29th October 2016

Lecture: 1 Baghdad medical college

Dr. Najah
Gross Anatomy of the eyeball:
The eyeball lies in a quadrilateral pyramid-shaped bony cavity situated on either side
of the root of the nose called Orbit. Each eyeball is suspended by extraocular muscles
and their fascial sheaths in to the bones of the orbit. The eyeball surrounded by a pad
of fat to provide a protective cushion. The eye occupies only about 1/5 of the size of
the orbit. At birth the eyeball measures antero-posteriorly about 17.5 mm and reaches
23-25 mm in adult. The average transverse diameter of the adult eye is 24 mm.
The globe has 3 main layers (coats), each of which is further divided:

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1- The outermost tunic (coat): consists of anterior one-sixth transparent part-
the cornea and the remainder five-sixths opaque part-the sclera. The transitional
junction area is –the limbus. The radius of curvature of the anterior corneal surface
(7.8 mm) is smaller than that of the sclera (12 mm), making the shape of the globe an
oblate spheroid. (see the above figure)
Function: the function of sclera is protection of intra ocular contents and also it
facilitates the insertion of external ocular muscles. Posteriorly, Sclera contains
many perforations and orifices for entrance and exit of vessels and nerves
including the optic nerve. The function of cornea is to refract light on the retina
and it is even more important than lens in focusing light on the retina. The
limbus contains rich vascular plexus that participates in corneal tissue nutrition
through diffusion; it also contains a reservoir of stem cells that aid in corneal
epithelial healing after injury.

2- The middle coat (uvea or uveal tract): consists of the posterior part which
is called the Choroid, a triangular shape muscular thickening called ciliary body
and anteriorly, diaphragm like structure called the iris. The iris is perforated
centrally by regular and round opening called the pupil.
Function: the Choroid, is nourishment to the outer 1/3 rd of the thickness of
retina. The Ciliary body is secretion of aqueous humor (at a rate of 2.5
microliters/min) and accommodation. The iris, is to determine the size of the
pupil in order to determine the amount of light enter the eye and also gives the
eye its color.
3- The inner coat: light sensitive layers, called retina, composed of 10 layers,
the inner 9 layers called sensory retina and outer one layer called retinal
pigment epithelium (RPE). There is a deep yellowish-color area at the center of
retina called macula lutea (lutea = yellow), the center of macula lutea is called
fovea centralis, which is the most sensitive area in the retina.

Retina has two types of photosensitive cells, cones and rods. Fovea centralis
contains only cones which are responsible of sharp day and color vision, while
rods are responsible for night and peripheral vision, as they are very sensitive
and have a much lower threshold for activation.

The lens: is crystalline and transparent structure suspended in its position

through the Zonule to the epithelium of Ciliary body.
Function: with the cornea forming the major refractive system of the eyeball
that converge light to focus on the retina. (the Cornea forming 2/3rd of the
power of the this system while the lens forming 1/3rd)

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The eye encloses 3 cavities
1- The anterior chamber: mushroom like cavity located between the cornea
anteriorly and iris diaphragm posteriorly. It is about 3 mm in deep, with an
average volume of 250 µL.
2- The posterior chamber: small slit cavity located between iris diaphragm
anteriorly and the lens and its zonules posteriorly. It has average volume of 60
µL.
The anterior chamber and posterior chamber communicate through the pupil
and both of them located in the anterior segment (the lens and all structures
anterior to it) of the eyeball and both of them filled with fluid called Aqueous
humor. The Aqueous humor is secreted by superficial non-pigmented
epithelium of the Ciliary body into the posterior chamber and then it is passes to
the anterior chamber through the pupil. In the angle of the anterior chamber
there is sieve like structure called trabecular meshwork, from here the aqueous
humor goes to the circular venous canal called schlemm's canal and from it to
the episcleral veins and then to systemic circulation again. The rate of secretion
of aqueous humor is equal to the rate of drainage so that the intraocular pressure
(IOP) is constant between 10-21mmHg (average 16 mm Hg).
3- The vitreous cavity: it is the largest cavity, located between lens and
zonules anteriorly and adjacent sensory retina posteriorly, filled with jelly-like
substance called vitreous humor. It comprises more than two-thirds of the
volume of the eye (5-6 ml). The total volume of the average adult eye is
approximately 6.5-7 ml.
Posterior segment of the eyeball includes all structures posterior to the lens
(vitreous cavity, retina, optic disc and choroid)

Blood supply of eyeball:

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The arteries of the eye are derived from the ophthalmic artery; a branch of internal
carotid artery.
The inner 2/3rd of retinal thickness tissue gets its blood supply from the central retinal
artery, a branch of ophthalmic artery, which enters the optic nerve about 10 mm
behind the eyeball.
The veins of retina do not accurately follow the course of the arteries, except at the
optic disc where they join to form the central retinal vein which accompanies the
central retinal artery. The Central Retinal Vein drains the blood into the cavernous
sinus through superior ophthalmic vein.
The Uveal tract is supplied by three groups of ciliary arteries; all of them are branches
of ophthalmic artery.
1. Short posterior ciliary arteries which are 20 in no.
2. Long posterior ciliary arteries which are 2 in no.
3. Anterior ciliary arteries are derived from 7 muscular branches of ophthalmic
artery. 2 muscular branches for each rectus muscle except the lateral rectus has
only one muscular artery, so the total is 2x3+1=7.
The venous drainage of the Uveal tract occurs through the ciliary veins which form 3
groups:
1. Posterior ciliary veins.
2. Vortex veins which are 4 in no.,
3. Anterior ciliary veins.

The bulk of the blood is drained through the vortex veins comprising 4 large trunks
which open into superior and inferior ophthalmic veins, then to cavernous sinuous.

Nerve supply of eyeball:

The sensory nerve supply to the eyeball is derived from the ophthalmic division of
the fifth cranial nerve (trigeminal).
The parasympathetic (visceral fibers) innervations to the eyeball derived from
oculomotor nerve to supply the sphincter pupillae and ciliary muscles.
Sympathetic innervations to the eyeball derived from superior cervical ganglion and
then with Internal Carotid Artery and its branches to the eye.

Visual Acuity:
Definition: it is the ability of the eye to distinguish the shape of symbols such
as letters, numbers and pictures. It is the cone function of the fovea centralis.

VA is designated by two numbers:

1st- Numerator: indicates the distance separating the test object from the
patient.
2nd- Denominator: indicates the distance at which the test
object subtends an angle of 5 minutes of arc, and each part of
the test object subtends an angle of 1 minute of arc.

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 The most familiar test objects are letters or numbers black in color drawing in
a white check board, which is uniformly illuminated. This test is called visual
acuity charts, the standard Snellen's and Bailey-Lovie charts.

Test letters require a literate and cooperative observer. The letters vary in their
recognizability. Thus, "L" is the easiest letter and "B" is the most difficult. So
the Landolt broken ring (C) in which the break subtends a 1 minute angle and
the entire ring subtends a 5 minutes angle, eliminates this variability.
Similarly, the letter "E" may be arranged so that it faces in different directions.
This E letter shape test used for illiterate person.

* For any object to be seen and discriminated by the eye, it must be (at least)
able to stimulate 2 cones and one unstimulated cone in between within fovea.
Each cone is 0.004mm in length (4 μm) and makes an angle of 20 seconds of
arc, so 3 cones make an angle of one minute of arc.

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VA: is for normal person.
1st (upper): 6 à represent the distance separating the test object from the patient.
2nd (lower): 6 à represent the distance at which the test object subtends an
angle of 5 minutes of arc, and each part of the test object subtends an angle of 1
minute of arc.

Snellen acuity is measured with test letters (optotypes) constructed so that the
letter as a whole subtends an angle of 5 minutes of arc, whereas each stroke of
the letter subtends 1 arc minute (arc min). Letters of different sizes are
designated by the distance at which the letter subtends an angle of 5 arc min.

The Snellen chart is designed to measure visual acuity in angular terms.

However, the accepted convention does not specify acuity in angular measure
but uses a notation in which the numerator is the testing distance (in feet or
meters), and the denominator is the distance at which a letter subtends the
standard visual angle of 5 arc min. Thus, on the 20/20 line (6/6 in meters), the
letters subtend an angle of 5 arc min when viewed at 20 ft ( 6 meters). On the
line (6/12), the letters subtend an angle of 10 arc min when viewed at 6 meters
or 5 arc min when viewed at 12 meters.

The standard Snellen eye chart, though widely accepted, is not perfect. The
letters on different Snellen lines are not related to one another by size in any
geometric or logarithmic sense. For example, the increase in letter size going
from the 6/6 line to the 6/9 line is different from that going from the 6/9 line to
the 6/12 line. In addition, letters (such as C, D, O, and G) are inherently harder
to recognize than others (such as A and J) because there are more letters of the
alphabet with which they can be confused.
For these reasons, alternative visual acuity charts have been developed and
popularized in clinical trials (eg Bailey-Lovie).

Color vision:
Most normal humans have 3 types of cones and consequently a 3-variable
color-vision (3 cone opsins) system. These 3 types are:
1- Middle wavelength sensitive (M) cones for detecting high resolution
achromatic (black and white) contrast.
2- Short wavelength sensitive (S) cones used only color by comparing its
signals with those of the M cones. This mechanism creates blue/yellow
color vision.
3- Long wavelength cones (L) which are creates red/green color vision.

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 Color vision deficiencies occur as a hereditary defect in about 7% of men
and 0.5% of women. They are usually transmitted as an X -chromosome linked
abnormality.
The most common hereditary color deficiency is red-green defect; usually
there is reduced color quality in these individuals, as absolute deficiency is
quite rare.
Recently, color blindness glasses have been developed (like EnChroma
glasses) these help color blind people to at least partially distinguish between
colors.
Color vision deficiencies can be autosomal, e.g. congenital achromatopsia &
cone degeneration.
Color vision abnormalities can be acquired: 50°
1- Retrobulbar neuritis.
2- Foveal degeneration caused by vascular disease.
3- Retinal detachment (involving the fovea). 90° 60°

Visual field:
Definition: Island of vision in sea of darkness.
The function of the extrafoveal retina is assessed 70°
by measurement of the visual field when the ability
to recognize the special target diminishes rapidly in
all directions away from the fovea centralis.
The macula also can be assessed through
performing central visual field, so we have 2 types
of visual field:
1- Central visual field (macular) à central 30°.
2- Peripheral visual field (extramacular) à out of
central 30°.

The peripheral extension of visual field is:

50° superioly (limited by eye brow), 60° nasally (limited by nose), 70°
inferiorly (limited by cheek) and 90° temporally (no limitation).

Assessment of peripheral visual field by:

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1- Confrontation visual field.
2- Goldmann visual field.
3- Automated and computer-assisted perimeters.
Assessment of central visual field by:
1- Goldmann visual field.
2- Automated perimeter.
3- Tangent screens.
4- Amsler grid.
5- Friedmann perimeter.

Interpretations of visual field abnormalities:

- Mono-ocular VF defect: Disease involving retina and optic nerve.
- Binocular VF defect: Disease involving the optic chiasma, optic tract, optic
radiation and occipital cortex.

Defects in the VF are usually described as:

1- Central (within central 30°).
2- Peripheral (outside central 30°).

- Central VF defect (central scotoma): characterized diseases involving the

fovea centralis and the papillomacular bundle of nerve fibers in the optic nerve.

- Centrocecal scotomas: involve both, physiological blind spot and fixation

point, e.g. toxic diseases of the optic nerve.

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- Annular scotoma: e.g. retinal pigmentary degenerations (retintis pigmentosa),
advance glaucoma, and senile miosis of pupil.

- Arcuate (arched) scotoma: Early Glaucoma.

- Hemianopia: half-blindness, left and right retina of opposite side.

- Homonymous hemianopia: binocular right or left Homonymous hemianopia.
- Heteronymous hemianopia: Binocular, right from one eye and left from
other, so, it is either bitemporal or binasal heteronymous hemianopia.

Lesion affecting the optic nerve or retina of one eye lead to VF defect in this
eye while the fellow (other) eye VF is normal.

Lesions affecting other parts of visual pathway i.e. optic tract, lateral geniculate
body, optic radiations and occipital cortex can leads to contralateral VF defect
affecting the same site of both eyes. For example demylination or ischemia
(CVA) of right side of any one of the above mention parts of the visual pathway
leads to left hemianopia. This type of hemianopia is called homonymous
because affecting the same side of VF of each eye (left).
Lesions affecting the cross fibers (from nasal retinae) of optic tract affecting the
temporal VF side of each eye. It is called bitemporal hetronymous hemianopia.
The hetronymous means, right VF for right eye and left VF of the left eye (e.g.
pituitary adenoma compressing optic chiasm). While Lesions affecting the
uncross fibers (from temporal retinae) of optic tract affecting the nasal VF side
of each eye. It is called binasal hetronymous hemianopia. The hetronymous
means, left VF for right eye and right VF of the left eye (e.g. bilateral carotid
arteries aneurysms) .