency (red), deutan deficiency
(green) and tritan deficiency (blue). Anopia occurs when one population is totally absent—for
example tritanopia is an absence of functional blue cones. An anomaly is a relative deficiency in
one cone population. Such patients are unable to match colours in some parts of the spectrum in
a normal way, but may perform normally in other parts of the spectrum. The genes for medium
(green) and long (red) wavelength pigments are found on the X chromosome and are inherited as
X linked recessive traits. Five per cent of males are deuteranomalous and 1 % are deuteranopes,
protanopes or protanomalous. The gene for short (blue) wavelengtii pigment is found on
chromosome 7. Defects are found in less than 0.001% of the male population and are inherited in
an autosomal dominant fashion.

7.15: Binocular vision and stereopsis

7. 15.1 Corresponding retinal points

a. These are points which are the same angular distances from the foveal centre.
b. Corresponding retinal points have zero binocular disparity.
c. They are connected to approximately the same are of the visual cortex.
d. A horopter is a curved line joining corresponding retinal points on the retina.
e. Images must fall on corresponding retinal points to be perceived as single.

Corresponding retinal points are the same angular distance from the two foveal centres. They
have zero binocular disparity and are connected to approximately the same areas of the visual
cortex. A horopter is a line in space connecting a set of points whose binocular disparity is zero.
Numerous types of horopters have been described, including the geometric, empirical and
distance horopters. Images found anywhere in Panum‘s area (a region bordering a horopter) will
be perceived as single even it they fall on slightly non-corresponding retinal points.

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7.15.2 Requirements for binocular single vision
a. Overlapping visual fields.
b. Sensory fusion.
c. Stimulation of corresponding retinal elements.
d. Normal stereopsis.
e. Normally functioning extraocular muscles.

Binocular single vision has a number of sensory aspects.

 Visual direction. This refers to a stimulus that falls on corresponding retinal points in
two eyes and is therefore perceived as being in the same visual direction whichever eye
views the stimulus. This will require normally functioning extraocular muscles if
binocular single vision is to be attained in all positions of gaze. However, even patients
with a paretic muscle (an isolated right sixth nerve palsy) will have some degree of
binocular single vision in the left field of gaze.
 Sensory fusion. Mere images that have a slight binocular disparity, but fall inside
Panum‘s area, will be perceived as single.
 Dichoptic stimulation. If dissimilar images or contours are present in the same retinal
area a binocular rivalry will develop.
 Stereopsis. This may be defined as the ability to use binocular disparities to perceive
distance in the third dimension of space. Stereopsis is not a prerequisite for binocular
single vision.

419
7.15.3 Diplopia
a. Diplopia is a sensation produced by stimulating two points outside Panum‘s area.
b. An uncrossed diplopia is produced by an image distant to the fixation point.
c. A crossed diplopia is caused by stimulation of the nasal retina.
d. Heterotropias are physiological diplopias.
e. Exotropias cause an uncrossed diplopia.

420
Diplopia may be defined as the sensation produced by stimulating two points outside Panum‘s
area. Diplopias may be physiological or non-physiological (heterotropias). An uncrossed or
homonymous diplopip h caused by the image of an object distant to the fixation site falling on
the nasal retina. A crossed diplopia, which is found in exotropias, is caused by stimulation of the
temporal retina.

7.15.4 Non-physiological diplopias

a. There are three types of binocular diploipa.

b. A heterotropia describes a latent deviation.
c. The angle of a concomitant squint varies with the fixating eye and the direction of gaza.
d. Primary deviation describes the deviation produced when the involved eye is fixating.
e. In extraocular muscle palsies the secondary deviation is initially less than the primary
deviation.

Heterotropias are manifest deviations and may be horizontal (esotropias, or exotropias), vertical,
or tortional. Heterophorias are latent deviations. The size of a concomitant squint will not vary
with the fixating eye or the direction of gaze, unlike that of an incomitant squint. The primary
deviation describes the deviation seen in an incomitant squint when the uninvolved eye

421
is fixating. After a cranial nerve palsy, that results in an incomitant strabismus, the secondary
deviation (present when the involved eye is fixing) is initially greater than the primary deviation.

7.15.5 Stereposis

a. Stereopsis is possible without binoculat single vision.

b. Stereopsis is poor beyond 20˚ from the fovea.
c. Disparities of 10‖ are undetectable.
d. Stereopsis varies with object size.
e. Stereopsis may be measured by the Frisby test.

Stereopsis is the ability to see an object in three dimensions. Binocular single vision is not a
prerequisite for stereopsis: depth perception is possible even though retinal images are
sufficiently disparate to be seen as double. The resolution of stereopsis enables disparities of 10"
(in some people 2") or 0.0028° to be detected but is poor beyond 20° from the fovea and varies
with object size. That is, disparity of a certain degree will be more easily detected in larger
objects. Stereoacuity may be measured using three dimensional test objects or by haploscopic
devices. In the latter test separate two dimensional targets are presented to each of the two eyes.
The Frisby test employs random dot stereograms to achieve this effect.

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8. General physiology
8-1: Cardiovascular physiology

8.1.1 Bloodvessels

a. The aorta and large arteries are responsible for the Windkessel effect.
b. Arteioles have the maximum resistnace to blood flow.
c. The total cross sectional area of the body‘s capillary beds is approximately 300 m2.
d. Most of the blood volume is found in capillaries.
e. The velocity of blood flow in the venules is faster than in the vena cava.

The aorta and other large arteries produce the Windkessel effect (the conversion of the
intermittent blood flow in the aortic arch to a smooth axial flow). Arterioles are responsible for
50% of the peripheral vascular resistance. Capillaries have a surface area of approximately 300
m2 but most (65%) of the blood volume is found in the veins and venules. The velocity of blood
flow is greater in the vena cava than in the venules, because the cross sectional area of the vena
cava is less than the total cross sectional area of the venules. The action of the ―thoracic pump‖
will also contribute to this increased velocity.

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8.1.2 Autoregulation of blood flow

a. Myogenic regulation is present in the blood vessels of the lungs.

b. Oxygen deficiency causes vasodilatation in all tissues.
c. Increased CO2 or H+ concentration will promote an increase in blood flow.
d. Endothelial factors influence local blood flow.
e. Autoregualtion is the main controlling influence on coronary blood flow.

Autoregulation is designed either to keep the blood flow constant in the face of changing blood
pressure or to adapt the blood flow to the needs of the local metabolism. The mechanisms of
autoregulation are myogenic or metabolic. In the former mechanism a rise in blood pressure
causing a dilatation will trigger a reflex vasoconstriction; however, this will not occur in die
pulmonary arterioles. In metabolic autoregulation (which is the main influence on coronary
blood flow) a decreased oxygen concentration, decreased pH, or raised C02 will cause
vasodilatation and hence increase blood flow. This does not o^cur in the lungs, where a decrease
in oxygen concentration causes vasoconstriction. Endothelial factors, such as endothelin
(vasoconstriction), and nitric oxide (also known as endothelium- derived relaxing factor—
vasodilatation) may have a marked effect on local blood flow.

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8.1.3 Physics of flow in blood vessels

a. The velocity of flow in a vessel is inversely proportional to the cross sectional area of
that vessel.
b. Flow rate of blood in a vessel is proportional to the pressure difference along that vessel.
c. The resistance of a vessel is inversely proportional to the fourth power of its radius.
d. The resistance to flow in a vessel is proportional to the visco sity of the blood.
e. The transmural pressure in a vessel (PT) equals the wall tension in the vessel (T)
multiplied by the radius of the vessel.

The velocity of fluid movement at any point in a system of tubes is inversely proportional to the
total cross sectional area at that point. Therefore the average velocity of blood flow is high in the
aorta, which has a small total cross sectional area, and low in the capillaries, which have a much
larger total cross sectional area. The flow rate in a vessel is proportional to the pressure
difference along that vessel. This is a modification of Ohm‘s law. The Poiseuille Hagen law
states

R=8Lε/πr4

where:

R = resistance to flow; L = length of the vessel; r=the radius of the vessel; and rj = viscosity of
the blood.

La Place‘s law states that

T =PTx. R.

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8.1.4 Neuronal control of blood flozu

a. Stimulation of α receptors causes vasoconstriction.

b. Vasodilatation is caused by β1 receptor stimulation.
c. When metabolic and neuronal signals conflict the metabolic ones take priority.
d. α and β receptors are found in veins.
e. Parasympatheitc vasodilatation occurs in the vessels of sweat and salivary glands

Neuronal control of blood vessels is mediated with only a few exceptions oy the sympathetic
nerves. Postganglionic transmission involves otj receptors and causes vasoconstriction, whereas
vasodilatation is produced by β2 stimulation. Metabolic signals (such as raised CQ2 or lowered
oxygen concentration) will override neuronal signalling. The α and β receptors in the venous
system allow for the regulation of venous return to the heart. Sweat and salivary glands are the
exception mentioned above because parasympathetic stimulation will produce vasodilatation.

8.1.5 Hormonal control of blood flow

a. Noradrenaline produces only vasoconstriction.

b. Adrenaline has a vasodilatory effect in low concentrations.
c. Angiotensin II is a potent vasoconstrictor.
d. Histamine causes a pronounced vasoconstriction.
e. Bradykinin causes vasodilatation.

Noradrenaline, which acts via α receptors, will produce only vasoconstriction. However, low
concentrations of adrenaline will stimulate β2 receptors, causing vasodilatation. Angiotensin II,
as well as being one of the most potent vasoconstrictors, will stimulate thirst and production of
aldosterone. Histamine and bradykinin produce vasodilatation of differing durations.

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8.1.6 Transcapillary exchange

Increased tissue fluid accumulation may be produced by:

a. Increased artetiolar pressure.
b. Decreased venous pressure.
c. Decreased plasma oncotic pressure.
d. Increased capillary permeability.
e. Blockage of lymphatic drainage.

The Starling hypothesis describes the driving forces responsible for filtration and reabsorption at
the capillary wall. Increased pressure at the arterial end of the capillary bed will cause increased
production of tissue fluid. Raised venous pressure decreases the absorption of tissue fluid.
Similarly, a drop in plasma oncotic pressure (hypoproteinaemia) will cause increased
accumulation of tissue fluid. Mediators of acute inflammation (such as histamine and
endotoxins) may increase the permeability of capillaries and so increase oedema. Excess tissue
fluid is normally drained via the lymphatics and so lymphatic blockage will predispose to
oedema.

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8.1.7 Control of blood pressure

a. Blood pressure = (heart rate x stroke volume) x peripheral resistance.

b. Stimulation of aortic baroreceptors causes a bradycardia via the bagus nerve.
c. Carotid baroreceptors are stimulated by a decrease in blood pressure.
d. Stimulation of the aortic baroreceptors results in decreased vagal tone.
e. The ocular cardiac reflex produces marked bradycardia.

These two simple equations summarise how any drug can affect the blood pressure:

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Blood pressure = cardiac output x peripheral resistance
Cardiac output = heart rate x stroke volume

Baroreceptors are specialised stretch receptors located in the aortic arci» and carotid sinuses;
they are stimulated by an increase in blood pressures and cause a reflex bradycardia. The aortic
baroreceptors act via the vagus (increasing vagal tone) and the carotid via the glossopharyngeal
nerves. The oculocardiac reflex will produce a bradycardia.

8.1.8 Starling‘s law

a. Increased venous return causes an increase in stroke volume.
b. Increased venous return may have positive chronotropic effect.
c. Increased afterload initially causes a decrease in the stroke volume.
d. Cardiac output continues to rise with increasing preload.
e. An increase in contractility may cause an increase in stroke volume.

Starling‘s law states that the force of a muscle contraction is proportional to the initial length of
that muscle. An increase in venous return or preload' will increase the stretching of the
myocardium and cause an increase in stroke volume: a positive inotropic effect. It may also
produce a positive chronotropic response by stimulating receptors at the venoatrial junctions.
This is known as the Bainbridge reflex. However, if the preload continues to increase the stroke
volume will eventually fall: this is congestive cardiac failure. An increase in peripheral resistance
or afterload will initially cause the stroke volume to fall as the heart works against this increased
resistance but will then result in an increased diastolic volume which increases the stretching of
the myocardium and causes the stroke volume to rise. Inotropic drugs will increase the
contractility of the myocardium, increasing stroke volume and cardiac output.

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8.2: Respiratory pHysiology

8.2.1 Oxygen dissociation of haemoglobin

a. The oxygen dissociation curve is a sigmoid curve.

b. Increased Pco2 causes a shift to the right.
c. Increased temperature causes a shift to the left.
d. An increase in pH causes a shift to the right.
e. The percentage oxygen saturation of mixed venous blood (Pvo2 40 mmHg) is about
75%.

The oxygen dissociation curve of haemoglobin is a sigmoid curve. This is because of the
―cooperative binding‖ of oxygen by haemoglobin (as haemoglobin takes up oxygen there is a
change in the position of the haem moieties that favours further oxygen binding). The curve is
shifted to the right (haemoglobin more readily gives up its bound oxygen) if C02 levels and
temperature increase or if the pH is decreased. Under normal conditions the body operates nccrr
the plateau of the oxygen dissociation curve, which is why even mixed venous blood has an
oxygen saturation of 75%.

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8.2.2 Oxygen binding proteins

a. the fetal haemoglobin oxygen dissociation curve lies to the right of that in the adult.
b. The oxygen dissociation curve of myoglobin lies to the left of that of haemoglobin in the
adult.
c. The carbon monoxide dissociation curve is much steeper than that of oxygen.
d. Methaemoglobin has no affinity for oxygen.
e. Anaemia changes the percentage oxygen saturation of the blood.

The curve for fetal haemoglobin lies to the left of adult haemoglobin, that is, fetal haemoglobin
has a higher affinity for oxygen. The curve for myoglobin also lies to the left of haemoglobin,
which means it will give up its oxygen only in relatively hypoxic conditions such as in exercising
muscle. Carbon monoxide has a very steep dissociation curve and even in small quantities will
displace large amounts of oxygen from haemoglobin. Methaemoglobin is formed when ferrous
iron is oxidised to ferric iron. It has no affinity for oxygen. Anaemia

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will decrease the total amount of oxygen carried but will not affect the percentage saturation.

8.2.3 Respiration
a. The tidal volume in an adult is approximately 0.5 litres.
b. The vital capacity is the maximum volume expired after the deepest possible
inspiration.
c. The total lung volume minus the vital capacity equals the tidal volume.
d. FEV1/FVC= 0.8 in a young person.
e. The FEV1/FVC ratio increases in asthma.

The average tidal volume in an adult is 500 ml. the vital capacity is the volume expired after the
deepest possible inspiration.

435
When this is subtracted from the total lung volume the remainder equals the residual volume,
which is approximately 1.5 litres. The ratio of FEV, (forced inspiratory volume in 1 second) to
FVC (forced vital capacity) is approximately 0.8 in a normal adult. This ratio will decrease in
asthma but is unchanged in restrictive hmg diseases, such as fibrosing alveolitis.

8.2.4 Ventilation: perfusion ratios

a. Ventilation (V) increases towards the base of the lungs (in the upright position).
b. Perfusion (Q) increases towards the base of the lungs (in the upright position).
c. The V:Q ration increases towards the base of the lungs (in the upright position).
d. The average alveolar Po2 is 100 mmHg (13.3 kPa).
e. The pressure across the pulmonary capillary bed is approximately 35-25 mmHg.

The ventilation of the alveoli increases towards the base of t he lungs. However, perfusion of the
capillary beds will increase to a greater extent and therefore the V:Q ratio will decrease towards
the base of the lungs. The normal alveolar Pco2 is 100 mmHg and the Pco2 is 40 mmHg. The
pulmonary circulation is a low

436
pressure circulation, with pressures across a pulmonary capillary bed of approximately 8 mmHg.

3.3: Endocrinology

8.3.1 Thyroid

a. Thyroid stimulating hormone is a peptide hormone.

b. Iodine ions are actively transported into the gland.
c. Thyroglobulin is stored in follicular cells.
d. Iodinated tyrosines couple to produce T3 and T4.
e. Lysosomal enzymes are instrumental in cleaving hormones from thyroglobulin.

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Thyroid stimulating hormone is a glycoprotein hormone, produced by the anterior pituitary,
which increases the active transport of iodine ions into the follicular cells. It will also increase
thyroglobulin production and the coupling of iodinated tyrosines to produce triiodothyronine
(T3) and thyroxine (T4). Thyroglobulin is synthesised in the rough endoplasmic reticulum and
Golgi apparatus of the follicular cells but is stored in the colloid. Lysosomal enzymes will cleave
T3 and T4 from thyroglobulin before they are released into the circulation.
Blood Follicular cell Colloid

8.3.2 Properties and functions of thyroid hormones

a. 99% of T3 and T4 is bound to albumin.
b. T4 is two to three times as potent as T3.
c. 80% of circulating T3 is derived from deiodinated T4.
d. Thyroxine increases oxygen consumption in all tissues.
e. T3 and T4 are needed for the conversion of carotenes to vitamin A in the liver.

The ratio of T3 to T4 in the circulation is 1:100. Approximately 99% of these hormones in the
circulation is bound to three different proteins: 80% tothyroid binding globulin, the
remainder to thyroid binding prealbumin, and to albumin.

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Triiodothyronine is two or three times as potent as thyroxine. Of the circulating T3 80% is
derived from deiodinated T4, not produced directly from the thyroid gland. The thyroid
hormones increase the metabolic activity of mos^ issues by increasing the oxygen consumption.
However, they will decrease the oxygen consumption of the anterior pituitary, aiding the
negative feedback loop for production of thyroid stimulating hormone. Conversion of carotenes
to vitamin A is facilitated by the thyroid hormones.

8.3.3 Insultin production

a. Insulin is produced by α cells in the islets of Langerhans.
b. Insulin is a peptide hormone.
c. Productin of insulin is stimulated by increased blood glucose or amino acids.
d. Production of insulin is stimulated by glucagon.
e. Release of insulin is inhibited by β blockers.

Insulin is an anabolic peptide hormone produced by the p cells of the islets of Langerhans in the
pancreas. Its main role is in carbohydrate homoeostasis and its production is stimulated by
increasing blood glucose, amino acids or glucagon. P blockers will inhibit insulin release and
their use should be avoided in diabetic patients, as they can also mask the warning signs of
hypoglycaemia.

8.3.4 Properties of insultin

a. Increase glucose uptake into all cells.
b. Increase glycogen production.
c. Stimulates Na+/K+ ATPase pumps.
d. Stimulates lipolysis.
e. Inhibits glucagon release.

Insulin increases the uptake of glucose into most tissues by increasing the number and activity of
glucose transporting proteins in cell membranes. The brain and the retina are

439
exceptions to this. The actions of insulin are anabolic, so it will promote glycogen production
and inhibit lipolysis, gluconeogenesis and glucagon production. The activity of the Na+/K+
ATPase pump is increased by insulin, which explains why potcssium supplementation is
required when treating diabetic ketoacidosis.

8.3.5 Features of insulin deficiency

a. Osmotic dieresis.
b. Plasma hyperosmolarity.
c. Acidosis.
d. A negative nitrogen balance.
e. Increased glucagon concentrations.

Poor control of insulin dependent diabetes mellitus may result in diabetic ketoacidosis. The
symptoms and biochemical upsets seen in this condition are as much due to increased glucagon
concentrations as they are to insulin deficiency. The triad of an osmotic diuresis (secondary to
glycosuria), plasma hyperosmolarity, and acidosis (secondary to ketones) is classically found in
diabetic ketoacidosis.

8.3.6 Production and functions of glucagon

a. Glucagon is produced by the β cells of the islets of Langerhans.

b. Glucagon decreases glycogenolysis.
c. Glucagon increases deamination of amino acids in the liver.
d. Blood levels of glucagon are increased by stress.
e. Production of glucagon is stimulated by insulin.

Glucagon is a peptide hormone produced by the α cells of the islets of Langerhans. It is a

catabolic hormone whose levels will be increased by ―stress‖ (exercise, fright, and flight).
Glucagon promotes glycogenolysis and the deamination of amino acids in the liver, which is
often the initial step in gluconeogenesis.

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Insulin is a more powerful hormone than glucagon and will inhibit its production.

8.3.7 Production of corticosteroids

a. Corticosteroids are produced in the zona glomerulosa.

b. The major precursor for corticosteroids is cholesterol.
c. Production is regulated by ACTH, which acts via cyclic AMP.
d. Most corticosteroids are unbound in the plasma.
e. Breakdown of corticosteroids occurs mainly in the liver.

Mineralocorticoids are produced in the zona glomerulosa and corticosteroids in the zona
fasciculata and reticularis of the adrenal cortex. Cholesterol is the main precursor for
corticosteroid hormones, whose production is controlled by adrenocorticotrophic hormone
(ACTH). This is a peptide hormone produced by the anterior pituitary, whose secondary
messenger is cyclic AMP. Circulating corticosteroids are bound to transcortin (a specific binding
protein) or albumin and are mainly metabolised in the liver by conjugation with sulphates or
glucuronic acid.

8.3.8 Effects of corticosteroids

a. Metabolic effects are generally anabolic.

b. Corticosteroids inhibit glucose uptake in most tissues.
c. Corticosteroids potentiate the pressor and bronchodilator effects of catecholamines.
d. Corticosteroids decrease protein breakdown.
e. Corticosteroids inhibit fibroblasts.

Corticosteroid secretion follows a diurnal pattern, with a peak at 0600 and a trough at 2400.
Corticosteroids have a myriad of actions, which include: (1) raising blood glucose by inhibiting
glucose uptake into most tissues; (2) potentiation of the effects of catecholamines on the
circulation and in the lungs; (3)

441
stimulating catabolism of proteins, which may cause myopathies and the striae seen in Cushing‘s
syndrome; (4) inhibiting fibroblasts, so impeding wound healing.

8.3.9 The adrenal medulla

a. The ratio of adrenaline to noradrenaline in the adrenal medulla is approximately 1:6.

b. Opioid peptides are also produced by the medulla.
c. Phenylethanolamine-N-methyltransferase is unique to the medulla and central
nervous system.
d. Preganglionic sympathetic neurons synapse on cells of the medulla.
e. Hypoglycaemia stimulates the medulla.

442
The adrenal medulla- is a neuroendocrine transducer in which neuronal impulses from
preganglionic sympathetic nerves are converted into hormonal signals. Phenylethanolamine-N-
methyltransferase is found only in the medulla and central nervous system and is responsible for
the conversion of noradrenaline to adrenaline. The ratio of noradrenaline to adrenaline in the
medulla is 1:6. Opioid peptides are also produced by the medulla. The classical symptoms and
signs of hypoglycaemia are in the main attributable to an increase in catecholamines, and may be
―masked‖ by β blockers.

8.3.10 Properties of catecholamines

a. Adrenaline causes a decrease in circulatory resistance.
b. Noradrenaline causes an increase in circulatory resistance.
c. Adrenaline and noradrenaline cause bronchodilatation.
d. The half life of adrenaline in the circulation is approximately 10 min.
e. Most catecholamines are converted to vanillylmandelic acid in the liver.

Catecholamines have differing cardiovascular actions. Adrenaline will produce a vasodilatation

(via p2 receptors) in skeletal muscle and liver blood vessels that exceeds its vasoconstrictive
effects elsewhere, so- decreasing total peripheral resistance. Noradrenaline, which has no
vasodilatory effects, will increase circulatory resistance, so increasing the blood pressure. This
stimulates the baroreceptor reflex which decreases cardiac output. Adrenaline is used to treat
bronchospasm because of its p2-agonist properties (noradrenaline also produces broncho-
dilatation). The half life of catecholamines in the circulation is approximately 2 min. About 50%
of catecholamines are methoxylated and excreted, 30% being converted to vanillylmandelic acid.

443
8.3.11 Pituitary hormones

a. Follicle stimulating hormone and luteinizing hormone are produced by the anterior
pituitary.
b. Antiduiretic hormone and oxytocin are produced by the cells of the posterior
pituitary.
c. Prolactin production is increased by thyrotrophin releasing hormone.
d. Adrenocorticotrophin and growth hormone are produced by the anterior pituitary.
e. Hormones from the posterior pituitary are released into the systemic circulation.

The pituitary gland is divided into two separate glands. The anterior pituitary (or
adenohypophysis) produces follicle stimulating hormone, luteinising hormone, thyroid
stimulating hormone, adrenocorticotrophin growth hormone, STH, and prolactin (whose release
is stimulated by thyrotrophin releasing hormone). The posterior pituitary (neurohypophysis) is
intimately connected with hypothalamic nuclei: antidiuretic hormone and oxytocin are produced
in these nuclei and travel

444
down axons by axoplasmic flow to the posterior pituitary. Here they are released directly into the
systemic circulation, unlike anterior pituitary hormones, which are released into the portal
hypophyseal circulation.

445
8.4 Renal physiology

8.4.1 Functions of the kidney

a. Acid-base regulation.
b. Erythropoietin production.
c. prostaglandin and kinin production.
d. Hydroxylation of 1-hydroxycholecalciferol.
e. Maintenance of the correct concentration of all ions in the interstitial fluid.

The kidney‘s most vital functions are the maintenance of the correct interstitial fluid ion
concentrations, and the excretion of the waste products of metabolism. The kidneys play an
integral part in acid-base balance by regulating bicarbonate production in their tubular cells. The
anaemia of patients with chronic renal failure is due to a deficiency in erythropoietin, which is
produced by the kidneys. The role of the kidney in vitamin D metabolism is to kydroxylate 25-
hydroxycholecalciferol to la25-dihydroxy- cholecalciferol. Prostaglandins and kinins are also
produced by the kidneys.

8.4.2 Glomerular filtration

a. The glomerular filtration rate is approximately 250 ml/ min.

b. Glomerular filtration is partly dependent on the hydrostatic pressure in the glomerular
capillaries.
c. The glomerular filtration rate may be varied by the action of mesangial cells.
d. Anions pass more freely into the filtrate than cations.
e. Autoregulation of the glomerular capillary pressure occurs.

The glomerular filtration rate is the volume filtered by all the glomeruli per unit time. An
average of 20% of the renal plasma flow is filteredj producing a rate of 120ml/min. The forces
governing glomerular filtration are the same as those described by Starling for any capillary bed.
One of these variables is the
blood pressure, in the glomerular capillaries, which may be autoregulated. This explains why the
glomerular filtration rate will remain constant over a wide range of blood pressures. Mesangial
cells found at the bifurcations of capillary loops have contractile properties which enable them to
alter the area available for filtration. The endothelium of the glomerular capillaries carries a
negative charge, therefore anions pass less readily into the filtrate than cations.

446
8.4.3 Function of the renal tubules
a. Tubules reabsorb a constant amount of the sodium filtered.
b. 80% of the filtered sodium is reabsorbed.
c. Glucose is reabsorbed in the proximal tubule by secondary active transport.
d. Water absorption is decreased by antidiuretic hormone.
e. Potassium is actively reabsorbed from proximal, and secreted from distal, tubules.

The renal tubules reabsorb a constant fraction of the sodium filtered, not a constant amount—this
is known as glomerulo- tubular balance. In the renal tubules 95—99.5% of filtered sodium

447
is actively reabsorbed. In die proximal tubules much of this resorption is closely coupled with the
cotransport of glucose and amino acids (known as secondary active transport). Antidiuretic
hormone will increase the permeability of collecting ducts to water, thus increasing water
reabsorption. Potassium is reabsorbed both passively and actively in the proximal tubules and is
secreted under the influence of aldosterone in the distal lubuJes.

8.4.4 Body water and osmolarity

a. 60% of total body water is intracellular.
b. 80% of the extracellular water is intravascular.
c. Osmolality = mosmol/kg of solvent.
d. Plasma proteins account for 90% of plasma osmolality.
e. The difference in sodium concentration is the main determinant of fluid distribution across
the capillary walls.

Most (60%) of the total body water is intracellular; 40% is extracellular. Intravascular water
accounts for only 20% of extracellular water. The osmolality of plasma is what determines the
osmotic pressure of plasma and is measured in mosmol/kg of solvent. Sodium accounts for 90%
of plasma osmolality but the sodium concentrations in the intravascular and extravascular
compartments are approximately the same and therefore do not influence water movement across
capillary walls. Plasma proteins produce an oncotic pressure which will, along with hydrostatic
pressure, determine interstitial fluid production.

448
8.4.5 Extracellular isotonic volume depletion of 500—1000 ml will cause
a. An increase in angiotensin II.
b. An increase in antidiuretic hormone.
c. Decreased aldosterone levels.
d. Increased sodium retention by the kidneys.
e. Thirst.

An isotonic loss of 500—1000 ml (such as in heavy bleeding) would be sufficient to stimulate

the renin-angiotensin system. Angiotensin II is the final product of this pathway and directly
stimulates aldosterone release and the thirst mechanism as well as causing vasoconstriction.
Aldosterone will increase sodium reabsorption, an effect that takes approximately 1 hour and
peaks at 4 hours. Antidiuretic hormone is released when hypertonic plasma stimulates
hypothalamic osmoreceptors. An

449
isotonic volume depletion of this magnitude will increase the production of this hormone by
stimulation of volume receptors in the left atrium.

8.4.6 Hypotonic fluid loss occurs in

a. Excess sweating.
b. Gastric losses.
c. Patients with burns.
d. Haemorrhage.
e. The comatose patient.

Sweat and gastric secretions are all hypotonic relative to plasma. Burns patients will suffer
hypotonic losses because of the increased rate of evaporation from the damaged skin. The
comatose patient, who may be ventilated, pyrexial and sweating, and unable to drink to replace
losses will have an increased

450
risk of hypotonic volume depletion. Isotonic losses are seen in haemorrhage or in biliary leaks.

8.4.7 Causes and effects of acidosis

a. A fall in the [HCO3-]/[CO2] ratio is seen in acidosis.
b. The net result of a metabolic acidosis is a decreased HCO3- concentration.
c. A metabolic acidosis may be compensated for by hyperventilating.
d. Respiratory acidosis is secondary to impaired alveolar ventilation.
e. Acute respiratory acidosis is compensated for by increased renal bicarbonate
production.

An acidosis of whatever origin may be defined as a decrease in the [HC03-]/[C02] ratio. In a

metabolic acidosis there is a net decrease in bicarbonate concentration. This may be caused by
decreased bicarbonate production, excess loss of bicarbonate, or by an increase in acid
production which binds the bicarbonate to produce H2C03. A metabolic acidosis is compensated
for by hyperventilating, which reduces the carbon dioxide concentration and so restores the
[HC03"]/[C02] ratio. Respiratory acidosis may be acute or chronic but" both result from
impaired alveolar ventilation. The former cannot be compensated for to any significant degree by
renal mechanisms.

8.4.8 Causes of alkalosis

a. A rise in the [HCO3-]/[CO2] ratio seen in alkalosis.

b. A respiratory alkalosis is commonly seen in obstructive aitways disease.
c. A metabolic alkalosis may be caused by pyloric stenosis.
d. A metabolic alkalosis is well compensated for by respiratory mechanisms.
e. A respiratory alkalosis may be caused by an increased intracranial pressure.

451
An alkalosis of whatever origin may be defined as an increase in the [HC03~]/[C02] ratio.
During vomiting there will be loss of acidic gastric contents and of alkaline duodenal juices and
therefore a metabolic alkalosis does not always occur. However, there is no compensatory loss of
alkaline duodenal juices in pyloric stenosis and vomiting invariably results in a metabolic
alkalosis. Hypoventilation can never compensate for a metabolic alkalosis because CO2 retention
will eventually stimulate the respiratory centres and increase ventilation. Chronic bronchitics are
usually in a state of respiratory acidosis secondary to retention of CO2. A raised intracranial
pressure can cause hyperventilation and a resultant respiratory alkalosis.

452
453
8.5: Muscle physiology

3.5.1 Properties of striated muscle

a. Fibres are arranged in a fusiform manner.
b. Striated muscle has a transverse tubular system which acts as a calcium reserve.
c. The longitudinal tubular system is a continuation of the sarcolemma.
d. Fast twitch fibres are more fatiguable than slow twitch fibres.
e. Slow twitch fibres have a higher myoglobin concentration than fast twitch fibres.

Striated muscle fibrils are organised into units known as sarcomeres. Postsynaptic potentials
spread through the muscle via the transverse tubular system* which is an extension of the
sarcolemma. The longitudinal tubular system runs parallel to the myofibrils and functions as the
calcium reservoir, it is a continuation of the sarcoplasmic reticulum. Fast twitch fibres are
designed for anaerobic activity and are more fatigueable chan slow twitch fibres, which are rich
in myoglobin.

8.5.2 The sarcomere

a. The sarcomere is the portion of the myofibril between two Z lines.
b. Actin and myosin fibrils overlap in the A band.
c. The H band consists solely of actin.
d. The length of sarcomere is 1.5-3.2 µm.
e. Sarcomeres are found in skeletal and cardiac muscle.

The sarcomere is the functional unit of striated muscle fibrils and is the region between two Z
lines. The A band is the region where the myosin and actin fibres overlap. The H band is found
in the middle of the A band and consists only of myosin. The sarcomere varies in length from 1.5
to 3.2 µm, the optimum length being 3—3.2 µm. This is the region of maximal tension

454
on the length/tension curve. Both striated and cardiac musclc are organised in sarcomeres.

8.5.3 Events in skeletal muscle contraction

a. An action potential causes a calcium influx from the extracellular space.

b. Calcium binds to tropinin.
c. Actin-myosin corss bridges form.
d. GDP bound to the myosin head is split by the GTPase in actin.
e. Magnesium is essential for contraction.

An action potential travelling in the transverse tubular system causes calcium release from the
longitudinal tubular system. The calcium binds to tropinin subunits (found on tropomyosin
which is wound around the actin filament) and frees the myosin binding sites, which then
combine with actin to form ―cross bridges‖. The myosin ATPase splits an ATP molecule with
the aid of magnesium, and the resultant energy is used to hinge the ratchet mechanism of the
myosin heads.

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8.5.4 Features of motor endplates

a. Motor endplates are found in all types of muscle.

b. Acetylcholine is the neurotransmitter.
c. Acetylcholine release is initiated by an efflux of calcium from the nerve endings.
d. Curare blocks transmission.
e. The action of acetylcholine is rapidly reduced by reuptake into the nerve terminal.

456
Motor endpiates are found only in skeletal muscle. Acetylcholine, which is found in vesicles, is
released into the synaptic cleft when an action potential causes a calcium influx into the neurone.
Curare displaces acetylcholine from its postsynaptic binding site but / does not itself produce a
depolarisation. The action of acetylcholine is terminated by the choline esterase enzyme, unlike
that of noradrenaline which relies on reuptake across the presynaptic membrane. .

8.5.5 Electrical activity in skeletal muscle

a. A change in the endplate potential is produced by sodium influx.

b. The action potential produced is approximately 2-5 ms long.
c. The frequency of action potentials needed to produce tentanus in fast twitch fibres is
60-100 Hz.
d. Skeletal muscle has a longer refractory period than cardiac muscle.
e. Succinylcholine will produce a postsynaptic potential.

When acetylcholine binds to its postsynaptic receptor it triggers an influx of sodium ions, which
produce an excitatory postsynaptic potential. Temporal or spatial summation of these potentials
may enable thresholds to be reached and a postsynaptic action potential to be produced. This
action potential is 2—5 ms long but frequencies of up to 100 Hz will not produce tetany in fast
twitch muscles. The long refractory period of cardiac muscle means that tetanus can not be
produced. Succinylcholine will cause initial depolarisation of the postsynaptic membrane before
causing neuromuscular blockage.

457
8.5.6 Properties of cardiac, smooth, and skeletal muscle
a. The action potential of cardiac muscle has a plateau and is approximately 200 ms.
b. The heart has no motor units.
c. Skeletal muscle normally operates on the plateau of the length/tension curve.
d. Both visceral smooth muscle and cardiac muscle have a pacemaker function.
e. A smooth muscle contraction follows approximately 150 ms after the action potential.

The cardiac muscle action potential has a characteristic plateau caused by the slow influx of
calcium ions, and has a duration of approximately 200 ms. Skeletal muscle, unlike cardiac
muscle, operates at the peak of the length/tension curve and is the only type of muscle that does
not require an intrinsic pacemaker. The smooth muscle contraction is a slow rising one that
begins approximately 150 ms after the action potential.

458
8.5.7 The muscle spindle
a. Intrafusal fibres are of two types.
b. Ia afferents have annulospiral endings.
c. γ efferents stimulate extrafusal fibres.
d. Muscle spindles respond primarily to a change in muscle tension.
e. The stretch reflex is monosynaptic.

The muscle spindle is the main regulatory unit of skeletal muscle. Its intrafusal fibres are of two
types: nuclear bag and nuclear chain fibres. The la afferents arising from the annulospiral
endings on these fibres travel to the spinal cord where they make a monosynaptic connection
with α motor neurones. These supply extrafusal fibres of the same muscle. The endings of the y
efferent fibres terminate either on nuclear bag fibres as plate endings, or on nuclear chain fibres
as trail endings. Stimulation of the γ efferent system shortens the intrafusal fibres so initiating
impulses in the la fibres. This can lead to reflex contraction of the muscle. Increased γ efferent
discharge thus increases spindle sensitivity, and the sensitivity of the spindles to stretch varies
with the rate of γ efferent discharge. The spindle responds primarily to changes in muscle length,
not to changes in muscle tension, which is the function of the Golgi tendon organ.

459
8.6: The central nervous system

8.6.1 Mechanisms involved in establishing the resting membrane potential

a. Active transport of sodium into and potassium out of the cell.
b. A cell membrane with a low sodium conductance.
c. A cell membrane that is permeable to proteins and phosphates.
d. A potassium conductance greater than a sodium conductance.
e. A very low chloride conductance.

The resting potential of the cell is due to the uneven distribution of cations and anions between
the intracellular and extracellular fluid according to an electrochemical gradient. Cell membranes
have a low sodium conductance and sodium is actively pumped out of the cell against a chemical
gradient. Potassium conductance is relatively high so potassium has a tendency to leak out of
cells. This is counteracted by its active transport in the opposite direction. Chloride conductance,
unlike that of other anions (such as proteins and phosphates), is relatively

460
high. Hie negative resting potential tends to drive chloride out of the cell against its chemical
gradient.

8.6.2 Properties of the action potential

a. An action potential is generated only when stimulation is sufficient to produce a change

in potential great enough to reach t5he threshold potential.
b. Depolarisation is caused by an influx of sodium ions.
c. sodium conductance increases uniformly throughout the action potential.
d. The membrane potential reaches positive values.
e. Repolarisation is caused by a slow rise in potassium conductance.

461
The initial depolarisation is caused by a slow increase in the sodium conductance- However, an
action potential will be produced:only if the threshold is reached and sodium channels are
activated, resulting in a massive influx of sodium ions. During this depolarisation phase, the
membrane potential will reach positive values. Repolarisation is secondary to a decrease in the
sodium conductance and a slow increase in the potassium conductance, which allows potassium
to diffuse out of the cell. The membrane potendal difference may become greater than the
original resting potential—this is called hyperpolarisation.

8.6.3 Types of nerve fibres

a. Aα fibres are found in muscle spindle afferents and skeletal muscle efferents.
b. Aγ fibres are muscle spindle efferents.
c. C fibres are fast pain fibres.
d. Aα fibres have a conduction of velocity of 70-120 m/s.
e. B fibres are unbyelinated.

Act fibres have the largest diameter of any nerve fibre and have a conduction velocity of 70—
120 m/s. They are found in the

462
muscle spindle afferents and skeletal muscle efferents. Ay fibres innervate the intrafusal fibres of
muscle spindles. C fibres are the only unmyelinated fibres. They are responsible for ―slow‖ pain
conduction, and postganglionic autonomic conduction. Aδ fibres are responsible for ―fast‖ pain
conduction.

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9. Statistics and epidemiology
The graph below (Figure 9.1) shows the distribution of intraocular pressure (IOP) in 10 000
subjects (adapted from Carel RS, et al. 1984).

9.1.1 Concerning this graph:

a. The distribution is positively skewed.
b. The mean IOP is approximately 13 mmHg.
c. The median is greater than the mode.
d. The standard deviation is the most appropriate measure of dispersion.
e. The interquartile range contains 50% of the observations.

The normal distribution is a bell shaped curve that is symmetrical about the mean. An
asymmetrical distribution is positively, or right, skewed if the longer tail is to the right, and
negatively, or left, skewed if the tail is to the left. The mean of a set of data is the sum of all the
observations divided by their number. The median is the middle value if die observations are
sorted into

464
order, or the average of the middle two values if there are an even number. The mode is the most
frequently observed reading. In a normal distribution the mean, median and mode are the same.
If the distribution is skewed the mode is still, by definition, the highest peak on the curve, but the
mean is influenced by the longer tail and is therefore shifted towards it—in the above example
the mean IOP is 15.8mmHg. The median falls somewhere between the mode and the mean. The
standard deviation gives a measure of the spread, or dispersion, of the observations about the
mean value in a normal distribution. However, it is very sensitive to outliers such as those
observations in the longer tail of a skewed distribution. In this case the interquartile range is a
better measure of dispersion about the median. The ordered data are divided into four quartiles,
each containing 25% of the readings. The interquartile range is between the first and third
quartiles and therefore contains 50% of the observations.

9.1.2 A small study measured the axial length of both eyes of 20 subjects and
found the length to be normally distributed with a mean of 24.4 mm ivith a
standard deviation of 1.7 mm.

a. The variance is the square root of the standard deviation.

b. 95% of eyes had axial lengths between 22.7 mm and 26.1 mm.
c. The standard deviation would be halved by doubling the number of measurements.
d. the 95% confidence interval for the mean is related to the standard error of the mean.
e. A Students‘ t test could be used to detect a difference in axial length between left and
right eyes.

A study draws on a small sample of random observations from a larger population. If the
variable is normally distributed in the population, then the observations will also be normally
distributed. Statistical calculations are used to describe the sample and how well it reflects the
population from which it is drawn. Variance is determined by calculating the difference between
each observation and the mean, squaring each value

465
and dividing tlieir sum by the number of readings. Variance is therefore also known as the mean
square deviation, and standard deviation (SI3) is the square root of the variance. Approximately
95% of observations fall within two standard deviations either side of the mean. Variance and
standard deviation describe the sample, and change little as die sample size is increased. The
standard error (SE) is a measure of the uncertainty of a sample statistic, such as the mean. The
confidence interval is the range of values in the sample likely to contain the true (but unknown)
population statistic. The standard error of the mean (SEM) is calculated by dividing the standard
deviation by the square root of the number of observations, and so gets smaller as the sample
increases. The 95% confidence interval for die mean is two SEMs either side of the mean. The
standard used to estimate the characteristics of the population the sample. These calculations
assume diat the sample is relatively large. For small samples, usually taken to be less than 30
observations, it can no longer be assumed that the sample will be normally distributed. The
Students‘ t test is a statistical test that takes die number of observations into account and allows
confidence limits to be calculated and groups to be compared.

9.1.3 A study of the efficacy of topical tropicamide 0.5% at dilating pupils in

different colour irides gave the following
blue iris Brown iris Totals
Pupil ≥7 mm 37 21 58
Pupil <7 mm 13 29 42
Totals 50 50 100

A x2 test with one degree of freedom gives X2 =10.5, p= 0.001.

466
 a. The χ2test compares observed with expected frequencies.
b. Before performing a χ2 test the numbers must be converted to percentages.
c. Yates correction must be used.
d. The null hypothesis is proven.
e. A type I error is committed when the null hypothesis is accepted when it is false.

The x2 test compares observed with expected frequencies of mutually exclusive events. The table
above is a two-way contingency table in which the rows and columns represent mutually
exclusive categories of each variable. The expected frequencies are calculated from the row and
column marginal totals. All calculations for the x2 test must use the actual values and not
percentages. The number of degrees of freedom is defined as (rows — 1) x (columns — 1), and
for comparisons with one degree of freedom Yates‘ correction must be used. The null hypothesis
is that there is no difference between the two groups and a study sets out to reject this hypothesis
at a particular confidence level, usually 95%. The %2 statistic is zero if there is no difference
between observed and expected frequencies. The larger the value, of x2> the greater the
discrepancy and the less likely it is that the null hypothesis is true. The p value depends on X2
and the number of degrees of freedom, and is the probability of the observed results arising by
chance. If any of the expected frequencies are small (usually five or less), Fisher‘s exact test
must be used to compute the p value. By convention p<0.05 (i.e., a confidence level of 95%) is
sufficient to reject the null hypothesis. A type I error is committed when the null hypothesis is
rejected when it is true (false positive), and a type II error when the null hypothesis is not
rejected when it is false (false negative).

467
9.1.4 A study examined the thickness of the retinal nerve fibre layer (KNFL) in
150 normal subjects using a scanning laser polarimeter (SUP). Linear regression
analysis of JRJSlFJL thickness against age calculates the slope of the regression
line to be —0,38umlyear, and the correlation coefficient, r— —0.5938, r2 =
0.3526, p<0.001. (From Poinoosazomy D, et al. 1997).
a. The accuracy of the SLP the smallest change in RNEL thickness that it can detect.
b. The coefficient of variation can be used to determine the reproducibility of the SLP
readings.
c. Between the age of 20 and 70 years, a normal subject can expect to lose 19 µm of RNFL
thickness.
d. There is a strong correlation between RNFL thickness and age.
e. The result of the study is highly clinically significant.

The accuracy of an observation is its closeness to the true value. Precision refers to the smallest
change that can be detected by a particular measuring method. The coefficient of variation, or
relative dispersion, of a set of observations is the standard deviation divided by the mean, and is
independent of the magnitude of the observations. Regression analysis determines the
dependence of one variable upon another. Linear regression analysis fits a straight line to the
data and allows the value of one variable to be predicted from the other. The correlation
coefficient, r, measures how well the data fit the straight line, and ranges from — 1 to 4-1. If r is
positive then, as one variable increases, so does the other, the converse being true if r is negative.
r=0 implies that there is no correlation between the variables, and the closer, r is to 1 (or —1),
the tighter is the correlation. The square of the correlation coefficient, r2, gives the proportion of
the variation of one variable that is explained by the other. In the above study, therefore, age
explains only about 35% of the reduction in RNFL thickness. The standard error of the
correlation coefficient is used to calculate p, the likelihood that the observed correlation could
have arisen by chance. A weak correlation may be statistically significant, and a strong one not.
Remember that statistical significance does not imply clinical significance.

468
9.1.5 A randomised trial was carried out to compare topical diclofenac with
placebo for control of eye pain after cataract surgery. Eight patients had diclofenac
and 10 placebo, and all were asked to grade their pain on a 10 cm visual analogue
scale. The result was as follows:

Diciofenac 1.7 2.9 5.0 4.9 4.4 1.4 4.2 3.5

Placebo 2.8 3.9 2.1 6.9 5.4 4.2 2.1 3.9 4.8 2.2

. a. A parametric test should be used when comparing normally distributed samples.

b. The Wilcoxon signed rank test is the non-parametric equivalent of the paired test.
c. A non-parametric test can always be used instead of a parametric test.
d. The Mann Whitney U test is appropriate for comparing the two groups above.
e. In the Wilcoxon rank sum test, the groups are measured by the ordinal scale.

A parametric test, such as the t test* must be used only to compare samples that are normally
distributed. If they are not, or the sample is too small to establish the normality of the data, a
non-parametric test should be used. There are non-parametric equivalents for most commonly
used parametric tests, e.g. the Wilcoxon signed rank test is equivalent to the paired t test, etc. A
non-parametric test makes no assumption about the distribution of the data and so can be used
for normally distributed data as well. However, for normal distributions a non-parametric test is
less likely than its parametric equivalent to detect a significant difference. In the example above,
two independent samples are to be compared, so the non-parametric equivalent of the two
sample or unpaired t test is required—this is the Mann—Whitney TJ test (the Wilcoxon rank
sum test is virtually identical). In all non-parametric tests the observations are ordered from low
to high and an ordinal rank assigned to each. For tied observations the average rank is used; for
example, there are two observations of 2.1 in the above data, # corresponding to ranks 3 and 4.
Each is therefore assigned the

469
rank of 3.5. The statistical calculations are performed on the ordinal rank, rather than the data
values.

9.1.6 Which of these statements about study design are true?

a. The case control study is an example of a longitudinal study.

b. A retrospective study takes longer to complete than a prospective study.,
c. Randomisation eliminates confounding factors.
d. Blinding eliminates errors of assessment.
e. The power of a study is the probability of not rejecting the null hypothesis incorrectly.

Longitudinal studies investigate a process over time, whereas cross sectional studies describe a
phenomenon at a particular fixed time. Longitudinal studies can be prospective, when subjects
are grouped according to exposure to some factor and followed to determine outcome, or
retrospective, when subjects are grouped according to outcome and examined for postulated risk
factors. Prospective studies are, on the whole, more costly and take longer than a retrospective
study, but are less likely to introduce bias as to the presence or absence of a particular risk factor.
Randomisation eliminates errors of allocation, such as patients with more severe disease being
allocated to the more aggressive treatment regimen. Blinding eliminates errors of assessment. In
a single blind trial, only the subject does not know which intervention he or she is receiving, and
ideally the subject should assess his or her own response to the intervention. In a double blind
trial neither the subject nor the investigator know which intervention is being given.
Confounding arises when the effects of two processes are not separated, for example when a
study demonstrates that people with asthma are less likely to develop lung cancer than people
without asthma. As asthma patients are also less likely to smoke, and non-smokers are less likely
to contract lung cancer than smokers, smoking is a confounding factor in this example.
Confounding factors can be eliminated by choosing appropriate controls that differ from the
study subjects only in the factor under investigation. The

470
power of a study depends on the size of the difference to be detected, the size of the study
population and the significance level required, and is the probability of detecting the specified
difference- Reliability is concerned with whether a test repeatedly administered to an individual
produces repeatable results.

9.1.7 Epidemiology
a. Genetic counseling is an example of secondary prevention.
b. Screening aims to detect symptomatic disease.
c. The number of cases of disease in a population is measured by the incidence.
d. The sensitivity of a screening test is its ability correctly to identify affected individuals.
e. To be related causally to a disease an aetiological factor must be found in all cases with
disease.

Primary prevention is action designed to prevent the occurrence of disease, for example health
education. Secondary prevention aims to detect and treat the occurrence of disease before
symptoms develop, for example treatment of high cholesterol. Tertiary prevention is action to
prevent sequelae once the disease is manifest, such as taking aspirin after myocardial infarction.
Screening is an example of secondary prevention, and aims to detect presymptomatic disease.
Incidence measures the number of new cases of disease per unit population per unit time,
whereas prevalence measures the total number of cases (old and new) at a particular time.
Sensitivity is the ability of a test correctly to identify affected individuals, and specificity its
ability correctly to identify those unaffected. To be related causally, an aetiological factor must
be found more frequendy among the diseased than the non-diseased, exposure must precede
onset of the disease and elimination of the factor should reduce the risk of the disease. An
epidemiological study can help clarify these points.

Answers
17. a, c, e 9.1.4 b, c 9.1.7 d
18. d, e 9.1.5 a, b,c, d,e
19. a, c 9.1.6 a, d, e

471
Index alpha agonists, topical 279
amacrine cells 39 (fig)
amblyopic eye 385
abducent nerve 2-3, 53, 56-7, 65 amikacin 185
fig) amoxycillin 146-7
abducent nucleus 57 (fig) amphetamine 336
Absidia 174 amphotericin 186
Acanthamoeba casteUanii 179—80 properties 185 a
accuracy of an observation 462 mygdala 75
acetazolamide, uses and side anaemia 428-9
effects 281 aneuploidy 115
acetylcholine 272, 354, 451 angiotensin II 423, 443
acidosis, causes 445, 447 (fig) angular veins 14
Actinomyces israelii 172—3 annulus of Zinn 50—1
action potential, properties 455—6 anopia 412
activated Hageman factor 197—8 ansa cervicalis 98—100
acute graft rejection 237—8 anterior cerebral artery 46 (fig),
acute inflammation 191—3 70
cellular phase 192—3 anterior chamber
characteristics 191 associated immune
vascular phase 191—2 deviation 229-30
acyclovir, properties 187—8, 189 introduction of antigen 229-30
(fig) anterior communicating artery 46
adenoviruses 157—8 (fig), 49
adherence 132 anterior speech cortex 72 (fig)
adhesion antibiotics, resistance 186-7
cell to cell 254—5 antibody interaction
cell to matrix 254-5 with antigen 213-14
Adie‘s pupil 89 with MH complexes 216—17
diagnosis 273 with T cell receptors 216-17
features 342 a antibody-dependent cell-mediated
drenal gland 436 (fig) cytotoxicity 222-5
medulla 436—7 antidiuretic hormone 438—9,
adrenaline 339, 437 442-3
topical 16 antigenic drift 151
adrenocorticotrophin growth aorta 420
hormone 438—9 aortic baroreceptors 425—6
aflatoxin 267 apoptotic cell deadi 255—8
alcohol 336 genes 256-7 a
aldosterone 443 praclonidine 279
alkaline injuries 205—6
alkalosis, causes 445-6, 447 (fig)
allografts 236

472
aqueous humour strategies against host
active production 308-9 defences 132—3
composition 310 structure 129—30
dynamics 311 toxins 133—4
formation 307 Bactervides fragilis 144
functions 309—10 bacuiovirus p35 256—8
immunosuppressive role 228 Bailey-Lovie (Log MAR)
outflow mechanisms 311—12 chart 393
protein content 310—1 t Barr body 120
rabecular meshwork, basal nuclei, connections 74—5
composition 312-13 basilar artery 46 (fig)
Argyll Robertson pupil, basilar vein 68 (fig)
features 341 Bax 256-8
arrestin 366 (fig), 369 Bcl-2 256-8
arrhythmias 240—1 Bell‘s phenomenon 295
arsenic 267 bends 243
arterioles 420 benoxinate 288
Arthus reaction 231—2, 234 3,4 benzpyrene 267
articular facet 98 {3 amyloid protein 256
Ascaris lumbricoid.es 175 p blockers (ocular)
Aspergillus fumigatus 172, 186 side effects 277—8
ataxic dysarthria 275 topical 278
atherosclerosis betaxolol 278
fibrolipid plaque, bifid spine 98 (fig)
characteristics 244 binocular single vision,
natural history and requirements 413-14
complications 245 bipolar cells 39 (fig)
plaque formation 243-4 blepharitis 294
risk factors 246 blinding 464
atropine 274-5, 335 blinking
mydriasis, reversal 273—4 reflex 294—5
auricular nerve 99 spontaneous 295
autografts 236 blood aqueous barrier 306—7
autosomal dominant trait 117—19 blood flow, autoregulation 421
azithromycin 146 hormonal control 423
azoles 186 neuronal control 423
B lyphocyte 208 blood pH, regulation 447 (fig)
Bacillus an.thra.cis 133, 139 blood pressure, control 425—6 blowout
Bacillus brevis 140 fractures 2, 59
Bacillus cereus 139—40 body water 442—3
bacteria Borrelia burgdorferi 146—7
characteristics 129 botulinum toxin 296
culture 131 Bowman‘s membrane 19—20, 298
gram staining 131-2 metabolism and healing 202—3
growth 130 brachiocephalic artery 100 (fig)
pathogenicity 132 bradykinin 198
sterilization and brimonidine 279
disinfection 134 Bloch‘s law of vision 400—1 Broca-
Sulzer effect 401 473
Brodmann‘s area 17 48, 49, 388 cephalosporins, properties 181
Brodmann‘s area 18 48 (fig) cerebellar arteries 54
brolene 180 cerebellum 71
Brubaker‘s correction 311—12 afferent connections 76—7
Brucella abortus 143, 182 efferent connections 78—9
brucellosis 183 cerebral artery 72 (fig)
Bruch‘s membrane 33—4, 35 (fig) cerebral vein of Galen 68 (fig)
buccinator 105 cerebral ventricles connections 68—9
C4b-binding protein 241 relations 69-70
cadherins 254-5 cerebrospinal fluid 70
Caenorhabditus elegans 257 cerebrum, blood supply 70—1
calcarine sulcus 47—9, 390 cervical plexus 98—9
caloric testing 349—50 cervical vertebrae 97—8
caipains 320 cestodes 174, 177
canal of Schlemm 21, 22—3 (figs) chalones 201
Candida albicans 170 chemotaxis 19 3—9
capillaries 420 chi-quadrat (x2)
carbachol 2.72—3, 336 test 460-1
carbonic anhydrase 281 Chlamydia pneumoniae 145
carcinogens, chemical 267 Chlamydia psittaci 145
cardiac muscle, properties 452—3 Chlamydia trachomatis 144—6
cardiac output 426 chloramphenicol, properties 183
cardiovascular physiology 420—7 cholineacetyl transferase 272
carotid artery 99—100 cholinergic agonists,
carotid baroreceptors 425—6 c uses and side effects 273
arotid bifurcation 100 (fig) cholinesterase enzyme 272, 451
carotid sheath, relations 100 chorda tympani 7 (fig), 90 (fig),
carteolol 278 97, 102, 104
cataract 274 choroid 33—4
diabetes 319 healing 203
catecholamines 276, 354 choroidal plexus 70
properties 276—7, 437—8 chromosomes 108—9
receptors in the eye 276 abnormalities 115—23
caudate nucleus 69, 71, 74—5 structure 108—9
cavernous sinus 54, 55—9 (figs) cigarette smoking 246
connections 63 ciliary artery 16, 29 (fig),
thrombosis 62 61—2
cell cycle 111—12 ciliary body 23—5
cell mediated embryology 23 e
hypersensitivity 234-5 pithelium 24
cell surface receptors 252-4 healing 203
cellular fatty acid binding proteins muscle 25
(cell FABP) 370 blood supply 30 (fig)
central retinal artery 42—3, 45, 47, 60-1 innervation 30 (fig)
occlusion 34, 380 structure 24
central retinal vein 62 ciliary epithelium 305—6 ciliary
central scotoma 342 ganglion 6, 30 (fig), 45, 54-5, 89, 90-1
(figs) lesion 334-5 474
ciliary muscle 25, 30 (fig), 90 (fig) limb us 21—2
accommodative power, physical properties 297—8
changes 327 proteoglycans 302—3
properties 327 structure 298—9
ciprofloxacin 184 fine 19—20
circle of Willis 70 gross 18
circle of Zinn 61—2 transparency, theories 303-4
claustrum 75 (fig) corneal barriers 270
clonal ―abortion‖ 236 corneal limbus 21—2
clonal ―anergy‖ 236 corpus callosum 70
Clostridium perfringens 140—1, 144 corresponding retinal points 412
Clostridium tetani 140—1 cortical areas 71—3
clotting 197—8 cortical blindness 48—9
cocaine 288, 296, 335-6, 339 cortical cells, physiology 389—90
Cogan‘s law 347 corticonuclear tracts 83—4
collagen 312 corticospinal (pyramidal) tract 83—4
collarette 27, 29 (fig) corticosteroids 283—7
colour vision assessment 411 effects 435—6
constancy 408—9 production 435
deficiencies 411—12 coxsackie viruses 161
neural encoding 410 cranial nerves 54—9
theories 409 Cryptococcus neofonnans 171, 186
complement system 196—7 crypts of Lieberkuhn 247
cone(s) cuneate nucleus 80 (fig)
photoreceptors, curare 451
fovea 395—6 cyclopentolate 274-5, 335
sensitivity 407—8 cyclophosphamide 267
structure 374 (fig) cystatin 293
congenital night blindness 376 cytokines 221—2
conjunctiva 15-17, 61 cytomegalovirus 156-7
blood supply 16 cytotoxic T cells 222—5
histology 16—17 dacryocystorhinostomy 10
innervation 16 dark adaptation 406—7
palpebral 12 (fig) decompression sickness 243
structure 15—16 deep petrosal nerve 96—7
connexins 323 Demodex follicularum 135, 274
contact dermatitis 234—5 dense bodies 239
cornea Descemet‘s membrane 18—19, 20 (fig), 22
ang|e anatomy 22—3 (fig), 298
carbohydrate, metabolism 299 healing 202
collagen 302 deutan deficiency 411—12
dehydratation 300—1 deuteranopes 412
development 18 dexamethasone 284
electrolyte and glucose content 300 maxidex (0.5%) 285-6
embryology 17 diclofenac 286, 287
epithelium/endothelium 20 digastric 105
innervation 21 dilator pupillae 27, 29-30
(figs)
475
diplopia 414-16 antigen presenting cells 2.27
non-physiological 415—16 movements
disinfection 134 extraocular control 345-6
dopamine 256, 351 fixation 348
dorsal motor nucleus 88 saccadic 348, 399-400
dorzolamide 282 smooth pursuit 347
dysplasia, characteristics 259 torsional 345
Echinococcus granulosus 175 vergence 346
echothiophate 273—4 version 346
Edinger-Westphal nucleus 29, 30 (fig), 55 normal flora 135
(fig), 88, 90 (fig), 92-3 sympathetic supply 340 (fig)
edrophonium 296 eyelash 12 (fig)
elastin 312 eyelids 11—15
electro-oculogram 380—1 blood supply 14—15
electroretinograms 375—80 effect of drugs 296
flicker 376—8 innervation 14_ 15
pattern 379, 382—3 lymphatic drainage 14-15
photopic 376—8 s stricture 11 — 12
cotopic 376—8 facial artery 14, 100 (fig), 103
uses 379—80 facial muscles, innervation 105
emissary vein 64 (fig) facial nerve 82, 97, 105
endocrinology 431—9 factor V Leiden mutation 241
endotoxins 133-4 Farnsworth Munsell ―100‖ hue test 411
enterobacteriaceae 142-4 fenamates 287
enteroviruses 161 Ferry-Porter law 403
epidemiology 465 fibrin 207
epidermal growth factor 248—9, 260 degradation 207
epidermic keratoconjunctivitis 158 fibrinolytic system 197-8
Epstein—Barr virus 151 fibroblast growth factor 249, 318
erythromycin 146 fibronectin 201, 250, 312
Escherichia coli 131—2, 142, 144, 180 Fick‘s axes 342—3
esotropias 273 filarias 174
ethanol 256 Fisher‘s exact test 461
ethmoidal air cells 2 (fig), fissures 97 fixation,
4 (fig) control 402
ethmoidal sinuses 35, 60 flickering stimulii 402-3
exotoxins 133-4 critical flicker frequency 403
exotropias 414 Floren‘s law 349
external carotid artery 100—1 flow, physics 422
external laryngeal nerve 101—2 fluconazole l 80
extraocular muscles 50—3, 342—5 flucytosine 186
gaze, fluorescein 271
cardinal positions 344 (fig) fluoromethalone 285-6 5-
innervation 52—3 fluorouracil 204
relations 53 eye flurbriprofen 287
amblyopic 385 follicle stimulating hormone 438―
foramen lacerum 96
476
foramen of Magendie 68 glossopharyngeal nerve 82, 90 (fig)
foramen magnum 97 glucagon 434—5
foramen ovale 64 (fig), 96 glucocorticoid receptors 283—4
foramen rotundum 58—9, 92 (fig), 93—4 glucose 441—2
foramen spinosum 63, 96, 106 glutamate 256, 352
foramen transversarium 97—8 glutathione 319—20
foramina of Luschka 68—9 glycerin 301
foramina of Munro 68—9 glycerol 280
forced inspiratory volume in one second glycine 352—3
(FEV1) 429-30 Golgi tendon organ 453
forced vital capacity 429—30 Gradenigo‘s syndrome 56
foscamet, properties 189 graft cell destruction 238 (fig)
fourth ventricle, floor 57 (fig) granulocyte and macrophage colony
fovea, centralis 41—2, 399 stimulating factor 221—2
foveal cone 41 ―grey baby‖ syndrome 183
foveola 42 grey line 11—12
frames of reference 342—3 growth factors 248—9
Francisella tularensis 143 guanethidine 296
Frisby Xest 416 haemoglobin, fetal 428
frontal bone 1 frontal eye field 72 (fig) haemolysins 132
frontal nerve 3 (fig) Haemophilus influenzae 133, 141, 180,
frontal sinus 4 (fig), 60 183 hard palate 96 (fig)
frontalis 105 head and neck,
iVill thickness skin sympathetic supply 88
central corneal laceration, healing 202—3 Heaf test 235
incision, heat shock protein (HSP-90) 283
healing 201 helminths 174—
fungi, general properties 171 5 immunity 225—6
G protein 252—4 hepatitis B virus properties 166
gamma radiation 134 gamma- serology 166—7
aminobutyrate acid 352—3 Hering‘s law 346
ganciclovir, properties 188 heroin 336
ganglion cells 39 (fig) herpes gladiatorum
gaze positions 342—3 (scrumpox) 153
gene expression 110—11 herpes simplex virus 150, 153
gene mutations 113—14 type-1 151, 153-6
geniculate body 7 (fig), 74 (fig) heterotropias 414
gentamycin, properties 182 hiatus semilunaris 3—4
gland of Moll 11—12 high density lipoprotein 246
gland of Zeis 12 (fig) histamine 191, 231, 233
glaucoma 379 Histoplasma capsulatum 173, 186
open angle 273 globe, homatropine 274, 335
venous drainage 62 horizontal cells 39 (fig)
globus pallidus 74—5 (figs) Homer‘s syndrome 296, 339—40
glomerular filtration 440—1
glomerulotubular balance 441

477
human immunodeficiency virus 161—5 intercellular adhesion molecules (ICAM) 192
infection, pathogenesis 162—3 interferon a 207-8 p 207-8
life cycle 164 (fig) Y 221
serology 16 3—5 interphotoreceptor retinoid
human mutations, molecular analysis 125—6 binding protein 369—70
human papillomavirus 168 interleukin-1 ^-converting enzyme 256-8
human T-lymphotropic virus type- 1 165 interleukin-8 192
hyaloid artery 36 intermedious nerve 6—7, 90 (fig), 104-5
hyaluronic acid 312 internal capsule 73—4
hyaluronidase 132 internal carotid artery 64—5, 70, 96-7
hydroxyamphetamine 336, 339 internal carotid plexus 30 (fig)
hyoglossus 102—3 internal jugular vein 64 (fig), 68 (fig), 100-1
hyperlipidaemia, type II 240—1 internal occipital protuberance 67
hypersensitivity reactions 231—5 intracranial pressure,
hypoglossal canal 97 increased 46, 445-6
hypoglossal nerve 100 intraocular pressure 314—15, 317 (fig)
hypothalamic pituitary system 439 (fig) short term fluctuations 316
hypothalamus 69 iris
hypotonic fluid loss 444—5 blood supply 28—9
immunoglobulins embryology 25—6
* functions 213 epithelial development 26-8
gene rearrangements 210—12 gross structure 27
structure 208—9 healing 203
types 212 innervation 29—30
incisive canal 96 (fig) muscle development 26
indomethacin 287 isolated agonist model, muscle action 343—4
inferior colliculus 334 isotonic volume depletion,
inferior orbital fissure 2 homeostatic response 444
inferior sagittal sinus 67—8 (fig)
inferior thyroid vein 102 (fig) Ixodes tick 147
inflammation jaw winking 295 Jones-Mote type of
chronic, properties 199—200 hypersensitivity reaction 235
natural history 198—9 jugular foramen 64 (fig), 67—8, 97
inflammatory corneal angiogenesis factors keratocytes 299 cornea 20 (fig)
contributing 207—8 ketokonazole 180
features 206—7
infraorbital nerve 15 (fig), 92 (fig)
infratemporal fossa 106
infratrochlear nerve 15 (fig)
insulin
deficiency, features 434
production 433
properties 433—4
integrins 251, 254—5

478
kidney, functions 440 light adaptation 404—5
kinin 197—8 lingual artery 100 (fig), 102
Koch-Weeks bacillus 143 lipocalin 293
La Place‘s law 422 Listeria monocytogenes 133
lacrimal artery 15 (fig) Joe'‘1 anaesthetic agents 287—8
lacrimal bone 9 long ciliary nerves 16, 21, 30 (fig)
lacrimal gland 289 long posterior ciliary arteries 61—2
lacrimal nerve 2—3, 7 (fig), 15 (fig), 53 luteinising hormone 438
lacrimal system 6—10 Lyon hypothesis 120
gland 7 (fig), 90-1, 289 macrophage colony stimulating factor 254
drainage 8—9 histology 7—8 parasympathetic macrophages, properties 195—6
innervation 6—7 macula 34, 41—2, 49, 390
structure 6 macular sparing phenomena 49
lacrimal sac 9—10 major histocompatibility complex 214—16
nasolacrimal duct 9—10 major intrinsic protein 323
lactoferrin 194, 293 Mann-Whitney U test 463
lamina fusca 36 mannitol 280
lamina terminalis 46 (fig) Marcus Gunn syndrome 295—6
laminin 250 margination 191 —2
Landholt C test 393 masseter 105 mast cells 231
latanoproat 282—3 activation 232 (fig)
lateral geniculate nuclei 47, 49, 387 mastoid air cells 94—5
physiology 388 lens matrix metalloproteinases 304—5
ot-crystallins 321—2 maxilla 1, 95—6 maxillary artery 100 (fig)
P-y-crystallins 322 maxillary nerve 2, 65 (fig), 91—2
biochemistry 319 maxillary sinus 2 (fig), 4—5, 59 (fig), 96 (fig)
embryology 30—1 Mazzotti skin test 175
epithelium 318 measles 159
functions 317 medial canthal tendon 10
glutathione 319—20 medial palpebral ligament 10
gross structure 31—2 Meibomian gland 11—12
histology 32 meiosis 112—13
membranes and intercellular junctions 323 melanin 271
metabolism 318— 19 metabolism 363
proteins and protein breakdown 320—1 melanoblasts, choroidal 33, 35—6
lentiform nucleus 74 (fig) melanocytes 24, 27
lesser petrosal nerve 90 (fig) melatonin 355—6
levator palpebrae metaplasia, characteristics 259
superioris 12-13, 55 (fig)> 295 metastasis 260
levobunolol 278 metazoa 17 4—5
methaemoglobin 428
methicillin resistant
Staphylococcus aureus (MRS A) 136-7

479
metronidazole, properties 183-4 nasociliary nerve 3 (fig), 5, 53, 57-8
mid brain lesion 334—5 nasolacrimal canal 2 (fig), 4 (fig), 95-6
middle cerebral artery 70 Neisseria gonorrhoea 133, 137—8
middle cranial fossa foramina, re,at;''ns1 Neisseria meningitidis 137—8
96—7 nematodes 174—5
middle ear 57 (fig) neomycin 179—80
middle meningeal artery 106 neoplasia 258—64
middle thyroid vein 102 (fig) characteristics 258
miosis chemical carcinogens 267
causes 336, 338 (fig) formation, mechanisms 260
prostaglandin induced 287 invasion, mechanism 265—6
mitochondrial inheritance 122-3 malignant,
mitomycin C 205 characteristics 259-60
mitosis 111—12 metastasis 266—7
molecular cloning 124-5 proto-oncogenes 261
molluscum contagiosum virus 169 activation 261—3
Moraxella lacunata 143 tumour suppressor genes 263-4
motor endplates, features 450—1 nerve fibres, types 456—7
Mucor 174 neurohypophysis 438-9
Mucoraceae 174 neutrophil rolling 192
mucosa associated lymphoid tissues 226—7 nicotine 336
MOller cells 38, 40, 354 nitric oxide 284
M.iiller*s muscle 12—13, 296 nitrosamines 267
mumps 160—1 Nocardia asteroides 144
mural thrombi 242 non-granulomatous
muscarinic acetylcholine receptors 252 iridocyclitis 206
muscarinic agonists * non-steroidal anti-inflammatory drugs 271,
properties 272-3 286
indirect acting 273-4 noradrenaline 437, 451
uses and side effects 274 normal distribution 458-9
muscarinic antagonists 274—5 null hypothesis 461—2
side effects 275 nystagmus 349—50
muscarinic receptors 272 congenital 402
muscle physiology 448—57 oblique muscles 51—2
muscle spindle 453—4 occipital artery 100 (fig)
myasthenia gravis 296 ocular absorbtion, rate and extent 270
Mycobacterium tuberculosis 133, 138-9, ocular cardiac reflex 425—6
230 mydriasis 335, 337 (fig) ocular cholinergic system 272
mydriatic agents 336 ocular medications, distribution and
myeloperoxidase 194 elimination 271
mylohyoid 102—3 \ ocular tissues, healing 203—4
Nagler reaction 141 2- oculomotor nerve 2—3, 30 (fig), 46 (fig),
naphthylamine 267 52-6, 65 (fig), 89.
nasociliary artery 60 oculomotor

480
Ohm‘s law 422 properties 180
Onchocerca volvulus 175 petrosal nerve 6—7
ophthalmic artery 2—3, 14, 45—6, 60 phagocytosis 194-5
ophthalmic nerve 53, 65 (fig) phenylephrine 335
ophthalmic vein 2—3, 14, 16 phosphatidylinositol 4,5-
optic canal 2—3, 94 (fig) biphosphanate 252-4
optic chiasma 45—6 photoreceptors 35 (fig), 39—40
optic cup 36 phagocytosis 372—3
optic nerve 2—3, 43—7, 60, 89 properties 370
demyelination 385—6 shedding 372—3
embryology 43 phrenic nerve 99
healing 203 Phthirus pubis 274
lesions 47 physostigmine 273, 336
relations 45 pilocarpine 272—3, 335
optic vesicle 36—7 pituitary fossa 64
orbicularis oculi 8, 11 — 14 pituitary gland 46 (fig), 65
orbit 1—3 hormones 438—9
connections 1 relations 1 Pityrosporon orbiculari 135
orbital floor 95—6 plasmin 242
fractures 2 plasminogen 310—11
orbital septum 11—12 plasminogen activator 207
oscillopsia control 402 platelet-derived growth
osmolanty 442 otic ganglion 90 (fig), 106 factor 247-9, 252, 260
ouabain 301 OVALE 96 platelet(s)
oxygen binding proteins 428—9 factor-3 238—9
oxygen dissociation of factor-4 207—8
haemoglobin 427—8, 429 (fig) structure 238—9
oxytocin 439 (fig) platysma 105
p53 256 p value 461 Poiseuille Hagen law 311, 422
palatine bone 1 palisades of Vogt 21—2 polyhexamethylene biguanide 180
palpebral artery 14 polymerase chain reaction 127—8
Panum‘s area 412, 414—15 pontine paramedian reticular formation
papilloedema 47 85—6
paranasal sinuses 2—5 medial longitudinal fasciculus 87
innervation 5 posterior auricular artery 100 (fig)
lymphatic drainage 5 posterior cerebral artery 46 (fig), 49, 70
parasympathetic nuclei 88—90 posterior ciliary arteries 46
parotid gland 88, 90 (fig), 103—4 posterior communicating
Pasteurella muhocida 143 artery 46 (fig), 49, 55 (fig), 70
pasteurisation 134 aneurysm 54
penicillin(s) 141 posterior speech cortex 72 (fig)
posterior vitreous detachment 331
potassium 442
poxviruses 149
prednisolone 285

481
presumed ocular histoplasmosis syndrome 173 recessive disorders,
pretectal nucleus 30 (fig) inheritance 119
primary visual cortex 48—9, 72 (fig) rectus muscles 50—1
proparicaine 288 recurrent laryngeal nerve 101-2
Propionibacteriunt acnes 135, 144 red nucleus 55 (fig) •
Propionibacterium granulosunt 135 renal physiology 440—7
prostaglandin(s) respiratory physiology 427—31
E2 192 resting membrane potential 454—5
ocular effects 239-40, 287 retina 36-43, 351-74
protan deficiency 411—12 acetylcholine, dopamine and catacholamine
protanomalous 411—12 354
protanopes 412 blood supply 42—3
protein C 241 differentiation 37—8
protein tyrosine kinase 220 disk morphogenesis 371—2
protein VP 16 154-5 embryology 41
proto-oncogenes 261—2 gamma-aminobutyrate and glycine 352—3
pseudo Graefe phenomenon 295 Pseudomonas gluconeogenesis 360—1
aeruginosa 143—4 glutamate 352
pterygoid 105 pterygoid canal 6—7, 93-4 glycolysis 357-8
pterygoid venous plexus 62—4 interhatoreceptor matrix 369—70
pterygopalatine fossa 2 (fig), 7 (fig) interhatoreceptor retinoid binding protein
pterygopalatine ganglion 58—9, 90-2 369—70
pupil Kreb‘s citric acid cycle 359—60
Adie‘s 342 macula 41—2
Argyll Robertson 341 melanin, metabolism 363
effects of increasing size 333 melatonin 355—6
efferent defect 334—5 membranes and glial cells 40
Homer‘s syndrome 339 metabolism 356-7
light near dissociation 340—1 neural 38-9
light reflexes 334 pentose phosphate pathway 362
miosis, causes 336, 338 (fig) phagocytosis 372—3
mydriasis 335, 337 (fig) photocascade, inhibition 369
mydriatic agents 336 photoreceptors 35 (fig), 39—40, 370
normal 332 retinal neurotransmitters and neuromodulators
reaction to light 332—3 351
tonic 89 rhodopsin 364—5
pupillary pathways 92—3, 341 (fig) shedding 372-3
pupillary reflexes 48—9 transduction 368
Purkinje cell 78 (fig) visual cycle 364—6
putamen 74 (fig) vitamin A metabolism 366—7
Q fever 183 retinal degeneration 379
randomisation 464 retinitis pigmentosa 376
retinoblastoma protein 264—7
rex gene 165
Rhizopus 174 '
rhodopsin 364—5

482
rifampicin 146 sphenoparietal sinus 63
right lateral rectus palsy 417 (fig) sphincter pupillae 27, 29 (fig)
right transverse sinus 68 (fig) spino-olivary tract 77 (fig)
Robertsonian sporing bacteria 139
translocation 115—16 squint 415
rod(s) standard deviation 459—60
sensitivity 407—8 Staphylococcus aureus 135—6, 180
structure 374 (fig) Staphylococcus epidermis 135—6
rubella 159—60 Starling‘s law 426—7
salicylate 287 statistics 458—65
salivary nucleus 88 stem cells 246—7
sarcomere 448—9 replication 247 (fig)
―scalded skin‖ syndrome 136 stereopsis 416
Schirmer‘s test 291—2 sterilisation 134
Schlemm‘s canal 311, 314 steroids, anti-inflammatory effects 284
Schwalbe‘s line 21—3 Stiles-Crawford effect 333
sclera 15, 22 (fig), 33-6, 61 strabismus 50, 416
embryology 33 straight sinus 68 (fig)
healing 203 Streptococcus pneumoniae 135, 137
histology 35-6 Streptococcus pyogenes 137
sclerocomeal limbus 15—16 Streptomyces caespitosus 205
secondary active transport 441—2 striate cortex 388
shingles 156 striated muscle, properties 448
short ciliary nerves 30 (fig), 91 (fig) Strickler syndrome 331
lesion 335 stylomastoid foramen 94—5, 97
sigmoid sinus 64 (fig), 67—8 subacute sclerosing
skeletal muscle pan encephalitis 159
electrical activity 451—2 subclavian artery 101
properties 452—3 submandibular ganglion 90 (fig)
skeletal muscle contraction, events 449— submandibular gland 102
50 substantia nigra 75 (fig)
smooth muscle, properties 452 succinylcholine 451—2
Snellen chart 393, 396 sulphonamides 146
sodium 441—2 superficial temporal artery 100 (fig)
somatosensory system superior ophthalmic vein 62, 64 (fig)
anterolateral (spinothalamic) system 81 superior orbital fissure 1—2, 55—8 (figs),
dorsal column/medial leminiscal pathway 63-4 (figs), 94 (fig)
79—80 superior sagittal sinus 67—8
sorbitol 318—19, 319 superior salivatory nucleus 6—7
speech area superior thyroid artery 100—2
anterior (Broca) 71—3 superior thyroid vein 102 (fig)
posterior (Wernicke) 73 supranuclear gaze pathways 85—6
sphenoethmoidal recess 4 (fig) supraorbital nerve 15 (fig)
sphenoid bone 1, 93—4 supratrochlear nerve 15 (fig)
sphenoidal sinus 3-4, 46 (fig), 65, 94 (fig) sutures 93

483
T ccll receptors 216-17 Toxocara canis 176
structure and signalling 219—20 Toxoplasma gondii 174
T lymphocyte 208 life cycle 178
tabes dorsalis 341 pathogenicity 179
tachyphylaxis 278 properties 177-8
Talbot‘s law 403—4 transcapillary exchange 424—5
tarsal plates 11, 15 transducin 368
tax gene 165 tcar(s) transforming growth factor beta 228, 247-8,
biochemistry 292 256
dynamics 291—2 transmembrane signalling 252—4
film 290-1, 294 transplantation,
production 289—90 immunology 235—8
protein components 293—4 rejection, types 237—8
temporal bone 94—5 tissue typing 236—7
temporalis 105 tolerance 235—6
tendinous ring 23, 55—8 (figs) types 236
Tenon‘s capsule 35—6 transverse process 97—8
Tensilon test 296 transverse sinus 64 (fig)
tetanus toxin 140—1 trematodes 174
tetracaine 288 Treponema pallidum 147
tetracycline 146 Treponema pertenue 147
properties 182—3 trigeminal ganglion 58—9 (figs)
thalamus 69, 71, 74—5 (figs), 78 trigeminal nerve 5, 14, 21, 105
third ventricle 46 (fig) maxillary division 58—9
thoracic pump 420 ophthalmic division 57—8
thrombocytopenia 240—1 sensory nucleii 82
thrombosis 238—43 tritanomaly 411—12
factors that inhibit 241—2 tritanopia 412
risk factors 240—1 trochlear nerve 3 (fig), 52—3, 55-6, 65 (fig)
thromboxane A2 239-40 trochlear nucleus 56 (fig)
thrombus tropicamide 274—5
formation 239—40 Troxler effect 401
natural history 242 Troxler‘s phenomenon 348
thymoxamine 336 tuberculous granuloma, properties 200—1
thymus-dependent tumour necrosis factor 220—2, 256
antigen 217—19 tumour supressor genes 263—4
thyroglossal duct 101 type I error 461 type II error 461
thyroid artery 100 (fig) ubiquitin 320
thyroid gland 101—2, 431—3 ultraviolet radiation 134
blood supply/venous/lymphatic drainage 101 — uncal herniation 334—5
2 relations 101 uveitis 287
structure 101 vagus nerve 82, 100
tidal volume 429—30 Valsalva manoeuvre 316
timolol 277—8
pharmacology 277
total lung volume 429—30
toxin A 143--4

484
vancomycin 136—7, 185 visual evoked potential 393-4,
varicella zoster virus 156 398
infection 188 visual evoked potentials 383—7
vasa vasorum 242 uses 386—7
vascular permeability 191 wave form 385
venous sinuses, dura mater 67—8 visual field deficits 4S (fig)
venous stasis 240-1 visual pathways 43—9, 387—91
ventilation:perfusion ratios 430—1 vertebral anterior, blood supply 46-7
body 98 (fig) lesions 47
vertebral foramen 98 (fig) vital capacity 429—30
vestibular dysfunction 402 vitamin A 366—7, 433
vestibulo-ocular reflexes 349—50 visual cycle 366—7
vidian nerve 92 (fig) vitreous
virulence 132 viruses collagen 329—31
immunity 223-5 biochemistry 331- 2
infection 150 properties 329
properties 148 synthesis 329—30
replication 148-9 physical properties 328
serology and rapid diagnostic tests 151—2 Von Michael‘s spur 26
strategies against host defences 150—1 vortex veins 28, 35, 62
transmission 149—50 Weber-Fechner relation 404—5
visual acuity WhitnalPs tubercle 1 Wilcoxon rank sum
anatomical factors affecting 395—6 test 463
assessment 392 Windkessel effect 420
contrast sensitivity 396-8 X chromosome 411 inactivation 120
infancy 398 linked disorders 120—1
objective measurement 393—4 Yates‘ correction 461
optical factors affecting 394 yaws 147—8
physiological factors affecting 395 yoked muscles 344
potential, assessment 398 zygomatic bone 1
subjective measurement 393 zygomaticotemporal artery 15 (fig)
visual cortex, representation of the visual zygomaticotemporal nerve 7 (fig), 91
field 390
visual cycle 364—6
visual deprivation in the perinatal period
391

485