Ophthalmology Pictures notes.

1. Retinal detachment: the separation of the neurosensory retina from the underlying
retinal pigment epithelium, to which normally it is loosely attached. This can be
classified into four types: rhegmatogenous, tractional, exudative and tumor-
related.The detached retina will be white and edematous and will lose its
transparency. Ophthalmoscopy will reveal a bullous retinal detachment.
2. Corneal abscess, caused by a bacterial inflammation. Most bacteria are unable to
penetrate the cornea as long as the epithelium remains intact. However, this patient
underwent perforating/penetrating keratoplasty through which probably bacteria were
introduced. The black lines in the pic are 10.0 runing sutures. This abscess can
cause perforation and lead to endophthalmitis.
3. Acanthamoeba keratitis: is a rare type of keratitis (inflammation of the cornea)
caused by the saprophytic protozoa acanthamoeba. It occurs usually in a patient who
wears soft contact lenses but doesn't clean it well enough. Therapy: Since the
corneal transparency is zero we have to do a keraroplasty - removing of the unclear
corneal part and transplanting a new cornea from a donor.
4. Exudative, age related macular degeneration:
• Exudative, more dangerous. There is a very
severe neovascularization under the macular
area. The peripheral vision is ok but the central
part is not functioning.
• Non exudative (dry) - Drusen.

5. Anophtalmus. Patient is missing his right eye. This patient had retinoblastoma when
he was young. The palpebral area (upper and lower eyelid) is shorter than the other
side because the removal of the eye was in childhood. Normal growth of the orbit and
the eyelids requires the eyeball to grow and when the eye is removed the eyelids stop
to grow.
6. Central artery retinal occlusion: Retinal infarction are due to occlusion of an artery
in the lamina cribrosa or a branch retinal artery occlusion. Paper-thin vessels and
extensive retinal edema in which the retina loses its transparency are typical signs. In
the middle a cherry red spot - the fovea centralis - can be seen because the other
parts of the retina are swollen so compared to that it just appears cherry red (red of
underlying choroid is showing under it).
7. Retinal arterial occlusion (macular area). Remember the macula is always on the
temporal side, thats why this is a left eye!
8. Basal cell carcinoma (basalioma) of the eyelid is a frequent, semi malignant tumor:
Grows slowly but can cause severe tissue destruction.
Rarely metastasizes.
Can be removed surgically.
9. Basal cell carcinoma, grows where the glasses contact the skin, it is and irritative
lesion. Color is the mother of pearl.
10. Basalioma recidivians, basal cell carcinoma, penetrates the frontal sinus in the
picture.
11. Congenital glaucoma (end stage). Buphthalmus (abnormally large eye) is seen
on both sides. This is caused because the iris inserts to far anteriorly in the trabecular

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 meshwork and as a result an embryonic mesodermal tissue in the form of a thin
transparent membrane (Barkanʼs membrane) covers the trabecular meshwork and
impedes the flow of aqueous humor into the canal of
Schlemm. Since this patient is at ends stage nothing can
help this condition. In an earlier stage it could have been
solved with a trabeculectomy (filtration surgery) which would
have released the high IOP.
12. Congenital glaucoma, patients left eye. Patient appears
to have big eyes, visual acuity is still fine at this phase.
Children with this disorder are irritable, poor eaters, and rub
their eyes in an attempt to compress some fluid out of their eye.
13. Traumatic cataract and rubeosis iridis - Contusion of the eyeball most commonly
will be the cause of a post traumatic cataract and will usually produce a rosette-
shaped cataract. However in this picture it appears more round. In addition to this
rubeosis iridis can be seen - a neovascularization in the iris that occurs in various
retinal disorders. In this picture you can see relatively large vessels in the iris
indcating the neovascularization.
14. Nuclear Cataract: In the fourth decade of life, the pressure of peripheral lens fiber
production causes hardening of the entire lens, especially the
nucleus. The nucleus takes on a yellowish-brown color
(brunescent nuclear cataract). This may range from reddish-
brown to nearly black discoloration of the entire lens (black
cataract). Visual acuity is obviously decreased but we can not
know from this pic by how much. However, if the visual
acuity of the patient under 16% we can do a
Phacoemulsification - by ultrasound we remove the
cataract lens from the eye and put an artificial lens inside
the eye. This is the treatment for this patient. Before the
surgery we conduct a biometry examination so we can plan
the diopter of the lens we need to later implant during
surgery.
15. Mature cataract: diffuse, complete opacification of the lens. visual acuity under
10% (preception of light/dark), also requires surgery as the previous cataract.
16. Focal Chorioretinitis: The chorion and the retina are always inflamated together.
This is focal because we can see the focal white part in the middle lower part of the
image. this Inflammation can be caused by toxocara, toxoplasma or leptospira for
example.
17. Corneal Cicatrix - cicatrix means scar. It is often caused by an accident, in this
image you can also see vessels pointing to the scar. Visual acuity decreased.
18. Congenital Iris Coloboma - A congenital anomaly that results from incomplete
fusion of the embryonic optic cup which normally occurs in about the sixth week of
pregnancy. Since this coloboma opens inferiorly it is safe to assume that it is
congenital since in the development of the eye this is the last part closing. Surgical
iris colobomas in cataract and glaucoma surgery are usually opened superiorly.

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19. Vernal conjuctivitis - vernal means seasonal, mosttly in springtime. The tarsal
conjunctiva shows a cobblestone/paving stone appearance. The tool used to invert
the upper eyelid is the Desmares spoon.
20. Bacterial conjunctivitis - discharge inside the eyelids, its very common, painful,
itchy and can cause blurry vision. Requires antibiotic eyedrops such as tobramycin or
neomycin and it can be solved in a week.
21.Acute bacterial conjunctivitis - same as the previous, bacterial discharge can be
seen, appears to be more severe than the previous.
22. Retinal hemorrage after ocular contousuion - can be caused by blunt trauma. It
is dangerous because blood contains iron which is toxic.
23. Conjuctival cyst: treatment depends, if its an old lady that had it for years than
there is no need to treat. However, if it is a newly appearing cyst which is growing
rapidly then you have to cut it out and send to histology.
24. Iris cyst - the part on the right is rubeosis iridis ( a neo revascularization of the iris).
The cyst itself can decrease the visual acuity because it is before of the pupil, Nd:Yag
laser therapy will make a hole in the cyst and drain it.
25.Acute dacrocystitis: inflammation of lacrimal
sac. It is a painful condition which requires
drainage. We also have to give local and oral
systemic antibiotics. If it recurs in 4-6 weeks
period we need to consider the possibility of a
tumor.
26. Allergic Dermatitis of the eyelids: severe
allergy to eyedrops can be seen.
27.Descemetocele: The descement membrane of
the cornea has a protrusion. in the middle
(white). The black lines are 10.0 running suture
because the patient underwent perforating
keratoplasty. It is a serious condition because
there is risk of perforation through which bacteria can go into the eye and cause
endophtalmitis.
28.Disinsertion of the levator superioris palpabrae muscle - The aponeurosis is
weak, the patient closes her eyes but still you can see her eye movements. When
she opens her eyes you can see a mechanical form of ptosis. This condition requires
Reinsertion surgery.
29. Diabetic retinopathy-. We can see in this image is a severe neovascularization
(small blood vessels on the top left of the image). Cotton white spots are debris.
Retinal hemorrhages are also sen. how can you treat it? Laser treatment, a panretinal
laser photocoagultive therapy.
30. Cavernous hemangioma of the upper eyelid and dislocation of the bulb: This
tumor requires treatment first with radiotherapy and then surgery of what is left. You
should do an MRI in order to know if it goes inside the orbit.
31.Dislocation of the bulb and ptosis of the upper eyelid : You have to ask the
patient when did this begin because if it is relatively new than it is probably caused by
a tumor, send this patient to do an MRI.

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32. Ectoprotesis - full reconstruction of palpebral area. Patient probably underwent a
very severe surgery in which the palpebral area and the full orbital cavity had to be
cleared of tumor. This is the best they could do for him...
33. Cicatriceal ectropion of the lower eyelid: ectropion means that the eyelid is
turned outwards. In this patient it is caused due to scarring. Incomplete closure of the
eyelids can lead to symptoms associated with dryness of the cornea including
ulceration. Correction via plastic surgery.
34. Senile ectropion of the lower eyelid - Surgery includes tightening the lower eyelid
via a tarsal wedge resection followed by horizontal tightening of the skin.
35. Endophtalmitis - The entire eye is involved, visual acuity is zero, maybe some
light/dark perception. The patient needs IV vancomycin. If it is not solved then we will
have to remove the whole eyeball in order to prevent the inflammation from going to
the brain.
36. Senile entropion of the lower eyelid: The eyelid is turned inside. The patient will
feel itching, foreign body feeling . Kettesy operating method will solve the problem. It
is caused by a scar.
37. Congenital entropion of the lower eyelid - use glue stick until the age of 2,
usually it helps. and if the condition persists then operate.
38. Exophtalmus - Graves disease. Protrusion of the eye.
39. Exudative, age related, macular degeneration - The end stage of the late
(exudative) type is what we call Khunt-Junuis.
40. Cooked Fish eye following alkali injury. What do you have to do in this case is
first wash the eye for half an hour with any watery solution of neutral PH in order to
remove all the alkalic material in the eye (Milk should be avoided as it increases the
penetration of the burn by opening the epithelial barrier). Later this condition will
require a special method for corneal transplantation - the sofort or ashor keratoplasty
(a lamellar keratoplasty).
41. Arcus Senillis (Gerontoxon): lipid containing circle. The Peripheral edge is sharp
and separated from the limbus by a clear zone. Arcus senilis is the most common
peripheral corneal opacity; it frequently occurs without predisposing systemic
conditions in elderly individuals. Occasionally arcus may be associated with familial
and non-familial dyslipoproteinaemias.
42. Protesis Bulbi: Prostesis located in left eye of the patient. Possible reasons for
prosthesis are: very severe inflamation, severe accident. On the other eye the patient
probably underwent cataract surgery and thats why this patient has aphakia (does not
have a lens).
43. Hemangioma of the upper eyelid: Treatment for this would be waiting and seeing,
this hemangioma is not in front of the pupil so it does not affect the vision. In most
cases hemangiomas spontaneously resolves before age 7. If it does not:
• small hemangioma - local excision.
• Small to medium - intra lesional steroids.
• Large - Superficial radiotherapy.
44. Herpes Zoster Ophtalmicus: a very severe reactivation of the virus, came from the
trigeminal ganglion, ophtalmic division. It always grows 3mm per day, this way you
can measure and calculate how many days before the inflammation began.

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45. Hemangioma in Von-Hippel-Lindau disease (before and after treatment):
Hemangiomas are benign congenital changes associated with VHL disease. Loss of
visual acuity will result where exudative retinal detachment occurs. Therefore
hemangiomas must be removed, there are several methods to treat the patient:
• Cryosurgery (TTT) - transpupilar thermo therapy.
• Nd:YAG surgery
• Ruthenium106 contact irradiation
46. Foreign body in the eye: A nail stuck in the eye. Visual acuity of the eye is
decreased since the nail went through the ciliary body and caused hemorrhage in
the eye. In case of penetrating trauma like this first a sterile bandage should be
applied, tetanus immunization or prophylaxis and prophylactic antibiotic treatment
are also indicated. Later surgery to remove the nail should be done which also
includes suturing the globe and reconstructing the anterior chamber.
47. Foreign body in the lens: Some aluminum part from a hammer. The entire lens
has to be removed.
48. Kayser Fleischer ring: This golden-brown to yellowish-green corneal ring is
caused by copper deposits at the level of Descemetʼs membrane in Wilsonʼs
disease.
49. Esotrpia: Left eye of the patient deviates inward. You can see that the light
reflection does not fall on both eyes symmetrically. On the left eye it falls on the
temporal part of the pupil indicating esotropia (hirschberg method).
50. Keratoprotesis: An artificial cornea. Just a plastic piece sutured to the conjuctiva.
51. Dendritic Keratitis: Caused by HSV, called dendritic because it has the
appearance of chinese letters or tree branches. It can be seen using fluorescein
staining that stains the injured collagen on the cornea. Hypopyon (pus) can also be
seen.Herpes simplex keratitis is usually very painful and associated with
photophobia, lacrimation, and swelling of the eyelids. Vision may be impaired
depending on the location of findings, for example in the presence of central
epitheliitis.
52. Keratitis and Hypopyon: probably bacterial, you can see a hypopyon (pus in ant.
chamber), an epithelial defect with an infiltrate. Chemosis is also present.
53. Marginal Keratitis: Marginal keratitis is probably caused by a hypersensitivity
reaction against staphylococcal exotoxins and cell wall proteins with deposition of
antigen-antibody complexes in the peripheral cornea with a secondary lymphocytic
infiltration. The lesions are culture negative but S. aureus can frequently be isolated
from the lid margins.Symptoms are mild discomfort, redness and lacrimation that
may be bilateral.
54. Acute Keratoconus: Keratoconus is the most frequently encountered deformation
of the cornea. In rare cases keratoconus can cause tears of Descemetʼs membrane
due to the continuous stretching, then ant. chamber fluid will enter the stroma totally
decreasing the transparency of the cornea. Symptoms of acute keratoconus include
sudden loss of visual acuity accompanied by intense pain, photophobia, and
increased tearing.
55. Deposits on the surface of contact lens. Jelly like deposits on the surface of the
contact lens probably due to hygenic problems of the patient.
56. Penetrating Keratoplasty With 10.0 running sutures.

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57. Penetrating Keratoplasty (three times): Smaller and smaller circles are seen.
58. Leucoma Cornea - Totaly white scar on the cornea.
59. Leucoma Cornea - This state is called Leucoma Vascularisatia Cornea.
revasculrization. In this case we can attempt to do a penetrating keratoplasty.
60. Epibulbar Dermoid on the Limbus of the cornea: Epibulbar dermoid is a round
dome-shaped grayish yellow or whitish congenital tumor. It is generally located on
the limbus of the cornea, extending into the corneal stroma to a varying depth. It has
to be removed because there can be hair, nails, inside...
61. Luxation of the lens into the anterior chamber and iris coloboma. This
coloboma is acquired because it openes superiorly. A sublaxated lens can also be
seen.
62. Retinal tear and retinal tamponade with elastic silicone sponge. The retinal
tear is the whitish membrane seen. This retinal detachments was
treated with a retinal tamponade with an elastic silicone sponge that
was sutured to the outer surface of the sclera, a so-called budding
procedure.This indents the wall of the globe at the retinal break and
brings the portion of the retina in which the break is located back into
contact with the retinal pigment epithelium.
63. Macula Cornea: A special scar of the cornea. If the entire cornea is
white we call it leucoma cornea, if only part of it is white - macula
cornea.
64. Exophtalmus Maligna: This patient has graves disease and exhibits
exophtahlamus.
65. Megalocornea: An abnormally large cornea (13-15mm), It is very important to
distinguish this situation from congenital glaucoma. In congenital glaucoma the total
bulb is getting bigger and bigger and in megalocornea just the anterior part of the
eye is larger than normal.
66. Megalocornea - same as above.
67. Uveal melanoma and nevus, Fluorescein angiography pictures on the right
side. In this picture you can see a melanoma (below, yellowish brown, elevated)
and a nevus (above, next to the optic cup). malignant uveal melanoma is the most
common primary intraocular tumor. It usually occurs as a choroidal melanoma, and
is almost always unilateral. These tumors become clinically symptomatic when
involvement of the macula reduces visual acuity or the patient notices a shadow in
his or her field of vision as a result of the tumor and the accompanying retinal
detachment. Choroidal tumors are treated with radioactive isotopes delivered by
plaques of radioactive material (brachytherapy). Enucleation is indicated for tumors
whose diameter exceeds 8mm and whose prominence exceeds 5mm. In this
fluorescin angiography picture we can see a typical salt and pepper presentation.
68. Melanoma of the ciliary body - Symptoms include changes in accommodation and
refraction resulting from displacement of the lens. Ciliary body melanomas are
resected en bloc.
69. Melanoma of the Iris: These tumors are often initially asymptomatic.
However,metastatic melanoma cells in the angle of the anterior chamber can lead to
secondary glaucoma. Circumscribed iris melanomas are removed by segmental
iridectomy.

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70. Membrana pupillaris persistens - Persistent pupillary membrane (PPM) is a
condition of the eye involving remnants of a fetal membrane that persist as strands
of tissue crossing the pupil. It generally does not cause any symptoms and using
topical atropine to dilate the pupil may help break down PPM.
71. Microcornea - When the diameter of the cornea is under 8 mm. Rare congenital
condition, may be associated with glaucoma (due to shallow anterior chamber).
72. Conjunctival nevus: Conjunctival nevi can degenerate into conjunctival
melanomas (50% of conjunctival melanomas develop from a nevus). Therefore,
complete excision and histologic diagnostic studies are indicated if the nevus
significantly increases in size or shows signs of inflammation.
73. Benign neurofibromatosis: Associated with neurofibromatosis which is regarded
as a phacomatosis (a developmental disorder involving the simultaneous presence
of changes in the skin, central nervous system, and ectodermal portions of the
eye).In this case we have to use radiotherapy to remove the tumor. This is also an
example of mechanical ptosis.
74. Zonular Opacity of the cornea: This a special type of calcification of the cornea.
rare. Visual acuity is decreased.
75. Panophtalmithis - Panophthalmitis is the inflammation of all coats of the eye
including all intraocular structures. We can try to treat this inflammation with
vancomycin but if it does not work we have to remove the entire eye so the
inflammation does not go to the brain.
76. Diabetic retinopathy after pantretinal laser treatment. The optic nerve head is
visible but the macula is not. These large vessels are signs of neovascularization.
The white spots represent the areas where the panretinal laser was directed at.
77. Phtisis bulbi - Phthisis bulbi is a shrunken, non-functional eye that results from
severe ocular disease, inflammation, or injury. Sometimes it may be painful to the
patient in which case we have to remove the eye.
78. Pterygium internum: A triangular (pterygium=wing) fold of conjunctiva that usually
grows from the medial portion of the palpebral fissure toward the cornea. This
progression is presumably the result of a disorder of Bowmanʼs layer of the cornea,
which provides the necessary growth substrate for the pterygium. It may represent a
response to UV exposure or other factors such as chronic surface dryness. A
pterygium only produces symptoms when its head threatens the center of the
cornea and with it the visual axis, surgical removal is indicated in such cases.
79. Congenital total ptosis of the upper of the upper eyelid. Treatment depends on
the visual acuity of the patient. If it is well developed then we donʼt have to operate
immediately. However, if it disturbs the development of the visual acuity of the
patient we need to operate.
80. Retinoblastoma and leucocoria: Retinoblastoma is a malignant tumor of early
childhood that develops from immature retinal cells. Leukocoria = white pupil, also
known as amaurotic catʼs eye. May be bilateral (usually inherited form), unilateral
(usually non hereditary) or trilateral (involving both eyes and the pineal body).
Tumors less than four pupil diameters can be managed with radiation therapy
delivered by plaques of radioactive ruthenium or iodine (brachytherapy) and
cryotherapy. Larger tumors require enucleation of the eye. What else can cause
leukocoria? Coatʼs disease and retinopathy of prematurity.

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81. Retinoblastoma (ophtalmascope): This is the “cottage cheese” appearance of the
retinoblastoma after treatment.
82. Intraoperative picture, brachytherapy, RU 106 contact irradiation. The plaque of
ruthenium is sutured to the sclera for 1-2 days and then removed.
83. Corneal Staphyloma: A staphyloma is an abnormal protrusion of the uveal tissue
through a weak point in the eyeball. The protrusion is generally black in color, due to
the inner layers of the eye. It occurs due to weakening of outer layer of eye by an
inflammatory or degenerative condition. Here we can see that the stroma of the
cornea is very thin and there is a big protrusion of the iris underneath.
84. Scleral Staphyloma: The sclera is very very thin and the protruding parts are parts
of the uvea.
85. Steven-Johnson syndrome: also the patient underwent penetrating keratoplasty
and 10.0 running sutures can be seen.
86. Subcunjunctival hemorrhages: no treatment, will disappear on itself.
87. Sympathetic ophtalmia: Sympathetic uveitis can occur in an otherwise unaffected
eye even years after penetrating injuries or intraocular surgery in the fellow eye,
especially where there was chronic irritation. Tissues in the injured eye (uveal tract,
lens, and retina) act as antigens and provoke an autoimmune disorder in the
unaffected eye. The earliest symptoms include limited range of accommodation and
photophobia. Later there is diminished visual acuity and pain.
88. Symblepharon and ankyloblepheron: this is the end stage of the cooked fish eye.
A symblepharon is a partial or complete adhesion of the palpebral conjunctiva of the
eyelid to the bulbar conjuntiva of the eyeball.
89. Congenital coloboma of the upper eyelid- etiology. Colobomas are rare defects
resulting from a reduction malformation (defective closure of the optic cup). They
require plastic surgery.
90. Conjunctival tumor - Since we see a sentinel vessel and we can notice that the
margins are not sharp we should remove this tumor since it may be malignant.
91. Orbital tumor: Requires an MRI examination to determine the exact location of the
tumor.
92. Corneal ulcer (Mooren): A special type of corneal ulcer which is associated with
rheumatoid arthritis, rosacea or systemic sclerosis. It has a circumferential crater
like depression of the cornea, just inside the limbus, usually with an overhanging
edge.
93. Bacterial Corneal Ulcer: It is very important to treat at an early phase since later it
can cause perforation and endophthalmitis - panophtalmitis.
94. Central retinal vein occlusion: Occlusion of the central vein of the retina or its
branches is frequently due to local thrombosis at sites where sclerotic arteries
compress the veins. In central retinal vein occlusion, the thrombus lies at the level of
the lamina cribrosa. It appears as a flame.
95. Vulnus ruptum cornea et sclera et collapsus bulbi - Total collapsed bulb due to a
very severe accident. Rupture injury of the sclera and cornea with collapsed bulb.
96. Xanthalesma of the upper eye lid: A xanthalesma is a creamy-yellow plaque like
lesion which frequently involves the skin of the upper and lower eyelids. It occurs
most commonly in middle aged women and is associated with diabetes mellitus and

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 high cholesterol levels. The treatment for this is surgical excision, mainly for
cosmetic reasons (but recurrences are common.
97. Uveal Melanoma: Treatment depends on the size of the tumor:
• The prominence of the tumor is smaller than 2 mm: Nd:YAG laser thermo therapy.
• Between 2mm-5mm: Ruthenium106 brachytherapy.
• Between 5mm-6mm: sandwich therapy, you treat from the sclera with ruthenium
and from the tumor part we treat it with Transpuppilary Thermo therapy (TTT).
• Larger than 6mm: enucleation of the eye.

Roei Singolda, Michael Freund 2012/2013